Why are we still talking about masks in 2023? Why is this even important? Well pandemics whether due
to influenza, covid-19, or other viruses happen periodically and if we don't have a definitive
answer on whether masking is helpful for these viruses and in what situations the
general population may be mandated to wear masks when they're not actually going to be beneficial.
Today I'm going to present the best data we have here on Medicine with Dr. Moran. I'm Dr Keith
Moran a consultant in Internal Medicine. I want to present two Cochrane reviews. Now Cochrane reviews
are considered one of the best in evidence-based medicine. The medical community considers them
to be the gold standard due to their methodology, thoroughness, and transparency. Despite this both
of these systematic reviews were heavily censored. Now they looked at properly done randomized
control trials in their research not observational studies. Will these reports finally give us some
definitive answers on masking? My main focus today is a recently published January 30th,
2023 a systemic evidence-based review from their library. As always there's a link below to the
document in the description. There's also a link to their November 2020 systematic review. First,
I need to mention that their review which was published in November 2020 was actually
delayed for seven months and this seven-month delay is important because it was at this time
where governments were making policy decisions on what to do with the pandemic specifically looking
at the non-pharmaceutical interventions such as masking in order to try to prevent
Covid-19 infection. It did not contain any Covid studies, but it points out that there was moderate
certainty of evidence that wearing a mask probably makes little or no difference, no statistical
difference that is to the outcome of laboratory confirmed influenza compared to not wearing a
mask. This was based on six randomized trials of 3,005 participants. They stated that harms meaning
harmful effects of masking were rarely measured in the studies and they were poorly reported.
They also looked at five trials also randomized of 8,407 participants using the N95 and compared them
to a surgical mask and again there was little or no difference in other words no statistical
difference. For hand washing they pooled randomized data of over 61,000 participants. Now
here they demonstrated a statistically significant 11% relative reduction of a respiratory illness.
Now they were ready to publish this in the spring of 2020 according to the lead author Tom Jefferson
but the heads of Cochrane actually held this publication up for seven months before it was
published in November 2020. After this they found themselves being censored. They were censored by
social media companies and here's an example of this on Instagram. It was very troubling for me
to see this happen censorship of Physicians and medical researchers including myself has
been present throughout the pandemic. Calling the Cochran's research to be misinformation when it's
clearly high-quality evidence-based information is just not right. Many countries were convinced by
non-randomized flawed biased observational studies to create mask mandates with the perception
that it had to do with appearing as if they were actually doing something but if you're going to do
something you want to do something that you know is going to work based on evidence. That's how we
do it in medicine. Now unfortunately good quality randomized studies with masks to prevent Covid
should have been done. I've talked about the two main randomized studies for masking in the general
population in other videos the bottom line is that the Danish surgical mask study showed no benefit
and the Bangladesh study showed no benefit of a three-ply cloth mask and marginal benefit
of the surgical mask although subsequent review of the data demonstrated that the randomization
in that study was not ideally done so there was some degree of sampling bias. So you saw medical
experts initially at the beginning of this Covid pandemic saying masks were not helpful and of
course this was based on the high quality data that the Cochrane collaboration had previously
reviewed. Then subsequently they flip-flopped in many countries leading quickly to strong
recommendations for masking then mask mandates all in the absence of good quality randomized
controlled trial evidence. All of this of course was been done without proper studies.
Recommendations to mask a two-year-old or the six feet / two meter rule that's not
based on any evidence. Certain situations did not make a whole lot of sense of course
such as walking into a restaurant with a mask on but then taking it off to eat
and of course wearing it on a plane but taking it off to drink and eat.
Masking young kids in daycare but then allowing them to take their masks off for their naps for
an hour or two was another of many examples. My last example I'm not suggesting that young
children should wear them while sleeping but many in the general population found these sorts of
things to be very hypocritical and rightly so. It's very difficult to force people to do things
when there's no evidence and that's why you saw a lot of resistance from the general population.
Some people will say that the absence of evidence is not evidence of absence but in the Cochrane
review as I will review we've got evidence, albeit perhaps not as robust as we all might like,
but this is simply because research around the world was severely lacking and the people that
should have promoted the research did not. This is one of the many pandemic mistakes that I highlight
in my video the Top 10 Pandemic Mistakes which I made quite a while ago last year actually.
Now talking about the Cochrane most recent review of January 30th 2023, again they only
looked at randomized control trials here and they were investigating physical interventions
for Covid-19 and in their review they didn't look at any observational studies and of course the
problem with observational studies and you see a lot of this it's that when you try to look back
on what's happened and pick out two groups let's say masking versus no masking, but it can be for
anything else. You try to make the groups similar. You control for variables like age, health, and
other covariates that you think are relevant but the problem is especially with the masking is the
people who mask they behave completely differently than people who don't. They may be more likely to
stay home, avoid interactions with people, they may be more likely to work from home, when they
get sick they may be less likely to test, and so behaviors can be very different and this is why we
need studies where people are randomly allocated to masking versus no masking, and look forward
into the future to see who gets infected, and have the same criteria for testing. This update that I
am talking about included 11 randomized control trials with 610,000 participants and they looked
at surgical masks compared to no masks N95 masks compared to medical masks and then hand hygiene
again compared to control. The hand hygiene once again as you might imagine showed benefit.
When they looked at surgical masks compared to no masks there were 12 trials there and they noted
that wearing masks in the community probably makes little or no difference to the outcome of
influenza-like illness or covid-like illness to not wearing a mask and they had moderate
certainty in the evidence. They also looked at wearing masks in the community to prevent lab
documented influenza or lab confirmed SARS Cov2 ie Covid infection compared to not wearing a mask
and again they found little or no difference with moderate standard certainty evidence.
I should point out that the 95% confidence intervals here were quite wide 0.72 to 1.42 and
what that means is it's possible that there might be a 28% lower rate of infection with masking but
there could also be a 42% higher rate with masking and the overall relative effect was 1.01 which
means there was no effect of masking and this was based on six randomized control trials with 13,919
participants. The harms of masking again were rarely measured and poorly reported. Now what did
they say about the N95 versus surgical masks? They concluded that they probably make little or no
difference in regards to lab confirmed influenza infection with moderate certainty evidence.
There was one single randomized trial published investigating medical and health care workers
providing direct contact to Covid-19 patients and the caveat in the study is that everybody
got to use an N95 if there was aerosolized procedures going on with their patient.
The most important point in the particular study is that there was low to moderate certainty of
evidence against Covid infection comparing these two masks and the authors of the specific study
felt that surgical masks were not inferior to the N95 masks and it's disappointing that there's low
to moderate certainty of the evidence in this situation and obviously it reduces confidence in
the estimates that I'm presenting and of course that could have been bolstered by additional
randomized studies which weren't done in health care workers caring for covid patients. Now I do
want to point out that this is not an anti-masking video. I'm simply presenting the best available
evidence that we have in 2023. Unfortunately the concept of masking has become polarized with many
people saying on one hand that we just don't need any randomized trials because physics models in
the lab using a robot with a mask show a reduction in aerosolized particles. The problem is that's
likely not the only way there's transmission and it's not how masks are used in the real world.
As I've mentioned people don't always wear them properly. They frequently touch the masks with
their hands and they spread their virus to their hands from their mask. They also take them off
to eat and drink. Even in regard to health care workers they don't wear their N95 throughout their
entire shift no health care worker does that. The longest I've ever worn an N95 was two hours and I
can tell you it was very uncomfortable and they do leave a significant imprint on your face when
you take them off. Healthcare workers also don't stay in the hospital the entire day and night.
They have other interactions outside of work. Now on the other side of the spectrum is the fact
that masks do nothing and that's not actually what the review says because those confidence
intervals around the estimate of one allow for decreased infection by 28% as well as increased
infection by 42%. Now these kind of numbers with the relative risk at 1.0 in the middle
when we typically see this with an intervention in medicine we tend to scrap that and not do any more
studies because it doesn't show any benefit. That's not what's happened with masking and
ideally a large well-designed randomized trial should have been done to try to improve upon
these wide confidence intervals so that people would buy into the conclusion. Of course some
people would say it's unethical to do a study where half the groups randomized to masking
and the other half isn't but it's definitely not unethical because we don't truly know that
masking particularly in the general population is helpful and we do want to answer the question
if it was helpful. I think that we probably would have seen this in randomized studies
so far which we haven't. As is always the case the onus of an intervention the onus of proof of
that intervention in this case masking is to prove that there's a setting in which it actually works
otherwise there's no point in having it for the Covid virus. This has not been shown definitively
at this time in 2023 due to lack of studies. Many of us simply want to know whether masking is
helpful and more specifically whether masking in certain situations might be helpful. I appreciate
you staying till the end and I appreciate you watching me. Get healthy and stay healthy.