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N95 vs FFP3 & FFP2 masks –

what’s the difference?
Published
Published Feb
Feb 3,
3, 2020
2020
-- Updated Jun 14, 2020
Updated Jun 14, 2020
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With the novel coronavirus outbreak globally, many people are understandably concerned about their health and safety.

In this post we’ll look at the di erence between respirator ltering standards such as N95 and FFP2/FFP3…

Contents [hide]

1 Masks vs Respirators
2 Respirator Standards
2.1 N95 vs FFP3 & FFP2
2.2 KN95 vs N95
2.3 Are N95/N100 actually better than FFP2/P3?
2.4 Valve vs Non-Valved Respirators
2.5 How big is the Coronavirus, and can respirators lter it?
2.6 N vs P respirators? (Oil Resistance)
2.7 Surgical vs Non-Surgical Respirators?
2.8 Risks With Using Respirators
2.9 Reliable Brands?
3 Surgical Masks
3.1 Can Surgical Masks Filter the Coronavirus?
4 DIY / Homemade Masks
5 What are respirators protecting us against?
5.1 Is Eye Protection Necessary?
6 Additional Subjects of Importance
6.1 Shave! (When Wearing a Respirator)
6.2 Important Hygiene Measures
6.2.1 Regular Hand Washing
6.2.2 Trim Finger Nails
6.2.3 Alcohol Based Hand Sanitizer
6.2.4 Sanitize your phone and other items you touch regularly
6.3 How to maintain a healthy immune system?
6.3.1 Sleep
6.3.2 Exercise
6.3.3 Vitamin D
6.3.4 Selenium
6.4 Indoors vs Outdoors Risk
7 Roundup
Next → 8 Further Learning
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8.1.1 See Post Sources Below:

Masks vs Respirators
 Masks vs Respirators
Before we go any further, let’s just clarify on a technical di erence between a “mask” and a “respirator”. In day to day
language we often say mask, when referring to what are technically called respirators.

Uses for Masks:

Masks are loose tting, covering the nose and mouth

Designed for one way protection, to capture bodily uid leaving the wearer

Example – worn during surgery to prevent coughing, sneezing, etc on the vulnerable patient

Contrary to belief, masks are NOT designed to protect the wearer

The vast majority of masks do not have a safety rating assigned to them (e.g. NIOSH or EN)

Uses for Respirators:

Respirators are tight tting masks, designed to create a facial seal

Non-valved respirators provide good two way protection, by ltering both in ow and out ow of air

These are designed protect the wearer (when worn properly), up to the safety rating of the mask

Available as disposable, half face or full face

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 Respirator Standards
Whilst surgical style masks are not redundant by any means (discussed more below), they aren’t designed to protect the
wearer, whilst respirators are.

The US Center for Disease Control (CDC) cites the N95 respirator standard as part of the advised protective equipment
in their Covid-19 FAQ and their SARS guidance (SARS being a similar type of Corona virus). Which suggests that an N95 or
better respirator is acceptable.

N95 vs FFP3 & FFP2

The most commonly discussed respirator type is N95. This is an American standard managed by NIOSH – part of the
Center for Disease Control (CDC).

Europe uses two di erent standards. The “ ltering face piece” score (FFP) comes from EN standard 149:2001. Then EN
143 standard covers P1/P2/P3 ratings. Both standards are maintained by CEN (European Committee for
Standardization).

Let’s see how all the di erent standards compare:

Respirator Standard Filter Capacity (removes x% of of all particles that are 0.3 microns in diameter or larger)

FFP1 & P1 At least 80%

FFP2 & P2 At least 94%

N95 At least 95%

N99 & FFP3 At least 99%

P3 At least 99.95%

N100 At least 99.97%

As you can see, the closest European equivalent to N95 are FFP2 / P2 rated respirators, which are rated at 94%,
compared to the 95% of N95.

Similarly, the closest to N100 are P3 rated respirators – with FFP3 following closely behind.

You could approximate things to say:

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 KN95 vs N95

According to 3M (source), the Chinese KN95 standard has an equivalent speci cation to N95/FFP2 respirators . To quote:

“It is reasonable to consider China KN95, AS/NZ P2, Korea 1st Class, and Japan DS FFRs as equivalent to US NIOSH N95 and
European FFP2 respirators”

In practice the issue is more complex, and I wouldn’t take for granted that all KN95 respirators are up to the same
standard.

Things to watch out for:

Typically KN95 respirators are held in place by over-ear elastic loops, rather than behind the head elastics. This can
result in a weaker seal. Fortunately there are methods for tightening – see this YouTube video for ideas. Products
called “ear savers” can also aid with tightening, and can be found on eBay or you can 3D print them.

There’s no guarantee that all KN95 respirators actually meet the Chinese KN95 standard. However, with the current
respirator shortage, unfortunately the same goes for N95/FFP also.

The KN95 speci cation is referred to as GB 2626-2006 (preview here) – so you will generally see that written on the KN95
respirators. From July 1st 2020, it’ll be replaced by GB 2626-2019, an updated speci cation (preview here).

I’ve linked below to a supplier of KN95 respirators in the USA – in case it’s of use to some readers.

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 Are N95/N100 actually better than FFP2/P3?

Not necessarily, it’s important to note that these standards only specify the minimum % of particles that the respirator
lters. For example, if a mask is FFP2 rated, it will lter at least 94% of particles that are 0.3 microns in diameter or larger.
But in practice it will lter somewhere between 94% and 99%. The precise gure will often be quoted by the
manufacturer in the product description.

A good example is the GVS Elipse respirator, which in the USA (link) is rated at P100 (99.7%), and in Europe (link) is rated
at P3 (99.95%). In practice it’s likely to have the same ltering capacity in both regions.

Valve vs Non-Valved Respirators

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Valved respirators make it easier to exhale air. This makes them more comfortable to wear, and leads to less moisture
 build-up inside the respirator. Ideal for things like DIY/construction work.

The problem with valved respirators is that they do not lter the wearer’s exhalation, only the inhale. This one-way
protection puts others around the wearer at risk, in a situation like Covid-19. It’s for this reason that hospitals and other
medical practices do not use valved respirators.

One hack to protect (and respect) others when wearing a valved respirator is to put a surgical mask or “cloth face
covering” over the valved respirator, to (partially) lter the out breath.

How big is the Coronavirus, and can respirators lter it?

TL;DR – yes, respirators with high e ciency at 0.3 micron particle size (N95/FFP2 or better) can in theory lter particles
down to the size of the coronavirus (which is around 0.1 microns). What that doesn’t tell us is how much protection
respirators will provide against coronavirus when in use – we will need to wait for future studies to con rm.

Read on to learn more…

A recent paper shows that the coronavirus ranges from between 0.06 and 0.14 microns in size. Note that the paper
refers to the coronavirus particle as 2019-nCoV, which was it’s old name. The virus is currently called SARS-CoV-2, and
the illness it presents in people is called Covid-19.

Respirator’s are measured by their e ciency at ltering particles of 0.3 microns and bigger (noting that the coronavirus
is smaller than that).

The reason for the focus on 0.3 microns is because it is the “most penetrating particle size” (MPPS). Particles above this
size move in ways we might anticipate, and will get trapped in a lter with gaps smaller than the particle size. Particles
smaller
Next → than 0.3 microns exhibit what’s called brownian motion – which makes them easier to lter. Brownian motion Menu
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refers to a phenomenon whereby the particle’s mass is small enough that it no longer travels unimpeded through the
air. Instead it interacts with the molecules in the air (nitrogen, oxygen, etc), causing it to pinball between them, moving in
an erratic pattern.
 According to researchers this point between “normal” motion and brownian motion is the hardest particle size for lters
to capture.

What we can take away from this, is that high lter e ciency at 0.3 micron size will generally translate to high lter
e ciency below this size also.

For more discussion and details on the subject of respirator lters and brownian motion – see this great post at
smart lters.com.

Now lets look at speci c research that measures the lter e ciency at 0.3 microns and below (coronavirus territory)…

This article by 3M discusses research showing that all 6 of the N95 respirators they tested can e ciently lter lower
than 0.1 micron size with approximately 94% e ciency or higher. The graph below is from that article, and illustrates
this:

Additionally, smart lters.com have a great article on this subject, citing research showing that the respirators tested
could lter down to 0.007 microns (much smaller than Covid-19). For example the 3M 8812 respirator (FFP1 rated)
was able to lter 96.6% of particles 0.007 microns or larger. Suggesting FFP2 or FFP3 would achieve even greater
ltration.

The below image (click it to expand) shows the size of the coronavirus, relative to other small molecules like a red blood
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 Image of coronavirus vs other particles – from smartair lters.com

N vs P respirators? (Oil Resistance)

Click to expand - N vs P respirators? (Oil Resistance)

Surgical vs Non-Surgical Respirators?

Click to expand - Surgical vs Non-Surgical Respirators?

Risks With Using Respirators

There are a number of possible risks with respirators that it’s worth being aware of, so that you can avoid making them.

1. Not tting and wearing respirators correctly – A respirator can’t fully protect you if it doesn’t t your face. See
OSHA guidance on t testing and t checking for more info.

2. Touching the front of the respirator (which catches viruses etc) and then transferring that to other objects, which
could eventually lead back to your mouth and nose.

3. Taking unnecessary exposure risks because you’re wearing a respirator. Don’t let it give you false con dence. The
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For further discussion on these 3 points, see the expandable box below:
 Click to expand - Risks with Using Respirators?

Reliable Brands?

Prior to the pandemic, there was easy access to reliable brands such as 3M, GVS, Moldex etc. Now, however, their supply
is either going to frontline workers (as it should be) or it’s very limited.

This means that the general public are left to either make their own face coverings (discussed below), or do their own
due diligence when sourcing less well known brands. Hopefully this whole article helps with that due diligence process.

Below I’ve listed a US retailer who currently have stock, and I’ve happily bought from before (see my brief review of them
for more info).

Health Bodyguard Store – KN95 rated respirators stocked in Ohio and shipped to all of mainland USA. From $4 to $6
per respirator, depending on quantity. They also currently stock 3-ply blue surgical masks.

Surgical Masks
Surgical masks are generally speaking a 3-ply (three layer) design, with 2 sheets of “non-woven” fabric sandwiching a
“melt-blown” layer in the middle. It’s the melt-blown layer that provides the ltering capability. A melt-blown material is
also used in respirators, and thus you can imagine it’s more expensive and hard to come by recently, due to demand.

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Image of the melt-blown laments under microscope come from mdpi.com

Th lt bl f b i i d b lti l ti th bl i it f ith id t hi h l it t t ti
 The melt-blown fabric is made by melting a plastic, then blowing it from either side at high velocity onto a rotating
barrel. Done right, this results in a fabric composed of tiny laments. For a more technical (!) explanation of the process
– see here.

Diagram of melt-blown machinery (left) comes from Erdem Ramazan’s book, and the image of melt-blowing
in progress (right) comes from 4FFF on wikipedia

Not all melt blown fabric has the same ltering capability, some are better than others. Unfortunately we can’t test the
ltering capability of the melt-blown layer without specialized knowledge and equipment. What we can do, however, is
at least check that the melt-blown layer is present.

Below I show an example of a surgical mask (left) that came without the melt-blown layer. You can imagine that, given
the extra cost and current scarcity of melt-blown fabrics, manufacturers might cut corners with this layer, so it’s worth
keeping an eye on.

Choosing surgical masks that have been tested according to a set of standardized test methods (ASTM F2100, EN 14683,
or equivalent) will help avoid low quality products. The ASTM standard for surgical masks (particularly levels 2 & 3) are
primarily focused around uid resistance during surgery. These higher levels don’t o er much extra in the way of
protection from Covid-19 under non-surgical conditions.

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Click to Expand - BFE95/BFE99 & PFE

 
 Can Surgical Masks Filter the Coronavirus?

Whilst FFP2/FFP3 or N95/N100 are the gold standard as far as face protection goes, what about surgical masks, do
they provide any protection?

Strictly speaking, surgical masks are primarily designed to protect vulnerable patients from medical professionals.
Stopping the wearer (e.g. surgeon) from spreading their germs when coughing/sneezing/speaking. So they’re designed
to protect patients, not to protect the wearer.

An obvious aw with surgical masks compared to respirators is their lack of a tight face t, which leaves gaps around the
edges.

There isn’t currently research available on the e cacy of surgical masks (or even respirators), for protecting wearers
against the coronavirus. Although this isn’t totally surprising given how new the virus is.

In lieu of that, the below looks at research around the use of surgical masks and N95 masks in the context of in uenza,
looking speci cally at the protection given to the wearers. In uenza may be a good virus particle to compare it to, as
they are both transmissible through droplets and aerosol, both cause respiratory infection, and both are similar in
particle size.

N.B. Please don’t con ate the comparison to the in uenza particle as suggestion that they are comparable illnesses –
current data suggests that the coronavirus may have a higher mortality rate.

Next →
Source for coronavirus (SARS-CoV-2) size is this paper, Explore Menu
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whilst sources for In uenza size are this paper (eventually
published in Vaccine), and a Frontiers in Microbiology
paper.
 In the rst study we will look at, 2,862 US health care personnel were split into 2 groups, those wearing N95 masks and
those wearing surgical masks[1]. There were 207 lab con rmed in uenza events in the respirator wearing group,
compared to 193 in the mask wearing group – a di erence that was not statistically signi cant.

In the next study, Canadian nurses were split into 2 groups, those wearing N95 masks and those wearing surgical masks.
There were 50 cases of in uenza in the surgical mask group, compared to 48 in the N95 respirator group[2]. Again, no
signi cant di erence.

So where does this leave us? Those 2 studies suggest that surgical masks are approximately comparable to N95 masks
when it comes to preventing in uenza illness in close contact clinical settings. What this doesn’t tell us, is whether they’re
better than wearing nothing on our faces.

To nd that out, we need a study that has a control group that doesn’t use any facial protection. Due to ethical
considerations, those studies aren’t abundant, but we do have at least one.

In this Australian study, they looked at 286 adults in 143 households who had children with in uenza-like illness[3]. For
clarity, in uenza-like illness is not the same as laboratory con rmed in uenza. It’s diagnosed by symptoms like fever, dry
cough and feeling sick, which could mean in uenza, but could also be caused by the common cold or other viruses. They
found that adults who wore masks in the home were 4 times less likely than non-wearers to be infected by children in
the household with a respiratory infection. There is nice analysis of the study here by Imperial College London.

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 Image via smartair lters.com

It’s de nitely fair to note that this Australian study was very small, and could not be considered de nitive by any means.
That being said, we’ve got to work with what he have, and this at least gives us some data points:

Wearing a surgical mask or N95 (FFP2) respirator was better (in the study) at protecting against in uenza-like illnesses
than wearing nothing at all

Whilst we can anticipate surgical masks to be inferior to respirators, the studies above suggest they are not as inferior
as one might assume. For example the rst two studies didn’t nd a signi cant di erence between surgical masks and
N95 respirators, when protecting wearers against in uenza.

Important to note that we’ve used in uenza protection as a proxy for SARS-CoV-2 (coronavirus). This is done because
SARS-CoV-2 is new and there are no comparable studies on it. But of course the drawback is that it still leaves a lot of
uncertainty, as SARS-CoV-2 may act quite di erently in terms of transmission.

In a lab setting, with arti cial conditions, we nd that surgical masks are able to block 80% of particles down to 0.007
microns. Compared to the 3M 8812 respirator in this study which blocked 96% (FFP1 rated). This generally aligns with
our discussion above.

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In conclusion: we don’t know how much protection surgical masks provide against the novel coronavirus. However, the
above at least suggests that a surgical mask may provide more than zero protection – and that’s worth being aware of.
 It makes sense to only wear them for protection as a method of last resort – with respirators being the primary choice.

It is much safer to avoid the company of people who are sick or potentially sick, and to reduce social contact overall,
especially to large groups of people (see the social distancing section below). To repeat, the use or surgical masks would
have to be a last resort – and wearing one should not encourage anyone to take unnecessary exposure risks.

If we are in the presence of someone sick, who has/might have the coronavirus, it makes sense for them to wear a mask
or respirator to reduce their ability to spread the disease.

DIY / Homemade Masks

The CDC has recently announced guidance to American citizens that “cloth face coverings” should be used in public
settings where social distancing measures are di cult to maintain. Noting that surgical masks and N95 respirators
should be reserved for healthcare workers. If citizens don’t buy respirators or surgical masks, they’re left to buy fabric
based masks from places like Amazon (yes, they do have some), or, they need to make their own.

Image from the masks4all.co DIY mask project

So how does one make their own mask?

Firstly, it’s worth noting how various household items compare in terms of lter e cacy and breathability. For that, we
can refer to a Cambridge University study (link), which revealed “the pillowcase and the 100% cotton t-shirt were
found to be the most suitable household materials for an improvised face mask”.

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 Image via SmartAirFilters

Interestingly, other items such as vacuum cleaner bags and dish towels showed greater ltration capacity, so why
didn’t the study pick them? Unfortunately those items performed badly in the breathability tests. A mask is little good if
you can’t breathe out of it. See this write-up of the study for more details (and nice graphs!)

Below are some DIY mask methods, listed from simple to advanced:

1) No modi cations T-Shirt Mask

Don’t want to get the scissors out? No problem. This method shows how to wrap a T-shirt around your face without
adjusting it. Based on the above study, use 100% cotton t-shirts where possible. Find the full guide for this method here.

2) No Sew T-Shirt Mask

This method uses just a t-shirt, scissors, pen and ruler. View the full instructions on Runa Ray’s YouTube video.

3) Sewing Machine Required Masks

For those with sewing machines… 2 good mask tutorials come to mind. The rst, a simple one (YouTube link), the second
– a more advanced design with ties, tted nose and lter pocket (YouTube link).

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 Of course, it *hopefully* goes without saying that the level of protection these DIY masks o er is below that of surgical
masks and respirators.

If you’ve seen other great DIY mask designs, please share them below in the comments.

What are respirators protecting us against?

Droplets
A primary reason for wearing a respirator is to protect from droplets. For example if a sick person coughs or sneezes
when in close proximity to us, the respirator forms a barrier to prevent their bodily uids reaching our face.

Droplets are generally large, and gravity drags them down to land on objects, rather than staying in the air. So they don’t
travel very long distances. There is however research into micro droplets, which get ejected even during talking. This
Vimeo video made by Japanese researchers, captures micro droplets on video using high speed cameras. We know large
droplets play a role in transmission, but it’s not yet clear what role micro droplets play.

Image from Sui Huang’s blog post on the need for mask usage

Aerosols
What may remain in the air for some time are aerosolized virus particles. So for example, you could imagine someone
creating two issues when sneezing, the rst are ejected droplets, which travel a short distance, then second, aerosolized
virus particles that stay in the air for longer.

Currently there is debate and uncertainty around how long Covid-19 can remain aerosolized, and how much of a risk
that vector is compared to others.

What we can do is be aware of what research currently says, and err on the side of caution until its been con rmed.

Scientists at the National Institute of Allergy and Infectious Diseases (NIAID) published a study in NEJM (link) on what can
happen
Next → under controlled lab conditions. They used a nebulizer, which creates an aerosol from liquids, and tested how
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long the Book Summary
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measurable in the …
air whilst aerosolized. They also tested how long the virus was measurable on
other surfaces. Their results showed the virus remained measurable for the full duration of the aerosolization
experiment; 3 hours. See the graphs below for more details:
 This image comes from the NIAID pre-print discussed above, showing the virus titer (viral
load)

Dr John Campbell has made a YouTube video discussing this paper in more detail.

Mouth & Nose

Then lastly, whilst the respirator covers our face, it makes it very hard for us to touch an object with the virus and
transfer it to our mouth and nose. This is a kind secondary bene t, in addition to the two mentioned above. We just
need to make sure we wash our hands carefully as soon as we take the respirator o .

Is Eye Protection Necessary?

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 Whilst the coronavirus can’t penetrate skin, it can penetrate all exposed mucous membranes, which includes the eyes.

This is why you often see medical professionals wearing eye masks when in contact with infected patients.

That said, eyes are presumably a lower risk as a route of entrance, compared to the mouth, which is constantly
breathing air directly into the lungs.

For eye protection, there are two routes that people go down; one is a disposable respirator and safety goggles, the
other is a full face respirator. Safety goggles with a rubber air seal provides a tighter air barrier. For example, Bollé make
some minimalist models which include a rubber seal, but there are many options available.

Additional Subjects of Importance

Shave! (When Wearing a Respirator)

When wearing a disposable respirator, it is important the wearer has no facial hair around the seal. Bad news guys!
This 2010 literature review found that “in the presence of facial hair, face seal leakage increases from 20 times to 1000
times“. However, hair under the mask (moustache, goaty, etc) doesn’t cause a problem. See this illustration from the US
CDC showing all the permutations of facial hair that are issues and non-issues. The alternative for those who want to
keep their beard is to wear a full-face respirator, for which facial hair wouldn’t typically cause an issue.

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Important Hygiene Measures

 Regular Hand Washing

– The CDC recommend regular hand washing with soap and water for at least 20 seconds.
– Prioritize washing prior to eating and after being out.
– Regular hand washing dries the hands, which at an extreme, may make them vulnerable to infection. To mitigate this,
regularly use a glycerin based moisturizer with pump or squeeze mechanism. Those that you scoop are less hygienic.
– A study showed that we touch our face on average 15x per hour. That behaviour may be di cult to change, but if we
keep our hands clean, it’s less detrimental.

Image showing the di erences in e ect between types of hand washing.

Trim Finger Nails

Short nger nails reduce the risk of trapping dirt (and viruses) under the nails. One method to check if your nails are too long is
by putting them against your palm. If you can’t feel your ngers but just nails, then they are too long to be kept clean easily.

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Alcohol BasedBook
HandSummary
Sanitizer– Including …

– The CDC recommend that if soap and water are not available, use an alcohol-based hand sanitizer with approximately 70%
 alcohol. For e ectiveness, you need to wait for the alcohol to fully air dry. Interestingly, alcohol contents above 90% are
regarded as less e ective (source).

Sanitize your phone and other items you touch regularly

– Given how often we use our phones, this seems like the next logical priority to be sanitized. Using antibacterial wipes
or alcohol swabs (typically 70% alcohol) to clean your phone and other items is a good option. If the antibacterial wipes
claim to be able to kill the u virus (H1N1) – that’s a good sign they may be able to do similar for the coronavirus. Once
nished wiping, leave to air dry.

Other items to consider include:

Computer keyboard and mouse

House and car keys

Re-usable water bottles

Car steering wheel

Clothing pockets

Door handles

And take appropriate caution when interacting with them – sanitizing where possible.

How to maintain a healthy immune system?

We don’t currently have a vaccine, or robust anti-viral medications to tackle Covid-19. In the meantime, we’re reliant
upon our immune system to ght the virus. Below we’ll look at steps we can take to maintain it, and put ourselves in the
best position, should the “worst case” happen:

Sleep

Get
Next → adequate, high quality sleep. For most people ‘adequate’ means 7-8 hours. It’s no coincidence that “burning the
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candle at bothBook
ends”Summary
increases–risk
Including … A 2004 literature review concluded that “sleep deprivation has a
of illness.
considerable impact on the immune response” and “should be considered a vital part of the immune system”[4]

Exercise
 Exercise

Exercise regularly, but don’t overdo it. To quote a 2007 study on exercise and the immune system – “moderate exercise
seems to exert a protective e ect, whereas repeated bouts of strenuous exercise can result in immune dysfunction”[5].

Vitamin D

Prior to the Covid-19 outbreak, there was evidence to suggest that:

Vitamin D plays a key role in immune function, and, being de cient in vitamin D can make you more susceptible to
infection[6]

Vitamin D supplementation protects against acute-respiratory tract infections – as seen in this BMJ meta-analysis
covering 25 randomized controlled trials (11,321 participants).

Now that Covid-19 has been around for a few months, we’re starting to see research about vitamin D status as it relates
to Covid-19. The two studies below point to vitamin D levels a ecting “severity of outcome”, i.e. if someone has low
levels of circulating vitamin D, they’re more likely to have a severe illness. As of yet, I haven’t seen any data on vitamin D
actually preventing illness. More research needed. For now, let’s look at the research we do have:

1. An April 9 paper from Mark Alipio in the Philippines (link) that retrospectively analyzed 212 cases of laboratory
con rmed Covid-19, and found that with each standard deviation increase in Vitamin D levels, the odds of having a
mild clinical outcome, rather than severe was approximately 7.94 times. And the odds of having a mild outcome,
rather than critical, was 19.61 times. This paper was discussed in the British Medical Journal here.

2. An April 30 paper from Indonesian researchers (link) retrospectively analyzed 780 cases with laboratory con rmed
Covid-19. They extracted vitamin D status from their medical records, and when controlling for age, sex and co-
morbidities, vitamin D status strongly correlated with risk of death from Covid-19. Speci cally they said that,
compared to normal, those with insu cient vitamin D were approximately 12.55 times more likely to die. Then those
who are de cient (less than insu cient) in vitamin D were 19.12 times more likely to die.

Both studies used the same de nitions for “normal”, “insu cient” and “de cient” levels of vitamin D:

Categorization Blood levels of Vitamin D - 25(OH)D

Normal 30 ng/ml or higher (75 nmol/L or higher)

Insu cient 21 to 29 ng/ml (52.5 - 72.5 nmol/L)

De cient Under 20 ng/ml (Under 50 nmol/L)

Whilst we still need more research to con rm these results, it seems the potential upside of maintaining normal (but not
excessive) vitamin D levels is high, and the downside is low to zero.

So how do we get enough vitamin D?

Whilst we can get vitamin D from some foods in our diet (for example oily sh, liver, egg yolks), it’s often hard to get
enough with these alone. The major source of vitamin D for humans is sunlight (speci cally UV-B rays). Without su cient
sun, it’s common to run a de cit on vitamin D. For example, in winter months in the UK, up to 40% of the population are
severely de cient (<10ng/ml / <25 nmol/L)[7].

If you’re concerned you’re not getting enough sunlight, then supplementing vitamin D is a way to mitigate this.
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What is an adequate amount of vitamin D? The National Institutes of Health (NIH) suggest getting 600iu (15mcg) from all
sources, per day, for adults. Similarly the National Institute for Health and Care Excellence (NICE) suggest a supplement
containing 400iu (10 micrograms) taken daily.
 Dr John Campbell has a great video on vitamin D and the immune system . He cites the NICE guidelines of
supplementing 400iu per day, but says he personally takes a vitamin D supplement containing 1,000iu daily.

When looking for a supplement, there is evidence to suggest (link) that vitamin D3 raises levels of vitamin D with 1.7x
greater e ciency than D2. Examples of NSF certi ed manufacturers selling vitamin D3 are Life Exension – 1,000iu,
Thorne Research – 1,000iu and Pure Encapsulations – 1,000iu.

Selenium

Whilst the evidence around vitamin D status and Covid-19 risk is becoming substantial, I would say that the evidence
around Selenium status is still in its infancy. However, I think it’s worth looking brie y. Prior to the outbreak there was
already evidence that selenium status plays an important role in immune function. For example:

Selenium de ciency increased virulence of RNA viruses such as coxsackievirus B3 and in uenza A[8][9]

Selenium status also mediated e ects of HIV[10], “epidemic hemorrhagic fever”[11] and hepatitis B[12]

As recently as April 28, an international team of researchers led by Surrey University’s Professor Margaret Rayma
identi ed a potential link between Covid-19 cure rate and regional selenium status in China[13]. The graph below
summarizes the ndings quite succinctly, suggesting that higher levels of selenium resulted in higher cure rates from
Covid-19. China is a particularly good country to analyze this in because across the country they have both some of the
highest, and lowest, levels of selenium intake globally.

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The authors note that there are signi cant limitations to their study, including:
 Most of their data on selenium status is from 2011 – 9 years ago.

Lack of data around age and co-morbidities for cities. Such that demographics make-up will vary, and this hasn’t been
controlled for.

Lack of info around regional variation in treatment protocols / capacity – which again hasn’t been controlled for.

So whilst the data isn’t robust enough to say that selenium status de nitely plays a key role in Covid-19 mortality rate,
it’s at least an indication more research should be done.

For a longer review on the paper, see this Surrey University post.

So how do we get enough selenium?

Unlike with vitamin D, where it’s hard to get adequate amounts from our diet alone – with selenium this should be
possible. Foods high in selenium include brazil nuts, tuna, sardines, ham, shrimp and more. See Table 2 on the NIH site
for a list of food sources. A simple dietary modi cation could be to add extra brazil nuts to your weekly food intake.
Another easy source of selenium are multivitamin supplements that contain selenium. For reference, the NIH
Recommended Daily Allowance is set at 55mcg for adults.

Indoors vs Outdoors Risk

Early on during some national lockdowns, there was a con ation of risk between indoor and outdoor settings –
assuming both were as bad as each other. This led to some countries prohibiting outdoor access altogether, save for
essential trips such as groceries. Not allowing people to get exercise and sun exposure (vitamin D) is likely to weaken
their bodies and immune system. Therefore it’s important we update our views as more evidence emerges

Whilst intuitively we might assume risk of transmission indoors is higher, due to poor ventilation, it’s important we
combine this theoretical idea with actual studies. Below we’ll look at some of the current evidence:

Indoors

Studies have found high transmission rates indoors, including on cruise ships (National Instatitute of Infectious Disease,
2020), in churches (CDC, May 22) and during indoor choir practice (CDC May 15). The cruise ship example (Diamond
Princess) was particularly unfortunate, whereby after detecting a single initial Covid-19 case, and then quarantining
everyone aboard the ship, it spread to 712 of the 3,711 people board (19%) (source).

Whilst locations such as cruise ships and churches may be more easily avoided, o ces and public transport may not.

A Korean analysis of a call-center outbreak (Emerging Infectious Diseases, April 2020) found that transmission was
relatively localized in the o ce. Despite workers interacting with people in the elevators and lobby, the spread was
limited almost exclusively to people who worked on the same oor. Indicating duration of contact was a key facilitator
for spread.

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 Schematic of Korean call center outbreak – blue indicates
seating location of infected people

Outdoors

Finding examples of outdoor spread has been less easy than indoor spread. Of course, absence of evidence does not
equal evidence of absence.

A Chinese pre-print study (medRxiv, April 7) analyzed 318 Chinese outbreaks involving 3+ people, covering 1,245
con rmed cases in 120 cities. They divided the locations in which the outbreaks occurred into 6 categories: homes,
transport, food, entertainment, shopping, and miscellaneous.

It found just 1 outbreak originated whilst people were outdoors. With homes and transport being 2 locations with the
most outbreaks.

The analysis was done during winter however, whilst people were spending less time outdoors. A similar study done
during warmer months is likely to nd a higher incidence of outdoor transmission. Particularly if we bear in mind
duration of contact is a key aspect also.

Figure from the Chinese study showing location of infections over time

As things stand, we’re still in the early days of research into indoor vs outdoors transmission. As it accumulates,
hopefully we can use it to make better risk-based decisions around our behaviour.

Roundup
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Hopefully if you’ve stumbled across this article, and you were confused about the di erence between N95, KN95 and
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FFP2/FFP3 masks, this has cleared things up for you.

For Spanish speaking friends who might nd this article useful, it’s translated here.
 If you have any further questions, please leave them below in the comments.

Further Learning
For preventative measures you can take as an individual (which also bene ts the collective) see this short list of videos
by Dr John Campbell:

Vitamin D and the immune system – YouTube video

Fevers – good or bad? Hint: often very good – YouTube video part 1 and part 2

How to avoid viruses around us (including cleaning tips) – YouTube video

How long Covid-19 stays viable and dangerous on surfaces and in the air – YouTube video

Dr John Campbell on YouTube

Post Change Log

Given that the situation with Covid-19 is evolving rapidly, I’ve decided to add a Change Log for this post. It will list
changes I’ve made from May 12 onwards.

See Post Sources Below:

1. N95 Respirators vs Medical Masks for Preventing In uenza Among Health Care Personnel – A Randomized Clinical
Trial – Lewis J. Radonovich Jr, MD et al. – JAMA – Sept 2019

2. Surgical Mask vs N95 Respirator for Preventing In uenza Among Health Care Workers – A Randomized Trial – Mark
Loeb et al. – JAMA – Nov 2009

3. Face Mask Use and Control of Respiratory Virus Transmission in Households – MacIntyre et al. – Emerging Infectious
Diseases Journal – Feb 2009

4. Sick and tired: does sleep have a vital role in the immune system? – Bryant et al. (2004)
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5. Exercise
Bredesen andBook
Protocol the Immune System
Summary – Brolinson
– Including … (2007)

6. Vitamin D and the Immune System – Cynthia Aranow (2011)

 7. SACN – Vitamin D & Health – UK Government Report (2016)

8. The in uence of selenium on immune responses – Ho mann and Berry (2008)

9. Host nutritional status: the neglected virulence factor – Beck et al. (2004)

10. High risk of HIV-related mortality is associated with selenium de ciency – Baum et al. (1997)

11. Inhibitory e ect of selenite and other antioxidants on complement-mediated tissue injury in patients with epidemic
hemorrhagic fever – Hou (1997)

12. Protective role of selenium against hepatitis B virus and primary liver cancer in Qidong – Shu et al. (1997)

13. Association between regional selenium status and reported outcome of COVID-19 cases in China – Rayman et al.
(2020)

Posted in: Covid-19, Home

Posted by John
Note: Not a Medical Doctor or PhD. I'm a researcher and writer, with a focus on the subjects of health and
longevity. My intent is to write about scienti c research in an accessible, understandable way. If you believe
something I've stated needs a reference, and I haven't done so, please let me know in the comments. Follow on:
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