COMMENTARY

Is It Time That We All Start Wearing Masks?

Amy L. Baxter, MD

Disclosures

April 01, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Deaths and economic destruction due to COVID-19 have been blunted in China, Japan, and South Korea. Much is made of the role of draconian quarantines, civil obedience, and world-class testing and tracking leading to this outcome.

Less discussed is the equally superior suppression of COVID-19 illness in the Czech Republic. As of today, Tuesday, March 31, there have been 24 deaths and 3002 cases. The Czech Republic shares distancing recommendations as well as adherence by the public to government mandates on the order of those of Southeast Asian countries.

What the Czechs also share with their Asian counterparts is universal, mandated use of face masks, with the added incentive of an $800USD fine for public disobedience.

COVID-19 has led Americans to a new grasp of graphs. We now understand how "flattening the curve" saves lives. The excellent daily graphs of COVID-19 spread by John Burn-Murdoch and colleagues at the Financial Times distill data from Johns Hopkins University into linear logarithmic paths.

The graphs allow us to project what to expect. Today, the United States has reported 3163 deaths. By next Sunday, April 5, simple math shows that the US will have 16,490. With an incubation period of almost a week, we can't do much about this number.

But to have even a chance at keeping the deaths below 100,000 by Easter morning, we can all wear masks in public.

Hong Kong has mandated school closures, and Singapore has strict quarantine and contact tracing. Both locations have flattened their curves. However, Japan, which has also slowed growth, has only relatively light testing and isolating but can claim mask-wearing as a distinguishing intervention. Of note, Hong Kong, Taiwan, and Singapore citizens also adopted mask-wearing spontaneously.

If we want to mimic areas with flatter curves, why aren't we wearing masks as well?

Wearing masks universally was initially discouraged in the United States. Healthcare professionals, including advice from the World Health Organization, told us to only wear masks if sick. The message was that this virus was spread by respiratory droplet, not aerosol. Distance and handwashing would be sufficient.

Some of this was an attempt to reserve N95 respirators for healthcare workers likely to be around aerosolized virus resulting from invasive procedures such as intubation. However, when confronted with the scenario of a self-isolating older couple with no access to masks, I published a YouTube video demonstrating mask creation from destruction of a bra. Many other bra cutters and mask makers posted similar instructions. DIY mask creation spread. JoAnn Fabric started sharing mask instructions and materials for free.

The discounting of homemade cloth masks—whether padded or two-ply cotton—that followed could have come from a desire to reduce panic, conserve resources, or a lack of understanding of efficacy of masks made by various types of fabric. On the other hand, it could underscore misplaced American prejudice: Inexpensive double-thickness cloth masks are widely used in Southeast Asia. Many US physicians disparaged the practice as useless. This appraisal may be part of what has kept us from considering that masks protect not just others but ourselves.

Data on efficacy of masks are scant, though evidence does suggest that masks reduce personal risk. The mode of transmission of high-attack-rate, fast-moving epidemics has been determined to be from respiratory droplets. Unless a cough is directly into the face of someone else, droplets and virus spread by that cough fall and then hang out on the surfaces on which they land. In public spaces, the sneeze/cough scenario with another individual in close range is all too possible.

Respiratory droplets have diameters in the range of 10 to 100 µm. The research studies looking at transmission have been about influenza, but the COVID-19 mechanism of spread is analogous.

One study that examined the capacity for a range of types of cloth masks to filter particulate matter of 10 μm or less (PM10) found that four different types had filtering efficiency that ranged from 63% to 84%. Mind you, we care most about a diameter over PM10. But even for this very small droplet size, these masks filtered better than nothing. As the SARS-CoV-2 virus lives on surfaces for hours to weeks, stopping the particles from landing on grocery aisles or other surfaces touched by multiple persons is even more critical.

Wearing masks in public isn't a panacea. Physical distancing is critical and we know that cities that distanced in the 1918 flu pandemic had later and lower death rates. We know that handwashing gets the particles off your hands and away from the portals in your face. And if we read the research and look at the numbers honestly, we must also recognize that masks keep us safe.

Stay home. Wash your hands. Watch the video from the Minister of Health of the Czech Republic. And from now until the time that we can congregate at weddings, graduations, and parties without fear, when you must leave your house, universally, please wear a mask.

Amy L. Baxter, MD, is the founder and CEO at Pain Care Labs in Atlanta, Georgia. Follow her on Twitter.

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