Mask mandate and use efficacy in state-level COVID-19 containment

Guerra, D.; Guerra, D. J.

Background: Containment of the COVID-19 pandemic requires evidence-based strategies to reduce transmission. Because COVID-19 can spread via respired droplets, many states have mandated mask use in public settings. Randomized control trials have not clearly demonstrated mask efficacy against respiratory viruses, but observational studies suggest greater mask compliance may be associated with lower infection rates. We hypothesized that statewide mask mandates and mask use are associated with lower COVID-19 case growth rates in the United States. Methods: We calculated total COVID-19 case growth and mask use for the continental United States with data from the Centers for Disease Control and Prevention and Institute for Health Metrics and Evaluation. We estimated post-mask mandate case growth in non-mandate states using median issuance dates of neighboring states with mandates. Results: Case growth was not significantly different between mandate and non-mandate states at low or high transmission rates, and surges were equivocal. Mask use predicted lower case growth at low, but not high transmission rates. Growth rates were comparable between states in the top and bottom mask use quintiles adjusted for normalized total cases early in the pandemic and unadjusted after peak Fall-Winter infections. Mask use did not predict Summer 2020 case growth for non-Northeast states or Fall-Winter 2020 growth for all states. Conclusions: Mask mandates and use are not associated with slower state-level COVID-19 spread during COVID-19 growth surges. COVID-19 containment requires future research and implementation of existing efficacious strategies.