Evaluating infectious disease outbreak potential and mitigation effectiveness on cruise ships.

The cruise ship sector is a major part of the tourism industry, and an estimated over 30 million passengers are transformed worldwide each year. Cruise ships bring diverse populations into proximity for many days, facilitating the transmission of respiratory illnesses. The objective of this study is to develop a modeling framework to inform the development of viable disease risk management policies and measures to control disease outbreaks on cruises. Our model, parameterized and calibrated using the data of the COVID-19 outbreak on the Diamond Princess cruise ship in 2020, is used to assess the impact of the mitigation measures such as mask wearing, vaccination, on-board and pre-traveling testing measures. Our results indicate mask wearing in public places as the cheapest and most affordable measure can drop the number of cumulative confirmed cases by almost 50%. This measure along with the vaccination by declining the number of the cumulative confirmed cases by more than 94% is the most effective measure to control outbreaks on cruises. According to our findings, outbreaks are more predominant in the passenger population than the crew members, however, the protection measures are more beneficial if they are applied by both crew members and passengers. Regarding the testing measure, pre-traveling testing is more functional than the on-board testing to control outbreaks on cruises.

The gendered behaviors displayed by Disney protagonists.

Previous research suggests that the portrayal of male and female protagonists in Disney animations may be changing over time. The current study examined the portrayal of gendered behaviors displayed within some of Disney's most successful animated feature length films, including those beyond the Disney princess franchise. Extending the scope of the Disney animated films analyzed was important because both young girls and young boys report little personal interest in male characters within the Disney princess animations. This suggests that it is important to look beyond the Disney princess franchise to understand the gendered behaviors displayed by potentially influential male Disney protagonists. The current study also considered a greater number of masculine and feminine behaviors as well as some gender-neutral traits which had yet to be incorporated. A quantitative content analysis of 39 Disney protagonists from films released between 1937 and 2021 was conducted. The results revealed that male and female protagonists were statistically higher in feminine than masculine traits. Female protagonists from the earliest animations were the most feminine. However, there was no statistical difference in the gendered portrayals of females in the animations released in the 1990s and those released from 2009 to 2021 suggesting some continued stereotyping in females' profiles. Alternatively, male characters were more feminine relatively consistently across time-points. This study concludes that Disney is persistently portraying stereotyped female protagonists, and this could have implications on young females' behavioral profiles. However, the extent to which feminine traits are being celebrated when displayed by male protagonists needs to be examined, as well as the potential relationship between such messages and boys' behaviors and children's conceptualizations of gender more broadly.

Balancing Public & Economic Health in Japan during the COVID-19 Pandemic: A Descriptive Analysis.

Despite loose restrictions and a low mortality rate due to COVID-19, Japan faced the challenge of stabilizing its economy during the pandemic. Here, we analyzed how the Japanese government attempted to maintain a balance between the health of the population and the health of the economy. We used a mix of quantitative data, information from policy documents, and news agency publications. Features of the Japanese government's handling of the pandemic include the lack of constitutional authority to enforce a lockdown, the laxer restrictions compared with other countries in which citizens were advised only to exercise self-restraint and avoid close social contact, and the existence of expert panels that had only an advisory role. Our findings address the slow initial response of the government, which feared that the 2020 Tokyo Olympics would be canceled, and the increased testing when the Olympics were postponed, as well as the expansion of vaccination efforts after the Olympics. In addition, there was a targeted campaign to promote national travel to increase economic revenue in the tourism sector, but this led to an increase in COVID-19 cases.

Mental health needs associated with COVID-19 on the diamond princess cruise ship: A case series recorded by the disaster psychiatric assistance team.

Coronavirus disease 2019 (COVID-19) infection prevention measures have led to a variety of mental health issues. Although several self-care methods have been recommended for those quarantined, evidence regarding how best to support quarantined people experiencing a mental health crisis is limited. In February 2020, the Diamond Princess cruise ship was quarantined in Yokohama port, Japan following a passenger testing positive for COVID-19. We were sent to address the mental health issues as the Disaster Psychiatric Assistance Team (DPAT). In the present study, we examined the acute mental health needs of the passengers and crew collected by the DPAT using the standard Emergency Medical Team daily reporting system. We assessed 206 cases (99 men and 107 women) with generic health issues and 127 cases (39 men and 88 women) with mental health issues. Mental health issues including disaster stress-related symptoms were as frequent as physical health events associated with COVID-19. The most significant mental health issue was anxiety, as an acute psychological reaction to the quarantine situation. Women and crews most frequently needed mental health support. Mental health improved in most clients after brief counseling. Although several passengers experienced suicidal ideation, there were no cases of actual suicide attempts during the quarantine period. This case has been regarded as a well-known public health event at the beginning of the COVID-19 era. In addition to physical health support, disaster mental health support was essential to save lives. Our findings may facilitate responses to future quarantines, accidents, and mental health crises.

Cruise tourism in the context of COVID-19: Dilemmas and solutions.

COVID-19 cases on international cruise ships have attracted extensive attention from the international community as well as the world's tourism and shipping industry. This virus highlighted the plight that must be faced by cruise ships in complicated times and situations such as pandemics. The comparative method is adopted to analyze the management measures taken by the "Diamond Princess", "Costa Serena", "Westerdam" and "Grand Princess" cruises in response to the COVID-19 pandemic and then to summarize the common dilemmas faced by these cruise ships, including defects of their internal environment, unclear health-care obligations during an epidemic, weak collaboration between the parties involved and their limited performance, and widespread infodemic and unfavorable public opinion. Given these dilemmas, measures are suggested to deal with the "cruise dilemma", including establishing and defining isolation standards on boards, enhancing the capacity of international organizations, the international community's joint response to the pandemic, promoting cooperation between countries, building an effective mechanism for the broad participation of the whole society, and standardizing the release of information and reasonably guiding public social opinion.

The use of dietary supplements for mental health among the Saudi population: A cross-sectional survey.

Introduction: Despite limited evidence about the efficacy and safety of dietary supplements (DSs) for improving mental health, people with or without mental disorders often tend to use them, especially during the ongoing COVID-19 pandemic. Previous studies focused on DS use for maintaining or improving overall health; Therefore, this study aimed to assess the prevalence of DSs for mental health among the SA population and to determine the factors that affect their use. Methods: This cross-sectional study was based on an online survey of Saudi Arabian participants between July and August 2021 with an anonymous, self-completed questionnaire distributed using convenience sampling. The questionnaire included queries related to demographic information, DS use assessment, and mental health evaluation using the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder 7-item (GAD-7), questionnaire, and the Insomnia Severity Index (ISI). Results: In total, 443 participants from various regions of Saudi Arabia completed the questionnaire. The prevalence of DS use in the Saudi population was 44%. Vitamin D (28%) and melatonin (20%) were the most commonly reported DSs used for mental health. The odds of DS use were three times higher in responders with previous mental health diagnoses (OR: 2.972; 95% CI: 1.602-5.515). Furthermore, the chances of using DSs almost doubled in patients with sub-threshold and moderate to severe insomnia (OR: 1.930; 95% CI: 1.191-3.126 and OR: 2.485; 95% CI: 1.247-4.954, respectively). Conclusion: Responders diagnosed by a specialist with psychiatric disorders or current insomnia had a higher chance of using DSs. Thus, healthcare providers must provide evidence-based information regarding DSs for mental health improvement and encourage the public to consult healthcare professionals before self-medicating for mental health problems.

Modelling COVID-19 outbreak on the Diamond Princess ship using the public surveillance data.

The novel coronavirus disease 2019 (COVID-19) outbreak on the Diamond Princess (DP) ship has caused over 634 cases as of February 20, 2020. We model the transmission process on DP ship as a stochastic branching process, and estimate the reproduction number at the innitial phase of 2.9 (95%CrI: 1.7-7.7). The epidemic doubling time is 3.4 days, and thus timely actions on COVID-19 control were crucial. We estimate the COVID-19 transmissibility reduced 34% after the quarantine program on the DP ship which was implemented on February 5. According to the model simulation, relocating the population at risk may sustainably decrease the epidemic size, postpone the timing of epidemic peak, and thus relieve the tensive demands in the healthcare. The lesson learnt on the ship should be considered in other similar settings.

A Network Dynamics Model for the Transmission of COVID-19 in Diamond Princess and a Response to Reopen Large-Scale Public Facilities.

Background: The current epidemic of COVID-19 has become the new normal. However, the novel coronavirus is constantly mutating. In public transportation or large entertainment venues, it can spread more quickly once an infected person is introduced. This study aims to discuss whether large public facilities can be opened and operated under the current epidemic situation. Methods: The dual Barabási-Albert (DBA) model was used to build a contact network. A dynamics compartmental modeling framework was used to simulate the COVID-19 epidemic with different interventions on the Diamond Princess. Results: The effect of isolation only was minor. Regardless of the transmission rate of the virus, joint interventions can prevent 96.95% (95% CI: 96.70-97.15%) of infections. Compared with evacuating only passengers, evacuating the crew and passengers can avoid about 11.90% (95% CI: 11.83-12.06%) of infections; Conclusions: It is feasible to restore public transportation services and reopen large-scale public facilities if monitoring and testing can be in place. Evacuating all people as soon as possible is the most effective way to contain the outbreak in large-scale public facilities.

Legal issues and challenges in addressing the coronavirus outbreak on large cruise ships: A critical examination of port state measures.

International cruises have drawn worldwide attention since the outbreak of coronavirus (COVID-19). This article first examines the legal issues, challenges and impact of the pandemic on large cruise ships, like the Diamond Princess, and then probes into corresponding pandemic preventive measures which port states employ. A State is obliged under the International Health Regulations 2005 (IHR) to grant foreign cruise ships free pratique, but there is an exception when public health emergencies of international concern occur. Therefore, this article argues that a port state is not obliged to allow foreign cruise ships to dock at its port at the cost of its domestic public health safety. Regarding the Diamond Princess, the Japanese government has undertaken pandemic preventive measures upon passengers on board the ship and complied with its domestic laws, including the Japanese Quarantine Act. This article further evaluates whether a port state's pandemic preventive measures concerning cruise ships are appropriate from the perspective of law. More importantly, it is necessary to consider the characteristics and specialities of international cruise ships to improve future pandemic preventive measures against large passenger ships and cruise passengers.

Alexandra General Hospital in Athens: Historical Connections to the Greek Royal Family.

Princess Alexandra of Greece (1870-1891), the eldest daughter of King George I of Greece (1845-1913), was known as the "beloved daughter of the Athenians". Her death at the age of 21 in 1891 due to a pregnancy complication caused nationwide grief. To honour her, the Alexandra Maternity Hospital in Athens was named in her memory. Affiliated with the University of Athens, Alexandra Maternity Hospital researches pregnancy and newborn care, including complications and maternal mortality. Today, the hospital contains various clinical and laboratory departments providing patients with exceptional health care.

The Association Between Psychological Disorders and Physical Activity Among Saudi Women at Princess Nourah Bint Abdulrahman University.

Introduction Psychological disorders are one of the leading causes of disability globally. Evidence suggests the positive role of physical activity on physical and mental health in various countries. However, a limited number of studies have been done in Saudi Arabia to investigate the association between physical activity and psychological health, especially among women. Objectives The objective of the study was to identify the prevalence of depression, stress, anxiety, and physical activity as well as examine the association between depression, anxiety, stress, and social support in relation to physical activity among Saudi women at Princess Nourah Bint Abdulrahman University (PNU). Methods A total of 712 Saudi students and staff from PNU, with a mean (SD) age of 20.59(5.30), voluntarily completed an electronic-based questionnaire, which included three validated scales in the Arabic language: The Depression, Anxiety and Stress Scale - 21 Items (DASS-21), Global Physical Activity Questionnaire (GPAQ), and Medical Outcomes Study (MOS) social support. Results The results of this cross-sectional study showed that the prevalence of depression, anxiety, and stress were 24%, 31%, and 22.1%, respectively. Levels of physical activity were not associated with psychological disorders while sedentary time was strongly correlated with depression, anxiety, and stress (p<0.001). Emotional support, affectionate support, and positive social interaction were negatively correlated with depression (p<0.05). Conclusion The findings indicate that stress, depression, and anxiety were relatively common among Saudi females, especially among young ages, and that social support was a significant protective factor of depression. Community-based psychological health prevention programs and social support groups are needed to address these issues. The second major finding was that 51% of the participants were insufficiently active and 61% were having a sedentary lifestyle. Depression, anxiety, and stress scores are strongly correlated with sedentary time, which highlights the need for establishing a national policy that encourages active living and discourages sedentary behavior.

Risk assessment model and application of COVID-19 virus transmission in closed environments at sea.

This paper focuses on the risk assessment methods of novel coronavirus pneumonia virus (COVID-19) pneumonia virus spreading in closed marine environment. Firstly, the possibility of the spread of new coronavirus in closed environments at sea and the consequences of the harm caused by the epidemic are classified into five levels, and the corresponding risk assessment framework is constructed, and the risk assessment model of the spread of COVID-19 pneumonia virus in closed environment at sea is established taking the Japanese "Diamond Princess" as an example, the model is applied and its output is analysed. Finally, the proportion of the cumulative confirmed cases on the Diamond Princess is calculated, and the possibility of viral infection of Diamond Princess passengers in this COVID-19 pneumonia epidemic in four different risk transmission stages are assessed, and the corresponding risk assessment is undertaken. Through the calculation of risk assessment value, the five stages of the epidemic are established to assess the risk of the "Diamond Princess" outbreak. The research method in the present work helps to provide a risk assessment and analysis idea for the risk of spread of the COVID-19 epidemic in a closed environment at sea.

Sociodemographic features of a cohort of people living with albinism in Botswana.

BACKGROUND: Oculocutaneous albinism is disproportionately prevalent in Africa; however, the medical and psychosocial characteristics of people living with albinism (PWA) in Botswana have not been studied. OBJECTIVE: To characterize the demographics, health-related factors, sun-protective behaviors, and psychosocial challenges of PWA in Botswana. METHODS: Overall, 50 PWA and 99 patients without albinism (non-PWA) were recruited and surveyed. RESULTS: Higher proportions of PWA lived in rural villages compared with non-PWA (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.26-5.34). PWA reported limited access to health care more frequently compared with non-PWA (OR, 2.72; 95% CI, 1.11-6.62). High proportions of PWA adopted sun-protective measures, including sunscreen, clothing, and sunlight avoidance. Despite high rates of feeling accepted by family and peers, PWA had increased odds of feeling unaccepted by their community (OR, 15.16; 95% CI, 5.25-31.81), stigmatized by society (OR, 9.37; 95% CI, 3.43-35.62), and affected by stigma in social interactions (OR, 2.21; 95% CI, 1.08-4.54) compared with non-PWA. Three-quarters of PWA had witnessed mistreatment of PWA. LIMITATIONS: Study limitations include the small sample size, convenience sampling, and a non-validated survey instrument. CONCLUSION: PWA faced increased medical and psychosocial challenges compared with non-PWA in Botswana. Our findings can begin to inform public health strategies aimed at promoting improved health care, education, and social inclusion for this population in Botswana and other regions in Africa.

"This is a different kingdom": A case study of gender-creative feminine expression during princess play.

Many children, but predominantly young girls, gravitate towards princess play. In response to previous academic findings suggesting that princess play is always detrimental to young children's developing perspectives of femininity, this qualitative study explores the potential for gender-creativity during this roleplaying game. In an effort to refute the pre-existing literature, the current case study asks the following question: To what extent does princess play offer creative or confining possibilities for childhood feminine expression? While much of the literature in early childhood education (ECE) indicates that Disney is the sole inspiration for every child's construction of this imagination game, the findings in this article indicate that Disney is one influence among many for focal participants. Using open coding to analyze data generated during play-based interviews with two cisgender girls, this article demonstrates that the creative possibilities of princess play remain underrepresented in research. Although princess play offers only partial potential for non-stereotypical feminine expression, gender normativity can be actively challenged, especially when adults support and encourage unconventional formats of princess play during early childhood.

Practice with confidence: Analyzing confidence level of final year dental students from four Saudi dental colleges in Riyadh.

OBJECTIVE: To investigate the confidence level of final year dental students in Riyadh. MATERIALS: Cross-sectional study was conducted at four dental colleges in Riyadh (N = 312, 220 and 70,5% responded). Oneway ANOVA and post hoc Tukey-Kramer was used. RESULTS: The greatest self-reported confidence scores were for pit fissure sealent (4.6(0.7)). Whereas, students reported least confidence in conducting surgical extractions (2.7 (1.2)). Females were found more confident in conducting preventive resin restorations, oral hygiene instructions, and rubber dam placement as compared to male who were more confident in surgical extraction, copy dentures, veneer preparation and managing orthodontic emergencies. CONCLUSION: All students were confident in performing essential dental procedures however higher confidence was observed in performing simple procedures compared to more complex ones.

First Report of Diaphorte terebinthifolii causing leaf spot on Pleoroma fotherghillae in Brazil.

Pleoroma fotherghillae, also known as "princess flower", is an ornamental species native to Brazil and naturalized in several countries (Faravani et al. 2007). P. fotherghillae has a high economic value, with an ornamental and landscape application (Nienow et al. 2010). In September 2018, leaf spots were observed in approximately 80% of the 50 P. fotherghillae plants grown in a nursery in the municipality of Curitiba-Paraná, Brazil. The spots were round-shaped, with a necrotic brown center and a reddish-brown halo, ranging from 1 to 4 mm in diameter. High leaf fall was observed among plants presenting a higher severity. Symptomatic leaves fragments were collected and disinfected as described by (Pereira et al. 2019). The fragments were transferred to a potato dextrose agar medium supplemented with streptomycin sulfate and incubated at 24 ± 1ºC with a photoperiod of 12 h for 7 days. Four monosporic cultures were obtained from colonies isolated. The isolates had a grayish-white cottony aerial mycelium and reverse olive-yellow with black dots. The colonies reached approximately 60 mm in diameter, forming globular and conical pycnidia, brown to black in color with white or cream globular conidial mass. Beta conidia were hyaline, smooth, curved to the size of 19 - 25 x 1 - 1.5 µm (n = 50). No alpha nor gamma conidia were observed. The characteristics are similar to the description of Diaporthe terebinthifolli (Gomes et al. 2013). The total genomic DNA of a representative isolate, LEMIDPRPf-19-02, was extracted for amplification and sequencing of the internal transcribed spacer (ITS) region and partial of the Tubby (TUB) and thyrotroph embryonic factor (TEF) genes. The sequences of the ITS (No MN415990.1), TUB (No MW505549), and TEF (No MW505550) genes were deposited in GenBank. BLAST analysis showed similarity above 99% with D. terebinthifolli sequences (KC343219.1, KC344187.1, and KC343945.1). The multigene phylogenetic analysis, based on Bayesian Inference, grouped the isolate in a clade with other sequences of Diaporthe terebinthifolii. Four healthy plants of P. fotherghillae about 5 months old, were used for pathogenicity testing. A suspension containing 105 conidia/ml was sprayed on the surface of the leaves of four plants to the point of runoff. The plants were covered with a transparent plastic bag for 24 hours. The leaves of four other plants received sterile distilled water and served as the control treatment. The plants were kept in a greenhouse at 20±5ºC. Necrotic lesions appeared 10 to 15 days after inoculation. No symptoms were observed in the control plants. The pathogen was reisolated from symptomatic leaves and had the same characteristics as the isolate LEMIDPRPf-19-02. A representative sample (MBM 331603) was deposited at the Museu do Jardim Botânico (Botanical Garden Museum) - Curitiba, Brazil. Diaporthe terebinthifolii was previously reported as endophytic in Brazil and Uruguay, isolated from Schinus terebinthifolius and Pyrus communis, respectively (Gomes et al. 2013; Sessa et al. 2017). To our knowledge, this is the first report of D. terebinthifolii causing leaf spot on P. fotherghillae in Brazil and worldwide.

Mechanistic transmission modeling of COVID-19 on the Diamond Princess cruise ship demonstrates the importance of aerosol transmission.

Several lines of existing evidence support the possibility of airborne transmission of coronavirus disease 2019 (COVID-19). However, quantitative information on the relative importance of transmission pathways of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains limited. To evaluate the relative importance of multiple transmission routes for SARS-CoV-2, we developed a modeling framework and leveraged detailed information available from the Diamond Princess cruise ship outbreak that occurred in early 2020. We modeled 21,600 scenarios to generate a matrix of solutions across a full range of assumptions for eight unknown or uncertain epidemic and mechanistic transmission factors. A total of 132 model iterations met acceptability criteria (R2 > 0.95 for modeled vs. reported cumulative daily cases and R2 > 0 for daily cases). Analyzing only these successful model iterations quantifies the likely contributions of each defined mode of transmission. Mean estimates of the contributions of short-range, long-range, and fomite transmission modes to infected cases across the entire simulation period were 35%, 35%, and 30%, respectively. Mean estimates of the contributions of larger respiratory droplets and smaller respiratory aerosols were 41% and 59%, respectively. Our results demonstrate that aerosol inhalation was likely the dominant contributor to COVID-19 transmission among the passengers, even considering a conservative assumption of high ventilation rates and no air recirculation conditions for the cruise ship. Moreover, close-range and long-range transmission likely contributed similarly to disease progression aboard the ship, with fomite transmission playing a smaller role. The passenger quarantine also affected the importance of each mode, demonstrating the impacts of the interventions.

The Bayesian Susceptible-Exposed-Infected-Recovered model for the outbreak of COVID-19 on the Diamond Princess Cruise Ship.

The outbreak of COVID-19 on the Diamond Princess Cruise Ship provides an unprecedented opportunity to estimate its original transmissibility with basic reproductive number (R0) and the effectiveness of containment measures. We developed an ordinary differential equation-based Susceptible-Exposed-Infected-Recovery (SEIR) model with Bayesian underpinning to estimate the main parameter of R0 determined by transmission coefficients, incubation period, and the recovery rate. Bayesian Markov Chain Monte Carlo (MCMC) estimation method was used to tackle the parameters of uncertainty resulting from the outbreak of COVID-19 given a small cohort of the cruise ship. The extended stratified SEIR model was also proposed to elucidate the heterogeneity of transmission route by the level of deck with passengers and crews. With the application of the overall model, R0 was estimated as high as 5.70 (95% credible interval: 4.23-7.79). The entire epidemic period without containment measurements was approximately 47 days and reached the peak one month later after the index case. The partial containment measure reduced 63% (95% credible interval: 60-66%) infected passengers. With the deck-specific SEIR model, the heterogeneity of R0 estimates by each deck was noted. The estimated R0 figures were 5.18 for passengers (5-14 deck), mainly from the within-deck transmission, and 2.46 for crews (2-4 deck), mainly from the between-deck transmission. Modelling the dynamic of COVID-19 on the cruise ship not only provides an insight into timely evacuation and early isolation and quarantine but also elucidates the relative contributions of different transmission modes on the cruise ship though the deck-stratified SEIR model. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at (10.1007/s00477-020-01968-w).

Use of US Public Health Travel Restrictions during COVID-19 Outbreak on Diamond Princess Ship, Japan, February-April 2020.

Public health travel restrictions (PHTR) are crucial measures during communicable disease outbreaks to prevent transmission during commercial airline travel and mitigate cross-border importation and spread. We evaluated PHTR implementation for US citizens on the Diamond Princess during its coronavirus disease (COVID-19) outbreak in Japan in February 2020 to explore how PHTR reduced importation of COVID-19 to the United States during the early phase of disease containment. Using PHTR required substantial collaboration among the US Centers for Disease Control and Prevention, other US government agencies, the cruise line, and public health authorities in Japan. Original US PHTR removal criteria were modified to reflect international testing protocols and enable removal of PHTR for persons who recovered from illness. The impact of PHTR on epidemic trajectory depends on the risk for transmission during travel and geographic spread of disease. Lessons learned from the Diamond Princess outbreak provide critical information for future PHTR use.

Mask-Ematics: Modeling the Effects of Masks in COVID-19 Transmission in High-Risk Environments.

The COVID-19 pandemic has placed an unprecedented burden on public health and strained the worldwide economy. The rapid spread of COVID-19 has been predominantly driven by aerosol transmission, and scientific research supports the use of face masks to reduce transmission. However, a systematic and quantitative understanding of how face masks reduce disease transmission is still lacking. We used epidemic data from the Diamond Princess cruise ship to calibrate a transmission model in a high-risk setting and derive the reproductive number for the model. We explain how the terms in the reproductive number reflect the contributions of the different infectious states to the spread of the infection. We used that model to compare the infection spread within a homogeneously mixed population for different types of masks, the timing of mask policy, and compliance of wearing masks. Our results suggest substantial reductions in epidemic size and mortality rate provided by at least 75% of people wearing masks (robust for different mask types). We also evaluated the timing of the mask implementation. We illustrate how ample compliance with moderate-quality masks at the start of an epidemic attained similar mortality reductions to less compliance and the use of high-quality masks after the epidemic took off. We observed that a critical mass of 84% of the population wearing masks can completely stop the spread of the disease. These results highlight the significance of a large fraction of the population needing to wear face masks to effectively reduce the spread of the epidemic. The simulations show that early implementation of mask policy using moderate-quality masks is more effective than a later implementation with high-quality masks. These findings may inform public health mask-use policies for an infectious respiratory disease outbreak (such as one of COVID-19) in high-risk settings.