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Mask Facts

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Curated by Marilyn Singleton, MD, JD

COVID-19 is as politically-charged as it is infectious. Early in the COVID-19 pandemic, the WHO, the CDC and NIH’s Dr. Anthony Fauci discouraged wearing masks as not useful for non-health care workers. Now they recommend wearing cloth face coverings in public settings where other social distancing measures are hard to do (e.g. grocery stores and pharmacies). The recommendation was published without a single scientific paper or other information provided to support that cloth masks actually provide any respiratory protection. Let’s look at the data.

The theory behind mask wearing:
*Source control: Cloth mask can trap droplets that come out of a person’s mouth when they cough or sneeze.
*Protection: Personal Protective Equipment – only N95 masks.

Transmission of SARS-CoV-2

Note: A COVID-19 (SARS-CoV-2) particle is 0.125 micrometers/microns (μm); influenza virus size is 0.08 – 0.12μm; a human hair is about 150 μm.

*1 nm = 0.001 micron; 1000 nm = 1 micron; micrometer (μm) is the preferred name for micron

*1 meter is = 1,000,000,000 [trillion] nm or 1,000,000 [million] microns

*For a complete explanation of aerosols and airborne particles, please see Understanding Particle Size and Aerosol-based Transmission by Steve Probst, https://www.4cconference.com/wp-content/uploads/2020/07/Understanding-Particle-Size-and-Aerosol-Based-Transmission.pdf

Droplets
Virus is transmitted through respiratory droplets produced when an infected person coughs, sneezes or talks. 

Larger respiratory droplets (>5 μm) remain in the air for only a short time and travel only short distances, generally <1 meter. They fall to the ground quickly. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30245-9/fulltext

This idea guides the CDC’s advice to maintain at least a 6-foot distance.

Small (<5 μm) aerosolized droplets can remain in the air for at least 3 hours and travel long distances. (up to 27 ft.) https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true;

https://www.cidrap.umn.edu/covid-19/podcasts-webinars/special-ep-masks;

https://www.nap.edu/catalog/25769/rapid-expert-consultation-on-the-possibility-of-bioaerosol-spread-of-sars-cov-2-for-the-covid-19-pandemic-april-1-2020

Air currents
In air conditioned environment these large droplets may travel farther. 

Ventilation
Even the opening of an entrance door and a small window can dilute the number of small droplets to one half after 30 seconds. This is clinically relevant because poorly ventilated and populated spaces, like public transport and nursing homes, have high SARS-CoV-2 disease transmission despite physical distancing. (This study looked at droplets from uninfected persons). https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30245-9/fulltext

Humidity
Since 1961, experiments showed that viral-pathogen-carrying droplets were inactivated within shorter and shorter times, as ambient humidity was increased. Dryness drives the small aerosol particles. See e.g., Review: https://aaqr.org/articles/aaqr-20-06-covid-0302

Conclusions
The preponderance of scientific evidence supports that aerosols play a critical role in the transmission of SARS-CoV-2. Years of dose response studies indicate that if anything gets through (and it always does, irrespective of the mask), then you are going to be infected.

  • Thus, any respiratory protection respirator or mask must provide a high level of filtration and fit to be highly effective in preventing the transmission of SARS-CoV-2.  (Works for TB that is 3 μm)
  • Public health authorities define a significant exposure to COVID-19 as face-to-face contact within 6 feet with a patient with symptomatic COVID-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). 
    • The chance of catching COVID-19 from a passing interaction in a public space is therefore minimal.

MASKS
Filter Efficiency and Fit
*Data from a University of Illinois at Chicago review
https://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data

  • HEPA (high efficiency particulate air) filters are 99.97 – 100% efficient. HEPA filters are tested with particles that are 0.125 μm (the size of SARS-CoV-2)
  • Masks and respirators work by collecting particles through several physical mechanisms, including diffusion (small particles) and interception and impaction (large particles)

OSHA/CDC:  A surgical mask is not a respirator. It cannot be used to protect workers who perform or assist with aerosol-generating procedures, which may create very fine aerosol sprays. A surgical mask can only be used to protect workers from contact with the large droplets made by patients when they cough, sneeze, talk or breathe. https://www.osha.gov/dts/guidance/flu/healthcare.html

Laboratory Studies
Filter efficiency was measured across a wide range of small particle sizes (0.02 to 1 µm) at 33 and 99 L/min.

  • N95 filtering facepiece respirators (FFRs) are constructed from electret (a dielectric material that has a quasi-permanent electric charge.) An electret generates internal and external electric fields so the filter material has electrostatic attraction for additional collection of all particle sizes. As flow increases, particles will be collected less efficiently.
  • N95.  A properly fitted N95 will block 95% of tiny air particles down to 
    0.3 μm from reaching the wearer’s face. https://www.honeywell.com/en-us/newsroom/news/2020/03/n95-masks-explained. 
    • But even these have problems: many have exhalation valve for easier breathing and less moisture inside the mask. 
    • An N-95 mask helps protect the wearer from others, but it does not filter exhaled air passing through the exhaust valve.  No source control.
    • A 2010 study found that all the cloth masks and materials had near zero efficiency at 0.3 µm, a particle size that easily penetrates into the lung (SARS-CoV-2 is 0.125 µm) https://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data; https://academic.oup.com/annweh/article/54/7/789/202744
      • T-shirts — 10% efficiency
      • Scarves — 10% to 20% efficiency
      • Cloth masks — 10% to 30% efficiency
      • Sweatshirts — 20% to 40% efficiency
      • Towels — 40% efficiency.
      • A 2014 study evaluated 44 masks, respirators, and other materials with similar methods and small aerosols (0.08 and 0.22 µm). https://aaqr.org/articles/aaqr-13-06-oa-0201
        • N95 FFR filter efficiency was greater than 95%. 
        • Medical masks — 55% efficiency 
        • General masks — 38% efficiency
        • Handkerchiefs — 2% (one layer) to 13% (four layers) efficiency.
      • Conclusion: Wearing masks (other than N95) will not be effective at preventing SARS-CoV-2 transmission, whether worn as source control or as personal protective equipment (PPE)
        • N95 masks protect health care workers, but are not recommended for source control transmission. 
        • Surgical masks are better than cloth but not very efficient at preventing emissions from infected patients. Cloth masks – they must be 3 layers, add static electricity by rubbing with rubber glove. 
        • The cloth that serves as the filtration for the mask is meant to trap particles being breathed in and out. But it also serves as a barrier to air movement because it forces the air to take the path of least resistance, resulting in the aerosols going in and out at the sides of the mask.

Human Studies

  • Strikingly, cloth masks resulted in significantly higher rates of infection than medical masks, and also performed worse than the control arm, some of whom may have worn masks.
    • The virus may survive on the surface of the face masks
    • Self-contamination through repeated use and improper doffing is possible. A contaminated cloth mask may transfer pathogen from the mask to the bare hands of the wearer. 
    • Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection.
    • Cloth masks should not be recommended for health care workers, particularly in high-risk situations.
  • Review of N95 and surgical masks against respiratory infection (2016) https://www.cmaj.ca/content/cmaj/188/8/567.full.pdf
    From January 1990 to December 2014.  6 clinical studies: 3 randomized controlled trials (RCTs), 1 cohort study and 2 case–control studies, and 23 surrogate exposure studies. In the meta-analysis of the clinical studies, “we found no significant difference between N95 respirators and surgical masks in associated risk of (a) laboratory-confirmed respiratory infection, (b) influenza-like illness, or (c) reported work-place absenteeism.”
  • Review of masks and N95s against respiratory infection (2017) https://doi.org/10.1093/cid/cix681
    Separate meta-analyses of 6 randomized controlled trials (RCTs) and 23 observational studies conducted during the 2003 SARS pandemic. Compared to medical masks, N95 respirators provided greater protection against clinical respiratory illness (CRI) and bacterial respiratory illness (BRI). These 2 outcomes were common in these trials (average risks of 8.7% and 7.3%, respectively). Compared to masks, N95 respirators conferred superior protection against clinical respiratory illness and laboratory-confirmed bacterial, but not viral infections or influenza like illness (ILI). Self-reported assessment of clinical outcomes was prone to bias. Evidence of a protective effect of masks or respirators against verified respiratory infection was not statistically significant.
  • *Randomized Controlled Trial: N95 vs Medical Masks in health care workers (HCWs) against influenza (2019). https://jamanetwork.com/journals/jama/fullarticle/2749214
    2862 randomized participants, 2371 completed the study and accounted for 5180 HCW-seasons. Among outpatient health care personnel, N95 respirators (8.2%) vs medical masks (7.2%) resulted in no significant difference in the incidence of laboratory-confirmed influenza. 90% said they wore the mask all the time.
  • Review of N95 respirators versus surgical masks against influenza (2020) https://doi.org/10.1111/jebm.12381
    6 randomized controlled trials (RCTs) involving 9,171 participants were included. (2015-2020). There were no statistically significant differences in preventing laboratory-confirmed influenza, laboratory-confirmed respiratory viral infections, laboratory-confirmed respiratory infection and influenza-like illness using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization. The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza.
  • CDC Review since 1946 – influenza (2020): Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective and Environmental Measures.” 
    There is limited evidence for their effectiveness in preventing influenza virus transmission either when worn by the infected person for source control or when worn by uninfected persons to reduce exposure. “In our systematic review, we identified 10 RCTs that reported estimates of the effectiveness of face masks in reducing laboratory-confirmed influenza virus infections in the community from literature published during 1946–July 27, 2018….In pooled analysis, we found no significant reduction in influenza transmission with the use of face masks…Our systematic review found no significant effect of face masks on transmission of laboratory-confirmed influenza….Proper use of face masks is essential because improper use might increase the risk for transmission.” https://wwwnc.cdc.gov/eid/article/26/5/19-0994_article
  • A study of 4 patients in South Korea (2020)
    Known patients infected with SARS-CoV-2 wore masks and coughed into a Petrie dish. “Both surgical and cotton masks seem to be ineffective in preventing the dissemination of SARS–CoV-2 from the coughs of patients with COVID-19 to the environment and external mask surface.” https://www.acpjournals.org/doi/10.7326/M20-1342
  • A study different types of face coverings – non-clinical setting (Aug 2020) https://advances.sciencemag.org/content/early/2020/08/07/sciadv.abd3083
    A person wears a face mask and speaks into the direction of an expanded laser beam inside a dark enclosure. Droplets that propagate through the laser beam scatter light, which is recorded with a cell phone camera. A simple computer algorithm then counts the droplets seen in the video. They used a black box, a laser, and a camera. “The laser beam is expanded vertically to form a thin sheet of light, which they shined through slits on the left and right of the box.” The is a hole in the front of the box where a speaker can talk into it. A camera is placed on the back of the box to record light that is scattered in all directions by the respiratory droplets that cut through the laser beam when they talk. 
    • The N95, led to a droplet transmission of below 0.1%. 
    • Cotton and polypropylene masks, some of which were made from apron material, proved beneficial, showing a droplet transmission ranging from 10% to 40%. 
    • Knitted mask released a higher number of droplets, with up to 60 percent droplet transmission.
    • Neck fleece, which had 110% droplet transmission (10% higher than not wearing a mask).
    • Speaking through some masks (particularly the neck fleece, bandanas) seemed to disperse the largest droplets into a multitude of smaller droplets … which explains the apparent increase in droplet count relative to no mask in that case.

Study from France

https://swprs.org/wp-content/uploads/2020/09/france-masks-cases2-e1600240628130-1024x570.jpg
https://swprs.org/face-masks-evidence/ (Swiss Policy Research)
Johns Hopkins, 9/21/2020

Negative Effects of Masks 
Air inside the mask is definitely stale.  In filtering particles, the mask makes it harder to breathe. 

  • Decreased PaO2
    • 2004. End stage renal disease patients during dialysis x 4 hours. 39 patients, mean 57 y/o. 70% had decreased PaO2 (from 100 to 92); increased respiratory rate 16 to 18; increased chest discomfort (3 to 11 patients); increased respiratory distress (1 to 17); 19% had hypoxemia. https://pubmed.ncbi.nlm.nih.gov/15340662/
    • One 2008 study of surgeons in the OR found a small drop in SpO2 (peripheral capillary O2 saturation). Scientists looked at O2 levels of surgeons wearing masks while performing surgery and found: “Our study revealed a decrease in the oxygen saturation of arterial pulsations (SpO2 went from 98 to 96) and a slight increase in pulse rates compared to preoperative values in all surgeon groups.” http://scielo.isciii.es/pdf/neuro/v19n2/3.pdf
  • Increased CO2 – This may be merely theoretical. It is hard to tell if the headaches experienced by HCWs with N95s is CO2 or having a strap around the head.
    • Carbon dioxide molecules freely diffuse through the masks, allowing normal gas exchange while breathing.
    • CO2 is present in the atmosphere at a level of about 0.04% (400ppm). According to the U.S. Department of Agriculture / OSHA, carbon dioxide becomes toxic at concentrations above 4 percent (40,000ppm); symptoms at 5-10,000 ppm. 10,000 ppm has been measured behind mask.
  • Scandinavian 2005 HCW study: 37.3% reported face-mask-associated headaches, 32.9% reported headache frequency >6 times per month. 7.6% had taken sick leave from March 2003 to June 2004 (mean 2 days; range 1-4 days) and 59.5% required use of abortive analgesics because of headache. https://pubmed.ncbi.nlm.nih.gov/16441251/
  • Japanese 2009 study with similar headache results. “Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: A randomized controlled trial” https://pubmed.ncbi.nlm.nih.gov/19216002/
  • While there are some articles reporting OSHA tests, it is not clear they were proper tests. 
    • Some people have mistakenly claimed that OSHA standards (e.g., the Respiratory Protection standard, 29 CFR 1910.134; the Permit-Required Confined Space standard 29 CFR 1910.146; and the Air Contaminants standard, 29 CFR 1910.1000) apply to the issue of oxygen or carbon dioxide levels resulting from the use of medical masks or cloth face coverings in work settings with normal ambient air (e.g. healthcare settings, offices, retail settings, construction). These standards do not apply to the wearing of medical masks or cloth face coverings in work settings with normal ambient air). These standards would only apply to work settings where there are known or suspected sources of chemicals (e.g., manufacturing facilities) or workers are required to enter a potentially dangerous location (e.g., a large tank or vessel). https://www.osha.gov/SLTC/covid-19/covid-19-faq.html
  • But when asked should we be worried about CO2, mask proponents say, “No” because you can exhale around the sides of the mask. Of course, this defeats the purpose. https://pubmed.ncbi.nlm.nih.gov/16441251/
  • Moisture retention, reuse of cloth masks, frequency and effectiveness of cleaning, and poor filtration may result in increased risk of infection. 
  • Self-contamination through repeated use and improper doffing is possible.  The virus may survive on the surface of the mask.  The pathogen goes from mask to bare hands.
  • “Mask mouth” reported by dentists.  Wearing masks increases dryness, which leads to decrease in saliva. It is the saliva that fights bacteria. Result is decaying teeth, receding gum lines and seriously sour breath. Gum disease — or periodontal disease — will eventually lead to strokes and an increased risk of heart attacks” https://nypost.com/2020/08/05/mask-mouth-is-a-seriously-stinky-side-effect-of-wearing-masks/
  • World Health Organization (WHO, June 5, 2020)
    “The likely disadvantages of the use of mask by healthy people in the general public include: 
    • potential increased risk of self-contamination due to the manipulation of a face mask and subsequently touching eyes with contaminated hands;
    •  potential self-contamination that can occur if non- medical masks are not changed when wet or soiled. This can create favourable conditions for microorganism to amplify; 
    • potential headache and/or breathing difficulties, depending on type of mask used; 
    • potential development of facial skin lesions, irritant dermatitis or worsening acne,
    • when used frequently for long hours;(50) 
    • difficulty with communicating clearly; 
    • potential discomfort;(41, 51) 
    • a false sense of security, leading to potentially lower 
    • adherence to other critical preventive measures such as physical distancing and hand hygiene; 
    • poor compliance with mask wearing, in particular by young children; 
    • waste management issues; improper mask disposal leading to increased litter in public places, risk of contamination to street cleaners and environment hazard; 
    • difficulty communicating for deaf persons who rely on lip reading; 
    • disadvantages for or difficulty wearing them, especially for children, developmentally challenged persons, those with mental illness, elderly persons with cognitive impairment, those with asthma or chronic respiratory or breathing problems, those who have had facial trauma or recent oral maxillofacial surgery, and those living in hot and humid environments.” 
  • The Hamburg Environmental Institute warned of the inhalation of chlorine compounds in polyester masks as well as problems in connection with face mask disposal.

Positive Mask Studies

  • A U.S. study of airborne transmission (May 2020) https://www.pnas.org/content/117/26/14857
    Study claimed that masks had led to a decrease in infections in three global hotspots (including New York City). This did not take into account the natural decrease in infections and other measures. The study was so flawed that over 40 scientists recommended that the study be withdrawn.
  • A U.S. study comparing states with mask mandates (June 2020).https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00818
    Study concluded that mandatory masks had led to a decrease in infections in 15 states. The study did not take into account that the incidence of infection was already declining in most states at that time. A comparison with other states was not made.
  • A U.S. study comparing masks, lockdowns in various countries (June 2020). https://www.medrxiv.org/content/10.1101/2020.05.22.20109231v3.full.pdf
    Study concluded that countries with mandatory masks had fewer deaths than countries without mandatory masks. But the study compared African, Latin American, Asian and Eastern European countries with very different infection rates and population structures.

Conclusions from Organizations

“Advice to decision makers on the use of masks for healthy people in community settings:
“The wide use of masks by healthy people in the community setting is not supported by current evidence and carries uncertainties and critical risks.”
“Medical masks should be reserved for health care workers. The use of medical masks in the community may create a false sense of security, with neglect of other essential measures, such as hand hygiene practices and physical distancing, and may lead to touching the face under the masks and under the eyes, result in unnecessary costs, and take masks away from those in health care who need them most, especially when masks are in short supply.” 

“Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.” WHO acknowledges that most people do not use masks properly.

But on June 8, 2020:  The World Health Organization has changed its stance on wearing face masks during the COVID-19 pandemic. People over 60 and people with underlying medical conditions should wear a medical-grade mask when they’re in public and cannot socially distance.” The general public should wear a three-layer fabric mask in those situations. Admitting that this was despite evidence with randomized controlled trials. “The use of a mask alone is insufficient to provide an adequate level of protection or source control, and other personal and community level measures should also be adopted to suppress transmission of respiratory viruses.”

  • Dr. Nancy Messonnier, director of the Center for the National Center for Immunization and Respiratory Diseases. 
    https://www.cdc.gov/media/releases/2020/t0131-2019-novel-coronavirus.html
    “We don’t routinely recommend the use of face masks by the public to prevent respiratory illness,” said on January 31. “And we certainly are not recommending that at this time for this new virus.”
  • The Centers for Disease Control and Prevention (CDC)
    https://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm
    In March 5, 2019 regarding the flu: “Masks are not usually recommended in non-healthcare settings; however, this guidance provides other strategies for limiting the spread of influenza viruses in the community:
    *Cover their nose and mouth when coughing or sneezing,
    *Use tissues to contain respiratory secretions and, after use, to dispose of them in the nearest waste receptacle, and
    *Perform hand hygiene (e.g., handwashing with non-antimicrobial soap and water, and alcohol-based hand rub if soap and water are not available) after having contact with respiratory secretions and contaminated objects/materials.
  • From the New England Journal of Medicine, Universal Masking in the Covid-19 Era, July 9, 2020; https://www.nejm.org/doi/full/10.1056/NEJMp2006372
    “We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.” 
    But later the authors said “A growing body of research shows that the risk of SARS-CoV-2 transmission is strongly correlated with the duration and intensity of contact: the risk of transmission among household members can be as high as 40%, whereas the risk of transmission from less intense and less sustained encounters is below 5%.  This finding is also borne out by recent research associating mask wearing with less transmission of SARS-CoV-2, particularly in closed settings.”https://www.nejm.org/doi/full/10.1056/NEJMc2020836
  • Holland’s Medical Care Minister Tamara van Ark
    https://www.thesun.co.uk/news/uknews/12292821/face-masks-not-necessary-say-holland-scientists/
    “Despite a global stampede of mask-wearing, data show that 80-90 percent of people in Finland and Holland say they “never” wear masks when they go out, a sharp contrast to the 80-90 percent of people in Spain and Italy who say they “always” wear masks when they go out. “From a medical point of view, there is no evidence of a medical effect of wearing face masks, so we decided not to impose a national obligation.” 

Panel: Recommendations on face mask use in community settings (March 2020)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118603/

WHO

  • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected SARS-CoV-2 infection.

China

  • People at moderate risk of infection: surgical or disposable mask for medical use.
  • People at low risk of infection: disposable mask for medical use.
  • People at very low risk of infection: do not have to wear a mask or can wear non-medical mask (such as cloth mask).

Hong Kong

  • Surgical masks can prevent transmission of respiratory viruses from people who are ill. It is essential for people who are symptomatic (even if they have mild symptoms) to wear a surgical mask.
  • Wear a surgical mask when taking public transport or staying in crowded places. It is important to wear a mask properly and practice good hand hygiene before wearing and after removing a mask.

Singapore

  • Wear a mask if you have respiratory symptoms, such as a cough or runny nose.

Japan

  • The effectiveness of wearing a face mask to protect yourself from contracting viruses is thought to be limited. If you wear a face mask in confined, badly ventilated spaces, it might help avoid catching droplets emitted from others but if you are in an open-air environment, the use of face mask is not very efficient.

USA

  • Centers for Disease Control and Prevention does not recommend that people who are well wear a face mask (including respirators) to protect themselves from respiratory diseases, including COVID-19.
  • US Surgeon General urged people on Twitter to stop buying face masks.

UK

  • Face masks play a very important role in places such as hospitals, but there is very little evidence of widespread benefit for members of the public.

Germany

  • There is not enough evidence to prove that wearing a surgical mask significantly reduces a healthy person’s risk of becoming infected while wearing it. According to WHO, wearing a mask in situations where it is not recommended to do so can create a false sense of security because it might lead to neglecting fundamental hygiene measures, such as proper hand hygiene.

Final Thoughts

  • Surgical masks are loose fitting. They are designed to protect the patient from the doctors’ respiratory droplets.  There wearer is not protected from others airborne particles
  • People do not wear masks properly. Most people have the mask under the nose. The wearer does not have glasses on and the eyes are a portal of entry.  If the virus lands on the conjunctiva, tears will wash it into the nasopharynx.
  • Most studies cannot separate out hand hygiene.
  • The designer masks and scarves offer minimal protection – they give a false sense of security to both the wearer and those around the wearer. 
    **Not to mention they add a perverse lightheartedness to the situation.
  • If you are walking alone, no mask – avoid folks – that is common sense.
  • Children under 2 should not wear masks – accidental suffocation and difficulty breathing in some
  • Even if a universal mask mandate were imposed, several studies noted that folks do not use the mask properly, over-report their wearing.  Additionally, how would the mandate be enforced?
  • The positive studies are models that assume universality and full compliance
  • If wearing a mask makes people go out and get Vitamin D – go for it. In the 1918 flu pandemic people who went outside did better.  Early reports are showing people with COVID-19 with low Vitamin D do worse than those with normal levels. Perhaps that is why shut-ins do so poorly. https://www.medrxiv.org/content/10.1101/2020.04.08.20058578v4

Wash your hands ———- If you are sick, stay home!

Objects and surfaces

  • Person to person touching
  • The CDC’s most recent statement regarding contracting COVID-19 from touching surfaces: “Based on data from lab studies on Covid-19 and what we know about similar respiratory diseases, it may be possible that a person can get Covid-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose or possibly their eyes,” the agency wrote. “But this isn’t thought to be the main way the virus spreads. https://www.cdc.gov/media/releases/2020/s0522-cdc-updates-covid-transmission.html.  
  • Chinese study with data taken from swabs on surfaces around the hospital
    https://wwwnc.cdc.gov/eid/article/26/7/20-0885_article?deliveryName=USCDC_333-DM25707
    • The surfaces where tested with the PCR (polymerase chain reaction) test, which greatly amplifies the viral genetic material if it is present. That material is detectable when a person is actively infected. At the time of the study, it was thought to be the most reliable test. Because of the amplification of the viral material, there are many false positives. It is not clear that the mere presence of virus means it is infectious.
      • Computer mouse (ICU 6/8, 75%; General ward (GW) 1/5, 20%) 
      • Trash cans (ICU 3/5, 60%; GW 0/8)
      • Sickbed handrails (ICU 6/14, 42.9%; GW 0/12) 
      • Doorknobs (GW 1/12, 8.3%) 
      • 81.3% of the miscellaneous personal items were positive: 
        • Exercise equipment
        • Medical equipment (spirometer, pulse oximeter, nasal cannula) 
        • PC and iPads
        • Reading glasses 
        • Cellular phones (83.3% positive for viral RNA)
        • Remote controls for in-room TVs (64.7% percent positive) 
        • Toilets (81.0% positive)
        • Room surfaces (80.4% of all sampled)
        • Bedside tables and bed rails (75.0%)
        • Window ledges (81.8%)
        • Plastic: up to 2-3 days 
        • Stainless Steel: up to 2-3 days 
        • Cardboard: up to 1 day 
        • Copper: up to 4 hours 
        • Floor – gravity causes droplets to fall to the floor. Half of ICU workers all had virus on the bottoms of their shoes

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