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Which Mask Should I Wear? An Exclusive Q&A with Genius Grant Professor

Janine Jagger, Ph.D, discusses mask use and research during the pandemic. One tip? Avoid cotton.



Face masks sporting different brands for sale in one of the open air markets in Iztapalapa, Mexico. (Meghan Dhaliwal/Direct Relief)

Janine Jagger, Ph.D., a professor emeritus of internal medicine and infectious diseases, as well as former director of the International Health Care Worker Safety Center at the University of Virginia School of Medicine, dedicated her career to helping improve the safety of nurses and health care providers through injury prevention, especially related to needles.

Her work in this field led President Bill Clinton to sign the Needle Stick Safety and Prevention Act of 2000. Today, the 2002 MacArthur Foundation grant recipient is focused on her NGO, Familial Mediterranean Fever Foundation, in addition to her advisory work for the Africa Action Network for Nurses & Nurse-Midwives, which has helped facilitate local PPE production in several African countries with the support of Direct Relief, BD, World Continuing Education Alliance, crowdfunding, and nursing organizations in the U.S., Denmark, Sweden, and Germany.

Eschewing Global Supply Chain, African Health Care Workers Making 1 Million Reusable Masks

In total, AAN and their partners have facilitated the local production of over 200,000 reusable masks in Uganda, Rwanda, and Malawi.

“In an African setting, medical masks can be produced locally by choosing the right materials,” she said. You do have to add a layer of testing, and we are working to get materials tested using evidence-based tests that were in effect before Covid,” she said.

During a conversation with Direct Relief, Jagger was adamant about correcting misinformation that has taken hold during this pandemic, including about effective materials for medical masks. Cotton and other natural fibers, she said, are inappropriate and only synthetics should be used.

Jagger was a member of the committee that produced a 2007 Institute of Medicine of the National Academies report entitled “Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers.”

This interview has been edited for length and clarity. 

DIRECT RELIEF: We’ve heard that some masks protect the wearer and that some masks protect others. Is this accurate?

JANINE JAGGER, Ph.D.: The more people who are wearing masks, the more protective they become to everybody. It’s not really a “you versus me” thing. It’s about the percentage of people who are infected who are wearing masks.

There are two kinds of respiratory protection: medical masks, which are also called surgical masks or 3-ply masks, and respirators, like N95s. There is a fundamental difference between those two. Respirators, which are now referred to as “masks,” but the respirator controls the quality of the air that’s breathed in. The air that you breathe in a respirator goes through a filter.

The medical mask blocks droplet spray. It does not filter the air. It has a two-way fluid barrier; the inner and outer layer meet the same fluid properties. Pre-Covid, medical masks had to meet high standards for blocking droplet spray. This is very important because pathogens are carried in fluids. Even as it was a widespread consumer item, the purpose was to protect patients from droplets from a surgeon.

They (medical masks) were very cheap to produce, they cost probably about 10 cents and hospitals were buying them for even less. In a sense, we became accustomed to a product that was a piece of significant technology without realizing what properties were inherent to it. It just became as a consumer product of little technical significance.

Janine Jagger, Ph.D., a retired University of Virginia Medical School professor and expert on PPE and safety in health care settings. (Photo Courtesy of Janine Jagger)
Janine Jagger, Ph.D., a retired University of Virginia Medical School professor and expert on PPE as well as safety in health care settings. (Photo Courtesy of Janine Jagger)

DR: How has the pandemic changed mask regulations and the public’s understanding of masks?

JJ: Covid has actually created extreme confusion over the efficacy of masks. The formal side of it is that the government, the FDA and CDC, jointly overturned all of the standards underlying respiratory protection. That created a situation where anybody could say anything about masks because there were no standards.

As soon as Covid created this demand that could not be met for PPE, the standards for PPE, for design, testing, etcetera, were just rescinded basically. And these major organizations, like the CDC and then the WHO, started creating instructions for what they called “face masks” or “face coverings” or “cloth masks” — terms other than medical masks. Every recommendation in the Institute of Medicine report I worked on in 2007 was ignored.

They knew that they were recommending something that didn’t meet the standard of medical masks and that’s where the craziness came in. They were giving instructions that did not comply with the standards of the medical mask. It’s not hard to meet those standards, you just have to pick the right materials.

They started recommending cotton, which is crazy because cotton is the worst material for PPE of any kind. There is no cotton PPE. Any natural fiber is inappropriate – linen, cotton, silk — they are all absorbent fibers. In a 2015 study by Raina MacIntyre, a group of nurses in respiratory care units were split in half. One half were given cotton masks and the other half were given regular medical masks. After a few months, the nurses using cotton masks had a 13 times higher incidence of  contracting respiratory illnesses.

Click to access e006577.full.pdf

DR: What do you make of the research that has been done on PPE and masks since the pandemic began?

JJ: The research being done on mask development since Covid shows a lack of understanding with how respiratory protection works. They don’t really understand what questions we need answered. They’re looking under special lighting conditions about how much and where droplets are going, basically, airflow.

Where droplet spray goes isn’t addressing the essential question – what makes the difference to the wearer is what’s going to reduce the amount of pathogen that’s breathed into their lungs over a period of time, like a shift of a healthcare worker.

They don’t test the material of mask and that’s what would make the difference in terms of infection rates. [Infection] doesn’t occur all at once — it’s breathing through that mask for hours and it not being resistant to fluid. If you’re wearing cotton, you’re breathing in absorbed fluid through the mask.

DR: What is the best mask to use?

JJ: People are grasping at straws as to what is are the best medical masks, what are the properties, and they don’t understand the science that exists.

A medical mask in itself will provide a lower level of respiratory protection because you’re breathing the ambient air, which is intended. You could breathe in air that has viral particles in it, they are not filtered out. When you have aerosolized virus floating in the air, it doesn’t start out like that, it starts as droplets, then evaporated. Medical masks catch a large percentage of them in the droplet phase. You’re going to have a lot less of it in the air.

Medical masks become significantly more effective as you mask patients. It’s the same principle in public, everyone should be wearing masks. It is blocking significant amount of virus at its source, which the patients’ respiratory tract. And wearing a mask reduces droplet spray in the environment.

Respiratory PPE is a layering process. Nothing is perfect but it (medical mask) reduces droplet spray.

An N95 offers more protection overall because the user breathes in filtered air. Ambient air should not be leaking in. But an N95 is imperfect as well. It’s just very common that it doesn’t have a perfect seal, so there’ll be some leakage in from the sides.

DR: Which mask do you wear?

JJ: I wear a medical mask, a standard one, blue one. If people have N95s, I’d say wear it during air travel.

In addition to supporting AAN, Direct Relief has contributed more than 57 million pieces of PPE to health care providers in 12 African countries through the Covid Action Fund for Africa and has also supported the South Africa Solidarity Fund

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