Are we Done with Masks? Experts Weigh In

(film reel clattering) - [Sandy] Welcome to today's Ethnic Media Services Zoom news briefing.

I'm Sandy Close.

Our topic today is masks.

[background music] Are we done with them?

Some experts say masks continue to be an effective tool in containing the spread of COVID-19 infections.

Other experts state that vaccines are the best prevention against infection and that masks are unnecessary.

A recently released study from Cochrane Collaborative, an independent nonprofit, highly respected medical research organization that does rigorous reviews of issues of the literature dealing with timely issues, casts doubts on the efficacy of N95 masks and P2 respirators as effective safeguards against COVID infections.

[background music fades] The researchers state that wearing a mask may make little to no difference in how many people actually caught a flu-like illness, a COVID-like illness according to data from 10 studies they reviewed.

Our speakers this week will debate this continuing and contentious issue and provide advice for keeping children safe amid the ongoing health concerns we face.

Now, we begin and we start with Dr. William Schaffner who'll discuss the findings of the Cochrane study, add his own analysis of the conclusions and his recommendations on whether or not to continue masking.

Welcome, Dr. Schaffner.

- Hello, Sandy!

It's good to be with you, for sure.

- And, it's great to see you take off your mask (chuckles) because it's so much easier to hear you without it!

- Of course, of course.

The exact utility of masks has received a great deal of attention during COVID.

And, as you said, Sandy, the COVID collaboration-- excuse me!

(laughs) The Cochrane Collaboration, named originally after a British epidemiologist by the name of Archie Cochrane, is very rigorous and they do survey the world's medical literature on topics that are very timely and are under discussion.

They are extremely meticulous, almost prissy, in which studies they will actually include for review.

So, I go through all of this to let you know that although there are dozens of studies- some large, some small, some better, some not so well designed in the literature- the Cochrane Collaboration finally decided only a very small handful of studies were sufficiently rigorous, and even they were not perfect, in order to review.

And, furthermore, most of these studies dealt not with COVID, but with influenza.

So, here we are.

We have-- and our best effort to indicate exactly how effective masks are, not in the healthcare, but in the community environment.

And, the Cochrane Collaboration, for all the reasons I've said, [audio distorts] comes out with a very conservative, cautious evaluation.

They may be kind of right, but let me make some points.

We all-- let's look at the masks, first.

So, whom do I think might seriously consider wearing a mask today when they are out in public?

Well, let's look at the persons involved.

We want to prevent serious disease, disease serious enough to require hospitalization, and it's those patients for whom I'm most concerned.

Yes, I would recommend older persons when they are out in the community in group settings indoors: religious services, going to a basketball game, going to some sort of a convention and the like, to wear a KN95 or N95 mask.

And then, anyone with a notable underlying serious disease that we know predisposes to serious COVID and influenza.

Namely, heart disease, lung disease, diabetes, for example; pregnant women, also.

And, in addition, anyone who is moderately or seriously immune compromised because of either their underlying illness or because of an immunocompromising medication they are taking.

So, it's a personal decision today.

I have some gray hair.

Do I wear a mask when I go to the supermarket?

Yes.

I must admit, in all honesty, when I went last Saturday early morning, fewer people in the supermarket, there were fewer and fewer people wearing masks.

In fact, last Saturday (laughs) I think I was the only one in the supermarket wearing a mask!

In my neck of the woods here in Nashville, people wanna get back to normal, but I offer the suggestion to the people in those high-risk groups.

I think masks do offer a small but finite additional layer of protection to protect themselves when they are in such vulnerable circumstances.

Thank you very much.

- Thank you.

I have one question is to what extent did masks actually prevent infections during the peak periods of the COVID spread?

Because the Cochrane study seems to suggest that there's no evidence they actually prevented, although that would seem to be hard to prove.

- It is hard to prove.

And, the Cochrane's conclusion is, of course, correct because we didn't do just one thing.

Yes, we wore our masks, but remember, we were also social distancing.

And, indeed, during certain periods of COVID in certain communities, we were in a lockdown.

We stayed home.

So, we did all those things more or less simultaneously and it's hard, impossible really, to determine what proportion of the reduction we saw in COVID was due to the mask itself.

- I am delighted to welcome Dr. Gandhi.

- Well, thank you so much.

So, you know, I am completely in agreement with Dr. Schaffner that vaccines are actually the strongest form of protection against severe disease from COVID-19 and have been very impressed with the vaccine effectiveness, and how we are where we are in this pandemic now with actually very little severe disease.

We really went through a winter, and that's the time to stress a pathogen.

And, we saw a lot of RSV; we saw flu.

But, the severe disease with COVID-19 was so much lower during this last winter.

And, that is because of population immunity, both from the vaccine preferably, but also there's a lot of natural infection.

So, the question here for this meeting is about masks and the Cochrane review.

And, I was actually very interested in masks for the first year of the pandemic and wrote a piece in spring of 2020 for "The New England Journal" really urging masks.

But, my interest in masks were around the concept of masking and reducing the severity of disease.

If you're getting in less virus, the theory was that 'could you have less inoculum, and would there be less severe disease?'

And, there's some data that supports that.

But, the question on the table now is whether there's enough evidence that masks reduce transmission at a population level to impose mask mandates.

That's one question.

We can talk about individual masking in a minute.

Let's just talk about mask mandates.

And, I think that the Cochrane review was not just data during influenza.

Actually, they were very careful to look at studies during COVID.

And, you're right that they are very rigorous and they considered RCTs, or "randomized controlled data", the highest level of evidence that they were going to review to make a recommendation or to determine if mask mandates made a difference.

And, there are three major randomized controlled trials that were performed during this pandemic.

One was in Denmark early on about individual-level masking published in the "Annals of Internal Medicine" called the DANMASK study that showed no effectiveness of masks.

And, I wrote a...editor-?

letter to the "Annals of Internal Medicine" and said, "This is not the way to study masks.

"You don't put it on an individual, "rely on them wearing it, and no one around them is wearing it."

There were no mask mandates in Denmark at the time.

And so, you're embarrassed to wear it and you're not gonna wear it and it's all about adherence.

So, we need a cluster randomized study to look at this question.

We need to randomize villages or towns, or big groups to wearing masks versus not.

And, that was actually performed.

It was the Bangladesh RCT of masking at a population level, cluster randomized trial, providing masks, teaching on masks to one village.

Everyone's wearing the same mask so they're all wearing it versus not.

And, there was very little effectiveness.

I'll explain it a little bit more, but cloth masks made no difference.

We pretty much know this by now.

Cloth is not the right way to stop transmission.

And, surgical masks were a bit better.

There was a small effectiveness for the villages that wore surgical masks probably 'cause surgical masks are made out of polypropylene material which are negatively charged: they reject the virus.

But, then unfortunately, to be fair, a reanalysis of the Bangladesh data, which was published in "Science", people got their raw data, reanalyzed it and said 'no, there's no effectiveness.'

And, that RCT did not show the effectiveness of population-level masking.

And then, finally, there was one in Guinea-Bissau recently: no effectiveness, but that was cloth masks.

So, where do we stand, then, for the pandemic at this moment?

I don't think we can impose mask mandates on the public anymore.

This is not enough level of evidence to mandate.

So then, it's Dr. Schaffner's question: should individuals wear masks?

And, the best science on this is physical science studies.

If you wear the right type of mask and it's really clamped down, and it's a respirator or it's a KN95, KF94, FFP2, really strong fit and filtered mask- on mannequin studies with viruses being particles being bombarded into those mannequins- it looks like these masks really do block virus.

And, I think that anyone who would like to can choose to wear a mask and can be encouraged to wear a mask.

My father's different.

He's 88.

He's had five doses of the vaccine and he does not mask like you do, Dr. Schaffner, but that's because he is hard of hearing.

He had had an accident and he's hard of hearing and it's harder for him to wear a mask.

And so, let's make it a personal choice at this point.

And, I think the one thing I've been really interested in from kind of a public health standpoint-- and I live in California which is very different than Tennessee, where we had a lot of mask mandates, a lot of lockdowns, a lot of vaccine mandates, but we also had distrust.

And, I am really interested moving forward in increasing trust in public health because we have so much to deal with.

We have avian flu someday.

We have HIV funding that we wanna continue.

So, I always think in the world 'where can we increase our trust?'

If the evidence is not high enough at this point to impose mask mandates, I would not do it.

But, I think we can encourage vulnerable populations if they'd like to, to mask with the physical science study data, but I don't think it can be mandated.

- Thank you so much.

Now, we're going to go to our third speaker, Dr. Mina Hakim.

And, Dr. Hakim is the [reads slowly] pediatrics specialist of the South Central Family Health Center which has been a great resource for us in these briefings.

Thank you for joining us.

Dr. Hakim will discuss the findings of the study as they relate to children.

Dr. Hakim, welcome.

- Hello, everybody.

I just wanna start with saying I'm honored to be in here with such distinguished colleagues, but I am not a researcher.

I just wanna give you that caveat.

I am a primary care doctor and I work basically in the very heavily-populated south central area as a pediatrician.

So, I guess I can give you my experience and my view from basically what we call, like, "down in the trenches."

So, first of all, there was a few questions that I just wanted to clear up.

A couple questions that I saw in the chat comparing the Cochrane review to other papers.

It's important to know that the Cochrane review is not just one paper that studied-- that did one study.

It's a collection that looked at all of the studies, looked at a collection of studies.

I think was 70-something studies; 610,000 participants.

And, it was very rigorous, as Dr. Schaffner said, in a selection of the studies that can make it into that.

So, comparing it to others, just one single study is just not fair.

So, it is a collection of studies that looked at many, many, many papers.

And, as everybody had already said, Dr. Schaffner and Dr. Gandhi, the results of the study was clear in that surgical masks, N95 masks did not make a difference in the transmission of viral illnesses.

That's COVID or the flu.

Now, specifically regarding children, the study did look at a few studies that were specifically children and these results were even worse.

And, as we already saw with Dr. Gandhi and Dr. Schaffner were saying, the limitation of you wearing masks is how to use it.

So, masks is a mode of prevention that in theory is an excellent mode of prevention, but in practice, it's not.

So, imagine if you had to give yourself your own vaccine.

If you walked in and they just handed a syringe and they told you, "Go ahead and give your own vaccine."

We don't know how to use vaccines.

The general public does not know how to give themselves vaccines.

It won't work.

They won't know how to mix it.

They won't know how to give it.

They won't know how to appropriately give it.

So, we're basically giving-- we gave the public a piece of equipment and we told them, "Hey, this prevents infections in theory, but go ahead and use it however you wanna use it."

And, especially for children, you can't do that!

You know, kids are the worst at keeping things on, no matter how many attachments you have.

Yeah!

(Sandy laughing) How many attachments you have!

You know, you'll be lucky if you have a kid with their pants on at the end of the day!

So, let alone having a mask on that increases humidity, increases difficulty of breathing, and is just overall uncomfortable.

Uncomfortable on the ear, uncomfortable on the head.

They're touching things.

They're wiping their nose.

They're taking it off to drink and eat.

They're sharing pencils and pens that have been in other kids' mouths.

And, that's not in all ages, but teenagers as well are horrendous at being compliant.

So, as far as children in general, the study was worse overall outcome for children.

Should we continue asking children to wear masks?

I get that question in my own practice a lot.

And, we shouldn't force them to wear masks.

I think we should educate 'em that mask is a small piece of a very, very large puzzle.

We would encourage to do vaccinations and other measures I'll get into to prevent.

But, no.

We shouldn't force or we shouldn't put that on children.

Now, there's kids that have asthma, severely, kids that have immunocompromised for one type of disease or another.

And, I would encourage the parents with these kids to have that conversation with their kids and continue wearing a well-fitted N95 mask if it's possible for them [computer alerts] because it is a very small piece of the puzzle.

But, in a larger context, as Dr. Schaffner was saying, it can make a big difference.

Now, if you know your kid is not gonna be able to cooperate and they're taking it off?

They're touching their face; they're sharing drinks; they're doing all of those things, then it's probably not a smart idea to be doing that in the first place.

The study didn't only look at masks.

The study also looked at hand sanitization versus soap versus surface sanitization.

Although these were smaller aspects of the study, it did look at it.

They found that hand hygiene, especially with hand sanitizer, was effective by about 11% to 14% reduction in transmission.

And, they did find-- they only looked at a few papers that looked at surface sanitization and they did find that surface sanitization can reduce the risk for transmission.

So, my recommendation as moving forward?

Of course, schools should not be mandating masks.

Masks should be a choice.

If it is a choice, please use a well-fitted N95 mask and in very high-risk patients.

But, the better things is the hand hygiene and good sanitization in the school.

So, surfaces.

Places that kids touch often: toys, utensils, pens, books, all of those things, sanitizing these things.

'Cause as Dr. Schaffner said, the transmission is contact.

So, droplets.

So, you sneeze on something, it can stay there for a long time.

Someone can touch it and then it gets transmitted.

So, it's not just aerosolization in the air, [computer alerts] it's not just in the air.

It's things that you touch and you touch your mouth; You touch things that you eat, things like that.

And then, good screening.

So, good screening for kids that come into the school.

Have you had fevers?

Are you sick?

So, the less amount you are around other kids or other people that are sick, the more-- the less likely you'll have transmission.

So, as far as surgical masks or masks in general for children, the study was clear in that for children, it's even worse results than they had for the general public.

- Thank you, Dr. Hakim.

A kind of wrap-up question.

And for me, the most important kind of issue that all of this raises is what each of you has spoken about as trust in the public health system.

To what extent has this-- have these new findings about masks affected the public?

- One of the most difficult things for the general public to understand is that we will give you our best advice today but if we learn something tonight, we may have to change that advice tomorrow and that this is an ongoing process.

That's why, when asked, many public health authorities will say the single most important aspect of dealing with a pandemic or any public health threat is communication: clear, science-based, repeated and once again, clear, given in language that people understand.

We've learned more about masks during these three years of COVID.

We're changing our minds.

We're giving better advice.

We're trying to communicate this right now.

We, in public health, all three of us and others, partner with journalists to provide the best information to the general public.

We try to do that in a sustained way, factually, but also in a reassuring fashion and we're going to have to keep trying to do that.

It's the best way that I know how.

- Dr. Gandhi, your thoughts on this.

[background music] - Science is a process of iteration of change, and all we can do in public health is be clear when there's been a change, say 'sorry' if we were too heavy-handed in some ways and we are gonna do our best in the next pandemic.

- Thank you.

I think what all of us who've been on these briefings with the three of you have come to develop is a real trust in the information you're sharing with us.

Many of us do not have personal doctors.

Not only are we in a position of having to inform our audiences as best we can, but we ourselves rely to some extent, on these briefings to inform ourselves.

Thank you so much.

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