Coronavirus Newsletter - Masks

General Update / Why Masks? / Masks in the World / Masks in the States / The Future

Today I'm going to talk about masks. So many times you've heard me say, "Put on the masks," but I haven't really explained why -- until now. If you'd like to learn the facts, keep on reading.

But first ...

General Update

The numbers keep rising. As the third wave begins, new case counts (on average) will shortly match the peak of mid July. Active cases are now already higher than they've ever been. Death rates are starting to rise again this week after being largely level for a few weeks.

New case counts per capita over the past week:

• The five worst states are: North Dakota, South Dakota, Montana, Wisconsin, Idaho (knocking Nebraska to 6th place)
• The five best states are: Vermont, Maine, Hawaii, New Hampshire, Oregon (knocking New York to 6th place)
• North Carolina is thinking about going back down again ... come on, my state -- you can do it!

Death counts per capita over the past week:

• The US is still in 8th place in the world. Peru is #1.
• The five worst states are: North Dakota, South Dakota, Montana, Arkansas, Kansas (knocking Missouri to 6th place)
• The five best states are: Vermont, Maine, Alaska, New York, New Hampshire (knocking Connecticut to 11th place, Oregon to 10th place, and New Jersey to 8th place)

Why Masks?

So why do so many people say we need to wear masks? And why do so many people say no? Are masks really that effective? How do they work? Are they affronts to our Constitutional rights? Let's take a closer look.

But keep in mind the main goal of epidemiology: to keep R(t) < 1.0, or in other words, create an environment where active cases are always decreasing. We don't have to be perfect in fighting the virus, but if we can get R(t) = 0.999 or lower, then the virus will die on its own ... simple math.

Now, let's go way back. I think the first time I remember seeing masks was during the 2003 SARS outbreak. I saw pictures from Asia, which showed all these people wearing masks.

And I'll be honest ... I didn't understand why they were wearing masks, and I thought back then, "Better them than us." I was glad it wasn't here in the states. It eventually infected over 8,000 people and killed 774 (almost a 10% mortality rate -- but perhaps that case count is an undercount).

And again in early 2020, this new SARS outbreak, what we call COVID-19, started again in Asia, and they put on masks. It started in the Wuhan area and quickly spread to the rest of the world. Some think that the masks worn across Asia helped them to contain it quickly. If it worked in 2003, perhaps it would work in 2020, and most Eastern Asian countries have had very low COVID-19 deaths per capita.

In contrast, Sweden, which has less than 1% mask coverage -- possibly the worst in the world -- is currently in 14th place in the world for deaths per capita.

Was it really the masks? Let's keep going.

The idea is that masks filter out the virus and allow us to breathe in virus-free air. We believe that the virus transmits primarily through "droplets" that we breathe out, and possibly through smaller "aerosols." The virus can't live very long outside of these shields of moisture. Droplets are heavy and tend to drop to the ground pretty quickly -- which is where the 6-feet separation rule comes in. Aerosols are much smaller and can linger in the air for much longer -- up to 30 minutes or more. If they are a major vehicle for virus transmission, then one can catch the virus more than 6 feet away ... and even from people who have already left the room. And aerosols are small enough to go directly into our lungs where the virus can do the most immediate damage.

To understand droplets and aerosols (microdroplets), I recommend this very information video.

The greatest takeaways from this video are:

• Aerosols can be a big issue if they do indeed transmit COVID-19 (and evidence seems to support that this does seem to exist in super spreader events).
• Plexiglass dividers may stop droplets effectively, but aerosols would have no problem floating around them.
• The biggest defense against aerosols is airflow. This implies that outside is better than inside, and the most dangerous environments would be closed rooms with no airflow.

What does this mean for masks? We know they're really good at catching droplets, but maybe not so much aerosols -- some may seep out. Here's a fun video showing more "shadowgraph" shots of people with and without masks.

If it hasn't become clear yet, you've probably picked up from that video that masks work best in holding in the virus -- more so than it does in keeping the virus out. However, in a recent outbreak of the virus in and around the White House, Senator Thom Tillis (one of the few Republicans who regularly wears masks) appears to have caught the virus even though he wore a mask to the suspect Supreme Court Nomination party. The mask didn't stop the virus, but he most likely caught it from someone not wearing a mask (my money is on Senator Lee being the main culprit). Also, masks quickly lose their effectiveness if you're going around hugging people and getting close. I hope you saw in the video that some airflow does seem to get through the mask, but doesn't travel very far.

I won't get into the different kinds of masks ... I'll let you research that on your own. But it turns out that the mask doesn't have to be perfect to get R(t) < 1.0. If you infect just one person instead of ten, then the mask is worth it. And get this ... with universal mask coverage (when almost everyone wears a mask), the effectiveness is more than doubled because the virus has to get through two filters and not just one. Check out this video discussing the math behind this idea ...

In other words ... many people wearing imperfect masks really can lead to the eventual disappearance in the virus. In fact, I think we witnessed a taste of that when mask usage in the US increased in July and new cases started coming down (toward the end of the 2nd wave).

By now, I hope you see the potential use of masks. If everyone were to wear masks ... say 85% coverage, then it really could allow us to more fully open up our economy. Maybe a few of us would still catch the virus, but with R(t) < 1.0, the virus would quickly go away, and then we'd be able to shortly take off the masks and go back to normal.

But as you're about to see, masks aren't the only factor.

Masks in the World

I'll start by pointing out some outliers. On the most part, wearing masks seems to stop the virus, and not wearing masks allows it to spread, but not in these two countries ...

Peru instituted a universal mask mandate in place early on ... wear the mask or be thrown into prison. By mid-April, they had over 80% mask coverage.

BTW, I'm getting these mask coverage estimates from the IHME COVID-19 website. It was the only place where I could find these figures for each country in the world (and every US state), but I have no idea as to their accuracy. They do seem reasonable when compared to reports I've heard from around the world. At the website, scroll down to the "Mask use" chart for each country to see % coverage throughout the year.

So, Peru had nearly perfect mask coverage, but they also have the highest deaths per capita in the world.

And on the flip side, look at New Zealand, where mask coverage never went above 17%. Yet, they've had one of the lowest deaths per capita in the world.

Does this blow up the mask theory? Not necessarily. Peru had a lot of spread due to poor sanitation issues. The people were wearing masks, but many of the poor weren't washing them, and being in close quarters made the masks practically useless.

And New Zealand? They instituted a very strict lockdown protocol ... even stricter than in the US. It brought down the virus counts quickly, but at a very steep cost. Their economy took a big hit. Perhaps if they had used universal mask wearing, they could have opened up their economy much sooner (or even avoided a lockdown all together), and keep COVID-19 counts down.

So, I thought I'd try some fun and look at some selected countries. I took the top 10 countries in case counts and added some countries I have been following over the past few months. BTW, I like to get my data from worldometers. It provides awesome data at granular levels, and I think that the numbers are actually more accurate than the numbers John Hopkins reports.

For each of these countries, I estimated the most recent 2-week R(t). And I compared the results with current mask usage as per the IHME website. And I put the numbers into Excel and added pretty colors. Let me show you the results:

Green means good in these graphs, and Red means bad. Currently, you can see that 7 of these selected countries have R(t) < 1.0, which means active cases are going down, and those countries are becoming safer. And all of those countries have 65% or more mask coverage.

And looking toward the bottom of the graph, the mask colors tend toward the orange side. Of course, you'll notice some outliers. I already mentioned Peru had been doing very poorly, but they've finally turned it around. I'm surprised to see China's mask coverage so low at 59%, but this could be because they've had very few cases these past few months. They are only recently having a small resurgence in cases. Sweden is starting their next wave, and projections are for a very bad winter for them. Spain, who has the highest mask coverage, only recently got it up to 90% in the last month and a half, and their COVID numbers started to go back down, but in the last week have started coming back up.

I have no idea why Italy's doing so poorly. They've clearly been doing something wrong these past two weeks after having done so well. They've also been slowly ramping up mask coverage over the past month.

Masks in the States

And what about in the states? Since the data existed, I decided to look at all 50 states. Sometimes the results can be screwy -- especially in the low population states, but I went ahead and did it to see if I could find similar patterns. Our states are kind of like tiny little countries, each with their own governors.

So, first I sorted my data by best R(t), and this is what it looks like ...

For the four states with R(t) < 1.0, the mask coverage is at least 61%. I'm surprised that Georgia is doing so well, but maybe that's good news that we only need 60+% coverage. There might be something else going on, though. They had been pretty high in the recent past.

But overall, I see more green and yellow than I do orange in the "Masks" column. It is interesting that the highest mask wearing states in this collection are experiencing R(t) > 1.0. A reminder that mask wearing is just one factor in the big equation ... if we're not doing contact tracing and adequate tracing and quarantining, or if we're allowing many indoor events or close contact, it could help lessen the effectiveness of masks.

Plus ... keep in mind that I only grabbed a snapshot in time, which may not provide a full accurate picture.  For example, Vermont, not on this exhibit, has 76% mask coverage, but is currently experiencing a small outbreak, bringing their R(t) to 1.5. If the masks are effective, we'll see this quickly come back down, much like what we've seen a couple of times in South Korea.

But look at this ... I decided to sort the data with worst mask wearing on top, and check it out!

The only three states to have mask coverage under 50% are all doing terribly. Also, in this exhibit, I see more red and yellow cells for two-week R(t), than I do green cells.

Georgia is the first state to appear with R(t) < 1.0, and we already talked about them.

The Future

What comes next is up to us. We struggle because we value this thing called freedom. You can't tell me what to wear on my face. Even though I understand this, I'll be honest ... it rubs me the wrong way. If I see a cheap method to save lives, I'm going to implement it, because I care about my country and I want it to succeed.

This cartoon captures the sentiment I have toward those who choose not to wear masks ...

But you know what? I think eventually, the vast majority of us are going to choose to wear masks very soon. We're almost at 70% coverage today, and it's slowly inching upward.

What's going to happen is that as deaths ramp up in combination with flu deaths starting in December and lasting through February, I think we're finally going to drop this strange Anti attitude, and we're finally going to band together and do what it takes to kill off this virus for good. How do I know this? Because I've already seen it happen.

In my state of North Carolina, a healthy 19-yr-old student died of COVID-19 complications and almost immediately, students started wearing masks. In Spain, the latest increase of mask wearing has been in response to a scary second wave.

Of course, we would all be better off if we were to comply now and save a lot of lives this winter. But we'll probably wait until we're compelled to wear a mask, and then it may already be too late. How better it would be to do it now rather than to be compelled later.

Conclusions: it appears that masks do have a level of effectiveness. They're not perfect, but again they don't have to be. Most states and countries that are succeeding have higher mask coverage. However, it appears mask wearing doesn't work alone. It seems other mitigation factors are still needed to work with mask wearing to get R(t) < 1.0, such as better contact tracing, testing, or better mitigation techniques such as holding events outside or increasing air flow inside of buildings to scatter and/or destroy aerosols.

I hope you stuck with me through this exposition ... I tried to make it fun and informative. It's not too late to work together to get R(t) < 1.0 ... to do our part to help out our country and open it up more safely. Perhaps you learned something, or at least I've given you something to think about. If you liked what you read, feel free to share with your friends. There's a whole library of truth waiting for anyone who really wants to learn it. They just have to do a little research and find it. And that knowledge will wait for those who become ready for it.