Original research

Arch Dis Child: first published as 10.1136/archdischild-2023-326215 on 2 December 2023. Downloaded from http://adc.bmj.com/ on December 6, 2023 by guest. Protected by copyright.
Child mask mandates for COVID-­19:
a systematic review
Johanna Sandlund ‍ ‍,1 Ram Duriseti,2 Shamez N Ladhani ‍ ‍,3,4 Kelly Stuart,5
Jeanne Noble,6 Tracy Beth Høeg7,8

► Additional supplemental ABSTRACT

material is published online Background Mask mandates for children during the WHAT IS ALREADY KNOWN ON THIS TOPIC
only. To view, please visit the ⇒ Child mask mandates have been extensively
journal online (http://d​ x.​doi.​ COVID-­19 pandemic varied in different locations. A
org/1​ 0.​1136/​archdischild-​ risk-­benefit analysis of this intervention has not yet been used as a public health measure during the
2023-3​ 26215). performed. In this study, we performed a systematic COVID-1­ 9 pandemic.
1 review to assess research on the effectiveness of mask ⇒ Masking recommendations appear to be
Board-­Certified Clinical
Microbiologist and Independent wearing in children. entirely based on mechanistic and observational
Scholar, Alameda, California, Methods We performed database searches up to data, and a systematic review assessing the
USA February 2023. The studies were screened by title and evidence has not been performed.
2
Stanford University School of
abstract, and included studies were further screened as WHAT THIS STUDY ADDS
Medicine, Stanford, California,
USA full-­text references. A risk-­of-­bias analysis was performed
3
by two independent reviewers and adjudicated by a third ⇒ In this systematic review, 16 studies found
Immunisation Department,
UK Health Security Agency, reviewer. no effect of mask wearing on infection or
London, UK Results We screened 597 studies and included 22 in transmission, while six studies reporting a
4
Centre for Neonatal and protective association had critical or serious risk
Paediatric Infection, St. George’s the final analysis. There were no randomised controlled
trials in children assessing the benefits of mask wearing of bias.
University of London, London,
UK to reduce SARS-­CoV-­2 infection or transmission. The six ⇒ Because benefits of masking for COVID-­19 have
5
SmallTalk Pediatric Therapy, observational studies reporting an association between not been identified, it should be recognised that
San Diego, California, USA
child masking and lower infection rate or antibody mask recommendations for children are not
6
Emergency Medicine, University supported by scientific evidence.
of California San Francisco, San seropositivity had critical (n=5) or serious (n=1) risk of
Francisco, California, USA bias; all six were potentially confounded by important HOW THIS STUDY MIGHT AFFECT RESEARCH,
7
Epidemiology and Biostatistics, differences between masked and unmasked groups and PRACTICE OR POLICY
University of California San two were shown to have non-­significant results when
Francisco, San Francisco, ⇒ COVID-­19-­related policy recommendations
California, USA reanalysed. Sixteen other observational studies found
should be informed by high-­quality evidence
8
Clinical Research, University no association between mask wearing and infection or
and consider the possibility of harm, especially
of Southern Denmark, Odense, transmission.
Denmark for children, who are vulnerable and an
Conclusions Real-­world effectiveness of child mask
ethically protected group.
mandates against SARS-­CoV-­2 transmission or infection
Correspondence to ⇒ Healthcare providers and adults working with
has not been demonstrated with high-­quality evidence.
Dr Johanna Sandlund, children should be educated about the absence
Independent, Alameda, USA; The current body of scientific data does not support
of high-­quality data supporting masking to
​johanna.​sandlund@g​ mail.​com masking children for protection against COVID-­19.
lower SARS-­CoV-­2 infection and transmission
Received 17 August 2023 risks.
Accepted 3 November 2023 ⇒ Because absence of harm is not established,
INTRODUCTION recommending child masking does not meet the
Mandating masks for children has been one of accepted practice of promulgating only medical
the most polarising public-­health measures imple- interventions where benefits clearly outweigh
mented during the COVID-­ 19 pandemic. Two harms.
Cochrane reviews of randomised controlled trials
(RCT) of masking for prevention of upper respira-
tory infections failed to find a benefit against infec-
tion or transmission.1 2 Most countries have now and facial gestures accelerate word recognition and
removed all public mask mandates, while the USA’s speech comprehension,5–8 the integration of facial
© Author(s) (or their Centers for Disease Control and Prevention (CDC) information is important for speech perception,9 10
employer(s)) 2023. Re-­use and American Academy of Pediatrics continue to and recognition of facial expressions is critical for
permitted under CC BY-­NC. No recommend masking down to the age of two.3 4 children’s abilities to communicate and understand
commercial re-­use. See rights and show emotions.7 11 12 Mask wearing may also
and permissions. Published This recommendation appears to be entirely based
by BMJ. on observational data finding associations with cause breathing difficulties, headaches, dermatitis,
lower case rates in masked versus unmasked indi- general discomfort and pain.2 13–17
To cite: Sandlund J, There is an urgent need to base pandemic-­related
viduals but does not take into account the poten-
Duriseti R, Ladhani SN, et al.
Arch Dis Child Epub ahead of tial adverse consequences of masking, especially in policy recommendations on robust scientific data
print: [please include Day young children, including but not limited to impact that include risk-­benefit analyses, preferably with
Month Year]. doi:10.1136/ on speech, language, learning, mental health and the long-­term goals and the beneficiaries of the
archdischild-2023-326215 physiological factors. Seeing mouth movements intervention clearly defined.18 Ethically, children
Sandlund J, et al. Arch Dis Child 2023;0:1–7. doi:10.1136/archdischild-2023-326215    1
Original research

Arch Dis Child: first published as 10.1136/archdischild-2023-326215 on 2 December 2023. Downloaded from http://adc.bmj.com/ on December 6, 2023 by guest. Protected by copyright.
should be treated as a protected group, where the benefits of any references and excluded 18 that did not meet the inclusion criteria
intervention should clearly outweigh harms. (figure 1). Details of the screened publications are presented in
The aim of this systematic review is to evaluate the body of table 1. The ROB analysis by the two reviewers resulted in 18
literature on mask wearing in children to assess the existing differences in ratings and four differences in overall ROB that
evidence regarding protection offered by face masks against needed to be adjudicated.
SARS-­CoV-­2 infection or transmission. To date, there are no RCTs assessing the effects of masking
children in reducing COVID-­ 19 transmission or disease.
METHODS Among the 22 observational studies identified, the overall
We conducted a systematic review to evaluate the evidence for ROB was critical in six studies (27.2%), serious in 10 studies
effectiveness of child mask mandates in reducing transmission or (45.5%), moderate in five studies (22.7%) and low in none of
disease severity in COVID-­19. the studies (table 2). Of the six studies reporting a significant
References were identified through searches of PubMed, negative correlation between masking and COVID-­19 cases,
Google Scholar, three major preprint servers (SSRN, MedRxiv five had critical and one had serious ROB. Of the 16 studies
and Research Square) and major public health agency publica- failing to find a significant correlation, 1 (6.3%) had critical,
tion databases and websites until February 2023 (online supple- 10 (62.5%) had serious, 5 (31.3%) had moderate and none had
mental appendix 1). We included primary studies of any design low ROB.
investigating mask effectiveness against COVID-­ 19 (SARS-­ All six studies,20 21 22 23 24 25 reporting a negative assocation
CoV-­2) transmission, infection and disease in individuals <18 were potentially confounded by crucial differences between
years old. Publications of case reports, case series, reviews and masked and unmasked groups, including the number of instruc-
comments without new data were excluded, as were studies tional school days, differences in school size, systematic baseline
where age groups were not specified or out of the paediatric differences in case rates in all phases of the pandemic, testing
range, or when the setting or study objective/design were not policies, contact-­tracing policy differences and teacher vaccina-
applicable. The systematic review was prepared according to tion rates. These confounders—alone and in combination—re-
Preferred Reporting Items for Systematic Reviews and Meta-­ sulted in a failure to demonstrate an isolated effect of masks
Analyses (PRISMA) guidelines. The quality risk of bias (ROB) themselves. 20–22
was estimated using the ROB-­2 and ROBINS-­I tools,19 a struc- One study from Boston found that lifting of school mask
tured approach for assessing the ROB utilising different domains mandates was associated with increased number of COVID-­19
of bias and an overall judgement. All ROB assessments were cases,23 which was questioned upon re-­ analysis.26 US studies
24 21
conducted by two independent reviewers (RD and SNL), and in North Carolina and Arizona found that mask require-
disagreements were resolved by a third reviewer (JS). ments had negative associations with in-­school transmission and
COVID-­19 outbreaks, respectively. In a 2020 Canadian study
RESULTS published as a preprint, children who did not wear a mask had
Our literature search identified 597 publications that were higher seropositivity than children who wore masks, but the
screened by title and abstract. We then screened 40 full-­text overall seropositivity was low (9/541 or 1.7% in total) and find-
ings were confounded by multiple external factors including
social distancing and attendance in schools, social functions and
organised sports.25
In a Spanish study of almost 600 000 children, the researchers
did not find a significant difference in cases between unmasked
5-­year-­olds and masked 6-­year-­olds; instead, case rates correlated
closely with the age of children,27 which was also observed in
another Spanish study.28 An observational CDC-­ funded US
study20 found no significant association between county-­wide
mask mandates and paediatric case counts on expanded reanal-
ysis.29 A lack of significant association between masking children
and risk of COVID-­19 was also reported by the UK Department
of Education.30 In three US studies, there was no correlation
between mask mandates and COVID-­19 rates,31 no significant
association between COVID-­19 incidence and face mask use,32
and no risk reduction for COVID-­ 19-­
related outcomes with
student mask mandates.33 Spanish and Irish studies have inde-
pendently observed similar primary-­school COVID-­19 transmis-
sion in young children with or without masking, respectively.28 34
In another CDC study, there was no reduction in COVID-­19
incidence in schools requiring student masking compared with
those with optional masking.35 When comparing adjacent school
districts with and without mask mandates, multiple studies
have reported no difference in transmission.36–38 A Finnish
study compared case rates in children with and without mask
mandates in 10–12 year-­olds, and the authors found no reduc-
tion in COVID-­ 19 case rates when mask recommendations
were extended to include 10–12 year olds.39 Face-­ mask use
Figure 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items among high school athletes was not found to have an impact on
for Systematic Reviews and Meta-­Analyses. transmission.32
2 Sandlund J, et al. Arch Dis Child 2023;0:1–7. doi:10.1136/archdischild-2023-326215
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Arch Dis Child: first published as 10.1136/archdischild-2023-326215 on 2 December 2023. Downloaded from http://adc.bmj.com/ on December 6, 2023 by guest. Protected by copyright.
Table 1 Characteristics of included observational studies
First author, year of
study, country Study design Child age groups Sample size Primary outcome Main findings
Budzyn, 2021 USA20 Case-­control study 5–18 years 520 counties Case detection, based on survey Negative association between county-­wide mask mandates
data and paediatric case counts.
Jehn, 2021 USA21 Case-­control study 5–18 years Two counties In-­school transmission, based on Negative association between mask requirements and
reported public-­health data COVID-­19 outbreaks.
Nelson, 2020–21, USA22 Cohort study 5–18 years Eight school In-­school transmission, based on Negative associations between mask requirements and in-­
districts reported school-­district data school transmission.
Cowger, 2022 USA23 Case-­control study 5–18 years 72 school districts Case detection, based on Negative association between mask requirements and
reported school-­district data COVID-­19 cases.
Boutzoukas, 2021, USA24 Cohort study 5–18 years 20 school districts In-­school transmission, based on Negative association between mask requirements and in-­
reported school-­district data school transmission.
Manny, 2020 Canada25 Cohort study 8–13 years n=565 Seropositivity, based on study Children who did not wear a mask had higher seropositivity
testing than children who wore masks.
Coma, 2021, Spain27 Case-­control study 3–11 years 1907 schools Case detection and in-­school No difference in cases between unmasked 3–5 year olds and
transmission, based on reported masked 6–11 year olds; instead, case rates correlated closely
public-­health data with the age of children.
Alonso, 2020, Spain28 Cohort study 3–17 years 5104 schools In-­school transmission, based Similar in-­school COVID-­19 transmission in young children
on reported school-­district and with or without masking, and in-­school transmission was
public-­health data age-­dependent.
UK Department for Case-­control study 11–16 years 1315 schools COVID-­19 absence rate, based No association between masking children and COVID-­19
Education, 2021, UK30 on reported school-­district data case-­rate declines.
Oster, 2020–21, USA31 Cohort study 5–18 years Three US states Case detection, based on school-­ No correlation between mask mandates and COVID-­19 rates.
district-, self-­reported-, and
survey data
Sasser, 2020 USA32 Cohort study 14–18 years 207 schools Case detection, based on survey No association between COVID-­19 incidence and face mask
data use in high school athletes.
Lessler, 2020–21, USA33 Cohort study 4–18 years One country Case detection, based on survey No risk reduction for COVID-­19-­related outcomes with student
(selection) data mask mandates.
White, 2020, Ireland34 Cohort study 4–18 years 604 schools Case detection, based on Similar in-­school COVID-­19 transmission in young children
reported public-­health cases with or without masking.
Gettings, 2020 USA35 Cohort study 5–11 years 169 schools Case detection, based on survey No significant reduction in COVID-­19 incidence in schools
data requiring masking.
Tennessee Department of Case-­control study 5–18 years Two counties Case detection, based on No difference in transmission when comparing adjacent
Health and Census, 2021 reported public-­health data school districts with and without mask mandates.
USA36
Cabrera, 2021 USA37 Case-­control study 5–18 years One county Case detection, reported school-­ No difference in transmission when comparing adjacent
district data school districts with and without mask mandates.
Sood, 2021–22, USA38 Case-­control study 5–18 years Two school districts Case detection, based on No difference in transmission when comparing adjacent
reported public-­health data school districts with and without mask mandates.
Juutinen, 2021, Finland39 Case-­control study 7–12 years Two cities Case detection, based on No additional benefit in case rates with an extension of mask
reported public health data recommendation to include 10–12 year olds.
Ludvigsson, 2020, Cohort study 1–16 years One country Morbidity and mortality, based In Sweden, where schools remained open and masks were not
Sweden41 on reported public health data required, only 15 of nearly 2 million children in the country
were hospitalised and none died during spring 2020 and
infection rate among teachers were similar to that of other
professions.
Suryawijaya, 2020–22, Cohort study 0–17 years One country Mortality, based on reported In Finland, where children have not masked under the age of
Finland42 public health data 10–12 years, no children have died from COVID-­19 by March
2022.
Brandal, 2020 Norway43 Cohort study 5–13 years n=292 In-­school transmission, based on In Norway, where masks were not recommended, in-­school
study testing transmission was<1% among children and<2% in child-­adult
contacts in schools.
Lam-­Hine, 2021 USA44 Case series 5–11 years n=27 In-­school transmission, based on Mask usage in a classroom did not prevent transmission from
reported public health data symptomatic adult, while very few of the children infected
their family members.

To explore the effect on disease severity, there was no <1% among children and< 2% in child-­ a dult contacts
association between viral load of index cases with confirmed during August–November 2020. 43 During a SARS-­ C oV-­
2
COVID-­1 9 and disease severity among secondary cases. 40 Delta variant outbreak in a US elementary school in May–
In Sweden, where schools remained open and masks were June 2021, mask use for staff and students in classrooms
not required, only 15 of the nearly 2 million children were did not significantly prevent transmission from symptom-
hospitalised and none died during the spring of 2020; also, atic adults, while very few children went on to infect their
the infection rate among teachers was similar to that of family members. 44 In New York City public schools with
other professions. 41 In Finland, where children have not more than 1600 schools and 1 million enrolled students, the
worn masks under the age of 10–12 years, no child died transmission rate (secondary attack rate) during the Delta
from COVID-­1 9. 42 In Norway, where masks in schools variant period (October–December 2021) was estimated to
have not been recommended, in-­ s chool transmission was be 0.5%. 45
Sandlund J, et al. Arch Dis Child 2023;0:1–7. doi:10.1136/archdischild-2023-326215 3
 Original research

Arch Dis Child: first published as 10.1136/archdischild-2023-326215 on 2 December 2023. Downloaded from http://adc.bmj.com/ on December 6, 2023 by guest. Protected by copyright.
Table 2 Risk-­of-­bias rating per study.
Deviation Selection
Selection of Classification of from intended Measurement of reported Overall risk of
Study Confounding participants intervention intervention Missing data of outcomes result bias
Budzyn et al20 Critical Critical Moderate Moderate Critical Serious Serious Critical
Jehn et al21 Critical Serious Moderate Moderate Critical Serious Serious Critical
Nelson et al22 Critical Critical Moderate Moderate Critical Serious Serious Critical
Cowger et al 23 Critical Critical Moderate Moderate Critical Serious Serious Critical
Boutzoukas et al24 Critical Critical Critical Moderate Critical Serious Serious Serious
Manny et al25 Critical Moderate Critical Serious Low Moderate Critical Critical
Coma et al27 Serious Serious Moderate Moderate Serious Moderate Moderate Moderate
Alonso et al28 Serious Serious Moderate Moderate Serious Moderate Moderate Moderate
UK Department for Critical Moderate Moderate Serious Critical Serious Serious Moderate
Education, 202230
Oster et al31 Critical Critical Moderate Serious Serious Serious Serious Serious
Sasser et al32 Critical Critical Moderate Moderate Critical Serious Serious Serious
Lessler et al33 Critical Critical Serious Moderate Critical Serious Serious Serious
White et al34 Critical Moderate Critical Moderate Low Moderate Moderate Critical
Gettings et al35 Serious Critical Moderate Serious Critical Moderate Moderate Serious
Tennessee Department of Critical Serious Moderate Moderate Critical Serious Serious Serious
Health and Census36
Cabrera37 Serious Moderate Moderate Critical Serious Serious Moderate Serious
Sood et al38 Serious Moderate Moderate Moderate Moderate Moderate Moderate Moderate
Juutinen et al39 Moderate Moderate Moderate Moderate Moderate Moderate Low Moderate
Ludvigsson41 Moderate Moderate Critical Low Low Low Low Serious
Suryawijaya et al42 Critical Moderate Low Critical Low Low Low Serious
Brandal et al43 Critical Low Critical Low Low Low Low Serious
Lam-­Hine et al44 Serious Critical Serious Low Low Moderate Low Serious

DISCUSSION expanding the population to include the entire state or using

In this systematic review on benefits of child masking against different statistical analysis and also found the initial study’s
SARS-­CoV-­2, we identified no RCT on the efficacy for use of results were likely confounded by differences in prior infection
face masks and the risk of transmission or disease. Among the rates.26
22 identified observational studies of masking for prevention Observational studies have also failed to find an association
of COVID-­19, more than 70% of the studies had a critical or between voluntary mask wearing among adults in schools and
serious overall ROB. None of the observational studies reporting lower odds of COVID-­19 in the school49 or between mask
a negative correlation between masking and COVID-­19 cases mandates or mask use and reduced transmission.50 In addi-
had a level of bias that was less than “serious.” tion, a systematic review showed a 10-­fold lower secondary
Specifically, of the 6 out of 22 observational studies that attack rate in schools compared with community/household
reported a significant negative correlation between masking and settings.51
COVID-­19 cases, five had critical and one had serious ROB. Of In adults, there are only a limited number of published
the 16 out of 22 studies failing to find a significant correlation, RCTs of mask wearing and COVID-­ 1 9 prevention.
only 6.3% had critical ROB, while 62.5% had serious and 31.3% DANMASK-­1 9 failed to find a 50% reduction in COVID-­1 9
had moderate ROB. Importantly, the largest studies with the infections in surgical mask wearers in the community. 52
lowest ROB did not identify a benefit from masking.27 28 30 The A cluster RCT in Bangladesh found no effect of commu-
study (currently in preprint publication) with the most robust nity cloth masking on COVID-­1 9 infections, no reduction
internal control showed no benefit from a mask mandate.38 from surgical masking for anyone under age 50, and only a
Observational studies reporting a negative association between marginal reduction among >50-­y ear olds and in the context
masking and COVID-­ 19 rates have failed to demonstrate a of observer-­enforced physical distancing, 53 an association
benefit when confounding factors have adequately been consid- that was found to be insignificant after re-­a nalysis. 54 In a
ered.20–24 Larger observational studies,28 31 including a regression-­ predominantly adult cluster RCT of almost 40, 000 partic-
discontinuity analysis39 and a more robust reanalysis29 of a prior ipants from age 10 and up (but not reported by age group
publication,20 as well as other observational studies,27 30 32–38 41–44 and, therefore, not included in our systematic review), there
failed to find benefit of masking against COVID-­19. Observa- was no difference in COVID-­ 1 9-­
l ike illness or mortality
tional studies in adults also repeatedly fail to properly adjust for between masked and unmasked groups. 55 A Cochrane
confounding factors to avoid bias.46–48 Furthermore, the Boston systematic review published in 2020 similarly found use of
observational study23 stated they could infer causality between surgical masks and respirators in adults to have ‘little to no
lifting school mask mandates and increases in student and staff effect’ on the transmission of respiratory viruses, while side
cases by using a difference-­in-­differences technique. However, a effects included discomfort. 1 In the 2023 updated version
subsequent reanalysis called the methodology and results of this that included COVID-­ 1 9, these conclusions remained
study into question and failed to find the same association when unchanged. 2
4 Sandlund J, et al. Arch Dis Child 2023;0:1–7. doi:10.1136/archdischild-2023-326215
 Original research

Arch Dis Child: first published as 10.1136/archdischild-2023-326215 on 2 December 2023. Downloaded from http://adc.bmj.com/ on December 6, 2023 by guest. Protected by copyright.
Perpetual masking in early childhood is without historical Correction notice This article has been corrected since it was first published.
precedent. In children, the harms associated with masking There were two minor spelling mistakes in ’What this study adds’.
are often challenging to identify, measure and quantify Twitter Shamez N Ladhani @shamezladhani
with correlational studies, and many of these outcomes will Contributors JS, RD, SNL, KS, JN and TBH participated in the search selection and
take years to fully evaluate. An extensive body of research directly accessed and verified the underlying data reported in the manuscript. JS
has found harms associated with mask wearing or mask wrote the first draft of the manuscript, with input from RD, SNL, KS, JN and TBH. JS
is guarantor.
requirements in children. 56 These associated harms include
negative impacts on speech, language and learning. Mask Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
wearing causes reduced word identification 57–59 and impedes
the ability to teach and evaluate speech.60 There is a link Competing interests None declared.
between observation of the mouth and language processing, Patient consent for publication Not applicable.
and people of all ages continue to focus on the mouth when Ethics approval Not applicable.
listening to non-­n ative speech. 61 The sensitive period for Provenance and peer review Not commissioned; externally peer reviewed.
language development is through age 4, and development of
Data availability statement Data are available upon reasonable request. All
connected speech is ongoing beyond age 10. 62 data relevant to the study are included in the article or uploaded as supplementary
Mask wearing may also impact mental health and social-­ information.
emotional well-­b eing by limiting the ability to accurately Supplemental material This content has been supplied by the author(s). It
interpret emotions, particularly in younger children. 63–66 has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
There is also evidence that masks hinder social-­e motional been peer-­reviewed. Any opinions or recommendations discussed are solely those
learning and language/literacy development in young chil- of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
dren. 67 Children with special-­e ducation needs and autism
includes any translated material, BMJ does not warrant the accuracy and reliability
may be disproportionately impacted by mask require- of the translations (including but not limited to local regulations, clinical guidelines,
ments as they rely heavily on facial expressions to pick terminology, drug names and drug dosages), and is not responsible for any error
up social cues. 68 Misinterpretation of facial expressions and/or omissions arising from translation and adaptation or otherwise.
increases anxiety and depression in individuals. 69 School Open access This is an open access article distributed in accordance with the
environments with mask mandates were also found to Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
have increased anxiety levels compared to those without permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
mandates. 70 In addition, mask wearing has been associated properly cited, appropriate credit is given, any changes made indicated, and the use
with physiological harm 2 13 13–17—many of which are more is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
frequently reported in children than in adults 2 17 71—which
may have multiple negative downstream effects, including ORCID iDs
Johanna Sandlund http://orcid.org/0009-0000-5534-1839
reduced time and intensity of exercise, additional sick Shamez N Ladhani http://orcid.org/0000-0002-0856-2476
days, reduced learning capacity, and increased anxiety.
Masking has also been found to lead to rapid increase in
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