Masking Covid-19’s ‘Power of One’ – Prof Alan Whiteside

Just how important it is to take radical individual responsibility in containing this runaway global pandemic is illustrated by one infected South Korean who visited several nightclubs, infecting 34 people and single-handedly putting his county on the global “increasing epidemics” Covid-19 map. There is now little argument that double-layered face masks significantly reduce infection, along with social distancing and regular hand-hygiene, but confusing messages from the world’s health and political leadership have caused massive damage. It’s a game of ‘choose your experts wisely.” Witness the World Health Organisation (WHO), recognising pre-symptomatic transmission, yet insisting that people who feel healthy do not need to wear face masks. Pre-symptomatic transmission accounts for half or more of new Covid-19 infections. The WHO says face masks lead to a ‘false sense of security’ and reduced usage of other methods – a notion unsupported by any preceding research literature. SA supermarkets quoted the WHO’s face mask advice on placards outside their stores – and suffered serious outbreaks. It’s simple, says this author; a cloth mask that fits well, made up of two or more layers, limits the spread of infected respiratory droplets and smaller particles (aerosols) when a person with the disease talks, shouts, laughs, sings, coughs or sneezes. End of story. There is no vaccine and there may never be one. Make a plan. – Chris Bateman

Covid-19 watch: Reproduction rates, graphs and face masks

By Alan Whiteside*

Introduction

When writing I use quotations, aphorisms, and occasionally lines of poetry. Leonard Courtney (1832 – 1918), a British politician and president of the Royal Statistical Society said, ‘the price of peace is eternal vigilance’. Our watchword must be ‘the price of epidemic control is eternal vigilance.’^[2] The Covid-19 pandemic is entering a new phase. That is not to suggest it is under control or that the battle is over. Far from it. In some countries cases and deaths continue to climb, in others the control is precarious. We need to monitor, and be ready to act.

This week has been especially fascinating with interesting new developments. There is more evidence the virus reached Europe before the end of 2019. In addition to the case in France, a choir in Bradford (UK) reported a cluster of illness in early January. It began with the partner of a man who returned from business in Wuhan on 17 or 18 December.^[3] Korea was a poster child for epidemic control but in the last week has seen a small number of new cases.

The pandemic is increasingly divergent, but also very fluid. We are getting a sense of what does and not work. This week’s communique includes a guest section by Warren Parker on face masks. In addition, I reflect on the appalling leadership in some countries. Sadly, one of these is the UK.

The Numbers

At 8am on 13th May 2020 the JHU Coronavirus Resource Centre recorded 4,262,799 global infections. ^[4] This is up from 3,664,011 a week ago. Absolute numbers are shown in Table 1, Russia has been added.

Table 1: Global & National Cumulative Numbers of Confirmed Covid-19 Cases (Alphabetical order)^[5]

Date	Global cases	China	France	Italy	Russia	South Korea	South Africa	Spain	United Kingdom	United States
15th Feb	69,000	68,400	12	3	2	28	0	2	9	43
4th Mar	93,000	80,480	288	3,100	3	5,600	0	222	86	149
11th Mar	120,000	80,900	2,300	12,500	20	7,800	13	2,300	459	1,300
18th Mar	201,500	81,100	9,100	35,700	147	8,400	116	13,900	2,600	7,800
25th Mar	423,000	81,700	25,600	74,400	658	9,100	709	49,500	9,600	65,800
1st April	861,000	82,400	57,000	110,600	2,777	9,900	1,400	104,100	29,900	213,400
8th April	1,431,357	82,783	110,070	135,586	8,672	10,384	1,749	141,942	55,949	399,886
15th April	1,982,552	83,351	131,362	162,488	24,490	10,591	2,415	174,060	94,845	609,422
22nd April	2,565,258	83,864	159,300	183,957	57,999	10,694	3,465	204,178	130,184	835,306
29th April	3,117,756	83,940	169,053	201,505	99,399	10,761	4,996	232,128	162,350	1,012,583
6th May	3,664,011	83,968	170,694	213,013	165,929	10,806	7,572	219,329	196,243	1,204,475
13th May	4,262,799	84,018	178,349	221,216	232,243	10,962	11,350	228,030	227,741	1,369,964

At the beginning of an epidemic actual cases provide the best, and often, the only data. As it evolves, other information becomes important and valuable. It is hard to compare absolute numbers in China with its population of 1.439 billion, with the United States’ 331 million people, or South Africa’s 59 million people. To make useful comparisons we need to look at rates.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order) ^[6]

	China	France	Italy	Russia	South Korea	South Africa	Spain	United Kingdom	United States
Deaths per million 12th May	3.33	397.34	508.66	13.91	5	3.57	572.39	482.26	246.2
Total Cases per million 11th May	58	2,130	3,623	75	212	168	4,799	3,228	4,017

It is worth revisiting some of the terms and concepts that are used in reporting on the epidemic. In the United Kingdom the number bandied about at nightly briefings is the reproduction rate. What exactly is this? It is the number of new infections one individual transmits.^[7] If each person infects more than one other person then the epidemic will continue to grow. If it falls below one, the epidemic will shrink. The period for which a person is infectious is finite. Those with no symptoms will be infectious for about 15 days. Those with mild to moderate symptoms can infect others for up to 3 weeks. People with severe to more critical symptoms will be infectious for much longer. What makes this pandemic unique is most have no symptoms for the first 4 to 5 days after acquiring Covid-19 but can infect others during some of this period. That is one of the major arguments for a period of lockdown. There is logic in trying to control the epidemic through this measure initially, but it has a cost.

Deaths and cases are counted and reported although there are many caveats about the reliability. Are they all recorded and reported? We still do not have an antibody test to tell who has been infected and recovered.^[8] This is increasingly important for knowing where we are in the pandemic and individual country epidemics. It would allow surveys that show what percentage of the population has been infected and, theoretically, may have some immunity.

Graphs

There are a huge number of publications ranging from blogs to peer reviewed articles (that have, inevitably, been fast tracked through the peer review process, which carries its own risks). To the credit of many news organisations, journals, and other media they are making their Covid-19 coverage free to users. Unfortunately, the lunatic fringe is also writing, publishing and distributing items that range from confused to malevolent. The Atlantic wrote: “If Someone Shares the ‘xxxxxxxx’ Video, How Should You Respond?  Experts provide scripts to help you push back as effectively as possible.”^[9] This is not a new phenomenon; we saw it in the AIDS epidemic and know bad science and denialism cost lives. In The Atlantic article the author, psychologist Joshua Coleman, suggests: “It’s always important to respond in a way that doesn’t suggest that the other [person] is foolish, naive, or gullible, as much as you think they may be.”

This week I want to highlight the New York Times’ interactive site.^[10] This allows readers to drill in on countries and see how their epidemics are progressing. Most interesting are the graphs showing, by country, where epidemics are increasing, decreasing or remaining the same. It should be noted that the category ‘mostly the same’ might be acceptable if cases were at a low level. The US and UK fall in this category but have high numbers of cases.

The surprising country in the ‘increasing epidemic’ category is South Korea with 34 new cases.^[11] This came mainly from an outbreak from nightclubs visited by a confirmed patient. Singapore saw an increase in new cases among migrant workers, but it seems to be under control. India has over 70,000 cases and numbers are rising rapidly. Covid-19 is taking off in some countries in Africa. Most concerning at this point are South Africa with over 10,000 cases and Nigeria with 4,641 cases. Numbers are rising in other African countries from a low base. In Latin America Brazil, Argentina, Chile, Peru, Colombia and Mexico all have significant numbers of cases and numbers are rising rapidly. The Russian epidemic is taking off rapidly with 221,000 cases there (166/100,000 pop). Numbers have fallen in Spain and Italy but overall infections have been very high (576/100,000 pop and (366/100,000 pop).

The other graph to highlight is of economic recovery. Politicians and economists talk of V, U and L shaped graphs. A ‘V’ would be a sharp fall in economic growth followed by a sharp recovery. The ‘U’ shape signifies a longer period with low growth while an ‘L’ would show a drop and no recovery. There is no sign of a V, especially since the crisis is not over.

The Consequences

Economics

Millions of people in OECD countries are losing their jobs, and government support of various levels is being put in place. In the global South the picture is much bleaker. The economies and unemployment are as badly, if not worse affected, and there is generally no social support system. As a result, there is a real danger of mass famine.

In the UK the scheme to pay wages of workers on leave will be extended to October. The Chancellor, Rishi Sunak, says employees will continue to receive 80% of monthly wages up to £2,500. However, “the government will ask companies to “start sharing” the cost of the scheme from August. …… Sunak said: “I’m extending the scheme because I won’t give up on the people who rely on it….Our message today is simple: we stood behind Britain’s workers and businesses as we came into this crisis, and we will stand behind them as we come through the other side.”^[12]

Leadership

The lack of leadership in the UK and the USA is extraordinary. The ravings of Donald Trump hit international media with depressing regularity and need no further comment this week. The UK is, however, another matter. On 10^th May Boris Johnson addressed the nation. He is desperate to unlock the economy and get Britain back to work. The slogans up to then were models of simplicity: “Stay at Home”, “Protect the NHS”. There was significant national compliance. His new slogan is “Stay Alert, Control the Virus”, generally regarded as too simplistic, causing confusion, bewilderment and bemusement.^[13] I am reminded of saying  ‘Don’t be alert, we have enough lerts’. This has marked a divergence in response with Wales, Scotland and Northern Ireland not easing their lockdown in any way. The implications of this for the ‘United Kingdom’ are unclear.

In South Africa the lockdown continues. There was an attempt to redefine it – the initial lockdown was extreme. In addition to restriction on movement the sale of alcohol and tobacco was banned. When the country moved from level 5 to level 4 it was believed (hoped) by many that these goods would be available. When the guidelines were published people learned cigarettes remained banned until the country moves to level 3 and alcohol until level 2.^[14] The logic is unclear and the consequences for the credibility of the government and the exchequer are bleak.^[15] The ANC leadership come across as killjoys!

The medical profession holds many people’s lives in their hands. In so many countries they have stepped forward and are providing top quality care whilst working long hours. We know that they are at risk of infection and death. It has been moving therefore to see senior leaders in global health writing about their brushes with Covid-19.

Paul Garner, professor of infectious disease at the Liverpool School of Tropical Medicine, published his experiences under the title “for seven weeks I have been through a rollercoaster of ill-health, extreme emotions, and utter exhaustion”. He describes how the illness went on and on. “The symptoms changed, it was like an advent calendar, every day there was a surprise, something new. The aim of this piece is to get the message out: for some people the illness goes on for a few weeks. Symptoms come and go, are strange and frightening. The exhaustion is severe, real and part of the illness. And we all need support and love from the community around us.”^[16]

Peter Piot is the director of the London School of Hygiene and Tropical Medicine. He was one of the discoverers of Ebola in 1976. He ran the joint United Nations Programme on HIV AIDS (UNAIDS) from 1995 to 2008. He spent a week in the hospital with Covid-19. His description of his experience is stark, “let’s be clear: without a Coronavirus vaccine we will never be able to live normally again the only real exit strategy from this crisis is a vaccine that can be rolled out worldwide… And despite the efforts, it is still not even certain that developing a Covid 19 vaccine is possible”^[17] It is salutary to read of people falling ill and suffering this way. Although the number of people who will have severe or critical symptoms is a minority, it is still significant.

The Importance of Facemasks by Warren Parker^[18]

Alan asked me to contribute 600 words on COVID-19 prevention with a focus on face masks. He knows that I could write 10,000.

Many people are enduring vast changes to their lives and lifestyles, including direct and severe impacts on families, friends and communities. It is quite hard to comprehend that in many countries globally COVID-19 has slowed and even been contained at low infection levels. But there is evidence that prevention measures work.

Most East Asian countries passed through their initial epidemics in less than four months and are mainly dealing with outbreaks. In most of these countries, wearing face masks was a requirement when in crowded spaces. Asian populations have been accustomed to moderating respiratory epidemics through this means to prevent onward transmission to others. Surgical face masks were either already widely available or rapidly manufactured to address the rapidly growing COVID-19 epidemic. Of interest, Singapore did not require face masks at the outset, and managed to minimize new infections through other methods. But these were insufficient to stop an outbreak from occurring among close-quartered migrant workers, and new infections thus reached very high levels.

Over a similar period, many European countries have moved past their peak and a number are already at levels lower than 1 new infection per 100,000 people per day. Austria, Czechia, Poland and Germany all fall within this group. All have incidentally also adopted face masks for COVID-19 prevention among other measures. Czechia, an early adopter of cloth face masks, had a flatter epidemic curve in comparison to other countries.

A few countries have rolling epidemics. That is, epidemics that reach a high peak and remain at high levels over many weeks. This is mainly due to the introduction of lockdowns and other social distancing measures when underlying infection levels are already very high. The UK is an example of this hubris, and here prevention efforts were further stymied by the only very recent inclusion of face masks as a prevention measure. Sweden has a rolling epidemic and high death rates but is yet to consider introducing face masks in public settings.

A face mask is simply a barrier that limits the spread of infected respiratory droplets and smaller particles (aerosols) when a person with the disease talks, shouts, laughs, sings, coughs or sneezes.^[19] Cloth masks are effective if they fit well and are made up of two or more layers.

Most transmission occurs during the pre-symptomatic phase when people are infectious but feel healthy and are thus mobile.^[20] Sans face mask, and in close proximity to others on public transport or at shops or workplaces, transmission is highly efficient.

To achieve a prevention effect at community level, wearing of face masks must be ubiquitous since it is impossible to know who is infectious. A combination of methods works best. Thus, face masks in conjunction with physical distancing of around 2 meters markedly increases the preventive effect. Add in some handwashing at key moments and we have highly efficient prevention.

While this is not hard to understand, and the basic science for preventing respiratory virus transmission has been available for years for influenza and coronaviruses such as SARS, there have been some baffling responses.

The WHO recognises pre-symptomatic transmission yet insists people who feel healthy do not need to wear face masks. This recommendation is long standing and is current to this day, yet pre-symptomatic transmission accounts for half or more of new COVID-19 infections. The WHO also single out face masks as leading to a ‘false sense of security’ and reduced utilisation of other methods – a notion not borne out in any preceding research literature whatsoever.^[21]

The harms of baffling recommendations are plain to see. In the early months of the COVID-19 epidemic in South Africa, supermarkets and pharmacies echoed the WHO’s ‘wisdom’ by placarding their stores with signs saying ‘WHO says face masks are not necessary for COVID prevention’. Instead, emphasis was prominently placed on hand hygiene.^[22] This was of immediate concern, and I and colleagues developed and distributed a scientific briefing document for retailers that highlighted the mechanisms of COVID-19 transmission. This included drawing attention to the misleading WHO guidance and requesting that signs be taken down. We were essentially told to mind our own business based on WHO guidance. Consequently, there were dozens of outbreaks in supermarkets and pharmacies in our country affecting hundreds of staff members and uncounted consumers.^[23]

This is but one example of the singular battle in the COVID-19 epidemic. It is not only the battle for public health measures and related practical steps for preventing and mitigating this epidemic. We are in the battle of our lives that centers false narratives undermining efforts to contain this disease, and the examples shared here apply to ‘experts’ and authorities globally. We are learning a harsh lesson and can only hope accountability will be included in our reflection of this complex pandemic.

Conclusion

Another week passes. Where is the global leadership to tell us where we are, and set out a roadmap for where we might go? Stephen Lewis, an iconic Canadian intellectual, politician and troublemaker, has, for a number of years produced a three to four-minute weekly review.^[24] It is a must watch for me. I do not think WHO’s Tedros needs to copy his outrage, but I do think he could do something similar. We need a regular ‘state of the world, state of the epidemic’ briefing from our leadership. If not Tedros perhaps someone like Bill Clinton or Bill Gates could take it on.

And finally another complete non-sequitur on aircraft movements. The house I am in lockdown in is 15 minutes’ walk from Norwich international airport. The runways do not point towards us, so I can enjoy the sight of planes without the noise. The taxiways are currently parking lots for grounded aircraft, many with British Airways liveries. On Monday 11^th two planes took off, turned, flew the downwind leg, made an approach, and landed. Exercise for aircraft? On a more serious note, pilots are not getting their flying hours, and this may cause problems. 

References (websites this week):

The Business portal in South Africa https://www.biznews.com/

Stephen Lewis https://aidsfreeworld.org/commentary

The New York Times www.nytimes.com/interactive/2020/world/coronavirus-maps.html

^[1] Red text indicates figures or information will change. Bold text indicates a key point.

^[2] I don’t mind using others’ wisdom, with attribution! Oscar Wilde is said to have responded to a particularly witty comment “I wish I’d said that”. His companion, quick as a flash, said, “You will, Oscar, you will.”

^[3] https://www.bbc.co.uk/news/health-52589449

^[4] https://coronavirus.jhu.edu/map.html

^[5] These data are from the JHUM website. The countries are chosen because of their epidemics.

^[6] The countries were chosen because of their epidemics. Sources: Deaths www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/

Case per million ourworldindata.org/grapher/total-confirmed-cases-of-covid-19-per-million-people

^[7] James Gallagher, Coronavirus R: Is this the crucial number?, www.bbc.co.uk/news/health-52473523

^[8] In the UK at least.

^[9] www.theatlantic.com/family/archive/2020/05/plandemic-video-what-to-say-conspiracy/611464/ the video is not named on purpose.

^[10] www.nytimes.com/interactive/2020/world/coronavirus-maps.html

^[11] https://www.theguardian.com/world/2020/may/10/it-isnt-over-south-korea-records-34-new-cases-the-highest-in-a-month

^[12] https://www.bbc.co.uk/news/business-52634759

^[13] https://edition.cnn.com/2020/05/11/uk/matt-lucas-boris-johnson-video-scli-intl-gbr/index.html

^[14] https://sacoronavirus.co.za/covid-19-risk-adjusted-strategy/

^[15] https://www.biznews.com/premium/2020/05/11/covid-19-cigarettes-alcohol-ban

^[16] The British Medical Journal Opinion https://blogs.bmj.com/bmj/2020/05/05/paul-garner-people-who-have-a-more-protracted-illness-need-help-to-understand-and-cope-with-the-constantly-shifting-bizarre-symptoms/

^[17] Dirk Draulans, ‘Finally, a virus got me.’ Scientist who fought Ebola and HIV reflects on facing death from COVID-19, https://www.sciencemag.org/news/2020/05/finally-virus-got-me-scientist-who-fought-ebola-and-hiv-reflects-facing-death-covid-19

^[18] Dr Warren Parker has worked in public health for 30 years with a focus on disease prevention. He is currently involved in diverse COVID-19 prevention efforts. He can be reached at [email protected]

^[19] Asadi S, Wexler AS, Cappa CD, Barreda S, Bouvier NM, Ristenpart WD. Aerosol emission and superemission during human speech increase with voice loudness. Scientific reports. 2019 Feb 20;9(1):1-0.

^[20]  Furukawa NW, Brooks JT, Sobel J. Evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.201595

^[21] Cheng KK, Lam TH, Leung CC. Wearing face masks in the community during the COVID-19 pandemic: altruism and solidarity. The Lancet. 2020 Apr 16. https://doi.org/10.1016/S0140-6736(20)30918-1

^[22] https://www.dailymaverick.co.za/article/2020-03-20-supermarkets-and-experts-step-up-efforts-to-keep-staff-and-customers-safe/

^[23] https://www.news24.com/SouthAfrica/News/covid-19-outbreaks-at-supermarkets-a-concern-for-western-cape-government-20200416

^[24] https://aidsfreeworld.org/commentary

• Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.