THE MASKERS COMIC
WHY WE MASK
By Shea O’Neil
Last updated: 12-1-23
1- Masking prevents infection, transmission, slows viral evolution, and
makes treatments stay more effective for longer.
COVID-19 is airborne– that is, primarily spread through aerosols emitted when we talk and breath. Omicron variants are especially transmissible and have high viral shedding– even when symptoms are not present. This means it can spread to others before symptoms start (presymptomatic), during asymptomatic infections, or after symptoms subside (a person is often contagious 10 to 14 days, sometimes longer). Because studies show that more than half of transmission is from asymptomatic carriers, it is important to mask when around others outside your household whether you/they are experiencing symptoms or not. Transmission can happen in as little time as 20 seconds to 4 minutes (depending on whether it's a high shedder or average shedder). A Nature study from December 2023 also showed transmission can happen in as little as a few minutes in normal conditions.
N-95, KF-94, KN-95, or better masks filter both the exhaled air (by a person who may be carrying COVID-19), and inhaled air by another, thus significantly reducing risks of transmission.
2- Vaccines do NOT prevent infection or transmission,
and do NOT prevent long COVID.
Vaccination can reduce chances of hospitalization during the acute phase of the disease in some people (not all, as there are still people who are vaccinated who do end up hospitalized or even dying of COVID-19). It does not prevent long COVID.
Vaccine protection also wanes over time, and, due to the high rate of evolution of variants, can be evaded by the virus as well. It is also worth noting that vaccine protection is not all or nothing. For instance, this 2023 study shows vaccines are much more effective in preventing transmission when the person inhales a smaller viral load. Masking can reduce inhaled viral load, which could increase the vaccines’ ability to actually prevent infection. Without masking, an infectious person can infect a person near them no matter what either of their vaccination statuses are.
When transmission occurs and infects higher numbers of people, newer variants are more likely to evolve, many of which become better at evading protections from vaccines and existing treatments.
Vaccines– without the addition of precautions that lower actually lower transmission, such as masking-- means the virus will always be a step ahead of vaccines and other treatments. Thus, a vaccine-only public health strategy is not sufficient.
3- Stopping transmission is vital on the individual health scale and on the societal scale.
It is the basis for health, care, and respect-- a prerequisite for prosocial interactions.
COVID-19 is highly transmissible, with the reinfection rate with Omicron variants being much higher than former COVID variants. COVID-19 continues to kill, as shown in both direct death rates as well as excess death studies. Yet, death metrics only catch part of the suffering, as many are left with worsening health outcomes and disabilities caused from long COVID. Unlike the flu and cold viruses, SARS-CoV-2 infiltrates cells' ACE receptors, allowing it to spread to many areas of the body causing the damaging effects commonly referred to as long COVID, which can be severe, chronic, and deadly.
Long COVID is not rare or limited to people with certain risk factors. It occurs in all ages and demographics. According to the World Health Organization (WHO), “Anyone can develop post COVID-19 condition. Research suggests that approximately 10–20% of COVID-19 patients go on to develop prolonged symptoms that are associated with post COVID-19 condition. Current evidence doesn’t allow us to confidently know who is more likely to be affected”.
Some research shows even higher prevalence, such as a JAMA systematic review in which more than 50% of COVID-19 survivors went on to develop long COVID. In a survey between June 2022 and December 2022 on long COVID in the United States, found that 14% of the more than half a million surveyed reported suffering from long COVID, a disease that affects energy production and often causes organ failure, especially to the heart, brain, and lungs. Millions of people in the United States and world-wide suffer from long COVID.
Long COVID can be serious and debilitating, often reported to impact life worse than cancer and other diseases.
4- Respirator masks, such as N95s, their equivalents, or better, provide significant respiratory protection from COVID-19; surgical masks do not provide adequate protection and should only be used as a last resort.
Decades of scientific research shows that N95 masks provide significantly better protection than surgical masks for aerosol particles, and there is a consensus on dominance of airborne transmission for COVID-19.
Many studies have been done showing that the SARS-CoV-2 virus travels in aerosols that are exhaled in breath, can travel through air vents, and linger in the air for hours, that most COVID is transmitted by aerosols (as opposed to fomite surface contamination or droplet-spread), and that masks that filter our aerosols and have a better fit, such as N95 respirator masks or above, can reduce infection significantly better than surgical masks.
The regulating agency, NIOSH, states: “Surgical masks are not respiratory protection: A surgical mask can help block large particle droplets, splashes, sprays or splatter … They do not form a tight seal against the skin or filter very small airborne pathogens…involved in airborne disease transmission. ”The US Food and Drug Administration (FDA), which regulates surgical masks in the U.S., states “surgical masks are not intended to provide protection against pathogenic biological airborne particulates and are not recommended for use in …any clinical conditions where there is significant risk of infection through inhalation exposure”, and “a filtering facepiece respirator (e.g. N95) with a tight fit is recommended to provide a more reliable level of respiratory protection against pathogenic biologic airborne particulates.”
A 2021 PNAS study found that when only the non-infected person wears a surgical face mask, with an infectious person speaking at a distance of six feet, the risk for infection reaches 90% after 30 minutes. With only the non-infected person wearing an N95 respirator mask in the same situation, infection risk remains at approximately 20% even after one whole hour. When neither wears a mask the risk of the infectious person transmitting to the non-infected is 90% after only a few minutes. However, when both wear a well-fitting N95 mask, infection risk is only 0.4% after an hour. (Note: newer variants are even more infectious since this study was done, meaning time to infectious dose may be lower than these estimates).
N95, equivalents, or better masks, often referred to as respirator masks, do protect against small aerosols and should be used for COVID-19 prevention. Gases such as carbon dioxide and oxygen, are very tiny and can flow through N95 respirator mask material. These masks are safe to wear, although those with certain breathing conditions may find anything that creates resistance difficult to wear, and may need to avoid heavy exercise, take mask breaks, and in rare cases if it interferes with breathing may not be able to wear them. In such situations, it is even more important that others outside their household mask around them.
5- Masking prioritizes the things that we value most: our health, our family, our ability to work, to support our communities, and to thrive.
Extensive research shows that long COVID does pose a significant risk in all populations, occurring in approximately 10-30% of COVID infections (or more), and resulting in symptoms/diseases that are often long-term and debilitating, for which there are no current medications to prevent or cure, and recovery remains rare. Intense fatigue and "brain fog" from long-COVID was rated higher than those recovering from stroke, and similar to that of Parkinson's disease.
People of all ages, health statuses, and vaccination statuses can be affected seriously by COVID infections (including children), some in the initial acute infection phase, some in the long-term stage, some in both.
According to a recent article, the US National Institutes of Health's (NIH) states: “The persistent symptoms after COVID-19 that have been described in children are similar to those seen in adults…” and “while the prevalence of Long Covid in children is lower than adults… given the high overall rate of SARS-CoV-2 infection in children, the burden of post-COVID conditions in children may be quite large.” A 2023 study found 1 in 6 kids have persistent COVID symptomsfor 3 months after infection. Immune-related brain inflammation in children related to COVID-19 infections can manifest as new or worsened anxiety, OCD, ticks, phobias, aggression, worsening in fine motor skills, math, or writing and is often termed Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS).
On top of this, a recent study shows more than 70% of US household-spread COVID-19 started with children, highlighting the need for children (ages 2 and up) to mask, especially in schools which involve many children from different households in a classroom (often poorly ventilated and without appropriate supplemental filtration) for long periods of time.
Not only are children shown to be large drivers of transmission, and able to suffer from the effects of long COVID, but COVID-19 is also a leading cause of death in US children, and the first in deaths caused by infectious or respiratory diseases.
6- Wearing a mask shows you acknowledge the severity of COVID and signals this information to others to take it seriously.
Many are unaware that the WHO now recommends masking irrespective of the local epidemiological situation due to the global spread of the virus, that the CDC recommends having your child wear masks in schools to protect them, and thatCOVID-19 is still classified as a pandemic posing significant threats, including over 1000 deaths per week (an undercount due to reduced testing and surveillance as can be seen in excess deaths data), and has left an estimated 65 million world-wide with long COVID.
Increased complacency and "Return to Normal" political/economic policies have led to rampant unchecked spread of COVID-19, which has resulted in rapid evolutions of omicron sub-variants that can evade antibodies from prior infection/vaccination.
Dropping of protections that reduce transmission has led to new, more contagious sub variants emerging, including those with evolutions to better evade the immune system, such as the ability to infiltrate cells without alerting killer immune cells, and thus avoid detection and destruction by the immune system. Masking reduces transmissions, and thus viral evolutions.
7- Wearing masks helps protect you and others from both short and long-term effects of COVID-19, which are often severe.
No matter whether the initial illness appears "mild" or "severe", the risks of longer-term effects remain. COVID can linger in the body, and can cause cascading effects throughout.
Studies have found evidence of viral persistence long after initial infection, creating negative health effects, and contributing to the long-term negative impacts from COVID-19.
Even in healthy and young people, COVID viruses can move into small blood vessels and cause inflammation, which in turn can cause formation of blood clots, and can lead to consequences such as stroke, pulmonary embolism, heart attacks, heart disorders, and brain disorders, and this can happen even after what appeared to be a mild initial case.
In fact, one study shows 76% of people with long COVID were not initially hospitalized, and another multi-country study shows 90% of people living with long COVID initially experienced only mild illness with COVID-19.
8- Wearing a mask helps keep the immune system healthy and strong and reduces health risks.
COVID-19 infection can cause the immune systemto become dysregulated– either over-activated resulting in cytokine storms and/or autoimmune diseases, or fatigued causing increased susceptibility to other infections such as RSV, flu, fungal, and bacterial infections.Immune dysregulation can be long-term, and lead to cascading effects in the blood, tissues, and functioning of the body. One study showed those infected with COVID-19 had a 43% higher likelihood of developing an autoimmune disease than those who had not. COVID-19 infection can make existing illnesses worse, including multiple sclerosis (MS), asthma, and autoimmune disease.
Digestive disorders, diabetes, (huge increases in incidence in children and adults, studies showing clinically significant changes in glucose metabolism, as well as high blood sugars even in people without diabetes due to liver infiltration of the SARS-CoV-2 virus), and lung damageare some of the many other potential threats from COVID-19 infection.
9- Masks protect our brains, the house of our memories, our thoughts, our emotions, and our identity.
The brain can be impacted, even after mild cases, which can result incognitive deficits, braindysfunction, and increased susceptibility tobrain disorders likeAlzheimer's. A new study showed that "brain fog" symptoms of long COVID may be partially caused by brain cells fusing together after COVID-19 infection, which severely compromises brain cell activity. Memories, emotions, ability to concentrate all can be affected, and many are diagnosed with anxiety and depression amongst other mental health problems due to COVID-related brain inflammation.
According to a July 2023 study, long COVID occurs in approximately a third of COVID survivors and is now the third leading neurologic disorder in the United States.
The symptoms/diseases associated with COVID-19 are often long-term and debilitating.
10- Masks help protect people from getting long COVID to begin with, or from repeat infections that could worsen prognosis, thus preventing new or worsened disabling conditions.
Because they do not show up right away, are harder to diagnose with conventional tests, may have come from an asymptomatic or mild initial COVID case (in some cases with the person unaware they were infected), long COVID symptoms can be difficult to track back to initial COVID infection.Testing can help identify and document an initial COVID infection which can help with getting later disability support if needed (getting disability support can be a difficult task). Knowing if you have been infected can help identify symptoms as caused bylong COVID,which will in turn help you to find doctors familiar with long COVID, and treatments and strategies to help manage symptoms better.
Even though over 16 million Americans suffer from chronic and often debilitating effects of long COVID, with over 4 million working age adults out of work because of it, the lack of attention and support by the media, government, and communities has left many in the dark about their risks. One way to show your support for these individuals while safeguarding yourself and your community, is by wearing an N95/equivalent or better mask any time you are around others not in your household. The best way to prevent long COVID is to prevent COVID infection to begin with, and that is not done by vaccines alone, or hand-washing and surface sanitation, or even only by air cleaning. Wearing a mask is essential for protection of a mostly airborne, aerosol-transmitted virus.
11- Masks provide significant and meaningful protection.
Wearing masks when you are outside your household may seem like a tough ask at first, but when you consider the alternative of the harms and risks of repeat infections and the effects they have on society as a whole, it doesn't seem that hard. In fact, we are lucky to have these modern, light-weight, excellent filtering technologies. Their comfort beats that of neckties, high heels, and other social practices that do not hold as great of purpose in protecting health as do masks. Systematic reviews show that masks help prevent COVID-19 infection, with N95 respirator masks having maximum efficacy, far out-performing surgical or cloth.
12- Wearing masks regardless of tests is the only responsible and safe way to protect yourself and others without a significant isolation period and numerous tests.
COVID tests are not as accurate as they used to be. Individuals should still continue to test (and use repeat testing), as it can help identify infections. However, rapid antigen tests have been missing many positive cases. For this reason, masking should not be dropped based on a negative RAT test. Symptoms, close exposures, and repeat testing all need to be taken into account.
PCR or NAAT tests are more accurate and can be purchased and kept at/taken at home to try to confirm a case, but even then,a single test cannot be used to rule out infections.A 2023 Nature study cited that PCR tests miss between 50-90% of COVID-19 cases in minors.
Repeat testing involves taking a test every 48 hours over a 4 day period, and it is importantin trying to pin down an infection. Repeat testing is a better way to use testing as a screening tool before higher risk events, or they can be used to be a part of another household's "bubble" (be around their household without masking).
Tests may falsely say you do not have COVID when you do, but it is extremely rare for them to say you do have it if you don't. Testing positive is a clear indicator to isolate. Symptoms and/or known exposure are also indicators. But remember, asymptomatic individuals can still spread, so symptoms alone are not sufficient as a screening tool for contagiousness.
13- Wearing a mask gives us all a healthier and longer life.
COVID still kills approximately 300/day in the US in its acute phase alone (and this is an underestimate due to the low amount of testing and reporting). Greater numbers show up in excess deaths data, of which many were vaccinated, and COVID remains a leading cause of death in the US.
Long COVID deaths are just starting to be tracked, and include heart attacks, stroke, and organ damage. A 2022 study found that heart attacks increased among all age groups, with the largest increase in people ages 25-44 (which increased by 30% compared to the expected number over the first two years of the pandemic). Long-COVID is known to cause increases in heart disease and mortality, with a 2023 JAMA studyshowing that most of the individuals in the cohort (72.5%) who experienced these increases in heart conditions and/or mortality did not experience hospitalization after the acute phase.
14- Wearing a mask, even after you have been infected and recovered, helps protect you from repeat infections that could have more harmful consequences.
Prior infections do not protect you from becoming reinfected. Immunity gained from past infections is short, and also does not protect you against different subvariants. The current dominant subvariants can reinfect a person who was recently infected with a different sub variant within 20-60 days. Variants have been evolving to be more immune-evasive, with the ability to get by both natural infections and vaccines.
People can experience negative health effects on the first infection, but worsened health consequences increase with each reinfection, with repeat infected twice as likely to die, and three times as likely to be hospitalized, have heart problems or experience blood clots than were people who were infected only once. Multiple reinfections (which are common due to rapidly evolving variants) and rapidly fading vaccine and/or prior infection immunity, will increase the chances of bad long-term outcomes.
15- Masks are a first line of defense. Antivirals are a back-up for some.
Paxlovid is an antiviral that can help reduce risks of hospitalization and death during the initial acute infection, and should be discussed with your doctor. It is only available to ages 12 and up currently, and some may not be able to take it due to medication interactions and/or health conditions. It does not prevent long COVID, but some research shows it may lower risks of some types of long COVID due to its ability to hinder viral replication. It has recently been shown to have a weaker effect on reducing hospitalizations on newer variants than it had previously with older variants (used to have 80% now about 30%) and.
Paxlovid does not prevent transmission to others, and it must be taken within 5 days of infection. It is a final-resort safeguard for some to reduce harm after being infected, whereas masks are a first line of defense from becoming infected.
Although many have failed to see the significance of the facts above, it doesn't mean we all should. Instead we should stay educated, lead by example, and continue to advocate for better practices at all levels.
16- Masking has a multiplicative effect: The more people who are masked in an area, the better the effectiveness at reducing transmission.
One-way masking (although better than nothing) is not sufficient on its own, and needs to be combined with good ventilation/filtration, with as many other people (who are two years or over and physically and mentally able to) as possible wearing masks in order to minimize the chances of Covid viruses spreading and accumulating in the air and entering through the mouth and nose, getting into gaps of masks, and/or entering through the eyes.
Universal masking options, remote options, and/or curbside options should be made available for all services. It is important that everyone who is able to mask (ages 2 and up who do not have a severe disability or experiencing a medical emergency that prevents masking) wears a mask to protect themselves and any who are unable to.
17- Enforcing universal mask requirements in healthcare facilities can protect patients, staff, and visitors, and ensure access to safe medical care.
It is especially important that medical services provide universal masked options, as they are treating people who are ill, in health crises, from infants to the elderly in ages, and those who have a variety of medical conditions and/or socioeconomic situations that classify them as at increased risk for severe outcome from COVID-19. Hospital-acquired infections result in more severe consequences (including deaths) than community-acquired infections, and wearing respirators helps both workers and patients.
It is important to note that all people are at risk for the severe and often debilitating long-term effects from COVID-19 infection, and therefore should be able to receive healthcare without being unduly exposed to COVID-19 when receiving medical care.
Often individuals themselves cannot mask when experiencing a medical emergency or for certain procedures, meaning they rely on others to be masked-- and that is anyone who is in the building or who has been in the building for the prior hours, due to the ability of COVID-19 to linger in the air for hours.
Medical staff can and are infecting the patients they are caring for, and calls from patients, staff, and experts for better infection-control policies including N95s be worn have been made after record-breaking hospital-acquired infections in the US in January 2022.
The Academics at the University of Oxford estimated that 112,628 cases of Covid were caught in hospital in England between August 2020 and August 2022 - representing one in six of all hospital cases. At the height of the Omicron wave in 2022 it was estimated that as many as 30% of the patients in hospital with Covid caught the virus after being admitted for another problem.
They are also at risk themselves, with a 2023 study showing 27% of healthcare workers developed long COVID after infection. Another study shows that more than half of doctors with long COVID could no longer work full time, with nearly 1 in 5 unable to work at all.
18- Masking allows you to lower illnesses, reduce transmission, and be part of the movement to truly end the pandemic.
There is a scientific consensus on how to truly end the pandemic. Testing and reporting have reached low frequencies and do not provide an accurate picture anymore. We know COVID-19 is out there, we know it is transmissible, and we know little is being done to stop it. Masking is one thing we can see, and places that have universal masking we know will reduce risks of transmission, thus increasing feelings of safety by providing a truly safer environment. It also buys time for new tools and treatments to be developed (such as this new siRNA COVID treatment that is about to go into clinical trials.) In the meantime, stay protected by using/continuing to wear N95 (equivalent or better) respirator masks.
19- You can support and find support in others who wear masks.
There are a large number of COVID-cautious individuals from every walk of life, and more are joining every day because they are sick of getting sick and are open to being part of a movement to truly end the pandemic. Institutions, including schools, healthcare providers, therapists, and businesses are starting to bring back masking protections as well.
20- Masking and living a COVID-aware lifestyle support positive character development, strength, and skills that are good for both adults and children.
Kids are great at adjusting. Prioritizing health builds self-esteem, trust, and confidence. Living according to logic and science builds a psychologically strong person and reduces anxiety. Standing up for your health teaches courage and integrity.
Virtual social and cooperative virtual activities, hobbies, education, and remote work are growing fields and can apply to many industries. Being socially aware and respectful of others' health including vulnerable people who hold an even higher burden of disease and need safe accessibility breeds true strength of character, morality, and community.
It can be hard, when you see many others around not masking, as there are fewer of us and often we are harder to see due to sheltering practices, but the amount of people masking is growing. The more who begin to mask, the easier it will be for others to feel comfortable masking as well. Adults and children alike have a continuing right to avoid infection.
If you are not using them yet, it is time to start masking with N-95s (or their equivalents or better) when you are around others not in your household.
About the Author:
SHEA O'NEIL
Creator of COVID-conscious advocacy works: writings, art, and social networking. BA degree in psychology, with over 11 years of continued education studies in allergy and autoimmune research, and continued research the past 3 years into airborne irritants and COVID-19. Parent, disabled rights advocate.
View Printable Google Document of WHY WE MASK here