Since the beginning of the COVID-19 pandemic, countries across the WHO European Region have implemented public health and social measures (PHSM) in efforts to reduce viral transmission and the subsequent burden affecting the health care systems.
Mask wearing has been a critical measure to limiting transmission of SARS-CoV-2 and reducing deaths and has been increasingly employed as one of the individual PHSM against COVID-19 since the beginning of the pandemic. Masks form part of the majority of countries’ PHSM response, but in the early stages of the pandemic many countries did not have mask policies even when they had implemented national lockdowns. At the beginning of the pandemic, mask policies were less frequently implemented when compared to other PHSM such as social and physical distancing measures, including business closures, school measures, limitations on domestic movement and gatherings restrictions (see Figure 1).
A previous HSRM policy snapshot looked at policies on the use of masks in public places up to May 2020. The purpose of this cross-country analysis is to provide an overview of the diverse range of mask policies implemented across the WHO European Region during the pandemic offering an expanded analysis up to May 2021.
WHO advises the use of masks as a component of a comprehensive package of infection prevention and control (IPC) measures and recommends that countries should apply a risk-based approach, where the general public should wear a non-medical well-fitting three-layered mask in indoor (e.g. in shops, shared workplaces, schools) or outdoor settings where physical distancing of at least 1 metre cannot be maintained.
The use of a masks alone, even when correctly used, is insufficient to provide an adequate level of protection for an uninfected individual or prevent onward transmission from an infected individual (source control). Hand hygiene, physical distancing of at least 1 metre, respiratory etiquette, adequate ventilation in indoor settings, testing, contact tracing, quarantine, isolation and other IPC measures are critical to prevent human-to-human transmission of SARS-CoV-2, whether or not masks are used.
Figure 1. Mask policy, business closures and gathering restrictions adopted by Member States in the European Region from mid-February 2020 to 3 April 20211
Information was collected from open sources and government websites by the COVID-19 Incident Management Support Team of the WHO Regional Office for Europe and the COVID-19 Health Systems Response Monitor (HSRM) (up to 19 April 2021). Country examples selected based on their level and type of mask policy are provided for Austria, Belgium, Czechia, Finland, France, Germany, Hungary, Ireland, Israel, Latvia, San Marino, Slovenia, Slovakia, Sweden, Ukraine and Uzbekistan. Common differences in country approaches include the levels of enforcement, settings where masks are required to be worn or the type of mask required. Furthermore, the trends regarding recommendation, risk-based and universal approaches for mask policy was examined. This analysis can help inform of the ongoing development of mask policies as the epidemiological situation changes.
Based on a composite index score for masks calculated using the WHO Regional Office for Europe’s PHSM severity index, Figure 2 provides a visual representation of mask policies across the region. Based on the severity of the measure, which is determined by the settings in which a person is required or recommended to wear a mask – the darker colour indicates that the measure has been implemented at a universal level while, the lighter the colour indicates that the measure is only recommended.
Figure 2. Status of mask policies across the WHO European Region, as of 08 April 2021.
Countries have recommended that citizens should wear masks
The national recommendation which encourages citizens to consider wearing a mask was the most common type (or category) of individual measures at the beginning of March 2020. This approach provided guidance that citizens should wear face masks and may also have offered guidance on where masks should be worn (e.g. in public transport when physical distancing could not be achieved). Following the spike in COVID-19 cases across the European Region in April 2020, most Member States quickly adapted more stringent risk-based requirements or universal use of face masks.
Sweden did not have a recommendation on wearing of masks in place until 24 December 2020, when the Public Health Agency changed their approach and began recommending that their citizens wear a face mask on public transport during rush hour and at other times when it was crowded. As of 19 April 2021, Sweden is the only country in the WHO EURO region which still utilizes a non-compulsory approach at a national level.
Finland first implemented a mask policy in August 2020, recommending that citizens wear a face mask in specific situations to protect other people. This recommendation was first implemented at the sub-national level within those Finnish regions where COVID-19 infections had been reported in the previous two-weeks. In January 2021, this policy was expanded, and some regional governments increased the requirement to wear masks using a risk-based approach, which requires masks to be worn on all means of public transportation.
Countries have made it mandatory to wear masks based on a risk-based approach by specifying different settings where masks were required
As of 19 April 2021, 18 of the 53 Member States in the WHO European Region implemented a mandatory requirement for citizens to wear masks in community settings within areas deemed a high risk for COVID-19 transmission. This policy approach is in line with the WHO recommendations that countries should adapt a risk-based approach. While WHO has identified locations and settings, which should be included within this approach (e.g. in shops, shared workplaces, schools, etc.), countries across the region have prioritized these areas in different ways. This PHSM approach was the most widely adopted mask policy from April 2020 until a rapid incline in COVID-19 cases in October 2020.
On 13 July 2020, Ireland introduced its first mandatory requirement for masks to be worn in situations where physical distancing was not possible. This requirement evolved and became more defined with the emergence of the variants of concern (VOC) in January 2021, when risk areas were expanded to include people visiting retail outlets, using public transport and for workers in customer-facing roles.
Latvia introduced the countries’ first mandatory risk-based policy on 11 July 2020, when it was recommended that citizens use masks in places where it is not possible to keep a 2-metre distance from others, including on public transport. This measure was further modified in October 2020 (Figure 3), when it was expanded to include shops, and also applied to employees of places who were not separated from visitors by a physical barrier.
Figure 3. Daily cases and PHSM in Latvia2
Mandatory mask wearing in all public settings gained momentum across the Region
As of 19 April 2021, 35 of the 53 Member States in the WHO European Region implemented a mandatory requirement for masks to be worn in all public settings. This mask policy approach has been the most widely used in the region since 16 October 2020.
On 19 March 2020, the Czech Republic implemented the first mandatory mask requirement within the WHO European Region. The mask approach prohibited citizens from moving and staying in any place outside of their residence without a respirator, face mask, scarf, shawl, or other means to cover the nose and mouth. This policy was in place until 24 May 2020, when the approach was changed to a mandatory risk-based approach which required that masks be worn in all inside spaces other than one’s place of residence, and on public transport and outdoors when in the immediate vicinity of people outside one’s household.
From 5 April 2020, Ukraine required all citizens to wear a mask in all public spaces, including parks, public gardens and playgrounds. This universal measure was in place until 22 March 2021, when the mask mandate was changed to enable citizens to take off their masks within parks and public squares if they were able to physically distance from other patrons. At the same time, wearing masks is mandatory in health care settings, education institutions, underpasses, public transport stops and other public areas where a physical distance of at least 1 metre cannot be achieved.
On 23 March 2020, Uzbekistan introduced a mandatory mask policy requiring citizens to wear face masks in all public spaces. This mask policy is the longest unchanged mask policy in the WHO European Region (Figure 4).
Figure 4. Daily cases and PHSM Uzbekistan2
The type of masks countries require/recommend citizens to wear is extremely diverse
According to the WHO guidance, Advice on the use of masks in the context of COVID-19, a non-medical mask, also called fabric mask, community mask or face covering, is neither a medical device nor personal protective equipment. Non-medical masks are aimed at the general population, primarily for protecting others from exhaled virus-containing droplets emitted by the mask wearer. They are not regulated by local health authorities or occupational health associations, nor is it required for manufacturers to comply with guidelines established by standards organizations. Non-medical masks may be home-made or manufactured.
In Belgium on 4 May 2020, citizens were recommended to consider covering their mouth and nose with a mask or an alternative piece of protective equipment such as a scarf or bandana. At this early stage of the pandemic, medical masks and FFP2 respirators were specifically reserved for health care professionals, residential care centres or facilities and security services across the country.
Countries such as Ireland advise that masks should be made from cloth materials such as cotton, silk, or linen. The Irish government also advocates for the use of plexiglass visors and recommends that masks should not be worn by people with difficulties breathing and that persons with specific disabilities should use a plastic face shield or plexiglass visor. Countries have taken different approaches towards the use of visors such that in February 2021, San Marino implemented a ban on the use of plexiglass visors by citizens only allowing citizens to use non-medical or medical masks.
According to the WHO guidance, medical masks are made based on specific performance characteristics which are tested according to a set of standardized testing methods (ASTM F2100, EN 14683, or equivalent). These performance characteristics aim to balance high filtration, allow adequate breathability and optionally, fluid penetration resistance.
In Hungary from 27 April 2020, citizens using public transport in Budapest were required to wear a face mask or had the option to cover their face with a scarf. This approach changed on 21 September 2020 when scarfs or shawls were no longer allowed, and thereafter only a non-medical or medical mask was the acceptable type of face mask permitted. This mask policy changed once more in March 2021 (Figure 5), when the country registered a record high in daily cases, so that a non-medical or medical mask were mandatory within all public areas.
Figure 5. Daily cases and PHSM Hungary2
Since October 2020, France has enforced a mandatory risk-based mask approach allowing any non-medical or medical masks to be worn in enclosed spaces open to the public. In response to the emergence of VOC, France changed its national recommendation in January 2021 requesting that citizens stop using home-made non-medical masks and wear medical mask in public. The French government announced that home-made cloth masks were an insufficient barrier to moderate the spread of the emerging VOC.
Similar actions were taken in the Czech Republic and Germany where the two countries stopped recommending non-medical masks, instead requiring citizens to wear at least a medical mask. In 2021, Austria and Slovakia have increased their mask requirements by requiring citizens to utilize FFP2/KN95 or higher-level respirators, with Austria attributing this change in mask policy to the spread of the VOCs.
Based on epidemiological criteria, some countries have eased mask policies
Since April 2021, several countries have changed from a universal mask approach and adopted risk-based policies. In Israel, due to a continued decrease in the infection rate across the country, the government declared that masks were no longer required within outdoor settings when not in a large gathering. Similarly, due to the improving epidemiological situation, Slovakia deemed that masks were no longer essential in outdoor settings where citizens can maintain at least 5 metres distance from people who are not their household. In Slovenia, the use of face masks in outdoor settings was also reduced and is only mandatory outdoors when it is not possible to maintain a 1.5-metre distance.
Masks will continue to be used as part of a comprehensive package of PHSM
Since the start of the pandemic, the European Region has observed an increase in the mask policy requirements both in the level of enforcement and the type of mask citizens are required to wear.
Masks – as a component of a comprehensive package of prevention and control measures – will remain among other key PHSMs as an important measure for the prevention and transmission of COVID-19. If countries across the region continue to experience an improvement in their epidemiological situation, the general trend may be a relaxation in mask requirements going forward, with more countries adopting risk-based approaches as opposed to the use of the more common universal approach.
Since the start of the pandemic based on several and regular expert consultations, WHO has issued and updated their mask guidance for health workers, the general public and children based on a review of the evolving evidence and continues to emphasize that masks should only ever be used as part of an overall comprehensive strategy. In areas with community transmission, WHO advises that members of the general public aged 60 and older and those with underlying conditions, should wear a medical mask in situations where physical distancing is not possible. The general public should wear non-medical masks where there is widespread transmission and when physical distancing is difficult, such as on public transport, in shops or in other confined or crowded environments.
IPC and PHSM have proven to be critical in mitigating and limiting transmission and deaths due to COVID-19. However, mask use as an IPC measure by itself is insufficient and therefore governments are encouraged to use masks as part of a comprehensive package of PHSM to reduce the transmission of SARS-CoV-2. The use of PHSM must be continuously monitored and adjusted, especially in the context of VOCs, to account for the intensity of transmission as well as the capacity of the health system at both national and sub-national levels.
Dominic Cocciolone, Tanja Schmidt, Ana Paula Coutinho Rehse
Reference for Figures
- World Health Organization Regional Office for Europe. Underlying Methodology and Application of the PHSM Database and PHSM Severity Index. https://apps.who.int/iris/handle/10665/337686
- World Health Organization Regional Office for Europe. COVID-19. EURO Situation Dashboard.
- Considerations for implementing and adjusting public health and social measures in the context of COVID-19. https://www.who.int/publications/i/item/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance
- Mask use in the context of COVID-19. https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak
- Advice on the use of masks for children in the community in the context of COVID-19. https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC_Masks-Children-2020.1
- Coronavirus disease (COVID-19) advice for the public: When and how to use masks. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks
- Using face masks in the community: first update Effectiveness in reducing transmission of COVID-19. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-face-masks-community-first-update.pdf