If you believe a covering over your face or anyone else’s is offering you all that much protection from the sometimes deadly SARS-CoV-2 virus, you might want to think again.
A research letter published last week at JAMA (formerly the Journal of the American Medical Association) would indicate masking isn’t doing much to slow infections rates in the U.S. The letter is not an argument to avoid masks, but a warning that adherence to other, so-called nonpharmaceutical interventions (NPIs) are equally or more important.
Americans have done a very good job of adapting to masks since April, but as a result they appear to be ignoring the other NPIs.
“Reported wearing of a mask or other face covering showed a significant increase among participants (going from) 39.2 percent to 88.6 percent” through November 24, said the report authored by researchers associated with the John Hopkins, Yale and Southern California universities. The survey was reported to have a margin of error of 4 to 6 percent.
It comes against the backdrop of a SARS-CoV-2 infection rate soaring in the U.S. since the start of October, and a warning from the Alaska Department of Health and Social Services that a new, more contagious strain of the virus first identified in the United Kingdom has arrived in the 49th state.
The World Health Organization (WHO) dashboard shows that both infections and deaths from COVID-19, the disease caused by SARS-CoV-2, began rising noticeably as fall approached in the U.S. with the weekly number of confirmed cases almost tripling from 328,000 on Oct. 5 to 1.25 million by November 30.
Deaths lagged behind infections given that it takes the infection time to kill people, but they almost tripled as well, the dashboard shows.
Correlation is not causation, but there are strong reasons to believe there is a connection between masking and rising infection rates given the results of the JAMA survey.
In the early April to late November time period, the survey reported that as the country embraced masks, there were significant drops in overall adherence to other NPIs known to reduce the spread of SARS-CoV-2.
Overall, the survey reported:
- The number of people staying home except for essential activities or exercise fell by almost half, dropping from 79.6 percent to 41.1 percent.
- The number of people who allowed visitors into their homes more than doubled, growing from 19.7 percent to 42.4 percent.
- And the number of people visiting restaurants almost tripled, increasing from 12.7 percent to 34.2 percent.
A U.S. Centers for Disease Control and Prevention (CDC) analysis of infections back in September concluded that bars, restaurants and coffee shops appear to represent environments in which people are most likely to encounter the SARS-CoV-2 virus.
“Restricting the analysis to participants without known close contact with a person with confirmed COVID-19, case patients were more likely to report dining at a restaurant (2.8 times more likely) or going to a bar/coffee shop (3.9 times more likely) than were control-participants,” the study said. “Exposures and activities where mask use and social distancing are difficult to maintain, including going to places that offer on-site eating or drinking, might be important risk factors for acquiring COVID-19.”
Given all of this, the latest JAMA study would suggest people should think of a face mask as much like a seatbelt. Seatbelts have been shown to reduce the odds of death in an accident by 45 percent for front-seat passengers and seriously reduce the odds of serious injury, according to the National Highway Traffic Safety Administration.
But they don’t help much if you drive around with your eyes closed. The absolute best way to avoid serious injury or death in a motor-vehicle accident is to stay alert and avoid crashes.
The protective value of face masks remains unclear, but it appears to be less than that of seatbelts, making other NPIs even more important in trying to avoid infection with SARS-CoV-2.
That people appear to be straying from those NPIs the authors of the JAMA study attributed to what they labeled “pandemic fatigue.” Fatigue is driving “an increasing attitude of apathy or resistance toward adherence to NPIs” other than masks, they concluded.
Overall the researchers reported, “all U.S. census regions experienced decreases in the overall NPI adherence index from early April to late November” with the rates falling from:
- 70.0 to 60.5 percent in the South
- 71.5 to 62.2 percent in the West
- 70.8 to 62.4 in the Northeast.
- And 70.3 to 54.4 in the Midwest
The authors were, however, happy about the uptick in the use of face coverings.
“The increase in reported mask wearing aligns with other national surveys of self-reported mask use,” they wrote, “and may reflect improved public health messaging.”
To “combat pandemic fatigue” as regards other NPIs, they suggested further “government mandates and consistent communication from authorities” may be in order, although they added that new research to quantify “the differential effect of NPIs in reducing COVID-19 transmission” is clearly needed.
An international team of researchers who studied a broad range of NPIs in 41 countries between January and the end of May reported in October that their “results cast doubt on reports that mask wearing is the main determinant shaping a country’s epidemic, (but) the policy still seems promising given all available evidence, due to its comparatively low economic and social costs.”
The authors led by Dr. Jan M. Brauner at the University of Oxford in England said their metanalysis of previous studies on masks found a negative 1 percent change linked to masks in a range of a minus 13 percent to a positive 8 percent between various examinations. The latter number is what suggested promise for masks.
The non-peer reviewed study also found other NPIs far more effective. It was posted at MedRxiv along with a link to a calculator governments could use to determine the best mix of NPIs to reduce infections, but it received little public attention.
The study concluded the most effective, government-ordered NPIs were closing schools and universities, limiting gatherings to 10 people or less, and closing most non-essential businesses.
All of those actions limit potential contacts between infected and uninfected individuals. It is possible for individuals to gain much the same protections on their own by themselves staying away from others, avoiding all but non-essentials business, and spending as little time as necessary in the latter when they must buy food and supplies.
The Brauner-led study of NPIs was followed by a peer-reviewed, random-controlled trail (RCT) of masks in Denmark that reported finding no difference in infection rates between the masked and the unmasked, but cautioned that “the findings…should not be used to conclude that a recommendation for everyone to wear masks in the community would not be effective in reducing SARS-CoV-2 infections because the trial did not test the role of masks in source control of SARS-CoV-2 infection.”
RCTs are considered the gold standard of medical research.
Other studies, largely limited to hospitals, have concluded that when a full range of personal protective equipment (PPE) is employed and used properly, it can reduce the risk of infection.
For those at greatest risk of death from SARS-CoV-2, the acquisition of full PPE and training would appear a sensible idea. More than 90 percent of those dead from COVID-19 in the U.S. appear to have been suffering from serious, pre-existing medical conditions or what are now commonly being called “comorbidities.”
The CDC at the end of December updated its list of conditions putting people at the greatest risk of serious illness or death from COVID-19. On its list of dangerous comorbidities are:
- Chronic kidney disease
- COPD (chronic obstructive pulmonary disease)
- Down Syndrome
- Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
- Immunocompromised state (weakened immune system) from solid organ transplant
- Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
- Severe Obesity (BMI ≥ 40 kg/m2)
- Sickle cell disease
- Type 2 diabetes mellitus
The CDC also provided a second list of chronic diseases that might increase the risk of serious illness from SARS-CoV-2. Those were:
- Asthma (moderate-to-severe)
- Cerebrovascular disease (affects blood vessels and blood supply to the brain)
- Cystic fibrosis
- Hypertension or high blood pressure
- Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
- Neurologic conditions, such as dementia
- Liver disease
- Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
- Pulmonary fibrosis (having damaged or scarred lung tissues)
- Thalassemia (a type of blood disorder)
- Type 1 diabetes mellitus
The updated CDC report also advised that the best way to avoid infection is to limit contacts with other people. The new JAMA analysis underlines that conclusion.
Other than living in a cabin in the middle of the Alaska wilderness with food supplies enabling you to stay there for a year without human contact, the CDC noted, “there is no way to ensure you have zero risk of infection. So it is important to understand the risks and know how to be as safe as possible if or when you do resume some activities, run errands, or attend events and gatherings.
“People at increased risk of severe illness from COVID-19, and those who live with them, should consider their level of risk before deciding to go out and ensure they are taking steps to protect themselves. Consider avoiding activities where taking protective measures may be difficult, such as activities where social distancing can’t be maintained.”