Why, And How, To Require Patient Masks
Bottom Line Up Front:
- Recent case studies demonstrate mask use when exposed to Covid-19, by reducing viral load, increases the likelihood of asymptomatic illness when infected
- Patients know that their health is your primary concern, and expect your guidance to prioritize their self-interest
- Staff should notify patients when setting appointments that "The doctor is prescribing that you wear a mask during your visit"
- Explaining this research to your patients will reinforce confidence in your practice and staff, while increasing the adoption of mask use
As vision health professionals, you have a higher level of responsibility to the health and well-being of your patients than those professionals who provide less essential services. Your patients also expect that you will be the best-informed professional with whom they are in contact regarding health-related issues. This is difficult during the present novel coronavirus SARS-CoV-2 pandemic as new symptoms and pathology emerge, while patient expectations of health professional expertise remains.
In a paper recently published in the Journal of General Internal Medicine by Monica Gandhi (MD, MPH), Chris Beyrer (MD, MPH) and Eric Goosby (MD), the authors bring attention to the prophylactic aspect of mask use in reducing the severity of SARS-CoV-2 infection. While there is general understanding that mask use can reduce the spread of infection from asymptomatic and presymptomatic individuals, Gandhi et al argue that a reduction in viral dose (inoculum) increases the likelihood that the mask wearer experiences asymptomatic SARS-CoV-2 infection. Their report is based upon extensive “virologic, epidemiologic and ecologic evidence.”
Asymptomatic infection is often understood as detection of SARS-CoV-2 by RT-PCR, in the absence of a clinical illness compatible with COVID-19
Understanding that the level of virus exposure may affect the severity of disease is not new to medical research; the authors refer to studies as early as 1938. They cite a more recent study from May 2020 with laboratory evidence that, with hamsters, this appears to be true for SARS-CoV-2. In addition, the authors call attention to the increase in asymptomatic cases of SARS-CoV-2, from ~15% prior to mask adoption in national populations, to ~40-45% as mask use was implemented. Possibly more relevant, and convincing, is the authors’ description of phenotype data from cruise ship populations.
Because cruise ships contain closed and captive populations, observations more closely reproduce laboratory conditions than studies of national populations. During the January-February 2020 Diamond Princess cruise ship SARS-CoV-2 outbreak the use of masking was limited at best. By March, when the Greg Mortimer cruise ship began its Antarctic cruise, all passengers and crew were issued surgical masks and N95 masks, respectively, when the first SARS-CoV-2 case was detected. The rates of asymptomatic infection were profoundly different:
Diamond Princess 17.9% asymptomatic
Greg Mortimer 81.0% asymptomatic
The authors go on to describe environments where consistent mask use increased the rate of asymptomatic infection: a pediatric hemodialysis unit in Indiana (100% asymptomatic); a seafood processing plant in Oregon (95%); and a chicken processing plant in Arkansas (95%). More information is available in the paper to support the theory that exposure to SARS-CoV-2 while wearing a mask increases the likelihood of asymptomatic infection and, therefore, decreases morbidity. In an interview Dr. Gandhi, infectious disease researcher at University of California, stated her opinion that "Masks, actually no matter what kind of mask, filter out the majority of virus particles” and “the less virus you get in the less likely you are to get sick” (i.e., develop COVID-19 symptoms).
Presymptomatic infection is often understood as detection of SARS-CoV-2 by RT-PCR, prior to the expression of a clinical illness compatible with COVID-19
In your practice you may receive resistance from patients due to the politically charged climate of mask use. As we have established, your patients have an expectation that you are better informed regarding health instruction; and have a proclivity to defer to your medical knowledge when it is directed toward their health preservation. Your ability to cite recent studies on the novel coronavirus will reinforce their tendency to follow your direction. Explaining the information to your staff will allow you to put into place effective procedures to increase the health and welfare for your patients, you, and your staff. Your practice might follow this model:
- Pre-visit and Reception. The staff informs every patient that “Doctor [Smith] is prescribing that all patients wear masks during their visit.” Patients that question this requirement are told “The doctor is happy to explain this requirement during your visit.”
- Pre-exam and Testing. Fully masked staff members answer patient questions, affirming that “Doctor [Smith] is staying up-to-date on all the current COVID-19 medical literature, and he’ll explain how important it is to your health to wear a mask.”
- Exam. During the exam, explain the difference between asymptomatic, presymptomatic, and those who are expressing an illness. Describe how masks reduce viral load if exposed, and studies show this reduction makes it far more likely that your patient will avoid severe illness.
Your patients have likely heard that masks are ineffective in stopping germs. By helping them to understand that the quantity of exposure (“viral load”) matters and how mask wearing is in their self-interest (not merely altruistic) you can increase their willingness to wear masks without challenging their preconceptions. Getting infected without getting sick is a reasonable goal no matter a person’s political stance. Demonstrating your knowledge of current COVID-19 research will reinforce your patients’ respect and confidence in your practice and your staff. And, most important of all, your actions will protect the health and save the life of your patients.
Sources:
COVID-19: in the footsteps of Ernest Shackleton
Public Health on Call: Asymptomatic Infection with COVID-19
One More Reason to Wear a Mask: You’ll Get Less Sick From COVID-19
Asymptomatic SARS-CoV-2 infection: the tip or the iceberg?
Covid-19: ’Silent’ Spread Rocks Adventure Cruise
Love this article. Technology has stopped us as human beings to apply critical thinking to how we communicate. We need to be up front and honest with our patients and that will result in much more positive experiences! Well done!
Store Market Manager Licensed Registered Optician at LensCrafters
4 年Absolutely letting patients know in advance allows them to decide if they still wish to come see us and eliminates the element of surprise by sharing the expectations in advance!!! We gotta work together to prevent continuous spread of this virus. Surprisingly most patients are understanding on the need to wear a mask during their visit however, great points here to reinforce for those few ones questioning the direction.
Store Market Manager Licensed Registered Optician at LensCrafters
4 年Absolutely letting patients know in advance allows them to decide if they still wish to come see us and elements the element of surprise by sharing the expectations in advance!!! We gotta work together to prevent continuous spread of this virus. Surprisingly most patients are understanding on the need to wear a mask during their visit however, great points here to reinforce for those odd ones questioning the direction.