Why Is Mask Wearing Political Rather than Based in Science?

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There is no single subject surrounding COVID-19 more confusing and emblematic of how our response to this virus has been disconnected from science and turned over to social media than the issue of masks. To this day, you can find conflicting information coming out from public health officials on this topic and as I’ll show you, we have very little high-level research that supports that wearing masks reduces the spread of respiratory viruses. We have even less evidence that supports that the use of masks reduces the spread of coronavirus. Let’s dig in.

My Mask Use

First, before anyone asks, I wear a cloth or surgical mask outside and in stores everywhere I’m supposed to wear one. Do I think, based on the research, that this is likely helping me or anyone else? No.

Since I’m a healthcare worker, I wear an N-95 mask or better in the office. Those masks have been shown to help. Hence, my whole clinical staff wears either an N-95 or N-99 mask.

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Masks as Politics

One of the more disturbing things I’ve seen lately is that mask use isn’t just about whether the science supports whether masks will help us decrease the spread of this respiratory virus, it’s instead become linked to political beliefs. For example, a recent Wahington Post poll found more Democrats have worn a mask than Republicans or Independents (25). Why remains a mystery.

The other problem I see is that mask “science” isn’t actually understood by those commenting on it. For example, I see science writers, bloggers, and social media influencers throwing around references to scientific articles that they often misquote or clearly have never read. Hence, it was high time for an updated deep dive into the actual science.

Masks 101

There are many different levels of masks, so let’s review those:

  • Cloth masks-This spans the gamut from a bandana to a scarf to now purpose-made masks by fashion designers. There are usually no filters, but just fabric.
  • Surgical masks-There is now so much variability here that I have to break these into two categories:
    • Fake and Bake: This is the one I recently was given at Whole Foods that didn’t conform to the nose to reduce airflow through this area and barely fit my face.
    • Real Deal: The kind that we used to wear in procedures (I now use an N-95 or better) that conform to the nose and limit airflow through this area and fit well.
  • KN95 Masks-The Chinese version of a mask that fits well to the face and filters 95% of particles.
  • N95 Masks-The US and European version of a mask that fits well to the face and filters 95% of particles.

The idea here is that since the coronavirus can be spread by aerosolized water droplets, the masks will block those droplets from being expelled or block them from being inhaled. These droplets that hang in the air are very small, at 0.1-3 microns.

Understanding the Scale of the Problem: Water Droplets Containing Virus

Before we get into the science, some commonsense education on the scale of these microscopic water droplets is critical. You could fit 1,000 one micron water droplets end to end inside one millimeter, which is less than one half of a tenth of an inch. Meaning, the water droplets expelled by people that we’re all concerned about with coronavirus are super duper tiny.

The first issue is that surgical masks can’t contain or block these particles (24). Based on the quality of the surgical mask construction (which is going to be poor if you bought the mask off Amazon), surgical masks pass between 25-80% of these particles through the front. That says nothing of the particles passing around the mask.

Then we have cloth masks which are a bigger problem. The best fabric you can buy has about 100 threads per inch. That makes the “holes” (pore size) in the fabric about 0.2mm. That means that 200 one micron water droplets could fit in each pore. Hence, 1-micron particles will have no issues passing right through your fabric mask. Again, that doesn’t even get into everything that will pass around your fashion accessory mask.

The CDC and WHO on Mask Use

You likely remember when the CDC said there was no benefit to wearing a mask. Then on April 3rd, 2020 they changed that guidance in favor of wearing masks (4). They cited the fact that there was now community transmission of the coronavirus and that there were known asymptomatic carriers. They gave some scientific references, none of which were studies where mask use was actually tested. In fact, they all relate to the possibility of asymptomatic transmission of the SARS-CoV-2 virus.

Looking at the same science, the WHO has maintained its stance that you shouldn’t be wearing a mask unless you’re a healthcare worker caring for COVID-19 patients or if you yourself are sick (23).

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The New Rationale Given for Wearing Masks

The new rationale for wearing masks in this pandemic used by the CDC is that there are asymptomatic carriers. In fact, I just heard the Governor of Virginia on NPR yesterday saying that he was asking everyone in his state to wear masks based on new scientific research (5). However, when I visit the Virginia state websites I see no new mask research cited. So where is this solid research on which to base public policy?

The “New” Research?

I have searched high and low for this new mask research that everyone seems to be quoting. The only thing I could find was that the media and others often point to a prepublication study as evidence that we need to enforce universal mask-wearing. This is a quote from a story on Vox on the topic (2):

“Now, new research suggests that East Asian countries’ early adoption of masks has played a role in their ability to control the transmission of Covid-19 — and the US government’s hesitation may have cost lives. “If we had masked up sooner, I think we could have prevented a lot of these infections,” says Shan Soe-Lin, a global health specialist at Yale University, who called for universal masking in a March Boston Globe op-ed co-written with Yale epidemiologist Robert Hecht.”

So what is this new research? Let’s dig in deep.

A Computer Model?

This “study” isn’t actually a true clinical study where they had one part of a population wear a mask and another not and then measured actual SARS-CoV-2 transmission rates through infections. It’s in fact just a computer model. What’s that?

A computer model seeks to use complex math or neural networks to make educated guesses about what might happen. The problem? First, all computer models of human and virus behavior are guesses layered on guesses. Second, as we all know by now know, the computer models of this virus have generally been wrong. Do you remember the Imperial College London model that predicted 2.2 million US deaths? (3)

So on what hard data was this computer model based? Let’s see what the authors write in the paper:

“We assumed an initial infected population of 1% and modelled the assumed effects of social distancing, lockdown, and universal masking over time on the rates of infection in the population.”

So they made assumptions on the total infected population and further assumptions about what effects the masks would have. Let’s dive into the mask assumptions:

“Varying degrees of mask effectiveness are modelled by the mask transmission rate T and mask absorption rate A, which denote the proportion of viruses that are stopped by the mask during exhaling (transmission) versus inhaling (absorption)…”

Huh? We have no idea of the real-world data that would need to be plugged in here as nobody has ever studied SARS-CoV-2 transmission this way. We don’t know the “mask transmission rate (T)” nor the “mask absorption rate (A)”. Even if someone could do a quick lab study, you would have to see how many people were actually infected with the virus to calculate the numbers that would make this model accurate.

So what did the authors reference here for this idea that masks reduce the transmission of this virus? They pointed to a small study measuring mask protection against water particles. That research found that cloth masks were not keeping the particles in and that surgical masks were better at protecting people than cloth masks and N-95 masks were even better (6). The masks also didn’t work on kids. In addition, this study didn’t look at the real-world ability of masks to reduce infections.

The researchers then tried to use Asian countries who had more mask-wearing to validate their model. However, this was also a problem:

“For validation of the foregoing SEIR and ABM predictive models it is necessary to compare against what little historical macro scale empirical data is available, since precise numbers are not yet known for masking rates, mask transmission and absorption rates, and infectious but asymptomatic cases.”

More unknowns!

An Error Multiplied by an Error Is a Really Big Error

Are you beginning to see the issues here? This whole computer model is an assumption multiplied by an assumption that has never been peer-reviewed by any journal but merely thrown up on a pre-print server. Basically, similar to university scientists using a computer model to read tarot cards and then uploading that paper to the Internet.

So let’s summarize. We have scientists who created a computer model and just plugged in “best guess” numbers for critical items that must be correct for the model to be accurate. They then tried to validate that guess multiplied by a guess model against real-world situations, but fully admit that the validation they used also has big unknowns. This crazy assumption layered on top of assumption model is now being used by the media to dictate public health policy.

What Do We Really Know About Mask Use?

So let’s leave the media Disneyland version of science and see what we actually know about masks and respiratory viruses. I’m going to focus mostly on real-world studies where researchers have tried to use masks to stem the actual infection rate of respiratory viruses. However, I’ll also share some other commonsense research on masks.

Home Made Cloth Masks

The National Institute for Occupational Safety and Health (NIOSH) performed a research study on whether common clothing items such as sweatshirts, t-shirts, and scarfs would work in hospitals to protect workers (7). They concluded that these items could only provide marginal protection against the small particles we’re all concerned about here.

How about in the real world? A randomized controlled trial has been done. The authors compared the ability of cloth masks to prevent healthcare workers from contracting influenza and they found that the workers wearing cloth masks were 13 times more likely to get a respiratory viral infection than those wearing the better medical masks (8).

Surgical Masks

The first thing to realize about surgical masks is that they just don’t work like N-95 masks. For example, a recent laboratory study of 5 different surgical masks found that almost all subjects wearing these masks failed an OSHA-accepted fit test with 12–25% leakage around the mask (9). The worst N-95 masks the researchers tested showed 1% leakage.

How good are surgical masks at preventing infections? After all, that’s why they’re worn in surgery, right? Well, a trio of studies has shown that surgical mask performance is so poor, that infection rates during surgeries weren’t increased when the staff didn’t wear a surgical mask! (10-12) Other research has reached similar conclusions about the poor performance of surgical masks (13-16).

However, have surgical masks been studied in preventing viral infections like this one? After all, a real-world test would tell us everything we need to know! Yes, the risk of contracting an aerosolized SARS virus (similar to the novel coronavirus) was studied. The good news was that wearing an N-95 mask significantly reduced infections among healthcare workers but the surgical masks did nothing to reduce infections (17). Then there’s a 2009 study that tested whether surgical masks would prevent people living together in a house from contracting a respiratory virus. The researchers found that this approach didn’t work (18).

How about in a dense community living situation like a dorm or apartment building? Surely surgical masks will help there? A study performed at the University of Michigan randomized more than a thousand students to either wear a mask 6 hours a day and use hand sanitizer, just use the mask, or a control group. (19). The hand sanitizer sort of worked, but the masks did nothing to stop the spread of the flu virus.

There is also a research review of seventeen different studies on mask use and whether that slowed the spread of respiratory viruses, but the findings were mixed (20). The authors concluded, “None of the studies established a conclusive relationship between mask/respirator use and protection against influenza infection.”

Is there any ray of hope for those who feel protected by wearing a surgical mask? One study found a 43% reduction in respiratory viral infections in immune comprised patients when everyone (patients, visitors, and healthcare workers) wore surgical masks (21). However, these were not patients who had a normal and functioning immune system.

Whole Governments Have Looked at this Issue

Everything you need to know about this topic is contained in one sentence from a recent Lancet article on this topic, “Evidence that face masks can provide effective protection against respiratory infections in the community is scarce, as acknowledged in recommendations from the UK and Germany.” (22)

The upshot? Putting politics aside, we do not have good data that wearing a mask will protect you or others or society at large from the coronavirus. Having said that, I also realize this is a personal decision, so I would encourage everyone to get educated on the science and draw their own conclusions. In addition, I also know that wearing masks makes some people feel protected and that that could have some value. All I want is for smart people to read the actual data and then write or speak accordingly.

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References:

(1) Kai et al. Universal Masking is Urgent in the COVID-19 Pandemic: SEIR and Agent Based Models, Empirical Validation,
Policy Recommendations. Arxiv {Pre-print Server]. https://arxiv.org/pdf/2004.13553.pdf

(2) Vox. Why 15 US states are suddenly making masks mandatory. https://www.vox.com/2020/5/29/21273625/coronavirus-masks-required-virginia-china-hong-kong Accessed 5/29/20.

(3) Imperial College of London. Report 9: Impact of non-pharmaceutical interventions (NPIs) to
reduce COVID-19 mortality and healthcare demand. https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf Accessed 5/29/20.

(4) Centers for Disease Control and Prevention. Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html Accessed 5/30/20.

(5) Commonwealth of Virginia, Office of the Governor. Executive Order. NUMBER 63 (2020) ORDER OF PUBLIC HEALTH EMERGENCY FIVE REQUIREMENT TO WEAR FACE COVERING WHILE INSIDE BUILDINGS. https://www.governor.virginia.gov/media/governorvirginiagov/executive-actions/EO-63-and-Order-Of-Public-Health-Emergency-Five—Requirement-To-Wear-Face-Covering-While-Inside-Buildings.pdf Accessed 5/30/20.

(6) van der Sande M, Teunis P, Sabel R. Professional and home-made face masks reduce exposure to respiratory infections among the general population. PLoS One. 2008;3(7):e2618. Published 2008 Jul 9. doi:10.1371/journal.pone.0002618

(7) Rengasamy S, Eimer B, Shaffer RE. Simple respiratory protection—evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles. Ann Occup Hyg 2010 Jun 28;54(7):789-98

(8) MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.BMJ Open 2015 Apr 22;5(4):e006577

(9) Oberg, T., and L. M. Brosseau. 2008. Surgical mask filter and fit performance. American Journal of Infection Control 36, (4) (May): 276-82.

(10) Orr, N. W. 1981. Is a mask necessary in the operating theatre? Annals of the Royal College of Surgeons of England 63, (6) (Nov): 390-2.

(11) Mitchell, N. J., and S. Hunt. 1991. Surgical face masks in modern operating rooms—a costly and unnecessary ritual? The Journal of Hospital Infection 18, (3) (Jul): 239-42.

(12) Tunevall, T. G. 1991. Postoperative wound infections and surgical face masks: A controlled study. World Journal of Surgery 15, (3) (May-Jun): 383,7; discussion 387-8.

(13) Saunders-Hastings P, Crispo JA, Sikora L, et al. Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis.Epidemics 2017 Sep;20:1-20

(14) Cowling B J, Zhou Y, Ip DKM, et al. Face masks to prevent transmission of influenza virus: a systematic review. Epidemiol Infect 2010 Jan 22;138(4):449-56

(15) bin‐Reza F, Chavarrias VL, Nicoll A, et al. The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza Other Respir Viruses 2011 Dec 11;6(4):257-67

(16) MacIntyre CR, Zhang Y, Chughtai AA, et al. Cluster randomised controlled trial to examine medical mask use as source control for people with respiratory illness.BMJ Open 2016 Dec 30;6(12):e012330

(17) Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto.Emerg Infect Dis 2004 Feb;10(2):251-5

(18) MacIntyre CR, Cauchemez S, Dwyer DE, et al. Face mask use and control of respiratory virus transmission in households. Emerg Infect Dis. 2009;15(2):233–241. doi:10.3201/eid1502.081167

(19) Aiello AE, Perez V, Coulborn RM, Davis BM, Uddin M, Monto AS. Facemasks, hand hygiene, and influenza among young adults: a randomized intervention trial. PLoS One. 2012;7(1):e29744. doi:10.1371/journal.pone.0029744

(20) Bin-Reza F, Lopez Chavarrias V, Nicoll A, Chamberland ME. The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza Other Respir Viruses. 2012;6(4):257–267. doi:10.1111/j.1750-2659.2011.00307.x

(21) Sung AD, Sung JA, Thomas S, et al. Universal mask usage for reduction of respiratory viral infections after stem cell transplant: a prospective trial.Clin Infect Dis 2016 Oct 15;63(8):999-1006

(22) Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med. 2020 Mar 20. pii: S2213-2600(20)30134-X. doi: 10.1016/S2213-2600(20)30134-X.

(23) World Health Organization. Coronavirus disease (COVID-19) advice for the public: When and how to use masks. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks Accessed 5/30/20.

(24) Chen CC, Willeke K. Aerosol penetration through surgical masks. Am J Infect Control. 1992;20(4):177‐184. doi:10.1016/s0196-6553(05)80143-9

(25) Washinton Post. 73% of Democrats are wearing masks to fight coronavirus. Only 59% of Republicans are. https://www.washingtonpost.com/politics/2020/05/15/73-democrats-are-wearing-masks-fight-coronavirus-only-59-republicans-are/ Accessed 5/31/20.

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