Hi I’m Wendy Zukerman and you’re listening to Science Vs from Gimlet. It’s been a week of social distancing for me ... I finished a puzzle.. I cooked for the first time in a million years. Well. I put more than 3 ingredients in a bowl… for some overnight oats. I was pretty proud of myself. All the while, I was glued to the news about this coronavirus… And I kept coming across questions around two specific things: ibuprofen and masks. So that’s what we’re diving into today.

Some reports are saying that ibuprofen … the stuff in Advil[1].. is making people with coronavirus sicker … and that they should steer clear of the drug.[2][3] What’s going on there?

But first, we want to talk about masks.

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We’re hearing a lot about shortages for health care[4][5]  workers - that they don’t have enough masks and other gear to keep them safe. In Italy, more than 35- hundred health care workers have gotten the virus[6][7] ... And in the U.S., we heard from those who were worried they could be next … Here’s what a few of them told us

ICU NURSE They’ve told us they’re only going to give us one mask every 5 days. What they’re having us do is re-wear the same dirty mask over and over and over again. And if we need a new mask, we need to show the old one to our supervisor to show that it needs to be thrown away

AYMAN: We get handed N95s masks and we're supposed to put them in bags, and put our names on them reuse them throughout the day-01

JAYNE-at this moment already rationing-0

SIYAB As of a few days ago, got to the point where we were almost completely out, and we had to start reusing some of our masks and gowns.

ICU NURSE It's horrifying. we're all completely horrified. Um we feel like we're soldiers being sent to war without the PPE we need. A lot of people are scared to go to work. -03

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All this … it’s starting to sound awful. So how important are these masks? And is it that bad to reuse them? 

For this, we called up Professor Raina [RYE-Nah (like rhina)] MacIntyre[8], infectious disease expert at the University of New South Wales in Australia.

RM Hello!

WZ Hi! <FADE UNDER>

Raina’s led several clinical trials look at how masks protect healthcare workers from respiratory viruses[9]. And she has found that the best kind -- the one health care workers need are the N95s,[10] [11] [12] [13]  you might have heard of these - Raina calls them respirator masks. They’re the ones that look like they’re kind of molded around your nose and mouth.[14] And how they fit… is part of their magic

RM the way you can tell is a respirator fits tightly around the face- doesn't allow the leakage of air and healthcare workers should wear a respirator[15]

 

And Raina has the data to show just how good these puppies are -- 

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in one of her studies[16][17] she took more than 3000 healthcare workers in Beijing - found that after a month - those given N95 masks - had roughly half the infection rate of workers using those classic surgical masks[18] like you might see at the dentist.[19] Not all studies have found this[20] … but Raina’s studies are some of the largest and best in this space.[21]

So what healthcare workers really need in this pandemic are the N95 respirator-style masks. But as we heard from healthcare workers, in some places there aren’t enough to go around[22] [23] [24] [25]

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WZ a lot of talk of healthcare workers have to reuse masks[26][27] - uh sometimes for multiple days in a row- how risky is that?

RM it probably carries some risk- they get contaminated, they get moist, that’s not good bacteria can grow in a moist environment.[28][29] [30]but if they have no choice it's a real dilemma.

One solution to the shortages is to reuse the masks -  but disinfect them.[31] To find out what might work.. Producer Rose Rimler and I called up an expert in this very field.

My name is Rachael Jones,my speciality is viral respiratory infections,

RR that's handy!

RJ It is!

Rachael - who’s at the University of Utah[32] - told us that she’d been hearing of all kinds of things that doctors and nurses were using to disinfect their respirators. There was alcohol sprays and bleach we know can kill this virus[33] - but you have to be careful so you don’t breathe in a face full of bleach. Other places are experimenting with UV radiation[34][35][36].

RJ That can be used to disinfect respirators

RR So you can disinfect them?-01

RJ YES[37]

RR Oh great I’m kind of surprised

RJ The challenge is that they haven’t been proven to work as robustly as we would like. And it’s not clear that the healthcare facilities have all the processes in place.

Studies in the lab [38][39][40] - using special machinery[41] - has found that similar viruses can be killed with UV radiation. But Rachael says that a lot of hospitals in the US - they aren’t set up for this kind of thing at the moment.

So. Another idea has been popping up. Making masks out of cloth - like sometimes T shirt material[42][43] . Crafting is joining the war movement. Some hospitals are calling on DIY crafters to sew masks to shore up the supply.[44] But can cloth stop a virus?

Well Rachael says put down your needles and thread. A lot of materials just aren’t made to stop viruses. Like thinking of T-shirt material. We like them because they’re airy - and they don’t make us sweat too much… And viruses can roll right through them.

RJ All of those properties that we like in our T shirt make them problematic to use as a mask.  Because small particles have been demonstrated in experimental studies to move readily through cloth that is used in a mask like a bandana or shirt[45][46][47],

The only clinical trial we have on cloth masks - which had around a thousand doctors and nurses - found that they didn’t work.[48] [49] And in that study - it actually increased their risk of viral infections - we don’t know exactly why.

RR It’s so interesting that the CDC[50] says that in dire straits, as a last resort, it’s a crisis there is nothing else, you can wear a cloth mask as a health care worker. Is that good advice?

RJ I don’t think that’s good advice, and I was really surprised that that came out as a recommendation. As were some of my colleagues

RR What were you guys saying to each other?

RJ Well mostly hahah, smacking our foreheads and saying oh no! Mostly we were just surprised because there really is no scientific evidence that using a cloth mask offers any benefit. To suggest a cloth mask is not based on science. And so it’s important to separate what is the science-based sort of controls and what is the shortage-based kind of controls.

WZ What do you mean? They're saying it to make healthcare workers feel better?

RJ I think so, So in my understanding out how respiratory viruses are transmitted, and the limited ability of cloth to filter out viruses from the air, suggests to me that they are mostly offering comfort rather than actual protection

WZ That is kind of heartbreaking

RJ Yes, and to be clear, the CDC says this was something during the crisis phase, when other options not available

WZ And we are not at crisis phase yet

RJ I do not think we are at the point of using cloth masks yet,

RR How did we get here?

RJ That we’re at a shortage?

RR I mean I've been reading all these papers, pandemic planning strategies - 2000, 2005, we plan for masks[51][52][53], I'm reading this and I'm like what the hell?-02

RJ Absolutely the idea that we need 300 million masks,[54] is not new news, it was anticipated years ago! We have not been able to as a public health system implement that preparation

RR Who can we blame

RJ Hahahah

RR laugh

RJ laugh

RJ Ultimately I'm not sure who is to blame, there is a national stockpile,[55] federal government and it is clearly inadequate

Now .. Raina - who you heard from at the beginning of the show - did have a slightly different opinion. She thought that cloth masks might stop people from touching their face with their grubby hands - which could put virus particles right in your mouth. So maybe they aren’t entirely useless.[56] 

Okay, so what do all these mask facts mean for you and me? Healthy people…  walking around -- what should we be doing here?

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Well - given there aren’t enough masks to go around, for now, we need to be saving them for healthcare workers. So don’t go stockpiling. If you do have some N95s or surgical masks lying around - there is some good evidence[57] [58] [59] [60] to suggest that if you’re in a high risk area - around lots of people who are sick ... these masks can reduce your risk of infection. [61] [62][63] 

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After the break… Advil. This little pill is one of the first things that many of us reach for when we get a fever and feel achy[64][65] - but when it comes to this coronavirus - is this stuff dangerous?

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Welcome back. So we’ve just talked about how our healthcare workers need good protective gear - and all these DIY approaches, don’t work like we need them too. Next up. Ibuprofen.

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Advil[66]  and other drugs with ibuprofen are so common[67][68] - that many of us don’t even think twice before we pop one…  But there was a lot of news this week that ibuprofen[69] could make people with coronavirus even sicker.

We’ve got new evidence that an anti-inflammatory like ibuprofen could be potentially harmful

The WHO now recommending that everyone having COVID 19 Symptoms avoid taking ibuprofen

This comes after French Minister warned this could worsen symptoms of coronavirus

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This whole thing really got going with this tweet from the French health minister,[70] warning people with fevers ... not to use these kinds of drugs … called non-steroidal anti-inflammatories, or NSAIDs. 

As you just heard, some news reports said the WHO backed up the French on this. But that’s not what they actually said. The confusion might have been fueled by one of the biggest gripes - that grammar narcs have: double negatives. <GASP SFX> The WHO responded to all this with a tweet saying “WHO does not recommend against the use of of ibuprofen.[71]” Yeah does NOT recommend AGAINST ibuprofen. They also repeated the of. Is there any wonder there is confusion here?

To find out more ... I first called up Carlos Del Rio, a doctor and public health researcher at Emory University in Atlanta.

I’m already recording - so let’s just jump right in, I’m guessing you’re busy…

CD: You have no idea! Hahaha

WZ: So what I wanted to talk to you Ibuprofen, really blew up in the news. It all started when the health minister tweeted - that taking anti inflammatory drugs, such as ibuprofen could be an aggravating factor of the infection. 

What did you think when you heard about it?

CD: Well I think - I immediately contacted a friend of mine, who’s an infectious disease physician in Paris, who I have the utmost respect for, I said, hey, what's going on with your French health Minister? Mandating us not to use ibuprofen? Is there any data? And he responded, he said unfortunately very limited data

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The only thing this doctor had heard - Carlos said - is that a few young covid patients - who were otherwise healthy - started developing serious symptoms after being given an NSAID. And this story has been going around[72] … but it seems to be super anecdotal … And Carlos’ friend noted that he doesn’t have much to go on here …

CD but I do not think this data has been published, so very limited evidence.

But there’s another piece to this puzzle … a letter in The Lancet[73] - a very fancy journal … that could explain how this drug might cause problems for people with Covid-19. To understand more about this … I called up this guy.

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YK I’m Yogen Kanthi - a cardiologist at the University of Michigan[74].

Yogen says that to understand the theory here -  why ibuprofen might be bad for covid patients - we first have to know how viruses - any viruses - make us sick. Ok so after a little viral particle gets into your body it has to get into your cells. And that’s not easy.

YK Think of each cells as a fortress,

A fortress. And each virus has to breaks into that fortress…  we think the way this coronavirus breaks in is by binding to a receptor called ACE2[75][76].

YK A-C-E-2. ACE2. ACE2 may be a gate to the fortress.

Ok so to bring this back to ibuprofen. And that letter in the Lancet. Those researchers said that drugs like ibuprofen can ramp up the production of ACE2 … leaving more for the virus to latch onto… 

YK The theoretical risk, is that ibuprofen could increase the level of ACE2, which may have more docking sites or binding sites for the coronavirus to attach to. If you have more gates, there is more room for invaders to come in.

WZ Even from a theoretical perspective, do we know, for sure, having more ACE2 receptors, or gates in the fortress - increasing the risk of infection?

YK No, we don’t know that.

The problem with this theory - there’s actually not great evidence that ibuprofen actually does increase ACE2 production - the science we have mostly comes from animal studies.[77][78] And a bigger issue - we don’t know that having more of these receptors lets more virus particles in. It’s all pretty speculative![79][80] I also reached out to a few doctors in China - where they’ve been dealing with this disease for months - to see if they had been having bad experiences with ibuprofen. One told me that they are regularly giving patients ibuprofen, he hadn’t heard anything about this, another said - “maybe, but there’s no clear evidence.”

But in the research cupboard - we did find something curious.

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Something that might suggest steering clear of ibuprofen could be the right move. It comes from work done into influenza - which also attacks the lungs. Some early research[81] is suggesting that for a small group of people taking high dose NSAIDS while you have respiratory infections can increase your risk of getting a heart attack.[82][83]  That could be because these kinds of drugs can interfere with a bunch of stuff related to your heart.[84]Now we know that quite a few of the people dying from coronavirus - are dying from heart failure.[85][86][87] But again, this is early research, and it wasn’t specifically into ibuprofen.

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So the available evidence that ibuprofen causes big problems for people with this coronavirus is pretty limited. Both the FDA[88] and the European Union’s similar body[89][90]  have said there’s no clear link here. We may hear more out of France about what they are seeing - then things could change.

But in the meantime, if you have a fever, a nasty headache - you think you have coronavirus - what should you do? Here’s Yogen ...  

YK If you're taking ibuprofen, we'd probably suggest you don't take it anyway, if you can change it and take acetaminophen.

Acetaminophen - that’s what Tylenol or Paracetamol is.

YK So if you have a fever, generally recommend take acetaminophen before you take NSAID, I don’t think that changes in the setting of COVID

Why is that?

Ibuprofen can have other side effects [91][92]  - if you take large doses and over long periods of time/

And other academics are on the Tylenol train too.[93][94] Including Carlos - who you met before.

CD Exactly, my recommendation would be exactly that. I feel like we're in uncharted territory, we're fighting an enemy, we’re getting bits of information, if ibuprofen is the only thing to treat a fever, I would say we’re stuck, because we have other options, then let’s use other things…in the off chance there may be something in this association. 

And now … we want to change gears for just a minute. Because, hey -- let’s take a moment to forget about that coronavirus. Just for a moment. And let me tell you about this... 

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Scientists recently discovered the oldest known scorpion[95]. It’s fossilised. And it’s more than 430 million years old.[96] It was found in the wilds of Waukesha, Wisconsin - and the amazing thing about this little critter - is that researchers think it might have been one of the very first creatures to move from water to land![97] …That's because some parts of this beastie look really similar to a horseshoe crabs, which can go back and forth between the land and sea. How cool is that. Scorpions!

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Orright. Back to social distancing … maybe another puzzle. We’ll be back on Thursday with more Science Vs. Everything we say in this show is furiously cited - and if you’re ever curious - follow the links to our show notes. Click on the transcript… and you’ll see all the citations there. Have fun!

This episode was produced by Meryl Horn, Wendy Zukerman, Rose Rimler, Michelle Dang, Laura Morris and Sinduja Srinivasan. We’re edited by Blythe Terrell and Caitlin Kenney. Fact checking by Lexi Krupp. Mix and sound design by Catherine Anderson. Music written by Peter Leonard, Emma Munger, and Bobby Lord. A big thanks to all the researchers and healthcare workers that we got in touch with for this episode, including Professor Paul Little, Dr Kirsty Short, Siyab Panhwar, and Ayman Saeyeldin

And special thanks to Meg Driscoll, the Zukerman family and Joseph Lavelle Wilson.


[1] https://www.advil.com/advil Active ingredient:  200 mg Ibuprofen (NSAID)* *Nonsteroidal anti-inflammatory drug

[2] Olivier Veranm French Health Minister’s tweet from March 14, 2020.

[3] “France says ibuprofen may aggravate coronavirus. Experts say more evidence is needed.”

[4] Cuomo Presser on Sunday, March 22, 2020 - said the state is now paying $7 for masks they used to pay 85 cents for.

[5] Cuomo Presser on Sunday, March 22, 2020 - said “we are competing against other states. In some ways we're savaging other states. I'm trying to buy masks. I'm competing with California and Illinois and Florida.”

[6] March 19 Report from ISS: ono stati diagnosticati 3.559 casi tra operatori sanitari (età mediana 49 anni, 35.8% di sesso maschile), circa il 10% dei casi segnalati. È evidente l’elevato potenziale di trasmissione in ambito assistenziale di questo patogeno. | 3,559 cases were diagnosed among healthcare professionals (median age 49 years, 35.8% male), about 10% of the reported cases. The high transmission potential in the care sector of this pathogen is evident..

[7] From March 20 ISS infographic: increased to 3654

[8] Professor Raina MacIntyre

[9]“Raina and her team set out to address this important evidence gap with this body of work, which includes 4 RCTs on facemasks and respirators (the largest published to date in Health Care Workers) and numerous other studies.

[10] Figure 1 “results” column

[11] Efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers -- see highlights

[12] NIOSH - Respirator Fact Sheet - Understanding Respiratory Protection Against SARS CDC doc for SARS- These guides recommend that health care workers entering the room of a SARS patient and medical transport workers transporting a patient with suspected SARS use the following:...A respirator that is at least as protective as an N-95 respirator approved by the National Institute for Occupational Safety and Health (NIOSH)...An N-95 respirator is one of nine types of disposable particulate respirators…Respirators that filter out at least 95% of airborne particles during “worse case” testing using a “most-penetrating” sized particle are given a 95 rating.

[13] Meta-analysis 2017 “Compared to non-rPPE wearing HCWs, those wearing medical masks or N95 respirators throughout their work shift were significantly protected against nonspecific respiratory infection….Compared to medical masks, N95 respirators provided greater protection against CRI and BRI…”

[14] the ability of an individual wearer to obtain good facepiece fits ... is a function of the facial dimensions of the wearer, the training received by users to ensure that the device is properly placed on the face each time the respirator is donned, and how closely the device matches the size and shape of the wearer’s face.

[15]https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html  N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure

[16]https://onlinelibrary.wiley.com/doi/pdf/10.1111/irv.12474  The data collected on 3591 subjects in two similar RCTs conducted in Beijing, China..., laboratory-confirmed viral infections (RR 0.46,

95% CI 0.23-0.91) and droplet-transmitted infections (RR 0.26, 95% CI 0.16-0.42)

were significantly lower in the continuous N95 arm.

[17] https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1750-2659.2011.00198.x Rates of infection in the medical mask group were roughly double that in the N95 group.

[18] For viral respiratory infection, healthcare workers who wore N95 masks continuously had a 1.7% infection rate. HCW who wore medical masks had a 3.0% infection rate. (See Figure 1)

[19] On dentist masks: classified as “MEDICAL MASKS” in the NAP report: “A mask used in a healthcare setting is a disposable face covering designed to fit loosely over the user’s nose and mouth….. Other masks, including laser, isolation, and dental masks, also possess these characteristics.”

[20] Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza. https://www.ncbi.nlm.nih.gov/pubmed/19797474 … NB This study has received some criticism e.g. “This study has pointed out the many challenges in assessing the effectiveness of respirators and face masks in preventing influenza transmission, including the rates of correct use and fit of respirators and masks, the level of environmental contamination, the duration and intensity of exposure”

[21] https://sci-hub.tw/https://doi.org/10.1136/bmj.h694 see fig 1 “Summary of high level evidence (GRADE guidelines) on facemasks and respirators in the healthcare setting” Design, Methods column (MacIntyre’s studies are the largest)

[22] https://www.nytimes.com/2020/03/21/world/coronavirus-updates-usa-world.html Washington’s Department of Health has told local leaders that only the highest-priority areas will have access to the government’s stockpile of protective equipment, including N95 masks.

[23]https://www.nytimes.com/2020/03/20/nyregion/ny-coronavirus-hospitals.html?referringSource=articleShare The state has three stockpiles of medical supplies, including millions of masks and gloves, as well as more sophisticated equipment like ventilators. On Friday, the state health commissioner, Dr. Howard Zucker, said those supplies had been tapped to help backfill shortages at some hospitals.

[24] Confirmed by Washington state nurse union-- convo with RR

[25] Confirmed by NY nurse union-- convo with RR

[26] Washington Post, March 19, 2020: “We’re normally not supposed to reuse masks from patient to patient,” said Mehta, a radiologist in Charlotte. “But a lot of people are posting that they are getting one for the entire day, if they even have one.”

[27]New York Times, March 22, 2020: Many doctors said they were being given just one mask, to use indefinitely.

[28] The physical properties of a cloth mask, reuse, the frequency and effectiveness of cleaning, and increased moisture retention, may potentially increase the infection risk for HCWs...Observations during SARS suggested double-masking and other practices increased the risk of infection because of moisture, liquid diffusion and pathogen retention

[29]  viruses may be able to penetrate or spread through the mask in the form of liquid diffusion by a capillary effect, particularly since the expired air will most likely wet the mask...During repeated breathing actions, a mask also becomes a collector of viruses, particularly when its outer surface is exposed to contaminated droplets. Study compared typical surgical masks to N95 masks and found that N95 respirators provide higher in-vivo filtration efficiency of 97% with significant reduction of air permeability and water vapor permeability. Compared to normal surgical masks/respirators, the nano-masks can provide additional protective functions in stopping capillary diffusion and antibacterial activities.

[30] https://www.medrxiv.org/content/10.1101/2020.03.15.20036673v1.full.pdf Strikingly, a significant level of infectious virus could still be detected on the outer layer of a surgical mask on Day 7 (0.1% of the original inoculum), indicating SARSCoV-2 is extremely stable on this surface.

[31] “...on Thursday, the center began an experimental procedure to decontaminate its masks with ultraviolet light and reuse them. Administrators plan to use each mask for a week or longer.”

[32] Rachael M. Jones, PhD, CIH - Faculty Details - U of U School of Medicine - | University of Utah

[33] The analysis of 22 studies reveals that human coronaviruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus or endemic human coronaviruses (HCoV) can persist on inanimate surfaces like metal, glass or plastic for up to 9 days, but can be efficiently inactivated by surface disinfection procedures with 62–71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute.

[34] Ultraviolet light is being used to decontaminate medical supplies at the University of Nebraska Medical Center in Omaha.

[35] University of Nebraska Process for Decontamination and Reuse of N95  In an effort to extend

the stockpile of N95 FFRs at our institution, we developed a decontamination procedure

involving the delivery of ultraviolet germicidal irradiation (UVGI) to used N95 FFRs

[36]https://www.northjersey.com/story/news/health/2020/03/23/coronavirus-nj-desperate-need-masks-health-worker-protection/2895533001/ At Holy Name, staff are reusing masks, Jarrett said, and the hospital is disinfecting about 2,000 masks a day with ultraviolet light, though staff members haven’t started to use those yet.

[37] Among these control techniques, ultraviolet germicidal irradiation (UVGI) was demonstrated to be extremely efficient for virus inactivation (Jensen 1964; Galasso et al. 1965; Gerba et al. 2002; Nuanualsuwan et al. 2003; Thurston-Enriquez et al. 2003).

[38]  This study demonstrates significant reductions in viable influenza under substantial soiling conditions after being exposed to ~1-minute UVGI treatment. UVGI-based FFR-DR would allow hospitals to treat FFRs in a quick and efficient manner, benefiting HCWs during a potential influenza pandemic. https://www.ajicjournal.org/article/S0196-6553(18)30140-8/fulltext

[39]In summary, UVGI was an effective method for inactivation of airborne virus, especially for single-stranded RNA viruses.

[40] Coronavirus is a single-stranded RNA virus

[41]  the eight Germicidal lamps (Philips Germicidal Lamp, TUV 8W/G8 T5, Holland) were low-pressure mercury-vapor discharge lamps consisting of a tubular glass envelope that emitted short-wave UV radiation with a radiation peak at 253.7 nm (UV-C) for germicidal action

[42] https://www.nytimes.com/2020/03/21/style/coronavirus-masks-dov-charney-christian-siriano.html 

[43]https://www.nytimes.com/2020/03/21/business/coronavirus-masks-hanes-trump.html 

“Matt Hall, a spokesman for Hanes, said Trump administration officials called the company about a week ago to see if Hanes could start making face masks. Hanes and a group of other yarn and clothing companies agreed to make up to 6 million masks a week, he said.”

[44]https://www.kiro7.com/news/local/sewing-community-steps-up-help-with-covid-19-medical-mask-shortage/RJBQO5UN3BDM5MII3KNWQNJMF4/ 

https://www.deaconess.com/How-to-make-a-Face-Mask?fbclid=IwAR3DkkN1ySO9KWuuV7X-WVfuX0mGubNsEMtkqG_m34ajmZ_Xi7yvArlS1M0

https://www.michiganradio.org/post/some-healthcare-workers-turn-homemade-masks-amidst-controlled-chaos-dwindling-supplies

[45] The results showed that cloth masks and other fabric materials tested in the study had 40–90% instantaneous penetration levels against polydisperse NaCl aerosols employed in the National Institute for Occupational Safety and Health particulate respirator test protocol at 5.5 cm s−1

[46] The filtration performance of the cloth and medical masks was tested according to the respiratory standard AS/NZS1716.24 The equipment used was a TSI 8110 Filter tester. To test the filtration performance, the filter is challenged by a known concentration of sodium chloride particles of a specified size range and at a defined flow rate. Penetration of cloth masks by particles was almost 97%

[47] “When the cloth masks were tested against lab-generated whole diesel particles, the filtration efficiency for three particle sizes (30, 100, and 500 nm) ranged from 15% to 57%... Compared with cloth masks, disposable surgical masks are more effective in reducing particulate exposure”

[48] https://bmjopen.bmj.com/content/5/4/e006577 This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.

[49] Intervention: Hospital wards were randomised to: medical masks, cloth masks or a control group (usual practice, which included mask wearing). Participants used the mask on every shift for 4 consecutive weeks. Main outcome measure: Clinical respiratory illness (CRI), influenza-like illness (ILI) and laboratory confirmed respiratory virus infection. Results: The rates of all infection outcomes were highest in the cloth mask arm, with the rate of ILI statistically significantly higher in the cloth mask arm (relative risk (RR)=13.00, 95% CI 1.69 to 100.07) compared with the medical mask arm. Cloth masks also had significantly higher rates of ILI compared with the control arm. An analysis by mask use showed ILI (RR=6.64, 95% CI 1.45 to 28.65) and laboratory confirmed virus (RR=1.72, 95% CI 1.01 to 2.94) were significantly higher in the cloth masks group compared with the medical masks group. Penetration of cloth masks by particles was almost 97% and medical masks 44%

[50] https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html

In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.

[51] Given the potential duration of a pandemic, even stepped-up production and stockpiling of disposable medical masks and N95 respirators may not be sufficient to meet demand, especially if community use of either device is widespread. CDC estimates that in the event of a severe influenza pandemic, at least 1.5 billion medical masks would be needed by the healthcare sector and an additional 1.1 billion would be needed by the public. Demand for N95 respirators by the healthcare sector could exceed 90 million for a 42-day outbreak (CDC, 2006).

[52]  shortages of respiratory protection may occur during a pandemic

[53] Consider stockpiling enough consumable resources such as respiratory masks and gloves for the duration of a pandemic wave (6-8 weeks).

[54] HHS estimates suggest the country needs 300 million masks. https://www.msn.com/en-us/video/news/300-million-masks-needed-for-healthcare-workers-coronavirus-azar/vp-BB10noOY 

Health and Human Services Secretary Alex Azar said the US needs at least 300 million face masks for healthcare workers as the country braces for the rapid spread of the coronavirus.

[55] Strategic National Stockpile

[56] Moreover, cloth masks and fabric materials covering the mouth and nose may serve as a reminder to not touch those areas with the hands serving to minimize contact transmission and reduce exposure to liquid splashes and droplets, although these premises would need to be confirmed experimentally.

[57] In one study, researchers randomized university residence halls housing 1,297 student participants to use of face masks, face masks with hand hygiene, or a control group for a 6-week period during the influenza season (Aiello et al., 2010). Significant reductions in influenza-like illnesses were seen in the group using face masks and hand hygiene as compared with the control group (reductions of 35 to 51 percent after adjusting for vaccination and other factors). (Described here)

[58] A cluster-randomized intervention trial was designed involving 1,178 young adults living in 37 residence houses in 5 university residence halls during the 2007–2008 influenza season. Participants were assigned to face mask and hand hygiene, face mask only, or control group during the study. A significant reduction in the rate of ILI [ influenza-like illness] was observed in weeks 3 through 6 of the study, with a maximum reduction of 75% during the final study week (rate ratio [RR] = 0.25, [95% CI, 0.07 to 0.87]).

[59] MacIntyre and colleagues (2009) conducted a study on the use of face masks in households in Australia during the winters of 2006 and 2007. The participating 145 households included adults with known exposure to a child with fever and other respiratory symptoms. Of those who used the masks, a reduction in the risk of acquiring a respiratory infection was noted in the range of 60 to 80 percent, and no differences were seen between surgical masks and P2 masks (Described here)

[60] Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset.

[61] https://sci-hub.tw/https://doi.org/10.1136/bmj.h694 See Table 2

[62]https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks 

[63]https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks (start at 44 seconds)

[64] Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used over-the-counter (OTC) medications in the United States

[65] For pain, ibuprofen is the most commonly prescribed for paediatrics (followed by paracetamol); however they share the top spot for adult patients.

[66]https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=1f01c10a-9434-91a4-2ee4-352315a6b610&type=display

[67] Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used over-the-counter (OTC) medications in the United States

[68] For pain, ibuprofen is the most commonly prescribed for paediatrics (followed by paracetamol); however they share the top spot for adult patients.

[69] https://trends.google.com/trends/explore?geo=US&q=ibuprofen

[70] https://twitter.com/olivierveran/status/1238776545398923264?s=20: Taking anti inflammatories (ibuprofin, cortizone) can be a factor in aggravating infection. In case of fever, take paracetamol. If you have already taken anti inflammatories or are uncertain, ask your doctor 

[71] https://twitter.com/WHO/status/1240409217997189128?s=20

[72] https://www.bmj.com/content/368/bmj.m1086 His comments seem to have stemmed in part from remarks attributed to an infectious diseases doctor in south west France. She was reported to have cited four cases of young patients with covid-19 and no underlying health problems who went on to develop serious symptoms after using non-steroidal anti-inflammatory drugs (NSAIDs) in the early stage of their symptoms.

[73] Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?  ACE2 can also be increased by thiazolidinediones and ibuprofen.

[74] Yogendra Kanthi MD

[75] Human pathogenic coronaviruses bind to their target cells through angiotensin-converting enzyme 2 (ACE2), which is expressed by certain cells of the lung, intestine, kidney, and blood vessels.

[76] https://blogs.sciencemag.org/pipeline/archives/2020/03/17/angiotensin-and-the-coronavirus

[77] NSAIDs typically increased ACE2, “Healthy rats and rats with adjuvant arthritis (AA) were

used.”

[78] . The protein expression of ACE and AT1-R and the amount of AngIIwere higher, and the protein expression of ACE2 and Mas-R and the amount of Ang (1-7) were lower in the diabetic group. The ratio of ACE to ACE2 was raised in the diabetic group. All these changes were ameliorated by ibuprofen administration.

[79]Epithelial cells are going to have ACE-2 protein on their surfaces no matter what, so the virus is going to be attacking those as a route of entry. If that second paper is right, then it could be that throwing more ACE-2 onto those membrane doesn’t make the viral infection much worse.

[80] Also discussed here https://twitter.com/angie_rasmussen/status/1238946941758615553

[81] A large trial (n=889) randomised patients presenting with RTIs to advice to take paracetamol, ibuprofen, or both (1). Consultations with new/unresolved symptoms or complications were documented in 12% with paracetamol and 20% with ibuprofen (adjusted risk ratio 1.67, 1.12 to 2.38). The 11 complications in the ibuprofen group were  quinsy, sinusitis (n=3), meningitis, pneumonia, otitis media (n=3), and progression/non-resolution of otitis media  (n=2), and the impact in a more severe COVID-19 population could possibly be greater. [Email with Prof. Paul Little]. In paper it notes “Most complications were not serious and were mainly self limiting, but there were three more serious complications in the ibuprofen group (pneumonia, meningitis, and quinsy”

[82] We identified 9793 patients with an incident admission for AMI between 2007 and 2011...NSAIDs use during ARI episodes was associated with a 3.4-fold increased risk of AMI

[83]  It is likely that the cardiovascular risk associated with nonselective and COX-2 inhibitors results from various mechanisms, including altering the balance of thromboxane and prostacyclin, leading to increased platelet aggregation and vasoconstriction, as well as fluid and sodium retention [17]. Acute respiratory infections induce a range of hemodynamic, procoagulant, and proinflammatory effects that contribute to the risk of cardiac complications“...they showed that acute respiratory infections treated with NSAIDs had a stronger association with AMI than ARIs not treated with NSAIDs or NSAID treatment alone.”

[84] Risk of new acute myocardial infarction hospitalization associated with use of oral and parenteral non-steroidal anti-inflammation drugs (NSAIDs): a case-crossover study of Taiwan's National Health Insurance claims database and review of current evidence. “Consistent with four previous studies which found a significantly increased AMI risk with current use of ibuprofen [18,25,37,47], we found a significant aOR of 1.45 ( 1.19 - 1.76) for ibuprofen in the present study. The level of association was within the range of 9% reduction to 56% elevation reported in previous studies”

[85] Coronavirus Disease 2019 (COVID-19) Provides Potent Reminder of the Risk of Infectious Agents The specific effects of COVID-19 on the cardiovascular system remain unclear, though there have been reports of acute cardiac injury, arrhythmias, hypotension, tachycardia, and a high proportion of concomitant cardiovascular disease in infected individuals, particularly those who require more intensive care.

[86] Sepsis was the most frequently observed complication, followed by respiratory failure, ARDS, heart failure, and septic shock

[87] Italy March 20 report: Respiratory failure was the most commonly observed complication in this sample ( 96.5% of cases ), followed by acute renal injury (29.2%), acute myocardial injury (10.4%) and superinfection (8.5%).

[88] "At this time, FDA is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms. The agency is investigating this issue further and will communicate publicly when more information is available."

https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19 

[89] There is currently no scientific evidence establishing a link between ibuprofen and worsening of COVID‑19. EMA is monitoring the situation closely and will review any new information that becomes available on this issue in the context of the pandemic.. https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19 

[90] NHS: There is currently no strong evidence that non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen can make coronavirus (COVID-19) worse. But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you.

[91] Gastroinsteninal problems  https://academic.oup.com/jid/article/215/4/497/2965359 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC128885/  for comparison with tylenol: upper gastrointestinal complications: see table 1. Also “We found a RR of 4.1 (95% CI, 3.6–4.8) for NA-NSAIDs studied as a therapeutic class…. Epidemiological data on the association between acetaminophen use and UGIC are limited and inconsistent (pooled RR, 1.4; 95% CI, 1.0–2.0)

[92] Cohort studies have shown that up to 13% to 18% of elderly and hospitalized patients develop acute renal failure in response to NSAIDs, and elderly high-dose NSAID users had a 26% increased risk of progression "

[93] Charlotte Warren-Gash, associate professor of epidemiology at the London School of Hygiene and Tropical Medicine, said: “For covid-19, research is needed into the effects of specific NSAIDs among people with different underlying health conditions. In the meantime, for treating symptoms such as fever and sore throat, it seems sensible to stick to paracetamol as first choice.”

[94] There is currently no strong evidence that ibuprofen can make coronavirus (COVID-19) worse. But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you.

[95] It occurs in strata that are older than those from Scotland yielding Dolichophonus loudonensis15, which was previously accepted as the oldest known scorpion

[96] we describe a new exceptionally preserved fossil scorpion from the Waukesha Biota (early Silurian, ca. 437.5–436.5 Ma)

[97]  https://www.nature.com/articles/s41598-019-56010-z.pdf At this early point in arachnid evolution, physiological changes concomitant with the marine-to-terrestrial transition must have occurred