Masks – What Makes Sense, And What Doesn’t
This post was written in response to 2 patients I saw last week. One who was incredibly anxious and stressed out, who was wearing 2 KN95 masks at the same time. And another, a conscientious teacher who was using 2 KN95 masks a day, meaning that they were wearing one in the morning and the other in the afternoon, throwing both out every day. They were lamenting the costs. Although they were both very careful, both practices were excessive, uncomfortable and costly. I will describe my own mask habits further on.
First, some basics.
Masks essentially serve 2 purposes.
- Protecting you from those around you and
- Protecting those around you from you!
I would add an additional 3rd purpose and that is to remind us all that we are still in the midst of a pandemic and we all need to be careful.
The original purpose when they were first devised was to protect patients actually. Although the droplet theory of infection was first proposed in 1897, along with the proposal of masks was introduced later that same year, doctors have been wearing some kind of facial coverings for long before that. In the 1600s, during the Bubonic Plague, doctors used to wear elaborate beak-like masks filled with herbs and spices thought to ward off the “evil humors” which they thought caused the plague. It wasn’t the herbs, just the layers of barrier which gave a modicum of protection.
In the Orient, masks have been worn for decades. Westerners would poke fun at the mask-wearing people in the East. They wore masks not necessarily for personal protection purposes, but more because of a sense of societal responsibility. And here we are now, doing the same thing. But sadly, most people’s attitude regarding masking and vaccination is more personal or political, than interest in protecting ourselves and those around us. Furthermore, being told that we should do these things is taken more as an affront to personal freedom. But to paraphrase Justice Oliver Wendell Holmes, your personal freedom ends where another man’s nose begins, in the case of Covid-19, quite literally.
When all this started 2 years ago, most physicians, me included, did not promote the notion of mask wearing. At the time, we thought this was like the flu, probably seasonal and spread through droplets let loose by a good sneeze, cough or from a snotty door handle.
Now we know that it is aerosolized and spread just by breathing.
Do masks work? Absolutely. However, all masks are not made equal. Nor is how you wear it. In addition, more detailed studies indicate that they actually protect the wearer from getting infected more than those around you if you are infected, particularly if you are not wearing it correctly. Lastly, vaccines work better. Masks are an adjunct, just like distancing and choosing who you interact with, and where, carefully.
Just to be clear, the term “face coverings” is misleading and stupid. It’s the head-in-the-sand approach. If I wear this doily or mesh on my face, that’s enough. Maybe to follow the rules, but not to do anything useful when it comes to getting infected or spreading it.
Just to get technique over with, masks must be fit well so air doesn’t leak around the edges, both in and out. Wearing it loosely or under your nose is essentially useless, other than letting others around you know that you are an imbecile and/or are probably infected. In that sense, they are still useful since it cautions everyone else to stay away. Obviously the under-the-chin technique is just moronic. In addition, how fine it is, meaning, what size of particle does it let through, is the most important factor.
Gaiters, or the masks made from similar synthetic materials, are useless and maybe even harmful. They actually aerosolize secretions more so they make you more prone to getting a good dose of virus, or spreading it.
Cotton is next best, especially if used with multiple layers and better yet, with a polypropylene filter inside. They do have the advantage of being washable. Some still argue they are useless. But again, better than nothing and significantly better than synthetic materials.
As a surgeon, operating on people now for over 25 years, I was shocked to learn how poorly surgical masks actually perform. Only marginally better than cotton actually, and only if tightly fit!!! They do have the advantage of being inexpensive and essentially are throw-away masks. I use them, but usually as a second layer over an N95, and typically in only higher risk situations, and more to protect the N95 underneath.
N95 or KN95 (the Chinese designation and equivalent in quality), are by far the most protective, other than the full face masks/ventilators car painters or graffiti artists use or papper-style suits used in the ER or OR with acutely ill, coughing-up-a-lung patients. Other N95 equivalent designations include FFP and KF94.
Now, they are more expensive BUT you can reuse them.
A recent study was published in The National Academy of the Sciences on masks comparing N95 with and without a nose piece (meaning tight fitting around the nose, as well as tightly fitted surgical masks). When exposed to a Covid infected person for 20 minutes, the risk of infection with a surgical mask was 10%. With an N95 without a nosepiece, the risk was 4% and with a nosepiece, the risk was 0.4%. Of course there are other variables such as the environment of the contact, ventilation…
I’m not going to tell you what to do, but this is what I do. I perform a full head and neck exam on 20-30 patients a day, many of whom are sick, and some of them are guaranteed to have covid. Thus far, I’ve managed to dodge the bullet. I wear an N95 all day long, other than to dictate notes in my little cubby hole. I re-use my mask many days in a row. I will use an N95 for up to a week, if not longer. I do something of a rotation, putting the one I wore that day on my dashboard or on a window ledge in the sun. The virus on the surface dies within a day or 2 at the most. If you take care of it and don’t beat it up too much, there is no reason that you can’t wear it for multiple days in a row, especially if you are only wearing it here and there in stores. STOP TOUCHING IT AND PULLING ON IT TO TALK and that will reduce wear and tear. As far as my mask practices are concerned outside the hospital and office, I am struggling a bit. I still wear a mask, usually an N95, everywhere I go. It is partly to limit exposing others to me, but honestly, I have some paranoia. Essentially, I don’t trust those around me enough. At best, 2/3rds of the people around me are vaccinated. So you are always guaranteed to be exposed to the virus everywhere you go. The estimate as it is, is that 50% of Europeans and at least 25% of Americans have already contracted Omicron, whether they know it or not. Even one of my partners was recently surprised to find out that he had antibodies to the virus, which he could not get from vaccination, despite no symptoms and regular negative home tests.
Masks are important. But again, the quality and technique of wearing it are equally important. But they are not as important as vaccination.
Do we need to vaccinate kids? Absolutely. Do we need to force them to wear masks in schools? There is a huge amount of debate over this. Although it is still quite clear that kids develop less significant disease, especially with Omicron, they can still get it, and they can still spread it. In some places like Britain, they don’t force kids to wear masks in schools, but they have a much higher vaccination rate, more vigorous testing and isolation if positive and ultimately, more responsible citizens, meaning, if they are sick, they stay home and are not out there spreading virus,
There is a lot of recent data and information I have been processing lately. This pandemic seems to be turning into an endemic infection, much the same way the Spanish Flu pandemic of 1918, when millions died, turned into the seasonal flu we deal with today. I don’t think we’re there yet, especially given the many millions and even billions of people who have not been vaccinated or have not gotten sick yet.
Please be careful out there, but be practical and not fearful. The most common risk factor for being admitted to the ICU with Covid complications is being overweight or obese. The second most common risk factor is fear and anxiety. Look out for yourselves and look out for everyone else.
Please get vaccinated. I still firmly believe in our vaccines. We may not need the frequency of booster which are being recommended and getting sick from Covid does provide some significant benefit. The numbers, however, are clear that if you are vaccinated, your chances of getting sick are significantly decreased (of course not zero), your chances of needing hospitalization are 87x less and your chances of dying are close to 100% less, as compared with non vaccinated people. In addition , some recent studies have shown that vaccination reduces the risks of developing long Covid symptoms both before you get Covid and even after you have had Covid and have symptoms.
Keep working on your physical and mental health.
Stay Safe and Be Well.
AC