Speaker 1: It's great to be joined today by Dr. Shira Doron, who is the chief infection
control officer for Tufts Medicine Health System, and also the hospital epidemiologist
at Tufts Medical Center in Boston.
Really great having you on today.
I appreciate your time.
Speaker 3: Great to be with you.
Speaker 1: So I've been reading all of these analyzes and meta analyzes and meta meta analyzes
of what might be thought of as a simple question Do masks work to prevent COVID?
And it seems as though even the most well-intentioned and sort of science facing people have had
different and sometimes changing perspectives on this question throughout the pandemic.
There's also sort of a question of what do we mean by do they work?
And that might mean what is the effect for an individual of their decision to wear a
mask versus what is a policy of saying we require masking in these those or other situations?
What does that do on the population level?
Infection rate.
So start wherever you want on this question and then we can kind of go from there.
Where are you maybe now on this issue?
Speaker 3: Yeah, I mean, I think you hit the nail on the head, right?
This is not a simple question.
Do masks work?
And you know, where I am now is is in many ways where I started before the pandemic was
even, you know, a glimmer in our eye, which is that I have quite literally trusted masks
with my life, my whole career.
I have obviously worn masks in health care.
I'm not a surgeon, so I've worn masks for my own protection.
And I believe in them.
I have taken care of patients with deadly bacterial meningitis in an ear loop surgical
mask.
I have taken care of patients with H1N1 influenza before there was a vaccine for it in a surgical
mask.
And I've taken care of patients with multidrug resistant tuberculosis in an N95, and I have
trusted it to protect me and keep me healthy and alive.
And I still do to this day.
But when the pandemic was bearing down on us SARS-CoV-2, the COVID 19 pandemic, I started
to have to really look at all of that literature because questions started to arise that were
really quite contentious.
The first question was, should we be using surgical masks or a 95 to take care of these
suspected COVID 19 patients?
That was a really difficult one because we didn't have nearly enough and 95 available
in this country to take care of every person with a respiratory infection in the winter
in an N95.
And so we really needed to start looking at the data, which suggested that it wasn't clear
cut, whether you needed an N95 in that situation.
And the CDC was really kind of hedging on its language.
W.H.O.
was being very clear that you did not need an N95.
And so you may have seen that there was relatively recently a clinical trial that assessed and
95 versus surgical masks.
They started back in those days when we really didn't know what to do and didn't have enough
95 and actually found that they couldn't detect a difference in health care worker infection
rates between those hospitals who used 95 for all of the care and those who used surgical
masks.
That's not to say that the 95 aren't more protective.
Many of those healthcare workers got those infections outside of health care.
Speaker 1: Right.
And that seems to be a lot of the difficulty where if we just say as sensible people, the
tighter the barrier that we place between ourselves and a pathogen seems pretty logical
that it reduces the chance of that pathogen getting through.
Great.
Okay, so we can start there.
But then you go to all sorts of different studies and you have to contend with questions
like just because you have a mandate doesn't mean everyone's doing it.
Just because people are doing it part of the day doesn't mean they're doing it all of the
day.
Just because you are ostensibly wearing an N95 mask doesn't mean you're wearing it correctly
or you don't have it pulled down or pulled up or, you know, on your sleeve.
So so are those some of the difficulties in getting to what is the the true answer?
Speaker 3: That's exactly right.
And that's really why the question is, is more than do masks work?
It's do mask mandates work or does masking on a community level result in a lower level
of infection transmission or number of infections that not masking on a community level?
And what are you comparing it to?
No masks at all.
Optional masking versus mandated masking.
You know, all of those things are there.
All of those comparisons are different comparisons.
And we have data that show that there was broader sort of community level interventions
are are quite a bit less effective than you would want them to be, given that we do believe,
although it is really hard to show with science, that masks are protecting us when we wear
them.
And some of the data evidence for that was also quite early on in health care.
In looking specifically at SARS-CoV-2, what we were seeing was that health care workers
did not have higher rates of SARS-CoV-2 antibody positivity.
People who weren't healthcare workers, even though we were surrounded by COVID 19 patients
all day long.
And that was telling me that our PPE was working.
Speaker 1: There's sort of a parallel, maybe we would call it an issue here that is separate
from a mask mandate, which maybe we can also introduce, which is I've read a couple of
studies which suggests that when news media is accurately informing people about the prevalence
of a virus, meaning people are aware of when risk is higher versus when when risk is lower,
that people choose to behave differently, not only in terms of optional mask wearing
in places like grocery stores, but also in terms of how social am I going to be, am I
going to go to sporting events, etc..
So this would be the idea that it's less about mandating one thing or another, but that if
people perceive, oh, there's a new variant like for example, after Thanksgiving of whichever
year it was when Delta first came or whichever one it was, when people perceive the risk
is higher, they will modify their behavior and that this is a way that we actually do
flatten the curve over a period of a couple of months.
And so it's less about mandating but more about informing, and that many people will
actually make the choice that is logical anyway.
Is that something that needs to be considered when the effectiveness is measured?
Speaker 3: Yeah, that's exactly right.
So, you know, this gets to one of the CDC studies that was really instrumental in the
development of their recommendations during the current wave to shift to the highest quality
mask you can wear instead of cloth masks, unless that's the highest quality mask you
can tolerate.
Yep.
So commendation was in 95 for the most protective.
Okay.
And 95 of the second most protective surgical masks and then cloth masks.
And then that was based on this paper that they put out.
And there MMW are report showing that people who used 95 or so people who tested positive
versus negative for SARS-CoV-2 infection, COVID infection, where were more likely to
be negative if they had used a higher quality mask, essentially was the result of that study.
And the critique to that is people who wear N95 are more likely to be COVID conscious
in general.
Right.
Which is, you know, because those were not that was not a randomized controlled clinical
trial.
And this is the critique for any observational study, any epidemiologic study, any study
where you compare to two geographical locations, for example.
So there's a new study that shows that, you know, states and counties with mask mandates
had lower infection in the United States, but not lower death rates, for example.
Some of those things are exactly what you're saying.
If you don't randomize in a randomized controlled clinical trial and you just observe the people
who choose to wear the the higher quality mask, people who choose to wear a mask over,
no masks are also taking COVID more seriously and doing those other things.
The states and counties that choose to issue mandates are also issuing mandates related
to other things.
They may have more business closures, they may have more people in them that take COVID
seriously.
Right.
That's fine.
The Conference of Systematic Review old and new.
And really any time they do a systematic review on anything, masks and treatments.
In medicine, we'll always focus on randomized controlled clinical trials because that's
the only way to take all those other factors out of the calculation.
Speaker 1: If we want to, in sort of one sentence, give what might be the most comprehensive
but also accurate assessment.
Is it fair to say that a correctly worn high quality mask does a good job of protecting
the individual wearing it?
But mask mandates are less effective at protecting a population for all of the different reasons
that you've cited so far.
Like, is that kind of where we land?
Speaker 3: That's what I believe to be true.
I can't say that we have great data.
Prove that you wearing an N95 is definitely going to protect you from COVID 19.
But that's what my three plus years of experience in a hospital being bathed in COVID 19.
Tell me a plus.
The what?
I you know, what I referred to as the seroprevalence data for health care workers, etc. the low
rate of transmission that I see on a day to day basis.
And it's my job to see that between patients and staff.
So I believe that a high quality well-fitting mask will protect me if I wear one.
But I agree with the second part of what you said, which is that I have been unable to
see convincing evidence that a mask mandate or that community masking makes any difference
in the incidence of infection.
And the data that we have from 78 clinical trials suggest that if there is a difference
there, it's very, very small.
The epidemiologic data comparing county to county and state to state and country to country
based on mask use suggests that if there's any difference there at all, it's very, very
small.
And that should really call into question that the discussion around future mandates.
In my opinion, even though, as I said, I've been trusting masks with my life.
Speaker 1: There are all sorts of claims that we've seen over the last few years about the
harms of masks.
Sometimes these are what people call psychological harms related to kids in schools or being
able to communicate or whatever the case may be.
You then have the stuff like, Well, it forces you to re breathe your own carbon dioxide
and all of these different things.
And they've to my relative satisfaction mostly been all debunked with the exception of it
does seem that for little babies exposure to an overwhelming number of people where
they don't see their mouth when they are being spoken to may delay language development to
some degree.
And it seems to be temporary.
I mean, I know I'm bringing a lot of new, new things in here, But on the criticisms
of the masks, what do we actually know at this point?
Speaker 3: Yeah, I mean, if we go back to when we first started to think about community
level masking, which was in health care.
So it's March of 2020, more and more of our health care workers are getting infected generally
at home and in the community, not through care of patients with COVID because they're
wearing masks with patients.
And we are and they're getting exposed and we're having to furlough them for two weeks.
We 5 minutes after we started to do that, we realize we can't run a hospital with the
number of people that are home waiting to, you know, usually not contract COVID.
After an exposure, we start bringing them back and we have them wear those were exposed
to COVID.
We have to wear masks.
So, you know, very quickly, half of our health care workforce was wearing masks, but we didn't
have a mask mandate in health care yet because masks had been shown in several meta analysis
not to be effective for that purpose.
And that's why we had avoided doing that.
But as I watched people wearing masks because of exposure, I saw a lot of people touching
them, you know, touching them, people putting them down on the table to eat on a surface
that somebody else was going to eat on.
I saw a lot of things that made me really nervous about that.
Even the having the conversation around bringing masks in as a long term strategy as a mandate
for health care workers.
But we did it.
We did it because, you know, it got to the point where everyone was exposed and we needed
to protect each other.
And then, as you know, it became standard and recommended by the CDC for the whole country.
You know, the data on its effectiveness hadn't changed.
The data on community masking hadn't changed between the CDC not recommending community
masking and recommending community masking.
But the stakes were so high, people were dying and the hospitals were filling up and people
were going to be dying of non-covid reasons because they couldn't get a bed in the hospital
and it was worth it.
It was worth it to try.
And I have to admit, I didn't have the creativity to think how we could possibly be implement
community masking on a national level given the supply chain issues.
I didn't think that people could make them at home and I lacked that creativity and I
was wrong.
We did it and we did it effectively.
But then what I started to see over time, especially as the children in schools were
wearing masks, was but also here in the hospital, working every day throughout the whole pandemic
was a loss of connection.
When you couldn't see people's expressions in people's faces, you were just much less
like.
To have those kind of intimate conversations.
We were able to drop masks in the hospital in areas where patients and the public were
restricted from entering, so after everyone was vaccinated.
In the summer of 2021, we stopped wearing masks in offices, in conference rooms and
break rooms.
And it was night and day in terms of morale, combating burnout and what we had just been
through.
And then we had to put the masks back on because the Delta variant was immune, evasive, and
people were vaccinated.
People were getting infected.
Yeah.
And it was hard.
So I think that sure, there are there are there are definite downsides when it comes
to people who are hearing impaired, not being able to tell what's going on, people who are
trying to learn language, people with speech impairments, you know, and children who have
developmental delays and that sort of social interaction piece.
But I, I really did see amongst my my children and my friends children and amongst my colleagues
just an impact on connection, mood, morale that has really improved.
Again, when we were able to take masks off about a year ago.
Speaker 1: And last thing, the re breathing of your own carbon dioxide does not seem to
be a problem.
Speaker 3: No, no, no.
I was sorry about that at all.
And you know that we do know that that our surgeons wear masks for our cases.
And, you know, there's there's there's no issue.
So that would not be one of my concerns now.
And 95, you know, OSHA does require that that workers be medically cleared to wear and 95
respirators, those will cause shortness of breath that can cause, you know, cardiovascular
issues when you wear them for prolonged periods of time.
And, of course, we've all seen the pictures of the skin breakdown that you can have if
you have to wear them for a prolonged period of periods of time, during a period where
everybody has COVID or suspected COVID, which was the case in spring of 2020.
So those can have some health implications.
Speaker 1: All right.
We've been speaking with Dr. Shira Darren from Tufts Medical Center in Boston and also
chief infection control officer for Tufts Medicine Health System.
Really appreciate your time and your insights today.
Speaker 3: It was such a pleasure.