Attribute to L. Neil Smith’s The Libertarian Enterprise

To mask, or not to mask. That is the question.
Whether ’tis nobler in the mind
To suffer the coughs and sneezes of outrageous fortune,
Or to take up masks, and by opposing, block them.
—Without apology to the Bard of Avon
If he were alive today, he would have said it too.

 

Author’s note: I continue to use https://www.worldometers.info/coronavirus/ as my primary source of Chinese Bug statistics. Note that the site has added statistics on number of tests administered, though it must also be noted that these early tests remain less than 70% effective and have an unstated false alarm rate.

 

Knowing something about the subject, I have been wondering at the CDC’s steadfast refusal to acknowledge that wearing masks in public would help reduce the spread of the disease. And I’m tired of getting mocked for expressing that opinion even after the CDC somewhat agrees to allowing public wearing of masks, no matter how reluctantly.

So I looked up the data. It was frightfully easy, with a little Google fu—and knowing enough to phrase my search terms meaningfully.

First, a summary of background. I will note that the DHS report at https://www.dhs.gov/sites/default/files/publications/mql_sars-cov-2_-cleared-for-public-release_2020_03_25.pdf is a good background source, but I am also capturing information from prior reading, including my "The Chinese Bug" of two weeks ago, without citing references.

• The virus apparently began circulating in Wuhan, Hubei province, in mid-November. However, reporting was actively suppressed until some physicians began getting news out in mid-December. China’s first formal report to the World Health Organization (WHO, and I respectfully submit to my readers that they presently deserve any knock-knock joke allusions or Time Lord allegories you care to attribute to that acronym) was on December 31, 2019. China did not lock down the country until mid-January, at least 4 weeks after the virus was being widely spread including exposure of early travelers for the Lunar New Year celebrations, and eventually imposed a thoroughly draconian lock-down regimen (see "The Chinese Bug" for discussion).
• Some notes about COVID-19. The virus has several unusual features, including a long and highly variable incubation period (2 - 14 days from exposure with at least one documented case at 24 days), and a long period of expression that can go from 1-2 weeks even for mild cases. Severe cases have persisted for six weeks. While these numbers are disputed, the fatality rate is fairly consistently about 3% for most populations, with high rates of fatality among elderly patients and patients of all ages with comorbidities. Most severe cases involve development of a pneumonia with a high density of fluid in the lungs (expressed as "glassy lungs " on x-rays), resulting in death either from respiratory failure or from cardiac arrest secondary to the pulmonary symptoms. There are numerous reports of promising results from treatment with a combination of the anti-malarial drug hydroxychloroquine and the antibiotic azithromycin. However, (1) this combination will not work for everyone (for example, hydroxychloroquine has a potentially fatal reaction when taken with the diabetic drug metformin), and (2) a number of jurisdictions have banned consideration of the drug solely because President Trump applauded the early test results, leaving their citizens to die without palliative treatment solely because of their hatred of Trump. (This latter concern was exacerbated when a couple in Arizona were injured, one dying, after taking a toxic fish tank cleaner that contained the related chemical chloroquine phosphate).
• Free market countries near China (such as Hong Kong, South Korea, and Japan) immediately imposed procedures meant to limit the spread of disease, including public masking, good hygiene, combined with taking the temperatures of persons entering public places and rejecting those with fevers, and rigorous quarantine of victims; in fact much of the early spread in South Korea was due to a victim who exposed the large congregation of her religious sect.
• However, the western experience was tempered by Northern Italy, a region of the country that presently has a large community of Chinese expatriates due to Chinese business expansion. Spread there was so dramatic, involved so much of the population, and had such a high fatality rate (in part, supposedly, because of the high rate of smoking among the native Italian population and the Chinese expats, and in part because the local medical systems became so saturated that treatment was eventually denied to patients over 60) that first that region, then all of Italy, was put into total lockdown. In general, most western countries including the United States have since followed the "lockdown" model, rather than the more moderate South Korean model, despite the success of that model in damping down the runaway cluster associated with the religious sect, and the failure of the lockdown model.

So the question arises, should we have masked up, quarantined only positives, and protected the elder population, or was a lock down totally necessary? Somewhat arguing in favor of a total lockdown has been the widespread fallout in increased coronavirus infection related to Mardi Gras in New Orleans and college spring break on the coastal beaches—until the beaches were shut and the students told to go home and continue classes by internet afterward. But again, "party but wear masks" was never entered into the equation. I can’t give a total answer, or do a full analysis, but I can share the results I found on the Internet (quotes in italics), together with a few comments.

 

https://www.healthline.com/health/cold-flu/mask

In the case of the novel coronavirus and COVID-19, the CDC notes that simple face coverings or masks can reduce its spread:

“CDC recommends that people wear a cloth face covering to cover their nose and mouth in the community setting. This is an additional public health measure people should take to reduce the spread of COVID-19 in addition to (not instead of) social distancing, frequent hand cleaning and other everyday preventive actions.”

The CDC recommends healthcare workers wear face masks when working with patients who have the flu.

The CDC also recommends patients who show signs of respiratory infections be given masks while they’re in healthcare settings until they can be isolated.

If you’re sick and need to be around others, properly wearing a mask can protect those around you from contracting your illness.

 

So masks help healthcare workers in high contact. So one would expect masks to help the general public in low contact. Why not say that? Masks help people who have the disease prevent spread. One would expect the barrier works both ways. Why not say that?

 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html

Provide Supplies for Recommended Infection Prevention and Control Practices

• Hand hygiene supplies:
• Put alcohol-based hand sanitizer with 60–95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym).
• Make sure that sinks are well-stocked with soap and paper towels for handwashing.
• Respiratory hygiene and cough etiquette:
  • Make tissues and facemasks available for coughing people.
  • Consider designating staff to steward those supplies and encourage appropriate use by residents, visitors, and staff.
• Make necessary Personal Protective Equipment (PPE) available in areas where resident care is provided. Put a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room, or before providing care for another resident in the same room. Facilities should have supplies of:
• facemasks
• respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP)
• gowns
• gloves
• eye protection (i.e., face shield or goggles).
• Consider implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing.
• Environmental cleaning and disinfection:
• Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment.
• Refer to the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.

 

Sounds reasonable…

 

Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza, World Health Organization, 2019 (pre-COVID)

Ten studies were pooled to conduct a meta-analysis to quantify the efficacy of community based use of face masks in the reduction of laboratory-confirmed influenza virus infection (Table 7). In the pooled analysis, there was a non-significant relative risk reduction of 22% (RR = 0.78, 95% CI: 0.51–1.20, I2 = 30%, p = 0.25) in the face mask group and 8% in the face mask group regardless of the addition of practice of hand hygiene (RR = 0.92, 95% CI: 0.75–1.12, I2 = 30%, p = 0.40). The evidence profile for face masks outcome is summarized in Table 8.

22%? This may hinge on the definition of non-significant.

 

https://www.japantimes.co.jp/news/2020/02/25/national/japan-mask-shortages-covid19/

Some experts advise that hand washing is more effective than wearing a face mask, or go as far as saying that reusable masks are dangerous to your health. But many still believe that any mask is better protection than no mask at all.

Virologists, on the other hand, have doubts about the effectiveness of masks against airborne viruses, although there is some evidence to suggest they can help prevent hand-to-mouth transfer.

 

What is the evidence, and why have masks apparently worked in Japan (and South Korea)?

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307882/#R26

Samantha M. Tracht,^a,b,* Sara Y. Del Valle,^a and Brian K. Edwards^a, Economic Analysis of the Use of Facemasks During Pandemic (H1N1) 2009, J Theor Biol. 2012 May 7; 300: 161–172. Published online 2012 Jan 28. doi: 10.1016/j.jtbi.2012.01.032

^aEnergy & Infrastructure Analysis Group, Decisions Applications Division, Los Alamos National Laboratory, Los Alamos, NM; ^bMathematics Department, University of Tennessee, Knoxville, TN

A large-scale pandemic could cause severe health, social, and economic impacts. The recent 2009 H1N1 pandemic confirmed the need for mitigation strategies that are cost-effective and easy to implement. Typically, in the early stages of a pandemic, as seen with pandemic (H1N1) 2009, vaccines and antivirals may be limited or non-existent, resulting in the need for non-pharmaceutical strategies to reduce the spread of disease and the economic impact. We construct and analyze a mathematical model for a population comprised of three different age groups and assume that some individuals wear facemasks. We then quantify the impact facemasks could have had on the spread of pandemic (H1N1) 2009 and examine their cost effectiveness. Our analyses show that an unmitigated pandemic could result in losses of nearly $832 billion in the United States during the length of the pandemic. Based on present value of future earnings, hospital costs, and lost income estimates due to illness, this study estimates that the use of facemasks by 10%, 25%, and 50% of the population could reduce economic losses by $478 billion, $570 billion, and $573 billion, respectively. The results show that facemasks can significantly reduce the number of influenza cases as well as the economic losses due to a pandemic.

 

That’s not what the CDC said. That’s not even what the Japan Times said.

Note that 25% coverage of the populations gives almost as much population protection as 50%! It doesn’t take much to bring the infamous parameter R0 down.

 

PLoS ONE | www.plosone.org 1 February 2010 | Volume 5 | Issue 2 | e9018

Mathematical Modeling of the Effectiveness of Facemasks in Reducing the Spread of Novel Influenza A (H1N1)

Samantha M. Tracht1,2*, Sara Y. Del Valle1, James M. Hyman3

Figure 6. Sensitivity to the Percentage of the Population Wearing Masks. The fraction of the population wearing masks greatly affects the number of cases. Even if only 10% of the population wears masks the number of cumulative cases is significantly reduced; however, the graph shows that the number of cases is drastically reduced if 25% of people wear masks.

Figure 7. Sensitivity to When Masks Are Implemented. Masks should be implemented as soon as possible. There is a large difference in the number of cases when masks are implemented at 100 infectious individuals versus waiting until there are 1000.

Figure 8. Sensitivity to Who Wears Masks. In order to achieve the greatest possible reduction in the cumulative number of cases both infectious individuals and susceptible and exposed individuals should wear masks. If only infectious individuals wear masks the number of cases is not significantly reduced.

I repeat, If only infectious individuals wear masks the number of cases is not significantly reduced. If I am not mistaken, that is a complete contradiction of what the CDC has said consistently through this "crisis."

https://smartairfilters.com/en/blog/coronavirus-pollution-masks-n95-surgical-mask/>

Bottom line: Masks can filter particles as small as 0.007 microns – 10 times smaller than viruses, and much, much smaller than PM2.5. What’s more, they work surprisingly well, even while people are wearing them. Surgical masks perform less well but are cheaper and more readily available.

(See page for figures and details.)

 

I know it’s only common sense, but I like it…

 

(Reprinted) JAMA, November 4, 2009—Vol 302, No. 17 1865

Loeb, et al, Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers, A Randomized Trial

Results Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, −0.73%; 95% CI, −8.8% to 7.3%; P=.86), the lower confidence limit being inside the noninferiority limit of −9%.

Conclusion Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory confirmed influenza.

 

Cloth masks work almost as well—statistically indistinguishable—as the much valued N95 respirators? Who knew?

 

To summarize all of the above, in hopefully less medical language:

Full disclosure, I have had Army mask training, as well as portions (not the full course) of hazardous waste operations, and I suggest taking a look at https://chemm.nlm.nih.gov/decontamination.htm#step3 for details.

So to bring this to a conclusion—- as well as filling in other holes in the guidance—I submit the following recommendations.

 

I assume that the WHO and CDC are aware of their own research. So why did they wait almost two months before publishing recommendations about wearing masks, while insisting up to that point that the wearing of masks by the public would not help? How many people have died because the US medical community willfully denied the effectiveness of the measures that South Korea and Japan have used?

Again, WHY?