Face masks during the COVID-19 pandemic

Person wearing a face shield and a surgical mask.

Face shields protect against splash and splatter. Cough simulation experiments show that they protect[19] the wearer[22] against large droplets immediately after the cough, but are less effective against smaller aerosols, which can remain airborne for extended periods and can easily flow around a face shield to be inhaled.

Because they lack a peripheral seal, face shields are used with nose-mouth masks, and to protect nose-mouth masks, but use of face shields alone is not recommended for healthcare workers.[19]

French cloth face masks certified by AFNOR.

Face masks retain most of the respiratory droplets released from the wearer through talking, coughing, or sneezing, thus reducing the spread of pathogens.[23]

A cloth face mask is a mask made of a common textile, usually cotton, worn over the mouth and nose. Although they are less effective than medical-grade masks, many health authorities recommend that the general public use them because medical-grade masks are in short supply.[24][25]

They were routinely used by healthcare workers starting from the late 19th century until the mid 20th century. In the 1960s they fell out of use in the developed world in favor of modern surgical masks, but their use has persisted in developing countries.[26][27][28]

There were calls for research into the effectiveness of improvised masks even before the emergence of COVID-19, motivated also by past epidemics and modelling of likely mask shortages. However, little research has been done. There are no studies of the use of cloth masks by the general public, one study on the use of cloth masks in hospitals (by healthcare workers, not patients), and many controlled-setting/lab studies of cloth masks' effects on aerosols as of May 2020.[19]

Cloth masks are low-cost and reusable. They vary widely in effectiveness depending on material, fit/seal, and number of layers, among other factors. Unlike disposable masks, there are no legal standards for cloth masks. Fit is important (as with disposable masks). Measures to improve fit, such as an outer layer made from sheer nylon stockings or sheer tights around the head, reduce leakage.[19]

Improvised cloth masks seem to be worse than standard commercial disposable masks, but better than nothing. There is, however, little good evidence on them. A single study gives evidence that an improvised mask was better than nothing, but not as good as soft electret-filter surgical mask, for protecting health care workers simulating treating a simulated infected patient, regardless of whether "patient" or carers wore the mask.[19] Another study had volunteers wear masks they made themselves, to a pattern like that of a standard surgical mask, but with ties rather than earloops,[29] from cotton T-shirts, and found that the number of microscopic particles that leaked inside the homemade masks was twice the number that leaked into the commercial masks, and that the homemade mask let three times as many microorganisms expelled by the wearer escape (median averages). There is limited evidence that cloth masks can significantly reduce droplet dispersal.[19]

Cloth masks are commonly made with one layer, two layers, or two layers with a pocket for a removable-filter interlayer [19] (disposable surgical masks also have three layers, with the filter layer midmost[30]). The CDC recommends more than one layer.[31] There is no research on the usefulness of a filter interlayer, as of May 2020. There were until recently no non-disposable materials designed for making masks (see end of paragraph). Common household fabrics which could be utilized (turned to a new use) as mask materials have been tested.[32][33][34][35] Cloth materials vary widely in filtration efficiency. Some cotton and polyester household fabrics have been found to compare with disposable surgical masks for dry particle filtering. Cotton T-shirt material, pillowcase material, and 70% cotton/30% polyester sweatshirt material are among the common materials that performed well in lab tests, with T-shirts preferred to pillowcases because it was thought that it would probably fit better. Teatowels and vacuum-cleaner bags were effective at filtering, but had a very high air resistance, so were not recommended. Scarves filtered poorly. Surgical sterilisation wrap, a polypropylene non-woven fabric made for wrapping sterilized things to keep them sterile, is designed to filter germs from the air. Using surgical sterilisation wrap to make masks, or as a filter interlayer in cloth masks, has been suggested. There are, however, no tests on using surgical sterilisation wrap for masks, as of May 2020.[19]

Other suggested materials for filter interlayers include air filter materials used in ventilation, heating, and air conditioning, some of which are similar to rigid electret masks in the size ranges of particles they filter. Electrostatic cotton and non-woven, meltblown fabric are the conventional materials used in disposible masks, but are not readily available during the COVID-19 epidemic. A new type of filter, a washable electrostatic cotton filter, has been reported since the start of the pandemic; it is said to withstand repeated washing and folding.[19] It is made of electrospun nanofibers; flanking insulating blocks lay these into quasi-aligned nonwoven sheets, which are layered criss-cross to make a meshlike multilayer mask.[36][37] There is a need for research comparing how well these materials work.[19][38]

There is no research on sterilizing and reusing cloth masks, as of May 2020.[19] The CDC recommends doffing the mask by handling only the ear loops or ties, placing it directly in a washing machine, and immediately washing one's hands in soap and water for at least 20 seconds. They also recommend handwashing before donning the mask and again immediately after one touches it.[39]

There is no information on reusing a interlayer filter, and disposing of it after a single use may be desirable.[19]

A surgical mask

A surgical mask is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. If worn properly, a surgical mask is meant to help block large-particle droplets, splashes, sprays, or splatter that may contain viruses and bacteria, keeping it from reaching the wearer's mouth and nose. Surgical masks may also help reduce exposure of the wearer's saliva and respiratory secretions to others.[40] A surgical mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures. Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the face.[40] However, in practice, with respect to some infections like influenza, surgical masks appear as effective as respirators (such as N95 or FFP masks).[41] Surgical masks may be labeled as surgical, isolation, dental, or medical procedure masks.[40] Surgical masks are made of a nonwoven fabric created using a melt blowing process.[42][43]

Surgical masks made to different standards in different parts of the world have different ranges of particles which they filter. For example, the People's Republic of China regulates two types of such masks: single-use medical masks (Chinese standard YY/T 0969) and surgical masks (YY 0469). The latter ones are required to filter bacteria-sized particles (BFE ≥ 95%) and some virus-sized particles (PFE ≥ 30%), while the former ones are required to only filter bacteria-sized particles.[44][45][46]

An N95 mask.

Dust masks can be confused for medical respirators.

An N95 mask is a particulate-filtering facepiece respirator that meets the N95 air filtration rating of the US National Institute for Occupational Safety and Health, meaning that it filters at least 95 percent of airborne particles, while not resistant to oil like the P95. It is the most common particulate-filtering facepiece respirator.[47] It is an example of a mechanical filter respirator, which provides protection against particulates, but not gases or vapors.[48] Like the middle layer of[30] surgical masks, the N95 mask is made of four layers[19] of melt-blown nonwoven polypropylene fabric.[49][50] The corresponding face mask used in the European Union is the FFP2 respirator.[51][52]

Hard electret-filter masks like N95 and FFP masks must fit the face to provide full protection. Untrained users often get a reasonable fit, but fewer than one in four gets a perfect fit. Fit testing is thus standard. A line of vaseline on the edge of the mask[53] has been shown to reduce edge leakage[19] in lab tests using manikins that simulate breathing.[53]

Hard electret-filter masks are designed to be disposable, for 8 hours of continuous or intermittent use. One laboratory found that there was a decrease in fit quality after five consecutive donnings.[19]

Hard electret-filter masks are often reused, especially during pandemics when there are shortages. Infectious particles could survive on the masks for up to 24 hours after the end of use, according to studies using models of SARS-CoV-2;[19] In the COVID-19 epidemic, the US CDC recommended that if masks run short, each health care worker should be issued with five masks, one to be used per day, such that each mask spends at least five days stored in a paper bag between each use. If there are not enough masks to do this, they recommend sterilizing the masks between uses.[54] Some hospitals have been stockpiling used masks as a precaution.[55] The US CDC issued guidelines on stretching N95 supplies, recommending extended use over re-use. They highlighted the risk of infection from touching the contaminated outer surface of the mask, which even professionals frequently unintentionally do, and recommended washing hands every time before touching the mask. To reduce mask surface contamination, they recommended face shields, and asking patients to wear masks too ("source masking").[56]

Apart from time, other methods of disinfection have been tested. Physical damage to the masks has been observed when microwaving them, microwaving them in a steam bag, letting them sit in moist heat, and hitting them with excessively high doses of ultraviolet germicidal irradiation (UVGI). Chlorine-based methods, such as chlorine bleach, may cause residual smell, offgassing of chlorine when the mask becomes moist, and in one study, physical breakdown of the nosepads, causing increased leakage.[19] Fit and comfort do not seem to be harmed by UVGI, moist heat incubation, and microwave-generated steam.[19]

Some methods may not visibly damage the mask, but they ruin the mask's ability to filter. This has been seen in attempts to sterilize by soaking in soap and water, heating dry to 160°C, and treating with 70% isopropyl alcohol, and hydrogen peroxide gas plasma[19] (made under a vacuum with radio waves[57]). The static electrical charge on the microfibers (which attracts or repels particles passing through the mask, making them more likely to move sideways and hit and stick to a fiber) is destroyed by some cleaning methods. UVGI (ultraviolet light), boiling water vapour, and dry oven heating do not seem to reduce the filter efficiency, and these methods successfully decontaminate masks.[19]

UVGI (an ultraviolet method), ethylene oxide, dry oven heating and (highly toxic) vaporized hydrogen peroxide are currently the most-favoured methods in use in hospitals, but none have been properly tested.[19] Where enough masks are available, cycling them and reusing a mask only after letting it sit unused for 5 days is preferred.[54]

Elastomeric full-face masks

Elastomeric respirators are reusable devices with exchangeable cartridge filters that offer comparable protection to N95 masks.[58] They were used as a substitute for N95 masks among shortages during the COVID-19 pandemic.[21]

The filters must be replaced when soiled, contaminated, or clogged. These components may be hard to find amidst shortages; the filters may thus be sterilized, in a way that does not harm the filter, and re-used. In medical use, they must be cleaned and disinfected, as some germs can survive on them for weeks.[21]

Full-face versions of elastomeric respirators seal better and protect the eyes. If they have exhalation valves, then they are counterrecommended in settings where the unfiltered exhaled air might infect others (for instance, surgery). Fitting and inspection is essential to effectiveness.[21]

A PAPR in a level-3 biosafety lab. Note waist pack and hose to blow air into headpiece.

PAPRs are expensive masks with a battery-powered blower that blows air through a filter to the wearer. Because they create positive pressure, they need not be tightly-fitted.[59] PAPRs typically do not filter exhaust from the wearer.[60] They are not generally designed for healthcare use, as of 2017.[18]

On 15 April 2020 scientists claimed to have developed a biodegradable material for face masks which is effective at removing particles smaller than 100 nanometres including viruses and has a high breathability.[61][62] Two Israeli companies reportedly have developed antiviral face masks – one of which is infused with antiviral copper oxide and zinc oxide nanoparticles, the other is made out of cotton embedded with accelerated copper oxide particles and a nanofiber textile.[63][64][65] Other Israeli researchers have developed a 3D-printed nanoscale fiber sticker coated with antiseptics which can be attached to a traditional mask for extra protection.[65] Other reseachers report that laser-induced graphene may be used to add self-cleaning and photothermal properties to face masks.[65] In March 2020, Huang Jiaxingq became the first scientist to receive a $200,000 grant by the United States' National Science Foundation to develop a chemical which can be safely built into common face masks to make them protect against SARS-CoV-2 and self-sanitize passing droplets.[65][66]

The World Health Organization (WHO), in accordance to its updated advice from 5 June, recommends that non-medical fabric masks should be worn by the general public where there is known or suspected widespread transmission and where physical distancing is not possible, and that vulnerable people (aged over 60 or with underlying health risks) and people with any symptoms suggestive of COVID-19 should wear medical masks.[74] The stated purpose of mask usage is to prevent the wearer transmitting the virus to others (source control) or to offer protection to healthy wearers against infection (prevention).[74]

Previously, early in the outbreak, the WHO only recommended medical masks for people who had respiratory symptoms and those sharing living space, caregivers, and healthcare workers.[75][76] In a 6 April advice, the WHO recognized that wearing a medical mask can limit the spread of certain respiratory viral diseases including COVID-19, but believed that the use of a mask alone is not sufficient to provide an adequate level of protection and that other measures (such as hand hygiene) should be adopted.[77] In the scope of the community setting, the WHO stated that masks should be reserved for healthcare workers, except for people with symptoms, claiming that medical masks would create a false sense of security and neglect of other measures.[77] The WHO advice was criticized, as experts and researchers have pointed out the asymptomatic transmission of the virus.[78][79] The WHO revised its mask guidance in June, with its officials acknowledging that studies have indicated asymptomatic or pre-symptomatic spread but that not much is known.[80]

Regarding cloth masks and their recommendation by countries as a means of source control in the general population, the WHO has stated that their protective effectiveness to the wearer is still unknown, however they may protect others if the wearer is a pre-symptomatic or asymptomatic carrier.[1] The WHO recommends that decision makers adopt a risk-based approach when deciding in which settings and circumstances non-medical masks should be used in the community.[1]

WHO's advice to the public in the context of COVID-19 endorsed the use of medical masks under the following conditions:[81]

• If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
• Wear a mask if you are coughing or sneezing.
• Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand sanitizer or soap and water.
• If you wear a mask, then you must know how to use it and dispose of it properly.

Guidance from the US Centers for Disease Control and Prevention on using and making cloth masks during the COVID-19 pandemic[82]

The United States Centers for Disease Control and Prevention (CDC) recommended in April 2020 that the general public wear cloth face coverings in public settings where other social distancing measures are difficult to maintain, such as grocery stores and pharmacies, especially in areas of significant community-based transmission, due to the significance of asymptomatic and pre-symptomatic disease transmission.[82][2]

In March 2020, the CDC recommended that if neither respirators nor surgical masks are available, as a last resort, it may be necessary for healthcare workers to use masks that have never been evaluated or approved by NIOSH or homemade masks, though caution should be exercised when considering this option.[83]

The CDC faced backlash over earlier advice that most healthy people did not need to wear a mask. When asked by National Public Radio about the April 3 reversal, the CDC cited studies from February and March showing presymptomatic and asymptomatic transmission.[84] Professor of public health Larry Gostin said that the CDC could have revised its recommendation sooner; by maintaining its initial recommendation throughout March, it had given the public the impression that widespread mask usage was ineffective even though scientific evidence to the contrary was already available.[84] The earlier recommendation damaged the agency's credibility,[79][85][86] and in June 2020 Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, admitted that the delay in recommending general mask use was motivated by a desire to conserve dwindling supplies for medical professionals.[87]

China has specifically recommended the use of disposable medical masks by healthy members of the public,[12][88] particularly when coming into close contact (1 metre (3 ft) or less) with other people.[89] Hong Kong recommends wearing a surgical mask when taking public transport or in crowded places.[90][91] Thailand's health officials are encouraging people to make cloth face masks at home and wash them daily.[92] The Republic of China (Taiwan), South Korean, and Japanese governments have also recommended the use of face masks in public.

In March 2020, when asked about the mistakes that other countries were making in the pandemic, the Chinese Center for Disease Control and Prevention director-general George Fu Gao said:

"The big mistake in the U.S. and Europe, in my opinion, is that people aren't wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role − you've got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others."[93]

People in Wuhan lining up in front of a drug store to buy surgical masks.

A notice at a supermarket in Beijing, which says each person can only buy one pack of surgical masks and one bottle of 84% disinfectant liquid a day.

Chinese electronics manufacturers, such as BYD Electronic, began to produce surgical masks after the outbreak.

As the epidemic accelerated, the mainland market in China saw a shortage of face masks due to increased public demand.[106] In Shanghai, customers had to queue for nearly an hour to buy a pack of face masks; stocks were sold out in another in half an hour.[107] Hoarding and price gouging drove up prices, so the market regulator said it would crack down on such acts.[108][109] In January 2020, price controls were imposed on all face masks on Taobao and Tmall.[110] Other Chinese e-commerce platforms – JD.com,[111] Suning.com,[112] Pinduoduo[113] – did likewise; third-party vendors would be subject to price caps, with violators subject to sanctions.

By March, the PRC had quadrupled its production capacity to 100 million masks per day.[95]

At the beginning of the COVID-19 outbreak in the United States, the U.S.'s Strategic National Stockpile contained just 12 million N95 respirators, far fewer than estimates of the amount required.[114] Millions of N95s and other supplies were purchased from 2005 to 2007 using congressional supplemental funding, but 85 million N95s were distributed to combat the 2009 swine flu pandemic, and Congress did not make the necessary appropriations to replenish stocks.[114] The Stockpile's primary focus has also primarily been on biodefense (defense against a terrorist or weapon of mass destruction attack) and response to natural disaster, with infectious disease a secondary focus.[114] By 1 April 2020, the Stockpile was nearly emptied of protective gear.[115] In January and February 2020, U.S. manufacturers, with the encouragement of the Trump administration, shipped millions of face masks and other personal protective equipment to the PRC, a decision that subsequently prompted criticism given the mask shortage that the U.S. faced during the pandemic.[116]

In France, 2009 H1N1-related spending rose to €382 million, mainly on supplies and vaccines, which was later criticized.[117][118] It was decided in 2011 to not replenish its stocks and rely more on supply from China and just-in-time logistics.[117] In 2010, its stock included 1 billion surgical masks and 600 million FFP2 masks; in early 2020, it was 150 million and zero respectively.[117] While stocks were progressively reduced, a 2013 rationale stated the aim to reduce costs of acquisition and storage, now distributing this effort to all private enterprises as an optional best practice to ensure their workers' protection.[117] This was especially relevant to FFP2 masks, more costly to acquire and store.[117][119] As the COVID-19 pandemic in France took an increasing toll on medical supplies, masks and PPE supplies ran low, causing national outrage. France needs 40 millions masks per week, according to French president Emmanuel Macron.[120] France instructed its few remaining mask-producing factories to work 24/7 shifts, and to ramp up national production to 40 million masks per month.[120] French lawmakers opened an inquiry on the past management of these strategic stocks.[121] The mask shortage has been called a "scandal d'État" (State scandal).[122]

In late-March/early-April 2020, as Western countries were in turn dependent on China for supplies of masks and other equipment, China was seen as making soft-power play to influence world opinion.[123][13] However, a batch of masks purchased by the Netherlands was reportedly rejected as being sub-standard. The Dutch health ministry issued a recall of 600,000 face masks from a Chinese supplier on 21 March which did not fit properly and whose filters did not work as intended despite them having a quality certificate.[123][13] The Chinese Ministry of Foreign Affairs responded that the customer should "double-check the instructions to make sure that you ordered, paid for and distributed the right ones. Do not use non-surgical masks for surgical purposes".[13] Eight million of 11 million masks delivered to Canada in May also failed to meet standards.[124][125]

N95 and FFP masks were in short supply and high demand during the COVID-19 pandemic.[126][117] Production of N95 masks was limited due to constraints on the supply of nonwoven polypropylene fabric (which is used as the primary filter), as well as the cessation of exports from China.[49][127] China controls 50 percent of global production of masks, and facing its own coronavirus epidemic, dedicated all its production for domestic use, only allowing exports through government-allocated humanitarian assistance.[49]

In March 2020, US President Donald Trump applied the Defense Production Act against the American company 3M, which allows the Federal Emergency Management Agency to obtain N95 respirators from 3M.[128][129] White House trade adviser Peter Navarro stated that there were concerns that 3M products were not making their way to the US.[128] 3M replied that it has not changed the prices it charges, and was unable to control the prices its dealers or retailers charge.[128]

In early April 2020, Berlin politician Andreas Geisel alleged that a shipment of 200,000 N95 masks that it had ordered from American producer 3M's China facility were intercepted in Bangkok and diverted to the United States. Berlin police president Barbara Slowik stated that she believed "this is related to the US government's export ban."[130] 3M said they had no knowledge of the shipment, stating "We know nothing of an order from the Berlin police for 3M masks that come from China," and the US government denied that any confiscation had taken place and said that they use appropriate channels for all their purchases.[130][131]

Berlin police later confirmed that the shipment was not seized by US authorities, but was said to have simply been bought at a better price, widely believed to be from a German dealer or China. This revelation outraged the Berlin opposition, whose CDU parliamentary group leader Burkard Dregger accused Geisel of "deliberately misleading Berliners" in order "to cover up its own inability to obtain protective equipment". FDP interior expert Marcel Luthe said "Big names in international politics like Berlin's senator Geisel are blaming others and telling US piracy to serve anti-American clichés."[132] Politico Europe reported that "the Berliners are taking a page straight out of the Trump playbook and not letting facts get in the way of a good story."[133] The Guardian also reported that "There is no solid proof Trump [nor any other American official] approved the [German] heist".[134]

Jared Moskowitz, head of the Florida Division of Emergency Management, accused 3M of selling N95 masks directly to foreign countries for cash, instead of the US. Moskowitz stated that 3M agreed to authorized distributors and brokers to represent they were selling the masks to Florida, but instead his team for the last several weeks "get to warehouses that are completely empty." He then said the 3M-authorized US distributors later told him the masks Florida contracted for never showed up because the company instead prioritized orders that came in later, for higher prices, from foreign countries (including Germany, Russia, and France). As a result, Moskowitz highlighted the issue on Twitter, saying he decided to "troll" 3M.[135][136][137] Forbes reported that "roughly 280 million masks from warehouses around the US had been purchased by foreign buyers [on March 30, 2020] and were earmarked to leave the country, according to the broker — and that was in one day", causing massive critical shortages of masks in the US.[138][139]

As more and more countries restricted the export of N95 masks, Novo Textiles in British Columbia announced plans to start producing N95 masks in Canada.[140] AMD Medicom in Quebec had long been the main Canadian company producing N95s, but after China, France, the Republic of China (Taiwan) and the United States barred them from repatriating the masks produced by Medicom in their factories, the Government of Canada awarded them a 10 year contract to build a factory to produce masks in Montreal.[141]

With population of 24 million, Taiwan has been producing 13 million masks per day since March.

As of 2019, mainland China manufactured half the world output of masks.[142] As Covid-19 spread, enterprises in several countries quickly started or increased the production of face masks.[143] Cottage industries and volunteer groups also emerged, manufacturing cloth masks for localized use. They used various patterns, including some with a bend-to-fit nosepiece inserts. Individual hospitals developed and requested a library of specific patterns.[144][145][146][147]

In the first five months of 2020, 70802 new companies registered in China to make or trade face masks, a 1256% increase compared to 2019, and 7296 new companies registered to make or trade meltblown fabric, a key component of face masks, a 2277% rise from 2019.[148]

In April, however, the Chinese government stepped in with tighter regulations. 867 producers of the meltblown fabric were shut down in Yangzhong city alone. Many speculative manufacturers have been forced to quit due to changing export rules and tighter licensing requirements in China and weaker demand for lower quality products globally.[148]

Some clinical stockpiles have proved inadequate in scale, and markets have expanded as non-medical consumers started obeying mandated mask-wearing or determined that masks might help or encourage them. Worldwide demand for face masks has resulted in masks shipping around the globe as a result of commercial transactions or of donations.[149]

Slovakia was one of the first countries in the world to introduce universal masking in public places.[150]

In East Asian societies, a primary reason for mask-wearing is to protect others from oneself.[151][152] It is seen as a collective responsibility to reduce the transmission of the coronavirus.[153] The broad assumption behind the act is that anyone, including seemingly healthy people, can be a carrier of the virus.[152] A face mask is thus seen as a symbol of solidarity.[153] Elsewhere, the need for mask-wearing is often seen in an individual's perspective where masks only serve to protect oneself.[151]

Cultural norms and social pressure may impede mask-wearing in public, which explains why masking has been avoided in the West.[154] According to Joseph Tsang, a Hong Kong doctor and infectious disease expert, the promotion of universal masking may resolve perceptions against mask-wearing, because mask-wearing is intimidating if few people wear masks due to cultural barriers, but if all people wear masks it shows a message that people are in this together.[100] Consistent with this intuition, empirical evidence shows that an individual's likelihood of voluntarily wearing a mask is positively correlated with the proportion of uptake in the surrounding area.[155]

In the Western world, the public usage of masks still often carries a large stigma,[151][153][156] as it is seen as a sign of sickness.[156] This stigmatization is a large obstacle to overcome, because people may feel too ashamed to wear a mask in public and therefore opt to not wear one.[157] Secondly, it is heavily racialized as an Asian phenomenon.[153] This has been reinforced in a lot of media discourses, where unrelated stories about the pandemic are often accompanied by imagery of Asian people in masks.[158] The focus on race has brought hostility towards Asians who are confronted with the choice to mask as precaution while they face discrimination for it.[159] Huang Yinxiang, a sociologist from the University of Manchester, described maskaphobia—negative prejudice, fear or hatred against people wearing face masks—as making Asians in Western countries into targets for racists who want to normalize and justify xenophobia during the COVID-19 outbreak.[160] However, there is also a divide within the western world, as seen in the Czech Republic and Slovakia where mass mobilization has occurred to reinforce the solidarity in mask-wearing since March 2020.[151]

On social media, there has been an effort with the #masks4all campaign to encourage people to use masks.[161] Mask-wearing has been called a prosocial behavior in which one protects others within their community.[162][163]

The U.S. Surgeon General urged people to wear face masks, reversing earlier statements that masks were not effective for the general public.[164]

In the United States, some who followed the CDC's recommendation to wear a face mask in public derided what they described as their opponents' ignorance, selfishness, anti-science stance and refusal to honor the social contract.[165] Others, however, who chose not to wear a mask in public and criticized those who did invoked conspiracy theories[166] to discredit their opponents while accusing mask enforcers and promoters of violating rights to free expression[167] and inhibiting the development of herd immunity. Although partisan leanings did not strictly define the controversy, the issue of whether or not to wear a mask became, for some, a demarcation line in the culture war between supporters of President Donald Trump who rejected masks and opponents of Trump who wore masks.[168] In the US, mask-wearing was politicized and seen as a political statement by some people.[169] For instance, Democrats were more likely than Republicans to say they were wearing a mask when leaving home, 76% to 59% according to one poll.[169]

Although authorities in especially Asia have been recommending people to wear face masks in public, in many other parts of the world, conflicting advice have caused a lot of confusion among the general population.[170] Several governments and institutions, such as in the United States, have initially dismissed the use of face masks by the general population, often with misleading or incomplete information about the usefulness of masks.[171][172][173] Commentators have attributed the anti-mask messaging to efforts to manage the mask shortages, as governments did not act quickly enough, remarking that the claims go beyond the science or were simply lies.[173][174][175][176] On 12 June 2020, Anthony Fauci, a key member of the White House coronavirus task force, confirmed that the American public were not told to wear masks from the beginning due to the shortages of masks and explained that masks do actually work.[177][178][179][180][181]

In April 2020, health officials from Taiwan's Central Epidemic Command Center (CECC) pushed back on school bullying of young boys in pink face masks. At a press conference breaking gender norm barriers, the health officials wore pink masks, as various government agencies demonstrated solidarity by changing the colors on their Facebook pages to pink. One of the officials participating in the press conference later tweeted, "Pink is for everyone and no color is exclusive for girls or boys. Gender equality lies at the heart of Taiwan values." The press conference was held amid reports that male students were too embarrassed to wear their pink face masks, jeopardizing their safety and the safety of others in the face of COVID-19.[182]

Face masks have had an impact on fashion, with the masks themselves becoming fashion statements, haute couture brands having pivoted to address both public health and aesthetic needs.[183][184][185][186]