Masks, Senior Care Facilities, Diet and Exercise
Before I probe the issue of further prevention in addition to vaccine inoculation, one new piece of very surprising news. Pfizer officials had recommended that Operation Warp Speed buy 200 million doses of its vaccines related to America’s proportion in the first world population, but the Trump administration chose to buy only 100 million doses, sufficient to inoculate 50 million people. Why? Evidently because it expected to get a cheaper vaccine earlier and wanted to save a buck rather than ensure, as Canada did, that the country would have sufficient supplies. The United States will not be able to buy more doses of coronavirus vaccine from Pfizer and BioNTech until late June or July since other countries and COVAX have purchased virtually all of the supply up until then.
In the meanwhile, it will be critical that everyone continue with precautions, especially over the next six months. Remember that 2% of coronavirus cases are lethal; only 0.1% of flu cases are. Precautions are necessary, for no drug or treatment exists to cure the disease, only procedures for reducing symptoms, important in itself. That means continuing to wear masks, practicing social distancing, washing hands and reducing the size of gatherings.
Government authorities all over the world will be faced with the problem of encouraging people to take the vaccines, especially in light of the rising distrust of government and the speed in which the vaccines were developed and approved. Something may be learned by the controversies over wearing masks to which there remains resistance everywhere, but clearly nowhere as much as in the U.S. where the president held little regard for wearing masks and discouraged wearing one by his personal example.
Though these are emotional and ideological issues, often complicated by outright myths, such as the vaccine disrupts your DNA (mRNA does not affect or interact with DNA) or that doctors have cooked the books on deaths financially to benefit themselves and the hospitals they run, or that washing with hand sanitizer too much weakens our immune system. The problem, however, more often begins with confusions over facts and the interpretation of policies.
Take the issue of masks. The recent paper below echoes the controversies in several contemporary academic and historical academic discussions of masks.
“Major Study Finds Masks Don’t Reduce COVID-19 Infection Rates” in The Federalist
In the Danish study above, the issue was, if I wear a mask, does it minimize or decrease the risk of my being infected with COVID-19. However, this is a misleading question since no respectable epidemiologist that I have read has argued that wearing a mask directly reduces your risk of getting COVID-19. COVID-19 is nanoscopic. The virus can penetrate the surgical mask barrier. However, for the wearer, it greatly decreases the amount and distance the wearer’s droplets travel. “(F)ace masks are not designed or certified to protect the wearer from exposure to respiratory hazards.” Masks are intended to minimizes the amount and range of distribution of respiratory droplets by the wearer. One wears the mask to reduce the risk of your infecting others. That is why general mask use was promoted – so that those who do not show symptoms but are carriers do not transmit the disease as much.
Further, wearing a mask does not even contribute in this way unless it is also accompanied by proper use, social distancing and washing hands. Note the conclusion of the November 2020 study: “The recommendation to wear surgical masks to supplement other public health measures did not reduce the SARS-CoV-2 infection rate among wearers by more than 50% in a community with modest infection rates, some degree of social distancing, and uncommon general mask use.” That is, it did reduce the rate of transmission, and, therefore, infection, by up to 50% with the following qualifications:
a) the spread was modest rather than extreme;
b) Other protection practices – social distancing and washing hands – were in place.
The issue in NOT whether there is any “statistically significant difference between wearing a mask or not, in preventing people from contracting COVID-19, but whether there was any significant difference in the spread, and thus contracting the disease if there was a general practice of a community wearing masks. In Doctor Robert Redfield’s testimony before the U.S. Senate, he testified that the CDC had concluded, based on its studies, that masks are “the most important, powerful public health tool we have” for combating the pandemic.
The Danish research took place in “a largely unmasked area.” So why would mask-wearing – not intended or proven to prevent contracting the disease – be relevant to reducing spread when masks in the study were not a matter of common practice. “42 of the mask-wearers in the study (1.8 percent) were infected with the virus while 53 of the non-mask-wearers (2.1. percent) were infected with the virus.” But what else would one expect if the masks were not intended to prevent getting but transmitting the disease, and that could only be accomplished by generalizing mask use.
The CDC study concluded that when comparing groups of people who had tested positive versus those tested negative for the coronavirus, a much higher percent of positive cases had had close contact with someone known to have covid-19 and were also more likely recently to have eaten at a restaurant. Further, it is not sufficient to simply compare mask wearing; you have to compare how the mask is kept, how it is put on, where in society the wearer has gone, with or without themselves wearing the mask, and when and where it is taken off. Thus, if you compare two groups with an equal percentage who wear and do not wear masks, you may find no statistically interesting distinction in the incidence of the disease in the two groups unless you compare for other factors.
That is why a conclusion that masks are “not a magic bullet” is a truism but irrelevant. As the study concluded: “These findings do offer evidence about the degree of protection mask wearers can anticipate in a setting where others are not [my bold and italics] wearing masks.” Right! But so what? We already knew that since we have known for some time that masks do not prevent contracting but only in reducing transmission of the disease.
In the history of recommendations, the American CDC in its initial 10 March guidelines re mask wearing and “interim infection prevention and control recommendations,” focused on wearing surgical masks versus N95s. Both were almost equally effective in reducing transmission when adopted as a general practice. Surgical masks were recommended because N95s were in very short supply and needed by frontline medical workers. Besides, they were more expensive. The surgical mask was explicitly recommended as a mode of reducing infection only by reducing transmission. Masks are designed to contain the wearer’s droplets not to prevent the entry of droplets into an individual’s respiratory system, though it will do this, but not sufficiently to prevent contracting the disease in statistically significant numbers.
That is why the article is misleading and does not distinguish between risk of being infected versus risk of infecting in a context not of individual but collective or communal responsibility. When the issue is reduced simply to individual choice, in contrast to New Zealand, Taiwan, South Korea and Vietnam, one gets much less uptake in the practice and not nearly as significant a degree of reduction in transmission.
The reality is that the controversy alone over whether or not to wear masks increases the risk of spreading the virus. The most telling critique is, in fact, not about its utility or efficaciousness in either the reception or the distribution of the virus, but whether its symbolic value is counter-productive. The mask communicates risk and danger. It thereby enhances readiness on one side for discomfort and a concern with the health of the other. But what if the mask is not stored properly? What if it is not clean? Most importantly, what if wearing the mask heightens fear rather than inducing socially responsible behaviour? Does the fear of infection outweigh the security against spread leading to counter-productive behaviour? Alternatively, does mask wearing create a false sense of security so that we become careless in how it is worn and less vigilant in other practices like social distancing and/or washing hands? In other words, does the mask itself mask what should really be feared? Have we been taught to expect too much from wearing a mask or should we be taught much more about the affective side of wearing a mask?
One is tempted to answer yes when our gross neglect of old age homes are examined where the majority of deaths by far have taken place. Recall when masks were in short supply. Rivera, a wholly-owned subsidiary of the federal Public Sector Pension Investment Board, is one of Canada’s major, for-profit operators of long-term care and retirement homes. It commissioned a report looking into the disaster that hit their senior care facilities over the first six months of the pandemic. The report concluded:
- they were late in introducing measures to limit spread so that 97% of the residents who were listed as positive during the first wave contacted the disease before protective measures were introduced;
- As part of the initial neglect of long-term old-age care facilities, the wearing of PPE (personal protective equipment) was not initially made mandatory to protect staff and residents;
- Further, the first priority for scarce PPE was hospitals and not long-term care facilities, a very major error;
- The first priority for testing should have been for new residents entering a nursing home facility; this was not the case;
- Dr. Theresa Tam did not make wearing masks mandatory in these facilities until 13 April; the vast majority of the outbreak (almost 97%) trace back to the pre-13 April period;
- The health system prioritizes acute care over chronic care;
- Little or conflicting advice was given on how to separate infected residents from others;
- The facilities handle staffing shortages by hiring many part time workers who work at two or more facilities;
- Outdated homes had multi-ward bed and shared bathroom arrangements.
The result: over 6,000 deaths in the first wave from this source or 80% of deaths.
Have we learned our lessons? My bet, given current morbidity statistics, is that if a systematic review was currently made of senior long-term care facilities, many of the above problems would still be extant.
Much deeper and more extensive educational programs for mask wearing and an immediate and radical reform of our senior care facilities are not enough. There has to be an emphasis on the positive. It has been well known for some time that diet and exercise are important factors in contributing to immunity. Yet the system in place encourages people to become couch potatoes as gyms are closed and, as a consequence. people often veg out on comfort takeout food and unhealthy diets. I have not seen a public educational campaign to counteract these propensities.
“According to the World Health Organization, healthy foods and hydration are vital. Individuals consuming a well-balanced diet are healthier with a strong immune system and have a reduced risk of chronic illness, infectious diseases. Vitamins and minerals are vital. Vitamin B, insoluble in water, protects from infection. Vitamin C protects from flu-like symptoms. Insufficient vitamin D and vitamin E can lead to coronavirus infection. Vitamin D can be found in sunlight, and vitamin E can be found in, for example, oil, seeds, and fruits. Insufficient iron and excess iron can lead to risk. Zinc is necessary for maintaining the immune system. Food rich in protein should be the top priority because it has immune properties (immunoglobulin production) and potential antiviral activity.” How many of you have been told to change or improve your diet to counteract COVID-19 by enhancing your immune system through diet? (Cf. https://www.health.harvard.edu/staying-healthy/how-to-boost-your-immune-system) How much encouragement have you had to get out in the fresh air and exercise?
The end is in sight. In the meanwhile, decrease the level of transmission by continuing to wear masks, and wear the mask properly even if you become immune from having the disease or by getting a vaccine shot. Each of us has to be an example for collective practices. We all wear seat belts even though a small minority are in automobile accidents where seat belts protect from serious injury and death. Eat well and get exercise. In the meantime, the government must take care of the more systemic problems.
Howard – you should look up a German study published after the Danish (which displayed no benefit but certainly did not establish no benefit). it compared all the regional govts in GErmany – over 100 – which each began masking at a different time. An observational study but a good one. Jena was the first jurisdiction to implement this policy. Conclusion was that masking diminishes disease occurrence by 45-70%.
Cornelia J. Baines MD, MSc, FACE Professor Emerita, Dalla Lana Faculty of Public Health, University of Toronto.
Thank you very much. That is valuable.