I’ve been observing the situation for the past several weeks regarding mask attire during this coronavirus outbreak. 

Note: At the time of writing this, the virus was a relatively new concern in America. Since that time, much has developed in terms of research and the understanding of transmission and the nature of this pandemic. I have included additional comments and resources at the bottom of this post.

The problem is that there are several factors in determining if or how a mask can protect you and protect those around you: 

The What: The material of the mask.  

The How: The fit, the handling and the care of your mask can help or hurt you.

The When: In what situation you should cover up?

The Who: The healthy? The vulnerable? Everyone? Who should wear one?

The “Why” is another story.  

Different countries and states have slightly different recommendations for their residents to wear masks.  COVID-19 is, of course, a respiratory infectious disease so we should consider the mechanisms of airborne particle transmissions.  

Did you know, when we exhale the small respiratory droplets evaporate in the colder, drier environment (outside our mouths) and form residual particulates called aerosol. These aerosols are less than 10 micrometers (um) in diameter and can travel across rooms depending on ventilation and wind factors.  Recent work has demonstrated that an exhalation, sneeze, and cough are made of a multi-phase turbulent gas (a puff) cloud, trapping the droplets and resisting evaporation for longer periods of time due to its warm, moist atmosphere. So, within the cloud, the particles can transmit much farther. Depending on the person’s physiology, the humidity and temperature of the environment, we are talking about a range up to 23 to 27 feet (7 to 8 m)!   These are significantly larger distances than the recommended 6 ft by the CDC and most countries.  

And the speeds on peak exhalation can reach up to 33 to 100 feet per second (10-30 m/s) 2,3 

We need to consider the “Dynamics” of Emissions when Someone Coughs, Sneezes, or even Exhales.  

Refer to the Jama news article cited below. 1 There is a fascinating video demonstrating emission distances of violent exhalations (sneezes) from healthy individuals showing carrying distances of a range that may surprise you. In this article in JAMA News, Dr. Lydia Bourouiba from MIT says:Even when maximum containment policies were enforced, the rapid international spread of COVID-19 suggests that using arbitrary droplet size cutoffs may not accurately reflect what actually occurs with respiratory emissions, possibly contributing to the ineffectiveness of some procedures used to limit the spread of respiratory disease.” 1

So, based on these numbers, she is saying our social distancing with or without masks isn’t helping to “flatten this curve” very much at all. 

To Mask, To Distance, or Both?

WHAT Type of Mask? 

The N95 Mask. These offer the best protection when fitted and handled properly. They are designed to filter out droplets as small as 0.3 um. For airborne particles to reach deep into the lung alveoli (where coronavirus does its damage), they need to be less than 10um in diameter (aerosol). 4 

We all know the N95’s are in short supply and we are encouraged to save them for medical and front line personnel.  So, the other options could be better than nothing. (Or not? Read the update at the bottom of this post.)

Large droplets (larger than 10um in diameter) are the ones you can see in the air generated by a cough or sneeze. These are usually trapped in the nasopharynx (nose and throat region) and can get as far as the bronchi in the upper lung region. Therefore the following two masks can help block the large droplets.

The Surgical Mask. These offer protection from the large droplets and can filter up to 80% of small particles. Keep in mind they do not fit snugly around the face and should be disposed after each use.

The Homemade Mask. Self-made masks need to be made from dense fabric, multilayered, and sized for enough tension to fit snugly behind the ears sufficiently and allow comfortable breathing. Pay attention to the weave and spacing between fabric fibers. Small droplets (<10um) may easily transmit through, however, these masks really just offer protection from large droplets.  Make sure your fabric does not contain any harmful chemicals and use a layer of cotton on both sides. These should be washed after each use.

The N95 Mask

HOW to wear it. 

It should fit firmly and snugly over the bridge of your nose and around the mouth. My concern with masks, especially homemade ones is the gapping I see around the sides which invites particle transmission as well as the subconscious tendency for the wearer to keep adjusting it. Touching their faces and the masks increase transmission risk. 

Applying and removing it should be done without touching the exterior surface.  Ideally, it should be stored in a secure container. N95 masks are meant to be disposed of after use, however, due to our shortage, you can preserve them securely for multiple-day usage. 

Washing reusable masks, such as homemade ones should be done in very hot water and hung outside in the hot sun to dry or in the dryer.  Remember to wash your hands after handling the mask (and before you touch it). 

If you are going to wear a mask, be extremely careful when handling it, meaning keep everything sterile. Don’t throw it down on your desk when you need a “breather”. Don’t touch the face-covering without washing your hands before you put it on and take it off. Oh, and don’t adjust it or touch it for any reason once it’s on your face unless you wash your hands first. How many people you know are really being this careful? I’m seeing them dangling down peoples’ faces during a break, large gaps out the sides of the masks, and some are even pulled down to expose their noses to air. Frustrated baristas moving them around in the drive-thru lines. I wonder how their brain function is with this type of oxygen restriction.

The ISSUES around the mask.

  1. Wearing a mask can put you at more risk for contamination. It’s quite possible to unconsciously touch your mask, contaminating your hands then touch your face!  Mask usage is not an exclusive practice. If you are not going to keep every mechanism of your contact with surfaces, other people, and your face completely safeguarded, masks will have low efficiency in protecting you and others. I see the misery in restaurant staff and bankers breaking sweats and periodically yanking their masks under their chins out of frustration. I say to myself, ‘why bother wearing one then?’
    But they have to. It could be mandated by their corporate headquarters.

  2. Wearing a mask can lower your atmospheric oxygen levels (between the mask and your face) creating a dangerous state of hypoxia. This is particularly dangerous for those with a history of breathing disorders, asthma, and the elderly. Did you know OSHA (Occupational Safety and Health Administration) sets the safe levels of oxygen in the atmosphere at your workplace? They consider anything below 19.5% oxygen by volume an oxygen-deficient atmosphere. Consider the air you are breathing under your mask when some of your oxygen is displaced by other gases such as carbon dioxide and trapped in that small space.

  3. On their website, OSHA states cloth and surgical masks “do not protect the wearer against airborne transmissible infectious agents due to loose fit and lack of seal or inadequate filtration.” They also state cloth masks “may be used by almost any worker, although those who have trouble breathing or are otherwise unable to put on or remove a mask without assistance should not wear one.”

WHEN to wear it. 

If any question can stir a debate this one will. Some of you reading this could be asking IF you should wear a mask. I’m not telling you if you should or shouldn’t wear a mask. That’s up to you. But I will share my own insights based on my state’s recommendation and what I do professionally and personally. I suggest checking with your own local guidelines or those of the CDC.  I personally do not wear a mask when I’m outside for whatever reason, whether it’s running errands, exercising, or walking my dog in the park. I believe you need the fresh air AND you need to be exposed to things to exercise your immune system. Building antibodies (your natural immunity) to this virus will not happen unless you give it the opportunity to do so.

WHO should wear a mask.  

Your personal health status is a determining factor as well as that of those around you.  

Are you vulnerable to the virus? Should you wear it to protect yourself? Or others? Or both? 

A healthy non-elderly individual (one with no chronic disease, exercises a longstanding healthy lifestyle, who is a non-smoker and has a good track record of overcoming colds and flues quickly) should wear masks when working with or near vulnerable individuals to protect them.  This of course, includes medical personnel. 

Individuals with questionable health status who get sick easily or those advised by their medical doctor to wear one, should follow that recommendation.

Unless you are in total isolated lockdown (or you seriously live in a bubble), you cannot control who comes within 6 ft of you. You can turn a corner in a grocery aisle and right into the path of a non-masked carrier or someone who is positive but doesn’t know it because he/she hasn’t been tested yet. How do you know if he or she is a carrier of this or any virus?

COVID OR NO COVID…

How do you know if this person is in denial or has an undiagnosed condition, rendering them more susceptible to even the flu? And this person ventured out right into your 6-foot danger zone range before you can dodge out of the way.
So, can you really control your environment? With or without a virus outbreak?

And, isn’t there always some kind of virus circulating? So, this can happen anytime and anywhere, not just during this coronavirus pandemic.

We do not have complete control of who we come in contact with, and who they have come in contact with recently.

The Anxiety of the Maskdemic

The “maskdemic” has heightened the anxiety among the following types of individuals:

A. Those panicking because they feel they really must wear one but can’t find any, or enough masks for their families. 
 
B.  Those feeling they may get someone else sick if they don’t wear a mask.

C. Feeling criticized or fear of being reported by someone else for not wearing one. 

D.  Those who can’t breathe efficiently under a mask. Lowered oxygen supply triggers stress hormone, cortisol which lowers your immune system.

The Bottom Line

There is no conclusive evidence that a mask will make a big difference. They can put you at risk for all sorts of other health problems; some potentially fatal.
 We do not have complete control of who we come in contact with. And keep in mind, a mask will not give you complete protection. 

Nothing is going to fully protect you from any bug or virus. The strategy is to build healthy lifestyle practices and do everything within your power to improve your function so when (not if) you come into contact with ANY virus or other types of bugs, you are in a better position to process it and build those antibodies. Do not be afraid of the virus.

What are your thoughts? Feel free to comment below.  

I welcome a healthy discussion on the Mask Confusion. 

Dr. Melanie

REFERENCES:

1.https://jamanetwork.com/journals/jama/fullarticle/2763852 

2. Bourouiba  L, Dehandshoewoercker  E, Bush  JWM.  Violent respiratory events: on coughing and sneezing.  J Fluid Mech. 2014;745:537-563.Google ScholarCrossref 

3 Bourouiba  L.  Images in clinical medicine: a sneeze.  N Engl J Med. 2016;375(8):e15.PubMedGoogle Scholar 

4. https://medium.com/@Cancerwarrior/covid-19-why-we-should-all-wear-masks-there-is-new-scientific-rationale-280e08ceee71 

5. OSHA https://www.osha.gov/SLTC/covid-19/covid-19-faq.html

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