The Case for COVID Mask-Wearing

"SARS-CoV-2 has the protean ability to cause myriad clinical manifestations, ranging from a complete lack of symptoms to pneumonia, acute respiratory distress syndrome, and death. Recent virologic, epidemiologic, and ecologic data have led to the hypothesis that facial masking may also reduce the severity of disease among people who do become infected. This possibility is consistent with a long-standing theory of viral pathogenesis, which holds that the severity of disease is proportionate to the viral inoculum received. Since 1938, researchers have explored, primarily in animal models, the concept of the lethal dose of a virus — or the dose at which 50% of exposed hosts die (LD50). With viral infections in which host immune responses play a predominant role in viral pathogenesis, such as SARS-CoV-2, high doses of viral inoculum can overwhelm and dysregulate innate immune defenses, increasing the severity of disease. Indeed, down-regulating immunopathology is one mechanism by which dexamethasone improves outcomes in severe Covid-19 infection. As proof of concept of viral inocula influencing disease manifestations, higher doses of administered virus led to more severe manifestations of Covid-19 in a Syrian hamster model of SARS-CoV-2 infection."

Monica Gandhi, M.D., M.P.H., George W. Rutherford, M.D. The New England Journal of Medicine

Law enforcement trainees wearing protective face masks as they take notes while being trained on how to handle civil disputes during class at San Bernardino County Sheriff’s Frank Bland Regional Training Center in San Bernardino on Wednesday, July 29, 2020. (Photo by Watchara Phomicinda, The Press-Enterprise/SCNG)

"If facial coverings decrease the amount of virus a person is infected with, they can provide a way of tilting towards infections that result in minimal or no symptoms, yet induce some degree of immunity."

Dr. Amesh Adalja, infectious disease expert, senior scholar, Johns Hopkins Center for Health Security, Baltimore

 

"If this theory bears out, population-wide masking, with any type of mask that increases acceptability and adherence, might contribute to increasing the proportion of SARS-CoV-2 infections that are asymptomatic."

Dr. Monica Gandhi, Dr. George Rutherford, University of California, San Francisco

 

"Covering mouths and noses with filtering materials serves 2 purposes: personal protection against inhalation of harmful pathogens and particulates, and source control to prevent exposing others to infectious microbes that may be expelled during respiration. When asked to wear face coverings, many people think in terms of personal protection. But face coverings are also widely and routinely used as source control. For instance, if given the choice between having surgery performed by a team not wearing some covering over their mouths and noses vs a team that does, almost all patients would reject the former. This option seems absurd because it is known that use of face coverings under these circumstances reduces the risk of surgical site infection caused by microbes generated during the surgical team’s conversations or breathing. Face coverings do the same in blocking transmission of SARS-CoV-2."

John T.Brooks, M.D., Jay C.Butler, M.D., Robert R.Redfield, M.D. Jama 

Masks -- the public is informed by authorities urging the use of facial coverings in this time of SARS-
CoV-2 disease roiling the world order -- are essential to protect others in the event you harbour the virus and have not displayed symptoms of COVID-19. There is also, health experts inform us, a good measure of protection for the mask-wearer from contracting the virus. On the other hand, a recent paper reflecting research published in The New England Journal of Medicine posits that mask wearing may have another residual and very important outcome.

Within communities where infection is widespread and many have yet to be diagnosed while shedding infectious droplets, mask-wearing which cannot entirely prevent some degree of infection penetration, by allowing a small amount of the virus to infect in essence acts as a vaccine. Allowing one's immune system to respond to trace amounts of infection without becoming overwhelmed by a large dose of infection. This is called variolation and its effect on a broad scale is to produce a kind of community 'herd effect'.

Masks, by limiting the amount of viral particles reaching tissues of those newly infected are then serving to inoculate more than massively infecting. In virology, the authors of this new paper explain, there is a tradition called the "LD-50" of a virus; the amount of an infection scaled to body mass that will produce great harm to those exposed to a full load. Viral disease toxicity may be dependent on "dose"; the lesser the dose the lesser the damage, enhancing opportunity for the body's immune system to adapt and fight the intruder.

Verification through research and observation appears as indirect evidence that SARS-CoV-2 doses if moderated through the preventive use of masks could produce a far less harmful outcome. A Japanese-led study that found "higher doses of administered virus led to more severe manifestations of COVID-19 in a Syrian hamster model of SARS-CoV-2 infection", appears to bear out the two authors' contentions.

Mask-wearing is now the norm in South Korea.Photo: Wonseok Jang 

Countries practising high-masking compliance are seen to have considerably lower rates of severe COVID-19 and consequent death numbers while resulting in fewer hospital admissions. The authors suggest that since being taken up as a first line of defence, (social isolation and mask-wearing), the result has been a mass protocol of "mask variolation". The original method of vaccination where fluids from smallpox patients were collected, to expose the non-infected to harmless amounts of diseased matter to induce mild infection providing immunity; hence variolation.

Health authorities early in the first wave of COVID believed that non-symptomatic people would not significantly shed as an infection source, until experience proved otherwise and then there arose an urgency to cope with the reality that asymptomatic carriers of the virus were indeed shedding infectious particles to the same degree as those infected with the virus who exhibited a wide range of symptoms. 

The message that the latest published research is delivering is that the eventual agreement that mask-wearing represented an integral approach to prevention ended up making far more of an impression in avoidance than might have been anticipated. The wearing of masks has proven successful in shielding the wearer from heavy infection doses, while the small amount of viral infection that did penetrate the shields has proven to have far-reaching consequences in making the wider public less susceptible to serious infections requiring hospitalization, while serving to reduce the death rate.

 

A line of people on Montgomery Street in San Francisco waits to get masks during the 1918 flu pandemic. Failure to wear a mask was punishable by imprisonment or a fine. Photo courtesy of the California History Room, California State Library, Sacramento.

Awaiting COVID's Second Wave With Bated Breath

"That [testing fewer symptomatic people] should not be confused with having a less severe disease present in the community."
"[A pandemic reveals society's nature]. It either exacerbates the disparities or it highlights the strengths."
"[Canadians, more than Americans] have embraced this ethic of communal responsibility. For the most part, people are on board with protecting other people, with wearing masks, with doing what's right for the community."
"That's not a message you see coming out of the U.S.A."
"It tells me we have the tools to contain this well."
"As long as the virus exists in the environment], it's going to find purchase and attempt to reassert itself. That's the way these things work."
Dr.Raywat Deonandan, epidemiologist, University of Ottawa

"This infection messes with me."
"Those I expect to do worse do well and those without traditional risk factors get admitted to ICU."
Dr.Jeff Powis, infectious disease physician, Toronto

Experts say lifting lockdown measures without a clear picture of where new cases are coming from, as Ontario and Quebec are doing, is cause for concern. (Evan Mitsui/CBC)

The SARS-CoV-2 virus in Canada is now recognized as being largely under control. That couldn't have been declared only two weeks ago, when doctors were run ragged attempting to save people who were presenting in "advanced respiratory failure", placing them on extra corporeal membrane oxygen machines the most extreme form of life support. "We've seen a dramatic drop off in the number of severe cases in the Toronto region", advised Dr. Niall Ferguson, head, critical care medicine, University Health Network, Toronto.

Still, Canada has lost close to 8,800 people. At present, however, the daily reported case and deaths have markedly diminished as has the numbers of individuals hospitalized. ICU admissions have been on the decline since the epidemic peaked in April. There has been a steep diminishing of transmission rates among the older demographic -- a slower decline in the 20- to 39-year olds, and with a corresponding rise in outbreaks in long-term care homes and among migrant workers.

This, while new infections are seen on a roll across the southern and western United States, where new daily records for deaths keep rising. According to epidemiologists this is a situation that was entirely predictable in the U.S. In Canada, the Deputy Chief Public Health Officer warns that should society slump into a relaxed attitude precipitately, the epidemic "will most likely rebound with explosive growth".

"Just because the fatality rate is incredibly high in people who are in their 80s or 90s does not mean the fatality rate is zero in their 40s, 50s and 60s."
"The overall story I see is that Canada has the resources and expertise to both contain COVID-19 and re-open schools and workplaces a the same time."
"I have a hard time with numbers, everybody has a hard time with numbers. It's hard o get your head around concepts like 0.5 percent of exponential growth at 1.1 -- what do these things mean?"
"Ninety-nine-point-five percent sounds pretty safe. But really, would you take a one-in-200 chance of dying? I wouldn't."
"It's very clear now, four months into the pandemic, that this is a serious illness that has resulted in great loss of life."
"In some ways [smaller incidence of infection among the elderly] that's unsurprising, because many older people know that they are especially vulnerable and so they're taking extra precautions."
Dr.Irfan Dhalla, general internist, vice-president Unity Health, Toronto

"In my opinion, the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface and someone else touches that surface soon after the cough or sneeze [within one or two hours]."
Dr.Emanuel Goldman, professor of microbiology, biochemistry and molecular genetics, Rutgers University

Covid-19 test\Niels Christian Vilmann/THE CANADIAN PRESS

The first wave of the global pandemic has struck and is now receding, as countries once desperately coping with an inrush of cases, seeing their hospital system begin to collapse under the sheer weight, now breathe a sigh of relief as the number of cases wane and ICU attendants catch their breath. On the other hand, expectations are high that another, second wave, is waiting in the wings. And perhaps another after that, and another yet.

The SARS-CoV-2 virus has amply demonstrated its lethal nature; in blood clots, sudden cardiac arrest, multi-organ failure on some affected people, while others have been infected and having exhibited none of the classic symptoms, go on to infect others. How to know, how to react if you don't know? Unknown to medical science is what increases risk of death.

A study of over 17 million people in England published in Nature this week verified that old age, and maleness are all hazards for COVID infection. Blacks and South Asians are two times likelier to suffer death related to COVID than are their white counterparts, and the reasons are as yet unknown. As with all other viral illnesses and conditions that sweep through communities, socio-economic underdogs are 1.8 times more likely to die from COVID than the least deprived.

Those suffering from diabetes, severe asthma, obesity, chronic heart or liver disease, dementia, reduced kidney function and autoimmune diseases like rheumatoid arthritis, lupus or psoriasis are as well linked with higher risk of death. COVID-19 disproportionately affects the vulnerable; those living in racialized groups, in poverty, in multi-generational families who live in cramped housing; those with low-paying essential-service employment.

People over age 60 represent 96 percent of deaths in Canada; age and  underlying health problems identified as risk factors. One drug only has been shown to keep people from dying from COVID; a steroid, called dexametasone that keeps the body's immune response to a foreign system circulating in the body from extreme reactions, with the steroid slashing ventilator-assisted patient deaths by one-third.

More people are surviving admission to ICUs and being placed on respirators. "They [China] were reporting  crazy things, like 90 percent mortality for people on ventilators", stated Dr.Ferguson. "We were able to rescue patients with ECMO when we needed to." No decisions required over which patients to route to ICU and who to leave to cope on their own were required, after all.

A recent paper published in the Canadian Medical Association Journal gave an estimate of less than 50 percent as representing the case rate for COVID-19 resulting in a fatality rate of around 1.6 percent. While the journal Nature reports a growing number of studies from various regions placing the infection fatality rate between 0.5 and one percent; five to ten people for every 1,000 infected, to die. The seasonal flu rate comes out to 0.1 to 0.2, identifying COVID as deadlier  and more infectious.

A favourable finding is that transmission by fomites (contaminated surfaces and objects) do not, after all, appear as serious a threat as first thought. A commentary published in the Lancet a week ago suggests most studies show large amounts of virus in excess of real-life scenarios must be present for infection to occur.