- COVID-19 public health measures continue to change and cause confusion among Americans.
- Inconsistent data on the effectiveness of mask use has divided Americans and the medical community.
- Communicating clear data on both the effectiveness and ineffectiveness of public health measures can help the public regain trust in public health officials.
Just when most Americans have tucked away their stash of masks, some parts of the country are requiring that they have them at the ready once again.
For instance, in early June, Alameda County in the San Francisco Bay area reinstated a mask mandate in most indoor spaces after hospitalizations due to COVID-19 increased by 35 percent.
While Alameda exempted schools from the mandate, at the end of May, neighboring Berkeley Unified School District decided to only require masks in schools.
In New York City, a mask mandate for toddlers ages 2 to 4 who attend day care and preschool ended June 13.
To confuse things further, there was a short-lived four-day indoor mask mandate in Philadelphia last spring that ended after the city’s health department cited improving conditions.
And of course, at the moment, different rules are in place at various airports across the U.S. Masks are required in the Los Angeles Airport but not at Orlando International Airport, for instance.
With the lack of consistency across the country and even within the same states and local jurisdictions, there’s no surprise that Americans are confused and losing trust in public health.
“Frequently changing public health policies are definitely confusing, especially if you don’t have public health training, which most of the world does not have. It is our job as medical professionals to take the data and translate it for our patients and community members,” Dr. Alexa Mieses Malchuk, assistant professor of family medicine at the UNC School of Medicine, told Healthline.
Lack of clear communication from public officials is exactly the issue, according to Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center in Nashville.
“Part of the reason is that when COVID first came on the scene, instead of having a national policy, our political leadership said, ‘I’ll leave it to the states’ and the moment they did that we had different governors saying different things and that leads to confusion because we didn’t have a national policy,” Schaffner told Healthline.
While he stressed that public health measures shouldn’t be identical in states like Maine and New Mexico, he said there should be some cohesion. Consider how an orchestra works.
“It has a lot of different instruments and the brasses don’t always play the exact same notes as the strings, but they are all playing from the same sheet of music. They have one conductor and from that, they are harmonizing,” he said. “We never had that in this country with COVID and we still don’t have it within in states.”
Still, it’s the job of public health officials and the medical community to communicate clearly what is occurring and what is needed to stay safe.
“We are the bridge. Spreading medical misinformation is unethical,” said Mieses Malchuk. “It’s also important to remember that public health policies change often based on new scientific data that become available. This can be frustrating… but we must remain flexible.”
Communication isn’t the only issue, though, according to Dr. Monica Gandhi, professor of medicine at University of California, San Francisco. She said scientists and doctors don’t agree on how best to manage the pandemic at this point, and believes the key to restoring harmony within the medical community and the country is to eliminate mask mandates.
A recent New York Times article that shed light on the mask debate, made its way into a public Centers for Disease Control and Prevention (CDC) briefing with the Senate in June.
“I really supported masks early on and wrote seven or so papers on that, but I am also able to re-evaluate the data as we go along,” Gandhi told Healthline.
Current data on mask effectiveness surprised her as it showed that mask mandates did not make a difference.
“We didn’t see that major of a difference with transmissions,” she said. “The strongest predictor of how places did were vaccination rates.”
Why are COVID-19 measures still in place?
The omicron variant and its subvariants are now the dominant COVID-19 strains and are spreading widely, said Schaffner.
“That’s because these variants have the capacity to infect people who were fully vaccinated and even people who have recovered from previous COVID. Now when that happens, in the vast majority of instances, you get relatively mild symptoms that don’t require you to be in the hospital,” he explained.
Because people survive the virus, they continue to spread it to people who are unvaccinated, who are partially vaccinated, or those who are immunosuppressed and do not respond well to the vaccine.
“Those are the people now who are being hospitalized,” said Schaffner.
The 7-day daily average of new COVID-19 hospitalizations for June 1–7 was 4,127, which is an 8.0% increase from the prior 7-day average, according to the CDC.
However, those who are admitted to the hospital with omicron are in the hospital for a shorter time and have less frequent admission to intensive care compared to those hospitalized with other coronavirus variants, according to researchers at the CDC.
“It’s a little bit confusing: the virus is spreading, vaccine provides protection against severe disease, but not very much protection against mild infection. So, cases are increasing and hospitalizations are a little in some areas. But for the most part, COVID is causing milder illness and [in turn] is continuing to spread,” said Schaffner.
In health jurisdictions and schools, local authorities may evaluate the spread and decide to reinstitute mask recommendations or mask mandates.
“This is not going to be uniform, which will lead to inconsistency throughout the country,” Schaffner said. “It’s often the case that public health officials look at the data and then they say, ‘we know what will be ideal, but here’s what our population will accept.’”
For example, during the early parts of the pandemic in Tennessee, the governor permitted individual cities to make their own rules on public health measures but did not impose a statewide mandate. This led to mask mandates in cities like Nashville and yet across the county line, no mandates were in place.
“A lot of debate and confusion occurred. You see similar things happening locally because no matter what the public health people say, the school board, the mayor, the county commissioners have to consider what’s acceptable to their local population, and that can change from location to location within the same state,” said Schaffner.
This is where political pressure can take root and cause inconsistency in public health initiatives.
“When things change based on political rhetoric rather than science, this can erode the public’s trust in the medical and public health communities,” said Mieses Malchuk.
But so can being unclear about data, added Gandhi.
“If we have really high cases right now, say more than what’s being recorded because people are doing home tests, and we have such low hospitalizations and deaths that continue to fall, that degree of immunity shows we are at a better point in the pandemic than we’ve ever been,” she said.
At this stage of the pandemic, Dr. Jeanne Noble, an emergency care physician and director of COVID-19 response at UCSF, said mandates are counterproductive.
“COVID is endemic and will continue to ebb and flow with or without mandates. As the entire population acquires natural or hybrid immunity, the peaks will become less and less noteworthy, a process which is already well underway,” she told Healthline.
The controversy around the effectiveness of masks
While the CDC, National Institutes of Health, and the infectious disease community adamantly stress that masks do reduce the spread of COVID-19, consistent and concrete data is hard to come by.
For instance, one study that examined mask-wearing policy and adherence in association with COVID-19 case rates used state-level data on mask-wearing policy for the general public and on the proportion of residents who stated they always wear masks in public.
For all 50 states and the District of Columbia, the data were taken by month from April through September 2020 to measure their impact on COVID-19 rates in the subsequent month.
The researchers found that mask-wearing adherence, regardless of mask-wearing policy, may curb the spread of COVID-19 infections. However, this was based on respondents stating whether or not they wore masks.
“Most well-done studies evaluating mask mandates do not show an association between mask mandates and the containment of spread or hospitalizations,” said Gandhi.
Data on masks in schools isn’t cut and dry, either.
A CDC study conducted in October 2021 looked at Arizona schools in Maricopa and Pima Counties. The results found that schools without mask requirements were 3.5 times more likely to have COVID-19 outbreaks than schools that started the school year with mask mandates.
However, according to an editorial in The Atlanitic authored by a group of doctors and scientists, more than 90 percent of schools that didn’t have mask requirements were based in an area that had much lower vaccination.
Additionally, the CDC is still basing its mask recommendations in schools on this study, yet Gandhi said, “This analysis was repeated recently with a longer period of follow-up and showed no benefit of masking (under review in the Lancet) using the same dataset the CDC used.”
Another CDC study found that counties that didn’t have mask mandates experienced greater increases in COVID-19 cases in children once schools opened, yet vaccination rates weren’t factored in.
Other studies from researchers at Duke University show that masks in schools help, but these studies don’t compare data with schools that didn’t require masks.
“The negative impacts of mask mandates for children, particularly for English language learners and those with speech challenges, have always been high. And now, they are all cost and no benefit,” said Noble.
Schaffner pointed out that the effects of masks are very difficult to assess because of all the variables. For instance, do people wear them in a sustained way? Are they worn appropriately? What type of masks are they wearing? And when during the outbreak are wearing masks being studied?
At the beginning of the pandemic, when COVID-19 variants were not that contagious, simple surgical masks seemed to work well. However, Schaffner said in a hyper-contagious area where omicron variants are spreading, N95 or KN95 are most effective.
“That’s what we’ve been wearing in healthcare for ages when we care for highly contagious patients in the hospital and they work, but we’re trained and tested on an annual basis to make sure that each one of us has an intact mask that we know how to wear properly. So that’s very different than saying to the general population, ‘wear a mask,’ ” Schaffner said.
When the correct mask is worn properly, he said they work and reiterated that the problems are proper wearing of masks, compliance, and acceptability.
“Wearing a mask below the nose is like not wearing a mask,” he said. “Early on when we were dealing with variants of the virus and had shutdowns and masking mandates, it all reduced transmission profoundly and then we opened too quickly again and the virus took off and began to spread.”
While Gandhi agreed that wearing masks can reduce COVID-19 transmission, she supported this notion for the general population prior to the availability of vaccines because “any little thing you could do with a deadly pandemic to prevent transmission like masking, proper ventilation, contact tracing, testing…prior to the vaccines was an important [public health] message.”
After vaccines became available, she said mask-wearing should have become optional.
“Some people really don’t mind getting a minor infection — they’ve been vaccinated and boosted and doing well and they know they’re going to have a minor infection and really believe in the vaccine, so putting back mask mandates especially when vaccinated, made people doubt the vaccine,” said Gandhi.
For those who want more protection, she said wearing a proper mask in crowded indoor spaces is an option, “but to impose it on a population when we had told people life will go back to normal once we have the vaccine, didn’t make sense.”
On February 12, 2022, the CDC stated it would not recommend masks unless hospitalizations from COVID-19 were high. This is exactly the approach it should take, according to Gandhi.
“This recognizes what we said at the beginning of the pandemic, which was that non-pharmaceutical interventions were always to protect our hospitals, so linking recommendations for masking to hospital rates in your area is [most effective],” she said.
Tracking mask-wearing is difficult
While Schaffner believes masking and mask mandates are effective, he notes that proving their effectiveness is difficult. Tracking vaccination, on the other hand, is more attainable.
“Once you’ve been vaccinated, you’ve been vaccinated and the databases for vaccination have been very good for COVID…every time anybody gets vaccinated it’s entered into a database, so we know who has gotten which vaccines when,” said Schaffner.
As data shows, he said the impact of vaccines is much greater than the impact of masks.
“They’re not comparable. Vaccine is absolutely fundamental to controlling COVID and the data are stunning to show the difference in cases and particularly in hospitalizations and deaths in populations that are more or less vaccinated,” Schaffner said.
A CDC study found that receiving two or three doses of an mRNA COVID-19 vaccine was associated with a 90 percent reduction in risk for COVID-19–associated invasive mechanical ventilation (IMV) or death. Protection from three mRNA vaccine doses during the period of omicron predominance was 94 percent.
Additionally, a study led by a Stanford Medicine researcher and Brazil colleagues found that immunization after having COVID-19 offers effective protection.
The researchers stated that the CoronaVac, AstraZeneca, Pfizer, and Johnson & Johnson vaccines prevented 40 percent to 65 percent of symptomatic illnesses while two-dose vaccines including CoronaVac, AstraZeneca, and Pfizer, prevented 80 percent to 90 percent of hospitalizations and deaths from reinfection.
With such powerful proof for vaccination being an effective intervention against COVID-19, Gandhi argued that enforcing mask-wearing actually gets in the way of people obtaining the vaccine.
“After vaccination, when people had to mask and could get fined in certain places if they didn’t, that didn’t fly well in the United States and caused distrust in public health,” she said.
For instance, in May 2021, the CDC announced that vaccinated people didn’t have to wear masks. In response, about 37 states dropped their mask mandates and never went back to them, even during delta and omicron surges, and 13 states went back and forth with mask mandates. Then in February 2022, all states dropped mask mandates.
“We didn’t see that major difference with transmissions. The strongest predictor of how the places did were vaccination rates. Especially among the elderly; vaccination saved lives beyond measure,” said Gandhi.
It’s time to loosen hospital restrictions
Before vaccination in January 2020, Noble feared for the lives of her patients. She worked around the clock devising protocols to care for COVID-19 patients with few treatment options while minimizing the chances that other patients would be exposed to COVID-19 while in the hospital.
In June 2022, she said the differences are stark.
“Now, my primary concern is limiting the collateral damage from COVID restrictions,” she said.
For example, she said at UCSF, there are no visitation rights for COVID-19 patients and restricted visitation rights for all patients as a COVID-19 precaution.
Additionally, homeless individuals lose their shelter beds when they test positive for COVID-19. Patients awaiting placement in psychiatric facilities languish in the emergency department for days when they test positive for COVID-19, as most psychiatric hospitals refuse them.
Important surgeries are also put on hold when a person tests positive for COVID-19, and parents are barred from their children’s school campuses as a precaution.
“The harms are vast yet underappreciated, if not entirely ignored,” Noble said.
Medical community divided on quarantine after exposures
Causing further divide across the country and in the medical field is the CDC’s recommendation that state health authorities require a 5-day period of home quarantine after exposure for people who are not “up to date” on vaccination. This refers to those who have not received every dose of vaccine for which they are eligible.
However, Gandhi points to large data analyses that showed even after three doses of the Pfizer vaccine, effectiveness against any infection versus no vaccine during the omicron surge approached zero by 20 weeks after receiving the last dose. “Although effectiveness against severe disease remains high,” she said.
Unless the country is willing to subject all Americans to postexposure quarantines again, Gandhi argued that they shouldn’t be imposed on anyone.
Since the CDC no longer recommends universal contact tracing, she said the majority of postexposure quarantine policies will fall on places like day care centers where intense case monitoring is occurring, “resulting in disproportionate impacts on the socialization and education of children and the earnings of women, single parents, and lower-income individuals,” Gandhi said.
Some areas of the country like Massachusetts are taking this into consideration. In May 2022, the state ended quarantine in daycares, schools, and camps. However, although quarantine for asymptomatic exposed children is no longer required in that state, mask-wearing and testing are still recommended.
Sticking to data, Gandhi added that the five-day isolation periods recommended by the CDC for those who are sick with COVID makes sense for now. As immunity across the United States continues to grow, she said public health officials should look to transition to a “stay home when sick” model like the United Kingdom has implemented.
Schaffner agreed that changes in measures need to evolve as COVID-19 continues to circulate and scientists learn more about the virus. For instance, the infectious disease community anticipates that a new booster will become available in the fall of 2022.
Schaffner explained it as a “kind of a vaccine 2.0 that protects traditionally and in the same vaccine, protects against the omicron variants.”
“I can assure everyone, unfortunately, that they’ll have to keep doing their homework and read and listen. This virus is not going to disappear,” he said.