What are the policies on wearing facemasks in public places?

Cross-Country Analysis

What are the policies on wearing facemasks in public places?

Wearing masks in public places is increasingly seen as having an important contribution to containing the spread of COVID-19 as countries transition out of lockdown measures, especially when physical distancing is not always possible.  

This policy snapshot describes the different policies across Europe that seek to encourage the general public to cover their mouth and nose (most often using facemasks) when outside the home. Masks can be medical or nonmedical, can be recommended or mandatory, can apply to different population groups and policies can vary by where people are. Using data extracted from the COVID-19 Health Systems Response Monitor (HSRM) (up to 18 May 2020) we summarize policies around wearing masks in public places in most countries of the WHO European region.

It is important to note that there are few studies on the effectiveness of using non-medical masks / face coverings in the community — this policy snapshot should not be interpreted as making a recommendation one way or another on the use of masks in the community.

There are clear variations in rules about who should wear a mask in public depending on someone’s role and age

People in public places because of the nature of their work (e.g. shop workers or police officers), as with health and social care workers, are bound by different rules for mask-wearing and the wider use of personal protective equipment (PPE) than the general public. 

Age is also a factor. Children are not generally expected to wear masks below a certain age – 2 years in Czechia, 6 years in Italy and Israel, and 12 years in Belgium.

Many countries advocate the use of nonmedical facemasks and facilitate access

WHO guidance on the use of medical facemasks is that only people with respiratory symptoms or those caring for people with respiratory symptoms need to wear them. Masks alone are insufficient to provide adequate protection and they need to be used alongside other measures such as frequent handwashing. Also, with global shortages, it is important that medical masks are reserved for health and social care workers. (How countries are finding new PPE is covered in a previous thematic analysis). The formal WHO guidance has informed official advice in many countries (FranceGermanyItalyLuxembourg), but as more is understood about asymptomatic transmission of COVID-19, governments have been more inclined to mandate mask wearing and facilitate access. 

Some countries provide templates or instructions for individuals on how to make their own cloth facemasks at home (e.g. EstoniaBelarusthe United Kingdom) and have made access to shops selling fabric possible during lockdown to facilitate people making their own face coverings (e.g. CzechiaFrance).  Countries have also boosted domestic production of masks to meet demand once transition measures are in place (e.g. AzerbaijanGeorgia), or made them available in other ways. Authorities in Luxembourg have given 50 masks to each citizen over the age of 16 and in Switzerland the government has released 10 million masks to be sold in supermarkets. 

Mask wearing in public has been part of the response since the beginning of the crisis in some countries

While in many countries, mask wearing has been introduced as a part of transition measures (e.g. ArmeniaBelgiumFrance, GermanyGreeceItaly, Latvia, LuxembourgMalta, the Netherlands, Portugal, Spain), in other countries mask wearing was mandatory outside the home as part of physical distancing measures under lockdown (e.g. AustriaBulgariaHungaryIsrael, SlovakiaSlovenia). Transition measures in Czechia and Ukraine are a relaxation of previous universal measures as mask wearing is now mandatory only on public transport or where physical distancing is not possible (see Figure 1). Many countries in Europe are not yet implementing transition measures but mask-wearing remains universal (Bosnia & HerzegovinaLithuaniaPoland, Turkey, Uzbekistan), or is required in certain circumstances, such as on public transport (North Macedonia). However, in many countries mask wearing is recommended but not mandatory as part of transition measures (GeorgiaSwitzerlandthe United Kingdom). 

It can also vary by region. In Romania and the Russian Federation mask wearing is compulsory in some regions but not others, and although transition measures cover the whole country, prior to this mask wearing was mandatory in some regions but not others in Italy and Germany.

Mask-wearing can face resistance and some countries have opted not to use them

In many countries, mask-wearing is an issue of etiquette; when someone has respiratory symptoms, not wearing a mask is considered unacceptable. However, where it is not a standard practice there can be resistance to wearing a mask and timing becomes more important. For example, in Bulgaria the government sought to mandate universal mask wearing early (prior to lockdown) but there was strong pushback from the public. The policy was refined under lockdown and then as part of transition measures to ensure it was acceptable and now mask wearing is only mandated in Bulgaria when physical distancing is not possible. 

Timing is also important to ensure mandatory mask-wearing outside the home does not cause shortages for those working in health and social care, and this concern shaped policy-making in France and the United Kingdom

WHO guidance highlights several risks that need to be balanced if governments are going to advocate mask wearing. Firstly, mask-wearing might give people a false sense of security that could lead to less adherence to other important preventive measures such as handwashing and physical distancing. Secondly, there is a risk of self-contamination with masks where people have not had sufficient guidance on how to use them safely. Thirdly, depending on the type of mask used, they could cause potential breathing difficulties. It should therefore be noted that some countries have declined to include mask-wearing policies in their approaches (Denmark, EstoniaFinland, Ireland). 

We need to find out what works, for whom and in what circumstances

Given that there is limited evidence on the effectiveness of mask-wearing for the general public outside the home, where such policies have been implemented they should be monitored and evaluated so that we can build the evidence base for the benefit of all. Research will need to reflect on not just efficacy, but also any challenges in acceptability and accessibility. All policies will be tailored to reflect local conditions, but there is still great scope for cross-country learning. 

Policy-makers need to balance risks when deciding whether to mandate mask wearing as part of transition measures, but it is likely that the success of these policies will also rely on effectively communicating these risks to the general public. 

Erica Richardson