Face Masks: What the Spanish Flu Can Teach Us About Making Them Compulsory
By Samuel Cohn
Should people be forced to wear face masks in public? That's the question facing governments as more countries unwind their lockdowns. More than 30 countries have made masks compulsory in public, including Germany, Austria and Poland. This is despite the science saying masks do little to protect wearers, and only might prevent them from infecting other people.
Nicola Sturgeon, the Scottish first minister, has nonetheless announced new guidelines advising Scots to wear masks for shopping or on public transport, while the UK government is expected to announce a new stance shortly. Meanwhile, U.S. Vice President Mike Pence has controversially refused to mask up.
This all has echoes of the great influenza pandemic, aka the Spanish flu, which killed some 50 million people in 1918-20. It's a great case study in how people will put up with very tough restrictions, so long as they think they have merit.
The Great Shutdown
In the U.S., no disease in history led to such intrusive restrictions as the great influenza. These included closures of schools, churches, soda fountains, theatres, movie houses, department stores and barber shops, and regulations on how much space should be allocated to people in indoor public places.
There were fines against coughing, sneezing, spitting, kissing and even talking outdoors — those the Boston Globe called "big talkers." Special influenza police were hired to round up children playing on street corners and occasionally even in their own backyards.
Restrictions were similarly tough in Canada, Australia and South Africa, though much less so in the UK and continental Europe. Where there were such restrictions, the public accepted it all with few objections. Unlike the long history of cholera, especially in Europe, or the plague in the Indian subcontinent from 1896 to around 1902, no mass violence erupted and blame was rare — even against Spaniards or minorities.
Face masks came closest to being the measure that people most objected to, even though masks were often popular at first. The Oklahoma City Times in October 1918 described an "army of young women war workers" appearing "on crowded street cars and at their desks with their faces muffled in gauze shields." From the same month, The Ogden Standard reported that "masks are the vogue," while the Washington Times told of how they were becoming "general" in Detroit.
There was scientific debate from the beginning about whether the masks were effective, but the game began to change after French bacteriologist Charles Nicolle discovered in October 1918 that the influenza was much smaller than any other known bacterium.
The news spread rapidly, even in small-town American newspapers. Cartoons were published that read, "like using barbed wire fences to shut out flies." Yet this was just at the point that mortality rates were ramping up in the western states of the U.S. and Canada. Despite Nicolle's discovery, various authorities began making masks compulsory. San Francisco was the first major U.S. city to do so in October 1918, continuing on and off over a three-month period.
Alberta in Canada did likewise, and New South Wales, Australia, followed suit when the disease arrived in January 1919 (the state basing its decision on scientific evidence older than Charles Nicolle's findings). The only American state to make masks mandatory was (briefly) California, while on the east coast and in other countries including the UK they were merely recommended for most people.
San Francisco gathering, 1918. Wikimedia
Numerous photographs, like the one above, survive of large crowds wearing masks in the months after Nicolle's discovery. But many had begun to distrust masks, and saw them as a violation of civil liberties. According to a November 1918 front page report from Utah's Garland City Globe:
The average man wore the mask slung to the back of his neck until he came in sight of a policeman, and most people had holes cut into them to stick their cigars and cigarettes through.
San Francisco saw the creation of the anti-mask league, as well as protests and civil disobedience. People refused to wear masks in public or flaunted wearing them improperly. Some went to prison for not wearing them or refusing to pay fines.
In Tucson, Arizona, a banker insisted on going to jail instead of paying his fine for not masking up. In other western states, judges regularly refused to wear them in courtrooms. In Alberta, "scores" were fined in police courts for not wearing masks. In New South Wales, reports of violations flooded newspapers immediately after masks were made compulsory. Not even stretcher bearers carrying influenza victims followed the rules.
England was different. Masks were only advised as a precautionary measure in large cities, and then only for certain groups, such as influenza nurses in Manchester and Liverpool. Serious questions about efficacy only arose in March 1919, and only within the scientific community. Most British scientists now united against them, with the Lancet calling masks a "dubious remedy."
These arguments were steadily being bolstered by statistics from the US. The head of California's state board of health had presented late 1918 findings from San Francisco's best run hospital showing that 78 percent of nurses became infected despite their careful wearing of masks.
Physicians and health authorities also presented statistics comparing San Francisco's mortality rates with nearby San Mateo, Los Angeles and Chicago, none of which had made masks compulsory. Their mortality rates were either "no worse" or less. By the end of the pandemic in 1919, most scientists and health commissions had come to a consensus not unlike ours about the benefits of wearing masks.
Clearly, many of these details are relevant today. It's telling that a frivolous requirement became such an issue while more severe rules banned things like talking on street corners, kissing your fiancé or attending religious services — even in the heart of America's Bible belt.
Perhaps there's something about masks and human impulses that has yet to be studied properly. If mass resistance to the mask should arise in the months to come, it will be interesting to see if new research will produce any useful findings on phobias about covering the face.
Reposted with permission from The Conversation.
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By Ana Maldonado-Contreras
- Your gut is home to trillions of bacteria that are vital for keeping you healthy.
- Some of these microbes help to regulate the immune system.
- New research, which has not yet been peer-reviewed, shows the presence of certain bacteria in the gut may reveal which people are more vulnerable to a more severe case of COVID-19.
You may not know it, but you have an army of microbes living inside of you that are essential for fighting off threats, including the virus that causes COVID-19.
How Do Resident Bacteria Keep You Healthy?<p>Our immune defense is part of a complex biological response against harmful pathogens, such as viruses or bacteria. However, because our bodies are inhabited by trillions of mostly beneficial bacteria, virus and fungi, activation of our immune response is tightly regulated to distinguish between harmful and helpful microbes.</p><p>Our bacteria are spectacular companions diligently helping prime our immune system defenses to combat infections. A seminal study found that mice treated with antibiotics that eliminate bacteria in the gut exhibited an impaired immune response. These animals had low counts of virus-fighting white blood cells, weak antibody responses and poor production of a protein that is vital for <a href="https://doi.org/10.1073/pnas.1019378108" target="_blank">combating viral infection and modulating the immune response</a>.</p><p><a href="https://doi.org/10.1371/journal.pone.0184976" target="_blank" rel="noopener noreferrer">In another study</a>, mice were fed <em>Lactobacillus</em> bacteria, commonly used as probiotic in fermented food. These microbes reduced the severity of influenza infection. The <em>Lactobacillus</em>-treated mice did not lose weight and had only mild lung damage compared with untreated mice. Similarly, others have found that treatment of mice with <em>Lactobacillus</em> protects against different <a href="https://doi.org/10.1038/srep04638" target="_blank" rel="noopener noreferrer">subtypes of</a> <a href="https://doi.org/10.1038/s41598-017-17487-8" target="_blank" rel="noopener noreferrer">influenza</a> <a href="https://doi.org/10.1371/journal.ppat.1008072" target="_blank" rel="noopener noreferrer">virus</a> and human respiratory syncytial virus – the <a href="https://doi.org/10.1038/s41598-019-39602-7" target="_blank" rel="noopener noreferrer">major cause of viral bronchiolitis and pneumonia in children</a>.</p>
Chronic Disease and Microbes<p>Patients with chronic illnesses including Type 2 diabetes, obesity and cardiovascular disease exhibit a hyperactive immune system that fails to recognize a harmless stimulus and is linked to an altered gut microbiome.</p><p>In these chronic diseases, the gut microbiome lacks bacteria that activate <a href="https://doi.org/10.1126/science.1198469" target="_blank" rel="noopener noreferrer">immune cells</a> that block the response against harmless bacteria in our guts. Such alteration of the gut microbiome is also observed in <a href="https://doi.org/10.1073/pnas.1002601107" target="_blank" rel="noopener noreferrer">babies delivered by cesarean section</a>, individuals consuming a poor <a href="https://doi.org/10.1038/nature12820" target="_blank" rel="noopener noreferrer">diet</a> and the <a href="https://doi.org/10.1038/nature11053" target="_blank" rel="noopener noreferrer">elderly</a>.</p><p>In the U.S., 117 million individuals – about half the adult population – <a href="https://health.gov/our-work/food-nutrition/2015-2020-dietary-guidelines/guidelines/" target="_blank" rel="noopener noreferrer">suffer from Type 2 diabetes, obesity, cardiovascular disease or a combination of them</a>. That suggests that half of American adults carry a faulty microbiome army.</p><p>Research in my laboratory focuses on identifying gut bacteria that are critical for creating a balanced immune system, which fights life-threatening bacterial and viral infections, while tolerating the beneficial bacteria in and on us.</p><p>Given that diet affects the diversity of bacteria in the gut, <a href="https://www.umassmed.edu/nutrition/melody-trial-info/" target="_blank" rel="noopener noreferrer">my lab studies show how diet can be used</a> as a therapy for chronic diseases. Using different foods, people can shift their gut microbiome to one that boosts a healthy immune response.</p><p>A fraction of patients infected with SARS-CoV-2, the virus that causes COVID-19 disease, develop severe complications that require hospitalization in intensive care units. What do many of those patients have in common? <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm" target="_blank" rel="noopener noreferrer">Old age</a> and chronic diet-related diseases like obesity, Type 2 diabetes and cardiovascular disease.</p><p><a href="http://doi.org/10.1016/j.jada.2008.12.019" target="_blank" rel="noopener noreferrer">Black and Latinx people are disproportionately affected by obesity, Type 2 diabetes and cardiovascular disease</a>, all of which are linked to poor nutrition. Thus, it is not a coincidence that <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6933e1.htm" target="_blank" rel="noopener noreferrer">these groups have suffered more deaths from COVID-19</a> compared with whites. This is the case not only in the U.S. but also <a href="https://www.washingtonpost.com/world/europe/blacks-in-britain-are-four-times-as-likely-to-die-of-coronavirus-as-whites-data-show/2020/05/07/2dc76710-9067-11ea-9322-a29e75effc93_story.html" target="_blank" rel="noopener noreferrer">in Britain</a>.</p>
Discovering Microbes That Predict COVID-19 Severity<p>The COVID-19 pandemic has inspired me to shift my research and explore the role of the gut microbiome in the overly aggressive immune response against SARS-CoV-2 infection.</p><p>My colleagues and I have hypothesized that critically ill SARS-CoV-2 patients with conditions like obesity, Type 2 diabetes and cardiovascular disease exhibit an altered gut microbiome that aggravates <a href="https://theconversation.com/exercise-may-help-reduce-risk-of-deadly-covid-19-complication-ards-136922" target="_blank" rel="noopener noreferrer">acute respiratory distress syndrome</a>.</p><p>Acute respiratory distress syndrome, a life-threatening lung injury, in SARS-CoV-2 patients is thought to develop from a <a href="http://doi.org/10.1016/j.cytogfr.2020.05.003" target="_blank" rel="noopener noreferrer">fatal overreaction of the immune response</a> called a <a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690" target="_blank" rel="noopener noreferrer">cytokine storm</a> <a href="http://doi.org/10.1016/S2213-2600(20)30216-2" target="_blank" rel="noopener noreferrer">that causes an uncontrolled flood</a> <a href="http://doi.org/10.1016/S2213-2600(20)30216-2" target="_blank" rel="noopener noreferrer">of immune cells into the lungs</a>. In these patients, their own uncontrolled inflammatory immune response, rather than the virus itself, causes the <a href="http://doi.org/10.1007/s00134-020-05991-x" target="_blank" rel="noopener noreferrer">severe lung injury and multiorgan failures</a> that lead to death.</p><p>Several studies <a href="https://doi.org/10.1016/j.trsl.2020.08.004" target="_blank" rel="noopener noreferrer">described in one recent review</a> have identified an altered gut microbiome in patients with COVID-19. However, identification of specific bacteria within the microbiome that could predict COVID-19 severity is lacking.</p><p>To address this question, my colleagues and I recruited COVID-19 hospitalized patients with severe and moderate symptoms. We collected stool and saliva samples to determine whether bacteria within the gut and oral microbiome could predict COVID-19 severity. The identification of microbiome markers that can predict the clinical outcomes of COVID-19 disease is key to help prioritize patients needing urgent treatment.</p><p><a href="https://doi.org/10.1101/2021.01.05.20249061" target="_blank" rel="noopener noreferrer">We demonstrated</a>, in a paper which has not yet been peer reviewed, that the composition of the gut microbiome is the strongest predictor of COVID-19 severity compared to patient's clinical characteristics commonly used to do so. Specifically, we identified that the presence of a bacterium in the stool – called <em>Enterococcus faecalis</em>– was a robust predictor of COVID-19 severity. Not surprisingly, <em>Enterococcus faecalis</em> has been associated with <a href="https://doi.org/10.1053/j.gastro.2011.05.035" target="_blank" rel="noopener noreferrer">chronic</a> <a href="https://doi.org/10.1016/S0002-9440(10)61172-8" target="_blank" rel="noopener noreferrer">inflammation</a>.</p><p><em>Enterococcus faecalis</em> collected from feces can be grown outside of the body in clinical laboratories. Thus, an <em>E. faecalis</em> test might be a cost-effective, rapid and relatively easy way to identify patients who are likely to require more supportive care and therapeutic interventions to improve their chances of survival.</p><p>But it is not yet clear from our research what is the contribution of the altered microbiome in the immune response to SARS-CoV-2 infection. A recent study has shown that <a href="https://doi.org/10.1101/2020.12.11.416180" target="_blank" rel="noopener noreferrer">SARS-CoV-2 infection triggers an imbalance in immune cells</a> called <a href="https://doi.org/10.1111/imr.12170" target="_blank" rel="noopener noreferrer">T regulatory cells that are critical to immune balance</a>.</p><p>Bacteria from the gut microbiome are responsible for the <a href="https://doi.org/10.7554/eLife.30916.001" target="_blank" rel="noopener noreferrer">proper activation</a> <a href="https://doi.org/10.1126/science.1198469" target="_blank" rel="noopener noreferrer">of those T-regulatory</a> <a href="https://doi.org/10.1038/nri.2016.36" target="_blank" rel="noopener noreferrer">cells</a>. Thus, researchers like me need to take repeated patient stool, saliva and blood samples over a longer time frame to learn how the altered microbiome observed in COVID-19 patients can modulate COVID-19 disease severity, perhaps by altering the development of the T-regulatory cells.</p><p>As a Latina scientist investigating interactions between diet, microbiome and immunity, I must stress the importance of better policies to improve access to healthy foods, which lead to a healthier microbiome. It is also important to design culturally sensitive dietary interventions for Black and Latinx communities. While a good-quality diet might not prevent SARS-CoV-2 infection, it can treat the underlying conditions related to its severity.</p><p><em><a href="https://theconversation.com/profiles/ana-maldonado-contreras-1152969" target="_blank">Ana Maldonado-Contreras</a> is an assistant professor of Microbiology and Physiological Systems at the University of Massachusetts Medical School.</em></p><p><em>Disclosure statement: Ana Maldonado-Contreras receives funding from The Helmsley Charitable Trust and her work has been supported by the American Gastroenterological Association. She received The Charles A. King Trust Postdoctoral Research Fellowship. She is also member of the Diversity Committee of the American Gastroenterological Association.</em></p><p><em style="">Reposted with permission from <a href="https://theconversation.com/a-healthy-microbiome-builds-a-strong-immune-system-that-could-help-defeat-covid-19-145668" target="_blank" rel="noopener noreferrer" style="">The Conversation</a>. </em></p>
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