Countering Misinformation Spread About the COVID-19 Pandemic

Tony Cundell, PhD - Principal Consultant - Microbiological Consulting, LLC

Introduction

Today it’s a free-for-all on social media, which has become the main source of information for people on the COVID-19 pandemic, and sometimes a major source of information for even conventional media, so there is a huge opening for misinformation. Whereas the goal of scientific journals is to disseminate science in an unbiased manner with checks and balances built in through the peer-review process and post-publication responses from readers, the goal of information about science on social media may or may not be about science, but could be about casting science from a political, ideological, and/or financial perspective. The author believes he can play a modest role in helping to correct some of this misinformation. An earlier review article, that I co-authored addressing controls to minimize disruption of the pharmaceutical supply chain during the COVID-19 pandemic was published in 2020.1

Misinformation is false information that is spread by posting and mindlessly sharing on social media platforms like LinkedIn, Facebook, Instagram, TikTok and Twitter, regardless of the intent to mislead. Disinformation, its more evil twin, means something slightly different, which is deliberately false or biased information, spread with the intent to mislead.

We are all desperate for accurate information. Where did the virus come from? Is there a cure? How can we keep staying safe during the pandemic? Will life get back to normal after the vaccine becomes widely available? Will the vaccines be effective against emerging variants? This article will address examples of commonly heard misinformation that can be countered with a technical argument, but not disinformation spread to disrupt society, which is difficult to counter with rational argument.

The SARS-CoV-2 Virus Was Man-Made in China

This misinformation arises from questions amongst the scientific community as well as the general public about the origin of SARS-CoV-2, the coronavirus responsible for the COVID-19 pandemic. That it emerged so suddenly, and spread so quickly, demands answers. 

Coronaviruses are lipid-enveloped, single-stranded, positive sense RNA viruses, with 26 to 32 kilobases that produced around 30 different proteins (compared to over 3 billion base pairs in humans producing in excess of 20,000 proteins), which include several relatively benign, seasonal, common cold viruses and three newer more virulent coronaviruses: SARS-CoV-1, MERS-CoV, and SARS-CoV-2 that emerged in late 2019 and became responsible for the COVID-19 pandemic in early 2020.2 The online publication of the SARS-CoV-2 genome was on January 10, 2020, which is critical for viral testing and vaccine production.

We now recognize that zoonotic respiratory viruses initially emerge by animal-to-human and then largely by human-to-human transmission, and to a much lesser degree surface to human transmission. Additional research should fully describe this process. The genome sequence of SARS-CoV-2 is 96.2% identical to a bat CoV RaTG13, whereas it shares 79.5% identity to SARS-CoV-1.3,4 Based on viral sequencing and evolutionary analyses, it suggests that SARS-CoV-2 may have been transmitted from bats to an intermediate host to infect humans and could not possibility be a man-made creation. Based on contact tracing, a wet food market in Wuhan, China appears to be a possible source of the original outbreak. Although bats were not on sale at the market, possible intermediate hosts such as turtles and pangolins that were, and could have been the source of the outbreak infecting humans.

A word about the naming of infectious diseases; they may be named after the discoverer of the infectious agent, e.g., Hansen’s Disease for leprosy; the place of original outbreak, e.g., Lyme Disease from East Lyme, Connecticut; the group of people first infected, e.g., Legionnaire’s Disease for the bacterium Legionella; or the site of the infection, or the major symptom, e.g., paralytic poliomyelitis. Recent WHO (World Health Organization) recommendations encourage a more descriptive naming and not using locations that may wrongly stigmatize a people or location. A classic example is the 1918 N1H1 Influenza Pandemic, popularly named the Spanish Flu. More recent studies suggest that virus emerged from pigs in Kansas, USA not Spain. More recently, the WHO recommended the use of Greek letters for SARS-CoV-2 variant. For example, variant B.1.1.7 originally isolated in the United Kingdom was designated the Alpha variant while the rapidly spreading variant B.1.617.2 originally isolated from India was designated the Delta variant. This designation, while helpful to the general public, may be confusing in the scientific community, as Greek letters have been used for subdividing broad groups within the different Coronaviruses.

COVID-19 is No Worse Than the Seasonal Flu

COVID-19 is caused by the novel coronavirus, called Severe Acute Respiratory Syndrome Coronavirus 2 or SARS-CoV-2, whereas any of the several different types and strains of influenza viruses cause flu. While both flu and COVID-19 are spread from person to person through aerosols in the air from an infected person coughing, sneezing or even talking, there are a few significant differences that make COVID-19 more likely to spread and cause more severe illness compared to the seasonal flu. Reproduction number (R0) refers to the number of secondary infections generated from one infected individual. For COVID-19, that number is 2 to 2.5, which means one person with COVID-19 goes on to infect two or two-and-a-half people as compared to an R0 of 1.3 for seasonal flu.5 Current estimates of the infection mortality rate for the coronavirus range from 0.4-1.5%. This means it is anywhere from 4 to 15 times higher than the seasonal flu which has a mortality rate estimated at 0.1%. The ability of asymptomatic people to shred the virus compounds and the transmission of the virus has worked against containment. If we use a conservative Reproduction Number (R0) of 3, the level of immunity in the population to achieve herd immunity due to past infection and vaccination would need to reach at least 70%, which is a significant vaccination challenge.

Vaccines Based on mRNA May Change Your DNA

Clearly mRNA vaccines cannot change your DNA. The so-called central dogma that genetic information flows in one direction from DNA to RNA to proteins was first proposed in 1958 by Francis Crick, co-discoverer of the chemical structure of DNA with James Watson, still applies to mammalian cells. The vaccine is injected into the muscle of the upper arm and travels to the lymph glands. The modified mRNA provides the nucleotide sequence for the synthesis of the spike protein of the SARS-CoV-2 virus by white blood cells of the recipient.

The modified mRNA is encapsulated in an 80-100 nm-diameter, lipid nanoparticle that enables it to enter mammalian cells. Once inside the cell, the lipid nanoparticle dissolves liberating the mRNA, which directs the biosynthesis of the spike protein on the cellular ribosome that is the antigen for triggering binding and neutralizing antibodies against the SARS-CoV-2 virus. The liberated mRNA has a short half-life of less than 24 hours and cannot enter the cell-walled nucleus that contains the generic DNA. Furthermore, the cells, unlike retroviruses, e.g., HIV, lack the enzyme reverse transcriptase that converts RNA to DNA so the mRNA vaccine cannot change the recipient’s DNA. In turn, the spike glycoprotein has a short half-life of around 48-72 hours, so it is degraded shortly after antibodies are generated and the killer T-cells activated.6 

In many ways, mRNA vaccines are ideal vaccines with a high degree of safety and effectiveness, as demonstrated in clinical trials and global vaccination programs that are reaching millions of people so if you are vaccinated you are not part of an experiment as believed by some people.

The Pandemic Would Recede Once the Warm Weather Arrives and Will Be Seasonal Like Influenza

It is not yet known whether weather and temperature affect the spread of COVID-19. Some other viruses, like those that cause the common cold and flu, spread more during cold weather months but that does not mean it is impossible to become sick with these viruses during other months. There is much more to learn about the transmissibility, severity, and other features associated with COVID-19 and investigations are ongoing.6 Therefore, because SARS-CoV-2 is so new, there’s no way to say for sure whether the virus will experience the same seasonality as other viruses such as Influenza.

Young People Are Not Infected with COVID-19 Virus Whereas Older People Are, So They Do Not Need to Social Distance

The COVID-19 virus can infect people of all ages. Unlike the 1918 flu pandemic where the highest mortality was amongst people in their 20’s, the COVID-19 virus can infect older people and younger people. Older people who may be less immune-competent, and people with pre-existing medical conditions such as asthma, diabetes, obesity, and heart disease are known to be more vulnerable to becoming severely ill with the virus.

Early in the pandemic, COVID-19 incidence was highest among older adults. However, during June–August 2020, the CDC reported that COVID-19 incidence was highest in persons aged 20–29 years, who accounted for >20% of all confirmed cases. Younger adults likely contribute to community transmission of COVID-19. Across the southern United States in June 2020, increases in percentage of positive SARS-CoV-2 test results among adults aged 20–39 years preceded increases among those aged ≥60 years by 4–15 days. Strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce infection and subsequent transmission to persons at higher risk for severe illness.8

In fact, a recent report from the CDC confirms that COVID-19 does not spare millennials and Gen Zers. Among the first 4,226 cases in the U.S., more than half of patients who were hospitalized were under the age of 65, and one in five were aged 20 to 44. In California, the majority of confirmed cases so far have been in people younger than 50. However, serious COVID-19 infection, the use of ventilators and mortality is much higher in those >75 years that have comorbidities such as extreme obesity, heart disease, and cancer.

States and Local Authorities Must Follow CDC Vaccination Priorities When Distributing the Vaccine

Because the U.S. supply of COVID-19 vaccine was expected to be limited at first, CDC provided recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on those from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. 

The recommendations were made with these goals in mind:

• Decrease death and serious disease as much as possible.
• Preserve functioning of society by protecting medical workers and first responders.
• Reduce the extra burden COVID-19 is having on people already facing disparities.

While CDC makes recommendations for who should be offered COVID-19 vaccine first, each state has its own plan for deciding who will be vaccinated first and how they can receive vaccines. Please continue to contact your local health department for more information on COVID-19 vaccination in your area.

The Increased Usage of Chlorine Disinfectants and Alcohol Hand Sanitizers Has Contributed to Increasing Antibiotic Resistant Bacteria

Using an alcohol-based hand sanitizer and chlorine-based disinfectants does not contribute to the spread of antibiotic resistant bacteria, as the overuse of antibiotics does in treating non-bacterial infections and agricultural usage. Ironically, hospitalized COVID-19 patients may be over treated with antibiotics due to the fact that they are vulnerable to hospital-associated infections. The active ingredient in most hand sanitizers is ethyl alcohol, which acts in a completely different manner than antibiotics. Similarly, the active component of chlorine-based disinfectants is chlorine, which is an oxidizing agent also acts in a completely different manner than antibiotics. Sanitizers and disinfectants actively destroy bacteria, fungi, yeasts, and viruses

by destroying cellular components and the nucleoid,9 whereas antibiotics prevent bacterial growth by inhibiting cell wall formation and protein synthesis. Resistance has not been documented in regards to disinfectants being used in cleanrooms and controlled areas and periodic rotation with a sporicide is recommended in USP <1072> Disinfectants and Antiseptics to control fungal and bacterial spores.

Rumors Circulated That COVID-19 Vaccines Affect Fertility

The June 13, 2021 issue of The New York Times reported that some area ultra-orthodox Jewish women were shunning vaccination because of rumors that the vaccine was a threat to a woman’s fertility. The ability to have children is of concern to all women, but this an example of misinformation in a hard-to-reach community. The CDC has reported that there is currently no evidence that any vaccines, including COVID-19 vaccines, cause female or male fertility problems - problems getting pregnant. They do not recommend routine pregnancy testing before COVID-19 vaccination. The CDC states that if you are trying to become pregnant, you do not need to avoid pregnancy after receiving a COVID-19 vaccine. Like with all vaccines, the FDA and CDC are studying COVID-19 vaccines carefully for side effects now amongst populations underrepresented in the clinical trials and will report findings as they become available.10

Furthermore, the American College of Obstetricians and Gynecologists states that if you are planning or trying to get pregnant, you can get a COVID-19 vaccine. There is no evidence that the COVID-19 vaccines cause infertility. You also do not need to delay getting pregnant after you get a vaccine. Furthermore, they recommend that as some COVID-19 vaccines will require two doses. If a woman finds that they are pregnant after the first dose, they should continue with the second dose.

In the June 15, 2021 issue of MMWR, the CDC reported that COVID-19 vaccination completion is lower in pregnant women (11.1%) compared with non-pregnant females aged 18–49 years reported in VSD for the same period (24.9%). They observed that the lower coverage among pregnant women might be attributable to various factors including limited available safety data on COVID-19 vaccines during pregnancy; need for increased vaccine confidence among health care providers and pregnant women; vaccine prioritization, access, and availability; and cultural and language barriers. Pregnant women are routinely excluded from clinical trials, and only very limited human data on safety and efficacy during pregnancy were available at the time that the vaccines received emergency use authorization. Surveys before COVID-19 vaccine authorization showed COVID-19 vaccination hesitancy among pregnant women, and the most frequently reported reasons for lack of intent to get vaccinated during pregnancy were limited safety data in pregnancy and concerns about possibility of harm to the fetus. 

The CDC reported that through early May 2021, COVID-19 vaccination coverage among pregnant women within VSD was low; however, coverage increased over the period across all age and racial and ethnic groups. The increase might be attributable to inclusion of pregnancy among the conditions that increase risk for severe COVID-19 and thus for prioritization for early allocation of COVID-19 vaccines, as well as the rollout of vaccines to the entire U.S. population in mid-April 2021. In addition, analyses of emerging data regarding safety of COVID-19 vaccines, specifically mRNA vaccines, have detected no safety signals for pregnant women.11

Previously Infected People Can Forgo Vaccination

A recent preprint of an un-reviewed study from a researcher at the Cleveland Clinic suggests that prior infection is highly effective against COVID-19 reinfection. This may indicate that vaccination may be unnecessary but this conclusion has been questioned.12 However, due to diagnosis uncertainty and questions around the level and duration of protection, the emergence of more infectious variants has forced authorities to recommend that this population get vaccinated. With sufficient vaccine available in the U.S. to vaccinate all adults, forgoing vaccination to conserve vaccine is no longer necessary. The need for rapid publication in response to the pandemic must be balanced by the role played by peer review in insuring scientific standards.

The Current Approved Vaccines Are Ineffective Against Newly Emerging SARS CoV-2 Variants.

As the pandemic spreads, the coronavirus SARS-CoV-2 will have the opportunity to evolve becoming more transmittable, more infectious, and perhaps even more lethal. As of July 7, 2021, The Johns Hopkins University COVID-19 dashboard reports 185 million confirmed global COVID-19 cases with 4 million deaths. The U.S. figures are 33.75 million cases and 606,000 deaths. This provides an enormous opportunity for viral mutation. 

Changes in clinical outcomes are difficult to monitor. The estimated R subzero is between 2.2 and 3.6, but this is lowered by non-pharmaceutical interventions like social distancing, limiting large gatherings, wearing facemasks, forgoing travel, and frequent hand washing. Positivity rates determined by high frequency of COVID-19 testing provide important epidemiological information. Also useful are hospitalization rate, number of patients in the ICU, on ventilators, and who die. Probably most useful to detect emerging SARS CoV-2 variants is the RNA base sequencing of clinical isolates.

Four variants may be familiar to the reader. They are the B.1.1.7 variant (Origin UK), the B.1.351 variant (Origin South Africa), the P.1 variant (Origin Brazil) and B 1.617.2 variant (Origin India). Preliminary data show that the neutralizing antibodies form in inoculated individuals in response to the mRNA vaccines (Moderna and Pfizer/BioNTech) are reduced but still active, especially in preventing serious infection, against the B.1.1.7 variant, but the effectiveness of the AstraZeneca vaccine reflects the prevalence of B.1.351 variant in the clinical trial population and varies by country. For example, the South African health authorities are not distributing this vaccine. The mRNA vaccines do produce neutralizing antibodies but appear slightly less effective against the newly emergent variant B 1.617.2 that is now designated as the Delta Variant but prevent serious infection, hospitalization and death.

Mutations are a natural by-product of viral replication. Although RNA viruses typically have higher mutation rates than DNA viruses, coronaviruses like SARS-CoV-2, acquire nucleotide substitutions more slowly than other RNA viruses including the influenza virus, due to a proofreading polymerase that corrects mistakes in transcription. The spike glycoprotein, recurrent deletions overcome this slow substitution rate. By altering stretches of amino acids, deletions accelerate SARS-CoV-2 antigenic evolution conferring resistance to neutralizing antibodies, increasing transmission rates, and infectivity.

Vaccines Against SARS CoV-2 Variants Are Difficult to Develop and Their Clinical Trials Must Be Repeated to Demonstrate Safety and Effectiveness.

Most of us are familiar with the need to reformulate annual flu vaccines with the antigens for emerging strains by hemisphere. With a highly seasonal respiratory virus like influenza, based on the immediately past hemispheric winter, three or four strains are selected for inclusion in the vaccine to protect people in the coming winter. Although the SARS CoV-2 mutation rate is estimated 3-4 times lower than the flu virus, the COVID-19 infection does not follow as strong a seasonal pattern that allows for planning and scheduling vaccine production. Another huge advantage is that COVID-19 vaccines have effectiveness rates of 70- 95% compared to typical 30-60% for flu vaccines. 

The author believes that COVID-19 vaccines could be reformulated to maintain their effectiveness against emerging strains without changes to their vaccine manufacturing platforms. As with annual flu vaccines, these changes will not require full randomized, blinded clinical trials and the reformulated COVID-19 vaccine may be given as a booster shot to maintain immunological responsiveness to the original virus and emerging variants and could even be combined with the flu vaccine.

The Government is Hiding That People Are Experiencing Serious Adverse Reactions and Dying From the Vaccine.

This misinformation is totally untrue. No serious adverse reactions related to vaccination were encountered in the vaccine arm of the large-scale clinical trials that included broad subject diversity. These clinical trials, that included 15,000 subjects in both the vaccine and placebo arms, contained a significant percentage of minority group members, the aged, and subjects with comorbidities for the COVID-19 pandemic. When a trial member exhibited a serious medical condition, the vaccination schedule may be placed on hold until the event is fully investigated and shown to be unrelated to the vaccine. As expected, the minor adverse reactions typical of vaccination was higher in those receiving the second dose of vaccine and may be considered evidence that the vaccine is working.

Surveillance is a critical safety element in the introduction of the COVID-19 vaccines. The Vaccine Adverse Event Reporting System (VAERS) is a 30-year-old, national voluntary vaccine safety surveillance program co-sponsored by the FDA and the Centers for Disease Control and Prevention (CDC). The purpose of VAERS is to detect possible signals of adverse events associated with vaccines and separate them from events unrelated to the vaccines. VAERS collects and analyzes information from reports of adverse events (possible side effects) that occur after the administration of U.S. licensed and emergency use authorized vaccines. Reports are welcome from all concerned individuals: patients, parents, health care providers, pharmacists and vaccine manufacturers. Everyone may gain access to VAERS, so there is transparency, but the database may be subject to misuse. In addition, people receiving the vaccine are directed to a downloadable Smartphone App V-Safe that may be used to report their experience with vaccination and any adverse events. Close to roll out is the new vaccination monitoring system BEST, Biologics Evaluation Safety Initiative to monitor the COVID vaccine.

For example, there were media reports of two high profile UK cases of anaphylactic shock amongst early vaccine recipients. The rate of anaphylaxis reported so far is 4.7 cases per million doses of the Pfizer/ BioNTech vaccine and 2.5 cases per million for the Moderna vaccine.13 These rates are comparable to any other vaccine. Most (86%) anaphylaxis cases had symptom onset within 30 minutes of vaccination, and most persons with anaphylaxis (81%) had a history of allergies or allergic reactions, including some with previous anaphylaxis events; up to 30% of persons in the general population might have some type of allergy or history of allergic reactions. People reporting past allergic reactions, especially to vaccines, are required to remain for 30 minutes after vaccination and Epi-Pens and other medical equipment are available to treat the extremely rare instances of anaphylaxis.

More recently, as vaccination rolled out to younger age groups, a rare heart inflammation was reported in persons younger than 30 years. Since April 2021, there have been more than a thousand reports to the Vaccine Adverse Event Reporting System (VAERS) of cases of inflammation of the heart, i.e., myocarditis and pericarditis in the first week after mRNA COVID-19 vaccination in the United States. In most cases the recovery was rapid and the frequency is small compared to the 300 million doses administered.

A COVID-19 Vaccine Could Not Possibly Be Developed, Clinically Tested, Reviewed, and Approved in As Little as Two to Three Months and Still Be Safe and Effective. 

The first reported demonstration of the use of mRNA injected into experimental animals to produce proteins, within their body, was in 1990 so that the idea was been around for thirty years. Both BioNTech and Moderna were working with big pharma companies on the development of cancer and infectious agent vaccines when the COVID-19 outbreak was reported. Chinese scientists published the SARS-CoV-2 RNA sequence in January 2020 and it was off to the races.

Key factors in the vaccine development were the NIH researcher’s construction of the mRNA sequence, federal government funding of Operation Warp Speed, the publication of two FDA guidance documents Clinical Development and Licensure of Vaccines for the Prevention of COVID-19 (June 2020), and Emergency Use Authorization (EUA) for COVID-19 Vaccines (October 2020), vaccine manufacturers posting the details of their clinical trials, and the independent review of the risk and benefits from the clinical data and recommendations for EUA approval by the independent FDA Vaccine and Related Biologics Advisory Committee. 

The resources, knowledge, skills and energies of dedicated professionals in vaccine development, volunteer recruitment and clinical trials, regulatory submission and review, vaccination priorities setting, cold chain operation, and vaccination delivery were fully engaged for the first 12 months. Many of these activities were conducted concurrently and not sequentially, speeding up the overall process. In the Fall of 2020, the public was reassured by the then FDA Commissioner Stephen Hahn and Center for Biological Evaluation and Research Director Peter Marks, M.D. that decisions were driven by scientific consideration and not subjected to political pressures. Yes, my wife and I took the vaccine as soon as it available for our priority group.

Social Distancing, Wearing Facemasks, and Isolating at Home Are Ineffective

The spread of the pandemic can be reduced by measures we all can take to protect family, friends, neighbors, and ourselves. This is popularly known as flattening the curve and prevents the healthcare system being overwhelmed. The two main mechanisms of SARS-CoV-2 transmission are airborne, in the form of larger droplets (10-20um), which can fall out of the air rapidly within seconds to minutes and land on horizontal surfaces; and with smaller droplets (aerosols) and particles (5-10 um). The aerosols can remain suspended for many minutes to hours and travel larger distances, depending on the direction and velocity of air currents. Studies indicate that the aerosolized viral particles have a half-life of the order of an hour. Transmission from contract with surface can occur but is less important. Importantly the preventative measures to avoid COVID-19 infection are physical (social) distancing, hand washing, adequate ventilation, surface disinfection, and wearing a mask.

Comprehensive, multi-country analyses found that societal norms and government policies supporting the wearing of masks by the public, as well as international travel controls, are independently associated with lower per-capita mortality from COVID-19.14-16

Other compelling evidence on the effective of wearing facemasks was obtained in the State of Kansas.17 After the Kansas governor’s executive order to encourage facemask wearing, COVID-19 incidence (calculated as the 7-day rolling average number of new daily cases per 100,000 population) decreased (mean decrease of 0.08 cases per 100,000 per day; net decrease of 6%) among counties with a mask mandate but infection continued to increase (mean increase of 0.11 cases per 100,000 per day; net increase of 100%) among counties without a mask mandate.

Conclusions

Misinformation confuses the members of the public and erodes confidence in our public healthcare system. Clearly infectious disease experts from lead federal government agencies like the Center for Disease Control and Prevention, Food and Drug Administration and National Institutes of Health have the key role to forcefully and clearly issue guidance so state, county, and local health authorities can implement controls to limit and turn back the COVI-19 pandemic. Building on the U.S. federal investment in medical research, the pharmaceutical industry developed safe and effective COVID-19 vaccines that offers the best chance to control the pandemic, so it is now up to the public to cut through the misinformation and get vaccinated.

References

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11. Shimabukuro, T.T., Y.S. Kim etal (2021) Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons. N Engl J Med 384:2273-2282
12. Shrestha, N.K.. P C. Burke et al (2021) Necessity of COVID-19 vaccination in previously infected individuals medRxiv 2021.06.01.21258176; doi:https://doi.org/10.1101/2021.06.01.21258176
13. Shimabukuro TT, Cole M, Su JR. (2020) Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US—December 14, 2020-January 18, 2021. JAMA. 2021;325(11):1101–1102. doi:10.1001/jama.2021.1967
14. Chu, D.K. et al (2020) Physical distancing, face mask, and eye protection to prevent person-to-person transmission of SARS-CoV-2: A systematic review and meta-analysis The Lancet June 1 2020
15. Leffler, C.T., E. Ing et al (2020) Association of Country-wide Coronavirus Mortality with Demographics, Testing, Lockdowns, and Public Wearing of Masks Am. J. Trop. Med. Hyg., 103(6): 2400–2411
16. Lyu W, Wehby GL. Community Use of Face Masks And COVID-19: Evidence From A Natural Experiment of State Mandates in the US. Health Aff (Millwood). 2020;39(8):1419 1425.10.1377/hlthaff.2020.00818. https://www.ncbi.nlm.nih.gov/pubmed/32543923
17. Van Dyke, M et al 2020 Trends in County-Level COVID-19 Incidence in Counties with and without a Mask Mandate — Kansas, June 1–August 23, 2020 MMWR / November 27, 2020 / 69(47):1777-1781

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