The introduction of a mandatory mask policy was associated with significantly reduced COVID-19 cases in a major metropolitan city

Abstract

Background: Whilst evidence of use of face masks in reducing COVID-19 cases is increasing, the impact of mandatory use across a large population has been difficult to assess. Introduction of mandatory mask use on July 22, 2020 during a resurgence of COVID-19 in Melbourne, Australia created a situation that facilitated an assessment of the impact of the policy on the epidemic growth rate as its introduction occurred in the absence of other changes to restrictions.

Methods and findings: Exponential epidemic growth or decay rates in daily COVID-19 diagnoses were estimated using a non-weighted linear regression of the natural logarithm of the daily cases against time, using a linear spline model with one knot (lspline package in R v 3.6.3). The model's two linear segments pivot around the hinge day, on which the mask policy began to take effect, 8 days following the introduction of the policy. We used two forms of data to assess change in mask usage: images of people wearing masks in public places obtained from a major media outlet and population-based survey data. Potential confounding factors (including daily COVID-19 tests, number of COVID-19 cases among population subsets affected differentially by the mask policy-e.g., healthcare workers) were examined for their impact on the results. Daily cases fitted an exponential growth in the first log-linear segment (k = +0.042, s.e. = 0.007), and fitted an exponential decay in the second (k = -0.023, s.e. = 0.017) log-linear segment. Over a range of reported serial intervals for SARS-CoV-2 infection, these growth rates correspond to a 22-33% reduction in an effective reproduction ratio before and after mandatory mask use. Analysis of images of people in public spaces showed mask usage rose from approximately 43% to 97%. Analysis of survey data found that on the third day before policy introduction, 44% of participants reported "often" or "always" wearing a mask; on the fourth day after, 100% reported "always" doing so. No potentially confounding factors were associated with the observed change in growth rates.

Conclusions: The mandatory mask use policy substantially increased public use of masks and was associated with a significant decline in new COVID-19 cases after introduction of the policy. This study strongly supports the use of masks for controlling epidemics in the broader community.

Fig 1. COVID-19 cases detected per day in Victoria.

Observed daily cases (dots) and fitted linear spline model with a hinge day on 31st July, with shading representing upper and lower 95% confidence interval of the fitted curves. Red: analysis period for pre-masks; Blue: analysis period for post-masks.

Fig 2. Results from the SCRUB survey.

Left: for Round 6 respondents (20–26 July) in Victorian Stage 4 restriction areas, reported frequency of mask use in the past 7 days. Numbers on top of bars represent total respondents. Right: the percentage of respondents who reported always or often wearing a mask over time, Victorian Stage 4 restriction areas and compared to major cities in other states. The number of respondents varied from survey to survey and state to state but averaged 38.6 for each state and time point and the details are listed in S1 File.