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As the COVID-19 pandemic rages on, it’s a tough time to be a rideshare driver or passenger. Arm yourself with the science to keep yourself and your passengers safe.
Since our first article on rideshare and COVID-19, we now know that hand washing and physical distancing are the two most effective ways to protect yourself and others from getting SARS-CoV-2. Specifically, wash your hands often with soap and water for at least 20 seconds, and keep a distance of 6 feet or more between yourself and the people around you. Use of hand sanitizer is recommended when hand washing isn’t an option. But what can you do to protect yourself and your passengers when you can’t remain 6 feet apart? You and your passengers can wear a mask. Masking, along with hand washing and physical distancing, poses a triple threat against the spread of coronavirus. It’s important to wear a mask when out in public, even if you don’t feel sick, because many people with COVID-19 show no symptoms.
How masks work to help prevent the virus from spreading
The virus primarily spreads when the respiratory droplets we emit while sneezing, coughing, singing, speaking, eating, or breathing enter another person’s eyes, nose, or mouth. Masks serve as a physical barrier to help reel these droplets in from infecting others. The kind of mask we wear and how we wear it influence our likelihood of spreading the virus.
Mask design and types
Three main types of face masks are worn to prevent viral spread: professional N95 and KN95 respirators, procedural and surgical masks, and cloth and paper masks.
Professional N95 and KN95 Respirators
Professional N95 and KN95 respirators protect others and the wearer. They protect against large, virus-spreading respiratory droplets and the vast majority of aerosols, tiny, virus-spreading droplets that remain suspended in the air. Health care workers and first responders need to wear these masks to stay healthy because they spend a significant amount of time around many people who are sick with COVID-19. They often wear face shields or eye shields for additional protection.
Note that there are many masks labeled as N95 and KN95 on the market, but unless they are from an FDA-Authorized manufacturer you cannot trust that they are filtering 95% of particulates.
Procedural and surgical masks
Procedural and surgical masks primarily protect others, and offer minimal protection to the wearer. They protect mostly against large respiratory droplets and some aerosols, and are more effective than cloth and paper masks. COVID-19 patients and their caregivers need to wear procedural and surgical masks because they have a greater risk of spreading the disease to those around them.
Cloth and paper masks
Cloth and paper masks primarily protect others, and offer minimal protection to the wearer. Like procedural and surgical masks, they protect mostly against large respiratory droplets and some aerosols.
Rideshare drivers and passengers are encouraged to wear cloth and paper masks to help protect against community spread of the virus. Comprehensive mask-making guides are available. Masks made with at least two layers offer greater protection. Even the least effective masks are better than wearing no mask at all.
Although masks help to decrease the spread of coronavirus, no mask is 100% effective. Professional N95 and KN95 respirators are designed to make sure they capture at least 95% of particles generated by a standard test, which translates to protection against the vast majority of particles capable of carrying the virus. From there, factors such as airflow, temperature, humidity, viral load, susceptibility to disease, and proper respirator use contribute to the wearer’s risk of becoming infected with the virus. As long as the respirator does not have a one-way valve, it can also prevent the wearer from spreading viral particles. In general, N95 and KN95 respirators are more effective at preventing the spread of SARS-CoV-2 than procedural masks, surgical masks, cloth masks, and paper masks.
Procedural masks, surgical masks, and cloth masks may be less effective than N95 and KN95 respirators. However, they still have a large and visible effect in preventing the wearer from spreading the coronavirus. Little data exists on the efficacy of paper masks. Factors such as type of material, number of layers, arrangement of different layers, and frequency of mask disinfection further contribute to mask efficacy. In comparison to respirators, these masks are minimally effective at protecting the wearer from airborne transmission of SARS-CoV-2.
Mask efficacy also depends upon proper wearing of the mask to cover both your nose and mouth. Specifically, the mask should extend from the bridge of your nose to the bottom of your chin. Moreover, the mask should fit comfortably but snugly, so it doesn’t irritate you, and so it remains in place even when you are speaking, without you having to adjust it. When you adjust your mask, it puts you at risk of pulling the mask out of place, limiting its effectiveness. It also puts you at risk of touching your face and infecting yourself with the virus.
The facts behind masking and COVID-19
1. Why did the CDC reverse its recommendation on masking?
On April 3, 2020, the CDC reversed its recommendation on the general public wearing masks to help prevent the spread of SARS-CoV-2. This recommendation changed as the supply of masks for front-line health care workers improved, and as more data became available, showing that pre-symptomatic and asymptomatic spread of the virus were common.
Since then, we’ve seen how states with mask mandates have slowed the daily COVID-19 case growth rate, and countries with cultural norms or policies supporting masking have had lower death rates. As a result, 42 states, the District of Columbia, and Puerto Rico now have mask orders. Worldwide data show that masking may be more effective than lockdowns. It’s estimated that if 80-90% of the population wore a mask daily, we could eliminate COVID-19.
2. We don't wear masks for the flu. Is COVID-19 really that much worse?
Yes, COVID-19 is worse than the flu because it’s more contagious, more deadly, and more burdensome to our health care system. Both diseases can be spread before symptoms begin, and even when no symptoms are present. The average infection rate and death rate of SARS-CoV-2 are still being determined. However, recent studies suggest that for every 1.5 people that come down with the flu, 2.5 will come down with COVID-19. Moreover, COVID-19 is often contagious for about 2 days before and 10 days after symptoms begin. In comparison, the flu is often contagious for about 1 day before and 7 days after symptoms begin.
A greater proportion of individuals with COVID-19 have to be hospitalized. About 20% of COVID-19 cases require hospitalization, while 1-2% of flu cases are serious enough to require hospitalization. Finally, according to current estimates, COVID-19 is ten times more deadly than the flu. It is particularly deadly for people 65 and older, and people living with chronic diseases, such as lung disease, heart disease, kidney disease, diabetes, and obesity.
3. How else can I prevent getting COVID-19 besides relying on others to wear a mask? Will hydroxychloroquine help?
Apart from masking, hand washing and physical distancing are the two most effective ways to protect yourself and others from COVID-19. You can also protect yourself by boosting your immune system with plenty of healthy food, water, and rest, and by avoiding stress as much as possible. Continue stress-relieving self-care practices such as relaxation, exercise, meditation, and connecting with loved ones.
Unfortunately, at this time, neither hydroxychloroquine, nor any other medications, supplements, or substances have been shown to reduce the risk of contracting COVID-19. Moreover, taking a medication, supplement, or substance without consulting your health care provider first can be harmful to your health. To face the pandemic head on, you can work with your provider to design a health and wellness plan that best serves your needs.
4. Do masks help or hurt herd immunity for COVID-19?
Masking and herd immunity are two different concepts with similar benefits. Herd immunity is when a large enough percentage of a community becomes immune to a disease, making person-to-person spread of the disease unlikely. Just like masking, herd immunity helps to protect whole communities. It can be acquired via active immunity from individual contraction of the disease or vaccination, or via passive immunity obtained from antibody-containing treatments. Active immunity creates a more robust immune response than passive immunity does, but active immunity via contraction of the disease comes at the cost of many people falling ill and dying from the disease.
Because masking protects communities from falling ill to COVID-19, it decreases the potential for active immunity via contraction of the disease but does not affect the potential for active immunity from vaccination. Moreover, by protecting and saving lives, masks buy communities precious time and resources. They help preserve health care capacity to continue treating COVID-19 patients until herd immunity can be achieved via vaccination.
5. Concerning cloth masks, how does a two-layer mask compare to a one-layer mask?
6. Are there exemptions from masking?
Yes. The current exemptions from masking include:
- Medical exemptions: According to the CDC, “a person who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the face mask without assistance should not wear a face mask or cloth face covering.” This exemption may cover certain groups of people with mental and physical disabilities, such as individuals with PTSD, anxiety, autism, cerebral palsy, paralysis, asthma, or chronic obstructive pulmonary disease.
- Age exemptions: Depending on the state or territory you live in, children between the ages of 2 and 12 may qualify for a masking exemption.
- Religious exemptions: Some parts of the country include exemptions for people attending religious services.
State mask mandates, however, can override some exemptions
7. Does mask-induced deoxygenation qualify as a medical exemption from masking?
No. Studies have shown that masking is associated with just a 1-2% decrease in oxygen levels. This decrease in oxygenation has little effect on healthy individuals. Similarly, wearing a mask for an extended period of time does not cause carbon dioxide intoxication. However, people with pre-existing heart and lung conditions may be medically-exempt from masking, and should share their concerns with their health care provider.
8. If I don’t wear a mask, can I be refused service?
It depends. Per state and territory mandates, individuals with an age exemption or religious exemption cannot be refused service. Moreover, under the Americans with Disabilities Act, if you have a medical exemption from masking as described in question 6, you cannot be refused service. If you qualify for one of these exemptions, you must be offered a reasonable modification to the masking policy so that you can participate in, or benefit from, the program offered or goods and services provided. However, there are three situations when a reasonable modification does not apply:
- Fundamental alteration: A business or government agency is not required to provide a reasonable modification if doing so would significantly change the original nature of the program, service, or activity.
- Undue burden: A business or government agency is not required to provide a reasonable modification if doing so would result in an excessive financial or administrative burden.
- Direct threat: A business or government agency is not required to provide a reasonable modification to an individual if that individual poses a real threat to the health or safety of others.
If your age, religious, or medical exemption from masking would not result in a fundamental alteration, undue burden, or direct threat, you can be refused service. A business or government agency may require customers to wear a mask to limit the spread of COVID-19. Updates on mask mandates by state and territory are available and can be obtained by contacting your local public health agency. These mandates can be enforced by law enforcement.
9. I heard the Department of Justice is issuing ADA face mask exempt cards. Are these cards legitimate?
10. Is there still a shortage of masks?
Yes, there is still a shortage of personal protective equipment (PPE), including professional N95 and KN95 respirators, and procedural and surgical masks. The need for masks for front-line health care workers consistently exceeds supply and distribution efforts. Health care workers continue to be forced to cut corners on PPE, reusing masks made for single-use, putting themselves at greater risk of contracting COVID-19. You can do your part to lessen the shortage of these masks by opting to wear a cloth or paper mask instead, unless you already have a respirator, procedural mask, or surgical mask at home.
11. Can masks be cleaned, disinfected, and reused?
Yes. Comprehensive guidelines are available on cleaning, disinfecting, and reusing masks. The guidelines differ for each mask type. Generally, cloth masks can be washed with water and detergent, just like clothing. Procedural and surgical masks and professional N95 and KN95 respirators can only be sanitized with special procedures, or else they will lose some filtration performance. However, all types of masks can be kept in a breathable container like a paper bag for 7 days, after which any trapped virus particles will be inactive and incapable of causing infection.
12. Where can I find masks?
Yes, several businesses and states are providing free masks. Some of the participating businesses include JOANN, Best Buy, Sam’s Club, the Apple store, Whole Foods, and Dhvani. The states that have offered free masks include Washington, Oregon, California, Utah, Arizona, Texas, Nebraska, Kansas, Illinois, Indiana, Wisconsin, Michigan, Ohio, Florida, Tennessee, North Carolina, Virginia, New York, and Rhode Island. More states and territories may soon be added to the list. Contact your local public health agency to find out if free masks are available near you. Some medical suppliers have KN95 masks available to the public as well.
The bottom line
As the COVID-19 pandemic rages on, more than 23 million cases and 800,000 deaths have been reported worldwide. In the United States, over 5.7 million cases and 176,000 deaths have been confirmed. (Updated through August, 25, 2020)
The average infection rate and death rate of SARS-CoV-2 are still being determined. However, we can definitively say SARS-CoV-2 is more infectious and deadly than the flu. No one, no matter their age, health status, socioeconomic status, or ethnicity, is immune to COVID-19. Anyone can develop serious illness and death from the disease. But the risk of serious illness and death is greater if you are 65 or older, or if you live with lung disease, heart disease, kidney disease, diabetes, or obesity.
The bottom line is masking works to help stop the spread of SARS-CoV-2. Stay informed, wear a mask, and ask your passengers to do the same.
Dr. Lauren Weinand M.D. is a medical writer and practicing family medicine physician. Her medical writing has been published in the Journal of Investigative Medicine; Pain Treatment Specialists blog; The Recovery Village blog; Oglethorpe Inc. blog; and several newspapers.