Why universal masking in healthcare?

The short answer: COVID-19 puts us all at risk, especially people with health problems, elderly people, children and pregnant people. Masks limit COVID-19 spread. The fact is that few people can avoid visiting healthcare settings like they can shops, restaurants, cinemas etc. Everyone has a right to access healthcare safely, which is why we need to bring back and maintain universal masking in healthcare settings.

The long answer:

Why Should Masks Be Worn in Hospitals?

1. COVID-19 has not gone away

Since January 2022, there have been over 100,000 cases of COVID-19 per day in the UK

ZOE Health Study App

In June 2022, at least 1 in 45 people in the UK had COVID-19

Ons.gov.uk. 2022. Coronavirus (COVID-19) Infection Survey, UK - Office for National Statistics. [online] Available at: <https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/24june2022>

COVID-19 is known to still contribute to hundreds of deaths each week- the actual number is likely higher as testing has decreased significantly

England Summary | Coronavirus (COVID-19) in the UK. [online] Coronavirus.data.gov.uk. Available at: <https://coronavirus.data.gov.uk/> [Accessed 29 June 2022].

 

2. Masks Reduce the Spread of COVID-19 

Masks reduce COVID-19 transmission

Wang et al., 2021. How effective is a mask in preventing COVID‐19 infection?. MEDICAL DEVICES & SENSORS, 4(1).

Eikenberry et al., 2020. To mask or not to mask: Modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic. Infectious Disease Modelling, 5, pp.293-308.

Coclite et al.., 2021. Face Mask Use in the Community for Reducing the Spread of COVID-19: A Systematic Review. Frontiers in Medicine, 7.

Universal masking in hospitals has been shown to reduce COVID-19 infections in healthcare workers

Wang et al., 2020. Association Between Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among Health Care Workers. JAMA, 324(7), p.703.

Lan et al., 2020. Effects of universal masking on Massachusetts healthcare workers’ COVID-19 incidence. Occupational Medicine, 70(8), pp.606-609.

Seidelman et al., 2020. Universal masking is an effective strategy to flatten the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic curve. Infection Control & Hospital Epidemiology, 41(12), pp.1466-1467.

 

3. Masks reduce other hospital-acquired infections

Universal masking in healthcare settings also prevents patients catching Flu and RSV while in hospital

Wong et al., 2020. Absence of nosocomial influenza and respiratory syncytial virus infection in the coronavirus disease 2019 (COVID-19) era: Implication of universal masking in hospitals. Infection Control & Hospital Epidemiology, 42(2), pp.218-221.

 

4. Masking reduces healthcare staff absences due to COVID-19, which the NHS cannot afford

Universal masking in hospitals limits absence of healthcare workers due to COVID-19

Temkin et al., 2021. Effect of a national policy of universal masking and uniform criteria for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) exposure on hospital staff infection and quarantine. Infection Control & Hospital Epidemiology, 43(6), pp.757-763.

COVID-19 increases burden on the workforce by increasing healthcare worker absences

Khorasanee et al., 2021. The effects of COVID-19 on sickness of medical staff across departments: A single centre experience. Clinical Medicine, 21(2), pp.e150-e154.

Increases in COVID-19 work pressures are associated with poorer healthcare worker mental health

van der Plaat et al., 2021. Impact of COVID-19 pandemic on sickness absence for mental ill health in National Health Service staff. BMJ Open, 11(11), p.e054533.

England is already struggling with a doctor shortage

The British Medical Association is the trade union and professional body for doctors in the UK. 2022. NHS medical staffing data analysis. [online] Available at: <https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/nhs-medical-staffing-data-analysis> [Accessed 29 June 2022].

Healthcare workers are already 7 times as likely to have severe COVID-19 infection as those with other types of ‘non-essential’ jobs

Mutambudzi et al., 2020. Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants. Occupational and Environmental Medicine, 78(5), pp.307-314.

The first omicron wave, when masks were still compulsory in hospitals, caused the BMA (doctors’ union) to warn that the NHS could have 50,000 staff off sick by Christmas Day. They warned this would have a devastating impact on even the most urgent care. Removing masks would worsen effects.

The British Medical Association is the trade union and professional body for doctors in the UK. 2022. BMA warns that without further measures, NHS could face almost 50,000 staff off sick with Covid-19 by Christmas Day - BMA media centre - BMA. [online] Available at: <https://www.bma.org.uk/bma-media-centre/bma-warns-that-without-further-measures-nhs-could-face-almost-50-000-staff-off-sick-with-covid-19-by-christmas-day>

During the first Omicron wave, when masks were still compulsory, high staff absences put severe strain on the NHS. Removing masks will worsen this.

Nytimes.com. 2022. U.K. System Strained as Health Care Workers Get Covid Themselves. [online] Available at: <https://www.nytimes.com/2021/12/22/world/europe/britain-health-care-covid-nhs.html>

 

5. COVID-19 risk increases if those around you aren’t in a mask

Benefits of masks increase when more people wear them

Eikenberry et al., 2020. To mask or not to mask: Modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic. Infectious Disease Modelling, 5, pp.293-308.

Two-way masking reduces risk of COVID-19 infection much more than one-way masking

Bagheri et al., 2021. An upper bound on one-to-one exposure to infectious human respiratory particles. Proceedings of the National Academy of Sciences, 118(49).

When only the susceptible person wears a mask, COVID-19 infection rates are still high

Bagheri et al., 2021. An upper bound on one-to-one exposure to infectious human respiratory particles. Proceedings of the National Academy of Sciences, 118(49).

 

6. Masks in only some areas of the hospital or only under certain circumstances is inadequate

Most healthcare-acquired COVID-19 infections in staff may not be from directly caring for COVID-19 patients

Seidelman et al., 2020. Universal masking is an effective strategy to flatten the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic curve. Infection Control & Hospital Epidemiology, 41(12), pp.1466-1467.

COVID-19 shows asymptomatic transmission

Kimball et al., 2020. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR. Morbidity and Mortality Weekly Report, 69(13), pp.377-381.

Vulnerable patients will still walk through shared areas of the hospital, sit in shared waiting rooms, talk to staff outside their department and visit shops.

 

7. Patients are at risk in a room if someone infected chose to be unmasked there previously

COVID-19 remains in poorly ventilated rooms for an extended period, even after an infected person has left

Fiorillo et al., 2020. COVID-19 Surface Persistence: A Recent Data Summary and Its Importance for Medical and Dental Settings. International Journal of Environmental Research and Public Health, 17(9), p.3132.

nidirect. 2022. Coronavirus (COVID-19): ventilation. [online] Available at: <https://www.nidirect.gov.uk/articles/coronavirus-covid-19-ventilation> [Accessed 29 June 2022].

Lewis, D., 2021. Why indoor spaces are still prime COVID hotspots. Nature, 592(7852), pp.22-25.

 

8. COVID is airborne, it does not spread predominantly through droplets

COVID-19 transmission is predominantly airborne. 

Lewis, D., 2021. Why indoor spaces are still prime COVID hotspots. Nature, 592(7852), pp.22-25.

Zhang et al., 2020. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proceedings of the National Academy of Sciences, 117(26), pp.14857-14863.

 

9. As COVID is airborne, other infection prevention measures are inadequate to stop COVID-19

Keeping a distance of 2m is inadequate

Wang et al., 2021. How effective is a mask in preventing COVID‐19 infection?. MEDICAL DEVICES & SENSORS, 4(1).

Evidence supporting hand sanitising to prevent COVID-19 spread is limited

Greenhalgh et al., 2021. Rapid evidence review to inform safe return to campus in the context of coronavirus disease 2019 (COVID-19). Wellcome Open Research, 6, p.282.

Hand sanitising does not reduce airborne transmission of COVID-19 

Zhang et al., 2020. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proceedings of the National Academy of Sciences, 117(26), pp.14857-14863.

 

10. Removal of COVID-19 protections makes vulnerable people less likely to seek healthcare

86% clinically vulnerable people have or would delay/cancel medical appointments due to high COVID-19 risks

Clinically Vulnerable Families [@cv_cev]. (28 June 2022). Available at:  https://twitter.com/cv_cev/status/1541881298901471234

54% of clinically vulnerable people have already delayed/cancelled appointments due to high COVID-19 risks

Clinically Vulnerable Families [@cv_cev]. (28 June 2022). Available at:  https://twitter.com/cv_cev/status/1541882988320915457

 

Why should COVID-19 Infection be Avoided?

11. We must protect children from COVID-19 – including children of any hospital patients, visitors and staff

SARS2 causes increased hospital admissions, mortality rate and absolute numbers of deaths in children, compared to influenza

Shein et al., 2022. Epidemiology and Outcomes of SARS-CoV-2 Infection or Multisystem Inflammatory Syndrome in Children vs Influenza Among Critically Ill Children. JAMA Network Open, 5(6), p.e2217217.

Asymptomatic infection in children can lead to a serious, multiorgan hyperinflammatory syndrome

Riphagen et al., 2020. Hyperinflammatory shock in children during COVID-19 pandemic. The Lancet, 395(10237), pp.1607-1608.

An epidemic of hepatitis in healthy children could be linked to previous COVID-19 infection

Wadmen, M., 2022. What’s sending kids to hospitals with hepatitis—coronavirus, adenovirus, or both?. [online] Science.org. Available at: <https://www.science.org/content/article/what-s-sending-kids-hospitals-hepatitis-coronavirus-adenovirus-or-both>

Pulmonary dysfunction persists even in children considered to be recovered from SARS2

Heiss et al., 2022. Persisting pulmonary dysfunction in pediatric post-acute Covid-19. - Preprint

Many children are not vaccinated- only 6.1% of primary school aged children (aged 5-11) have received a vaccine

Ons.gov.uk. 2022. COVID-19 Schools Infection Survey, England - Office for National Statistics. [online] Available at: <https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/covid19schoolsinfectionsurveyengland/pupilantibodiesandvaccinesentimentmarch2022> [Accessed 29 June 2022].

A vaccine is not yet available for children under 5 in the UK

We do not know what effect multiple COVID-19 infections will have on children's development

 

12. We must protect pregnant people from COVID-19 – including those related to patients, visitors and staff

COVID-19 infection during pregnancy increases risk of preterm delivery

Edlow et al., 2022. Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy. JAMA Network Open, 5(6), p.e2215787.

COVID-19 infection at delivery increases risk of stillbirth

DeSisto et al., 2021. Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization — United States, March 2020–September 2021. MMWR. Morbidity and Mortality Weekly Report, 70(47), pp.1640-1645.

COVID-19 infection during pregnancy increases risk of neurodevelopmental disorder diagnosis in babies by 2.17x during first year of life

Edlow et al., 2022. Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy. JAMA Network Open, 5(6), p.e2215787.

 

13. COVID-19 increases risk and progression of illnesses within the brain

COVID increases the risk of neurodegenerative disorders- Alzheimer’s disease risk is 3.5x increased; Parkinson’s disease risk is 2.6x increased; ischaemic stroke risk is 2.7x increased and intracerebral haemorrhage (bleeding in the brain) risk is 4.8x increased.

Medicalxpress.com. 2022. COVID-19 positive patients at higher risk of developing neurodegenerative disorders, new study shows. [online] Available at: <https://medicalxpress.com/news/2022-06-covid-positive-patients-higher-neurodegenerative.html>

Covid-19 produces proteins that form cytotoxic aggregates which damage neuronal cells, which parallels Alzheimer’s disease mechanism

Charnley et al., 2022. Neurotoxic amyloidogenic peptides in the proteome of SARS-COV2: potential implications for neurological symptoms in COVID-19. Nature Communications, 13(1).

Mild COVID-19 infection can cause impaired neurogenesis (nervous tissue growth), myelin and oligodendrocyte (nerve insulation) loss and increased neurotoxic molecules around the central nervous system

Fernández-Castañeda et al., 2022. Mild respiratory COVID can cause multi-lineage neural cell and myelin dysregulation. Cell.

COVID-19 is associated with accelerated progression of Alzheimer’s disease

AAIC. 2022. COVID-19 Associated with Long-Term Cognitive Dysfunction, Acceleration of Alzheimer’s Symptoms | AAIC 2021. [online] Available at: <https://aaic.alz.org/releases_2021/covid-19-cognitive-impact.asp>

COVID-19 invades cognitive centers of the brain and induces Alzheimer’s-like neuropathology

Shen et al., 2022. SARS-CoV-2 invades cognitive centers of the brain and induces Alzheimer’s-like neuropathology.

COVID-19 infection is associated with increased risk of mental health diagnosis and neurocognitive decline 

Xie et al., 2022. Risks of mental health outcomes in people with covid-19: cohort study. BMJ, p.e068993.

 

14. COVID-19 increases risk of diagnosis with serious illness following infection

1 in 5 (20-30%) develop a new health condition following COVID-19 infection

Bull-Otterson et al. 2022. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021. MMWR Morb Mortal Wkly Rep 2022;71:713–717

Mild COVID-19 infection is associated with increased risk of kidney damage

Bowe et al., 2021. Kidney Outcomes in Long COVID. Journal of the American Society of Nephrology, 32(11), pp.2851-2862.

COVID-19 infection results in 3x increased risk of End Stage Kidney Disease, requiring dialysis or kidney transplant

Bowe et al., 2021. Kidney Outcomes in Long COVID. Journal of the American Society of Nephrology, 32(11), pp.2851-2862.

COVID-19 patients have a 40% increased risk of being diagnosed with diabetes after first infection

Xie et al., 2022. Risks and burdens of incident diabetes in long COVID: a cohort study. The Lancet Diabetes & Endocrinology, 10(5), pp.311-321.

COVID-19 infection, even when mild, substantially increases risk of cardiovascular illness up to at least 1 year later

Xie et al., 2022. Long-term cardiovascular outcomes of COVID-19. Nature Medicine, 28(3), pp.583-590.

COVID-19 routinely affects organs throughout the body, not just the respiratory system, including the brain, heart, liver, GI tract, endocrine system and skin

Gupta et al., 2020. Extrapulmonary manifestations of COVID-19. Nature Medicine, 26(7), pp.1017-1032.

Accelerated biological ageing is seen in COVID-19 infection

Cao et al., 2022. Accelerated biological aging in COVID-19 patients. Nature Communications, 13(1).

 

15. COVID-19 damages the immune system

COVID-19 causes T-cell exhaustion, meaning the immune system is less able to fight off pathogens

Loretelli et al., 2021. PD-1 blockade counteracts post–COVID-19 immune abnormalities and stimulates the anti–SARS-CoV-2 immune response. JCI Insight, 6(24).

Previous infection with earlier SARS2 strains can lead to impaired immune responses to Omicron

Reynolds et al., 2022. Immune boosting by B.1.1.529 (Omicron) depends on previous SARS-CoV-2 exposure. Science.

COVID-19 infects and kills T-lymphocytes (key cells of the immune system), causing low T-lymphocyte counts

Shen et al., 2022. ACE2-independent infection of T lymphocytes by SARS-CoV-2. Signal Transduction and Targeted Therapy, 7(1).

Guan et al., 2020. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, 382(18), pp.1708-1720.

 

16. COVID-19 causes the body to attack itself

Covid causes production of a wide range of autoantibodies which target immune system as well as vascular cells, coagulation factors and platelets, connective tissue, extracellular matrix components and various organ systems, including lung, the central nervous system compartment, skin, gastrointestinal tract and other tissues. Autoantibodies are when the body’s own immune system attacks itself.

Wang et al., 2021. Diverse functional autoantibodies in patients with COVID-19. Nature, 595(7866), pp.283-288.

 

17. COVID-19 may affect fertility

COVID-19 virus can be found and continues to replicate in the testes even after death

Costa et al., 2022. SARS-CoV-2 infects, replicates, elevates angiotensin II and activates immune cells in human testes. – Preprint

COVID-19 infects the testes and damages spermatogenesis (sperm production)

Ma et al., 2020. Pathological and molecular examinations of postmortem testis biopsies reveal SARS-CoV-2 infection in the testis and spermatogenesis damage in COVID-19 patients. Cellular & Molecular Immunology, 18(2), pp.487-489.

 

18. Long Covid is common, serious and can be disabling

Just below 1 in 10 (9.3%) triple vaccinated people are not recovered 4-8 weeks after Omicron infection

Ons.gov.uk. 2022. Self-reported long COVID after infection with the Omicron variant in the UK - Office for National Statistics. [online] Available at: <https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/selfreportedlongcovidafterinfectionwiththeomicronvariant/6may2022>

Only 29% of UK COVID-19 hospital patients recover within a year

McKie, R., 2022. Only 29% of UK Covid hospital patients recover within a year. [online] the Guardian. Available at: <https://www.theguardian.com/world/2022/apr/24/only-29-of-uk-covid-hospital-patients-recover-within-a-year?CMP=share_btn_tw>

1 in 7 (14%) of 11-18 year olds have symptoms 15 weeks after COVID-19 infection

Stephenson et al., 2021. Long COVID - the physical and mental health of children and non-hospitalised young people 3 months after SARS-CoV-2 infection; a national matched cohort study (The CLoCk) Study. -Preprint

Long covid can cause disability and unemployment

Bearne, S., 2022. Long Covid: what are you entitled to if you can’t work in the UK?. [online] the Guardian. Available at: <https://www.theguardian.com/society/2021/oct/16/long-covid-what-are-you-entitled-to-if-you-cant-work-in-the-uk>

 

19. Long Covid in healthcare workers is worsening staff shortages

As of May 2021, nearly 1 in 10 NHS healthcare staff reported suffering Long Covid. A year later this number will be even higher.

2022. NHS England » Supporting colleagues affected by Long COVID. [online] England.nhs.uk. Available at: <https://www.england.nhs.uk/supporting-our-nhs-people/support-now/supporting-long-covid/>

Healthcare staff are the 3rd more common employment group to suffer Long Covid

Russell, P., 2022. Healthcare Workers 'Most Likely to Report Long COVID Symptoms'. [online] Medscape UK. Available at: <https://www.medscape.co.uk/viewarticle/healthcare-workers-most-likely-report-long-covid-symptoms-2022a10001dt>

2 million days of healthcare staff absences were lost to Long Covid during the first 18 months of the pandemic

Sample, I., 2022. Long Covid: nearly 2m days lost in NHS staff absences in England. [online] the Guardian. Available at: <https://www.theguardian.com/society/2022/jan/24/long-covid-nearly-2m-days-lost-in-nhs-staff-absences-in-england>

On average, healthcare staff absent with Long Covid are off for more than 80 days

Sample, I., 2022. Long Covid: nearly 2m days lost in NHS staff absences in England. [online] the Guardian. Available at: <https://www.theguardian.com/society/2022/jan/24/long-covid-nearly-2m-days-lost-in-nhs-staff-absences-in-england>

 

20. Repeated COVID-19 infections are increasingly detrimental to health

Reinfection with SARS2 increases risk of hospitalization, death and long covid by more each time 

Al-Aly et al., 2022. Outcomes of SARS-CoV-2 Reinfection. -Nature Preprint

Epstein, J., 2022. WHO official says the more times a person gets COVID-19, the more likely they are to be 'unlucky' and get long COVID. [online] Business Insider. Available at: <https://www.businessinsider.com/who-official-individuals-coronavirus-infection-unlucky-long-covid-2022-6?r=US&IR=T>

 

21. COVID-19 reinfection risk should be taken seriously

COVID-19 reinfections are common and frequent

Al-Aly et al., 2022. Outcomes of SARS-CoV-2 Reinfection. -Nature Preprint

Mean time between 1st and 2nd infection is 79 days, and between 2nd and 3rd infection is 65 days.

Al-Aly et al., 2022. Outcomes of SARS-CoV-2 Reinfection. -Nature Preprint

 

22. COVID-19 persists in the body after initial infection

COVID-19 can persist throughout the body and brain even following mild/asymptomatic infections, for at least 230 days

Chertow et al., 2021. SARS-CoV-2 infection and persistence throughout the human body and brain. – Nature Preprint

Residual COVID-19 virus has been found in the appendix and breast tissue, 175- and 462-days post-infection, respectively

Goh et al., 2022. Persistence of residual SARS-CoV-2 viral antigen and RNA in tissues of patients with long COVID-19. – Preprint

COVID-19 virus can be found and continues to replicate in the testes even after death

Costa et al., 2022. SARS-CoV-2 infects, replicates, elevates angiotensin II and activates immune cells in human testes. – Preprint

COVID-19 can persist within the gut for at least 7 months after infection

Gaebler et al., 2021. Evolution of antibody immunity to SARS-CoV-2. Nature, 591(7851), pp.639-644.

Natarajan et al., 2022. Gastrointestinal symptoms and fecal shedding of SARS-CoV-2 RNA suggest prolonged gastrointestinal infection. Med, 3(6), pp.371-387.e9.

COVID-19 can persist in the eyes after initial infection

Armstrong, L., Collin, J., Mostafa, I., Queen, R., Figueiredo, F. and Lako, M., 2021. In the eye of the storm: SARS‐CoV‐2 infection and replication at the ocular surface?. STEM CELLS Translational Medicine, 10(7), pp.976-986.

 

23. Viral persistence (when the virus remains inside the body after initial infection) can cause serious illness many years later

We do not know the long-term effects of COVID-19 viral persistence.

Persistent Hepatitis C infection increases risk of Hepatocellular carcinoma (liver cancer)

Mitchell et al., 2015. How do persistent infections with hepatitis C virus cause liver cancer?. Current Opinion in Virology, 14, pp.101-108.

Persistent Human Papillomavirus (HPV) infection causes cervical cancer

Sudenga et al., 2013. Key considerations and current perspectives of epidemiological studies on human papillomavirus persistence, the intermediate phenotype to cervical cancer. International Journal of Infectious Diseases, 17(4), pp.e216-e220.

Persistent HIV infection leads to immunodeficiency and AIDS

Pauza, C., 1988. HIV persistence in monocytes leads to pathogenesis and AIDS1. Cellular Immunology, 112(2), pp.414-424.

Persistence of Epstein Barr Virus (EBV) can cause development of multiple sclerosis

Ruprecht, K., 2020. The role of Epstein-Barr virus in the etiology of multiple sclerosis: a current review. Expert Review of Clinical Immunology, 16(12), pp.1143-1157.

Persistence of varicella zoster virus (VZV), which causes chickenpox, can result in shingles

Gershon et al., 2015. Varicella zoster virus infection. Nature Reviews Disease Primers, 1(1).

 

Note: Preprint sources have yet to be peer reviewed