Be angry. But do it with a mask on. Some FAQ answered...

Yesterday, the CDC took backsies on mask guidance. Last night I had a glass of wine, screamed into a pillow, and slept on my responses to your great questions, so they weren’t riddled with frustration. While this was, by far, the correct policy, the CDC is not making scientific communication easy.

So… good morning! Here are some answers to your questions…

Why did the CDC remove the mask recommendations in May?

On paper, they wanted to increase vaccine acceptance. At the time, transmission was also extremely low among the vaccinated. Should they have had the foresight that this could change? Probably.

In between the lines, they were also pressured by lawmakers. I don’t think it’s a coincidence that the night before the May decision, the CDC Director (Walensky) met with Louisiana lawmakers. Public health departments were informed of the policy change from NYT breaking news. Then two days later, a deeply respected public health leader and CDC’s second in command, Dr. Anne Schuchat, just happened to retire.

I still stand by my opinion that the CDC made a mistake in May. But we need to move forward.

Do you disagree with any of the guidance?

The CDC has a really good handle on science and data. There’s no question about that. Their ability to disseminate and implement that science continues to be a disappointment though. I think the CDC should have just simply recommended universal mask wearing. A simple, consistent message. They also desperately need a deimplementation plan. In other words, when will this end for the vaccinated?

Does this mean vaccinated people can spread the virus?

Yes. Before Delta, vaccines reduced transmission by about 90%. With a 1000% increased viral load, Delta changed the game. Yesterday, the CDC said that they had unpublished data showing breakthrough infections with high amounts of virus. This means vaccinated can spread the virus. No one has seen this study or the data. We don’t know the rate of transmission. We don’t know the R(0). We don’t know a lot. This is one of the main reasons the WHO has continued to recommend masking for vaccinated.

A higher viral load does not necessarily mean increased severity of disease. We believe (and continue to see on a local level) that vaccines continue to protect against severe disease at a much higher rate than unvaccinated protection.

A third dose could help with high viral loads among vaccinated. A third dose would increase naturalizing antibodies, which would decrease viral shedding from the nose and the mouth. It might be time for us, as a nation, to consider it. This could get life back to normal for vaccinated.

How do I know if I’m in a geographical area where I should be masking?

Go here. If your county is orange or red, wear a mask indoors. This means that your county has a higher than 50 new cases per 100,000 persons in the past 7 days OR test positivity rate is greater than 8%. If you’re in a yellow or blue county, you probably don’t need to wear a mask. But, full disclosure, I have continued to wear a mask indoors regardless of which color my county was in.

Since the mask is intended to prevent me from spreading my germs to others, does it also protect me from others?

Yes, masks protect others (outward protection). But masks also protect the wearers (inward protection). This is especially true is the mask is fit and filtered right. The best protection is a N95. The next level of protection is double masked (cloth over surgical) and results in a 83% reduction in exposure. A knotted surgical mask is the next best option (see Panel C below), resulting in a 65% reduction in exposure. Protection from a loose-fitting cloth mask is low.

I have to say, I am beyond annoyed that yet again, those of us who have been super careful, masking, DOUBLE masking, getting vaccinated as soon as possible, distancing, staying home, following all the rules.... Now, AGAIN we are being asked to be the adults in the room so 30% can remain children. Frankly, I honestly don't much care if the vaccine refusers become a statistic. I'm tired of having to care about those who do not care about me.

You should be annoyed!! And frustrated. And tired. I am. But the solution is deeply rooted in complex issues: chronically underfunded public health system; polarization in politics; public health integrated into politics; terrible scientific communication; a fragmented healthcare system; suboptimal scientific illiterate base; and, health equity. We aren’t going to solve these tomorrow.

So, don’t do it for the never maskers. Don’t do it for the unvaccinated. Do it for the immunocompromised. Do it for the kids. Do it for the elderly. We can’t leave them behind. Once we get those folks fully protected, I’m all for survival of the fittest. Be angry. But just do it with a mask on.

How is outdoor transmission changing with the delta variant? Is being outdoors still a meaningful buffer?

The risk hasn’t been quantified with Delta, but outdoors is safer than indoors. If you’re not shoulder to shoulder in a crowd outside, I’m still comfortable saying that outdoor activities are still low risk.

If schools do not follow mask recommendations, what is the best advice for parents?

The CDC cannot mandate masks. Schools do not have to listen to CDC or American Academy of Pediatrics. This can only be done on the federal level and/or state level.

So, what do we do? I don’t have a silver bullet. But, if I were a parent with a kid going to school, I would advocate for masks and surveillance testing. To the school. To the local health department. To local politicians. To schools again. And to the schools again. Parents have power and influence in numbers. Don’t think that you don’t. If it’s helpful, I can put together a one-pager of talking points.

Then, I would ask my kids’ teacher if s/he were vaccinated. Then I would go out and buy a well fit respirator for my kid (there are KN95’s on Amazon for kids). Then I would send my kid to school, have a glass of wine, probably cry, and do my best to parent given the increasingly difficult landscape we are forced to navigate.

What are you doing with your kids?

My kids are young, so we are in a little bit of a different position. One is 9 months old, so she is naturally considered high risk. My 2.5 year old is healthy. Both are in childcare. Over the weekend, my husband and I decided that we’re going to pull our daughters out of childcare for a month or two.

It came to my attention that their teachers were unvaccinated and not wearing masks. The childcare facility would not change their policy. So, we consulted two pediatricians. Both of which said the risk of keeping them in childcare is much higher than the benefit of keeping them in. They don’t need the socialization like older kids need. At least right now, until we have a better understanding of Delta and where this new wave is going. If our kids were older than 4/5 years old, this decision would have been different.

At what point does this thing become endemic, and we get a booster every year like the flu because there are different variants, but we no longer take drastic measures like universal masking? 

An endemic stage will look like small pockets of outbreaks: A nursing home here, a school outbreak there. An endemic stage is not entire states or even counties with outbreaks. The South is burning right now. We are still very much in a pandemic/epidemic stage. Progress towards endemic will be slow and painful.

We will reach this point once everyone gets vaccinated or everyone gets exposed to Delta. Some scientists think we will reach endemic by next Spring. But only if the virus doesn’t mutate again to completely escape vaccines.

Hope this is helpful,