The debate between scientist warrants the immediate attention of
global health officials and physicians in the USA, especially because it
appears that the countries that are flattening curves are following
recommendations that differ from those of the CDC and WHO.
THE DEBATE ON FACE MASKS: OPINION & EVIDENCE
The video presents expert opinions, evidence from research and discusses alternative approaches to using surgical masks. Text from the slides are available along with in line citations. http://bit.ly/3ddcu2f
Here are a few opinions from experts:
1. Evidence for masks is inconclusive “not a reason to
dismiss” since “can’t randomize people to not wear a mask, and some to
wear a mask, and then expose them all to the virus.” “If you are standing in
front of someone who is sick, the mask will give some protection.” “The mask
provides a barrier from respiratory droplets, which is predominantly how the
virus spreads.” -David Hui, respiratory medicine expert, Chinese University of
Hong Kong, studied the 2002 to 2003 SARS outbreak extensively
2. We need to make policy decisions and clinical decisions
now…You can’t say, ‘Let’s wait a month until we have the data…Right now, we
need to do anything that buys us one week, two weeks; anything to delay will
have a dramatic impact…[because]…If London, Seattle or Paris goes through what
northern Italy is going through at the moment, it will be devastating.”-Dr.
Jeremy Farrar, infectious disease specialist and director of the research
charity Wellcome, in London.
3. “If there’s a general recommendation that people wear face
masks, we won’t have enough supply for healthcare workers…Scant
evidence..don’t fit snugly” for members of general public” -Dr. William
Schaffner, professor in Vanderbilt University’s Division of Infectious
4. “The likelihood that any of these are going to protect anyone in these environments is minimal…Wearing these things can in some ways be worse than not wearing one.” -Bruce Ribner,MD MPH medical director of Emory University Hospital’s Serious Communicable Diseases Unit
ASK YOUR HEALTH OFFICIALS FOR COMMENT
I would appreciate if CDC, World Health Organization (WHO) and experts from The John Hopkins Center for Health Security, Harvard T.H. Chan School of Public Health New York State Department of Health can answer this question immediately since we are running out of time.
Transcript First Paragraph (click to expand)
Remaining transcript (click to expand)
It’s important to note that both the department of health and CDC have in the past recommended the use of face masks during supply shortages. For example. In Africa for hemorrhagic fever. When surgical masks were not available, they recommended the use of cotton masks for infection control. In influenza plans of different department of health, though the one that was referenced in this article was the Sonoma County department of health.
They discussed the use of a cloth mask in the event of a shortage. Of surgical masks as well as N95 masks. That implies that cloth masks may also protect against airborne particles, not only large droplets. Again, , if they can be used instead of an N95 during shortage. That implies that they have some sort of filtering ability, and that has been shown in research where penetration testing shows that Hanes sweatshirts, filter out approximately 55% of particles in the 20 to 1000 nanometer range. Now, you would have to look at what size particles on average are aerosolized.
In a particular virus to know if this was effective, but it’s likely better than nothing. Let’s look at how most Corona virus COVID-19transmission occurs. As you know, large droplets are responsible for most coronavirus. Here you can see that somebody is coughing and it has a trajectory of about three feet where it can then land on a person directly.
It can land on a surface or someone’s hands now that could land on the hand of the person who’s infected and you could then touch a doorknob, or he could shake somebody’s hand, or he could touch somebody’s bag of groceries as he’s checking them out on a line where he is checking out groceries for a hundred people.
What do we do about that? Well, if we recommend wearing masks for every person. In order to prevent them from getting sick. Of course, it’s possible that if somebody coughs onto their face, they’ll be protected. However, it’s also possible somebody could cough and it could get into their eye, or it’s possible that they will touch their own eye while they have the virus on their hand or it’s been transmitted to their hands somehow.
From the perspective of preventing infection, any mask wearing may or may not help by itself, which is why most individuals wear visors in a hospital setting. However, wearing masks prevents most of the spread. If you are sick, that is because you are blocking the entire trajectory and therefore you are.
Looking at the infection chain and stopping the spread of infection earlier in the chain. This all appears to be common sense to me. However, this has not been idea, at least in the USA and who does not appear to also recommend that everybody wears masks.
It’s been cited by other people that the main reason for that is, yeah, they are concerned about leading to further shortages. Here are our proposed recommendations, but I’m going to skip that for now.
I’m just going to share other individual expert ideas because. Some people might feel that a neurologist is not qualified to comment on public health. Let’s just look at what some experts say throughout the world. this is an individual deviated, way that. Says, masks may be particularly important in COVID-19, and this is a divergence of expert opinion.
He says patients with COVID-19frequently have only minor symptoms. In fact, if you look at recent literature, it seems as though there may be up to. 80% of individuals who are responsible for transmitting infections that have either minor symptoms or they are asymptomatic, or they’re pre-symptomatic and developing symptoms and will take several days until they show up at a healthcare professional before they’re diagnosed.
And during that critical stage. Is when up to 80% of infections are taking place according to mathematical models. So
There is inconclusive evidence for masks but according to David Hui, that is not a reason to dismiss wearing masks. Since it would be impossible to randomize individuals in a study. And conduct a randomized controlled trial to not wear a mask and expose people to the virus. That would be unethical.
So it’s unlikely to ever get this evidence. he then goes on to say, which I’ve said, if you’re standing in front of someone who is sick, the mask will give some protection as demonstrated in my graphics above. The mass provides a barrier from respiratory droplets, which is predominantly how the virus spreads and his credential is respiratory medicine expert.
Chinese university of Hong Kong studied the 2002 to three SARS outs outbreak extensively. here’s what dr Jeremy Farrar, an infectious disease specialist, and a director of a research charity called welcome in London, talking about the need to make urgent decisions.
We need to make policy decisions, clinical decisions. Right now he says, because we can’t wait a month until we have the data right now. We need to do anything that buys us a week or two. Because that delay could have a dramatic effect. I think that is what we’re doing. it looks like FDA’s already testing out vaccines and individuals, and that’s obviously much faster than we would normally see in typical drug development.
obviously people realize this. the reason why we’re not recommending masks to the public, as I mentioned before and as it’s pointed out by professor Schaffner at Vanderbilt, is that if there’s a general recommendation that people wear face masks, we won’t have enough supply for healthcare workers as well as the fact that there were scant evidence or they don’t fit snugly for members of the general public.
They only fit snugly. I suppose for healthcare workers, but there are other reasons. anecdotally, I’ve heard individuals dismiss the wearing of face masks by saying they don’t work. They just, there’s little chance that they’re going to work. and then they qualify. But there’s little harm in it.
Now, I haven’t seen any data that shows that they don’t work. But here are other reasons why they might not be recommended. There’s a lack of quality assurance and regulation. According to Chughtai 2015 does extensive studying on face masks, so I guess he would be the world’s authority on it, along with McIntire: regulation, wide range of cloth masks or improvise masks.
Use around the world, these kind of go more towards just wearing cloth masks rather than the surgical masks supplied to hospitals, which we have come to rely on. he’s commenting on, you know, why not recommend cloth masks? And I think that there’s this lack of reproducibility. So if you’re recommending a mass or making an official recommendation for a mask, well, which mask are you recommending?
It makes it politically difficult, I suppose, to make a recommendation when you don’t know exactly what you’re getting. Right. Cloth masks include cotton and gauze masks that are homemade or woven according to his definition of what cloth masks mean. So that includes what you would call a DIY face mask.
Surgical masks face similar issues. Unlike NIOSH certified and N95, he points out that actually these surgical masks that we’re using, at least in 2015, his article was citing that they’re also lacking in these, types of regulations. So we have NIOSH approved and N95, but when you look at surgical masks, they have to meet, I believe the FDA’s criteria. But how that exactly is certified? I don’t know. It seems like the company itself can go ahead and just meet those guidelines. best I know is that they are mostly resistant to, liquids. in a surgical setting, they would be useful to protect against splashes, where if you had a massive splash of water or of blood, it would just go straight through the mass.
Then there’s a concern that cloth masks may encourage risk taking or decrease other hygiene measures due to a false sense of protection. . That might be true. it’s a concern that I don’t see a lot of data for. So I think if we were to summarize the data we would have to say the data for any face mask, including the surgical masks, is scant.
Let me go to these recommendations that I would. Consider, and I think we need to consider, because what our healthcare workers to do if they don’t have surgical masks. Okay. Should I wear a face mask if you’re sick?
Let me try to summarize this as fast as possible. this says that individuals who are not sick should wear a face mask whenever they go out in public. To a hospital, or if you’re caring for someone who’s sick, that diverges from some recommendations that will say, well, only the sick person in a household needs to wear a mask.
That a sick person should wear it, , only when they’re near another person. But if they’re just in their house alone, maybe they don’t have to wear it. I would say that they should wear it whenever they move around in a house. , and potentially consider all the time, though, that would be hard to do if you were wearing a surgical mask and, and 95 respirator not comfortable to wear, you may be contaminating it.
That’s a possibility as well. , but that doesn’t seem to concern healthcare workers who have, said things like, Hey, I think I’m touching my masks well as I’m too. , I don’t think that, . The public is more likely to touch their face. Mass. Nan a, physician would be, I think that is unproven and probably incorrect.
I think there was a press conference with a well known health official. Who is telling people not to touch their face and unconsciously was touching their face and nose throughout the press conference. I think that’s a good example and I don’t think that I’m less likely to do something that is just something that I do without thought like.
Fixing my hair, then the general public, I think that’s a myth. Most likely I can’t prove it, but I feel that’s just the case. now I’m addressing what type of face mask to wear. And I specifically say reserve professional masks for healthcare workers.
They need them for surgery procedures and caring for many sick patients. But. I also say that a do it yourself mask, including cotton and gauze masks that are homemade or woven may substantially reduce the spread of coronavirus and that that’s just common sense. If I were to stand in front of this camera lens and cough on it, it would get all wet.
If I just took anything, some piece of paper that I have lying around, for example, folded it up and coughed on it. There’s going to be nothing on that lens. And really that barrier of prevention is the most important thing. Similarly, I’m at, at the very least, going to, , prevent myself from touching my mouth or nose if it fits over my mouth or nose.
There may be a need to educate the public on exactly how to wear it properly or to take it off or dispose of it or clean it, if in fact, that is the recommendation that’s being made. But I think almost any healthcare professional would agree that something covering your face is better than nothing.
I think we would also agree that if something does not lead to depleted resources for healthcare workers, that it should be something that is tried, if it’s going to impact the number of people that end up infected because ultimately stopping the infection earlier in the chain will require less face masks to be warned by healthcare workers.
It’s sort of the short term versus long term strategies that have to be balanced. Unfortunately. It seems as though healthcare workers are also now out of face masks in general, the end, the end 90 fives, as well as just the surgical face mask, and I have to clarify that those surgical face masks, there’s no data as far as I know.
There’s no good data that shows that they work any better for barrier protection. Then a piece of paper does or then a cloth mask with several layers. There might be some data on paper, but it’s not substantial. It’s going to be scant evidence. So now let’s go back to the count, the point and counterpoint.
All right, and then we’ll look at some history. Actually, let’s start there. In the past, cloth masks have worked and been recommended by the DOH and CDC during supply shortages. So according to McIntyre, another authority on face, Massachusetts worked with chug Thai non-disposable cloth masks were used to protect healthcare workers from Scarlet fever, measles, influenza, plague, and tuberculosis.
This is before regular disposable face mass came about. They used continued today in developing countries. Like India because they last long. They’re easy to carry. Non-allergenic comfortable, affordable, and washable. This comes out in an Institute of medicine, 2006 report where they were charged with looking at the reusability of respirator masks.
Now they also, even though this wasn’t their mission. Or directive. They also did mention cloth masks in this study and they did not conclude not to wear cloth masks. They did not conclude that. They said, we’ve got to do more research on this. Of course, we don’t have great data on this, nor will we ever, during the SARS outbreak in 2002 according to this Institute of medicine report, the public and Asia was encouraged to where we usable gauze or cotton masks that could be washed with disinfectants.
It could be sterilized with high pressure and temperature. I think there’s some data to suggest that a microwave would be useful to disinfect or sterilize a cloth mask after it’s been used. So theoretically, somebody could put on a mask that’s made at home with some cotton, wear it outside when they go to the supermarket, come back home, put it in the microwave with possibly some water for one minute.
Or so, and that should probably kill virus if it is their use of masks. Social distancing and hygiene were found to be strongly protective and significantly reduced the risk for SARS. Now, use of masks goes along hand in hand with social distancing and hand hygiene in these circumstances. Encouraging masks in the public did not lead to decreasing other methods, and I think that.
It’s unlikely that it’s going to encourage people already sitting at home and scared for their lives to not wear face masks in the public. If we were to say, go ahead and make a cloth face mask, CDC, then again, just to repeat this, the CDC has recommended the use of cotton masks for infection control of viral hemorrhagic fevers in the African health care setting.
When surgical masks are not available, and regional pandemic influenza plans. Discuss the use of cloth masks in the event of shortage of and surgical masks, which implies both barrier protection against large droplets as well as against airborne particles, which research has shown based on their penetration testing.
There is some reduction in airborne particles. . Let’s go to counterpoints where I explain some of the arguments for and against. if there’s a general recommendation that people wear face masks, we won’t have enough supply. Agreed. If we were direct and used exactly the same masks, . That would potentially lead to diminishing supply, it has to be pointed out to the public that we need to prioritize masks and other equipment for healthcare workers such as gloves. However, recommendations for cloth, DIY or home masks will not affect the health care worker supply.
Secondly, scant evidence. First point, there is no conclusive evidence for any medical masks. It’s sufficient for medical professionals. So if this data is sufficient for medical professionals, it should be enough to recommend to the general public. Then in addition, even if the evidence, as Dr. Hui said, evidence is lacking, that is not a reason to dismiss because we need to do anything to buy us time.
Any delay could be devastating. You can’t say, let’s wait a month. You can’t say, let’s wait a year. We need to make decisions now. RCT for masks not possible. Okay. Not ethical won’t happen, but there are at least 19 studies on cloth masks that suggests efficacy as well as anecdotal data, from those IOM reports.
Then the other question, snug fit, I think that not an issue for barriers from large droplets, and not relevant. The current guidelines is N95s are only recommended for physicians who are performing procedures that are going to aerosolize the virus, or theoretically are going to aerosolize the virus doing intubation and bronchoscopy and other procedures in the ICU.
Surgical masks used in healthcare, have similar issues to cloth masks because they don’t have the same NIOSH certifications. if you’re worried about the fact that we’re not going to have a reproducible effect, if we make these recommendations, I think that’s true. But also something that exists in regular surgical masks that we take for granted must be proven, must be researched, must have these standard new standards and certifications, which they probably don’t.
As I mentioned here, surgical masks, superiority, and this is from the IOM report as well, appears to be in its ability to be used in an operating room because of the ability to resist fluids. as I mentioned, it’s currently used throughout the world where they run out of masks and their doctors who are quite smart they’ve found over time.
I guess you would call it not evidence based medicine, but medical based evidence shows that they work. And here are about 18 or 19 studies just on masks that are homemade or woven or made out of cotton. All of them seem to show there’s some effect. You could argue that they’re not strong data.
And that would be fair, but I think it is common sense that any barrier. Will work better than no barrier. these are the recommendations that are proposed. And I would just say that you have to consider, even if there are social isolation, which is a good idea, and we’re all sitting around in our house, , that’s going to work to stop infection because we’re lowering the probabilities of each person being exposed.
However. just like a, a mosquito in malaria that finds its way to somebody who’s sitting around in a house, not, not outside drinking, something that would infect them with malaria, that vector comes along and bites them. It comes around from outside the home. And what happens is that naturally people have to leave their house to go, to get groceries, to go to get food, to go to a hardware store.
And there’s people there at the checkout counters that are just not wearing masks. Okay. They are typically wearing gloves, which would be great if it weren’t just acting like their hands. They cough into their glove and they touch their eye or face. Now, that’s not going to help unless they keep on switching their gloves and let’s face it, they’re not doing that.
If they were wearing a mask and sanitizing their hands every once in awhile. I think what you would end up with is individuals who. We’re not going to be infected and are not going to be passing it on and touching cough, and then touch every single item on that conveyor belt and then handing it to somebody right away where you have the risk of this indirect transfer of particles that.
Clearly as a risk. And then the problem is of course, that that person then goes back to their isolated home where there might be old people, fragile individuals, and they in theory, will in fact those people. it’s isolation is better than nothing. Social isolation is better and great. And of course is used for the same reason that we go ahead and we.
Tell people to, uh, stay six feet apart. Cough into the nook of your elbow. Okay. Those, that’s another barrier method. We’re trying to stop these large droplet transfers, but there are situations where that is not happening. That’s why we have a virus that’s spreading like crazy and we need to do everything we can.
You look at data, you will get anecdotal data. It seems to suggest that, wearing a face mask. Whenever you go out in public, like they do an agent like they do in countries. By the way, we’re in the curve is somewhat flattened and I’ll show you a little video that I put together, which is still a work in progress. so it seems to be done in other countries that, or doing the job to flat in the curve, and it’s still work in progress. But I’ll share this with you. I think that we really need to strongly consider advising the public to wear face masks. Now. It doesn’t have to be a face mask. It really has to be a barrier of protection.
I think another thing that could be considered, it doesn’t have to necessarily be a mask. It has to cover that area. It can be made out of plastic material that also acts as visor, but also would trap particles, large droplets. And I think there’s a benefit to those because if. For example, you cough into a shield or there’s any liquid on a shield, you can see it and wipe it off.
That is in contrast to a mask that even if it’s slightly wet, you might not notice it. So if you’re going ahead and you cough into a shield, or you. cough on a shield or have something on it, you’ll see it. And then you won’t necessarily touch it and then go ahead. And in fact, so it kind of gets around the issue that you have and the concern of individuals who are coughing into a mass or contaminating their mass and then touching contaminated a mask and doing a worse damage than better.
But I think overall it makes sense that any mask is better than no mask. And that. Having the public wear masks that don’t interfere with the supply of healthcare workers would be a good idea and something that should be implemented ASAP. If we’re going to flatten out this curve, thank you for your time and feel free to reach out to me if you have any questions.