Fulton County Superior Court

***EFILED***AC
Date: 7/27/2020 8:51 AM
Cathelene Robinson, Clerk

IN THE SUPERIOR COURT OF FULTON COUNTY

STATE OF GEORGIA

GOV. BRIAN P. KEMP,

Plaintiff,

v.

HON. KEISHA LANCE BOTTOMS,

FELICIA A. MOORE, CARLA SMITH,
AMIR R. FAROKHI, ANTONIO
BROWN, CLETA WINSLOW, Civil Action File
NATALYN MOSBY ARCHIBONG, 2020CV338387
JENNIFER N. IDE, HOWARD SHOOK,
J.P. MATZIGKEIT, DUSTIN R. HILLIS,
ANDREA L. BOONE, MARCI
COLLIER OVERSTREET, JOYCE
SHEPAERD, MICHAEL JULIAN
BOND, MATT WESTMORLAND, and
ANDRE DICKENS,

Defendants.

DEFENDANTS’ RESPONSE BRIEF IN

OPPOSITION TO MOTION FOR INTERLOCUTORY INJUNCTION

Michael B. Terry
Robert L. Ashe III
Manoj S. Varghese
Jane D. Vincent
BONDURANT MIXSON & ELMORE LLP
1201 West Peachtree St. NW, Suite 3900, Atlanta, GA 30309

Counsel for Defendants

 TABLE OF CONTENTS
INTRODUCTION ..................................................................................................... 1

STATEMENT OF FACTS ........................................................................................ 2

ARGUMENT ............................................................................................................. 7

I. THE GOVERNOR’S CLAIMS AGAINST ATLANTA ARE BARRED

BY ATLANTA’S SOVEREIGN IMMUNITY .................................................. 7

A. The Governor must establish a waiver of Atlanta’s sovereign immunity

in order to sue .................................................................................................. 7

B. There is no applicable waiver of Atlanta’s sovereign immunity .................... 8

1. O.C.G.A. § 36-33-1 confirms Atlanta’s sovereign immunity. .................... 8

2. City of College Park v. Clayton County does not establish a waiver

here. ............................................................................................................ 9

3. Other states’ authority supports immunity here. ...................................... 10

II. THE GOVERNOR’S MOTION FAILS TO MEET THE STANDARD

FOR AN INTERLOCUTORY INJUNCTION .............................................. 12

A. The Governor has not suffered—nor can he identify—an irreparable

injury that would warrant an interlocutory injunction................................... 13

B. The risk of increased infections outweighs the harm of allowing

local governments to mandate masks ............................................................ 14

C. The Governor is not likely to succeed on the merits ..................................... 17

1. The Governor’s Order purporting to suspend the Mayor’s Order

is invalid. ................................................................................................. 17

i
 i. The Governor’s Order violates the statute’s directive
to “promote and secure the safety and protections”
of Georgians.................................................................... 17

ii. The Governor’s Order violates the statute’s directive

that emergency orders should be consistent with
federal recommendations. ............................................... 19

iii. The General Assembly has not delegated the public

health police power to the Governor. ............................. 21

iv. The Governor’s Order is invalid because it exceeds

the public health emergency declaration approved
by the General Assembly. .............................................. 23

2. The City of Atlanta is authorized to mandate face coverings to

protect public health. ................................................................................ 25

i. The City of Atlanta is authorized to take action to

protect the health, safety, and general welfare of the
public................................................................................. 25

ii. The Mayor’s Order is neither inconsistent with

nor preempted by the Governor’s Order.......................... 26

iii. The legislature cannot delegate to the Governor the

ability to abrogate a municipality’s exercise of
its authorized legislative power. ..................................... 30

iv. The Governor’s Order cannot prohibit the wearing

of masks on the City’s own property. ............................. 31

3. The Governor is unlikely to prevail on the merits because he lacks

standing and fails to state a claim for declaratory judgment. ................. 32

D. An interlocutory injunction will disserve the public interest ........................ 35

ii
III. THE RELIEF SOUGHT IN THE REQUESTED INJUNCTION
VIOLATES THE FEDERAL AND STATE CONSTITUTIONS AND
GEORGIA STATUTES. ................................................................................ 36

A. The Constitution prohibits “enjoining Mayor Bottoms from issuing

any further press releases or public statements” ...................................... 38

B. Supreme Court Authority also prohibits enjoining voting, passage,

or adoption of a law, resolution, ordinance, or order ............................... 40

C. The relief requested violates Georgia law and the Due Process
Clause because it does not provide sufficient specificity......................... 41

D. Equitable relief is statutorily unavailable to the extent such

enforcement involves criminal law or criminal penalties ........................ 44

CONCLUSION ........................................................................................................ 48

iii
 INTRODUCTION

Despite the rapidly growing threat to Georgians from COVID-19, Governor

Brian Kemp sued Mayor Keisha Lance Bottoms to prevent her from implementing

critical life-saving measures in Atlanta. Nevertheless, she persisted.

The Governor’s suit fails for several reasons. First, his suit is barred by

sovereign immunity. Second, he cannot prevail on his motion for an interlocutory

injunction because he fails to satisfy any of the four elements for granting such relief.

Importantly, the Governor has no likelihood of success on the merits of his claims.

His reliance on the authority provided by the Georgia Emergency Management Act

to exercise powers to promote the safety and protection of the public cannot be used

to nullify the City’s valid exercise of its powers to protect its citizens’ health and

safety. His attempt is antithetical to the purpose of that Act and exceeds the power

granted to him by the Act. Further, granting the relief he seeks disserves the public

interest by increasing the spread of COVID-19 and the number of lives damaged and

lost to it. Finally, even assuming he had asserted any viable claims, the Governor

seeks relief prohibited by the U.S. and Georgia Constitutions, several Georgia

statutes, and equitable doctrines adopted by our Supreme Court. The Governor’s

motion must be denied.

1
 STATEMENT OF FACTS

COVID-19—the disease caused by the novel coronavirus SARS-Cov-2—is

currently spreading in a dramatic and uncontrolled manner in Georgia.1 More than

165,000 Georgians have been infected with COVID-19, and nearly 3,500 Georgians

have died as a result.2 The spread of the disease in Georgia is getting worse.3 In light

of the alarming expansion of this public health crisis in Georgia, Keisha Lance

Bottoms, Mayor of the City of Atlanta, has exercised the City’s police powers and

the authority granted to the City by the legislature to issue Executive Orders “to

protect the health, safety, and general welfare of the public.”4 The Mayor’s Order

recognizes:

(1) the scope of the COVID-19 pandemic in Georgia;5

1
See July 26, 2020 Affidavit of Dr. Carlos Del Rio (“Del Rio Aff.”), Ex. 1, ¶¶ 4, 7,
8.
2
Id ¶ 5.
3
Id. ¶¶ 6–8.
4
See Executive Order Number 2020-119 (“Mayor’s Order”), Ex. 2, at 1, 3. The
Governor appears to erroneously believe that the Mayor’s COVID-related
executive orders issued pursuant to Atlanta Code Section 2-181 are subject to
ratification by the City Council. See Compl. ¶ 40 (seeking to “enjoin the City
Council of Atlanta from ratifying Mayor Bottoms’ COVID-related executive
orders”). However, the Mayor’s orders issued pursuant to that section do not
necessitate and are not subject to the Council’s ratification. In contrast, orders
issued pursuant to Code Section 2-182(2) are subject to ratification by the City
Council, but the Mayor has not issued any COVID-related executive orders
pursuant to that code section.
5
Mayor’s Order at 2.

2
 (2) that CDC-issued guidance advises use of masks or cloth face coverings
to protect oneself and others from COVID-19;6 and

(3) that a July 14, 2020 report prepared for the White House Coronavirus
Task Force identifies Georgia as being in the “red zone” for both cases
and test positivity and recommends Georgia “mandate statewide
wearing of cloth face coverings outside the home.”7

Given this public health emergency and recommendations, the Mayor ordered

that:

(1) no establishment may allow more than 50 persons to gather if doing so

requires any person to be within six feet of anyone else;8

(2) no gatherings of persons may occur on City property;9

(3) subject to certain exceptions, every person in the City shall wear a mask
or face covering over the nose and mouth when (i) inside a commercial
space open to the public and (ii) when outside if appropriate social
distancing is not feasible10; and

(4) nothing in the Mayor’s Order shall impede the operation of any business
or establishment as provided in Governor Brian Kemp’s Executive Order
07.15.20.01 issued on July 15, 2020 (“Governor’s Order”).11

6
Id.
7
Id. (emphasis added).
8
Id. § 3(b)(1).
9
Id. § 3(b)(2).
10
Id. § 4.
11
Id. § 5.

3
The Mayor’s Order and those that preceded it do not, as the Governor concedes,12

roll back the City’s restrictions from phase II to phase I.13

As noted, the Mayor’s Order requires the use of face coverings in Atlanta, and

with good reason. Face masks protect the public by helping to stop the spread of

COVID-19 and are most effective when the vast majority of the public wears

masks.14 One study that compared COVID-19 infection rates before and after states

implemented mandatory face coverings showed that such mandates reduced

transmission and prevented between 230,000–450,000 new cases in those states

between April 1 and May 22.15 Unfortunately, and despite the Governor’s best

wishes, the majority of the public will not adopt use of face masks without a

mandate.16 The “level of mask compliance necessary to stop the spread of COVID-

19 can only be achieved through laws mandating the use of face coverings in

public.”17

12
Compl. ¶¶ 37, 46.
13
The Governor also erroneously makes the inflammatory accusation that that the
Mayor “tied the hands of the Atlanta Police Department by instructing them not
to enforce [his] Executive Orders.” Compl. ¶ 38. However, the Governor offers
no evidence in support of this baseless accusation.
14
Del Rio Aff. ¶¶ 12, 14.
15
Id. ¶ 19.
16
Id. ¶¶ 18, 20, 27.
17
Id. ¶ 28 (emphasis added).

4
 The Mayor’s Order mandating use of face masks will save lives.18 If the

Governor did the same, it would flatten the curve in Georgia, bring the COVID-19

epidemic in the state under control in four to eight weeks, and save the lives of an

estimated 2,500 Georgians between now and November 1, 2020.19 The Governor

recognizes the life-saving ability of using face masks. His order strongly encourages

individuals to wear face masks, allows certain governmental entities to mandate use

of face masks, and mandates the use of face masks in a number of settings.20 While

the Governor contends that “Georgia’s COVID-19 restrictions are similar to those

of a large majority of sister states,”21 Georgia sits on an island alone among its

neighbors. Every neighboring state has either mandated mask use or allowed local

governments to do so; none has sought to strip local governments of this power.22

18
Id. ¶¶ 21, 23.
19
Id. ¶¶ 23–26.
20
Governor’s Order at Sections I, IV, V, VII, IX, and X. Among the governmental
entities mandating the use of face masks are the University System of Georgia at
all of its institutions (www.usg.edu/coronavirus (last visited July 26, 2020)), and
this Court, in order “to further safeguard the health and safety of everyone visiting
and working in the courthouse and the justice center complex.”
https://www.fultoncourt.org/PublicNoticeFaceMasks_6-19-20.pdf (last visited
July 26, 2020).
21
Pl.’s Br. In Supp. of Mot. for Emergency Interlocutory Inj. (“Inj. Mot.”) at 9 (Jul.
17, 2020).
22
See https://governor.alabama.gov/assets/2020/07/Safer-at-Home-Order-Mask-
Amendment-7.15.2020-FINAL.pdf (Alabama order mandating statewide use of
face masks); https://files.nc.gov/governor/documents/files/EO147-Phase-2-
Extension.pdf (North Carolina order mandating statewide use of face masks);

5
 In addition to saving lives, the only evidence in the record demonstrates that

the City’s face mask requirement helps businesses. A chef and owner of an Atlanta

restaurant with almost two decades of experience, and a deep network within the

Atlanta hospitality industry, “strongly support[s]” the mandate and sees “no

downside” for him or his business as a result.23 “Rather than being burdened by the

City’s mask ordinance, [his business is] helped by it.”24 Additionally, he understood

that the Mayor’s recommendation to return to an earlier stage of coronavirus

protective measures was a recommendation and did not require his business to

close.25 Nor did it close.26 Finally, he is not aware of any Atlanta restaurant owner

that believed the Mayor’s recommendation required them to be closed—they all

understood they could remain open.27

https://www.tn.gov/governor/news/2020/7/3/gov--lee-grants-mayors-in-89-
counties-authority-to-issue-covid-19-mask-requirements.html (Tennessee order
allowing local governments to mandate use of face masks);
http://www.scag.gov/archives/40771 (South Carolina allows local governments to
institute mask ordinances);
https://www.miamiherald.com/news/coronavirus/article241720381.html (Florida
governor allows local governments to require face masks).
23
July 24, 2020 Affidavit of Zeb Stevenson (“Stevenson Aff.”), Ex. 3, ¶¶ 2, 3, 6, 9.
24
Id. ¶ 9.
25
Id. ¶ 10.
26
Id.
27
Id.

6
 ARGUMENT

I. THE GOVERNOR’S CLAIMS AGAINST ATLANTA ARE BARRED BY

ATLANTA’S SOVEREIGN IMMUNITY

A. The Governor must establish a waiver of Atlanta’s sovereign immunity

in order to sue.
Atlanta28 enjoys the protection of sovereign immunity absent waiver of that

immunity. See City of Atlanta v. Mitcham, 296 Ga. 576, 577 (2015). Atlanta’s

sovereign immunity bars all suits against Atlanta, not just those seeking monetary

damages. Lathrop v. Deal, 301 Ga. 408, 413 (2017) (“[sovereign immunity] never

was limited to suits for monetary damages.”); McCobb v. Clayton Cty., 309 Ga. App.

217, 217-18 (2011) (“Under Georgia law, sovereign immunity is an immunity from

suit, rather than a mere defense to liability”). Sovereign immunity bars claims for

declaratory and injunctive relief. Georgia Dep’t of Nat. Res. v. Ctr. for a Sustainable

Coast, 294 Ga. 593 (2014) (sovereign immunity bars injunctive relief); Olvera v.

Univ. Sys. of Ga. Bd. of Regents, 298 Ga. 425, 428, n.4 (2016) (same for declaratory

relief); and in Lathrop, the Georgia Supreme Court confirmed this is true even for

acts alleged to be unconstitutional. 301 Ga. at 409.

28
Claims asserted against government officers, such as Mayor Bottoms, Council
President Moore, and the members of City Council, in their official capacity are
claims against the City. See Brewer v. Schact, 235 Ga. App. 313 (1998). Thus,
when an officer is sued in his or her official capacity, the City’s sovereign
immunity applies. See Cameron v. Lang, 274 Ga. 122, 126 (2001).

7
 The Governor must affirmatively establish a waiver of sovereign immunity to

proceed. Ctr. for a Sustainable Coast, 294 Ga. at 596-603 (sovereign immunity

precludes injunctive relief absent specific statutory waiver); Olvera, 298 Ga. at 426-

27 (declaratory judgment action barred by sovereign immunity);29 City of Atlanta v.

Durham, 324 Ga. App. 563, 564 (2013). He cannot satisfy this burden.

B. There is no applicable waiver of Atlanta’s sovereign immunity.

1. O.C.G.A. § 36-33-1 confirms Atlanta’s sovereign immunity.

The General Assembly has statutorily waived Atlanta’s sovereign immunity

only under certain limited circumstances. No waiver is applicable here. “It is the

public policy of the State of Georgia that there is no waiver of the sovereign

immunity of municipal corporations of the state.” O.C.G.A. § 36-33-1(a). The

statute then sets forth a partial waiver of immunity. Crucially, O.C.G.A. § 36-33-

1(b) does not waive sovereign immunity for a legislative act, such as the city council

ratifying an executive order. Specifically, O.C.G.A. § 36-33-1(b) commands that

29
City of Rincon v. Ernest Communities, LLC, No. A20A0765, 2020 WL 3529346,
at *2 (Ga. App. June 30, 2020) counsels no different result. It holds that, “‘In any
proceeding involving the validity of a municipal ordinance or franchise, the
municipality shall be made a party and shall be entitled to be heard as a party.’
Thus, it can be inferred from this language that a municipality is subject to a
declaratory judgment action where, as here, the validity of its ordinance is
challenged.” (emphasis added). But in this case, no municipal ordinance or
franchise is challenged, and the City was not made a party. City of Rincon does
not apply.

8
cities “shall not be liable for failure to perform or for errors in performing their

legislative ... powers.” See Durham, 324 Ga. App. at 565 (applying O.C.G.A. § 36-

33-1). The suit’s various attacks on prospective actions of the Atlanta City Council

are direct attacks on Atlanta’s legislative powers, which state law squarely forbids.30

2. City of College Park v. Clayton County does not establish a

waiver here.
The Georgia Supreme Court has recently held that some suits between

government entities are not precluded by common law-based sovereign immunity.

See City of College Park v. Clayton Cty., 306 Ga. 301 (2019).31 But this case is about

statutory immunity of municipalities, not common law immunity of counties. The

General Assembly’s codification of municipal sovereign immunity overrides

questions about whether, absent such codification, sovereign immunity would attach

here. Because O.C.G.A. § 36-33-1 does not even hint that it only applies if the

plaintiff is not a government entity, this Court should apply it as written, i.e.,

regardless of the plaintiff’s identity. To do otherwise would be to commit precisely

the error condemned by the Supreme Court in Sustainable Coast, where the Court

30
See, e.g., Compl. ¶¶ 40, 48, 55.
31
Notably, the Supreme Court went to lengths to emphasize that it was ruling solely
on the exact situation before it, and that its opinion should not be overread. See
City of College Park, 306 Ga. at 313, n.8 (“This analysis is limited to the facts of
the present case. We do not reach the question of whether sovereign immunity
may be applicable in any theoretical situation where a political subdivision is
acting on behalf of or ‘in the shoes of’ the State of Georgia. We also do not address
other scenarios in which, for example, a city brings an action against the State or
a State agency.”).
9
insisted that the constitutional text regarding sovereign immunity be read literally.

See Ctr. for a Sustainable Coast, 294 Ga. at 599-600 (“[T]he straightforward text of

the 1991 amendment does not allow for exceptions ... because the amendment is

‘clear and capable of a natural and reasonable construction,’ we may not read an

exception into the text or interpret the text to provide for an exception where none is

present.”).
3. Other states’ authority supports immunity here.
The Texas Supreme Court directly addressed whether the State must establish

a waiver of sovereign immunity to sue a municipality in City of Galveston v. State,

217 S.W.3d 466 (Tex. 2007). In that case, the State of Texas sued the City of

Galveston for damages to a state highway caused by the City’s alleged negligent

installation, maintenance and upkeep of a water line.32 The trial court held that the

suit was barred by governmental immunity.33 A divided court of appeals reversed,

holding that cities have no immunity from a suit by the State.34 The Texas Supreme

Court granted certiorari and reversed the court of appeals, ruling that the State’s

claims were barred in the absence of a statutory waiver.35

32
Id. at 468.
33
Id.
34
Id.
35
Id. A subsequent ruling of the Texas Court of Appeals distinguished the City of
Galveston case, holding that a city’s governmental immunity does not bar claims
for declaratory relief. See City of Alton v. City of Mission, No. 13-08-00582, 2010
WL 4018526, at *2 (Tex. App. Oct. 14, 2010). Obviously, as discussed above,

10
 The Texas Supreme Court began its analysis by noting that in Texas (as in

Georgia), “a governmental unit is immune from tort liability unless the Legislature

has waived immunity.”36 In City of Galveston, as in the case at bar, the State was

unable to identify a statutory waiver of immunity applicable to its claims.37

Like Governor Kemp in this case, the State of Texas asserted that “the

question is not one of waiver, but of the existence of immunity in the first instance.”38

In rejecting that argument, the Texas Supreme Court held that “this distinction is a

fine one, as waiving immunity or finding it nonexistent have precisely the same

effect. Due to the risk that the latter could become a ruse for avoiding the Legislature,

courts should be very hesitant to declare immunity nonexistent in any particular

case.”39 The Texas Supreme Court concluded that:

[W]hile the State undoubtedly may revoke the City’s immunity at any
time, the question is whether it can do so at the instance of the Attorney
General rather than the Legislature. As the divided opinions here and
below suggest, reasonable judges may disagree whether the inherent
nature of cities and states should render the former immune from suits
by the latter. We can avoid basing today’s decision on our personal
inferences only by adhering to the traditional rule that requires
unambiguous legislation before setting immunity aside.

sovereign immunity in Georgia does bar claims for declaratory relief. Olvera, 298
Ga. at 428 n.4.
36
Id.
37
See id. at 470.
38
Id. at 471.
39
Id. (internal citations omitted).
11
Id. at 474 (citations omitted). This Court should reach the same conclusion—that

immunity may only be modified or abrogated by the General Assembly. There is no

waiver applicable to the claims against the City of Atlanta’s officers, and, therefore,

they are barred by sovereign immunity.

As the Governor cannot identify a waiver of sovereign immunity permitting

any claims against the Atlanta Defendants to move forward, this suit is prohibited

by sovereign immunity, and O.C.G.A. § 36-33-1 provides no waiver for those

claims. Therefore, the Governor’s claims are barred. Calloway v. City of Warner

Robins, 336 Ga. App. 714, 715 (2016); Mitcham, 296 Ga. at 577.

II. THE GOVERNOR’S MOTION FAILS TO MEET THE STANDARD FOR

AN INTERLOCUTORY INJUNCTION
In considering whether to grant an interlocutory injunction, the trial court

should weigh:

(1) whether there exists a substantial threat that a moving party will
suffer irreparable injury if the injunction is not granted; (2) whether the
threatened injury to the moving party outweighs the threat and harm
that the injunction may do to the party being enjoined; (3) whether there
is a substantial likelihood that the moving party will prevail on the
merits at trial; and (4) whether granting the interlocutory injunction will
not disserve the public interest.

Veterans Pkwy. Devs., LLC v. RMW Dev. Fund II, LLC, 300 Ga. 99, 102 (2016).

The Court is urged to remember that its power to grant an interlocutory

injunction “shall be prudently and cautiously exercised and, except in clear and

urgent cases, should not be resorted to.” Id. (citation omitted).

12
 A. The Governor has not suffered—nor can he identify—an irreparable
injury that would warrant an interlocutory injunction.
The Governor himself is not harmed if the Court denies the injunction. He

does not allege that he wants to walk about Atlanta without a mask—indeed, he

consistently wears a mask and encourages others to do the same.40 Further, as

discussed in Section II(3) below, he has no standing to sue for the alleged harm to

Atlanta businesses or individuals from a mask mandate. Even reaching beyond the

strict equities rules to consider a potentially wider circle of harm—the moderate

inconvenience to those individuals who do not want to wear a mask—such harm

would be insufficient. Even the Governor must concede any incremental “harm”

caused by the inconvenience to those who would not otherwise wear a mask

undermines his rationale for not mandating masks: that Georgians “will do the right

thing.” It cannot be both that: (1) mask mandates are unnecessary because

recommendations are sufficient to increase mask compliance, and (2) there are

enough Georgians not wearing masks that would be “harmed” by having to comply

with the Mayor’s mandate so as to warrant an interlocutory injunction. Regardless,

40
See, e.g., Greg Bluestein, Kemp to embark on a ‘wear a mask’ tour of Georgia,
Atlanta Journal Constitution, June 30, 2020, available at:
https://www.ajc.com/blog/politics/kemp-embark-wear-mask-tour-
georgia/WtLr3XqfMwLCWvkTvraOUI/ (last visited July 26, 2020).

13
the Governor has failed to identify any injury to himself, let alone an irreparable one,

and cannot satisfy this element of obtaining an interlocutory injunction.

B. The risk of increased infections outweighs the harm of allowing local

governments to mandate masks.
COVID-19 is a public health emergency.41 The number of COVID-19 cases

in Georgia has increased substantially since the Governor “re-opened” the state on

April 23, 2020.42 Since the beginning of July alone, the number of COVID-19 cases

in Georgia has increased by nearly 100% and the positivity rate—the percentage of

the total number of tests coming back positive—has been hovering around 15% for

several weeks.43 Since the epidemic began in Georgia, more than 165,000 Georgians

have been infected, more than 17,000 have been hospitalized, and nearly 3,500 have

died.44 As of July 24th, the State’s critical care bed space was at 87% capacity, and

our rate of new cases is still rising.45 And Atlanta’s Grady Hospital has been

operating at 100%—hospital–wide—since July 21.46 Our hospitals and healthcare

workers are being pushed to their limits, with no relief in sight. In the absence of

41
Governor’s Emergency Declaration(s).
42
See April 23, 2020 Executive Order; see also Del Rio Aff. ¶ 6 (“[A]fter leveling
off in mid-April, new cases in Georgia have been rapidly increasing.”).
43
Del Rio Aff. ¶¶ 7, 8.
44
Id. ¶ 5.
45
July 20, 2020 Georgia Situation Report COVID-19, Georgia Department of
Emergency Management, available at:
https://gema.georgia.gov/document/document/sitrep-720/download.
46
https://www.wabe.org/coronavirus-updates-grady-hospital-operating-at-full-
capicity-ceo-says/.
14
state leadership on this issue, local governments have stepped in to protect their

citizens.

When deciding whether to grant an interlocutory injunction, courts should

balance the risk of harm to the petitioner of denying the motion and the risk of harm

created by granting the injunction. Veterans Pkwy. Devs., 300 Ga. at 102. As just

discussed, there is little, if any, harm caused by allowing the Mayor’s Order to stand.

Yet, enjoining the mask mandate risks the health and lives of thousands of

Georgians.

Everyone agrees that increasing the number of people wearing masks will

save lives. The evidence—and our own experiences—bear out that we will see

greater mask compliance if there is a government mandate.47 Indeed, experts believe

that Georgia could bring the COVID-19 epidemic under control in the next 4–8

weeks if Georgia adopted a statewide mask mandate.48 A simple review of the

national maps in Dr. Del Rio’s affidavit confirms that widespread use of face masks

in public is highly correlated with lower rates of COVID-19.49 Unfortunately, as in

Georgia, the reverse is also true: lower rates of mask use is highly correlated with

higher rates of COVID-19.

47
Del Rio Aff. ¶¶ 15, 18–20, 27.
48
Id. ¶ 26.
49
Id. ¶¶ 16–17.

15
 The Governor’s objection to mask mandates appears to be based on his

optimistic—but dangerously incorrect—thinking that “we shouldn’t need a mask

mandate for people to do the right thing.”50 We should not, but we do. There is

abundant evidence that people are more likely to comply with public health

mandates than with recommendations.51 Mandates requiring masks in public—like

the Mayor’s Order—increase the number of people wearing masks, which in turns

prevents more virus transmission. The most fundamental infectious disease principle

for getting an epidemic under control is interrupting transmission.52 Second only to

returning to a shelter-in-place scenario, mandating face masks in public is the best

intervention available for stopping the spread of COVID-19.53

Enjoining Atlanta’s mask mandate will reduce mask usage, which will result

in more preventable deaths.54 There is little else that could be more important when

balancing the equities on a motion for interlocutory injunction than avoiding

unnecessary deaths.

50
Gov. Brian Kemp, Press Conference (July 1, 2020), available at:
https://www.wsbtv.com/news/local/atlanta/ kemp-begins-tour-state-encourage-
mask-wearing/IVBKZX2C6ZFKJAZGW7Z QH4BDHI/.
51
Del Rio Aff. ¶ 20.
52
Id. ¶ 21
53
See id. ¶¶ 10–29.
54
Id. ¶ 24.
16
 C. The Governor is not likely to succeed on the merits.

1. The Governor’s Order purporting to suspend the Mayor’s

Order is invalid.

i. The Governor’s Order violates the statutory directive

to “promote and secure the safety and protections” of
Georgians.

The purpose of the Emergency Management Act is “to protect the public

peace, health, and safety; and to preserve lives and property of the people of this

state.” O.C.G.A. § 38-3-2. Consistent with this purpose, the Governor’s emergency

powers can only be used for good: his actions must be “necessary” to “promote and

secure the safety and protection of the civilian population.” O.C.G.A. § 38-3-

51(c)(4). Admittedly, this is a broad provision, but it contains one simple,

overarching principle: whatever the action is, it must be “necessary” to ensure the

public’s “safety and protection.”55 The Governor agrees that masks are an important

tool for reducing the spread of COVID-19. Yet, the Governor’s Order nonetheless

attempts to prevent the City from adopting this very intervention. An order

prohibiting successful public health interventions is manifestly not “necessary” to

“promote and secure the safety and protection” of Georgians—and if it is not

necessary to protect the public’s health or safety, then the Governor’s Order is not

authorized by his emergency powers.56

55
O.C.G.A. § 38-3-51(c)(4).
56
Id.

17
 As discussed above, there is no dispute that masks and cloth face coverings

prevent the spread of COVID-19.57 And because the primary function of masks is

“source control”—i.e., it protects others by preventing the person wearing the mask

from spreading the virus—masks are most effective when they are widely used in a

community.58 As one of our nation’s leading experts affirmed, mandatory laws are

the only way to reach the level of mask compliance that will slow the spread of

COVID-19 in Georgia communities.59 Thus, it is the Mayor’s Order that complies

with the Emergency Management Act, because mandatory masks in public will

“protect the public…health” and “preserve the lives…of the people of this state.”

O.C.G.A. § 38-3-2.

The Governor implicitly concedes the necessity of mask mandates to ensure

compliance because in the very same order where he purports to ban local

governments from requiring masks in their jurisdictions, he mandates masks for

eight different categories of “workers.”60 He claims local mask mandates are not

57
Del Rio Aff. ¶¶ 10–11, 14–17, 21; see also Gov. Brian Kemp, Interview with
Laura Ingraham, Fox News (July 18, 2020), available at:
https://www.foxnews.com/media/brian-kemp-georgia-lawsuit-atlanta-mayor-
bottoms.
58
Del Rio Aff. ¶¶ 12–14, 16–17.
59
Id. ¶ 15.
60
See, e.g., Governor’s Order §§ IV V, VII, IX, X (schools, camps, restaurants, bars,
tattoo parlors, hair salons, amusement parks, sports and live performance venues,
and conventions). Concerningly, these requirements are intended only to protect
“patrons” from the “workers.” Because the primary mechanism of face coverings

18
necessary because he is “confident Georgians don't need a mandate to do the right

thing.”61 But if he really believed recommendations were sufficient, why does he

mandate masks under specific circumstances? Indeed, why mandate anything? Why

not just encourage restaurants to comply with health guidelines or encourage

contractors to comply with building codes? Because he knows recommendations are

not enough. That is the same reason the State requires people wear seat belts and get

vaccinated.62 It doesn’t take a medical degree or a PhD in epidemiology to

understand that more Georgians will wear masks if it is mandated and that more

widespread use of masks in public will save lives.

ii. The Governor’s Order violates the statute’s directive
that emergency orders should be consistent with
federal recommendations.

The Emergency Management Act also directs that “all action taken under

Articles 1 through 3 of this chapter and all orders, rules, and regulations made

pursuant thereto shall be … consistent with … recommendations [of federal

authorities].”63 The Centers for Disease Control and Prevention “recommends all

is source control, by not requiring the patrons to wear masks, the Governor’s order
places the workers at much higher risk for contracting COVID-19.
61
Gov. Brian Kemp, Press Conference (July 17, 2020), available at:
https://www.cbs46.com/news/ kemp-georgians-dont-need-a-mandate-to-do-the-
right-thing/article_dde255d8-c82f-11ea-a34d-6bb50aa512c3.html.
62
Del Rio Aff. ¶ 20.
63
O.C.G.A. § 38-3-28(c); see also O.C.G.A. § 38-3-2(b) (“[A]ll emergency
management functions of this state be coordinated to the maximum extent with

19
people 2 years of age and older wear a cloth face covering in public settings and

when around people who don’t live in your household.”64 Dr. Anthony Fauci,

Director of the National Institute of Allergy and Infectious Diseases, recommends

that state and local governments mandate masks: “If governors and others essentially

mandate the use of masks when you have an outbreak … that would be very

important.”65 A July 14 report issued by the White House Coronavirus Task Force

identified Georgia as a “red zone” for new cases66 and recommended that Governor

Kemp “[m]andate statewide wearing of cloth face coverings outside the home.”67

The same report also recommended adoption of stricter social distancing guidelines

and specifically recommended that local governments be “[a]llow[ed] … to

implement more restrictive policies.”68

The Governor’s Order contradicts these federal recommendations. It is the

Mayor’s Order that is consistent with them.

the comparable functions of the federal government, including its various

departments and agencies [and] other states and localities.”).
64
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-
cover-guidance.html.
65
Interview by Sen. Doug Jones with Dr. Anthony Fauci (Jul 7, 2020), available at:
https://www.youtube.com/watch?v=KnOD6hJuwLU (quoted remark at
approximately 6:40).
66
Del Rio Aff., Ex. B at 1 (the report identified States that have more than 100 new
cases per 100,000 population, and a test positivity rate above 10%, as being in the
“red zone” of the pandemic).
67
Id.
68
Id.
20
 iii. The General Assembly has not delegated the public
health police power to the Governor.

Under our tri-parte system of government, the General Assembly normally

may not divest itself of the legislative power granted to it by Art. III, § 1, ¶ 1 of the

Georgia Constitution. See generally, Mistretta v. United States, 488 U.S. 361 (1989).

However, the General Assembly may delegate administrative power to executive

agencies or officials, so long as the “delegations are made with sufficient

guidelines.” Dep't of Transp. v. City of Atlanta, 260 Ga. 699, 703 (1990).

The General Assembly has delegated authority for oversight of infectious

disease control and response to the Department of Public Health (“DPH”). See

O.C.G.A. § 31-12-1 et seq. Among other authorizations, DPH is “empowered” …

[to] “require such other measures to prevent the conveyance of infectious matter

from infected persons as may be necessary and appropriate.” O.C.G.A. § 31-12-3(a).

When the General Assembly passed the Public Health Emergency Act in 2002,69 it

delegated the new emergency public health powers to DPH: “[t]he department shall

promulgate rules and regulations appropriate for management of any public health

emergency … with particular regard to coordination of the public health emergency

response of the state.” O.C.G.A. § 31-12-2.1(b); see also O.C.G.A. § 31-12-3(a).

Pursuant to these new emergency powers and this directive from the General

Assembly, DPH promulgated a rule that—in addition to its other powers—during a

69
Ga. Laws 2002, p. 1386.

21
“declared state of emergency, the Department shall establish any other public health

control measures necessary to prevent and suppress disease and conditions

deleterious to health as directed by the Governor.” Ga. Comp. R. & Regs. 511-9-1-

.03(5). The General Assembly also authorized DPH—as part of the 2002 Public

Health Emergency Act—to “adopt and implement emergency rules and regulations”

during “the course of management of a declared public health emergency.” O.C.G.A.

§ 31-12-2.1.
The General Assembly did not delegate these powers directly to the Governor.

Thus, to the extent the Governor wants to address “public health control measures”

during an emergency, he must act through the Department of Public Health. He did

not. Because he did not follow the process as delegated by the General Assembly,

his order is invalid. See Wisconsin Legislature v. Palm, 942 N.W.2d 900 (Wis. 2020)

(invalidating social distancing order because it was not adopted in accordance with

applicable administrative rules).

It may seem like a technicality when we are talking about facemasks, but in

the greater context of the Public Health Emergency Act the requirement that such

measures be adopted only through the agency’s rule making process is an important

check on the government’s power. The Public Health Emergency Act grants broad

powers to DPH, including the power to require vaccinations and quarantine

individuals—measures that are critical to stabilizing the state and protecting its

citizens in a disease outbreak. But they are also measures that implicate real civil
22
liberty concerns. See Jacobson v. Massachusetts, 197 U.S. 11, 26–27 (1905) (“[I]n

every well-ordered society charged with the duty of conserving the safety of its

members the rights of the individual in respect of his liberty may at times, under the

pressure of great dangers, be subjected to such restraint, to be enforced by reasonable

regulations, as the safety of the general public may demand.”). So while the

Governor’s failure to follow the administrative procedure by issuing orders and rules

through DPH may seem like a technicality that could be glossed over in this case,

the Court is respectfully urged to consider the consequences that an exception like

that might have when the stakes are higher than wearing a mask.

iv. The Governor’s Order is invalid because it exceeds

the public health emergency declaration approved by
the General Assembly.

The Governor’s Order exceeds the General Assembly’s authorization of his

declaration of a public health emergency and is therefore invalid. O.C.G.A. § 38-3-

51(a) gives the Governor the authority to unilaterally declare a state of emergency

in response to various crises. However, in the case of a public health emergency, the

General Assembly explicitly reserved the ability either to approve or terminate the

Governor’s declaration within two days. Id. In order to comply with that

requirement, and as part of his March 14, 2020 Declaration of Public Health State

of Emergency (“Original Declaration”), Ex. 4, the Governor convened a special

session of the General Assembly on March 16, 2020 “for the purpose of concurring

23
with or terminating this Public Health State of Emergency.”70 The General Assembly

met and approved the Governor’s Original Declaration.71

The Emergency Management Act also provides that no state of emergency

“may continue for longer than 30 days unless renewed by the Governor.” O.C.G.A.

§ 38-3-51(a). But the provisions of the Governor’s Order he relies on to argue that

the Mayor’s Order is invalid were not included in his Original Declaration that was

approved by the General Assembly. Importantly, there is nothing in the Original

Declaration that suggests the General Assembly intended to give the Governor the

authority to prevent local governments from taking actions to promote public health

and safety. The Governor’s Order is not a renewal of his Original Declaration as

authorized by the Emergency Management Act, but a significant expansion thereof.

Because the General Assembly explicitly limited the Governor’s ability to declare a

public health emergency to that with which it concurred, and because the legislature

only approved the Original Declaration—and nothing more—those provisions in the

Governor’s Order that exceed the authority given to him by the General Assembly

in approving the Original Declaration are invalid and unenforceable.

70
Original Declaration at 5.
71
H.R. 4EX, Ex. 5, at 2:27-29 (concurring with “Executive Order No.03.14.20.01
issued by Governor Brian P. Kemp declaring a public health state of emergency”).
24
 2. The City of Atlanta is authorized to mandate face coverings to
protect public health.
The City of Atlanta is authorized by the Georgia Constitution, the Georgia

Code, and its Charter to take actions to protect the public health, including

mandating the use of face coverings. The Mayor’s exercise of this authority through

her Executive Order is not prohibited or preempted by the Constitution, Code, or the

Governor’s Emergency Order and is therefore valid.

i. The City of Atlanta is authorized to take action to protect

the health, safety, and general welfare of the public.

“The inherent police power of the state extends to the protection of lives,

health and property of the citizen.” Hayes v. Howell, 251 Ga. 580, 585 (1983)

(citation omitted); see also De Berry v. City of La Grange, 62 Ga. App. 74, 77 (1940)

(stating that the existence of the life and health of citizens is dependent upon the

police power). “‘Police powers’ have been expressly granted to municipal and

county governments pursuant to Art. III, Sec. VI, Par. IV, and Art. IX, Sec. II, Par.

III of the Georgia Constitution.” Ga. Op. Atty. Gen. 83-60.

“Under its police power, a city may enact ordinances to protect the health,

safety and general welfare of the public.” City of Atlanta v. McKinney, 265 Ga. 161,

165 (1995). The legislature, in adopting the Charter of the City of Atlanta (1996 Ga.

L. Act No. 1019), expressly gave the City “all powers necessary and proper to

promote the safety, health, peace, and general welfare of the city and its inhabitants.”

Atl. Muni. Charter § 1-102.

25
 Beyond its general authority to act to protect public health and safety, the

General Assembly also explicitly contemplated local governments like the City

exercising this power in times of emergency to protect public health. Specifically,

the Georgia Emergency Management Act authorizes local governments to “make,

amend, and rescind such orders, rules, and regulations as may be necessary for

emergency management purposes and to supplement the carrying out of” that Act.

O.C.G.A. §38-3-28 (a); see O.C.G.A. §38-3-2 (a) (the Act’s purpose is to protect

health and safety and preserve the lives of Georgians). The only statutory limitation

on the authority of the City to supplement the actions of the Governor under the Act

is that those actions be consistent with the Governor’s action. As discussed below,

here they are consistent. In addition to the explicit authority granted to the City by

the legislature, the Atlanta Municipal Code also authorizes the Mayor, in times of

emergency, to take all action necessary to protect the lives of Atlantans. Atl. Muni.

Code § 2-181(b)(6).

ii. The Mayor’s Order is neither inconsistent with nor

preempted by the Governor’s Order.

As the Governor’s Order recognizes, O.C.G.A. §38-3-28(a) grants municipal

governments the authority to make orders, rules, and regulations as may be necessary

for emergency management purposes and to supplement the carrying out of his

26
Order, as long as they are not inconsistent with that Order.72 As that Order makes

abundantly clear, wearing face coverings in public is necessary to combat the spread

of COVID-19. Indeed, the Order states that “all residents and visitors of the State of

Georgia are strongly encouraged to wear face coverings as practicable while outside

their homes or place of residence, except when eating, drinking, or exercising

outdoors.”73 However, the Order does not just encourage wearing of masks, it

provides public authorities with the ability to mandate the use of masks and further

requires the use of masks in numerous settings.

For example, Section VII of the Governor’s Order authorizes local school

boards to “requir[e] Workers and students to take mitigating steps to prevent the

spread of COVID-19, which may include requiring Workers and students to wear

facemasks or face coverings while indoors on school property during school

hours.”74 The Order also affirmatively mandates the use of face masks in at least

eight other settings.75 Thus, there is no question that mandating face masks is

appropriate to “provide for the health, safety, and welfare of Georgia’s residents and

72
Governor’s Order at 32.
73
Id. at 2.
74
Id. at 24 (emphasis added).
75
See Section IV (restaurants and dining rooms) (p. 8); Section V (body art studios,
bars, and amusement parks) (p. 15–16, 17–18, 20); Section VII (summer camps)
(p. 29–30); Section IX (live performance venues) (p. 33–34, 35–36); Section X
(conventions) (p. 38).

27
visitors,”76 as the Governor’s Order seeks to do, and that such a mandate by the City

“supplement[s]” the Governor’s Order. O.C.G.A. § 38-3-28(a).

The Mayor’s Order is consistent with these provisions in the Governor’s

Order. Her Order is also consistent with the directive in the Emergency Management

Act to “promote the safety” of Georgians. How then is the Mayor’s Order

inconsistent with the Governor’s Order? It is only “inconsistent” under the unique

definition of the term that the Governor himself created out of whole cloth. The

Governor’s Order states that local orders “that are more or less restrictive than the

terms of this Order shall be considered inconsistent with this Order.”77 However, the

Governor does not get to co-opt the power of the legislative branch by defining

statutory terms. See Ga. Const. art. III, § 1, ¶ I (vesting legislative powers in the

General Assembly). His power is limited to faithfully executing the law as written.

Ga. Const. art. V, § 1, ¶ I; see Ga. Const. art. I, § 2, ¶ III (legislative and executive

powers “shall forever remain separate and distinct”).

The sui generis definition the Governor attempts to create for “inconsistent”

is also incompatible with the rest of the statutory framework. Specifically, O.C.G.A.

§ 38-3-28(a) gives local governments the ability to make rules to “supplement”

76
Id. at 2.
77
Governor’s Order at 32; see also id. (seeking to suspend face mask requirements
that are more restrictive than the Order).
28
carrying out the duties of the Emergency Management Act, the purpose of which is

to protect the health and safety of the public. O.C.G.A. § 38-3-2(a). The Governor

cannot define “inconsistent” to unilaterally eliminate the ability of local

governments to supplement his Order.

Neither is the Mayor’s Order preempted by the Governor’s Order or the

Emergency Management Act. The appropriate analysis under Georgia law to

determine whether a municipality’s action is preempted by laws passed by the

legislature is not whether the municipal action is “more or less restrictive,” but rather

whether a local act directly contradicts a general law or impairs or detracts from its

operation. See e.g., Dixon v. City of Perry, 262 Ga. 212, 212 (1992) (“the purpose

underlying the ordinance does not conflict with the purpose of [the statute]”). Indeed,

when a local act strengthens the purpose of a state law, Georgia courts have routinely

found there is no preemption. See Grovenstein v. Effingham Cty., 262 Ga. 45, 47

(1992) (local government can add restrictions to those required by state statute to

further its purpose); Board of Comm’rs v. Callan, 290 Ga. 327, 332 (2012) (no

impermissible conflict when the local restriction augments and strengthens state

law’s purpose); Powell v. Bd. of Comm’rs, 234 Ga. 183, 185 (1975) (same); Atlantic

Coast Line R.R. Co. v. Adams, 7 Ga. App. 146 (1909) (supplementary ordinance

enhancing safeguards provided by state statute permissible).

29
 The purpose of the Mayor’s Order—to protect the public and limit the spread

of COVID-19—is the same as the purpose of the Governor’s Order and supplements

that Order. The Mayor’s Order does not directly contradict the Governor’s authority

to act “to promote and secure the safety and protection of the civilian population.”

O.C.G.A. § 38-3-51(c)(4). Neither does it restrict or limit the State’s ability to protect

the public health. Rather it augments that ability by further limiting the spread of

COVID-19 through use of face masks. It is therefore not preempted by the

Governor’s Order or the Emergency Management Act.

iii. The legislature cannot delegate to the Governor the

ability to abrogate a municipality’s exercise of its
authorized legislative power.

The General Assembly can delegate its legislative powers to municipalities,

Ga. Const. Art. 9, §2, ¶ II, and it has delegated such powers to Atlanta. Atl. Muni.

Charter § 1-102; see also e.g., O.C.G.A. § 38-3-28(a). The General Assembly may

also delegate power to the Governor, but such delegation is only permissible when

it provides “sufficient guidelines” to make the executive’s exercise of that power an

administrative act rather than a legislative one. City of Atlanta, 260 Ga. at 703. The

General Assembly may not delegate power to the executive “to decide what shall

and what shall not be an infringement of the law, because any statute which leaves

the authority to a ministerial officer to define the thing to which the statute is to be

30
applied is invalid.” Howell v. State, 238 Ga. 95, 95-96 (1976). See also Sundberg v.

State, 234 Ga. 482, 484 (1975).

The legislature’s delegation of power to the Governor through the Georgia

Emergency Management Act is cabined by the requirement that the exercise of such

power be “necessary to promote and secure the safety and protection of the civilian

population.” O.C.G.A. § 38-3-51(c)(4). If the Act allows the Governor to nullify any

municipal act or order, without regard to whether it enhances public health or safety,

as the Governor contends, it is an improper transfer of legislative authority.

Interpreting the Act in such a manner would render its delegation of power to the

Governor unenforceable as a violation of the Georgia Constitution’s separation of

powers, so such an interpretation should be rejected. City of Atlanta, 260 Ga. at 703;

Howell, 238 Ga. at 95–96; Ga. Const. Art. 1, § 2, ¶ III; Ga. Const. Art. 3, § 1, ¶ 1.

iv. The Governor’s Order cannot prohibit the wearing of

masks on the City’s own property.

The Governor’s Order purports to eliminate the ability of local governments

to require the wearing of masks on their own property.78 The Governor lacks the

power to do so. First, just as the Governor cannot prohibit a private property owner

78
See Governor’s Order at 32 (any requirement to wear face coverings “on public
property are suspended to the extent that they are more restrictive than this
Executive Order”).

31
from requiring visitors to wear a face mask, as many businesses have done,79 he

cannot prohibit the City from doing the same on its own property. See Pope v. Pulte

Home Corp., 246 Ga. App. 120 (2000) (property ownership includes the rights of

the owner in relation to the property). Second, “when the General Assembly creates

a city, it limits the state’s power within the sphere of that municipality. It carves out

an area in which the state may not, by fiat, operate in any manner in which it pleases.”

Dep’t. of Transp. v. City of Atlanta, 255 Ga. 124, 130 (1985). Specifically, the

legislature empowered the City to operate and regulate public buildings. Atl. Muni.

Charter § 1-102(c)(14). This power, specifically delegated to the City by the

legislature, cannot be eliminated by executive fiat.

3. The Governor is unlikely to prevail on the merits because he

lacks standing and fails to state a claim for declaratory
judgment.
To have standing to bring a declaratory judgment claim, the Governor had to

allege that he is personally unsure of his potential liability under the Mayor’s Order

and is not certain how to govern his future personal behavior. It is not enough that

those he claims to represent are uncertain of their future course of conduct. The

Georgia Supreme Court addressed this issue earlier this year in Williams v. DeKalb

79
See Full List: Stores requiring customers to wear face masks, Atlanta Journal
Constitution, July 17, 2020, available at: https://www.wsbtv.com/news/local/full-
list-stores-requiring-customers-wear-face-
masks/6OER3ZICKJFQNFVYPK43CNZFQA/ (identifying major Atlanta
retailers that require customers to wear masks).

32
Cty., 840 S.E.2d 423, 429–30 (Ga. 2020). The Court held first that standing for a

declaratory judgment claim had to be established separately from other claims: “A

plaintiff must demonstrate standing separately for each form of relief sought.” This

is because “the question of standing is a jurisdictional issue.” Id. (citations omitted).

The Court went on to hold that the plaintiff in Williams had no “standing to seek

relief under O.C.G.A. § 9-4-2, the Declaratory Judgments Act, because he does not

allege or argue that he faces any uncertainty or insecurity as to his own future

conduct. And without any such uncertainty or insecurity, a declaratory judgment is

merely advisory and dismissal of a claim for such relief is required.” Id. (emphasis

added). The assertion that “Governor Kemp is at risk for having to take future action

to correct the actions of Mayor Bottoms and the City Council,”80 is not an allegation

of uncertainty and insecurity as to his future conduct.

In other words, in order to have standing, the Governor would have to

demonstrate that he personally wants to go out in public in Atlanta without a mask,

and he is afraid and uncertain as to whether he will be prosecuted. But he has made

no such allegation, nor provided any evidence to that effect. He has in fact urged

others to wear a mask in public and conspicuously modeled that behavior.

Similarly, to get a declaratory judgment as to the group size limit, he would

need to allege and prove that he wanted to hold a public gathering of more than 10

but fewer than 50 people, and that he was uncertain as to whether he was allowed to

80
Compl. ¶ 48.
33
do that. Not only has the Governor failed to allege such uncertainty: he has

affirmatively alleged that he is aware the Mayor did NOT issue an order on that

point.81 The alleged confusion of others gives him no standing. As the Attorney

General successfully argued in Baker v. City of Marietta, 271 Ga. 210, 214 (1999):

Where the party seeking declaratory judgment does not show it is in a

position of uncertainty as to an alleged right, dismissal of
the declaratory judgment action is proper; otherwise, the trial court will
be issuing an advisory opinion.

(emphasis added).82

There are two other, related reasons that the Governor lacks standing to assert

the interest of citizens, whether in the Declaratory Judgment Count or in the

Injunction Count. First, the plaintiff in this case is the Governor, not the State. The

State can sue in parens patriae. Brown & Williamson Tobacco Corp. v. Gault, 280

Ga. 420, 421 (2006) (“The doctrine of parens patriae grants standing to a state to sue

on behalf of its citizens.”). In certain limited instances provided by statute, the

Attorney General can do so (e.g., cases involving Charitable Trusts). But there is no

81
Id. ¶¶ 37, 46.
82
The general assertion in paragraph 49 (“Governor Kemp and the citizenry of this
State are in a position of uncertainty and insecurity as to the validity and
enforceability of Mayor Bottoms’ COVID-related executive orders) is not
enough. Uncertainty as to validity of a law is insufficient unless a plaintiff pleads
an intent to engage in conduct prohibited by the law in “his own future conduct.”
Williams, 840 S.E.2d at 429–30.

34
authority which we have found that allows the Governor to do so except when suing

under certain federal statutes not at issue here.

Second, our Supreme Court has made it clear that even the State, as parens

patriae, may not represent its citizens’ private interests except under certain

exceptions. See id. at 422. “[I]t is clear that a state may sue to protect its citizens

against ‘the pollution of the air over its territory; or of interstate waters in which the

state has rights.’ But it is equally clear that a state may not sue to assert the rights of

private individuals.” Id. Thus, the Governor may not sue in parens patriae at all. Nor

may the State represent the private interests of individuals who might want to

venture out without a mask or gather in groups of more than 10, or businesses who

want to violate the Mayor’s guidelines.83

D. An interlocutory injunction will disserve the public interest.

The Governor has not alleged any harm that warrants an interlocutory injunction.

In contrast, the harm of increased exposure to COVID-19 is real and undisputed. As

discussed in more detail in Section B above, if Georgia continues on its current

trajectory, COVID-19 will claim the lives of another estimated 2,500 Georgians. But

83
The Mayor recognizes the immense economic challenges faced by businesses
throughout the City during these trying times, but also recognizes that the quickest
path to recovery is through reducing the spread of COVID-19. See also Stevenson
Aff. ¶¶ 6, 8, 9 (business and employees are helped by mask mandate). And the
Mayor’s Order explicitly states that it shall not “impede the operation of any
businesses, [or] establishments … as provided in the [Governor’s Order].”
Mayor’s Order § 5.
35
a mask mandate could keep that number under 1,500. The Mayor’s mask order will

save lives and the Governor does not allege—and cannot show—a countervailing

harm that would outweigh saving them. In balancing the equities and weighing the

harm to the public, the injunction sought should be denied.

III. THE RELIEF SOUGHT IN THE REQUESTED INJUNCTION

VIOLATES THE FEDERAL AND STATE CONSTITUTIONS AND
GEORGIA STATUTES
The Governor’s Motion for Interlocutory Injunction seeks four specific forms

of injunctive relief.84 All four forms of relief violate the federal and state

constitutional rights of the Defendants. To be clear: even if the Governor were right

on the merits, all of the relief sought is illegal and unconstitutional on its face. The

requested injunctions simply cannot be granted.

The relief sought by the Governor is quoted below and for ease of reference

will be referred to here by their number: 1, 2, 3, or 4.

(1) Suspending the enforcement of Mayor Bottoms’ Executive Orders

Nos. 2020-113, 2020-114, and 2020-115 to the extent they are more
or less restrictive than any extant state law or COVID-19 executive
order of Governor Kemp, in particular, the more restrictive mask-
wearing mandates and more restrictive capacity limitations that
purport to be set forth therein;

(2) Enjoining the Defendants, collectively, from entering any future

executive orders or taking any future independent legislative or
executive action that is more or less restrictive than the terms of any
extant state law or executive order of Governor Kemp concerning
COVID-19, including but not limited to issues concerning the

84
Inj. Mot. at 10–11.
36
 wearing of masks, stay-at-home mandates, capacity limitations, and
business closures;

(3) Enjoining Mayor Bottoms from issuing any further press releases or
public statements stating or implying that she has authority to
impose more or less restrictive COVID-19 related measures than
those contained within Governor Kemps COVID-19 executive
orders; and

(4) Directing Mayor Bottoms, as chief executive of the City of Atlanta,

to immediately comply with and enforce within the City of Atlanta
all provisions of Governor Kemp’s existing COVID-19 executive
orders.
Different paragraphs of the proposed injunction violate different

constitutional and statutory provisions. For example, paragraph 1 violates the Due

Process Clause, O.C.G.A.§ 9-11-65(d), O.C.G.A. § 9-5-2, and O.C.G.A.§ 36-30-2,85

and three of the four requested injunctions (paragraphs 2–4) are prohibited by the

free speech guarantees of the Constitution of the United States and of Georgia. In

particular, paragraph 2 is an unconstitutional prior restraint to enjoin future speech.

U.S. Const. amend. 1; Ga. Const. art. I, § 1, ¶ V (“No law shall be passed to curtail

or restrain the freedom of speech or of the press. Every person may speak, write, and

85
To the extent that the any of Paragraphs 1-4 of the requested injunctions seek to
limit, compel or enjoin ordinances, rules or orders concerning masks, occupancy
or other requirements for City-owned property, any injunction would also
violate O.C.G.A.§ 36-30-2, which provides that the “governing body of a
municipal corporation has discretion in the management … of its property”, and
that “[w]here such discretion is exercised in good faith, equity will not interfere
therewith.” (emphasis added).

37
publish sentiments on all subjects but shall be responsible for the abuse of that

liberty.”).

As described below, these free speech protections apply to the press releases

and public statements the Governor seeks to enjoin (see requests in paragraph 3).

Further, while courts may enjoin enforcement of unconstitutional laws, ordinances,

and orders once passed or adopted, the courts cannot prohibit any government,

municipal or otherwise, from adopting whatever ordinances or laws it chooses, even

if they are illegal, unconstitutional, or ill-advised. To do so is a violation of the

prematurity doctrine recognized by the United States Supreme Court and the

Georgia Supreme Court. Finally, paragraph 4 appears to try and compel the

Defendants to violate the First Amendment rights of those who gather to protest. The

Governor is asking this Court to commit constitutional error.

A. The Constitution86 prohibits this Court from “enjoining Mayor Bottoms

from issuing any further press releases or public statements”.

There could be little more prototypical violation of the First Amendment than

that sought by paragraph 2 of the requested injunction. First, speech on public policy

issues is a core free speech right that is entitled to the “broadest protection” under

the First Amendment:

86
The analysis under Ga. Const. art. I, § 1, ¶ V is the same as the First Amendment
analysis.

38
 Discussion of public issues and debate on the qualifications of
candidates are integral to the operation of the system of government
established by our Constitution. The First Amendment affords the
broadest protection to such political expression in order to assure the
unfettered interchange of ideas for the bringing about of political and
social changes desired by the people….[T]here is practically universal
agreement that a major purpose of [the First] Amendment was to protect
the free discussion of governmental affairs.
McIntyre v. Ohio Elections Comm'n, 514 U.S. 334, 346 (1995).

Second, elected public officials are given the “widest latitude” to express their

views, whether critical of policy or law, and even if incorrect. Bond v. Floyd, 385

U.S. 116, 136 (1966) (“Legislators have an obligation to take positions on

controversial political questions so that their constituents can be fully informed by

them.”); see also New York Times v. Sullivan, 376 U.S. 254, 270 (1964) (the “debate

on public issues should be uninhibited, robust, and wide-open”).

That is why, for example, Presidents, Governors, and Mayors may publicly

state their disagreement with rulings of the Court even if they are bound thereby. If

this Court rules in favor of the Mayor, the Governor is free to give a press conference

vehemently disagreeing with that ruling and insisting he can legally prohibit mask

ordinances and orders. He cannot act in violation of the Court’s order, but he can say

whatever he wants about it. The Governor can also criticize the decisions of the

Mayor, and vice versa, and disagree with the legal analysis and rationale of the

Court’s decision or any executive orders or ordinances. That is the essential

guarantee of the First Amendment: “There can be no doubt that the freedom to

express disagreement with state action, without fear of reprisal based on the

39
expression, is unequivocally among the protections provided by the First

Amendment.” McCurdy v. Montgomery Cty., Ohio, 240 F.3d 512, 520 (6th Cir.

2001).

The Governor’s request that this Court issue a prior restraint to enjoin an

elected public official from speaking or issuing press releases is simply an invitation

to error. As our State Constitution commands in prohibiting prior restraints: “Every

person may speak, write, and publish sentiments on all subjects but shall be

responsible for the abuse of that liberty.” Ga. Const. Art. I, § 1, ¶ V (emphasis added)

B. Supreme Court Authority also prohibits enjoining voting, passage or

adoption of a law, resolution ordinance or order.

The United States Supreme Court, Supreme Court of Georgia and several

other courts have repeatedly held that a court cannot enjoin passage of a municipal

resolution, order, or ordinance even if the order or ordinance would be illegal, ultra

vires, or unconstitutional. Instead, a court must wait for the ordinance or order to be

adopted and then act to prevent enforcement.87 McChord v. Cincinnati, N.O. & T.P.

Ry. Co., 183 U.S. 483, 496 (1902) (“[W]hen the city council shall pass an ordinance

87
This applies no matter the nature of the alleged illegality. See, e.g., Bristol-Myers
Co. v. F.T.C., 424 F.2d 935, 940 (D.C. Cir. 1970) (A requested injunction is
premature before a rule is passed even where challenged “on the ground that the
Commission has no statutory or constitutional authority to promulgate its
proposed rule.”).

40
that…is unconstitutional and void…it will be time enough for equity to interfere,

and by injunction to prevent the execution of such ordinance.”); accord Alpers v.

City & Cty. of San Francisco, 32 F. 503, 506–07 (C.C.N.D. Cal. 1887) (“The courts

cannot…forbid the passage of a law nor in the other the passage of a resolution,

order, or ordinance.”).

The Supreme Court of Georgia has repeatedly held that the plea of prematurity

is a valid defense to an attempt to enjoin passage of an ordinance or regulation,

including in Zaring v. Adams, 188 Ga. 97, 98 (1939):

plaintiff seeks to enjoin the consideration of and passage by the

board of commissioners of a proposed zoning regulation which will
be applicable to certain property owned by him. The passage by the
board of such a proposed regulation will not of itself work such an
injury to the plaintiff. It will be in sufficient time to appeal to the
courts to determine the legality of this regulation when there is in
some manner an attempt to enforce it.
(emphasis added).88 The law is uniform that this defense of “prematurity” precludes

an injunction to stop passage of a statute or ordinance.

C. The relief requested violates Georgia law and the Due Process Clause
because it does not provide sufficient specificity.
The statute the Governor is proceeding under requires that the injunction “be

specific in terms” and “describe in reasonable detail” “the act or acts sought to be

88
See generally Royal Peacock Soc. Club, Inc. v. City of Atlanta, 226 Ga. 817, 820
(1970) (“injunctive relief should not have been granted regardless of the
applicability or constitutionality of the ordinance in question” because it was
premature until a prosecution thereunder is commenced.)

41
restrained.” O.C.G.A. § 9-11-65. This specificity is also required by the notice

requirements inherent in the Due Process Clause. Yet his request for a mandatory

injunction seeks to require the Mayor to “enforce” the terms of “roughly thirty”

orders on a “variety of topics.”89

The Governor’s requests run afoul of the specificity requirements of O.C.G.A.

§ 9-11-65 and the Due Process clause: “[W]e have held injunctions to be too vague

when they enjoin all violations of a statute in the abstract without any further

specification, or when they include, as a necessary descriptor of the forbidden

conduct, an undefined term that the circumstances of the case do not.” United States

v. Philip Morris USA Inc., 566 F.3d 1095, 1137 (D.C. Cir. 2009). Rule 65 “embodies

the elementary due process requirement of notice,” and the level of specificity

required has been described as that which “an ordinary person reading the court’s

order [would] be able to ascertain from the document itself exactly what conduct is

proscribed.” Scott v. Schedler, 826 F.3d 207, 211–12 (5th Cir. 2016) (emphasis

added).90 The United States Supreme Court has said that the failure to comply with

Rule 65 is “both serious and decisive” because “[t]he judicial contempt power is a

potent weapon, [and] [w]hen it is founded upon a decree too vague to be understood,

89
Inj. Mot. at 2, 11.
90
See also, e.g. Axia NetMedia Corp. v. Mass. Tech. Park Corp., 889 F.3d 1, 12 (1st
Cir. 2018) (“The purpose of the specificity requirement is to protect “the
elementary due process requirement of notice.”); U. S. Steel Corp. v. United Mine
Workers of Am., 519 F.2d 1236, 1246 (5th Cir. 1975) (specificity provision of
Rule 65 “embodies the elementary due process requirement of notice.”).
42
it can be a deadly one.” Int'l Longshoremen's Ass'n, Local 1291 v. Philadelphia

Marine Trade Ass'n, 389 U.S. 64, 76 (1967).

Each of the four injunctions sought by the Governor violates this “serious and

decisive” statutory provision and requirement of due process.

Paragraph 1 seeks to enjoin “enforcement of Mayor Bottoms’ Executive

Orders Nos. 2020-113, 2020-114, and 2020-115 to the extent they are more or less

restrictive than any extant state law or COVID-19 executive order of Governor

Kemp….” (emphasis added).

Paragraph 2 similarly seeks to enjoin “any further independent legislative or

executive action that is more or less restrictive than the terms of any extant state law

or executive order of Governor Kemp concerning COVID-19, including, but not

limited to issues concerning the wearing of masks, stay-at-home mandates, capacity

limitations, and business closures…” (emphasis added). The “including but not

limited to” language illustrates rather than cures the problem. See Sanford v. RDA

Consultants, Ltd., 244 Ga. App. 308, 312 (2000) (reversing injunction order which

listed categories of prohibited conduct and then stated “including, but not limited to”

certain specified conduct, because such generalized language “lacks sufficient detail

to fully apprise” the defendant of the prohibited conduct).

Paragraph 3 also fails to give the guidance required by the Due Process

Clause and Rule 65 where it seeks to prohibit the Mayor from “stating or implying

that she has authority to impose more or less restrictive COVID-19 related

43
measures….” What measures? What does “more or less restrictive” mean? If the

Mayor says, “I would really suggest we all do X” is she implying she has the power

to impose X? If she says “You had better do X if you know what is good for you,”

is she implying she has the power to impose X? She is left to guess.

Paragraph 4 is the broadest and vaguest of all because it seeks to require that

the Mayor “comply with and enforce within the City of Atlanta all provisions of

Governor Kemp’s existing COVID-19 executive orders.” As described by the

Governor, such an injunction would include “roughly” 45 different executive orders

covering “a broad variety of topics, including providing for emergency funding,

ordering the closure of schools, directing Georgia’s citizens to shelter-in-place,

directing certain non-essential businesses to close, and providing for the eventual

lifting of these restrictions.”91 An order enjoining the Mayor to “comply with and

enforce” “all provisions” of these “roughly” 45 orders on a “broad variety of topics”

grossly violates the Due Process Clause and O.C.G.A. § 9-11-65.

The constitutionally required notice is simply absent.

D. Equitable relief is statutorily unavailable to the extent such enforcement

involves criminal law or criminal penalties.
“Equity will take no part in the administration of the criminal law.” O.C.G.A.

§ 9-5-2. “Prosecutions for violations of municipal ordinances which are punishable

by fine or imprisonment are quasi-criminal in nature and come within the above

91
Inj. Mot. at 11 (emphasis added); Compl., ¶ 24.
44
rule.” Staub v. Mayor, etc., of Baxley, 211 Ga. 1, 1 (1954). For the same reason,

equity may not interfere with the enforcement of the “mask-wearing mandates and

more-restrictive capacity limitations”92 to the extent that they are “punishable by fine

or imprisonment.” Id.; O.C.G.A. § 9-5-2. To the extent that such rules, orders, or

ordinances are illegal or unenforceable, they can be challenged only in the context

of a prosecution for violation thereof:

[A] court has no power, upon an application for injunction against its
enforcement, to inquire into its validity, either upon constitutional or
other grounds, and to enjoin the city from attempting to enforce it. ‘If
the ordinance is invalid, by reason of its unconstitutionality, or for other
cause, such invalidity would be a complete defense to any prosecution
that might be instituted for its violation.

Staub, 211 Ga. at 1 (emphasis added); see also Paulk v. City of Sycamore, 104 Ga.

24 (1898). The Governor is not entitled to a mandatory injunction requiring the

Mayor to comply with and enforce the Governor’s orders.

But even assuming the Governor had the power to issue his order, and even if

it were enforceable, this Court still could not issue a mandatory injunction as

requested in paragraph 4.

First, to the extent that request asks that the Mayor be ordered to “comply

with” the law, it would be an illegal order, as a court of equity cannot order someone

to “comply with” the law. The punishments and consequences (if any) for failing to

92
Of course, the Mayor’s Order does not mandate stricter capacity restrictions. See
Mayor’s Order § 3(b).
45
comply with a law are as set forth in the law, and relief in equity and the concomitant

contempt power is “unavailable.”

[T]he superior court erred in granting [plaintiff’s] injunctive relief

against the Board from future violations of the Act, in effect, requiring
the Board to obey the law, a duty which it already had and as to which
relief in equity is generally unavailable.

Wiggins v. Bd. of Comm'rs, 258 Ga. App. 666, 668 (2002) (physical precedent only);

see also Patterson v. Ellerbee, 268 Ga. App. 826, 828 (2004) (“[I]t would be highly

unorthodox for the superior court to order the juvenile court to follow the law which

it is already required to uphold.”).

Second, an injunction directing an official to “enforce the law” is also illegal.

The enforcement of the law is inherently discretionary and not subject to such

mandatory injunctions. “[T]he decision of whether to enforce the law by making an

arrest is a basic judgmental or discretionary governmental function.” Lewis v. City

of St. Petersburg, 260 F.3d 1260, 1265 (11th Cir. 2001). Such a discretionary

function is not subject to mandatory injunctions. Bland Farms, LLC v. Georgia Dep't

of Agric., 281 Ga. 192, 194 (2006) (the court cannot force the defendant to enforce

the rules and regulations promulgated in connection with the Vidalia Onion Act).93

93
Accord Cates v. Graves, 281 F. Supp. 951, 955 (E.D. Tenn. 1968)
(“Mandatory injunction or mandamus writs will not be issued to control
the discretionary acts of government officials.”).

46
 Third, the consequences of a mandatory injunction requiring officials to

enforce laws could be catastrophic on City employees, as such an order would likely

deprive them of immunity.94 Public employees “may be liable for injuries and

damages caused by … negligent failure to perform, their ministerial functions.” Ga.

Const. of 1983, Art. I, Sec. II, Par. IX (d) (emphasis added). Mercado v. Swoope,

340 Ga. App. 647, 650 (2017). Under this doctrine of official, or qualified,

immunity, law enforcement officers may be personally liable for negligent actions

taken in the performance of ministerial functions, but they are immune from

personal liability for discretionary acts taken within the scope of their official

authority (and performed without willfulness, malice, or corruption). The rationale

for this immunity is to preserve the public employees’ independence of action and

relieve them of the fear of lawsuits based on hindsight. Graham v. Cobb Cty., 316

Ga. App. 738, 742 (2012).95

It is well-established that a public official who fails to perform

ministerial duties required by law can be subject to an action for damages if someone

94
And to the extent the Governor is seeking to have the City officials arrest otherwise
law-abiding individuals who are engaged in protest protected by the First
Amendment, the risks to those officials multiply.
95
A ministerial act is commonly one that is simple, absolute, and definite and
requiring merely the execution of a specific duty. Graham, 316 Ga. App. at 742.
A duty required by law is a ministerial duty. City of Atlanta v. Heard, 252 Ga.
App. 179, 182 (2001). “A discretionary act calls for the exercise of personal
deliberation and judgment, which in turn entails examining the facts, reaching
reasoned conclusions, and acting on them in a way not specifically directed.” Id.

47
is injured by his omission. City of Atlanta v. Heard, 252 Ga. App. 179, 182 (2001);

“[T]he complete failure to perform a discretionary act is the same as the negligent

performance of that act for the purposes of determining whether such action

was discretionary or ministerial.” Kelly v. Lewis, 221 Ga. App. 506, 509 (1996);

Odum v. Harn, 344 Ga. App. 488, 489 (2018). Generally, the decision by a law

enforcement officer to enforce a law, by arrest or citation, is a discretionary act

within the scope of an officer’s official functions. See Selvy v. Morrison, 292 Ga.

App. 702, 704 (2008). But if expressly required by law or court order to enforce a

law, any negligent act or negligent omission of the law enforcement officer of that

duty would arguably strip that officer of immunity and would subject the officer to

personal liability. The Governor’s request for a mandatory injunction asks this Court

to issue an order that could strip officers of their official or qualified immunity. The

Court should decline that invitation.

CONCLUSION

For the reasons stated herein, the Court should deny the Governor’s motion

and uphold the Mayor’s valid exercise of her authority under Georgia law.

This 27th day of July, 2020.

/s/ Michael B. Terry
Michael B. Terry
Georgia Bar No. 702582
terry@bmelaw.com
Robert L. Ashe III
Georgia Bar No. 208077
ashe@bmelaw.com
Manoj S. Varghese

48
 Georgia Bar No. 734668
varghese@bmelaw.com
Jane D. Vincent
Georgia Bar No. 380850
vincent@bmelaw.com
BONDURANT MIXSON &
ELMORE, LLP
3900 One Atlantic Center
1201 West Peachtree Street, NW
Atlanta, GA 30309
Telephone: (404) 881-4100
Facsimile: (404) 881-4111

Attorneys for Defendants

49
 CERTIFICATE OF SERVICE

I hereby certify that I filed a true and correct copy of the foregoing

DEFENDANTS’ RESPONSE BRIEF IN OPPOSITION TO MOTION FOR

INTERLOCUTORY INJUNCTION using the Fulton County Superior Court

eFileGA electronic filing system, which will send notice of same to all electronic

filing participants who have appeared to date as follows:

Christopher M. Carr
Julie Adams Jacobs
Logan B. Winkles
Ron J. Stay
40 Capitol Square, SW
Atlanta, GA 30334
ccarr@law.ga.gov
jjacobs@law.ga.gov
lwinkles@law.ga.gov
rstay@law.ga.gov

This 27th day of July, 2020.

/s/ Michael B. Terry

Michael B. Terry

50
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 IN THE SUPERIOR COURT OF FULTON COUNTY
STATE OF GEORGIA

GOV. BRIAN P. KEMP,

Plaintiff,

v.

HON. KEISHA LANCE BOTTOMS,

FELICIA A. MOORE, CARLA SMITH, Civil Action File No.:
AMIR R. FAROKHI, ANTONIO BROWN, 2020CV3338387
CLETA WINSLOW, NATALYN MOSBY
ARCHIBONG, JENNIFER N. IDE,
HOWARD SHOOK, J.P. MATZIGKEIT,
DUSTIN R. HILLIS, ANDREA L. BOONE,
MARCI COLLIER OVERSTREET, JOYCE
SHEPAERD, MICHAEL JULIAN BOND,
MATT WESTMORLAND, and ANDRE
DICKENS,

Defendants.

County of Fulton )
) ss.
State of Georgia )

AFFIDAVIT OF CARLOS DEL RIO, M.D.

1. My name is Carlos Del Rio. I am over twenty-one (21) and am competent to testify as to the
matters set forth in this declaration.

2. I am a Distinguished Professor of Medicine at Emory University School of Medicine and

Professor of Global Health and Epidemiology at the Rollins School of Public Health. The
opinions offered in this affidavit are mine and are not expressed on behalf of Emory University.

3. I am trained and Board Certified in Infectious Diseases, have served on the Board of Directors
of the Infectious Diseases Society of America (IDSA) and was Board Member and Chair of
the HIV Medicine Association. I was elected this year as Vice-President of IDSA, the society
that represents over 12,000 infectious disease physicians. I am also a member of the National
Academy of Medicine (NAM) and was recently elected as the Foreign Secretary of the NAM.
Less than 1% of American physicians are elected to NAM. I regularly publish and speak on
matters of infectious disease prevention and control. My current curriculum vitae is attached

#3060654v1
 as Ex. A. During the COVID-19 pandemic specifically, I have written five Viewpoint articles
in the Journal of the American Medical Association as well as a Clinical Practice article in the
New England Journal of Medicine.

4. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 to be a global
pandemic. COVID-19 is the disease caused by the novel coronavirus SARS-Cov-2.

5. Globally, more than 16.1 million people have been infected by COVID-19 and more than
645,000 have died. In the United States, more than 4.2 million people have been infected and
more than 145,000 have died. Here in Georgia, more than 165,000 people have been infected
and more than 3,495 have died. And in Fulton County and DeKalb counties, more than 26,000
have been infected and 578 people have died. See https://coronavirus.jhu.edu/us-map (last
accessed July 26, 2020) and Georgia Department of Public Health, COVID-19 Status Report,
https://dph.georgia.gov/covid-19-daily-status-report (last accessed July 26, 2020).

6. Unfortunately, after leveling off in mid-April, new cases in Georgia have been rapidly
increasing since the middle of June.

(Source: Institute for Health Metrics and Evaluation, https://covid19.healthdata.org/united-

states-of-america/georgia, accessed July 26, 2020)

7. The rate of COVID-19 infection in Georgia has also been increasing rapidly. On July 1st there
were 84,000 COVID-19 cases in Georgia, by July 25th there were 165,000 cases. That is nearly
a 100% increase.

8. In addition, Georgia’s SARS-CoV-2 test positivity rate was 14.8% for the week of July 7–14.
This was a 1.5% increase over the previous week and more than 5% higher than the national
average. Ex. B (July 14, 2020 Governor’s Report prepared by the White House Coronavirus
Task Force). This increase in the positivity rate is troubling because it means that the increase
in reported cases is not the result of increased testing, but rather the increase in new cases
reflects an actual increase in the prevalence of COVID-19 in the community.

#3060654v1
9. We know that a significant proportion of people infected with SARS-CoV-2 (around 30–40%)
are asymptomatic yet still infectious. And people who are infected and who will eventually
develop symptoms are infectious 48–72 hours before developing symptoms. This is called the
“pre-symptomatic stage.” Asymptomatic transmission was the reason given by Governor
Kemp when he issued a “stay at home” executive order on April 2, 2020.

10. According to the CDC and the WHO, SARS-CoV-2 is transmitted through a combination of
droplet, contact, and possible airborne (aerosol) modes. The traditional model for respiratory
disease transmission suggests infection via infectious droplets (generally 5–10 μm) that have
a short lifetime in the air and infect the upper respiratory tract, or finer aerosols, which may
remain in the air for many hours. Ex.C (https://doi.org/10.1016/j.idm.2020.04.001).

11. Masks can substantially limit forward dispersion of exhaled respirations that contain
potentially infectious respiratory particles in the 1- to 10-μm range that includes aerosol-sized
particles.

12. While many people think of masks for personal protection, masks are best at reducing
transmission of SARS-CoV-2 through what is called “source control.” Masks protect others
by containing the infectious microbes that may be expelled during breathing, talking, coughing,
and sneezing.

13. When assessing personal exposure risk when going out in public, there are several important
considerations: minimizing the number of non-household contacts, maintaining a physical
distance of at least 6 ft, and limiting the amount of time around others, especially while indoors
and in poorly ventilated areas. An additional factor in this calculus is the extent that individuals
and communities will also be practicing source control by wearing masks.

14. Public mask wearing is most effective at stopping spread of the virus when the vast majority
of the public wear masks.

15. During the first months of their epidemic, countries with cultural norms or government policies
supporting public mask-wearing saw per-capita COVID-19 mortality increase on average by
just 7.2% each week. By comparison, countries without such cultural norms or government
policies saw COVID-19 mortality increase 55.0% each week. Ex. D
(https://www.researchgate.net/publication/342198360).

#3060654v1
16. This map, prepared by the New York Times based on data from State and local health agencies
and hospitals, shows in dark orange and red the areas of the country with the highest numbers
of new COVID-19 cases between July 17–24:

17. In contrast, this map, also prepared by the New York Times, but based on household survey
data collected between July 2–14, shows in dark pink and purple the areas where mask adoption
is high:

#3060654v1
18. Mandatory mask laws appear to be highly effective at increasing compliance and slowing or
stopping the spread of COVID-19.

(Source: www.masks4all.co; The Philadelphia Inquirer).

19. One study that compared COVID-19 growth rates before and after states implemented
mandatory face coverings showed that the mask mandates reduced infection growth rates by
2%. The study model suggests that these mandates prevented between 230,000–450,000 new
cases in these states between April 1 and May 22. Ex. E (Health Affairs
www.doi.org/10.1377/hlthaff.2020.00818).

20. This type of behavior change as a result of mandatory laws is consistent with historical public
health interventions such as seatbelts and vaccinations. Behavior change is one of the hardest
public health goals to achieve because it relies on individuals to evaluate many different factors
in a complex social environment. Laws mandating certain public health interventions have
historically been very effective in reducing morbidity and mortality.

21. The preponderance of evidence, in both laboratory and clinical settings, indicates that mask
wearing reduces the transmissibility per contact by reducing transmission of infected droplets.

#3060654v1
 The decreased transmissibility could substantially reduce the death toll, other harms to public
health, job losses and economic losses. The cost of such masks is very low by comparison.

22. Models using economic analysis with the epidemiological data suggest that even if masks
reduced transmission by only 10%, such a reduction would save $3,000-6,000 per capita in
reduced mortality. Ex. F (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3567438).

23. Modeling done by the Institute for Health Metrics and Evaluation suggests that widespread
public mask use, in conjunction with other measures, could bring the effective reproduction
number (R) beneath 1.0, thus halting the growth of the pandemic. In the graph below, the
brown (top) dashed line indicates the current projections for COVID-19 mortality in Georgia.
The green (bottom) dashed line shows how the rate of new deaths could be flattened (ultimately
turned downward) if a statewide mandate was in place.

(Source: Institute for Health Metrics and Evaluation, https://covid19.healthdata.org/united-states-

of-america/georgia, accessed July 26, 2020)

24. Under the status quo, by November 1, 2020, COVID-19 will have claimed the lives of more
than 7,336 Georgians. By contrast, a statewide mask mandate could bring that number down
to under 4,951.

25. It is my professional opinion that mask compliance rates of 80% or higher will halt the growth
of COVID-19 infections in Georgia.

26. It is my professional opinion that Georgia could bring the COVID-19 epidemic under control
in 4–8 weeks if everyone wore masks.

#3060654v1
2?. It is pml‘cssional opinion that. given the current slate of the epidemic and public attitudes.
my
recommendations alone arc insufficient 10 increase mask usage to a level {hat can stop the
spread oFCOVID—I‘J.

28. It is professional opiniOn that reaching the level of mask compliance necessary lo stop- the
my
spread of COVlD-l 9 can only be achieved through laws mandating the use of face covermgs
in public.

29. The infimnalion, data, and sources I have relied on lo reach these conclusions are of the type
normally used and relied upon by professionals in my field.

FURTHER AFFIANT SAYETH NAUGHT

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This affidavit was notarized pursuant to Executive Order 04.09.20.01 using Zoom
as real-time audio-visual communication technology.
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 EMORY UNIVERSITY
CURRICULUM VITAE

Name: CARLOS DEL RIO, MD

E-mail Address: cdelrio@emory.edu

Citizenship: United States of America and Mexico

Websites:
https://sph.emory.edu/faculty/profile/#!cdelrio & http://medicine.emory.edu/infectious-
diseases/emory-first-faculty-directory/profile.html?f=CDELRIO
Current Titles and Affiliations:
a. Academic appointments:
Sept. 1, 2003 – present: Professor of Medicine (Tenured), Emory University School of
Medicine
April 1, 2019 – present: Professor of Global Health, Rollins School of Public Health
December 1, 2019 – present: Distinguished Professor for Emory Clinical and Academic
Affairs at Grady

b. Clinical Appointments:
March 1997 – July 2011: Active Medical Staff, Grady Health System
Oct 1999 – present: Medical Staff member, The Emory Clinic
July 2011 – present: Active-Courtesy staff member, Grady Health System
June 2013 – Feb 2020: Infectious Diseases Clinical Chief of Service at Emory University
Hospital

c. Other administrative appointments:

Oct 1, 2005 – present: Co-Director, Emory Center for AIDS Research
Nov 1, 2019 – present: Executive Associate Dean for Emory at Grady and Chairman of
the EMCF Board
July 1, 2020 – present: Foreign Secretary, National Academy of Medicine

Previous Academic and Professional Appointments:

1990 – 1996: Associate Professor of Medicine, Universidad La Salle, Mexico City, Mexico.
1989 – 1996: Chief of Infectious Diseases and Chairman of the Infection Control
Committee, Hospital Angeles del Pedregal, Mexico City, Mexico.
1993 – 1999: National Investigator, National Research Council (Sistema Nacional de
Investigatores), Mexico.
1996 – 1997: Assistant Professor of Medicine (transient appointment), Emory University
School of Medicine (EUSM).
1997 – 2001: Associate Director for Clinical Services at the Ponce de Leon Center of the
Grady Health System and Director of the Special Immunology Service at Grady Memorial
Hospital.
September 1, 1997 – August 31, 2003: Associate Professor of Medicine (Infectious
Diseases), Emory University School of Medicine.
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 December 18, 1997 – August 31, 2005: Adjunct Associate Professor of International
Health, Rollins School of Public Health, Emory University.
September 1, 2005 – March 31, 2009: Adjunct Professor of Global Health, Rollins
School of Public Health, Emory University.
April 1, 2009 – Oct 31, 2019: Hubert Professor & Chair, Hubert Dept. of Global Health,
Rollins School of Public Health of Emory University.
Jan 1, 2017 – Oct 31, 2019: Interim Executive Associate Dean for Clinical Services for
Grady and Chairman of the EMCF Board.

Previous Administrative Appointments:

1992 – 1994: Executive Director of the National AIDS Council (CONASIDA), Mexico.
1994 – 1996: General Coordinator of the National AIDS Council (CONASIDA), Mexico.
1995 – 1997: Member of the Program Coordinating Board, Joint United Nations Program
on HIV/AIDS (UNAIDS)
July 1999 – July 2000: Associate Director of the Internal Medicine Residency Program
January 1998 – July 2001: Director, Clinical Core of the Emory CFAR
July 1, 2000 – March 31, 2001: Program Director, Emory Internal Medicine Residency
Program
April 1, 2001 - January 31, 2006: Co-Director, J. Willis Hurst Internal Medicine
Program.
April 1, 2001 - March 31, 2009: Chief of Medical Service, Grady Memorial Hospital
February 1, 2006 – February 29, 2008: Director for Resident Scholarly Activities, J.
Willis Hurst Internal Medicine Residency Program.
July 1, 2001 – September 30, 2005: Associate Director for Clinical Sciences and
International Research, Emory Center for AIDS Research
July 1, 2004 – June 1, 2006: Executive Director, Hope Clinic of the Emory Vaccine
Center.
February 1, 2006 – March 31, 2009: Vice Chair for Grady Affairs, Dept. of Medicine,
EUSM
March 1, 2008 – May 31, 2010: Program Director, J. Willis Hurst Internal Medicine
Residency Program of Emory University.
Sept. 1998 – June 2015: Director and Principal Investigator, AIDS International Training
and Research Program (AITRP) of Emory University.

Licensures/Boards:
Georgia Medical License: 027282
1981: ECFMG (Educational Commission for Foreign Medical Graduates)
1982: VQE (Visa Qualifying Examination)
1984: FLEX (Federation Licensing Examination)

Specialty Boards:
1986, American Board of Internal Medicine (#108785)
1988, American Board of Internal Medicine (Infectious Diseases)

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Education:
1977-83: Medical School, Universidad La Salle, Mexico City, Mexico
1981-82: Pregraduate internship (senior year of medical school), six months at the University
of Oregon, Portland, Oregon and six months at Emory University, Atlanta, Georgia
1982-83: Social Service, Department of Critical Care Medicine, Instituto Nacional de la
Nutrición Salvador Zubirán, Mexico City, Mexico

Postgraduate Training:
1983-86: Internal Medicine Residency, Emory University School of Medicine, Atlanta,
Georgia (five months in JAR year at Johns Hopkins Hospital, Baltimore, MD)
1986-88: Infectious Disease Fellowship, Emory University School of Medicine, Atlanta,
Georgia
1988-89: Chief Resident in Medicine at Crawford Long Hospital of Emory University,
Atlanta, Georgia
Executive Training:
Jan 2007: Program for Chiefs of Clinical Services. Department of Health Policy and
Management, Harvard School of Public Health.
Jan 2008: Woodruff Health Sciences Center Quality Academy.
Committee Memberships:
a. National and International:
 Member of the Scientific Advisory Committee of the Latin-American AIDS Initiative
(SIDALAC) (1996 – 2000)
 Member of the Monitoring of the AIDS Pandemic (MAP) Network (1996 – 2000)
 Chair, Committee on the Status of Minority Microbiologists, Public and Scientific
Affairs Board, American Society for Microbiology (June 1997 - June 2003)
 CDC, Member of the Task Force to develop the “HIV Prevention Strategic Plan
Through 2005” (February 2000).
 Member of the CDC Advisory Committee on HIV and STD Prevention (September
2000 – November 2003)
 Member of the UNAIDS Performance Monitoring and Evaluation Plan Working Group
(1997)
 NIH Office of AIDS Research, Member of the Planning Group on International AIDS
Research Priorities (April, 2001 and February 2002)
 NIH, Chairman of Special Emphasis Panel for NIH NOT AI-01-018 “Comprehensive
International Program of Research on AIDS” (August, 2001)
 NIH, Member of Special Emphasis Panel for NH-00-0048 “Early detection of HIV:
Implications for Prevention Research” (June 2000)
 NIH, Member of Special Emphasis Panel for NH-00-004 “Long-term Maintenance of
HIV/STD Behavior Change” (June 2000)
 Elizabeth Glaser Pediatric AIDS Foundation, Member of Review Panel for “Call for
Action Projects” (January 1996 to present)
 Member, Institute of Medicine’s Committee on the Ryan White Care Act: Data for
Resource Allocation, Planning and Evaluation. (January 2002 – October 2003).

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 NIH, Member of the Outcomes Committee of the Adult AIDS Clinical Trials Group
(July 2001 – December 2006)
 Member, International AIDS Society – USA Core Faculty (April 2002 to present)
 NIH, Chairman of Special Emphasis Panel ZAI1-GPJ-A-S2 “Comprehensive
International Program of Research on AIDS - CIPRA” (May, 2003)
 CDC, Member Special Emphasis Panel 2003-N-008922 “A US Clinical Trial Site to
Conduct Evaluation of Topical Microbicides in Heterosexual Women and Men”
(August, 2003)
 Member, Education Committee, Infectious Diseases Society of America (2003 – 2005)
 NIH, Member of Special Emphasis Panel ICP-2 “International Bioethics Reviews”
(March 2004)
 NIH, Member of Special Emphasis Panel ZAI1 GP J-M (M1) “NIAID Enhancement
Awards for Underrepresented Minority Scientists” (June 28 – 30, 2004)
 CDC, Member on Special Emphasis Panel PA 04156, “Simplified Procedures for
Routine HIV Screening in Acute Care Settings” (August 17, 2004)
 NIH – Charter Member of the AIDS Clinical Studies and Epidemiology Study Section
(formerly AARR-6), November 2004 – July 2009.
 Member of the Board of Directors, International AIDS Society – USA (January 2005 –
present)
 NIH, Member of Special Emphasis Panel ZAI1 LD-A-J1 “Unsolicited Research Project
Grant Application” (January 2006)
 NIH, Member of Special Emphasis Panel ZAI1 SV-A (S1) “TB/HIV Immune Cell
Expression” (August 2006)
 NIH, Chair of Special Emphasis Panel ZAI1QV-1 “Review of Clinical Trials and
Implementation Grants” (September 2006)
 NIH, Member of Special Emphasis Panel ZRG1 IC2-B (51) “Phase II Comprehensive
ICOHRTA-AIDS/TB (U2R) Review” (November 2006)
 Representative of HIVMA on the Education Committee of IDSA (2006 – 2010)
 External Reviewer of the draft report by the Committee on the “President’s Emergency
Plan for AIDS [PEPFAR] Implementation Evaluation”. (November 2006)
 Member, Institute of Medicine‘s Committee on Methodological Challenges in HIV
Prevention Trials (January 2007 – February 2008).
 Member, DHHS Panel for Antiretroviral Guidelines for Adults and Adolescents
(February 2007 – February 2010 and February 2010 – February 2014)
 NIH, Member of Special Emphasis Panel ZAI1 ESB-A (M1) “HIV Prevention in Men
Review” (April 2007)
 NIH, Member of Special Emphasis Panel ZRG1 BDA-A (52) “FICRS Resource and
Support Center Review” (April 2007)
 CDC, Member of Special Emphasis Panel ZPS1 FXR (03) “Minority HIV/AIDS
Research Initiative to Build Capacity in Black and Hispanic Communities and Among
Black and Hispanic Researchers to Conduct HIV/AIDS Epidemiologic and Prevention
Research – MARI” (May 2007)
 NIH, Member of Special Emphasis Panel ZAI1 SR-M (1) “NIAID Clinical Trials
Planning Grants” (June 2007)

4
 Member of the Board of Directors of the HIVMA - HIV Medicine Association of IDSA
- (October 2007 – Oct 2017)
o Chair of the Board (Oct 2015 – Oct 2016)
 Member of the Board of Advisors of Health STAT (July 2007 – present)
 NIH, Member of Special Emphasis Panel ZRG1 ICP2-B (51) “Global Infectious
Diseases Training Program” (February 2008)
 NIH, Member of Special Emphasis Panel ZRG1 ICP2-B (50) “International Research in
Infectious Diseases” (February 2008)
 NIH, Member of Special Emphasis Panel ZDA1 NXR-B 13 1, “International
Collaborations for HIV and Drug Abuse” (April 2, 2008)
 Member of the OpMAN (Optimization of Co-Infection and Co-Morbidity Committee)
of the AIDS Clinical Trials Group (May 2008 – May 2010)
 Member of the Advisory Committee on HIV and STD Prevention and Treatment of the
Centers for Disease Control and Prevention and Health Resources and Services
Administration (July 1, 2008 – June 30, 2012 and July 1, 2012 – December 30, 2016)
 NIH, Member of Special Emphasis Panel ZDA1 NXR-B 08 1, “Pre-Applications for the
Avant-Garde Program” (April 19, 2009)
 NIH, Member of Special Emphasis Panel ZRG1 AARR-C 22 “AIDS Fellowship
Review” (July 28-29, 2009)
 Member, Institute of Medicine Committee on HIV Social Security Disability Criteria
(Dec 2009 – June 2010)
 Member, WHO Influenza A(H1N1) Clinical Advisory Group (2009)
 Member, CDC Influenza A(H1N1) Task Force (2009)
 NIH, Member of Special Emphasis Panel ZCA1 RTRB-8 M2 R “A Developing
Research Capacity in Africa for the Studies of HIV-Associated Malignancies” (March
15, 2010)
 NIH, Member of Special Emphasis Panel ZDA1 NXR-B 08 1, “Pre-Applications for the
Avant-Garde Program” (April 23, 2010)
 Member of the ACTG Executive Committee (June 1, 2010 – May 31, 2013 & )
 Member of the Board of Directors of the Infectious Diseases Society of America
(October 2010 – September 2013)
 Member, Institute of Medicine Committee to Review Data Systems for Monitoring HIV
Care (February 2011 – September 2012)
 NIH, Member of Special Emphasis Panel ZRG1 IDM-R (50) R, “International Research
in Infectious Diseases including AIDS (IRIDA)”. (February 11, 2011)
 NIH, Chair, Special Emphasis Panel ZRG1 F12B-U (20) L, “Fellowships:
Psychopathology, Disabilities, Stress and Aging. (February 24, 2011)
 NIH, Member of Special Emphasis Panel ZDA1 NXR-B 15, “Pre-Applications for the
2011 Avant-Garde Program for HIV/AIDS Research” (March 28, 2011)
 NIH/NIAID – Charter Member, Acquired Immunodeficiency Syndrome Research
Review Committee (AIDS RRC), (July 1, 2011 – June 30, 2015).
 NIH, Member of Special Emphasis Panel ZRG1 AARR-H (55) “Career Development in
International Settings”. (June 29, 2011)
 NIH/FIC – Member, US-India Joint Working Group on Prevention of Sexually
Transmitted Diseases and HIV/AIDS (Oct 31, 2011)

5
 NIH, Member of Special Emphasis Panel ZDA1 NXR-B, “Pre-Applications for the
Avant-Garde Program” (Jan 11, 2012)
 NIH, Chair of Special Emphasis Panel ZRG1 AARR-H, “HIV International Research
Training” (Oct 31 – Nov 1, 2012)
 Member of the Board of Directors, ACTHIV (April 2013 – present)
 Co-Chair, International Antiviral Society-USA Panel on Development of
Recommendations for Biomedical Prevention of HIV Infection (2013)
 NIH, member of Special Emphasis Panel ZAI1 BP-A (S4), “Clinical Trials
Implementation UO1 Grants” (Aug 26, 2013)
 NIH, member of Special Emphasis Panel ZRG1 AARR-F (52), “Methodologies and
Formative Work for Combination HIV Prevention Approaches” (Dec 16, 2013)
 Member, Office of HIV/AIDS Network Coordination (HANC) Behavioral Sciences
Consultative Group (Jan 1, 2015 – Dec 31, 2018)
 NIH/NIAID – Chair, Acquired Immunodeficiency Syndrome Research Review
Committee (AIDS RRC), (July 1, 2014 – June 30, 2017)
 Member, UNAIDS Scientific and Technical Advisory Committee (Dec 2014 – present)
 Member, Fulton County Task Force on HIV/AIDS (Dec 2014 – Sept 2017)
 Chair, PEPFAR Scientific Advisory Board (March 1, 2015 – present)
 Vice-Chair, ACTG Underrepresented Populations Committee (Dec 1, 2016 – Nov 30,
2019)
 NIH, member of Special Emphasis Panel ZRG1 MOSS-R (70), “NIH Director’s New
Innovator Award” (March 26 – 27, 2018)
 NIH, Member of the NIDA National Advisory Council on Drug Abuse (May 2018 –
present)
 Member of the Division Committee of the Health and Medicine Division of the National
Academies of Science, Engineering and Medicine (Nov 1, 2018 – Oct 31, 2021)
 Track B – Clinical Science Lead, Scientific Program Committee, International AIDS
Conference 2019, Mexico City, Mexico (July 21 – 24, 2019)

b. Regional and State:

 Member of the Scientific Advisory Committee of the AIDS consortium of Atlanta (1996
– 2004)
 Member of the Board, AID Atlanta (1998 – 2004)
 Member of the Board of Trustees, The Paideia School (1998 – 2004)
 Member of the Parent Council of Emory University (2007 – 2010)
 Member of the Board of Directors, Atlanta Symphony Orchestra (2011 – present)

c. Institutional
 LCME Graduate Medical Education/Continuing Education Committee (1998)
 Dean of School of Nursing Search Committee (1999)
 GME Advisory Committee (July 1999 - present)
 Representative of the School of Medicine on the International Affairs Council
(November 2000 to 2009)
 Member of the School of Medicine Faculty Committee on Appointments and
Promotions (June 2001 – September 2004)
 Member of the Faculty Council of Emory University (2000- 2004)

6
 Member, Advisory Board of the Center for the Study of Health, Culture and Society
(December 2000 – May 2009)
 Internal Medicine House Staff Evaluation Committee (March 1998 - present)
 Orthopedic Chair Search Committee (2001)
 Medical Executive Committee, Grady Health System (April 2001 – March 2009)
 Chair, Education and Training Subcommittee, Woodruff Health Sciences Center
Bioterrorism Taskforce (April 2002 – December 2003)
 Representative of the School of Medicine on the Coordinating Committee for
University Internationalization (September 2002 – April 2009)
 Chair, Medical Records Committee, Grady Health System (May 2002 – December
2005)
 Member, EMCF Practice Committee (June 2002 – March 2009)
 Member, Emory GCRC Advisory Committee (June 2002 – June 2007)
 Radiology Chair Search Committee (2003-2004)
 Member, Emory University Strategic Planning Committee (Subcommittees on Global
Health and Internationalization).
 Co-Chair, Curriculum Planning Steering Committee of Emory University School of
Medicine (September 2004 – December 2005)
 GCRC Director Search Committee (2005)
 Member, Faculty Development Committee for the Department of Medicine (2005 –
2009)
 Chair, Department of Medicine Promotions and Tenure Subcommittee (2005 – 2007)
 Member, Honorary Degrees Committee of Emory University (2006 – 2009)
 Member, Global Health Institute Advisory Committee, Emory University (2006 –
present)
 Member, Institute for Developing Nations Academic Board, Emory University (2006
– present)
 Co-Chair Task Force on Faculty and Staff Development, Emory University School of
Medicine (December 2006 – August 2007)
 Member, Search Advisory Committee for the Senior Vice President for Health
Affairs of the Woodruff Health Sciences Center of Emory University (January – July
2007)
 Member, LCME Faculty Subcommittee (2007)
 Member, Presidential Advisory Committee (PAC) of Emory University (September
2007 – August 2009)
 Member, Surgery Chair Search Advisory Committee (2007-08)
 Member, Director of Critical Care for Emory Healthcare Search Advisory Committee
(2008-09)
 Member, Research Advisory Committee of the School of Medicine (March 1, 2009 –
August 31, 2010)
 Member, Woodruff Health Sciences Center Research Advisory Council (April 2009 –
present)
 Chair of the Research Training and Education subcommittee for the WHSC Research
Strategic Plan (August 2009 – May 2010)
 Co-Chair, Culture Transformation Group, Woodruff Health Sciences Center (May

7
 2009 – May 2011).
 Member, Task Force on Protest, Dissent and Community (May 2011 – May 2015)
 Member, Emory University Faculty Advisory Committee for Finance and
Administration (Oct 2011 – May 2015)
 Member, Family and Preventive Medicine Chair Search Committee (2012)
 Member, Graduate Medical Education Strategic Planning Committee (2013)
 Member, Director of Yerkes National Primate Research Center Search Committee
(2013)
 Member, LCME Taskforce (2015)
 Co-Chair, Emory University’s Provost Search Advisory Committee (Oct 2016 – Feb
2017)
 Member, Interdisciplinary Advisory Committee, Emory Healthcare (Sept 2018 – Aug
2021)

Consultantships:
 Centers for Disease Control and Prevention, Consultant for the drafting of the “HIV
Prevention Strategic Plan Through 2005”. September 2000.
 Centers for Disease Control and Prevention, External consultant for the “Control of
Neisseria gonorrheae infection in the United States”. Oct 10 – 11, 2001.
 Centers for Disease Control and Prevention, Consultant on “Bioterrorism Education
for Clinicians”, August 2002.
 Abbott Laboratories. HOPE Partnership (December 2001 – December 2002)
 Centers for Disease Control and Prevention, Consultant on implementing HIV
Testing in Acute Care Settings. March 2004.
 NIH/Harvard Medical School Division of AIDS, Participant in the scientific
workshop addressing “When to Switch HIV Antiviral Therapy in Resource-Limited
Settings”. Boston, MA. November 12, 2004.
 Centers for Disease Control and Prevention, Participant in Satellite Broadcast/Web
Cast “Incorporating HIV Prevention into the Medical Care of Persons Living with
HIV”. November 13, 2004.
 Centers for Disease Control and Prevention, Consultant in drafting the “HIV
Screening Recommendations for Adults, Adolescents, and Pregnant Women in Health
Care Settings”. November 1 – 2, 2005. Published as “Revised Recommendations for
HIV testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings”.
MMWR 2006; 55(RR-14)
 Interagency Task Force on Antimicrobial Resistance, Consultant in drafting “A
Public Health Action Plan to Combat Antimicrobial Resistance”. December 12-13,
2007.
 Centers for Disease Control and Prevention, consultant for the “External Peer Review
of DHAP Surveillance, Research, and HIV Prevention Programs”. April 13 – 15,
2009
 Centers for Disease Control and Prevention, consultant for the “Consultation on
Revised Guidelines for HIV Counseling, Testing, and Referral in non-clinical
settings”. June 1 – 2, 2009.
 Centers for Disease Control and Prevention, consultant during a meeting entitled:

8
 “Developing a Rapid Impact Assessment Framework for Pandemic Influenza
Response”. August 26, 2010
 Centers for Disease Control and Prevention, consultant for the “Consultation on
Monitoring and Use of Laboratory Data Reported to HIV Surveillance”. Jan 12 – 13,
2011
 Centers for Disease Control and Prevention, consultant for the “Consultation on MSM
Pre-Exposure Prophylaxis (PrEP) Implementation Guidelines”. May 3 – 4, 2011.
 Centers for Disease Control and Prevention, consultant for the “HIV surveillance
Case Definition”. Feb 7 – 8, 2012.
 Centers for Disease Control and Prevention, consultant for the “STD Treatment
Guidelines 2013”. April 30 – May 2, 2013.

Editorship and Editorial Boards:

 Chief Editor, HIV/AIDS Journal Watch Infectious Diseases (2014 – present)
 Associate Editor, Clinical Infectious Diseases (2016 – present)
 Senior Clinical Editor, AIDS Research and Human Retroviruses (2007 – 2017)
 Editorial board, AIDS Clinical Care (2000 – 2014)
 Editorial Board, Journal of AIDS
 Editorial Board, Global Public Health
 Editorial Board, Women, Children and HIV
 Editorial board, Archives of Medical Research
Manuscript reviewer
 AIDS  Gaceta Médica de México
 AIDS Research and Human Retroviruses  JAMA
 AIDS and Behavior  Journal of AIDS
 American Journal of Medicine  Journal of General Internal Medicine
 American Journal of Public Health  Journal of Infectious Diseases
 American Journal of Preventive Medicine  Lancet
 American Journal of the Medical Sciences  New England Journal of Medicine
 Annals of Internal Medicine  PLoS One
 Annals of Emergency Medicine  Salud Pública de México
 Archives of Internal Medicine  Sexually Transmitted Infections
 Archives of Medical Research  Social Sciences and Medicine
 Clinical Infectious Diseases  Vaccine
 Emerging Infectious Diseases

Honors and Awards:

1982 Valedictorian, medical school class of 1982, Universidad La Salle, Mexico
1983 Awarded "Los mejores estudiantes de México" (Best students in Mexico)
1987 Elected member of A.O.A.
1988 Trainee Travel Award, American Federation for Clinical Research
1990 Fellow of the American College of Physicians
1989, 91, 96 Physician Recognition Award, American Medical Association
1992-99 "Investigador Nacional Nivel I” (National Researcher) by the “Sistema Nacional de
Investigadores” in Mexico

9
1993 Award “Hermano Miguel” given by the Universidad La Salle in Mexico in
recognition of academic achievement
1996 Glaxo-Wellcome Foundation Award for Clinical Research. Mexico City, Mexico.
1996 Fellow of the Infectious Diseases Society of America
2001 James H. Nakano Citation (for an outstanding scientific paper published in 2000)
2002 Finalist, Atlanta Business Chronicle “Health-Care Heroes” Award in the
Physician category
2006 Outstanding Achievement Award in the Field of HIV/AIDS awarded by the First
Lady of Georgia for “Personal Contribution in Developing a modern HIV/AIDS
Control Program in Georgia”
2007 Marion V. Creekmore Award for Internationalization, Emory University
2006, 2007, 2009, 2010, 2011, 2012, 2013, 2017 and 2019 “Best Conference Award”, as
voted by the residents for the most outstanding conference in the Emory Internal
Medicine Residency Program.
2007 Selected by “Atlanta Magazine” as one of the 55 most influential foreign-born
Atlantans (October 2007 issue)
2009 Elected member of the American Clinical and Climatological Association
2011 Elected member of the American Epidemiological Society
2011 Silver Pear Research Mentoring Award, Department of Medicine, Emory Univ.
2013 Fellows Award for Distinguished Educator in Infectious Diseases, University of
Pittsburgh Division of Infectious Diseases
2013 Elected to the National Academy of Medicine (formerly the Institute of Medicine)
2014 Winner of the Thomas Jefferson Award at Emory University
2015 Winner of the Department of Medicine R. Wayne Alexander Research
Achievement Award
2015 Department of Medicine Research Day, 3rd place winner in the “Clinical, Quality
and Health Services Research Poster” category.
2016 Elected to Delta Omega (Honorary Society in Public Health) by the member
students of the Phi Chapter at the Rollins School of Public Health
2016 Recipient of the “Ohtli Award” from the Mexican Government for "distinguished
work that benefits the interests of the Mexican community or communities of
Mexican origin living in the US".
2017 John P. McGovern Award Lectureship delivered at the 47th Annual Meeting of
the American Osler Society. Atlanta, GA April 10th, 2017.
2017 Distinguished Medical Alumni Achievement Award – Emory University School
of Medicine
2017 Inducted to the Emory MilliPub Club (The MilliPub Club honors and recognizes
Emoy faculty who have published one or more papers that have garnered more
than 1,000 citations).
2017 Winner of the Emory University School of Medicine Mentoring Award
2018 James H. Steele Annual Lecture delivered at University of Texas, Houston.
April 5, 2018.
2019 Clinician Educator Award 2019, HIVMA
2020 Elected Foreign Secretary of the National Academy of Medicine (July 2020 –
June 2024)
2020 Selected by “Atlanta Magazine” one of “Atlanta 500 Most Powerful Leaders

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Organization of National or International Conferences:
a. Administrative positions:
 Organizing committee of the 8th International Pathogenic Neisseria Conference, October
1992, Cuernavaca, Mexico
 Coordinator of the IV National AIDS Conference, October 1993, Mexico City, Mexico
 Organizing committee of the IV International Conference on Travel Medicine, April 1995,
Acapulco, Mexico
 Coordinator of the V National AIDS Conference, November 1995, Mexico City, Mexico
 Scientific Committee, 1st IAS Conference on HIV Pathogenesis and Treatment, Buenos
Aires, Argentina, July 2001
 Track Co-chair, 2001 National HIV Prevention Conference, Atlanta, GA, August 2001
 Scientific Program Committee Member, 3rd Conference on Global Strategies for the
Prevention of HIV Transmission from Mothers to Infants. Kampala, Uganda. September
2001.
 International Scientific Committee, XIV International Conference on AIDS, Barcelona,
Spain, July 2002
 Scientific Program Committee, 8th World STI/AIDS Congress, Punta del Este, Uruguay,
December 2-5, 2003.
 Joint Program Committee Track Co-chair, XVI International Conference on AIDS, Mexico
City, Mexico, August 2008.
 Track Co-chair, 2009 National HIV Prevention Conference, Atlanta, GA, August 2009
 Planning Committee Member, 36th Remington Winter Course in Infectious Diseases. Vail,
CO. February 21 - 26, 2010
 Co-Chair, AIDS Vaccine 2010. Atlanta, GA. September 28 – October 1, 2010
 Regional Chair, HIVDART 2010. Los Cabos, Mex. December 7 – 10, 2010
 Planning Committee Member, 37th Remington Winter Course in Infectious Diseases.
Snowmass, CO. February 6 – 11, 2011
 Member, Clinical Science Track Committee, XIX International Conference on AIDS,
Washington, DC. July 22 – 27, 2012
 Member, Scientific Advisory Committee, 2nd International Treatment as Prevention (TasP)
Workshop. Vancouver, BC. April 22 – 25, 2012
 Member, Scientific Advisory Committee, 3rd International Treatment as Prevention (TasP)
Workshop. Vancouver, BC. April 22 – 25, 2013
 Co-Chair of Planning Committee, The American Conference for the Treatment of HIV
(ACTHIV), Denver, Co. May 8 – 10, 2014
 Scientific Advisory Committee, HIVDART 2014. Key Biscayne, Fla. December 9 – 12,
2014
 Member of the Scientific Program Committee, HIV Drug Therapy in the Americas 2015.
Mexico City, Mx. April 16 – 18, 2015.
 Co-Chair of Planning Committee, The American Conference for the Treatment of HIV
(ACTHIV), Dallas, Tx. Apr 29 – May 3, 2015
 Member of the Core Committee, HIV & Hepatitis in the Americas 2016. Mexico City,
MEX. April 28 – 30, 2016.
 Member of the Core Committee, HIV & Hepatitis in the Americas 2017. Rio de Janeiro,
Brazil. April 6 – 8, 2017.

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Research focus:
My research efforts focus on access to care, linkage to care and barriers to care among HIV-infected
hard to reach populations in the United States and abroad. I also do research on treatment and
prevention of HIV/AIDS as well as adherence and the impact of therapy on behavior. I also work on
TB and other co-infections like HCV an STI’s, in particular gonorrhea. Finally, my research has
expanded to include the emerging opioid epidemic and looking for ways to improve opioid
prescribing and management of pain in clinical settings.

Grant Support:
a. Active support:
 NIH/NIAID (2P30 AI 50409). Emory CFAR. (PI: C. del Rio) 08/01/17 – 7/31/22.
 NIH/NIAID (AI069418). Emory-Duke-Orlando-CDC Clinical Trials Unit. (co-PIs: J.
Lennox & C. del Rio) 12/10/13 – 11/30/20
 NIH/NIDA (1RO1DA037768). Improving Physician Opioid Prescribing for Chronic Pain
in HIV-infected Persons (co-PIs: J. Samet & C. del Rio), 09/15/2014 – 08/31/2019.
 NIH/NIDA (5U10DA013720). Florida Node of the Drug Abuse Clinical Trials Network
(PI: J. Szapocznik & L. Metsch; Emory site PI: C del Rio) 00/30/2000 – 08/31/2020
 NIH (D43 TW007124). Emory-Georgia Tuberculosis Research Training Program (PI: H.
Blumberg), 05/01/15 - 01/31/21.
 NIH (D43 TW009127) Emory-Ethiopia Tuberculosis Research Training Program (PI: H.
Blumberg), 03/22/19 - 12/31/23.
 NIH/NIAID (1UM1A148576). Emory Vaccine and Treatment Evaluation Units (coPIs:
Rouphael, Anderson & del Rio), 12/11/19 – 11/30/26.

Lectureship, Seminar Invitations, and Visiting Professorship: (last ten years)

* “High Impact Research Transforming Public Policy”, Keynote Speaker at the 2nd Annual
iTHRIV Scholars Clinical Translational Research Symposium at the University of
Virginia.
* “Same Day ART”. Lecture presented at the HIV LatinaForum 2019. Mexico City, MX
July 20, 2019
* “Treatment as Prevention”. Opening Plenary Talk at the Inter-CFAR Working Group
Antiretrovirals for Prevention Conference. Atlanta, GA January 28, 2019
* “Issues and Controversies in Antiretroviral Therapy”. Small Group Workshop
Discussant at the 2018 Ryan White Clinical Conference. Washington, DC. December 9,
2018
* “New Developments in HIV Treatment Research Globally”. Invited speaker at the Third
Coast CFAR Annual Symposium. Chicago, IL Nov 1, 2018
* “Challenging Cases in HIV Prevention and Management”. Moderator and speaker, HIV
Glasgow 2018. Glasgow, UK, Oct 28 – 31, 2018
* “Advances in HIV Pre-exposure prophylaxis”. Invited lecture at the 15th National
Congress of the Chinese Society of Infectious Diseases. Beijing, China. July 26 – 29,
2018.
* “High Impact Research Transforming Public Policy”. Lecture presented at the
IDSA/NIAID Infectious Diseases Research Careers Meeting 2018. Bethesda, MD. June
12
 8, 2018.
* “From Africa to Washington DC: What we have learned from the 90-90-90 Treatment
for all Initiative”. Lecture presented at the Annual IAS-USA Course Improving the
Management of HIV disease. Washington, DC. April 26, 2018.
* “Conducting research that transforms healthcare policy”. 26th Annual James H. Steele,
DVM Lecture. Univ Texas School of Public Health. Houston, TX. April 5, 2018
* “From Africa to Georgia: What we have learned from the 90-90-90 Treatment for all
Initiative”. Lecture presented at the Annual IAS-USA Course Improving the
Management of HIV disease. Atlanta, GA. March 16, 2018.
* “Global and regional priorities in Infectious Diseases”. Opening plenary talk at the
XLII Congress of the National Infectious Diseases Society of Mexico. Puebla, MEX.
May 24, 2017
* “Top 10 in HIV”. Closing Plenary Speaker at the 11th Annual ACTHIV meeting. Dallas,
TX April 20-22, 2017.
* “Improving patient outcomes by focusing on the HIV Care Continuum”. Keynote speaker
at the Symposium: Emerging Strategies for HIV and Viral Hepatitis Co-Infection
Symposium. Atlanta, GA. Dec 1st, 2016.
* “What reviewers look for in your RPG application: perspectives from reviewers”.
Invited talk at the NIAID Research Career (“K”) Development: Fostering Science
Leaders Workshop. NIH/NIAID Bethesda, MD. November 29, 2016.
* “Health Equity: Improving outcomes in Hard to Reach Populations”. Invited talk at the
10th Annual Meeting of the CFAR Social and Behavioral Sciences Research Network.
Miami, FLA. October 20, 2016.
* “The HIV Care Continuum”. Invited Talk at the Symposium on Clinical and Prevention
Care organized by the Fulton County Department of Health and Wellness. Atlanta, Ga.
June 20, 2016.
* “High Impact Research Transforming Health Policy”. HIV Grand Rounds organized by
the Univ. of Pennsylvania CFAR. Philadelphia, Penn June 16, 2016.
* “High Impact Research Transforming Health Policy”. Invited talk at the 3rd Annual
“Advancing Healthcare Quality Research at Emory University: Symposium. Atlanta, Ga.
May 18, 2016.
* “Improving retention and viral suppression among hard-to-reach HIV-infected
populations”. University of Miami CFAR Visiting Professor. Miami, Fla. May 5th,
2016.
* “Sexual Transmission and Mosquitoes: A New Phenomenon in Arbovirology?” Bridging
the Sciences: Zika Virus. Atlanta, GA May 1 – 2, 2016.
* “Global Health and US Universities”, invited speaker at the University of South
Carolina Global Health Initiative Workshop. Columbus, SC Oct 22 -23, 2015.
* “Becoming an investigator: From Medicine Resident to Professor of Medicine and CFAR
co-Director”, invited lecture at the NIAID/IDSA Infectious Diseases Careers Meeting
2015. Bethesda, MD June 4 – 6, 2015.
* “Tactical decision making in Health and Humanitarian Supply Chain Management”.
Invited lecture at the Georgia Tech course “Health & Humanitarian Supply Chain
Management”. May 14th, 2015.
* “Ebola and other Global Issues of Local Concern”. Invited talk at the 2015 Infectious
Diseases Association of California (IDAC) Spring Symposium. Costa Mesa, CA May 2-

13
 3, 2015.
* “The Ebola Crisis: Lessons in International Cooperation for Global Health”. Invited
talk at the Association of Academic Health Centers 2015 International Forum.
Washington, DC April 20 - 21, 2015.
* Keynote speaker “What will it take to end the AIDS epidemic?”. Invited talk at the HIV
Drug Therapy in the Americas Congress 2015. Mexico City, MEX. April 16 – 18, 2015.
* Keynote Address at the 12th Annual Graduate Division of Biological and Biomedical
Sciences Student Research Symposium. Emory University School of Medicine. Jan 15th,
2015.
* “How Far We’ve Come and How Far We Still Need to Go: Engagement in HIV Care for
our Most Vulnerable Populations of People Living with HIV in Atlanta and the Southern
United States”. Invited talk at the 16th World AIDS Day Symposium organized by the
UNC Center for AIDS Research and the Institute for Global Health and Infectious
Diseases. Dec 5th, 2014.
* “The Past, Present, and Future of Global Health Engagement by Academic Institutions”.
Keynote Lecture at the CFAR HIV Research in International Settings (CHRIS) Meeting
hosted by the UCSD CFAR. Oct 1st, 2014.
* “Advances in Seek, Test and Treat Strategies/Treatment as Prevention”. Invited talk at
the US-Georgia Program Development Workshop on HIV/AIDS, Tuberculosis and
Hepatitis. Tbilisi, Georgia. June 16 – 18, 2014.
* “The Diagnosis and Treatment of HIV infection: Translating research into policy and
practice”. Invited talk at the 7th Anniversary of CISIDAT (Consorcio de Investigacion
sobre VIH/SIDA/TB). Mexico City, Mex. June 5, 2014.
* “Can we end the HIV epidemic”. Life of the Mind Lecture Series organized by the
Provost of Emory University. March 26, 2014.
* “Linkage and Retention: What works and what doesn’t”. Invited talk at the 4th
International HIV Workshop on Treatment as Prevention. Vancouver, BC. April 1 – 4,
2014.
* “Challenges in the HIV Continuum of Care and its Relevance to Treatment as
Prevention”. University of Miami CFAR Visiting Professor. February 28, 2014.
* “Current Status of HIV Continuum of Care Research”, Invited Talk at the 2nd National
CFAR/APC HIV Continuum of Care Working Group Meeting: Implementation Science
to Address the Challenges of the HIV Continuum of Care. Washington, DC. Feb 3 – 4,
2014.
* “The Fight Against AIDS”, Invited TEDx Talk at Institut LeRosey, Switzerland. Nov 9,
2013 (http://tedxtalks.ted.com/video/The-Fight-Against-AIDS-Dr-Carlo &
http://www.youtube.com/watch?v=F2Hz4t66-Ig)
* “Seek, Test, Treat and Retain Among Vulnerable Populations”, Invited Speaker to the
Spring Meeting of the Massachusetts Infectious Diseases Society. Boston, Mass May 14,
2013.
* “Treatment is Prevention: novel approaches to HIV therapy”, Key Note Speaker, AIDS
United Access to Care Grantee Meeting, Atlanta, GA April 5, 2012.
* “The Future of HIV Prevention”, Key Note Speaker at the 5th Research Meeting on
HIV/AIDS diagnosis, care and prevention among vulnerable populations. Mexico City,
Mexico. November 14, 2011
* “History of HIV/AIDS in the US”, Speaker at the 2011 American Conference for the

14
 Treatment of HIV (ACTHIV). Denver, CO. April 7, 2011.
* “Building on Success”. Speaker at the CDC World AIDS Day Event. Atlanta, GA.
December 1, 2010
* Invited Keynote speaker: “Evidence Based Global Health”. Annual Meeting of the
Mexican National Epidemiological Surveillance System (Reunion Nacional del Sistema
Nacional de Vigilancia Epidemiologica). Cancun, Mex. November 22, 2010
* Invited Keynote address: “Recent Advances in Biomedical HIV Prevention: Translating
Research into Practice”. 5th National Scientific Meeting of the CFAR’s Social and
Behavioral Sciences Research Network. Atlanta, GA. October 8, 2010
* “14th Annual Paul J. Galkin Lectureship” Brown University, Providence, RI. September
20-21, 2010.
* “University of Massachusetts Center for Global Health Visiting Professor” University of
Massachusetts, Worchester, MA. May 19, 2010
* “Facilitators and Barriers to HIV testing in hospital and other ambulatory care
settings”. Presentation to the Institute of Medicine Workshop to identify facilitators and
barriers to HIV testing. Washington DC. April 15, 2010.
* “Tim Gills Visiting Professorship” University of Colorado at Denver Center for AIDS
Research, Denver CO. March 30-31, 2010.
* “Viral Zip Codes: Novel Influenza A (H1N1): what have we learned in the last 6
months? Invited speaker at the Fifth Annual National Symposium on Predictive Health
“Human Health: Molecules to Mankind”. Atlanta, GA. December 14, 2009
* “Public Health and Health Care: Working Together for HIV Prevention”. Discussant in
CDC Panel for World AIDS Day. Atlanta, GA. December 1, 2009
* “The Healthcare needs of Migrants. Key Note Speaker at the Hispanic Health Coalition
of Georgia Latino Health Summit. Atlanta, GA. February 27, 2009.
* “Challenges in improving the National Response to the HIV/AIDS Epidemic”. Invited
Speaker at the Seminar organized by the Instituto Nacional de Salud Publica and the
Secretaria de Salud, Mexico. February 20, 2009
* “Challenges and Controversies in Infectious Diseases in the XXI Century”. Invited
Lecture at the XXI Annual Meeting of the Medical Society of Hospital Angeles, Mexico
City, Mex. February 19, 2009
* “Antiretroviral Therapy: 25 years of Progress”. Medical Grand Rounds, SUNY
Downstate Medical Center, Brooklyn NY. December 11, 2008
* “Confronting the Global HIV epidemic: moving forward after Mexico City”. Invited key
note speaker to the Second Annual International; HIV/AIDS Research Day of the UCSD
CFAR. San Diego, CA. October 7, 2008
* “In the Eye of the Storm: The Emerging Epidemics of HIV, Hepatitis and Tuberculosis in
the Former Soviet Republic of the Caucasus”. Invited Global Health Institute seminar
speaker, University of North Carolina, Chapel Hill, NC. December 8, 2007.
* “Strategies for Initial Antiretroviral Therapy through Complicated Failure: A Case-
Based Discussion”. Lecture presented at the Annual IAS-USA Course Improving the
Management of HIV Disease. New York, NY. October 19, 2007
* “New Antiretrovirals”. Lecture presented at the Annual IAS-USA Course Improving the
Management of HIV Disease. Washington, DC. May 23, 2007.
* “Antiretroviral Therapy Failure: A case based discussion”. Lecture presented at the
Annual IAS-USA Course Improving the Management of HIV disease. Atlanta, GA.

15
 April 27, 2007.
* “The Perfect Storm: Emerging Epidemics of HIV, HCV and TB in the Republics of the
Former Soviet Union”. Invited Lecture in the course: AIDS: A Multidisciplinary
Approach” at the University of Washington. Seattle, WA. April 2, 2007

Invitations to National or International Conferences: (last ten years)

 “Integrating the response at the Intersection of Opioid Use Disorder and Infectious
Diseases”. Invited talk at IDWeek 2019. Washington, DC Oct 2 – 6, 2019
 “Treatment as Prevention”. Opening Plenary Talk at the Inter-CFAR Working Group
Antiretrovirals for Prevention Conference. Atlanta, GA January 28, 2019
 “Issues and Controversies in Antiretroviral Therapy”. Small Group Workshop
Discussant at the 2018 Ryan White Clinical Conference. Washington, DC. December 9,
2018
 “New Developments in HIV Treatment Research Globally”. Invited speaker at the Third
Coast CFAR Annual Symposium. Chicago, IL Nov 1, 2018
 “The Evolving HIV Epidemic in the United States”. Invited talk during the Symposium
“Strategies for Improving the US Care Cascade: Confronting a Fragmented Health
System. 25th Conference on Retroviruses and Opportunistic Infections (CROI). Boston,
MA. March 4 – 7, 2018
 “Progress in achieving the UNAIDS durable virus suppression & the 90-90-90 goals in
HIV Care”. Invited lecture at: Bridging the Sciences – Advances in HIV, Viral Hepatitis
and Emerging Viruses. France/Atlanta 2017. Emory University Oct 26, 2017
 “Linkage to Care” Plenary Speaker at ANAC2016. Atlanta, GA. Nov 10 – 12, 2016
 “What’s Hot in HIV Clinical Research”. Invited speaker at IDWeek2016. New Orleans,
LA. Oct 26 – 30, 2016
 “What’s New, What’s Next, What’s Ahead?” Invited Plenary Speaker at AIDS2016.
Durban, South Africa. July 17 – 22, 2016.
 “Meeting the Health Care Workforce Challenge”, Invited speaker at the 2016 Pre-
Conference UN 90-90-90 Target Workshop. Durban, South Africa. July 17, 2016.
 “Diagnosis and management of Zika infected and exposed pregnant women”, Invited talk
at the XXI Congreso Mexicano de Especialistas en Ginecologia y Obstetricia, A.C.
Mexico City, Mex. June 23, 2016.
 “Interactive Cases: Infectious Diseases in Travelers”, Invited speaker at the XLI
Congress of the Mexican Infectious Diseases Society. Monterrey, Mex. May 25 – 28,
2016.
 “Optimizing Adherence to Antiretroviral Therapy: Current and Future Options”, Invited
speaker at IDWeek2015. San Diego, Calif. Oct 7 – 11, 2015.
 “Update on vaccines for HIV-infected Patients”, Invited speaker at the 54th Interscience
Conference on Antimicrobial Agents and Chemotherapy (ICAAC). Washington, DC
Sept 5 – 9, 2014.
 “Infectious Diseases in the context of Global Health”, Invited Plenary Speaker at the
XXXIX Congress of the Mexican Infectious Diseases Society. Acapulco, Mex. May 28
– 31, 2014.
 “HIV Prevention 2013”, Invited Plenary Speaker at the 26th Annual Conference of the
Association of Nurses in AIDS Care (ANAC). Atlanta, GA November 22, 2013

16
  “Vaccines in Immunocompromised patients”, Invited Speaker at the 4th International
Workshop on HIV & Aging. Baltimore, MD Oct 31, 2013
 “Addressing the Gaps in the HIV Care Cascade”. Invited talk at the “Treatment as
Prevention and Pre-Exposure Prophylaxis Summit”. London, UK. Sept 22 – 24, 2013.
 “Early Diagnosis and Treatment of HIV Infection”, Invited talk at the 15th International
Symposium on HIV/AIDS of the Mexican Infectious Diseases Society. Queretaro, Mex.
Aug 29 – 31, 2013.
 “Confronting the challenge of infectious diseases among substance abusers” Invited
Conference at the XIII Congress of the Argentinian Society for Infectious Diseases. Mar
del Plata, Argentina. June 9 – 11, 2013
 “Biomedical HIV Prevention” Invited Conference at the XIII Congress of the
Argentinian Society for Infectious Diseases. Mar del Plata, Argentina. June 9 – 11, 2013
 “Introduction to Global Health”. Invited Speaker to Lab Medicine 2013. 48th Annual
Meeting of the Academy of Clinical Laboratory Physicians & Scientists. Atlanta, GA
June 6 – 8, 2013
 “How Should We Spend our Prevention Dollars? Invited Speaker to the 20th Conference
on Retroviruses and Opportunistic Infections (CROI). Atlanta, GA March 3 – 6, 2013
 “Opportunistic Infections in Patients with HIV Infection” and “The Pregnant Patient
with HIV”. Invited Speaker at the 39th Remington Winter Course in Infectious Diseases.
Beaver Creek, CO. February 10 – 15, 2013
 “The Importance and Implications of Antibiotic Resistance for the Clinician”. Keynote
Speaker at the VII Congress Group Angeles. Mexico City, Mex. Oct 25 – 27, 2012.
 “Adherence and Retention in Care”. Invited Speaker to the AWACC (Annual Workshop
on Advanced Clinical Care) – AIDS 2012 Conference. Durban, South Africa. October 5,
2012.
 “Antiretroviral Therapy as Prevention: A Debate on the Role of ART as Prevention in
Clinical Practice”. Open Plenary Speaker at the 2012 American Conference for the
Treatment of HIV (ACTHIV), Denver, CO. May 10 -12, 2012,
 “Aging and HIV: Update from CROI”. Invited Speaker at the 5th International Course
HIV: Pathogenesis, Prevention and Treatment. Lima, Peru. March 23 – 24, 2012.
 “Neurological Complications of HIV Infection” and “Clinical Spectrum of Acute
Retrovirus Syndrome”. Invited Speaker at the 37th Remington Winter Course in
Infectious Diseases. Snowmass, CO. February 6 – 11, 2011
 “Retention in Care”. Invited Speaker at the 48th Annual Meeting of the Infectious
Diseases Society of America Vancouver, Canada. October 21-24, 2010
 “HIV infection – beginning HAART” and “HIV infection – Managing opportunistic
infections”. Invited Speaker at the 36th Remington Winter Course in Infectious Diseases.
Vail, CO. February 21 – 26, 2010
 “HIV Prevention among hard to reach populations”. United States-Russia Workshop on
HIV Prevention Science organized by the Office of AIDS Research. Moscow, Russia.
October 28 – 30, 2009.
 “The role of Integrase inhibitors in the treatment of HIV infection”. Invited speaker at
the 9th International Symposium of the Mexican Association of HIV Providers
(AMMVIH). Cancun, Mex. November 22, 2008
 “Current Issues and Controversies in HIV Infection Management” Invited panelist to an

17
 Interactive Symposium at the 48th Annual ICAAC/46th Annual IDSA. Washington, DC.
October 27, 2008
 “HIV, STDs and the Global AIDS Pandemic: Lethal Synergy 2008” Invited panelist to an
Interactive Symposium at the 48th Annual ICAAC/46th Annual IDSA. Washington, DC.
October 28, 2008
 “Treating Tuberculosis in People Living with HIV”. Invited Plenary Speaker at the
Second Eastern Europe and Central Asia AIDS Conference. Moscow, Russian
Federation, May 3 – 5, 2008.
 Poster discussant in the session “New approaches to HIV testing” at the 15th Conference
on Retroviruses and Opportunistic Infections (CROI). Boston, MA. February 4, 2008.

Bibliography:
a. Published and accepted research articles in refereed journals:
1. Gallo S, Marin E, Ramírez A, del Río C, Elizondo J, Ramírez J. Colocación Endoscópica de
Sondas para Alimentación Enteral. Rev. Gastroenterology Mex. 1984; 49(4): 247-50
[PMID 6442452].
2. Guarner J, del Río C, Slade BA. Tuberculosis as a Manifestation of the Acquired
Immunodeficiency Syndrome. JAMA 1986; 256(22):3092. [PMID 3783842]
3. del Río C, McGowan J. Severe diarrhea in pneumococcal bacteremia: croupous colitis.
JAMA 1987; 257(2): 189 [PMID 3795402].
4. Levy D, del Río C, Stephens DS. Meningococcemia in identical twins: changes in serum
susceptibility after rifampin chemoprophylaxis. J Infect Dis 1988; 157:1064-8 [PMID
3129520].
5. del Río C, Guarner J, Honig EG, Slade BA. Sputum examination in the diagnosis of
Pneumocystis carinii pneumonia in the acquired immune deficiency syndrome. Arch
Pathol Lab Med 1988; 112:1229-1232 [PMID 3142440].
6. Mirra SS, del Río C. The fine structure of AIDS encephalopathy. Arch Pathol Lab Med
1989; 113:858-65. [PMID 2757485]
7. del Río C, Stephens DS, Knapp JS, Rice RJ, Schalla WO. Comparison of isolates of
Neisseria gonorrhoeae causing meningitis and report of gonococcal meningitis in a
patient with C8 deficiency. J Clin Microbiol 1989; 27(5): 1045-49 [PMID
2473091/PMC 267480].
8. Guarner J, del Río C, Williams P, McGowan JE. Fungal peritonitis caused by Curvularia
lunata in a patient undergoing peritoneal dialysis. Am J Med Sci 1989; 298 (5): 320-23
[PMID 2683770].
9. del Río C, Soffer O, Widell JL, Judd RL, Slade BA. Acute Human Immunodeficiency
virus infection temporally associated with rhabdomyolysis, acute renal failure and
nephrosis. Rev. Infect Dis 1990; 12(2): 282-85 [PMID 2330481].
10. Guarner J, del Río C, Hendrix L, Unger ER. Composite Hodgkin's and non-Hodgkin's
lymphoma in a patient with AIDS. In situ demonstration of Epstein-Barr Virus. Cancer
1990; 66(4): 796-800 [PMID 2167145].
11. Beciewicz PA, del Río C, Goncalves MA, Lattouf OM, et al. Catastrophic thrombosis of
porcine aortic bioprosthesis. Ann Thorac Surg 1990; 50: 817-9 [PMID 2241350].
12. Guarner J, del Río C, Carr D, Hendrix LE, Eley JW, Unger ER. Non-Hodgkin's lymphomas
in patients with HIV infection: Presence of Epstein - Barr virus by "in-situ"

18
 hybridization. Clinical Presentation and Follow-up. Cancer 1991; 68: 2460-65 [PMID
1657357].
13. Majluf-Cruz AS, Hurtado R, Mijangos C, Souto C, del Río C, Simón J. Síndrome
Hemofagocítico en Asociación a Histoplasmosis en el Síndrome de Inmunodeficiencia
Adquirida: descripción de tres casos y revisión de la literatura. (Haemophagocytic
syndrome associated to histoplasmosis in AIDS: report of three cases). Sangre 1993;
38(1): 51-55 [PMID 8470036].
14. del Río C, Téllez I. Ganancia de peso con el uso del acetato de megestrol (MegaceR) en
pacientes con SIDA y pérdida de peso en México. (Weight gain with the use of MegaceR
in Mexican patients with AIDS). Enf Infecc y Microbiol 1993; 13(5): 249-52.
15. Guarner J, Izazola J, del Río C. Los problemas de conteo células T CD4+. (Problems in
CD4+ T-cell count). Rev Invest Clin 1994; 46:163-4 [PMID 7914377].
16. Souto-Meriño CA, Simón-Domínguez J, Pulido-Priego MA, Hernández-Pérez A, García-
Hernández IC, del Río C. Prevalencia de Marcadores para Hepatitis A, B y C en un
Hospital de México. (The Prevalence of markers for hepatitis A, B and C in a hospital in
Mexico). Salud Públ Mex 1994; 36:257-262 [PMID 7940005].
17. Izazola JA, Valdez M, Sánchez HJ, del Río C. Mortalidad por el Síndrome de
Inmunodeficiencia Adquirida (SIDA) en México de 1983 a 1992. Tendencias y años
perdidos de vida potencial. (AIDS mortality in Mexico, 1983 to 1992. Trends and years
of potential life lost). Salud Públ Méx 1995; 37:140-148 [PMID 7618114].
18. del Rio C, Muñiz M, Mellado E, et al. Premarital HIV testing: the Case of Mexico. AIDS &
Public Policy Journal 1995; 10(2): 104-106.
19. del Río C, Guarner J, Izazola JA. The use of oral fluid to determine HIV-1 prevalence rates
among men in Mexico City. AIDS 1996; 10(2): 233-235 [PMID 8838717].
20. Uribe-Salas F, del Rio-Chiriboga C, Conde C, Juarez-Figueroa L, Uribe-Zuniga P,
Calderón –Jaimes E, Hernandez-Ávila M. Prevalence, incidence and determinants of
syphilis in female commercial sex workers in Mexico City. Sex Transm Dis 1996;
23(2): 120-126 [PMID 8919738].
21. del Río-Chiriboga C y Orzechowski A. Sarampión en adultos: características clínicas en
25 pacientes hospitalizados. (Measles in adults: characteristics of 25 hospitalized adults).
Enf Infec Microbiol 1996; 16 (1): 12-15.
22. del Río C, Tellez I, Orzechowski A, Alanis A. The spectrum of HIV infection in patients
seen at a private hospital in Mexico City: 115 patients seen from 1984 to 1990. Arch
Med Res 1996; 27(2): 201-204 [PMID 8696065].
23. Ponce de León S, del Río C, Rangel S, Magis C. Infección por VIH en trabajadores de la
salud en México. (HIV infection in healthcare workers in Mexico). SIDA-ETS 1996;
2(1): 14-16.
24. Guarner J, Sánchez Mejorada G, del Río C, Mohar A. Simplificación en el conteo de
linfocitos T-CD4 positivos en 500 personas con infección por VIH/SIDA en México. (A
simplified CD4 T-lymphocyte cell count in patients with HIV/AIDS in Mexico). Salud
Públ Méx 1996; 38(3): 207-211 [PMID 8757546].
25. Guarner J, Uribe-Zúñiga P, Hernández G, Terán X, del Río C. Comparison of CD4 positive
T-cell counts in men and women recently diagnosed with HIV infection on Mexico City,
Mexico. AIDS 1997; 11(5): 701-2 [PMID 9108965].
26. Hernández C, Uribe F, Conde C, Cruz A, Juárez L, Uribe P, del Río C, Hernández M.
Seroprevalencias a diversos virus y características sociodemográficas en mujeres que

19
 buscan detectarse VIH (Seroprevalence of viruses and sociodemographic characteristics
in women seeking HIV screening). Revista de Investigación Clínica 1997; 49(1):5-13
[PMID 9229756].
27. Juárez-Figueroa L, Uribe-Salas F, Conde-González C, Hernández-Avila M, Hernández-
Nevárez P, Uribe-Zúñiga P, del Río-Chiriboga C. Hepatitis B markers in men with
high risk sexual behavior in Mexico City. Sexually Transm Dis 1997; 24(4): 211-217
[PMID 9101632].
28. del Río C, Edupuganti S, Cassoobhoy M, et al. Malaria in an Immigrant and Travelers -
Georgia, Vermont, and Tennessee, 1996. MMWR 1997; 46(23):536-539. [PMID:
9191036]
29. Uribe-Salas F, Conde-González C, Allen B, del Río-Chiriboga C, de Zalundo B,
Hernández-Avila M, Juárez-Figueroa L, Anaya-Ocampo R, Uribe-Zúñiga P. Low HIV
and STD Prevalence in a Random Sample of Female Commercial Sex Workers in
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1380940].
30. Guarner J, Montoya P, del Río C, Hernández-Tepichin G. CD4+ T-Lymphocyte variations
in Patients with Advanced HIV Infection and Counts Below 100 cells/µL. Cytometry
(Communic Clin Cytometry) 1997; 30:178-80 [PMID 9298835].
31. del Rio C, Orzechowski A, Sánchez Mejorada G. Toxoplasmosis of the Central Nervous
System in Patients with AIDS in Mexico. Arch of Medical Research 1997; 28(4):527-
530 [PMID 9428578].
32. del Río-Chiriboga C, Sánchez Mejorada G, Orzechowski A, Lanfranchi R, Esponda J,
Robles M. El síndrome de inmunodeficiencia adquirida en la unidad de terapia intensiva
del Hospital Angeles del Pedregal. (AIDS in the intensive care unit at Hospital Angeles).
Enf Infecc y Microbiol 1997; 17(6): 156-159.
33. Albrecht H, del Rio C, Rimland D. Seminal viral load. AIDS 1998; 12(3):333-334 [PMID
9518003].
34. del Río C, Kamarulzaman A, Schüklenk U. Ethics, Economic Realities and Medical
Research in Developing Countries. Repr Health Matters 1998; 6(11): 135-6.
35. Jurado R, del Río C, Nassar G, Navarrete J, Pimentel JL. The Low Anion Gap. Southern
Med J 1998; 91(7):625-629 [PMID 9671832].
36. Volkow P, Pérez R, del Río C, Mohar A. The role of commercial plasmapheresis facilities
on the AIDS epidemic in Mexico. Rev Invest Clin 1998; 50(3): 221-226 [PMID
9763887].
37. López C, Guarner J, Magis C, Uribe P, del Río C. Zidovudina más didanosina en pacientes
asintomáticos infectados por VIH previamente tratados con zidovudina (Zidovudine
plus didanosine in the treatment of HIV asymptomatic patients previously treated with
zidovudine). Rev Invest Clin 1998; 50 (4): 335-339 [PMID 9830323].
38. Rothenberg RB, Scarlett M, del Rio C, Reznik D, O’Daniels C. Oral Transmission of HIV.
AIDS 1998; 12:2095-2105 [PMID 9833850].
39. Wilfert CM, Ammann A, Bayer R, Curran JW, del Rio C, et al. Science, ethics, and the
future of research into maternal infant transmission of HIV-1. Lancet 1999; 353:832-35.
40. Beard CB, Carter JL, Keely SP, Hung L, Pieniazek NJ, Moura I, Freeman AR, Lee S,
Stringer JR, Duchin JS, del Rio C, Rimland D, Baughman RP, Levy DA, Dietz VJ,
Simon P, Navin TR. Genetic Variation in Pneumocystis carinii Isolates from Different

20
 Geographic Regions: Implications for Transmission. Emerg Inf Dis 2000; 6(3): 265-272
[PMID 10827116/ PMC 26400877].
41. Hung L, Beard CB, Creasman J, Levy D, Duchin JS, Lee S, Pieniazek N, Carter J, del Rio
C, Rimland D, Navin TR. Sulfa or Sulfone Prophylaxis and Geographic Region Predict
Mutations in the P. carinii Dihydropteroate Synthase Gene. J Inf Dis 2000; 182:1192-8
[PMID 10979917].
42. Bruce BB, Blass MA, Blumberg HM, Lennox JL, del Rio C, Horburgh CR. Risk of
Cryptosporidium parvum Transmission between Hospital Roommates. Clin Infect Dis
2000; 31:947-50 [PMID 11049775].
43. Green S, del Rio C. HIV pretest and posttest counseling: still missing from medical school
curriculum. Arch Intern Med 2000; 160: 3326 [PMID 11088096].
44. Albrecht H. Lennox JL, del Rio C. Quinidine and Malaria. Arch Intern Med 2001; 161:
1118-1119 [PMID 11322855].
45. Fox KK, del Rio C, Holmes KK, Hook EW, Judson FN, Knapp JS, et al. Gonorrhea in the
HIV Era: A reversal in Trends among Men who have sex with men. Am J Publ Health
2001; 91:959-964 [PMID 11392941/PMC 1446475].
46. del Rio C, Franco-Paredes C, Duffus W, et al. Routinely Recommended HIV Testing at an
Urban Urgent-Care Clinic - Atlanta, GA 2000. MMWR 2001; 50(25): 538-541.
47. Navin TR, Beard CB, Hung L, del Rio C, Lee S, Pieniazek NJ, Carter JL, Lee T, Hightower
A, Rimland D. Effect of Mutations in the Pneumocystis carinii dihydropteroate synthase
gene do not affect outcome of P. carinii pneumonia in HIV-infected patients. Lancet
2001; 358: 545-549 [PMID 11520525].
48. Blumberg H & del Rio C. Management of Tuberculosis (correspondence). New Engl J
Med 2001; 345(20):1501 [PMID 11794210].
49. Eichler M, del Rio C, Ray S. The Effectiveness of HIV post-test counseling in determining
healthcare seeking behavior. AIDS 2002; 16(6): 943-945 [PMID 11919504].
50. Nimri L, Moura IN, Huang L, del Rio C, Rimland R, Duchin J, Dotson E, Beard CB.
Genetic Diversity of Pneumocystis carinii f. sp. hominis Based on Variations in
Nucleotide Sequences of Internal Transcribed Spacers of rRNA Genes. J. Clin
Microbiol 2002; 40(4):1146-1151 [PMID 11923323/PMC 140386].
51. Hernández –Girón C, Tovar V, del Rio C. AIDS Mortality in Mexico, 1988 – 1997. Salud
Publica de Mexico 2002; 44: 207 – 212 [PMID 12132317].
52. del Rio C, Sepúlveda J. AIDS in Mexico: lessons learned and implications for developing
countries. AIDS 2002; 16: 1445 – 1457 [PMID 12131182].
53. DiClemente R, Wingood GM, del Rio C, Crosby RA. Prevention Interventions for HIV-
Positive Individuals: A Public Health Priority. Sex Trans Inf 2002; 78:393-395
[PMID 12473796].
54. Franco-Paredes C, Guarner J, Mehrabi D, McCall C, del Rio C. Clinical and Pathological
Recognition of Leprosy. Am J Med 2003; 114:246-47 [PMID 12637144].
55. Duffus WA, Barragán M, Metsch L, Krawczyk CS, Loughlin AM, Gardner LI,
Anderson-Mahoney P, Dickinson G, del Rio C. Effect of Physician Specialty on
Counseling Practices and Medical Referral Patterns for Physicians Caring for
Disadvantaged HIV-infected Populations. Clin Infect Dis 2003; 36:1577-84 [PMID
12802759].
56. Rothenberg R, Campos P, del Rio C, Johnson W, Jacob Arriola K, Brown M. Once and
Future Treatment: A comparison of Clinic and Community Groups. Int J of STD &

21
 AIDS 2003; 14(7): 438-447 [PMID 12869222].
57. Tobin M, Blass M, del Rio C, Havlosa S, Blumberg H, Horsburgh CR. Hospital water as
a source of Mycobacterium avium complex (MAC) isolates in respiratory specimens.
J Infect Dis 2004; 189:98-104 [PMID 14702159].
58. Hutchinson AB, Corbie-Smith G, Thomas S, Mohanan S, del Rio C. Understanding the
Patients Perspective on Rapid and Routine HIV Testing in an Inner-City Urgent Care
Center. AIDS Education and Prevention 2004; 16(2):101-114 [PMID 15154119].
59. Zaller N, Nelson K, Aladashvili M, Badridze N, del Rio C, Tsertsvadeze T. Risk Factors
for Hepatitis C virus infection among Blood donors in Georgia. Eur J Epidiemiol
2004; 19:547-553 [PMID 15330127].
60. Metsch LR, Pereyra M, del Rio C, Gardner L, Duffus W, Dickinson G, Kerndt P,
Anderson-Mahoney P, Strathdee S, Greenberg A. The Delivery of HIV Prevention
Counseling by Physicians at HIV Medical Care Settings in Four US Cities. Am J Publ
Health 2004; 94:1186-1192 [PMID 15226141/PMC 1448419].
61. Valverde E, del Rio C, Metsch L, et al. Characteristics of Ryan White and Non-Ryan
White-Funded HIV Medical Care Facilities across Four Metropolitan Areas. Results
from the ARTAS Site Survey. AIDS Care 2004; 16(7): 841-850 [PMID 15385239].
62. del Rio C, Barragan M, Franco-Paredes C. Pneumocystis Pneumonia (correspondence).
New Engl J Med 2004; 351(12):1262 -3 [PMID 15371588].
63. Vicas A, Albrecht H, Lennox JL, del Rio C. Imported Malaria at an inner-city Hospital
in the United States. Am J Med Sci 2005; 329(1): 6-12 [PMID 15654173].
64. Tkeshelashvilli-Kessler A, del Rio C, Nelson K, Tsertsvadze T. The Emerging
HIV/AIDS Epidemic in Georgia. Int J of STD & AIDS 2005; 16(1): 61-67 [PMID
15705276].
65. Volkow P, del Rio C. Paid donation and plasma trade: unrecognized forces that drive the
AIDS epidemic in developing countries. Int J of STD & AIDS 2005; 16(1): 5-8
[PMID 15705264].
66. Leonard MK, Osterholt D, Kourbatova EV, del Rio C, Wang W, Blumberg HM. How
many sputum specimens are necessary to diagnose pulmonary tuberculosis? Am J
Infect Control 2005; 33:58-61 [PMID 15685138].
67. Priddy, F, Tasfaye F, Mengistu Y, Rothenberg R, Fitzmaurice D, Mariam, DH, del Rio
C, Oli K, Worku A. Potential for Medical Transmission of HIV in Ethiopia. AIDS
2005; 19 (3): 348-350 [PMID 15718849].
68. Franco-Paredes C, Rodriguez A, del Rio C. Lepromatous Leprosy. Infections in
Medicine 2005; 22(5): 229.
69. Gardner LI, Metsch LR, Anderson-Mahoney P, Laughlin AL, del Rio C, Strathdee S,
Samsom SL, Siegal HA, Greenberg AE, Holmberg SD. Efficacy of a case
management intervention to link recently diagnosed HIV-infected person to care.
AIDS 2005; 19: 423-431. [PMID 15750396]
70. Beckwith CG, Flanigan TP, del Rio C, Simmons E, Wing EJ, Carpenter CCJ, Bartlett
JG. It is Time to Implement Routine, Not Risk-Based HIV Testing. Clin Infect Dis
2005; 40:1037-40 [PMID 15824997].
71. Rudy E, Mahoney-Anderson P, Loughlin A, Metsch L, Kerndt P, Gaul Z, del Rio C.
Perceptions of HIV Testing Services among HIV-positive Persons not in Medical
Care. Sex Transm Dis 2005; 32(4): 207-21 [PMID 15788917].
72. Barragán M, Hicks G, Williams M, Franco-Paredes C, Duffus W, del Rio C. Low

22
 Health Literacy is Associated with HIV Test Acceptance. Journal of Gen Intern Med
2005; 20 (5): 422-425.[PMID 15963165/PMC1490105]
73. Cassoobhoy M, Wetterhall SF, Collins DF, Cantey PT, Iverson CJ, Rudnick JR, del Rio
C. Bridging the gap between clinicians and public health through the development of
an interactive bioterrorism and emerging infections curriculum for medical students
and internal medicine residents. Publ Health Reports 2005; 120 (suppl 1): 59-63.
[PMID 16025708/PMC 2569989]
74. Rimland D, Guest JL, Hernandez I, del Rio C, Anh Le N, Brown WV. Increased
ApoCIII to Triglyceride Ratios in HIV Positive Men on Antiretroviral Therapy. HIV
Medicine 2005; 6: 326-333. [PMID 16156880]
75. Silk B, del Rio C, Kim Ivansco L, Wetterhall S, Augustine J, Blumberg HM, Berkelman
R. Pre-event Willingness to receive smallpox vaccine among physicians and public
safety personnel. Southern Med Journal 2005; 98 (9):876-882 [PMID 16217979].
76. Beard CB, Fox MR, Lawrence GG, Guarner J, Hanzlick RL, Huang L, del Rio C,
Rimland D, Duchin JS, Colley DG. Genetic Differences in Pneumocystis Isolates
from Immunocompetent Infants and from Adults with AIDS: Epidemiological
Implications. Journal of Infect Dis 2005; 192:1815-8 [PMID 16235182].
77. Nicholls DJ, King M, Holland D, Bala J, del Rio C. Intracranial Tuberculomas
Developing while on Therapy for Pulmonary Tuberculosis. Lancet Infect Dis 2005;
795 – 801 [PMID 16310151].
78. Beckwith CG, Flanigan TP, del Rio C, Bartlett JG. Screening for HIV (Letter to the
Editor). Annals of Intern Med 2005; 143:916.
79. Moanna A, Bajaj R, del Rio C. Emphysematous cholecystitis due to Salmonella derby.
Lancet Infect Dis 2006; 6:118-120. [PMID 16439332]
80. Richards DC, Mikiashvili T, Parris JJ, Kourbatova EV, Wilson JC, Shubladze N,
Tsertsvadze T, Khechinashvili G, del Rio C, Blumberg HM. High Prevalence of
Hepatitis C Infection but not HIV co-infection among patients with Tuberculosis in
the Republic of Georgia. Int J TB and Lung Dis 2006; 10(4): 1-6. [PMID 16602403]
81. Leonard MK, Egan KB, Kourbatova E, White N, Parrott P, del Rio C, Blumberg HM.
Increased efficiency in evaluating patients with suspected pulmonary tuberculosis by
use of a dedicated airborne infection isolation unit. Am J Infect Cont 2006; 34: 69-72.
[PMID 16490609].
82. Whitney EA, Heilpern KL, Woods CW, Bahn CC, Franko EA, del Rio C, Silk BJ,
Ratcliff JJ, Bryant KA, Park MM, Watkins SJ, Caram LB, Blumberg HM, Berkelman
RL. West Nile Virus Infection among Hospitalized Febrile Patients: a case for
expanding diagnostic testing. Vector Borne and Zoonotic Diseases 2006; 6(1): 42 –
49. [PMID 16584326]
83. Stvilia K, Tsertsvadze T, Sharvadze L, Aladashvili M, del Rio C, Kuniholm MH, Nelson
KE. Prevalence of Hepatitis C, HIV, and Risk Behaviors for Blood-Borne Infections:
A population-based study of the adult population of Tbilisi, Republic of Georgia. J
Urban Health 2006; 83 (2): 289 – 298. [PMID 16736377/PMC 2527157]
84. Shapatava E, Nelson KE, Tsertsvadze T, del Rio C. Risk Behaviors and the Transmission
of HIV, Hepatitis B and Hepatitis C among Injecting Drug Users in Georgia. Drug
and Alcohol Dependence 2006; 82 (suppl 1): S35 – S38. [PMID 16769443]
85. Rimland D, Guest JL, Hernandez-Ramos I, del Rio C, Le AN, Brown WV. Antiretroviral
Therapy in HIV Positive Women is Associated with Increased ApoCIII and Total

23
 Cholesterol. J Acquir Immune Def Synd 2006; 42: 307 – 313. [PMID 16770290]
86. Valverde E, Waldrop-Valverde D, Anderson-Mahoney P, Loughlin A, del Rio C, Metsch
L, Gardner L. System and Patient Barriers to Appropriate HIV Care for
Disadvantaged Populations: the HIV Medical Care Provider Perspective. Journal of
the Association of Nurses in AIDS Care 2006; 17(3): 18-28. [PMID 16829359]
87. Hutchinson AB, Farnham PG Dean HD, Ekwueme DU, del Rio C, Kamimoto L,
Kellermann SE. The Economic Burden of HIV in the US in the Era of Highly Active
Antiretroviral Therapy: Evidence of Continuing Racial and Ethnic Differences.
JAIDS 2006; 43: 451 – 457. [PMID 16980906]
88. Hicks G, Barragán M, Franco-Paredes C, Williams M, del Rio C. Health Literacy is a
Predictor of HIV/AIDS Knowledge Level. Family Medicine 2006; 38(10): 717-23.
[PMID 17075745]
89. Kourbatova K, Leonard M, Romo J, Kraft C, del Rio C, Blumberg HM. Risk Factors for
Mortality among patients with intrapulmonary tuberculosis at an academic inner-city
hospital in the US. European J Epidemiol 2006; 21(9): 715-21. [E-pub Oct 27, 2006]
[PMID 17072539]
90. Kourbatova K, Borodulin B, Borodulina E, Leonard M, del Rio C, Blumberg H. Risk
factors for mortality among patients with newly diagnosed tuberculosis in Samara,
Russia. Int J TB & Lung Dis 2006; 10(11): 1224-1230. [PMID 17131780]
91. Markosyan KM, Babikian T, DiClemente RJ, Hirsch JS, Grigoryan S, del Rio C.
Correlates of HIV Risk and Preventive Behaviors in Armenian Female Sex Workers.
AIDS and Behavior 2007; 11(2): 325 – 34. [PMID 16823626]
92. Anthony MN, Gardner L, Marks G, Anderson-Mahoney P, Metsch L, Valverde E, del
Rio C, Loughlin A. Factors associated with use of HIV primary care among persons
recently diagnosed with HIV: Examination of variables from the behavioral model of
health-care utilization. AIDS Care 2007; 19(2): 195-202. [PMID 17364398]
93. Kelley C, Hernandez-Ramos I, Franco-Paredes C, del Rio C. The Clinical and
Epidemiologic Characteristics of Foreign Born Latinos with HIV/AIDS at an Urban
Clinic in the Southeastern United States. The AIDS Reader 2007; 17: 73 – 88. [PMID
17323506]
94. Priddy FH, Pilcher CD, Moore RH, Tambe P, Park MN, Fiscus SA, Feinberg MB, del
Rio C. Detection of acute HIV in an urban HIV counseling and testing population in
the United States. JAIDS 2007; 44(2): 196 - 202. [PMID 17312561]
95. Brewer T, Zhao W, Pereira M, del Rio C, Loughlin A, Anderson-Mahoney P, Gardner L.
Metsch L: ARTAS Study Group. Initiating HIV Care: Attitudes and Perceptions of
HIV Positive Crack Cocaine Users. AIDS and Behavior 2007; 11(6): 879-904. [Epub
ahead of print Feb 13th, 2007] [PMID 17295070].
96. del Rio C, Hall G, Hook EW, Holmes KK, Whittington WLH, Judson FN, et al. Update
to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2006:
Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections.
MMWR 2007; 56(14): 333 – 336.
97. Hirsch JS, Meneses S, Thompson B, Negroni M, Plancarte B, del Rio C. The
inevitability of Infidelity: Sexual Reputation, Social Geographies, and Marital HIV
Risk in Rural Mexico. Am J Publ Health 2007; 97 (6): 986 – 96 [Epub ahead of print
Apr 26th, 2007] [PMID 17463368/PMC 1874214]
98. Gardner LI, Marks G, Metsch LR, Loughlin AM, O’Daniels C, del Rio C, Anderson-

24
 Mahoney P, Wilkinson JD. Psychological and Behavioral correlates of entering care
for HIV infection: The Antiretroviral Treatment Access Study (ARTAS). AIDS
Patient Care and STD 2007; 21 (6): 418-25. [PMID 17594251]
99. Wang SA, Harvey AB, Conner SM, Zaidi AA, Knapp JS, Whittington WLH, del Rio C,
Judson FN, Holmes KK. Trends in antimicrobial resistance for Neisseria gonorrheae
in the United States, 1988 – 2003: the increasing spread of fluoroquinolone-
resistance. Ann Intern Med 2007; 147: 81-88. [PMID 17638718]
100. Vargas-Infante Y, Guerrero L, Ruiz-Palacios G, Soto-Ramirez L, del Rio C, Carranza J,
Dominguez-Cherit G, Sierra-Madero J. Improving Outcome of Human
Immunodeficiency Virus Infected Patients in a Mexican Intensive Care Unit. Arch
Med Res 2007; 38:827-833. [PMID 17923262]
101. Kuniholm M, Mark J, Aladashvili M, Shubladze N, Khechinashvili G, Tsertsvadze T,
del Rio C, Nelson K. Risk factor and algorithms to identify Hepatitis C, Hepatitis B
and HIV infection in Tuberculosis patients in Georgia. Intl J Infect Dis 2008; 12 (1):
51-6. {E-pub 2007 Jul 23} [PMID 17644020/PMC 2649965].
102. Tellez I, Barragán M, Franco-Paredes C, Petraro P, Nelson K, del Rio C. Pneumocystis
jiroveci infection in patients with AIDS in the Inner City: A Persistent and Deadly
Opportunistic Infection. Am J Med Sci 2008; 335(3): 192-97 [PMID 18344692].
103. Salomon MM, Smith MJ, del Rio C. Low educational level: a risk factor for sexually
transmitted infections among commercial sex workers in Quito, Ecuador. Intl J. STD
& AIDS 2008; 19:264 – 267 [PMID 18482947].
104. Mirtskhulava V, Kempker R, Shields KL, Leonard MK, Tsertsvadze T, del Rio C,
Salakaia A, Blumberg HM. Prevalence and Risk Factors for latent tuberculosis
infection among health care workers in Georgia. Int J Tuberc Lung Dis 2008; 12(5):
513-519. [PMID 18419886/PMC 2742226].
105. Frew PM, Archibald M, Martinez N, del Rio C, Mulligan MJ. Promoting HIV Vaccine
Research in African American Communities: Does the Theory of Reasoned Action
Explain Potential Outcomes of Involvement? Challenge (Atlanta Ga). 2007;13(2):61-
97. [PMID 20686675/ PMC2913490]
106. Frew P, del Rio C, Clifton S, Hormes JT, Mulligan J. M. Factors influencing HIV
vaccine community engagement in the urban South. J Community of Health 2008;
33:259-269 {Epub ahead of print Apr 4}, [PMID 18389351].
107. Miller JD, van der Most RG, Akondy RS, Glidewell JT, Albott S, Masopust D, Muraqli-
Krishna K, Mahar PL, Edupuganti S, Lalor S, Germon S, del Rio C, Mulligan MJ,
Staprans SI, Altman JD, Feinberg MB, Ahmed R. Human effector and memory
CD8+ T cell responses to smallpox and yellow fever vaccines. Immunity 2008
May;28(5):710-22. [PMID 18468462]
108. Metsch L, Pereyra M, Messinger S, del Rio C, Strathdee SA, Anderson-Mahoney P,
Rudy E, Marks G, Gardner L. HIV transmission Risk behaviors among HIV-infected
persons who are successfully linked to care. Clin Infect Dis 2008; 47:577-584 [PMID
18624629].
 Article selected for reprint as part of “2009 Clinical Issues in HIV Medicine”,
published by the Infectious Diseases Society of America
109. Mdivani N, Zangaladze E, Volkova N, Kourbatova E, Jibuti T, Shubladze N,
Kutateladze T, Khechinashvili G, del Rio C, Salakaia A, Blumberg HM. High
Prevalence of Multidrug-Resistant Tuberculosis in Georgia. Int J Inf Dis 2008;

25
 12:635 – 644. [PMID 18514008/PMC 2645041].
110. Pulendran P, Miller J, Troy DQ, Akondy R, Moseley N, Laur O, Glidewell J, Monson
N, Zhu T, Staprans S, Lee D, Brinton MA, Perelygin AA, Vellozzi C, Brachman P,
Lalor S, Teuwen D, Eidex RB, Cetron M, Priddy F, del Rio C, Altman J, Ahmed R.
Case of Yellow Fever Vaccine-Associated Viscerothropic Disease with Prolonged
Viremia, Robust Adaptive Immune Responses and Polymorphisms in CCR5 and
Rantes Genes. J Infect Dis 2008; 198: 500-507 [PMID 18598196/PMC 3734802].
111. Smith DJ, Wakasiaka S, Hoang TD, Bwayo JJ, del Rio C, Priddy FH. An evaluation of
intravaginal rings as a potential HIV prevention device in urban Kenya: Behaviors
and attitudes that might influence uptake within a high-risk population. Journal of
Woman’s Health 2008; 17(6): 1-10 [PMID 18681822/PMC 2942749].
112. Kuniholm MH, Aladashvili, del Rio C, Stvilia K, Gabelia N, Chitale RA, Tsertsvadze T,
Nelson KE. Not all Injection Drug Users are Created Equal: Heterogeneity of HIV,
Hepatitis C Virus and Hepatitis B Virus Infection in the Republic of Georgia.
Substance Use and Misuse 2008; 43: 1424-1437, [PMID 18696377/PMC2825388].
113. Gardner LI, Metsch L, Strathdee SA, del Rio C, Mahoney P, Holmberg SD for the
ARTAS Study Group. Frequency of discussing HIV prevention and care topics with
HIV-infected patients: Influence of physician gender, race-ethnicity and practice
characteristics Gender Med 2008; 5(3): 259 – 269 [PMID 18727992]
114. Shuster JM, Sterk CE, Frew P, del Rio C. The Cultural and Community-Level
Acceptance of Antiretroviral Therapy (ART) Among Traditional Healers in Eastern
Cape, South Africa. J of Community Health 2009; 34(1): 16-22 {e-pub ahead of print
Oct 16, 2008} [PMID 18923887].
115. Buchbinder SP, Mehrotra DV, Duerr A, Fitzgerald DW, Mogg R, Li D, Gilbert PB,
Lama JR, Marmor M, del Rio C, McElrath MJ, Casimiro DR, Gottesdiener KM,
Chodakewitz JA, Carey L, Robertson MN, and the Step Study Protocol Team.
Efficacy assessment of a cell-medicated immunity HIV-1 vaccine (the Step Study): a
double-blind, randomized, placebo-controlled, test-of-concept trial. The Lancet 2008;
372(9653):1881-93. [PMID 19012954/PMC 2721012]
116. Frew PM, Archibald M, Martinez N, del Rio C, Mulligan MJ. Promoting HIV Vaccine
Research in African American Communities: Does the Theory of Reasoned Action
Explain Potential Outcomes of Involvement? Challenge 2007; 13(2): 61-97. [PMID
20686675]
117. Frew P, del Rio C, Lu Lu, Clifton S, Mulligan M. Understanding Differences in
Enrollment Outcomes among High-Risk Populations in a Phase IIb HIV Vaccine
Trial. JAIDS 2009; 50 (3): 214-391 [PMID 19194310].
118. Kelley CF, Checkley W, Maninno DM, Franco-Paredes C, del Rio C, Holguin F. Trends
in hospitalizations for AIDS-Related Pneumocystis jeroveci Pneumonia in the United
States (1986 – 2005). Chest 2009; 36(1): 190-7. [PMID 19255292].
119. Metsch LR, Bell C, Cardenas G, Pereyra M, Sullivan T, Rodriguez A, Gooden L,
Khoury N, Kuper T, Brewer T, del Rio C. Hospitalized HIV-infected Patients: A
Population of Concern in the Era of HAART. Am J Publ Health 2009, 99 (6): 1045-9.
[PMID 19372520/PMC 2679801].
120. Gardner L, Marks G, Craw J, Metsch L, Strathdee S, Anderson-Mahoney P, del Rio C.
for the Antiretroviral Treatment Access Study Group. Demographic, psychological,
and behavioral modifiers of the Antiretroviral Treatment Access Study Group. AIDS

26
 Patient Care & STD 2009; 23 (9): 1 – 8. [PMID 19645619].
121. Schaffner J, Chochua S, Kourbatova EV, Barragan M, Wang YF, Blumberg HM, del
Rio C, Walker HK, Leonard MK. High mortality among patients with positive blood
cultures at the children’s hospital in Tbilisi, Georgia. J Infect Dev Ctries 2009 May
1; 3(4): 267-72. [PMID 19759489/PMC 2864639]
122. Akondy RS, Monson ND, Miller JD, Edupuganti S, Teuwen D, Quyyumi F, Garg S,
Altman JD, del Rio C, Keyserling HL, Ploss A, Rice C, Mulligan MJ, Orenstein WA,
Ahmed R. The Yellow Fever Virus Vaccine Induces a Broad and Polyfunctional
Human Memory CD8+ T-cell Response. J Immunol 2009 Dec 15; 183(12):7919-30;
[PMID 19933869/PMC 3374958].
123. Asmuth DM, Brown EL, DiNubile MJ, Sun X, del Rio C, Harro C, Keefer MC, Kublin
JG, Dubey SA, Kierstead LS, Casimiro DR, Shiver JW, Robertson MN, Quick EK,
Mehrotra DV. Comparative Cell-Mediated Immunogenicity of DNA/DNA,
DNA/Ad5, or Ad5/Ad5 HIV-1 Clade B gag Vaccine Prime-boost Regimens. J Infect
Dis 2009 Jan 1; 201(1): 132-41. [PMID 19929694].
124. Bell DM, Weisfuse IB, Hernandez-Avila M, del Rio C, Bustamante X, Rodier G.
Pandemic influenza as 21st century urban health crisis. Emerg Infect Dis 2009;
15(12): 1963 – 9 [PMID 19961676/PMC 3044553]
125. Frew PM, Archibald M, Dixon Diallo D, Hou SI, Horton T, Chan K, Mulligan M, del
Rio C. An Extended Model of Reasoned Action to Understand the Influence of
Individual and Network-Level Factors on African American’s Participation in HIV
Vaccine Research. Prev Sci 2010; 11:207-218, [PMID 20012200; PMC2858782]
126. Esteves-Jaramillo A, Omer SB, Gonzalez-Diaz E, Salmon DA, Hixson B, Navarro F,
Kawa-Karaski S, Frew P, Morfin-Otero R, Rodriguez Noriega E, Ramirez Y, Rosas
A, Acosta E, Varela-Badillo V, del Rio C. Acceptance of a Vaccine Against Novel
Influenza A (H1N1) Virus Among Health Care Workers in Two Major Cities in
Mexico. Arch Med Res 2009; 40: 705-711 [PMID 20304260/PMC2854164]
127. Vogenthaler NS, Hadley C, Lewis S, Rodriguez A, Metsch L, del Rio C. Food
Insufficiency among HIV-infected Crack Cocaine users in Atlanta and Miami. Public
Health Nutr 2010 Jan 15:1-7, [PMID 20074395/PMC 2973997].
128. Narayan KM & del Rio C. Comparative efficacy of influenza vaccines. New Engl J
Med 2010; 362(2): 179-80. [PMID 20071712]
129. Vogenthaler NS, Hadley C, Rodriguez AE, Valverde EE, Metsch L, del Rio C.
Depressive symptoms and food insecurity among HIV-infected crack users in Atlanta
and Miami. AIDS and Behavior 2010; 15(7): 1520-6. [PMID
20099017/PMC2934749].
130. Zaragoza-Macias E, Cosco D, Nguyen M, del Rio C, Lennox JL. Predictors of success
with highly active antiretroviral therapy in an antiretroviral naive urban population.
AIDS Res Hum Retroviruses 2010; Feb;26(2):133-8 [PMID
20156096/PMC2858896].
131. Bell C, Metsch L, Vogenthaler N, Cardenas G, Rodriguez A, Locascio V, Kuper T,
Scharf E, Marquez A, Yohannan M, del Rio C. Never in Care: Characteristics of
HIV-infected crack cocaine users in two U.S. cities who never been to primary
outpatient HIV care. JAIDS 2010; Aug 1; 54(4): 376-80. [PMID
20173648/PMC2888612].
132. Frew PM, Hou SI, Davis M, Chan K, Horton T, Shuster J, Hixson B, del Rio C. The

27
 likelihood of participation in clinical trials can be measured: The Clinical Research
Involvement Scales (CRIS). Journal Clin Epidemiol. 2010; 63: 110-1117. [PMID
20303711/PMC2892193].
133. Crabtree-Ramirez B, Villasis-Keever A, Galindo-Fraga A, del Rio C, Sierra-Madero J.
Effectiveness of Highly Active Antiretroviral Therapy (HAART) among HIV-
infected patients in Mexico. AIDS Res Human Retroviruses 2010; 26 (4): 373 – 378.
[PMID 20377418/ PMC 2933160].
134. Frew PM, Mulligan MJ, Hou, SI, Chan K, del Rio C. Time will tell: community
acceptability of HIV vaccine Research before and after the “Step Study” vaccine
discontinuation. Open Access Journal of Clinical Trials 2010; 2: 149 - 156. [PMID
21152413/PMC 2996614]
135. Wrammert J, Koutsonanos D, Li GM, Edupuganti S, Sui J, Morrissey SM, McCausland
M, Skoutzou I, Hornig M, Lipkin WI, Mehta A, Razavi B, del Rio C, et al. Broadly
cross-reactive antibodies dominate the acute B cell response against pandemic 2009
H1N1 influenza virus infection in humans. J Exp Med 2011, 208(1): 181-93. [PMID
21220454/PMC 3023136]
136. Hixson BA, Omer SB, del Rio C, Frew PM. Spatial Clustering of HIV Prevalence in
Atlanta, Georgia and Population Characteristics Associated with Case
Concentrations. J Urban Health 2011 Feb 8; 88(1):129-41. [PMID 21249526/PMC
3042078].
137. Tsertsvadze T, Chkhartishvili N, Sharvadze L, Dvali N, Chokoshvili O, Gabunia P,
Abutidze A, Nelson K, DeHovitz J, del Rio C. Outcomes of Universal Access to
Antiretroviral Therapy (ART) in Georgia. AIDS Research and Treatment 2011;
2011: 621078. [PMID 21490781/PMC 3065882]
138. Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The Spectrum of
Engagement in HIV Care and its Relevance to “Test and Treat” Strategies for
Prevention of HIV Infection. Clin Infect Dis 2011; 52 (6): 793-800. [PMID
21367734/PMC 3106261]. {Article selected for reprint as part of “2010 Clinical
Issues in HIV Medicine”, published by the Infectious Diseases Society of America}
-Article was published with an accompanying editorial: Lange JMA. “Test and
Treat”: Is It Enough? Clin Infect Dis 2011 (52): 801-2.
139. Priddy FH, Wakasiaka S, Hoang TD, Smith JD, Farah B, del Rio C, Ndinya-Achola J.
Anal sex, vaginal practices and HIV incidence in female commercial sex workers in
urban Kenya: Implications for development of intravaginal HIV prevention methods.
AIDS Res Human Retroviruses 2011; 27(10: 1067-72. [PMID 21406032]
140. Rebolledo-Esteinou P, Kourbatova E, Rothenberg, R, del Rio C. Factors Associated
with Utilization of HAART amongst hard-to-reach HIV-infected individuals in
Atlanta, GA. J AIDS and HIV Research 2011; 3(3): 63-70 [PMID 21866279/PMC
3159491].
141. Frew PM, Hixon B, del Rio C, Esteves-Jaramillo A, Omer S. Acceptance of pandemic
2009 influenza A (H1N1) vaccine in a minority population: determinants and
potential points of intervention. Pediatrics 2011; May; 127 Suppl 1:S113-9. {Epub
2011, Apr 18} [PMID 21502254].
142. Dionne-Odom J, Tambe P, Yee E, Weinstock H, del Rio C. Antimicrobial Resistant
Gonorrhea in Atlanta: 1988 – 2006. Sex Trans Dis 2011; 38 (8): 780 - 782 {Epub
ahead of print March 18; doi: 10.1097/OLQ.0b013e318214e306} [PMID

28
 21844728/PMC 3156986/NIHMS 280105].
143. Wheatley MA, Copeland B, Shah B, Heilpern K, del Rio C, Houry D. Efficacy of
Emergency Department Based HIV Screening Program in the Deep South. J Urban
Health 2011; 88(6): 1015-1019. [PMID 21630105/PMC 3232419].
144. Hong NT, Wolfe MI, Dat TT, McFarland DA, Kamb ML, Thang NT, Thai HN, del Rio
C. Utilization of HIV Voluntary Counseling and Testing in Vietnam: An Evaluation
of Five Years of Routine Program Data for National Response. AIDS Education and
Prevention, 2011 June:23(3 Suppl):30-48. [PMID 21689035]
145. Frew PM, Archibald M, Hixson B, del Rio C. Socioecological influences on
community involvement in HIV vaccine research. Vaccine 2011; 29 (36): 6136 - 43
[PMID 21722689/PMC 3170874/NIHMS 314370].
146. del Rio C, Hall G, Hook EW, Whittington W, Kirkcaldy R, Papp JR, Weinstock H,
Murray EL. Cephalosporin Susceptibility Among Neisseria gonorrheae isolates –
United States, 2000 – 2010. MMWR 2011; 60(26): 873 – 977. [PMID 21734634]
147. Kandelaki G, Butsashvili M, Geleishvili M, Avaliani N, Macharashvili N, Topuridze M,
del Rio C, Blumberg H, Tsertsvadze T. Nosocomial Infections in Tbilisi, Georgia: A
retrospective study of microbiological data from 4 major tertiary hospitals. Infect
Control Hosp Epidemiol 2011; 32 (9): 933- 4. [PMID 21828982].
148. Talati N, Gonzalez-Diaz E, Mutemba C, Wendt J, Kilembe W, Mwananyanda L,
Chomba E, Allen S, del Rio C, Blumberg H. Diagnosis of Latent Tuberculosis
Infection among HIV discordant partners using interferon Gama Releasing Assays.
BMC Infectious 2011 Sept 30, 11:264 (doi:10.1186/1471-2334-11-264). [PMID
21962029/PMC 3198954].
149. Steinau M, Reddy D, Sumbry A, Reznik D, Gunthel CJ, del Rio C, Lennox JL, Unger
ER, Nguyen ML. Oral Sampling and human papillomavirus genotyping in HIV-
infected patients. J Oral Pathol Med 2012; 41(4): 288 – 91 [PMID 22082117]
150. Hogan C, DeGruttola V, Sun X, Fiscus SA, del Rio C, Bradley Hare C, Markowitz M,
Connick E, Macatangay B, Tashima KT, Kallungal B, Camp R, Frazier T, Daar ES,
Little S. The Setpoint Study (ACTG A5217) – Effect of Immediate versus Deferred
Antiretroviral Therapy on Virologic Setpoint in Recently HIV-1 Infected Individuals.
J Infec Dis2012; (1): 87 – 96 [PMID 22180621/PMC 3242744]
151. Doshi RK, Vogenthaler N, Lewis S, Rodriguez A, Metsch L, del Rio C. Correlates of
antiretroviral utilization among hospitalized HIV-infected crack cocaine users. AIDS
Res Hum Retroviruses 2012; 28 (9): 1007 – 14. [PMID 22214200/PMC 3423644]
152. Bonney LE, Cooper HL, Caliendo AM, del Rio C. Hunter-Jones J, Swan DF,
Rothenberg R, Druss B. Access to Health Services and Sexually Transmitted
Infections in a Cohort of Relocating African American Public Housing Residents: An
Association Between Travel Time and Infection. Sex Transm Dis 2012 Feb; 39(2):
116 – 121 [PMID 22249300]
153. Copeland BL, Shah B, Wheatley M, Heilpern K, del Rio C, Houry D. Diagnosing HIV
in Men Who Have Sex with Men: An Emergency Department’s Experience. AIDS
Patient Care and STD 2012; 26 (4): 202 – 7. [PMID 22356726/PMC 3317392]
154. Ofotokun I, Sheth AN, Sanford SE, Easley KA, Shenvi N, White K, Eaton ME, del Rio
C, Lennox JL. A Switch in Therapy to a Reverse Transcriptase Inhibitor Sparing
Combination of Lopinavir/Ritonavir and Raltegavir in Virologically Suppressed HIV-
infected Patients: A Pilot Randomized Trial to Assess Efficacy and Safety Profile:

29
 the KITE Study. AIDS Res Human Retroviruses 2012; 28 (10): 1196 – 206 [PMID
22364141/ PMC3448110].
155. Kalokhe A, Paranjape A, Bell CE, Cardenas GA, Kuper T, Metsch LR, del Rio C.
Intimate Partner Violence among HIV-infected crack cocaine users. AIDS Patient
Care and STDS 2012; 25(4): 234 – 40. [PMID 22364209/PMC 3317393]
156. Leeds IL, Magee MJ, Kurbatova EV, del Rio C, Blumberg HB, Leonard MK, Kraft CS.
Site of extrapulmonary tuberculosis is associated with HIV infection. Clin Infect Dis
2012; 55(1): 75 – 81 [PMID 22423123/PMC 3493181].
157. Frew PM, Painter JE, Hixson B, Kulb C, Moore K, del Rio C, Esteves-Jaramillo A,
Omer SB. Factors mediating seasonal and influenza A (H1N1) vaccine acceptance
among ethnically diverse populations in the urban south. Vaccine 2012; 30 (28):
4200 – 8. [PMID 22537991/PMC 35222428]
158. Duerr A, Huang Y, Buchbinder S, Coombs RW, Sanchez J, del Rio C, Casapia M,
Santiago S, Gilbert P, Corey L, Robertson MN, for the Step/HVTN 504 study team.
Extended follow-up confirms early vaccine-enhanced risk of HIV acquisition and
demonstrates waning effect over time among participants in a randomized trial of a
recombinant adenovirus HIV vaccine (Step study). J Infect Dis 2012; 206 (2): 258 –
66. [PMID 22561365/PMC 3490694]
159. Goldstein E, Kirkcaldy RD, Reshef D, Berman S, Weinstock H, Sabeti P, del Rio C,
Hall G, Hook EW, Lipsitch M. Factors Related to Increasing Prevalence of
Resistance to Ciprofloxacin and other Antimicrobial Drugs in Neisseria gonorrheae,
United States. Emerg Infect Dis 2012; 18(8): 1290 – 7. [PMID 22840274/PMC
3414012]
160. del Rio C, Hall G, Holmes K, Soge O, Hook EW, et al. Update to CDC’s Sexually
Transmitted Diseases Treatment Guideline, 2010: Oral Cephalosporins no Longer a
Recommended Treatment for Gonococcal Infections. MMWR 2012; 61(31): 590 –
594. [PMID 22874837] (also published in JAMA 2012; 308(18): 1850 – 1853)
161. Kelley CF, Rosenberg ES, O’Hara BM, Sanchez T, del Rio C, Sullivan PS. Prevalence
of Urethral Trichomonas vaginalis in Black and White Men Who Have Sex with
Men. Sex Transm Dis 2012; 39(9): 739. [PMID 22902674/PMC 3665349]
162. Edupuganti S, Eidex R, Keyserling H, Orenstein W, del Rio C, Akondy R, Lanciotti R,
Pan Y, Querec T, Lipman H, Barrett A, Ahmed R, Teuwen D, Cetron M, Mulligan
M. A Randomized, double-blind, controlled trial of the 17D Yellow fever virus
vaccine in combination with immune globulin or placebo: comparative viremia and
immunogenicity. Am J Trop Med & Hyg 2013; 88 (1): 172 – 7. [PMID
23208880/PMC 3541731]
163. Kelley CF, Rosenberg ES, O’Hara BM, Frew PM, Sanchez T, Peterson JL, del Rio C,
Sullivan PS. Measuring Population Transmission Risk for HIV: An Alternative
Metric of Exposure in Men Who Have Sex with Men (MSM) in the US. PLoS One
2012; 7 (12): e53284. Doi: 10.1371/journal.pone.0053284. [PMID 23285274/PMC
3532405].
164. Hodder SL, Justman J, Hughes J, Wang J, Haley D, Adimora AA, del Rio C, Golin CE,
Kou I, Rompalo A, Soto-Torres L, Mannheimer SB, Johnson-Lewis L, Eshleman SH,
El-Sadr W for the HIV Prevention Trials Network 064 ; the Women’s HIV
SeroIncidence Study Team. HIV Acquisition Among Women from Selected Areas of
the United States: A Cohort Study. Ann Intern Med 2013; 158 (1): 10 – 18. [PMID

30
 23277896]
165. Kirkcaldy RD, Zaidi A, Hook EW, Holmes KH, Soge O, del Rio C, Hall G, Papp J,
Bolan G, Weinstock HS. Neisseria gonorrheae Antimicrobial Resistance among
Men who Have Sex with Men and Men who have Sex with Women, The Gonococcal
Isolate Surveillance Project, 2005 – 2010. Ann Intern Med 2013; 158: 321 – 328
[PMID 23460055]
166. Dionne-Odom J, Karita E, Kilembe W, Henderson F, Vwalika B, Bayingana R, Li
Zhigang, Mulenga J, Chomba E, del Rio C, Khu NH, Tichacek A, Allen S. Syphilis
Treatment Response among HIV Discordant Couples in Zambia and Rwanda. Clin
Infect Dis 2013; 56(23): 1829 – 37. [PMID 23487377/PMC 3658364]
167. Acosta AM, Bonney LE, Fost M, Green VL, del Rio C. HPV Knowledge among a
Marginalized Population [Letter]. Prev Chronic Dis 2013 Mar; 10;E44. doi:
10.5888/pcd10.130088. [PMID 23537518].
168. Martin D, Dbouk RH, Deleon-Carnes M, del Rio C, Guarner J. Haemophilus influenzae
acute endometritis with bacteremia: case report and literature review. Diagn
Microbiol Infect Dis 2013 Jun; 76(2): 235 – 6. [PMID 23537790]
169. Guarner, J, Armstrong WS, Satola SW, Mehta AK, Jerris R, Hilinski J, Burd, EM, Kraft
CS, del Rio C. Development, Implementation, and Evaluation of a 4th year Medical
School Elective Course in Clinical Microbiology Using Case-Based Vignettes. J Med
Microbiol 2013 Jul; 62(Pt 7): 1098 - 110 [PMID 23579393].
170. Guarner J, Burd EM, Williams TC, Jerris R, del Rio C. Unusual empyema
Pseudozyma aphidis. J Clin Microbiol 2013; 51(7): 2017 [PMID 23785070/PMC
3697655] & Answer to July 2013 Photo Quiz. J Clin Microbiol 2013; 51(7): 2473
[PMID 23785071/PMC 3697724].
171. Koblin BA, Mayer KH, Esheman SH, Wang L, Mannheimer S, del Rio C, Shaptaw S,
Magnus M, Buchbinder S, Wiltion L, Lui TY, Cummings V, Piwowar-Manning E,
Dields SD, Grifith S, Elharrar V, Wheeler D for the HPTN 061 Protocol Team.
Correlates of HIV acquisition in a cohort of Black men who have sex with men in the
United States: HIV Prevention Trials Network (HPTN) 061. PLoS ONE 2013 Jul 26;
8(7): e70413. doi:10.1371/journal.pone.0070413. [PMID 23922989/PMC 3724810]
172. Adimora AA, Hughes JP, Wang J, Haley DF, Golan CE, Magus M, Rompalo A,
Justman J, del Rio C, El-Sadr W, Mannheimer S, Soto-Torres L, Hodder S. for the
HPTN 064 Protocol Team. Characteristics of Multiple and Concurrent Partnerships
among Women at High Risk for HIV Infection. JAIDS 2014; 65(1): 99 – 106 {Epub
ahead of print Sept 4, 2013} [PMID 24056163; PMC 4172374]
173. Hussen SA, Stephenson R, del Rio C, Wilton L, Wallace J, Wheeler D, for the HPTN
061 Protocol Team. HIV Testing Patterns among Black Men who have Sex with
Men: A Qualitative Typology. PLoS One 2013, Sept 19; 8(9): e75382.
Doi:10.1371/journal.pone.0075382. [PMID 24069408/PMC 3777907]
174. Marzinke MA, Clarke W, Wang L, Cummings V, Liu T-Y, Piwowar-Manning E,
Breaud A, Griffith S, Buchbinder S, Shoptaw S, del Rio C, Magnus M, Mannheimer
S, Fields SD, Mayer KH, Wheeler DP, Koblin BA, Eshleman SH, and Fogel JM.
Non-disclosure of HIV status in a clinical trial setting: antiretroviral drug screening
can help distinguish between newly-diagnosed and previously-diagnosed HIV
infection. Clin Infect Dis. 2014; 58(1) 117 - 120. [PMID 24092804/PMC 3864502].
175. DeMoss M, Bonney L, Grant J, Klein R, del Rio C, Backer JC. Perspectives of Middle-

31
 Aged African American Women in the Deep South on Antiretroviral Therapy
Adherence. AIDS Care 2014; 26(5):532-7. [PMID 24099510].
176. Chkhartishvili N, Kempker RR, Dvani N, Abashidze L, Sharavdze L, Gabunia P,
Blumberg H, del Rio C. Tsersvadze T. Poor agreement between interferon-gamma
release assays and the tuberculin skin test among HIV-infected individuals in the
country of Georgia. BMC Infect Dis 2013; Nov 1; 13(1): 513 [PMID 24176032/PMC
3817813].
177. Marconi VC. Wu B, Hampton J, Ordonez CE, Johnson BA, Singh D, John S, Gordon M.
Hare A, Murphy R, Nachega J, Kuritzkes DR, del Rio C, Sunpath H and South
Africa Resistance Cohort Study Team. Early Warning Indicators for First-line
Failure Independent of Adherence Measures in a South African Urban Clinic. AIDS
Patient Care STDS 2013 Dec; 27(12): 657 – 68. [PMID 24320011/PMC 3868291]
178. Lomtadze N, Kupreishvili L, Salakaia A, Vashakidze S, Sharvadze L, Kempker RR,
Mcgee MJ, del Rio C, Blumberg HM. Hepatitis C Virus co-infection increases the
Risk of Anti-Tuberculosis Drug-Induced Hepatotoxicity among Patients with
Pulmonary Tuberculosis. PLoS ONE 2013; 8(12): e83892. doi:
10.1371/journal.pone.0083892. [PMID 24367617/PMC 3817813]
179. Imai K, Sutton MY, Mdodo R, del Rio C. HIV and Menopause: A Systematic Review
of the Effects of HIV Infection on Age at Menopause and the Effects of Menopause
on the Response to Antiretroviral Therapy. Obstet Gynecol Int. 2013; 2013: 340309.
doi: 10.1155/2013/340309. [PMID 24454386/PMC 3880754]
180. Chkhartishvili N, Sharvadze L, Chokoshvili O, Bolokadze N, Rukhadze N, Kempker R,
DeHovitz J, del Rio C, Tsertsvadze T. Mortality and causes of death among HIV
infected individuals in the country of Georgia: 1989 – 2012. AIDS Res Hum
Retroviruses 2014 Jun; 30(6): 560 – 6. [PMID 24472093/PMC 4046195]
181. Mayer KM, Wang L, Koblin S, Mennheimer S, Magus M, del Rio C, Buchbinder S,
Wilton L, Cummings V, Watson C, Piwowar-Manning E, Gaydos C, Eshleman SH,
Clarke W, Liu T-Y, Griffith S, Wheeler S for the HPTN 061 Team. Concomitant
Socioeconomic, Behavioral, and Biological Factors Associated with the
disproportionate HIV infection burden among Black Men who have Sex with Men in
6 US Cities. PLoS ONE 2014 Jan 31, 9(1): e87298.
Doi:10.1371/journal.pone.0087298. [PMID 24498067/PMC 3909083]
182. Hussen SA, Tsegaye M, Argaw MG, Andes K, Gilliard D, del Rio C. Spirituality,
Social Capital and Service: Factors Promoting Resilience among Expert Patients
living with HIV in Ethiopia. Glob Public Health 2014; 9(3):286-98. [PMID
24520996]
183. Winskell K, Evans D, Stephenson R, del Rio C, Curran JW. Incorporating Global
Health Competencies into the Public Health Curriculum. Publ Health Reports 2014;
129 (2): 203 – 208. [PMID 24587558]
184. Sullivan PS, Peterson J, Rosenberg ES, Kelley CF, Cooper H, Vaughan A, Salazar LF,
Wingood G, DiClemente R, del Rio C, Mulligan M, Sanchez TH. Understanding
Racial HIV/STI Disparities in Black and White Men Who Have Sex with Men: A
Multilevel Approach. PLoS ONE 9(3): e90514.doi:10.1371/journa.pone.0090514.
[PMID 24608176/PMC 3946498]
185. Rosa-Chuha I, Hootoon TM, Cardenas GA, del Rio C, Bonney LE, Pereyra M. Metsch
LR. Human Papillomavirus Awareness among HIV-infected drug users in two urban

32
 areas. Int J STD AIDS 2014; 25(14): 992-996. Doi: 10.1177/0956462414527070
[PMID 24616115]
186. White D, Rosenberg ES, Cooper HL, del Rio C, Sanchez TH, Salazar LF, Sulllivan PS.
Racial differences in the validity of self-reported drug use among men who have sex
with men in Atlanta, GA. Drugs & Alcohol Dep 2014; 138: 146 – 53.
doi.org/10.1016/j_drugalcdep.2014.02.25 [PMID 24629628]
187. Piwowar-Manning E, Fogel JM, Leayendecket O, Wolf S, Cummings V, Merzinke MA,
Clarke W, Breaud A, Wendel S, Wang L, Swanson P, Hackett J, Manheimer S, del
Rio C, Kuo I, Harawa NT, Koblin BA, Moore R, Blakson JN, Echleman SH. Failure
to Identify HIV-Infected Individuals in a Clinical Trial Using Single HIV Rapid Test
for Screening. HIV Clin Trials 2014; 15(2): 62 – 68. [PMID 24710920/PMC
4167641]
188. Chkhartishvili N, Rukhadze N, Svanidze M, Sharadze L, DeHovitz JA, Tsertsvadze T,
McNutt LA, del Rio C. Evaluation of multiple measures of antiretroviral adherence
in the Eastern European country of Georgia. J Int AIDS Soc 2014; Apr 9; 17 (1):
1885. doi: 10.7448/IAS.17.18885.eCollection 2014. [PMID 24721464/PMC
3983475]
189. Peterson JL, Bakeman R, Sullivan P, Millett GA, Rosenberg E, Salazar L, DiClemente
RJ, Cooper H, Kelley CF, Mulligan MJ, Frew P, del Rio C, Social Discrimination
and Resiliency are not associated with Differences in Prevalent HIV Infection in
Black and White Men who had Sex with Men. J Acquir Immune Defic Syndr 2014;
66(5): 538 – 43. [PMID 24820109].
190. Hussen SA, Andes K, Gilliard D, Chakraborty R, del Rio C, Malebranche DJ.
Transition to Adulthood and Antiretroviral Adherence Among HIV-Positive Young
Black Men Who Have Sex with Men. Am J Public Health 2015 Apr; 105(4):725-31
[PMID 24922167]
191. Chkhartishvili N, Sharavdze L, Chokoshvili O, DeHovitz J, del Rio C, Tsertsvadze T.
The Cascade of Care in the Eastern European Country of Georgia. HIV Med 2015;
16(1): 62 - 66. doi: 10.1111/hiv.12172. [PMID 24919923 /PMCID 4264988/].
192. Hare AQ, Ordonez CE, Johnson BA, del Rio C, Kearns RA, Wu B, Hampton J, Wu P,
Sunpath H, Marconi VC. Gender-Specific Risk Factors for Virologic Failure in
KwaZulu-Natal: Automobile Ownership and Financial Insecurity. AIDS Behav
2014; 18(11): 2219-2229 [PMID 25037488]
193. Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH,
Montaner JS, Wheeler DP, Grant RM, Grinsztejn B, Kumarasamy N, Shoptaw S,
Walensky RP, Dabis F, Sugarman J, Benson CA. HIV Prevention in Clinical Care
Settings: 2014 Recommendations of the International Antiviral Society-USA Panel.
JAMA 2014; 312(4): 390 – 409. [PMID 25038358]
194. Hernandez-Romieu AC, Sullivan PS, Sanchez TH, Kelley CF, Peterson JL, del Rio C,
Salazar LF, Frew PM, Rosenberg ES. The comparability of men who have sex with
men recruited from venue-time-space sampling and Facebook: a cohort study. JMIR
Res Protoc 2014 July 17; 3(3):e37.doi:10.2195/resprot3342. [PMID 25048694]
195. Sanchez TH, Kelley CF, Rosenberg E, Luisi N, O’Hara B, Lambert R, Coleman R, Frew
PM, Salazar LF, Tao S, Clarke W, del Rio C, Sullivan PS. Lack of Awareness of HIV
Infection: Problems and Solutions with Self-reported HIV Serostatus of Men Who
Have Sex with Men. Open Forum Infect Dis 2014 Sept 13; 1(2):ofu084. doi:

33
 10.1093/ofid/ofu084 [PMID 25734150].
196. Chen I, Cummings V, Fogel JM, Marzinke MA, Clarke W, Connor MB, Griffith S,
Buchbinder S, Shaptaw S, del Rio C, Magnus M, Mannheimer S, Wheeler DP,
Mayer KH, Koblin BA, Eshleman SH, . Low-level Viremia Early in HIV Infection.
J Acquir Immune Defic Syndr 2014; 67(4): 405 – 8. [PMID 25140905; PMC
4213245]
197. Cooper HLF, Linton S, Haley DF, Kelley ME, Dauria EF, Karnes CC, Ross Z, Hunter-
Jones J, Renneker KK, del Rio C, Adimora A, Wingood GM, Rothenberg RR,
Bonney LE. Changes in Exposure to Neighborhood Characteristics Are Associated
with Sexual Network Characteristics in a Cohort of Adults Relocating from Public
Housing. AIDS and Behavior 2015 Jun; 19(6):1016-30. [PMID 25150728]
198. Mannheimer SB, Wang L, Wilton L, Tieu HV, del Rio C, Buchbinder S, Fields S, Glick
S, Conor MB, Cummings V, Eshleman SH, Koblin B, Mayer KH. Infrequent HIV
Testing and Late HIV Diagnosis Are Common Among A Cohort of Black Men who
have Sex with Men (BMSM) in Six US Cities. J Acquir Immune Defic Syndr 2014;
67(4): 438-45. [PMID 25197830]
199. Cooper HLF, Haley DF, Linton S, Hunter-Jones J, Martin M, Kelley ME, Karnes CC,
Ross Z, Adimora AA, del Rio C, Rothenberg R., Wingood GM, Bonney LE. Impact
of Public Housing Relocations: Are changes in neighborhood conditions related to
STIs among relocaters? Sex Transm Dis 2014 Oct;41(10):573-9. doi:
10.1097/OLQ.0000000000000172. [PMID 25211249]
200. Lofgren SM, Friedman R, Ghermay R, George M, Pittman JR, Shahane A, Zeimer D,
del Rio C, Marconi VC. Integrating Early Palliative Care for patients with HIV:
Provider and patient perceptions of symptoms and need for services. Am J Hosp
Palliat Care 2014 Sept 12; doi: 10.1177/1049909114550391. [PMID 25216735]
201. Okafor N, Rosenberg ES, Luisi N, Sanchez T, del Rio C, Sullivan PS, Kelley, CF.
Disparities in herpes simplex virus type 2 infection between Black and White Man
who have Sex with Men in Atlanta, GA. Int J STD AIDS 2014; Sept 22. Pii:
0956462414552814. [PMID 25246424].
202. Guarner, J, Burd EM, Kraft CS, Armstrong WS, Lennorr K, Spicer JO, Martin D, del
Rio C. Evaluation of an online program to teach microbiology to internal medicine
residents. J Clin Microbiol 2015; 53(1): 278-81. doi: 10.1128/JCM.02696-14. [PMID
25392364]
203. Ali, MK, McKeever K, Gregg EW, del Rio C. A Cascade of Care for Diabetes in the
United States: Visualizing the Gaps. Ann Intern Med 2014; 161: 681-689. doi:
10.7326/M14-0019 [PMID 25402511]
204. Kirkcaldy RD, Soge O, Papp JR, Hook EW, del Rio C, Kublin G, Weinstock HS.
Neisseria gonorrhoeae azithromycin susceptibility in the United States, the
Gonococcal Isolate Surveillance Project: 2005 – 2013. Antimicrob Agents
Chemother 2015; 59(2): 998 – 1003. Doi: 10.1128/AAC.04337-14. [PMID
25451056]
205. Rosenberg ES, Millett GA, Sullivan PS, del Rio C, Curran JW. Understanding the HIV
disparities between Black and White men who have sex with men in the USA using
the HIV care continuum: a modelling study. Lancet HIV 2014; 1(3):e112-e118.
[PMID 25530987/PMC 4269168]
206. Kenya S, Chida N, Cardenas G, Pereyra M, del Rio C, Rodriguez A, Metsch L. Case

34
 Management: Steadfast Resource for Addressing Linkage to Care and Prevention
with Hospitalized HIV-infected Crack Users. J HIV AIDS Soc Serv 2014; 13(4): 325
– 26. [PMID 25635176; PMC 4307800]
207. Chow JY, Alsan M, Armstrong WS, del Rio C. Marconi VC. Risk factors for AIDS-
defining illnesses among a population of poorly adherent people living with
HIV/AIDS in Atlanta, Georgia. AIDS Care 2015; Feb 9: 1 – 5. [PMID 25660100].
208. GuarnerJ, Amukele T, Mehari M, Gemechu T, Woldeamanuel Y, Winkler AM, Wilson
ML, del Rio C. Building Capacity in Laboratory Medicine in Africa by Increasing
Physician Involvement: A Laboratory Medciine Course for Clinicians. Am J Clin
Pathol 2015; 143(3): 405 -411. [PMID 25696799].
209. Leon JS, Winskell K, McFarland DA, del Rio C. A case-based, problem-based learning
approach to prepare master of public health students for the complexities of global
health. Am J Public Health 2015 Mar ; 105 (Suppl 1): S92 -6. [PMID 25706029]
210. Weissman HM, Biousse V, Schechter MC, del Rio C, Yeh S. Bilateral central retinal
artery occlusion associated with herpes simplex virus-associated acute retinal artery
necrosis and meningitis: case report and literature review. Ophthalmic Surg Lassers
Imaging Retina 2015; 46(2): 279 – 83. [PMID 25707059]
211. Kelley C, Vaughan A, Luisi N, Sanchez TH, Salazar LF, Frew P, Cooper H, DiClemente
R, del Rio C, Sullivan P, Rosenberg E. The effect of high rates of bacterial sexually
transmitted infections on HIV incidence in a cohort of black and white men who have
sex with men in Atlanta, GA. AIDS Res Hum Retroviruses 2015; Jun; 31(6): 587 –
92. doi: 10.1089/AID.2015.0013. [PMID 25719950]
212. Sanchez T, Kelley CF, Rosenberg E, Luisi N, O’Hara B, Lambert R, Coleman R, Frew
P, Salazar LF, Tao S, Clarke W, del Rio C, Sullivan PS. Lack of Awareness of
Human Immunodeficiency Virus (HIV) Infection: Problems and Solutions with Self-
reported HIV Serostatus of Men who have Sex with Men. Open Forum Infect Dis
2014; Sept 13; 1(2):ofu084. doi: 10.1093/ofid/ofu084. [PMID 25734150; PMC
4281805]
213. Ezewudo MN, Joseph SJ, Castillo-Ramirez S, Dean D, del Rio C, Didelot X, Dillon JA,
Delden RF, Shafer WM, Turingan RS, Unemo M, Read TD. Population structure of
Neisseria gonorrhoeae based on whole genome data and its relationship with
antibiotics resistance. Peer J 2015 Mar 5; 3:e806. doi: 10.7717/peerj.806. eCollection
2015. [PMID 25780762; PMC 4358642]
214. Kalokhe AS, Potdar RR, Stephenson R, Dunkle KL, Paranjape A, del Rio C, Sahay S.
How Well Does the World Health Organization Definition of Domestic Violence
Work in India? PLoS One 2015; Mar 26; 10(3):e0120909. doi:
10.1371/journal.pone.0120909. [PMID 25811374; PMC 4374684].
215. Chen I, Connor MB, Clarke W, Marzinke MA, Cummings V, Breaud A, Fogel JM,
Laeyendecker O, Fields SD, Donnell D, Griffith S, Scott HM, Schoptaw S, del Rio
C, Magus M, Mannheimer S, Wheeler DP, Mayer KH, Koblin BA, Eshleman SH.
Antiretroviral drug use and HIV drug resistance among HIV-infected Black men who
have sex with men: HIV Prevention Trials Network 061. J Acquir Immune Defic
Syndr 2015 Aug 1;69(4): 446 – 53. doi: 10.1097/QAI.0000000000000633. [PMID
25861015]
216. Vaughan AS, Kelley CF, Luisi N, del Rio C, Sullivan PS, Rosenberg ES. An
application of propensity score weighting to quantify the casual effect of rectal

35
 sexually transmitted infections on incident HIV among men who have sex with men.
BMC Med Res Methodol 2015 Mar 21; 15(1):25. doi: 10.1186/s12874-015-0017-y.
[PMID 25888416]
217. Sullivan PS, Rosenberg ES, Travis TH, Kelley CF, Luisi N, Cooper HL, DiClemente RJ,
Wingood GM, Frew PM, Salazar LF, del Rio C, Mulligan MJ, Peterson JL.
Explaining racial disparities in HIV incidence in black and white men who have sex
with men in Atlanta, GA: a prospective observational cohort study. Ann Epidemiol
2015 Jun; 25(6): 445 - 54. doi: 10.1016/j.annepidem.2015.03.006. [PMID 25911980]
218. Piñeirua A, Sierra-Madero J, Cahn P, Guevara Palmero RN, Martinex Buitrago E,
Young B, del Rio C. The HIV care continuum in Latin America: challenges and
opportunities. Lancet Infect Dis 2015 Jul; 15(7): 833 – 9. doi: 10.1016/S1473-
3099(15)00108-3. [PMID 26122456].
219. Polgreen PM, Santibanez S, Koonin LM, Rupp ME, Beekmann SE, del Rio C.
Infectious Disease Physician Assessment of Hospital Preparedness for Ebola Virus
Disease. Open Forum Infect Dis 2015 Jun 18; 2(3):ofv087. doi: 10.1093/ofid/ofv087.
[PMID 26180836/PMCID 4499670].
220. Kelley CF, Kahle E, Siegler A, Sanchez T, del Rio C, Sullivan PS, Rosenberg ES.
Applying a PrEP Continuum of Care for Men who Have Sex with Men in Atlanta,
GA. Clin Infect Dis 2015 Nov 15; 61(10): 1590-7. doi:10.1093/cid/civ664. {Epub
2015 Aug 13} [PMID 26270691].
221. Caro-Vega Y, del Rio C, Dias Lima V, Lopez-Cervantes M, Crabtree-Ramirez B,
Bautista-Arredondo S, Colchero MA, Sierra-Madero J. Estimating the Impact of
Earlier ART Initiation and Increased Testing Coverage on HIV Transmission among
Men Who Have Sex with Men in Mexico using a Mathematical Model. PLoS One
2015 Aug 24; 10(8): e0136534. doi: 10.1371/journal.pone.0136534. [PMID
26302044].
222. Tukvadze N, Sanikidze E, Kipiani M, Hebbar G, Easley KA, Shenvi N, Kempker RR,
Frediani JK, Mirtskhulava V, Alvarez JA, Lomtadze N, Vashakidze L, Hao L, del
Rio C, Tangpricha V, Blumberg HM, Ziegler TR. High-dose vitamin D3 in adults
with pulmonary tuberculosis: a double-blind, randomized controlled trial. Am J Clin
Nutr 2015 Nov; 102(5): 1059 – 69. doi: 10.2945/ajcn.115.113886. [PMID 26399865]
223. Kirkcaldy RD, Hook EW 3rd, Soge OO, del Rio C, Kublin G, Zenilman JM, Papp JR.
Trends in Neisseria gonorrhoeae susceptibility to Cephalosporins in the United States,
2006 – 2014. JAMA 2015; Nov 3; 314(17): 1869 – 71. doi:
10.100/jama.2015.10347. [PMID 26529166]
224. Colasanti J, McDaniel D, Johnson B, del Rio C, Sunpath H. Marconi V. Novel
Predictors of Poor Retention Following a Down-referral from a Hospital-based ART
Program in South Africa. AIDS Res Hum Retroviruses 2016 Apr, 32(4):357 – 63.
doi: 10.1089/AID.2015.0227. [PMID 26559521].
225. Colasanti J, Kelly J, Pennisi E, Hu YJ, Root C, Hughes D, del Rio C, Armstrong WS.
Continuous retention and viral suppression provide further insights into the HIV care
continuum compared to the cross-sectional HIV care cascade. Clin Infect Dis 2016;
62(5): 648 – 54. doi: 10.1093/cid/civ941. [PMID 26567263].
226. Goswami ND, Schmitz MM, Sanchez T, Desqupta S, Sullivan P, Cooper H, Rane D,
Kelly J, del Rio C, Waller LA. Understanding Local Spatial Variation along the Care
Continuum: The Potential Impact of Transportation Vulnerability on HIV Linkage to

36
 Care and Viral Suppression in High-Poverty Areas, Atlanta, Georgia. J Aquir
Immune Def Syndr 2016 May 1: 72(1): 65 – 72.
doi:10.1097/QAI.0000000000000914. [PMID 26630673].
227. Kalokhe AS, Stephenson R, Kelly ME, Dunkle KL, Paranjape A, Solas V, Karve L, del
Rio C. Sahay S. The Development and Validation of the Indian Family Violence and
Control Scale. Plos One 2016 Jan 29; 11(1):e0148120. doi:
10.1371/journal.pone.014820. eCollection 2016. [PMID 26824611].
228. Nelson LE, Wilton L, Moineddin R, Zhang N, Siddiqi A, Sa T, Harawa N, Regan R,
Dyer TP, Watson CC, Kobin B, del Rio C, Buchbinder S, Wheeler DP, Mayer KH;
HPTN 061 Study Team. HPTN 061 Study Team. Economic, Legal, and Social
Hardships Associated with HIV Risk among Black Men who have Sex with Men in
Six US Cities. J Urban Health 2016 Feb; 93(1): 170 – 88. doi: 10.1007/s11524-015-
0020-y [PMID 26830422].
229. Kalokhe A, del Rio C, Dunkle K, Stephenson R, Metheny N, Paranjape A, Sahay S.
Domestic violence against women in India: A systematic review of a decade of
quantitative studies. Glob Public Health 2016 Feb 17: 1 – 16 [PMID 26886155].
doi:10.1080/17441692.2015.1119293.
230. Shah M, Perry A, Risher K, Kapoor S, Grey J, Sharma A, Rosenberg ES, del Rio C,
Sullivan P, Dowdy DS. Effect of the US National HIV/AIDS Strategy targets for
improved HIV care engagement: a modelling study. Lancet HIV 2016 Mar;
3(3):e140-6. [PMID 26939737/PMC4787987] doi: 10.1016/S2352-3018(16)00007-2.
231. Colasanti, J, Goswami ND, Khoubian JJ, Pennisi E, Root C, Ziemer D, Armstrong WS,
del Rio, C. The perilous road from HIV diagnosis in the hospital to viral suppression
in the outpatient clinic. AIDS Res Hum Retroviruses 2016 Aug, 32(8): 729 -36
{epub ahead of print March 22} [PMID 27005488]. doi:10.1089/AID.2015.0346.
232. Hernandez-Romieu AC, del Rio C, Hernandez-Avila JE, Lopez-Gatell H, Izazola-Licea
JA, Uribe-Zuniga P, Hernandez-Avila M. CD4 Counts at Entry to Care in Mexico for
Patients under the “Universal Antiviral Treatment Program for the Uninsured
Population”, 2007-2014. PLOS One 2016 Mar 30; 11(3):e0152444. [PMID
27027505/ PMCID 4814060]. doi: 10.1371/journal.pone.0152444.
233. Frew PM, Archibald M, Schamel J, Saint-Victor D, Fox E, Smith-Bankhead N, Diallo
DD, Holstad MM, del Rio C. An Integrated Service Delivery Model to Identify
Persons Living with HIV and to Provide Linkage to HIV Treatment and Care in
Prioritized Neighborhoods: A Geotargeted, Program Outcome Study. JMIR Public
Health Surveill 2015; Oct 8; 1(2): e16. [PMID 27227134]. doi:
10.2196/publichealth.4675.
234. Bazan JA, Peterson AS, Kirkcaldy RD, et al. Notes from the Field. Increase in Neisseria
meningitidis–Associated Urethritis Among Men at Two Sentinel Clinics —
Columbus, Ohio, and Oakland County, Michigan, 2015. MMWR Morb Mortal Wkly
Rep 2016; 65:550–552. [PMID 27254649]. doi: 10.15585/mmwr.mm6521a5.
235. Gardner LI, Marks G, Strathdee SA, Loughlin A, del Rio C, Kerndt P, Mahoney P,
Pitasi MA, Metsch LR. Faster entry into HIV care among HIV-infected drug users
who had been in drug-use treatment programs. Drug and Alcohol Dependence 2016
Aug 1; 165:15 – 21. [PMID 2729678]. doi:10.1016/drugalcdep.2016.05.018
236. Chen I, Huang W, Connor MB, Frantzell A, Cummings V, Beauchamp GG, Griffith S,
Fields SD, Scott HM, Shoptaw S, del Rio C, Magus M, Mannheimer S, Tieu HV,

37
 Wheeler DP, Mayer KH, Koblin BA, Eshelman SH. CXCR4-using HIV variants in a
cohort of Black men who have sex with men: HIV Prevention Trials Network 061.
HIV Clin Trials 2016 Jun 14: 1 – 7 [PMID 27300696]. doi:
10.1080/15284336.2016.1180771.
237. Unemo M, dela Rio C, Shafer WM. 2016. Antimicrobial resistance expressed by
Neisseria gonorrhoeae: a major global public health problem in the 21st century.
Microbiol Spectr 2016 Jun; 4(3): EI10-0009-2015. [PMID 27337478; PMCID
4920088]. doi: 10.1128/microbiolspec.EI10-0009-2015.
238. Metsch LR, Feaster DJ, Gooden L, Matheson T, Stitzer M, Das M, Jain MK, Rodriguez
A, Armstrong WS, Lucas GM, Nijhawan AE, Drainoni ML, Herrera P, Vergara-
Rodriguez P, Jacobson JM, Mugavero MJ, Sullivan M, Daar ES, McMahon DK,
Lindblad R, VanVeldhuiseP, Oden N, Catellon P, Tross S, Haynes LF, Douaihy A,
Sorensen JL, Metzger DS, Mander RN, Colfax GN, del Rio C. Effect of Patient
Navigation with or without financial incentives on viral suppression among
hospitalized patients with HIV infection and substance abuse: A Randomized Clinical
Trial. JAMA 2016; 316(2): 156 – 70. doi:10.1001/jama.20168914 [PMID
27404184].
239. Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero
MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM,
Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection
in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel.
JAMA 2016; 316(2): 191 – 210. doi: 10.1001/jama.2016.8900. [PMID 27404187].
240. Kirkcaldy RD, Harvey A, Papp JR, del Rio C, Soge OO, Holmes KK, Hook EW 3rd,
Kubin G, Riedel S, Zenilman J, Pettus K, Sanders T, Sharpe S, Torrone E. Neisseria
gonorrhoeae Antimicrobial Susceptibility Surveillance – The Gonococcal Isolate
Surveillance Project, 27 Sites, United States, 2014. MMWR 2016; 65(7): 1 – 19.
doi: 10.15585/mmwr.ss6508a1. [PMID 27414503].
241. Evans DP, Anderson M, Shahpar C, del Rio C, Curran JW. Innovation in Graduate
Education for Health Professionals in Humanitarian Emergencies. Prehosp Disaster
Med 2016; Aug 5: 1 – 7. [PMID 27492749].
242. Frew PM, Parker K, Vo L, Haley D, O’Leary A, Dialo DD, Colin CE, Hou I, Soto-
Torres L, Wang J, Adimora AA, Randall LA, del Rio C, Hodder S, HIV Prevention
Trials Network 064 (HPTN) Study Team. Socioecological factors influencing
woman’s HIV risk in the United States: qualitative findings from the woman’s HIV
Seroindicence Study (HPTN 064). BMC Public Health 2016 Aug 17; 16 (1): 803;
doi:10.1186/s12889-016-3364-7. [PMID 27530401; PMCID 4988035].
243. Santibanez S, Polgreen PM, Beekmann SE, Rupp ME, del Rio C. Infectious Disease
Physicians’ Perceptions About Ebola Preparedness Early in the US Response: A
Qualitative Analysis and Lessons for the Future. Health Secur 2016 Sept 1 [Epub
ahead of print]. doi: 10.1089/hs/2016.0038 [PMID 27584854]
244. Kalokhe AS, Ibegbu CC, Kaur SP, Amara RR, Kelley ME, del Rio C, Stephenson R.
Intimae Partner Violence is Associated with Increased CD4+ R-cell Activation
Among HIV-Negative High-Risk Women. Pathog Immun 2016 Spring; 1(1): 193 -
213. [PMID 27668294].
245. Nance RM, Delaney JA, Golin CE, Wechsberg WM, Cunningham C, Altice F,
Christopoulos K, Knight K, Quan V, Gordon MS, Springer S, Young J, Crane PK,

38
 Mayer KH, Mugavero MJ, del Rio C, Kronmal RA, Crane HM. Co-calibration of
two self-reported measures of adherence to antiretroviral therapy. AIDS Care 2016
Dec 2: 1 – 5. doi: 10.1080/09540121.2016.1263721. [PMID 27910703].
246. Chen I, Chau G, Wang J, Clarke W, Marzinke MA, Cummings V, Breaud A,
Laeyendecke O, Fields SD, Griffith S, Scott HM, Shoptaw S, del Rio C, Magnus M,
Mannheimer S, Tieu HV, Wheeler DP, Mayer KH, Koblin BA, Eshleman SH.
Analysis of HIV Diversity in HIV-Infected Black Men Who Have Sex With Men
(HPTN 061). PLoS One 2016 Dec 9; 11(12):e0167629. doi:
10.1371/journal.pone.0167629. [PMID 27936098].
247. Chkhartishvili N, Chokoshvili O, Abutidze A, Dvali N, del Rio C, Tsertsvadze T.
Progress towards achieving the UNAIDS 90-90-90 goals in HIV care: from diagnosis
to durable viral suppression in the country of Georgia. AIDS Res Hum Retroviruses
2017 Jan 4. doi: 10.1089/AID.2016.0103 [PMID 28051324].
248. Colasanti J, Stahl N, Farber EW, del Rio C, Armstrong WS. An Exploratory Study to
Assess Individual and Structural Level Barriers Associated with Poor Retention and
Re-engagement in Care Among Persons Living with HIV/AIDS. J Acquir Immune
Defic Syndr 2017 Feb 1; 74 Suppl 2: S113 – S120. doi:
10.1097/QAI.0000000000001242. [PMID 28079721].
249. Mengistu BS, Vins H, Kelly CM, McGee DR, Spicer JO, Derbew M, Bekele A, Matiam
DH, del Rio C, Blumberg HM, Comeau DL. Student and faculty perceptions of the
rapid scale-up of medical students in Ethiopia. BMC Med Educ 2017 Jan 13;
17(1):11. doi: 10.1186/s12909-016-0849-0. [PMID 28086953].
250. Goswami ND, Colasanti J, Khoubian JJ, Huang Y, Armstrong WS, del Rio C. A
Minority of Patients Newly Diagnosed with AIDS are Started on Antiretroviral
Therapy at the Time of Diagnosis in a Large Public Hospital in the Southeastern
United States. J Int Assoc Provid AIDS Care 2017 Mar/Apr; 16(2): 174 – 179. doi:
10.1177/2325957417692679. [PMID 28198210].
251. Levy ME, Phillips G 2nd, Mangus M, Kuo I, Beauchamp G, Emel L, Hucks-Ortiz C,
Hamilton RL, Wilton L, Chen I, Mannheimer S, Tieu HV, Scott H, Fields SD, del
Rio C, Shoptaw S, Mayer K. A Longitudinal Analysis of Treatment Optimism and
HIV Acquisition and Transmission Risk Behaviors Among Black Men Who Have Sx
with Men in HPTN 061. AIDS Behav 2017 Mar 28. Doi: 10.1007/s10461-017-1756-
z. [PMID 28352984].
252. Tzeng YL, Bazan JA, Turner AN, Wang X, Retchless AC, Read TD, Toh E, Nelson
DE, del Rio C, Stephens DS. Emergence of a new Neisseria meningitidis clonal
complex 11 lineage 11.2 clade as an effective urogenital pathogen. Proc Natl Acad
Sci USA 2017 Apr 3. pii: 201620971. doi: 10.1073/pnas.1620971114. [PMID
28373547].
253. Chen I, Zhang Y, Cummings V, Cloherty GA, Connor M, Beauchamp G, Griffith S,
Rose S, Gallant J, Scott HM, Shoptaw S, del Rio C, Kuo I, Mannheimer S, Tieu HV,
Hurt CB, Fields SD, Wheeler DP, Mayer K, Koblin BA, Eshelman SH. Analysis of
HIV Integrase Resistance in Black Men Who Have Se with Men in the United States.
AIDS Res Hum Retroviruses 2017 Apr 6. doi: 10.1089/1id.2017.0005. [PMID
28384059].
254. Bazan JA, Turner AN, Kirkcaldy RD, Retchless AC, Kretz CB, Briere E, Tzeng YL,
Stephens DC, Maierhofer C, del Rio C, Abrams AJ, Trees DL, Ervin M, Licon DB,

39
 Fields KS, Roberts MW, Dennison A, Wang X. Large Cluster of Neisseria
meningitidis Urethritis in Columbus, Ohio, 2015. Clin Infect Dis 2017; 65(1): 92 -
99. doi: 10.1093/cid/cix215. [PMID 28481980].
255. Alsan M, Beshears J, Armstrong WS, Choi JJ, Marian BC, Nguyen MLT, del Rio C,
Laibson D, Marconi VC. A commitment contract to achieve virologic suppression in
poorly adherent patients with HIV/AIDS. AIDS 2017 May 16. doi:
10.1097/QAD.0000000000001543. [PMID 28514277].
256. Rolle CP, Rosenberg ES, Luisi N, Grey J, Sanchez T, del Rio C, Peterson JL, Frew
PM, Sullivan PS, Kelley CF. Willingness to use pre-exposure prophylaxis among
Black and White men who have sex with men in Atlanta, Georgia. Int J STD AIDS
22017; Aug 28(9): 849-857. doi: 10.1177/0956462416675095. [PMID 28632468].
257. Evans DP, Luffy SM, Parisi S, del Rio C. The development of a massive open online
course during the 2014-15 Ebola virus disease epidemic. Ann Epidemiol 2017; Aug
12. doi:10.10.16/j.annepidem.2017.07.137 [PMID 28844550].
258. Hussen SA, Chakraborty R, Knezevic A, Camacho-Gonzalez A, Huang E, Stephenson
R. del Rio C. Transitioning young adults from pediatric to adult care and the HIV
care continuum in Atlanta, Georgia, USA: a retrospective cohort study. J Int AIDS
Soc 2017 Sept 1; 20(1): 1-9. doi: 10.7448/IAS.20.1.21848 [PMID 28872281].
259. Kirkcaldy RD, Bartoces MG, Soge OO, Riedel S, Kubin G, del Rio C, Papp JR, Hook
EW 3rd, Hicks LA. Antimicrobial Drug Prescription and Neisseria gonorrheae
Susceptibility, United States, 2005 – 2013. Emerg Infect Dis 2017 Oct; 23(10): 1657-
1663. doi: 10.3201/eid2310.170488 [PMID 28930001].
260. Howatt Donahoe EL, RochatRW, McFarland D, del Rio C. From Albania to
Zimbabwe: Surveying 10 years of Summer Field Experiences at the Rollins School
of Public Health. Glob Health Sci Pract 2017 Sept 28; 5(3): 468 – 475. doi:
10.9745/GHSP-D-16-00262. [PMID 28963176].
261. Shiu-Yee K, Brincks AM, Feaster DJ, Frimpong JA, Nijhawan A, Mandler RN,
Schwartz R, del Rio C, Metsch LR. Patterns of Substance Use and Arrest Histories
Among Hospitalized HIV Drug Users: A Latent Class Analysis. AIDS Behav 2018
Jan 5. doi:10.1007/s10461-017-2024-y [PMID 29305761].
262. Kempker RR, Tukvade N, Sthreshley L, Sharling L, Comeau D, Magee MJ, del Rio C,
Avaliani Z, Blumberg HM. The Impact of Fogarty International Center Supported
Tuberculosis Research Training Program in the Country of Georgia. Am J Trop Med
Hyg 2018 Apr’ 98(4): 1069-1074. doi: 10.4269/ajtmh.17-0667 [PMID 29405100].
263. Elliott JC, Brincks AM, Feater DJ, Hasin DS, del Rio C, Lucas GM, Rodriguez AE,
Nijhawan AE, Metsch LR. Psychological Factors Associated with Problem Drinking
Among Substance Users with Poorly Controlled HIV Infection. Alcohol Alcohol
2018 Mar 27. doi: 10.1093/alcalc/agy021. [PMID 29596589]
264. Spaulding AC, Drobeniuc A, Frew PM, Lemon TL, Anderson EJ, Cerwonka C,
Bowden C, Freshley J, del Rio C. Jail, an unappreciated medical home: Assessing
the feasibility of a strengths-based case management intervention to improve the care
retention of HIV-infected persons once released from jail. PLoS One 2018 Mar 30;
13(3):e0191643. doi: 10.1371/journal.pone.0191643. [PMID 29601591]
265. Kalokhe AS, Iyer SR, Kolhe AR, Dhayarkar S, Paranjape A, del Rio C, Stephenson R,
Sahay S. Correlates of domestic violence experience among recently-married women
residing in slums in Pune, India. PLoS One 2018 Apr 2; 13(4):e0195152. doi:

40
 10.1371/journal.pone.0195152. [PMID 29608581].
266. Hussen SA, Easley KA, Smith JC, Shenvi N, Harper GW, Camacho-Gonzalez AF,
Stephenson R, del Rio C. Social Capital, Depressive Symptoms, and HIV viral
Suppression Among Young Black, Gay, Bisexual and Other Men Who Have Sex with
Men Living with HIV. AIDS Behav. 2018 Sept; 22(9): 3024-3032. doi:
10.1007/s10461-018-2105-6. doi: 10.1007/s10461-018-2015-6. [PMID 29619586].
267. Serota DP, Rosenberg ES, Lockard AM, Rolle CM, Luisi N, Cutro S, del Rio C,
Siegler AJ, Sanchez TH, Sullivan PS, Kelley CF. Beyond the Biomedical: PrEP
Failures in a Cohort of Young Black Men who have Sex with Men in Atlanta, GA.
Clin Infect Dis 2018 Aug 31; 67(6): 965-970. doi: 10.1093/cid/ciy297. [PMID
29635415].
268. Schechter MC, Bizune D, Kagei M, Holland DP, del Rio C, Yamin A, Mohamed O,
Oladele A, Wang YF, Rebolledo PA, Ray SM, Kempker RR. Challenges Across the
HIV Care Continuum for Patients with HIV-1 TB co-infection in Atlanta, GA. Open
Forum Infect Dis 2018 Mar 21; 5(4):ofy063. doi: 10.1093/ofid/ofy063. [PMID
29657955].
269. Kalokhe AS, Iyer SR, Gadhe K, Katendra T, Paranjape A, del Rio C, Stephenson R,
Sahay S. Correlates of domestic violence perpetration among recently-married men
residing in slums in Pune, India. PLoS One 2018 May 17; 13(5):e0197303. doi:
10.1371/journal.pone.0197303. [PMID 29771949].
270. Panagiotoglou D, Olding M, Enns B, Feaster DJ, del Rio C, Metsch LR, Granich RM,
Strathdee SA, Marshall BDL, Golden MR, Shoptaw S, Schackman BR, Nosyk B;
Localized HIV Modeling Study Group. Building the case for Localized Approaches
to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS
Epidemic in Six US Cities, AIDS Behav 2018 Sept; 22(9): 3071-3082. doi:
10.1007/s10461-018-2166-6. [PMID 29802550].
271. Colasanti J, Lira MC, Cheng DM, Liebschultz JM, Tsui JI, Forman LS, Sullivan M,
Walley AY, Bridden C, Root C, Podolsky M, Abrams C, Outlaw K, Harris CE,
Armstrong WS, Samet JH, del Rio C. Chronic Opioid Therapy in HIV-infected
Patients: Patients’ Perspectives on Risks, Monitoring and Guidelines. Clin Infect Dis
2018 May 31. doi: 10.1093/cid/ciy452. [PMID 29860411].
272. Stitzer ML, Hammond AS, Matheson T, Sorensen JL, Feaster DJ, Duan R, Gooden L,
del Rio C, Metsch LR. Enhancing Patient Navigation with Contingent Incentives to
Improve Healthcare Behaviors and Viral Load Suppression of Persons with HIV and
Substance Abuse. AIDS Patient Care STDS 2018 Jul; 32(7): 288 – 296. doi:
10.1089/apc.2018.0014. [PMID 29883190].
273. Hussen SA, Chakraboty R, Camacho-Gonzalez A, Nijemoun B, Grossniklaus E,
Goodstein E, Stephenson R, del Rio C. Beyond “purposeful andplanned”: varied
trajectories of healthcare transition for pediatric to adult-oriented care among youth
with HIV. AIDS Care 2018; Jun 13:1 – 3. doi: 10.1080/09540121.2018.1488029.
[PMID 29897258].
274. Karkashadze E, Dvali N, Bolokadze N, Sharvadze L, Gabunia P, Karchava M,
Tschelidze T, Tsertsvadze T, DeHoviit J, del Rio C, Ckhartishvili N. Epidemiology
of human immunodeficiency virus (HIV) drug resitance in HIV patients with
virologic failure of first-line therapy in the country of Georgia. J Med Virol 2019
Feb; 91(2): 325 – 240. doi: 10.1002/jmv.25245. [PMID 29905958].

41
275. Phiblin MM, Feaster DJ, Gooden L, Duan R, Das M, Jacobs P, Lucas GM, Batey DS,
Nijhawan A, Jacobson JM, Mander R, Daar E, McMahon DK, Armstrong WS, del
Rio C, Metsch LR. The North-South divide: substance use risk, care engagement,
and viral suppression among hospitalized HIV-infected patients in 11 U.S. cities.
Clin Infect Dis 2019 Jan 1; 68(1): 146 – 149. doi: 10.1093/cid/ciy506. [PMID
29920584].
276. Safeek RH, Hall KS, Lobelo F, del Rio C, Khoury AL, Wong T, Morey MC, McKellar
MS. Low Physical Activity among Persons Living with HIV/AIDS is Associated
with Poor Physical Function. AIDS Res Hum Retroviruses 2018 Nov; 34(11): 929-
935. doi: 10.1098/AID.2017.0309. PMID [29984584].
277. Colasanti J, Sumitrani J, Mehta CC, Zhang Y, Nguyen ML, del Rio C, Armstrong WS.
Implementation of a Rapid Entry Program Decreases Time to Viral Suppression
Among Vulnerable Persons Living with HIV in the Southern United States. Open
Forum Infect dis 2018 Jun 28; 5(6);ofy104. doi: 10.1093/ofid/ofy104. eCollection
2018 Jun. PMID [29992172].
278. Hussen SA, Argaw MG, Tsegaye M, Andes KL, Gillard D, del Rio C. Gender, power
and intimate relationships over the life course among Ethiopian female peer educators
livingwith HIV. Cult Health Sex 2018 Jul 11: 1 – 15. doi:
10.1080/13691058.2018.1487999. PMID [29993350].
279. Saag MS, Benson CA, Gandhi RT, Hoy JF, Landovitz RJ, Mugaveron MJ, Sax PE,
Smith DM, Thompson MA, Buchbinder SP, del Rio C, Eron JJ Jr, Fatkenheuer G,
Gunthard HF, Molina JM, Dacobsen DM, Volberding PA. Antiretroviral Drugs for
Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the
International Antiviral Society-USA Panel. JAMA 2018 Jul 24; 320(4): 379 – 296.
doi: 10.1001/jama2018.8431. [PMID 30043070].
280. Carroll JJ, Colasanti J, Lira MC, del Rio C, Samet JH. HIV Physicians and Chronic
Opioid Therapy: It’s Time to Raise the Bar. AIDS Behav 2018 Dec 5. doi:
10.1007/s10461-018-2356-2 [PMID 30519904].
281. Hussen SA, Jones M, Moore S, Hood J, Smith JC, Camacho-Gonzalez A, del Rio C,
Harper GW. Brothers Building Brothers by Breaking Barriers: development of a
resilence-building social capital intervention for Young Black gay and bisexual men
living with HIV. AIDS Care 2019 Jan 9: 1 – 8. doi:
10.1080/09540121.2018.1527007. [PMID: 30626207].
282. Tsui JI, Walley AY, Cheng DM, Lira MC, Liebschultz JM, Sullivan MM, Colasanti J,
Root C, O’Connor K, Shanahan CW, Bidden CL, del Rio C, Samel JH. Provider
Opioid prescribing practices and the belief that opioids keep people living with HIV
engaged in care: a cross-sectional study. AIDS Care 2019; Jan 11: 1- 5. doi:
10/1080/09540121.2019.1566591. [PMID 30632790].
283. Kalokhe AS, Iyer S, Katendra T, Gadhe K, Kolhe AR, Paranjape A, del Rio C,
Stephenson R, Sahay S. Primary Prevention of Intimate Partner Violence Among
Recently Married Dyads Residing in the Slums of Pune, India: Development and
Rationale for a Dyadid Intervention. JMIR Res Protoc 2019 Jan 18; 8(1):e11533.
doi: 10.2196/11533. [PMID 30664483].
284. Nijhawan AE, Metsch LR, Zhang S, Feaster DJ, Gooden L, Jain MK, Walker R,
Huffaker S, Mugavero MJ, Jacobs P, Armstrong WS, Daar ES, Sullivan M, del Rio
C, Halem EA. Clinical and Sociobehavioral Prediction Model of 30-Day Hospital

42
 Readmissions Among People with HIV and Substance Use Disorder: Beyond
Electronic Health Record Data. J Acquir Immune Def Syndr 2019 Mar 1:80(3): 330
– 341. doi: 10.1097/QAI.0000000000001925. [PMID 30763292].
285. Rao, SG, Galaviz KI, Gay HC, Wei J, Armstrong WS, del Rio C, Narayan KMV, Ali
MK. Factors Associated with Excess Myocardial Infarction Risk in HIV-Infected
Adults. J Acquir Immune Defic Syndr 2019 Feb 20. doi:
10.1097/QAI.0000000000001996 [PMID 30865179].
286. Brincks AM, Shiu-Yee K, Metsch LR, del Rio C, Schwartz RP, Jacobs P, Osorio G,
Sorensen JL, Feaster DJ. Physician Mistrust, Medical System Mistrust, and
Perceived Discrimination: Associations with HIV Care Engagement and Viral Load.
AIDS Behav 2019 Mar 16. doi: 10.1007/s10461-019-02464-1 [PMID 30879211].
287. Velasquez GE, Huaman MA, Powell KR, Cohn SE, Swaminathan S, Outlaw M, Schute
G, McNeil Q, Currier JS, del Rio C, Castillo-Mancilla J. Outcomes of a Career
Development Program for Underrrepresented Minority Investigators in the AIDS
Clinical Trials Group. Open Forum Infect Dis 2019 Feb 11; 6(3):ofz069. doi:
10.1093/ofid/ofz069. [PMID 30895207].
288. Nosyk B, Min JE, Zang X, Feaster DJ, Metsch L, Marshall BDL, del Rio C, Granich R,
Shackman BR, Montaner JSG. Why Maximizing Quality-Adjusted Life Years, rather
than Reducing HIV Incidence, must remain Our Objective in Addressing the
HIV/AIDS Epidemic. J Int Assoc Provid AIDS Care 2019 Jan-Dec;
18:2325958218821962. doi: 10.1177/2325958218821962 [PMID 30798657].
289. Nance RM, Trejo MEP, Whitney BM, Delaney JAC, Altice F, Beckwith CG, Chander
G, Chandler R, Christopoulus K, Cunningham C, Cunningham WE, del Rio C, et al.
Impact of abstinence and of reducing illicit drug use without abstinence on HIV viral
load. Clin Infect Dis 2019 Apr 17. doi: 10.1093/cid/ciz299 [PMID30994900].
290. Krebs E, Enns B, Wang L, Zang X, Panagiotoglou D, del Rio C, Dombrowski J, Feaster
DJ, Golden M, Granich R, Marshall B, Mehta SH, Metsch L, Schackman BR,
Strathdee SA, Nosyk B; localized modeling study group. Developing a dynamic HIV
transmission model for 6 cities: An evidence of synthesis. PLoS One 2019 May 30;
14(5):e0217559. doi: 10.1371/journal.pone.0217559.eCollection2019 [PMID
31145752].
291. Pan Y, Metsch LR, Gooden LK, Philibin MM, Daar ES, Douaihy A, Jacobs P, del Rio
C, Rodirguez AE, Feaster DJ. Viral suppression and HIV transmission behaviors
among hospitalized patients living with HIV. Int J STD AIDS 2019 Jun
3:956462419846726. doi: 10.1177/0956462419846726. [PMID 31159715].
292. Kempker RR, Chkhartshvili N, Kinkladze I, Schechter MC, Harrington K, Rukhadze N,
Dzigua L, Tserstvadze T, del Rio C, Blumberg HM, Tukvadze N. High Yield of
Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert
MTB/RIF Testing. Open Forum Infect Dis 2019; May 17; 6(6):ofz233. Doi:
10.1093/ofid/ofz233.eCollection 2019 Jun [PMID 31211163].
293. Elliott JC, Critchley L, Feaster DJ, Hasin DS, Madler RN, Osorio G, Rodriguez AE, del
Rio C, Metsch LR. The roles of heavy drinking and drug use in engagement in HIV
care among hospitalized substance using individuals with poorly controlled HIV
infection. Drug Alcohol Depend 2019 Aug 1; 201: 171 – 177. doi:
10.1016/j.drugalcdep.2019.03.024 [PMID 31234013].
294. Lira MC, Tsui JI, Liebschutz JM, Colasanti J, Root C, Cheng DM, et al. Study protocol

43
 for the targeting effective analgesia in clinics for HIV (TEACH) study – a cluster
randomized controlled trial and parallel cohort to increase guideline concordant care
for long-term opioid therapy among people living with HIV. HIV Research &
Clinical Practice. 2019;20(2):48-63 [PMID 31303143].
295. Scott H, Vittinghoff E, Irvin R, Liu A, Nelson L, del Rio C, Magnus M, Mannheimer S,
Fields S, Van Tieu H, Kuo I, Shaptaw S, Grinsztejn B, Sanchez J, Wakefield S, Fuch
JD, Wheeler D, Mayer KH, Koblin BA, Buchbinder S. Development and Validation
of the Personalized Sexual Health Promotion (SexPro) HIV Risk Prediction Model
for Men Who Have Sex with Men in the United States. AIDS Behav 2019 July 27.
doi: 10.1007/s10461-019-02616-3 [PMID 31452633].
296. Kalohe AS, Riddick C, Piper K, Schiff J, Getachew B, del Rio C, Sales JM. Integrating
program-tailored universal trauma screening into HIV care: an evidence-based
participatory approach. AIDS Care 2019 Jul 30: 1 – 8. doi:
10.1080/09540121.2019.1640841 [PMID 31357876].
297. Solomon H, Linton SL, del Rio C, Hussen SA. Housing Instability, Depression, and
HIV Viral Load Among Young Black Gay, Bisexual, and other Men Who Have Sex
with Men in Atlanta, Georgia. J Assoc Nures AIDS Care 2019 Jul 31. doi:
10.1097/JNC.00000000000000114. [PMIC 31369417].
298. Wu X, Gordon O, Jiang W, Antezana BS, Angulo-Zamudio U, del Rio C, Moller A,
Brissac T, Tierney ARP, Warncke K, Orihuela CJ, Read TD, Vidal JE. Interaction
between Steptococcus pneumoniae and Staphylococcus aureus generates OH radicals
that rapidly kills Staphylococcus aureus strains. J Bacteriol 2019 Aug 12. pii:
JB.00474-19. doi: 10.1128/JB.00474-19 [PMID 31405914].
299. Stitzer ML, Gukasyan N, Matheson T, Sorensen JL, Feaster DJ, Duan R, Gooden L, del
Rio C, Metsch LR. Enahncing patient navigation with contingent financial incentives
for substance use abatement in persons with HIV and substance use. Psychl Addict
Behav. 2019 Aug 22. doi: 10.1037/adb0000504. [PMID 31436447].
300. Moore S, Jones M, Smith JC, Hood J, Harper GW, Camacho-Gonzalez A, del Rio C,
Hussen SA. Homonegativity Experienced over the Life Course by Young Black Gay,
Bisexual and Other Men Who Have Sex with Men (YB-GBMSM) Living with HIV
in Atlanta, Georgia. AIDS Behav 2019 Aug 28. doi: 10.1007/s10461-02658-7
[PMID 31463712].
301. Kelly CM, Vins H, Spicer JO, Mengistu BS, Wilson DR, Derbew M, Dekele A, Mariam
DH, del Rio C, Kempker RR, Comeau DL, Blumberg HM. The rapid scale up of
medical education in Ethiopia: Medical student experiences and the role of e-learning
at Addis Ababa University. PLoS One 2019 Sept 5; 14(9):e0221989. doi:
10.1371/journal.pone.0221989.eCollection2019. [PMID 31499518].
302. Serota DP, Rosenberg ES, Sullivan PS, Thorne AL, Rolle CM, del Rio C, Cutro S, Luisi
N, Siegler AJ, Sanchez TH, Kelley CF. Pre-exposure prophylaxis uptake and
discontinuation among young black men who have sex with men in Atlanta, Georgia:
A prospective cohort study. Clin Infect Dis 2019 Sept 10. Pii: ciz894. doi:
10.1093/cid/ciz894. [PMID 31499518].
303. Merlin JS, Samet JH, Cheng DM, Lira MC, Tsui JI, Forman LS, Colasanti J, Walley
AY, del Rio C, Liebschutz JM. Marijuana use and its Associations with Pain, Opioid
Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic
Opioid Therapy. J Acquir Immune Defic Syndr 2019 Oct 1; 82(2): 195 -201. doi:

44
 10.1097/QAI.0000000000002119 [PMID 31513554].
304. Evans DP, Sales JM, Krause KH, del Rio C. You have to be twice as good and work
twice as pard: a mixed-methods study of perceptions of sexual harassment, assault
and women’s leadership among female faclty at a research university in the USA.
Global Health, Epidemiology and Genomics 3, e6, 1-8. doi: 10.1017/gheg.2019.5
[PMID 31523439]
305. Pullen SD, del Rio C, Brandon D, Colonna A, Denton M, Ina M, Lancaster G,
Schmidtke AG, Marconi VC. Associations between chronic pain, analgesic use and
physical therapy among adults living with HIV in Atlanta, Georgia: a retrospective
cohort study. AIDS Care 2019 Spet 17: 1 – 7. doi: 10.1080/09540121.2019.1661950
[PMID 31529994].
306. Nosyk B, Zang X, Krebs E, Nin JE, Behrends CN, del Rio C, Dombrowski J, Feaster
DJ, Golden M, Marshall BDL, Mehta SH, Metsch L, Schackman BR, Shoptaw S,
Strathdee SA. Ending the epidemic in America will not happen if the status quo
continues: modeled projections for HIV incidence in 6 U.S. cities. Clin Infect Dis
2019 Oct 14. pii: ciz1015. doi: 10.1093/cid/ciz1015. [PMID 31609446].
307. Fogel JM, Sivay MV, Cummings V, Wilson EA, Hart S, Gamble T, Laeyendecker O,
Fernandez RE, del Rio C, Batey DS, Mayer KH, Farley JE, McKinstry L, Hughes JP,
Remien RH, Beyrer C, Eshleman SH. HIV drug resitance in a cohort of HIV-infected
men who have sex with men in the United States. AIDS 2019 Oct 10. doi:
10.1097/QAD.0000000000002394. [PMID 31634196].
308. Krebs E, Zang X, Enns B, Min JE, Behrends CN, del Rio C, Dombrowski JC, Feaster
DJ, Gebo KA, Golden M, Marshall BDL, Metsch LR, Schackman BR, Shoptaw S,
Strathdee SA, Nosyk B,; localized economic modeling study Group. The Impact of
Localized implementation: determining the cost-effectiveness of HIV prevention and
care interventions across six United States cities. AIDS 2019 Dec 2. doi:
10.1097/QAD. 0000000000002455. [Epub ahead of print]. [PMID 31794521].
309. Yount KM, Cheong YF, Miedema SS, ChenJS, Menstell E, Maxwell L, Ramakrishnan
U, Clarck CJ, Rochat R, del Rio C. Gender equality in global health leadership:
Cross-sectional survey of global health graduates. Glob Public Health 2019 Dec 23:
1 – 13. doi: 10.1080/17441692.2019.1701057 [PMID 31869280].
310. Summers N, Colasanti J, Feaster D, Armstrong WS, Rodriguez A, Jain M, Jacobs P,
Metsch L, del Rio C. Predictors for Poor Linkage to Care Among Hospitalziaed
Persons Living with HIV and co-occuring Substance Use Disorder. AIDS Res Hum
Retroviruses 2020 Jan 9. doi: 10.1089/AID.2019.0153 [PMID 31914790].
311. Nosyk B, Zang X, Krebs E, Enns B, Min JE, Behrends CN, del Rio C, Dombrowski JC,
Feaster DJ, Colden M, Marshall BDL, Mehta SH, Metsch LR, Pandya A, Schackman
BR, Shoptaw S, Strathdee SA. Ending the HIV epidemic in the USA: an economic
modelling study in six cities. Lancet HIV 2020 Mar 5. pii: S2352-3018(20)30033-3.
doi: 10.1016/S2352-3018(20)30033-3 [PMID 32145760].
312. Serota DP, Capozzi C, Lodi S, Colasanti JA, Forman LS, Trui JI, Walley AY, Lira MC,
Samet J, del Rio C, Merlin JS. Predictors of pain-related functional impairment
among people living with HIV on long-term opioid therapy. AIDS Care 2020 Apr
3:1-9. doi:10.1080/09540121.29020.1748866 [PMID 32242463].
313. Sullivan PS, Sailey C, Guest JL, Guarner J, Siegler AJ, Valentine-Graves M, Gravens
L, del Rio C, Sanchez TH. Detection of SARS-CoV-2 RNA and antibodies in

45
 diverse samples: Protocol to validate the sufficiency of provider-observed home-
collected blood, saliva and oropharyngeal samples. JMIR Public Health Surveill
2020 Apr 19. doi:10.2196/19054 [PMID 32310815].
314. Gandhi RT, Lynch JB, del Rio C. Mild or Moderate Covid-19. N Engl J Med 2020
Apr 24. doi: 10.1056/NEJMcp2009249 [PMID 32329974].
315. Pullen SD, Acker C, Kim H, Mullins M, Sims P, Strasbaugh H, Zimmerman S, del Rio
C, Marconi VC. Physical Therapy for Chronic Pain Mitigation and Opioid Use
Reduction Among People Living with Human Immunodeficiency Virus in Atlanta,
GA: A Descriptive Case Series. AIDS Res Hum Retroviruses 2020 Jun 2.
doi:10.1089/AID.2020.0028. [PMID 32390457].
316. Nosyk B, Krebs E, Zang X, Piske M, Enns B, Min JE, Behrends CN, del Rio C, Feaster
DJ, Golden M, Marshall BDL, Mehta SH, et al. ‘Ending the Epidemic’ will not
happen without addressing racial/ethnic disparities in the U.S. HIV epidemic. Clin
Infect Dis 2020 May 19:ciaa566. doi: 10.1093/cid/ciaa566. [PMID 32424416].
317. Guest JL, Sullivan PS, Valentine-Graves M, Valencia R, Adam E, Luisi N, Nakano M,
Guarner J, del Rio C, Sailey C, Geodecke Z, Siegler AJ, Sanchez TH. Suitability and
Sufficiency of telehealth clinician-observed Participant-collected samples for SARS-
CoV2 testing: the iCollect Cohort Pilot Study. JMIR Public Health Surveill. 2020
May 29. doi: 10.2196/19731 [PMID 32479412].
318. Kaslow NJ, Friis-Healy EA, Cattie JE, Cook SC, Crowell AL, Cullum KA, del Rio C,
et al. Flattening the emotional distress curve: A behavioral health pandemic response
strategy for COVID-19. Am Psychol 2020 Jun 15. doi:10.1037/amp0000694 [PMID
32538638].
319. Critchley L, Carrico A, Gukasyan N, Jacobs P, Mandler RN, Rodriguez AE, del Rio C,
Metsch LR, Feaster DJ. Problem Opioid use and HIV Primary care engagement
among hospitalized people who use drugs and/or alcohol. Addict Sci Clin Pract 2020
Jun 19;15(1):19. doi:10.1186/s13722-020-00192-9. [PMID 32560669].

b. Review articles and Editorials:

1. del Río C. Sarampión: Conceptos actuales sobre un padecimiento antiguo. Gaceta Med Mex
1990; 126(2): 121.
2. Izazola JA, Sánchez HJ, del Río-Chiriboga C. El examen serológico para el virus de
Inmunodeficiencia Humano (VIH) como parte de los exámenes prenupciales. (The
serological exam for the human immunodeficiency virus (HIV) as part of the premarital
exams). Gaceta Med Mex 1992; 128(3):317-27 [PMID 1302741].
3. del Río C, Uribe-Zuñiga P. Prevención mediante el uso del condón de enfermedades
sexualmente transmisibles incluyendo el SIDA. (The prevention of sexually transmitted
diseases and HIV/AIDS through the use of condoms). Salud Públ de México 1993; 35: 508-
17 [PMID 8235898]
4. del Río C. Report from Washington. AIDS Clinical Care 1994; 6(3):21-22.
5. del Río C. Linfopenia ideopática de Linfocitos T CD4+ ("SIDA sin VIH"). Enf Infecc y
Microbiol 1994; 14(2): 108-9.
6. del Río C. New signs on a difficult road. AIDS Clinical Care 1994; 6(10):98-112.

46
7. Valdespino-Gómez JL, del Rio-Chiriboga C, García-García ML, del Río-Zolezzi A, Magis-
Rodríguez C, Salcedo-Alvarez RA, Loo-Méndez ER. Situación y perspectivas del VIH/SIDA
en México. Enf Infecc y Microbiol 1995; 15(1): 29-42.
8. del Río C. Second National Conference on Human Retroviruses: Good News, Bad News,
and No News. AIDS Clinical Care 1995 7(4):30-33 [PMID 11370657].
9. Valdespino-Gómez JL, García-García L, del Río-Chiriboga C, Cruz-Palacios C, Loo-
Méndez E, López-Sotelo A. Las enfermedades de transmisión sexual y la epidemia de
VIH/SIDA. (Sexually Transmitted diseases and the AIDS epidemic in Mexico). Salud Públ
Méx 1995; 37 (6): 549-555 [PMID 8599129].
10. Uribe-Zúñiga P, Hernández-Tepichín G, del Río-Chiriboga C, Ortiz V. Prostitución y
SIDA en la Ciudad de México. (Prostitution and AIDS in Mexico City). Salud Públ Méx
1995; 37 (6): 592-601 [PMID 8599133].
11. Izazola-Licea JA, Avila-Figueroa C, Gortmaker SL, del Río C. Transmisión homosexual
del VIH/SIDA en México. (The Homosexual transmission of HIV/AIDS in Mexico). Salud
Públ Méx 1995; 37 (6): 592-601 [PMID 8599134].
12. Vallejo-Aguilar OJ, Navarrete-Navarro S, del Río-Chiriboga C, Avila-Figueroa C, Santos-
Preciado JI. El trabajador de salud y la consejería sobre el VIH y SIDA. (The healthcare
workers and counseling about HIV/AIDS). Salud Públ Méx 1995; 37 (6): 636-642 [PMID
8599137].
13. Rico B, Bronfman M, del Río-Chiriboga C. Las campañas contra el SIDA en México:
¿Los sonidos del silencio o puente sobre aguas turbulentas? (Campaigns against AIDS in
Mexico: The sounds of silence or a bridge over troubled waters?). Salud Públ Méx 1995; 37
(6): 643-653 [PMID 8599138].
14. Rico-Galindo B, Uribe-Zúñiga P, Panebianco-Labbe S, del Río-Chiriboga C. El SIDA y
los derechos humanos. (AIDS and Human Rights). Salud Públ Méx 1995; 37 (6): 661-668
[PMID 8599140].
15. del Río-Chiriboga C & del Río-Rodríguez C. Clásicos en Salud Pública. Salud Públ Méx
1995; 37 (3):256-263. (Translated into English and published with the title “Yellow-fever in
Veracruz” in Public Health Pap Rep 1892; 18: 292 – 295; [PMC 2266564])
16. del Río C. Tratamientos para el SIDA y Padecimientos Asociados: Costo y Efectividad.
Gaceta Médica de México 1996; 132 (suppl 1): 77-82.
17. del Río C. El tratamiento de la infección por el VIH. Estado actual del arte en 1996 y
posibilidades a futuro. Gaceta Médica de México 1996; 132 (suppl 1): 125-131.
18. Magis C, Loo EL, del Río C. La epidemia de SIDA en México. Análisis global, 1981-
1996 (Epidemic of AIDS in Mexico. Global Analysis 1981 – 1996). Gaceta Médica de
México 1996; 132 (5): 545-550 [PMID 8966625].
19. del Río C & Hernández-Tepichín G. Conference Report: Optimism Rises on Combination
Therapy and Protease Inhibitor Data. AIDS Clinical Care 1996; 8(3):19-23 [PMID
11363408].
20. del Río C & Panebianco-Labbé S. AIDS, Human Rights, and NAFTA: Challenges and
Opportunities. Canadian HIV/AIDS Policy & Law Newsletter 1996; 3(1): 5-6.
21. del Rio C. Report from Washington Meeting January 22-26. AIDS Clinical Care 1997;
9(3):20-23 [PMID 11364122].
22. del Rio C & Soto-Ramírez LE. Bridging the Gap? AIDS Clinical Care 1998; 10(9): 65-72
[PMID 11365808].

47
23. del Rio C. Is ethical research feasible in Developed and Developing Countries? Bioethics
1998; 12(43): 328-330 [PMID 11657299].
24. Little S & del Rio C. Time for a change? AIDS Clinical Care 1998; 10 (12): 92-98 [PMID
11366070].
25. Izazola-Licea JA, del Rio-Chiriboga C, Tolbert K. Las Infecciones de transmision sexual y
la pandemia del VIH/SIDA en el ambito de la salud sexual y reproductiva. Gaceta Med Mex
2000; 136 (supl 3): S55-S68.
26. Sobel A, del Rio C, Friedland G, O’Rourke M, Rouzioux C, May T. Access to HIV Medical
Care. AIDS Clinical Care 2000; 12(6): 47-51 [PMID 12212542].
27. del Rio-Chiriboga, C & Franco-Paredes, C. Bioterrorismo: un Nuevo problema de salud
pública. Salud Publica de Mex 2001; 43(6):585-588 PMID 11816235].
28. Bartlett JG & del Rio C. Antiretroviral rounds. When success is a pain. AIDS Clinical Care
2001; 13(8): 74-5 [PMID 11547461].
29. del Rio C. HIV: it’s beginning to look like a chronic disease. AIDS Clinical Care 2001; 13(9):
82-3 [PMID 11547601].
30. Franco-Paredes C, Rebolledo P, Folch E, Hernandez I, del Rio C. Diagnosis of Diffuse CD8+
Lymphocytosis Syndrome in HIV-Infected Patients. The AIDS Reader 2002; 12: 408-413
[PMID 12402804].
31. Franco-Paredes C, del Rio C, Jurado R. The Clinical Utility of the Urine Gram Stain. Infect
Dis Clin Pract 2002; 11(9):561-563.
32. Palefsky J & del Rio C. Is high-grade dysplasia on anal Pap a high-grade problem? AIDS
Clinical Care 2002; 14(5): 44-5. [PMID 12004877]
33. O’Rourke M, Auerbach J, del Rio C, Dooley S, Friedland G. Ridzon R. The place of
prevention in HIV clinical care: a roundtable discussion. AIDS Clinical Care 2002; 14(6):
49-53 [PMID 12061143].
34. Abdool Karim SS, Currier J, del Rio C, Feinberg J, Friedland GH, Sax PE, Zuger A.
Report on the XIV International AIDS Conference. AIDS Clin Care. 2002 Sep;14(9):77-
85 [PMID 12236208]
35. Franco-Paredes C, del Rio C, Nava-Frias M, Rangel-Frausto S, Tellez I, Santos-Preciado JI.
Enfrentando el bioterrorismo: aspectos epidemiologicos, clinicos y preventivos de la viruela
(Confronting bioterrorism: Epidemiologic, Clinical and preventive aspects of smallpox).
Salud Publica de Mexico 2003; 45 (4):298-309 [PMID 12974047].
36. O’Rourke M, Branson B, del Rio C, Larrabee S, Sax PE. Rapid fingerstick testing: a new era
in HIV diagnostics. AIDS Clinical Care 2003; 15(3): 19-23 [PMID 12685418].
37. del Rio, C. Report from the Tenth Retrovirus Conference. Adherence. AIDS Clin Care.
2003 Apr;15(4):35 [PMID 12712951]
38. del Rio C. Report from the Tenth Retrovirus Conference. Diagnostics. AIDS Clin Care.
2003 Apr;15(4):35 [PMID 12712950]
39. del Rio C. Report from the Tenth Retrovirus Conference. Acute and recent infection.
AIDS Clin Care. 2003 Apr;15(4):34-5 [PMID 12712949]
40. del Rio C. Report from the Tenth Retrovirus Conference. Postexposure prophylaxis
(PEP). AIDS Clin Care. 2003 Apr;15(4):35-6 [PMID 12712952]
41. del Rio C. New Challenges in HIV Care: Prevention among HIV-infected patients. Top
HIV Med. 2003 Jul-Aug (4)140-4 [PMID 12876332].
42. Bartlett J, del Rio C, DeMaria A Jr., Sepkiwitz KA. Smallpox vaccination and the HIV-
infected patient: a roundtable. AIDS Clinical Care 2003; 15(7): 61-63 [PMID 12913953].

48
43. Franco-Paredes C, Tellez I, del Rio C. Inverse Relationship between Decreased Infectious
Diseases and Increased Inflammatory Disorder Occurrence: The Price to Pay. Arch Med
Research 2004; 35:258-261 [PMID 15163470].
44. del Rio C. Report from the 11th conference on retroviruses and opportunistic infections.
HIV in resource-limited countries. AIDS Clin Care. 2004 Apr;16(4):34-5.
[PMID15124588]
45. del Rio C. Report from the 11th conference on retroviruses and opportunistic infections.
STI. AIDS Clin Care. 2004 Apr;16(4):27-8. [PMID 15124582].
46. del Rio C. Report from the 11th conference on retroviruses and opportunistic infections.
Acute and recent infection. AIDS Clin Care. 2004 Apr;16(4):25-6. [PMID 15124580]
47. del Rio C. Report from the 11th conference on retroviruses and opportunistic infections.
Epidemiology. AIDS Clin Care. 2004 Apr;16(4):25. [PMID 15124579]
48. del Rio C. Updated guidelines for the use of rifamycins in HIV/TB-coinfected patients. AIDS
Clinical Care 2004; 16(10): 85 [PMID 15526395].
49. Franco-Paredes C, Tellez I, del Rio C, Santos-Preciado JI. Pandemia de Influenza: posible
impacto de la influenza aviaria. Salud Publ Mex 2005; 47(2): 1 – 2 [PMID 15889635].
50. Franco-Paredes C, Rodriguez A, del Rio C. Lepromatous Leprosy (Images in Infectious
diseases). Infections in Medicine 2005; 22(5): 229.
51. del Rio C & Priddy FH. Outcomes for Patients Receiving Antiretroviral Therapy in the
Developing World Appear to be Not Much Different from those in the Developed World
(Editorial). Clin Infect Dis 2005; 41:225-6. [PMID 15983919]
52. del Rio C. Top Stories of 2004. ACTG5095:efavirenz beats AZT+3TC+abacavir. AIDS
Clin Care 2005 Jan;17(1)4 [PMID 1517367].
53. del Rio C. New guidelines for antiretroviral therapy in non-occupational post-exposure
prophylaxis. AIDS Clinical Care 2005; 17(3): 22 [PMID 15828116].
54. del Rio C. Report from the 12th Retrovirus Conference. HIV-associated dementia. AIDS
Clin Care. 2005 Apr;17(4):41. [PMID 15884151]
55. Albrecht H, del Rio C. Report from the 12th Retrovirus Conference. Vaccines,
microbicides, and novel prophylactic interventions. AIDS Clin Care. 2005 Apr;17(4):42,
44 [PMID 15880874]
56. del Rio, C. Report from the 12th Retrovirus Conference. Opportunistic infections. AIDS
Clin Care. 2005 Apr;17(4):41. [PMID 15880872]
57. del Rio C, Friedland GH. Report from the 12th Retrovirus Conference. HIV/AIDS in
resource-limited settings. AIDS Clin Care. 2005 Apr;17(4):39-40. [PMID 15875314]
58. del Rio C. New USPSTF guidelines on HIV screening. AIDS Clinical Care 2005; 17(8): 74.
[PMID 16193572]
59. del Rio C. AIDS: The Second Wave. Arch Med Res 2005; 36:682-688.
60. del Rio C. Updated Guidelines for occupational postexposure prophylaxis. AIDS Clinical
Care 2005; 18 (12): 114. [PMID 16388540]
61. Franco-Paredes C, Rouphael N, del Rio C, Santos-Preciado JI. Vaccination strategies to
prevent tuberculosis in the new millennium: from BCG to new vaccine candidates. Int J Infect
Dis 2006; 10(2): 93-102. [PMID 16377228]
62. Koenig SP, Kuritzkes DR, Hirsch MS, Leandre F, Mukherjee JS, Farmer PE, del Rio C.
Monitoring HIV Treatment in Developing Countries. Br Med J 2006; 332: 602 – 604. [PMID
16528087/PMC 1397781]

49
63. del Rio C. Report from the 13th Retrovirus Conference: More on False-positive results in
rapid HIV testing. AIDS Clinical Care 2006; 18(4): 39. [PMID 16718855]
64. del Rio C. Report from the 13th Retrovirus Conference: The new ABC’s: Antiretrovirals,
Barriers and Circumcision. AIDS Clinical Care 2006; 18(4): 38 - 9.[PMID 16718884]
65. Buehler JW, Craig AS, del Rio C, Koplan JP, Stephens DS, Orenstein WA. Critical
issues in responding to pandemic influenza [conference summary]. Emerg Infect Dis
[serial on the Internet]. 2006 Jul; 12 (7). Available from
http://www.cdc.gov/ncidod/EID/vol12no07/06-0463.htm
66. del Rio C. Current Concepts in Antiretroviral Therapy Failure. Top HIV Med 2006;
14(3): 102-106. [PMID 16946454]
67. del Rio C. Guideline watch. CDC recommends universal, routine adult HIV screening.
AIDS Clinical Care 2006 Nov;18(11):1.
68. Franco-Paredes C, Tellez I, del Rio C. Rapid HIV Testing: a review of the literature and
implications for the clinician. Current HIV/AIDS Reports 2006; 3: 159 – 165. [PMID
17049869]
69. Tellez I, Calderon O, Franco-Paredes C, del Rio C. West Nile Virus: a reality in Mexico.
Gaceta Med Mex 2006; 142(6): 493-499.
70. del Rio C. Report from the 14th Retrovirus Conference. The HIV/AIDS epidemic in the
U.S. AIDS Clin Care. 2007 May;19(5):37-8. [PMID 18398986]
71. del Rio C. Report from the 14th Retrovirus Conference. The promise of prevention: male
circumcision and microbicides. AIDS Clin Care. 2007 May;19 (5):41. [PMID 18401877]
72. Tellez I, Franco-Paredes C, Bendix JM, Caliendo A, del Rio C. Assessing the Strengths
and Limitations of Rapid HIV Tests. Infect Med 2007; 24: 381-85. [PMID 17201112]
73. Bonney LE & del Rio C. Challenges Facing the US HIV/AIDS Medical Care System.
Future HIV Therapy 2008; 2(2): 1 – 6.
74. del Rio C. Report from the 15th Retrovirus Conference. Continued problems with late
diagnosis and new problems with testing scale-up. AIDS Clinical Care 2008 Apr;
20(4):26-7 [PMID 19256086].
75. del Rio C. Report from the 15th Retrovirus Conference. More setbacks in HIV
Prevention. AIDS Clinical Care 2008 Apr; 20(4):25-6 [PMID 19256085].
76. del Rio C. Updated antiretroviral treatment guidelines from DHHS and EACS. AIDS
Clin Care. 2008 Jan;20(1):7. [PMID 18399008]
77. del Rio C. HIV-1 vaccine might increase infection risk in certain subgroups. AIDS Clin
Care. 2008 Jan;20(1):5. [PMID 18399007]
78. del Rio C. To stories of 2008. Crash and burn of HIV vaccine candidates. AIDS Clinical
Care 2009 Jan; 21(1):4 [PMID 19219958].
79. Whitaker, J, Franco-Paredes C, del Rio C, Edupuganti S. Rethinking Typhoid Fever
Vaccines: Implications for Travelers and Those Living in Highly Endemic Areas. J
Travel Med 2009; 16: 49 – 52 [PMID 19192128].
80. Franco-Paredes C, Hidron A, Tellez I, Lesesne J, del Rio C. HIV Infection and Travel:
Pretravel Recommendations and Health-Related Risks. Topics HIV Med 2009; 17(1): 2
– 11 [PMID 19270343].
81. Garcia-Calleja JM, del Rio C, Souteyand Y. HIV Infection in the Americas: Improving
Strategic Information to Improve Response. JAIDS 2009; 51 (suppl 1): S1-S3. [PMID
19384095]
82. Franco-Paredes C, del Rio C, Carrasco P, Santos Preciado JI. Respuesta en Mexico al

50
 actual brote de influenza A H1N1. Salud Publ Mex 2009; 51 (3): 183 – 186 [PMID
19967302].
83. Tamma PD, Ault KA, del Rio C, Steinhoff MC, Halsey NA, Omer SB. Safety of
Influenza Vaccination during Pregnancy. Am J Obst & Gynecol 2009 Dec; 201 (6): 547 –
52. {E-pub ahead of print Oct 21} [PMID 19850275].
84. Bonney LE & del Rio C. An HIV/AIDS Fellowship Program for Minority Physicians. J
Natl Med Assoc 2009; 1011: 1297 – 8.[PMID 20070021]
85. Armstrong WS & del Rio C. HIV-associated resources on the internet. Top HIV Med
2009; 17(5): 151-62. [PMID 20068262]
86. del Rio C. Report from the 16th Conference on Retroviruses and Opportunistic
Infections. First (sort of) positive anti-HIV microbicide trial. J Watch AIDS Clin Care.
2009 Apr; 21(4):34. [PMID 19544618]
87. del Rio, C. Report from the 16th Conference on Retroviruses and Opportunistic
Infections. Treatment is preventive, but some risk remains. J Watch AIDS Clin Care.
2009 Apr; 21(4):32. [PMID 19544616]
88. del Rio C, Sierra-Madero J. Swine-origin influenza A (H1N1) and HIV. The CDC offers
guidance for HIV-infected patients potentially exposed to swine flu. J Watch AIDS Clin
Care. 2009 Jun;21(6):51 [PMID 19544612]
89. del Rio C & Franco-Paredes C. The perennial threat of influenza pandemics. Arch Med
Res 2009; 40(8): 641-2. [PMID 20304250]
90. Santos-Preciado J, Franco-Paredes C, Hernandez-Florez I, Tellez I, del Rio C, Tapia-
Conyer R. What have we learned from the Novel Influenza A (H1N1) Pandemic in 2009
for Strengthening Pandemic Influenza Preparedness? Arch Med Res 2009; 40: 673-676
[PMID 20304255]
91. del Rio C & Hernandez-Avila M. Lessons from Previous Influenza Pandemics and from
the Mexican Response to the Current Influenza Pandemic. Arch Med Res 2009; 40: 677-
680 [PMID 20304256].
92. Franco-Paredes C, Hernandez-Ramos I, del Rio C, Alexander KT, Tapia-Conyer R,
Santos-Preciado JI. H1N1 Influenza Pandemics: Comparing the Events of 2009 in
Mexico with those of 1976 and 1918-1919. Arch Med Res 2009; 40: 669-672. [PMID
2030452]
93. Southwick F, Katona P, Kauffman C, Monroe S, Pirofski LA, del Rio C, Gallis H,
Dismukes W. IDSA Guidelines for Improving the Teaching of Preclinical Medical
Microbiology and Infectious Diseases. Academic Medicine 2010; 85(1): 19 – 22. [PMID
20042815]
94. del Rio C. Report from the 17th Conference on Retrovirus and Opportunistic Infections.
Expanding HIV testing and treatment. J. Watch AIDS Clin Care 2010; Apr; 22(4): 29-30.
[PMID 20480617]
95. del Rio C. Report from the 17th Conference on Retrovirus and Opportunistic Infections.
2009 H1N1 influenza and HIV infection. J Watch AIDS Clin Care 2010; Apr; 22(4): 32 -
3. [PMID 20480931]
96. Vogenthaler N & del Rio C. Is directly observed therapy worthwhile in the Treatment of
HIV infection? J Watch AIDS Clin Care 2010; Jun; 22(6):55. [PMID 20666005]
97. del Rio C. CD4-cell counts at entry into care: improving but far from ideal. J Watch
AIDS Clin Care 2010; Jun; 22(6):52 [PMID 20648722]
98. del Rio C & Guarner J. The 2009 Influenza A (H1N1) Pandemic: what have we learned

51
 in the past 6 months. Trans Am Clin Climatol Assoc 2010; 121: 128 - 140. [PMID
20697556/PMC 2917128]
99. Albarracin D, Rothman AJ, DiClemente R, del Rio C. Wanted: A Theoretical Roadmap
to Research and Practice Across Individual, Interpersonal and Structural Level of
Analysis. AIDS Behav 2010; Sept 8 {E-pub ahead of print}. [PMID 20824321]
100. Armstrong WS & del Rio C. Gender, Race, and Geography: Do They Matter in
Primary Human Immunodeficiency Infection? J Infect Dis 2011; 203: 437-438 [PMID
21245158/PMC 3071221]. {Article selected for reprint as part of “2010 Clinical Issues in
HIV Medicine”, published by the Infectious Diseases Society of America}
101. Margoles L, del Rio C, Franco-Paredes C. Leprosy: a modern assessment of an ancient
neglected disease. Bol Med Hosp Infant Mex 2011; 68(2): 110-116.
102. del Rio, C. Obstacle course: the role of health care providers in helping overcome
stigma, denial, and ignorance. Posit Aware 2011 Spring; 23(4): 7 – 9. [PMID 21710874]
103. del Rio C. Latinos and HIV Care in the Southeastern United States: New Challenges
Complicating Longstanding Problems. Clin Infect Dis 2011; 53: 488 – 489 [PMID
21844032].
104. Narayan KM, Ali MK, del Rio C, Koplan JP, Curran J. Global Noncommunicable
Diseases – Lessons from the HIV-AIDS Experience. N Engl J Med 2011; 365 (10): 876
– 878. [PMID 21899448]
105. del Rio C, Armstrong WS. Antiretroviral therapy programmes in resource limited
settings. BMJ 2011 Nov 9 343:d6853. doi: 10.1136/bmj.d6853. [PMID 22074712]
106. Koplan JP, Curran J, Debas H, del Rio C, Gostin LO, Keusch GT, Wasserheit JN, In
support of the US Centers for Disease Control and Prevention. Lancet 2012; 379(9826):
1585. [PMID 22541570]
107. del Rio C, Mayer, K. A Tale of Two Realities: What are the challenges and the
solutions to improving engagement in HIV care? Clin Infect Dis 2013 57(8): 1172 – 4.
{Epub ahead of print June 23} [PMID 23797287]
108. Guarner J & del Rio C. What educators do not like to deal with. Am J Clin Pathol
2014; 141(6): 770 – 1. [PMID 24838318].
109. Nachega, JB, Uthman OA, del Rio C, Mugavero MJ, Rees H, Mills EJ. Addressing the
Achilles’ Heel in the HIV Care Continuum for the Success of a Test-and-Treat Strategy
to Achieve an AIDS-Free Generation. Clin Infect Dis 2014; 59 (Suppl 1): S21 – 7.
[PMID 24926028]
110. Armstrong WS, del Rio C. Falling through the cracks and dying: missed clinic visits
and mortality among HIV-infected patients in care. Clin Infect Dis 2014; 59(10): 1480-
82 {Epub ahead of print August 4}. [PMID 25091313]
111. Crabtree-Ramirez B, del Rio C, Grinsztejn B, Sierra-Madero J. HIV and
Noncommunicable Diseases (NCDs) in Latin America: A Call for an Integrated and
Comprehensive Response. J Acquir Immune Defic Syndr 2014; 67 (suppl 1): S96 – 8.
[PMID 25117966].
112. del Rio C, Mehta AK, Lyon III GM, Guarner J. Ebola Hemorrhagic Fever in 2014: The
Tale of an Evolving Epidemic. Ann Intern Med 2014; 161(10): 746-8 {Epub Aug 19;
doi: 10.7326/M14-1880} [PMID 25133433].
113. del Rio C. HIV prevention: integrating biomedical and behavioral interventions. Top
Antivir Med 2014; Dec-2015; Jan 22(5): 702 – 6. [PMID 25612180]
114. Greenberg AE, Purcell DW, Gordon CM, Barasky RJ, del Rio C. Addressing the

52
 Challenges of the HIV Continuum of Care in High-Prevalence Cities in the United States.
JAIDS 2015; May 1; 69 (suppl 1): S1 – S7. [PMID 25867773]
115. del Rio C, Guarner J. Ebola: Implications and Perspectives. Trans Am Clin Climatol
Assoc 2015; 126:93 – 112. [PMID 26330663].
116. Flannery B, del Rio C. Appreciation: Phillip S. Brachman, 1927 – 2016. Int J
Epidemiol 2016 Jun; 45(3): 602 – 4. doi:10.1093/ije/dyw190. [PMID 27450860].
117. del Rio C. HIV Infection in Hard-to-Reach Populations. Top Antivir Med 2016
Jul/Aug; 24 (2): 86 – 89. [PMID 27841977].
118. Benson CA, Currier JS, del Rio C, Gallant JE, Gulick RM, Marrazzo JM, Richman DD,
Saag MS, Schooley RT, Volberding PA. A Conversation Among the IAS-USA Board of
Directors: Hot Topics and Emerging Data in HIV Research and Care. Top Antivir Med
2017 Dc/Jan; 24 (4): 142 – 151. [PMID 28208122].
119. Armstrong WS, del Rio C. Patient tracking as a tool to improve retention in care, is the
juice worth the squeeze? Clin Infect Dis 2017 Mar 17. doi: 10.1093/cid/cix196. [PMID
28329039].
120. Walensky RP, del Rio C, Armstrong WS. Charting the Future of Infectious Diseases:
Anticipating and Addressing the Supply and Demand Mismatch. Clin Infect Dis 2017
Apr 6. doi: 10.1093/cid/cix173. [PMID 28387806].
121. del Rio C. The global HIV epidemic: What the pathologist needs to know. Semin
Diagn Pathol 2017 May 19. pii: S0740-2570(17)30059-X. doi:
10.1052/j.semdp.2017.05.001. [PMID 28566241].
122. del Rio C & Armstrong WS. Progress Toward Achieving UNAIDS 90-90-90 in Rural
Communities in East Africa. JAMA 2017 Jun 6; 317(21): 2172 – 2174. doi:
10.1001/jaja.2017.5704. [PMID 28586873].
123. del Rio C. From Trained Infectious Diseases Clinician to Global Health Leader,
Reflections on the last 30 years. J Infect Dis 2017; 216 (suppl 5): S622 – 623. doi:
10.1093/infdis/jix248. [PMID 28938037]
124. Castro KG, Evans DP, del Rio C, Curran JW. Seven Deadly Sins Resulting from the
Centers for Disease Control and Prevention’s Seven Forbidden Words. Ann Intern Med
2018 Jan 9. doi:10.7326/M17-3410. [PMID 29310140].
125. Frew PM, Lutz CS, Ofotokun I, Marconi VC, del Rio C. Geospatial mapping to
identify feasible HIV prevention and treatment strategies that target specific settings.
Ann Transl Med 2018 Feb; 6(3):59. doi: 10.21037/atm.2017.12.20. [PMID: 29610750].
126. Springer SA, Korthuis PT, del Rio C. Integrating Treatment at the Intersection of
Opioid Use Disorder and Infectious Disease Epidemics in Medical Settings: A Call for
Action After a National Academies of Sciences, Engineering and Medicine Workshop.
Ann Intern Med 2018 Jul 13. doi: 10.7326/M18-1203. [PMID 30007032].
127. del Rio C, Armstrong WS. Policy and advocacy for the HIV practitioner. Top Antivir
Med 2018 Sep; 26(3):94 – 95. [PMID 30384333].
128. del Rio C, Armstrong WS, Curran J. Can the US Achieve Epidemic Control? A new
initiative offers hope. Clin Infect Dis 2019 Feb 28. pii: ciz155. doi: 10.1093/cid/ciz/155.
[PMID 30805595].
129. del Rio C. Can we end HIV as a public health problem globally? Progress towards the
UNAIDS 90-90-90 goals. Curr Opin HIV AIDS 2019 Nov 14(6): 439 – 441. doi:
10.1097/COH. 0000000000000592. [PMID 31580265].
130. Kimmel SD, del Rio C. Improving Outcomes for People with Injection Drug-related

53
 Endocarditis: Are Medications for Opioid Use Disorder Enough? J Addict Med 2019 Oct
18. doi: 10.1097/ADM. 0000000000000573. [PMID 31634203].
131. Colasanti JA, del Rio C. Declining hospitalizations among persons with HIV; Time to
leave no one behind. Clin Infect Dis 2019 Oct 22. pii: ciz1047. doi: 10.1093/ciz1047
[PMID 31637419].
132. Springer SA, del Rio C. Co-located Opioid use disorder and HCV treatment is not only
right but it is also the Smart think to do as it improves outcomes! Clin Infect Dis 2020
Feb 3. pii: ciaa111. doi: 10.1093/cid/ciaa111 [PMID 32011653].
133. del Rio C, Malani PN. 2019 Novel Coronavirus – Improtant Information for
Clinicians. JAMA 2020 Feb 5. doi: 10.1001/jama.2020.1490 [PMID 32022836].
134. del Rio C, Malani PN. COVID-19 – New Insights on a Rapidly Changing Epidemic.
JAMA 2020 Feb 5. doi: 10.1001/jama.2020.3072 [PMID 32108857].
135. del Rio C, Armstrong WS. How much are we willing to pay for Preexposure
Prophylaxis in the United States. Ann Intern Med 2020 Mar 10. doi: 10.7326/M20-0799
[PMID 32150617].
136. Springer SA, Merluzzi AP, del Rio C. Integrating Responses to the Opioid Use
Disorder and Infectious Diseases Epidemics: A Report From the National Academies of
Science, Engineering and Medicine. JAMA 2020 Mar 11. doi: 10.1001/jama.2020.2559.
[PMID 32159771].
137. Guest JL, del Rio C, Sanchez T. The Three Steps Needed to End the COVID-19
Pandemic: Bold Public Health Leadership, Rapid Innovations and Courageous Political
Will. JMIR Public Health Surveill 2020 Apr 6(6):e19043. doi:10.2196/19043 [PMID
32240972].
138. Omer SB, Malani P, del Rio C. The COVID-19 Pandemic in the US: A Clinical
Update. JAMA 2020 Apr 6. doi: 10.1001/jama.2020.5788 [PMID 32250388].
139. Walensky RP, del Rio C. From Mitigation to Containment of the COVID-19
Pandemic: Putting the SARS-CoV-2 Genie Back in the Bottle. JAMA 2020 Apr 17.
doi: 10.1001/jama.2020.6572 [PMID 32301959].
140. Nosyk B, Armstrong WS, del Rio C. Contact tracing for COVID-19: An opportunity
to reduce health disparities and End the HIV/AIDS Epidemic in the US. Clin Infect Dis
2020 Apr 27. pii: ciass501. doi: 10.1093/cid/ciaa501. [PMID 323339245].
141. del Rio C, Camacho-Ortiz A. Will environmental changes in temperature affect the
course of COVID-19? Braz J Infect Dis 2020 May 4:S1413-8670(20)30034-9.
doi:10.1016/j.bjid.2020.04.007 [PMID 32380010].
142. Faust JS, del Rio C. Assessment of Deaths From COVID-19 and From Seasonal
Influenza. JAMA Intern Med 2020 May 14. doi: 10.1001/jajainternmed.2020.2306
[PMID 32407441]
143. del Rio C & Malani P. Translating Science on COVID-19 to Improve Clinical Care
and Support the Public Health Response. JAMA 2020. doi:10.1001/jaja.2020.9252
[PMID 32442244].
144. Ward JW & del Rio C. The COVID-19 Pandemic: An Epidemiologic, Public Health
and Clinical Brief. Clinical Liver Dis 2020 May 21;15(5): 170-174.
doi:10.1002/cld.973.eCollection 2020 May. [PMID 32489652].
145. Ali MK, Shah DJ, del Rio C. Preparing Primary care for COVID-20. J Gen Intern Med
2020 Jun 9:1-2. doi: 10.1007/s11606-05945-5. [PMID 32519324].
146. Escudero X, Guarner J, Galindo-Fraga A, Escudero-Salamanca M, Alcocer-Gamba M,

54
 del Rio C. The SARS-CoV-2 (COVID-19) Coronavirus Pandemic: Current Situation
and Implications for Mexico. Arch Cardiol Mex 2020; 90(Supl): 7 – 14.
doi:10.24875/ACM.M20000064 [PMID 32523137].

c. Book chapters:
1. Stephens DS, del Río C. Gonococcal Diseases. In: Kelly WN (ed.), Textbook of Internal
Medicine, 1989 (1st. Ed.), pp 1519-1524 & 1991 (2nd. Ed.), pp 1382-1387; JB Lippincott,
Philadelphia.
2. McGowan JE Jr, del Río C. Other Gram-Negative Bacilli, In: Mandell, Douglas, Bennett
(eds.): Principles and Practice of Infectious Diseases, 3rd. Ed. 1990. pp 1782-93.
3. Bartley DC, del Río C, Shulman JA. Clinical Complications. In: Schlossberg D. Infectious
Mononucleosis, 2nd Ed. Springer-Verlag Publ. 1989. pp 35-48.
4. Prokesch R, del Río C, Shulman JA. Amebiasis. In: Hurst JW. Medicine for the Practicing
Physician, 3rd Ed. Butterworth-Heinemann 1992. pp 425-28.
5. del Río C, Shulman JA. Chronic Fatigue Syndrome. In: Hurst JW. Medicine for the
Practicing Physician, 3rd Ed. Butterworth-Heinemann 1992. pp 467-69.
6. del Río C. Human T cell Lymhotropic virus type 1 infections. In: Hurst JW. Medicine for
the Practicing Physician, 3rd Ed. Butterworth-Heinemann 1992. pp 479-81.
7. del Río C. Enfermedades de Transmisión por Contacto Sexual. In: Antología de la
Sexualidad Humana. CONAPO 1994. Vol III pp 423-450. (ISBN 970-628-063-4).
8. del Río C. Infección por el Virus de Inmunodeficiencia Humana. In: Antología de la
Sexualidad Humana. CONAPO 1994. Vol III pp 451-491. (ISBN 970-628-063-4).
9. del Rio C. Parvovirus. In: Uribe M. Tratado de Medicina Interna, 2nd De. Editorial
Panamericana 1995. pp 1471-1473. (ISBN 986-7157-56-9).
10. del Rio C. Infección por Citomegalovirus durante el embarazo. In: Uribe M. Tratado de
Medicina Interna, 2nd De. Editorial Panamericana 1995. pp 1840-1842. (ISBN 986-7157-
56-9).
11. del Rio C, Schwarzmann SW, Hugley CM. Infectious Mononucleosis. In: Hurst JW.
Medicine for the Practicing Physician, 4th Ed. Appleton & Lange 1996. pp 497-499 (ISBN
0-8385-6317-1).
12. del Río C & Shulman JA. Chronic Fatigue Syndrome. In: Hurst JW. Medicine for the
Practicing Physician, 4th Ed. 1996. pp 500-502 Appleton & Lange (ISBN 0-8385-6317-1).
13. Morgan J & del Río C. Amebiasis. In: Hurst JW. Medicine for the Practicing Physician,
4th Ed. Appleton & Lange 1996. pp 457-459 (ISBN 0-8385-6317-1).
14. Gunthel CJ & del Río C. Human T-cell Lymphotrophic Virus Type I Infections. In: Hurst
JW. Medicine for the Practicing Physician, 4th Ed. Appleton & Lange 1996. pp 514-517
(ISBN 0-8385-6317-1).
15. del Río C. Tuberculosis y SIDA. En: Sifuentes J & Sada E. Tuberculosis en México.
Interamericana-McGraw-Hill Vol III (4), 1995. pp 795-808 (ISBN-968-25-2471-7).
16. del Rio C, Granter SR, Duray PH. Lyme Borreliosis. In: Horsburgh CR & Nelson AM:
Pathology of Emerging Infections. American Society for Microbiology 1997. pp269-283
(ISBN 1-55581-120-5).
17. del Rio C. Mujer y SIDA: Conceptos sobre el tema. En: Rico B, Vandale S, Allen B y
Liguori AL. Situación de las Mujeres y el VIH/SIDA en América Latina. Instituto
Nacional de Salud Pública 1997. Pp: 15-19. (ISBN 968-6502-30-0).

55
18. Schuklenk U, del Rio C, Magis C, Chokeviat V. AIDS in the Developing World. In:
Chadwick, Ruth (Ed.) Encyclopedia of Applied Ethic, Vol 1. Academic Press 1998, San
Diego, Ca. pp: 123-127.
19. Schuklenk U, Chokevivat V, del Río C, Gbadegesin S, Magis C. AIDS: ethical issues in
the Developing World. In: H. Kuhse & P. Singer (Eds): A Companion to Bioethics.
Blackwell Publishers Ltd. Oxford 1998, pp. 355-365. (ISBN 0-631-19737-0).
20. del Rio C & Meier FA. Yellow fever. In: Nelson AM & Horsburgh CR: Pathology of
Emerging Infections 2. American Society for Microbiology 1998. pp 13-41 (ISBN 1-55581-
140-X).
21. del Rio C & Curran JW. Epidemiology of HIV Infection and AIDS. In: Goldman and
Bennett: Cecil Textbook of Medicine, 21st Ed. 2000, pp 1898-1904. (ISBN 0-7216-7995-1).
22. del Rio C & Curran JW. Epidemiology and Prevention of AIDS and HIV Infection. In:
Mandell, Bennett & Dolin: Principles and Practice of Infectious Diseases, 5th Edition. W.B.
Saunders 2000, pp 1340-1368 (ISBN 0-443-07593-X).
23. Steinberg J & del Rio C. Other Gram-Negative Bacteria. In: Mandell, Bennett & Dolin:
Principles and Practice of Infectious Diseases, 5th Edition. W.B. Saunders 2000, pp 2459-
2474 (ISBN 0-443-07593-X).
24. del Rio C & Cahn P. Antiretroviral Therapy and Treatment of Illnesses Associated with
HIV/AIDS: General Considerations and Implications for Latin America and the Caribbean.
In: JA Izazola: AIDS in Latin America and the Caribbean: a multidisciplinary view.
Funsalud/SIDALAC/UNAIDS 1999, pp 85-106 (ISBN 968-5018-17-0).
25. Magis C & del Rio C. Epidemiología del VIH y del SIDA en México. In Ponce de Leon
S & Rangel S. SIDA: Aspectos Clínicos y Terapéuticos. McGraw-Hill Interamericana
2000, pp 1-10 (ISBN 970-10-2527-X)
26. del Rio C & Franco-Peredes C. Bioterrorism: A New Public Health Problem. In: Sepulveda
J: Panamerican Health in the 21st Century: Strengthening International Cooperation and
Development of Human Capital. National Institute of Public Health 2002, pp 115 –118
(ISBN 968-6502-59-9).
27. del Rio C & Sepulveda J. Infection by HIV/AIDS in Mexico. In: Sepulveda J: Panamerican
Health in the 21st Century: Strengthening International Cooperation and Development of
Human Capital. National Institute of Public Health 2002, pp 97 - 101 (ISBN 968-6502-59-
9).
28. del Rio C & Curran JW. Epidemiology and Prevention of AIDS and HIV Infection. In:
Mandell, Bennett & Dolin: Principles and Practice of Infectious Diseases, 6th Edition.
Elsevier Inc. 2005; pp 1477-1506 (ISBN 0-443-06643-4).
29. Steinberg J & del Rio C. Other Gram-Negative and Gram-Variable Bacilli. In: Mandell,
Bennett & Dolin: Principles and Practice of Infectious Diseases, 6th Edition. 6th Edition.
Elsevier Inc. 2005; pp 2751-2768 (ISBN 0-443-06643-4).
30. del Rio C. Prevention of Human Immunodeficiency Virus Infection. In Goldman &
Ausiello: Cecil Medicine 23rd Ed. Elsevier Inc 2008; pp 2567 - 2571 (ISBN 987-1-4160-
2805-5)
31. Celentano DD, Bayer C, Davis WW and del Rio C. The HIV/AIDS Epidemic of the
Americas. In: DD Celentano C Bayer: Public Health Aspects of HIV/AIDS in Low and
Middle Income Countries. Epidemiology, Prevention and Care. Springer 2008; 525 – 530.
(ISBN 978-0-387-72710-3)

56
32. Dionne-Odom J, Bonney L & del Rio C. Access to Culturally Competent Care for Patients
Living with HIV/AIDS. In: Stone, Ojikutu, Rawlins et al: HIV/AIDS in Minority
Communities. Springer 2009; 69 – 82. (ISBN 978-0-387-98151-2)
33. del Rio C & Curran JW. Epidemiology and Prevention of AIDS and HIV Infection. In:
Mandell, Bennett & Dolin: Principles and Practice of Infectious Diseases, 7th Edition.
Elsevier Inc. 2010; pp 1635 – 1661 (ISBN 978-0-4430-6839-3).
34. Guarner J & del Rio C. Pathology, Diagnosis, and Treatment of Anthrax in Humans. In:
Bergman NH: Bacillus anthracis and Anthrax. Wiley-Blackwell 2011; pp 251 – 267 (ISBN
978-0-470-41011-0)
35. Doshi RK, del Rio C & Marconi VC. (2011) Social Determinants of HIV Health Care: A
Tale of Two Cities. In: Understanding HIV/AIDS Management and Care – Pandemic
Approaches in the 21st Century. Fyson Hanania Kasenga (Ed.) (ISBN 978-953-307-603-4;
InTech, available at: http://www.intechopen.com/books/understanding-hiv-aids-
management-and-care-pandemic-approaches-in-the-21st-century/social-determinants-of-
hiv-health-care-a-tale-of-two-cities)
36. del Rio C & Curran JW. Chapter 121: Epidemiology and Prevention of Acquired
Immunodeficiency Syndrome and Human Immunodeficiency Virus Infection. In:
Bennett & Dolin & Blaser: Principles and Practice of Infectious Diseases, 8th Edition
pp: 1483 – 1502. Elsevier 2015. ISBN-13: 9781455748013
37. del Rio C & Cohen MS. Chapter 387: Prevention of Human Immunodeficiency Virus
Infection. In: Goldman-Cecil Medicine 25th Edition pp: 2285 – 2287. Elsevier-Saunders.
2016. ISBN: 978-1-4557-5017-7.
38. Franco-Paredes C, Hare A, del Rio C. Leprosy in Latin America and the Caribbean:
Burden of Disease and Approaches to Elimination. In: Franco-Paredes C & Santos-
Preciado JI Ed). Neglected Tropical Diseases – Latin America and the Caribbean.
Springer-Verlag 2015; pp: 175 – 184. (INBN 978-3-7091-1421-6)
39. Vermund SH, El-Sadr W, del Rio C, Wingood GM. Policy and Human Rights
Imlications of Woman’s Poverty and Vulnerability in the USA. In: A. O’Leary & PM
Frew: Poverty in the United States. Springer Link 2017; pp: 221 – 232. doi:
10.1007/978-3-319-43833-7_13. (ISBN 978-3-319-43831-3)

f. Books edited and written:

1. del Río C, Hernandez G, Uribe P (editores): Guía para la Atención Domiciliaria de Personas
que viven con VIH/SIDA. CONASIDA 1993. (ISBN 968-811-211-9).
2. del Río C y Uribe P (editores): Guía para la Atención Psicológica de personas que viven con
VIH/SIDA. CONASIDA 1994. (ISBN 968-811-246-1).
3. del Río C, Hernández Tepichín G, Uribe Zúñiga P (editores): Guía para la Instalación de
Centros de Información sobre VIH/SIDA. CONASIDA 1994 (ISBN 968-811-342-5).
4. McCary JL, McCary SP, Alvarez-Gayou JL, del Río C, Suárez JL. Sexualidad Humana de
McCary. 5a. edición. El Manual Moderno 1996. (ISBN 968-426-707-X).
5. Ponce de Leon S & del Río C. (editores). Guía para la atención médica del paciente con
VIH/SIDA en Consulta Externa y Hospitales. 2nd Ed. CONASIDA 1996. (ISBN 968-811-
291-7) and 3rd Ed. CONASIDA 1997 (ISBN 968-811-617-3).

57
6. Institute of Medicine (IOM). 2004. Measuring What Matters: Allocation, Planning and
Quality Assessment for the Ryan White CARE Act. Washington DC: The National Academies
Press (ISBN 0-309-09115-2)
7. Institute of Medicine (IOM). 2008. Methodological Challenges in Biomedical HIV
Prevention Trials. Washington DC: The National Academies Press. (ISBN 978-309-11430-
1)

g. Book reviews:
 Guarner J & del Río C. Book review, AIDS Pathology. JAMA 1990; 264:1476.
 del Río C. Book Review: Fatal Extraction. Am J Med Sci 1998; 315(5):343-44.

h. Manuals, videos, computer programs, and other teaching aids:

 del Rio C & Lennox J. HIV/AIDS Guideline. In: EBM Solutions
(http://www.ebmsolutions.com/)
 del Rio C. Human Immunodeficiency Virus. In: Clinical Decision Support: Hospital
Infection Control, edited by Wenzel, RW and Bearman, G. 2014. Decision Support in
Medicine, LLC. Wilmington, DE

58
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 GEORGIA
STATE REPORT 07.14.2020 |

SU MMARY
Georgia is in the red zone for cases, indicating more than 100 new cases per 100,000 population last week, and the
red zone fc-r test positivity, indicating a rate above 10%.
Disease trends are moving in the wrong direction in Georgia with record numbers 0f new cases occurring in urban,
suburban and ru ral areas. Test positivity continues to increase. The number 0f tests has increased, but more
testing is needed.
Thefollowing three counties had the highest number of new cases over the past 3 weeks: 1. Gwinnett County, 2.

Fulton County, and 3. DeKalb County. These counties represent 25.9 percent of new cases in Georgia.
Georgia had 202 new cases per 100,000 population in the past week, compared t0 a national average of 119 per
100,000.
Thefederal government has deployed the following staff as assets to supportthe state response: 122 t0 support
leadership, administrative, operations, and logistics activities from HHS, USCG, VA, and FEMA; and 8 to support
medical activities from VA.

RECOMMENDATIONS
° Protegt those in nursing homes and long—term carefacilities by testing all staff each week and requiring staff to wear cloth face
coverings.
Continue to vigorously investigate outbreaks and implement testing and intensified contacttracing.
Move community—led testing and work with local community groups to increase testing access. In high transmission
to
settings, consider pooling specimens to test 2—3 persons at once to increase access and reduce turnaround times. Fcrfamilies
and cohabiting households. screen entire households in a single test by pooling specimens. Provide clearguidance for
households that test positive, includingon individual isolation.
In all counties with 7—day average test positivity greaterthan 10%, close bars, require strict social distancing within restaurants,
close gyms, and limit gatherings to 10 orfewer people.
Allow localjurisdictions to implement more restrictive policies.

Mandate statewide wearing of cloth face coverings outside the home.

Encourage individuals that have participated in large social gatherings to get tested.
Increase messaging cfthe risk ofserious disease in all age groups with preexisting medical conditions. including obesity.
hypertension and diabetes mellitus.

Specific, detailed guidance on community mitigation measures can be found on the

fire purpose of this repair J's 3‘0 develop (I shared understanding of the current Srams of rhe pandemic a! the national, regional, stare and focal
feuds. We recognize (ha? data at the sfare may d.g'fl'erfiom that available a! fhefederaf level. Our objective is to use consistent dam sources
?evel'

and mefhoa’s {hat allow for comparisons f0 be made across Eocalifigs. We appreciate your comm wed support in idenflfilfng dam discrepancies and
improving dam comp Iefeness and Sharing across glsfgms. We Jookforward to yo urfeedback

_= cown-19
 COVID-19

GEORGIA
STATE REPORT | 07.14.2020
STATE, % CHANGE FEMA/HHS
STATE, FROM PREVIOUS REGION, UNITED STATES,
LAST WEEK WEEK LAST WEEK LAST WEEK

NEW CASES 21,210 135,129 389,358

+20.6%
(RATE PER 100,000) (202) (204) (119)

DIAGNOSTIC TEST
14.8% +1.5%* 15.7% 9.6%
POSITIVITY RATE

TOTAL DIAGNOSTIC
72,355 738,971 3,833,229
TESTS -3.3%
(688) (1,113) (1,172)
(TESTS PER 100,000)

COVID DEATHS 137 1,114 4,616

+65.1%
(RATE PER 100,000) (1) (2) (1)
MOBILITY

* Indicates absolute change in percentage points

DATA SOURCES
Cases and Deaths: State values are calculated by aggregating county-level data from USAFacts; therefore, the values may not
match those reported directly by the state. Data is through 7/10/2020; last week is 7/4 - 7/10, previous week is 6/27 - 7/3.
Testing: State-level values calculated by using 7-day rolling averages of reported tests. Regional- and national-level values
calculated by using a combination of CELR (COVID-19 Electronic Lab Reporting) state health department-reported data and HHS
Protect laboratory data (provided directly to Federal Government from public health labs, hospital labs, and commercial labs)
through 7/8/2020. Last week is 7/2 - 7/8, previous week is 6/25 - 7/1.
Mobility: Descartes Labs. This data depicts the median distance moved across a collection of mobile devices to estimate the
level of human mobility within a county; 100% represents the baseline mobility level. Data is anonymized and provided at the
county level. Data through 7/11/2020.
 COVID-lg

GEORGIA
STATE REPORT 07.14.2020
|

LOCALITIES IN LOCALITIES IN
RED ZONE YELLOWZONE
Atla nta-Sandy Sprin -

Alpharetta
Columbus Warner Robins
Savannah Calhoun
Augusta-Richmond County Vidalia
M ETRO AREA Brunswick Chattanooga
(CBSA)
LAST WEE K Top 12
Macon-Bibb County
Valdosta
9 Hinesville
Toccoa
shown Dalton Cornelia
Gainesville Thomaston
LaGrange Summerville
Athens-Clarke County
Douglas

Gwinnett Fo rsyth
Fulton Houston
DeKalb Newton
Cobb Paulding
Chatham Coweta
COUNTY
LAST WEEK
94 Muscogee
Gl nn
44 Gordon
Fa ette
TOP 12 Clgyton
TOP 12 Waylton
shown Bibb
shown Toombs
Whitfield Cook
Lowndes Stephens
Hall Habersham

Red Zone: Those core—based statistical areas {CBSAS} and counties that during the last week reported both new cases above 100
per 100,000 population, and a diagnostic test positivity result above 10%.
Yellow Zone: Those core—based statistical areas {CBSAS} and counties that during the last week reported both new cases
'
between 10—100 per 100,000 population, and a diagnostic test positivity result between 5—1095, or one ofthose two cond'
and one condition qualifying as being in the “Red Zone.”

Note: Top 12 localjons are selected based on the highest number 0f new cases in the last three weeks.

DATA SOU RCES

Cases and Deaths: State values are calculated by aggregating county—Ievel data from USAFacts; therefore, the values
match those reported directly by the state. Data is thro ugh ?f10i2020; last week is 7M — 73‘10, three weeks is 6H!) — THO.
Testing: H HS Protect [a boratory data {provided directly to Federal Govern ment from pu blic health labs, hospital labs, an
commercial labs} through Tl8f2020. Last week is 71'2 — 7/8.
 POLICY RECOMMENDATIONS FOR COUNTIES IN THE RED ZONE
Public Messaging
Wear a mask at all times outside the home and maintain physical distance
Limit social gatherings to 10 people or fewer
Do not go to bars, nightclubs, or gyms
Use take out or eat outdoors socially distanced
Protect anyone with serious medical conditions at home by social distancing at home and using high levels of personal hygiene, including
handwashing and cleaning surfaces
Reduce your public interactions and activities to 25% of your normal activity

Public Officials
Close bars and gyms, and create outdoor dining opportunities with pedestrian areas
Limit social gatherings to 10 people or fewer
Institute routine weekly testing of all workers in assisted living and long-term care facilities. Require masks for all staff and prohibit
visitors
Ensure that all business retailers and personal services require masks and can safely social distance
Increase messaging on the risk of serious disease for individuals in all age groups with preexisting obesity, hypertension, and diabetes
mellitus, and recommend to shelter in place
Work with local community groups to provide targeted, tailored messaging to communities with high case rates, and increase community
level testing
Recruit more contact tracers as community outreach workers to ensure all cases are contacted and all positive households are
individually tested within 24 hours
Provide isolation facilities outside of households if COVID-posi i e indi id als can q aran ine s ccessf ll

Testing
Move to community-led neighborhood testing and work with local community groups to increase access to testing
Surge testing and contact tracing resources to neighborhoods and zip codes with highest case rates
Diagnostic pooling: laboratories should use pooling of samples to increase testing access and reduce turnaround times to under 12
hours. Consider pools of 2-3 individuals in high incidence settings and 5:1 pools in setting where test positivity is under 10%
Surveillance pooling: For family and cohabitating households, screen entire households in a single test by pooling specimens of all
members into single collection device

POLICY RECOMMENDATIONS FOR COUNTIES IN THE YELLOW ZONE IN ORDER

TO PREEMPT EXPONENTIAL COMMUNITY SPREAD
Public Messaging
Wear a mask at all times outside the home and maintain physical distance
Limit social gatherings to 25 people or fewer
Do not go to bars or nightclubs
Use take out, outdoor dining or indoor dining when strict social distancing can be maintained
Protect anyone with serious medical conditions at home by social distancing at home and using high levels of personal hygiene
Reduce your public interactions and activities to 50% of your normal activity

Public Officials
Limit gyms to 25% occupancy and close bars until percent positive rates are under 3%; create outdoor dining opportunities with
pedestrian areas
Limit social gatherings to 25 people or fewer
Institute routine weekly testing of all workers in assisted living and long-term care facilities. Require masks for all staff and prohibit
visitors
Ensure that all business retailers and personal services require masks and can safely social distance
Increase messaging on the risk of serious disease for individuals in all age groups with preexisting obesity, hypertension, and diabetes
mellitus, and recommend to shelter in place
Work with local community groups to provide targeted, tailored messaging to communities with high case rates, and increase community
level testing
Recruit more contact tracers as community outreach workers to ensure all cases are contacted and all positive households are
individually tested within 24 hours
Provide isolation facilities outside of households if COVID-posi i e indi id als can q aran ine s ccessf ll

Testing
Move to community-led neighborhood testing and work with local community groups to increase access to testing
Surge testing and contact tracing resources to neighborhoods and zip codes with highest case rates
Diagnostic pooling: laboratories should use pooling of samples to increase testing access and reduce turnaround times to under 12
hours. Consider pools of 3-5 individuals
Surveillance pooling: For family and cohabitating households, screen entire households in a single test by pooling specimens of all
members into single collection device
 COVID-19

GEORGIA
STATE REPORT | 07.14.2020
NEW CASES
TESTING

Top counties based on greatest number of new cases in

last three weeks (6/20 - 7/10)
TOP COUNTIES

DATA SOURCES
Cases: County-level data from USAFacts. State values are calculated by aggregating county-level data from USAFacts;
therefore, the values may not match those reported directly by the state. Data is through 7/10/2020.
Testing: HHS Protect laboratory data (provided directly to Federal Government from public health labs, hospital labs, and
commercial labs) through 7/8/2020.
 COVID-19

Top 12 counties based on number of new cases in the

last 3 weeks
TOTAL DAILY CASES

DATA SOURCES
Cases: County-level data from USAFacts through 7/10/2020. Last 3 weeks is 6/20 - 7/10.
 COVID-19

GEORGIA
STATE REPORT | 07.14.2020

CASE RATES AND DIAGNOSTIC TEST POSITIVITY DURING THE

LAST WEEK
NEW CASES PER 100,000 DURING TEST POSITIVITY DURING LAST
LAST WEEK WEEK

WEEKLY % CHANGE IN NEW WEEKLY CHANGE IN TEST

CASES PER 100K POSITIVITY

DATA SOURCES
Cases: County-level data from USAFacts through 7/10/2020. Last week is 7/4 - 7/10, previous week is 6/27 - 7/3
Testing: HHS Protect laboratory data (provided directly to Federal Government from public health labs, hospital labs, and
commercial labs) through 7/8/2020. Last week is 7/2 - 7/8, previous week is 6/25 - 7/1.
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 Infectious Disease Modelling 5 (2020) 293e308

Contents lists available at ScienceDirect

Infectious Disease Modelling

journal homepage: www.keaipublishing.com/idm

To mask or not to mask: Modeling the potential for face mask

use by the general public to curtail the COVID-19 pandemic
Steffen E. Eikenberry, Marina Mancuso, Enahoro Iboi, Tin Phan,
Keenan Eikenberry, Yang Kuang, Eric Kostelich, Abba B. Gumel*
School of Mathematical and Statistical Sciences, Arizona State University, Tempe, AZ, 85287, USA

a r t i c l e i n f o a b s t r a c t

Article history: Face mask use by the general public for limiting the spread of the COVID-19 pandemic is
Received 6 April 2020 controversial, though increasingly recommended, and the potential of this intervention is
Accepted 16 April 2020 not well understood. We develop a compartmental model for assessing the community-
Available online 21 April 2020
wide impact of mask use by the general, asymptomatic public, a portion of which may
be asymptomatically infectious. Model simulations, using data relevant to COVID-19 dy-
Keywords:
namics in the US states of New York and Washington, suggest that broad adoption of even
Face mask
relatively ineffective face masks may meaningfully reduce community transmission of
Non-pharmaceutical intervention
Cloth mask
COVID-19 and decrease peak hospitalizations and deaths. Moreover, mask use decreases
N95 respirator the effective transmission rate in nearly linear proportion to the product of mask effec-
Surgical mask tiveness (as a fraction of potentially infectious contacts blocked) and coverage rate (as a
SARS-CoV-2 fraction of the general population), while the impact on epidemiologic outcomes (death,
COVID-19 hospitalizations) is highly nonlinear, indicating masks could synergize with other non-
pharmaceutical measures. Notably, masks are found to be useful with respect to both
preventing illness in healthy persons and preventing asymptomatic transmission. Hypo-
thetical mask adoption scenarios, for Washington and New York state, suggest that im-
mediate near universal (80%) adoption of moderately (50%) effective masks could prevent
on the order of 17e45% of projected deaths over two months in New York, while
decreasing the peak daily death rate by 34e58%, absent other changes in epidemic dy-
namics. Even very weak masks (20% effective) can still be useful if the underlying trans-
mission rate is relatively low or decreasing: In Washington, where baseline transmission is
much less intense, 80% adoption of such masks could reduce mortality by 24e65% (and
peak deaths 15e69%), compared to 2e9% mortality reduction in New York (peak death
reduction 9e18%). Our results suggest use of face masks by the general public is potentially
of high value in curtailing community transmission and the burden of the pandemic. The
community-wide benefits are likely to be greatest when face masks are used in
conjunction with other non-pharmaceutical practices (such as social-distancing), and
when adoption is nearly universal (nation-wide) and compliance is high.
© 2020 The Authors. Production and hosting by Elsevier B.V. on behalf of KeAi
Communications Co., Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

* Corresponding author.
E-mail address: agumel@asu.edu (A.B. Gumel).
Peer review under responsibility of KeAi Communications Co., Ltd.

https://doi.org/10.1016/j.idm.2020.04.001
2468-0427/© 2020 The Authors. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the
CC BY license (http://creativecommons.org/licenses/by/4.0/).
294 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

1. Introduction

Under the ongoing COVID-19 pandemic (caused by the SARS-CoV-2 coronavirus), recommendations and common prac-
tices regarding face mask use by the general public have varied greatly and are in rapid flux: Mask use by the public in public
spaces has been controversial in the US, although as of April 3, 2020, the US Centers for Disease Control and Prevention (CDC)
is recommending the public wear cloth masks. Public mask use is far more prevalent in many Asian countries, which have
longer experience with novel coronavirus epidemics; public mask use may have been effective at limiting community spread
during the 2003 SARS epidemic (Lau, Tsui, Lau, & Yang, 2004; Wu et al., 2004), and widespread mask use is a prominent
feature of the relatively successful COVID-19 response in Taiwan (Wang, Ng, & Brook, 2020), for example. Masks have also
been suggested as a method for limiting community transmission by asymptomatic or at least clinically undetected carriers
(Chan & Yuen, 2020), who may be a major driver of transmission of COVID-19 (Li et al., 2020). Various experimental studies
suggest that masks may both protect the wearer from acquiring various infections (Davies et al., 2013; Lai, Poon, & Cheung,
2012) or transmitting infection (Dharmadhikari et al., 2012). Medical masks (i.e., surgical masks and N95 respirators) in
healthcare workers appear to consistently protect against respiratory infection under metanalysis (MacIntyre et al., 2017;
Offeddu, Yung, Low, & Tam, 2017), although clinical trials in the community have yielded more mixed results (Canini et al.,
2010; Cowling et al., 2009; MacIntyre et al., 2009). While medical-grade masks should be prioritized for healthcare providers,
homemade cloth masks may still afford significant, although variable and generally lesser, protection (Davies et al., 2013; van
der Sande, Teunis, & Sabel, 2008), but clinical trials in the community remain lacking.
Given the flux in recommendations, and uncertainty surrounding the possible community-wide impact of mass face
masks (especially homemade cloth masks) on COVID-19 transmission, we have developed a multi-group Kermack-McKen-
drick-type compartmental mathematical model, extending prior work geared towards modeling the COVID-19 pandemic (e.g.
Ferguson et al., 2020; Li et al., 2020; Tracht, Del Valle, & Hyman, 2010), as well as models previously used to examine masks in
a potential influenza pandemic (Brienen, Timen, Wallinga, Van Steenbergen, & Teunis, 2010; Tracht et al., 2010). This initial
framework suggests that masks could be effective even if implemented as a singular intervention/mitigation strategy, but
especially in combination with other non-pharmaceutical interventions that decrease community transmission rates.
Whether masks can be useful, even in principle, depends on the mechanisms for transmission for SARS-CoV-2, which are
likely a combination of droplet, contact, and possible airborne (aerosol) modes. The traditional model for respiratory disease
transmission posits infection via infectious droplets (generally 5e10 mm) that have a short lifetime in the air and infect the
upper respiratory tract, or finer aerosols, which may remain in the air for many hours (Leung et al.,2020 ), with ongoing
uncertainties in the relative importance of these modes (and in the conceptual model itself Bourouiba, 2020) for SARS-CoV-2
transmission (Bourouiba, 2020; Han, Lin, Ni, & You, 2020). The WHO (World Health Organization, 2020, p. 27) has stated that
SARS-CoV-2 transmission is primarily via coarse respiratory droplets and contact routes. An experimental study (van
Doremalen et al., 2020) using a nebulizer found SARS-CoV-2 to remain viable in aerosols ( < 5 mm) for 3 h (the study dura-
tion), but the clinical relevance of this setup is debatable (World Health Organization, 2020, p. 27). One out of three symp-
tomatic COVID-19 patients caused extensive environmental contamination in (Ong et al., 2020), including of air exhaust
outlets, though the air itself tested negative.
Face masks can protect against both coarser droplet and finer aerosol transmission, though N95 respirators are more
effective against finer aerosols, and may be superior in preventing droplet transmission as well (MacIntyre et al., 2017).
Metanalysis of studies in healthy healthcare providers (in whom most studies have been performed) indicated a strong
protective value against clinical and respiratory virus infection for both surgical masks and N95 respirators (Offeddu et al.,
2017). Case control data from the 2003 SARS epidemic suggests a strong protective value to mask use by community
members in public spaces, on the order of 70% (Lau et al., 2004; Wu et al., 2004).
Experimental studies in both humans and manikins indicate that a range of masks provide at least some protective value
against various infectious agents (Davies et al., 2013; Driessche et al., 2015; Stockwell et al., 2018; van der Sande et al., 2008;
Leung et al.,2020 ). Medical masks were potentially highly effective as both source control and primary prevention under
tidally breathing and coughing conditions in manikin studies (Lai et al., 2012; Patel, Skaria, Mansour, & Smaldone, 2016), with
higher quality masks (e.g. N95 respirator vs. surgical mask) offering greater protection (Patel et al., 2016). It is largely un-
known to what degree homemade masks (typically made from cotton, teacloth, or other polyesther fibers) may protect
against droplets/aerosols and viral transmission, but experimental results by Davies et al. 7 suggest that while the homemade
masks were less effective than surgical masks, they were still markedly superior to no mask. A clinical trial in healthcare
workers (MacIntyre et al., 2015) showed relatively poor performance for cloth masks relative to medical masks.
Mathematical modeling has been influential in providing deeper understanding on the transmission mechanisms and
burden of the ongoing COVID-19 pandemic, contributing to the development of public health policy and understanding. Most
mathematical models of the COVID-19 pandemic can broadly be divided into either population-based, SIR (Kermack-
McKendrick)-type models, driven by (potentially stochastic) differential equations (Li et al., 2020; Tang et al., 2020; Wu,
Leung, & Leung, 2020; Kucharski et al., 2020; Calafiore, Novara, & Possieri, 2020; Simha, Prasad, & Narayana, 2020;
Dehning et al., 2020; Nesteruk, 2020; Zhang et al., 2020; Anastassopoulou, Russo, Tsakris, & Siettos, 2020; Moore & Okyere,
2004), or agent-based models (Biswas, Khaleque, & Sen, 2020; Chang, Harding, Zachreson, Cliff, & Prokopenko, 2020;
Ferguson et al., 2020; Ruiz Estrada & Koutronas, 2020; Wilder et al., 2020), in which individuals typically interact on a
network structure and exchange infection stochastically. One difficulty of the latter approach is that the network structure is
time-varying and can be difficult, if not impossible, to construct with accuracy. Population-based models, alternatively, may
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 295

risk being too coarse to capture certain real-world complexities. Many of these models, of course, incorporate features from
both paradigms, and the right combination of dynamical, stochastic, data-driven, and network-based methods will always
depend on the question of interest.
In Li et al. (2020) imposed a metapopulation structure onto an SEIR-model to account for travel between major cities in
China. Notably, they include compartments for both documented and undocumented infections. Their model suggests that as
many as 86% of all cases went undetected in Wuhan before travel restrictions took effect on January 23, 2020. They addi-
tionally estimated that, on a per person basis, asymptomatic individuals were only 55% as contagious, yet were responsible for
79% of new infections, given their increased prevalence. The importance of accounting for asymptomatic individuals has been
confirmed by other studies (Calafiore et al., 2020; Ferguson et al., 2020; Moriarty, 2020; Verity et al., 2020). In their model-
based assessment of case-fatality ratios, Verity et al. (2020) estimated that 40e50% of cases went unidentified in China, as of
February 8, 2020, while in the case of the Princess Diamond cruise ship, 46.5% of individuals who tested positive for COVID-19
were asymptomatic (Moriarty, 2020). Further, Calafiore et al. (2020), using a modified SIR-model, estimated that, on average,
cases in Italy went underreported by a factor of 63, as of March 30, 2020.
Several prior mathematical models, motivated by the potential for pandemic influenza, have examined the utility of mask
wearing by the general public. These include a relatively simple modification of an SIR-type model by Brienen et al. (2010),
while Tracht et al. (2010) considered a more complex SEIR model that explicitly disaggregated those that do and do not use
masks. The latter concluded that, for pandemic H1N1 influenza, modestly effective masks (20%) could halve total infections,
while if masks were just 50% effective as source control, the epidemic could be essentially eliminated if just 25% of the
population wore masks.
We adapt these previously developed SEIR model frameworks for transmission dynamics to explore the potential
community-wide impact of public use of face masks, of varying efficacy and compliance, on the transmission dynamics and
control of the COVID-19 pandemic. In particular, we develop a two-group model, which stratifies the total population into
those who habitually do and do not wear face masks in public or other settings where transmission may occur. This model
takes the form of a deterministic system of nonlinear differential equations, and explicitly includes asymptomatically-
infectious humans. We examine mask effectiveness and coverage (i.e., the fraction of the population that habitually wears
masks) as our two primary parameters of interest.
We explore possible nonlinearities in mask coverage and effectiveness and the interaction of these two parameters; we
find that the product of mask effectiveness and coverage level strongly predicts the effect of mask use on epidemiologic
outcomes. Thus, homemade cloth masks are best deployed en masse to benefit the population at large. There is also a
potentially strong nonlinear effect of mask use on the epidemiologic outcomes of cumulative death and peak hospitalizations.
We note a possible temporal effect: Delaying mass mask adoption too long may undermine its efficacy. Moreover, we perform
simulated case studies using mortality data for New York and Washington state. These case studies likewise suggest a
beneficial role to mass adoption of even poorly effective masks, with the relative benefit likely greater in Washington state,
where baseline transmission is less intense. The absolute potential for saving lives is still, however, greater under the more
intense transmission dynamics in New York state. Thus, early adoption of masks is useful regardless of transmission in-
tensities, and should not be delayed even if the case load/mortality seems relatively low.
In summary, the benefit to routine face mask use by the general public during the COVID-19 pandemic remains uncertain,
but our initial mathematical modeling work suggests a possible strong potential benefit to near universal adoption of even
weakly effective homemade masks that may synergize with, not replace, other control and mitigation measures.

2. Methods

2.1. Baseline mathematical models

2.1.1. Model with no mask use

We consider a baseline model without any mask use to form the foundation for parameter estimation and to estimate
transmission rates in New York and Washington state; we also use this model to determine the equivalent transmission rate
reductions resulting from public mask use in the full model.
We use a deterministic susceptible, exposed, symptomatic infectious, hospitalized, asymptomatic infectious, and recov-
ered modeling framework, with these classes respectively denoted SðtÞ, EðtÞ, IðtÞ, HðtÞ, AðtÞ, and RðtÞ; we also include DðtÞ to
track cumulative deaths. We assume that some fraction of symptomatic infectious individuals progress to the hospitalized
class, HðtÞ, where they are unable to pass the disease to the general public; we suppose that some fraction of hospitalized
patients ultimately require critical care (and may die) (Zhou et al., 2020), but do not explicitly disaggregate, for example, ICU
and non-ICU patients. Based on these assumptions and simplifications, the basic model for the transmission dynamics of
COVID-19 is given by the following deterministic system of nonlinear differential equations:

dS S
¼  bðtÞðI þ hAÞ ; (1)
dt N
296 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

dE S
¼ bðtÞðI þ hAÞ  sE; (2)
dt N

dI
¼ asE  4I  gI I; (3)
dt

dA
¼ ð1  aÞsE  gA A; (4)
dt

dH
¼ 4I  dH  gH H; (5)
dt

dR
¼ gI I þ gA A þ gH H; (6)
dt

dD
¼ dH; (7)
dt

where

N ¼ S þ E þ I þ A þ R; (8)

is the total population in the community, and bðtÞ is the baseline infectious contact rate, which is assumed to vary with time in
general, but typically taken fixed. Additionally, h accounts for the relative infectiousness of asymptomatic carriers (in
comparison to symptomatic carriers), s is the transition rate from the exposed to infectious class (so 1=s is the disease in-
cubation period), a is the fraction of cases that are symptomatic, 4 is the rate at which symptomatic individuals are hospi-
talized, d is the disease-induced death rate, and gA , gI and gH are recovery rates for the subscripted population.
We suppose hospitalized persons are not exposed to the general population. Thus, they are excluded from the tabulation of
N, and do not contribute to infection rates in the general community. This general modeling framework is similar to a variety
of SEIR-style models recently employed in (Ferguson et al., 2020; Li et al., 2020), for example.
For most results in this paper, we set bðtÞ≡b0 . However, given ongoing responses to the COVID-19 pandemic in terms of
voluntary and mandated social distancing, etc., we also consider the possibility that b varies with time and adopt the
following functional form from Tang et al. (Tang et al., 2020), with the modification that contact rates do not begin declining
from the initial contact rate, b0 , until time t0 :


b0 ; t < t0
bðtÞ ¼ (9)
bmin þ ðb0  bmin Þexpð  rðt  t0 ÞÞ; t  t0

where bmin is the minimum contact rate and r is the rate at which contact decreases.

2.2. Baseline epidemiological parameters

The incubation period for COVID-19 is estimated to average 5.1 days (Lauer et al., 2020), similar to other model-based
estimates (Li et al., 2020), giving s ¼ 1=5:1 day1. Some previous model-based estimates of infectious duration are on the
order of several days (Ferguson et al., 2020; Li et al., 2020; Tang et al., 2020), with (Tang et al., 2020) giving about 7 days for
asymptomatic individuals to recover. However, the clinical course of the disease is typically much longer: In a study of
hospitalized patients (Zhou et al., 2020), average total duration of illness until hospital discharge or death was 21 days, and
moreover, the median duration of viral shedding was 20 days in survivors.
The effective transmission rate, b0 (as a constant), ranges from around 0.5 to 1.5 day1 in prior modeling studies (Li et al.,
2020; Read, Bridgen, Cummings, Ho, & Jewell, 2020; Shen, Peng, Xiao, & Zhang, 2020), and typically trends down with time (Li
et al., 2020; Tang et al., 2020). We have left this as a free parameter in our fits to Washington and New York state mortality
data, and find b0 z0:5 and b0 z1:4 day1 for these states, respectively, which is consistent with the cited range.
The relative infectiousness of asymptomatic carriers, h, is not known, although Ferguson et al. (Ferguson et al., 2020)
estimated this parameter at about 0.5, and Li et al. (Li et al., 2020) gave values of 0.42e0.55. The fraction of cases that are
symptomatic, a, is also uncertain, with Li et al. 5 suggesting an overall case reporting rate of just 14% early in the outbreak in
China, but increasing to 65e69% later; further, a ¼ 2=3 was used in (Ferguson et al., 2020). In the case of the Diamond Princess
Cruise ship 43, 712 (19.2%) passengers and crews tested positive for SARS-CoV-2, with 331 (46.5%) asymptomatic at the time
of testing. Therefore, we choose a ¼ 0:5 as our default.
Given an average time from symptom onset to dyspnea of 7 days in 44, 9 days to sepsis, and a range of 1e10 days to
hospitalization, a midpoint of 5 days seems reasonable (see also 15); 4z0:025 day1 is consistent with on the order of 5e15%
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 297

of symptomatic patients being hospitalized. If about 15% of hospitalized patients die (Ferguson et al., 2020), then dz 0:015
day1 (based on gH ¼ 1=14 day1).

2.2.1. Model with general population mask use

We assume that some fraction of the general population wears masks with uniform inward efficiency (i.e., primary
protection against catching disease) of εi , and outward efficiency (i.e., source control/protection against transmitting disease)
of εo . We disaggregate all population variables into those that typically do and do not wear masks, respectively subscripted
with U and M. Based on the above assumptions and simplifications, the extended multi-group model for COVID-19 (where
members of the general public wear masks in public) is given by:

dSU S S
¼  bðIU þ hAU Þ U  bðð1  εo ÞIM þ ð1  εo ÞhAM Þ U ; (10)
dt N N
dEU S S
¼ bðIU þ hAU Þ U þ bðð1  εo ÞIM þ ð1  εo ÞhAM Þ U  sEU ; (11)
dt N N
dIU
¼ asEU  4IU  gI IU ; (12)
dt
dAU
¼ ð1  aÞsEU  gA AU ; (13)
dt
dHU
¼ 4IU  dHU  gH HU ; (14)
dt
dRU
¼ gI IU þ gA AU þ gH HU ; (15)
dt
dDU
¼ dHU ; (16)
dt
dSM S S
¼  bð1  εi ÞðIU þ hAU Þ M  bð1  εi Þðð1  εo ÞIM þ ð1  εo ÞhAM Þ M ; (17)
dt N N
dEM S S
¼ bð1  εi ÞðIU þ hAU Þ M þ bð1  εi Þðð1  εo ÞIM þ ð1  εo ÞhAM Þ M  sEM ; (18)
dt N N
dIM
¼ asEM  4IM  gI IM ; (19)
dt
dAM
¼ ð1  aÞsEM  gA AM ; (20)
dt
dHM
¼ 4IM  dHM  gH HM ; (21)
dt
dRM
¼ gI IM þ gA AM þ gH HM ; (22)
dt
dDM
¼ dHM ; (23)
dt
where

N ¼ SU þ EU þ IU þ AU þ RU þ SM þ EM þ IM þ AM þ RM : (25)

While much more complex than the baseline model, most of the complexity lies in what are essentially bookkeeping
terms. We also consider a reduced version of the above model (equations not shown), such that only symptomatically infected
persons wear a mask, to compare the consequences of the common recommendation that only those experiencing symptoms
(and their immediate caretakers) wear masks with more general population coverage.

2.3. Mask efficiency parameters

We assume a roughly linear relationship between the overall filtering efficiency of a mask and clinical efficiency in terms of
either inward efficiency (i.e., effect on εi ) or outward efficiency (εo ), based on Brienen et al. (2010). The fit factor for homemade
masks averaged 2 in Davies et al. (2013), while the fit factor averaged 5 for surgical masks. When volunteers coughed into a
298 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

mask, depending upon sampling method, the number of colony-forming units resulting varied from 17% to 50% for home-
made masks and 0e30% for surgical masks, relative to no mask (Davies et al., 2013).
Surgical masks reduced P. aeruginosa infected aerosols produced by coughing by over 80% in cystic fibrosis patients in
Driessche et al. (2015), while surgical masks reduced CFU count by > 90% in a similar study (Stockwell et al., 2018). N95 masks
were more effective in both studies. Homemade teacloth masks had an inward efficiency between (58) and 77% over 3 h of
wear in van der Sande et al. (2008), while inward efficiency ranged 72e85% and 98e99% for surgical and N95-equivalent
masks. Outward efficiency was marginal for teacloth masks, and about 50e70% for medical masks. Surgical masks worn
by tuberculosis patients also reduced the infectiousness of hospital ward air in Dharmadhikari et al. (2012), and Leung et al.
(2020) very recently observed surgical masks to decrease infectious aerosol produced by individuals with seasonal coro-
naviruses. Manikin studies seem to recommend masks as especially valuable under coughing conditions for both source
control (Patel et al., 2016) and prevention (Lai et al., 2012).
We therefore estimate that inward mask efficiency could range widely, anywhere from 20 to 80% for cloth masks, with
50% possibly more typical (and higher values are possible for well-made, tightly fitting masks made of optimal materials),
70e90% typical for surgical masks, and > 95% typical for properly worn N95 masks. Outward mask efficiency could range
from practically zero to over 80% for homemade masks, with 50% perhaps typical, while surgical masks and N95 masks are
likely 50e90% and 70e100% outwardly protective, respectively.

2.4. Data and model fitting

We use state-level time series for cumulative mortality data compiled by the Center for Systems Science and Engineering
at Johns Hopkins University (2020), from January 22, 2020, through April 2, 2020, to calibrate the model initial conditions and
infective contact rate, b0 , as well as bmin when bðtÞ is taken as an explicit function of time. Other parameters are fixed at
default values in Table 1. Parameter fitting was performed using a nonlinear least squares algorithm implemented using the
lsqnonlin function in MATLAB. We consider two US states in particular as case studies, New York and Washington, and total
population data for each state was defined according to US Census data for July 1, 2019 (US Census).

3. Results

3.1. Analytic results

Closed-form expressions for the basic reproduction number, R 0 , for the baseline model without masks and the full model
with masks are given, for bðtÞ≡b0, in Appendix A and B, respectively.

3.2. Masks coverage/efficacy/time to adoption in simulated epidemics

3.2.1. Mask/efficacy interaction under immediate adoption

We run simulated epidemics using either b0 ¼ 0.5 or 1.5 day 1, with other parameters set to the defaults given in Table 1.
These parameter sets give epidemic doubling times early in time (in terms of cumulative cases and deaths) of approximately
seven or three days, respectively, corresponding to case and mortality doubling times observed (early in time) in Washington
and New York state, respectively. We use as initial conditions a normalized population of 1 million persons, all of whom are
initially susceptible, except 50 initially symptomatically infected (i.e., 5 out 100,000 is the initial infection rate), not wearing
masks.
We choose some fraction of the population to be initially in the masked class (’‘mask coverage’‘), which we also denote p,
and assume εo ¼ εi ¼ ε. The epidemic is allowed to run its course (18 simulated months) under constant conditions, and the
outcomes of interest are peak hospitalization, cumulative deaths, and total recovered. These results are normalized against
the counterfactual of no mask coverage, and results are presented as heat maps in Fig. 1.

Table 1
Baseline model parameters with brief description, likely ranges based on modeling and clinical studies (see text for further details), and default value chosen
for this study.

Parameter Likely range (references) Default value

b (infectious contact rate) 0.5e1.5 day-1 (Li et al., 2020; Read et al., 2020; Shen et al., 2020), this work 0.5 day1
s (transition exposed to infectious) 1/14e1/3 day-1 (Lauer et al., 2020; Li et al., 2020) 1/5.1 day1
h (infectiousness factor for asymptomatic carriers) 0.4e0.6 (Ferguson et al., 2020; Li et al., 2020) 0.5
a (fraction of infections that become symptomatic) 0.15e0.7 (Ferguson et al., 2020; Li et al., 2020; Moriarty, 2020; Verity et al., 2020) 0.5
4 (rate of hospitalization) 0.02e0.1 (Ferguson et al., 2020; Zhou et al., 2020) 0.025 day1
gA (recovery rate, Asymptomatic) 1/14e1/3 day-1 (Tang et al., 2020; Zhou et al., 2020) 1/7 day1
gI (recovery rate, symptomatic) 1/30e1/3 day-1 (Tang et al., 2020; Zhou et al., 2020) 1/7 day1
gH (recovery rate, hospitalized) 1/30e1/3 day-1 (Tang et al., 2020; Zhou et al., 2020) 1/14 day1
d (death rate, hospitalized) 0.001e0.1 (Ferguson et al., 2020) 0.015 day1
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 299

Fig. 1. Relative peak hospitalizations and cumulative mortality under simulated epidemics, under either a base b0 ¼ 0.5 or 1.5 day 1, under different general
mask coverage levels and efficacies (where εo ¼ εi ¼ ε). Results are relative to a base case with no mask use. The left half of the figure gives these metrics as two-
dimensional functions of coverage and efficacy. The right half gives these metrics as one-dimensional functions of coverage  efficacy.

Note that the product ε  p predicts quite well the effect of mask deployment: Fig. 1 also shows (relative) peak hospi-
talizations and cumulative deaths as functions of this product. There is, however, a slight asymmetry between coverage and
efficacy, such that increasing coverage of moderately effective masks is generally more useful than increasing the effec-
tiveness of masks from a starting point of moderate coverage.

3.2.2. Delayed adoption

We run the simulated epidemics described, supposing the entire population is unmasked until mass mask adoption after
some discrete delay. The level of adoption is also fixed as a constant. We find that a small delay in mask adoption (without any
changes in b) has little effect on peak hospitalized fraction or cumulative deaths, but the ‘‘point of no return’’ can rapidly be
crossed, if mask adoption is delayed until near the time at which the epidemic otherwise crests. This general pattern holds
regardless of b0 , but the point of no return is further in the future for smaller b0.

3.3. Mask use and equivalent b reduction

The relationship between mask coverage, efficacy, and metrics of epidemic severity considered above are highly nonlinear.
The relationship between b0 (the infectious contact rate) and such metrics is similarly nonlinear. However, incremental re-
ductions in b0 , due to social distancing measures, etc., can ultimately synergize with other reductions to yield a meaningful
effect on the epidemic. Therefore, we numerically determine what the equivalent change in b0 under the baseline would have
been under mask use at different coverage/efficacy levels, and we denote the equivalent b0 value as b ~ .
0
That is, we numerically simulate an epidemic with and without masks, with a fixed b0 . Then, we fit the baseline model to
~ . An excellent fit giving b
this (simulated) case data, yielding a new equivalent b0 , b ~ can almost always be obtained, though
0 0
occasionally results are extremely sensitive to b0 for high mask coverage/efficacy, yielding somewhat poorer fits. Results are
summarized in Fig. 2, where the b ~ values obtained and the relative changes in equivalent b (i.e., (b
~ )/(b )) are plotted as
0 0 0
functions of efficacy times coverage, ε  p, under simulated epidemics with three baseline (true) b0 values.
From Fig. 2, we see that even 50% coverage with 50% effective masks roughly halves the effective disease transmission rate.
Widespread adoption, say 80% coverage, of masks that are only 20% effective still reduces the effective transmission rate by
about one-third.

3.4. Outward vs. inward efficiency

Fig. 3 demonstrates the effect of mask coverage on peak hospitalizations, cumulative deaths, and equivalent b0 values
when either εo ¼ 0:2 and εi ¼ 0:8, or visa versa (and for simulated epidemics using either b0 ¼ 0.5 or 1.5 day1). These results
suggest that, all else equal, the protection masks afford against acquiring infection (εi ) is actually slightly more important than
protection against transmitting infection (εo ), although there is overall little meaningful asymmetry.
300 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

~ (infectious contact rate) under baseline model dynamics as a function of mask coverage  efficacy, with the left panel giving the absolute
Fig. 2. Equivalent b0 , b0
~ to the true b in the simulation with masks. That is, simulated epidemics are run with mask coverage and effectiveness
value, and the right giving the ratio of b0 0
ranging from 0 to 1, and the outcomes are tracked as synthetic data. The baseline model without mask dynamics is then fit to this synthetic data, with b0 the
~
trainable parameter; the resulting b0 is the b0 . This is done for simulated epidemics with a true b0 of 1.5, 1, or 0.5 day1.

Fig. 3. Epidemiologic outcomes and equivalent b0 changes as a function of mask coverage when masks are either much better at blocking outgoing (εo ¼ 0:8,
εi ¼ 0:2) or incoming (ε0 ¼ 0:2, εi ¼ 0:8) transmission. Results are demonstrated for both mask permutations under simulated epidemics with baseline b0 ¼ 0.5
or 1.5 day 1.

3.5. Masks for symptomatic alone vs. general population

Finally, we consider numerical experiments where masks are given to all symptomatically infected persons, whether they
otherwise habitually wear masks or not (i.e., both IU and IM actually wear masks). We explore how universal mask use in
symptomatically infected persons interacts with mask coverage among the general population; we let εIo represent the
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 301

effectiveness of masks in the symptomatic, not necessarily equal to εo . We again run simulated epidemics with no masks, or
with universal masks among the symptomatic, and then compare different levels of mask coverage in the general (asymp-
tomatic) population in addition to universal masks for the symptomatic. In this section, we use equivalent b0 as our primary
metric. Fig. 4 shows how this metric varies as a function of the mask effectiveness given to symptomatic persons, along with
the coverage and effectiveness of masks worn by the general public.
We also explore how conclusions vary when either 25%, 50%, or 75% of infectious COVID-19 patients are asymptomatic (i.e.,
we vary a). Unsurprisingly, the greater the proportion of infected people that are asymptomatic, the more benefit there is to
giving the general public masks in addition to those experiencing symptoms.

3.6. Simulated case studies: New York & Washington states

Fitting to cumulative death data for New York and Washington states, we use the baseline model to determine the best
fixed b0 and Ið0Þ. We use New York state data beginning on March 1, 2020, through April 2, 2020, and Washington state data
from February 20, 2020 through April 2, 2020. For New York state, best-fit parameters are Ið0Þ ¼ 208 (range 154e264) and b0
¼ 1.40 (1.35e1.46) day1 under fixed b0 . For the time-varying bðtÞ, we fix r ¼ 0:03 day1 and t0 ¼ 20, yielding a best-fit b0
¼ 1.33 (1.24e1.42) day1, bmin ¼ 0.51 (0.25e1.26) day1, and Ið0Þ ¼ 293 (191e394).
For Washington state, parameters are Ið0Þ ¼ 622 (571e673) and b0 ¼ 0.50 (0.49e0.52) day1 under fixed b0 . For time-
varying bðtÞ, we fix r ¼ 0:04 day1 and t0 ¼ 0, to yield a best-fit b0 ¼ 1.0 (0.87e1.23) day1, bmin ¼ 0.10 (0e0.19) day1,
and Ið0Þ ¼ 238 (177e300).
We fix r and t0 , as it is not possible to uniquely identify r, t0 and bmin from death or case data alone (see, e.g., Roda,
Varughese, Han, & Li, 2020 on identifiability problems). Fig. 5 gives cumulative death and case data versus the model pre-
dictions for the two states, and for the two choices of bðtÞ. Note that while modeled and actual cumulative deaths match well,
model-predicted cases markedly exceed reported cases in the data, consistent with the notion of broad underreporting.
We then consider either fixed b0 or time-varying bðtÞ, according to the parameters above, in combination with the
following purely hypothetical scenarios in each state.

1. No masks, epidemic runs its course unaltered with either bðtÞ≡b0 fixed or bðtÞ variable as described above.
2. The two b scenarios are considered in combination with: weak, moderate, or strong deployment of masks, such that
p ¼ 0.2, 0.5, or 0.8; and weak, moderate, or strong masks, such that ε ¼ 0.2, 0.5, or 0.8. No masks are used up until April 2,
2020, and then these coverage levels are instantaneously imposed.

This yields 18 scenarios in all (nine mask coverage/efficacy scenarios, plus two underlying trends). Following the modeled
imposition of masks on April 2, 2020, the scenarios are run for 60 additional simulated days. Figs. 6 and 8 summarize the

Fig. 4. Equivalent b0 under the model where all symptomatic persons wear a mask (whether they otherwise habitually wear a mask or not), under varying levels
of efficacy for the masks given to the symptomatic (εIo ), and in combination with different degrees of coverage and effectiveness for masks used by the rest of the
general public. Results are for simulated epidemics with a baseline b0 of 1.5 day1.
302 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

Fig. 5. The left half of the figure gives model predictions and data for Washington state, using either a constant (top panels) or variable b (bottom panel), as
described in the text. The right half of the figure is similar, but for New York state.

Fig. 6. Simulated future (cumulative) death tolls for Washington state, using either a fixed (top panels) or variable (bottom panels) transmission rate, b, and nine
different permutations of general public mask coverage and effectiveness. The y-axes are scaled differently in top and bottom panels.
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 303

Fig. 7. Simulated future daily death rates for Washington state, using either a fixed (top panels) or variable (bottom panels) transmission rate, b, and nine
different permutations of general public mask coverage and effectiveness. The y-axes are scaled differently in top and bottom panels.

future modeled death toll in each city under the 18 different scenarios, along with historical mortality data. Figs. 7 and 9 show
modeled daily death rates, with deaths peaking sometime in late April in New York state under all scenarios, while deaths
could peak anywhere from mid-April to later than May, for Washington state. We emphasize that these are hypothetical and
exploratory results, with possible death tolls varying dramatically based upon the future course of bðtÞ. However, the results
do suggest that even modestly effective masks, if widely used, could help ‘‘bend the curve,’’ with the relative benefit greater in
combination with a lower baseline b0 or stronger underlying trend towards smaller bðtÞ (i.e., in Washington vs. New York).

4. Discussion & conclusions

There is considerable ongoing debate on whether to recommend general public face mask use (likely mostly homemade
cloth masks or other improvised face coverings) 4, and while the situation is in flux, more authorities are recommending
public mask use, though they continue to (rightly) cite appreciable uncertainty. With this study, we hope to help inform this
debate by providing insight into the potential community-wide impact of widespread face mask use by members of the
general population. We have designed a mathematical model, parameterized using data relevant to COVID-19 transmission
dynamics in two US states (New York and Washington), and our model suggests nontrivial and possibly quite strong benefits
to general face mask use. The population-level benefit is greater the earlier masks are adopted, and at least some benefit is
realized across a range of epidemic intensities. Moreover, even if they have, as a sole intervention, little influence on epidemic
outcomes, face masks decrease the equivalent effective transmission rate (b0 in our model), and thus can stack with other
interventions, including social distancing and hygienic measures especially, to ultimately drive nonlinear decreases in
epidemic mortality and healthcare system burden. It bears repeating that our model results are consistent with the idea that
face masks, while no panacea, may synergize with other non-pharmaceutical control measures and should be used in
combination with and not in lieu of these.
Under simulated epidemics, the effectiveness of face masks in altering the epidemiologic outcomes of peak hospitalization
and total deaths is a highly nonlinear function of both mask efficacy and coverage in the population (see Fig. 1), with the
product of mask efficacy and coverage a good one-dimensional surrogate for the effect. We have determined how mask use in
~ , in the baseline model (without masks), finding this equivalent b
the full model alters the equivalent b0 , denoted b ~ to vary
0 0
nearly linearly with efficacy  coverage (Fig. 2).
Masks alone, unless they are highly effective and nearly universal, may have only a small effect (but still nontrivial, in
terms of absolute lives saved) in more severe epidemics, such as the ongoing epidemic in New York state. However, the
relative benefit to general mask use may increase with other decreases in b0 , such that masks can synergize with other public
health measures. Thus, it is important that masks not be viewed as an alternative, but as a complement, to other public health
304 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

control measures (including non-pharmaceutical interventions, such as social distancing, self-isolation etc.). Delaying mask
adoption is also detrimental. These factors together indicate that even in areas or states where the COVID-19 burden is low
(e.g. the Dakotas), early aggressive action that includes face masks may pay dividends.
These general conclusions are illustrated by our simulated case studies, in which we have tuned the infectious contact rate,
b (either as fixed b0 or time-varying bðtÞ), to cumulative mortality data for Washington and New York state through April 2,
2020, and imposed hypothetical mask adoption scenarios. The estimated range for b is much smaller in Washington state,
consistent with this state’s much slower epidemic growth rate and doubling time. Model fitting also suggests that total
symptomatic cases may be dramatically undercounted in both areas, consistent with prior conclusions on the pandemic (Li
et al., 2020). Simulated futures for both states suggest that broad adoption of even weak masks could help avoid many deaths,
but the greatest relative death reductions are generally seen when the underlying transmission rate also falls or is low at
baseline.
Considering a fixed transmission rate, b0 , 80% adoption of 20%, 50%, and 80% effective masks reduces cumulative relative
(absolute) mortality by 1.8% (4,419), 17% (41,317), and 55% (134,920), respectively, in New York state. In Washington state,
relative (absolute) mortality reductions are dramatic, amounting to 65% (22,262), 91% (31,157), and 95% (32,529). When bðtÞ
varies with time, New York deaths reductions are 9% (21,315), 45% (103,860), and 74% (172,460), while figures for Washington
are 24% (410), 41% (684), and 48% (799). In the latter case, the epidemic peaks soon even without masks. Thus, a range of
outcomes are possible, but both the absolute and relative benefit to weak masks can be quite large; when the relative benefit
is small, the absolute benefit in terms of lives is still highly nontrivial.
Most of our model projected mortality numbers for New York and Washington state are quite high (except for variable bðtÞ
in Washington), and likely represent worst-case scenarios, as they primarily reflect b values early in time. Thus, they may be
dramatic overestimates, depending upon these states’ populations ongoing responses to the COVID-19 epidemics. Never-
theless, the estimated transmission values for the two states, under fixed and variable bðtÞ, represent a broad range of possible
transmission dynamics and are within the range estimated in prior studies (Li et al., 2020; Read et al., 2020; Shen et al., 2020),
and so we may have some confidence in our general conclusions on the possible range of benefits to masks. Note also that we
have restricted our parameter estimation only to initial conditions and transmission parameters, owing to identifiability
problems with more complex models and larger parameter groups (see e.g. Roda, Varughese, Han, & Li, 2020). For example,
the same death data may be consistent with either a large b0 and low d (death rate), or visa versa.
Considering the subproblem of general public mask use in addition to mask use for source control by any (known)
symptomatic person, we find that general face mask use is still highly beneficial (see Fig. 4). Unsurprisingly, this benefit is
greater if a larger proportion of infected people are asymptomatic (i.e., a in the model is smaller). Moreover, it is not the case
that masks are helpful exclusively when worn by asymptomatic infectious persons for source control, but provide benefit
when worn by (genuinely) healthy people for prevention as well. Indeed, if there is any asymmetry in outward vs. inward
mask effectiveness, inward effectiveness is actually slightly preferred, although the direction of this asymmetry matters little
with respect to overall epidemiologic outcomes. At least one experimental study (Patel et al., 2016) does suggest that masks
may be superior at source control, especially under coughing conditions vs. normal tidal breathing and so any realized benefit
of masks in the population may still be more attributable to source control.
This is somewhat surprising, given that εo appears more times than εi in the model terms giving the forces of infection,
which would suggest outward effectiveness to be of greater import at first glance. Our conclusion runs counter to the notion
that general public masks are primarily useful in preventing asymptomatically wearers from transmitting disease: Masks are
valuable as both source control and primary prevention. This may be important to emphasize, as some people who have self-
isolated for prolonged periods may reasonably believe that the chance they are asymptomatically infected is very low and
therefore do not need a mask if they venture into public, whereas our results indicate they (and the public at large) still stand
to benefit.
Our theoretical results still must be interpreted with caution, owing to a combination of potentially high rates of
noncompliance with mask use in the community, uncertainty with respect to the intrinsic effectiveness of (especially
homemade) masks at blocking respiratory droplets and/or aerosols, and even surprising amounts of uncertainty regarding
the basic mechanisms for respiratory infection transmission (Bourouiba, 2020; MacIntyre et al., 2017). Several lines of evi-
dence support the notion that masks can interfere with respiratory virus transmission, including clinical trials in healthcare
workers (MacIntyre et al., 2017; Offeddu et al., 2017), experimental studies as reviewed in (Davies et al., 2013; Dharmadhikari
et al., 2012; Lai et al., 2012; Patel et al., 2016; van der Sande et al., 2008), and case control data from the 2003 SARS epidemic
(Lau et al., 2004; Wu et al., 2004). Given the demonstrated efficacy of medical masks in healthcare workers (Offeddu et al.,
2017), and their likely superiority over cloth masks in MacIntyre et al. (2015), it is clearly essential that healthcare works
be prioritized when it comes to the most effective medical mask supply. Fortunately, our theoretical results suggest significant
(but potentially highly variable) value even to low quality masks when used widely in the community.
With social distancing orders in place, essential service providers (such as retail workers, emergency services, law
enforcement, etc.) represent a special category of concern, as they represent a largely unavoidable high contact node in
transmission networks: Individual public-facing workers may come into contact with hundreds or thousands of people in the
course of a day, in relatively close contact (e.g. cashiers). Such contact likely exposes the workers to many asymptomatic
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 305

carriers, and they may in turn, if asymptomatic, expose many susceptible members of the general public to potential
transmission. Air exposed to multiple infectious persons (e.g. in grocery stores) could also carry a psuedo-steady load of
infectious particles, for which masks would be the only plausible prophylactic (Lai et al., 2012). Thus, targeted, highly effective
mask use by service workers may be reasonable. We are currently extending the basic model framework presented here to
examine this hypothesis.
In conclusion, our findings suggest that face mask use should be as nearly universal (i.e., nation-wide) as possible and
implemented without delay, even if most masks are homemade and of relatively low quality. This measure could contribute
greatly to controlling the COVID-19 pandemic, with the benefit greatest in conjunction with other non-pharmaceutical in-
terventions that reduce community transmission. Despite uncertainty, the potential for benefit, the lack of obvious harm, and
the precautionary principle lead us to strongly recommend as close to universal (homemade, unless medical masks can be
used without diverting healthcare supply) mask use by the general public as possible.

Declaration of competing interest

None.

Acknowledgements

One of the authors (ABG) acknowledge the support, in part, of the Simons Foundation (Award #585022) and the National
Science Foundation (Award 1917512).

Appendix A. Basic Reproduction Number for the Baseline Model

The basic reproduction number is calculated for the special case when bðtÞ≡b0 . The local stability of the disease-free
equilibrium (DFE) is explored using the next generation operator method (Diekmann, Heesterbeek, & Metz, 1990; van den
Driessche & Watmough, 2002). Using the notation in (van den Driessche & Watmough, 2002), it follows that the matrices
F of new infection terms and V of the remaining transfer terms associated with the baseline model are given, respectively,
by
2 3
0 b0 b0 h
F ¼40 0 0 5;
0 0 0
2 3
s 0 0
V ¼ 4 as ð4 þ gI Þ 0 5:
ð1  aÞs 0 gA

The basic reproduction number of the model, denoted by R 0, is given by

b0 a b0 hð1  aÞ
R0¼ þ : (26)
ð4 þ gI Þ gA

Appendix B. Basic Reproduction Number for Full Model

The local stability of the DFE is explored using the next generation operator method (Diekmann et al., 1990; van den
Driessche & Watmough, 2002). Using the notation in van den Driessche and Watmough (2002), it follows that the
matrices F of new infection terms and V of the remaining transfer terms associated with the version of the model are given,
respectively, by
306 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308

2 3
SU ð0Þ SU ð0Þ SU ð0Þ SU ð0Þ
6
0 b0 b0 h 0 b0 ð1  εo Þ b0 ð1  εo Þh 7
6 Nð0Þ Nð0Þ Nð0Þ 7Nð0Þ
6 7
60 0 0 0 0 0 7
6 7
6 7
60 0 0 0 0 0 7
F ¼6
6
7;
6 0 b ð1  ε Þ SM ð0Þ SM ð0Þ S ð0Þ S ð0Þ 7
6 0 i b0 ð1  εi Þh 0 b0 ð1  εo Þð1  εi Þ M b0 ð1  εo Þð1  εi Þh M 7 7
6 Nð0Þ Nð0Þ Nð0Þ Nð0Þ 7
6 7
60 7
4 0 0 0 0 0 5
0 0 0 0 0 0
2 3
s 0 0 0 0 0
6 as ð4 þ gI Þ 0 0 0 0 7
6 7
6 ð1  aÞs 0 gA 0 0 0 7
V ¼6
60
7
7
6 0 0 s 0 0 7
40 0 0 as ð4 þ gI Þ 0 5
0 0 0 ð1  aÞs 0 gA

The basic reproduction number of the model, denoted by R 0, is given by

  
SU ð0Þ SM ð0Þ a hð1  aÞ
R 0 ¼ b0 þ ð1  εo Þð1  εi Þ þ : (27)
Nð0Þ Nð0Þ 4 þ gI gA

Fig. 8. Simulated future (cumulative) death tolls for New York state, using either a fixed (top panels) or variable (bottom panels) transmission rate, b, and nine
different permutations of general public mask coverage and effectiveness.
 S.E. Eikenberry et al. / Infectious Disease Modelling 5 (2020) 293e308 307

Fig. 9. Simulated future daily death rates for New York state, using either a fixed (top panels) or variable (bottom panels) transmission rate, b, and nine different
permutations of general public mask coverage and effectiveness.

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Association of country-wide coronavirus mortality with demographics, testing,

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Association of country-wide coronavirus mortality with demographics, testing,
lockdowns, and public wearing of masks (Update July 2, 2020).
Christopher T. Leffler, MD, MPH.1,2 *
Edsel Ing MD, MPH, CPH, MIAD.3
Joseph D. Lykins V, MD.4,5
Matthew C. Hogan, MS, MPH.6
Craig A. McKeown, MD.7
Andrzej Grzybowski, MD, PhD, MBA.8,9
1. Department of Ophthalmology. Virginia Commonwealth University. Richmond, VA 23298.
chrislefflermd@gmail.com

2. Department of Ophthalmology. Hunter Holmes McGuire VA Medical Center, Richmond, VA.

3. Department of Ophthalmology & Vision Sciences, University of Toronto.

4. Department of Internal Medicine, Virginia Commonwealth University. Richmond, VA 23298.

5. Department of Emergency Medicine. Virginia Commonwealth University. Richmond, VA 23298.

6. School of Medicine, Virginia Commonwealth University, Richmond, VA 23298.

7. Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine.

8. Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.

9. Institute for Research in Ophthalmology, Poznan, Poland.

*Corresponding author: Christopher T. Leffler, MD, MPH.

Department of Ophthalmology. Virginia Commonwealth University. 401 N. 11th St., Box 980209,
Richmond, VA 23298. chrislefflermd@gmail.com.

July 2, 2020.

None of the authors has any conflicts of interest to disclose.

1
Abstract.
Background. There is wide variation between countries in per-capita mortality from
COVID-19 (caused by the SARS-CoV-2 virus). Determinants of this variation are not
fully understood.
Methods. Potential predictors of per-capita coronavirus-related mortality in 198
countries were examined, including age, sex ratio, obesity prevalence, temperature,
urbanization, smoking, duration of infection, lockdowns, viral testing, contact tracing
policies, and public mask-wearing norms and policies. Multivariable linear regression
analysis was performed.
Results. In univariate analyses, the prevalence of smoking, per-capita gross domestic
product, urbanization, and colder average country temperature were positively
associated with coronavirus-related mortality. In a multivariable analysis of 194
countries, the duration of infection in the country, and the proportion of the population
60 years of age or older were positively associated with per-capita mortality, while
duration of mask-wearing by the public was negatively associated with mortality (all
p<0.001). The prevalence of obesity was independently associated with mortality in
models which controlled for testing levels or policy. International travel restrictions were
independently associated with lower per-capita mortality, but other containment
measures and viral testing and tracing policies were not. In countries with cultural
norms or government policies supporting public mask-wearing, per-capita coronavirus
mortality increased on average by just 7.2% each week, as compared with 55.0% each
week in remaining countries. On multivariable analysis, lockdowns tended to be
associated with less mortality (p=0.41), and increased per-capita testing with higher
reported mortality (p=0.55), though neither association was statistically significant.
Conclusions. 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.

2
Introduction.
The COVID-19 global pandemic caused by infection with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) has presented a major public health
challenge. For reasons that are not completely understood, the per-capita mortality
from COVID-19 varies by several orders of magnitude between countries.1 Numerous
sources of heterogeneity have been hypothesized. Higher mortality has been observed
in older populations and in men.2,3 Patient-level behaviors, such as smoking, might also
have an impact.3 Other potentially relevant factors include economic activity, and
environmental variation, such as temperature.4 More urban settings and increased
population density would be expected to enhance viral transmission.5
In addition, public health responses to the COVID-19 pandemic may influence
per-capita mortality. Various strategies have been implemented, ranging from robust
testing programs to lockdown or stay-at-home orders, to mandates regarding social
distancing and face mask usage. Practices with theoretical benefit, such as social
distancing, stay-at-home orders, and implementation of mandates regarding use of
masks in public spaces, must be assessed quickly, as implementation has the potential
to reduce morbidity and mortality.
Mask usage by the public is postulated to decrease infection by blocking the
spread of respiratory droplets,1 and was successfully implemented during other
coronavirus outbreaks (i.e. SARS and MERS).6 In the context of the ongoing pandemic,
we assessed the impact of masks on per-capita COVID-19-related mortality, controlling
for the aforementioned factors. We hypothesized that in countries where mask use was
either an accepted cultural norm or favored by government policies on a national level,
the per-capita mortality might be reduced, as compared with countries which did not
advocate masks.

Methods.

Data acquisition.
Country-wide coronavirus mortality data was retrieved from the publicly available
Worldometers Database on May 9, 2020.7 Countries were included if either: 1)
coronavirus testing data were available by May 9, 2020,7 or if: 2) testing and lockdown
policies had been graded by the University of Oxford Coronavirus Government
Response Tracker.8-9
Oxford University defined and scored several composite government response
indices. The stringency index was defined in terms of containment policy and public
information.8 The government response index incorporated containment, economic
measures, public information, and testing and tracing policies.8 The containment and
health index was defined in terms of containment measures, public information, and
testing and tracing policies.8
Archived viral testing data for April 2020 were also downloaded.10 The date of
the country’s first reported infection and first death were obtained from the European
Centre for Disease Prevention and Control (which did tabulate worldwide data).11
Mean temperature in each country during the pandemic was estimated using the
average monthly temperature in the country’s largest city from public sources.12,13

3
 Online news reports and government statements, including those cited by a
previous review14 and a public database,15 were searched to identify countries in which
the public wore masks early in the outbreak based on tradition, as well as countries in
which the national government mandated or recommended mask-wearing by the public
before April 16, 2020.
For each country, the population,16 fraction of the population age 60 years and
over, and age 14 and under, male: female ratio per country,17 surface area,16,17 gross
domestic product per capita,18 percent urbanization,16,19 adult smoking prevalence20-23
and prevalence of adult obesity24-43 were tabulated. Whether a nation was an isolated
political entity on an island was also recorded.

Statistical analysis.
The prevalence of an infectious process undergoing exponential growth (or
decay) appears linear over time when graphed on a logarithmic scale.1 Therefore, we
postulated that the logarithm of the country-wide infection prevalence would be linearly
related with the duration of the infection in each country. In addition, our analysis
postulated that deaths from coronavirus would follow infections with some delay.
On average, the time from infection with the coronavirus to onset of symptoms is
5.1 days,44 and the time from symptom onset to death is on average 17.8 days.45
Therefore, the time from infection to death is expected to be 23 days.1,46 These
incubation and mortality times were prespecified.1,46 Therefore, the date of each
country’s initial infection was estimated as the earlier of: 5 days before the first reported
infection, or 23 days before the first death.10,11,47 Deaths by May 9, 2020 would typically
reflect infections beginning 23 days previously (by April 16). Therefore, we recorded the
time from the first infection in a country until April 16. We also recorded the period of
the outbreak: 1) from the mandating of activity restrictions until April 16, and 2) from
when public mask-wearing was recommended until April 16. In addition, we calculated
the mean time-weighted score for each lockdown and testing policy as graded by the
University of Oxford for the duration of the country’s outbreak, from beginning through
April 16.8 For instance, if the school closure score was 1 for half the outbreak and 2 for
the other half, then the mean score was 1.5.
Per-capita mortality can be analyzed as a binary outcome (low or high), or as a
continuous variable. Each approach has strengths and weaknesses.
Analysis of a binary outcome is not unduly influenced by outliers. Countries with
extremely low or high mortality are included in the appropriate group, but the exact
mortality value does not change the results. Moreover, analysis of a binary outcome
facilities clear communication, because one can describe the characteristics of low and
high mortality countries.
On the other hand, per-capita mortality is in fact a continuous variable, and the
separation of countries just below or just above a threshold value is somewhat arbitrary,
or susceptible to chance variation. Analysis of mortality as a continuous variable uses
all the information available, and can appropriately model the exponential growth of an
infection. We view the binary and continuous analyses as complementary. When one
sees that a univariate association is found with both types of analysis, one gains

4
confidence that the association is not an artifact of the analytic method selected.
Therefore, we used both methods for initial univariate selection of variables.
In univariate analysis, characteristics of countries with above-median per-capita
mortality were compared with the remaining (lower mortality) countries by the two-
sample t-test using groups. The odds ratio for being in the high-mortality group was
calculated by logistic regression. In addition, logarithm (base 10) of per-capita
coronavirus-related mortality was predicted by linear regression.
Significant predictors of per-capita coronavirus mortality in the univariate analysis
were analyzed by stepwise backwards multivariable linear regression analysis. The
dependent variable was the logarithm (base 10) of per-capita coronavirus-related
mortality. Because of the importance relative to public health, the weeks the country
spent in lockdown and using masks, and per-capita testing levels, were retained in the
model. In addition, because of their biological plausibility and presumed importance,
urbanization, prevalence of obesity, and average ambient temperature were retained in
most of the multivariable models presented below. Statistical analysis was performed
with xlstat 2020.1 (Addinsoft, New York). An alpha (p value) of 0.05 was deemed to be
statistically significant. The study was approved by the Virginia Commonwealth
University Office of Research Subjects Protection.

Results.
We studied coronavirus mortality in 198 countries, of which 183 had testing
data,7 161 had government policies scored by Oxford University,8 and 146 fell into both
categories.
The 99 lower-mortality countries had 1.0 deaths per million population, in
contrast with an average of 94.2 deaths per million population in the 99 higher-mortality
countries (p<0.001, Table 1, Appendix Table A1). The median value was 3.7 deaths
per million population. The same independent variables were found to be statistically
significant on univariate analysis regardless of whether per-capita mortality was
considered a binary or continuous variable, as outlined below (Table 1, Appendix Table
A2).
We assumed that island nations might find it less challenging to isolate and
protect their populations. However, 20 of 99 low-mortality countries were isolated on
islands, compared with 27 of 99 high-mortality countries (p=0.32). Country surface area
and population were not associated with coronavirus mortality (Table 1).

Population characteristics.
Countries with older populations suffered higher coronavirus mortality. Countries
with low mortality had on average 8.9% of their population over age 60, as compared
with 18.9% in the high-mortality countries (Table 1). The proportion of the population
which was male was not associated with country-wide mortality (p=0.98, Table 1).
Smoking prevalence was on average 13.8% in low mortality countries and 18.5% in
high-mortality countries (p<0.001, Table 1). The prevalence of obesity was on average
14.7% in low-mortality countries and 24.0% in high-mortality countries (p<0.001, Table
1).

5
Temperature.
Colder countries were associated with higher coronavirus mortality in univariate
analysis. The mean temperature was 22.3 C (SD 7.6 C) in the low-mortality countries,
and 14.0 C (SD 9.1 C) in the high-mortality countries (p<0.001, Table 1).

Economics.
Urbanization was associated with coronavirus mortality in univariate analysis. In
low-mortality countries, on average 53% of the population was urban, as compared with
71% of the population in the high-mortality countries (p<0.001, Table 1). Richer
countries suffered a higher coronavirus related mortality. The mean GDP per capita
was $9,350 in the low-mortality countries, and was $27,380 in the high-mortality
countries (Table 1, p<0.001).

Table 1. Characteristics of countries with low and high per-capita coronavirus mortality
by May 9, 2020 in 198 countries.
Mean (SD) p value
Odds ratio (95% CI) Low Mortality High Mortalilty
Deaths (per million) -- 1.02 (1.18) 94.2 (183.4) <0.001
Deaths (per capita, log) -- -6.46 (0.76) -4.54 (0.64) <0.001
Duration infection (weeks) 1.23 (1.09-1.38) 6.51 (2.87) 7.84 (2.31) <0.001
Duration infection without 1.43 (1.24-1.66) 5.01 (2.25) 6.81 (2.31) <0.001
masks (weeks)
Duration infection without 1.08 (0.97-1.20) 2.83 (2.93) 3.37 (2.39) 0.16
lockdown (weeks)
Temperature, mean (C) 0.90 (0.86-0.93) 22.3 (7.6) 14.0 (9.1) <0.001
Urban population (%) 1.04 (1.02-1.05) 53.2 (22.4) 70.6 (19.9) <0.001
GDP per capita ($1000) 1.05 (1.03-1.07) 9.350 (17.140) 27.380 (27.530) <0.001
Age 14 & under (% of pop.) 0.85 (0.81-0.89) 32.2 (9.7) 20.1 (6.6) <0.001
Age 60 & over (% of pop.) 1.20 (1.14-1.27) 8.9 (5.3) 18.4 (7.9) <0.001
Surface area (million km2) 1.08 (0.92-1.26) 0.557 (1.12) 0.804 (2.455) 0.37
Population (million) 0.998 (0.995-1.001) 53.1 (20.1) 24.9 (48.2) 0.18
Prevalence males (%) 1.001 (0.921-1.088) 50.1 (2.1) 50.2 (4.2) 0.98
Smoking prevalence, adult (%) 1.09 (1.04-1.13) 13.8 (7.8) 18.5 (7.7) <0.001
Obesity prevalence, adult (%) 1.14 (1.10-1.19) 14.7 (9.0) 24.0 (7.3) <0.001
Tests per cap. (log) by Apr 4 2.99 (1.92-4.68) -3.73 (1.20) -2.65 (0.76) <0.001
Tests per cap. (log) by Apr 16 3.60 (2.31-5.80) -3.09 (0.87) -2.31 (0.67) <0.001
Tests per cap. (log) by May 9 4.69 (2.85-7.73) -2.76 (0.85) -1.91 (0.61) <0.001
Durations run from the estimated date of first infection in the country until 23 days before May 9,
2020 (i.e. April 16), or the stated event (mask recommendation or lockdown). Obesity data available for
194 countries. Testing data available for 135 countries by April 4, 162 countries by April 16, and 183
countries by May 9.

6
Masks: Early Adoption.

The World Health Organization initially advised against widespread mask

wearing by the public, as did the United States CDC.1,48 The WHO reversed course and
recommended masks in public on June 5, 2020.49
Despite these initial recommendations, a number of countries did favor mask
wear by the public early in their outbreak, and such countries experienced low
coronavirus-related mortality (Table 2, Figure 1).50-132 It is likely that in Mongolia50 and
Laos,52 both of which reported no coronavirus-related mortality by May 9, the public
began wearing masks before any cases were confirmed in their countries (Table 2). We
identified 20 countries with recommendations or cultural norms favoring mask-wearing
by the public within 21 days of the estimated onset of the country’s outbreak:1 including
(beginning with those favoring masks earliest in the course of their outbreak):
Japan,53,54 Venezuela, the Philippines,62 Macau,63 Hong Kong,53,64,65 Sierra Leone,
Cambodia,71,72 Vietnam,74 Malaysia,77 Bhutan,79 Taiwan,82 Slovakia, South Korea,53,89
Grenada, Mozambique, Uzbekistan, Thailand,98 and Malawi (Table 2). The average
mortality by May 9 for the 20 early mask-wearing countries was 1.5 per million (SD 2.1).
Sixteen of the 20 were lower-mortality countries (p=0.008).

An additional 9 countries had recommended that the public wear masks by 31

days into their outbreak: Czechia, Zambia, Benin, Sudan, Antigua and Barbuda, Bosnia,
Côte d'Ivoire, Kenya, and El Salvador (Table 2). The average mortality by May 9 for this
group was 10.4 per million (SD 14.2).

7
Table 2. Countries in which masks were widely used by the public or recommended by
the government within 31 days of the estimated local onset of the outbreak, by
timeliness of mask-wearing.
Mask First Case Mortality Comment.
Delay Date (per
(days) mil.), by
May 9.
Mongolia 0 Mar. 10 0.0 Mongolians began wearing masks in January.50
Laos 0 Mar. 24 0.0 Health officials in Laos advised mask-wearing by
March 6,51 and the public began wearing masks
even before any cases were reported in the
country.52
Japan 5 Jan. 16 4.8 Public use of masks is traditional.48 Surveys
indicate that 64% of adults habitually wore a mask
in Winter.53 Public masking was manifest by Jan.
16 when the first domestic case was announced.54-
56
The government initially recommended masks
when in “confined, badly ventilated spaces”.48 One
survey documented mask wear prevalence over
60% by March 14, increasing to over 75% by Aprail
12.57 In another poll, 62% indicated wearing a
mask in public by March 17, and 76% by April 13,
2020.58
Venezuela 5 Mar. 1360 0.4 President Maduro demonstrated wearing of masks
on live television on March 13 (the day the first
case was confirmed), and required masks on
public transport.59-60 Masks were required in any
public space by March 20.61
Philippines 5 Jan. 30 6.4 Masks were used extensively as early as Jan. 30.62
In a poll, 60% indicated wearing a mask in public
on Feb. 24, and 82% by March 30.58 Masks were
mandated on April 2.
Macau 6 Jan. 22 0.0 Mask use is traditional. By Jan. 23, the
government had implemented a mask distribution
program for the public.63
Hong Kong 6 Jan. 2365 0.5 Surgical masks were traditionally used, and also
were recommended on public transport and in
crowded places, on January 24, 2020.48,64 Surveys
indicated that masks were worn by about 73% in
the week of Jan. 21, and by 98% of the public by
mid-February, which persisted into May.66 In
February 2020, 94.8% of pedestrians were
observed to wear masks, and 94.1% believed
mass masking reduces the chance of community
outbreak.67 A poll consistently found that 85% or
more wore masks in public between Feb. 25 and
Apr. 21, 2020.58
Sierra Leone 6 Mar. 3168 2.3 Masks were recommended in public on April 1.69
Compliance has been incomplete.70
Cambodia 6 Jan. 2771 0.0 Masks were widely used by the public by January
28.72,173
Vietnam 9 Jan. 23 0.0 Masks were widely used by the public by January
27,74,75 and were mandated by the government on
March 16. One survey found the prevalence of
mask wear consistently from 85-90% from March

8
 12 to April 14.57 A poll reported 59% wore a mask
on March 23, and over 80% from March 30 to Apr.
20.58 From March 31 to April 6, 2020, 99.5% of
respondents reported using a mask when
outside.76
Malaysia 10 Jan. 25 3.3 Masks were used by the public by January 30.77 A
poll reported 55% wore a mask in public on Feb.
24, 69% on Mar. 23, and 82% on Apr 6.58
Bhutan 10 Mar. 678 0.0 On Mar. 11, the Ministry of Health advised wearing
of masks in “a crowded place”.79
Taiwan 11 Jan. 21 0.3 Use of masks is traditional. By January 24, Taiwan
banned the export of surgical masks.80,81 By
January 27, the government had to limit mask
exports and limit sales from pharmacies to those
needed for personal use.82 On January 28, the
government began releasing 6 million masks daily,
with each resident able to purchase 3 masks
weekly at a set price.80 A poll consistently found
over 80% wore a mask from Feb. 25 to Apr 21,
2020.58
Slovakia 13 Mar. 7 4.8 Masks were mandated in shops and transit on
March 15,83 and more broadly in public on March
25.84
South Korea 15 Jan. 20 5.0 Use of masks is traditional.48 The alert level was
raised from yellow to orange on Jan. 27.85
Children were advised to wear masks at school by
January 30.86 By Feb. 2, mask sales increased
373 times year-over-year.85 Stores were selling
out of masks by February 3.87 A superspreader
event in mid-February was associated with a
religious group which did not use masks at their
gatherings.88 South Korea initially had trouble
obtaining enough masks, but at the end of
February the government began to control the
distribution of masks to the public.91 On Feb. 22,
the government instructed the wearing of masks in
the epidemic area.85
Grenada 18 Mar. 2190 0.0 On April 3, the Ministry of Health recommended all
wear a mask, which could be purchased at a
pharmacy, to “prevent asymptomatic people from
transmitting the disease unknowingly”.91 Masks
were mandated outside the home on April 6.92
Mozambique 18 Mar 2293 0.0 Masks were recommended by health authorities on
April 4,94 and were required on public transport or
in gatherings on April 8.95
Uzbekistan 19 Mar. 1596 0.3 The first coronavirus death was on March 29.
Masks were mandated on March 25.97
Thailand 20 Jan. 13 0.8 Masks, including N95 masks, were already worn
outdoors in early January to combat smog. The
Thai government was handing out masks and
advising wearing of masks in public to prevent
coronavirus by January 28, 2020.98-101 The
recommendation of cloth masks for the public was
reaffirmed by the Ministry of Public Health on
March 3, 2020.102 Enforcement of a mask

9
 mandate on public transport began on March 26.102
One survey reported high mask-wearing: 73% by
Feb. 24, 80% by March 23, and 89% by March
30.58 During March 2020, another survey found
masks were worn “all the time” by 14% of COVID-
19 cases and 24% of controls, and “some of the
time” by 38% of cases and 15% of controls.102
Malawi 20 Apr. 2 0.2 The first death was on April 7.103 The public was
required to wear masks on April 4.104,105 A survey
in Karonga from April 25 to May 23 found that 22%
of urban residents and 5% of rural residents wore a
mask.106
Czechia 23 Mar. 1107 25.8 Masks were required in public on March 19.108
Zambia 24 Mar. 18 0.4 The first death was recorded on April 2. On April 4,
masks were recommended for the public “at all
times” by the Zambian Minister of Health.109 This
spurred the manufacture of cloth masks.110 On
April 16, masks were mandated for the public.111
Benin 26 Mar. 16112 0.2 Masks were recommended in public on April 6,113
mandated on April 7,114 and enforced by police
beginning April 8.115
Sudan 27 Mar. 12 1.5 The first death occurred on March 12. Masks were
dispensed by pharmacists for free in Sudan by
March 16.116.117 A survey from March 25 to April 4
of 2336 adults found that 703 (30.1%) had been to
a crowded area, and 1153 (49.4%) had worn a
mask outside the home in the previous few days.118
Antigua and 28 Mar. 13119 30.6 Masks were required in all public spaces on April
Barbuda 5.120
Bosnia and 29 Mar. 5121 31.1 Masks were required in public by March 29.122-123
Herzegovina
Côte d'Ivoire 29 Mar. 11124 0.8 On April 4, senior health officials recommended
masks when in public.125
Kenya 30 Mar. 12126 0.6 The March 12 case had arrived from the U.S. on
March 5.126 The first death was on March 26, of a
man who arrived in Kenya on March 13.127 Masks
were mandated in Kenya on public transport on
April 2,128 and more broadly in public on April
4.128,129 A survey in Nairobi published on May 5,
2020 found that 89% had worn a face mask in the
previous week, and 73% said they always did so
outside the home.130
El Salvador 31 Mar. 18131 2.6 The first death was reported March 31. Masks
were mandated in public on April 8.132
The delay was the number of days from the start of the outbreak until masks were
recommended by the government or became widespread due to cultural norms. The estimated
start of the outbreak was 5 days before the first infection was reported, or 23 days before the
first death (whichever was first).

10
Masks in Asia.

Throughout much of East, South, and Southeast Asia, masks were worn by the
public as a preventive measure, rather than a policy implemented after evidence
emerged of health system overload (Table 2). The public sometimes implemented
masks before government recommendations were issued.
As the country where the pandemic started, China is a noteworthy case of a
nation which traditionally has favored mask-wearing by the public for respiratory
illnesses, but which did not deploy masks immediately. The first cases in China had
begun by December 1, 2019.133 By the time human-to-human transmission was
confirmed on Jan. 20, 2020, many in Beijing were already wearing masks.134 The
government required masks in public in Wuhan on Jan. 22.135 From Jan. 23-25, thirty
regions in China mandated masks in public.85,136 Masks were ordered throughout
China when around others in public on Jan. 31.137 China suffered a very significant
outbreak in Wuhan, but appears not to have experienced the same level of infection in
other regions. Surveys indicate that the prevalence of public mask wear in China
remained between 82% and 89% between February 24 and April 20.58 Another survey
confirmed mask wear from 80-90% from March 12 to April 14.57 The reported country-
wide per-capita mortality by May 9, 2020 was 3.2 per million population.
For several countries in South or Southeast Asia with mortality lower than in the
West, we did not score the country as mask-wearing in the primary analysis until their
governments issued recommendations to do so. Nonetheless, there is evidence of
significant mask wear by the public before the recommendations: Nepal, India,
Indonesia, Bangladesh, Myanmar, and Sri Lanka.
In Nepal, facemasks are commonly seen in urban centers due to air pollution.138
The first case of COVID-19 in the country was reported on January 13, in a student
returning from Wuhan for winter break.139 However, no subsequent cases were
reported in Nepal until the second week of March.139 By January 29, all students at
some schools were wearing masks.140 By February 3, pharmacies were selling out of
masks due to increased demand.141 With the outbreak, tailors began sewing cloth
masks.107 By February 8, 2020, “a majority” of the public was wearing masks.142 The
recommendation to wear masks in public became more formalized on March 25.143 The
Ministry of Health distributed masks to children and elderly in shelters by March 25.144
A survey in Nepal at the end of March found that 83% of respondents agreed that
asymptomatic people should wear masks to prevent COVID-19 infection.139 As of May
9, Nepal reported no coronavirus-related mortality. We used the March 25
recommendation as the date in the mask analysis, but earlier mask use might have
forestalled the epidemic in Nepal.
In Indonesia, the public scrambled to buy face masks in February before any
cases had been identified in the country.145 The first cases of coronavirus in Indonesia
were announced on March 2,146 and the first death occurred on March 3.147 A poll
reported that the proportion of Indonesian adults wearing a mask in public was 54% on
Feb. 24, 2020, 47% on March 29, 71% on March 30, and 79% on April 13.58 In
Indonesia, masks were mandated in public on April 5.148 By May 9, the per-capita
mortality was 3.5 per million.

11
 In India, the first case of coronavirus was diagnosed on January 30.149 The
Health Ministry recommended homemade face masks on April 4, 2020.150 However,
mask wear was high both before and after the recommendation. According to one poll,
masks were worn by 60% of the public from March 12-14, 67% from March 19-21, and
then from 73% to 76% between March 26 through April 12.57 According to another poll,
masks were worn by 43% of the public on March 16, 46% on March 20, 65% on March
27, 71% on April 3, 79% on April 10, and 84% on April 17.58 By May 9, the per-capita
mortality was 1.5 per million.
In Sri Lanka, the public immediatedly bought masks at the end of January when
the first cases were identified.151 Masks were mandated in public on April 11.152 The
per-capita mortality by May 9 was 0.4 per million.
In Myanmar, the first cases of COVID-19 were reported on March 23,153 and the
first death on March 31.154 A study from March 3-20, 2020 found that 72% of adults
reported that they were confident they would wear a surgical mask whenever visiting a
crowded area.155 This study concluded just 12 days after the likely onset of the
outbreak. By May 9, the per-capita mortality in Myanmar was 0.1 per million.
In Bangladesh, from March 11-19, 2020, when students age 17 to 28 were asked
if they were wearing a surgical face mask in public, 53.8% responded “yes” and 6.6%
responded “occasionally”.156 A survey from March 29 to April 29 found that 98.7%
reported wearing a face mask in crowded places.157 By May 9, the per-capita mortality
was 1.3 per million.
Singapore was slower than its Asian neighbors to embrace masks, but when the
government shifted course, the public was ready to respond. On March 27, only 27% of
respondents indicated that they wore a mask.58 On April 3, when the government
announced that they would no longer discourage mask-wearing by the public, and
would instead distribute masks,158-160 37% indicated that they wore a mask.58 By April
10, just one week later, 73% of the public wore a mask.58
Early in the pandemic, masks were noted to be “somewhat common” in
Afghanistan.161 By March 29, 2020, the Taliban had begun distributing masks to the
public in areas under their control.162
In March 2020, 78% of Pakistanis in Sargodha were in favor of wearing a mask
to prevent coronavirus.163 Another survey conducted from April 1-12 indicated that 80%
of Pakistanis believed the government should mandate mask wearing for adults outside
the home.164

Masks in the Middle East.

In parts of the Middle East, masks were embraced by the public even before
government requirements. In the United Arab Emirates, the first cases were reported
on January 29.165 By February 29, mask usage had become “more prominent”, but the
Ministry of Health and Community Protection advised that N95 masks should be
reserved for medical personnel treating coronavirus patients, and could cause
“respiratory illness” if worn by the public.166 Despite this warning, a poll of UAE
residents found that masks were worn by 39% of the public on March 18, and 44% on
March 25.58 On March 27, the government followed the people’s lead, and mandated

12
masks when indoors.167 Subsequently, masks were worn by 63% on April 1 and 79%
on April 14.58 By May 9, the per-capita mortality was 18.7 per million.
In Saudi Arabia, the first case was announced on March 2.168 A poll of Saudi
residents found that 35% wore a mask on March 18, 54% on April 1, and 59% on April
14,58 despite the lack of any official guidance to do so. By May 9, the per-capita
mortality was 6.9 per million.
In Lebanon, the first case was reported on February 21.169 Masks were popular
among the public from mid-March to early April.170,171 By May 9, the per-capita mortality
was 3.8 per million.
In March 2020 in Egypt, 76.4% of adults expressed an understanding of the
value of wearing a mask in public, but only 36.4% agreed that they actually did so.172 At
this time, the government was not mandating masks, but by March 20, prices of masks
had soared, and volunteer organizations were advocating public masking in Egypt.173
In Iran, no infections were announced until February 19, when two deaths were
reported.174 By March 12, satellite imagery demonstrated the digging of mass graves in
Qom.175 In accord with WHO guidelines, the guidance of the Iranian Health Ministry
available on March 24, 2020 advised that the public wear a mask only if symptomatic or
caring for the sick.14 However, a new guidance which recommended universal masking
in gyms, parks, and public transit was issued by the Ministry by March 29,14 an
estimated 62 days after the start of the outbreak (assuming the reported deaths were
really the first). A survey conducted from February 25 to April 25 found that 64% of the
public reported wearing a mask and gloves in crowded places.176 By May 9, the
reported per-capita mortality in Iran was 78.4 per million, though many, even those
within the Iranian government, have questioned the official figures.177-179
In Yemen, 90% of women wear the niqab, which local doctors believe might
reduce transmission of the virus by functioning as a mask.180 By May 9, the per-capita
mortality in Yemen was 0.2 per million.
Government mandates or recommendations for mask wearing by the public were
issued in Kuwait for gatherings on March 23,177 in Israel on April 1,181 and in Bahrain on
April 9.182

Masks in Africa.

As noted above, eight African countries recommended masks within 31 days of

the onset of their outbreak: Sierra Leone, Mozambique, Malawi, Zambia, Benin, Sudan,
Côte d'Ivoire, and Kenya (Table 2). The public widely sought masks to wear early in the
outbreak in Gambia.183,184
In Ethiopia, 75.7% of chronic disease patients surveyed from March 2-April 10,
2020 agreed that it was important to wear a mask outside the home to prevent infection
with coronavirus.185 A survey from March 20-24 found that 87% of the public believed
wearing a mask could prevent spread of the virus, but only 14% had done so in the few
days before the survey.186 Masks were mandated in public on April 11.187 In a survey
in that country from April 15-22, 84% believed a mask could provide protection from
coronavirus, 137 people (40%) had gone to a crowded place after the onset of the

13
pandemic, and 82 people (24%) had worn a mask outside the home.188 By May 9,
Ethiopia had reported no deaths from coronavirus.
In Cameroon, the first cases of coronavirus were identified on March 6.189 From
March 10-18, a study found that 93.5% of the public viewed the wearing of face masks
as protective, and 21.7% had already purchased them.189 A study in Northern
Cameroon conducted from March 1-28 found that only 13% wore a mask outside the
home.190 A survey in Cameroon conducted from April 1 to 25 found that 83.6% reported
wearing a mask at gatherings.191 Masks were mandated in public in Cameroon on April
13.192 By May 9, the per-capita mortality was 4.1 per million.
In a city in the Democratic Republic of the Congo not yet affected by the
pandemic at the time of a survey conducted from April 17 to May 11, 61% of
respondents were aware of the value of wearing a face mask, 27% reported wearing a
face mask since the pandemic began, and 65% felt that wearing a face mask was
difficult.193
In Ghana, a study from March 27 to 29 of 43 public transport stations found that
masks were worn by many people at one station, worn by a few people at 27 stations,
and not worn at the remainder.194 Ghana required masks to be worn in public on April
25.195
Masks were required in public in Nigeria on April 14.196,197 A study in Nigeria
from May 7 to 18 found that 65% of respondents had worn a mask outside the home in
recent days.198
In South Africa from April 8-24, 2020, 85.6% of the public agreed that wearing a
mask could help to prevent coronavirus infection.199 South African health officials
recommended mask wear in public on April 10.200
In addition, government mandates or recommendations for mask wearing by the
public were issued in: Mauritius on March 31;200 Tunisia202 and Morocco203 on April 6;
Gabon on April 10;204 Equatorial Guinea on April 14;205 and Libya on April 16.206

Masks in Europe.

Most countries in Europe and North America failed to embrace masks early in
their outbreaks, and only adopted mask policies after signs of health system overload
became apparent. Only two countries in Europe appear to have had government
recommendations for the public to wear masks within 31 days of the onset of their
outbreak: Slovakia and Czechia (Table 2).
The first country in Europe to be strongly affected by the outbreak was Italy,
which reported its first cases on January 31, among a family who arrived from China on
January 23.207 By March 10, doctors in Lombardy indicated that all intensive care beds
were taken, and the system did not have enough respirators for the affected.208 A poll
found that only 26% of Italians wore a mask in public on March 11, but, with the rising
health system overload, 59% did so on March 1958—at least 60 days from the local
onset of the outbreak. Another poll confirms that the prevalence of mask wear
exceeded 50% for the first time from March 19-21.57 Lombardy (April 5) and Tuscany
(April 6) required the public to wear masks in early April.209 A poll found that 85% of

14
Italians wore a mask in public on April 16.58 By May 9, the per-capita mortality in Italy
was 502.7 per million.
The next country to suffer was Spain, which reported its first case on January
31,210 and experienced its first death from the virus on February 13.211 The prevalence
of mask wear among the Spanish public was 5% on March 12, 25% on March 19, 42%
on March 25, and 56% on April 858—potentially 72 days after the entry of the virus into
the country. Masks were mandated when in transit beginning April 11.212 Mask wearing
in public had climbed to 65% by April 16.58 According to another survey, the prevalence
of mask wear was 50% by March 21, 53% by April 4, and 61% by April 12.57 The per-
capita mortality by May 9 was 566.3 per million.
In France, the first case of coronavirus was reported on January 24,213 and the
first death on February 14, of a man who arrived from China on January 16.214 A poll
found on March 10 that only 5% of those in France wore a mask in public.58 This
number increased to 22% on March 27 and 25% on April 3,58 the day that the Académie
Nationale de Médecine announced that masks should be compulsory in public215—at
least 72 days into their outbreak. Polls indicated that mask wear among the public
climbed to 38% on April 10, and 43% on April 17.58 Mask wear below 50% in early April
was confirmed in another survey.57 By May 9, the per-capita mortality in the country
was 403.1 per million.
In Germany, the first case of COVID-19 was reported on January 27. The patient
had contact with a colleague visiting from China beginning January 19.216 By March 30,
only 7% of the public reported wearing a mask in public.58 On March 31, the city of
Jena mandated use of masks by the public.217 The Robert Koch Institute recommended
that the public wear masks on April 1218—at least 70 days from the onset of the
outbreak. Masks were worn by 14% of the public on April 6, 17% on April 13, and 24%
on April 20.58 Another survey confirms mask wear at or below 20% in March and early
April.59 By May 9, the per-capita mortality was 90.1 per million.
In the United Kingdom, the first cases of coronavirus were reported on January
219
31. Here, 2% of the population wore a mask by March 20, and 11% by April 17.58
Another survey confirms mask wear below 20% from March 12 to April 12.59 By May 9,
the per-capita mortality was 465.3 per million.
In the Scandinavian countries of Sweden, Norway, Denmark, and Finland, polls
repeatedly showed masks to be worn by 10% or less of the population from March 16
through April 19.58 Finland began recommending that the public wear masks on April
14,220 and therefore was scored as falling under a mask recommendation for just 3 days
in this study (April 14 to 16).
In Poland, the health minister announced on April 9 that a public mask mandate
would go into effect on April 16, and mask vending machines began to be installed.221
In Poland, from April 12-14, 2020, 60.4% of Polish students age 18 to 27 wore a face
mask in the previous 7 days.222 By May 9, the per-capita mortality was 20.7 per million.
The first cases of coronavirus in Russia were reported on January 31, 2020.223
In Russia, the prevalence of mask wear among the public was 11% by March 14, 19%
by March 21, 36% by March 28, and 57% by April 457—69 days after the estimated start
of the outbreak. Mask wearing prevalence had increased to 59% by April 12.57 By May
9, the per-capita mortality was 12.5 per million.

15
 In Serbia, in April 2020, 60% of the public agreed they were willing to wear a
mask during a pandemic, and respondents on average answered 3.25 (SD 1.6) on a 1
to 5 scale when asked if they wore masks, where 4 represented “agree” and 5
represented “strongly agree”.224
Some additional Western governments mandated or recommended mask-
wearing in public in March 2020. By March 29, masks were mandated in indoor public
spaces in Slovenia.225 In Austria, a mandate to wear masks in shops was announced
on March 30, with the expectation that masks would be available by April 1.226 In
addition, the requirement to wear masks on public transit was announced there on April
6.227 Masks were recommended for the public in Bulgaria on March 30.228 Government
mandates or recommendations for mask wearing by the public were issued by April 16
in: Turkey,229 Cyprus,230 and Ukraine231 on April 3; and Estonia on April 5.232 In
Lithuania, masks were recommended for the public on March 26,233 and mandated on
April 8.234

Masks in the United States and Canada.

The earliest case of COVID-19 in the United States was a 35-year-old man who
returned from China to Washington state on January 15, 2020, and presented at an
urgent care clinic on January 19.235 In the United States, the prevalence of mask wear
in public was 7% on March 2, 5% on March 17, and 17% on March 30. The U.S. C.D.C.
began recommending that asymptomatic people wear a mask in public on the evening
of April 3236—at least 79 days after the virus had entered the country. Subsequently,
the prevalence of mask wear was 29% on April 6, 49% on April 13, and 58% on April
20.58 Another survey found that the prevalence of mask wear was 32% from April 2-4,
and 50% from April 9-12.57 According to another survey, from April 14-20, 36% of U.S.
adults always wore a mask outside the home, 32% did so sometimes, and 31% never
did.237 By May 9, the per-capita coronavirus-related mortality was 241.8 per million.

In Canada, the prevalence of mask wear was 6% on March 17, and 18% on April
6,58 when the government announced that masks were now recommended in public.238
Uptake was slow, with mask wearing still just 16% on April 13, and 31% on April 20.58
Another survey confirms mask wear below 30% in March and early April.57 By May 9,
the per-capita coronavirus-related mortality was 124.3 per million.

Masks in Australia.

In Australia, surveys of the public indicated that 10% wore a mask by March 15,
which gradually increased to 27% by April 19.58 Another survey confirms mask wear
below 25% in March and early April.57

16
Masks in Latin America and the Caribbean.
Masks were an accepted preventive measure in some parts of Latin America and
the Caribbean (though not all). Four countries in the region recommended masks by 31
days into their outbreak: Venezuela, Grenada, Antigua and Barbuda, and El Salvador
(Table 2).
Government mandates or recommendations for mask wearing by the public were
issued by April 16 in multiple countries, including: Cuba239 on April 2; Peru on April 3;240
Honduras on April 6;241 Paraguay242 and Panama243 on April 7; Guatemala on April
9;244 Sint Maarten on April 14;245 and the Dominican Republic on April 16.246
In Trinidad and Tobago, masks were recommended early in the outbreak by the
Health Minister and Chief Medical Officer.247 The recommendation was made official on
April 5.248 Compliance was almost immediate, as many people were already wearing
masks, and shops would not provide service without them (Vijay Naraynsingh, personal
communication, June 30, 2020).
On April 3, a reporter in Bogotá noted that 90% of the people on the street were
wearing face masks.249 On April 4, the government of Colombia mandated masks on
public transport and shops.132,250-251
On April 6, the Minister of Health in Chile announced that masks would be
mandatory on public transport starting April 8.252 Due to the shortage of medical masks,
the public was invited to make their own out of cloth.252
Surveys indicate that in Mexico, the prevalence of public mask wear increased
steadily from 17% on March 17 to 37% on April 6, 46% on April 13, and 60% on April
20.58 According to another survey, the prevalence was 31% by March 14, 36% by
March 21, 46% by April 4, and 58% by April 9.57 By May 9, the per-capita mortality was
26.0 per million.
Ecuador did not require masks early in their outbreak. The first case of COVID-
19 in Ecuador was reported on February 29 in a woman who had arrived from Spain on
February 14.253 The first death was reported on March 13.254 By April 3, it was noted in
Guayaquil that mortuary facilities were overwhelmed, and bodies were being left on the
streets.255 On April 7, the Interior Minister of Ecuador announced that face masks were
mandatory in public256—at least 48 days (and possibly 53 days) after the local onset of
the outbreak. By May 9, the reported mortality was 97.3 per million.
The first case of COVID-19 in Brazil was reported on February 26.257 In Brazil,
the prevalence of mask wear in public was 25% by March 14, 28% by March 21, 39%
by April 4, and 56% by April 1257—50 days after the virus is estimated to have arrived in
the country. By May 9, the per-capita mortality was 50.1 per million.

Graphical Analysis of Mask Effect.

Before the formal statistical analysis, we graphically illustrate the effect of mask
wear (Figures 1, 2). The first figure demonstrates the effect of early mask usage
(Figure 1). In the countries not using masks by April 16, the per-capita mortality by May
9 rises dramatically if the infection has persisted in the country over 60 days (Figure 1,
red line). On the other hand, countries in which a mask was used from 16 to 30 days
17
after infection onset had per-capita mortality several orders of magnitude less by May 9
(Figure 1, orange line). When countries recommended masks within 15 days of the
onset of the outbreak, the mortality was so low that the curve is difficult to distinguish
from the x-axis (Figure 1, blue line).

Figure 1. Per-capita mortality by May 9 versus duration of infection according to

whether early masking was adopted. Data grouped by whether country did not recommend
masks by April 16, 2020 or recommended them more than 60 days after outbreak onset (red
line); recommended masks 16 to 30 days after onset of the country’s outbreak (orange line); or
recommended masks (or traditionally used masks) within 15 days of the outbreak onset (blue
line close to the x-axis). Country mortality was averaged for the following country groups of
infection duration: 0-15 days, 16-30 days, 31-45 days, 46-60 days, 61-75 days, 76-90 days, 91-
105 days. For instance, per-capita mortality for all non-mask or late-masking countries with
infection duration between 61 and 75 days was averaged, and graphed at the x-value 68 days.
Data for graph derived from 198 countries.

For instance, for the early mask-wearing countries in which the infection had
arrived by January (Thailand, Japan, South Korea, Taiwan, Macau, Hong Kong,
Vietnam, Cambodia, Malaysia, the Philippines), the virus was present in the country by
80 or more days by April 16 (Table 2). If masks had no effect, we might have expected
these countries to have a mortality well over 200 deaths per million (Figures 1, 2).

18
Instead, the mortality for these 10 regions was 2.1 per million (SD 2.5, Table 2)—
approximately a 100-fold reduction.
On the other hand, the mortality curves for mask and non-mask countries look
reasonably similar if they are compared based on the period of their outbreaks without
masks (Figure 2). The red line in the figure displays the mean per-capita mortality as a
function of the duration of infection in the countries which did not recommend masks by
April 16 (Figure 2). Countries are averaged in two-week (14-day) groups. For instance,
the per-capita mortality data from all countries with an outbreak which had lasted
between 1 and 14 days by April 16 are averaged and displayed together. Not
surprisingly, the longer the outbreak lasts in the country, the higher the mortality.
Beyond 8 weeks (56 days), the per-capita mortality sharply increases. Data from
countries which recommended masks before Apr. 16 are displayed with the thick blue
line (Figure 2). Here, the x-axis is not the total time of the infection, but rather the
period of the infection before masks were recommended. Of note, the curves
demonstrate the same general behavior. The mortality in the mask countries by 11
weeks is lower by a factor of two, but not by a factor of 100. Thus, when compared on
their mask-free periods, mask and non-mask countries appear reasonably similar.

Figure 2. Per-capita mortality by May 9 as a function of the period of the country’s

outbreak without mask recommendations or norms. Data grouped by whether country
recommended (or traditionally used) masks by April 16 (blue line), or not (red line). Data for
graph derived from 198 countries.

In order to provide some graphical idea of the scatter of the data when
exponential growth is assumed, we graphed per-capita mortality by May 9 on a

19
logarithmic scale as a function of the duration of the country’s outbreak not using masks
in all 198 countries (Figure 3). This simple model explained 28.0% of the variation in
per-capita mortality.

Figure 3. Scatter-plot of per-capita mortality by May 9, 2020 as a function of the period

of the country’s outbreak without mask recommendations or norms. The dotted line
represents the best fit using least-squares linear regression. Data for graph derived from 198
countries. Start of outbreak defined as 5 days before first case reported, or 23 days before the
first death (whichever was earlier).

20
Initial multivariable analyses.

An initial multivariable analysis was conducted including all 198 countries. By

multivariable linear regression, significant predictors of the logarithm of each country’s
per-capita coronavirus mortality included: duration of infection in the country, duration of
wearing masks (p<0.001), percentage of the population over age 60, and urbanization
(all p≤0.009, Appendix Table A3). The model explained 47.2% of the variation in per-
capita mortality (Table A3).
We wanted to determine whether the association of mask use with lower
mortality was simply an artifact of the definition of the start of the outbreak as 5 days
before the first case or 23 days before the first death (whichever was earlier).
Therefore, we ran the multivariable model for all 198 countries with the outbreak start
defined simply as the first case date (Appendix Table A4). In this model, each week of
the outbreak without masks was associated with a 38.5% increase in per-capita
mortality. On the other hand, each week a country wore masks was associated with a
reduction in mortality of 4.6% because 1.3847(0.6887) = 0.954 (Table A4). The model
explained 43.8% of the variation in per-capita mortality—i.e. slightly less than with the
original definition of outbreak start.

We also prepared a multivariable model to predict the logarithm of per-capita

coronavirus mortality in the 194 countries with obesity data. In this model, lockdown,
obesity, temperature, and urbanization were retained due to their plausibility as
important factors (Table 3).
By multivariable linear regression, significant predictors of the logarithm of each
country’s per-capita coronavirus mortality included: duration of infection in the country,
duration of wearing masks, and percentage of the population over age 60 (all p<0.001,
Table 3). The association of obesity with increased mortality approached statistical
significance (p=0.07, Table 3). When controlling for the duration of infection in the
country, there appeared to be a negative association between time in lockdown and
per-capita mortality, but this association was not statistically significant (p=0.41) (Table
3). The model explained 50.3% of the variation in per-capita mortality.

21
Table 3. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9 by
Multivariable Linear Regression in 194 Countries.
10coefficient Coefficient (SE) 95% CI P
Duration in country (wks) 1.5499 0.190 (0.033) 0.126 to 0.255 <0.001
Time wearing masks (wks) 0.6917 -0.160 (0.030) -0.218 to -0.102 <0.001
Time in lockdown (wks) 0.9376 -0.028 (0.034) -0.094 to 0.038 0.41
Population, age ≥ 60 (%) 1.1144 0.047 (0.010) 0.027 to 0.067 <0.001
Urbanization (%) 1.0128 0.00552 (0.004) -0.002 to 0.013 0.13
Obesity prevalence (%) 1.0378 0.016 (0.009) -0.001 to 0.034 0.07
Temperature, ambient (C) 0.9825 -0.00767 (0.009) -0.025 to 0.009 0.38
Constant -- -7.714 (0.371) -8.45 to -6.98 <0.001
Duration of infection in country from estimated date of first infection until 23 days before May 9, 2020
(i.e. April 16). Mask and lockdown durations run from the stated event (mask recommendation or
lockdown) or estimated date of first infection in the country (whichever was later) until 23 days before
May 9, 2020 (i.e. April 16). Model r2=0.503.

In countries not recommending masks, the per-capita mortality tended to

increase each week by a factor of 1.550, or 55.0%. In contrast, in countries
recommending masks, the per-capita mortality tended to increase each week by a
factor of 1.5499 * 0.6917 = 1.072, or just 7.2%. Under lockdown (without masks), the
per-capita mortality increased each week by (1.5499)(0.9376) = 1.453, or 45.3%, i.e.
slightly less than the baseline condition (Table 3).
A country with 10% more of its population living in an urban environment than
another country tended to suffer a mortality 13.6% higher (100.0552 = 1.136, Table 3). A
country in which the percentage of the population age 60 or over is 10% higher than in
another country tended to suffer mortality 195% higher (100.47 = 2.95, Table 3). A
country with a prevalence of obesity 10% higher tended to suffer mortality 45% higher
(100.16 = 1.45, Table 3).

Survey-modified Model.
Surveys of mask wearing by the public during the exposure period were available
for 41 countries (see above). To determine the influence that actual mask-wear, as
opposed to mask policies, might have on the model, we scored countries as mask-
wearing if at least 50% of the public wore a mask, and non-mask wearing if less than
50% of the population did so.
Based on surveys, Canada, Finland, France, Germany, and Malawi were not
considered mask-wearing countries at any time during the exposure period (ending April
16). In contrast, Indonesia was scored as mask-wearing beginning February 24,
Bangladesh beginning March 11, Italy beginning March 19,58 Myanmar beginning March
20, Spain58 and India beginning March 21,57 Saudi Arabia beginning April 1,58 Russia
beginning April 4, Singapore beginning April 10,58 and the United States, Brazil and
Mexico beginning April 12.57,58
In this survey-modified model in 198 countries, duration of the outbreak, duration
of mask wear, proportion of the population age 60 or over, and urbanization were all

22
significant predictors of per-capita mortality (all p<=0.01, Appendix Table A5). Each
week that the infection persisted in the country without masks was associated with a
50.6% increase in per-capita mortality. On the other hand, when masks were worn, the
per-capita mortality only increased by 3.1% weekly, (1.5056)(0.6845) = 1.031,
(Appendix Table A5). The model explained 45.9% of the variance in mortality.

Numbers of Viral Tests.

Among the 183 countries with viral (PCR) testing data by May 9, per-capita
testing performed at all 3 time points was positively associated with per-capita mortality
in univariate analysis (all p<0.001, Table 1). By May 9, 2020, low-mortality countries
had performed 1 test for every 575 members of the population, while high-mortality
countries had performed 1 test for every 81 members of the population (p<0.001, Table
1).
To the multivariable model (Table 3), we added testing by May 9, using data from
179 countries with both testing and obesity data. Duration of infection in the country,
the duration that masks were recommended, and age at least 60 years continued to be
significant predictors of per-capita mortality (all p≤0.001, Appendix Table A6). The
model explained 52.1% of the variation in per-capita mortality. Each week the infection
persisted in a country without masks was associated with a 56.7% increase in per-
capita mortality (Table A6). In contrast, in countries where masks were recommended,
the per-capita mortality tended to increase each week by 10.7% (because
(1.5673)(0.7060) = 1.107, Table A6). In this model, the prevalence of obesity was
significantly associated with country-wide per-capita mortality (p=0.04). If the
prevalence of obesity increased by 10% (e.g. from 10% to 20% of a population), the
per-capita mortality tended to increase by 58% (Appendix Table A6)
In this model, a 10-fold increase (i.e. one logarithm) in per-capita testing tended
to be associated with a 17.0% increase in reported per-capita mortality, though the
trend was not close to reaching statistical significance (p=0.55, Appendix Table A6).
Duration of the infection in the country, time during the outbreak in which masks were
recommended, and the fraction of the population over age 60 were all still significant
predictors of mortality (all p≤0.001, Appendix Table A3).
If early testing lowers mortality, one might expect negative regression
coefficients. Testing on both April 16 and May 9 were added to the multivariable model
of Table 3, using data from the 158 countries with both obesity and testing data by
these dates. Per-capita testing (log) by April 16 was not negatively associated with per-
capita mortality (log) by May 9 (coefficient 0.330, 95% CI -0.254 to 0.915, p=0.27).
Likewise, testing on both April 4 (the earliest archived data) and May 9 were
added to the multivariable model of Table 3, using data from the 131 countries with both
obesity and testing data by these dates. Per-capita testing (log) by April 4 was not
significantly associated with per-capita mortality (log) by May 9 (coefficient -0.022, 95%
CI -0.343 to 0.299, p=0.89). Given the coefficient, a 10-fold (one log) increase in early
testing would be associated with a (non-significant) decrease in per-capita mortality of
5.0%.
Only 5 countries had performed over 1 test for every 10 people in the country by
May 9, 2020 (in order of most testing to least): the Faeroe Islands, Iceland, the Falkland

23
Islands, the UAE, and Bahrain. The Faeroe and Falkland Islands reported no
coronavirus-related deaths. The remaining 3 countries had per-capita mortality above
the median value. The highest per-capita mortality among this group was 29.0 per
million population (or 1 in 34,480 people), seen in Iceland.

Containment and Testing Policies.

For 161 countries, containment, testing, and health policies were scored by
Oxford University.8 The following countries with mask policies by April 16 were included
in this analysis, but not in the previous multivariable model, for lack of data on numbers
of tests performed: China, Macau, Cameroon, Sierra Leone, and Sudan. In univariate
analysis, scores for school closing, cancelling public events, restrictions on gatherings,
and international travel controls were significantly associated with lower per-capita
mortality (all p<=0.03, Table 4). Policies regarding workplace closing, closing public
transport, stay at home requirements, internal movement restrictions, public information
campaigns, testing, and contact tracing were not significant predictors of mortality (all
p>0.05, Table 4). Likewise, overall indices of stringency, government response, and
containment and health were not associated with mortality (all p>0.05, Table 4).

24
 Table 4. Government policies in 161 countries with low and high per-capita coronavirus
mortality by May 9, 2020.
Mean (SD) p value
Odds ratio (95% CI) Low Mortality High Mortalilty
School closing (0-3) 0.46 (0.26 to 0.82) 2.09 (0.66) 1.83 (0.48) 0.006
Workplace closing (0-3) 1.62 (0.98 to 2.66) 1.14 (0.77) 1.33 (0.47) 0.07
Cancel public events (0-2) 0.32 (0.14 to 0.74) 1.38 (0.45) 1.20 (0.34) 0.008
Restrictions on gatherings (0-4) 0.76 (0.53 to 1.09) 1.99 (0.91) 1.78 (0.82) 0.03
Close public transport (0-2) 0.83 (0.43 to 1.59) 0.62 (0.50) 0.58 (0.45) 0.21
Stay at home requirements (0-3) 1.27 (0.73 to 2.21) 0.81 (0.66) 0.88 (0.44) 0.33
Internal movement restrictions (0-2) 0.71 (0.35 to 1.42) 0.92 (0.52) 0.85 (0.36) 0.06
International travel controls (0-4) 0.44 (0.28 to 0.68) 2.87 (0.78) 2.36 (0.82) <0.001
Income support (0-2) 40.3 (11.1 to 147.0) 0.13 (0.21) 0.50 (0.40) <0.001
Debt / contract relief (0-2) 4.44 (2.04 to 9.66) 0.28 (0.39) 0.57 (0.49) <0.001
Public information campaigns (0-2) 0.63 (0.30 to 1.33) 1.68 (0.39) 1.60 (0.45) 0.31
Testing policy (0-3) 0.84 (0.48 to 1.49) 1.10 (0.60) 1.05 (0.49) 0.22
Contact tracing (0-2) 0.89 (0.54 to 1.47) 1.06 (0.63) 1.02 (0.60) 0.17
Stringency Index (0-100) 0.98 (0.96 to 1.01) 52.2 (15.6) 49.0 (12.4) 0.09
Government response index (0-100) 0.99 (0.97 to 1.03) 44.6 (12.3) 44.5 (11.1) 0.42
Containment & health index (0-100) 0.98 (0.96 to 1.01) 50.9 (14.3) 48.1 (11.9) 0.10
Economic support index (0-100) 1.07 (1.04 to 1.10) 9.8 (12.8) 24.7 (17.4) <0.001
Government policies were scored by Oxford University.8 Characterization as low or high mortality was
defined by the median for all 198 countries.

A multivariable model in 161 countries found that duration of the infection,

duration masks were recommended, prevalence of age at least 60 years, obesity, and
international travel restrictions were independently predictive of per-capita mortality
(Table 5). The model explained 67.3% of the variation in per-capita mortality. At
baseline, each week of the infection in a country was associated with an increase in
per-capita mortality of 29.5% (Table 5). In contrast, for each week that masks were
worn, the per-capita mortality was associated with a decrease of 2.0% each week
(given that 1.2952(0.7567) = 0.980, Table 5).
International travel restrictions were scored by Oxford as: (0) no measures, (1)
screening, (2) quarantine arrivals from high-risk regions; and ban on arrivals from some
(3) or all (4) regions. The regression analysis suggested that as compared with no
border controls, a complete ban on entries from abroad was associated with a change
in mortality of 104*(-0.213) = 0.14, meaning an 86% reduction in per-capita mortality (Table
5). The international travel restrictions were scored as 4 in Greenland, 3.8 in Bermuda,
3.6 in Israel, 3.5 in Czechia and New Zealand, 3.1 in Taiwan, and 2.9 in Australia, and
at the other extreme, were scored as 1.1 in Sweden, and as 0 in Iran, Luxembourg, and
the UK.

25
Table 5. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9 by
Multivariable Linear Regression in 161 Countries.
10coefficient Coefficient (SE) 95% CI P
Duration in country (wks) 1.2952 0.1123 (0.032) 0.050 to 0.175 0.001
Time wearing masks (wks) 0.7567 -0.1211 (0.025) -0.171 to -0.071 <0.001
Time in lockdown (wks) 0.9419 -0.0260 (0.028) -0.082 to 0.030 0.36
Population, age ≥ 60 (%) 1.1659 0.0667 (0.009) 0.049 to 0.084 <0.001
Urbanization (%) 1.0141 0.00610 (0.004) -0.001 to 0.013 0.08
Obesity prevalence (%) 1.0594 0.0250 (0.008) 0.008 to 0.042 0.003
Temperature, ambient (C) 1.0141 0.00607 (0.008) -0.009 to 0.021 0.42
Testing policy (0-3) 1.1602 0.0645 (0.107) -0.147 to 0.276 0.55
Contact tracing (0-2) 0.7194 -0.143 (0.095) -0.331 to 0.045 0.14
Internat. travel controls (0-4) 0.6126 -0.213 (0.076) -0.362 to -0.063 0.006
Constant -- -7.228 (0.397) -8.01 to -6.45 <0.001
Duration of infection in country from estimated date of first infection until 23 days before May 9, 2020
(i.e. April 16). Mask and lockdown durations run from the stated event (mask recommendation or
lockdown) or estimated date of first infection in the country (whichever was later) until 23 days before
May 9, 2020 (i.e. April 16). Policies on testing, contact tracing, and international travel controls were
scored by Oxford University. Model r2=0.673.

Per-capita mortality was not significantly associated with policies regarding either
testing policy (p=0.55), or contact tracing (p=0.14, Table 5). Testing policy was scored
as: no policy (0), symptomatic with exposure, travel history, hospitalization, or key
occupation (1), all symptomatic (2), or open to anyone (3). Testing policy tended to be
positively associated with mortality. Contact tracing was scored as: none (0), some
cases (1), or all cases (2), and tended to be inversely related with per-capita mortality
(though not significantly). These countervailing associations meant that as compared
with a country with no testing or tracing policy, a country which opened testing to the
entire public with comprehensive contact tracing might be associated with a reported
change in mortality of 10(3*0.0645+2*(-0.143)) = 0.808, i.e. a 19.2% reduction in per-capita
mortality (though statistical significance was not demonstrated). Thus, testing and
tracing seem unlikely to account for the almost 100-fold variation in per-capita mortality
between low and high mortality countries.

26
Discussion.
These results confirm that over 4 months since the appearance of COVID-19 in
late 2019, there is marked variation between countries in related mortality. Countries in
the lower half of mortality have experienced an average COVID-19-related per-capita
mortality of 1.1 deaths per million population, in contrast with an average of 94.2 deaths
per million in the remaining countries. Depending on the model and dataset evaluated,
statistically significant independent predictors of per-capita mortality included
urbanization, fraction of the population age 60 years or over, prevalence of obesity,
duration of the outbreak in the country, international travel restrictions, and the period of
the outbreak subject to cultural norms or government policies favoring mask-wearing by
the public.
These results support the universal wearing of masks by the public to suppress
the spread of the coronavirus.1 Given the low levels of coronavirus mortality seen in the
Asian countries which adopted widespread public mask usage early in the outbreak, it
seems highly unlikely that masks are harmful.
Our key finding that the logarithm of per-capita coronavirus mortality is linearly
and positively associated with the duration of the outbreak without mask norms or
mandates was recently confirmed by Goldman Sachs chief economist Jan Hatzius.258
The Goldman Sachs team saw our online preprint dated June 15, and had reached out
to us to discuss our model. The regression analysis performed by Goldman Sachs
confirms that, for prediction of both infection prevalence and mortality, the significance
of the duration of mask mandates or norms in the model persists after controlling for
age of the population, obesity, population density, and testing policy.258
One major limitation is that evidence concerning the actual prevalence of mask-
wearing by the public is unavailable for most countries. Our survey of the literature is
one of the more complete evaluations of the question to date. Available scholarship
and surveys do corroborate reports in the news media that mask wear was common in
public in many Asian countries, including Japan, the Philippines, Hong Kong, Vietnam,
Malaysia, Taiwan, Thailand, China, Indonesia, India, Myanmar and Bangladesh (Table
2). Mask wear was widespread in some low-mortality countries even before, or in the
absence of, a formal government recommendation.
In addition, it is likely that the policies favoring mask-wearing in parts of the
Middle East, Africa, Latin America and the Caribbean were markers of a general cultural
acceptance of masks that helped to limit spread of the virus. Had there been adequate
survey data to fully reflect the early wearing of masks in these regions, it is possible that
the association of masks with lower mortality would be even stronger.
Conversely, in Western countries which had no tradition of mask-wearing, and
which only recommended (rather than mandated) mask-wearing by the public, such as
the United States, the practice has been steadily increasing, but change has not been
immediate.
Much of the randomized controlled data on the effect of mask-wearing on the
spread of respiratory viruses relates to influenza. One recent meta-analysis of 10 trials
in families, students, or religious pilgrims found that the relative risk for influenza with
the use of face masks was 0.78, a 22% reduction, though the findings were not
statistically significant.259 Combining all the trials, there were 29 cases in groups

27
assigned to wear masks, compared with 51 cases in control groups.259 The direct
applicability of these results to mask-wearing at the population level is uncertain. For
instance, there was some heterogeneity in methods of the component trials, with one
trial assigning mask wearing to the person with a respiratory illness, another to his close
contacts, and the remainder to both the ill and their contacts.259 Mask-wearing was
inconsistent. The groups living together could not wear a mask when bathing, sleeping,
eating, or brushing teeth.260-262 In one of the studies reviewed, parents wore a mask
during the day, but not at night when sleeping next to their sick child.262 In a different
trial, students were asked to wear a mask in their residence hall for at least 6 hours
daily (rather than all the time).260 The bottom line is that it is nearly impossible for
people to constantly maintain mask wear around the people with whom they live. In
contrast, wearing a mask when on public transit or shopping is quite feasible. In
addition, as an infection propagates through multiple generations in the population, the
benefits multiply exponentially. Even if one accepts that masks would only reduce
transmissions by 22%, then after 10 cycles of the infection, mask-wearing would reduce
the level of infection in the population by 91.7%, as compared with a non-mask wearing
population, at least during the period of exponential growth (because 0.7810 = 0.083). It
is highly unlikely that entire countries or populations will ever be randomized to either
wear, or not wear, masks. Public policies can only be formulated based on the best
evidence available.
Some countries which used masks were better able to maintain or resume
normal business and educational activities. For instance, in Taiwan, schools reopened
on February 21, 2020, with parents directed to purchase 4 to 5 masks per week for
each child.82
Limits on international travel were significantly associated with lower per-capita
mortality from coronavirus. As compared with no restrictions, complete shutdown of the
border throughout the outbreak was independently associated with 86% lower per-
capita mortality.
Nationwide policies to ban large gatherings and to close schools or businesses,
tended to be associated with lower mortality, though not in a statistically significant
fashion. However, businesses, schools, and individuals made decisions to limit contact,
independent of any government policies. The adoption of numerous public health
policies at the same time can make it difficult to tease out the relative importance of
each.
Colder average monthly temperature was associated with higher levels of
COVID-19 mortality in univariate analysis, but not when accounting for other
independent variables. One reason that outdoor temperature might have limited
association with the spread of the virus is that most viral transmission occurs indoors.263
We acknowledge that using the average temperature in the country’s largest city during
the outbreak does not model the outbreak as precisely as modelling mortality and
temperature separately in each of the thousands of cities around the world. However,
to a first approximation, our method did serve to control for whether the country’s
climate was tropical, temperate, or polar, and whether the outbreak began in late Winter
(Northern hemisphere) or late Summer (Southern hemisphere). Environmental factors
which could influence either human behavior or the stability and spread of virus particles
are worthy of further study.

28
 Presumably, high levels of testing might identify essentially all coronavirus-
related deaths, and still higher levels of testing, combined with contact tracing, might
lower mortality. However, statistical support for the benefit of testing and tracing on
mortality could not be demonstrated. Policies on testing and tracing were not
significantly associated with mortality. In addition, per-capita testing both early (April 4,
16) and later (May 9) were positively associated with reported coronavirus-related
mortality. It seems likely that countries which test at a low level are missing many
cases. We previously identified just 3 countries (Iceland, the Faeroe Islands, and the
UAE) which had performed over 75,000 tests per million population by April 16, and all
3 had mortality below 1 in 46,000 at that point.264 By May 9, we could add to this “high-
testing” group, the Falkland Islands and Bahrain, as all 5 countries had tested over one
tenth of their population. All 5 countries had a mortality of 29 per million (1 in 34,480
people) or less. The degree to which these results would apply to larger, less isolated,
or less wealthy countries is unknown. Statistical support for benefit of high levels of
testing might be demonstrated if additional and more diverse countries are able to test
at this level.
One limitation of our study is that the ultimate source of mortality data is often
from governments which may not have the resources to provide a full accounting of
their public health crises, or an interest in doing so. It should be noted that the benefit
of wearing masks persisted in a model which excluded data from China (because no
testing data were available, Appendix Table A3). We also acknowledge that country-
wide analyses are subject to the ecologic fallacy.
The source for mortality and testing data we selected is publicly available,7 has
been repeatedly archived,10 contains links to the source government reports for each
country, and agrees with other coronavirus aggregator sites.265 In the interest of
transparency, we presented the per-capita mortality data in Appendix Table A1. One
might question whether any of these data sites or governments provide a complete and
accurate picture of coronavirus mortality. But we must remember that this information
does not exist in a vacuum. Independent sources confirm when mortality has been
high. Social media alerted the world to the outbreaks in Wuhan, Iran, Italy, and New
York. News reports have used aerial photography to confirm the digging of graves in
Iran, New York, and Brazil. Long lines were seen to retrieve remains at crematoria in
Wuhan. Mortuary facilities were inadequate to meet the demand in New York, and
Guayaquil.255 Conversely, signs of health system overload have been noted to be
absent in the countries reporting low mortality. The health systems in Hong Kong,
Taiwan, Japan, and South Korea are believed to be transparent. Reporters in Vietnam
have even called hospitals and funeral homes to confirm the absence of unusual levels
of activity.266 Therefore, while no data source is perfect, we believe that the data used
in the paper are consistent with observations from nongovernmental sources, and are
comparable in reliability to those in other scholarly works.
It is not the case that countries which reported no deaths due to coronavirus
simply were not exposed to the virus. All 198 countries analyzed did report COVID-19
cases. Several countries which traditionally use masks and sustained low mortality (or
none) are close to and have strong travel links to China. Some of these countries
reported cases early in the global pandemic (Table 2). Community transmission has
been described in Vietnam.267

29
 In summary, older age of the population, urbanization, obesity, and longer
duration of the outbreak in a country were independently associated with higher
country-wide per-capita coronavirus mortality. International travel restrictions were
associated with lower per-capita mortality. However, other containment measures,
testing and tracing polices, and the amount of viral testing were not statistically
significant predictors of country-wide coronavirus mortality, after controlling for other
predictors. In contrast, societal norms and government policies supporting mask-
wearing by the public were independently associated with lower per-capita mortality
from COVID-19. The use of masks in public is an important and readily modifiable
public health measure.

Funding: None.
Disclosures: The authors have no conflicts of interest.

30
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medRxiv 2020.04.04.20053058; doi: https://doi.org/10.1101/2020.04.04.20053058
Accessed June 13, 2020.
264. Leffler CT, Zhan S. Suppression of the Covid-19 Outbreak by Mass Testing and
Tracing, and Other Measures: Real-World Data. April 17, 2020. Available from:
https://www.researchgate.net/publication/340720271_Suppression_of_the_Covid-
19_Outbreak_by_Mass_Testing_and_Tracing_and_Other_Measures_Real-
World_Data?_sg=gmL3zeijOGrKwY3pKS5BGQ_-
H9KzOsEYC2mgy_71nifHMme737SciFndah2rLwHEKXAlQQN_-
JNV5_rCOIawtoo36uhRDVW7cXDeCEId.MivUKSPrK2FO3h6BPweYc9Nwomngmcwd
CrIxkXVDJWBozq01jbOPpwb5y4G1IVs3Gsgu2QZcmND_XnYclY_j1g Accessed May
17, 2020.
265. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE)
at Johns Hopkins University (JHU). Available from: https://coronavirus.jhu.edu/map.html
Accessed June 10, 2020.
266. Vu K, Nguyen P, Pearson J. After aggressive mass testing, Vietnam says it
contains coronavirus outbreak. Reuters. April 29, 2020. Available from:
54
https://www.reuters.com/article/us-health-coronavirus-vietnam-fight-insi/after-
aggressive-mass-testing-vietnam-says-it-contains-coronavirus-outbreak-
idUSKBN22B34H Accessed June 13, 2020.
267. Pham TQ, Rabaa M, Duong LH, Dang TQ, Dai Tran Q, Quach HL, Hoang NA,
Phung DC, Ngu ND, Tran AT, La NQ. The first 100 days of SARS-CoV-2 control in
Vietnam. medRxiv. 2020 Jan 1

55
Appendix. Supplemental Tables.

Table A1. Per-capita COVID-19 Mortality by May 9 and Date of Mask

Recommendation or Widespread Use Based on Cultural Norms.
Country. COVID-19 Date Masks
Mortality Recommended
(per mil. or Widely
pop.) Used by
Cultural
Norms.
Afghanistan 3.0
Albania 10.8
Algeria 11.3
Andorra 621.2
Angola 0.1
Antigua & Barbuda 30.6 4/5/2020
Argentina 6.6
Armenia 14.8
Aruba 28.1
Australia 3.8
Austria 68.3 3/30/2020
Azerbaijan 3.1
Bahamas 28.0
Bahrain 4.7 4/9/2020
Bangladesh 1.3
Barbados 24.4
Belarus 13.3
Belgium 740.4
Belize 5.0
Benin 0.2 4/6/2020
Bermuda 112.4
Bhutan 0.0 3/11/2020
Bolivia 9.8
Bosnia & Herzegov. 31.1 3/29/2020
Botswana 0.4
Brazil 50.1
British Virgin Is. 33.1
Brunei 2.3
Bulgaria 13.0 3/30/2020
Burkina Faso 2.3
Burundi 0.1
Cabo Verde 3.6
Cambodia 0.0 1/28/2020
Cameroon 4.1 4/13/2020
Canada 124.3 4/6/2020
Carib. Netherlands 0.0

56
Cayman Is. 15.2
Central Afric. Rep. 0.0
Chad 1.9
Channel Is. 235.8
Chile 15.9 4/6/2020
China 3.2 1/20/2020
Colombia 8.7 4/4/2020
Congo 1.8
Costa Rica 1.2
Croatia 21.2
Cuba 6.5 4/2/2020
Curacao 6.1
Cyprus 12.4 4/3/2020
Czechia 25.8 3/19/2020
Dem. Rep. Congo 0.4
Denmark 90.8
Djibouti 3.0
Dominica 0.0
Dominican Republic 35.5 4/16/2020
Ecuador 97.3 4/7/2020
Egypt 5.0
El Salvador 2.6 4/8/2020
Equatorial Guinea 2.9 4/14/2020
Estonia 45.2 4/5/2020
Eswatini 1.7
Ethiopia 0.0 4/11/2020
Faeroe Islands 0.0
Falkland Islands 0.0
Fiji 0.0
Finland 47.8 4/14/2020
France 403.1 4/3/2020
French Polynesia 0.0
Gabon 3.6 4/10/2020
Gambia 0.4
Georgia 2.5
Germany 90.1 4/1/2020
Ghana 0.7
Gibraltar 0.0
Greece 14.5
Greenland 0.0
Grenada 0.0 4/3/2020
Guatemala 1.3 4/9/2020
Guinea-Bissau 1.5
Guyana 12.7 4/9/2020
Haiti 1.1
Honduras 10.8 4/6/2020
Hong Kong 0.5 1/24/2020
Hungary 41.9
Iceland 29.3

57
India 1.5 4/4/2020
Indonesia 3.5 4/5/2020
Iran 78.4 3/29/2020
Iraq 2.7
Ireland 292.8
Isle of Man 270.5
Israel 28.5 4/1/2020
Italy 502.7
Ivory Coast 0.8 4/4/2020
Jamaica 3.0
Japan 4.8 1/16/2020
Jordan 0.9
Kazakhstan 1.7
Kenya 0.6 4/4/2020
Kuwait 11.5 3/23/2020
Krgyzstan 1.8
Laos 0.0 3/6/2020
Latvia 9.5
Lebanon 3.8
Liberia 4.0
Libya 0.4 4/16/2020
Liechtenstein 26.2
Lithuania 18.0 3/26/2020
Luxembourg 161.3
Macao 0.0 1/23/2020
Madagasgar 0.0
Malawi 0.2 4/4/2020
Malaysia 3.3 1/30/2020
Maldives 5.5
Mali 1.8
Malta 11.3
Mauritania 0.2
Mauritius 7.9 3/31/2020
Mayotte 40.3
Mexico 26.0
Moldova 39.9
Mongolia 0.0 1/31/2020
Montenegro 12.7
Montserrat 200.3
Morocco 5.0 4/6/2020
Mozambique 0.0 4/4/2020
Myanmar 0.1
Namibia 0.0
Nepal 0.0 3/25/2020
Netherlands 316.4
New Caledonia 0.0
New Zealand 4.4
Nicaragua 0.8
Niger 1.9

58
Nigeria 0.6 4/14/2020
North Macedonia 43.7
Norway 40.4
Oman 3.3
Pakistan 2.9
Palestine 0.4
Panama 54.9 4/7/2020
Papua New Guinea 0.0
Paraguay 1.4 4/7/2020
Peru 55.0 4/3/2020
Philippines 6.4 1/30/2020
Poland 20.7 4/10/2020
Portugal 110.4
Qatar 4.5
Réunion 0.0
Romania 48.8
Russia 12.5
Rwanda 0.0
Saint Kitts & Nevis 0.0
Saint Lucia 0.0
San Marino 1208.3
Sao Tome & Principe 22.8
Saudi Arabia 6.9
Senegal 1.0
Serbia 24.4
Seychelles 0.0
Sierra Leone 2.3 4/1/2020
Singapore 3.4 4/3/2020
Sint Maarten 349.8 4/14/2020
Slovakia 4.8 3/15/2020
Slovenia 48.6 3/29/2020
Somalia 3.0
South Africa 3.1 4/10/2020
South Korea 5.0 1/30/2020
South Sudan 0.0
Spain 566.3 4/11/2020
Sri Lanka 0.4 4/11/2020
St. Vincent & Gren. 0.0
Sudan 1.5 3/16/2020
Suriname 1.7
Sweden 318.8
Switzerland 211.4
Syria 0.2
Taiwan 0.3 1/27/2020
Tanzania 0.4
Thailand 0.8 1/28/2020
Timor-Leste 0.0
Togo 1.2
Trinidad & Tobago 5.7 4/5/2020

59
Tunisia 3.8 4/7/2020
Turkey 44.3 4/3/2020
Turks and Caicos 25.8
Uganda 0.0
Ukraine 8.6 4/3/2020
United Arab Emir. 18.7 3/27/2020
United Kingdom 465.3
United States 241.8 4/3/2020
Uruguay 5.2
Uzbekistan 0.3 3/25/2020
Venezuela 0.4 3/13/2020
Vietnam 0.0 1/27/2020
Yemen 0.2
Zambia 0.4 4/4/2020
Zimbabwe 0.3

60
Table A2. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9
by Univariate Linear Regression in 198 Countries.
10coefficient Coefficient (SE) 95% CI p value
Duration infection (weeks) 1.4182 0.152 (0.030) 0.093 to 0.210 <0.001
Duration infection without 1.8092 0.257 (0.029) 0.199 to 0.316 <0.001
masks (weeks)
Duration infection without 1.2573 0.099 (0.031) 0.039 to 0.160 0.002
lockdown (weeks)
Temperature, mean (C) 0.8819 -0.055 (0.008) 0.071 to -0.038 <0.001
Urban population (%) 1.0477 0.0203 (0.003) 0.014 to 0.027 <0.001
GDP per capita ($1000) 1.0424 0.0180 (0.003) 0.012 to 0.024 <0.001
Age 14 & under (% of pop.) 0.8755 -0.058 (0.007) -0.072 to -0.044 <0.001
Age 60 & over (% of pop.) 1.1945 0.077 (0.009) 0.060 to 0.094 <0.001
2
Surface area (million km ) 1.1311 0.053 (0.044) -0.034 to 0.141 0.23
Population (million) 1.0002 0.00010 (0.0006) -0.001 to 0.001 0.86
Prevalence males (%) 0.9745 -0.011 (0.025) -0.061 to 0.039 0.66
Smoking prevalence, adult (%) 1.0489 0.021 (0.010) 0.000 to 0.041 0.047
Obesity prevalence, adult (%) 1.1248 0.051 (0.008) 0.035 to 0.067 <0.001
Tests per cap. (log) by May 9 4.9220 0.692 (0.093) 0.509 to 0.875 <0.001
Durations run from the estimated date of first infection in the country until 23 days before May 9,
2020 (i.e. April 16), or the stated event (mask recommendation or lockdown). Obesity data available for
194 countries. Testing data available for 183 countries by May 9.

61
Table A3. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9
by Multivariable Linear Regression in 198 Countries.
10coefficient Coefficient (SE) 95% CI P
Duration in country (weeks) 1.5305 0.185 (0.033) 0.120 to 0.249 <0.001
Time wearing masks (weeks) 0.6604 -0.180 (0.029) -0.237 to -0.123 <0.001
Time in lockdown (weeks) 0.9749 -0.011 (0.034) -0.078 to 0.056 0.75
Population, age≥60 (%) 1.1407 0.057 (0.009) 0.040 to 0.074 <0.001
Urbanization (%) 1.0180 0.00773 (0.003) 0.002 to 0.014 0.01
Constant -- -7.809 (0.236) -8.273 to -7.344 <0.001
` Duration of infection in country from estimated date of first infection until 23 days before May 9, 2020
(i.e. April 16). Mask and lockdown durations run from the stated event (mask recommendation or
lockdown) or estimated date of first infection in the country (whichever was later) until 23 days before
May 9, 2020 (i.e. April 16). Model r2=0.472.

62
Table A4. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9
by Multivariable Linear Regression in 198 Countries, with Outbreak Start Defined by
Date of First Case.

10coefficient Coefficient (SE) 95% CI P

Duration in country (weeks) 1.3847 0.141 (0.033) 0.076 to 0.207 <0.001
Time wearing masks (weeks) 0.6887 -0.162 (0.030) -0.221 to -0.103 <0.001
Time in lockdown (weeks) 1.0282 0.012 (0.035) -0.058 to 0.082 0.73
Population, age≥60 (%) 1.1434 0.058 (0.009) 0.040 to 0.076 <0.001
Urbanization (%) 1.0197 0.00845 (0.003) 0.002 to 0.015 0.007
Constant -- -7.506 (0.221) -7.942 to -7.070 <0.001
` Duration of infection in country from estimated date first case reported until 23 days before May 9,
2020 (i.e. April 16). Mask and lockdown durations run from the stated event (mask recommendation or
lockdown) or date first case reported in the country (whichever was later) until 23 days before May 9,
2020 (i.e. April 16). Model r2=0.438.

63
Table A5. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9
by Multivariable Linear Regression in 198 Countries, with Mask Wear Determined by
Recommendations and Surveys (When Available).
10coefficient Coefficient (SE) 95% CI P
Duration in country (weeks) 1.5056 0.178 (0.033) 0.112 to 0.243 <0.001
Time wearing masks (weeks) 0.6845 -0.165 (0.029) -0.221 to -0.108 <0.001
Time in lockdown (weeks) 0.9669 -0.015 (0.034) -0.082 to 0.053 0.67
Population, age≥60 (%) 1.1411 0.057 (0.009) 0.040 to 0.075 <0.001
Urbanization (%) 1.0175 0.00754 (0.003) 0.001 to 0.014 0.01
Constant -- -7.737 (0.236) -8.203 to -7.271 <0.001
` Duration of infection in country from estimated date of first infection until 23 days before May 9, 2020
(i.e. April 16). Mask and lockdown durations run from the stated event (mask recommendation or
lockdown) or estimated date of first infection in the country (whichever was later) until 23 days before
May 9, 2020 (i.e. April 16). Model r2=0.459.

64
 Table A6. Predictors of (log) Country-wide Per-capita Coronavirus Mortality by May 9
by Multivariable Linear Regression in 179 Countries.
10coefficient Coefficient (SE) 95% CI P
Duration in country 1.5673 0.195 (0.034) 0.127 to 0.263 <0.001
(weeks)
Time wearing masks 0.7060 -0.151 (0.032) -0.214 to -0.088 <0.001
(weeks)
Time in lockdown 0.9591 -0.018 (0.039) -0.095 to 0.059 0.64
(weeks)
Population, % age 60 or 1.0930 0.039 (0.011) 0.016 to 0.061 0.001
over
Urbanization (%) 1.0119 0.00512 (0.004) -0.002 to 0.013 0.18
Obesity prevalence (%) 1.0478 0.020 (0.010) 0.001 to 0.039 0.04
Temperature (C) 0.9758 -0.01065 (0.009) -0.029 to 0.007 0.24
Testing (log per cap., 1.1698 0.068 (0.114) -0.156 to 0.293 0.55
by May 9)
Constant -- -7.539 (0.582) -8.69 to -6.39 <0.001
Based on 179 countries with both obesity and testing data by May 9. Duration of infection in country
from estimated date of first infection until 23 days before May 9, 2020 (i.e. April 16). Mask and
lockdown durations run from the stated event (mask recommendation or lockdown) or estimated date
of first infection in the country (whichever was later) until 23 days before May 9, 2020 (i.e. April 16).
Model r2=0.521.

65

View publication stats

E
X
H
I
B
I
T

E
COVID-19

By Wei Lyu and George L. Wehby

doi: 10.1377/hlthaff.2020.00818

Community Use Of Face Masks

HEALTH AFFAIRS 39,
NO. 8 (2020): 1–7
©2020 Project HOPE—
The People-to-People Health

And COVID-19: Evidence From Foundation, Inc.

A Natural Experiment Of State

Mandates In The US
Wei Lyu is a research
ABSTRACT State policies mandating public or community use of face associate in the Department
of Health Management and
masks or covers in mitigating novel coronavirus disease (COVID-19) Policy, College of Public
spread are hotly contested. This study provides evidence from a natural Health, University of Iowa, in
Iowa City, Iowa.
experiment on effects of state government mandates in the US for face
mask use in public issued by 15 states plus DC between April 8 and May George L. Wehby (george-
wehby@uiowa.edu) is a
15. The research design is an event study examining changes in the daily professor in the Department
county-level COVID-19 growth rates between March 31, 2020 and May 22, of Health Management and
Policy, College of Public
2020. Mandating face mask use in public is associated with a decline in Health, University of Iowa,
the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage- and a research associate at
the National Bureau of
points in 1–5, 6–10, 11–15, 16–20, and 21+ days after signing, respectively. Economic Research.
Estimates suggest as many as 230,000–450,000 COVID-19 cases possibly
averted By May 22, 2020 by these mandates. The findings suggest that
requiring face mask use in public might help in mitigating COVID-19
spread. [Editor’s Note: This Fast Track Ahead Of Print article is the
accepted version of the peer-reviewed manuscript. The final edited version
will appear in an upcoming issue of Health Affairs.]

O
ne of the most contentious issues
being debated worldwide in the
response to the novel coronavirus
disease (COVID-19) pandemic is
the value of wearing masks or
facial coverings in public settings.1 A key factor
fueling the debate is the limited direct evidence
thus far on how much widespread community
use would affect COVID-19 spread. However,
there is now substantial evidence of asymptom-
atic transmission of COVID-19.2,3 For example, a
recent study of antibodies in a sample of custom-
ers in grocery stores in New York State reported
an infection rate of 14% by March 29 (projected
to represent nearly 2.1 million cases), which sub-
stantially exceeds the number of confirmed
COVID-19 cases.4 Moreover, all public health
authorities call on symptomatic individuals to
wear masks to reduce transmission risk. Even
organizations that have not yet recommended
widespread community use of facial masks for
COVID-19 mitigation (i.e. everyone without
symptoms should use a face mask outside of their
home), such as the World Health Organization,
strongly recommend that symptomatic individ-
uals wear them.5 Since mask wearing by infected
individuals can reduce transmission risk, and
because of the high proportion of asymptomatic
infected individuals and transmissions, there
appears to be a strong case for the effectiveness
of widespread use of face masks in reducing the
spread of COVID-19. However, there is no direct
evidence thus far on the magnitude of such ef-
fects, especially at a population level.
Researchers have been reviewing evidence
from previous randomized controlled trials for
other respiratory illnesses examining mask use
and types among individuals at higher risk of
contracting infections (such as health care work-
ers or individuals in infected households). Sys-
tematic reviews and meta-analyses of such stud-
ies have provided suggestive, although generally

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COVID-19
weak, evidence.6 The estimates from the meta-
analyses based on the randomized controlled
trials suggest declines in transmission risk of
influenza or influenza-like illnesses to mask
wearers, although estimates are mostly statisti-
cally insignificant possibly due to small sample
sizes or design limitations especially related to
assessing compliance.7–9 There is also a relation-
ship between increased adherence to mask use
specifically and effectiveness of reducing trans-
mission to mask wearers; in one randomized
study of influenza transmission in infected
households in Australia, transmission risk for
mask wearers was lower with greater adher-
ence.10 Further, the evidence is mixed from ran-
domized studies on types of masks and risk of
influenza-like illnesses transmission to mask
wearers; for example, a recent systematic review
and meta-analysis comparing N95 respirators
versus surgical masks found a statistically insig-
nificant decline in influenza risk with the N95-
respirators.11
Positions on widespread facial mask use have
differed worldwide but are changing over time.
In the US, public health authorities did not rec-
ommend widespread facial mask use in public
at the start of the pandemic. The initially limited
evidence on asymptomatic transmission and
concern about mask shortages for health care
workforce and individuals caring for patients
contributed to that initial decision. On April 3,
2020, the Centers for Disease Control and Pre-
vention (CDC) issued new guidance advising all
individuals to wear cloth facial covers in public
areas where close contact with others is unavoid-
able, citing new evidence on virus transmission
from asymptomatic or pre-symptomatic individ-
uals.12 Guidelines differ between countries, and
some including Germany, France, Italy, Spain,
China, and South Korea have mandated use of
face masks in public.13–16
This study adds complementary evidence to
the literature on impacts of widespread commu-
nity use of face masks on COVID-19 spread from a
natural experiment based on whether states in
the US have mandated the use of face masks in
public for COVID-19 mitigation or not. Specifi-
cally, we identify the effects of mandating face
mask use in public on daily COVID-19 growth
rates based on differences in the timing and is-
suance of state mandates.
In the US, 15 states plus DC have issued man-
dates for face mask use in public between April 8
and May 15.We examine the effects of state man-
dates for use of face masks in public on the daily
COVID-19 growth rate using an event study that
examines the effects over different periods. We
also consider the impact of mandates for mask
use targeted only to employees in some work
2 Health A ffairs August 2020 39:8
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settings, as opposed to community-wide man-
dates. This evidence is critical as states and coun-
tries worldwide begin to shift to “reopening”
their economies and as foot traffic increases.
Mandating public use of masks has become a
socially and politically contentious issue, with
multiple protests and even acts of violence di-
rected against masked employees and those ask-
ing customers to wear face masks.17 Face cover
recommendations and mandates are part of the
current set of measures, following earlier social
distancing measures such as school and non-
essential business closures, bans on large gath-
erings, and shelter-in-place orders being consid-
ered by states and local governments, especially
as regions of the country reopen. For example,
most recently, Virginia started its phase one re-
opening on May 22, 2020 and required everyone
in the state to wear face masks in public where
people congregate.18 Therefore, it is critical to
provide direct evidence on this question not only
for public health authorities and governments
but also for educating the public.
Study Data And Methods
Data We collect information on statewide face
covering mandate orders from public datasets on
such policies and from searching and reviewing
all state orders issued between April 1 and May
21, 2020. Our study focuses on state executive
orders or directives signed by state governors
that mandate use. Recommendations or guide-
lines from state departments of public health are
not included as these largely follow the CDC
guideline and may not necessarily add further
information or impact. See online appendix A
for more detailed description of the data sources
and measuring the mandates.19
States differ in whether they require their citi-
zens to wear face masks (covers) to limit COVID-
19 spread or not. Between April 8 and May 15,
governors of 15 states and the mayor of the Dis-
trict of Columbia (DC) have signed orders man-
dating all individuals who can medically tolerate
the wearing of a face mask do so in public set-
tings (e.g., public transportation, grocery stores,
pharmacies, or other retail stores) where main-
taining 6-feet of “social distance” may not always
be practicable; these 15 states also have specific
mandates requiring employees in certain profes-
sions to wear masks at all times while working.
Besides these 15 states and DC, 20 additional
states have employee-only mandates (but no
community-wide mandate) requiring that some
employees (e.g., close-contact services providers
like barber shops and nail salons) wear a face
mask at all times while providing services. The
face mask defined in these orders primarily re-
fers to cloth face covering or non-medical masks.
The state orders strongly discourage the use of
any medical/surgical masks and N95 respira-
tors, which should be reserved for health care
workers and first responders. The orders also
clearly specify that the face masks are not a re-
placement for any other social distancing proto-
cols. Fifteen states have yet not issued public
or employee mandates. Further information on
dates is in appendix exhibit A1. Links to these
state orders are in appendixes D and E.19
The main model uses publicly available daily
county-level data of confirmed COVID-19 cases
starting on March 25 through May 21.20 The data
covers all states plus DC, and the analytical sam-
ple includes 2,930 unique counties plus New
York City (five boroughs combined). See appen-
dix A for more detailed description of COVID-19
data.19
Statistical Analysis We employ an event
study, which is generally similar to a differ-
ence-in-differences design, to examine whether
statewide mandates to wear face masks in public
affect the spread of COVID-19 based on the state
variations noted above. This design allows us to
estimate the effects in the context of a natural
experiment: comparing the pre-post mandate
changes in COVID-19 spread in the states with
mandates to the states that did not pass these
mandates over time. The model tests whether
states issuing these mandates had differential
pre-trends in COVID-19 rates before they were
issued. This is a critical assumption of the validi-
ty of an event study that must be upheld under
testing. In addition, the model allows us to con-
trol for a wide range of time-invariant differences
between states and counties such as population
density and socioeconomic and demographic
factors, plus time-variant differences between
states and counties such as other mitigation
and social distancing policies in addition to
state-level COVID-19 tests.
We estimate the effects of face cover mandates
on the daily county-level COVID-19 growth rate,
which is the difference in the natural log of cu-
mulative COVID-19 cases on a given day minus
the natural log of cumulative cases in the prior
day, multiplied by 100.21 This measure gives the
daily growth rate in percentage points.
The reference period for estimating the face
cover mandate effects is 1–5 days before signing
the order. We examine how effects change over
five post-periods: 1–5 days, 6–10 days, 11–15
days, 16–20 days, and 21+ days. The model also
tests for pre-trends over 6–10 days, 11–15 days,
and 16+ days before signing the mandate. For all
counties in the analytical sample, the main mod-
el includes daily data from March 31 (7 days
before the first state signed a face cover man-
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
date) through May 22. The models are estimated
by least squares weighted by the county 2019
population with heteroscedasticity-robust and
state-clustered standard errors.
As noted above, all of the 15 states plus DC that
mandate facial cover use in public also mandated
employee mask use. To assess the effects of em-
ployee face cover mandates, we estimate another
event-study model that focuses on the employee
face cover mandate as the policy intervention. In
this analysis, we exclude the 15 states plus DC
with both public and employee face cover man-
dates and focus on the 20 states with employee
only mandate and the 15 states without an em-
ployee mandate.
Limitations We are unable to measure facial
cover use in the community (i.e. compliance with
the mandate). As such, the estimates represent
the intent-to-treat effects of these mandates, i.e.
their effects as passed, and not the individual-
level effect of wearing a face mask in public on
own COVID-19 risk. Related, we do not measure
enforcement of the mandates, which might af-
fect compliance. We also do not have data on
county-level mandates for wearing public-
face masks. In some states without state-level
mandates such as California,22 Texas,23 and
Colorado,24 multiple counties have enacted such
mandates. These county-level mandates do not
bias the intent-to-treat estimates of effects of
state-level mandates as actually passed, but they
do add local-level heterogeneity not directly ac-
counted for in the model. We do examine the
robustness of estimates to excluding some of
these states. Finally, we are able to examine only
confirmed COVID-19 cases. However, there is
evidence of a higher infection rate in the com-
munity than confirmed cases.25
Study Results
Effects Of Mandates For Face Covering In
Public Supplemental exhibit 1 in the online ap-
pendix19 plots the event study estimates of effects
of state mandates for face covering in public on
the county-level daily growth rate of COVID-19
cases with their 95% CIs, obtained from the
main regression model (in appendix B) using
county-level daily data from March 31 through
May 22;19 appendix exhibit C1 (column 1) reports
the exact estimates.19 The effects are shown over
five periods after signing the orders, relative to
the five days before signing (reference period).
Also shown are estimated differences in daily
COVID-19 growth rates between states with and
without the mandates over three periods before
the reference period.
There is a significant decline in daily COVID-19
growth rate after mandating facial covers in pub-
August 2020 39:8 Health Affairs 3
Downloaded from HealthAffairs.org on July 20, 2020.
COVID-19
lic, with the effect increasing over time after sign-
ing the order. Specifically, the daily case rate
declines by 0.9, 1.1, 1.4, 1.7, and 2.0 percent-
age-points within 1–5, 6–10, 11–15, and 16–20,
and 21+ days after signing, respectively. All
of these declines are statistically significant
(p < 0:05, or less). In contrast, the pre-trends
in COVID-19 case growth rates are small and
statistically insignificant.
We also project the number of averted COVID-
19 cases with the mandates for face mask use in
public by comparing actual cumulative daily
cases to daily cases predicted by the model if
none of the states had enacted the public face
cover mandate at the time they did (see details in
appendix B).19 The main model estimates suggest
that as many as 230,000–450,000 cases may
have been averted due to these mandates by
May 22. Estimates of averted cases should be
viewed cautiously and only as general approxi-
mations.
Robustness Checks We estimate multiple ex-
tensions of the main event study model to assess
the robustness of estimates to different model
specifications and sample choices. These checks
start the event study on March 26, add flexible
controls for social distancing and state reopen-
ing measures, employee face mask use man-
dates, and county-specific time trends, and allow
time trends to vary by sociodemographic indica-
tors. Other checks use the mandate effective date
instead of signing date; use hyperbolic sine
transformation to account for 0 cases; include
states as the unit instead of counties; include
only urban counties; exclude some states with-
out state-level mandates but multiple counties
having local mandates. The detailed description
and results of these robustness checks are listed
in appendix C.19 The results are robust across
these checks; effects are smaller when using
the effective date instead of the signing date,
which differ by about 2–3 days on average sug-
gesting earlier compliance, and when using
states as the unit of analysis. But the estimates
remain meaningful and statistically significant
in all checks.
Effects Of Employee Only Face Covering
Mandates As noted above, we also directly as-
sess the effects of states mandating only that
certain employees wear face masks. Twenty
states issued employee only mandates but did
not issue public use mandates. We re-estimate
the event-study model described above for
this employee-only mandate including those
20 states (issued between April 17 and May 9)
and the 15 states without mandates and exclud-
ing the 15 states plus DC that issued the public
use mandates (plus the employee use mandates).
Supplemental exhibit 219 plots the event study
4 Health Affairs August 2020 39:8
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estimates of changes in county-level daily
COVID-19 growth rates with the employee only
face cover mandates and their 95% CIs. All pre-
and post-mandate estimates are small and insig-
nificant. Overall, these results indicate no evi-
dence of declines in daily COVID-19 growth rates
with the employee-only mandates.
Discussion
Around the world, governments have been fight-
ing COVID-19 spread through a mix of policies
and mitigation measures such as school and non-
essential business closures and shelter-in-place
orders. Some countries have also recommended
or mandated widespread community use of facial
masks as a mitigation measure. However, the
effectiveness of this measure is highly debated.
The debate and uncertainty are fueled by the
limited direct empirical evidence on the magni-
tude of effects of widespread face mask use in
public on COVID-19 mitigation. There is a critical
need for empirical evidence on the magnitude
of these effects from natural experiments.8 This
evidence is especially relevant as governments
reopen their economies and loosen social dis-
tancing restrictions at times while new infec-
tions continue without a vaccine or widely acces-
sible and effective treatments in sight.
The study provides direct evidence on the ef-
fectiveness of widespread community use of face
masks from a natural experiment that evaluates
effects of state government mandates in the US
for face mask use in public on COVID-19 spread.
Fifteen states plus DC in the US have mandated
this use between April 8 and May 5. Using an
event study that examines daily changes in coun-
ty-level COVID-19 growth rates, the study finds
that mandating public use of face masks is asso-
ciated with a reduction in the COVID-19 daily
growth rate. Specifically, we find that the average
daily county-level growth rate decreases by 0.9,
1.1, 1.4, 1.7, and 2.0 percentage-points in 1–5,
6–10, 11–15, 16–20, and 21+ days after signing,
respectively.
These estimates are not small and represent
nearly 16–19% of the effects of other social dis-
tancing measures (school closures, bans on large
gatherings, shelter-in-place orders, and closures
of restaurants, bars, and entertainment venues)
after similar periods from their enactment.21
The estimates suggest increasing effectiveness
and benefits from these mandates over time.
By May 22, the estimates suggest that as many
as 230,000–450,000 COVID-19 cases may have
been averted based on when states passed these
mandates. Again, the estimates of averted cases
should be viewed cautiously as these are sensitive
to assumptions and different approaches for
transforming the changes in the daily growth
rate estimates to cases.
The early declines in the daily growth rate over
5 days after signing the order are broadly consis-
tent with timing of effects of other social distanc-
ing measures such as business closures.21 While
the median incubation period is estimated to be
around 5 days,26 there is a wide range from 2.2
(2.5th percentile) days to 11.5 days (97.5th per-
centile) suggesting that for many individuals
symptoms may appear relatively early. Further,
individuals may become aware of the mandates
early through the governors’ briefings and relat-
ed media reports or may be anticipating them.
There is no evidence of differential pre-man-
date COVID-19 trends with respect to issuing
these mandates. The estimates represent the in-
tent-to-treat effects of the statewide face cover
mandates as passed, conditional on other na-
tional and local measures. In that way, the effects
are independent of the CDC national guidance to
wear facial masks issued on April 3. These effects
are robust to several model checks. The study
provides evidence from a natural experiment
on effectiveness of mandating public use of face
masks in mitigating COVID-19 spread.We find no
evidence for effects of states mandating employ-
ee face mask use, perhaps because many busi-
nesses themselves have been requiring their
employees to wear masks.27,28 In that sense, man-
dating employee mask use may be reinforcing
what many businesses are already choosing to
do on their own.
While the intent-to-treat estimates are of inter-
est for understanding the effectiveness of these
policies in limiting COVID-19 spread at the com-
munity and population level, understanding
how their effects change with compliance and
enforcement strategies is important for design-
ing effective policies. Our study builds the first
step in estimating the overall effect of these poli-
cies as enacted. However, these policies vary in
their strictness and consequences of noncompli-
ance. The mandates generally require wearing
a face mask in public whenever the social dis-
tance cannot be maintained. Some states (such
as Delaware, Maryland, Massachusetts, and
Maine) clarify what “public” areas are, for exam-
ple indoor space in retail establishments, out-
door space in busy parking lots and waiting areas
for take-out services, semi-enclosed areas, such
as in public transportation stops, and enclosed
space, such as in taxis and other public transpor-
tation means. The language on enforcement and
[Published online June 16, 2020.]
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For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
penalties for non-compliance also vary. In some
states such as Delaware, Hawaii, Maryland, and
Massachusetts, the face mask orders state that
they have the force and effect of law, with a willful
violation subject to a criminal offense with pen-
alties. For example, the order in Maryland states
that “a person who knowingly and willfully
violates this order is guilty of a misdemeanor
and on conviction is subject to imprisonment
not exceeding one year or a fine not exceeding
$5,000 or both”.29 In contrast, the orders of some
other states such as Connecticut, Maine, and
Pennsylvania, while clearly mandating the wear-
ing of a face mask in public, do not appear to
clearly specify that violations of the order are
subject to criminal offense or penalties. Future
work should examine if and how differences in
strictness and enforcement modify the effects of
these mandates.
Compliance and enforcement may also differ
across contextual factors (such as other social
distancing measures, workforce distribution,
population demographic, socioeconomic, and
cultural factors). In that regard, it is important
to clarify that the suggested benefits from man-
dating face mask use are not substitutes for other
social distancing measures; the effects are con-
ditional on the other enacted social distancing
measures and how communities are complying
with them. It is also important to extend the
evidence into additional measures of exposure
to the virus in the community as data become
available such as from serological testing for
antibodies. Finally, future work can examine ef-
fects on deaths, which lag cases and change not
only with number of cases but also with case
severity.
Conclusion
The study provides evidence that states in the US
mandating use of face masks in public had a
greater decline in daily COVID-19 growth rates
after issuing these mandates compared to states
that did not issue mandates. These effects are
observed conditional on other existing social
distancing measures and are independent of
the CDC recommendation to wear facial covers
issued on April 3. As countries worldwide and
states begin to relax social distancing restric-
tions and considering the high likelihood of a
second COVID-19 wave in the fall/winter,30 re-
quiring use of face masks in public might help in
reducing COVID-19 spread. ▪
August 2020 39:8 Health Affairs 5
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COVID-19
NOTES
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11 Long Y, Hu T, Liu L, Chen R, Guo Q,
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13 Pleitgen F, Schmidt N. Germans face
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germany-face-mask-mandatory-grm-
intl/index.html
14 Bostock B. France has made wearing
face masks compulsory in public,
while maintaining a controversial
ban on burqas and niqabs. Business
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compulsory-burqas-niqabs-banned-
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15 Duncan C. Coronavirus: Spain makes
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strict lockdown. The Independent
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16 Which countries have made wearing
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compulsory-200423094510867.html
17 Morning Briefing. Tensions Over
Masks, Social Distancing Lead To
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Death, Pipe Bomb Threats. Kaiser
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2020 May 5 [cited 31 Jun 9]. Avail-
able from: https://khn.org/
morning-breakout/tensions-over-
masks-social-distancing-lead-to-
violent-altercations-shooting-death-
pipe-bomb-threats/
18 Commonwealth of Virginia. Office of
the Governor, Executive Order
Number 63 (2020) [Internet].
Richmond (VA): The Office; 2020
May 26 [cited 2020 Jun 9]. Available
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.virginia.gov/media/governor
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63-and-Order-Of-Public-Health-
Emergency-Five---Requirement-To-
Wear-Face-Covering-While-Inside-
Buildings.pdf
19 To access the appendix, click on the
Details tab of the article online.
20 Github. An ongoing repository of
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[cited 2020 Apr 28]. Available from:
https://github.com/nytimes/covid-
19-data
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27 Peterson H. Walmart is now requir-
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August 2020 39:8 H ea lt h A f fai r s 7

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E
X
H
I
B
I
T

F
 The Case for Universal Cloth Mask Adoption &
Policies to Increase the Supply of Medical Masks for Health Workers
April 1 2020

Jason Abaluck, PhD. Associate Professor of Economics, Yale School of Management

Judith Chevalier, PhD. William S Beinecke Professor of Economics and Finance, Yale
School of Management
Nicholas A. Christakis, MD., PhD., MPH. Sterling Professor of Social and Natural
Science, Department of Sociology, Department of Statistics and Data Science,
Department of Ecology and Evolutionary Biology, Department of Biomedical
Engineering, Department of Medicine, Yale University.
Howard Forman, MD, MBA. Professor of Radiology and Biomedical Imaging,
Economics, and Public Health (Health Policy); Professor in the Practice of
Management, Yale School of Management.
Edward H. Kaplan, PhD. William N. and Marie A. Beach Professor of Operations
Research, Yale School of Management; Professor of Public Health, Yale School of Public
Health; Professor of Engineering, Yale University.
Albert Ko, MD. Professor of Epidemiology and Medicine and Department Chair,
Epidemiology of Microbial Diseases, Yale School of Public Health.
Sten H. Vermund, MD, PhD. Dean and Anna M.R. Lauder Professor of Public Health,
Yale School of Public Health; Professor of Pediatrics, Yale School of Medicine.

Introduction

The urgent need to stop the spread of COVID-19 is among the most important health
policy challenges of our lifetimes. Millions of lives are at stake globally, and the
economic security of tens of millions of Americans is threatened.

In this white paper, we discuss the potential effectiveness of the universal adoption of
homemade cloth facemasks in mitigating this public health crisis; we find that this policy
could have very large benefits, but that it should be coupled with policies that protect
and increase the availability of medical masks for frontline healthcare workers.

We estimate that the benefits of each additional cloth mask worn by the public are
conservatively in the $3,000-$6,000 range due to their impact in slowing the spread of
the virus. The benefits of each medical mask for healthcare personnel may be hundreds
of times larger, and there is an ethical imperative to safeguard frontline healthcare
workers. We must both encourage universal mask adoption and deal with the urgent
policy priority that front-line healthcare workers face shortages of personal protective
equipment, such as N95 respirators and surgical masks.

Current medical advice from the CDC, the US Surgeon General’s Office, and WHO
discourages mask-wearing by the general public. This is due primarily to the shortage of
protective equipment for healthcare workers as well as the limited evidence that non-

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 medical masks protect the wearer from infection.1 Thus, masks are currently only
recommended for healthcare workers, and in some circumstances, for symptomatic
individuals while receiving care.

However, there is broad agreement about two crucial points:

 People infected with the SARS-COV-2 virus can have minimal symptoms or can be
completely asymptomatic.2 Thus, seemingly healthy people, including young people, are
spreading the virus by transmitting it to others.
 Masks, including cloth masks and surgical masks, have measurable efficacy at preventing
infected people from transmitting viruses to others.3

These facts suggest that it is not sufficient only for people with symptoms to wear
masks. Adoption of masks by everyone – including those with no symptoms – could slow
the spread of the virus.4 Additionally, masks may have some value in protecting
susceptible individuals, although of course they are not a substitute for other

1
For example, Dr. Jerome Adams, the Surgeon General, tweeted, “They are NOT effective in
preventing general public from catching #Coronavirus, but if healthcare providers can’t get them
to care for sick patients, it puts them and our communities at risk!”
(https://twitter.com/surgeon_general/status/1233725785283932160) . The Surgeon General
confirmed in an interview on April 1 that the Surgeon General’s office has asked the CDC to
reevaluate this advice.
2
Japanese National Institute of Infectious Diseases. Field Briefing: Diamond Princess COVID-19
Cases, 20 Feb Update. https://www.niid.go.jp/niid/en/2019-ncov-e/9417-covid-dp-fe-02.html
(Accessed on March 01, 2020).
3
See, for example:
Davies, A., Thompson, K.A., Giri, K., Kafatos, G., Walker, J. and Bennett, A., 2013. Testing the
efficacy of homemade masks: would they protect in an influenza pandemic? Disaster medicine
and public health preparedness, 7(4), pp.413-418.
Ferguson, N.M., Laydon, D., Nedjati-Gilani, G., Imai, N., Ainslie, K., Baguelin, M., Bhatia, S.,
Boonyasiri, A., Cucunubá, Z., Cuomo-Dannenburg, G. and Dighe, A., 2020. Impact of non-
pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare
demand. Imperial College, London. DOI: https://doi. org/10.25561/77482.
Jefferson, T., Foxlee, R., Del Mar, C., Dooley, L., Ferroni, E., Hewak, B., Prabhala, A., Nair, S. and
Rivetti, A., 2008. Physical interventions to interrupt or reduce the spread of respiratory viruses:
systematic review. Bmj, 336(7635), pp.77-80.
Rengasamy, S., Eimer, B. and Shaffer, R.E., 2010. Simple respiratory protection—evaluation of
the filtration performance of cloth masks and common fabric materials against 20–1000 nm size
particles. Annals of occupational hygiene, 54(7), pp.789-798.
van der Sande, M., Teunis, P. and Sabel, R., 2008. Professional and home-made face masks
reduce exposure to respiratory infections among the general population. PLoS One, 3(7).
4
Obviously, individuals with symptoms should quarantine entirely. Further, while we are not
aware of studies that demonstrate that a sick person can become sicker due to mask-wearing,
there is a plausible mechanism by which that could occur. This suggests that mask-wearing
should be limited to circumstances in which the mask-wearer could otherwise contaminate
others.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 precautions.5 While physical distancing measures (often called “social distancing”) are of
paramount importance in preventing the spread of the virus, they cannot be fully
enforced. People interact at close quarters when they perform essential activities such
as buying food or seeking healthcare, and cashiers or delivery workers may interact with
hundreds of people a day. Preventing the transmission of the virus from asymptomatic
individuals in such cases is likely the principal benefit of broader mask adoption. For
example, in settings in which a worker interacts with the public, both the worker and
the public are safer if the other party is wearing a mask.

An important concern is the hoarding of medical masks before there is adequate supply
for front-line medical workers. Non-medical alternatives should therefore be
considered. For example, there is scientific evidence that homemade cloth masks can
prevent viral transmission.6 Encouraging production of cloth masks may help counteract
and discourage medical mask hoarding; this can include homemade production and
perhaps industrial production, but only to the extent that supply chains do not interfere
with those for critically important medical masks. People equipped with cloth masks
may feel more comfortable donating existing respirators and surgical masks to medical
personnel and first responders. Thus, encouraging the production of cloth masks,
including homemade masks, could help protect healthcare workers. Due to the serious
concern that any mask recommendation will lead the public to demand more surgical
and N95 respirators, any recommendation for broader mask use should be coupled with
policies designed to improve their availability to healthcare workers, including subsidies,
invoking the Defense Production Act (DPA), and mandating that orders of medical masks
from healthcare workers must be given absolute priority.

The Economic Value of Masks

To compute the value of masks, we need to know by how much masks impede the
transmission of the SARS-COV-2 virus and the value of reductions in transmission. To
analyze the impact of masks on viral transmission, we consider the relationship between
norms of mask-use and viral spread at the country level.

Figure 1 shows confirmed positive tests for COVID-19 in all countries with at least 5
million people for which at least 8 days of data are available after the first day with 100
reported cases (select countries are labeled).7 Time 0 is the first day with 100 cases, and

5 While existing RCTs fail to find a reduction in risk for mask-wearers outside of high-risk
settings, these studies (even collectively) are not powered to detect large effects, and they do
not address at all the critical question of whether masks prevent transmission of the virus from
infected individuals (Cowling et. al. 2009, MacIntyre and Chunghtai 2015).
6
See van der Sande et. al. 2008, Rengasamy et. al. 2010, Davies et. al. 2013.
7 The data used in Figure 1 are taken from the COVID-19-Israel Data Respository,

https://github.com/COVID-19-Israel/Covid-19-data (Accessed on April 1st, 2020). Jason Abaluck

undertook the regression analysis and we are grateful for the research assistance of Emily
Crawford.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 the figure shows the progress of the epidemic thereafter. Countries with pre-existing
norms that all sick people wear masks are shown with a solid black line, countries which
do not, but later required masks for infected individuals or the whole population are
shown with a dotted line, and countries with no mask norm and no official
recommendation as of March 29, 2020 are shown in grey.

Figure 1: Confirmed Positive Tests Since 100 Cases

The pattern in the figure is quite stark: countries with pre-existing norms that sick
people should wear masks – including South Korea, Japan, Hong Kong and Taiwan –
have been among the most effective at containing the spread of the epidemic. The
average daily growth rate of confirmed positives is 18% in countries with no pre-existing
mask norms and 10% in countries with such norms.8

This evidence is far from definitive: norms do not perfectly predict actual mask
availability and use, these countries may have instituted other policies which contained
the spread of the epidemic (such as widespread testing in South Korea), and infection
rates are imperfectly measured and may appear higher in countries with more testing
among other factors.

8The “dotted-line” countries which imposed stronger requirements on mask use typically did
not do so until the epidemic was well-developed, so we would not expect to see an effect in the
graph.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 Table 1

To aid in interpreting the graph, we conduct several additional analyses, shown in Table
1. When we control for the timing of school closings, workplace closings, the
cancellation of public events and the closing of public transport, we find that the
estimated effect of masks is unchanged or grows slightly larger.9 Deaths from COVID-19
may be better measured than cases. If we repeat the analysis above using deaths as the
outcome variable, we find that the growth rate of deaths is 21% in countries with no
mask norms and 11% in countries with such norms. Even with the small number of
observations, the impact of masks in all reported analyses is statistically significant at
the 5% level, and usually at the 1% level.

There are many factors that cannot be controlled for in an ecological study of this
type.10 One should note that this is a country-level model and we recommend caution in
generalizing these results to settings such as hospitals where, especially when masks are
scarce, directed use of masks may be desirable compared with universal use. These

9 These policy variables come from the Oxford COVID-19 Government Response Tracker,
https://www.bsg.ox.ac.uk/research/research-projects/oxford-covid-19-government-response-
tracker (Accessed on March 30th, 2020). Specifications with “Baseline Policy Controls” control
for policies in place at time 0 (100 cases or 10 deaths). Specifications with “Average Policy over 8
Days” controls control for the average value of the policy variables over the first 8 days after
time 0.
10 For example, in addition to norms of mask wearing, handshakes are rare in Japan which may

slow the spread of the virus.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 results are far from the final word, but they do complement the epidemiological studies
of masks cited above. While our analysis principally concerns the impact of norms that
sick people wear masks, it has direct implications for universal mask adoption. If the
causal interpretation of the above results is correct, the impact of mask norms (which
increase the likelihood of mask wearing relative to no norm countries) should
understate the impact of universal mask adoption for both visibly sick and healthy
individuals (who are potentially asymptomatically infected).

Our economic analysis suggests that that even if masks are far less effective than the
evidence above suggests, the potential benefits are substantial. If masks reduce the
transmission rate of the virus by only 10%, epidemiological models suggest that
hundreds of thousands of deaths could be prevented globally,11 creating trillions of
dollars in economic value. According to one commonly used epidemiological model, a
10% reduction in transmission probabilities would generate $3,000-6,000 in value per
capita from reduced mortality risk in the US alone.12 This estimate is conservative with
respect to the benefits, as it does not include the economic benefits from a quicker
resumption of normal activity. And our estimates above suggest that the effect of masks
could be 5-6 times as large. Of course, all such estimates are only as reliable as the
underlying epidemiological models. But even if these models overstated risk by a factor
of ten, the benefits of cloth masks, would conservatively be $300 per person.

In a report whose coauthors include former FDA Commission Scott Gottlieb, former FDA
Commissioner and former administrator for the Centers for Medicare and Medicaid
Services Mark McClellan, former FDA Chief of Staff Lauren Silvis, and Johns Hopkins
Center for Health Security Faculty Caitlin Rivers and Crystal Watson, the authors argue
that the eventual transition from the current extreme social distancing should involve
universal wearing of cloth masks. Dr. Gottlieb argues in a recent interview, "if you
mandated that the entire population had to wear a mask when they went out, all those
asymptomatic carriers that are now transmitting it through respiratory droplets… it
would be much harder for them to transmit it."13

Note that all of our arguments for the value of masks for the average person are
magnified many times when we consider the current value of medical masks such as

11
Ferguson et. al. suggest that a 10% reduction in viral transmission probabilities (and thus R
would reduce by about 10% total deaths from COVID-19 through October).
12
Greenstone and Nigam (2020) estimate that the total mortality risk from the virus is $60,000
per capita. From Ferguson et. al., a 10% reduction in transmission probability would lead to 10%
lower mortality risk, giving $6,000 per capita. With social distancing measures in place, the
reduction in mortality risk would be $3,000 per capita.
13
See Gottlieb, Scott, et. al. (2019) for the report. The interview can be found at Moreno, E.,
“Former FDA Commissioner Mulls Mask Requirements for Some Age Groups in Public”, The Hill,
March 18, 2020.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 N95 respirators for healthcare workers.14 First, healthcare workers are especially
exposed to the virus if they lack protection: they cannot socially distance from their
patients, they interact with a large number of patients, and those patients are especially
likely to be exposed. Second, if infected, healthcare workers without adequate
protection are especially likely to expose others for similar reasons. Third, the people
healthcare workers interact with are especially likely to have pre-existing medical
conditions and thus high mortality rates from the virus. Fourth, there is substantial
evidence that N95 respirators and surgical masks protect healthy individuals, and that
N95 respirators are most effective since medical procedures can lead to the
aerosolization of droplets which makes medical masks essential.15 Fifth, as discussed
previously, medical masks are extremely effective at preventing infected healthcare
workers from transmitting the virus. Sixth, keeping healthcare workers healthy during a
pandemic is especially critical to prevent healthcare facilities from being overwhelmed,
increasing mortality.16 Multiplying these factors together, the social value of each N95
mask for a healthcare worker could easily be more than a million dollars per mask.17
This calculation illustrates the tremendous value of subsidizing the production of
medical masks. This calculation, clearly, is in addition to the overwhelming moral
imperative to protect healthcare workers during this crisis.

Homemade Masks as an Antidote to Hoarding

Our read of the disparity between the scientific evidence for masks and the public
discourse on masks is that policymakers are rightly concerned that an emphasis on the
private benefits of wearing masks will lead to hoarding of commercially-produced masks
reducing availability in the healthcare system. However, we believe that an emphasis
on the social benefits of mask-wearing and an emphasis on the wearing of homemade
masks by the public could lead to a substantial fraction of the health benefits without
the negative impacts of mask hoarding.

14Yan, J., Guha, S., Hariharan, P. and Myers, M., 2019. Modeling the Effectiveness of
Respiratory Protective Devices in Reducing Influenza Outbreak. Risk Analysis, 39(3), pp.647-
661.
15Long, Y., Hu, T., Liu, L., Chen, R., Guo, Q., Yang, L., Cheng, Y., Huang, J. and Du, L., 2020.
Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and
meta‐analysis. Journal of Evidence‐Based Medicine.
16Fong, M.W., Gao, H., Wong, J.Y., Xiao, J., Shiu, E.Y., Ryu, S. and Cowling, B.J., 2020.
Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Social
Distancing Measures. Emerging infectious diseases, 26(5).
17 The value of the above parameters is difficult to know, as in normal times, healthcare workers
would not operate without protective equipment. To take one back of the envelope calculation,
if healthcare workers are 10 times as likely to become infected without adequate protection,
three times as likely to infect others, encounter patients with a 6x higher mortality rate than the
average person, our $6,000 value above would translate to more than $1 million per mask.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 An example of a socially influenced mask movement is the Czech Republic. In the Czech
Republic, homemade mask-making was led by celebrity influencers, and the country
went from masks being unusual to being nearly universal in 10 days.18

We are also concerned that recent media and other reports have emphasized the
private benefits of mask-wearing (that is, infection protection to the wearer) without
discussing the efficacy of non-medical fabric face masks in lowering transmission.19 This
could exacerbate existing supply shortages for hospital-quality masks. Healthcare
leaders can responsibly respond to this information by emphasizing the relative efficacy
of cloth masks in preventing transmission and the need to increase home production.

18
See https://www.youtube.com/watch?v=HhNo_IOPOtU&feature=youtu.be.
19
See, for example, the recent New York Times Op Eds, Tupekci,, Zeynep, “Why Telling People
they don’t need masks Backfired”, New York Times, March 17, 2020 or Sheikh, Knvul, “More
Americans Should Probably Wear Masks for Protection”, March 27, 2020.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 Policy Recommendations

Given the evidence of the benefits of universal mask-wearing and the urgent need for
medical masks for health workers, we have two principal recommendations. Political
officials should:

1) Promote every market and policy lever to increase the production of medical
grade masks and guarantee adequate supply for healthcare workers.
o Suppliers who produce and sell medical masks should be heavily
rewarded. State and federal governments should authorize large
subsidies for medical masks. This will expand manufacturing capacity
while increasing the affordability of medical masks for healthcare
providers. Subsidies many times greater than the usual price of masks
are called for to properly incentivize production.
o Priority for all mask orders should be given to medical personnel,
using fines or other penalties for manufacturers who fail to prioritize
such orders.
o The Defense Production Act should be invoked to increase production
of medical grade masks. However, care must be taken to heavily
reward private firms who efficiently produce medical masks or the
concurrent supply from the private market will be undermined.
o Technologies and strategies for mask sterilization or reprocessing
should be developed and deployed as a stopgap until sufficient N95
masks are available for all health workers.
2) Emphasize that everyone should make and wear cloth masks in public at all
times, not just those with symptoms. Once surgical masks are no longer in
short supply, encourage the universal adoption of these higher-quality
protective devices.

Additionally, political officials can and should lead by:

 Themselves wearing cloth masks in public at all times. If these masks are
obviously homemade, this will emphasize the pro-social benefits of protecting
both healthcare workers (who need commercial masks) and the public at large.
 Emphasizing that mask wearing is a complement to other social distancing
measures, not a substitute. 20 Mask wearers who violate social distancing
recommendations continue to place themselves and others at high risk.

20
See, Pourbohloul, B., et.al. 2005 for a discussion of the relative efficacy of various control
strategies.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
  Supporting or requiring mask-wearing in essential services such as grocery stores
where employees have many contacts in a day.
 Emphasizing that one of the main goals of mask wearing is to protect others (As
we have seen from the recent spate of COVID-19 cases among public officials, it
is reasonable for asymptomatic public officials to behave as if they are at
constant risk of infecting the public and to take precautions in their interactions
with others).
 Reaching out to visible persons such as media members and strongly
encouraging them to do the same.
 Encouraging and demonstrating the correct production and use of homemade
masks.
 Providing public health messages with mask-making instructions and instructions
on fit. For example, one of the limitations of homemade masks identified by
Davies et. al. (2013) is the poor fit achieved by amateur mask-makers. For
example, public health instructions would inform individuals with beards to trim
the beard to achieve the best fit. Mask users should also be instructed to wash
hands after removing masks and wash or dispose of masks after repeated use.
 Partnering with non-medical mask industry to provide free or reduced-price
cloth masks to everyone.

Conclusion

The economic case for universal mask wearing is convincing and urgent, but the moral
need to provide adequate equipment to frontline healthcare workers is an even higher
imperative. Enacting policies to increase medical mask production, and concurrently
encouraging the widespread production and use of cloth masks can achieve both
objectives. Public officials should encourage and support universal cloth mask adoption
immediately. These masks should be dust-prevention quality (as sold in hardware
stores) or home-made fabric masks that are worn snugly) until which time as surgical or
N95 masks are no longer in short supply.

Outside of crises, policies do not exist where a few dollars of expenditure per person can
produce thousands of dollars in benefit. We are in a rare moment when such benefits
are achievable--this is an urgent crisis and action is necessary.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 References to Academic Articles:

Cowling, B.J., Chan, K.H., Fang, V.J., Cheng, C.K., Fung, R.O., Wai, W., Sin, J., Seto, W.H.,
Yung, R., Chu, D.W. and Chiu, B.C., 2009. Facemasks and hand hygiene to prevent
influenza transmission in households: a cluster randomized trial. Annals of internal
medicine, 151(7), pp.437-446.

Davies, A., Thompson, K.A., Giri, K., Kafatos, G., Walker, J. and Bennett, A., 2013. Testing
the efficacy of homemade masks: would they protect in an influenza pandemic?
Disaster medicine and public health preparedness, 7(4), pp.413-418.

Ferguson, N.M., Laydon, D., Nedjati-Gilani, G., Imai, N., Ainslie, K., Baguelin, M., Bhatia,
S., Boonyasiri, A., Cucunubá, Z., Cuomo-Dannenburg, G. and Dighe, A., 2020. Impact of
non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare
demand. Imperial College, London. DOI: https://doi. org/10.25561/77482.

Fong, M.W., Gao, H., Wong, J.Y., Xiao, J., Shiu, E.Y., Ryu, S. and Cowling, B.J., 2020.
Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Social
Distancing Measures. Emerging infectious diseases, 26(5).

Gottlieb, S., Rivers, C., McClellan, M.B., Silvis, L., and Watson, C., “National Coronavirus
Response: A Road Map to Reopening,” American Enterprise Institute, March 28, 2020.
Greenstone, M. and Nigam, V. 2020. Does Social Distancing Matter? BFI Working Paper,
No 2020-26.

Jefferson, T., Foxlee, R., Del Mar, C., Dooley, L., Ferroni, E., Hewak, B., Prabhala, A., Nair, S. and
Rivetti, A., 2008. Physical interventions to interrupt or reduce the spread of respiratory viruses:
systematic review. Bmj, 336(7635), pp.77-80.

Long, Y., Hu, T., Liu, L., Chen, R., Guo, Q., Yang, L., Cheng, Y., Huang, J. and Du, L., 2020.
Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and
meta‐analysis. Journal of Evidence‐Based Medicine.

MacIntyre, C.R. and Chughtai, A.A., 2015. Facemasks for the prevention of infection in
healthcare and community settings. BMJ, 350, p.h694.

Pourbohloul, B., Meyers, L. A., Skowronski, D. M., Krajden, M., Patrick, D. M., &
Brunham, R. C. (2005). Modeling control strategies of respiratory pathogens. Emerging
infectious diseases, 11(8), 1249.

Rengasamy, S., Eimer, B. and Shaffer, R.E., 2010. Simple respiratory protection—
evaluation of the filtration performance of cloth masks and common fabric materials
against 20–1000 nm size particles. Annals of occupational hygiene, 54(7), pp.789-798.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
 van der Sande, M., Teunis, P. and Sabel, R., 2008. Professional and home-made face
masks reduce exposure to respiratory infections among the general population. PLoS
One, 3(7).

Yan, J., Guha, S., Hariharan, P. and Myers, M., 2019. Modeling the Effectiveness of
Respiratory Protective Devices in Reducing Influenza Outbreak. Risk Analysis, 39(3),
pp.647-661.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3567438
E
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T

2
Executive Order
Office of the Mayor
City 0f Atlanta

EXECUTIVE ORDER NUMBER 2020-Li

BY THE MAYOR

THAT IN ACCORDANCE WITH SECTION 2-181(A) OF THE CITY OF ATLANTA

CODE OF ORDINANCES; DECLARING THERE TO BE AN EMERGENCY IN
EXISTENCE WITHIN THE JURISDICTIONAL LIMITS OF THE CITY OF
ATLANTA DUE TO THE ONGOING COVm-l9 PANDEMIC; EXERCISING MY
EMERGENCY POWERS IN ACCORDANCE WITH SECTION 2-181(B) OF THE
CITY OF ATLANTA CODE OF ORDINANCES TO ENSURE THE
ENFORCEMENT OF THE GOVERNOR’S EXECUTIVE ORDER; PROHIBITING
GATHERINGS OF ANY NUMBER OF INDIVIDUALS ON CITY 0F ATLANTA
PROPERTY; REQUIRING ALL PERSONS WITHIN THE JURISDICTION OF THE
CITY OF ATLANTA TO WEAR A MASK OR A CLOTH FACE COVERING OVER
THE NOSE AND MOUTH; AND FOR OTHER PURPOSES.

WHEREAS, pursuant to its police power, the City of Atlanta may enact ordinances and take action to protect
the health, safety, and general welfare of the public; and

WHEREAS, pursuant to that power, and specifically, pursuant to Code of the City
Section 2-181(a) of the
of Atlanta (“City”), the Mayor, as Chief executive of the City, shall have the emergency power to declare an
emergency to exist when, in the mayor’s opinion, there is an extreme likelihood of destruction of life or
property due to an unusual condition; and

WHEREAS, pursuant to Section 2—181(b) of the Code of the City of Atlanta, the Mayor, as chief executive
0f the City, shall have the right to exercise any or all of the following options afier such declaration of
emergency:

(1) To use employees of the city other than employees of the department of police to assist in the
safety and preservation of life, limb and property ofthe citizenry of the city.

(2) To close streets and sidewalks and to delineate areas within the city wherein an emergency exists.

(3) To impose emergency curfew regulations.

(4) To close business establishments within the affected area.

(5) To close any and all city-owned buildings and other facilities to the use ofthe general public.

(6) To do any and all acts necessary and incidental to the preservation of life, limb and propeny of
the citizenry of the city; and

WHEREAS, no emergency power as set forth in this section may be effective for more than 72 hours afier
the declaration of an emergency; and

WHEREAS, pursuant to Code of the City of Atlanta, the Mayor may issue executive
Section 2-182 of the
orders which apply to events of short duration and which expire at the next meeting of the City Council
subsequent thereof unless ratified by a majority vote of the members present and voting; and
‘

1
 WHEREAS, like much of the world the United States, the State of Georgia, and the City of Atlanta are
currently responding to an outbreak of respiratory disease caused by a novel coronavirus named “SARS-
CoV-2” and the disease it causes named “coronavirus disease 2019” (abbreviated “COVID-19”); and

WHEREAS, on March 11, 2020 the World Health Organization declared the COVID-19 outbreak a
pandemic; and

WHEREAS, on March
2020 the President of the United States announced a national emergency in
13,
response to the COVID-19 pandemic, which
included two emergency declarations: one under the National
Emergencies Act and one under the Stafi‘ord Disaster Relief and Emergency Assistance Act; and

WHEREAS, on March 14, 2020 Governor Brian Kemp signed a public health state of emergency to address
the COVID-19 pandemic through and emergency management officials across Georgia by
assisting health
deploying all available resources for the mitigation and treatment of COVID-19; and

WHEREAS, due to the COVID-19 pandemic, on March 16, I declared there to be an emergency in existence
within the City of Atlanta pursuant to Section 2-1 81(a) of the City of Atlanta Code of Ordinances; and

WHEREAS, the Center for Disease Control (“CDC”) has issued guidance on the emerging and rapidly
evolving situation of the COVID-l9 pandemic, including how to protect oneself fiom this illness; and

WHEREAS, social distancing is recommended by the CDC to prevent the continued spreading ofthis illness
in the community; and

WHEREAS, the CDC also advises that the use of masks or cloth face coverings will slow the spread of
COVID-19; and

WHEREAS, in a document obtained by the Center for Public Integrity, which was prepared for the White
House Coronavirus Task Force but not publicized, dated July 14, it is suggested that more than a dozen states
should revert to more stringent protective measures, such as limiting social gatherings to 10 people or fewer,
closing bars and gyms and asking residents to wear masks at all timesl;

WHEREAS, document asserts that 18 states including Georgia are in the “red zone” for COVID-19
this
cases, meaning they had more than 100 new cases per 100,000 population last week; and that eleven states,
including Georgia are in the “red zone” for test positivity, meaning more than 10 percent of diagnostic test
results came back positive; and

WHEREAS, this document specifically recommends that Georgia, in the red zone for both cases and test
positivity, “mandate statewide wearing of cloth face coverings outside the home”; and

WHEREAS, on April 2, 2020, Governor Brian Kemp signed an Executive Order to Ensure a Safe and
Healthy Georgia (Governor’s Executive Order 04.02.20.01) to address the COVID-l9 pandemic by
implementing temporary actions necessary and appropriate to protect the health, safety, and welfare of
Georgia’s residents and visitors; and

1
See https ://publicintegritv.org/health/coronavirus-and—inequality/exclusive-white-house-document—shows- 1 8-states—in—
coronavirus-red-zone-covid- 1 9/
WHEREAS, subsequently, Governor Kemp has issued a series of Executive Orders which amend and revise
the temporary action necessary and appropriate t0 protect the health, safety, and welfare of Georgia’s
residents and visitors; and

WHEREAS, on July 15, 2020, Governor Kemp issued Executive Order 07.15.20.01, (Governor’s July
Executive Order) which is the latest direction from the Governor concerning temporary actions necessary
and appropriate to address the COVID-19 pandemic; and

WHEREAS, the Governor’s July Executive Order provides in pertinent part as follows:

all persons within the state are required to practice social distancing as defined in the order and are
prohibited from gathering in groups 0f more than 50 persons if to be present, persons are required to
stand or be seated Within 6 feet of any other person;

all persons within the state are strongly encouraged to wear face coverings as practicable while
outside their homes or place of residence, except when eating, drinking, or exercising outdoors;

all persons within the state Who meet certain specified criteria for higher risk of severe illness as
defined by the CDC are required to shelter in place within their homes or places of residence as
provided in the order; and

WHEREAS, in accordance therewith, and during the pendency ofthe term ofthe Govemor’s July Executive
Order, the City isempowered to make, amend and rescind such orders, rules, and regulations as may be
necessary for emergency management purposes and to supplement the carrying out of the Governor’s July
Executive Order, but such orders, rules, and regulations shall not be inconsistent with the Governor’s July
Executive Order or any orders, rules, or regulations promulgated by the Governor or by any state agency
exercising a power derived fiom the Public Health State of Emergency declaration; and

WHEREAS, the Governor’s July Executive Order, asserts that orders, rules, and regulations that are
promulgated by the City that are more or less restrictive than the terms of the Governor’s July Executive
Order shall be considered inconsistent with the Governor’s July Executive Order; and

WHEREAS, the Governor’s July Executive Order, asserts that any City law, order, ordinance, rule or
regllation that requires a person towear face coverings, masks, face shields, or any other Personal Protective
Equipment while of public accommodation or on public property arc suspended to the extent that
in places
they are more restrictive than the Governor’s July Executive Order; and

WHEREAS, assuming the Governor’s assertion about what makes a local regulation inconsistent with the
Governor’s July Executive Order and assertion that he has the authority to suspend rules that protect the
health, safety, and well-Jaeing of the public that are more resm..lctive than the chemor’ s Executive Order are
correct, the City may nonetheless enter emergency orders, including those which require the wearing of
masks 01' face coverings which are not inconsistent with that Order, and which arc designed to enforce
compliance therewith; and

WHEREAS, the Governor’s July Executive Order generally prohibits municipalities from allowing more
than 50 persons to be gathered at a single location if such gatherings require persons to stand or to be seated
within six feet of any other person; and

WHEREAS, the requirement concerning gatherings contained in the Governor’s July Executive Order, is a
direction of prohibition against the gathering of groups of more than 50 persons, not one of permission

3
 concerning gatherings of less than 50 persons; and thus, as applied to municipal governments does not
conflict with any municipal prohibition against smaller groups on municipal propertyzg and

WHEREAS, the Governor’ s July executive Order does not contain a requirement or a prohibition concerning
the use of masks or facial coverings, but instead encourages their use; and

WHEREAS, accordingly an action by the City to prohibit the use of masks or facial coverings would
properly be inconsistent with the Governor’s July Executive Order, while an action of the City to require
such use would not be inconsistent; and

WHEREAS, wearing a face covering is important not only to protect oneself, but also to avoid unknowingly
banning others, especially given that many people who go into public may have COVID— 1 9 without knowing
it because they have no symptoms; and

WHEREAS, requiring the use of masks or face coverings is a targeted response that can combat the threat
to public health using the least restrictive means, and if people follow this requirement, more extreme
measures may be avoided; and

WHEREAS, on June 29, 2020 Goldman Sachs economists released an analysis which concluded that a
national mandate requiring the face coverings would boost their use by 15 percent and cut the daily rise in
COVID~19 cases a full percentage point to 0.6 percent; and that reducing the spread of COVID-19 by just
that small increment “could potentially substitute for lockdowns that would otherwise subtract nearly 5%
from GDP”, and could salvage roughly $1 trillion of economic activity; and

WHEREAS, powers and the authority granted to the City to enter

in accordance with the City’s police
emergency orders which are not in conflict with the Governor’s Executive Orders
and which are designed to
enforce compliance therewith, I am hereby declaring there to be the existence of an emergency within the
City of Atlanta pursuant to Section 2-181(a) ofthe City of Atlanta Code of Ordinances; and

WHEREAS, pursuant this declaration, compliance with the Governor’s July Executive Order shall be
enforced, and gatherings of any number of individuals shall be prohibited on City of Atlanta property; and

WHEREAS, of the City of

additionally, pursuant to this declaration, all persons within the jurisdiction
Atlanta shall wear a mask or a cloth face covering over the nose and mouth when inside a commercial entity
or other building or space open to the public, or when in an outdoor public space, wherever it is not feasible
to maintain appropriate social distancing from another person not in the same household provided specifically
herein; and

WHEREAS, this Order is designed to enforce compliance with the Governor’s July Executive Order during
the pendency thereof, and to take action consistent therewith; and

WHEREAS, all provisions of this Order should be interpreted to effectuate this intent.

NOW THEREFORE, KEISHA LANCE BOTTOMS, AS MAYOR OF THE CITY 0F ATLANTA,

I,

NOW HEREBY AUTHORIZE, ORDER AND DIRECT AS FOLLOWS:

SECTION 1. It is my opinion that there exists an extreme likelihood ofdestruction of life or property within
the jurisdictional limits of the City of Atlanta due to the unusual condition of the COVID-19 pandemic, and

2
Willis v. Cifl ofAtlanta, 285 Ga. 775, 776, 684 S.E.Zd 271, 273 (2009).

4
in accordance With Section 2-1 81(a)0f the City of Atlanta Code of Ordinances, I hereby declare there t0 be
an emergency in existence within the jurisdictional limits of the City of Atlanta.

SECTION 2. In accordance with this emergency declaration, I am exercising my emergency powers in

accordance with Section 2-181(b) of the City of Atlanta Code of Ordinances t0 ensure the enforcement of
the Governor’s July Executive Order.

SECTION 3.

(a) In accordance with the Governor’s July Executive Order, persons who meet criteria for higher risk
of severe illness as set forth therein are required to shelter in place within their homes of places of
residence, meaning remaining their place of residence and taking every possible precaution to limit
social interaction to prevent the spread 0r infection of COVID-19, except as provided therein.

(b) (1) In accordance with the Governor’s July Executive Order, neither the City of
Atlanta or any business, establishment, corporation, non-profit corporation, organization may
allow more than 50 persons to be gathered at a single location if such gathering requires
persons to stand or be seated within six (6) feet of any person; and

(2) A11 gatherings of any number of individuals shall be prohibited on City of Atlanta property;
and

(3) This subsection shall not apply to cohabitating persons outside of their homes, family units
or roommates residing together in private homes, (persons in the same households), or to any
businesses or activities specifically governed by the Governor’s July Executive Order.

SECTION 4.

(a) A11 persons within the jurisdiction of the City of Atlanta shall wear a mask or a cloth face covering
over the nose and mouth when inside a commercial entity 0r other building or space open to the
public, or When in an outdoor public space, wherever it is not feasible to maintain appropriate social
distancing fiom another person not in the same household.

(b) The requirement contained in this Section shall not apply to the following:

(1) any person younger than ten (10) years of age;

(2) any person with a medical condition or disability that prevents the wearing or a
mask or face covering;

(3) any person While the person is consuming food or drink, or is smoking;

(4) any person while the person is in a personal motor vehicle;

(5) any person obtaining a service that requires temporary removal of the mask or face
covering for security surveillance, screening, or a need for specific access to the
face, such as while visiting a bank or while obtaining a personal care service
involving the face or head, but only to the extent necessary fort the temporary
removal;

(6) any person while the person is in a swimming pool;

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 (7) any person who is voting, assisting a voter, serving as a poll watcher, or actively
administering an election;

(8) any person while the person is speaking for a broadcast or to an audience.

SECTION 5. Nothing in this Order shall impede the operation of any businesses, establishments,
corporations, non-profit corporations, and organizations as provided in the Governor’s July Executive
Order.

SECTION 6. If one or more of the provisions contained in the Order shall be held to be invalid, in
violation of the Constitution of the United States, the Georgia Constitution, in violation of Georgia
law, in violation of the Govemor’s July Executive Order, or unenforceable in any respect, such
invalidity, Violation, or unenforceability shall not affect any other provisions herein, but in such case,
this Order shall be construed as if such invalid, illegal, or unenforceable provision had never been
contained with this Order.

This Eday of July 2020.

Kei a Lance Bottomé, Mayor

TTESTED:

/_\
Municipal Clerk

Foris
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Webb, |II

Municipal Clerk
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 IN THE SUPERIOR COURT OF FULTON COUNTY
STATE OF GEORGIA

GOV. BRIAN P. KEMP,

Plaintiff,

v.

HON. KEISHA LANCE BOTTOMS,

FELICIA A. MOORE, CARLA SMITH, Civil Action File
AMIR R. FAROKHI, ANTONIO 2020CV3338387
BROWN, CLETA WINSLOW,
NATALYN MOSBY ARCHIBONG,
JENNIFER N. IDE, HOWARD SHOOK,
J.P. MATZIGKEIT, DUSTIN R.
HILLIS, ANDREA L. BOONE, MARCI
COLLIER OVERSTREET, JOYCE
SHEPAERD, MICHAEL JULIAN
BOND, MATT WESTMORLAND, and
ANDRE DICKENS,

Defendants.

County of Fulton )
) ss.
State of Georgia )

AFFIDAVIT OF ZEB STEVENSON

1. My name is Zeb Stevenson. I am over twenty-one (21) and am competent to testify as to the

matters set forth in this declaration. I am personally familiar and have personal knowledge of

the matters set out in this Affidavit.

2. I am the Chef and owner of Redbird, a full-service restaurant in the City of Atlanta located at

1198 Howell Mill Road, Atlanta, Georgia.

#3060694v11
3. I’ve been involved in the hospitality industry for 24 years, including 19 years in Georgia. I

know innumerable people in the Atlanta hospitality industry, and consider many among my

closest friends.

4. The COVID pandemic has been extremely hard on the hospitality industry, including my

restaurant. Pre-pandemic, Redbird employed 50 full and part time employees. Currently, I

employ 18.

5. Over the past several weeks, as we have re-opened and resumed operations, we have asked

our staff and customers to wear masks in and around our restaurant, unless of course they are

actively eating or drinking.

6. I strongly support mask wearing, as I understand that it is an easy, inexpensive, and effective

way to contain and control the spread of COVID. Both my staff and customers are safer and

more comfortable, and thus more likely to want to be in and around my restaurant, if most if

not all of the people are wearing masks.

7. Unfortunately, some customers object to wearing masks, and there have been instances in

which my staff has been confronted by anger or hostility once they’ve explained our policy

of requesting mask usage.

8. My business will work better, and my staff will be more comfortable and less likely to be the

target of hostility, if the City of Atlanta’s mask ordinance remains in place, as we will be

able to point to the government as the source of the mask requirement, rather than just our

preference as a business, much as we do when we need to stop serving an intoxicated person

alcohol.

#3060694v12
 9. Rather than being burdened by the City’s mask ordinance,
I am helped by it, and strongly

support it. I see no downside for me or my business fiom the City’s mask ordinance, nor do

Iknow anyone in the Atlanta hospitality industry who feels difl‘erently.

10.At the time Mayor Keisha Lance Bottoms annou

nced a few weeks ago that she was

recommending that the City retum to Stage One of its reopening, I understood that her

announcement was a recommendation that did not require my business to close, which is

why we have remained open. I know that she has subsequently publicly reiterated that her

announcement was a recommendation, not a mandate, includ

ing as recently as yesterday. I

do not know of any Atlanta restaurant owner who believes that

her recommendation requires

them to be closed. To the contrary, every owner know

I understands that Atlanta has not

ordered them to close.

FURTHER AFFIANT SAYETH NAUGHT

Sworn to and subscribed before me

'

2020

\‘ l.

My Commission Expires: Ju lg 5. ZQ ’LI

This affidavit was notarized pursuant to Execut

ive Order 04.09.20.01 using Zoom as real-time
audio visual communication technology.

#3060694v13
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 EXECUTIVE ORDER

BY THE GOVERNOR:
DECLARATION OF PUBLIC HEALTH STATE OF EMERGENCY

WHEREAS: In late 2019, a new and significant outbreak 0f respiratory disease

caused by a novel coronaw'rus emerged in Wuhan, China; and

WHEREAS: The respiratory disease caused by the novel coronavirus, known as

“COVID-lg,” is an infectious virus that can spread from person-to—
person and can result in serious illness 01' death; and

WHEREAS: On March 13, 2020, President Donald Trump declared the outbreak
of COVID-lg a national emergency; and

WHEREAS: The Centers for Disease Controland Prevention has identified the
potential public health threat posed by COVID—lg both globally and
in the United States, and has advised that the person—to-person
spread of COVID—19 wili continue t0 Occur globally, including within
the United States; and

WH EREAS 3 The Centers for Disease Control and Prevention has noted that
COVID—lg is proliferating via “community spread,” meaning people
have contracted the virus Georgia as a result 0f direct 01‘
in areas 0f
indirect contact With infected persons, including some who are not
sure how 01' where they became infected; and

WHEREAS: Laboratory testing has confirmed more than sixty cases of COVID—19
in Georgia; and

WHEREAS: In consultation with the Commissioner of Public Health, the Georgia

Coronavirus Task Force, and other state health and emergency
preparedness officials, I have determined a public health emergency
exists, and that it is necessary and appropriate t0 take action t0
protect the health, safety, and welfare of Georgia’s residents and
visitors t0 ensure COVID-lg remains controlled throughout this
State, as provided by Code Section 38—3-51; and

WHEREAS: The uninterrupted supply 0f medical goods and other emergency

related materials, supplies, goods, and sewices during this
 emergency is an essential need 0f the public and any perceived 01‘

actual shortage threatens public welfare; and

WHEREAS: The Federal Motor Carrier Safety Regulations, 49 C.F.R. §§ 390 et

seq, prescribes limits on the hours 0f service for operators 0f
commercial vehicles, and federal law, 23 U.S.C. § 127, sets forth
certain weight limitations for vehicles on interstate highways; and

WHEREAS: 49 C.F.R. § 390.23 allows the Governor of a state t0 suspend these

rules and regulations for commercial vehicles responding to an
emergency for up t0 thirty (30) days, if the Governor determines an
emergency condition exists.

NOW, THEREFORE, PURSUANT T0 CODE SECTION 38-3-51, AND

THE AUTHORITY VESTED 1N ME As GOVERNOR 0F THE STATE 0F
GEORGIA, 1T IS HEREBY

ORDERED: That a Public Health State of Emergency exists in the State 0f Georgia
due t0 the public health emergency from the spread 0f COVID~19.

IT IS FURTHER

ORDERED: That all resources 0f the State 0f Georgia shall be made available. t0
assist in activities designed t0 address this emergency, control the
spread of COVID-lg, and aid recovery efforts.

IT IS FURTHER

ORDERED: That the Georgia Emergency Management and Homeland Security

Agency shall activate the Georgia Emergency Operations Plan
(GEOP) in response t0 this emergency.

IT IS FURTHER

ORDERED: That the Georgia Department 0f Public Health, as the state agency
responsible for emergency management sewices under GEOP
Emergency Support Function (ESF) 8 w Public Health and Medical
Services, shall coordinate With the Center for Disease Control and
Prevention for release 0f the Strategic National Stockpile as
necessaly and appropriate in response t0 this Public Health State 0f
Emergency.

IT IS FURTHER

ORDERED: That the Georgia Emergency Management and Homeland Security

Agency is designated as the lead agency for responding t0 this public
health emergency and shall coordinate all emergency response
activities and other matters pertaining t0 this Public Health State 0f
Emergency.
 IT IS FURTHER

ORDERED: That acting pursuant to the Governor’s authorization, the Georgia

Department 0f Public Health shall coordinate With the Georgia
Emergency Management and Homeland Security Agency t0 take any
action necessary t0 protect the public’s health, including, without
limitation:

(1) Planning and executing pubiic health emergency assessments,

mitigation, preparedness response, and recovery for the state;
(2) Coordinating public health emergency responses between
state and local authorities;
(3) Establishing protocols t0 control the spread of COVID-lg;
(4) Coordinating recovely Operations and mitigation initiatives;
(5) Collaborating With appropriate federal government
authorities, elected officials 0f other states, private
organizations, private sector companies;
01‘

(6) Organizing public information activities regarding the state’s

public health emergency response operations, including
educating the public on prevention 0f the spread 0f COVID—19
based 011 Centers for Disease Control and Prevention’s
guidelines and the best scientific evidence available;
(7) Providing special identification for public health personnel
involved in this Public Health State 0f Emergency;
(8) For all persons meeting the Centers for Disease Control and
Prevention’s definition 0f a Person Under Investigation
(“PUI”), implementing a program 0f active monitoring, which
may include a risk assessment within twenty-four (24) hours
of learning that the person meets the PUI criteria and twice—
daily temperature checks for a period 0f at least fourteen (14)
days 0r until the PUI tests negative for COVID—lg; and
(9) Implementing quarantine, isolation, and other necessary
public health interventions consistent With Code Sections 31—
12-4 and 38—3~51(i)(2) or as otherwise authorized by law.

IT Is FURTHER

ORDERED: That ail state and local authorities as well as public and private
and medical personnel shall
hospitals, healthcare facilities, Clinics,
fully comply with orders by the Governor as authorized by Georgia
law, in furtherance 0f this Order.

IT lS FURTHER

ORDERED: The Georgia Composite Medical Board authorized t0 grant

is

temporary licenses t0 physicians who apply for a temporary medical

license and are currently licensed as a physician in good standing by
equivalent boards in other states t0 assist with the needs 0f this
public health emergency.
 IT IS FURTHER

ORDERED: The Georgia Board of Nursing is authorized to grant temporary

licenses t0 nurses who apply for temporary license and are
a
currently licensed in good standing as an Advanced Practice
Registered Nurse, Licensed Practical Nurse, 01‘ Registered
Professional Nurse by an equivalent board in another state t0 assist
with the needs 0f this public health emergency.

IT IS FURTHER

ORDERED: That accordance with 49 C.F.R. 390.23(a)(1)(i)(A), the federal

in
rules and regulations limiting hours Operators 0f commercial
vehicles may drive are suspended t0 ensure that carrier crews are
available as needed t0 provide emergency relief. This declared
emergency justifies a suspension 0f Part 395 (driver’s hours of
service) of Title 49 0f the Code 0f Federal Regulations. The
suspension will remain in effect for thirty (30) days from the date of
this Order or until the emergency condition ceases t0 exist,
whichever is less.

IT Is FURTHER

ORDERED: That no motor carrier Operating under the terms 0f this emergency
declaration will require 01' allow an
fatigued driver t0 operate a
ill 01‘

motor vehicle. A driver who notifies a motor vehicle carrier that he

01‘ she needs immediate rest will be given at least ten (10) consecutive

hours off—duty before being required t0 return t0 service.

IT IS FURTHER

ORDERED: That \yveight, height, and length for any such vehicle traveling
through the State 0f Georgia for the purposes of providing disaster
relief and/or preparation, which traverses roadways maintained by
the State 0f Georgia, shall not exceed the following:

(1) A maximum gross vehicle weight for vehicles equipped with

five (5) weight bearing axles, with an outer bridge Span of not
less than fifty—one (51) feet, shall not exceed a gross vehicle
weight 0f ninety-five (95) thousand pounds, a maximum
width 0f ten (10) feet and an overall length of one hundred
(100) feet. Continuous travel is authorized, with the proper
escorts.

(2) If the width 0f said vehicle exceeds eight (8) feet six (6) inches
ad is traveling after daylight, defined as thirty (30) minutes
before sunset t0 thirty (30) minutes after sunrise, the
transporter is required t0 have a vehicle front and a rear
escort/amber light when traveling 0n a two lane roadway and
a vehicle rear escort when traveling 0n a four lane highway.
 Transporters are responsible for ensuring they have proper
oversize signs, markings, flags, and escorts as defined in the
Georgia Department 0f Transportation Rules and
Regulations.

IT IS FURTHER

ORDERED: That commercial vehicles operating outside the normal weight,

height, and length restrictions under the authority 0f this Executive
Order shall be issued permits by the Georgia Department 0f Public
Safety. Said vehicles shall be subject t0 any special conditions the
Georgia Department 0f Public Safety may list 0n applicable permits.
Nothing in this Executive Order shall be construed t0 allow any
vehicle t0 exceed weight limits posted for bridges and like structures,
nor shall anything in this Executive Order be construed t0 refieve
compliance with restrictions other than those specified in this
Executive Order 01' from any statute, rule, order or other legal
requirement not Specifically waived herein. Oversize permits may be
issued by the Georgia Depamnent of Public Safety, Motor Carrier
Compliance Division, during normal business hours, Monday
through Friday by calling 404-624—7700 01' through the Georgia
Permitting and Routing Optimization System online portal at
https: //gap1'os.d0t.ga.g0V/.

IT Is FURTHER

ORDERED: That during preparation, response, and recovery activities for this
Public Health Emergency, price gouging 0f goods and services
necessary t0 support Public Health would be detrimental t0 the social
and economic welfare of the citizens 0f this State, and thus Code
Section 10-1—3934, prohibiting price gouging, remains in effect.

IT IS FURTHER

ORDERED: That pursuant t0 Code Section 38—3-51(a), the General Assembly

shall convene for a special session, beginning on March 16, 2020, at
8:00 A.M. for the purpose 0f concurring with 01‘ terminating this
Public Health State 0f Emergency.

IT Is FURTHER

ORDERED: That the State 0f Emergency shall terminate 011 April 13, 2020, at
11:59 P.M., unless it is renewed by the Governor.

This 141“ day 0f March 2020, at 9% " ég A.M.

I
GOVERNOR
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House Resolution 4EX

By: Representatives Burns of the 159th, Kelley of the 16th, and Hatchett of the 150th

A RESOLUTION

1 Concurring with Governor Brian P. Kemp's Executive Order No. 03.14.20.01 declaring a
2 public health state of emergency; and for other purposes.

3 WHEREAS, in late 2019, a new and significant outbreak of respiratory disease caused by a
4 novel coronavirus, known as COVID-19, was first identified in Wuhan, China; and

5 WHEREAS, COVID-19 is an infectious virus that can spread from person to person, causing
6 respiratory disease that can result in serious illness or death; and

7 WHEREAS, on March 13, 2020, President Donald Trump declared the outbreak of
8 COVID-19 a national emergency; and

9 WHEREAS, the Centers for Disease Control and Prevention has identified the potential
10 public health threat posed by COVID-19 both globally and in the United States, and has
11 advised that the person-to-person spread of COVID-19 will continue to occur globally,
12 including within the United States; and

13 WHEREAS, the Centers for Disease Control and Prevention has noted that COVID-19 is
14 now "community spread," meaning people have contracted the virus in areas of Georgia as
15 a result of direct or indirect contact with infected persons, including some who are not sure
16 how or where they became infected; and

17 WHEREAS, as of March 14, 2020, laboratory testing had confirmed more than 60 cases of
18 COVID-19 in Georgia; and

19 WHEREAS, on March 14, 2020, under the authority granted in Code Section 38-3-51 of the
20 Official Code of Georgia Annotated, Governor Brian P. Kemp declared a public health
21 emergency and issued Executive Order No. 03.14.20.01 as a necessary and appropriate action

H. R. 4EX
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22 to protect the health, safety, and welfare of Georgia's residents and visitors to ensure
23 COVID-19 remains controlled throughout this State; and

24 WHEREAS, pursuant to Code Section 38-3-51 of the Official Code of Georgia Annotated,
25 action by the General Assembly is necessary to concur with or terminate the executive order
26 as a condition precedent to the public health state of emergency going into effect.

27 NOW, THEREFORE, BE IT RESOLVED BY THE GENERAL ASSEMBLY OF

28 GEORGIA that the members of this body concur with Executive Order No. 03.14.20.01
29 issued by Governor Brian P. Kemp declaring a public health state of emergency.

30 BE IT FURTHER RESOLVED that pursuant to Code Section 38-3-51 of the Official Code
31 of Georgia Annotated, the General Assembly by concurrent resolution may terminate a state
32 of emergency at any time.

33 BE IT FURTHER RESOLVED that the Clerk of the House of Representatives and the
34 Secretary of the Senate are authorized and directed to make appropriate copies of this
35 resolution available for distribution to Governor Brian P. Kemp and members of the public
36 and the press.

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