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HomeMy WebLinkAboutBOH Packet 052120Public H Board of Health Meeting May 21, 2020 Jefferson County Public Health Agenda Minutes V,,r�ffeolbsson Public Health May 21, 2020 JEFFERSON COUNTY BOARD OF HEALTH May 21, 2020 Jefferson County Public Health Special Meeting 2:30 — 4:30 PM DRAFT AGENDA COVID-19 NOTICE: NO IN-PERSON ATTENDANCE ALLOWED (Per Governor Inslee's Proclamation 20-28) To view this meeting live go to www.co.iefferson.wa.us Follow the links under "Quick Links: Videos of Meetings -Streaming Live" Those without internet can listen by dialing 1 (872) 240-3311 -- enter Access Code: 508-681-005 Approval of Agenda II. Approval of Minutes April 16, 2020 Board of Health Meeting III. Old Business and Information Reports 1. Jefferson Healthcare Report IV. New Business 1. Health Officer Recommendations Re: Variance Request to Move from Phase 1 to Phase 2 of Safe Start Washington Plan (to be distributed by 5/20/20) 2. Draft Jefferson County Board of Health Variance Plan Request (to be distributed 5/20/20) 3. Masking Directives V. Agenda Planning Calendar: 1. Next Scheduled Meeting: June 18, 2020 2:30-4:30 PM Jefferson County Public Health Virtual Meeting JEFFERSON COUNTY BOARD OF HEALTH MINUTES April 16, 2020 Jefferson County Public Health, 615 Sheridan Street, Port Townsend WA 98368 DRAFT Board Members Pamela Adams, Vice Chair, Port Townsend City Council Greg Brotherton, County Commissioner, District #3 Kate Dean, County Commissioner District #1 Kees Kolff, Public Hospital District #2 Commissioner Denis Stearns, Citizen at large David Sullivan, County Commissioner, District #2 Sheila Westerman, Chair, Citizen at large Staff Members Michael Dawson, Water Quality Manager Vicki Kirkpatrick, Public Health Director Thomas Locke, Health Officer Apple Martine, Community Health Director Pinky Mingo, Interim Env. Public Health Director Veronica Shaw, Public Health Deputy Director Vice Chair Pamela Adams called the April 16, 2020 meeting of the Jefferson County Board of Health to order at 2:30 p.m. A quorum was present. Members Present: Pamela Adams, Greg Brotherton, Kate Dean, Kees Kolff, Denis Stearns, David Sullivan, Sheila Westerman Staff Present: Michael Dawson, Vicki Kirkpatrick, Thomas Locke, Apple Martine, Pinky Mingo, Veronica Shaw APPROVAL OF AGENDA Vice Chair Pamela Adams asked for approval of the agenda for April 16, 2020. Member Greg Brotherton motioned to approve the agenda. The motion was seconded by Member Kate Dean. No further discussion. The motion passed unanimously. APPROVAL OF MINUTES Vice Chair Pamela Adams asked for approval of the minutes for the March 19, 2020 BOH meeting. Member Kate Dean motioned to approve the minutes as amended. The motion was seconded by Member Greg Brotherton. No further discussion. The motion passed unanimously. Page 1 of 4 PUBLIC COMMENTS Zoe Ann Lamp emailed the Board to thank them, Jefferson County Public Health, Jefferson Healthcare, and the Department of Emergency Management for their coordinated efforts on the local response to the COVID-19 pandemic. OLD BUSINESS AND INFORMATIONAL ITEMS 1. Jefferson Healthcare Update Member Kees Kolff said Jefferson Healthcare has done a remarkable job at keeping their staff safe and prepared for a possible surge of patients with COVID-19. He also said: 1) no patients with COVID-19 have been treated in the hospital, 2) only one complaint was received regarding how they are providing information, 3) visits to the emergency room and express clinic are down, 4) the in-patient census is down, and 5) the hospital has taken an enormous financial hit to comply with state and federal guidelines to keep patients safe due to COVID-19. Vice Chair Pamela Adams shared her experience with telemedicine at JHC. Member Kate Dean asked about relief funding for the hospital. NEW BUSINESS 1. 2019 Novel Coronavirus (COVID-19) Pandemic Emergency: Situation Report, Epidemiological Modelling of Disease Activity, Local Response Efforts Dr. Tom Locke, Health Officer, said there has been extraordinary teamwork and multiagency collaboration in Jefferson County in response to the COVID-19 pandemic. At this point, there have been a total of 28 confirmed cases of COVID-19 in Jefferson County. He compared the rates of transmission in Jefferson County to other counties, including King and Snohomish counties, and said the demand on hospitals is starting to drop. Dr. Locke reviewed modeling data predictions and explained why social distancing works. He said a phased approach to restarting the economy is being developed and stressed the importance of increasing testing capabilities so the rates of virus transmission can be monitored as each phase is implemented. Dr. Locke reviewed the four-phase outline and requirements for moving on to Phase II. The Board had questions about essential services, testing limitations, communicating virus transmission information of local congregate settings, and recommendations for wearing masks and gloves. 2. Environmental Public Health: Essential Food Service Establishment Outreach Efforts to Prevent Disease Transmission Pinky Mingo, Interim Environmental Public Health Director, provided an update on infection control measures implemented by local grocery stores. She said Chimacum Farm Stand is one of the best examples of a store modifying protocols to prevent disease transmission. There are various levels of compliance within the County and JCPH is working on increasing education and outreach. A letter Page 2 of 4 specifying how to implement infection control measures will be sent to food service establishments. Next week they will be looking at how restaurants offering take-out food are implementing practices to prevent disease transmission. The Board had questions about recommendations and protocols for sneeze guards, gas stations, self -serve and hot food stations, reusable cups, personal grocery bags, and the farmer's market. Chair Sheila Westerman read a letter from the City of Port Townsend regarding new stipulations for short- term rentals due to the COVID-19 pandemic. Member Greg Brotherton said the Policy Management Group will be issuing a similar press release and conducting outreach. 3. Jefferson County Public Health: Continuity of Services, Implementation of Social Distancing Protocols Vicki Kirkpatrick, Director of Jefferson County Public Health, provided an update on measures taken by JCPH to protect employees and clients. This includes telecommuting, health checks, cross -training staff to help prevent burn -out, daily situation report meetings, reducing clinical services, providing alternatives so the Syringe Exchange Program and Plan B services can be accessed, etc. Ms. Kirkpatrick also said they expect to experience a loss of funding and are looking at ways to reduce costs and address the revenue reductions. Apple Martine, Community Health Director, provided a status update on how community health services have been modified to meet the needs of clients. Some of which includes offering telehealth for the Nurse Family Partnership program and family planning services, offering school-based health care services at the main clinic and following up with individuals on a case-by-case basis. Ms. Martine said she is participating in interagency roundtables to address behavioral health issues due to COVID -19 and trauma informed care for pandemic stress. 4. Climate Change and the Coronavirus Pandemic Dr. Locke spoke about the link between the Coronavirus and Climate Change and the effects of each on the global population. Member Kate Dean said the Climate Action Committee recently released the Greenhouse Gas Inventory for the County. She also said, although Earth Day celebrations scheduled for April 25th have been cancelled, the County and City are planning to issue Earth Day proclamations. There was no activity update. ACTIVITY UPDATE PUBLIC COMMENT Patty Charnas, Director of Jefferson County Community Development, asked Dr. Locke a question about antibody testing. Page 3 of 4 AGENDA PLANNING CALENDAR There was a discussion about providing time at the end of the meeting so the public could ask questions. NEXT SCHEDULED MEETING The next Board of Health meeting will be held online as a GoToMeeting on Thursday, May 21, 2020 from 2:30 — 4:30 p.m. ADJOURNMENT Vice Chair Pamela Adams adjourned the April 16, 2020 Jefferson County Board of Health meeting at 4:38 p.m. JEFFERSON COUNTY BOARD OF HEALTH Sheila Westerman, Chair Pamela Adams, Vice Chair David Sullivan, Member Denis Stearns, Member Kate Dean, Member Greg Brotherton, Member Kees Kolff, Member Respectfully submitted J. Matter Page 4 of 4 Board of Health IV New Business Item 3 Masking Directives Oy�e�is°r` Public He-alth May 21, 2020 Face Masks Against COVI D-19: An Evidence Review Jeremy Howarda,°,1, Austin Huangb, Zhiyuan Li k, Zeynep Tufekcim, Vladimir Zdimal', Helene -Mari van der Westhuizenf,g, Arne von Delfto,g, Amy Price", Lex Fridmand, Lei -Han Tang'', Viola Tang', Gregory L. Watson'', Christina E. Baxa, Reshama Shaikhq, Frederik Questier', Danny HernandezP, Larry F. Chu", Christina M. Ramirez'', and Anne W. Rimoint "fast.ai, 101 Howard St, San Francisca, CA 94105, US; bWarren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903; `Data Institute, University of San Francisco, 101 Howard St, San Francisco, CA 94105, US; d Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technalogy, 77 Massachusetts Ave, Cambridge, MA 02139; 'Institute of Chemical Process Fundamentals, Czech Academy of Sciences, Rozwjovd 135, CZ -165 02 Praha.6, Czech Republic: "Department of Primary Health Care Sciences, Woodstock Road, University oI Oxford, OX2 6GG, United Kingdom; sTB Proof, Cape Town, South Africa; (' Department of Slostatlstics. UCLA Fielding School of Public Health, 650 Charles E Young Drive, Los Angeles, CA 90095; ' Department o1 Physics, Hong Kong Bakptiai Unlverslly, Kowloon Tong, Hong Kong SAR, China; komplex Systems Division, Beijing Computational Science Research Center, Haidlan, Beijing 100193, China; Center for Quantitative Biology, Peking University, Haid !an, 8elJing 100871, China; 1Depart ment of Information Systems, Business Statistics and Operations Management, Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong SAR, China;'" University of North Carolina at Chapel Hill; "School of Medicine Anesthesia Informatics and Media (AIM) Lab, Stanford University, 300 Pasteur Drive, Grant S268C, Stanford, CA 94305; 'School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, 7925, South Africa; POpenAl, 3180 18th St, San Francisco, CA 94110; "Data Umbrella, 345 West 145th St, New York, NY 10031;'Vrije Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium; 'Universily of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104; tDepartment of Epidemiology, UCLA Fielding School of Public Health, 650 Charles E Young Drive, Los Angeles, CA 90095 This manuscript was compiled on May 12, 2020 The science around the use of masks by the general public to Impede COVID-19 transmission is advancing rapidly. Policymakers need guidance on how masks should be used by the general population to combat the COVID-19 pandemic. Here, we synthesize the relevant literature to inform multiple areas: 1) transmission characteristics of COVID-19, 2) filtering characteristics and efficacy of masks, 3) esti- mated population impacts of widespread community mask use, and 4) sociological considerations for policies concerning mask -wearing. A primary route of transmission of COVID-19 is likely via respiratory droplets, and is known to be transmissible from presymptomatic and asymptomatic individuals. Reducing disease spread requires two things: first, limit contacts of Infected individuals via physical dis- tancing and other measures, and second, reduce the transmission probability per contact. The preponderance of evidence Indicates that mask wearing reduces the transmissibility per contact by reduc- ing transmission of infected droplets in both laboratory and clinical contexts. Public mask wearing is most effective at reducing spread of the virus when compliance is high. The decreased transmissibil- ity could substantially reduce the death toll and economic impact while the cost of the intervention is low. Given the shortages of med- ical masks for now we recommend the adoption of public cloth mask wearing, as an effective form of source control, In conjunction with existing hygiene, distancing, and contact tracing strategies. We rec- ommend that public officials and governments strongly encourage the use of widespread face masks in public, including the use of ap- propriate regulation. COVID-19 I SARS-CoV-2 1 Masks I Pandemic olicymakers need urgent guidance on the use of masks by the general population as a tool in combating SARS-CoV- 2, the respiratory virus that causes COVID-19. Masks have been recommended as a potential tool to tackle the COVID- 19 pandemic since the initial outbreak in China (1), although usage during the outbreak varied by time and province (2). Globally, countries are grappling with translating the evi- dence of public mask wearing to their contexts. These poli- cies are being developed in a complex decision-making envi- ronment, with a novel pandemic, rapid generation of new re- search, and exponential growth in cases and deaths in many areas. There is currently a global shortage of N95/FFP2 res- www.pnas.org/cgi/dol/I 0. 1 073/pnas.XXXXXX XXXX pirators and surgical masks for use in hospitals. Simple cloth masks present a pragmatic solution for use by the public. This has been supported by the United States and European Cen- tres for Disease Control. We present an interdisciplinary nar- rative review of the literature on the role of simple cloth masks and policies in reducing COVID-19 transmission. 1. Components to Evaluate for Public Mask Wearing In order to identify whether public mask wearing is an appro- priate policy, we need to consider these questions: a Do asymptomatic or pre -symptomatic patients pose a risk of infecting others? b Would a face mask likely decrease the number of people infected by an infectious mask wearer? c Are there face covers that will not disrupt the medical supply chain, e.g. homemade cloth masks? d Will wearing a mask impact the probability of the wearer becoming infected themselves? e Does mask use reduce compliance with other recom- mended strategies, such as physical distancing and quar- antine? Significance Statement Governments are evaluating the use of non-medical masks in the community amidst conflicting guidelines from health orga- nizations. This review synthesizes available evidence to pro- vide clarity, and advances the use of the 'precautionary princi- ple' as a key consideration in developing policy around use of non-medical masks in public. Jeremy Howard prepared the Initial literature list; Reshama Shaikh prepared the Initial literature summarles; Frederik Ouestler conducted additional literature searches and summaries; Zhlyuan LI, violet Tang, Lel-Han Tang, and Danny Hernandez did Impact modeling; Zeynep Tufekcl provided sociological research and analysts; Helene -Marl van der Westhuizen and Arne von Delft provided analysis of additional Impacts; Christina Bax provided review and feedback; All authors contributed to the writing. Anne W. Rlmoln is an editor of the British Medical Journal. Larry F. Chu Is a member of the editorial advisory board of the British Medical Journal. 'To whom correspondence should be addressed. E-mail: 1phoward@usfca.edu PNAS I May 12, 2020 1 vol. XXX I no. XX 1 1-9 f Are there any other sociological considerations that will lead to unintended benefits or harm? g What could the overall population -level impact of public mask wearing be? We will evaluate each consideration in turn. 2. Transmission Characteristics of COVID-19 A primary route of transmission of SARS-CoV-2 is likely via respiratory droplets that are ejected when speaking, cough- ing or sneezing. The most common droplet size threshold has a minimum at 5 pm to 10 pm (3, 4). There is much debate about whether these droplets should sometimes be considered an aerosol (5). An added complexity is that aerosols are not consistently defined in the literature. Although earlier studies assumed that droplets were spread mainly through coughing, a more recent analysis has found that transmission through talking may be a key vector, with louder speech creating in- creasing quantities and sizes of droplets (6). SARS-CoV-2 is highly transmissible, with a basic reproduc- tion number estimated to be approximately 2.4 (7) although estimates vary (8) and will likely change as improved mea- surements of asymptomatic spread become available. Many COVID-19 patients are asymptomatic, and nearly all have a pre -symptomatic incubation period ranging from 2 to 15 days, with a median length of 5.1 days (9). Patients are most infectious during the initial days of infection (10-15), when symptoms are mildest or not present. This characteris- tic differentiates SARS-CoV-2 (COVID-19) from SARS-CoV, as replication is activated early in the upper respiratory tract (14, 16). High viral titers of SARS-CoV-2 are reported in the saliva of COVID-19 patients. These titers have been highest at time of patient presentation and viral levels are just as high in asymptomatic or presymptomatic patients (11, 16). A consequence of these disease characteristics is that any successful intervention policy must properly address transmis- sion due to infectious patients that display few or no symp- toms and may not realize that they are infected. 3. Ingress: Filtering Capability of Masks Masks can be made of different materials and designs (17) which influence their filtering capability. There are rigorous standards evaluating masks used in healthcare settings but these focus on personal protective equipment (PPE) efficacy, that is, the ability of the mask to protect the wearer from infectious particles. Masks can also be used for source con- trol, which refers to blocking droplets ejected by the wearer. Although we consider both of these as important, our focus in this paper is on source control. If everyone is wearing masks to decrease the chance that they themselves are unknowingly infecting someone, everyone ends up being more protected. Multiple studies show the filtration effects of cloth masks relative to surgical masks. Particle sizes for speech are on the order of 1 pm (18) while typical definitions of droplet size are 5 pm -10 pm (5). Generally available household materials had between a 49% and 86% filtration rate for 0.02 pm exhaled par- ticles whereas surgical masks filtered 89% of those particles (19). In a laboratory setting, household materials had 3% to 60% filtration rate for particles in the relevant size range, find- ing them comparable to some surgical masks (20). In another laboratory setup, a tea cloth mask was found to filter 60% of particles between 0.02 pm to 1 pm, where surgical masks filtered 75% (21). Dato et al (22), note that "quality com- mercial masks are not always accessible." They designed and tested a mask made from heavyweight T-shirts, finding that it "offered substantial protection from the challenge aerosol and showed good fit with minimal leakage." Many recommended cloth mask designs also include a layer of paper towel or coffee filter, which could increase filter effectiveness for PPE, but it does not appear to be necessary for blocking droplet emission (6, 23, 24). One of the most frequently mentioned papers evaluating the benefits and harms of cloth masks has been by MacIntyre et al (25). Findings have been misinterpreted, and therefore justify detailed discussion here. The authors "caution against the use of cloth masks" for healthcare professionals compared to the use of surgical masks and regular procedures, based on an analysis of transmission in hospitals in Hanoi. We empha- size the setting of the study - health workers using masks to protect themselves against infection. The study compared a "surgical mask" group which received 2 new masks per day, to a "cloth mask" group that received 5 masks for the entire 4 week period and were required to wear the masks all day, to a "control group" which used masks in compliance with exist- ing hospital protocols, which the authors describe as a "very high level of mask use". It is important to note that the au- thors did not have a "no mask" control group because it was deemed "unethical to ask participants to not wear a mask." The study does not inform policy pertaining to public mask wearing as compared to the absence of masks in a community setting, since there was not a "no mask" group. The results of the study show that the group with a regular supply of new surgical masks each day had significantly lower infection of rhinovirus than the group that wore a limited supply of cloth masks. This study lends support to the use of clean, surgi- cal masks by medical staff in hospital settings to avoid rhi- novirus infection by the wearer, and is consistent with other studies that show surgical masks provide poor filtration for rhinovirus, compared to seasonal coronaviruses (NL63, OC43, 229E and HKU1) (26). It does not inform the effect of using cloth masks versus not using masks in a community setting for source control of SARS-CoV-2. Guideline development for health worker PPE have focused on whether surgical masks or N95 respirators should be rec- ommended. Most of the research in this area focuses on in- fluenza. At this point, it is not known to what extent findings from influenza studies apply to COVID-19 filtration. Wilkes et al (27) found that "filtration performance of pleated hy- drophobic membrane filters was demonstrated to be markedly greater than that of electrostatic filters." However, even sub- stantial differences in materials and construction do not seem to impact the transmission of droplet -borne viruses in prac- tice, such as a meta analysis of N95 respirators compared to surgical masks (28) that found "the use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory -confirmed influenza." Radonovich et al (29) found in an outpatient setting that "use of N95 respirators, compared with medical masks in the outpatient setting re- sulted in no significant difference in the rates of laboratory - confirmed influenza." 2 1 www.pnas.org/cgl/dol/10.1073/pnas.XXXXXXXXXX Howard etaL 4. Egress: Masks for Source Control When considering the relevance of studies of ingress (masks as protection for the wearer), it is important to note that they are likely to substantially underestimate effectiveness of masks for source control. When someone is breathing, speak- ing, or coughing, only a small amount of what is coming out of their mouths is already in aerosol form. Nearly all of what is being emitted is droplets. Many of these droplets will then evaporate and turn into aerosolized particles that are 3 to 5 - fold smaller. (30) Wearing a mask as source control is largely to stop this process from occurring, since big droplets dehy- drate to smaller aerosol particles that can float for longer in air (26). In a study by Johnson et al (31) on 9 influenza patients, surgical and N95 masks appeared to be equally effective in blocking egress droplets, given that no influenza could be de- tected by RT -PCR on sample plates at 20 cm distance of the coughing patients, while it was detectable without mask for 7 of the 9 patients. Milton et al (32) checked whether exhaled droplets might be large enough prior to evaporation to be effectively captured by masks used as source control. They found surgical masks produced a 3.4 (95% CI 1.8 to 6.3) fold reduction in viral copies in exhaled breath by 37 influenza patients. Vanden Driessche et al (33) used an im- proved sampling method based on a controlled human aerosol model, allowing longer time for droplets to evaporate and be- come airborne. By sampling a homogeneous mix of all the air around the patient, the authors could also detect any aerosol that might leak around the edges of the mask. Among their 6 cystic fibrosis patients producing infected aerosol particles while coughing, the airborne Pseudomonas aeruginosa load was reduced by 88% when wearing a surgical mask compared with no mask (95% confidence interval [CI], 81-96%; P=0.03). Wood et al (34) found for their 14 cystic fibrosis patients with high viable aerosol production during coughing, a reduc- tion in aerosol Pseudomonas aeruginosa concentration at 2 meters from the source by using a N95 mask (94% reduction, P<0.001), surgical mask (94%, P<0.001), or cough etiquette (53%, P<0.001). Stockwell et al (35) confirmed in a similar Pseudomonas aeruginosa aerosol cough study that surgical masks are effective as source control and tolerable after ex- tended wear. Dharmadhikari et al (36) found surgical masks to decrease transmission of tuberculosis (an airborne bacterial infection) by 56% (95% Cl, 33-70.5%) when used as source control and measuring differences in guinea pig tuberculosis infections. Anfinrud et al (6) used laser light -scattering to sensitively detect droplet emission while speaking. Their analysis showed that virtually no droplets were "expelled" with a homemade mask consisting of a washcloth attached with two rubber bands around the head, while significant levels were expelled when speaking without a mask. The authors stated that "wearing any kind of cloth mouth cover in public by every per- son, as well as strict adherence to distancing and handwashing, could significantly decrease the transmission rate and thereby contain the pandemic until a vaccine becomes available." One of the most relevant papers (26), with important im- plications for public mask wearing during the COVID-19 out- break, is one that compares the efficacy of surgical masks for source control for seasonal coronaviruses (NL63, OC43, 229E and HKU1), influenza, and rhinovirus. With ten participants, the masks were effective at blocking coronavirus droplets of all sizes for every subject. However, masks were far less effective at blocking rhinovirus droplets of any size, or of blocking small influenza droplets. The results suggest that masks may have a significant role in source control for the current coronavirus outbreak. The study did not use COVID-19 patients, and it is not yet known whether SARS-CoV-2 behaves the same as these seasonal coronaviruses; however, they are closely related viruses, so similar behavior is likely. In another potentially relevant, but very under -powered study (37), four patients with COVID-19 were asked to cough repeatedly, alternating between no mask, surgical mask, cloth mask and then again without a mask onto a sample plate placed approximately 20 cm from the coughing per- son's mouth. The authors state "The median viral loads after coughs without a mask, with a surgical mask, and with a cot- ton mask were 2.56 log copies/mL, 2.42 log copies/mL, and 1.85 log copies/mL, respectively." In this statement, they ex- clude Patient 2 who had detectable virus in all experiments except when she was wearing a cotton mask. If we assume, conservatively, the limit of detection is 1.4 log copies/mL and use this value for the ND value for Patient 2, and allow each patient to serve as their own control (using the fact that the study design allows for paired comparisons) the median within patient difference of no mask control versus wearing a cotton mask results in an approximately 1 log (10 fold) decrease in virus. Note that we, like Bae et al, exclude Patient 4 in these calculations as they did not have detectable virus in the first 3 trial conditions. While the study is under -powered, the re- sults are suggestive that cloth masks are able to reduce the level of SARS-CoV-2 escaping from an infected person cough- ing. However, more studies are needed. A comparison of homemade and surgical masks for bac- terial and viral aerosols (19) observed that "the median -fit factor of the homemade masks was one-half that of the sur- gical masks. Both masks significantly reduced the number of microorganisms expelled by volunteers, although the surgical mask was 3 times more effective in blocking transmission than the homemade mask." Research focused on aerosol exposure has found all types of masks are at least somewhat effective at protecting the wearer. Van der Sande et al (38) found that "all types of masks reduced aerosol exposure, relatively stable over time, unaffected by duration of wear or type of activity," and concluded that "any type of general mask use is likely to decrease viral exposure and infection risk on a population level, despite imperfect fit and imperfect adher- ence." However, overall analysis of particle filtration is likely to underestimate the effectiveness of masks, since the frac- tion of particles that are emitted as aerosol (vs. droplet) is quite small (30). Analysis of seasonal coronavirus compared to rhinovirus (26) suggests that filtration of COVID-19 may be much more effective, especially for source control. In summary, there is laboratory -based evidence that house- hold masks have some filtration capacity in the relevant droplet size range, as well as efficacy in blocking droplets and particles from the wearer (26). That is, these masks help people keep their droplets to themselves. 5. Evaluating masks as intervention When evaluating the available evidence for the impact of masks on community transmission, it is critical to clarify the Howard etaL PNAS I May 12, 2020 1 vol. XXX I no. XX 1 3 setting of the research study (health care facility or commu- nity), whether masks are evaluated as source control or pro- tection for the wearer, the respiratory illness being evaluated and what control group was used. Although no randomized controlled trials (RCT) on the use of masks as source control for SARS-CoV-2 have been conducted, a number of studies have investigated masks during other disease outbreaks. A Cochrane review (39) on physical interventions to interrupt or reduce the spread of respiratory viruses included 67 stud- ies that were randomized controlled trials and observational studies. It found that "overall masks were the best performing intervention across populations, settings and threats." The re- view recommended that "the following effective interventions should be implemented, preferably in a combined fashion, to reduce transmission of viral respiratory disease: 1. frequent handwashing with or without adjunct antiseptics; 2. barrier measures such as gloves, gowns, and masks with filtration apparatus; and 3. suspicion diagnosis with the isolation of likely cases." However, it cautioned that routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic. There is an updated review available in preprint format by the same lead author (40). In the update, only studies where mask wearing was tested as a stand-alone intervention were included, without combining it with hand hygiene and physical distancing. Observational studies from previous epidemics were also excluded. The up- dated review concluded that "there was insufficient evidence to provide a recommendation on the use of facial barriers with- out other measures" but this has not been broadened to eval- uate combinations of interventions as to update the Cochrane review. Several other systematic reviews have recently been con- ducted. MacIntyre (41) published a review evaluating masks as protective intervention for the community, protection for health workers, and as source control. The authors conclude that "community mask use by well people could be benefi- cial, particularly for COVID-19, where transmission may be pre -symptomatic. The studies of masks as source control also suggest a benefit, and may be important during the COVID- 19 pandemic in universal community face mask use as well as in health care settings." Two other preprint systematic re- views by Brainard (42) and (43) concluded against and for the use of face masks by the public respectively. This con- flicting interpretation of the literature points to fundamen- tal disagreements in what is considered to be best available evidence. Greenhalgh (44) argues that an "interpretive and discursive synthesis" is needed when analysing the evidence base for cloth masks instead of "narrowly -defined biomedical questions'. Randomised control trial evidence that investigated the im- pact of masks on household transmission during influenza and SARS epidemics indicate potential benefit. Suess et al con- ducted an RCT (45) that suggests household transmission of influenza can be reduced by the use of non -pharmaceutical in- terventions, namely the use of face masks and intensified hand hygiene, when implemented early and used diligently. Con- cerns about acceptability and tolerability of the interventions should not be a reason against their recommendation (45). Cowling et al (46) investigated hand hygiene and face masks in an RCT that seemed to prevent household transmission of influenza virus when implemented within 36 hours of in- dex patient symptom onset. These findings suggest that non- pharmaceutical interventions are important for mitigation of pandemic and inter -pandemic influenza. RCT findings by Aiello et al (47) "suggest that face masks and hand hygiene may reduce respiratory illnesses in shared living settings and mitigate the impact of the influenza A (H1N1) pandemic". A randomized intervention trial (48) found that "face masks and hand hygiene combined may re- duce the rate of ILI [influenza -like illness] and confirmed in- fluenza in community settings. These non -pharmaceutical measures should be recommended in crowded settings at the start of an influenza pandemic." The authors noted that their study "demonstrated a significant association between the combined use of face masks and hand hygiene and a sub- stantially reduced incidence of ILI during a seasonal influenza outbreak. If masks and hand hygiene have similar impacts on primary incidence of infection with other seasonal and pan- demic strains, particularly in crowded, community settings, then transmission of viruses between persons may be signifi- cantly decreased by these interventions." An observational study in Hong Kong on SARS (49) found that "frequent mask use in public venues, frequent hand wash- ing, and disinfecting the living quarters were significant pro- tective factors (OR 0.36 to 0.58)". An important observation was that "members of the case group [infected with SARS] were less likely than members of the control group [not in- fected] to have frequently worn a face mask in public venues (27.9% vs. 58.7%)." Although case reports from aeroplanes could have multi- ple confounders, they provide some contribution to under- standing SARS-CoV-2 transmission outside of controlled ex- perimental settings. One case report (50) describes a man who flew from China to Toronto and then tested positive for COVID-19. He was wearing a mask during the flight. The 25 people closest to him on the plane and the flight attendants all tested negative. Nobody from that flight has been reported as acquiring COVID-19. Another case study involving a masked influenza patient on an airplane (51) found that "wearing a face mask was associated with a decreased risk for influenza acquisition during this long -duration flight." 6. Sociological Considerations Some of the concerns about public mask wearing have not been around primary evidence for the efficacy of source con- trol, but concerns about how they will be used. A. Risk compensation behavior. It is difficult to predict the behavior change that would accompany regulations encour- aging public mask use. One concern around public health messaging promoting the use of face -covering has been that members of the public may use risk compensation behavior. This involves neglecting other important preventative mea- sures like physical distancing and hand hygiene based on over- valuing the protection a surgical mask may offer due to an exaggerated or false sense of security (52). Similar arguments have previously been made for HIV prevention strategies (53) (54) motorcycle helmet laws (55), seat -belts (56) and alpine skiing helmets (57). However, contrary to predictions, risk compensation behaviors have not been significant on popu- lation level, being out -weighed by increased safety in each case (56, 58-60). Risk compensation is unlikely to undo the 4 1 www.pnas.org/cgi/dol/10.1073/pnas.XXXXXXXXXX Howard et al. positive benefits at the population level. (61) These findings strongly suggest that, instead of withholding a preventative tool, accompanying it with accurate messaging that combines different preventative measures would display trust in the gen- eral public's ability to act responsibly and empower citizens. B. Managing the stigma associated with wearing a mask. Stigma is a powerful force in human societies, and many ill- nesses come with stigma for the sick as well as fear of them. Managing the stigma is an important part of the process of controlling epidemics, as stigma also leads to people avoiding treatment as well as preventative measures that would "out" their illness (62). Tuberculosis is an example of an illness where masks are used as source control, but become a public label associated with the disease. Many sick people are reluc- tant to wear a mask if it identifies them as sick, and thus end up not wearing them at all in an effort to avoid the stigma of illness (63, 64). Some health authorities have recommended wearing masks for COVID-19 only if people are sick; however, reports of people wearing masks being attacked, shunned and stigmatized have also been observed (65). Having masks worn only by the people with disease also has led to employers in high-risk environments like grocery stores, hospitals and pris- ons, banning employees from wearing masks to prevent them from scaring the customer, patients or inmates. (66, 67). In many countries, minorities suffer additional stigma and as- sumptions of criminality (68). Black people in the United States have reportedly been reluctant to wear masks in public during this pandemic for fear of being mistaken as criminals (69, 70). Even if it were possible to encourage only infected people to wear masks, given the lack of access to testing in many countries, it is not possible for many people to know for sure if they are infected or not (71). Thus, while this pa- per has shown the importance of masks for source -control — preventing asymptomatic and pre -symptomatic people from infecting others — it may not even be possible to have sick peo- ple wear masks due to stigma, employer restrictions, or sim- ple lack of knowledge of one's status without mask -wearing becoming universal policy. C. Creating new symbolism around wearing a mask. Ritual and solidarity are important in human societies and can com- bine with visible signals to shape new societal behaviors (72, 73). Universal mask wearing could serve as a visible signal and reminder of the pandemic. Signaling participa- tion in health behaviors by wearing a mask as well as visible enforcement (for example, shops asking customers to wear masks) can increase compliance with public mask wearing, but also other important preventative behaviors (74). His- torically epidemics are a time of fear, confusion and help- lessness (75, 76). Mask -wearing, and even mask -making or distribution, can provide feelings of empowerment and self- efficacy (77). Health, especially during an epidemic, is a form of public good in that everyone else's health behaviors im- prove the health odds of everyone else, and that it is non - rivalrous in that one person's health does not diminish the health of anyone else (78, 79). This can make masks symbols of altruism and solidarity (80). In Hong Kong, for example, a community -driven focus on epidemic prevention started in the early days of COVID-19, and included community activists acquiring and distributing masks especially to those without resources and the elderly, even before it was officially declared a pandemic or before the government had taken strong steps (81, 82). Currently, Hong Kong has not only a relatively con- tained epidemic compared with many other countries, but a significant reduction in influenza cases as well which their health authorities attribute, among other factors, to the near - universal mask wearing and strong norms around it (83-85). 7. Implementation considerations Globally, health authorities have followed different trajecto- ries in recommendations around the use of face masks by the public. In China, Taiwan, Japan and South Korea, face masks were utilized from the start of the pandemic (2). Other coun- tries, like Czechia and Thailand, were early adopters in a global shift towards recommending cloth masks. We present considerations for the translation of evidence about public mask wearing to diverse countries across the globe, outside of the parameters of a controlled research setting. A. Supply chain management of N95 respirators and surgi- cal masks. There has been a global shortage of protective equipment for health workers, with health workers falling ill and dying of occupationally acquired COVID-19 disease (86). N95 respirators (the equivalent in Europe is FFP2 respira- tors) are recommended for health workers conducting aerosol - generating procedures during clinical care of COVID-19 pa- tients, while surgical masks are recommended for non -aerosol generating procedures (87). The importance of masks for health worker protection was emphasised in the early phases of the global pandemic in hospitals in China (88). Strategies to manage this critical shortage of PPE has been to appeal to the public to reduce their use of medical masks, and explore options like sterilization and re -use of respirators (89). There have been major concerns that public messaging encouraging mask use will deplete critical supplies. Some regions, like South Korea and Taiwan, have combined recommendations for the public to use surgical masks with rapidly increasing production of surgical masks. In other regions where surgical mask supplies are limited or unreliable due to supply chain interruptions, cloth masks are promoted as alternative to sur- gical masks as source control. This has been accompanied by public messaging to avoid using medical masks. Cloth masks offer additional sustainability benefits through re -use, thus limiting costs and reducing environmental waste. B. Mandatory mask wearing. Ensuring compliance with non- pharmaceutical interventions can be challenging, but would likely rapidly increase during a major pandemic (90). Per- ceptions of risk play an important role in mask use (91). Telephone surveys during the SARS-CoV-2 outbreak in Hong Kong reported enhanced adherence to public mask wearing as the pandemic progressed over three weeks, with 74.5% self reported mask wearing when going out increasing to 97.5%, without mandatory requirements (92). Similar surveys re- ported face mask use in Hong Kong during the SARS out- break in 2003 as 79% (93), and approximately 10% during the influenza A(H1N1) pandemic in 2009 (94). This suggests that the public have enhanced awareness of their risk, and display higher adherence levels to prevention strategies than during other epidemics. At the height of the 2009 influenza epidemic in Mexico City it was found (95) that mandatory mask requirements increased compliance compared to volun- tary recommendations. Voluntary compliance was strongly Howard et al. PNAS I May 12, 2020 1 vol. XXX I no, XX 1 5 influenced by public perception regarding the effectiveness of the recommended measures. Countries like Czechia and Hong Kong offer interesting perspectives on the role of citizen ad- vocacy and on the acceptability of face -covering in public. Modelling suggests (96) that population level compliance with public mask wearing of 70% combined with contact trac- ing would be critical to halt epidemic growth. Population level uptake of an intervention to benefit the whole popula- tion is similar to vaccinations. A common policy response to this conundrum is to ensure compliance by using laws and regulations, such as widespread state laws in the US which re- quire vaccinations to attend school. Research shows that the strength of the mandate to vaccinate greatly influences com- pliance rates for vaccines and that policies that set a higher bar for vaccine exemptions result in higher vaccination rates (97). The same approach is now being used in many juris- dictions to increase mask wearing compliance, by mandating mask use in a variety of settings (such as public transporta- tion or grocery stores or even at all times outside the home). Early results suggest that these laws are effective at increasing compliance and slowing the spread of COVID-19 (98). C. Additional benefits for concurrent epidemics. While the focus of this article is on preventing the spread of COVID- 19 disease through public mask wearing, many countries face concurrent epidemics of contagious respiratory diseases like tuberculosis and influenza. Tuberculosis kills 1.5 million peo- ple globally per year, and in 2018, 10 million people fell ill (99). Face covering has been shown to also reduce the trans- mission of tuberculosis (36). Similarly, influenza transmission in the community declined by 44% in Hong Kong after the implementation of changes in population behaviors, includ- ing social distancing and increased mask wearing, enforced in most stores, during the COVID-19 outbreak (92). 8. Estimating COVID-19 Impacts At the national and global scale, effective local interventions are aggregated into epidemiological parameters of disease spread. The standard epidemiological measure of spread is known as the basic reproduction number Ro which parameter- izes the number of cases infected by one case, in a completely susceptible population. The goal of any related healthcare policy is to have an aggregate effect of reducing the effective reproduction number Re to below 1. Efficacy of face masks within local interventions would have an aggregate effect on the reproduction number of the epidemic. What is the possible magnitude of such an effect? The HKBU COVID-19 Modelling Group developed a trans- mission model that incorporated mask wearing and mask effi- cacy as a factor in the model (96). They estimate reductions in the effective reproduction number Re under common inter- vention measures. For wearing masks, they find that wearing masks reduces Re by a factor (1 — ep,n,)2, where a is the ef- ficacy of trapping viral particles inside the mask, and p,,, is the percentage of the population that wears masks. When combined with contact tracing, the two effects multiply. A conservative assessment applied to the COVID-19 esti- mated Ro of 2.4 (7) might posit 50% mask usage and a 50% mask efficacy level, reducing Re to 1.35, an order of magnitude impact rendering spread comparable to the reproduction num- ber of seasonal influenza. To put this in perspective, 100 cases RO s 2.4 Mask Reduction Fedor (1-9•pm)2 100% More people w<w­ks t so I >s ti aaNt��e: 60 Adherence: Proportion of the public that wears masks 40 y 20 Fe—people w . masks _Z_ 20 40 60 60 100% M"k blocks less Efficacy' Mask blocks more rims pArtklrs ♦— How well the mask � vlrus particles blocks the virus 0.5 Fig. 1. Impact of public mask wearing under the full range of mask adherence and efficacy scenarios. The color indicates the resulting reproduction number Re from an initial Ro of 2.4 (7). Blue area is what is needed to slow the spread of COVID-19. Each black line represents a specific disease transmission level with the effective reproduction number Re indicated. An Re below 1, if sustained, will lead to the outbreak ending. at the start of a month become 31,280 cases by the month's end (Ro = 2.4) vs. only 584 cases (Re = 1.35). Such a slow- down in case -load protects healthcare capacity and renders a local epidemic amenable to contact tracing interventions that could eliminate the spread entirely. A full range of efficacy a and adherence p,,, is shown with the resulting Re in Figure 1, illustrating regimes in which growth is dramatically reduced (Re < 1) as well as pessimistic regimes (e.g. due to poor implementation or population com- pliance) that nonetheless result in a beneficial effect in sup- pressing the exponential growth of the pandemic. Yan et al (100) provide an additional example of an incre- mental impact assessment of respiratory protective devices using an augmented variant of a traditional SIR model in the context of influenza with N95 respirators. They showed that a sufficiently high adherence rate (-- 80% of the population) resulted in the elimination of the outbreak with most respira- tory protective devices. Qualitative comparisons of outcomes between countries (98, 101) are suggestive of policy differences leading to dif- ferences in disease spread of up to three orders of magni- tude. Although between -country comparisons do not allow for causal attribution, they suggest mask wearing to be a low- risk measure with a potentially large positive impact on num- ber of cases. In these countries, masks seem to be a part of a broadly successful suite of interventions and appears not to have meaningfully reduced compliance with other measures. Abaluck et al (102) extend the between -country analyses from a cost perspective, estimating the marginal benefit per cloth mask worn to range from $3,00046,000. They also found that "the average daily growth rate of confirmed posi- tives is 18% in countries with no pre-existing mask norms and 10% in countries with such norms" and "that the growth rate of deaths is 21% in countries with no mask norms and 11% in countries with such norms." 6 1 www.pnas.org/cgi/dol/10.1073/pnas.XXXXXXXXXX Howard etaL 9. Discussion and Recommendations Our review of the literature offers evidence in favor of widespread mask use as source control to reduce community transmission: non-medical masks use materials that obstruct droplets of the necessary size; people are most infectious in the initial period post-infection, where it is common to have few or no symptoms (10-16); non-medical masks have been effective in reducing transmission of influenza; and places and time periods where mask usage is required or widespread have shown substantially lower community transmission. The available evidence suggests that near -universal adop- tion of non-medical masks when out in public, in combination with complementary public health measures could successfully reduce Re (effective -R) to below 1, thereby reducing commu- nity spread if such measures are sustained. Economic analysis suggests that the impact of mask wearing could be thousands of US dollars saved per person per mask (102). Interventions to reduce COVID-19 spread should be priori- tized in order of their expected multiple on effective R divided by their cost. By this criterion, experimentation with and deployment of universal masks look particularly promising. When used in conjunction with widespread testing, contact tracing, quarantining of anyone that may be infected, hand washing, and physical distancing, face masks are a valuable tool to reduce community transmission. All of these mea- sures, through their effect on Re, have the potential to reduce the number of infections. As governments talk about relax- ing lockdowns, keeping transmissions low enough to preserve health care capacity will be critical until a vaccine can be de- veloped. Mask wearing may be instrumental in preventing a second wave of infections from overwhelming the health care system - further research is urgently needed here. UNESCO states that "when human activities may lead to morally unacceptable harm that is scientifically plausible but uncertain, actions shall be taken to avoid or diminish that harm" (103). This is known as the "precautionary principle." The World Charter for Nature, which was adopted by the UN General Assembly in 1982, was the first international endorse- ment of the precautionary principle. It was implemented in an international treaty in the 1987 Montreal Protocol. The loss of life and economic destruction that has been seen already from COVID-19 is a "morally unacceptable harm." The pos- itive impact of public mask wearing on this is "scientifically plausible but uncertain". This notion is reflected in Figure 1 - while researchers may reasonably disagree on the magni- tude of transmissibility reduction and compliance, seemingly modest benefits can be massively beneficial in the aggregate due to the exponential character of the transmission process. Therefore, the action of ensuring widespread use of masks in the community should be taken, based on this principle (104). Models suggest that public mask wearing is most effective at reducing spread of the virus when compliance is high (96). We recommend that mask use requirements are implemented by governments, or when governments do not, by organiza- tions that provide public -facing services, such as transit ser- vice providers or stores, as "no mask, no service" rules. Such mandates must be accompanied by measures to ensure access to masks, possibly including distribution and rationing mech- anisms so that they do not become discriminatory, but remain focused on the public health benefit. Given the value of the source control principle, especially for presymptomatic peo- ple, it is not good enough for only employees to wear masks, customers must wear masks as well. It is also important for health authorities to provide clear guidelines for the production, use and sanitization or re -use of face masks, and consider their distribution as shortages allow. A number of countries have distributed surgical masks (South Korea, Taiwan) from early on, while Japan, Singapore and Belgium are now distributing cloth masks to their entire populations. Clear and implementable guidelines can help increase compliance, and bring communities closer to the goal of reducing and ultimately stopping the spread of COVID-19. 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XX 1 9 Office of the Director Public Health 401 Fifth Avenue, Suite 1300 Seattle, WA 98104-1818 Seattle & King County La 206-296-4600 Fax 206-296-0166 TTY Relay: 711 www.kingcounty.gov/health LOCAL HEALTH OFFICER DIRECTIVE WHEREAS, on January 21, 2020, the first case of novel coronavirus disease (COVID-19, caused by the SARS-CoV-2 virus) was confirmed in a person from Washington, who had traveled from China through King County; and WHEREAS, throughout February 2020, the number of cases of COVID-19 increased significantly within King County and its local cities and towns, with the first COVID-19 related death in the United States announced on February 29, 2020; and WHEREAS, on February 29, 2020, Governor Jay Inslee proclaimed a state of emergency within the State of Washington due to COVID-19; and WHEREAS, on March 1, 2020, King County Executive Dow Constantine proclaimed a state of emergency within King County due to COVID-19; and WHEREAS, local jurisdictions within King County have also issued proclamations of emergency; and WHEREAS, on March 11, 2020, the World Health Organization declared a state of pandemic due to COVID=19; and WHEREAS on March 13, 2020, President Donald Trump declared a National Emergency due to COVID-19, and on March 22, 2020 a Major Disaster was declared for the State of Washington; and WHEREAS, on March 23, 2020, Governor Inslee imposed a "Stay Home — Stay Healthy" Order throughout Washington State prohibiting all people in Washington State from leaving their homes or participating in social, spiritual, and recreational gatherings of any kind regardless of the number of participants, and all non-essential businesses in Washington State; and WHEREAS, on May 4, 2020, Governor Inslee issued a Proclamation modifying his "Stay Home — Stay Healthy" Order, with a phased -in approach to re -open Washington, which will increase the number of King County residents and frequency of their encounters with non -household members, and will increase their risk of exposure to persons with infectious COVID-19; and WHEREAS, the age, condition, and health of a significant portion of the population of King County and its local cities and towns places it at risk for serious health complications, including death, from COVID-19; and WHEREAS, a large surge in the number of persons with serious infections can compromise the ability of the regional healthcare system to deliver necessary healthcare to the public; and WHEREAS, individuals can be infected and contagious before or even without developing symptoms (pre -symptomatic and asymptomatic), and the evidence suggests a significant number of infections may be transmitted in this manner; and WHEREAS, the United States Centers for Disease Control and Prevention ("CDC") confirmed that a significant number of individuals who are infected remain asymptomatic and that as many as 25 percent of these individuals may contribute to transmission of the SARS_CoV-2 virus; and WHEREAS, one key transmission method for COVID-19 is respiratory droplets that individuals expel when they breathe, talk, cough or sneeze; and WHEREAS, the CDC recommended that members of the public should cover their noses and mouths with a cloth face covering to prevent inadvertently spreading COVID-19 while interacting with others outside their homes in public settings where other social distancing measures are difficult to maintain, especially in areas like King County with significant community-based transmission; and WHEREAS, on April 1, 2020, Public Health — Seattle & King County issued updated guidance on wearing face covers, stating that: "wearing a fabric mask can help prevent the spread of infection to others when the mask is worn by someone who already is infected with the virus that causes COVID-19, even if they don't have symptoms. The mask could help by blocking infectious droplets from spreading when someone with the infection coughs, sneezes or speaks"; and WHEREAS, there is a national shortage of medical grade masks, surgical masks, and N-95 respirators that are critically needed for healthcare providers who are on the front lines working to protect all of us, and health officials are increasingly urging non-medical workers to wear non-medical grade cloth face coverings to help curb the spread of COVID-19; and WHEREAS, workers of certain essential businesses and other frontline employees must be protected because they face greater exposure and risk of contracting COVID-19 due to their frequent in person contact with members of the public and inability to work from home and widespread mask use may decrease the risk of spread from someone with unrecognized infection; and WHEREAS, there is a long history of racism and discriminatory policies that Native, People of Color, immigrant and refugee, LGBTQ communities, homeless, and other marginalized communities have faced in Washington state that may impact an individual's ability to feel safe while wearing a face covering; and WHEREAS, King County government is dedicated to providing all its residents with fair and equal access to services, opportunities, and protection; inviting and encouraging public engagement; and reflecting consideration for cultural differences; and WHEREAS, King County government is partnering with community based and faith based organizations to distribute cloth face coverings to the public, as are several cities including Seattle and Kenmore; and WHEREAS, the Revised Code of Washington, Title 70.05.070(2)-(3), requires and empowers the local health officer to take such action as is necessary to maintain health and to control and prevent the spread of any contagious or infectious diseases within the jurisdiction; and WHEREAS, the Washington Administrative Code, Title 246-100-036, requires the local health officer, when necessary, to institute disease control measures as he or she deems necessary based on his or her professional judgment, current standards of practice, and the best available medical and scientific information; and Based upon the above, as the Local Health Officer, I hereby find that directing the population of King County to wear face coverings in certain public places is reasonable and conducive to maintain health and to the control and prevention throughout King County of COVID-19, a contagious and infectious disease. EFFECTIVE on May 18, 2020, as the Local Health Officer I hereby DIRECT as follows: FACE COVERING DIRECTIVE A. All individuals must wear face coverings over their noses and mouths when they will be at (1) indoor public settings, or (2) outdoor public locations and cannot maintain distancing of approximately six feet from another individual who does not share their household. At this time, because it is still important to conserve medical -grade or N95 respirators for health care workers, unless a particular health reason requires it, individuals should use fabric coverings, such as cloth face masks, scarves and bandana coverings or other material as recommended by CDC. Cloth face masks must be worn properly in order to avoid contaminating the hands or face of the user. Before putting on a mask and after removing a mask, an individual should clean their hands with alcohol -based hand rub or soap and water and change masks when moist and wash after use. While in use, avoid touching the mask. Worn masks may be contaminated with infectious agents. B. The following individuals do not need to comply with this Directive: Any child aged two years or less; 2. Any child aged 12 years or less unless parents and caregivers supervise the use of face coverings by children to avoid misuse; Any individual who has a physical disability that prevents easily wearing or removing a face covering; 4. Any individual who is deaf and uses facial and mouth movements as part of communication; 5. Any individual who has been advised by a medical professional that wearing a face covering may pose a risk to that individual health related reasons; 6. Any individual who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the face covering without assistance. C. This Directive applies to any indoor public setting or outdoor public location where a person will be in within six feet of another individual, who does not share the same household, and includes, but is not limited to the following sectors: 1. Groceries, pharmacies, and other retail that sells food and beverage products, including but not limited to grocery stores, corner stores and convenience stores (including liquor stores), farmers' markets, food banks, farm and produce stands, supermarkets, big box stores that sell groceries and essentials and similar food retail establishments. 2. Commercial retail stores that supply essential sectors, including convenience stores, pet supply stores, auto supplies and repair, hardware and home improvement, garden stores and nurseries that support food cultivation and production, office supply stores that support working -from -home, and home appliance retailers. 3. Restaurant carry -out and quick -serve food operations — including food preparation, carry -out, and delivery food employees. 4. Cannabis retail and dietary supplement retail stores. 5. Tobacco and vapor sellers. 6. Buses, light rail, and other forms of public transportation. D. Nothing in this Directive reduces or eliminates the requirements imposed by Directives and Orders from the Local Health Officer, Governor, or other regulatory local, state, or federal agency including employer specific directives from the Washington State Department of Labor and Industries. E. Face covering use does not replace the need to practice physical distancing (staying away from ill people, staying home and avoiding all non-essential activities and contact with others), frequent handwashing, and avoiding touching of the face; F. Violation of this Directive does not create grounds for residents or law enforcement to stop, detain, issue a citation, arrest, intimidate, or harass individuals who do not comply with it. This Directive may and should be used to educate, encourage, and persuade individuals to wear face coverings. G. All commercial establishments in King County are directed to post signage advising individuals to wear face coverings on the premises. Establishments can download a sign that can be used for this purpose at http://www.kingcounty.gov/masks. I strongly urge all people in King County to support the health and well-being of the community by complying with this Directive without delay. This Directive shall EXPIRE upon determination by the Local Health Officer that there is no longer a need for face coverings due to COVID-19. Signed and directed this 11 day of May 2020, in Seattle, Washington, by Dr. Jeff Duchin Local Health Officer Public Health — Seattle & King County San Juan County in the northwest corner of Washington state is about to become the first in the Pacific Northwest to require wearing a face covering in public places. Elsewhere in the region, governments have highly recommended wearing masks, but it's not the law. The order to wear a cloth mask when mingling out in public comes from the local health officer of San Juan County. Dr. Frank James said community effort has stopped the coronavirus in the island archipelago. He wants to make sure it's not reintroduced when visitors and tourists come. "We need to be certain that these people who could be harboring coronavirus have the kind of tools like masks that will help prevent them from spreading it unchecked in our community," Dr. James said during a meeting of the county Board of Health on Friday. San Juan County has a high number of older residents, and that puts Dr. James on heightened guard since Covid-19 disproportionately kills the elderly. The county has recorded 15 cases of Covid-19 since the pandemic began and no deaths. Around 42% percent of the county's population is aged 60 years or older, according to the U.S. Census Bureau. The mandatory mask requirement takes effect when the county moves to the next stage of reopening, probably around June 1. Violations would be a misdemeanor, but County Sheriff Ron Krebs told Dr. James there is no staff to enforce it. It will be up to businesses to compel compliance. The mask order includes an "educational" period between its publication this weekend and the upcoming date when San Juan County moves to Phase 2 in the gradual relaxation of the governor's stay-at-home order. The federal Centers for Disease Control recommends the use of cloth face coverings in public settings. The CDC says some people who are infected may show no symptoms, so widespread wearing of masks can slow the spread of the virus. Non-medical grade masks do not guarantee against inhalation of airborne virus particles, so mask use does not replace social distancing as a disease control strategy. Weeks ago, the governors of Hawaii, New York, Connecticut, Michigan, Massachusetts and Illinois ordered all residents to wear masks under threat of fines in public places where social distancing isn't possible, but enforcement is reportedly lax. Costco and Alaska Airlines are high-profile examples of individual businesses that decided this month to require all staff and customers to sport face coverings. The San Juan County action comes on the heels of Seattle -King County announcing a face covering directive, which goes into effect on Monday. A directive is stronger than a recommendation but not enforceable by law. The Public Health Seattle & King County direct does not include penalties. Other Pacific Northwest government and health officials are teeing up similar discussions. In the wake of the King County directive, Spokane County Health Officer Dr. Bob Lutz told his local newspaper that there is "a strong likelihood" that he will follow King County's lead in the next week or two. Pierce County Executive Bruce Dammeier told the Tacoma News Tribune that he supports wearing a mask in public places, but would prefer to keep that guidance voluntary. The mandatory mask requirement drew support and a few dissents on Friday during a special meeting of the San Juan County Board of Health. "I think that's a good step," said Matt Fiske of Orcas Island, one of more than a dozen islanders who addressed the issue during a public comment period before the board voted. "No mask, no service," should be the standard in the islands, said another commenter. Others urged county officials to include enforcement to get the high level of compliance that would make face covering most effective in stopping the spread of the new coronavirus. Martin Taylor of Orcas Island was in a minority voicing strong opposition. "It would introduce a lot of divisive conflict between people and the police," Taylor testified. "It's clearly unnecessary. The levels of sickness don't warrant it." "I, for one, would go to jail before wearing a mask," he added in a written comment. Dr. James, the county health officer, said he had the authority to impose the face covering requirement by emergency order, but would welcome a vote of support from the county council. The county council voted 2-1 on Friday to endorse the emergency order. Council chair Rick Hughes said he had heard from many local businesses that being able to point to a mandatory order would help in gaining customer compliance. Hughes voted yes. Councilmember Jamie Stephens said while he believes in the sensibility of wearing a mask, he disagreed with imposing a potentially controversial rule that the county sheriff would not enforce. "This is superfluous," Stephens said before voting no. "Since it's toothless, it just doesn't sit well." Copyright 2020 Northwest News Network