Masks. Masks. Masks... Which one Should I pick? N95, 3-Ply, Cloth
“Behind every mask, there is a face and behind that a story.” This quote was likely meant, by author Marty Rubin, to be that of inspiration and understanding. Individuals often wear their own mask of sorts to the general population, and behind the facade-like mask is the real face and the real story. I found this quote to be profound in today’s climate, as there are those equipped with literal masks and those without. Both groups, however, do have their own stories and concerns for choosing their paths, whether they are legitimate or not.
We are currently in the age of information. There is access to everything you could possibly wish to know, with the stroke of a finger. Recently, however, the ability to publish whatever one would like, combined with difficulty in parsing fact from opinion has led rather to an age of disinformation. One such rift has occurred with the general population and the wearing of masks during this pandemic. There have been countless arguments in social media, on television and in person concerning the efficacy and danger involved with mask wearing. Stats, figures and opinion have been bandied about often without sources. When switching from one news station to the next, the gamut is run. Either mask wearing is the saving grace to our society or they are slowly killing us and are an insult to our liberties. One presidential candidate swears by them, while the current President does not wear them at his rallies. For the average American, it is a near impossibility to know what to believe. So what does the data tell us?
The three main types of masks in use are the mass produced, often self made cloth masks, the surgical masks and N 95 masks. They all have various degrees of efficacy and different manners in which each should be employed. In the following paragraphs, statistics with studies and “expert” opinions will be linked. Where I inject my own opinion (Emergency Room physician, informed but non expert) I will designate. One of the difficult portions of gathering data for the use of masks against COVID-19 is that there has not been much of a precedence from which to glean information. Much of this data is currently rolling in, which causes plenty of policy changes and, unfortunately, has resulted in further confusion.
I think it may be best to start with the individually made, reusable cloth masks that have been at the center of much attention and ire to many people. I feel the need here to state that I will always try my best to keep political leans completely out of this. This is a medical issue. It has always been a medical issue. Somehow it has resulted in somewhat of a political platform, which I believe never should have occurred and the blame is bipartisan. You may have seen certain facebook quotes stating “cloth masks filter nothing,” “cloth masks trap carbon dioxide,” “moisture of the cloth masks cause mildew” and “cloth masks are worse than no masks.” First, I’d like to examine these statements with some critical thinking before diving into what the data shows.
Its an odd paradox that it ‘cannot filter anything’, while at the same time, trap carbon dioxide. The virus is considered a “large virus” measuring close to 120 nm. This is compared to the carbon dioxide molecule that is 232 picometers and oxygen that is 152 picometers. Essentially the viral particle is on a scale of 1000 times bigger than either of these that it supposedly traps (carbon dioxide) or doesn’t allow in (oxygen). So it is odd to proclaim that it can simultaneously block carbon dioxide from escaping while also being unable to filter the exhaled viral particles. I’ll go into this part further later, however it has been shown that coughing and sneezing is what produces that most viral particles, which is what will saturate the masks causing this moisture in the mildew hypothesis. To this I say, if it is blocking these bodily events well enough to cause a moisture build up, then isn’t it blocking the release of these particulates from entering the immediate atmosphere? Sure its not anywhere near a perfect seal, but to me that implies it is far better than stating “cloth masks are worse than no masks,” even if its only blocking a portion that is produced. Finally, when I have a solid work out, my gym clothes most assuredly become quite moist. If I let them sit in a hamper for a number of days, they will definitely become mildewy and start to smell. But I wash them. Wash your mask. Mildew problem solved.
Now to the data. One of the better medical institutions, Stanford, performed a study that demonstrated when two individuals wear these masks, particulates can travel up to 5 feet. If unmasked, it is closer to 30 feet. It is postulated that these viral particles can hang around in the air for upwards to 30 hours in the right settings. UCSF published a study that demonstrated when the average person spoke, they emitted around 20-500 micrometers of particulates (this is significantly more in other studies when examining coughing and sneezing). When a simple damp rag was held to the individual’s mouth, the particulates dispersed during talking was reduced nearly to zero. This is enough for me to conclude that cloth masks, though absolutely imperfect in blocking the passage of the virus, is most assuredly better than nothing. The WHO have published some guidelines as to what they feel is the appropriate cloth mask. I will not bore you with all the specifics, but it recommends 3 layers, the outermost being somewhat water resistant, the innermost having some sort of wicking material to draw moisture from the face and the middle should be comprised of some sort of polypropylene material or a 3 ply type of tissue paper. Furthermore, it was found that some of these cloth masks were able to be just as effective as surgical masks when applying a negative charge to them (static build up when rubbing the material with a latex glove prior to use). So mask makers of the world, here’s the bar. Reach for it.
On to the surgical masks. On the surface, these are thin, rather flimsy appearing material that have difficulty fully adhering to anyone’s face perfectly. As someone with an oversized head, I can speak to breaking the bungee on these fairly frequently. So I get it, how does something like this really help us? I’ve seen copy/paste facebook posts about these as well. Apparently there was an article from OSHA that proclaimed these masks were only “made for sterile environments,” “they clog easily”, and when you’re “exposed to COVID, it will get trapped inside” which will then “cause you to be a virus dispenser.” The last part of this is pretty ridiculous, but more about that in a minute.
First, lets examine the OSHA (essentially our leading expert on safety) article that these facts were supposedly a direct quote from. From their actual website, if you comb through the portion in question (https://www.osha.gov/covid-19-faq.html), the only detrimental statement written against surgical masks is the following: “Will not protect the wearer against airborne transmissible infectious agents due to loose fit and lack of seal.” Reading this, without fully comprehending its meaning, as well as not reading further on the website, appears fairly damning as COVID-19 is most assuredly an airborne transmissible virus. This, however, basically means that if a healthcare worker was to walk into a patient's room that has tuberculosis or COVID 19, for example, a simple surgical mask isn’t going to cut it for protection. Reading further, the website states “Are used to protect workers against splashes or sprays,” which essentially is the direct inoculation from coughs and sneezes. This is followed by “worn to contain a wearer’s respiratory droplets'' and “should be placed on sick individuals to prevent transmission of respiratory illnesses.” If you can take away anything from this long diatribe its this: The masks block YOUR OWN junk from being transmitted to OTHER PEOPLE. This is it everyone. The masks you wear are not necessarily for your own protection, rather the protection of others FROM YOU. Point OSHA.
Jumping back now to the other odd quotes from this lengthy facebook post. I cannot find any evidence of “clogging easily” because they’re only made for “sterile environments” any where in the OSHA article. I’m guessing this was the author’s postulate about using these types of masks in non sterile areas (i.e. the real world - no not the show). This is where these copy pastes are dangerous. This is not a fact. This is an opinion. OSHA makes no mention of clogging masks or the duration of use of the mask before it loses its quality. The popular facebook post surmised 20-30 minutes in a non sterile area, however I cannot find any evidence of this. Finally, having Covid trapped in your mask causing you to become a viral dispenser is such an odd statement. Again, this is opinion and not science based. I’m not entirely sure what it means to be a viral dispenser. If the virus did happen to bypass the mask and inoculate you, it takes 5-14 days for you to become even able to transmit to others. I don’t know if the author of the post believes that if you happen to get some viral particulates behind your mask (which you then clearly will breath in) will somehow multiply exponentially enough to the point that your mask is somehow a viral dispenser. Wish I could ask the person responsible for the post. For now… No idea.
I will touch on N-95s but, for the general population, I do feel this is less important, as the vast majority of these SHOULD ONLY be used in the healthcare industry, most importantly in the hospitals. Purposefully beating a dead horse, the author of this long facebook post incorrectly generalizes that N-95 masks have exhale valves which, if you are sick and wearing an n-95 mask, you essentially “spray” the virus everywhere through the valve. While this is true, the medical grade N-95 masks do not generally have these exhale valves (they’re more common in the construction variety). Furthermore, if everyone else is wearing masks, doesn’t that block the exhalation anyways? Moving on, these are the masks that we use when in very close contact with those we know, or assume, have COVID-19 or when we have to be in the same room as a COVID-19 patient undergoing an aerolizing procedure (nebulizers, intubations, etc). If you’re in your normal life, adequately social distancing, you probably do not need these.
Now onto the data of masks in general. The United States has been a lovely case study for the use of masks, as it was left to the states, or, in select states, the cities themselves to enact mandatory mask ordinates. A simple stat was produced by PBS that delineated states that did and did not mandate mask wearing. In states that did not, cases have risen 84% while in areas where masks were mandated, they have decreased 25%. Now, I do need to point out a caveat here that likely the states that were hit hardest early (MI, NY, NJ) had committed to mask wearing and there really was only one way to go (down). As opposed to a state such as my home, Arizona, where we didn’t have much of an initial outbreak, so masks seemed to be a second or even third thought for most citizens. So let us dive a bit further into areas that implemented mask wearing.
One study I found (please see below for all the sources I used), examined 15 states and DC to determine the growth rates before and after mask mandates for the COVID-19 pandemic. This is huge. This is actual data of our actual pandemic. This isn’t projection. This isn’t using influenza data (an entirely different virus that behaves much differently). After just 5 days of mask wearing, the spread of the virus had decreased almost 1% across the board. Granted, that doesn’t on the surface seem to be a huge amount and may even disappoint many. I, however, feel that a) in terms of exponential growth under which this virus operates, anything helps and b) since we have established mask wearing does not cause harm, 0% harm vs 1% gain seems like a no brainer. This trend of decreasing spread in the mask wearing states became more significant over the additional three weeks which they were observed.
Now for a few predictive model studies. I generally hold these with less regard than cold hard facts, but I still think its helpful in shaping the manner in which we think about masks. Many states have been shut down. This clearly hurts the economy, can ruin many small businesses and in turn, causes financial ruin. In one predictive model, researchers found that if we could achieve greater than 80% mask wearing, this would be even more affective than shut downs and mandated stay home orders. I can’t speak to the data here, but for everyone who hates not going to the movie theatres, gyms or their favorite restaurant, here’s your chance to get back on track to returning. One study from the Institute of Health Metrics concluded that by Oct 1st if everyone wore masks in public, as many as 33,000 lives could be saved. To me, that seems like an awfully low cost to potentially save a great deal of people.
All right so masks aren’t going anywhere. I get it. They are annoying to wear, they are often uncomfortable, they break easily and they are far from any degree of fashion. But let’s examine our stories as to why we choose to wear or not wear. Let’s be sure to look up our facts about them before promoting further information or disinformation. Let’s do better. These masks, in many studies, do show plenty of benefit and there is little to no actually factual information demonstrating that they do any harm. The more people that don masks, the shorter we, as a society, have to wear them. They are absolutely far from perfect, and you may even still get ill wearing a mask, but I implore you to do your best in doing your part to help us back onto the right path and reduce the spread of COVID-19.
I am Brandon Lawrence, MD. I am an Emergency Medicine physician in Phoenix, Arizona. I am passionate about jump starting our society in as safe a way as possible in light of the ongoing pandemic. This is achieved by ongoing discussion, research and trying to reach as many people as possible. I enjoy creative writing, endurance athletics and spending time with my awesome family. Just getting started with the 21st century, follow me on twitter at Lawre237.
