Thank you for this review. As a family doc in small examining rooms I’ve never stopped wearing an N95. It has never failed me (or failed to protect my patients).
As an older physician, married to an older dentist: I remember when we didn't wear gloves, and the huge push back when we started in the 1980's--"do you think I have AIDS??" My husband was always appalled that I didn't wear a mask with patients when they had respiratory illness. If we've learned anything, it's that universal precautions should be updated. We now understand airborne transmission: so update universal precautions. It should be simple, but there's so much vitriol and polarization. Thank you Katelyn, as always!
Yes!! I was a dental assistant back in the 80’s and never wore gloves or mask until AIDS. I hated wearing both at first but once I got used to working in them I wouldn’t consider putting my hands in a mouth without gloves again although we did stop wearing masks in general except for surgical settings until Covid.
I have never stopped- n95. My staff may wear surgical masks, but are required to wear PPE (n95, face shield) for all testing - we a lot in Peds. I would LOVE to show my face. My smile is one of my most memorable features I have been told, one of the reasons I love telemedicine is I can see my patients and visa versa.
My patients and families have always been required to mask w ANY respiratory symptoms but we stopped for well visits. We will have to reassess this. I know we will go back to requesting masks for that, but I hate being the first. We get flack from a mixed community.
I actually began wearing a mask in Nov 2019 when leaning in to examine patients. I just got tired of getting flu when kids coughed just as I was inspiring and leaning in. I know nobody recalls that. We have historically asked flu positive patients to mask when coming in with the diagnosis or heavy cough. Pre pandemic. I know nobody recalls this either.
Nobody, ever, in 3.5 years became ill inside my office from working or a visit. I plan on keeping it like that.
Masks for symptoms. Masks for all soon.
And BTW, we already have a local small Flu A outbreak by PCR. So welcome home flu. Again.
Thank you! I worked as an MA 15+ years ago, and I now look back at how many strep and flu tests I did with obviously sick patients coughing in my face, and wonder how/why it never occurred to me (or anyone else) to put on a surgical mask 🤯. I claim young and dumb ignorance (I was 19/20 when I started), and wished I had realized it in the 10-ish years I spent in family practice. However, I still can't figure out how/why the incredibly knowledgeable, thoughtful, caring physicians, np's or our MA manager (an RN) who were always on top of best practices and safety didn't think of masking or other respiratory precautions. We always made sure to wash hands, wear gloves, all the PPE that was appropriate for the task we were doing, but no thought was given to airborne particals even though we talked about it often, because we were often so sick 🤦🏼♀️.
I still remember the boy who gave me a terrible case of flu, because his mother insisted I check him for strep and got a full face cough. I do remember! Thanks for the heads up on the flu
Thank you so much for yet another timely and clear presentation. Your bottom line is an excellent take-home and worth repeating: “Infectious diseases violate the assumption of independence— what we do directly impacts those around us. A low-cost, minimally invasive intervention, like masking, is a great way to start protecting our community’s highest-risk individuals this fall and winter season.”
As a former healthcare risk manager, I appreciate this review. From a risk perspective, I never stopped wearing an N95 respirator. Dropping universal masking policies in health care settings only makes risky situations worse. Many people seeking healthcare are already vulnerable from pre-existing health conditions, disease, cancer, disabilities, or age, which places them at an increased risk of contracting Covid-19 and other potentially life-threatening illnesses. I spent years investigating system issues and adverse events, including deaths from hospital-acquired infections. I'm serious when I say hospitals are Petri dishes of infection. Every healthcare facility of which I am aware has seen an increase in staff and patient Covid infections since mask requirements were dropped. Hospitals aren't required to test for Covid, and since people can be asymptomatic, or shed virus before they become symptomatic, it's almost impossible to know who is sick. As a patient myself, it leaves me feeling vulnerable, wondering how many people who were exposed became infected, how many died or developed Long Covid as a result? Based on my work background, any mask is better than no mask, but especially N95's decrease aerosol transmission and the chance of becoming infected with a respiratory virus like Covid. It makes sense to wear them if you can. During my career, I also worked in the Operating Room - where masks are not optional and where wearing one never adversely affected us psychologically or impeded communication. Hopefully soon, hospitals and healthcare facilities will bring back good infection control policies that work to protect, not infect.
We had 4 COVID+ and 1 awaiting results on my unit (Women’s Health) over the weekend. I stopped wearing a mask, but I knew as soon as I started seeing COVID +, I would start again. I am now wearing my goggles and mask while in the hospital.
I swear Dr. Jetelina addressed this in another post but I couldn't find it. My suspicion is that it may reduce it, but not significantly enough to make a statistical difference, for several reasons. A mask is most likely to prevent an infection when a) it's a well-fitted N-95 being worn properly, and b) when the exposure is relatively short-term, i.e. a 1 hour doctor's visit, or a 5-minute pass by of someone infectious at a grocery store. But a lot more transmission at the population level likely happens in situations where people aren't going to, for all practical purposes, be properly wearing high-quality well-fitted masks and where exposure periods are longer, i.e. a small family or friend gathering for several hours in someone's home, or a kid sitting in a classroom all day, or an adult sitting in an office all day. Basically, you'd have to have the vast majority of people correctly wearing well-fitted N-95s for the vast majority of time they are ever around other people. Even for the most well-intentioned, this isn't practicable forever.
That explains the reality, but not the language :-) The fact is, if everyone did wear properly fitting N95 masks, there would be a HUGE reduction in transmission at the population level. It's poor messaging, IMO.
That claim has been repeatedly falsified. South Korea had one of the worst outcomes of any country in the world despite having the one of the highest uses of high quality n95.
This is why those clinging to the mask hypothesis have now retreated to "individual level" (first coined by Fauci IIRC when confronted on CNN) - all the predictions of how much impact masks would make have turned out to be false, all the predictions of how much worse things would get if we stopped masking, also failed.
It's a hypothesis which can't be falsified which is the foundation of pseudoscience.
The problem throughout the pandemic is that people making claims aren't being held accountable for them failing. In this case the author of the article of the NCBI piece conveniently stops his study at "March 2022" which is right before South Korea would see all cause mortality double - something which didn't even happen in the US in 2020.
(The columns "RG analysis" was me recreating someone else's hypothesis on how to predict excess deaths who I disagree with - those are not my projections)
As for the science direct article you linked, it was from 2020. Since then, we have seen their claim falsified.
When South Korea was having good results, plenty of articles praising them for their methods. Now they have among the highest mortality in the world, why aren't we going back and finding how that is possible? Deaths doubling for weeks on end is a major story that no one is talking about.
This was common pattern throughout pandemic, the logical fallacy of "counting your hits and forgetting your misses".
All Cause Mortality. South Korea had the 2nd worst year over year increase in death of any country in the last 100 years. Jumped from expected 310K deaths to 372K in 2022.
Now that your claim has been demonstrated false are you open to changing your mind?
Here is a comparison of Sweden against every other country, see for yourself:
Here is a more detailed year by year analysis of South Korea (columns B and E were me using someone's proposed method for estimating deaths to show it was flawed, you can largely ignore that part)
All cause mortality? Seriously? Masks are for protection against a very specific hazard - airborne pathogens transmitted from the nose and mouth. What do you expect a mask to do, make you bulletproof? Lose weight? Deliver extended release insulin? Make you buoyant? Prevent objects from making it into your windpipe (actually they *could * help with that one)?
(Referencing this really interesting and relevant conversation-looking forward to reading the citations!) *IF* Michael D's perspective is correct, does that mean it doesn't matter (*all else equal*) whether *I* (or for that matter, others) wear a properly-fitted N95 on a bus or train or plane, in a hospital, in a crowded conference hall, etc? (and assuming an average community prevalence of SARS-CoV-2 and ignoring my vaccination history)
Maybe continue along the same lines: Wear my KN95 (who knows if it's properly fitted) for high-risk situations, try to do as much large-group socializing out of doors as possible, and forget about masking otherwise. Stay up to date on vaccines! (Though not easy to get appointments for the latest booster, here in NYC. Not easy to find Covid tests, either. Walgreen's was even out of rubbing alcohol and thermometer probes. Shades of the pandemic.)
Also how much (useful) guidance do (or even can) we have on individualized situations like "If I'm on a four hour flight wearing a well-fitting N95 and regular glasses and unknowingly sitting within 6 feet of an unmasked person in the early stages of Covid (or asymptomatic Covid)...how protected am I?" And there are still variables to consider including the airport bus or Uber to get to the airport, being in the airport, my definition of "well-fitting", etc. The risk probably isn't 0.000%. Yet we navigate large and small decisions like that every day.
I agree with you - that doesn't make any sense. Amoxicillin works at individual and population levels. Access to free birth control reduces unwanted pregnancies at individual and population level. By contrast, "Abstinence Only" education only "works" at the individual level and not the population level, which is why we know it doesn't work.
The mask hypothesis is now in retreat, as it has failed to predict anything [1] and all claims have been repeatedly falsified. [2]
Because all of the population level predictions failed, those who still believe in masks have to resort to "well it could work on individual levels". Consider just 3 years ago Katelyn firmly believed cloth masks granted population level protection from Covid, claiming it " ... decreases R(t) below 1, leading to the mitigation of epidemic spread. ", " ... stopped more than 200,000 COVID-19 cases in the US by May 22, 2020" "...80% of the population wore masks, this would do more to reduce COVID-19 spread than a strict lockdown" [3]
All of that has failed. It was clear the early studies which lead to the hypothesis that they had weak foundation, and we should have been more skeptical (consider how widely circulated ridiculous studies like "2 hairstylists in Missouri", "Kansas Mask Study" and PNAS "Identifying airborne transmission as the dominant route for the spread of COVID-19")
It was always an extraordinary claim - that a tool we tested for 100 years and never found beneficial halting viral spread was somehow capable of ending pandemics [4]. And we simply sat on this knowledge while 20 million people died from the Flu in the 21st century alone, simply extraordinary.
Well, now 45 countries tested the hypothesis, and it failed. The few countries with the least mask use had the best outcome which should be a damning indictment on the hypothesis. The country with the highest use of quality masks had the 2nd worst outcome of any nation in the world. Damning.
Once we realized it was airborne that should have been enough to realize we would need Moon Suits to stop it. You can place 3,000 covid virions side-by-side in the space of a single n95 micropore, trillions in the size of the gaps around your nose, chin, which is where air flows through. What started the hypothesis in the first place was belief covid was transmitted on large droplets from coughs, but we clung to it despite emerging evidence - again, hallmark of pseudoscience. This is not unique in medicine -we saw the same thing with bloodletting, mercury elixers, lobotomies, and possibly Tamiflu.
I do find it utterly fascinating how quick the hypothesis became embedded in so many people, the fervent passion for this one single hypothesis is unlike anything I have seen in the history of science.
__________________
[1] "A theory that can't predict anything is not a scientific theory". - Peter Woit
[2] For one of many examples, both of these predictions failed:
"CDC Director Robert Redfield: If Everyone Wore a Mask for Next 6 Weeks We Could Drive Pandemic 'Into the Ground'"
right, we've gone from Katelyn and others saying...
"the science clearly says that cloth/surgical mask work. They will protect the population, reduce infections, and save lives. Everyone should wear them."
to
"fitted N95 may have a marginal benefit for healthcare workers in high-risk situations"
I mean, come on. The totality of evidence of efficacy for even fitted N95 on health care workers is pretty weak. Mask mandates of all types have repeatedly and consistently failed over the last 3+ years.
Two answers to this, a mathematical one and a what-counts-as-evidence one.
The mathematical one is that the effect of an intervention that is X% effective at reducing individual risk of infection for a given exposure will not translate linearly in a X% reduction of total yearly infections. The exact numbers depend on what you assume for R0 (number of immune-naive people who would be infected by each infectious case), duration of protection due to previous infection, duration of protection from vaccination, etc. Roughly, though, small values of X — say less than 20% — will do almost nothing for total community infection rates. But large values of X — over 80%, again depending on assumptions that are hard to measure precisely — will drive total infection rates down by *more* than X. Which of course we saw early in the pandemic when Taiwan, Australia, New Zealand, South Korea and other countries were able to drive infections to nearly zero.
The evidence question is that medicine over-emphasizes the randomized controlled trial compared to other sources. It’s nearly impossible to do an RCT of mask wearing on *community* infection levels, because you would have to randomize entire communities, not just individuals within them, to mask wearing or not. It’s hard for a research group to get that kind of influence over thousands of people at once (and for modern interconnected societies, even “thousands” may not be a large enough “community”).
The alternative is to use natural experiments — where one area imposed mask mandates and another did not. The problem here is that the causality is rarely one-directional. Yes, masking reduces infections — but typically the recommendation (or order) for masking is *caused* by (alarm over) rising cases.
In other areas of public health, we trust the math that large reductions of individual risk will result in a reduction of community risk. E.g. we know condoms reduce transmission of STDs. If overall STD rates don’t go down, we don’t say “oh, condoms don’t reduce community risks of STDs”. Instead we figure out what more we could do — free supply of condoms (free supply of masks has been exceedingly rare in the US, and especially not respirators), education (communication that Covid is airborne has been terrible in the US; lots of yelling about how respirators should be fit-tested, but no clinics at schools or non-medical workplaces to fit test people), free access to testing (nearly nonexistent in the US now), etc, etc.
And clean air. Air in hospitals is mostly quite good, but everywhere else we’re still at “open the windows”. Open the windows is an emergency response (and not even a great idea with recurrent wildfire smoke). In-room air filters are a minimum and engineered solutions should be the goal.
I like the condom analogy. In lab tests, condoms are essentially 100% effective at blocking STDs and pregnancies. But in the real world their efficacy rate is around 85%, because... people. They're used incorrectly, or left to age too long, or break, or someone says he used one but didn't... and so on.
To me, masks are like this. Except, it seems people are way worse at correctly using masks than they are at correctly using condoms!
Yah, I feel like the standard of proof here should be more like an indictment ("credible and legally sufficient") vs a guilty verdict ("beyond a reasonable doubt"). Let's embrace our inner Bayesians!
I wish they'd stop setting the bar so high. The hospital isn't responsible for reducing population level transmission, only for the portion of population level transmission that they're responsible for, on their watch. There are 24 hours in the day. A worker might be there for 8 of those hours, a patient might be in the waiting room for a few hours.
I'm a deputy fire warden on my floor. I police non-UL certified space heaters that people bring in - meaning, I tell my co-workers I don't want to see them if they have them, and that they should be aware that they aren't allowed and could face disciplinary action if they're caught. Anything that happens after that - it's on my co-worker. I've done my due diligence. My role is simple: make sure that if things go sideways, it's not my employer's fault.
Another example - we require vehicles get annual safety inspections. Car owners that fail to meet those safety inspection requirements can lose their license and insurance. In the event of a two car accident cause by the driver's negligence in maintaining their vehicle, the innocent party is made whole by their own insurance company and can then recover the money through subrogation. Because a legal framework exists for assigning fault. The system works, even if it doesn't result in people remembering to stay up to date on their inspections.
Mask requirements need not be about any particular population level outcome. They're about the facility covering its ass. That's OK! Rules are for managing human conflict, not for eliminating risks.
I agree, I have a similar thought process. I understand it's hard, or nearly impossible to study on a population level, but we can observe it's effectiveness in smaller sample sizes.
Ah, I see. There's probably some specific language in public health around this, but yeah, it's probably the unwillingness to extrapolate conclusions for conditions that are nearly impossible to achieve. Kind of like saying, "Healthy diet and exercise reduces an individual's risk for heart attack" and then jumping to "If every single adult ate healthy and exercised we'd see a sharp decline in the rate of heart attacks everywhere". Probably! But a) there are always confounding factors and so there's likely some base rate of heart attacks that will happen regardless of behavior, and b) you will never get every single adult eating healthy and exercising regularly in perpetuity, so you can't actually test this hypothesis.
But to follow up on that: *lecturing* everyone about healthy diet and exercise has little effect. Ensuring everyone has the $ to buy healthy food, and a job that pays enough that they only have to work one job, leaving time for exercise, and has air in their neighborhood that’s not so polluted that that exercise does more harm than good, etc, would do so much more.
If only the public health apparatus had the actual teeth to influence policy geared toward maximizing incentives and removing systemic barriers toward healthier outcomes :p
Also it's probably impossible for every adult to eat healthily and consume sufficient calories to live since we are well into late stage capitalism. Which is analogous in some ways to masks! Not enough to go around if we all wore them properly and discarded N95's after every use
I don’t understand how after all this time people need to continually adjust their mask, especially doctors and other people in healthcare. The mask is simply not appropriate for their face. I don’t have to readjust the N95 and KN95 masks that I wear.
Yeah I went to services yesterday, and was pleasantly surprised that the majority* of people had *95s, with a couple surgicals. And I chose to wear a pretty kf94. I didn't do any adjusting of it until the ear loops really started bothering me at which point I switched into a bloxdirect duckbill that needed no adjustment.
*Not enough of a majority that those who were not masking felt uncomfortable enough to start
I worked in the dental field going into and through the Covid pandemic. I have since retired but have found all along there is almost no guidance or consideration given to dental office personnel. It was very frustrating during the pandemic as a manager of a large dental clinic to find info on how to protect my staff and patients. Dentistry is a highly aerosolized environment meaning when we work in a patients mouth our high speed hand pieces (drills) aerosolize saliva and send it out far and wide in microscopic droplets. I am hoping that at some point the CDC and CDPH will consider dentistry as essential healthcare workers and give the same advice and consideration as is given to hospitals, medical offices and long term care facilities.
Thank you for clearly stating an issue that gets lost in "personal freedoms" and "government overreaches". Preventing (or at least limiting) the spread of illness is a key facet of health care, and that is what masking should be about - and in hospitals, doctors' offices, nursing homes, and anywhere else that ill, potentially ill, and/or high risk people congregate, that should be the key determinant. I was not comfortable in a mask - but I found masks that were effective and, if not comfortable, at least less uncomfortable.
I understand that they can be hard to breath in, that people reach for their faces and inadvertently touch/move the mask - but I also remember when my dentist was at the cutting edge of service provision when he, and his hygienists, began wearing masks because they were constantly getting breathed on, and then face shields to protect against bodily fluids, and then both - and as a patient, I appreciate their caution, as they are much less likely to contract, much less pass on, illnesses that way.
Which, it seems to me, should be a key issue for health care providers at all levels - but that idea's been lost in the political noise.
I live in Marin County, and we've been lucky to have outstanding Public Health throughout the pandemic, a true partnership with the community.
I checked the Walgreen's website today, and there are no covid booster appointments for Marin. In order to get a shot, one must drive to the East Bay. I don't know if that means all covid booster appointments are already booked, or whether there's a shortage in the Bay Area? And only Pfizer is available; Moderna is nowhere to be found.
(Marin county-specific) https://coronavirus.marinhhs.org/vaccinefinder, though they do say that the vaccine will arrive late Sept or early Oct. Hopefully they'll reopen the vaccine clinic at Northgate Mall.
Thank you for this review! As a NICU nurse I appreciate the steps taken to ensure the health and safety of all patients. Surprisingly we have not had a single infant test positive for COVID thus far!
Thank you for this review. As a family doc in small examining rooms I’ve never stopped wearing an N95. It has never failed me (or failed to protect my patients).
At my dentist's office, in addition to always wearing masks, they open all the windows.
Cheers. Yes. This.
Thank you!
As an older physician, married to an older dentist: I remember when we didn't wear gloves, and the huge push back when we started in the 1980's--"do you think I have AIDS??" My husband was always appalled that I didn't wear a mask with patients when they had respiratory illness. If we've learned anything, it's that universal precautions should be updated. We now understand airborne transmission: so update universal precautions. It should be simple, but there's so much vitriol and polarization. Thank you Katelyn, as always!
Yes!! I was a dental assistant back in the 80’s and never wore gloves or mask until AIDS. I hated wearing both at first but once I got used to working in them I wouldn’t consider putting my hands in a mouth without gloves again although we did stop wearing masks in general except for surgical settings until Covid.
Immunocompromised and disabled people are literally everywhere, not just in hospitals or parts of hospitals.
Anyone is just one cortisone injection away from being immunocompromised.
I have never stopped- n95. My staff may wear surgical masks, but are required to wear PPE (n95, face shield) for all testing - we a lot in Peds. I would LOVE to show my face. My smile is one of my most memorable features I have been told, one of the reasons I love telemedicine is I can see my patients and visa versa.
My patients and families have always been required to mask w ANY respiratory symptoms but we stopped for well visits. We will have to reassess this. I know we will go back to requesting masks for that, but I hate being the first. We get flack from a mixed community.
I actually began wearing a mask in Nov 2019 when leaning in to examine patients. I just got tired of getting flu when kids coughed just as I was inspiring and leaning in. I know nobody recalls that. We have historically asked flu positive patients to mask when coming in with the diagnosis or heavy cough. Pre pandemic. I know nobody recalls this either.
Nobody, ever, in 3.5 years became ill inside my office from working or a visit. I plan on keeping it like that.
Masks for symptoms. Masks for all soon.
And BTW, we already have a local small Flu A outbreak by PCR. So welcome home flu. Again.
Thank you! I worked as an MA 15+ years ago, and I now look back at how many strep and flu tests I did with obviously sick patients coughing in my face, and wonder how/why it never occurred to me (or anyone else) to put on a surgical mask 🤯. I claim young and dumb ignorance (I was 19/20 when I started), and wished I had realized it in the 10-ish years I spent in family practice. However, I still can't figure out how/why the incredibly knowledgeable, thoughtful, caring physicians, np's or our MA manager (an RN) who were always on top of best practices and safety didn't think of masking or other respiratory precautions. We always made sure to wash hands, wear gloves, all the PPE that was appropriate for the task we were doing, but no thought was given to airborne particals even though we talked about it often, because we were often so sick 🤦🏼♀️.
I still remember the boy who gave me a terrible case of flu, because his mother insisted I check him for strep and got a full face cough. I do remember! Thanks for the heads up on the flu
My son's pediatrician's office always required surgical masks for flu symptoms during flu season, even pre-Covid. Always made sense to me!
I welcome this. My kids and I are often the only in the masks in medical facilities, and I hate it.
Thank you so much for yet another timely and clear presentation. Your bottom line is an excellent take-home and worth repeating: “Infectious diseases violate the assumption of independence— what we do directly impacts those around us. A low-cost, minimally invasive intervention, like masking, is a great way to start protecting our community’s highest-risk individuals this fall and winter season.”
As a former healthcare risk manager, I appreciate this review. From a risk perspective, I never stopped wearing an N95 respirator. Dropping universal masking policies in health care settings only makes risky situations worse. Many people seeking healthcare are already vulnerable from pre-existing health conditions, disease, cancer, disabilities, or age, which places them at an increased risk of contracting Covid-19 and other potentially life-threatening illnesses. I spent years investigating system issues and adverse events, including deaths from hospital-acquired infections. I'm serious when I say hospitals are Petri dishes of infection. Every healthcare facility of which I am aware has seen an increase in staff and patient Covid infections since mask requirements were dropped. Hospitals aren't required to test for Covid, and since people can be asymptomatic, or shed virus before they become symptomatic, it's almost impossible to know who is sick. As a patient myself, it leaves me feeling vulnerable, wondering how many people who were exposed became infected, how many died or developed Long Covid as a result? Based on my work background, any mask is better than no mask, but especially N95's decrease aerosol transmission and the chance of becoming infected with a respiratory virus like Covid. It makes sense to wear them if you can. During my career, I also worked in the Operating Room - where masks are not optional and where wearing one never adversely affected us psychologically or impeded communication. Hopefully soon, hospitals and healthcare facilities will bring back good infection control policies that work to protect, not infect.
We had 4 COVID+ and 1 awaiting results on my unit (Women’s Health) over the weekend. I stopped wearing a mask, but I knew as soon as I started seeing COVID +, I would start again. I am now wearing my goggles and mask while in the hospital.
Heating, Ventilation, and Air Conditioning (HVAC) systems need to be set for a higher percentage of fresh air / makeup air.
"Masks work on individuals. We have limited evidence on whether they work to reduce population-level transmission."
I read this often, and it always gives me pause.
If masks work on individuals, how can they not reduce population-level transmission? For me, cognitive dissonance.
I think this may be a case where the more scientifically-minded understand what is being said. Or for all I know, maybe everyone else gets it but me.
But if my reaction is at all typical, I wonder: why continue to make the statement?
I swear Dr. Jetelina addressed this in another post but I couldn't find it. My suspicion is that it may reduce it, but not significantly enough to make a statistical difference, for several reasons. A mask is most likely to prevent an infection when a) it's a well-fitted N-95 being worn properly, and b) when the exposure is relatively short-term, i.e. a 1 hour doctor's visit, or a 5-minute pass by of someone infectious at a grocery store. But a lot more transmission at the population level likely happens in situations where people aren't going to, for all practical purposes, be properly wearing high-quality well-fitted masks and where exposure periods are longer, i.e. a small family or friend gathering for several hours in someone's home, or a kid sitting in a classroom all day, or an adult sitting in an office all day. Basically, you'd have to have the vast majority of people correctly wearing well-fitted N-95s for the vast majority of time they are ever around other people. Even for the most well-intentioned, this isn't practicable forever.
That explains the reality, but not the language :-) The fact is, if everyone did wear properly fitting N95 masks, there would be a HUGE reduction in transmission at the population level. It's poor messaging, IMO.
That claim has been repeatedly falsified. South Korea had one of the worst outcomes of any country in the world despite having the one of the highest uses of high quality n95.
This is why those clinging to the mask hypothesis have now retreated to "individual level" (first coined by Fauci IIRC when confronted on CNN) - all the predictions of how much impact masks would make have turned out to be false, all the predictions of how much worse things would get if we stopped masking, also failed.
It's a hypothesis which can't be falsified which is the foundation of pseudoscience.
Strange, South Korea did relatively well in their response to SARS-CoV-2. This is from a number of different sources but I find this interesting.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9669502/
and this
https://www.sciencedirect.com/science/article/pii/S0305750X20301832
The problem throughout the pandemic is that people making claims aren't being held accountable for them failing. In this case the author of the article of the NCBI piece conveniently stops his study at "March 2022" which is right before South Korea would see all cause mortality double - something which didn't even happen in the US in 2020.
https://imgur.com/a/fClDxf0
Author claims there are "only 12000 deaths", despite the fact by the end of 2022 South Korea had accumulated between 70K-110K excess deaths.
https://imgur.com/a/Y5n9zKH
(The columns "RG analysis" was me recreating someone else's hypothesis on how to predict excess deaths who I disagree with - those are not my projections)
As for the science direct article you linked, it was from 2020. Since then, we have seen their claim falsified.
When South Korea was having good results, plenty of articles praising them for their methods. Now they have among the highest mortality in the world, why aren't we going back and finding how that is possible? Deaths doubling for weeks on end is a major story that no one is talking about.
This was common pattern throughout pandemic, the logical fallacy of "counting your hits and forgetting your misses".
You, of course, realized the S. Korea has dropped most of its masking mandate. Updated : 2023-01-30 11:22 https://www.koreatimes.co.kr/www/nation/2023/01/113_344414.html
https://ourworldindata.org/covid-deaths?country=IND~USA~GBR~CAN~DEU~FRA~KOR
What metric over what time period are you using to claim that South Korea had “one of the worst outcomes in the world”? Because it’s simply not true.
All Cause Mortality. South Korea had the 2nd worst year over year increase in death of any country in the last 100 years. Jumped from expected 310K deaths to 372K in 2022.
Now that your claim has been demonstrated false are you open to changing your mind?
Here is a comparison of Sweden against every other country, see for yourself:
https://imgur.com/a/Elt51gr
Here is a more detailed year by year analysis of South Korea (columns B and E were me using someone's proposed method for estimating deaths to show it was flawed, you can largely ignore that part)
https://imgur.com/a/Y5n9zKH
Raw numbers for a single year, not population adjusted, and ignoring South Korea’s enormous success in 2020 and 2021, are a terrible comparison. South Korea greatly outperformed the US — but New Zealand did better than anyone. https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2020-03-01..latest&facet=none&country=USA~IND~SWE~KOR~NZL~JPN&pickerSort=asc&pickerMetric=location&Metric=Excess+mortality+%28count%29&Interval=Cumulative&Relative+to+Population=true&Color+by+test+positivity=false
Further, there’s reason to believe Sweden’s relatively good recent numbers are wrong. Thread: https://x.com/DavidSteadson/status/1615320704622239744?s=20, compiled here: https://threadreaderapp.com/thread/1615320704622239744.html)
S. Korea excess deaths https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-16546-2
Sweden: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00885-0/fulltext
All cause mortality? Seriously? Masks are for protection against a very specific hazard - airborne pathogens transmitted from the nose and mouth. What do you expect a mask to do, make you bulletproof? Lose weight? Deliver extended release insulin? Make you buoyant? Prevent objects from making it into your windpipe (actually they *could * help with that one)?
All cause mortality is an idiotic metric here
(Referencing this really interesting and relevant conversation-looking forward to reading the citations!) *IF* Michael D's perspective is correct, does that mean it doesn't matter (*all else equal*) whether *I* (or for that matter, others) wear a properly-fitted N95 on a bus or train or plane, in a hospital, in a crowded conference hall, etc? (and assuming an average community prevalence of SARS-CoV-2 and ignoring my vaccination history)
I think the problem lies here: “if everyone did wear properly fitting N95 masks”, but that’s my opinion. Not science.
Perhaps thinking of this post? https://yourlocalepidemiologist.substack.com/p/a-quick-note-on-masks-and-cdc-guidance
Thanks. I appreciate the thoughtful response.
Maybe continue along the same lines: Wear my KN95 (who knows if it's properly fitted) for high-risk situations, try to do as much large-group socializing out of doors as possible, and forget about masking otherwise. Stay up to date on vaccines! (Though not easy to get appointments for the latest booster, here in NYC. Not easy to find Covid tests, either. Walgreen's was even out of rubbing alcohol and thermometer probes. Shades of the pandemic.)
Also how much (useful) guidance do (or even can) we have on individualized situations like "If I'm on a four hour flight wearing a well-fitting N95 and regular glasses and unknowingly sitting within 6 feet of an unmasked person in the early stages of Covid (or asymptomatic Covid)...how protected am I?" And there are still variables to consider including the airport bus or Uber to get to the airport, being in the airport, my definition of "well-fitting", etc. The risk probably isn't 0.000%. Yet we navigate large and small decisions like that every day.
I agree with you - that doesn't make any sense. Amoxicillin works at individual and population levels. Access to free birth control reduces unwanted pregnancies at individual and population level. By contrast, "Abstinence Only" education only "works" at the individual level and not the population level, which is why we know it doesn't work.
The mask hypothesis is now in retreat, as it has failed to predict anything [1] and all claims have been repeatedly falsified. [2]
Because all of the population level predictions failed, those who still believe in masks have to resort to "well it could work on individual levels". Consider just 3 years ago Katelyn firmly believed cloth masks granted population level protection from Covid, claiming it " ... decreases R(t) below 1, leading to the mitigation of epidemic spread. ", " ... stopped more than 200,000 COVID-19 cases in the US by May 22, 2020" "...80% of the population wore masks, this would do more to reduce COVID-19 spread than a strict lockdown" [3]
All of that has failed. It was clear the early studies which lead to the hypothesis that they had weak foundation, and we should have been more skeptical (consider how widely circulated ridiculous studies like "2 hairstylists in Missouri", "Kansas Mask Study" and PNAS "Identifying airborne transmission as the dominant route for the spread of COVID-19")
It was always an extraordinary claim - that a tool we tested for 100 years and never found beneficial halting viral spread was somehow capable of ending pandemics [4]. And we simply sat on this knowledge while 20 million people died from the Flu in the 21st century alone, simply extraordinary.
Well, now 45 countries tested the hypothesis, and it failed. The few countries with the least mask use had the best outcome which should be a damning indictment on the hypothesis. The country with the highest use of quality masks had the 2nd worst outcome of any nation in the world. Damning.
Once we realized it was airborne that should have been enough to realize we would need Moon Suits to stop it. You can place 3,000 covid virions side-by-side in the space of a single n95 micropore, trillions in the size of the gaps around your nose, chin, which is where air flows through. What started the hypothesis in the first place was belief covid was transmitted on large droplets from coughs, but we clung to it despite emerging evidence - again, hallmark of pseudoscience. This is not unique in medicine -we saw the same thing with bloodletting, mercury elixers, lobotomies, and possibly Tamiflu.
I do find it utterly fascinating how quick the hypothesis became embedded in so many people, the fervent passion for this one single hypothesis is unlike anything I have seen in the history of science.
__________________
[1] "A theory that can't predict anything is not a scientific theory". - Peter Woit
[2] For one of many examples, both of these predictions failed:
"CDC Director Robert Redfield: If Everyone Wore a Mask for Next 6 Weeks We Could Drive Pandemic 'Into the Ground'"
https://www.complex.com/life/a/gavin-evans/cdc-director-robert-redfield-says-if-everyone-wore-masks-pandemic-could-be-stomped-out-in-4-to-6-weeks
"Texas and Mississippi lifting their Covid mask mandates is like pouring gas on a fire"
https://www.nbcnews.com/think/opinion/texas-mississippi-lifting-their-covid-mask-mandates-pouring-gas-fire-ncna1259733
[3] https://www.facebook.com/permalink.php?story_fbid=202002698114314&id=101805971467321
[4] https://archive.ph/Tdej9 (note that WebMD took this article down)
right, we've gone from Katelyn and others saying...
"the science clearly says that cloth/surgical mask work. They will protect the population, reduce infections, and save lives. Everyone should wear them."
to
"fitted N95 may have a marginal benefit for healthcare workers in high-risk situations"
I mean, come on. The totality of evidence of efficacy for even fitted N95 on health care workers is pretty weak. Mask mandates of all types have repeatedly and consistently failed over the last 3+ years.
Two answers to this, a mathematical one and a what-counts-as-evidence one.
The mathematical one is that the effect of an intervention that is X% effective at reducing individual risk of infection for a given exposure will not translate linearly in a X% reduction of total yearly infections. The exact numbers depend on what you assume for R0 (number of immune-naive people who would be infected by each infectious case), duration of protection due to previous infection, duration of protection from vaccination, etc. Roughly, though, small values of X — say less than 20% — will do almost nothing for total community infection rates. But large values of X — over 80%, again depending on assumptions that are hard to measure precisely — will drive total infection rates down by *more* than X. Which of course we saw early in the pandemic when Taiwan, Australia, New Zealand, South Korea and other countries were able to drive infections to nearly zero.
The evidence question is that medicine over-emphasizes the randomized controlled trial compared to other sources. It’s nearly impossible to do an RCT of mask wearing on *community* infection levels, because you would have to randomize entire communities, not just individuals within them, to mask wearing or not. It’s hard for a research group to get that kind of influence over thousands of people at once (and for modern interconnected societies, even “thousands” may not be a large enough “community”).
The alternative is to use natural experiments — where one area imposed mask mandates and another did not. The problem here is that the causality is rarely one-directional. Yes, masking reduces infections — but typically the recommendation (or order) for masking is *caused* by (alarm over) rising cases.
In other areas of public health, we trust the math that large reductions of individual risk will result in a reduction of community risk. E.g. we know condoms reduce transmission of STDs. If overall STD rates don’t go down, we don’t say “oh, condoms don’t reduce community risks of STDs”. Instead we figure out what more we could do — free supply of condoms (free supply of masks has been exceedingly rare in the US, and especially not respirators), education (communication that Covid is airborne has been terrible in the US; lots of yelling about how respirators should be fit-tested, but no clinics at schools or non-medical workplaces to fit test people), free access to testing (nearly nonexistent in the US now), etc, etc.
And clean air. Air in hospitals is mostly quite good, but everywhere else we’re still at “open the windows”. Open the windows is an emergency response (and not even a great idea with recurrent wildfire smoke). In-room air filters are a minimum and engineered solutions should be the goal.
I like the condom analogy. In lab tests, condoms are essentially 100% effective at blocking STDs and pregnancies. But in the real world their efficacy rate is around 85%, because... people. They're used incorrectly, or left to age too long, or break, or someone says he used one but didn't... and so on.
To me, masks are like this. Except, it seems people are way worse at correctly using masks than they are at correctly using condoms!
Yah, I feel like the standard of proof here should be more like an indictment ("credible and legally sufficient") vs a guilty verdict ("beyond a reasonable doubt"). Let's embrace our inner Bayesians!
Thank you for the thoughtful reply.
I wish they'd stop setting the bar so high. The hospital isn't responsible for reducing population level transmission, only for the portion of population level transmission that they're responsible for, on their watch. There are 24 hours in the day. A worker might be there for 8 of those hours, a patient might be in the waiting room for a few hours.
I'm a deputy fire warden on my floor. I police non-UL certified space heaters that people bring in - meaning, I tell my co-workers I don't want to see them if they have them, and that they should be aware that they aren't allowed and could face disciplinary action if they're caught. Anything that happens after that - it's on my co-worker. I've done my due diligence. My role is simple: make sure that if things go sideways, it's not my employer's fault.
Another example - we require vehicles get annual safety inspections. Car owners that fail to meet those safety inspection requirements can lose their license and insurance. In the event of a two car accident cause by the driver's negligence in maintaining their vehicle, the innocent party is made whole by their own insurance company and can then recover the money through subrogation. Because a legal framework exists for assigning fault. The system works, even if it doesn't result in people remembering to stay up to date on their inspections.
Mask requirements need not be about any particular population level outcome. They're about the facility covering its ass. That's OK! Rules are for managing human conflict, not for eliminating risks.
I agree, I have a similar thought process. I understand it's hard, or nearly impossible to study on a population level, but we can observe it's effectiveness in smaller sample sizes.
Ah, I see. There's probably some specific language in public health around this, but yeah, it's probably the unwillingness to extrapolate conclusions for conditions that are nearly impossible to achieve. Kind of like saying, "Healthy diet and exercise reduces an individual's risk for heart attack" and then jumping to "If every single adult ate healthy and exercised we'd see a sharp decline in the rate of heart attacks everywhere". Probably! But a) there are always confounding factors and so there's likely some base rate of heart attacks that will happen regardless of behavior, and b) you will never get every single adult eating healthy and exercising regularly in perpetuity, so you can't actually test this hypothesis.
But to follow up on that: *lecturing* everyone about healthy diet and exercise has little effect. Ensuring everyone has the $ to buy healthy food, and a job that pays enough that they only have to work one job, leaving time for exercise, and has air in their neighborhood that’s not so polluted that that exercise does more harm than good, etc, would do so much more.
If only the public health apparatus had the actual teeth to influence policy geared toward maximizing incentives and removing systemic barriers toward healthier outcomes :p
100%
Also it's probably impossible for every adult to eat healthily and consume sufficient calories to live since we are well into late stage capitalism. Which is analogous in some ways to masks! Not enough to go around if we all wore them properly and discarded N95's after every use
Thanks. Comforting to know I"m not alone!
I don’t understand how after all this time people need to continually adjust their mask, especially doctors and other people in healthcare. The mask is simply not appropriate for their face. I don’t have to readjust the N95 and KN95 masks that I wear.
Yeah I went to services yesterday, and was pleasantly surprised that the majority* of people had *95s, with a couple surgicals. And I chose to wear a pretty kf94. I didn't do any adjusting of it until the ear loops really started bothering me at which point I switched into a bloxdirect duckbill that needed no adjustment.
*Not enough of a majority that those who were not masking felt uncomfortable enough to start
I worked in the dental field going into and through the Covid pandemic. I have since retired but have found all along there is almost no guidance or consideration given to dental office personnel. It was very frustrating during the pandemic as a manager of a large dental clinic to find info on how to protect my staff and patients. Dentistry is a highly aerosolized environment meaning when we work in a patients mouth our high speed hand pieces (drills) aerosolize saliva and send it out far and wide in microscopic droplets. I am hoping that at some point the CDC and CDPH will consider dentistry as essential healthcare workers and give the same advice and consideration as is given to hospitals, medical offices and long term care facilities.
Thank you for clearly stating an issue that gets lost in "personal freedoms" and "government overreaches". Preventing (or at least limiting) the spread of illness is a key facet of health care, and that is what masking should be about - and in hospitals, doctors' offices, nursing homes, and anywhere else that ill, potentially ill, and/or high risk people congregate, that should be the key determinant. I was not comfortable in a mask - but I found masks that were effective and, if not comfortable, at least less uncomfortable.
I understand that they can be hard to breath in, that people reach for their faces and inadvertently touch/move the mask - but I also remember when my dentist was at the cutting edge of service provision when he, and his hygienists, began wearing masks because they were constantly getting breathed on, and then face shields to protect against bodily fluids, and then both - and as a patient, I appreciate their caution, as they are much less likely to contract, much less pass on, illnesses that way.
Which, it seems to me, should be a key issue for health care providers at all levels - but that idea's been lost in the political noise.
I live in Marin County, and we've been lucky to have outstanding Public Health throughout the pandemic, a true partnership with the community.
I checked the Walgreen's website today, and there are no covid booster appointments for Marin. In order to get a shot, one must drive to the East Bay. I don't know if that means all covid booster appointments are already booked, or whether there's a shortage in the Bay Area? And only Pfizer is available; Moderna is nowhere to be found.
My elderly parents who live in another state had an easy time booking an appointment for a Moderna covid booster. I hear at CVS, overworked pharmacists are doing walkouts. Bumpy booster rollout, for sure. https://www.kctv5.com/2023/09/25/impossible-cvs-pharmacists-demand-more-staff-meet-demand-covid-vaccines-prescriptions/
I am still waiting for Novavax. I really hope FDA updates us soon on timing - days, weeks or months?
(Marin county-specific) https://coronavirus.marinhhs.org/vaccinefinder, though they do say that the vaccine will arrive late Sept or early Oct. Hopefully they'll reopen the vaccine clinic at Northgate Mall.
We've seen similar here in SW Washington (near Portland OR). It shouldn't be this hard.
Thank you for this review! As a NICU nurse I appreciate the steps taken to ensure the health and safety of all patients. Surprisingly we have not had a single infant test positive for COVID thus far!
Masks/Respirators (N-95) should be the "new normal" for all healthcare settings. Period.