SPOTLIGHT

Through Plagues and : The Evolution of Medical Face Masks

KELLY PAN, ANUVA GOEL, LILIANA R. AKIN, SUTCHIN R. PATEL, MD, FACS 72 75 EN KEYWORDS: face masks, , conversation could disseminate COVID-19 respiratory droplets with bacte- ria. This led Mickulicz-Radecki to create and wear a face mask PLAGUES AND PANDEMICS in 1897, which he described as The first face masks were created to a “piece of gauze tied by two combat the earliest plagues. The Bubon- strings to the cap, and sweeping ic Plague, otherwise known as the Black across the face so as to cover the Death, spread throughout the Roman nose, mouth and beard.”6 Empire in the 6th Century AD.1 When Gregory I became Pope in 590 AD, an out- The Manchurian Plague, break was reaching Rome. To combat the 1910–1911 disease he ordered unending prayer. At The Manchurian Plague of 1910– the time, sneezing was thought to be an 1911 started along the Russian early symptom of the plague, thus stat- border of Manchuria, an area ing “God bless you” became a common of Northeast Asia, and quickly Paul Fürst, engraving, c. 1721, of a plague doctor of phrase spoken to help halt the disease.2 spread south along the railways. Marseilles (introduced as ‘Dr. Beaky of Rome’). His nose- The plague ravaged Europe and Asia The pneumonic form of plague case is filled with herbal material to keep off the plague. from the 14th to the 17th Centuries and killed every person it infected. [CC-PD] is estimated to have killed 200 million Most believed it was spread by people in the 14th Century alone.2 Plague rodents so the idea that it was airborne by the population to wear masks in order doctors wore the iconic bird-beak masks caused fear. The masks during the Man- to curb the led to a shift from in which the beaks were filled with a churian Plague consisted of a 4x6 inch the belief in superstitions and the super- mixture of herbs such as garlic and rue cotton rectangle secured over the mouth natural towards an acceptance of science to block the odors of the dead and dying by a long piece of gauze. The gauze was to help combat the plague.4 that were ever-present.1,4 This form of folded so that the rectangle was con- protection was thought to neutralize the tained within the gauze lengthwise. The The Spanish Influenza of 1918–1919 “miasma” in the air which was thought ends of the gauze were then cut so that The Spanish Influenza of 1918–1919 to be the cause of the illness.3 one end had two flaps and the other had brought worldwide hardship and halted In 1867, the British surgeon JOSEPH an opening for the flaps to tie into behind the normalcy of everyday life. The Span- LISTER (1827–1912) brought about the the head. The flaps and opening were ish Flu did not originate in Spain, but age of antisepsis, championing the use placed around the ears, similar to modern because Spain was a neutral country in of carbolic acid to sterilize surgical in- face masks, to secure the mask in place. World War I with a free media; the out- struments and clean wounds. At the The ends were then tied together to finish break was covered from the start, with time, LOUIS PASTEUR (1822–1895), the contraption.4 The final product was it being first reported in May of 1918. the French microbiologist and chemist, similar in appearance to a modern day During this time, there was a shortage had recently described the presence of cotton face mask, but the covering over of healthcare workers because those car- germs as the microscopic source of infec- the mouth and nose area were thicker ing for the sick were themselves ill with tion. Lister suggested eliminating germs than they are now. The mask was made the virus. The First World War added to through the use of antiseptic substances.6 for the entire population; however, the the severity of the pandemic as soldiers’ JOHANN MIKULICZ-RADECKI (1850 harsh winter conditions may have ad- immune systems, already weakened by –1905), Chair of the Department of Sur- versely affected the efficacy of the mask.4 the stress and ravages of war, allowed the gery at the University of Breslau, worked This plague and the widespread usage of virus to spread throughout the trench- with local bacteriologist, CARL FLÜGGE masks had a cultural effect on the Man- es. Increased travel due to the war effort (1847–1923), who showed that ordinary churian population. The collective effort further contributed to the spread of the

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virus.2 Deaths worldwide were estimated rubber bands. The introduction of anti- The Hawk’s Nest Tunnel disaster to be 50 million, with 675,000 deaths in biotics in the 1940s briefly decreased in- Respirator-type masks that protect the the United States.7 During the 1918–1919 terest in surgical masks, but it was soon wearer from inhaling pathogens have be- influenza pandemic, masks were manda- discovered that antibiotics were not a come heavily associated with the medical tory for medical workers, police officers, substitute for good aseptic technique.8 field today during the COVID-19 pandem- and in certain American cities (citizens in The standardization and testing of sur- ic. These respirators were originally de- San Francisco were fined $5 if they were gical face masks began in earnest in the veloped in the mining industry. In 1919, caught in public without a mask), but the 1950s, establishing the basis for our pres- the U.S. Bureau of Mines (USBM) began mandate of face masks was not without ent-day practices. Numerous tests were working to address the high fatality rate protest.5 By this time, most masks were conducted to assess the effectiveness of of mineworkers by establishing the first made of layers of cotton gauze with oc- masks in preventing the dissemination respirator certification program.10 From casionally another layer of a less porous of germs from the wearer. Some tests in- the beginning, inequalities existed in material surrounded by a metal frame. volved placing petri dishes or glass slides workers’ access to respiratory protection, Furthermore, these masks were reusable at varied intervals from an individual as exemplified by one of the deadliest and could be sterilized.5 The 1918–1919 to pick up exhaled germs. Other more disasters in American industrial history, influenza pandemic ended approximately tech-savvy tests visualized droplets and the Hawk’s Nest Tunnel disaster of the 18 months after its outbreak. The wearing aerosols using high-speed cameras and 1930s. From 1930–1935, three thousand of face masks was thought to have played strobe lights. Many of the principles es- men, the majority of whom were Black an important role in helping stop the tablished by these tests remain important migrant workers from the South, worked spread of the disease during its course.2 to keep in mind today. For instance, it on the construction of a tunnel near was discovered that the closeness of fit of Gauley Bridge, West Virginia. In the con- THE DEVELOPMENT AND the mask to the face is just as important struction process, they found the mineral EVOLUTION OF FACE MASKS as the material, that semi-porous filtering silica and were forced to mine it without As discussed earlier, one of the first sur- masks are more effective than nonporous any respiratory protection. As a result, an gical masks, composed of a single layer deflector masks, and that masks quickly estimated one-third of the workers died of gauze, was described by Johann Mi- lose their filtration capability once wet.9 from acute silicosis and related condi- kulicz-Radecki in 1897. In 1899, Flug- In the modern era, there has been a tions. Notably, the dangers of silica dust ge, who was working with tuberculosis, scarcity of experimental evidence to sup- were well-known to the company, as demonstrated that ordinary conversation port the effectiveness of face masks in their engineers wore respirators inside could disseminate bacteria-filled droplets the prevention of surgical site infections.6 the tunnel.11 The disaster accelerated the from the nose and mouth. The droplet What literature there is on the subject adoption of standards for dust, fume, and theory of infection substantiated the is dated and has had poorly explained mist respirators, but it was not until the need for an effective face mask. In 1905, methodology. Furthermore, it is uncer- passage of the Occupational Safety and ALICE HAMILTON (1869–1970), a Chica- tain that the results of these studies can Health Act of 1970 that the federal gov- go physician, proposed that scarlet fever be extrapolated to today given the usage ernment began requiring employers to was transmitted through droplet infection of new antiseptic techniques since their provide adequate respiratory protection and recommended doctors wear masks completion. Face masks have also been to all workers. at the time of surgery because of heavy thought to have utility in that they act In 1972, the USBM approved the first droplet transmission from the mouth and as a physical barrier against blood and single-use , which is the nose while talking and teaching. This bodily fluid splashes during surgery. De- respirator-type mask that many of us are may have been the first recommendation spite clear evidence that face masks act familiar with today. The designation of that surgeons wear masks. While the use to protect the staff from macroscopic fa- “N95” is a government efficiency rating of gauze face masks to protect patients cial contamination, there are studies that that means the mask blocks about 95 per- against wound infections was widespread suggest that they fail to protect surgeons cent of particles that are 0.3 microns in in operating rooms by the late 1920s, the from sub-micrometer contaminants. The size or larger.12 The material in these res- following decade saw a burst of innova- use of face shields may help mitigate pirators is designed to trap small particles tion in surgical mask design. Some de- this risk. Given that there has been lit- using a method called corona electrostatic signs were especially creative: one mask tle evidence that face masks cause harm, charging, which allows the fabric to filter proposed in 1930 consisted of a 14-karat proponents err on the side of caution and particles ten times more efficiently than gold-filled frame covered with wax paper, encourage their continued use, stressing uncharged fabrics. The importance of the and another consisted of a paper napkin, there is no room for complacency when it electrostatic charge also means that a wet two paper clips or safety pins, and two comes to both patient and surgeon safety. N95 mask loses its effectiveness. The

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adoption of respirator-type masks in the hygiene and collective health benefits. long-term use, sterilization procedures, medical field began in the 1990s, when In contrast, in countries like the Unit- or other means, could reduce the elec- healthcare workers began wearing them ed States, which value individualism, trostatic nature of the mask, reducing its to protect themselves from drug-resistant mask-wearing had not initially been read- effectiveness.19 tuberculosis, and their use in healthcare ily accepted.17 The lack of compliance con- Cloth masks, recommended for use for and other industries continues to the pres- veys an urgency to communicate proper the general public, are less effective at ent day. Unfortunately, with the scarcity information about mask type and usage protecting the wearer, but can substan- of personal protective equipment during to the U.S. population. There are several tially reduce spread of the virus. A recent the COVID-19 pandemic, complaints of types of masks that are being common- study visualized the spread of aerosol unequal access to respiratory protection ly used during the pandemic, including particles ejected from respiratory jets by in the workplace have again arisen, with medical masks (such as N95 respirators utilizing mask-wearing mannequins and accounts of allied health professionals, and surgical masks) and cloth masks, of- found that each cloth mask reduced pro- interpreters, and room cleaners not re- ten made out of common household ma- pulsion by at least half the distance of an ceiving the same level of protection as terials, such as bandanas or T-shirts. The uncovered individual.20 Although ban- doctors and nurses, despite their equally varying characteristics of mask materials danas had the highest thread count per close contact with COVID-19 patients.13 affect their effectiveness, particularly in inch, they only reduced propulsion to 4 the context of source control, restrict- feet, while a folded handkerchief limit- FACE MASKS TODAY ing an infected person’s viral shedding ed propulsion to just over one foot, and SARS-CoV-2 is a viral respiratory illness, to protect others in close proximity.14,16 a stitched mask made of quilting cotton which has grown within six months from N95 respirators, reserved primarily for limited propulsion to just 2.5 inches. an outbreak in Wuhan, China to a pan- healthcare workers, are made of multi- Thus, aside from thread count, a greater demic that has claimed over a million ple fibers of polymer, and have the added number of layers of material in the mask lives. To stem the spread of the virus, face benefit of protecting the wearer with a also contributes to limiting propulsion, masks have been one measure at the center nearly one hundred percent filtration effi- while increasing filtration efficiency of the debate around health guidance, in ciency.18 With the shortage in the supply as well, although an increase in layers addition to social distancing, shut-downs, of personal protective equipment (PPE), can reduce mask breathability.18,20 Even testing, and quarantining. even healthcare workers were finding a though cloth masks do not match the The guidance around mask usage, need to reuse these masks. However, a efficacy of N-95 respirators and surgical through the World Health Organiza- recent study found that autoclave steril- masks, expansive use of these masks tion (WHO) and the United States Cen- ization procedures reduced the filtration can drastically reduce spread.14 Mask fit ters for Disease Control and Prevention efficiency of N95 respirators, particular- and placement play an important role (CDC), has shifted over the course of the ly for small- to medium-sized particles, in preventing droplet escape. The most pandemic. These shifts are attributed to indicating that multiple uses of these common sites of droplet escape include new evidence that has come to light on masks come with disadvantages to per- the top of a mask (which can be seen as the asymptomatic transmission of SARS- sonal safety.19 The N95 mask with a valve fogging of glasses or eye protection) when CoV-2, whereby an infected individual can is a variation that is also being commonly there is not a tight fit at the nose as well spread the virus through aerosol, before or used. However, this mask has a one-way as from the sides of the mask by the without the presence of symptoms.14 The filtration system, such that, contrary to cheeks.20 Curtailing the spread of the vi- initial WHO recommendations, in Jan- the source control method, it only pro- rus requires wearing a mask when there is uary 2020, recommended medical mask tects the wearer by filtering inhaled air, limited social distancing, and keeping the use only for individuals with respiratory without conferring protection to people mask covering the mouth and nose while symptoms and for healthcare workers.15 nearby.14 Thus, for public health purpos- speaking, to limit droplet propulsion. Our However, by June 2020, the agency’s guid- es of mitigating COVID-19 spread, this understanding of how to best utilize face ance was recommending cloth mask use type of mask should be avoided. Surgi- masks and their effectiveness continues among the general population, with med- cal masks are made of multiple layers of to evolve. We thus recommend checking ical mask use still restricted for vulner- propylene, and demonstrate a filtration up to date information on the websites for able populations, those with respiratory capability not by physically blocking the the CDC (https://www.cdc.gov/coronavirus/ symptoms, and healthcare workers.16 particle through Van der Waals interac- 2019-ncov/prevent-getting-sick/cloth-face- Despite the recent WHO guidance, the tions with the fibers, but rather by cre- cover-guidance.html) and WHO implementation of these guidelines has ating an electrostatic charge difference (https://www.who.int/emergencies/diseases/ varied geographically. In China, mask between the fiber and particle.18 Howev- novel-coronavirus-2019/advice-for-public/ usage reflected cultural norms around er, exposure to moisture, perhaps from when-and-how-to-use-masks).

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Mask wearing is not a new phenom- 10. 100 Years of Respiratory Protection Acknowledgment History. NPPTL, NIOSH, CDC. Pub- enon when it comes to protecting our- This manuscript was written as part of lished June 3, 2020. (https://www.cdc. selves from pandemics. People have used gov/niosh/npptl/Respiratory-Protec- the 2020 BrownConnect Summer Institute masks for hundreds of years in an early, tion-history.html Accessed July 16, (BCSI) Program. but not completely understood, attempt 2020) Authors to halt the spread of disease. Progressive- 11. Crandall RE. Revisiting the Hawks Nest Tunnel Incident: Lessons Learned Kelly Pan is a first-year medical student at ly we have begun to better understand from an American Tragedy. Journal of the Alpert Medical School of Brown the science behind protective equipment Appalachian Studies. 2002;8(2):261-283. University, Providence, RI. since the last pandemic at the begin- 12. N95 Respirators and Surgical Masks. Anuva Goel is a senior at Brown Blogs, CDC.(https://blogs.cdc.gov/ University, Providence, RI. ning of the 20th century. From the Black niosh-science-blog/2009/10/14/n95/ Death to the Manchurian Plague to the Accessed July 19, 2020) Liliana R. Akin is a junior at Brown 1918–1919 Influenza Pandemic to the 13. ‘They don’t let us use masks. They say University, Providence, RI. COVID-19 Pandemic today, the use of we don’t need them.’ Center for Public Sutchin R. Patel, MD, FACS, is an Integrity. (https://publicintegrity.org/ Alpert Medical School alum and is a facial coverings has been a simple but health/coronavirus-and-inequality/low- Clinical Adjunct Assistant Professor powerful tool to help combat infectious profile-hospital-workers-bemoan-their- in the Department of Urology at the COVID-19-risk/ Accessed July 19, 2020) disease. v University of Wisconsin School of 14. Gawande A. Amid the Coronavirus Medicine and Public Health. Crisis, a Regimen for Reentry. The New Yorker. May 13, 2020. Correspondence 15. World Health Organization. Advice on Sutchin R. Patel, MD References the use of masks in the community, 1. Archaeological Medica XLVI. How our during home care and in healthcare 3 S. Greenleaf, Suite J Forefathers Fought the Plague. Br Med settings in the context of the novel Gurnee, IL 60031 J. 1898;2:903-908. coronavirus (2019-nCoV) outbreak. [email protected] 2. Patrick BK, Thompson JM. An Un- June, 5 2020. (https://www.who.int/ common History of Common Things. publications/i/item/advice-on-the-use- National Geographic. 2009; p.74. of-masks-in-the-community-during- 3. Snowden F. Plague I-III. Hist 234: Epi- home-care-and-in-healthcare-settings- demics in Western Society since 1600s. in-the-context-of-the-novel-coronavi- Lecture conducted from Yale Universi- rus-(2019-ncov)-outbreak. Accessed ty, New Haven, CT. 2010. (https://oyc. July 21, 2020) yale.edu/history/hist-234#overview 16. World Health Organization. Advice Accessed July 20, 2020) on the use of masks in the context of 4. Lynteris C. Plague Masks: The Visual COVID-19. April 6, 2020. (https://apps. Emergence of Anti-Epidemic Personal who.int/iris/handle/10665/331693. protection Equipment. Med Anthropol, Accessed July 21, 2020) Aug/Sep2018;37(6):442-457. 17. Katz J, Sanger-Katz M, Quealy K. A 5. Schlich T, Strasser BJ. A History of Detailed Map of Who Is Wearing Masks the Medical Mask and the Rise of in the U.S. The New York Times. July Throwaway Culture. The Lancet. 2020; 17, 2020. 396(10243):19-20. 18. Zangmeister CD, Radney JG, Vicenzi 6. Da Zhou C, Sivathondan P, Handa A. EP, Weaver JL. Filtration Efficiencies Unmasking the Surgeons: The Evidence of Nanoscale Aerosol by Cloth Mask Base Behind the Use of Face masks in Materials Used to Slow the Spread of Surgery. Journal of the Royal Society SARS-CoV-2 [published online ahead of of Medicine; 2015, Vol. 108(6):223–228. print, 2020 Jul 7]. ACS Nano. 2020. 7. CDC. 1918 Pandemic (H1N1). March 19. Grinshpun SA, Yermakov M, Khodoun 20, 2019. https://www.cdc.gov/flu/ M. Autoclave Sterilization and Ethanol pandemic-resources/1918-pandem- Treatment of Re-used Surgical Masks ic-h1n1.html and N95 Respirators during COVID-19: 8. Spooner JL. History of Surgical Face Impact on their Performance and Masks: The myths, the masks, and the Integrity [published online ahead of men and women behind them. AORN print, 2020 Jun 26]. J Hosp Infect. Journal. 1967;5(1):76-80. 2020;105(4):608-614. 9. Rockwood CA, O’Donoghue DH. The 20. Verma S, Dhanak M, Frankenfield J. Surgical Mask: Its Development, Usage, Visualizing the effectiveness of face and Efficiency: A Review of the Liter- masks in obstructing respiratory jets. ature, and New Experimental Studies. Phys Fluids 2020;32(6):061708. AMA Arch Surg. 1960;80(6):963-971.

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