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Effect of Wearing a Face Mask on Hand-to-Face Contact by Children in a Simulated School EnvironmentThe Back-to-School COVID-19 Simulation Randomized Clinical Trial

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Does wearing a face mask lead to increased hand-to-face contact in children?

Findings  In this randomized clinical trial of 174 children aged 5 to 18 years, the rate of hand-to-face contact was not significantly different between children wearing a face mask and the control group in a simulated school environment.

Meaning  Face mask wearing did not increase hand-to-face or hand-to-mucosa contact in children, suggesting that mask wearing is unlikely to increase infection risk through self-inoculation.


Importance  Wearing a face mask in school can reduce SARS-CoV-2 transmission but it may also lead to increased hand-to-face contact, which in turn could increase infection risk through self-inoculation.

Objective  To evaluate the effect of wearing a face mask on hand-to-face contact by children while at school.

Design, Setting, and Participants  This prospective randomized clinical trial randomized students from junior kindergarten to grade 12 at 2 schools in Toronto, Ontario, Canada, during August 2020 in a 1:1 ratio to either a mask or control class during a 2-day school simulation. Classes were video recorded from 4 angles to accurately capture outcomes.

Interventions  Participants in the mask arm were instructed to bring their own mask and wear it at all times. Students assigned to control classes were not required to mask at any time (grade 4 and lower) or in the classroom where physical distancing could be maintained (grade 5 and up).

Main Outcomes and Measures  The primary outcome was the number of hand-to-face contacts per student per hour on day 2 of the simulation. Secondary outcomes included hand-to-mucosa contacts and hand-to-nonmucosa contacts. A mixed Poisson regression model was used to derive rate ratios (RRs), adjusted for age and sex with a random intercept for class with bootstrapped 95% CIs.

Results  A total of 174 students underwent randomization and 171 students (mask group, 50.6% male; control group, 52.4% male) attended school on day 2. The rate of hand-to-face contacts did not differ significantly between the mask and the control groups (88.2 vs 88.7 events per student per hour; RR, 1.00; 95% CI, 0.78-1.28; P = >.99). When compared with the control group, the rate of hand-to-mucosa contacts was significantly lower in the mask group (RR, 0.12; 95% CI, 0.07-0.21), while the rate of hand-to-nonmucosa contacts was higher (RR, 1.40; 95% CI, 1.08-1.82).

Conclusions and Relevance  In this clinical trial of simulated school attendance, hand-to-face contacts did not differ among students required to wear face masks vs students not required to wear face masks; however, hand-to-mucosa contracts were lower in the face mask group. This suggests that mask wearing is unlikely to increase infection risk through self-inoculation.

Trial Registration  ClinicalTrials.gov Identifier: NCT04531254

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Article Information

Accepted for Publication: July 22, 2022.

Published Online: October 24, 2022. doi:10.1001/jamapediatrics.2022.3833

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Science M et al. JAMA Pediatrics.

Corresponding Author: Michelle Science, MD, MSc, Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada (michelle.science@sickkids.ca).

Author Contributions: Drs Science and Matava had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Jüni and Matava contributed equally.

Concept and design: Science, Caldeira-Kulbakas, Anthony, Bitnun, Bourns, Campbell, Cohen, Dodds, Friedman, Greenwood, Hopkins, Imgrund, Mertz, Nashid, Streitenberger, Walsh, Matava.

Acquisition, analysis, or interpretation of data: Science, Caldeira-Kulbakas, Parekh, Maguire, Carroll, Bitnun, Cohen, Dubey, Hopkins, Imgrund, Korczak, Looi, Louca, Panzera, Schneiderman, Schwartz, Vuppal, Walsh, Jüni, Matava.

Drafting of the manuscript: Science, Maguire, and Matava.

Critical revision of the manuscript for important intellectual content: Science, Caldeira-Kulbakas, Parekh, Carroll, Anthony, Bitnun, Bourns, Campbell, Cohen, Dubey, Friedman, Greenwood, Hopkins, Imgrund, Korczak, Looi, Louca, Mertz, Nashid, Panzera, Schneiderman, Schwartz, Streitenberger, Vuppal, Walsh, Jüni, Matava.

Statistical analysis: Science, Parekh, Maguire, Jüni, Matava.

Obtained funding: Science.

Administrative, technical, or material support: Science, Caldeira-Kulbakas, Parekh, Dodds, Greenwood, Hopkins, Looi, Louca, Mertz, Nashid, Panzera, Schneiderman, Schwartz, Streitenberger, Vuppal, Walsh, Matava.

Supervision: Campbell, Dodds, Imgrund, Matava.

Conflict of Interest Disclosures: Mr Imgrund reported nonfinancial support from Canada Strong Masks, outside the submitted work. Dr Korczak reported grants from the Canadian Institutes of Health Research and fees from SickKids, Chair of Child, and Youth Medical Psychiatry Research funds, outside the submitted work. Dr Schwartz reported receiving consulting fees from the Greater Toronto Airports Authority. Dr Jüni reported honoraria to the institution from Amgen, Ava, Fresenius, and grants from Appili Therapeutics to the institution, outside the submitted work; and Dr Jüni serves as unpaid member of the steering group of trials funded by Appili Therapeutics, Abbott Vascular, and Terumo, and has participated in advisory boards and/or consulting for Amgen, Ava, and Fresenius. No other disclosures were reported.

Funding/Support: This work was supported by the Hospital for Sick Children Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Back to School COVID-19 School Study Group: The Back-to-School COVID-19 Simulation Study investigators are listed in Supplement 5.

Data Sharing Statement: See Supplement 6.

Additional Contributions: The authors would like to thank the following Hospital for Sick Children research assistants for their contribution to this work: Muzna Ahmad, MD, Luiza Azzouz, Bsc, Tonny H.M Banh, HBSc, Crystal L.Y. Chan, BSc Janice Chen, BSc, Marlena Colasanto, MSc, Isabel de Verteuil, BSc, Ria G. Evans, BSc (Hons), Y. Ingrid Goh, PhD, Haifan Gong, MSc, Victoria A. Gudzak, BSc, Anjelica Guytingco, BSCN, Melisa Hayalioglu, BSc, Kristina N. Kaganovich, M.FSc, Seyed H. Karimzad, PharmD, Katelynn Lundy, BSc(Hons), Lucie C. Marigliano, Bsc, Roxanne R. Noronha, BSc, Monica Prajapati, Anna Pupco, MD, Jana Radosavljevic, BSc(Hons), Olivia Rennie, Maria Salman, Arunthathy Shanmuganathan, BSc, Kristina L. Stevens, BSc (Hon), Maria Isabel T. Suarez, MPH, Maya Sumaida, RN, Milcah E. Sutanto, BSc (Hons), Nicole C. Tagle, BA(Hons), My An Tran, BSc(Hons), Carlone Van Rooyen, BHSc, RJ Williams, MA, and Yuyang Wu, BSc (Hons). The authors would also like to thank: Allison McGeer for her input on the study design; Elena Blackwood, Grace Borosz, Sally-Jane Casey, Anjelica Guytingco, Rachel Koh, Christine McGovern, Natasha Mills, Chirath Ranaweera, Melyssa Stoute, Megan Verrydt for their help facilitating the COVID testing; Tim Guimond for his help with randomization; and Derek Stephens for his statistical support. We would like to thank the schools and their teams for their considerable support of the study.

Brooks  JT , Butler  JC .  Effectiveness of mask wearing to control community spread of SARS-CoV-2.   JAMA. 2021;325(10):998-999. doi:10.1001/jama.2021.1505PubMedGoogle ScholarCrossref
Howard  J , Huang  A , Li  Z ,  et al.  An evidence review of face masks against COVID-19.   Proc Natl Acad Sci U S A. 2021;118(4):e2014564118. doi:10.1073/pnas.2014564118PubMedGoogle ScholarCrossref
Mendez-Brito  A , El Bcheraoui  C , Pozo-Martin  F .  Systematic review of empirical studies comparing the effectiveness of non-pharmaceutical interventions against COVID-19.   J Infect. 2021;83(3):281-293. doi:10.1016/j.jinf.2021.06.018PubMedGoogle ScholarCrossref
Prather  KA , Wang  CC , Schooley  RT .  Reducing transmission of SARS-CoV-2.   Science. 2020;368(6498):1422-1424. doi:10.1126/science.abc6197PubMedGoogle ScholarCrossref
Chu  DK , Akl  EA , Duda  S , Solo  K , Yaacoub  S , Schünemann  HJ ; COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors.  Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.   Lancet. 2020;395(10242):1973-1987. doi:10.1016/S0140-6736(20)31142-9PubMedGoogle ScholarCrossref
Esposito  S , Principi  N .  To mask or not to mask children to overcome COVID-19.   Eur J Pediatr. 2020;179(8):1267-1270. doi:10.1007/s00431-020-03674-9PubMedGoogle ScholarCrossref
Ontario Agency for Health Protection and Promotion (Public Health Ontario).  SARS-CoV-2 Omicron variant and community masking.  Accessed September 20, 2022. https://www.publichealthontario.ca/-/media/documents/ncov/voc/2021/12/omicron-variant-community-masking.pdf?sc_lang=en. 2021
Volpp  KG , Kraut  BH , Ghosh  S , Neatherlin  J .  Minimal SARS-CoV-2 transmission after implementation of a comprehensive mitigation strategy at a school—New Jersey, August 20-November 27, 2020.   MMWR Morb Mortal Wkly Rep. 2021;70(11):377-381. doi:10.15585/mmwr.mm7011a2PubMedGoogle ScholarCrossref
Hershow  RB , Wu  K , Lewis  NM ,  et al.  Low SARS-CoV-2 transmission in elementary schools—Salt Lake County, Utah, December 3, 2020-January 31, 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(12):442-448. doi:10.15585/mmwr.mm7012e3PubMedGoogle ScholarCrossref
Gold  JAW , Gettings  JR , Kimball  A ,  et al; Georgia K–12 School COVID-19 Investigation Team.  Clusters of SARS-CoV-2 infection among elementary school educators and students in one school district—Georgia, December 2020-January 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(8):289-292. doi:10.15585/mmwr.mm7008e4PubMedGoogle ScholarCrossref
Falk  A , Benda  A , Falk  P , Steffen  S , Wallace  Z , Høeg  TB .  COVID-19 cases and transmission in 17 K-12 schools—Wood County, Wisconsin, August 31-November 29, 2020.   MMWR Morb Mortal Wkly Rep. 2021;70(4):136-140. doi:10.15585/mmwr.mm7004e3PubMedGoogle ScholarCrossref
Ehrhardt  J , Ekinci  A , Krehl  H ,  et al.  Transmission of SARS-CoV-2 in children aged 0 to 19 years in childcare facilities and schools after their reopening in May 2020, Baden-Wurttemberg, Germany.   Euro Surveill. 2020;25(36):2001587. doi:10.2807/1560-7917.ES.2020.25.36.2001587Google ScholarCrossref
Coronado  F , Blough  S , Bergeron  D ,  et al.  Implementing mitigation strategies in early care and education settings for prevention of SARS-CoV-2 transmission—eight states, September-October 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(49):1868-1872. doi:10.15585/mmwr.mm6949e3PubMedGoogle ScholarCrossref
Jehn  M , McCullough  JM , Dale  AP ,  et al.  Association between K-12 school mask policies and school-associated COVID-19 outbreaks—Maricopa and Pima Counties, Arizona, July-August 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(39):1372-1373. doi:10.15585/mmwr.mm7039e1PubMedGoogle ScholarCrossref
Budzyn  SE , Panaggio  MJ , Parks  SE ,  et al.  Pediatric COVID-19 cases in counties with and without school mask requirements—United States, July 1-September 4, 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(39):1377-1378. doi:10.15585/mmwr.mm7039e3PubMedGoogle ScholarCrossref
Spitzer  M .  Masked education? The benefits and burdens of wearing face masks in schools during the current Corona pandemic.   Trends Neurosci Educ. 2020;20:100138. doi:10.1016/j.tine.2020.100138PubMedGoogle ScholarCrossref
Ontario Agency for Health Protection and Promotion (Public Health Ontario).  Mask wearing in children and COVID-19—what we know so far.  Accessed September 20, 2022. https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2021/08/wwksf-wearing-masks-children.pdf?sc_lang=en
Nicas  M , Best  D .  A study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract infection.   J Occup Environ Hyg. 2008;5(6):347-352. doi:10.1080/15459620802003896PubMedGoogle ScholarCrossref
Hendley  JO , Wenzel  RP , Gwaltney  JM  Jr .  Transmission of rhinovirus colds by self-inoculation.   N Engl J Med. 1973;288(26):1361-1364. doi:10.1056/NEJM197306282882601PubMedGoogle ScholarCrossref
Belser  JA , Gustin  KM , Maines  TR , Pantin-Jackwood  MJ , Katz  JM , Tumpey  TM .  Influenza virus respiratory infection and transmission following ocular inoculation in ferrets.   PLoS Pathog. 2012;8(3):e1002569. doi:10.1371/journal.ppat.1002569PubMedGoogle ScholarCrossref
Killingley  B , Nguyen-Van-Tam  J .  Routes of influenza transmission.   Influenza Other Respir Viruses. 2013;7(suppl 2):42-51. doi:10.1111/irv.12080PubMedGoogle ScholarCrossref
Schulz  KF , Altman  DG , Moher  D , CONSORT Group.  CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials.   BMC Med. 2010;8(1):18. doi:10.1186/1741-7015-8-18Google ScholarCrossref
Ontario Ministry of Education.  Approach to reopening schools for the 2020-2021 school year.  Accessed September 20, 2022. https://www.ontario.ca/page/approach-reopening-schools-2020-2021-school-year
Lin  J , Pol  SJ , Korczak  DJ ,  et al; Back to School COVID-19 Study Group.  Impact of COVID-19 public health protocols on teachers instructing children and adolescents during an in-person simulation.   J Can Acad Child Adolesc Psychiatry. 2022;31(2):52-63.PubMedGoogle Scholar
Coelho  SG , Segovia  A , Anthony  SJ ,  et al.  Return to school and mask-wearing in class during the COVID-19 pandemic: student perspectives from a school simulation study.   Paediatr Child Health. 2022;27(suppl 1):S15-S21. doi:10.1093/pch/pxab102PubMedGoogle ScholarCrossref
Julian  TR , Canales  RA , Leckie  JO , Boehm  AB .  A model of exposure to rotavirus from nondietary ingestion iterated by simulated intermittent contacts.   Risk Anal. 2009;29(5):617-632. doi:10.1111/j.1539-6924.2008.01193.xPubMedGoogle ScholarCrossref
Contreras  RD , Wilson  AM , Garavito  F , Sexton  JD , Reynolds  KA , Canales  RA .  Assessing virus infection probability in an office setting using stochastic simulation.   J Occup Environ Hyg. 2020;17(1):30-37. doi:10.1080/15459624.2019.1691219PubMedGoogle ScholarCrossref
Gamer  M , Lemon  J , Fellows  I , Singh  P .  Coefficients of Interrater Reliability and Agreement: R package version 0.84.1.  Accessed September 20, 2022. https://cran.r-project.org/web/packages/irr/index.html
Karun  KM , Puranik  A .  BA.plot: an R function for Bland-Altman analysis.   Clinical Epidemiology and Global Health. 2021;12:100831. doi:10.1016/j.cegh.2021.100831Google ScholarCrossref
Liebst  LS , Ejbye-Ernst  P , de Bruin  M , Thomas  J , Lindegaard  MR .  Face-touching behaviour as a possible correlate of mask-wearing: a video observational study of public place incidents during the COVID-19 pandemic.   Transbound Emerg Dis. 2022;69(3):1319-1325. doi:10.1111/tbed.14094PubMedGoogle ScholarCrossref
Chen  YJ , Qin  G , Chen  J ,  et al.  Comparison of face-touching behaviors before and during the Coronavirus disease 2019 pandemic.   JAMA Netw Open. 2020;3(7):e2016924. doi:10.1001/jamanetworkopen.2020.16924PubMedGoogle ScholarCrossref
Lucas  TL , Mustain  R , Goldsby  RE .  Frequency of face touching with and without a mask in pediatric hematology/oncology health care professionals.   Pediatr Blood Cancer. 2020;67(9):e28593. doi:10.1002/pbc.28593PubMedGoogle ScholarCrossref
Grunwald  M , Weiss  T , Mueller  S , Rall  L .  EEG changes caused by spontaneous facial self-touch may represent emotion regulating processes and working memory maintenance.   Brain Res. 2014;1557:111-126. doi:10.1016/j.brainres.2014.02.002PubMedGoogle ScholarCrossref
Beamer  PI , Plotkin  KR , Gerba  CP , Sifuentes  LY , Koenig  DW , Reynolds  KA .  Modeling of human viruses on hands and risk of infection in an office workplace using micro-activity data.   J Occup Environ Hyg. 2015;12(4):266-275. doi:10.1080/15459624.2014.974808PubMedGoogle ScholarCrossref
Macias  AE , de la Torre  A , Moreno-Espinosa  S , Leal  PE , Bourlon  MT , Ruiz-Palacios  GM .  Controlling the novel A (H1N1) influenza virus: don’t touch your face!   J Hosp Infect. 2009;73(3):280-281. doi:10.1016/j.jhin.2009.06.017PubMedGoogle ScholarCrossref
Elder  NC , Sawyer  W , Pallerla  H , Khaja  S , Blacker  M .  Hand hygiene and face touching in family medicine offices: a Cincinnati Area Research and Improvement Group (CARInG) network study.   J Am Board Fam Med. 2014;27(3):339-346. doi:10.3122/jabfm.2014.03.130242PubMedGoogle ScholarCrossref
Kwok  YL , Gralton  J , McLaws  ML .  Face touching: a frequent habit that has implications for hand hygiene.   Am J Infect Control. 2015;43(2):112-114. doi:10.1016/j.ajic.2014.10.015PubMedGoogle ScholarCrossref
Wilson  AM , Verhougstraete  MP , Beamer  PI , King  MF , Reynolds  KA , Gerba  CP .  Frequency of hand-to-head, -mouth, -eyes, and -nose contacts for adults and children during eating and non-eating macro-activities.   J Exp Sci Environ Epidemiol. 2021;31(1):34-44. doi:10.1038/s41370-020-0249-8PubMedGoogle ScholarCrossref
Rutter  H , Parker  S , Stahl-Timmins  W ,  et al.  Visualising SARS-CoV-2 transmission routes and mitigations.   BMJ. 2021;375:e065312. doi:10.1136/bmj-2021-065312PubMedGoogle ScholarCrossref
Port  JR , Yinda  CK , Owusu  IO ,  et al.  SARS-CoV-2 disease severity and transmission efficiency is increased for airborne compared to fomite exposure in Syrian hamsters.   Nat Commun. 2021;12(1):4985. doi:10.1038/s41467-021-25156-8PubMedGoogle ScholarCrossref
Klompas  M , Milton  DK , Rhee  C , Baker  MA , Leekha  S .  Current insights into respiratory virus transmission and potential implications for infection control programs : a narrative review.   Ann Intern Med. 2021;174(12):1710-1718. doi:10.7326/M21-2780PubMedGoogle ScholarCrossref
Kampf  G , Todt  D , Pfaender  S , Steinmann  E .  Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents.   J Hosp Infect. 2020;104(3):246-251. doi:10.1016/j.jhin.2020.01.022PubMedGoogle ScholarCrossref
Rabie  T , Curtis  V .  Handwashing and risk of respiratory infections: a quantitative systematic review.   Trop Med Int Health. 2006;11(3):258-267. doi:10.1111/j.1365-3156.2006.01568.xPubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

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