What you need to know about facemasks.
In early publications the World Health Organization stated that “facemasks are not required, as no evidence is available on its usefulness to protect non-sick persons” .
In the same publication, the WHO declared that “cloth (e.g. cotton or gauze) masks are NOT recommended under any circumstance” .
Conversely, in later publication the WHO stated that the usage of fabric-made facemasks (Polypropylene, Cotton, Polyester, Cellulose, Gauze and Silk) is a general community practice for “preventing the infected wearer transmitting the virus to others and/or to offer protection to the healthy wearer against infection (prevention)” .
The same publication further conflicted itself by stating that due to the lower filtration, breathability and overall performance of fabric facemasks, the usage of woven fabric mask such as cloth, and/or non-woven fabrics, should only be considered for infected persons and not for prevention practice in asymptomatic individuals .
The Central for Disease Control and Prevention (CDC) made similar recommendation, stating that only symptomatic persons should consider wearing facemask, while for asymptomatic individuals this practice is not recommended .
Consistent with the CDC, clinical scientists from Departments of Infectious Diseases and Microbiology in Australia counsel against facemasks usage for health-care workers, arguing that there is no justification for such practice while normal caring relationship between patients and medical staff could be compromised .
Moreover, the WHO repeatedly announced that “at present, there is no direct evidence (from studies on COVID-19) on the effectiveness face masking of healthy people in the community to prevent infection of respiratory viruses, including COVID-19”. Despite these controversies, the potential harms and risks of wearing facemasks were clearly acknowledged.
These including self-contamination due to hand practice or non-replaced when the mask is wet, soiled or damaged, development of facial skin lesions, irritant dermatitis or worsening acne and psychological discomfort.
Vulnerable populations such as people with mental health disorders, developmental disabilities, hearing problems, those living in hot and humid environments, children and patients with respiratory conditions are at significant health risk for complications and harm .
Physiological effects of wearing facemasks
Wearing facemask mechanically restricts breathing by increasing the resistance of air movement during both inhalation and exhalation process , . Although, intermittent (several times a week) and repetitive (10–15 breaths for 2–4 sets) increase in respiration resistance may be adaptive for strengthening respiratory muscles , , prolonged and continues effect of wearing facemask is maladaptive and could be detrimental for health , , . In normal conditions at the sea level, air contains 20.93% O2 and 0.03% CO2, providing partial pressures of 100 mmHg and 40 mmHg for these gases in the arterial blood, respectively.
These gas concentrations significantly altered when breathing occurs through facemask. A trapped air remaining between the mouth, nose and the facemask is rebreathed repeatedly in and out of the body, containing low O2 and high CO2 concentrations, causing hypoxemia and hypercapnia , , , , . Severe hypoxemia may also provoke cardiopulmonary and neurological complications and is considered an important clinical sign in cardiopulmonary medicine , , , , , .
Low oxygen content in the arterial blood can cause myocardial ischemia, serious arrhythmias, right or left ventricular dysfunction, dizziness, hypotension, syncope and pulmonary hypertension . Chronic low-grade hypoxemia and hypercapnia as result of using facemask can cause exacerbation of existing cardiopulmonary, metabolic, vascular and neurological conditions , , , , , . Table 1 summarizes the physiological, psychological effects of wearing facemask and their potential long-term consequences for health.
Table 1. Physiological and Psychological Effects of Wearing Facemask and Their Potential Health Consequences.
|Physiological Effects||Psychological Effect||Health Consequences|
|•Hypoxemia•Hypercapnia•Shortness of breath•Increase lactate concentration•Decline in pH levels•Acidosis•Toxicity•Inflammation•Self-contamination•Increase in stress hormones level (adrenaline, noradrenaline and cortisol)•Increased muscle tension•Immunosuppression||•Activation of “fight or flight” stress response•Chronic stress condition•Fear•Mood disturbances•Insomnia•Fatigue•Compromised cognitive performance||•Increased predisposition for viral and infection illnesses•Headaches•Anxiety•Depression•Hypertension•Cardiovascular disease•Cancer•Diabetes•Alzheimer disease•Exacerbation of existing conditions and diseases•Accelerated aging process•Health deterioration•Premature mortality|
In addition to hypoxia and hypercapnia, breathing through facemask residues bacterial and germs components on the inner and outside layer of the facemask. These toxic components are repeatedly rebreathed back into the body, causing self-contamination. Breathing through facemasks also increases temperature and humidity in the space between the mouth and the mask, resulting a release of toxic particles from the mask’s materials , , , , , .
A systematic literature review estimated that aerosol contamination levels of facemasks including 13 to 202,549 different viruses . Rebreathing contaminated air with high bacterial and toxic particle concentrations along with low O2 and high CO2 levels continuously challenge the body homeostasis, causing self-toxicity and immunosuppression , , , , , .
A study on 39 patients with renal disease found that wearing N95 facemask during hemodialysis significantly reduced arterial partial oxygen pressure (from PaO2 101.7 to 92.7 mm Hg), increased respiratory rate (from 16.8 to 18.8 breaths/min), and increased the occurrence of chest discomfort and respiratory distress . Respiratory Protection Standards from Occupational Safety and Health Administration, US Department of Labor states that breathing air with O2 concentration below 19.5% is considered oxygen-deficiency, causing physiological and health adverse effects. These include increased breathing frequency, accelerated heartrate and cognitive impairments related to thinking and coordination . A chronic state of mild hypoxia and hypercapnia has been shown as primarily mechanism for developing cognitive dysfunction based on animal studies and studies in patients with chronic obstructive pulmonary disease .
The adverse physiological effects were confirmed in a study of 53 surgeons where surgical facemask were used during a major operation. After 60 min of facemask wearing the oxygen saturation dropped by more than 1% and heart rate increased by approximately five beats/min .
Another study among 158 health-care workers using protective personal equipment primarily N95 facemasks reported that 81% (128 workers) developed new headaches during their work shifts as these become mandatory due to COVID-19 outbreak. For those who used the N95 facemask greater than 4 h per day, the likelihood for developing a headache during the work shift was approximately four times higher [Odds ratio = 3.91, 95% CI (1.35–11.31) p = 0.012], while 82.2% of the N95 wearers developed the headache already within ≤10 to 50 min .
With respect to cloth facemask, a RCT using four weeks follow up compared the effect of cloth facemask to medical masks and to no masks on the incidence of clinical respiratory illness, influenza-like illness and laboratory-confirmed respiratory virus infections among 1607 participants from 14 hospitals .
The results showed that there were no difference between wearing cloth masks, medical masks and no masks for incidence of clinical respiratory illness and laboratory-confirmed respiratory virus infections. However, a large harmful effect with more than 13 times higher risk [Relative Risk = 13.25 95% CI (1.74 to 100.97) was observed for influenza-like illness among those who were wearing cloth masks .
The study concluded that cloth masks have significant health and safety issues including moisture retention, reuse, poor filtration and increased risk for infection, providing recommendation against the use of cloth masks .
Psychological effects of wearing facemasks
Psychologically, wearing facemask fundamentally has negative effects on the wearer and the nearby person. Basic human-to-human connectivity through face expression is compromised and self-identity is somewhat eliminated , , . These dehumanizing movements partially delete the uniqueness and individuality of person who wearing the facemask as well as the connected person . Social connections and relationships are basic human needs, which innately inherited in all people, whereas reduced human-to-human connections are associated with poor mental and physical health , .
Despite escalation in technology and globalization that would presumably foster social connections, scientific findings show that people are becoming increasingly more socially isolated, and the prevalence of loneliness is increasing in last few decades , . Poor social connections are closely related to isolation and loneliness, considered significant health related risk factors , , , .
A meta-analysis of 91 studies of about 400,000 people showed a 13% increased morality risk among people with low compare to high contact frequency . Another meta-analysis of 148 prospective studies (308,849 participants) found that poor social relationships was associated with 50% increased mortality risk. People who were socially isolated or fell lonely had 45% and 40% increased mortality risk, respectively. These findings were consistent across ages, sex, initial health status, cause of death and follow-up periods .
Importantly, the increased risk for mortality was found comparable to smoking and exceeding well-established risk factors such as obesity and physical inactivity . An umbrella review of 40 systematic reviews including 10 meta-analyses demonstrated that compromised social relationships were associated with increased risk of all-cause mortality, depression, anxiety suicide, cancer and overall physical illness .
As described earlier, wearing facemasks causing hypoxic and hypercapnic state that constantly challenges the normal homeostasis, and activates “fight or flight” stress response, an important survival mechanism in the human body , , . The acute stress response includes activation of nervous, endocrine, cardiovascular, and the immune systems , , , . These include activation of the limbic part of the brain, release stress hormones (adrenalin, neuro-adrenalin and cortisol), changes in blood flow distribution (vasodilation of peripheral blood vessels and vasoconstriction of visceral blood vessels) and activation of the immune system response (secretion of macrophages and natural killer cells) , .
Encountering people who wearing facemasks activates innate stress-fear emotion, which is fundamental to all humans in danger or life threating situations, such as death or unknown, unpredictable outcome. While acute stress response (seconds to minutes) is adaptive reaction to challenges and part of the survival mechanism, chronic and prolonged state of stress-fear is maladaptive and has detrimental effects on physical and mental health. The repeatedly or continuously activated stress-fear response causes the body to operate on survival mode, having sustain increase in blood pressure, pro-inflammatory state and immunosuppression. , .
Long-Term health consequences of wearing facemasks
Long-term practice of wearing facemasks has strong potential for devastating health consequences. Prolonged hypoxic-hypercapnic state compromises normal physiological and psychological balance, deteriorating health and promotes the developing and progression of existing chronic diseases , , , , , , , , , . For instance, ischemic heart disease caused by hypoxic damage to the myocardium is the most common form of cardiovascular disease and is a number one cause of death worldwide (44% of all non-communicable diseases) with 17.9 million deaths occurred in 2016 .
Hypoxia also playing an important role in cancer burden . Cellular hypoxia has strong mechanistic feature in promoting cancer initiation, progression, metastasis, predicting clinical outcomes and usually presents a poorer survival in patients with cancer. Most solid tumors present some degree of hypoxia, which is independent predictor of more aggressive disease, resistance to cancer therapies and poorer clinical outcomes , . Worth note, cancer is one of the leading causes of death worldwide, with an estimate of more than 18 million new diagnosed cases and 9.6 million cancer-related deaths occurred in 2018 .
With respect to mental health, global estimates showing that COVID-19 will cause a catastrophe due to collateral psychological damage such as quarantine, lockdowns, unemployment, economic collapse, social isolation, violence and suicides , , . Chronic stress along with hypoxic and hypercapnic conditions knocks the body out of balance, and can cause headaches, fatigue, stomach issues, muscle tension, mood disturbances, insomnia and accelerated aging , , , , .
This state suppressing the immune system to protect the body from viruses and bacteria, decreasing cognitive function, promoting the developing and exacerbating the major health issues including hypertension, cardiovascular disease, diabetes, cancer, Alzheimer disease, rising anxiety and depression states, causes social isolation and loneliness and increasing the risk for prematurely mortality , , , , .
The existing scientific evidences challenge the safety and efficacy of wearing facemask as preventive intervention for COVID-19. The data suggest that both medical and non-medical facemasks are ineffective to block human-to-human transmission of viral and infectious disease such SARS-CoV-2 and COVID-19, supporting against the usage of facemasks.
Wearing facemasks has been demonstrated to have substantial adverse physiological and psychological effects. These include hypoxia, hypercapnia, shortness of breath, increased acidity and toxicity, activation of fear and stress response, rise in stress hormones, immunosuppression, fatigue, headaches, decline in cognitive performance, predisposition for viral and infectious illnesses, chronic stress, anxiety and depression. Long-term consequences of wearing facemask can cause health deterioration, developing and progression of chronic diseases and premature death. Governments, policy makers and health organizations should utilize prosper and scientific evidence-based approach with respect to wearing facemasks, when the latter is considered as preventive intervention for public health.
Credit authorship contribution statement
Baruch Vainshelboim: Conceptualization, Data curation, Writing – original draft.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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Seek and you will find it.
Be a messenger.
Thank you for your continued support. God bless you all.