Major Update: Masks for Prevention of SARS-CoV-2 in Health Care and Community Settings-Final Update of a Living, Rapid Review

Abstract

Background: Optimal use of masks for preventing COVID-19 is unclear.

Purpose: To update an evidence synthesis on N95, surgical, and cloth mask effectiveness in community and health care settings for preventing SARS-CoV-2 infection.

Data sources: MEDLINE, EMBASE, medRxiv (3 June 2022 to 2 January 2023), and reference lists.

Study selection: Randomized trials of interventions to increase mask use and risk for SARS-CoV-2 infection and observational studies of mask use that controlled for potential confounders.

Data extraction: Two investigators sequentially abstracted study data and rated quality.

Data synthesis: Three randomized trials and 21 observational studies were included. In community settings, mask use may be associated with a small reduced risk for SARS-CoV-2 infection versus no mask use, on the basis of 2 randomized trials and 7 observational studies. In routine patient care settings, surgical masks and N95 respirators may be associated with similar risk for SARS-CoV-2 infection, on the basis of 1 new randomized trial with some imprecision and 4 observational studies. Evidence from observational studies was insufficient to evaluate other mask comparisons due to methodological limitations and inconsistency.

Limitation: Few randomized trials, studies had methodological limitations and some imprecision, suboptimal adherence and pragmatic aspects of randomized trials potentially attenuated benefits, very limited evidence on harms, uncertain applicability to Omicron variant predominant era, meta-analysis not done due to heterogeneity, unable to formally assess for publication bias, and restricted to English-language articles.

Conclusion: Updated evidence suggests that masks may be associated with a small reduction in risk for SARS-CoV-2 infection in community settings. Surgical masks and N95 respirators may be associated with similar infection risk in routine patient care settings, but a beneficial effect of N95 respirators cannot be ruled out.

Primary funding source: None.

Figure 1.. Literature flow diagram.

ILI = influenza-like illness; MERS-CoV = Middle East respiratory syndrome coronavirus; VRI = viral respiratory illness. * Includes 37 studies of SARS-CoV-1, MERS-CoV, influenza, ILI, or VRI. † Not addressed in this update.

Figure 2.. Masks for prevention of SARS-CoV-2 evidence map.

RCT = randomized controlled trial. * N95 or equivalent/similar respirators (for example, P2, FFP2, FFP3). † New evidence added for this update.