The new debate in Spain: should medical-grade face masks be mandatory?

Spain is facing another debate about face masks. At the beginning of the coronavirus pandemic, Spanish health authorities did not recommend the use of face masks, partly because there were not enough to supply everyone. One year on, non-medical face masks continue to be allowed, even though health experts say they are not safe, given what is now known about how the virus is spread, and the emergence of new, more contagious strains, such as the B.1.1.7 variant detected in the United Kingdom. But if FFP2 masks – theoretically the most effective at stopping the virus – were mandatory, it is not likely that there would be sufficient capacity to produce this level of supply, according to the Association of Personal Protective Equipment Companies (Asepal).

Other countries are already cracking down on non-medical masks on the grounds that they do not provide enough protection from the virus. France issued a decree last Thursday banning certain homemade masks from being worn in public. Under the decree, only three types of masks are recommended: surgical, the FFP2 and fabric masks made to category 1 standards, which filter at least 90% of three-micrometer particles. In Germany, residents cannot enter closed spaces, such as supermarkets and offices, with fabric masks. Only FFP2 and KN95, both considered personal protective equipment (PPE), and blue surgical masks, which filter more than 90% of particles, are allowed. In Bavaria, FFP2 masks have been mandatory since last Monday.

In Spain, the debate around what type of face masks should be used was raised on Wednesday by Alberto Núñez Feijóo, the premier of the northwestern Galicia region. “It would boost confidence if the central government clarified if FFP2 masks can be mandatory in certain places or social occasions. We think that they can,” he told parliament, adding he would discuss the issue with Spanish Prime Minister Pedro Sánchez on Friday.

Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES), has supported the use of surgical and PPE masks. “The greater the protection, the better,” he said at a press conference last week. But he also defended the use of fabric masks that meet specifications outlined by the Spanish Association for Standardization (UNE). This type of face covering was approved in Spain last April, when face masks were declared mandatory in all public spaces. The decision was made in order to allow non-specialized companies to produce large numbers of face masks so that the needs of the public could be quickly met.

But the use of fabric masks, like homemade ones, has come under growing scrutiny. “They are not subject to meet specific requirements from a health point of view,” says Luis Gil, the secretary general of Asepal. EL PAÍS asked the Spanish Health Ministry if it is planning on changing the current rules, but the ministry replied that any changes would not be announced ahead of time.

Ideal protection: FFP2 and FFP3

José Jiménez, a researcher at the infectious diseases department in King’s College in London, believes that the use of hygienic masks (cloth, paper) and especially homemade coverings “should not be allowed,” given that their effectiveness depends a lot on what material they are made from and the filters they contain. “In an ideal world, the right thing would be for everyone to wear PPE masks because they are the most effective when it comes to stopping us from getting infected and being able to infect others,” he says. “However, they are face masks that not everyone is able to have, they are not always available and they can only be used for a very limited time. That’s why, although they are not perfect, I think the accepted minimum should be surgical masks that health workers are used to wearing and are more accessible and easy to use.”

While surgical masks can be bought for €0.15, PPE masks cost at least €2. Given that they are only effective for eight hours of use, an individual would have to spend €60 a month if they needed to use one a day. Making matters worse, Asepal says there is not enough manufacturing capacity to deal with a surge in demand. “Making this type of mask mandatory, which could happen both in Spain or across Europe, could risk causing supply problems again. Right now, it [production] is normalized to supply health workers, but the supply is not ready for a global demand from all citizens,” says Gil.

Given this problem, José María Lagaron, founder of the New Materials and Nanotechnology research group at the Agrochemical and Food Technology Institute (IATA-CSIC), proposes that authorities recommend the use of FFP2 masks, especially indoors. “We know that the virus is mainly spread through the air and in closed spaces where aerosols build up, meaning that the best protection is PPE masks. In open spaces, surgical masks should be enough,” he says.

Safe, if worn properly

One of the arguments used by health authorities to justify not recommending PPE masks to the general population, is that most people do not know how to wear them. Although this type of mask offers the greatest protection, its effectiveness depends on whether it is fitted properly and forms a hermetic space, ensuring that all air expired is filtered through the mask. Gil from Asepal explains that the level of protection could be diminished if the user has a beard or if the mask is not tightly fitted over the nose and mouth, as aerosols could get through these holes and bypass the filter. Using a surgical mask on top of an FFP2 is also counterproductive as it creates gaps. An improperly worn PPE mask can be up to 50% less effective.

With respect to surgical masks, Jiménez says the problem is that they are designed to stop someone who has the virus from spreading it to others. “They serve to protect those around us, meaning the protection it provides to the person wearing it is very limited,” he says. “But if everyone wore at least surgical masks and used them correctly, the number of infections would fall significantly.”

Lagarón says that surgical masks are designed for bacterias, not viruses like SARS-CoV-2, which causes Covid-19. “Traditionally, health workers use them in surgery so as to not infect patients they are operating on [which is how they got their name],” he explains. “With a respiratory virus, like the one of this pandemic, it’s not that you are going to be totally unprotected, but we know that in surgical masks, between 35% and 15% of potentially contagious particles can penetrate. Faced with a more virulent strain, like the one detected in Britain, it is evident that we are going to have to be more serious about protection.”

English version by Melissa Kitson.