Mixed Messages on COVID-19 Masks: Science Falls Short As Deaths Mount
Different hospital policies as to who should wear a mask—and when—pit a shaky evidence base against a supply chain shortage.
Different hospital policies as to who should wear a mask—and when—are pitting the evidence base against the supply chain, with cardiologists and other health professionals turning to social media for guidance and support.
Doctors at institutions which have announced policies of masks for all, as Harvard hospitals did this week, reacted on Twitter with pride and relief.
Today, my health system took a big step: Notified staff that they're adopting the model described here, with face masks at all times & a health check each shift for even mild ill symptoms. Effective Wednesday. Kudos to @PartnersNews @BrighamWomens @MassGeneralNews https://t.co/619Cb1gqMP— Atul Gawande (@Atul_Gawande) March 22, 2020
Others, however, have received instructions from hospital administrators telling them they are not allowed to wear masks, or that if they want to do so, they must supply their own. Banner Health, the largest employer in Arizona, instructed hospital employees that they could wear “social comfort masks,” a mysterious term that Banner later clarified to TCTMD meant “personal masks brought in” and paid for by the employee.
“While Banner does not endorse personal mask use as effective in preventing disease transmission, we recognize that team members may want to engage in the use of these masks for their own personal relief,” a Banner spokesperson told TCTMD.
The thing about #COVID19 is how fast it changes. Today, no masks. Can’t follow @Atul_Gawande and Brigham way A) if docs where masks, all HCW have to. B) If all HCW wear masks we quickly burn through supply. Cc @rkwadhera pic.twitter.com/a5sp8vVMFX— John Mandrola, MD (@drjohnm) March 24, 2020
As previously reported by TCTMD, physicians, nurses, and other frontline workers say they are frankly terrified to be heading into high-risk situations without the proper personal protective equipment (PPE). Healthcare workers have now been identified as one of the highest risk groups for contracting the SARS-CoV-2 virus. Increasingly there are stories of hospital personnel getting reprimanded for wearing masks and fearing for their jobs if they speak out. On Friday, 54 health and public advocacy organizations wrote a letter to the American Hospital Association asking the group to publicly denounce “any threats of disciplinary action for speaking out against coronavirus caseloads and supply shortages.”
Friends who are #residents #fellows sharing experiences like 👇🏿 of being REPRIMANDED for trying to wear gear to protect themselves & patients— Rishi Wadhera (@rkwadhera) March 24, 2020
*TOTALLY UNACCEPTABLE*#Trainees are truly on the FRONTLINES of the #COVID19 pandemic.
Their safety MUST BE a priority #GetTraineesPPE https://t.co/6MlIy7lhpy pic.twitter.com/UhukRbMdum
“I’ve heard a lot of people say that they are scared to speak out, that they are being intimidated, that they worry they’re going to be fired if they speak up,” C. Michael Gibson, MD (Baim Institute for Clinical Research, Boston, MA), told TCTMD. He’s hoping to launch an anonymous site where people can report situations in which they feel they are being unduly put at risk, or unduly pressured to take risks, to the Occupational Safety and Health Administration.
“There's the science, which should guide the decision-making, and then there's the supply, which seems to be guiding the decision-making,” Gibson said. “Let's not let the supply considerations overtake what the science shows.”
A Dearth of Science
The trouble with the science is that there’s very little in the way of concrete proof that wearing a surgical mask, or even a N95 filter, stops the spread of COVID-19 during patient interactions not covered by the current CDC guidance.
“To me the policy that has been set largely by the CDC and even the [World Health Organization] to consider this as a droplet-type of spread does run counter to what we’ve seen for instance in Asia and China, specifically,” said Ajay Kirtane, MD, SM (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY). “It may be that they took extraordinary measures because they didn't want to risk any single exposure, even though the risk of the exposure with a standard surgical mask might be low for routine care, but from the standpoint of a physician, or a nurse, or somebody who is actually on the front line, I'm sure folks would rather be over-protected than under-protected, and that’s driving a lot of this.”
I hope all the Hospital administrators around the country- NOTE THIS!— Dr. Purvi Parwani (@purviparwani) March 22, 2020
HARVARD hospital requires ALL the healthcare WORKERS to wear a MASK ALL THE TIME!!! @HashimKhan_1 @RezaEmaminia @onco_cardiology @mmamas1973 @Atul_SharmaMD @DmitryAbramovMD @DrJenniferCo_Vu @DBelardoMD https://t.co/m7YRR453ps
It’s also not yet clear to what extent the disease is spread by droplets versus aerosolized virus, Gibson noted. A preprint publication posted to MedRXiv.com on March 26 suggests that the disease is spread not only by droplets and direct contact, but also by indirect contact, including contaminated objects and airborne transmission, “supporting the use of airborne isolation precautions,” the authors conclude.
Most of the science, notes David Cohen, MD (Kansas City, MO), is mechanistic—what particle size can fit through the filters/fabric. “Has anyone done a meaningful study to show what the effects of these policies are on virus transmission? Certainly not specific to COVID-19,” he said.
Instead, said Cohen and Kirtane, healthcare workers in other hard-hit countries are taking pains to explain the personal protective measures they’ve taken, including ubiquitous use of masks in countries where the outbreak appears to have turned a corner. A minority of US hospitals are following suit. Countries like China, Cohen continued, “instituted levels of PPE that frankly we don't have in the US and it would be impossible for us currently to institute those levels of protection. But that's what they did and what we've observed, assuming we believe the data coming out of China, is that they relatively rapidly got control of a horrible epidemic in ways that we've not yet been able to achieve here. People are putting those two things together and saying, well, if we don't know which various components worked, we'd better do as many as we can.”
While no prospective studies can be done in the midst of the crisis, Gibson had one suggestion—that different countries with different policies be compared as you would a cluster randomized trial. “It’s not perfect, but if millions of people wore masks in different countries, and in other countries they didn’t, it's almost like cluster randomization. You’d ‘randomize’ China and Singapore and Hong Kong where they did aggressive PPE, to Italy, Spain, and the US, where they did not. It’s a billion anecdotes of data: in a certain way, at a certain scale, it becomes data that we have to look at.”
Based upon the existing data, including data published in the New England Journal that #COVID19 particles can remain airborne for hours & that asymptomatic transmission accounted for 80% of cases in China, do you feel wearing a mask throughout the hospital is justified? Thoughts?— C. Michael Gibson MD (@CMichaelGibson) March 26, 2020
Meanwhile, the lack of evidence means other scenarios are also possible. Gibson points out that hospitals advising all personal to wear a surgical mask throughout the day, but not mandating a new mask for each patient encounter, means that the masks may end up gathering virus that is then distributed elsewhere by the physician or health professional when he or she exhales.
“In the right scenario, you'd dispose of the mask after every patient, after every encounter,” Gibson said. “By having to use it for a day or multiple days, the bad thing is we may be turning the doctor into a viral vector if they are wandering around among people who do not have the infection.”
The optimal solution—a new mask for every encounter—is untenable amid the dire shortages. “If we had more masks, we wouldn't even be having this conversation,” he said.
If only we in the USA had enough PPE. Compare this to universal mask policies in which staff are given one surgical mask per shift.#COVID19— John Mandrola, MD (@drjohnm) March 26, 2020
Make no mistake, I don’t have the answer, but wonder about real protection vs facades of protection. https://t.co/QmIybqyVaN
Kirtane and Cohen, too, expressed concerns that the current ‘guidance’ is based more on supply than it is on science.
“My feeling is that some of the recommendations from the CDC are based on equipment shortages and based on practicalities more than evidence, and that's what bothers a lot of physicians and nurses and people on the front lines,” said Kirtane. “People would rather know that we're doing it because of a shortage rather than, this is a formal recommendation,” soundly based on science.
The fact that the number of US cases has so quickly outstripped those of the rest of the world, as well as mixed messages being given from different branches of the US government, has not helped the situation.
“The problem,” said Cohen, “is that a lot of people feel that the government is not trustworthy at the moment, and that's a huge problem in an epidemic, in a crisis. You need the government to be trustworthy and they have squandered a lot of trust.”