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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

Article Information and Disclosures

Michelle Science, MD, MSc^1,2,3;

Monica Caldeira-Kulbakas, PhD⁴;

Rulan S. Parekh, MD, MSc, FRCPC^5,6;

Bryan R. Maguire, MSc⁷;

Stacie Carroll, DipCS, OCT, ECE^8,9;

Samantha J. Anthony, PhD, MSW^5,10;

Ari Bitnun, MD, MSc^1,3;

Laura E. Bourns, MD²;

Douglas M. Campbell, MD, MSc, FRCPC^3,11,12,13;

Eyal Cohen, MD, MSc, FRCPC^3,5,14,15,16;

Alison Dodds, BScN, MEd¹⁷;

Vinita Dubey, MD, MPH^18,19;

Jeremy N. Friedman, MBChB, FRCP^3,20;

Jodi L. Greenwood, BSPsyc, BMus, Bed, PGD, Music Therapy^8,9;

Jessica P. Hopkins, MD, MHSc^2,19,21;

Ryan Imgrund, BSc, BEd²²;

Daphne J. Korczak, MD, MSc^23,24;

Thomas Looi, PhD, MBA, PEng^25,26;

Emily Louca, RRT, BSc, MA¹⁷;

Dominik Mertz, MD, MSc^27,28;

John Nashid, MBA²⁹;

Giovanna Panzera, BEd^8,9;

Jane E. Schneiderman, PhD^30,31;

Kevin L. Schwartz, MD, MSc^2,19,32;

Laurie Streitenberger, BSc, RN, CIC³³;

Sunayna Vuppal, MN, BScN¹⁷;

Catharine M. Walsh, MD, Med, PhD^3,5,15,17,34;

Peter Jüni, MD, FESC^15,35,36;

Clyde T. Matava, MBChB, MHSc^4,37;

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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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.

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.

AMA CME Accreditation Information

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:

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 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

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