Masks Do More Than Protect Others During COVID-19:

Reducing the Inoculum of SARS-CoV-2 to Protect

Although the benefit of population-level public facial On April 3, 2020, the Centers for Disease Control and
masking to protect others during the COVID-19 pandem- Prevention issued recommendations on wearing cloth face
ic has received a great deal of attention, we discuss for one coverings by the public to reduce community spread.1 The
of the first times the hypothesis that universal masking
World Health Organization did not recommend population-
reduces the “inoculum” or dose of the virus for the mask-
wearer, leading to more mild and asymptomatic infection
level face masking in April,2 but changed their guidance on
manifestations. Masks, depending on type, filter out the June 5, 2020,3 when the extent of transmission from pre-
majority of viral particles, but not all. We first discuss the symptomatic or even asymptomatic individuals was clear.4, 5
near-century-old literature around the viral inoculum One recent model showed that population-level masking is
and severity of disease (conceptualized as the LD50 or one of the most efficacious interventions to reduce further
lethal dose of the virus). We include examples of rising spread of SARS-CoV-2, allowing for less-stringent lock-down
rates of asymptomatic infection with population-level requirements in countries adopting this strategy.6 Countries
masking, including in closed settings (e.g., cruise ships)
with and without universal masking. Asymptomatic in-
worldwide have had a range of responses to the recommenda-
fections may be harmful for spread but could actually be tion on universal masking, with many countries (and US
beneficial if they lead to higher rates of exposure. Expos- states)7 issuing mandates and enforcement strategies.8 Coun-
ing society to SARS-CoV-2 without the unacceptable con- tries accustomed to universal population-level masking since
sequences of severe illness with public masking could the SARS epidemic in 2003 adopted the intervention more
lead to greater community-level immunity and slower readily.9
spread as we await a vaccine. This theory of viral inocu- There are two likely reasons for the effectiveness of facial
lum and mild or asymptomatic disease with SARS-CoV-2
masks: The first—to prevent the spread of viral particles from
in light of population-level masking has received little
attention so this is one of the first perspectives to discuss asymptomatic individuals to others—has received a great deal
the evidence supporting this theory. of attention.10, 11 However, the second theory—that reducing
the inoculum of virus to which a mask-wearer is exposed will
J Gen Intern Med 35(10):3063–6 result in milder disease12–27—has received less attention and is
DOI: 10.1007/s11606-020-06067-8
the focus of our perspective which compiles virologic, epide-
© Society of General Internal Medicine 2020
miologic and ecologic evidence.
Masks, depending on the material and design, filter out a
majority of viral particles, but not all.28 The theory that expo-
sure to a lower inoculum or dose of any virus (whether
respiratory, gastrointestinal or sexually transmitted) can make
T hispublicperspective outlines a unique angle on why universal
masking during the COVID-19 pandemic should
subsequent illness far less likely to be severe12–27 has been
propounded for some time. Indeed, the concept of the 50%
be one of the most important pillars of disease control. Our lethal dose (LD50), the virus dose at which 50% of exposed
theory is based on the likelihood of masking reducing the viral hosts die, determined via controlled experiments in which a
inoculum to which the mask-wearer is exposed, leading to range of exposure doses are administered to animals to calcu-
higher rates of mild or asymptomatic infection with COVID- late a dose-mortality curve, was first described in 1938.18
19. No prior perspective has specifically focused on this link Other studies have examined the LD50—or the dose that leads
between population-level facial masking, the viral inoculum, to severe disease or death—for a variety of viruses in hosts or
and increasing rates of asymptomatic infection with SARS- animal models.17, 21, 29–34
CoV-2. These studies have limitations, since experiments to exam-
ine the dose of virus to achieve its LD50 have necessarily not
Received June 22, 2020
Accepted July 15, 2020 been conducted in humans. Studies to experimentally examine
Published online July 31, 2020 the dose of virus associated with different levels of diseases

3063
3064 Gandhi et al.: Masks Reduce Viral Inoculum of SARS-CoV2 JGIM

Figure 1 a Busy Hong Kong Street on May 14, 2020, demonstrating universal public masking;44 only five deaths reported in Hong Kong from
COVID-19. b Georgia Tech football game with fans wearing masks packed in a campus stadium in the midst of the 1918 influenza pandemic.45

severity in humans have been limited to non-lethal viruses. In associated with SARS-CoV-2. For example, one of the earliest
one experiment in preparation for vaccine development, estimates of the rate of asymptomatic infection due to SARS-
healthy human volunteers exposed to different doses of wild- CoV-2 was in the 20% range from a report of a COVID-19
type influenza A virus developed more severe symptoms at outbreak on the Diamond Princess cruise ship.37 In a more
higher inocula of administered virus.34 Giving SARS-CoV-2 recent report from a different cruise ship outbreak, all passen-
in a range of doses to humans experimentally would be un- gers were issued surgical masks and all staff provided N95
ethical, but an animal model has tested this theory of masking masks after the initial case of COVID-19 on the ship was
attenuating disease severity. In a frequently cited study show- detected.38 In this closed setting with masking, where 128 of
ing that hamsters are less likely to contract SARS-CoV-2 217 passengers and staff eventually tested positive for SARS-
infection with a surgical mask partition, those hamsters that CoV-2 via RT-PCR, the majority of infected patients on the
did contract COVID-19 with simulated masking had milder ship (81%) remained asymptomatic,38 compared with 18% in
manifestations of infection.27 the cruise ship outbreak without masking.37
Increasing rates of asymptomatic and mild infection with A report from a pediatric hemodialysis unit in Indiana,
COVID-19 have been seen over time during the pandemic in where all patients and staff were masked, demonstrated that
settings adopting population-level masking. A systematic re- staff rapidly developed antibodies to SARS-CoV-2 after ex-
view of earlier studies, before facial masking was widely posure to a single symptomatic patient with COVID-19. In the
practiced, placed the proportion of asymptomatic infection setting of masking, however, none of the new infections was
with SARS-CoV-2 at 15%.35 A more recent narrative review symptomatic.39 And in a recent outbreak in a seafood process-
of 16 different studies estimated the rate of asymptomatic ing plant in Oregon where all workers were issued masks each
infection at 40–45%.36 The CDC has now (since article sub- day at work, the rate of asymptomatic infection among the 124
mission) also placed the rate of asymptomatic infection at 40% infected was 95%.40, 41 An outbreak in a Tyson chicken plant
- the reference is as follows and could this new reference be in Arkansas with masking also showed a 95% asymptomatic
placed here: “Centers for Disease Control and Prevention rate of infection.42, 43
(CDC). COVID-19 Pandemic Planning Scenarios. July 10, One model showed a correlation between population-level
2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/plan- masking and number of COVID-19 cases in various countries,
ning-scenarios.html.” Closed settings, such as cruise ships, but an even stronger correlation with suppression of COVID-
can be particularly illustrative when examining phenotypes related death rates.9 However, it should be acknowledged that
JGIM Gandhi et al.: Masks Reduce Viral Inoculum of SARS-CoV2 3065

this model could not account for all confounders that led to University of California, San Francisco (UCSF) San Francisco, CA,
USA (e-mail: [email protected]).
such low death rates in the regions examined. This group
showed that, if 80% of the population wears a moderately
Funding Information Funding source for this perspective: NIAID/
effective mask, nearly half of the projected deaths over the NIH 2P30 AI027763 (Gandhi, P.I.)
next two months could be prevented.9 Countries accustomed
to masking since the 2003 SARS-CoV pandemic, including
Japan, Hong Kong (Fig. 1a),44 Taiwan, Thailand, South Ko- Compliance with Ethical Standards:

rea, and Singapore,9 and those who newly embraced masking Conflict of Interest: The authors declare that they do not have a
early on in the COVID-19 pandemic, such as the conflict of interest.
Czech Republic,46 have fared well in terms of rates of severe
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