By Frederick L. Greene, MD
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The recent emergence of a deadly mutated strain of coronavirus (COVID-19) and its spread across the world has heightened interest in the role of the surgical mask as one possible barrier to a potential pandemic. The media has touted the use of surgical masks and the types of masks that should be worn as a barrier to airborne viral spread. The need and desire of entire urban populations and travelers for facial barriers have literally created a worldwide shortage of surgical masks and viral barrier respirator masks. The largest surgical mask provider, Prestige Ameritech, no longer is accepting orders for masks from individuals as it focuses on supplying U.S. hospitals. Not since the SARS epidemic in 2002-2003 has there been such interest in the varieties of mask protection.

Initial interest in the use of masks as protection against infection, especially tuberculosis, began in the late 19th century but did not routinely translate to usage in the OR until the 1920s. It is reported that Paul Berger, a Parisian surgeon, first began routinely using a mask during surgical procedures in 1897. These early masks were made of fine mesh gauze and used to cover the mouth only. During World War I, the use of gauze masks in military hospitals was introduced to protect patients who were placed in mixed wards with a high incidence of respiratory infections.

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During the influenza pandemic of 1918, wearing of gauze masks became commonplace, but sadly in retrospect, masks were not protective in trapping viral particles. Throughout the early 20th century, varieties of masks were introduced to prevent bacterial transmission from OR personnel to patients. With the recognition of viral contamination, this filter concept gained greater importance.

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As we began operating on HIV-infected patients with laparoscopic techniques in the late 1980s, the release of a “viral plume” into the OR from the escape of the carbon dioxide used for creation of a pneumoperitoneum became a concern. This led to the development of mask filters that would lessen transmission of viral particles and afford increased protection for the operating team. Later improvements would usher in the mask respirator concept now designated as the N-95 mask recommended for protection against viral particles and especially COVID-19.

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While the wearing of surgical masks during seasons of heightened respiratory illness has been commonplace in Asian cultures, this protective strategy remains infrequently used in North America. The current spread of COVID-19 is changing all of this. While the wearing of surgical masks may be beneficial in locales with smog or other environmental pollutants, they are woefully inadequate for protection against the mutated coronavirus.

It is both appropriate and beneficial as a public health mandate that surgeons should have proper knowledge regarding mask protection that could be shared with patients, their families and, when asked, the media. The assumption that the wearing of a surgical mask is protective for populations at risk from respiratory-mediated viral epidemics should be dispelled. Adequate hand-washing is a better preventive measure than wearing nonprotective facial barriers. While the spread of COVID-19 has rightly engendered fear, the ultimate antidote against fear is fact, and who is best suited to provide appropriate facts regarding the drawbacks of surgical masks and the benefits of hand-washing? Surgeons—that’s who!


Dr. Greene is a surgeon in Charlotte, N.C.