The Effectiveness Of Government Masking Mandates On COVID-19 County-Level Case Incidence Across The United States, 2020

Face mask mandates alter major determinants of adherence to protective health behaviours in Australia

Face mask wearing is a protective health behaviour that helps mitigate the spread of infectious diseases such as influenza and COVID-19. Understanding predictors of face mask wearing can help refine public health messaging and policy in future pandemics. Government mandates influence face mask wearing, but how mandates change predictors of face mask wearing has not been explored. We investigate how mandates changed predictors of face mask wearing and general protective behaviours within Australia during the COVID-19 pandemic using cross-sectional survey data. We compared four machine learning models to predict face mask wearing and general protective behaviours before and after mandates started in Australia; ensemble, tree-based models (XGBoost and random forests) performed best. Other than state, common predictors before and after mandates included age, survey week, average number of contacts, wellbeing, and perception of illness threat. Predictors that only appeared in the top ten before mandates included trust in government, and employment status; and after mandates were willingness to isolate. These distinct predictors are possible targets for future public health messaging at different stages of a new pandemic.

Associations between local COVID-19 policies and anxiety in the USA: a longitudinal digital cohort study

ABSTRACT

Introduction

A lack of coordinated federal guidance led to substantial heterogeneity in local COVID-19 policies across US states and counties. Local government policies may have contributed to increases in anxiety and mental health disparities during the COVID-19 pandemic.

Methods

We analysed associations between composite policy scores for containment and closure, public health or economic support from the US COVID-19 County Policy Database and self-reported anxiety scores (Generalised Anxiety Disorder-7) from COVID-19 Citizen Science participants between 22 April 2020 and 31 December 2021.

Results

In 188 976 surveys from 36 711 participants in 100 counties across 28 states, associations between anxiety and containment and closure policy differed by employment (p<0.0001), with elevated anxiety under maximal policy for people working in hospitality and food services (+1.05 vs no policy; 95% CI: 0.45, 1.64) or arts and entertainment (+0.56; 95% CI 0.15, 0.97) and lower anxiety for people working in healthcare (-0.43; 95% CI -0.66 to -0.20) after adjusting for calendar time, county-specific effects and COVID-19 case rates and death rates. For public health policy, associations differed by race and ethnicity (p=0.0016), with elevated anxiety under maximal policy among participants identifying as non-Hispanic Black (+1.71; 95% CI 0.26, 3.16) or non-Hispanic Asian (+0.74; 95% CI 0.05, 1.43) and lower anxiety among Hispanic participants (-0.63, 95% CI -1.26 to -0.006). Associations with public health policy also differed by gender (p<0.0001), with higher anxiety scores under maximal policy for male participants (+0.42, 95% CI 0.09, 0.75) and lower anxiety for female participants (-0.40, 95% CI -0.67 to -0.13). There were no significant differential associations between economic support policy and sociodemographic subgroups.

Conclusions

Associations between local COVID-19 policies and anxiety varied substantially by sociodemographic characteristics. More comprehensive containment policies were associated with elevated anxiety among people working in strongly affected sectors, and more comprehensive public health policies were associated with elevated anxiety among people vulnerable to racial discrimination.

Political and educational dynamics behind the Evangelicals' stance against mask mandates during COVID-19 in the U.S

This study investigates the mediation effect of conservative political ideology on the relationship between Evangelical identities and attitudes against the mask mandate during COVID-19 in the U.S., using a nationally representative survey administered over three waves from September 2020 to June 2021. We employ a moderated mediation analysis to examine the pathway from Evangelical identity to political conservativeness to anti-mask-mandate attitudes, and the interaction effect between years of education and political ideology. A logistic regression model is used to investigate each path in the mediation analysis. Results suggest that controlling for socio-demographic background, self-identified Evangelical status positively drives resistance to the mask mandate. Additional findings confirm that political orientation is not only an established predictor of the polarized public support of masking, as found in existing studies, but is also a key mechanism by which Evangelical identities positively predict anti-mask-mask attitudes. Finally, a higher level of education is associated with greater political polarization of public opinions on the mask mandate during the pandemic.

The Costs of Polarizing a Pandemic: Antecedents, Consequences, and Lessons

Polarization has been rising in the United States of America for the past few decades and now poses a significant-and growing-public-health risk. One of the signature features of the American response to the COVID-19 pandemic has been the degree to which perceptions of risk and willingness to follow public-health recommendations have been politically polarized. Although COVID-19 has proven more lethal than any war or public-health crisis in American history, the deadly consequences of the pandemic were exacerbated by polarization. We review research detailing how every phase of the COVID-19 pandemic has been polarized, including judgments of risk, spatial distancing, mask wearing, and vaccination. We describe the role of political ideology, partisan identity, leadership, misinformation, and mass communication in this public-health crisis. We then assess the overall impact of polarization on infections, illness, and mortality during the pandemic; offer a psychological analysis of key policy questions; and identify a set of future research questions for scholars and policy experts. Our analysis suggests that the catastrophic death toll in the United States was largely preventable and due, in large part, to the polarization of the pandemic. Finally, we discuss implications for public policy to help avoid the same deadly mistakes in future public-health crises.

Exploring adolescents' experiences of continuing to wear face masks during COVID-19: A qualitative descriptive study in Barcelona (Spain)

BACKGROUND

The COVID-19 pandemic prompted the use of face masks as a social distancing measure. Although evidence supports their effectiveness in preventing infection, it remains unclear why some adolescents choose to continue wearing them postpandemic, even when it is no longer mandatory. This study aims to explore adolescents' experiences of wearing face masks during the COVID-19 pandemic when their use was no longer mandatory.

METHOD

In this exploratory qualitative study, data were collected from 16 adolescents through face-to-face semistructured interviews. The participants were asked about the reasons and feelings associated with continuing to wear masks, as well as the contexts in which they felt safe without a mask. The collected data were analysed using Braun and Clarke's thematic analysis.

RESULTS

Three main themes were identified: (1) Navigating complex decision-making: balancing safety and self-image, (2) peer influence dynamics and (3) managing the future: weather dynamics and pandemic evolution.

DISCUSSION

The potential implications of withdrawing COVID-19 preventive measures, such as mask-wearing, beyond the pandemic remain understudied. It is crucial to further investigate the perceptions related to wearing masks and its cessation, especially amongst vulnerable individuals.

PATIENT OR PUBLIC CONTRIBUTION

Due to methodological constraints associated with participants' age, they were not engaged in the design, data analysis, data interpretation or manuscript preparation phases of the study.

County-Level Mandates Were Generally Effective At Slowing COVID-19 Transmission

Throughout the COVID-19 pandemic in the US, counties adopted numerous nonpharmaceutical interventions, such as mask mandates and stay-at-home orders, to slow COVID-19 transmission and prevent hospitals from reaching full capacity. Early evidence has been mixed about whether these interventions are effective. However, most studies only covered the early waves of COVID-19 and did not account for county-level variation in the adoption and repeal of such policies. Using daily county-level data from the Centers for Disease Control and Prevention, we evaluated the joint impact of bans on large gatherings, stay-at-home orders, mask mandates, and bar and restaurant closures on slowing COVID-19 transmission during waves 1-4 of the pandemic in the US (March 1, 2020-June 30, 2021). Our survival analysis showed that these interventions were generally effective at slowing COVID-19 transmission during this period. The mitigating effect was particularly strong during waves 2 and 3 and less substantial during waves 1 and 4. We also found strong evidence of the overall protective effect of mask mandates and, to a lesser degree, anticongregation policies. These study findings provide crucial evidence for public health officials to reference for support when using nonpharmaceutical interventions to flatten the curve of future waves of COVID-19 or other infectious disease outbreaks.

Child mask mandates for COVID-19: a systematic review

BACKGROUND

Mask mandates for children during the COVID-19 pandemic varied in different locations. A risk-benefit analysis of this intervention has not yet been performed. In this study, we performed a systematic review to assess research on the effectiveness of mask wearing in children.

METHODS

We performed database searches up to February 2023. The studies were screened by title and abstract, and included studies were further screened as full-text references. A risk-of-bias analysis was performed by two independent reviewers and adjudicated by a third reviewer.

RESULTS

We screened 597 studies and included 22 in the final analysis. There were no randomised controlled trials in children assessing the benefits of mask wearing to reduce SARS-CoV-2 infection or transmission. The six observational studies reporting an association between child masking and lower infection rate or antibody seropositivity had critical (n=5) or serious (n=1) risk of bias; all six were potentially confounded by important differences between masked and unmasked groups and two were shown to have non-significant results when reanalysed. Sixteen other observational studies found no association between mask wearing and infection or transmission.

CONCLUSIONS

Real-world effectiveness of child mask mandates against SARS-CoV-2 transmission or infection has not been demonstrated with high-quality evidence. The current body of scientific data does not support masking children for protection against COVID-19.

Differential associations of mask mandates on COVID-19 infection and mortality by community social vulnerability

BACKGROUND

The COVID-19 pandemic in the United States has disproportionately impacted communities deemed vulnerable to disease outbreaks. Our objectives were to test (1) whether infection and mortality decreased in counties in the most vulnerable (highest) tercile of the Social Vulnerability Index (SVI), and (2) whether disparities between terciles of SVI were reduced, as the length of mask mandates increased.

METHODS

Using the New York Times COVID-19 and the Centers for Disease Control and Prevention SVI and mask mandate datasets, we conducted negative binomial regression analyses of county-level COVID-19 cases and deaths from 1/2020-11/2021 on interactions of SVI and mask mandate durations.

RESULTS

Mask mandates were associated with decreases in mid-SVI cases (IRR: 0.79) and deaths (IRR: 0.90) and high-SVI cases (IRR: 0.89) and deaths (IRR: 0.88). Mandates were associated with the mitigation of infection disparities (Change in IRR: 0.92) and mortality disparities (Change in IRR: 0.85) between low and mid-SVI counties and mortality disparities between low and high-SVI counties (Change in IRR: 0.84).

DISCUSSION

Mask mandates were associated with reductions in COVID-19 infection and mortality and mitigation of disparities for mid and high-vulnerability communities.

CONCLUSIONS

Ongoing COVID-19 response efforts may benefit from longer-standing infection control policies, particularly in the most vulnerable communities.

Assessing the effectiveness of international government responses to the COVID-19 pandemic

This paper examines the effectiveness of non-pharmaceutical measures adopted by governments to control the evolution of the COVID-19 pandemic. Using a Panel VAR model for the OECD countries, we test for Granger causality between the 7-day cumulative incidence, mortality rate, and government response indexes. Granger-type statistics reveal evidence that the evolution of the COVID-19 pandemic influenced the measures taken by governments. However, limited or nonexistent evidence supports the reverse situation. This suggests that government measures were not highly effective in controlling the pandemic. While not implying total ineffectiveness, our results indicate a considerable lack of efficacy, emphasizing a lesson for governments to learn from and correct in preparation for similar events in the future.

Cardiovascular Complications of COVID-19: A Scoping Review of Evidence

This scoping review sought to identify the nature and extent of clinical evidence regarding the acute and long-term cardiovascular complications associated with COVID-19. Forty-nine studies published between 2020 and 2023 were selected for review. The studies were divided into two groups. The referential group included 22 studies. The second group of 27 studies was used for a detailed review to assess the strength of the evidence. The aggregate evidence indicates that the most common cardiac complications associated with COVID-19 include but are not limited to acute pericarditis, acute myocardial injury, acute myocarditis, various arrhythmias, microvascular angiopathy, left ventricular dysfunction, heart failure, acute cardiac injury, and acute coronary syndrome. Clinical and epidemiological implications of the findings are investigated, and future research recommendations are proposed.

Population-Level Disparities in Exposure to COVID-19 Mitigation Policies, April 2020-April 2021

CONTEXT

Studies have found that COVID-19 stay-at-home orders (SHOs) and face mask policies (FMPs) were associated with reduced COVID-19 transmission and deaths. But it is unknown whether exposure to these policies varied by sociodemographic characteristics across the US population.

OBJECTIVE

The goal of this study was to quantify and characterize the sociodemographic characteristics and geographic distribution of populations exposed to evidence-based COVID-19 mitigation policies.

DESIGN

We obtained statewide SHOs and FMPs for all US counties from April 10, 2020, to April 10, 2021, calculated median policy lengths, and categorized counties into 4 groups based on length of policy exposure: low SHO-low FMP, high SHO-low FMP, low SHO-high FMP, and high SHO-high FMP. We described exposure groups by COVID-19 cumulative case/death and vaccination rates and county sociodemographic characteristics.

SETTING

In total, 3142 counties from all 50 states and Washington, District of Columbia, were included in the analysis.

MAIN OUTCOME MEASURES

County-level sociodemographic factors and county cumulative rates for COVID-19 cases, deaths, and vaccinations.

RESULTS

The largest percentage of the US population lived in counties with high exposure to SHOs and FMPs. However, populations living in high SHO-high FMP counties had the lowest percent non-Hispanic Black (NHB) and highest percent non-Hispanic White (NHW) populations. Populations living in high SHO-low FMP counties had the highest percent NHB and Hispanic populations and the lowest percent NHW population.

CONCLUSION

This study identified county-level racial, ethnic, and sociodemographic disparities in exposure to evidence-based statewide COVID-19 mitigation policies.

POLICY IMPLICATIONS

Exposure to evidence-based policies is an important consideration for studies evaluating the root causes of health inequities.

Masks During Pandemics Caused by Respiratory Pathogens-Evidence and Implications for Action

Importance

As demonstrated by the influenza virus and SARS-CoV-2, viruses spread by the respiratory route can cause deadly pandemics, and face masks can reduce the spread of these pathogens. The effectiveness of responses to future epidemics and pandemics will depend at least in part on whether evidence on masks, including from the COVID-19 pandemic, is utilized.

Observations

Well-designed observational studies have demonstrated the association of mask use with reduced transmission of SARS-CoV-2 in community settings, and rigorous evaluations of mask mandates have found substantial protection. Disagreement about whether face masks reduce the spread of SARS-CoV-2 has been exacerbated by a focus on randomized trials, which are limited in number, scope, and statistical power. Many effective public health policies have never been assessed in randomized clinical trials; such trials are not the gold standard of evidence for the efficacy of all interventions. Masking in the community to reduce the spread of SARS-CoV-2 is supported by robust evidence from diverse settings and populations. Data on the epidemiologic, environmental, and mask design parameters that influence the effectiveness of masking provide insights on when and how masks should be used to prevent transmission.

Conclusions and Relevance

During the next epidemic or pandemic caused by a respiratory pathogen, decision-makers will need to rely on existing evidence as they implement interventions. High-quality studies have shown that use of face masks in the community is associated with reduced transmission of SARS-CoV-2 and is likely to be an important component of an effective response to a future respiratory threat.

Leveraging the COVID-19 pandemic as a natural experiment to assess changes in antibiotic use and antibiotic-resistant E. coli carriage in semi-rural Ecuador

The coronavirus 2019 (COVID-19) pandemic has had significant impacts on health systems, population dynamics, public health awareness, and antibiotic stewardship, which could affect antibiotic resistant bacteria (ARB) emergence and transmission. In this study, we aimed to compare knowledge, attitudes, and practices (KAP) of antibiotic use and ARB carriage in Ecuadorian communities before versus after the COVID-19 pandemic began. We leveraged data collected for a repeated measures observational study of third-generation cephalosporin-resistant E. coli (3GCR-EC) carriage among children in semi-rural communities in Quito, Ecuador between July 2018 and September 2021. We included 241 households that participated in surveys and child stool sample collection in 2019, before the pandemic, and in 2021, after the pandemic began. We estimated adjusted Prevalence Ratios (aPR) and 95% Confidence Intervals (CI) using logistic and Poisson regression models. Child antibiotic use in the last 3 months declined from 17% pre-pandemic to 5% in 2021 (aPR: 0.30; 95% CI 0.15, 0.61) and 3GCR-EC carriage among children declined from 40 to 23% (aPR: 0.48; 95% CI 0.32, 0.73). Multi-drug resistance declined from 86 to 70% (aPR: 0.32; 95% CI 0.13; 0.79), the average number of antibiotic resistance genes (ARGs) per 3GCR-EC isolate declined from 9.9 to 7.8 (aPR of 0.79; 95% CI 0.65, 0.96), and the diversity of ARGs was lower in 2021. In the context of Ecuador, where COVID-19 prevention and control measures were strictly enforced after its major cities experienced some of the world's the highest mortality rates from SARS-CoV-2 infections, antibiotic use and ARB carriage declined in semi-rural communities of Quito from 2019 to 2021.

Open data for COVID-19 policy analysis and mapping

As the COVID-19 pandemic unfolded in the spring of 2020, governments around the world began to implement policies to mitigate and manage the outbreak. Significant research efforts were deployed to track and analyse these policies in real-time to better inform the response. While much of the policy analysis focused narrowly on social distancing measures designed to slow the spread of disease, here, we present a dataset focused on capturing the breadth of policy types implemented by jurisdictions globally across the whole-of-government. COVID Analysis and Mapping of Policies (COVID AMP) includes nearly 50,000 policy measures from 150 countries, 124 intermediate areas, and 235 local areas between January 2020 and June 2022. With up to 40 structured and unstructured characteristics encoded per policy, as well as the original source and policy text, this dataset provides a uniquely broad capture of the governance strategies for pandemic response, serving as a critical data source for future work in legal epidemiology and political science.

Invited Commentary: To Make Long-Term Gains Against Infection Inequity, Infectious Disease Epidemiology Needs to Develop a More Sociological Imagination

In a recent article in the Journal, Noppert et al. (Am J Epidemiol. 2023;192(3):475-482) articulated in detail the mechanisms connecting high-level "fundamental social causes" of health inequity to inequitable infectious disease outcomes, including infection, severe disease, and death. In this commentary, we argue that while intensive focus on intervening mechanisms is welcome and necessary, it cannot occur in isolation from examination of the way that fundamental social causes-including racism, socioeconomic inequity, and social stigma-sustain infection inequities even when intervening mechanisms are addressed. We build on the taxonomy of intervening mechanisms laid out by Noppert et al. to create a road map for strengthening the connection between fundamental cause theory and infectious disease epidemiology and discuss its implications for future research and intervention.

Esoteric Beliefs and Opposition to Corona Restrictions in Germany

Governmental measures against the spread of the Corona virus have been met with varying levels of opposition in many countries worldwide. Existing research has claimed that some of this opposition is linked to esoteric and anthroposophical beliefs. This research note tests this in an observational study using election results from the 2021 parliamentary election in Germany and new data on the distribution of natural healers, homeopathic doctors and Steiner schools. Results show that counter to common expectations, there is no evidence that esoteric beliefs systematically lead to increased support for the established right-wing AFD. Rather, some indicators for esoteric beliefs - in particular, the presence of homeopathic doctors and Waldorf schools - are related to higher support for the new fringe party dieBasis, a single-issue party campaigning against governmental Corona measures.

Judicial Review of Public Health Powers Since the Start of the COVID-19 Pandemic: Trends and Implications

During the COVID-19 pandemic, officials in the United States at all levels of government utilized their legal authorities to impose a wide range of measures designed to control the spread of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; the causative agent of COVID-19), including shutting down businesses, limiting the size of gatherings, requiring masking, and mandating vaccination. These orders and regulations were challenged in court cases that resulted in more than 1000 judicial decisions. Common claims were based on alleged procedural and substantive due process violations, violations of religious liberty, and violations of officials' scope of authority. In more than three fourths of the decisions, the court refused to grant the plaintiffs the relief sought. However, plaintiffs found success in several notable cases, especially in federal court. These recent decisions, as well as broader prepandemic trends, have important implications for public health officials' exercise of their public health powers, especially when those exercises implicate religious liberty. In this legal environment, officials may need to rely more on the powers of persuasion than on their legal authority alone. (Am J Public Health. 2023;113(3):280-287. https://doi.org/10.2105/10.2105/AJPH.2022.307181).

Mask Adherence and Social Distancing in Houston, TX from January to April 2021

Shortly after the identification of COVID-19, public health experts recommended the use of face masks and social distancing to slow the spread of the virus. Early research indicates that there are associations between gender, age, and mask-wearing behavior. The primary aim of this paper was to explore how demographics, location, and mask mandates may affect COVID-19 mitigation strategies such as mask-wearing and social distancing. A prospective, cross-sectional observational study was conducted in Houston, TX from January to April 2021 at three outdoor locations: an urban park, an urban park with a trail, and a farmer's market. During each two-hour data collection period, trained observers recorded the total number of people in the designated spaces; people were categorized by approximate age, sex, race/ethnicity, physical activity level, social distancing, and mask adherence using the Systematic Observation of Mask Adherence and Distancing (SOMAD) protocol. Multivariable logistic regression was used to determine associations with gender, race, age, location, and the mask mandate. A total of 7778 observations were recorded after exclusion of inconclusive demographic data. Females had higher odds, reported as an odds ratio, of mask use than males (OR = 1.35, 95% CI 1.18-1.54). Compared to White individuals, Asian individuals had higher odds of mask use (OR = 1.84, 95% CI 1.48-2.30). The odds of mask use were higher while the Texas mask mandate was in effect (OR = 1.60, 95% CI 1.40-1.84). Regarding location, the odds of mask use were much higher in the urban park than in the urban park with a trail (OR = 13.33). Individuals had higher odds of social distancing at the urban park with a trail compared to the farmer's market (OR = 4.61, 95% CI 4.10-5.17). Mask wearing and social distancing behaviors differ by demographics, locality, and mask mandate. Thus, state policies can be effective tools to encourage mask wearing for disease mitigation.

A computational cognitive model of behaviors and decisions that modulate pandemic transmission: Expectancy-value, attitudes, self-efficacy, and motivational intensity

We present a computational cognitive model that incorporates and formalizes aspects of theories of individual-level behavior change and present simulations of COVID-19 behavioral response that modulates transmission rates. This formalization includes addressing the psychological constructs of attitudes, self-efficacy, and motivational intensity. The model yields signature phenomena that appear in the oscillating dynamics of mask wearing and the effective reproduction number, as well as the overall increase of rates of mask-wearing in response to awareness of an ongoing pandemic.

Psychosocial Factors Predict Mask-Wearing: A Longitudinal Study Across 3 Phases of the COVID-19 Pandemic

Determinants of mask-wearing during a pandemic range from the personal to the political. Using a repeated measures design, we examined psychosocial predictors of self-reported mask-wearing 3 times during the early stage of the COVID-19 pandemic. Participants completed surveys at baseline (summer 2020), 3 months (fall 2020), and 6 months (winter 2020-2021). The survey assessed the frequency of mask-wearing and psychosocial predictors from various theories, including fear of COVID-19, perceived severity, perceived susceptibility, attitude, health locus of control, and self-efficacy. Results indicated that the strongest predictors of mask-wearing varied as a function of the stage in the pandemic. In the earliest phase, fear of COVID-19 and perceived severity were the strongest predictors. Three months later, attitude was the strongest predictor. Finally, another 3 months later, self-efficacy became the strongest predictor. Overall, the results suggest that the primary determinants of a novel protective behavior shift over time and with increased familiarity.

Association of Trends in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Seroprevalence and State-Issued Nonpharmaceutical Interventions: United States, 1 August 2020 to 30 March 2021

BACKGROUND

We assess if state-issued nonpharmaceutical interventions (NPIs) are associated with reduced rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as measured through anti-nucleocapsid (anti-N) seroprevalence, a proxy for cumulative prior infection that distinguishes seropositivity from vaccination.

METHODS

Monthly anti-N seroprevalence during 1 August 2020 to 30 March 2021 was estimated using a nationwide blood donor serosurvey. Using multivariable logistic regression models, we measured the association of seropositivity and state-issued, county-specific NPIs for mask mandates, gathering bans, and bar closures.

RESULTS

Compared with individuals living in a county with all three NPIs in place, the odds of having anti-N antibodies were 2.2 (95% confidence interval [CI]: 2.0-2.3) times higher for people living in a county that did not have any of the 3 NPIs, 1.6 (95% CI: 1.5-1.7) times higher for people living in a county that only had a mask mandate and gathering ban policy, and 1.4 (95% CI: 1.3-1.5) times higher for people living in a county that had only a mask mandate.

CONCLUSIONS

Consistent with studies assessing NPIs relative to COVID-19 incidence and mortality, the presence of NPIs were associated with lower SARS-CoV-2 seroprevalence indicating lower rates of cumulative infections. Multiple NPIs are likely more effective than single NPIs.