The role of masks and respirators in preventing respiratory infections in healthcare and community settings
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2023-078573 (Published 27 February 2025) Cite this as: BMJ 2025;388:e078573
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Dear Editor,
The article by Macintyre et al. (BMJ 2025;388:078573) rightly prioritizes respirators for healthcare workers facing serious pathogens. However, its decision-support tree (Figure 4) recommends medical masks for community settings, even during high transmission. This stands in direct contradiction to the article's own finding that "community use of N95 respirators is more protective than surgical masks."
The article correctly notes that medical masks are not designed for airborne protection and may, in the long run, be costlier than reusable respirators. Yet, the decision tree disregards this, potentially justifying policies that provide inadequate protection against airborne pathogens. If the lack of respirators is the reason for recommending less protective medical masks, this should be explicitly stated in the decision tree and communicated clearly to the public.
This discrepancy must be addressed to prevent misleading public health guidance. All individuals, not just healthcare workers, deserve accurate and effective safety recommendations. I urge the authors to revise the decision tree to explicitly prioritize respirators in high-transmission community settings, ensuring it aligns with the article's own caution to only use medical masks as a last resort when respirators are not available.
Sincerely,
Maarten De Cock
Competing interests: No competing interests
Dear Editor
The authors provide an impressively comprehensive review of masks and respirators in preventing respiratory infections¹. I commend them on the depth and clarity of their work. However, there is an issue with their use of the precautionary principle. The precautionary principle isn’t simply about taking any action that might reduce risk; instead, it is a prompt to avoid actions that might introduce new risks of harm.
If we were to apply the precautionary principle, we may hesitate to impose universal mask mandates or require children to wear masks without robust evidence that the benefits outweigh the risks. Instead of focusing solely on masks reducing viral transmission, we should carefully balance that benefit against potential downsides. Masks obscure facial expressions and non‑verbal cues that are essential for effective communication in both social and educational settings. Face coverings can significantly impair emotion recognition, thereby affecting interpersonal interactions².
Furthermore, we should also consider the mental health impact of mask mandates on the population. Constant exposure to messaging that emphasises a deadly disease, may lead people to internalise that threat, potentially increasing anxiety and distorting their perception of risk³. Moreover, mandating masks for children raises questions about their impact on social and cognitive development, risks that we still don't have enough evidence to understand.
We are tasked not only with stopping respiratory transmission but with ensuring overall well‑being. In a healthcare system dedicated to keeping people safe, we must weigh the protective benefits of masks against these broader aspects of health. By focusing narrowly on respiratory virus transmission, we risk neglecting other crucial elements of public health, elements that are vital to fostering a resilient and well‑balanced community.
References
¹ MacIntyre C R et al. The role of masks and respirators in preventing respiratory infections in healthcare and community settings BMJ 2025; 388 :e078573
² Rinck M et al. Face masks impair facial emotion recognition and induce specific emotion confusions. Cogn Res Princ Implic. 2022 Sep 5;7(1):83.
³ Brooks, S. K., Webster, R. K., Smith, L. E., et al. (2020). “The psychological impact of quarantine and how to reduce it: rapid review of the evidence.” The Lancet Psychiatry, 7(9), 875–883.
Competing interests: No competing interests
The widespread use of PAPR devices needs further consideration
Dear Editor,
I note that the authors provide a hierarchy of respirator effectiveness from (least effective) to FFP3/N95 masks.[1] It would have been nice to see them include also powered air purifying respirator (PAPR) devices. PAPR respirators likely provide better protection than N95/FFP3 masks; and they are more comfortable to wear for prolonged periods, and allow better communication. They are even cheaper in the medium to long term.[2]
It is unfortunate that the Department of Health, early in the pandemic, declined to fund a project to develop a cheap PAPR device; but, given the advantages of PAPR devices, this, and training staff in their use, should be a priority.[3]
Peter M B English
1. MacIntyre CR, Chughtai AA, Kunasekaran M, et al. The role of masks and respirators in preventing respiratory infections in healthcare and community settings. BMJ 2025;388:e078573. doi: 10.1136/bmj-2023-078573Available from: https://www.bmj.com/content/388/bmj-2023-078573 or https://www.bmj.com/content/bmj/388/bmj-2023-078573.full.pdf388.
2. English P. Switching from disposable to reusable PPE - Rapid Response. BMJ 2024;384:e075778. doi: 10.1136/bmj-2023-075778Available from: https://www.bmj.com/content/384/bmj-2023-075778/rr384.
3. English PMB. All healthcare workers should get used to wearing powered air-purifying respirators 2023 updated 27 Aug 2023.
Competing interests: No competing interests