Fully protected/Muzammil Mughal at Wikimedia Commons
No one who reads this commentary should take it as advice to avoid wearing a face-covering in public in these days of COVID-19. But neither is it an argument for masking.
True believers in masking can probably stop reading now and click here for a link to Dr. Trisha Greenhalgh’s argument for public masking. She offers solid, reasoned arguments for what you wish to believe.
She brought them to the attention of Carl Heneghan and Tom Jefferson at Oxford University’s Centre for Evidence-Based Medicine (CEBM) after they earlier posted a review of what science can say in reply to the question of “masks on or off.”
“That review was mostly focused on medical masks for healthcare workers but also looked at randomized controlled trials of masks and face coverings for the lay public. Heneghan and Jefferson’s interpretation of that evidence was that there is insufficient evidence to support mask-wearing by members of the public. They also speculated that masks could cause harm,” Greenhalgh later wrote on the CEBM website.
Let us start there with some observations.
World of medicine
One of the first things to recognize in this discussion is that the use of face masks in public is little like the use of face masks in the medical community where people are trained in their use to try to minimize the spread of pathogens.
When those in the medical community expect to be exposed to dangerous viruses, they wear full personal protective equipment (PPE), consisting not only of masks but adding gowns, gloves, goggles, caps and shoe covers.
Most importantly, they are careful when they remove that PPE to avoid cross-contamination of the working environment. After you have been in an room likely to smear your PPE with SARS-CoV-2 viruses – the pathogens that cause COVID-19 – you want to carefully dispose of that PPE so as to avoid contaminating anything else.
No one at this time knows exactly how SARS-CoV-2 spreads, but so-called fomites, objects of any sort on which SARS-CoV-2 viruses land, are one likely source along with respiratory droplets, which have been much discussed, and aerosols, which are basically invisible, free-floating germs.
The medical world recognizes all these forms in which infectious diseases spread and takes steps to halt them all. Those steps – regular changes of PPE, periodic handwashing, proper handing of contaminated PPE – are not so easy in the real world.
Let’s take for example someone headed out on a shopping trip. They wash their hands before leaving the house and take a face covering with them. They put their face covering on at their destination, do their shopping, and then what?
Pull it off? Hang it from the mirror in the car? Throw it on the empty passenger seat? Since most motor vehicles lack sinks and running water, handwashing is out of the question. Do most people carry disinfectant wipes with which to clean up after unmasking?
They should be. The only study of masks and SARS-CoV-2, specifically, found the virus passing through the masks in some way.
The sample size for the study was small, but given that it was a simple examination of the physical filtering capabilities of masks this is somewhat irrelevant. The study answered the simplest question of whether masks will block emissions of SARS-CoV-2, and it appears they won’t.
It didn’t, however, answer the most important question: Will masks reduce the spread of SARS-CoV-2? That question hinges on aerosols and fomites, which present their own questions.
If the mask stops droplets, do the exhalations of infected people forced SARS-CoV-2 out of the droplets and fill the air with SARS-CoV-2 aerosols, and can those aerosols infect others?
If SARS-CoV-2 is accumulating on the masks – “all swabs from the outer mask surfaces of the masks were positive for SARS–CoV-2,” the Korean doctors reported – can people who touch the front of the mask with their hand grab a handful of SARS-CoV-2 to subsequently deposit on anything they touch?
The answer to these questions remains unknown. The U.S. Centers for Disease Control (CDC) caused a bit of an uproar last week when it rewrote its SARS-CoV-2 safety warnings in such a way that some journalists read the new advice to indicate fomites are not a danger.
The federal agency was subsequently forced to put out a media statement clarifying its position.
“Based on data from lab studies on COVID-19 and what we know about similar respiratory diseases, it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose or possibly their eyes,” it said. “But this isn’t thought to be the main way the virus spreads.”
The keywords there are “isn’t thought to be.” The reality is that science is still in the dark on this one.
“Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days.”
Those damn germs
Though we cannot see what used to be called simply “germs,” microscopic pathogens are everywhere in our world. Over the last 300,000 years or so, the human immune system evolved to deal with them. Humans notably did not – nor did any mammal – develop a respiratory filtering system as a protective measure.
Evolutionary biology settled on respiratory systems that maximize the transfer of air in order to optimize individual supplies of oxygen, an invisible chemical in the air without which we die. An argument can be made that this style of respiratory system is now outdated.
It evolved to support a species required to be constantly active to survive. The oxygen needs of those living what is now called the “sedentary lifestyle” are notably lower than for those engaged in strenuous physical activity although there does appear to remain some value in efficiently functioning lungs.
A previously unknown pathogen believed to have evolved sometime in late 2019, SARS-CoV-2 is now methodically killing those with lower VO2max and lifestyle-related diseases. In Massachusetts, which has witnessed a major outbreak of the disease and carefully tracked the demographics of its victims, the average age of the dead is 82 and 98.3 percent suffered from an underlying health condition.
VO2max is a measure of a mammal’s ability to bring in and process oxygen. In humans, VO2max usually peaks in the 20s or early 30s, and then begins a steady decline, the extent of which is linked to activity levels.
Various studies have found a VO2max drop of less than 5 percent per decade to more than 10 percent per decade depending on the level of fitness training. Though the American Heart Association today advises that a low VO2max is associated with an increased risk of dying from any disease – not just COVID-19 – there is no inherent need for a high VO2max in today’s society.
Since most humans are no longer involved in running down wild animals on foot to feed themselves, it really doesn’t matter if a 40 year old has the VO2max of a 60 year old or a 20 year old. The decreased need might help explain the steady, global decline in cardiovascular fitness – the simplest, population-wide measure of VO2max.
This broad-scale, global, societal change could be read to buttress Greenhalgh’s argument for public masking not just for COVID-19 but in perpetuity if masks truly work to stop the spread of infectious respiratory diseases.
The CDC estimated 61,000 deaths from flu in the U.S. during the 2017-2018 flu season. That is near twice the number of Americans dying in motor-vehicle accidents every year with a five-year average of 35,945.
Motorists are now required by law to buckle themselves into their cars and trucks to minimize the death rate. If masks work, if masks can help to reduce deaths, why shouldn’t they be required at all times of everyone who goes out in public – just as seatbelts are now required?
If they work
Whether masks work is, however, a hotly debated question.
There are now studies underway to try to find some answers. A Chinese manuscript published by BMJ, formerly the British Medical Journal on Thursday, reported they do, at least when worn by family members of someone with SARS-CoV-2.
There were, however, some confounding elements to the study.
“Wearing a mask after illness onset of primary case was not significantly protective,” the study said. The study does not make clear whether illness onset was defined by a SARS-CoV-2 test or symptoms of illness.
The idea behind public masking is that it protects everyone else from someone who has COVID-19. The authors offered no theories on why putting a mask on a COVID-19 suffered after illness onset showed no protective effect in keeping them from spreading SARS-CoV-2.
The study did make clear the value of social distancing and the big advantage it holds over masking.
“The risk of household transmission was 18 times higher with frequent daily close contact with the primary case,” the study said. It defined close contact as “being within one meter or three feet of the primary case, such as eating around a table or sitting together watching TV.”
Three feet is half the social-distancing recommendation in the U.S.
The study shed no light on how the disease might have been transmitted within the home, but noted “daily use of chlorine or ethanol-based disinfectant in households was 77 percent effective.”
Those disinfectants are used to clean counters, tabletops and more. Their effectiveness in lowering the spread of the disease would suggest there was some fomite spread going on in the homes, where it was also noted that “household ventilation” – an old Spanish flu prevention technique – was “protective.”
Ventilation serves to disperse and dilute virus aerosols. All of which brings the discussion back to droplets, aerosols and fomites in public.
I did my own little experiment in the South Anchorage Costco on Friday. I wanted to see how long it would take to count 100 people touching the fronts of their masks. It took approximately 14 minutes and 45 seconds.
No attempt was made to quantify mask touching activities by customers leaving Costco, where everyone is required to wear a mask, but the general observation was that most people pulled their masks off after leaving the store, and they usually pulled them off by the front.
One man pulled his mask off, always by the front, three-times in the liquor store. Several people left their noses hanging out. A couple appeared to have snot running down the fronts of the mask. Snot could be considered a giant SARS-CoV-2 droplet.
If any of these people were infected with SARS-CoV-2, they would have had it on their hands and spread it everywhere.
The possibility of picking up SARS-CoV-2 fomites while out of your home is the reason for the constant advice to wash your hands, wash your hands, wash your hands. Though fomite spread has not been proven, it would help explain the “community spread” cases of COVID-19 which happen to people who have no contact with a known SARS-CoV-2 carrier but come down with the disease anyway.
The real world
Randomized controlled trials to study masking in the real world are difficult to design and manage because of the many variables that come into play as the CEBM’s Jefferson and Heneghan observed.
“For starters, most of the trials were poorly reported and carried out during seasons of influenza-like illness when viral circulation is variable, but probably way below that (for SARS-CoV-2) in the Lombardy areas (of Italy) at the beginning of March. The design and execution of some of the trials were also questionable and as most were cluster-allocated, blinding was difficult, if not impossible.
“The trials carried out ‘in the community’ were in fact in specific settings such as halls of residence, family clusters or worshipping pilgrims.”
More studies are underway, but there might already be a simple, population-level comparison as to effectiveness available.
Taiwan is now all covered up.
“In the streets of Taipei, almost every second person wears a mask and on public transit nine in 10 if not more,” Jennings reported. “Hospitals and some schools in Taiwan require that anyone who enters wear a mask.”
Taipei is Taiwan’s capital city, and forms the core of the Taipei–Keelung metropolitan area home to roughly a third of Taiwan’s population. With a population o more than 7 million people, it is the 40th most-populous urban area in the world. The density of 25,000 people per square mile aids in the spread of any infectious disease.
Were mass masking significantly effective in slowing or stopping the spread of infectious disease, one would expect to see that reflected in annual mortality for the world’s most common, infectious respiratory diseases – pneumonia and flu.
Our World in Data includes other respiratory fatalities, such as flu, in the pneumonia number. The CDC lumps pneumonia and flu deaths together in the U.S, and reports a similar rate with individual states varying from a high of 29.6 per 100,000 (Hawaii) to a low of 9.6 per 100,000 (Florida).
More than 2.5 million people died from pneumonia in 2017, Our World in Data reported. “Almost a third of all victims were children younger than five years, it is the leading cause of death for children under five.”
Like SARS-CoV-2, pneumonia infects the lungs.
The COVID-19 death rate as of Saturday stood at 371,289, but the death toll continues to grow. Unlike with pneumonia, most of the victims are older. Of the 15,230 dead in U.S., only nine were 17 or younger, and only 610 were in the age class from 44 to newborn.
Nearly half – 7,419 – were age 75 or older, according to the website Worldometers. That is in line with data from China where the SARS-CoV-2 outbreak originated in late 2019.
Taiwan, at this time, is doing orders of magnitude greater than the U.S. in battling COVID-19, but the World Atlas website cites ten reasons for this starting with an early ban travelers from mainland China, prompt and early testing of any reporting flu-like symptoms, aggressive tracking of SARS-CoV-2 infections and strict quarantines for those who might have been infected, and more.
Sorting out the role masks play is difficult. On the one hand, some say they can’t hurt, although even that is not known for certain. On the other hand, some argue the lack of proven effectiveness isn’t worth the fear and social discord masks are generating.
You can now argue among yourselves.
.
Categories: Commentary, Uncategorized
I just want to know Fauci’s ties to Moderna. Follow the money as they say.
Seems like a very weird coincidence that just as our economy was tanking and record levels of unemployment hit the country that masks somehow became the “new norm” ?
Now as riots are hitting the streets of America it is acceptable for looters and anarchists to be wearing masks?
I have known from day one that the unconstitutional lockdowns and medical mandates would eventually lead to an environment of “martial law” in our country.
Today, residents of LA woke up this morning to military troops armed with M-16’s patrolling their streets.
Masks aren’t about safety or even halting the spread of the disease. They are about compliance. Cheers –
Anyone who is familiar with using PPE in the work place knows that PPE is the last line of defense against whatever the hazard is, in other words if you can avoid the hazard any other way you do so. If I need to wear a mask because the hazard is so great, I probably don’t need to be in that area.
Social distancing should provide the majority of people in Alaska with enough protection, hand washing provides the next layer of defense. Common sense should be enough to protect everyone, unfortunately it has been demonstrated time and time again that not many have common sense anymore.
The eyes, surounded by surface blood vessels, seem to be the perfect entryway for COVID.
Good job Craig. As usual you dismiss the science that does not support your views. Then you dismiss the use of mask because people don’t use them properly. The social discord comes from the people who will find any reason to not do what they are requested by authorities. These are the same citizens who complain about the cost of gas while driving a 10mpg truck, who complain about taxes while enjoying its benefits, who don’t get their kids vaccinated, who complain about the speeding ticket they earned. We wear mask because it is helpful in some small way. People make mask for others because they want to contribute in some way. We wear mask because it is based on the best science we have at this time. I’ve been reading your opinions for a couple decades. Keep up the good writing. But don’t give people another reason to not do the right thing. It just might save someone you care about.
John: It is a good idea to read stories before commenting on them. This one pretty clearly points out the science for the masks.
The issue is not with my agreeing or disagreeing with what the science says. The issue is that the science – as is often the case – doesn’t provide a simple yes or no answer.
If one believes in science – as I do – one cannot disregard this fundamental reality of science. It is often better at raising new questions than providing answers, especially in the short term. We have a lot of questions as to the behavior of SARS-CoV-2 and few answers.
The only thing we really know definitively in terms of protection is that a younger age is protective and a lack of co-morbidities (ie. fundamentally sound health) are protective. There have been but 610 deaths of people under age 44 in this country.
Seventy-nine percent of them (482/610) are known to involve people with pre-existing conditions. The percentage is likely higher given that in the case of 108 previous health history was unknown.
These people under 44 represent less than 4 percent of U.S. COVID-19 fatalities. Many of them who caught COVID-19 and lived throught it tell horror stories, but they lived. The odds of survival for older people fall rapidly.
https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/
Almost half the deaths are people 75 or older. If one were a conspiracy theorist, he or she could almost come to believe that the masking effort is nothing but a scam to avoid the need to protect older Americans from this disease:
“Let’s just put a mask on everybody, call it good, and if these old farts keep dying be thankful we don’t have to pay out so much in Social Security and Medicaid anymore.”
I started wearing a mask in public to protect others, not myself, after viewing a demonstration that showed a mask reduced by more than half the dispersal distance of aerosols from the lungs. I view it as a prudent, auxiliary form of social distancing. I help protect you, and when you wear a mask, you help protect me. Seems smart and responsible, especially If the number of asymptomatic carriers is as has been reported.
Mark: To my knowledge, there is no demonstration showing the mask protecting people from aerosols. I believe the demonstrations to which you refer involve droplets.
No one is sure what happens to aerosols, although the Koreans who studied the mechanics of masks seemed to believe aerosols from air escaping through and around the edges of the masks were what accounted for the virus being all over the fronts of the masks of COVID-19 sufferers.
Little is known about those aerosols. Could they be better or worse than droplets? Who knows. Droplets pretty rapidly fall to the ground. Aerosols hang in the air like fog or smoke.
So don’t wear a mask. Who gives a shit? Don’t wear a rubber, or a helmet or use a seat belt. Why did you spend the time to write this useless essay? You spend a lot of time making nothing into something.
Come on Monk, the article was very informative, but, would you at least advocate for cages to work on the rioting disease?
Aerosols and fine droplets (less than 5 nanometers in size) are the same things. CDC research shows that surgical quality masks worn by an infected patient stops more than 90% of coarse droplets (from sneezing or coughing) and more than 60% of fine droplets (from talking or breathing.) The demonstration Mark cites is correct.
Aerosols and droplets are not the same. Virus-containing droplets are greater than 5 to 10 micrometers (μm) and aerosols something less than 5 μm, sometimes considerably less. SARS-CoV-2 particles have been estimated to be in the range of to 0.08 to 0.14 μm.
We’re talking very small particles here. In the air, they are the difference between rain and fog or, better yet, maybe rain and haze.
You need to actually read the story before you comment.
Masks do stop droplets. The question then centers on where the viral load in those droplets go. Korean scientists who actually studied masks found SARS-CoV-2 all over the outside of them, but not on the inside.
Air pressure from people breathing could break droplets down and push SARS-CoV-2 aerosols through a mask, or people could be pushing aerosols around the outside edges of a mask to deposit on the front. Which is unknown.
What is known is that droplets fall to the ground. Aerosols stay suspended like the smoke in the air from forest fires that hung over Anchorage for a good part of last summer. Here are some scientists explaining that and arguing there is a net plus to masks: https://science.sciencemag.org/content/early/2020/05/27/science.abc6197
There is scientific consensus on much of what they write in that “perspective,” most importantly on the subject of ventilation. Fresh air has been known to be protective since the Spanish flu, which was far deadlier than what we are facing now.
The linked “perspective” also contains a good description of the aerosol problem:
“The distance from a smoker at which one smells cigarette smoke indicates the distance in those surroundings at which one could inhale infectious aerosols. In an enclosed room with asymptomatic individuals, infectious aerosol concentrations can increase over time. Overall, the probability of becoming infected indoors will depend on the total amount of SARS-CoV-2 inhaled. Ultimately, the amount of ventilation, number of people, how long one visits an indoor facility, and activities that affect air flow will all modulate viral transmission pathways and exposure.”
What the perspective doesn’t do is provide any insight, let alone new evidence, into what happens to the SARS-CoV-2 that is in droplets stopped by the mask. The SARS-CoV-2 particles could be just like cigarette smoke. If someone blows it through a mask, you will still smell it because it is being aerosolized and carried through the air in that manner.
If you wish to minimize your risks, the best advice here is to avoid small spaces crowded with people, stay six-feet or more from people as much and as often as you can, and get plenty of fresh air. If wearing a mask makes you feel better, wear a mask. If you think you’re saving humanity by doing that, all the better.
But there’s no real evidence one way or the other, there are just anecdotes as cited in that “perspective.” Yes, Taiwan has largely dodged the SARS-CoV-2 pandemic. Is that because of masking? Hard to say, they’ve worn masks for quite some time (as the story noted) and their flu/pnuemonia rate is about twice that of the U.S., and both of those pathogens are significanlty larger than SARS-CoV-2 and thus more likely to be contained by a mask.
Sorry, but you are wrong. The definition of aerosolized virus is when it is carried by a fine droplets — I.e. less than 5 micrometer in size. A surgical quality mask stops the emission of over 60% of droplets of that size. There is direct research that shows this and failure to acknowledge means you haven’t read the research.
JoAnn: Do you have a reading comprehension problem?
Masks stop the emission of droplets. Droplets are like raindrops.
Think of a mask as like Gore-Tex. The Gore-Tex membrane stops moisture based on size. A raindrop is too big to penetrate the outside and thus rolls off. But vaporized moisture (sweat) – what you might call aerosolized moisture – passes through.
REI used to have a great demonstration in its stores. A Gore-Tex membrane was used to cap a clear cylinder of water. The cylinder was turned on its side and heated. You could then see that the Gore-Tex membrane held the water in the cylinder, but water vapor went right through.
This is the question with the SARS-CoV-2 virus. It is known that masks stop droplets big and small. It is not known what happens to the SARS-CoV-2 viruses in those droplets after they are stopped.
The Koreans found no SARS-CoV-2 inside masks. The virus clearly didn’t stay there with the blocked droplets. The Koreans found lots of SARS-CoV-2 on the outside of the mask. It got there somehow.
Scientists back in the 2000s were warning against the idea that “large-droplet transmission is the predominant mode by which influenza virus infection is acquired. As a consequence of this opinion, protection against infectious aerosols is often ignored for influenza, including in the context of influenza pandemic preparedness.
“Influenza infection has been documented by aerosol exposure in the mouse model, the squirrel monkey model, and human volunteers. Observations made during experimental infections with human volunteers are particularly interesting and relevant. In studies conducted by Alford and colleagues, volunteers were exposed to carefully titrated aerosolized influenza virus suspensions by inhaling 10 L of aerosol through a face mask. The diameter of the aerosol particles was 1 μm–3 μm. Demonstration of infection in participants in the study was achieved by recovery of infectious viruses from throat swabs, taken daily, or by seroconversion, i.e., development of neutralizing antibodies.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372341/
Theoretically, science is dealing with the same problem here only with potentially even smaller particles that could be infectious. Where exactly do you think that SARS-CoV-2 puffed into masks by the infected Koreans went?
Do you think that SARS-CoV-2 was somehow rendered non-existent? That would be called magical thinking, and admittedly it is sometimes nice to delude ourselves.
Sadly, I’m not into delusions. The SARS-CoV-2 that was in the droplets stopped by the mask went somewhere. Some of it ended up stuck on the outside of the mask. The researchers found viruses there, but they didn’t find all the viruses there.
The only logical explanation is that the rest were aerosolized and left floating in space.
Thus the question becomes this: Is it safer to inhale a couple SARS-CoV-2 laden droplets or two when you walk past someone inside a building, or is it safer to walk into an invisible cloud of SARS-CoV-2 trapped inside of the same building? Nobody knows.
Does masking at a population level to stop droplets slow the spread of the disease? Nobody knows that either.
What is known is that wearing masks makes some people feel better. If you are among those people, by all means wear a mask. Masks make others uncomfortable. Some people actually have trouble wearing them; they have trouble breathing when they do.
The evidence would indicate this is psychosomatic, but to them it is very real. So leave them the hell alone. There is absolutely no evidence their failure to wear a mask is any threat to your well being.
You’ve thoroughly convinced me that you believe masks are good. It’s fine that you believe.
Religious friends have also convinced me that they believe Christianity is all good. The history would indicate that is not always true. But it’s fine with me that they believe what they want to believe as long as they don’t try to force their beliefs on others.
Craig, you have the patience of a saint. I hope jo ann has a seeing eye dog for safety sake . Never pay felonious a bit of heed , hes regressed pre neanderthal. Maybe gene therapy could help him . Keep up your kindness to others, it becomes you . You are an inspiration.