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Summaries of Mask studies
Health Freedom Ohio Research Team
Summaries of Mask studies
Introduction: Here we provide an extensive summary of peer-reviewed literature as well as quotes from medical professionals on the effectiveness of face masks against viruses, as well as potential health concerns that could arise from improper face mask use. We also note where studies are flawed by making our own comments in [brackets].
Update: Studies published prior to 2020 did not include SARS-CoV2, since it was a presumably new virus, yet it is not significantly different in size or biologic properties so the earlier studies are very relevant. This report has since been updated with studies from 2020, which do focus on COVID19.
Scientific literature examining the effectiveness of face masks of various types against SARS-CoV-2 and other viruses
A cluster randomised trial of cloth masks compared with medical masks in healthcare workers
Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Cloth masks should not be recommended for health care workers, particularly in high risk settings such as emergency, infectious disease, respiratory disease and intensive care wards.
N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial
In this pragmatic, cluster randomized trial that involved multiple outpatient sites at 7 health care delivery systems across a wide geographic area over 4 seasons of peak viral respiratory illness, there was no significant difference between the effectiveness of N95 respirators and medical masks in preventing laboratory-confirmed influenza among participants routinely exposed to respiratory illnesses in the workplace. In addition, there were no significant differences between N95 respirators and medical masks in the rates of acute respiratory illness, laboratory-detected respiratory infections, laboratory-confirmed respiratory illness, and influenza like illness among participants (including coronaviruses). A sensitivity analysis suggested that the primary analysis reported was fairly robust to the missing outcome data with quantitative outcomes varying by less than 5%. This supports the finding that neither N95 respirators nor medical masks were more effective in preventing laboratory-confirmed influenza or other viral respiratory infection or illness among participants when worn in a fashion consistent with current US clinical practice.
Effectiveness of N95 Respirators Versus Surgical Masks in Protecting Health Care Workers From Acute Respiratory Infection: A Systematic Review and Meta-Analysis
A meta-analysis of several published studies to look at comparing N95 respirators and surgical masks for the prevention of transmissible acute respiratory infections in a hospital setting and also surrogate exposure studies to detect leakage and penetration from the masks were done. Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, the meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings. The clinical significance was further put into question by the wide 95% CI of the data used in the meta analysis. The potential harm or negative effects of using respirators and masks were also excluded from the study. The surrogate studies showed that the N95 masks were superior to surgical masks when it came to droplet penetration and leakage but the effects were not statistically significant to prevent infection.
Simple Respiratory Protection--Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 20-1000 Nm Size Particles
Testing filtration performance against virus nano sized particles using various cloth materials were tested against N95 masks. After using two different face velocities, the results showed a range of 40-90% instantaneous penetration in all fabrics tested. Aerosol particles were much
higher than the penetration for N95 respirator filter. Conclusions of results indicate fabric masks of any type provide marginal protection including virus particles.
2?fbclid=IwAR0EA2SwcOc6o5fpnE8EOK4NToCjsMD7y5HQ_TaR5L0J8fUCIGKMNCB7h9MRespiratory virus shedding in exhaled breath and efficacy of face masks
Surgical masks reduce detection of influenza RNA in respiratory droplets and coronavirus RNA in aerosols from individuals that were diagnosed with those infections. Viral RNA was detected in respiratory droplets from individuals both wearing and not wearing a mask: 30% of coronavirus patients wearing a mask vs 40% of those not wearing a mask, which was not statistically significant. The authors concluded that aerosol transmission is a potential mode of transmission for coronavirus, and that masks could be used by ill people to reduce onward transmission.
Optical Microscopic Study of Surface Morphology and Filtering Efficiency of Face Masks
Authors observe that the pore sizes of cloth masks are substantially larger than the particular matter they are intended to filter. Filtering efficiency was noted to range between 63% and 84% with a 20% decrease in filtering efficiency after the 4th washing and drying cycle.
Surgical mask filter and fit performance.
Masks have been used since the early 1900’s to help reduce bacteria spread. The goal of this study was to evaluate the filter performance since the shift has been to use masks as respiratory protection devices. Filter penetration was measured for at least 3 replicates of 9 surgical masks using monodisperse latex sphere aerosols and facial fit was measured on 20 subjects for the 5 masks. The study concluded that none of these surgical masks exhibited adequate filter performance and facial fit characteristics to be considered respiratory protection devices.
The Use of Masks and Respirators to Prevent Transmission of Influenza: A Systematic Review of the Scientific Evidence
Of 17 eligible studies, mask use appeared to reduce transmission of some viruses in some cases, however study authors note that findings were not conclusive and may not be applicable to all viruses, such as influenza, and that many of the studies were of suboptimal quality. Personal hygiene (washing hands) and correct and consistent usage (uncommon outside medical professionals in medical settings) are most likely the main factors in reducing viral transmission.
Evaluating the Efficacy of Cloth Facemasks in Reducing Particulate Matter Exposure
”Standard N95 mask performance was used as a control to compare the results with cloth masks, and our results suggest that cloth masks are only marginally beneficial in protecting individuals from particles<2.5 μm. Compared with cloth masks, disposable surgical masks are more effective in reducing particulate exposure.”
Viruses are 0.004 to 0.1 μm in size or about 100 times smaller than bacteria.
Identifying airborne transmission as the dominant route for the spread of COVID-19
This study examined the impact of different mitigation strategies (social distancing, mask wearing, etc) implemented in different world governments on changes in epidemic curves. The analysis was based on linear interpolation on the observed epidemic curves. This article makes strong claims about airborne transmission and significant impact of the aforementioned mitigation strategies; in other words, the claim that “masks work”. However, this analysis is
biased by an ecological fallacy, that observations made at the population level are appropriate at the individual-level, and disregards any impact of changing treatment modalities, differences in susceptibility by age, and differences over time in other important public health parameters including recovery rate, hospitalization rate, and death rate, all of which declined in many principalities independent of mitigation strategy.
Universal Masking is Urgent in the COVID-19 Pandemic: SEIR and Agent Based Models, Empirical Validation, Policy Recommendations
This paper develops an SEIR (susceptible-exposed-infectious-recovered) theoretical transmission model to better understand the impact of wearing masks. As with many theoretical models, the parameter estimates were based on hypothesized values not rooted in actual data. A few papers were cited that said masks were effective, but the authors did not describe how these few reports led to their parameter estimates. A “validation study” compared the “degree of success in managing COVID-19” by countries and provinces with different “masking cultures”; [such an analysis is prone to ecological fallacy and confounding]. While this paper makes strong recommendations for universal masking, it is based on strong underlying assumptions.
Association of country-wide coronavirus mortality with demographics, testing, lockdowns, and public wearing of masks (Update June 15, 2020)
This presents an ecological analysis, examining the association between country-level coronavirus mortality and several population-level factors. In multivariable analyses, lockdowns and per-capita mask wearing were associated with lower mortality, though importantly, neither were statistically significant.
Assessment of influenza virus exposure and recovery from contaminated surgical masks and N95 respirators
These results also support previous studies that suggest that virus trapped on the outside of facemasks and respirators may pose an indirect contact transmission risk as the healthcare worker doffs these PPE after seeing a patient or continues to wear their PPE for an extended period of time.
Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers
Virus positivity was significantly higher in masks samples worn for > 6 h. Respiratory pathogens on the outer surface of the used medical masks may result in self-contamination. The risk is higher with longer duration of mask use (> 6 h). Most of the participants (83.8%, 124/148) reported at least one problem associated with mask use. Commonly reported problems were pressure on face (16.9%, 25/148), breathing difficulty (12.2%, 18/148), discomfort (9.5% 14/148), trouble communicating with the patient (7.4%, 11/148) and headache (6.1%, 9/148).
Surgical masks as source of bacterial contamination during operative procedures
This study provides strong evidence for the identification that surgical masks as source of bacterial contamination during operative procedures, which should be a cause for alarm and attention in the prevention of surgical site infection in clinical practice. The bacterial count on the surface of SMs increased with extended operating times; significant difference was found between the 4- to 6-hour and 0-hour groups. These results demonstrated that the contamination of the SM surface worsens with wearing time extension. We recommend that surgeons should change the mask after each operation, especially those beyond 2 hours.
Reduction of secondary transmission of SARS-CoV-2 in households by face mask use, disinfection and social distancing: a cohort study in Beijing, China
The new study was a retrospective cohort study of 124 households with an index SARSCoV-2 case and 355 uninfected household contacts. Households in which masks were used by at least one family member (including the index case) prior to the development of symptoms by the index case were associated with decreased risk of incident infections, after adjusting for other hygiene and infection control practices, physical distance to index case, environmental factors, and presence of diarrhea in the index case (adjusted odds ratio 0.21, 95% confidence interval 0.06 to 0.79). There was no association between mask use after illness onset in the index case and risk of SARS-CoV-2 infections in family members. Masks included N95 respirators, surgical masks, or cloth face coverings, and the study did not conduct analyses by specific mask type. The study was susceptible to recall bias; in addition, the analysis used households (rather than exposed individuals) as the unit of analysis and did not analyze mask use by the index case (“source control”) separately from mask use by household contacts. The applicability of findings to wearing of masks in public is also uncertain. Therefore, the strength of evidence on masks in community settings for prevention of SARS-CoV-2 infection is insufficient.
*** Summary provided by https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/masks prevention-covid-surveillance-report.pdf?fbclid=IwAR2Dnd1Lqb2tpB-NJR0A Ae_SXYeZ2tacqrugyunNAke1ce4hn8FbQgVvUM
Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis
Meta-analysis of randomized controlled trials indicated a protective effect of masks and respirators against self-reported clinical respiratory illness (CRI) and influenza-like illness (ILI) in healthcare workers, and the protective effect against laboratory-confirmed viral infections was not statistically significant. N95 respirators conferred superior protection compared to standard face masks against CRI and laboratory-confirmed bacterial, but not viral infections or ILI. Meta analysis of observational studies provided evidence of a protective effect of masks and N95 respirators against severe acute respiratory syndrome (SARS). The existing evidence is sparse and findings are inconsistent within and across studies, and the studies included in this analysis may have been prone to recall bias.
Community and Close Contact Exposures Associated with COVID-19 Among Symptomatic Adults ≥18 Years in 11 Outpatient Health Care Facilities —United States, July 2020
The purpose of this study was to identify risk factors associated with COVID19 in a national survey conducted by the CDC and collaborating hospitals. This study did not find a significant difference in mask wearing behaviors between people who tested positive for COVID19 (N=154) versus those that did not (N=160) (p=0.86). Of the people who tested positive, 70.6% reported “always” wearing a mask, versus ]74.2% of those that tested negative. Among those who reported “never” wearing a mask, 3.9% texted positive for COVID19 versus 3.1% who tested negative.
Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial
As stated in the title, this was a randomized controlled trial in Denmark to assess whether recommending surgical mask use outside the homereduces wearers' risk for SARS-CoV-2 infection. The primary outcome of SARS-CoV-2 infection was defined as a positive result on an oropharyngeal/nasal swab test for SARS-CoV-2, development of a positive SARS-CoV-2 antibody test result (IgM or IgG) during the study period, or a hospital-based diagnosis of SARS CoV-2 infection or COVID-19. The study found no significant difference in that composite endpoint between the mask-wearing group and the non-mask wearing group (p=0.38).
Effects of mask-wearing on the inhalability and deposition of airborne SARS-CoV-2 aerosols in human upper airway
The study looked at the effects of wearing a standard surgical mask on airflow and aerosol dynamics using a computer model and compared it to not wearing a mask. They tried to determine the amount of ambient aerosols through the mask landing on the face and in the respiratory tract. Some of the findings were that wearing a mask significantly slows down
particle flows through the mask and disperses the area of particle spread increasing the amount of aerosols going into the nasal and oral cavity. They also found high concentrations of particles in the mask pleats. Then they go on to say that for a standard 3-layer surgical mask with 65% filtering efficiency all particle sizes are reduced except those between 1-3 microns (which is the size (which means SARS-COV2 is not stopped). Lastly, this article concludes that the same surgical masks should not be worn over a long period of time; as they get older, the flow rates drop and the risk of infection is higher from COVID like particles entering the respiratory area in larger numbers due to higher particle density. In summary, this article provides some evidence that particles may be prevented from entering the airway due to wearing a mask, but also provides evidence that viral particles may not be stopped and that extended mask wearing reduces the effectiveness of the mask.
[note, this is a preprint server]
COVID-19 Mitigation Practices and COVID-19 Rates in Schools: Report on Data from Florida, New York and Massachusetts
While staff COVID19 rates were higher in areas without mask mandates, this difference was no longer statistically significant after adjusting for community-level COVID-19 rates. There was no difference in student COVID19 rates in areas with and without mask mandates. The authors are careful to point out that these analyses do not reflect individual behavior, only the presence of mandates.
Mask Use and Ventilation Improvements to Reduce COVID-19 Incidence in Elementary Schools — Georgia, November 16–December 11, 2020
While COVID-19 incidence rates were significantly lower when there were mask requirements for teachers and staff, the rate was not significantly different when masks were required for students. These analyses were adjusted for county-level COVID-19 incidence.
[note this is a preprint server]
Mask mandate and use efficacy in state-level COVID-19 containment: A Systematic Review and Meta-Analysis
While 80% of US states implemented mask mandates, COVID-19 case growth varies with time, not as a direct result of mask mandates. Mask mandates are not associated with, nor can be used as a prediction of, state COVID-19 case spread.
Commentaries not using data
https://www.thenewamerican.com/print-magazine/item/35788-should-i-wear-a-face-maskShould I Wear a Face Mask?
While this is not in a scientific journal, it is written by an environmental, health and safety manager, responsible for respiratory protection. The writer has degrees in engineering/materials science, and pharmacology and toxicology.
First, cloth face masks show only marginal filtration performance against virus-size particles when sealed around the edge. Face seal leakage will further decrease the respiratory protection offered by fabric materials. Thus, cloth masks are not recommended. Second, surgical masks also do not form a seal, which allows for air leakage and thus respiratory droplets. Third, N95 do not provide complete protection against small virions. In addition, training is required for effective PPE use. Frequently touching ones face to adjust an ill-fitting or uncomfortable mask increases the risk of viral exposure. In summary, the general public should not be wearing face mask to lessen viral transmission because of the potential drawbacks.
COMMENTARY: Masks-for-all for COVID-19 not based on sound data
Masks may give people a false sense of security. The general public who do not have symptoms of COVID-19-like illness should not routinely wear cloth or surgical face masks. There is no scientific evidence that face masks are effective in reducing the risk of SARS-CoV-2 transmission. Cloth masks exhibit very low filter efficiency. Even masks that fit well against the face will not prevent inhalation of small particles by the wearer or emission of small particles from the wearer. Cloth masks offer no protection for healthcare workers inhaling infectious particles near an infected or confirmed patient.
Universal Masking in Hospitals in the Covid-19 Era
Universal masking of the public offers little, if any protection and is mostly a knee jerk reaction to fear and anxiety over the virus. Universal masking of hospital personnel offers very little protection and must be used in conjunction with other meticulous measures as outlined below. It could actually lead to more infections if the other measures are not followed since people wearing masks have a tendency to touch their face more often.
Quoting directly from the New England Journal of Medicine:
"We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic."
In hospital settings where Covid-19 infections are present, the article states, “A mask alone in this setting will reduce risk only slightly, however, since it does not provide protection from droplets that may enter the eyes or from fomites on the patient or in the environment that providers may pick up on their hands and carry to their mucous membranes (particularly given the concern that mask wearers may have an increased tendency to touch their faces)….What is clear, however, is that universal masking alone is not a panacea. A mask will not protect providers caring for a patient with active Covid-19 if it’s not accompanied by meticulous hand hygiene, eye protection, gloves, and a gown. A mask alone will not prevent health care workers with early Covid-19 from contaminating their hands and spreading the virus to patients and colleagues. Focusing on universal masking alone may, paradoxically, lead to more transmission of Covid-19 if it diverts attention from implementing more fundamental infection-control measures.”
Universal Masking in the Covid-19 Era
This letter was a response to the letter cited above. It is interesting that in the original article, the authors state that is “unclear to what extent transmission from asymptomatic individuals contributed to the spread of infection”, but in this article, they say that asymptomatic or presymptomatic individuals may be “highly contagious”. Here, the authors emphasize the importance of masks for passing encounters in public spaces, then say that the risk of SARS CoV-2 transmission is strongly correlated with intensity and duration of contact [though “passing encounters” are not intense or of long duration]. The authors close by saying they “support the calls of public health agencies for all people to wear masks when circumstances compel them to be within 6 ft of others for sustained periods.”
Comprehensive Review of Mask Utility and Challenges During the COVID-19 Pandemic
The paper discusses the universal masking strategy and challenges faced during COVID-19. Symptomatic patients who wore cloth or surgical masks were seen to not filter out SARS-COV2 during coughing. In one study more contamination was found outside the mask than on the inside owing to the masks’ aerodynamic properties. Universal masking may also give a false impression of protection and may result in increased face touching leading to more contamination.
Furthermore, even the most effective mask is useless if not worn correctly or fitted properly. Though healthcare workers may feel falsely safe or protected while wearing a mask (particularly loose-fitting industrial masks), minimal air leakage, regular fit-testing and seal checks with N95 respirators are of paramount importance. The authors conclude that masking alone is not sufficient to stop the spread of COVID-19 and other non-pharmacological interventions such as social distancing, quarantining/isolation, and diligent hand hygiene must be coupled with mask wearing for better outcomes.
A possible solution to alleviate mask shortages that might arise due to universal mask wearing is to modify the mask policy to stagger the requirement based on the severity of community transmission in each particular area of residence.
Rational use of face masks in the COVID-19 pandemic
(The following are direct quotes from the paper.)
“Evidence that face masks can provide effective protection against respiratory infections in the community is scarce, as acknowledged in recommendations from the UK and Germany…. It would be reasonable to suggest vulnerable individuals avoid crowded areas and use surgical face masks rationally when exposed to high-risk areas. As evidence suggests COVID-19 could be transmitted before symptom onset, community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wear face masks…. One advantage of universal use of face masks is that it prevents discrimination of individuals who wear masks when unwell because everybody is wearing a mask…. WHO currently recommends that people should wear face masks if they have respiratory symptoms or if they are caring for somebody with symptoms. Perhaps it would also be rational to recommend that people in quarantine wear face masks if they need to leave home for any reason, to prevent potential asymptomatic or presymptomatic transmission. In addition, vulnerable populations, such as older adults and those with underlying medical conditions, should wear face masks if available. Universal use of face masks could be considered if supplies permit.”
Health concerns associated with wearing face masks
Preliminary Report on Surgical Mask Induced Deoxygenation During Major Surgery
“Our study revealed a decrease in the oxygen saturation of arterial pulsations (SpO2) and a slight increase in pulse rates compared to preoperative values in all surgeon groups. The decrease was more prominent in the surgeons aged over 35.”
“Oxygen saturation of hemoglobin decreased significantly after the operations in both age groups (p<0.0001). The post operational decrease was more prominent in surgeons over 35 when compared to the surgeons under 35 (p=0.0073)”
The Physiological Impact of Wearing an N95 Mask During Hemodialysis as a Precaution Against SARS in Patients With End-Stage Renal Disease
Seventy percent of the patients showed a reduction in partial pressure of oxygen (PaO2), and 19% developed various degrees of hypoxemia. Wearing an N95 mask significantly reduced the
PaO2 level (101.7 +/- 12.6 to 92.7 +/- 15.8 mm Hg, p = 0.006), increased the respiratory rate (16.8 +/- 2.8 to 18.8 +/- 2.7/min, p < 0.001), and increased the occurrence of chest discomfort (3 to 11 patients, p = 0.014) and respiratory distress (1 to 17 patients, p < 0.001).”
Headaches Associated With Personal Protective Equipment - A Cross-Sectional Study Among Frontline Healthcare Workers During COVID-19
Healthcare workers assigned to high risk Covid hospital areas in Singapore were mandated to wear personal protective equipment, so a questionnaire was given to them to determine if increased in headaches were occurring in 158 participants. The study indicates this population wore a mask and goggles greater than 4 hours per day. Out of 158 respondents, 128 (81.0%) respondents developed de novo PPE-associated headaches.
Carbon Dioxide Rebreathing in Respiratory Protective Devices: Influence of Speech and Work Rate in Full-Face Masks
Overall, the results of the study indicate speech and low work rates significantly increase CO2 rebreathing in RPDs. Based on Australian respirator design standards it is evident speech could contribute to inspired CO2 exceeding the maximal allowable concentrations in inspired air…The implication of these findings is that high CO2 concentrations in full face RPDs may be linked to wearer discomfort and contribute to reduced tolerability and wear time of the device. Since many occupations require workers to communicate while wearing RPDs these findings must be taken into consideration.
The Physiological Impact of N95 Masks on Medical Staff
Authors of this clinical trial observe that, "Wearing N95 masks results in hypooxygenemia [lowered blood oxygen levels] and hypercapnia [increased blood carbon dioxide levels] which reduce working efficiency and the ability to make correct decision[s]... dizziness, headache, and short[ness] of breath are commonly experienced by the medical staff wearing N95 masks."
Corona children studies "Co-Ki": First results of a Germany-wide registry on mouth and nose covering (mask) in children
This study, in Germany, utilized a registry to allow parents, teachers, and older children to report the effects of wearing masks in children. 17,854 parents answered the survey. Impairments
caused by wearing the mask were reported by 68% of the parents. These included irritability (60%), headache (53%), difficulty concentrating (50%), less happiness (49%), reluctance to go to school/kindergarten (44%), malaise (42%) impaired learning (38%) and drowsiness or fatigue (37%). Other complaints included worsened skin, rashes and allergic reactions, and fungal diseases around the mouth. The authors stated, “it can be said that the effects of compulsory masks on the quality of life and presumably also on the health of individual children should not be ignored by politics and society.”
Is a Mask That Covers the Mouth and Nose Free from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?
This study reviewed data from 65 publications regarding the adverse effects of wearing face masks, including some published prior to the COVID-19 pandemic and some during the pandemic. Using regression analysis, they demonstrated a statistically significant correlation between blood-oxygen depletion and fatigue in mask wearers. They also observed common appearance of statistically significant confirmed effects of masks including rise in carbon dioxide, decrease in oxygen saturation, respiratory impairment, headaches, fatigue, increase in pulse rate, drop in blood oxygen partial pressure, and increase in heart rate and respiratory rate. The authors point out that while these issues may seem minor at first, exposure over longer periods of time may lead to long-term disease-relevant consequences.
Media reports including interviews with physicians and scientists
Gregory Poland, MD, an infectious disease & vaccine expert at the Mayo Clinic, stated that the mask is an indicator of a constellation of behaviors that collectively reduce transmission. Wearing a mask leads someone to touch their face less often & serves as a constant psychological reminder to do other known infection prevention behaviors, such as frequent, rigorous hand-washing and keeping a good distance from other people.
America’s surgeon general, Jerome Adams, M.D., M.P.H., said in an interview in March that masks can be dangerous is because people tend to touch their masks many times per hour and can spread the disease that way. [The media has reported that Dr. Adams has backtracked on this statement.]
Dr. Jennie Harries says that masks could actually “trap the virus” and cause the person wearing it to breathe it in. “For the average member of the public walking down a street, it is not a good idea” to wear a face mask in the hope of preventing infection. “Because of these behavioural issues, people can adversely put themselves at more risk than less.”
Dr. Jake Dunning said “Face masks must be worn correctly, changed frequently, removed properly, disposed of safely and used in combination with good universal hygiene behaviour in order for them to be effective.”
This media article presents the analysis of researchers at RationalGround.com, a clearinghouse of COVID-19 data trends run by a grassroots group of data analysts. Though this is data driven, because it is not in a scientific journal, we list it here under media reports. They compared states with mandates vs. those without, or periods of times within a state with a mandate vs. without (ecological analysis). In total, in the states that had a mandate in effect, there were 9,605,256 confirmed COVID cases over 5,907 total days, an average of 27 cases per 100,000 per day. When states did not have a statewide order (which includes the states that never had them and the period of time masking states did not have the mandate in place) there were 5,781,716 cases over 5,772 total days, averaging 17 cases per 100,000 people per day. In short, this shows an inverse relationship between mask mandates and case numbers, where the states without mask mandates had a lower daily rate of COVID19 case identification. The data were analyzed in a number of ways to account for various confounding factors, and the conclusion remained the same.
'How To' Guide for Mask Exemptions
By Heather Groves
*Disclaimer: The strategies conveyed in this article are not intended to substitute for legal or medical consultation.
There are currently no statewide orders for wearing a face covering.
What might parents do who wish to file an exemption to the mask mandate
1. Submit a handwritten letter or email to the school district stating simply:
a. “To whom it may concern: Due to my deeply held religious beliefs, and in accordance with my family’s established and sincerely held religious practices, my child is exempt from wearing a facial covering while at school and/or during any school related activities. Thank you.”
b. “To whom it may concern: Due to a medical condition that contraindicates my child from wearing a facial covering, my child is exempt from wearing a facial covering while at school and/or during any school related activities. Thank you.”
2. Only communicate with the school in writing, and request that all responses to your requests be clearly defined and in writing.
a. If you’ve previously had a verbal conversation that has not been documented, follow up with an email where you list the topics of your conversation and ask for a response.
3. If the school district requests additional information about your religious beliefs and/or medical disability, respond with something similar to addendum 1. Do NOT answer their questions related to your personal beliefs or child’s medical history. They do NOT have the right to ask these questions. Please see addendum 3 for more information.
4. If your school district and or/ health department pushes back and states that you will be required to submit additional documentation, that your child will still be forced to wear a face shield or that your child will be pushed into online learning, you should immediately file a public records request to both the school district and the health department asking for their masking policy, their exemption policies and any and all communications between any school district staff, the local health department as well as with any other school districts as it relates to masking policies and exemptions. You will want this information to keep in your personal records as well as for possible legal recourse. Please see a sample public records request below: addendum 2.
5. After completing the public records request, respond to the school district with something similar to addendum 3.
6. If your school district states that your child is being forced into online/remote learning or extreme isolation i.e, transitioning into the hallways and bathroom alone, eating lunch alone, etc, refuse busing for your child, etc, simply for utilizing the mask exemption, remind them that they are in direct violation of the Ohio Revised Code which defines the separation or segregation of one group from another based on religious beliefs or disability as discrimination. http://codes.ohio.gov/orc/4112.01
a. Schools do not have the authority to force students who utilize a religious exemption into online learning. Per the DOJ, “Public primary and secondary schools, as well as public colleges and universities, should be open to all members of the public, regardless of their faith. Students should not face discrimination or harassment because of their faith background, their beliefs, their distinctive religious dress, or their religious expression.”
7. Contact your state legislators and let them know what is going on in your school district and ask them to for their feedback. Find out who represents you here: https://www.legislature.ohio.gov/
8. Contact the Department of Justice here: https://www.justice.gov/contact-us
a. “Public primary and secondary schools, as well as public colleges and universities, should be open to all members of the public, regardless of their faith. Students should not face discrimination or harassment because of their faith background, their beliefs, their distinctive religious dress, or their religious expression.”
b. “The Civil Rights Division's Educational Opportunities Section enforces Title IV of the Civil Rights Act of 1964, which prohibits discrimination based on religion in public primary and secondary schools, as well as public colleges and universities. Subsection (a)(1) authorizes the Attorney General to bring suit in response to a written complaint by a parent that a child is being "deprived by a school board of the equal protection of the laws." Subsection (a)(2) permits the Attorney General to bring suit upon receiving a written complaint that a student has been "denied admission to or not permitted to continue in attendance at a public college by reason of race, color, religion, sex or national origin." The Attorney General has delegated this authority to the Civil Rights Division.
c. Additionally, Title IX of the Civil Rights Act of 1964 permits the Attorney General to intervene in any action in federal court, involving any subject matter, "seeking relief from the denial of equal protection of the laws under the Fourteenth Amendment to the Constitution on account of race,color, religion, sex or national origin," if such intervention is timely made and the Attorney General certifies that the case is of "general public importance." Enforcement of this provision also has been delegated to the Civil Rights Division, and the Division has participated in a number of education-related religious discrimination cases under Title IX.”
9. Consider joining Health Freedom Ohio, where we will help prepare you to advocate for your rights in both social and legislative arenas.
10. Consider joining the Ohio Assembly to learn more about your constitutional rights!
11. Most importantly, do not give up! This may seem like a daunting task, but advocating for your children’s best interest is the most important job that you have! Stand firm, be concise in your communications and if all else fails, reach out to Health Freedom Ohio for more guidance!
Addendum 1: Response to School District for more information on exemptions
Thank you for your response to my religious exemption statement as it pertains to the Ohio Educational Setting Mask Mandate Order. The intrusive line of questioning contained within your email was not only out of line, but that in asking these questions the school district is exercising authority outside of its legal scope of practice and is at risk of legal retaliation.
Nowhere in any founding document will the school district find the authority to question, review or otherwise scrutinize or "approve" the deeply held religious convictions and or/beliefs and practices of its students. Asking for any religious documentation, clarification or exposition of our religious beliefs in an attempt to approve or disapprove of them is exercising authority outside of the scope of the mandate and is a direct violation of our family's freedom of religion and religious expression.
1. The individual has a medical condition INCLUDING respiratory conditions that restricts breathing, mental health conditions, or a disability that contraindicates the wearing of a facial covering. a. The language of this exemption does not LIMIT the exemption to only those individuals that have respiratory conditions, mental health conditions or a disability that contraindicates the wearing of a facial covering but rather lists these conditions as examples of medical conditions that would fall under the exemption. The language of the order does not list specific conditions that are acceptable for an exemption, and therefore an individual is not required to meet any specific medical condition standard.
b. School districts and health departments have not been granted authority to narrow the scope of the language of this order, and therefore are unable to deny exemptions based on health conditions that THEY do not believe requires an exemption to facial coverings.
c. Nowhere in this order does it state that a medical professional must provide a letter stating that an individual has a medical condition that prevents them from masking; requiring a “doctor’s note” before accepting an exemption based on medical conditions is exercising authority outside of the scope of the order.
d. On August 4th, 2020, Governor DeWine tweeted a letter from the Ohio Children’s Hospital Association and Ohio Pediatricians recommending masks for school children; the letter listed specific exemptions and states that “asthma, allergies and sinus infections are not a contraindication” for using face coverings. THIS LETTER IS NOT PART OF THE ORDER, and is therefore NOT legally binding. Hospital Associations do not make laws and they can not enforce their medical opinion on the general public when the general public is not under their care. If your school district is using this letter as a platform to deny medical exemptions, kindly remind them that they are enforcing a general RECOMMENDATION, and in doing so, they are exercising authority outside of the scope of the mandate and making medical decisions for your family without a medical license.
2. When an established sincerely held religious requirement exists that does not permit a facial covering. a. The language of this exemption does NOT grant the school district or health department the authority to question, review, scrutinize or otherwise “approve” of the deeply held religious requirement held by the individual utilizing the exemption.
b. The language of this bill does not grant the school district or health department authority to require a signature or conversation with the individual’s religious leaders in an attempt to “validate” one's personal religious beliefs.
c. Per Welsh v. United States, 398 U.S. 333, The Supreme Court has broadened the definition of religion to include an individuals “deeply held moral and ethical beliefs.”
i. 3. Section 6 (j) contravenes the Establishment Clause of the First Amendment by exempting those whose conscientious objection claims are founded on a theistic belief,while not exempting those whose claims are based on a secular belief. To comport with that clause, an exemption must be "neutral" and include those whose belief emanates from a purely moral, ethical, or philosophical source. Pp. 398 U. S. 356-361.
For legal precedent, I have attached the Ohio Legal Service Commission's review of individual school districts' role in approving or denying student's religious exemptions as they pertain to vaccination exemptions, as the wording of the Mask Mandate religious exemption clause and Ohio Revised Code 3313.671 pertaining to vaccine exemptions are very similar. As you can see below, Ohio School districts do not have the authority to question, review, approve of or inquire about their student's religious beliefs as they pertain to exercising their legal right to claim a religious exemption. It is specifically mentioned that the school district is not permitted to request documentation from or a conversation with the student's religious leaders as it pertains to the religious exemption.
As you can see, the only documentation that I am required to provide to you is a statement of intent to exercise my legal authority to utilize a religious exemption as provided in Section 2.H of the Ohio Educational Setting Mask Mandate Order, and as I have already provided that statement of intent, I fully expect that my religious exemption be honored without further delay. Thank you for your time and attention to this matter, and I look forward to receiving the confirmation that my child's exemption has been approved and processed without any further intrusion into my family's personal religious beliefs and without any retaliation or unfair treatment to my child.
I have CC'd my state representatives as they are interested parties in this conversation. Thank you.
(CC your state representatives)
Addendum 2: Public Records Request
ALL Board of Education Members
Attorney for School District
Local Health Department
Re: Official Public Records Request
To ALL Concerned Parties,
Under the Ohio Open Records Law, §149.43 et seq., I am requesting an opportunity to inspect or obtain copies of public records for:
1. The school districts board approved policy on student mandated facial coverings as well as the date that the policy was approved.
2. The school districts board approved policy on the approval of facial covering exemptions as well as the date that the policy was approved.
3. The school districts board approved policy on the appeals process when an exemption is denied.
4. ANY and ALL communications that have taken place via email, letters and phone communication between the (name school district ) Superintendent, School Board Members, School Faculty, School Staff, the school’s legal counsel, any and all other school districts and any and all county and/or state health department staff and/or officials regarding FACE MASKS, FACE COVERINGS and FACE SHIELDS.
5. The liability insurance employed by the school district as it relates to any harm and/or injury sustained by students resulting from prolonged facial covering use.
6. The FDA approval of cloth face coverings for preventing viral spread that the school district relies on to state that cloth face coverings offer protection to students from COVID19.
7. All educational materials provided to school district staff and/ or students on the proper donning, doffing and storing of facial coverings to prevent cross contamination and viral spread.
8. All educational and or training materials provided to school district staff on recognizing adverse health reactions in students due to prolonged masking and what policies are put in place to ensure the health and safety of students as it relates to prolonged masking.
9. All published, peer reviewed studies on the long term safety of prolonged masking in children as it relates to the educational setting.
10. The Oaths of Office taken by any School Board Member and or School District Staff.
11. The surety bond information for all School Board Members and or School District Staff.
12. The insurance information related to the surety bond information mentioned above.
I am requesting this information along with the waiver of all fees associated with the request in that the disclosure of the requested information is in the public interest and will contribute significantly to the public’s understanding of the school districts Facial Covering Policy as well as the Facial Covering Exemption policy and process.
I would request a prompt response to this request. If you expect a significant delay in responding to or in fulfilling this request, please contact me with information about when I might expect copies or the ability to inspect the requested records. All information responsive to this request can be sent via mail to my attention at: INSERT YOUR ADDRESS.
If you deny any or all of this request, please cite each specific exemption that you feel justifies the refusal to release the information and notify me of the appeal procedures available to me under the law.
Thank you for your prompt attention to my request.
Addendum 3: Additional Responses to School
Thank you for your response to my exemption statement pertaining to the mask requirement at school. I have again reviewed your request for additional information pertaining to my family’s deeply held religious beliefs, and must again remind you that, per the Ohio Constitution, I am only obligated to inform the school district that my family has an established, sincerely held religious belief that does not permit my child from wearing facial coverings while at school.
Nowhere in founding documents will the school district find the authority to question, review or otherwise scrutinize or "approve" the deeply held religious convictions and or/beliefs and practices of its students. Asking for any religious documentation, clarification or exposition of our religious beliefs in an attempt to approve or disapprove of our religious beliefs is exercising authority outside of the scope of the mandate and is a direct violation of our family's freedom of religion and religious expression. I am requesting that you provide me with the policy that grants you the authority to request documentation and/or details of my personal religious beliefs before accepting my religious exemption at your earliest convenience
You have stated that the school district has a responsibility to public health, and I couldn’t agree more.
The school district will be in violation of state law in your effort to deprive my child of their constitutionally protected right to an appropriate public education if you attempt to deny our religious exemption further.
1. The Ohio Constitution article I.07 states:
a. “nor shall any person be INCOMPETENT to be a witness on account of his religious beliefs.” Requiring additional documentation on one’s religious beliefs, including requests to speak to religious leaders or to obtain a pastors signature is in direct violation of the Ohio Constitution.
b. “All men have a natural and indefeasible right to worship Almighty God according to the dictates of THEIR OWN conscience.” A school district may not deny a religious exemption because they do not believe that a particular religious denomination supports and/or qualifies for a religious exemption. An example of this would be denying an exemption because the student is Catholic and citing the Vatican’s statement on following government COVID19 orders; religion is personal and not confined to the religious tenets of a particular doctrine or denomination.
2. The Ohio Revised Code defines the separation or segregation of one group from another based on religious beliefs or disability as discrimination. Any attempt to isolate, separate or segregate my child from the rest of the class i.e, dismissing them into the hallways or bathroom before or after other students, forcing them to eat lunch alone or with extreme social distancing, separating their desks from the rest of the class, etc, will be considered discrimination and retaliation and will be dealt with accordingly.
3. Ohio Revised Code 3313.601 states that “No board of education of a school district shall adopt any policy or rule... prohibiting any pupil from the free, individual, and voluntary exercise or expression of the pupil's religious beliefs in any primary or secondary school.”
4. In Steele v. Hamilton Cty. Cmty. Mental Health Bd, the Ohio Supreme Court held that: a. “The right to refuse medical treatment is a fundamental right in our country, where personal security, bodily integrity, and autonomy are cherished liberties. These liberties were not created by statute or case law. Rather, they are rights inherent in every individual. Section 1, Article I of the Ohio Constitution provides that “[a]ll men are, by nature, free and independent, and have certain inalienable rights, among which are those of enjoying and defending life and liberty, acquiring, possessing, and protecting property, and seeking and obtaining happiness and safety.” (Emphasis added.) Our belief in the principle that “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body,” Schloendorff v. Soc. of N.Y. Hosp. (1914), 211 N.Y. 125, 129, 105 N.E. 92, 93, is reflected in our decisions. See, e.g., Nickell v. Gonzalez (1985), 17 Ohio St.3d 136, 17 OBR 281, 477 N.E.2d 1145 (setting out the test for establishing the tort of lack of informed consent); In re Milton (1987), 29 Ohio St.3d 20, 29 OBR 373, 505 N.E.2d 255 (holding that potentially life- saving treatment for cancer could not be forced upon mentally ill person who had the capacity to give or withhold informed consent).”
The school district will be in violation of federal law in your effort to deprive my child of their constitutionally protected right to an appropriate public education if you attempt to deny our religious exemption further.
1. Per the Civil Rights Act of 1964 Section 201, Section 202:
a. “All persons shall be entitled to the full and equal enjoyment of the goods, services, facilities, and privileges, advantages, and accommodations of any place of public accommodation, as defined in this section, without discrimination or segregation on the ground of race, color, religion, or national origin.”
2. CONSPIRACY AGAINST RIGHTS—USC 18 §241
a. If two or more persons conspire to injure, oppress, threaten, or intimidate any person in any State in the free exercise or enjoyment of any right, they shall be fined under this title or imprisoned not more than ten years, or both.
3. DEPRIVATION OF RIGHTS—USC 18 §242
a. Whoever, under color of any law, statute, ordinance, regulation, or custom, willfully subjects any person in any State the deprivation of any rights, shall be fined under this title or imprisoned not more than one year, or both.
4. DEPRIVATION OF RIGHTS—USC 42 §1983
a. Every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State subjects, or causes to be subjected, any person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law.
5. The Free Exercise Clause Prohibits Unequal Treatment of Religious Individuals and Organizations . a. The Free Exercise Clause guarantees to all Americans the “right to believe and profess whatever religious doctrine [they] desire.” Empl’t Div. v. Smith, 494 U.S. 872, 877 (1990).
b. The free exercise of religion includes the right to act or abstain from action in accordance with one's religious beliefs.
i. The Free Exercise Clause protects not just the right to believe or the right to worship; it protects the right to perform or abstain from performing certain physical acts in accordance with one's beliefs. Federal statutes, including the Religious Freedom Restoration Act of 1993 (“RFRA”), support that protection, broadly defining the exercise of religion to encompass all aspects of observance and practice, whether or not central to, or required by, a particular religious faith.”
c. The Free Exercise Clause recognizes and guarantees Americans the “right to believe and profess whatever religious doctrine [they] desire [ ].” Empl't Div. v. Smith, 494 U.S. 872, 877 (1990). Government may not attempt to regulate religious beliefs, compel religious beliefs, or punish religious beliefs. See id.; see also Sherbert v. Verner, 374 U.S. 398, 402 (1963); Torcaso v. Watkins, 367 U.S. 488, 492-93, 495 (1961); United States v. Ballard, 322 U.S. 78, 86 (1944). It may not lend its power to one side in intra-denominational disputes about dogma, authority, discipline, or qualifications for ministry or membership. Hosanna-Tabor Evangelical Lutheran Church & Sch. v. EEOC, 565 U.S. 171, 185 (2012); Smith, 494 U.S. at 877; Serbian Eastern Orthodox Diocese v. Milivojevich, 426 U.S. 696, 724-25 (1976); Presbyterian Church v. Mary Elizabeth Blue Hull Mem'l Presbyterian Church, 393 U.S. 440, 451 (1969); Kedroff v. St. Nicholas Cathedral of the Russian Orthodox Church, 344 U.S. 94, 116, 120-21 (1952). It may not discriminate against or impose special burdens upon individuals because of their religious beliefs or status. Smith, 494 U.S. at 877; McDaniel v. Paty, 435 U.S. 618, 627 (1978). And with the exception of certain historical limits on the freedom of speech, government may not punish or otherwise harass churches, church officials, or religious adherents for speaking on religious topics or sharing their religious beliefs. See Widmar v. Vincent, 454 U.S. 263, 269 (1981); see also U.S. Const., amend. I, cl. 3. The Constitution's protection against government regulation of religious belief is absolute; it is not subject to limitation or balancing against the interests of the government. Smith, 494 U.S. at 877; Sherbert, 374 U.S. at 402; see also West Virginia State Bd. of Educ. v. Barnette, 319 U.S. 624, 642 (1943) (“If there is any fixed star in our constitutional constellation, it is that no official, high or petty, can prescribe what shall be orthodox in politics, nationalism, religion, or other matters of opinion or force citizens to confess by word or act their faith therein.”).
d. The Free Exercise Clause protects beliefs rooted in religion, even if such beliefs are not mandated by a particular religious organization or shared among adherents of a particular religious tradition. Frazee v. Illinois Dept. of Emp't Sec., 489 U.S. 829, 833-34 (1989). As the Supreme Court has repeatedly counseled, “religious beliefs need not be acceptable, logical,consistent, or comprehensible to others in order to merit First Amendment protection.” Church of the Lukumi Babalu Aye v. Hialeah, 508 U.S. 520, 531 (1993) (internal quotation marks omitted).They must merely be “sincerely held.” Frazee, 489 U.S. at 834.
e. Importantly, the protection of the Free Exercise Clause also extends to acts undertaken in accordance with such sincerely-held beliefs. That conclusion flows from the plain text of the First Amendment, which guarantees the freedom to “exercise” religion, not just the freedom to“believe” in religion. See Smith, 494 U.S. at 877; see also Thomas, 450 U.S. at 716; Paty, 435U.S. at 627; Sherbert, 374 U.S. at 403-04; Wisconsin v. Yoder, 406 U.S. 205, 219-20 (1972).Moreover, no other interpretation would actually guarantee the freedom of belief that Americans have so long regarded as central to individual liberty. Many, if not most, religious beliefs require external observance and practice through physical acts or abstention from acts. The tie between physical acts and religious beliefs may be readily apparent (e.g., attendance at a worship service) or not (e.g., service to one's community at a soup kitchen or a decision to close one's business on a particular day of the week). The “exercise of religion” encompasses all aspects of religious observance and practice. And because individuals may act collectively through associations and organizations, it encompasses the exercise of religion by such entities as well.See, e.g., Hosanna-Tabor, 565 U.S. at 199; Church of the Lukumi Babalu Aye, 508 U.S. at525-26, 547; see also Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751, 2770, 2772-73(2014) (even a closely held for-profit corporation may exercise religion if operated in accordance with asserted religious principles).
6. The Religious Freedom Restoration Act of 1993 prohibits the federal government from substantially burdening any aspect of religious observance or practice, unless imposition of that burden on a particular religious adherent satisfies strict scrutiny.
a. RFRA does not permit the federal government to second-guess the reasonableness of a religious belief.
i. RFRA applies to all sincerely held religious beliefs, whether or not central to, or mandated by, a particular religious organization or tradition. Religious adherents will often be required to draw lines in the application of their religious beliefs, and government is not competent to assess the reasonableness of such lines drawn, nor would it be appropriate for government to do so.
b. A governmental action substantially burdens an exercise of religion under RFRA if it bans an aspect of an adherent's religious observance or practice, compels an act inconsistent with that observance or practice, or substantially pressures the adherent to modify such observance or practice.
i. Because the government cannot second-guess the reasonableness of a religious belief or the adherent's assessment of the religious connection between the government mandate and the underlying religious belief, the substantial burden test focuses on the extent of governmental compulsion involved. In general, a government action that bans an aspect of an adherent's religious observance or practice, compels an act inconsistent with that observance or practice, or substantially pressures the adherent to modify such observance or practice, will qualify as a substantial burden on the exercise of religion. c. The strict scrutiny standard applicable to RFRA is exceptionally demanding i. Once a religious adherent has identified a substantial burden on his or her religious belief, the federal government can impose that burden on the adherent only if it is the least restrictive means of achieving a compelling governmental interest. Only those interests of the highest order can outweigh legitimate claims to the free exercise of religion, and such interests must be evaluated not in broad generalities but as applied to the particular adherent. Even if the federal government could show the necessary interest, it would also have to show that its chosen restriction on free exercise is the least restrictive means of achieving that interest. That analysis requires the government to show that it cannot accommodate the religious adherent while achieving its interest through a viable alternative, which may include, in certain circumstances, expenditure of additional funds, modification of existing exemptions, or creation of a new program.
d. Agencies Engaged in Enforcement Actions
i. Much like administrative agencies engaged in rule making, agencies considering potential enforcement actions should consider whether such actions are consistent with federal protections for religious liberty. In particular, agencies should remember that RFRA applies to agency enforcement just as it applies to every other governmental action. An agency should consider RFRA when setting agency-wide enforcement rules and priorities, as well as when making decisions to pursue or continue any particular enforcement action, and when formulating any generally applicable rules announced in an agency adjudication. Agencies should remember that discriminatory enforcement of an otherwise nondiscriminatory law can also violate the Constitution. Thus, agencies may not target or single out religious organizations or religious conduct for disadvantageous treatment in enforcement priorities or actions
Thank you for your time and attention to this matter, and I look forward to receiving the confirmation that my child's exemption has been approved and processed without any further intrusion into my family's personal religious beliefs and without any retaliation or unfair treatment of my child.
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