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Consensus Guidance on Face Coverings

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While America’s health care workforce has played a critical role since COVID-19 infected its first patient in the United States, physicians and scientists alone can’t save American lives from being lost to COVID-19. We need a national, comprehensive, coordinated response to the pandemic, which the AAMC has previously described.

download pdf of the guidance

Wearing a mask is one step everyone can take to protect themselves, their family, and their community. Clinicians and others working with patients wear masks and require all visitors to clinical sites to do the same regardless of their suspected COVID-19 status. A mask is not always comfortable and has not been a part of everyday life in the United States, but for the foreseeable future, the benefits outweigh the discomfort. In the absence of national policy, we are asking that state and local governments, and all Americans, join us in this effort.

Face coverings are critical for slowing the spread of the coronavirus. The medical community’s understanding of this novel virus has grown and evolved since March, when efforts to slow the spread were first introduced. While we still have more to learn, our understanding of effective practices for prevention continues to grow. A study by the Centers for Disease Control and Prevention (CDC) followed up with 139 clients of coronavirus-positive hair stylists and found no symptomatic secondary cases; both parties had worn masks during the appointment.1 A study in Health Affairs examined the natural experiment of states’ mask mandates on community spread of COVID-19. The study estimates that, by late May, between 230,000 and 450,000 potential COVID-19 cases were averted by the imposition of state mask mandates.2

Reinforcing the importance of prevention measures beyond monitoring symptoms, including wearing face coverings, is essential. Evidence shows that people unknowingly spread the coronavirus because they are asymptomatic, are not yet manifesting their symptoms, or have mild symptoms. One such study by the CDC found that of the 1,000 infected service members on the Navy ship U.S.S. Theodore Roosevelt, one in five had no symptoms and many had only mild symptoms.3 Wearing a face covering is one step most people can take to protect themselves, their loved ones, and the most vulnerable in our communities.

While research into the exact preventive efficacy of face coverings in combatting transmission of COVID-19 is not completely quantified, local and national guidance on face coverings will be helpful in the interim. State and local officials should consider the level of disease and community spread in their areas when considering how to implement this guidance. As knowledge grows about the virus and its methods of spread and transmission, these guidelines should be regularly reevaluated and updated.

List of Do’s and Don’ts

Do’s

  • DO take a face mask with you wherever you go. Before you leave your home, check that you have your wallet, keys, phone, and a mask.
  • DO cover your mouth and nose with a face mask to stop the spread of COVID-19.
  • DO wear a well-fitted face covering with no gaps around your nose and chin.
  • DO wear a cloth mask with at least two layers (three layers when possible).
  • DO wear a face mask indoors around people who are not members of your household. (Everyone 2 years of age and older.)
  • DO wear a mask outdoors in public settings when you expect to be around others — the safest option is to wear a mask, even when briefly passing by others (e.g., running or walking by someone on the sidewalk). (Everyone 2 years of age and older).
  • DO roll down the window of a car when sharing a ride or traveling with others who are not members of your household.
  • DO wash your cloth face covering frequently.

Don’ts

  • DON’T forget to wear a face covering and stop the spread. Protect yourself and others.
  • DON’T leave your home without a face mask.
  • DON’T touch the front of your mask.
  • DON’T wear the face covering under your nose.
  • DON’T share your mask with others.

Download printable PDF

Consensus Guidance on Face Coverings

In regions where community spread is growing, wearing face coverings should be mandatory. The following practices are recommended:

  • Well-fitted face coverings that minimize gaps around the nose and chin are important. Loosely folded face masks and bandana-style coverings are better than no coverings; however, they still allow for the smallest aerosolized respiratory droplets to be dispersed.4

  • Wear face coverings with at least two layers (three layers when possible). Studies have shown a double-layer cloth face covering was significantly better at reducing the droplet spread caused by coughing and sneezing, as compared to a single-layer one.5

Indoors

  • “CDC recommends all people 2 years of age and older wear a cloth face covering in public settings and when around people who don’t live in your household, especially when other social distancing measures are difficult to maintain.”6 This guidance should be followed by the general public.

  • The use of face coverings is critically important indoors, as compared to outdoors. Superspreader events, in which an infected individual causes many subsequent infections, are likely to occur indoors.7

  • All businesses open to the public, no matter how limited, should insist all customers be masked while indoors.

  • Wear face coverings when indoors, even when six feet apart, if not with household members. Some studies suggest that smaller droplets, known as aerosols, can remain in the air longer, though how long is not yet known.8

Outdoors

  • “CDC recommends all people 2 years of age and older wear a cloth face covering in public settings and when around people who don’t live in your household, especially when other social distancing measures are difficult to maintain.”6 The safest option is to wear a face covering even for brief moments of close exposure, such as when walking by someone on the sidewalk.
  • Face coverings are unnecessary outside if an individual does not reasonably expect to come within six feet of others.

State and local officials should support distribution of masks for people experiencing homelessness, people who are incarcerated, and other vulnerable populations.

As the level of COVID-19 community spread reaches sufficiently low levels, face coverings may become optional. “Low levels” can be defined as low regional spread, no national hot spots that could seed the local ecosystem, and adequate contact tracing so all contacts of infected individuals can be identified and quarantined.

Face coverings do not fully prevent the spread of infection. As a result, widespread mask use does not diminish the importance of frequent hand-washing or replace social distancing practices, such as avoiding large gatherings. Nonessential activities and gatherings that bring people in the same room closer than within six feet of each other for more than a fleeting amount of time or that cause a more forceful exhalation, such as playing sports or singing, should continue to be avoided with or without face coverings when possible.

If all Americans work together, we can protect our communities and reopen our schools and economy. Please join health care leaders in encouraging your family, friends, and community to wear a face covering every time they come within six feet of someone outside their household. The quicker we make face coverings our “new normal,” the faster we can overcome COVID-19.

Acknowledgments

Acknowledgments

The AAMC Research and Action Institute appreciates the expertise of the following individuals in developing this guidance:
Atul Grover, MD, PhD, Executive Director, AAMC Research and Action Institute
Ross McKinney Jr., MD, Chief Scientific Officer, AAMC
Sheila P. Burke, MPA, RN, FAAN, Adjunct Lecturer in Public Policy, Harvard Kennedy School
Ashish K. Jha, MD, MPH, K.T. Li Professor of Global Health, Director, Harvard Global Health Institute
Megan L. Ranney, MD, MPH, Associate Professor of Emergency Medicine, Assistant Dean of Brown Institute for Translational Sciences, Director of the Brown-Lifespan Center for Digital Health, Associate Professor of Health Services, Policy and Practice

The AAMC also thanks the following individuals for helping to develop this document:
Laura M. Pincus, MHA, Manager, Strategy and Planning, AAMC Research and Action Institute
Amanda Field, PhD, Senior Science Policy Specialist, AAMC

References

  1. Hendrix MJ, Walde C, Findley K, Trotman R. Absence of apparent transmission of SARS-CoV-2 from two stylists after exposure at a hair salon with a universal face covering policy — Springfield, Missouri, May 2020. MMWR Morb Mortal Wkly Rep. 2020;69:930-932. doi:10.15585/mmwr.mm6928e2.
  2. Lyu W, Wehby G. Community use of face masks and COVID-19: evidence from a natural experiments of state mandates in the US [published online ahead of print June 16, 2020]. Health Aff. doi:10.1377/hlthaff.2020.00818.
  3. Payne DC, Smith-Jeffcoat SE, Nowak G, et al. SARS-CoV-2 infections and serologic responses from a sample of U.S. Navy service members — USS Theodore Roosevelt, April 2020. MMWR Morb Mortal Wkly Rep. 2020;69:714-721. doi:10.15585/mmwr.mm6923e4.
  4. Verma S, Dhanak M, Frankenfield J. Visualizing the effectiveness of face masks in obstructing respiratory jets. Phys Fluids. 2020;32,061708. doi:10.1063/5.0016018 @ phf.2021.FATV2020.issue-1.
  5. Bahl P,  Bhattacharjee S,  de Silva C, Chughtai AA, Doolan C, MacIntyre CR. Face coverings and mask to minimise droplet dispersion and aerosolisation: a video case study [published ahead of print July 24, 2020]. Thorax. doi: 10.1136/thoraxjnl-2020-215748.
  6. Centers for Disease Control and Prevention. Considerations for wearing masks. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html. Updated July 16, 2020. Accessed July 31, 2020.
  7. Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 attack rate following exposure at a choir practice — Skagit County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:606-610. doi: 10.15585/mmwr.mm6919e6.
  8. Prather KA, Wang CC, Schooley RT. Reducing transmission of SARS-CoV-2. Science. 2020;368(6498):1422-1424. doi: 10.1126/science.abc6197.

© 2020 Association of American Medical Colleges. May be reproduced and distributed with attribution for educational or noncommercial purposes only.