Please join me in wearing a mask

We should all be working together to protect ourselves, our communities, and our healthcare professionals: that means covering your mouth and nose, in addition to hand-washing and social distancing.

If you’ve read this before, please skip down to “Updates and New Information” for a summary of all updates.

The subject of mask wearing in Western countries led to unusually heated arguments over the past few weeks, so here’s a cited piece on why everyone should be wearing a mask, in addition to practicing proper hygiene and social distancing.

In this world of Coronavirus Disease 2019 (COVID-19) misinformation, I have extensively sourced official guidance from other countries or scientific, peer-reviewed papers to enable you to make your own well-informed decisions.

TL;DR: You should assume you’re sick, and cover your mouth and nose when you go out.

Unless you already have the supplies, leave the N95 and surgical masks for the HCP (Healthcare Providers). Protect your face with a homemade cloth mask, bandanna, or even a scarf. Any face covering is better than nothing, as long as you use it properly. Masks are not a replacement for other quarantine and suppression efforts, they’re additive. Face masks are a tried and true solution that has been used effectively throughout Asia for Coronavirus COVID-19 and SARS before it.

The mask shortage in the United States

First things first: there IS a national shortage on masks for medical professionals, people working in grocery stores, and workers in other critical and essential roles. I am NOT telling you to hoard them. Hoarding medical grade masks will only put you at increased risk if your local HCP becomes ill from not having access to proper protection.

However, the US Surgeon General did us a massive disservice by saying that they were ineffective for the general population. This tweet below will age poorly.

It is absolutely true that “if healthcare providers can’t get them…it puts them and our communities at risk.”

It is extremely misleading to say that “they are NOT effective in preventing the general public from catching #Coronavirus,”

The idea that masks are not effective at preventing the spread of COVID-19 makes little logical sense, and further, the science suggests the opposite. The reality is we have a shortage and HCP must have priority on N95 masks and other PPE (personal protective equipment).

But rather than saying they’re “NOT effective,” we should be taking cues from places like Taiwan and Hong Kong who have reduced the spread within their own borders despite close ties to mainland China. The United States should have been educating everyone on alternative ways to protect their face, IN ADDITION to hand-washing and social distancing.

Wait, so are masks effective?

Yes. If you already know that masks work, feel free to skip to the next section.

The comparisons to SARS, H1N1 and the flu are fine analogues because the primary spread is through droplets. Further, since you can be positive for COVID-19 but not show any symptoms, it’s important that “healthy” people wear face coverings as well. Even healthy people cough or sneeze on a daily basis just to clear their throat. Have you ever had someone accidentally spit on you while talking? Now imagine if they had been wearing a mask. Wearing a mask helps those who are already ill from spreading droplets. But since the majority of cases are mild or asymptomatic, and we still do not have widespread testing, it’s only polite to assume that you’re infected and protect your community.

But the US is out of N95 masks! What do we do now?

Use a cloth mask.

With the current lack of masks, doctors in some hospitals are starting to ask the general public for homemade masks. Deaconess Health System, who employs 6,000+ workers in southwest Indiana (shout out to fellow Hoosiers), put out a call to the public for cloth masks because of the N95 mask shortage. The public was very gracious, and they now have more than they need. As they point out,

“Prior to modern disposable masks, washable fabric masks were standard use for hospitals,”

Many of you reading this were probably alive when cloth masks were still used in hospitals. It is still standard in many parts of the developing world.

[Added 3/29/2020] The National Health Commission of the PRC (China) put out official guidance on the types of masks people should use based on risk — please note they recommend the wearing of surgical masks for basically the average situation an American would find themselves during a grocery store run.

Source: “Guideline on Masks for Different Groups of People” [National Health Commission of the People’s Republic of China]

We should also be looking abroad to see how this crisis is being handled. We aren’t the only country facing a mask shortage.

Look to Asia (Taiwan, specifically).

It is fairly common to wear masks in Asia, both when you’re sick and to protect yourself from getting sick. I lived in Japan for six years and came to love that people wore them on crowded subway trains, but I was also a bit unnerved the first time I saw people wearing masks.

Taiwan

Let’s look at Taiwan, currently being hailed as a success story in handling the COVID-19 crisis. Some context: WHO does not work with Taiwan, so they have to handle health crises independently. After SARS, Taiwan learned quite a few lessons which they’ve applied to the current epidemic.

At the time of writing this, Taiwan had 135 confirmed cases and 2 deaths. This is less than any country in Western Europe despite having much, much closer ties to mainland China.

A few days after Wuhan, China went into quarantine, Reuters reported that Taiwan had banned the export of masks. They quickly ramped up production and are now producing 10 million masks a day. Taiwan has a rationing system for their citizens, who get 3 masks a week. This is not effort that would be expended if masks were “not effective” for the general population.

“ A sign that says that masks are sold in Taiwan.” / Credit: Wikipedia, Andrew20070223 — Own work

Hong Kong

As of writing, Hong Kong has a mere 256 cases and 4 deaths. This is fewer cases than New York City currently has.

According to Kwok Ka-ki, a lawmaker and doctor in Hong Kong, emphasis mine:

“The most important thing is that Hong Kong people have deep memories of the SARS outbreak. Every citizen did their part, including wearing masks and washing their hands and taking necessary precautions, such as avoiding crowded places and gatherings.”

But let’s look somewhere else. What is being done in countries without the experience or resources that Taiwan and Hong Kong have?

In Thailand, a country without the same level of healthcare as Taiwan, the New York Times reported that N95 masks have been reserved for HCP while the government is encouraging people to make their own.

The notion that governments were encouraging their citizens to make their own masks may seem to contradict recommendations in the US, until recently. Now hospitals and the CDC are also recommending the use of cloth masks.

Are cloth masks even effective?

To be clear, nothing is 100% effective. But the CDC has guidance for HCP in crisis situations (like right now) where no appropriate PPE (personal protective equipment) is available:

HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort.

A HCP’s last resort is not the same as the general public’s last resort. HCPs spend extended amounts of time around COVID-19 patients every single day. The rest of us are (or should be) practicing social distancing, hand washing, and self-isolating when we’re sick. Masks or other alternatives are additive protections. If they’re good enough in a crisis situation for a nurse caring for COVID-19 patients, they’re good enough for you while you stand 6 feet away from someone in Costco as long as you also practice proper hygiene.

Here are some studies on the topic:

A study from City University of Hong Kong found that the efficacy of a mask made at home out of two pieces of paper towel + a tissue “…were proven to have achieved 80 to 90 per cent of the function of regular surgical masks in terms of their filtration of aerosol and droplets.” That’s pretty good for something you can make from home.

Additionally, researchers from Cambridge University tested various materials the average person might have at home for efficacy in filtering aerosols of bacteria. From the chart below, some of the options you have are better than others.

Filtration Efficiency and Pressure Drop Across Materials Tested with Aerosols of Bacillus atrophaeus and Bacteriophage MS2 (30 L/min) a

Source: “Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic?” Disaster Medicine and Public Health Preparedness / FirstView Article / July 2013,pp 1-6 DOI: 10.1017/dmp.2013.43

There’s a lot of people on the internet currently trying to figure out the best materials to use. But let’s remember that the primary reason people in Asia wear masks for COVID-19 is to prevent the spread of droplets — not aerosols. Use what you have first. Worry about optimizing for materials later.

It’s also more important to choose a material that will enable proper usage, rather than blocking microns of a particular size. It’s great that a vacuum cleaner bag is nearly as effective as a surgical mask, but if you can’t breathe and keep fiddling with the mask (and touching your face), it will not be effective and will likely be harmful.

Although the use of cloth masks by HCP around the world is still standard, some research shows their use to be potentially dangerous.

Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection

You cannot reuse cloth masks disinfecting them. You cannot depend on any mask alone to protect you. You must wash your hands before and after removing masks

Proper mask use is critically important

Wearing a face covering is a good practice, but it isn’t “better than nothing” unless used properly. People in Asia are routinely educated on proper mask usage, but in the West we’ve stigmatized face masks and lack common guidance.

Thankfully, WHO has a guide for us: Coronavirus disease (COVID-19) advice for the public: When and how to use masks.

You may have noted the WHO says,

“I“If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection,”

Emphasis mine. Let’s remember that the term “healthy” is pretty subjective, especially for an international organization like WHO. In some countries that I lived in, my chronic condition (asthma) means I’m not “healthy.” I may feel “healthy” but I am also in a “high risk” category. I don’t personally know the WHO’s definition of health, but I find it extremely unlikely that a 70 year old with heart disease who has never been tested for COVID-19 counts as “healthy” either. Again, since most cases are mild or asymptomatic, you don’t actually know if you’re healthy or not. You should assume you’re not healthy when you do leave the house and interact with others.

You may have also seen guidance from WHO — “Advice on the use of masks the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak” — that seems to say masks don’t work.

Please note this is interim guidance from January 29, 2020. That was a mere week after Wuhan was quarantined. Many, many things have changed since then, including official guidance from various countries around the world. The guidance actually says:

Wearing a medical mask is one of the prevention measures to limit spread of certain respiratory diseases, including 2019- nCoV, in affected areas. However, the use of a mask alone is insufficient to provide the adequate level of protection and other equally relevant measures should be adopted. If masks are to be used, this measure must be combined with hand hygiene and other IPC measures to prevent the human-tohuman transmission of 2019-nCov

Please note the emphasis on alone. A mask alone will not protect you. This bears repeating: A mask alone will not protect you.

Since we don’t have guidance from the US government yet (though I suspect we will shortly), here is guidance from the Centre for Health Protection of Hong Kong (CHP). It’s HK’s version of the CDC.

Here’s what they say to their citizens on wearing masks, it begins with the the following:

The following preventive measures, apart from wearing a mask, should be emphasised: Hand hygiene is the single most important measure of reducing the spread of diseases. Members of the public should perform hand hygiene properly and frequently, especially before touching eyes, nose and mouth;

Again, you a mask alone will not protect you.

Here are links on CHP’s guidance for COVID-19 and masks.

We should have been educating

I strongly believe that we should have been educating Western people about proper usage of masks, rather than claiming they’re “not effective.”

A common statement in American media is that it creates a “false sense of security.” That’s quite condescending. Are the billions of people in Asia more capable of learning how to wear a mask properly, in conjunction with hand washing and social distancing? No. They simply get educated on proper use.

It’s like saying that we shouldn’t use condoms because they are not 100% effective at preventing unwanted pregnancy or STDs, and used incorrectly can also be dangerous. We know the only thing that can 100% prevent unwanted pregnancy or STDs is abstinence. Telling people not to use condoms and to rely on abstinence as the only way to prevent unwanted pregnancy or STDs has been proven not to work.

It is extremely important to wear a mask properly and in conjunction with other hygiene practices. This is not an excuse to go to a rave wearing a cool bandanna and thinking that will protect you from COVID-19. But since you’re practicing social distancing (right?), you are probably only wearing this for that quick stop to the grocery store, so your mask removal practices should be much more simple than a doctor or nurses.

You must also be very careful to properly disinfect a cloth mask, or properly dispose of disposable masks. How do you disinfect a cloth mask? The general guidance for countries where cloth masks are used is to throw it in the laundry.

UV light (like the sun) could possibly be helpful as well. This study looks at a “block and burn” tactic as a Plan B for disposable face masks if they have to be reused by HCP:

The tactic proposed is one of “block and burn” — masks to block and UV irradiation to burn the viral pathogen. The focus is on attacking the virus in the environment, rather than in the patient.

We need to de-stigmatize mask wearing

Beyond limiting the spread of COVID-19, you should wear a mask (or alternative) for the social aspect as well. In the United States, the stigma against wearing masks is both a public health disservice and causing harm to people who do wear them.

There are thousands of people out there who are at high-risk of contracting COVID-19, who have valid medical reasons to wear masks: cancer patients, people who are immunocompromised, etc. Further, there are thousands of people from Asia (and also Latin America) reading news from countries where governments are wisely telling the public to wear masks. An unfortunate spike in hate crimes towards Asians, particularly Asians wearing masks, has been reported.

We should all be working together to protect ourselves, our communities, and especially our healthcare professionals and front line workers during the time.

Are you on board but don’t have anything you can use? Wear a scarf. It’s winter. If you sneeze into it, that’s still SOME droplets not landing on someone else. But wash your hands when you take that scarf off, throw it immediately in the laundry, and wash your hands again.

Here are some resources on home made masks (these have not been vetted as thoroughly as other links):

I am still unconvinced!

If the sources and citations above did not help sway you, then:

Please share a peer reviewed study that says masks do more harm than good when used properly and in conjunction with hand-washing practices.

Please ask yourself why you’re quibbling over a few percentage points? Condoms are also not 100% effective and neither are seat belts. They need to be used properly for greatest efficacy, same with masks (homemade or otherwise). Given that hospitals are asking for homemade masks, I think we can all agree this is a pedantic argument at a time when our collective brain power would be better utilized elsewhere.

Please reflect on why you think that multiple governments in Asia have less rigorous scientists or experts than the United States, especially given our delayed response to this crisis. In particular, Taiwan’s Vice President is an epidemiologist who led the SARS response team.

If you’re still on the fence, that’s fine as long as you let other people wear them. Do your part to de-stigmatize it. Don’t give the rest of us dirty looks, and educate others who wish to wear one on how to do so safely.

If you want to know what I’m doing beyond writing long Medium posts and hoping someone will listen, I am currently trying to use my company to produce as many cloth masks as possible so that I can donate them to those in need: hospitals, the homeless, and vulnerable communities. I am happy to report that many of the factories I work with are already producing hundreds of thousands of masks so can’t take on my tiny request.

I believe that within the next few weeks official guidance in the United States will be to start wearing masks in addition to social distancing, hand washing, and self-isolation when sick.

Until that time, I hope you’ll join me in wearing a mask.

Story updates and new information added on 3/29/2020