Has everyone gone utterly insane?.
The Phantom of the CDC
by T.J. Mason
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.
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.
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?
Provide Supplies for Recommended Infection Prevention and Control Practices
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.
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)?
Samantha M. Tracht,a,b,* Sara Y. Del Valle,a and Brian K. Edwardsa, 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."
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:
1. There has never been any justification in saying that it does not help for the general public to wear masks. There is possibly some justification in saying that the general public has not been trained or fitted for wearing N95 masks or more sophisticated respiratory protection—but that training takes five minutes, the fitting takes 5 minutes, and with two more minutes of training you can do very effective self-fitting. This is not rocket science—Army grunts get this training including self-fitting when they are issued their chemical gear, on much more sophisticated masks than N95 respirators.
2. Cloth masks—including field expedient cloth masks—work almost as well as respirators for people who have only casual environmental exposure. In fact, that statement is true for clinical exposures.
3. Masks by themselves help. Masks with proper hygiene help three times as much.
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.
1. Use the mask you have. If what you have is a bandana, tie it around your nose and mouth like an old-time bandito or The Man With No Name. Folding it into a semblance of a surgical mask as the CDC suggests (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html) seems unnecessarily frivolous, but if you want to—or are told by your boss—to follow the official line, make it so. The important thing is to cover both nose and mouth, and to seal it as much as possible to prevent aerosols from entering from above or below around the mask. This includes aerosols that settle on your clothing and are re-disturbed, so that may be one (minor) advantage of using the folded surgical-style bandana instead of the bandito mask. Any more sophisticated mask short of a full-face respirator is at best slightly better, as long as you follow that guidance.
2. Practice good hygiene. Wash your hands frequently with soap and warm water, or use an alcohol based sanitizer with at least 60% alcohol. Scrub thoroughly with at least 20-30 seconds contact with either water or sanitizer. This is true even if you glove up for handling of potentially contaminated materials.
3. This is the first thing that I don’t see being said anywhere else. The mask will inhibit risk from aerosols that are around you as you move about. The aerosols will settle on the mask—and on your face and head above it, and your body and clothing below it. When removing the mask, be careful not to touch it with your hands, then wash your hands and face thoroughly at the first opportunity.
4. If you want to go for the full treatment—particularly if you think you might have been exposed, or are in a high risk group—remove your outer clothing as quickly as possible after contamination, place it in a bag where it won’t recontaminate anything, and wash as soon as possible. Spray your shoes with a non-bleach decontaminant (to prevent discoloration or destruction). Spray down or wipe down any furniture, etc. that was in contact with the clothing. Then shower thoroughly, and shower again (and again) after contacting anything that possibly has been exposed to virus-containing aerosols. Note that a lot of people with extreme pollen allergies do this on a routine basis. Think of Meryl Streep’s character in Silkwood, whenever they get a radioactive material detection when she leaves the plant. And I also suggest, as both information and cautionary tale, the story of a nursing home norovirus infection at https://accordingtohoyt.com/2020/02/19/breaking-out-a-guest-post-by-helen-miller-rn/.
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?
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