The efficacy and risk of Masking (Children) in Context of COVID-19

Background

Mandatory universal masking of the nose and mouth for the general public is promoted by the South African Government as one of the most effective and benign ways to stop the spread of SARS-CoV-2.

With respect to children, the edicts stipulate that mouth and nose covering is mandatory for being on any school premises. From the gazetted Government regulations: 

“Should a learner arrive at school or early childhood development centre without a cloth face mask, homemade item, or another appropriate item that covers the nose and mouth - the learner may be provided with an appropriate item that covers the nose and mouth, … or if the school or early childhood development centre cannot provide such learner with an appropriate item that covers the nose and mouth, such learner must be isolated and his or her parent, guardian or caregiver must be contacted to, without delay - bring, for the learner … (an) item that covers the nose and mouth to the school or early childhood development centre; or arrange for safe transport for the learner back home. "[34]

This paper examines the evidence behind the claims that face coverings are effective at saving lives while simultaneously causing negligible harm.

Research on masking

Despite the widespread use of masks and other face coverings, and mandates to this effect, available research is mainly focused on the use by adults in healthcare settings, and on masks specifically designed for this purpose. Research on cloth masks, the impacts of prolonged or continuous masking, and masking of children is very limited.

• The World Health Organization (WHO) has developed guidelines for Governments around masking according to situation and differentiating between workers in a healthcare setting, infected individuals, and universal masking of the general public.
• Universal use of fabric masks and face coverings is not supported by scientific evidence. According to the latest recommendation published by the WHO on 1 December 2020, “At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking of healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2.” [25] As such, the WHO urges countries who adopt this approach to follow a risk-based regime taking note of potential benefits and harms for the purpose of acquiring data on the efficacy of this approach [1]. Despite these guidelines, the WHO can in no way compel any country to actually follow their recommendations or interfere with mandatory universal masking regulations.
• Due to the limited availability of data on the effects of universal masking, mandatory universal masking of the South African population, particularly South African children, is highly experimental.

The main premise for masks: Stopping the spread

The assumption on which masking is based relies on stopping the spread of a virus by either protecting the mask wearer from infection, or acting as source control when worn by an infected individual.

Protecting the mask wearer

• N95 respirators and medical masks have been shown to protect healthcare workers in a medical setting. No protective effect was found for cotton, paper or disposable masks [2].
• The WHO guidance in June 2020 stated that “A non-medical mask is neither a medical device nor personal protective equipment.”[1]
• In a study comparing cloth masks to medical masks in healthcare workers, workers wearing cloth masks experienced more respiratory infections than the medical mask or control groups. This is attributed to moisture and pathogen retention associated with cloth masks [3].
• A randomised controlled study using surgical masks in community, compared to no masking, showed a slightly lower incidence of Covid-19 for the mask wearers, although the difference was not statistically significant [4].
• Filtering^[a] facepiece respirators have shown to be protective for health-care workers when properly fit-tested. [46]
• There is therefore no evidence that cloth or other face coverings protect the general public from infection.

Infection source control

Where face coverings are mandated for source control, a distinction needs to be made between masking infected individuals and masking the general public, which includes healthy people.

• The WHO guidelines advise masking infected individuals with medical masks in transmission scenarios where these individuals are able to tolerate masking [1].
• A study evaluating the efficacy of masks for source control compared respiratory droplets and aerosols collected from infected individuals wearing surgical masks to those wearing no masks. The masks reduced viral emissions in droplets, but not aerosols. Droplets are defined as respiratory fluid emissions (for example, from coughs and sneezes) with diameters of more than 5 micrometers (0.005 millimetres). Aerosols are emissions with diameters below 5 micrometers. A SARS-CoV-2 virion is 50–200 nanometres in diameter (0.00005 to 0.0002 millimetres) [36]. The spread of SARS-CoV-2 aerosol particles is therefore not reduced by masks due to the size of the virions (very small complete virus particles).

Less than half of infected individuals without masks shed detectable virus in droplets or aerosols, and, where found, the viral load was very low. Researchers concluded from this data that prolonged close contact with an infected individual is required for transmission to occur, or, otherwise, forced coughing would be required to increase viral load.[5]

• Surgical masks are not effective as source control for aerosols. Furthermore, detectable viral shedding from infected individuals requires prolonged contact for transmission, and would suggest that avoiding crowds is a more effective means of infection control [5]. The general WHO recommendation is that masks should be worn where distance is not possible. [1]
• The idea of universal masking of healthy people to stop pandemics comes from mathematical simulation exercises. These simulation exercises assume the validity of the theory of asymptomatic transmission and mask efficacy for the purpose of trying to ascertain how much public participation is required to make a difference under such assumptions.[11, 12]
• In adults and pediatric studies evaluating symptoms for positive Covid-19 tests, asymptomatic incidence has been found (people testing positive for Covid-19 without any symptoms) and ranged anywhere from 15.8% to 78%. [9]
• The efficacy of face covering as source control for pre-symptomatic transmission is based on the case study of a man who wore a mask on an airplane, who subsequently tested positive for Covid-19, while 25 people who were closest to him on the plane tested negative [6].
• The incidence of asymptomatic spread for any disease is extremely rare. With respect to Covid-19, the initial evidence was based on a case study where two business men met and both tested positive for Covid-19 later. [8, 10]
• Surgical masks offer no protection from inhaled agents, but can reduce the spread of droplets from infected persons. However, the reduction in small aerosols is not significant.[46]
• Small droplet aerosols in poorly ventilated spaces and SARS-CoV-2 transmission Studied drop dispersalAlthough we only studied healthy volunteers and did not study patients with COVID-19 or virus-laden aerosol droplets directly, our data on droplet size distribution and persistence does have implications on requirements to use face masks to prevent virus transmission. Transmission by aerosols of the small droplets studied here can only be prevented by use of high-performance face masks; a conventional surgical mask only stops 30% of the small aerosol droplets studied here for inhaled breath;9 for exhaled breath the efficacy is much better.[47]
• Not sure whether covid is airborne (thus in aerosols), but should where masks [48]
• Saying that transmission through aerosols and asymptomatic people, aerosols for other respiratory viruses and masks stop droplets but not aerosols and therefore people should wear masks. Can’t even make sense of this. [49]
• Mandatory school masking falls in the category of masking healthy children. Children are screened daily for possible symptoms, which can disallow them from entering the school grounds. Children are thus masked on the premise of pre-symptomatic or asymptomatic transmission. Asymptomatic spread is the idea that upon becoming infected with a viral pathogen an individual does not show evidence of the symptoms typically associated with viral pathogen. Most importantly, the person in this state where no symptoms are present is just as likely to pass on the viral pathogen to another person as is someone displaying symptoms. While it is common for people to have mild cases of one or another coronavirus;  a mild case in itself, is evidence that one’s system is prepared for the virus and that viral transmission is unlikely. With respect to the argument from above mentioned case study that asymptomatic spread is an important feature in the transmission of SARS-Cov-2, we now have confirmation, in the form of several studies, that asymptomatic positive cases are not contributing to the transmission of SARS-Cov-2. [39, 40]

Miscellaneous premises for universal masking

Reasons given to adopt universal masking that do not directly relate to protection, or stopping virus spread and saving lives, are as follows:

• WHO guidance cites the advantage of mask use by healthy people as “reduced potential exposure risk from infected persons before they develop symptoms”[1]. The word ‘potential’ here is key, as pre-symptomatic or asymptomatic incidence and transmission is highly questionable. [39,40]
• Wearing masks could act as a reminder for people to not touch their faces and to wash their hands regularly, but the discomfort of mask wearing could also have the complete opposite effect and lead to more face touching.[1]
• Mask manufacturing, even on a micro level, may have potential socio-economic benefits in countries where many live below the poverty line and masks are mandatory.[1]
• Seeing masked faces everywhere acts as a constant reminder of the pandemic and enhances peoples’ risk awareness, but also increases perpetual fear. The WHO states that wearing a mask signals solidarity among people, without clearly defining the agreement or cause for support around which they see this solidarity revolving. There is no agreement that universal masking does more good than harm and support for a purpose (like defeating the pandemic) can be shown without risking peoples’ health. An example would be things like the CANSA ribbons or casual day stickers.
• Other research is of the opinion that if masks were only required “for use in symptomatic patients, they become a symbol of illness and could lead to public stigmatization’ [6]. Thus it is argued, all persons should be masked to avoid this discrimination. The opposite is also possible, that if a healthy person experiences detrimental health effects from masking and does not want to cover his or her face, the unmasked individual could be stigmatized.
• More recent WHO guidelines also list avoiding the stigmatization of sick people as a possible benefit of universal masking. The new document omits the potential economic benefit previously listed and adds TB prevention as a possible gain from universal masking. They also state that by mandating face coverings people could be made to feel as if they are contributing to stopping the virus. [25] The available research on cloth masks does not support the premise that these types of face coverings stop the virus and the contributory feelings are not underwritten by any scientific evidence.

An historical interlude on stopping the spread

During the 1918 Flu pandemic, mandatory masking was introduced when decision makers realised it was not possible to keep people apart. This was a particularly novel public health practice. Gauze masks had been used in operating theatres during World War 1 and in TB wards; and policy makers introduced mask laws in order to lift bans on public gatherings and end isolation orders. These medical gauze masks received more publicity, but public health authorities also supported cloth handkerchiefs as a common alternative. Fashionable ladies used chiffon to sew masks. [23]

Following the pandemic, several studies on the efficacy of public masking saw the light. Conclusions stated that masks “did not decrease cases and deaths, as confirmed by comparisons of cities with widely divergent policies on masking”, and “the efficacy of face masks is still open to question”. [26]. The Arizona Historical Society said that, “in Tucson, as in San Francisco, the wearing of masks had little effect on the outcome. In fact, the case and death rates of cities which had masking orders proved to be no better, and often worse, than elsewhere.” [38]

A Risk Based Approach to Masking

Despite the aforementioned WHO guidance that warns about the lack of data on the efficacy of universal masking of healthy people, and their suggestion to implement a risk based approach, the general statement from the South African government and the media has been that mandatory universal masking presents no health risks. A variant of this message has been that the risks are not significant and are outweighed by the benefit of masking, which actually amounts to potentially stopping pre-symptomatic transmission. The fact that the ability of non-medical face coverings to stop the spread of the virus is contentious, should also weigh into the risk based approach. Frequently this is not the case as the benefit of masks stopping the spread are simply more strongly asserted.

In order to follow a risk based approach, as suggested by the WHO, it has to be established what, if any, the risks are of face coverings and what amount of risk exists from wearing a mask or face covering. Should risk be established this needs to be compared to the validity of the premises for universal masking. From this we can conclude whether masking all children can be justified or not.

SARS-CoV-2 Risk

• The Covid-19 risk for children and adolescents younger than 19 years old is almost zero.[7, 42]

• 62% of children between 6 and 16 were found to have immunity to Covid-19 despite never being infected [13]. Most children will never contract or spread SARS-CoV-2.
• The argument is made that despite the low infection risk to themselves, children should be masked in order to protect the elderly. This argument is not supported by evidence. Masks inhibit the spread of droplets but not aerosols, from infected persons. Therefore a masked, sick child does not protect an older person [5]. Given that medical masks can protect people from infection [2], the sensible argument is that older people should wear medical masks around infected persons to protect themselves, or otherwise avoid sick people, including children. Asymptomatic people do not infect others, so there is no reason to burden perfectly healthy children with the theory that they need to protect the elderly. [39,40] 

Masking Risk and common side effects

This section lists results from adult masking studies. Research specific to children is discussed in a subsequent section.

• The WHO lists the risks of universal masking as headaches and/or breathing difficulties; skin lesions, dermatitis and acne; communication problems; discomfort; medical waste issues and  special groups like children, people with asthma, developmentally or mentally challenged persons and people living in hot or humid climates experiencing difficulty when trying to comply with masking requirements.[25]
• The WHO guidance frequently references breathability as a problem: “The lower filtration and breathability standardized requirements, and overall expected performance, indicate that the use of non-medical masks, made of woven fabrics such as cloth, and/or non-woven fabrics, should only be considered for source control (used by infected persons) in community settings and not for prevention. They can be used ad-hoc for specific activities (e.g., while on public transport when physical distancing cannot be maintained).”[1] This clearly states cloth masks for infected persons or ad-hoc. There is no guidance that recommends continuous and universal masking of children such as is mandated in South-African schools.
• A study using 10 healthy adults wearing masks, who alternated activity between rest and walking in 10 minute intervals, found that temperature, humidity and skin temperature inside the facemask increased as soon as subjects started walking. This led to changing perceptions of humidity, heat and high breathing resistance in the mask. High breathing resistance made it difficult for the subject to breathe and take in sufficient oxygen. A shortage of oxygen “stimulates the sympathetic nervous system and increases heart rate...subjects felt unfit, fatigued and overall discomfort due to this reason.”[18] This indicates that the breathability of a mask is not constant.  An oft-quoted argument in favour of continuous masking is that healthcare workers wear masks for hours on end without significant consequences. However, healthcare workers wear masks in climate controlled hospital environments. Children are expected to wear masks under all climatic conditions. Heat and humidity are significant aspects of the South-African climate and this has not been taken into account.
• A large meta-analysis of studies on the negative effects of masks found effects like warmth, pain and shortness of breath (increased respiratory resistance of over 100% within 30 seconds of breathing), headaches (increasing with duration of use), difficulty breathing, and discomfort due to pressure on the nose, skin reactions and skin rashes. The study also lists psychological effects like perceptions of fear and loneliness and communication difficulties.[19]
• Health care workers wearing cloth masks had higher infection rates compared to workers wearing medical masks or the control group. This was attributed to the moisture and pathogen retention of cloth masks.[3]
• Cloth masks have “lower filtration and breathability” characteristics than medical masks [1], whereas masks like N95 respirators “are designed to minimize breathing resistance as much as possible”. Breathing resistance reduces the frequency in breathing (hypoventilation) of healthcare workers wearing medical masks with continuous use. Hypoventilation does not pose a significant risk over less than one hour of continuous use, but when working continuously; defined as “past the 1-hour mark”, increased blood CO2 levels have physiological effects on the wearer. These effects include “Headache; Increased pressure inside the skull; Nervous system changes (e.g., increased pain threshold, reduction in cognition – altered judgement, decreased situational awareness, difficulty coordinating sensory or cognitive, abilities and motor activity, decreased visual acuity, widespread activation of the sympathetic nervous system that can oppose the direct effects of CO2 on the heart and blood vessels); Increased breathing frequency; Increased “work of breathing”, which is result of breathing through a filter medium; Cardiovascular effects (e.g., diminished cardiac contractility, vasodilation of peripheral blood vessels); Reduced tolerance to lighter workloads.” [37] Prolonged use of medical masks designed to reduce breathing resistance is defined as longer than one hoer. Cloth masks are known to have higher breathing resistance and are only recommended for ad hoc use [1]. Children are expected to wear cloth masks for hours on end. This is highly irregular and experimental.
• Again, looking back at the 1918 flu pandemic, researchers looked at lung tissue sections from victims of the past pandemic obtained during 58 autopsies, and reviewed pathologic and bacteriologic data describing 8398 individual autopsy investigations. The results clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory flora as cause of death and not flu, and researchers concluded that deaths could have been far less had antibiotics been available. [21, 33] They posit the theory that the flu might have opened a pathway, making it easier for the upper respiratory tract bacteria to find their way to the lungs. This pathway is created where the virus induces tissue damage to bronchial epithelial cells “sufficiently to break down the mucociliary barrier to bacterial spread, and if able to gain access to the distal respiratory tree–perhaps on the basis of receptor affinity –creates both a direct pathway for secondary bacterial spread and an environment ... favorable to bacterial growth.”[33] Although association does not prove causation, it is interesting that masks were frequently mandated during the 1918 pandemic and people switch to mouth breathing due to the breathing resistance of masks. This might also open a pathway to the lungs. 
• In support of mask induced pneumonia, a case study describes a case of pneumonia due to the use of a CPAP mask that had not been cleaned regularly [13]. Also in support of mask induced bacterial pneumonia, media reports are surfacing of doctors warning that bacterial pneumonia is on the rise due to masking. “I’m seeing patients that have facial rashes, fungal infections, bacterial infections. Reports coming from my colleagues, all over the world, are suggesting that the bacterial pneumonias are on the rise. Why might that be? Because untrained members of the public are wearing medical masks, repeatedly… in a non-sterile fashion… They’re becoming contaminated.” [22, 41].
• Used masks are medical waste and the WHO describes very specific protocols with which to dispose or store then until such time as they could be sterilised and cleaned in order to avoid contamination and increased risk of spread of pathogens. [25] In the context of mandatory masking, children are allowed to remove their masks when eating and the Department of Basic Education’s Standard Operating Procedures also allows for mask breaks in order to breathe every two hours. [32] This random practice of masking and removing and placing masks on the face again is in direct violation of any safe handling of medical waste. This could presumably lead to  increased infectious outbreaks, not only of the SARS-CoV-2 virus, but of other viral pathogens too.

Paediatric Masking Studies

There is not much research available around the use of face coverings in children.

•  A 2011 overview of available literature on the use of face masks by children for purposes of protection from respiratory infectious agents, found relatively few articles dealing specifically with the topic. “Little is known about the physiological and psychological burdens imposed by these devices and a child's ability to correctly use and tolerate them.” This article concludes that it hopes to inspire much-needed research. [16]
• A study evaluating mask safety for children was done in 2019. The study evaluated children between the ages of 7 and 14 years doing activities like reading or walking, as would happen in a school, whilst wearing N95 respirators. End-tidal carbon dioxide (ETCO2) was measured as the primary outcome, but the study also lists other physiological outcomes like respiratory rate (RR), heart rate (HR), oxygenation and fractional inspired carbon dioxide (FICO2) after 5 minutes of masking.  The study concluded that although 7% of children complained about breathing difficulties, and both ETCO2 and FICO2 values increased over baseline, that the end ETCO2 values were within the acceptable range after 5 minutes of mask wearing.  Although FICO2 was not a primary outcome of the study, the values over rest increased from 8.2 to 10.7 mmHg at rest and higher values of 9.9 to 12.1 mmHg during the activity of walking after 5 minutes of mask wearing. [27]

• FICO2 is the measure of carbon dioxide rebreathing, and is known, among other side-effects, to induce headaches. The relationship found between carbon dioxide rebreathing and headaches is that for every 1 mmHg increase in CO2 the odds of people reporting a headache doubled. [28]. In the paediatric study cited under [27] the mmHg increased by more than 2 points for both levels of exertion after 5 minutes. Headaches are known to be a common side effect of mouth and nose coverings.
• Increased carbon dioxide rebreathing as measured by FICO2 levels, when carbon dioxide is retained in the air surrounding the nose and mouth, is clinically known as hypercapnia. This has been studied in ophthalmic procedures performed under local anaesthesia and spontaneously breathing patients. During such procedures patients’ heads are covered with surgical drapes and the result is an increase in carbon dioxide in the ambient air surrounding the patient’s head. Fresh oxygen is supplied to patients under the drapes to prevent hypoxia (too little oxygen), but this does not prevent hypercapnia. Hypercapnia during ophthalmic surgery leads to adverse outcomes due to pressure in the eyes from increased blood flow to the organs and brain as the body compensates for the higher carbon dioxide pressure.  [29,30]
• The ophthalmic study referenced under [30] defines hypercapnia as carbon dioxide pressure continuously increasing as soon as drapes are placed over the patients face to average values of around 10 mmHg (whilst fresh oxygen is supplied under the drapes) for a duration of 25 minutes. In the discussion it is mentioned that previous studies of this type had measured ETCO2 and oxygenation as primary outcomes, but that these values do “not give a clear picture of carbon dioxide accumulation or carbon dioxide rebreathing.”
• The carbon dioxide pressure indicative of hypercapnia measured in the ophthalmic study above, is lower than the value that was measured for the paediatric study after 5 only minutes of mask wearing. This is to be expected as no fresh oxygen is supplied under children’s masks. Also, the study used N95 respirators which, as cited before, are designed to minimize breathing resistance [37]. Cloth mask breathability standards are lower [1] and therefore children masked in the school context would probably experience worse outcomes than those measured in this study.
• Apart from increased blood flow and intracranial pressure, the physiologic consequences of hypercapnia are increased respiratory rate, hypertension, blood acidification and confusion. [29]
• This paediatric study included only healthy children with no pre-existing medical conditions such as cardiorespiratory conditions, asthma, recent infections or psychological disorders including anxiety. The carbon dioxide rebreathing measured is therefore applicable to healthy children.[27] In a study of masked children and the side-effects experienced, it is important to note that only just under 80% of children fit the profile and requirements of being completely healthy.[31] If completely healthy children are experiencing masking side-effects like breathing difficulties and increased FICO2, it is possible that children with pre-existing conditions experience even more adverse effects; and sooner than within the 5 minute time-frame.
• Most studies on the effects of masking are of short duration, or in the context of healthcare workers who remove masks as soon as the reason for wearing them (e.g. surgery) is over. With widespread mask mandates, a study investigated the effects of more continuous nose and mouth covering in children and adolescents. The study includes more than 25,000 children who wore masks for an average of 270 minutes per day (four and a half hours which still falls short of the average school day of 7 hours). The majority of masks worn were fabric (65.2%) and surgical (21.4%) and 11.3% were not specified.[31]
• Less than half of participants were required to wear masks in class as is required in South-Africa, most (81.1%) only had to wear masks outside or in corridors. 67.7% of children suffered impairments of which some of the physical symptoms (and prevalence) were headache (53.3%), concentration difficulties (49.5%), syncope/loss of consciousness (20.7%), nausea (16.6%), unwillingness to move or play (17.9%) and many others, including references to tachycardia, fainting spells, vomiting and flickering eyes.[31]
• Psychological impacts (and prevalence) in the above mentioned study included irritation (60.4%), changes to sleep routines (56.1%), being less cheerful (49.3%), no longer wanting to attend school or kindergarten (44%), developing new fears (25.3%) and others such as playing less and restlessness. The changing sleep routines included children sleeping worse than usual,  and nearly 40% of children in the older age group of 13 to 18 years sleeping more than usual.[31]
• These reported side effects are in line with established scientific risks of face coverings.

The Mechanisms behind Universal Masking

Masking compliance is problematic from the perspective of convincing healthy people to adopt universal masking. Given masking risk, discomfort and dubious benefits, this is not surprising. For this reason various approaches have been attempted to foster adoption of the practice on the premise that masks circumvent droplet transmission and must therefore be effective for disease control [14].

• Researchers from psychological research arenas have suggested psychological methods of coercion in order to convince people to wear masks. From this research, the Health Behavioural Model (HBM) is a proposed strategy for policy makers to assist them in increasing mask compliance. Studies found that “among the three methods used to handle an influenza pandemic – vaccination, isolation and mask-wearing – willingness to comply with mask-wearing was the lowest”. This leads to the idea that the basis for mask wearing needs to be uncovered in order to overcome the barriers to compliance. Researchers propose that healthcare policy-makers intervene using factors derived from the “multipronged HBM, which focuses on increasing the public’s perceived susceptibility, perceived severity and perceived benefits; decreasing perceived barriers; and increasing the cues to appropriate actions. From our literature review, perceived susceptibility appears to be the most significant factor influencing compliance with mask-wearing. To increase the public’s perceived susceptibility, there should be increased education on respiratory infections …. There should also be timely updates about outbreaks. By making information about new outbreaks more easily available to the public, and at an earlier time, awareness and understanding of the emergent epidemic would improve. This would, in turn, increase the public’s perceived susceptibility and severity, hence potentially improving compliance.” This strategy has been in action since the start of the new outbreak, with psychological cues such as referring to an individual’s  “Mask of honour” and the use of statements such as “True heroes wear masks”. Proclamations such as these are particularly appealing to children and the model is aware of this.  In the HBM children in school are perceived as a target group: “Schools have a role to play too. They can help inculcate mask-wearing habits in the young,…. By instilling these habits from a young age, we may be able to cultivate a generation of individuals who grow up perceiving mask-wearing as a normalised, socially acceptable practice, rather than an odd or embarrassing one.”[20]
• The incessant focus on SARS-CoV-2 case numbers and death tallies has also contributed to the psychological pressure, despite being dwarfed by the epidemics of hunger, TB and crime. The continuous assertion is that masking is the best way to “stop the spread” of the virus.
• From a policy perspective, in order to force compliance, non-compliance has been criminalized together with the threat of prosecution and/or fines for not masking up. Despite losing out on their education, children can be sent home for not having an item covering their mouths and noses. This puts pressure on parents to mask their children even if they might have reservations about the practice, as childcare and the need to earn a salary becomes problematic.

Summary

• South African government masking regulations up until recently made no allowance for mask exceptions or admit to any risks connected with mask wearing. Amendments to the Disaster Management Act made on the 11th January 2021 allows under the adjusted regulations, that children under the age of 6 are no longer required to wear a face mask. This is aligned with UNICEF and the WHO recommendations. According to the guidelines set out by those global organisations, children under the age of 6 should not be required to wear face masks. The WHO states that, “This advice is based on the safety and overall interest of the child.”
• Regardless of the amendments and in contravention of WHO and UNICEF guidance, the implemented regime during the lockdown regulations of 2020, failed to take into account the lack of research in support of masking healthy people, and completely overlooked the heightened risk that incurs to those who wear masks for extended periods of time.
• While the SA government has finally heeded WHO recommendations for children under the age of six, the WHO has recommendations that address all age groups 18 years and younger. The WHO and UNICEF advises that for children between the ages of six and eleven years of age, a risk-based approach should be applied to masking. “If authorities decide to recommend mask-wearing ..., key information should be collected on a regular basis to accompany and monitor the intervention. Monitoring and evaluation should be established at the onset and should include indicators that measure the impact on the child’s health, including mental health.” [14] This health monitoring of physiological and psychological impacts of nose and mouth coverings has not been implemented by the South African Department of Education and children are only screened for Covid-19 symptoms upon entering school premises.
• For children aged 12 and over the WHO and UNICEF advises mask wearing under the same conditions as adults, in particular when they cannot guarantee at least a 1-metre distance from others and there is widespread transmission in the area.[14] Nowhere in any WHO guidance is the continuous masking of children with cloth face coverings ever recommended.
• The general WHO and UNICEF guidance on use of cloth masks in children 18 years and younger is that any such policies should be driven by three principles. The principles are that no harm should be done and the best interest, health and well-being of all children should be prioritised. The second principle is that learning outcomes and development of children should not be negatively impacted and lastly that masking policies should consider feasibility within different environmental and societal contexts.[33]
• School masking regulations prescribe that children that do not have nose and mouth covering be provided with such covering or be sent home. [34] The effect of this is that children who do not cover their nose and mouth can be denied the right to education. The right to an education is a fundamental right, protected by the South African constitution.
• The Department of Basic Education published a Standard Operating Procedure (SOP) for the containment and management of Covid-19 for schools and school communities in September 2020. Some mask reservations are present in the SOP document. For instance paragraph 13.13 states that, “there are risks associated with wearing masks that educators must be aware of, to ensure that learners are safe”, but the risks are listed as drooling on; sharing of or strangulation from masks [31].  These are not representative of the known side-effects of masking and will not enable educators to correctly address side-effects by removing a child’s mask when other symptoms appear.
• Paragraphs 13.14  and 13.15 of the SOP states that “it is strongly recommended that mask-wearing is addressed on a case-by-case basis” as “wearing a mask may be more of a risk than a benefit for certain learners. Schools should be advised that the screening, identification, assessment and support (SIAS) process must be followed….^[b][c][d][e]Educators may need to consult with parents, guardians or caregivers, and use their own knowledge and discretion to ascertain the best practices for mask-wearing, or any other type of face protection, in the classroom or school environment. It is critical to ensure that the learners and their needs are respected, with respect for their human rights.”[31] Despite admitting to the harm of masking, these procedures are not implemented by schools.
• The SIAS process mentioned is a 2014 Department of Basic Education document talks about identifying barriers to learning like communication, learning and cognition, health (including mental health); and behaviour and social skills that might originate from physical handicaps or societal problems, but not once mentions mouth and nose coverings.  The closest mention made of masks is that the aim of the document is in line with Education White Paper 6 to “Ensure a barrier-free physical environment”, which is clearly violated by masking children.[43]
• Masks do not protect wearers. Masks do not inhibit the spread of aerosols, only droplets, from infected persons. Pre-symptomatic people and children do not cough or sneeze and therefore do not spread infected droplets. Asymptomatic and healthy people do not transmit viruses. Despite this, all children, including healthy ones, are masked and experiencing serious physiological and psychological harm, the long-term effects of which are unknown.
• Masking comes with definite risks that far outweigh any benefit that might come from inhibiting the mostly non-existent spread of droplets from possibly pre-symptomatic people. More than 60% of children have pre-existing immunity to SARS-CoV-2, and yet recent research mentioned above shows that more than two in three children are potentially being harmed by universal masking of healthy individuals, and that these harms are of a serious nature. That asymptomatic spread has been found to not be a feature in the transmission of SARS-Cov-2 is unquestionably very important news, because the unsupported claim that asymptomatic spread is a driver of viral transmission underpins mask orders everywhere. Without the specter of asymptomatic spread there is simply no justification for orders that direct healthy individuals to wear masks for any amount of time at work, school, or anywhere else, and harm clearly outweighs benefit where no benefit exists.
• As individuals, we are part of a greater system and we depend on the health of the whole system for our own existence. If we try to get some benefit in a way that harms others, whatever benefit we get will be outweighed by the harm that comes to us as participants in that system. From this it follows that, since masks cannot inhibit the spread of aerosols from infected persons, there is no benefit to universal masking and known risks of masking completely outweigh any imagined or hoped-for benefit. This is even more noteworthy given that the risks of longer and universal face covering, especially in children, are unknown. A whole generation cannot be sacrificed on the unsubstantiated belief that masking a healthy individual might prevent a SARS-CoV-2 case.

References

1. Advice on the use of masks in the context of COVID-19, World Health Organization, Interim Guidance, 5 June 2020 https://apps.who.int/iris/handle/10665/332293
2. Vittoria Offeddu, Chee Fu Yung, Mabel Sheau Fong Low, and Clarence C Tam, Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis, Clinical Infectious Diseases 2017;65:1934-1942 https://pubmed.ncbi.nlm.nih.gov/29140516
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