Common Cents

To mask or not to mask?

Dr. Alan O. Perantoni,

(7/1) In the June issue of the Emmitsburg News-Journal, PA State Senator Doug Mastriano addressed the issue of mask usage during the pandemic. Unfortunately, his selective use of information is only adding to the chaos and confusion rather than presenting a balanced assessment of our current scientific knowledge. The information on COVID-19 is rapidly evolving and, as such, is modifying or changing recommendations that were made earlier in the pandemic. Science is built upon an ever-expanding base of facts generated from research performed and duplicated by others. Because SARS-Cov2/COVID-19 is genetically similar to other coronavirus family members, certain assumptions were made initially based upon the others, such as SARS and MERS. Those assumptions, however, have been modified over time as new studies compare their features.

For example, as Mr. Mastriano indicates, the US Surgeon General did discourage the use of masks in February and March. However, what he failed to mention is that the Surgeon General had always encouraged mask usage by symptomatic individuals to limit the spread of virus, and that the Surgeon General has since changed that recommendation to support mask usage as new studies have revealed the value of such use. The epidemiologic data now clearly demonstrate that even cloth mask usage reduces the transmission of the virus to others and helps control the spread of the disease. Mr. Mastriano also indicates that NIAID Director Dr. Anthony Fauci discouraged mask usage, but the quote he provides dates to March 8th, when the leadership feared that the public would devour the limited supplies of masks, making them unavailable to first responders. On June 5th, Dr. Fauci stated that he has "no doubt" that Americans who are not wearing face masks, especially in large crowds, are increasing the risk of spreading the coronavirus.

Mr. Mastriano further confuses the issue by clumping all masks together, including both the N95 masks which are essential for first responders and cloth masks recommended for the rest of us, and then citing research focused on N95 mask use. Since we now also know that asymptomatic individuals shed active virus, cloth mask usage and social distancing by everyone has been shown to reduce the likelihood that we unwittingly transmit the virus to others: our elderly parents, our children, and our friends, even though the cloth masks will not prevent us from becoming infected ourselves.

The point is, the masks are recognition of the serious nature of COVID-19 transmissibility and a sign of concern for the well-being of those around us. No, we are not required by law to wear them, but it is our moral imperative not to endanger the lives of those around us should we be infected but asymptomatic. Who among us wants to be responsible for someone else’s death because it is our right not to wear a mask? It is simply common sense to abide by this recommendation. The health of our citizens is still profoundly at risk, as healthcare professionals voice concern over spiking case numbers in nearly half of the states.

There has never been any equivocation on the hazards of COVID-19 by the scientific community. As soon as the viral sequence was published online by Chinese scientists in the beginning of January, scientists at the National Institutes of Health began producing material for a targeted vaccine. In record time they were ready for a clinical trial in early February, while politicians were calling the pandemic "a hoax". Yet, it was not until the middle of March that our leadership finally recognized what the scientific community had understood two months earlier. We now know from epidemiologic modeling that had recommendations regarding sheltering, masks, and distancing been implemented one or two weeks earlier on March 8th or March 1st, respectively, there would have been 36,000 or 54,000 fewer deaths (Pei, S., et al. medRxiv, In Press, 2020).

South Korea reported their first case on the same day as the US, yet they have experienced fewer than 300 deaths in a population that is one sixth that of the US, and we are now approaching 120,000 deaths with estimates in excess of 200,000 before October. The difference resulted from immediate action by the government to encourage social distancing and making tests available. This modeling indicates that we can expect a similar rapid expansion of case numbers and deaths again in the future, if no immediate actions, such as mask usage, are taken to contain the spread. Due to space considerations, the peer-reviewed scientific publications that investigate the use of masks in virus containment will only be summarized here; however, the references are also provided below for those interested.

• For historical reasons (2003 SARS epidemic), residents of Hong Kong responded rapidly and universally (>97% compliance) to adopt masks (typically the loose surgical masks) at the beginning of the COVID-19 epidemic. Researchers found significantly more case clusters in places where mask usage was ignored. Moreover, when compared with other countries in the region, such as Singapore and South Korea where mask usage was not adopted with the same fervor, the incidence of infection nearly doubled. In particular in South Korea, where mask usage was discouraged in churches, nearly half of case clusters were associated with church activities. Finally, relative to other countries where the pandemic has raged and mask usage was spotty, such as Spain and Italy, incidences of infection are more than 20 times higher than in Hong Kong. - Cheng, V. C-C, et al., Journal of Infection, In Press, 2020.

• In a systematic review of more than 170 studies involving COVID-19, and related SARS and MERS, physical distancing, mask usage, and eye protection all facilitated a reduction in the likelihood of viral transmission. With face masks, the strongest association with protection, not surprisingly, occurred in studies using N95 masks both in clinical and nonclinical settings; however, lower infection incidences were also observed with disposable surgical masks and multilayered recyclable cotton masks. - Chu, D.K., et al., The Lancet, online – June 1, 2020.

• Mathematical modeling of the benefits of face masks shows that the greater the percentage in a population wearing a mask, the lower the incidence of infection for the entire population. The authors conclude, "facemask use by the public could significantly reduce the rate of COVID-19 spread, prevent further disease waves and allow less stringent lock-down regimes. The effect is greatest when 100% of the public wear facemasks." - Stutt, R.O.J.H., et al., Proceedings of the Royal Society A 476: 20200376.

The science provides us with a direction. Epidemiologic evidence supports the use of masks in both clinical and nonclinical environments to reduce viral transmission, and modeling tells us that the greatest protection is afforded when every person is wearing one to the benefit of each other.