The novel coronavirus disease 2019 (COVID-19) pandemic resulted in 3, 016,515 confirmed cases and 131,666 deaths in the United States by July 8^th, 2020¹ and led to the devastation of hospital systems across America².  As evidence grew of surgical masks effectiveness in transmission prevention ^3,4 , the Centers for Disease Control and Prevention (CDC) revised its recommendations, urging everyone excluding infants to wear a mask or face covering in public settings where social distancing measures are difficult to maintain^5,6. Further, the CDC simultaneously recommended the use of full-face shields to cover homemade masks, however, available designs are obtrusive and can reasonably be presumed to reduce community and healthcare worker compliance rates. 

Early and sustained debate on the validity of public mask use was guided by supply shortages rather than established mitigation practices⁷.  When national leaders advised and pleaded with the public to conserve and donate PPE for healthcare workers⁸, this validated and reinforced public opinions that mask use does not significantly mitigate public spread.  At one point, the Surgeon General of the United States vehemently argued, emphasis his own, “Seriously people- STOP BUYING MASKS!  They are NOT effective in preventing general public from catching [COVID-19]…!”⁸  Other actions and inactions from some federal agents and healthcare leaders inappropriately helped shift mask use to a political issue, rather than a public health issue⁹.   The leading US infectious disease specialist Anthony Fauci would eventually state, “Masks are not 100% protective.  However, they certainly are better than not wearing a mask…So masks work.”¹⁰    

The threats imposed by COVID-19 have not passed and as stay at home orders and other social distancing restrictions prematurely ease, the rates of COVID-19 infection have begun to exponentially resurge.  In the first week of July 2020, Arizona and Florida had 20,989 and 54,797 new cases of COVID-19, respectively¹.  Additionally, in the midst of this worsening global pandemic, the death of George Floyd sparked outrage against unlawful police brutality towards communities of color. Americans have rightfully crowded streets to protest these moral and legal injustices¹¹, despite the established role mass gatherings play in viral transmission of COVID-19.  Further, COVID-19 has disproportionately affected communities of color¹² due to established health care access disparities^13,14 and lack of public outreach efforts¹⁵.  These coinciding realities raise grave concerns and will almost certainly re-invigorate and require community efforts to generate accessible, affordable and comfortable personal protective equipment (PPE) for community and healthcare worker needs.

Reports on transmissibility of COVID-19 suggest up to 44% of cases may be due to transmission through asymptomatic patients¹⁶, which is identified as a major barrier to containment¹⁷.  Current evidence establishes respiratory droplets as the major mode of COVID-19 transmission.¹⁸ The nose, eyes, and mouth are all potential sites of viral entry. Current Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines establish routine facial protection with face shield or goggles during all patient care for illnesses, such as severe acute respiratory syndrome (SARS) and avian influenza, which spread by respiratory aerosol droplets.¹⁹  Therefore, the production and distribution of efficient, durable, and inexpensive PPE has become of remarkable, unprecedented importance.

Face shield overcome some of the major limitations of standard masks. They provide superior face coverage, while remaining durable and reusable. In contrast to goggles, face shield may be superior, as they guard the entirety of the face from infectious respiratory droplets, but admittedly do lack a reasonable seal with the skin. A 2014 study showed that using a face shield resulted in a 96% reduction of inhalation exposure immediately after a cough.²⁰ Full face shield also reduced surface contamination of a respirator by 97%. When a smaller cough aerosol was used (VMD = 3.4 μm), the face shield was less efficacious, reducing only 68% of inhalation exposure after a cough and 76% of respirator surface contamination. These findings indicate adjunctive use of face shields can effectively reduce short-term exposure to large and small aeroslized particles, however they cannot replace respiratory protection.²⁰

Demand for PPE has already outpaced world commercial supplies.²¹   In response, the FDA stated it will not object to the distribution and use of improvised face shields that are intended to serve a medical purpose throughout the duration of the COVID-19 public health emergency.²¹ A number of homemade face shield models have already been published. One design secured to the forehead utilizes transparent sheets, hole punchers, string, and paper surgical tape.²² A separate design utilizes a transparency plastic slide, which is secured onto a cloth or disposable mask using sewing materials, hole puncher, and strings.²³  Our similar design was first publicly available April 3, 2020 via publication in the Wall Street Journal²⁴.  Our design is advantageous, as the printable model guarantees a broad, accessible distribution model; print and assembly time are minimal (< 2 minutes); and materials are inexpensive and widely available.  

Our societies cannot repeat past mistakes in their relationships with homemade PPE.  Where hospital and community face shield use can be predicted to rise together in the coming weeks and months²⁵, so can further supply constraints.  The need for community resource generation has been established and will continue to be essential to viral mitigation.  We can no longer wait for commercial industries to answer this call.   There is an immediate need for community manufacture and distribution of PPE to health care workers and communities; with proper education and motivation, communities can be depended upon to help assist with this effort, as they showed with homemade masks²⁶. Our face shield design is an imperfect, yet adequate solution that is simple, cost-effective, and available now.