Intended for healthcare professionals

Rapid response to:


Face coverings for covid-19: from medical intervention to social practice

BMJ 2020; 370 doi: (Published 19 August 2020) Cite this as: BMJ 2020;370:m3021

Read our latest coverage of the coronavirus outbreak

Rapid Response:

Psychosocial, biological, and immunological risks for children and pupils make long-term wearing of mouth masks difficult to maintain

Dear Editor,

IIn a recent article, Westhuizen and colleagues [1] argued for a global implementation of face covering to control COVID-19 virus spread. In doing so, they do not differentiate between adults, adolescents, and children. This rapid response considers the negative effects at the immunological and psychological level of mandating facemasks for children and adolescents and maintains that they outweigh the possible gains.

1. SARS-COV-2 infection and transmission in children and adolescents is low
Infections with the virus SARS-COV-2 can occur in children and adolescents. The course of the disease is often mild or asymptomatic. In exceptional cases, severe Covid19 symptoms can occur in children or adolescents with underlying diseases. In a number of studies of hospitalized children with Kawasaki syndrome or multiple inflammations, there is a suspicion of a relationship with SARS-COV-2 infection, but this has not been unequivocally proven; antibodies and / or a positive rtPCR test were not detected in all patients [2]. Analyses by the Karolinska and Pasteur Institute concluded that children and adolescents are unlikely to be the main spreaders in the Covid19 pandemic [4-6]. Contamination from children to parents or teachers is sporadic. To date, the risk of infection appears to be greatest in the home situation, nursing homes and hospitals. In Sweden, where facemasks are not used in schools and schools even remained open during the first wave, as in other countries, the number of older people in intensive care has dropped from June to a few per week. Despite the recent increase in “Covid19 infections” in many other countries, only a small increase in Covid19 patients in intensive care units can be observed.

2. Facemasks at school: a slippery slope from virus protection to mental breakdown?
Reducing virus contamination using facemasks remains a topic of heated debate among scientists and policy makers [6-9]. At the outset of the pandemic, WHO experts advised that use of facemasks is not recommended as potential benefits are rather limited and there is a potential risk of self-contamination if used improperly. Moreover the WHO stated in their report of June 5 “At present, there is no direct evidence (from studies on Covid19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including Covid19 [10] Contamination of the upper respiratory tract by viruses and bacteria on the outside of medical face masks has been detected in several hospitals [11]. Another research shows that a moist mask is a breeding ground for (antibiotic resistant) bacteria and fungi, which can undermine mucosal viral immunity. This research advocates the use of medical / surgical masks (instead of homemade cotton masks) that are used once and replaced after a few hours [12]. This means that a family with 2 children and 2 parents who go to work by public transport and do their shopping will consume 20 facemasks per day (€ 25 / day, € 9,000 / year per family). Today, facemasks are considered an easily enforceable low-cost measure when 1.5 m social distance cannot be respected, in unventilated areas or in the presence of immunocompromised patients. Limited experimental and observational studies report a reduced risk of SARS-CoV2 virus transmission of 6-80%: the effectiveness varies greatly depending on the type and quality of the masks, the basic contamination level of the studied population, laboratory test used, and epidemic context [7-9, 13-14].

Aside from the highly variable protective effects, WHO mentions several negative aspects of frequent / long-term use of facemasks, fuelling the debate as to whether the benefits outweigh the drawbacks [10].
Many people report claustrophobic experiences and difficulty getting sufficient oxygen due to the increased resistance to inhaling and exhaling. This can lead to an increased heart rate, nausea, dizziness and headaches and several other symptoms [15,16]. In an inquiry among Belgian students wearing mouthmasks for one week, 16 % reported skinproblems and 7 % sinusitis, Also problems with eyes and headaches and fatigue were frequently mentioned [14]. Furthermore, face masking can provoke an increase in stress hormones with a negative impact on immune resilience in the long term [17]. Facemasks prevent the mirroring of facial expressions, a process that facilitates empathetic connections and trust between pupills and teachers. This potentially leads to a significant increase in socio-psychological stress. During childhood and puberty the brain undergoes sexual and mental maturation through hormonal epigenetic reprogramming [18-21]. Several studies show that long-term exposure to socio-psychological stress leaves neuro-epigenetic scars that are difficult to cure in young people and often escalate into mental behavioural problems and a weakened immune system [22-26]. A recent study by the CDC concludes that in young adults (18-24 years), the level of anxiety and depression has increased by 63% (!) since the corona crisis. A quarter of them think about suicide. As a result, the use of antidepressants has increased by 25% [27]. Several researchers have shown a relationship between the increase in stress experiences and the risk of upper respiratory tract infections and mortality [28-31].

3. A healthy diet and lifestyle for young people is more important than ever in the context of Covid19
At this moment the health protective benefits of non-professional use of facemasks are doubtful [32]. Hence, we argue for a less one-sided focus on facemasking, paying more attention for healthy lifestyle and psychological well-being [33-35] Especially for children and young people from families with a low economic status, malnutrition or chronic illnesses, explicit government support is requested [36] Attention to underexposed but important preventive nutritional support including vitamins D and C is needed to increase the anti-viral immune resistance, control disease and virus spread [37-39]. Complementary integration of healthy nutrition and lifestyle measures will further allow to reduce comorbidity risks (obesity, diabetes, CVD) for severe covid19 infections, which at long term will contribute to improved health and reduction in healthcare costs and promote resilience for a healthier society [36-39].

Dr.Carla Peeters (corresponding author)
CEO and Founder
COBALA Good Care Feels Better®
Utrecht, The Netherlands

Prof. dr. Wim Vanden Berghe
Department Biomedical Sciences
PPES Lab Proteinchemistry, Proteomics & Epigenetic signalling
University Antwerp

Prof. dr. Mattias Desmet
Faculty Psychology and Educational Science
University Gent
Gent, Begium>

1. Van der Westhuizen HM, Kotze K, Tonkin-Crine S, Gobat N, Greenlagh T. Face coverings for covid-19: from medical intervention to social practice. BMJ 2020; 370:m3021|doi.10136/bmj.m3021
2. Toubiana J, Poirault C, Corsia A, Bajolue F, Fourgeeand D, Augoulvant F et al. Kawasaki like multisystem inflammatory syndrome in children during covid-19 pandemic in Paris. France prospective observational study. BMJ. 2020;3091.
3 Zhang R, Li Y, Zhang AL, Wang Y, Morina MJ. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proc Natl Acad Sci U S A, 2020. 117(26): p. 14857-14863.
4. Ludvigsson JF, Children are unlikely to be the main drivers of the COVID-19 pandemic - A systematic review. Acta Paediatr, 2020. 109(8): p. 1525-1530.
5. Munro APS, Faust SN, Children are not COVID-19 super spreaders: time to go back to school. Arch Dis Child, 2020. 105(7): p. 618-619.
6. Howard J, Hunag A, Li Z, Tufeckzi Z, Zolminal V, Van der Westhuizen HM et al., Face Masks Against COVID-19: An Evidence Review. Proc Natl Acad Sci U S A, 2020. DOI: 10.20944/preprints202004.0203.v3.
7. Schünemann HJ, Akl AE, Chou R, Chu DL, Loeb M, Loffi T et al.Use of facemasks during the COVID-19 pandemic. Lancet Respir Med., 2020. doi: 10.1016/S2213-2600(20)30352-0.
8. Bartoszko JJ,Forooqi MEM, Ahazzani W, Loeb M. Medical masks vs N95 respirators for preventing COVID-19 in healthcare workers: A systematic review and meta-analysis of randomized trials. Influenza Other Respir Viruses, 2020. 14(4): p. 365-373. doi: 10.1111/imv12745
9. Radonovich LJ, Simberkoff MS, Bessesen MT, Brown AC, Cummings DAT, Gaydos CA et al. N95 respirators vs Medical Masks for preventing influenza among health care personnel. JAMA 2019. Sep 3; 322 (9): 824-833. Doi. 10.1001/jama.2019.11645.
10. Advice on the use of masks in the context of COVID-19. World Health Organization Interim guidance 5 June 2020 WHO/2019-nCov/IPC_Masks/2020.4
11. Chughtai AA, Stelzer-Braid S, Rawlinson W, Pontivivio G, Wang Q, Pan Q, Zang D et al. Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers. BMC Infect Dis, 2019. 19(1): p. 491.
12. Coronavirus: can the mask turn into a “bacteria nest”?, 2020.
13. Jefferson T, Henegham C. Masking lack of evidence with politics.
14. Na amper week al huiduitslag en schorre kelen door mondmaskers op school: " Als het zo moet willen leerlingen liever thuis les volgen. Het nieuwsblad september 4th 2020
15. Ong JJ, Bharatendu C, Goh Y, Tang JZ, Sooi KWX, Tan YL, et al. Headaches associated with personal protective equipment- a cross sectional study among frontline healthcare workers during Covid-19. Headache 2020 May60 (5); 864-877. Doi: 10.111/head.13811
16. Li Y, Tokura H, Guo YP, Wong ASW, Wong T, Chung J et al. Effect of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int. Arch.Occup. Environment Health. 2005; 7896): 501-508 doi. 10.1007s00420-004-0584-4
17. Hal JMF, Cruser D, Podawiltz A, Mummert DI, Jones H, Mummert ME. Psychological stress and the cutaneous immune response: role of the HPA axis and the sympathetic nervous system in atopic dermatitis and psoriasis. Dermatol. Res. Practi 2012;2012:403908. Doi:10.1155/2012/403908. Doi: 10.1155/2012/403908
18. Morrison KE, Rogers AB, Morgan CP, Bale TL. Epigenetic mechanisms in pubertal brain maturation. Neuroscience, 2014. 264: p. 17-24. doi.10.1016/j.neuroscience.2013.11.1014
19. Toro CA, Aylwin CF, Lomniczi A, Hypothalamic epigenetics driving female puberty. J Neuroendocrinol, 2018. 30(7): p. e12589.
20. Lomniczi A, Ojeda SR. The Emerging Role of Epigenetics in the Regulation of Female Puberty. Endocr Dev, 2016. 29: p. 1-16.
21. Notterman DA, Mitchell C. Epigenetics and Understanding the Impact of Social Determinants of Health. Pediatr Clin North Am, 2015. 62(5): p. 1227-40.
22. Essex MJ, Boyce T, Hertzmann C, Lam LL, Armstrong JM, Neumann SMA. Epigenetic vestiges of early developmental adversity: childhood stress exposure and DNA methylation in adolescence. Child Dev, 2013. 84(1): p. 58-75. doi.1111/j. 1467-8624.2011.01641.x
23. Bhopal S, et al., The contribution of childhood adversity to cortisol measures of early life stress amongst infants in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS). Psychoneuroendocrinology, 2019. 107: p. 241-250.
24. Cunliffe VT. The epigenetic impacts of social stress: how does social adversity become biologically embedded? Epigenomics, 2016. 8(12): p. 1653-1669.
25. Bush NR, Edgar RD, Park M, MacIsaac J:, McEwan LW, Adler NE et al. The biological embedding of early-life socioeconomic status and family adversity in children's genome-wide DNA methylation. Epigenomics, 2018. 10(11): p. 1445-1461. doi. 10.2217/epi-2018-0042
26. Gudsnuk K, Champagne FA. Epigenetic influence of stress and the social environment. ILAR J, 2012. 53(3-4): p. 279-88.
27. Young Adults’ Pandemic Mental Health Risks.
28. Prior A, Tenger-Gron M, Larsen KK, Larsen FB, Robinson M, Nielsen MG et al. The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study. Am J Epidemiol, 2016. 184(3): p. 199-210. doi.10.1093/gje/kwv324
29. Wieduwild E Girard-Madoux MJ, Quatrin L, Laprie C, Chasson L, Rossignol R et al. beta2-adrenergic signals downregulate the innate immune response and reduce host resistance to viral infection. J Exp Med, 2020. 217(4). doi: 10.1084/jem.20190554
30. Nielsen NR, Kristensen TS, Schohr P, Gronbaek M. Perceived stress and cause-specific mortality among men and women: results from a prospective cohort study. Am J Epidemiol, 2008. 168(5): p. 481-91; discussion 492-6. doi: 10.1093/aje/kwn157
31. Calder PC, Carr AC, Gombart AF, Eggersdorf M. Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections. Nutrients, 2020. 12(4). doi.10.3390/nu12041181
32. Jefferson T, Heneghan C. Masking lack of evidence with politics CEBM.2020. lack of evidence with poltics
33. Kim S-W, Su K-P. Using psychoneuroimmunity agains COVID-19. Brain Behavior and Immunity 27 (2020) 4-5.
34. Lazzari D, Bottacioli AG, Bottaciolo F. Letter to the Editor Kim S-W, Su K-P. Using psychoneuroimmunity against COVID-19. Brain Behavior and Immunity 27 (2020) 4-5.
35. Arshad MS, kahn U, sadio A, Khaldi W, Hussain M, Ysaween A et al. Coronavirus Disease (COVID-19) and Immunity Booster Green Foods: A Mini Review. Food Sci Nutr, 2020. 31719
36. Wolfson JA, Leung CW, Food Insecurity and COVID-19: Disparities in Early Effects for US Adults. Nutrients, 2020. 12(6).
37. Richardson D, Lovegrove L, Nutritional status of micronutrients as a possible and modifiable risk factor for COVID19: a UK perspective. British journal of nutrition, 2020.
38. Godlee F. Covid19: What we eat matters all the more now. BMJ 2020; 370: m2840 |
39. Holuka C, Merz MP, Fernandes SB, Charalambous EG, Seal SV. The Covid-19 pandemic: does our early life environment, life trajectory and socio economic status determine disease susceptibility and severity? 2020. Jul19;219140:5094. Doi: 10.3390/ijms21145094

Competing interests: No competing interests

09 September 2020
Carla Peeters
CEO and Founder
Wim Vanden Berghe, Mattias Desmet
COBALA Good Care Feels Better®
Utrecht, The Netherlands.