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Infectious Diseases

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
JAMA Pediatrics
Published Online: October 24, 2022
Original Investigation
Michelle Science, MD, MSc1,2,3;
Monica Caldeira-Kulbakas, PhD4;
Rulan S. Parekh, MD, MSc, FRCPC5,6;
Bryan R. Maguire, MSc7;
Stacie Carroll, DipCS, OCT, ECE8,9;
Samantha J. Anthony, PhD, MSW5,10;
Ari Bitnun, MD, MSc1,3;
Laura E. Bourns, MD2;
Douglas M. Campbell, MD, MSc, FRCPC3,11,12,13;
Eyal Cohen, MD, MSc, FRCPC3,5,14,15,16;
Alison Dodds, BScN, MEd17;
Vinita Dubey, MD, MPH18,19;
Jeremy N. Friedman, MBChB, FRCP3,20;
Jodi L. Greenwood, BSPsyc, BMus, Bed, PGD, Music Therapy8,9;
Jessica P. Hopkins, MD, MHSc2,19,21;
Ryan Imgrund, BSc, BEd22;
Daphne J. Korczak, MD, MSc23,24;
Thomas Looi, PhD, MBA, PEng25,26;
Emily Louca, RRT, BSc, MA17;
Dominik Mertz, MD, MSc27,28;
John Nashid, MBA29;
Giovanna Panzera, BEd8,9;
Jane E. Schneiderman, PhD30,31;
Kevin L. Schwartz, MD, MSc2,19,32;
Laurie Streitenberger, BSc, RN, CIC33;
Sunayna Vuppal, MN, BScN17;
Catharine M. Walsh, MD, Med, PhD3,5,15,17,34;
Peter Jüni, MD, FESC15,35,36;
Clyde T. Matava, MBChB, MHSc4,37;
for the Back-to-School COVID-19 School Study Group
Author Affiliations
  • 1Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 2Public Health Ontario, Toronto, Ontario, Canada
  • 3Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 4Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 5Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 6Division of Nephrology, Department of Pediatrics and Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 7Biostatistics Design and Analysis Unit, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 8Child and Family Centred Care, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 9Education and Community Partnership Program, Toronto District School Board, Toronto, Ontario, Canada
  • 10Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
  • 11Neonatal Intensive Care Unit, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
  • 12Allan Waters Family Simulation Program, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
  • 13Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
  • 14Complex Care Program, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 15Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 16Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
  • 17SimKids Simulation Program, The Learning Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 18Communicable Disease Control, Toronto Public Health, Toronto, Ontario, Canada
  • 19Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 20Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 21Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  • 22Biostatistics, Southlake Regional Health Centre, Newmarket, Ontario, Canada
  • 23Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 24Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
  • 25Department of Neuroscience and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 26The Wilfred and Joyce Posluns Centre for Image-Guided Innovation and Therapeutic Intervention, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 27Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  • 28Department of Infection Prevention and Control, Hamilton Health Sciences, Hamilton, Ontario, Canada
  • 29Corporate Strategy, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 30Division of Respiratory Medicine, Clinical Research Services, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 31Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
  • 32Division of Infectious Diseases, Department of Medicine, Unity Health Toronto, Toronto, Ontario, Canada
  • 33Infection Prevention & Control (IPAC) Program, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 34Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 35Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
  • 36Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 37Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • Back-to-School COVID-19 School Study Groupfor the
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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.

Abstract

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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Infectious Diseases Pediatrics Public Health Coronavirus (COVID-19)
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.

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  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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