Updated August 11, 2020
COVID-19 continues to rear its ugly head. The COVID Tracking Project states that as of August 11, 2020, there are 48,612 people hospitalized with COVID-19 in the United States.1 ICUs are becoming overwhelmed in parts of the southern US 2,3,4 and California.5 Because COVID-19 is a novel (new) coronavirus that acts in a very peculiar manner, medical researchers were initially baffled and even at odds as to exactly how it was transmitted. Unfortunately, the initial confusion about transmission coupled with the shock of a shortage of N95 masks and Personal Protective Equipment for healthcare workers resulted in a lot of mixed messaging to the general public, which then resulted in rampant conspiracy theories. People are understandably upset, confused and distrustful at this point.
We Now Know that COVID-19 Is Airborne
Because new evidence has shown that COVID-19 is indeed airborne, i.e., spreads through microscopic aerosol droplets,6 science tells us that mask wearing and social distancing are paramount in slowing the spread of the virus.7,8,9 Universal masking combined with social distancing and good hand hygiene can also help lessen the risk for transmission of COVID-19 during times when social distancing is not possible, or during phases in which social distancing measures have become relaxed.10
Aerosol Cough Droplets
The following video simulation from Live Science shows exactly how masks dramatically reduce the distance aerosol droplets travel from coughing.
“Researchers at Florida Atlantic University's College of Engineering and Computer Science created these simulated coughs, which appear as a glowing green vapor flowing from a mannequin's mouth. The researchers then placed several types of masks on the head of a mannequin to test their effectiveness at blocking these 'coughs.' The unprotected heavy cough not only lingered in the air, but they found that with no mask covering, the simulated coughs traveled up to 12 feet. They also tested simulations of a heavy cough aided by a downwind breeze and a heavy cough in a cooler counter breeze (sped up 4x). Cloth face masks (non-stitch pleated fabric face masks) were able to capture and reduce the spread of cough droplets to varying degrees.11
With a single-layer bandana mask, droplets leaked through the mask material and traveled more than 3.5 feet.
With a folded cotton handkerchief, droplets traveled a little over a foot.12
A non-sterile cone-style mask also worked well, with droplets traveling about 8 inches from the face.13
A homemade stitched cotton mask was the most effective at reducing droplet spread. With this mask, droplets traveled only 2.5 inches from the face."14
Seeing this visualization will hopefully convey the importance of wearing a mask and social distancing.15
Shared Air Is the Most Dangerous Air
We now know that COVID-19 is not only transmitted by coughing and/or sneezing, but also through microscopic aerosol droplets that are emitted while singing or talking. Shared air in an enclosed space where people are closely talking or singing makes for a highly contagious situation. Aerosolization of the virus happens even just from normal breathing.16 In March, a group of 61 people in Skagit County, Washington, got together for choir practice for 2.5 hours. There was one asymptomatic person present. From that rehearsal, 32 of the choir members contracted COVID-19, 20 people had probable secondary cases, three had to be hospitalized, and two people died.17 Unfortunately, talking closely together, laughing or singing18 is a recipe for a high amount of viral transmission, and thus the extreme importance of wearing a mask when attending church, going to a salon, or any place that has shared air.19
Dr. Malcolm Butler of the Chelan-Douglas Health District, gives an excellent explanation of what happens with shared air:
“COVID-19 seems to fit the 'eighty-twenty rule' of biology. 80% of the disease is caused by 20% of the transmission. Here’s how that 20% works with this virus. Imagine a keyhole, and only a specific shape can fit through that hole. The COVID-19 virus has a specific shape and must land on a specific keyhole to pass through the lining of your nose, mouth, or lungs and into your bloodstream. These keyholes are spread out randomly. So, it takes multiple hits for a virus to infect you. If you are peppered with enough virus, eventually one will land on the keyhole, pass through and cause an infection. The total volume of virus that peppers your system is the key. How much time you are in contact with an infected person and the time sharing their air determines if you will contract COVID-19.”20
What Universal Masking Can Do
Reduce Transmission of COVID-19 and Save Lives
“High levels of mask wearing could reduce forecasted deaths by over 45,000. … we all have come to recognize, wearing masks can substantially reduce transmission of the virus,” said IHME (Institute for Health Metrics and Evaluation) Director, Dr. Christopher Murray.21 A study of mandated public mask wearing involving 15 states plus DC between April 8 and May 15, “provides evidence that states in the US mandating use of face masks in public had a greater decline in daily COVID-19 growth rates after issuing these mandates compared to states that did not issue mandates.”22 19 randomized controlled trials – 8 in community settings, 6 in healthcare settings and 5 as control settings showed that “community mask use by well people could be beneficial for COVID-19, where transmission may be pre-symptomatic.” 23
Using trends and procedures from Italy, China and New York City, a team of researchers led by Texas A&M University Professor, Renyi Zhang, examined the chances of contracting COVID-19 and how the virus quickly spread from one person to another. Professor Zhang said,
“By analyzing the pandemic trends without face-covering using the statistical method and by projecting the trend, we calculated that over 66,000 infections were prevented by using a face mask in little over a month in New York City. We conclude that wearing a face mask in public corresponds to the most effective means to prevent inter-human transmission. This inexpensive practice, in conjunction with social distancing and other procedures, is the most likely opportunity to stop the COVID-19 pandemic.”24
Open the Economy Sooner
Because lock-downs are unsustainable, and are extremely harmful to the economy and to people's mental health and well being,25 universal mask wearing is imperative in order to open the economy sooner. 26,27,28 No one wants a re-emergence of COVID-19. Until (and if) there is a safe and effective vaccine, universal masking can lower consumer anxiety and eliminate the need for repeated partial lock-downs.29
COVID-19 Is Not a Conspiracy
Just as it is difficult for people who have not had a severe case of COVID-19 and don't know anyone who has been hospitalized or died from the virus to believe or understand the gravity of the virus—it is equally difficult for those of us who have experienced it on the front lines and for those who have survived a severe case of COVID-19 to understand those who refuse to believe it! Dr. Michael Saag, who works on the front lines of COVID-19 in Alabama, contracted the virus, became severely ill, and thankfully, survived. When asked how he handles seeing people milling around in public places without masks and not social distancing, he says of the profound disconnection, “It’s a mixture of emotions, from anger to being demoralized to bewilderment to frustration.”30
Traveling nurses certainly understand that COVID-19 is no conspiracy! Nurse, Olumide Peter Kolade, traveled from California to New York to assist for over three months on the front lines of what he described as a “war zone,” wherein they would “wake up with fear and go to bed with fear.” When his friends at home and others made comments about COVID-19 being an “agenda driven conspiracy theory,” Olumide said, “I just felt like it was an insult to anybody that’s putting their life at risk just to provide care."31
The COVID-19 Death Toll Is Not a Conspiracy
Sadly, apparently nearly a third of Americans believe the COVID-19 death toll is a “conspiracy theory.”32 The reality of the COVID-19 death toll is that it may actually be nearly 30% higher than reported. In January, February and March of 2020, there were 122,300 excess deaths in the United states that occurred before COVID-19 diagnostic testing was available. A JAMA study published on July 1, states: “Excess deaths provide an estimate of the full COVID-19 burden and indicate that official tallies likely undercount deaths due to the virus. The mortality burden and the completeness of the tallies vary markedly between states.”33 In his video, "Are COVID Deaths Over-Reported?" Dr. Zubin Damania indicated that the Prevalence data from March 1 through the end of May using antibodies shows there has been a great deal more infection (probably even ten times or more) in the community than what we've been able to test for.34 Dr. Jose Morey, who works on the front lines of the pandemic in eastern Virginia, said that the death toll is, “largely being underestimated, as many countries do not have the capability to perform such wide-scale testing...even here in the United States, testing has been poor,”35 Also, there are people who die at home, and people who die quickly upon entering the emergency room. In cases that are not straight forward, a main challenge in reporting has been, “Who died of COVID-19 versus who died with COVID-19,” said Dr. Jeremy Faust, an ER doctor at Brigham and Women’s Hospital in Massachusetts. Another issue in reporting is that there are a number of healthy young people (with no pre-existing conditions) who have died of strokes and heart attacks, who then tested positive for COVID-19.36
Why Are Some Officials Asking People to Wear Masks at Home?
The reason people in some COVID-19 hot spots are being asked to wear masks at home is to avoid in-home transmission currently happening in multi-generational homes. In multi-generational homes, the younger members of the family are coming and going to and from work or the store, thus putting more vulnerable family members at risk. 37,38
Please Wear a Mask—It's a Small Thing to Ask
Please take COVID-19 seriously. As a doctor who works on the front lines of this pandemic, I implore you, wear a mask! It really is a small thing to ask.
The Doctor Emi Team
1. The COVID Tracking Project. The Atlantic Monthly Group. US Historial Data. Updated Daily. https://covidtracking.com/data/us-daily#reach-skip-nav
2. WXXV News Staff (Mississippi). ICU beds fill up as COVID-19 cases surge across the state. July 21, 2020. https://www.wxxv25.com/2020/07/21/icu-beds-fill-covid-19-cases-surge-across-state/
3. Chavez N, Jones K. A Texas hospital overwhelmed by the coronavirus may send some patients home to die. CNN. Updated 12:02 AM ET, Sat July 25, 2020. https://www.cnn.com/2020/07/24/us/texas-starr-county-hospital-coronavirus/index.html
4. Tallahassee Reports Staff. July 28: Tracking Florida COVID-19 Cases, Hospitalizations, and Fatalities. July 24, 2020. https://tallahasseereports.com/2020/07/24/two-charts-show-positive-trends-for-florida-in-coronavirus-battle/
6. Ries J. Experts Say COVID-19 Is Airborne: Here’s How You Can Stay Safe. Healthline. July 7, 2020. https://www.healthline.com/health-news/experts-say-covid-19-is-airborne-heres-how-you-can-stay-safe
7. Tomiyoshi T. UC Davis experts: Science says wearing masks and social distancing slow COVID-19 (VIDEO). UCDavid Health Newsroom. July 6, 2020. https://health.ucdavis.edu/health-news/newsroom/uc-davis-experts-science-says-wearing-masks-and-social-distancing-slow-covid-19/2020/07
9. Vincent Chi-Chung Cheng, Shuk-Ching Wong, Vivien Wai-Man Chuang, et al. The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2. Journal of Infection. Volume 81, Issue 1, July 2020, Pages 107-114. https://doi.org/10.1016/j.jinf.2020.04.024
10. About Cloth Face Coverings. CDC. Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Last Updated June 28, 2020.
11. Best Masks to Keep COVID-19 to Yourself. Live Science Video. Researchers at Florida Atlantic University's College of Engineering and Computer Science made visualizations to show exactly how face masks stop COVID-19 transmission. https://www.youtube.com/watch?v=RkB0k81oNiI
12. Florida Atlantic University, College of Engineering and Computer Science. Efficacy of Facemasks - Folded Cotton Handkerchief (IMAGE). EurekAlert! American Association for the Advancement of Science (AAAS) https://www.eurekalert.org/multimedia/pub/236090.php?from=469060
13. Florida Atlantic University, College of Engineering and Computer Science.Efficacy of Facemasks - Cone-style Facemask (IMAGE). EurekAlert! American Association for the Advancement of Science (AAAS) https://www.eurekalert.org/multimedia/pub/236091.php?from=469060
14. Florida Atlantic University, College of Engineering and Computer Science. Efficacy of Facemasks - Stitched Quilted Cotton Mask (IMAGE). EurekAlert! American Association for the Advancement of Science (AAAS) https://www.eurekalert.org/multimedia/pub/236089.php?from=469060
15. FLORIDA ATLANTIC UNIVERSITY. Seeing is believing: Effectiveness of facemasks. EurekAlert! American Association for the Advancement of Science (AAAS). June 30, 2020. https://www.eurekalert.org/pub_releases/2020-06/fau-sib062920.php
16. Cohen E, Senior Medical Correspondent. Experts tell White House coronavirus can spread through talking or even just breathing. CNN. Updated April 4, 2020. https://www.cnn.com/2020/04/02/health/aerosol-coronavirus-spread-white-house-letter/index.html
17. Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — Skagit County, Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:606–610. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e6external icon.
18. Asadi, S., Wexler, A.S., Cappa, C.D. et al. Aerosol emission and superemission during human speech increase with voice loudness. Sci Rep 9, 2348 (2019). https://doi.org/10.1038/s41598-019-38808-z
19. McCrimmon K K. COVID-19 and airborne aerosols: What you need to know. UCHealth. July 9, 2020.
20. Butler M. Opinion | Dr. Malcolm Butler: Why you should wear a mask (It’s the air you share). The Wenatchee World. June 25, 2020. https://www.wenatcheeworld.com/news/coronavirus/opinion-dr-malcolm-butler-why-you-should-wear-a-mask-it-s-the-air-you/article_998e2394-b5a1-11ea-b609-27e947f1e3fe.html
21. New IHME Forecasts Show More Than 200,000 US Deaths by November 1. Institute for Health Metrics and Evaluation (IHME). July 7, 2020. http://www.healthdata.org/news-release/new-ihme-forecasts-show-more-200000-us-deaths-november-1
22. Wyu W, Wehby G. Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US. June 16. 2020. https://doi.org/10.1377/hlthaff.2020.00818
23. MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients. Int J Nurs Stud. 2020;108:103629. doi:10.1016/j.ijnurstu.2020.103629
24. Texas A&M University. "Face masks critical in preventing spread of COVID-19: Study found that wearing a face mask stopped person-to-person spread of the virus." ScienceDaily. ScienceDaily, 12 June 2020. .
25. Esposito S, Principi N, Leung CC, Migliori GB. Universal use of face masks for success against COVID-19: evidence and implications for prevention policies. Eur Respir J. 2020;55(6):2001260. Published 2020 Jun 18. doi:10.1183/13993003.01260-2020
26. Drillinger M. Wearing a Mask Can Help Us Get Out of Lockdown Safely. Healthline. June 7, 2020. https://www.healthline.com/health-news/wearing-a-mask-can-help-us-get-out-of-lockdown-safely
27. Berger M, Sonmez F, Denham H, et al. Coronavirus could be ‘under control’ in weeks if everyone wore masks, CDC director says. The Washington Post. July 14, 2020. https://www.washingtonpost.com/nation/2020/07/14/coronavirus-live-updates-us/
28. Yan H. Top health officials have changed their minds about face mask guidance -- but for good reason. Clayton New-Daily. Jul 19, 2020. https://www.news-daily.com/features/health/top-health-officials-have-changed-their-minds-about-face-mask-guidance----but/article_d20e14cc-d4e7-54bb-a7d0-3039cfe2c313.html
29. Polyakova M, Andrews J, Luby S, Goldhaber-Fiebert J. Can masks help with reopening the economy? April 2020. Stanford Institute for Economic Policy Research (SIEPR). https://siepr.stanford.edu/research/publications/can-masks-help-reopening-economy
30. Reeves J. Doctor who survived COVID-19 bewildered by public disregard. AP News. July 18, 2020. https://apnews.com/d3f548ec32bf6b7dd198f26c90b8cff2
31. Cosgrove J. Traveling nurses say conspiracies around coronavirus are 'an insult to anybody that's putting their life at risk to just to provide care.' July 24, 2020. https://www.yahoo.com/lifestyle/nurses-say-conspiracies-around-coronavirus-are-an-insult-205018852.html
32. Durkee A. Nearly A Third Of Americans Believe Covid-19 Death Toll Conspiracy Theory. Forbes. July 21, 2020. https://www.forbes.com/sites/alisondurkee/2020/07/21/nearly-a-third-of-americans-believe-covid-19-death-toll-conspiracy-theory/#161d234740ab
33. Weinberger D, Chen J, Cohen T, et al. Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020. JAMA Intern Med. Published online July 1, 2020. doi:10.1001/jamainternmed.2020.3391
35. Krans B. 25% of People Believe Unproven Conspiracy Theories About COVID-19. Healthline. June 12, 2020. https://www.healthline.com/health-news/people-believe-unproven-conspiracy-theories-about-covid-19
36. Pappas S. How COVID-19 Deaths Are Counted. Scientific American. May 19, 2020. https://www.scientificamerican.com/article/how-covid-19-deaths-are-counted1/
37. Baker S. Miami's mayor asks people to wear face masks in their own homes to reduce the spread of coronavirus within families. MSN News. July 24, 2020. https://www.msn.com/en-us/news/us/miami-s-mayor-asks-people-to-wear-face-masks-in-their-own-homes-to-reduce-the-spread-of-coronavirus-within-families/ar-BB178AXh
38. Ellis R. Face Masks at Home Reduce COVID-19 Risk, Study Says. WebMD. May 28, 2020. https://www.webmd.com/lung/news/20200528/face-masks-at-home-reduce-covid-19-risk-study-says