Jennifer Araiza
May 27, 2020
The global COVID 19 pandemic has brought with it a change in the way class instruction has occurred. With the anticipated return to the classroom, there is much discussion about mandatory face coverings for students and school personnel. When face masks became a requirement for the public at large, there were increasing complaints of anxiousness, headaches, fatigue and overall feelings of discomfort. In response, numerous articles have been published suggesting these feelings are not related to face mask specifically. At the same time, there is consensus across the board that face masks are unsafe for young children. This paper seeks to review literature regarding the impacts of CO2 and face masks on children; especially within the classroom. Based on the review, face masks do not appear to be conducive to classroom safety; however, more research is needed.
HUMAN BREATHING – GAS EXCHANGE
The human body and plants have a dependency upon one another. During human respiration, the body inhales oxygen and exhales carbon dioxide. The carbon dioxide exhaled by humans is then used by plants during the photosynthesis process. The carbon dioxide moves from the air into the leaves. During plant respiration, oxygen is produced and released. Humans depend on plants for oxygen while plants depend on humans for carbon dioxide. Humans depend on oxygen, yet carbon dioxide is their waste product. Plants depend on carbon dioxide, yet oxygen is their waste product. Hence the interdependency of humans and plants upon each other.
CARBON DIOXIDE AND HUMANS
Carbon Dioxide is emitted by humans during the respiration process, as it is a waste product that is harmful to humans in high levels. Carbon Dioxide is an odorless, colorless and nonflammable gas that makes up less than 4% of Earth’s atmosphere (Easterbrook, 2016). Carbon dioxide is essential to normal day to day activity. “It is a key factor in the control of respiration and cerebral circulation. It acts peripherally, both as vasodilator and as vasoconstrictor, and is a powerful cerebral vasodilator. At high concentrations, it exerts a stimulating effect on the central nervous system, while excessive levels exert depressant effects” (NIOSH, 1976). Multiple studies have indicated that high levels of carbon dioxide can cause hyperventilation, a loss of consciousness and other psychological effects. In a study, 37 young adults were exposed to 30% carbon dioxide by mask for 50-52 seconds. On average, consciousness was lost within 24-28 seconds and regained after 110 seconds (NIOSH, 1976).
Carbon dioxide exposure, in excess levels, can cause many health issues such as headaches, dizziness, restlessness, tingling, difficulty breathing, sweating, tiredness, increased heart rate, elevated blood pressure, coma, asphyxia and convulsions. As carbon dioxide is a gas, it is measured in parts per million (ppm). Normal levels in outdoor air are 250-400 ppm and 400-1000 ppm in indoor spaces with good air flow. Effects of excess exposure begin being experienced at 1,000 ppm and above. At 1,000 – 2,000 ppm complaints of drowsiness are typical. Headaches, sleepiness, poor concentration, loss of attention, increased heart rate and slight nausea can be experienced at 2,000-5,000 ppm. Over 5,000 ppm is considered toxic and can lead to oxygen deprivation. This is the maximum permittable exposure limit in adult workplace environments (WDHS, 2019). One study suggested psychological changes begin occurring at exposures as low as 500 ppm while cognitive performance is affected at 1000 ppm (Azuma, Kagi, Yanagi, & Osawa, 2018).
Respiratory symptoms have been indicated in children exposed to indoor carbon dioxide concentrations exceeding 1000 ppm. Experimental studies have suggested short term exposure to CO2 levels of 1000 ppm or higher also affect cognitive performances including decision making and problem resolution (Azuma, Kagi, Yanagi, & Osawa, 2018).
STUDENTS AND CLASSROOMS
With the prevalence of cognitive and psychological effects as a result of excess levels of carbon dioxide, the impact on children and classrooms must be considered. “The accepted standard CO2 levels in classrooms is 1000 ppm. This level is easy to maintain when students aren’t present. The levels are harder to maintain within a classroom filled with students. A study of California classrooms revealed CO2 levels as high as 2200 ppm and even higher in office and computer lab settings. Likewise, in Texas, 21% of classrooms tested were found to have levels over 3000 ppm. These levels are not effective for learning environments (Kilpatrick, 2014).
Often times, proper consideration isn’t given soon enough, resulting in tragic consequences. In 2020, two 14-year-old boys died in China while wearing a face mask during physical activity. In response, Dr. Sarah Fankhauser, assistant professor of biology and infectious disease expert at Oxford College, stated “wearing masks while exercising comes with a risk, since covering your face restricts air flow” (Harris, 2020). Michael Figueroa, EdD, further explained, “a mask will restrict airflow in and out of the mouth and nose, creating a situation where oxygen and carbon dioxide exchange are compromised.” The levels of carbon dioxide increase resulting in faster breathing and increased heart rate. Carbon dioxide could become trapped inside with levels that could result in fatigue (Harris, 2020). While excess physical activity can be minimized for children in classroom settings, there are additional health and mental considerations for this type of limitation.
Another consideration is the impact of face coverings for those with respiratory conditions. Children with underlying conditions such as asthma or cystic fibrosis may be unable to tolerate further constriction of their airways. Asthma UK advises that those with respiratory conditions shouldn’t wear a face covering if breathing is compromised by doing so (Asthma UK, 2020). The American Academy of Pediatrics advises “children with severe cognitive or respiratory impairments may have a hard time tolerating a face mask, so special precautions may be needed with children, such as monitoring with a pulse oximeter” (AAP, 2020). Confirming that face masks can compromise oxygen so greatly that external monitoring is required.
While those with severe respiratory conditions have plans in place to control excruciating circumstances; those with milder conditions are mainstreamed into traditional environments. Twenty-five million American’s, approximately 8.4 percent of all American children, have asthma (AAFA, 2020). Teachers and school personnel must be prepared to address the compromised conditions that may come with prolonged use of facial coverings.
ARE FACE MASKS EFFECTIVE?
There is a plethora of conflicting data regarding the effectiveness of masks in the prevention of airborne illnesses. Surgical masks are “primarily designed to prevent the passage of relatively large particles, such as sputum droplets and hair. A high-tech version – the so-called N95 respirator – seals tightly around mouth and nose and is made of material certified to block 95% of particles 0.3 μm or larger in diameter, roughly the size of a single virus.” Yet multiple research studies have provided conflicting evidence on the effectiveness of either. Overall, N95 masks seem to provide the greatest level of protection but are intolerable for those with respiratory illness. N95 mask provide the best protection but are difficult to breathe through causing feelings of suffocation and claustrophobia (Phend, 2009).
In 2010, a study was conducted to test the effectiveness of alternative face coverings in the event of face mask shortages. The study analyzed the ability for viruses to pass through fabrics such as cotton shirts. It was found that “the use of fabric materials may provide only minimal levels of respiratory protections to a wearer against virus-sized submicron aerosol particles…Similarly, home-made face masks made of tea cloths tested on human subjects provided marginal protection.” These results were consistent with surgical masks indicating both surgical masks and fabric materials “may be of some value compared to no protection.” The study did find that N95 respirators were the most effective. In conclusion, “The penetration values obtained for common fabric materials indicate that only marginal respiratory protection can be expected for submicron particles taking into consideration face seal leakage” (Rengasamy, Eimer& Shaffer, 2010).
The FDA warns that N95 masks can make it more difficult for the wearer to breathe. A version of the N95 has been designed with an exhalation valve however they are not conducive to sterile conditions. They are also not designed for children or people with facial hair due to improper fitting which will not provide full protection (Center for Devices and Radiological Health & FDA, 2020).
The CDC advises that surgical masks “do NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is not considered respiratory protection. Leakage occurs around the edge of the mask when user inhales” (CDC, 2020). The CDC confirms N95 is effective in filtering small particles, reducing wearers exposure when properly fitted and can cause difficulty breathing (CDC, 2020).
In two separate studies of health care workers, N95 masks showed an increase in CO2 levels and a decrease in oxygen levels. A two-phased controlled clinical study found that volume of oxygen consumption and carbon dioxide expired were significantly reduced. “Although no changes in the inspired oxygen and carbon dioxide concentrations were demonstrated, breathing through N95-mask materials during low intensity work reduced expired oxygen concentration and increased expired carbon dioxide” (Pearl et al, 2015). In a second study, health care workers were monitored while wearing masks and conducting realistic levels of exertion. Results of the study showed that oxygen and carbon dioxide levels did not meet OSHA standards (Roberge, Coca, Williams, Palmiero, & Powell, 2010).
Another study investigated whether surgical masks could be a source of bacterial exposure. The study found an increase of mask bacteria after 2 hours (Zhiqing, et al., 2018). A second study tested used masks for bacteria and found viable bacteria present on all masks immediately after loading and up to 98% of mask showed recovery of bacteria 5 days after storage (Brosseau, Mccullough, & Vesley, 1997).
MANDATORY FACE MASKS FOR STUDENTS
In light of the anticipated return to school date for California amid the COVID 19 pandemic, Superintendent Tony Thurmond said, “We know that having access to this personal protective equipment is a critical factor in the ability to reopen. Quite frankly, our schools cannot reopen without it” (Mays, 2020). The CDC is also recommending that students and school personnel wear face coverings. It is recommended that cloth face coverings be worn in an effort to reserve surgical and N95 masks for health care professionals (CDC, 2020).
ARE FACE MASKS SAFE FOR STUDENTS?
Nationwide Children’s Organization reports that face coverings should never be used on children under age two. Due to smaller airways and the potential of suffocations, face masks are not deemed safe for this age group. They also advise that younger children are not able to remove the mask if needed and are likely to touch their face and mask more often. It is also explained that N95 masks are not approved for young children (Eby & Vegh, 2020).
“An effective face mask seal requires moulding of the top of the mask over nasal bridge, and the bottom of the mask pulled down over the chin. Masks are not effective once they are wet or soiled…When masks are worn, they increase the resistance against breathing coupled with an increase in the levels of carbon dioxide in the dead space contained behind the mask. This may result in hypoventilation in infants and children below the age of 3 (who have smaller lung capacities) and poorer clearance of carbon dioxide. This accumulation of higher levels of carbon dioxide can be dangerous.” Furthermore, they explain that most N95 masks on the market are designed for ages 12 and above. There have been studies to support the use of masks of this type for 7 to 12 years, if they fit appropriately (Rajakulendran, 2020).
DISCUSSIONS
There is a lot of conflicting data on the effectiveness of masks, especially for children. There is agreement that young children should not wear masks due to issues associated with compromised breathing. There is consistency that masks are breeding grounds for bacteria and should be changed and cleaned regularly. Some studies suggest that face coverings should be changed every two hours and should not be touched or handled in an effort to contain bacteria captured within the material.
Data regarding carbon dioxide levels are inconclusive and have recently been challenged during the COVID pandemic. However, it cannot be disregarded that studies have proved elevated levels of CO2 in many classrooms. Consider these increased levels with the potential of trapped CO2 due to face coverings. At the very least it could be argued that more studies should be completed. Without conclusive studies on the impact of mixing high level CO2 levels in classrooms with facial coverings, it should be assumed there is potential for compromised breathing, drowsiness and loss of attention.
Without properly fitting face masks, there is a potential for particles to escape open spaces. If students are constantly touching their masks, there is an increased potential to spread bacteria through touch. Combine this with the barrier that muffles sound preventing for clear communication between students and teachers; masks do not seem to have a place within a classroom. Instead social distancing, regular hand washing, and surface cleaning seem to be more effective and conducive to learning and the health and safety of our students.
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