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Mask-induced medical effects
at 04.12.2021“Mask-Induced Exhaustion Syndrome” (MIES) is the generic name given to a multitude of forms of physical and psycho-social damage induced by mask wearing. The concept is recent and has been proposed in an extensive meta-analysis by a group of German researchers in various medical and psychosocial fields (molecular and cellular anatomy, pathology, neuroscience, neurosurgical pathophysiology, psychology), who exposed the adverse medical effects caused by mask wearing.
According to the paper [1], masks have adverse medical effects not only on sick people, but also on healthy ones, and the severity of the problems is directly proportional to the duration of wearing the mask. The main cause of side effects is an increase in the level of carbon dioxide in the bearer's blood and a decrease in oxygen saturation in the blood. Wearing the mask for several hours a day, on a long-term basis, determines a pathological adaptation of respiratory physiology. Thus, the dead respiratory space (nose, throat, trachea, bronchi) expands, which, along with CO2 retention, causes significant changes in blood gases, leading to hypercapnia (a condition characterized by excessive accumulation of carbon dioxide in the blood) and hypoxia (a pathological condition that involves an insufficient supply of oxygen in the body). The mask wearers, being forced to inhale the carbon dioxide accumulated in the volume of the respiratory dead space, intensify the respiratory activity, hence the greater need for oxygen. Repeated and prolonged exposure to such conditions, some of which are subliminal, can lead to pathological changes that affect health, such as blood pressure and arteriosclerosis, but also coronary heart disease (metabolic syndrome) or neurological.
Internistic Side Effects
Increased mask-induced airway resistance leads to increased respiratory activity, bringing with it a greater need and consumption of oxygen. Thus, according to research, the heart tries to compensate for the obstacles induced by the mask in the proper functioning of the lungs, compensation that may work to a certain extent in healthy people, but in patients with low cardiac output is problematic [2]. This increase is significant in hypertensive patients, but also in healthy people with blood pressure limit values because ranges of pathological values can be induced. Also, a review [3] on the risks and benefits of masks worn during the COVID-19 crisis by German and Dutch specialists presents a critical assessment of the mandatory use of masks for patients with pneumonia.
Neurological Side Effects
Scientists have found neurological deficiencies due to wearing a mask, explained by a decrease in blood oxygen levels (towards hypoxia) or by a latent increase in the level of carbon dioxide in the blood gases (towards hypercapnia). Thus, a study [4] by a group of researchers in New York found that wearing a mask causes measurable neurological side effects, such as cognitive impairment (24% of participants) and headaches (71.4% of participants). Confusion, disorientation, even drowsiness, as well as reduced motor skills, associated with reduced reactivity and impaired overall performance (measured on the Roberge Subjective Symptomsdurant-Work Scale) have also been documented in other studies [5]. In a 2020 experiment [6], significant thinking and concentration impairments were found for all types of masks (textile, surgical, and N95) used after only 100 minutes of wearing. Thinking impairments have been significantly correlated with a decrease in oxygen saturation during mask use.
In another study [7], a group of neurologists from Israel, the United Kingdom and the United States claim that a mask is unsuitable for epileptics because it can trigger hyperventilation. The use of a mask significantly increases the respiratory rate by up to 20%, and an increase in respiratory rate that induces hyperventilation causes seizures in 80% of patients with generalized epilepsy and up to 28% of focal epileptics.
Psychiatric Side Effects
As masks cause a re-inhalation of carbon dioxide, with an excessive accumulation of it, panic attacks can be triggered [8]. Thus, absolute concentrations of 5% CO2 are already sufficient to trigger panic reactions in just 15-16 minutes [9]. Thus, people undergoing treatment for dementia, paranoid schizophrenia, personality disorders with anxiety and panic attacks, but also panic disorders with claustrophobic components, are difficult to adjust to wearing a mask, because even small increases in CO2 can cause and intensify. panic attacks [10]. Also, to avoid a state of unconsciousness triggered by CO2 retention, medically sedated patients without the possibility of continuous monitoring should not wear a mask, according to the criteria of the Centers for Disease Control and Prevention (CDC), USA. This is because the possible retention of CO2 can determine the risk of unconsciousness, aspiration, and suffocation.
Gynecological Side Effects
In pregnant women, the level of carbon dioxide in the blood should always be lower than that of the unborn child to ensure the diffusion of CO2 from the fetal blood through the placenta. Therefore, the pathological phenomena that the mask causes - changes in respiratory physiology with increased resistance to respiration, increased volume of dead respiratory space, and retention of expired carbon dioxide - can be harmful to the pregnant woman, who needs more oxygen and a lower level of carbon dioxide. If you inhale more and more CO2 under the mask, this phenomenon could cause clinically relevant conditions [11]. In addition, it has been found that masks cause additional stress on the metabolic system. Another issue is that it is not clear whether or not the substances contained in industrially manufactured masks, which are inhaled for long periods of time (formaldehyde as an ingredient in textiles and thiram as an ingredient in ear strips), have teratogenic effects.
Dermatological Side Effects
Wearing the mask leads not only to a measurable increase in temperature in the covered area but also to a significant increase in humidity due to the condensation of expired air. The mask considerably modifies the natural environment of the skin in the perioral and perineal areas [12], increases redness, pH value, fluid loss through the skin epithelium, increases hydration and sebum production [13]. Pre-existing skin diseases are aggravated by wearing a mask. In general, the skin becomes more susceptible to infections and acne. There is also a risk of germs (bacteria, fungi, and viruses) accumulating on the outside and inside of the mask due to the hot and humid environment inside the mask, causing clinically relevant fungal, bacterial or viral infections.
On the other hand, an unnaturally humid and warm environment is created in the area covered by the mask. A study [14] showed a significant increase in humidity and temperature in the area after only one hour of wearing the mask. The feeling of humidity and high temperature in the face area is more crucial for well-being than other regions of the body. This can increase the discomfort under the masks. In addition, rising temperatures favor bacterial growth.
ENT and Dental Side Effects
It is a scientifically proven fact that the phenomenon of "dry mouth” [15] is due to wearing a mask. Breathing through the mouth while wearing a mask is justifiable, as this pattern of breathing compensates for the increased resistance to breathing, especially when inhaled through masks [16]. There is an increase in the dry mouth due to reduced saliva flow and increased breathing through the open mouth under the mask. Mouth breathing causes dehydration of the surface and reduced salivary flow. On the other hand, the moisture of the outer skin with an altered skin flora causes inflammation of the lips and corners of the mouth. This clearly shows the reversal of the natural conditions caused by masks - the internal physiological humidity associated with external dryness in the oral cavity - which favors the disease. The appearance of gingivitis (inflammation of the gums), halitosis (bad breath), candidiasis (fungal infestation of the mucous membranes with Candida albicans), and cheilitis (inflammation of the lips), especially the corners of the mouth, and even plaque and cavities are attributed to the use excessive and inappropriate use of masks. In addition, ENT doctors found a voice disorder in 33% of mask users.
Microbiological Consequences for Wearer and Environment
The warm and humid environment created by the masks, in the absence of protection mechanisms - antibodies, complement system, defense cells, and pathogen-inhibiting - provides the ideal ground for various pathogens [17], such as bacteria and fungi, and allows virus accumulation [18]. The warm and humid mask microclimate favors the accumulation of various germs on and underneath the masks, and the germ density is directly proportional to the length of time the mask is worn. After only 2 hours of wearing the mask, the pathogen density increases almost tenfold in experimental observational studies. For all these reasons, poor filtering performance and incorrect use of surgical masks and community masks, as well as their frequent reuse, involve an increased risk of infection.
From a microbiological and epidemiological point of view, masks for daily use present a risk of contamination, both of another person, and the risk of self-contamination. On the one hand, germs are sucked in or attached to masks by convection currents. On the other hand, potential infectious agents in the nasopharynx accumulate excessively both on the outside and inside the mask during respiration [18]. Since masks are constantly penetrated by germ-containing breath and the pathogen reproduction rate is higher outside mucous membranes, potential infectious pathogens accumulate excessively on the outside and inside of masks. On and in the masks, there are quite serious, potentially disease-causing bacteria and fungi such as E. coli (54% of all germs detected), Staphylococcus aureus (25% of all germs detected), Candida (6%), Klebsiella (5%), Enterococci (4%), Pseudomonads (3%), Enterobacter (2%) and Micrococcus (1%) even detectable in large quantities [19].
It has also been shown that all mask-wearing subjects release significantly smaller particles, 0.3–0.5 _m in size, than those without a mask, both when breathing, speaking or coughing through masks of different types (textile, surgical, N95) [20]. Another indication of this phenomenon is the detection of rhinoviruses in a higher percentage, according to the 2020 sentinel studies of the German institute "Robert-Koch” [21].
Epidemiological Consequences
A major risk of using the mask on a large scale is creating a false sense of security when it comes to protection against viral infections. In a laboratory experiment, it was shown that both surgical and N95 masks have deficiencies in protection against SARS-CoV-2 viruses and aerosol-using influenza viruses [22]. In the mentioned experiment, the N95 mask equivalent to FFP2 had significantly better protection (8-12 times more effective) than the surgical mask, but no type of mask established reliable protection against corona and influenza viruses. Both types of masks can be freely penetrated by aerosol particles with a diameter of 0.08 to 0.2 _m. SARS-CoV-2 pathogens, with dimensions of 0.06 to 0.14 _m, and Influenza viruses, with 0.08 to 0.12 _m, are, unfortunately, well below the size of the mask's pores.
Moreover, a recent experimental study showed that all people wearing masks (surgical, N95, material masks) release significantly smaller particles into the air (size 0.3 to 0.5 _m) than people without a mask, both when they breathe, speak and cough [23]. Thus, the masks act as nebulizers and contribute to the production of very fine aerosols. Smaller particles, however, spread faster and farther than larger ones, for physical reasons. In a meta-analysis coordinated by the WHO, no effect of masks could be demonstrated in the context of pandemic influenza virus prevention [24].
Pediatric Side Effects
It can be said that children are even more vulnerable to the potential side effects of the mask (internal physiological, neurological, psychological, psychiatric, dermatological, ENT, dental, sociological, professional and social medical, microbiological and epidemiological deficiencies) than adults. Another aspect is that the masks currently used for children are adult masks made in smaller geometric dimensions and have neither been tested nor specifically approved for this purpose [25].
Particular attention should be paid to children's breathing, which is a critical and vulnerable physiological variable due to increased oxygen requirements, increased sensitivity to hypoxia, lower respiratory reserve, lower airways, with a stronger increase in resistance when the lumen is narrowed. The diving reflex caused by stimulation of the nose and upper lip can cause respiratory arrest to bradycardia in case of oxygen deficiency.
For these reasons, there should be certain criteria for exemption from wearing a mask in children [26]: any cardio-pulmonary disease including asthma, bronchitis, cystic fibrosis, congenital heart disease, emphysema, but not limited to them; any condition that may be aggravated by physical exertion, such as exercise-induced asthma; lower respiratory tract infections (pneumonia, bronchitis); anxiety disorder, diabetes, high blood pressure or epilepsy disorder; any physical disability due to a medical, orthopedic or neuromuscular disease; any acute upper respiratory tract disease or symptomatic rhinitis (nasal obstruction, runny nose or sneezing); any condition with a deformity that does not allow the correct placement of the mask on the face (for example, grown facial hair, craniofacial deformities, etc.). It is also important to highlight the possible effects of masks in neurological diseases, as described in adults.
A recent observational study [27] of tens of thousands of children wearing a mask (25,930) in Germany monitored the following symptoms: headache (53% of participants), difficulty concentrating (50%), lack of joy (49%) ), learning difficulties (38%) and fatigue (37%). Of the children observed, 25% had anxiety and even nightmares.
According to experts, another aspect [28] is that masks block the foundation of human communication and the transmission of emotions, which is the human face, and not only hinders the learning process but also deprives children of the positive effects of smiles, laughter, and emotional mimicry. The effectiveness of masks in children as viral protection is controversial and there is a lack of evidence to prove their widespread usefulness.
Sports medicine
The sports physicians found that mask use in sport is not without risks as mask wearers showed significantly lower oxygen saturation values (SpO2%) during exercise (SpO2 of 94% for mask wearers versus 96% for mask-less, which can be explained by an increased dead space volume and increased resistance during breathing.
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Based on all these data from different medical fields, the authors are of the opinion that further research is needed to shed light on the long-term consequences of the widespread use of masks. The drastic decrease in oxygen saturation and the increase in mask-induced carbon dioxide levels can generate or aggravate especially cardio-respiratory diseases, such as hypertension, sleep apnea, and metabolic syndrome, but also other medical phenomena of clinical relevance.
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[12] Johnson, A.T. Respirator Masks Protect Health but Impact Performance: A Review. J. Biol. Eng. 2016, 10, 4. Roberge, R.; Bayer, E.; Powell, J.; Coca, A.; Roberge, M.; Benson, S. Effect of Exhaled Moisture on Breathing Resistance of N95 Filtering Facepiece Respirators. Ann. Occup. Hyg. 2010, 54, 671–677. COVID-19: Considerations for Wearing Masks|CDC. Available online: https://www.cdc.gov/coronavirus/2019-ncov/preventgetting-sick/cloth-face-cover-guidance.html.
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[14] Scarano, A.; Inchingolo, F.; Lorusso, F. Facial Skin Temperature and Discomfort When Wearing Protective Face Masks: Thermal Infrared Imaging Evaluation and Hands Moving the Mask. Int. J. Environ. Res. Public Health 2020, 17, 4624.
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[17] Monalisa, A.C.; Padma, K.B.; Manjunath, K.; Hemavathy, E.; Varsha, D. Microbial Contamination of the Mouth Masks Used by Post-Graduate Students in a Private Dental Institution: An In-Vitro Study. IOSR J. Dent. Med. Sci. 2017, 16, 61–67.
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[20] Asadi, S.; Cappa, C.D.; Barreda, S.; Wexler, A.S.; Bouvier, N.M.; Ristenpart, W.D. Efficacy of Masks and Face Coverings in Controlling Outward Aerosol Particle Emission from Expiratory Activities. Sci. Rep. 2020, 10, 15665.
[21] Robert Koch-Institut. Influenza-Monatsbericht; Robert Koch-Institut: Berlin, Germany, 2020.
[22] Lee, S.-A.; Grinshpun, S.A.; Reponen, T. Respiratory Performance Offered by N95 Respirators and Surgical Masks: Human Subject Evaluation with NaCl Aerosol Representing Bacterial and Viral Particle Size Range. Ann. Occup. Hyg. 2008, 52, 177–185.
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[23] Asadi, S.; Cappa, C.D.; Barreda, S.; Wexler, A.S.; Bouvier, N.M.; Ristenpart, W.D. Efficacy of Masks and Face Coverings in Controlling Outward Aerosol Particle Emission from Expiratory Activities. Sci. Rep. 2020, 10, 15665.
[24] Xiao, J.; Shiu, E.Y.C.; Gao, H.;Wong, J.Y.; Fong, M.W.; Ryu, S.; Cowling, B.J. Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective and Environmental Measures. Emerg. Infect. Dis. 2020, 26, 967–975.
[25] Smart, N.R.; Horwell, C.J.; Smart, T.S.; Galea, K.S. Assessment of the Wearability of Facemasks against Air Pollution in Primary School-Aged Children in London. Int. J. Environ. Res. Public Health 2020, 17, 3935.
[26] Goh, D.Y.T.; Mun, M.W.; Lee, W.L.J.; Teoh, O.H.; Rajgor, D.D. A Randomised Clinical Trial to Evaluate the Safety, Fit, Comfort of a Novel N95 Mask in Children. Sci. Rep. 2019, 9, 18952.
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