Conquering COVID Part 1.5:
“Research
has spoken: time for clean, breathable,
effective (CBE) mask utilization!”
(aka Dodgeball without rules/masks? No thanks!)
April 10, 2020
by Mark A. Moyad, MD, MPH
“I am concerned, of course, but I am also incredibly optimistic.”
I went to the grocery store a few days ago and I felt as if the experience was somewhat similar to playing the game of dodgeball when I was a kid. In dodgeball it was all about strategic proximity - stay as far away as possible from a person(s) on the other team, especially if they ha
d one, or many red balls in their hands, and if
they had a strong reputation for speed and accuracy when throwing that circular red projectile. BE ALERT. Yet, with this pandemic, even though we are all supposed to be on the same team, we do not currently know during the height of this problem who does or does not have this virus (no one knows who is carrying the red ball), and we are always looking for new ways to protect others while simultaneously protecting ourselves (including better and faster diagnostic testing). My whole adult life I have had no problem standing cart to cart in the grocery store line, but now personal space has taken on a whole new meaning.
Back to my recent grocery store experience - some people were wearing masks and keeping a
safe distance, others with masks were getting close, some people were without masks keeping a distance, and then there were the non-masked, no boundaries folks happy to walk right up into my personal space. This is a perfect example of public health compliance, awareness and education. There are the people who overestimate, underestimate and more accurately estimate risk as the research continues to further construe the situation.
Research is a massive moving target, especially in an ongoing pandemic, and what we have learned is that it is now appropriate to recommend wearing some kind of mask when out and about. Several new studies (
CDC.gov) suggest many individuals are either
ASYMPTOMATIC (have no symptoms) or
PRE-SYMPTOMATIC (will eventually develop symptoms) and can still transmit the virus during this time. Speaking, coughing and sneezing, for example, when near other folks can transmit this thing. It is for this reason the
CDC made the recent decision to recommend WEARING CLOTH FACE COVERINGS in public situations where social distancing
may be a challenge such as in grocery stores, pharmacies, and especially in areas where there is community-based transmission occurring (basically almost anywhere right now). And, these cloth face coverings should be
washed regularly (this is critical) or use a different one each time. Additionally, recent preliminary evidence from a small study in the
American Journal of Respiratory and Critical Care Medicine (De Chang, et al. doi.org/10.1164/rccm.202003-0524LE) found some patients who recovered from COVID-19 continued to be viral positive up to 8 days (median, 2.5 days; range, 1 to 8 days) after symptoms resolved- basically half the patients in this small study were still positive after symptoms were gone. Regardless, if this data holds, it will only further strengthen the new CDC mask recommendations (aka now
POST-SYMPTOMATIC transmission is theoretically possible for a short period of time).
The CDC had to make this recommendation now to PROTECT OTHERS based on new RESEARCH. You should cover your mouth and nose with a cloth face cover because again YOU can spread the virus to others even if you feel perfectly fine. So, this is a good recommendation because it is designed to protect others in case you are infected, and again it is based on the latest research. Cloth face coverings should not be placed on young kids under the age of 2, anyone with difficulty breathing, or anyone who is not conscious, incapacitated or those unable to remove the mask without assistance (according to CDC). It is time for a NONMEDICAL fabric face mask while in public. The CDC website also includes the video of Dr. Jerome Adams (aka Surgeon General of the U.S.) demonstrating how easy it is to make your own face mask using simple at home items. Awesome video! There is also a tutorial on the CDC website for making masks (
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html).
Although, recent research continues to suggest that some materials for face masks are better than others. Dr Scott Segal, Chair of Anesthesiology at Wake Forest Baptist Health in North Carolina, recently studied the impact of materials utilized to construct a homemade mask. He suggests a “light test”, which means hold up your homemade mask to a bright light and if you are able to see light between the fibers of your mask then it is not an ideal mask. Keep in mind that the more you wash your mask, the more likely it will NOT be able to pass this test and ergo (love that word) you will need a new mask. Next, Dr. Segal suggests a “breathability test” whereby you place the mask against your nose and mouth and should be able to breathe freely before using it outside (important point). Thick jersey cotton/stretchy shirt, tea towels and many other household items apparently worked well, but again people should test their own masks before wearing them (Buckwald E., and
https://www.marketwatch.com/story/some-fabrics-are-more-effective-than-others-for-making-diy-face-masks-heres-which-ones-are-best-2020-04-07).
Still, where is the strong and consistent research that public masks work? There is not a lot research out there, but there is indirect research, and it first suggests washing the mask regularly or using a new one each time is absolutely necessary, or it could undermine the intent of wearing them. Other preliminary studies and past reviews of research suggest something clean and efficient is better than nothing (Davies A, et al.
Disaster Med Public Health Prep 2013;7:413-418. & Brienen NC, et al.
Risk Analysis 2010;30:1210-1218). Some folks cite 1918 pandemic data where some major cities enforced public mask wearing for a period of time as strong evidence, but this was not so-called definitive evidence.
So, what other indirect research is there? Well, basically the health care professional mask research should impact your personal decision to wear a clean, breathable and effective (CBE- not CBD but CBE, folks) mask when going outside. Researchers are confident that when it comes to the virus that causes COVID-19 that N95 are the most protective masks for health care professionals (
CDC.gov). The N95 mask received it’s name because it filters at least 95% of airborne particles of a specific size range (like many bacteria and viruses), “but is not resistant to oil.” Since it is
Not resistant to oil then this is where the “N” in the N95 comes from (no kidding here). There are also R masks, which are “somewhat
Resistant” to oil, and P masks, which are “strongly resistant” (oil
Proof), so there are not just N95 masks but R95 and P95 masks and there are even N, R, and P 99 and 100 masks. Some industrial oils in some working situations can reduce the filter effectiveness of the mask (hence the N, R, P letters again). There are also cost, convenience, and research debates over whether going to a N99 mask, for example, is that much better than an N95. Regardless, what also makes a respirator mask versus a regular surgical mask different is the airtight seal, and it should be certified by the National Institute for Occupational Safety and Health or NIOSH, which is the U.S. government agency that handles certification/thumbs up for respiratory devices for occupational utilization.
Interestingly, a variety of research including randomized trials suggested a medical (surgical) mask
OR an N95 reduces the risk of a health care worker being diagnosed (laboratory confirmed infection) with a transmissible respiratory illness (Radonovich LJ Jr, et al.
JAMA 2019: 322:824-833.), and it also could protect the patient and the surrounding area if the health care worker is asymptomatic, pre-symptomatic, post-symptomatic or, of course, symptomatic. More recent published research (over the past few weeks) suggests medical masks could prevent transmission of coronavirus and other respiratory conditions in people with symptoms (Leung NHL, et al.
Nature Medicine 2020;
https://www.nature.com/articles/s41591-020-0843-2
). And, yet there is one observation from health care worker studies in outpatient settings during respiratory virus season that appears to get missed …
you can argue all day about the best or worst mask but, whenever a clean, breathable and effective (CBE again, folks) mask is utilized and you look at infection rates then they tend to be remarkably low! In other words, some type of CLEAN, BREATHABLE, and EFFECTIVE mask is usually better than no mask at all when dealing with a common medical condition transmitted by respiratory droplets.
Now, the goal of a cloth mask in public is somewhat similar to what much of the research shows in health care workers, which is to also prevent you from touching your mouth and nose and preventing harm to someone else. More people wearing masks during this specific period of time increases the probability that more of the population will be protected. Thus, as the research mounts that masks could make a difference, I believe now and in the NEAR future going to the grocery store, and other places folks congregate will continue until the effective medications and vaccine(s) are available. Customers and workers will wear some type of mask (
hopefully medical masks will be massively produced to eventually give the public the option of moving to these better researched products), 6-foot or even greater distance markers will continue to be placed on the floors, regular cart sanitation will occur, controlled store capacity will be necessary, safety or cough/sneeze guards made of plexiglass or another material will separate you from the cashier, traffic will only be allowed to go one way through the store aisles … No kidding. Many grocery stores are now suggesting and implementing these changes,
including using (the regularly updated) EPA approved disinfectants against the virus, some of which you can also use at home. (FYI, for the latest list of EPA approved COVID virus disinfectants go to
https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
).
Remember, respiratory viruses are, in general, transmitted by large droplets and a smaller percentage appear to be transmitted by aerosol, which means protecting yourself simultaneously protects others. Again, the game of dodgeball is not fun when we have no idea who or what is throwing the ball at us. Please wear a CLEAN, easy to BREATH and EFFECTIVE mask when going out and about until research suggests otherwise.
Ultimately, the public health goal should arguably be the production of an overabundance of medical grade masks (supply exceeding demand), including enough for health care workers AND the general population since almost all of the best clinical research for effectiveness comes from “medical” masks. Although, I look forward to research beating this thing soon, so in the near future public masks are only utilized on Halloween and other such festive events (you get the idea).
Thank you for reading my latest installment and I wish you and your family the best of health.
I am concerned, of course, but I am also incredibly optimistic! I look forward to modern day science and you, of course, kicking COVID-19 and cancer in the gluteus maximus!
All of my best always,
Mark A. Moyad MD, MPH
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