Debate - No takers?

Mbkahn, thank you for commenting.

There's a lot to digest.

First, I am not sure you read the first post on Masks and Covid-19, entitled

“The Unmasking of Masks or the Data behind the Mask and Covid-19 Prevention. Part 1 – Preventing Infection in the Mask Wearer”.

In this post, I cited the Annals of Internal Medicine several times. The Annals repeatedly review the available data on masks in preventing Covid. The rate the data as weak. Again, there are trials on influenza and other resp viruses. Most of which showed masks didn’t help.

Regarding your comments –

“Masks don't stop transmission, masks reduce transmission. They protect you from me when I may not realize I am infected… There is evidence that masks are effective in reducing transmission of respiratory viruses.”

Sorry, but actually the data, as I pointed in my first post on the topic, do not support your claims. If you don’t believe my interpretation of the existing data, you should believe the Annals of Internal Medicine’s.

“I disagree with the assertion that there is damning evidence in the study claiming to show that putting a mask on after a family member is sick doesn't reduce infection. The mask is supposed to be on the infected one, not the others.”

That’s not accurate. We use surgical masks to prevent transmission from Covid pt to HCW. For years, we have used these masks to prevent HCW infection with other droplet-transmitted diseases. In the hospital, Covid pts don’t wear masks; we do. I wear several new ones each day, changing it after seeing a Covid pt. The CDC actually presents data in which all wore masks. If masks worked, they should also work when a infected person is most contagious, just after developing symptoms. But again, it’s the quality of the data that’s important. This isn’t a study. It’s just reporting on people, who wear masks at home and had a household member get Covid. It is as far from a randomized, controlled study as you can get.

Further, you have to realize, masks only filter your breath if they are tightly sealed and your breath goes through them. In the vast, vast majority of time, people wear surgical masks loosely, because that’s how they are designed. Surgical masks are not designed to filter the wearer’s breath. So, when people wearing a surgical mask exhale, the vast, vast majority of their breath goes around, not through, the mask. This is even true with N95 masks, if they are not properly fitted. Finally, this theory, that surgical masks reduce infective droplets and then transmission, has never been established in clinical trials at all.

“It would be better if mask data was from randomized trials rather than epidemiological, observational, and/or model-based evidence. However, it seems foolhardy to ignore one aspect of established programs that have been successful in reducing infections without clear and convincing evidence to the contrary.”

Your logic is circular. You have already concluded that the available data are conclusive; they are not even close to being conclusive. Again, please show me the data. There simply are not quality data proving any of your points (Please see my critique of your citations below).

And this is really my main point. Everyone on CNN, MSNBC, or NYT calls for HCQ’s efficacy to be established in a RCT, despite, in some cases, overwhelming observational data. Just from a scientific viewpoint, the HCQ efficacy data are much, much more robust than those in support of surgical masks reducing the spread of Covid.

As a country, we MUST evaluate and critique data evenly and without passion. If we don’t, we might as well not collect any data, because we have made up our minds a priori.

Regarding your 5 citations, here is my review.

Citations #1-3 https://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/

https://www.advisory.com/daily-briefing/2020/07/24/coronavirus-restrictions

https://www.sciencemag.org/news/2020/08/how-will-covid-19-affect-coming-flu-season-scientists-struggle-clues

#1 and # 2 are simply reports on influenza (flu) activity. Such influenza activity reports are done every year and updated weekly during each flu season. #3 is an article discussing flu and attempting to predict what will happen this flu season. These citations do not contain any data on the masks.

However, these 3 references remind me that flu disappeared from Jersey as soon as people started social distancing and well before the widespread use of surgical masks. In Jersey, we test everyone who comes to the ER with cold symptoms with a RPP2, Respiratory Pathogen Panel-2. This nucleic acid based test detects 21 different respiratory pathogens (meaning viruses or bacteria), including 5 strains of influenza, four strains of other coronaviruses, RSV, rhinovirus, and more. The test is very sensitive.

Typically, the RPP2 is positive in 50% of more people tested in the ER. I remember talking to Dr. Lejla Mujic, a very good Emergency Medicine doc at Saint Barnabas, around March 18th. I had just evaluated a pt she had admitted with cough, chest pressure, fever, chills and fatigue. Lejla had diagnosed the pt with Covid-19. I suggested that we wait for the RPP2 results before labeling this pt as having Covid-19. Lejla pointed out to me that she hadn’t seen a positive RPP2 in over a week. Lejla was correct, of course. The pt had Covid and correct that flu, by the third week of March in Jersey had disappeared. Flu went away because of social distancing, not because of surgical mask use in the community. And flu went away very quickly.

In fact, in the last week of February, we had high state-wide flu activity. In March, they stopped even reporting it. March proved that social distancing works well on flu and other respiratory viruses. The confusing part was why it didn’t work as well on SARS-CoV-2 or Covid-19.

Citations #4 & #5 –

#5 is just a newspaper article, which refers to #4, and reference #4 is simply a commentary article. The authors, Dr. Gandi, Beyer and Goosby, put forth the idea that surgical masks confer protection to those around a sick, asymptomatic person by filtering out the infective droplets. The authors then discuss the idea of inoculum and lethality. They are simply wrong that the higher inoculum increases mortality in viral disease. Trust, one HIV-1 virion is all you need to die from AIDS. A person is infected with 1 virion to a few hundred. Once infected, the virus replicates to several billion. The idea that a higher inoculum would affect mortality in Covid-19 is not supported by existing literature on viral diseases. Worse, the authors do not cite literature proving that when a person has Covid-19, that wearing a surgical mask reduces the amount of virus-containing droplets. The authors merely refer to and don’t even discuss one reference. Their only reference on the efficacy of masks in reducing or filtering virus particles isn’t even a study, it is a letter to the Editor, which lists the filter-size of different masks. In other words, neither the authors of citation #4 nor the articles referenced present any data the ability of surgical masks to filter out virus droplets.

We both agree that COVID patients are contagious. Most feel they are contagious in the asymptomatic, presymptomatic, and/or minimally symptomatic period.

Masks don't stop transmission, masks reduce transmission. They protect you from me when I may not realize I am infected.

Surgical masks deflect and disperse droplets and aerosols. When in close proximity (<6-10ft) this may be important as it keeps the plume emanating from my mouth and nose from getting directly into your inhaled air, allowing more time and space for dilution and inactivation of the virus.

There is evidence that masks are effective in reducing transmission of respiratory viruses. Prior to COVID there was no real disagreement that masks are part of the solution for fighting respiratory viruses. A successful public health program includes isolation, testing, contact tracing, hand washing, and masks. The incremental benefit of the individual components can be debated and is hard to define. Most countries (political allies of the US as well as enemies and frenemies) accept that conclusion.

Recent data suggests that the above methods, now in widespread use because of COVID, have contributed to the especially mild flu season in South America (1,2,3). On cruise ships mask have reduced infection and symptoms of COVID (4, 5).

There is little if any risk from wearing masks. Until the COVID controversy, I was not aware of serious health concerns regarding surgical masks. Thousands of people have worn them all day for years (surgeons, anesthesiologists, nurses, industrial workers, etc) without serious issues. If there were serious concerns, please let me know.

Fomite transmission from the mask is a theoretical risk, but fomite transmission is general does not seem to be a big problem with COVID. Given the large number of people wearing masks, it probably would have been an issue with mask use and other respiratory viruses, for which fomite transmission seems to be more important.

It would be better if mask data was from randomized trials rather than epidemiological, observational, and/or model-based evidence. However, it seems foolhardy to ignore one aspect of established programs that have been successful in reducing infections without clear and convincing evidence to the contrary. Maybe we will move to that point with regard to masks, but it seems most ID and epidemiology experts do not feel we are there at this point.

I disagree with the assertion that there is damning evidence in the study claiming to show that putting a mask on after a family member is sick doesn't reduce infection. The mask is supposed to be on the infected one, not the others. Part of the problem with mask studies is all of the confounding variables, and these are no exception.

One benefit of wearing masks is that they remind everyone to be careful!

Controlling for that particular variable is difficult, especially given the variety of masks and how they are worn, but that social factor could partially account for why places that mandate masks seem to have lower infection rates.

Risks like anxiety, violence, etc. could be better managed with a clear, consistent, and coordinated message from elected leaders and public health officials, as has been done in other countries.

Masks do not need to be worn in cars, walking apart outside, walking alone outside, etc. They should be worn when unable to keep "social distance", ie: they should be worn when there may be unpreventable, accidental, or intentional close interactions with people outside of your household or "pod". They should be worn inside public places to catch and diffuse (some, but not all) droplets, and to catch and diffuse (some, but not all) aerosols. Masks should be disposable or washed every day.

The law of unintended consequences extends to the consequences of doing nothing, such as anxiety from helplessness, etc. during a pandemic.

We have to make choices regarding which consequences we are willing accept. Does the general public want to trade some discomfort to avoid some illness and death, or would it rather risk some illness and death to avoid some discomfort? If so, how much and what kind of discomfort vs how much illness and death?

This is why effective, honest, and consistent leadership and education is so important.

I agree that people should not be in each other's faces regarding masks, but I also think it is reasonable that masks be mandated inside, or in places where people may be in close proximity and breathing on each other, even unintentionally.  

1. https://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/

2. https://www.advisory.com/daily-briefing/2020/07/24/coronavirus-restrictions

3. https://www.sciencemag.org/news/2020/08/how-will-covid-19-affect-coming-flu-season-scientists-struggle-clues

4. Masks Do More Than Protect Others During COVID-19: Reducing the Inoculum of SARS-CoV-2 to Protect the Wearer; https://link.springer.com/article/10.1007/s11606-020-06067-8

5. https://www.ucsf.edu/news/2020/07/418181/one-more-reason-wear-mask-youll-get-less-sick-covid-19