As the coronavirus pandemic continues, some countries around the world are having to come to terms with a resurgence in new cases after easing lockdown restrictions imposed earlier in the year.

Parts or all of Israel, Australia, Serbia, Hong Kong, Spain, South Africa, England, and Japan have recently seen the reintroduction of restrictive measures after spikes in reported COVID-19 cases. The U.S. has cemented its status as the global coronavirus hotspot in recent weeks, with Brazil close behind, after poorly timed state “reopenings” resulted in a huge upsurge in new cases.

States like Florida, Texas, California, and Arizona are recording massive numbers of new cases on a daily basis. To put it into perspective for residents of British Columbia, Florida’s daily average of about 11,000 new cases during the past week is more than triple the total number of B.C. cases since the start of the pandemic.

After the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) started recommending the wearing of masks as an effective component (along with social distancing and frequent handwashing) of prevention and control measures for coronavirus, their usage has become much more widespread worldwide, including in Canada.

Transport Canada mandated wearing a mask or face covering on all air travel in Canada effective April 20. It has also been mandatory to wear a face mask at indoor and enclosed public spaces in Toronto, including public transit, since July 7, and Quebec has a similar regulation that becomes effective on July 18.

Some municipalities have enacted such mask rules as well, but other than a May 20 nonmandatory recommendation by Canada’s chief public health officer, Dr. Theresa Tam, to do so where physical distancing is difficult or impossible, there is no federal push to compel citizens to wear masks in public. Enforcement measures are generally left to businesses, and penalties (fines) are almost nonexistent.

Poll results released on June 9 after a Leger and Association for Canadian Studies online survey showed that only 14 percent of respondents claimed to wear a mask on public transit, although approximately half of all those surveyed said they wore a mask when grocery shopping or in a pharmacy.

But are those numbers high enough for effective control and suppression of the pandemic? A study published in a Cornell University open-access archive, arXiv.org, on April 21 indicated that an 80-percent mask-wearing compliance in a population would be more effective in halting the spread of the virus than a near-complete lockdown.
And University of California San Francisco infectious-disease expert Dr. Peter Chin-Hong said in a university publication on June 26  that of the three most important standbys to prevent transmission of the coronavirus—frequent and thorough handwashing, physical (social) distancing, and wearing a mask—he recommends the latter: “Of the three, the most important thing is wearing a mask.”

And although most recommendations for wearing masks focus on the altruistic aspect of not infecting others (especially considering the presence of asymptomatic spreaders), a meta-analysis of 172 studies from 16 countries published in the Lancet on June 1 indicated that masks can decrease the risk of infection for the wearer by up to 65 percent.

Finally. a paper published on July 7 in the Center for Economic Policy Research’s Covid Economics, Vetted and Real-Time Papers journal delivered some significant, if sobering, news. The study, Causal Impact of Masks, Policies, Behavior on early Covid-19 pandemic in the US—by MIT economics professor Victor Chernozhukov, UBC economics professor Hiroyuki Kasahara, and UBC economics associate professor Paul Schrimpf—looked at, among other aspects of U.S. pandemic actions, the effect of a national policy to mandate face masks for employees of public businesses. Such a policy, the researchers found, would have reduced new COVID-19 cases and deaths by more than 10 percent in April alone and could have resulted in “as much as 17 to 55 percent less deaths nationally by the end of May, which roughly translates into 17 to 55 thousand saved lives”.

Given that the U.S. now leads the world in COVID-19 cases and deaths—as of July 17, 3.55 million confirmed cases and almost 138,000 deaths—and that the study’s numbers applied to April and May only, and also taking into account CDC director Robert Redfield’s June 25 estimate that, based on antibody tests, the number of Americans infected by the coronavirus is probably 10 times the official estimates, the paper’s upper limit of 55,000 saved lives is likely grossly underestimated.

Here in B.C., there has been a gradual increase in the numbers of new COVID-19 cases reported on a daily basis since the province entered phases two and three of its economic reopening. Although the uptick was expected, it is still of concern, as is the spectre of fall school reopenings and the widely predicted and almost universally accepted autumn “second wave” of the coronavirus.

So should you wear a mask when outdoors in crowded spaces or in any public or enclosed indoor spaces? The evidence seems to point to an answer of “yes”, for both personal and social protection. B.C.’s provincial health officer, Dr. Bonnie Henry, said at a July 16 media briefing about wearing a mask on public transportation: “I absolutely think everybody on transit should be wearing a mask, everybody who can.”

But if all of the preceding information isn’t enough to help you make up your mind about wearing a mask—and if concern about the well-being and safety of your fellow citizens is not one of your primary motivations—maybe the following facts that are now known about the effects of COVID-19, including some of the latest science, will scare you into doing so.

Vascular disease versus respiratory disease

Although the illness caused by the novel coronavirus is usually referred to (and is officially classified as) a respiratory disease, some scientists are rethinking that designatilon as new evidence comes in. A paper published in Circulation Research on May 8  established that 40 percent of COVID-19 deaths were related to cardiovascular complications. Another study, published in the Lancet on April 20, found that the coronavirus can infect cells that line the inside of blood vessels in the kidneys, heart, intestines, and liver of people with COVID-19, not just in the lungs. According to a Johns Hopkins University health bulletin: “Early reports say that up to 30% of patients hospitalized with COVID-19 in China and New York developed moderate or severe kidney injury. Reports from doctors in New York are saying the percentage could be higher…The kidney damage is, in some cases, severe enough to require dialysis.” And an NYU pathologist found extensive blood clotting “in almost every organ that we looked at in our autopsy study”.

Recovery times

As more cases are studied by researchers—especially those involving extended hospitalization, sometimes with invasive treatment such as ventilator intubation for oxygen and assisted breathing—it has become obvious that many people require an extended period of time to recover, sometimes for several months. Muscle-mass loss often requires physiotherapy to enable walking again. And hospital stays can turn into marathons, often with tragic endings. Canadian Broadway star Nick Cordero spent three months in hospital, in a medically induced coma, undergoing a leg amputation, being hooked up to a heart-lung machine, having kidney dialysis, and requiring a tracheotomy before dying at age 41. Many people, even after being declared “recovered”, suffer debilitating symptoms, including extreme fatigue, for months.

Heart attacks and strokes

After observing an unusual number of strokes, heart attacks, and pulmonary embolisms in COVID-19 patients who would not normally be considered at risk for such events, especially younger ones, researchers started looking at the causes. One study, reported in ScienceDaily on June 30, found the possible reason: “Changes in blood platelets triggered by COVID-19 could contribute to the onset of heart attacks, strokes, and other serious complications in some patients who have the disease, according to scientists. The researchers found that inflammatory proteins produced during infection significantly alter the function of platelets, making them ‘hyperactive’ and more prone to form dangerous and potentially deadly blood clots.”

Other serious complications

A whole suite of serious COVID-19–related complications are emerging as the pandemic continues. Other than the well-known and potentially lethal ones such as pneumonia, acute respiratory distress syndrome (ARDS), and the abovementioned kidney and heart damage and serious blood-clotting problems, others include acute liver injury and failure, potentially lethal strep and staph secondary infections, sometimes deadly septic shock, multisystem inflammatory syndrome in children (MIS-C, similar to toxic-shock syndrome), and rhabdomyolysis (a rare and sometimes deadly condition where muscle tissues break down and overwhelm the kidneys). As well, lung scarring can sometimes result in long-term breathing problems, and in rare cases it has landed patients on a double-lung transplant list. And delirium, a relatively common affliction for those admitted to ICUs with COVID-19, can lead to “long-term cognitive impairments such as memory deficits”, according to the journal Science. (A 2007 paper published in PubMed.gov found that more than a third of people admitted to ICUs for SARS had moderate to severe depression and anxiety a year later.)

Amputations

When blood clots get stuck in a vein or artery, very serious complications can develop, sometimes requiring amputation of affected extremities. A Netherlands study published in the Thrombosis Research journal on April 10 showed a rather astonishing incidence of abnormal blood clotting in COVID-19 patients admitted to hospital. The paper concluded: “The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high.” A critical-care doctor—Shari Brosnahan at the NYU Langone Health academic medical-care centre—interviewed for an AFP news agency article said of the clotting she observed in her patients: ““I have had 40-year-olds in my ICU who have clots in their fingers that look like they’ll lose the finger, but there’s no other reason to lose the finger than the virus.” She said that one of her patients had a blood-flow problem with both feet and hands and that amputations might be necessary—or the blood vessels may get so damaged that extremities might drop off by themselves.

Pregnancy

Although most researchers thought early in the pandemic that pregnant women were no more likely than anyone else to be hospitalized as a result of contracting COVID-19, the CDC did an about-face after examining data on the subject (although the CDC did acknowledge that there were some gaps in the data analyzed). According to a weekly (June 26) CDC bulletin, infected pregnant women had a 50 percent higher chance than nonpregnant women of childbearing age of ending up in intensive care, as well as a 70 percent greater chance of being intubated. (Recent studies of intubated COVID-19 patients show a range of survival rates. One study—published in the journal Critical Care Medicine on May 26—that involved six ICUs in three hospitals found that 35.7 percent of the studied patients who required mechanical ventilation died.) And a small Italian study recently found that the coronavirus can be passed to the fetus, although all the babies tested after birth appeared to be healthy.

Brain complications

A British study published on July 7 in the neurology journal Brain found that nerve damage, delirium, and strokes can occur in people with even “mild” cases of COVID-19. Brain inflammation and temporary dysfunction were also observed. UBC psychiatry professor Steven Taylor was lead author of a study in the May issue of the Journal of Anxiety Disorders that identified five elements of what the researchers termed “COVID stress syndrome”. And an article in Psychology Today referenced a study that warned of sobering future mental-health consequences of the pandemic: “In addition to the direct effects on the brain, the COVID-19 pandemic is causing unprecedented psychological distress, threatening a “crashing wave” of mental health problems.”

Immunity loss

Researchers are still unclear on how effective antibodies generated by “recovered” COVID-19 patients will be in preventing future infections, if at all, but a British preprint (non–peer reviewed) paper published on July 11 in medRxiv suggests that antibodies circulating in the blood decline precipitously after only about two months. A larger Spanish study that appeared in the Lancet on July 6 showed that only five percent of study subjects maintained antibodies to the virus.

Airborne transmission

Most scientists and health agencies still maintain that the novel coronavirus is spread through droplets that are coughed or sneezed out by infected persons. These droplets are breathed in or settle on surfaces where the virus is picked up and transmitted by touch, the reasoning goes. However, there is a growing body of evidence that it can be spread through aerosols—much smaller droplets, less than five micrometres in diameter, that are simply exhaled while breathing and talking and that can even hitchhike on dust particles and travel on air currents—that remain airborne and linger for a long time, especially in poorly ventilated enclosed spaces. (An excellent updated review of the known science in this regard is contained in this July 8 article in the science journal Nature.) The WHO said on July 7 that it will be modifying some of its recommendations in light of this evidence. If the airborne-transmission model becomes widely accepted, the wearing of more effective and better-fitting masks in public will become even more important.

Age and infection

Finally, if you think being under the age of 60—or 50, or even 40—exempts you from having to worry about the virus, you aren’t paying attention. Although early days of the pandemic seemed to indicate that young adults comprised only a small percentage of COVID-19 cases, increasing numbers of young people are showing up in analysis of new infections. A study from Washington state published in medRxiv on May 20 showed that more than half of the new COVID-19 cases in the Seattle area in March and April were in people in their 20s and 30s. And prominent U.S. epidemiologist George Lemp, in a June 19 article in NPR’s health publication, Shots, said that 44 percent of new infections in California are showing up in those under 35. Increasing numbers of infections in young people in Ontario have also been observed. Canada’s chief public health officer, Dr. Theresa Tam, said on June 29: ““As the epidemic has slowed the incident rate has steadily declined in all age groups. But the decline has been relatively slow in younger age groups...Individuals under the age of 40 now account for a greater proportion of total cases in recent weeks.”