People wearing face masks in a movie theater

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Our on again, off again relationship with masks

Periodic mask-wearing is here to stay, but basic risk assessment skills can help us weigh the pros and cons of ever-changing conditions

As COVID-19's delta variant creates dangerous hotspots of community spread across the country, the Centers for Disease Control and Prevention has recommended that everyone—including the vaccinated—resume mask-wearing while indoors in public places where transmission rates are on the rise.

At this point, it's starting to feel like we'll be wearing masks forever. While that's not exactly the case, it's an oversimplification with a kernel of truth: Whether facing a global pandemic or a typical cold and flu season, mask-wearing carries significant public health benefits, so periodic masking is here to stay, according to Crystal Watson, a senior associate at the Johns Hopkins Center for Health Security.

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Watson's policy research focuses on public health risk assessment and medical preparedness and response to emerging infectious diseases. She specializes in helping to improve the decision-making process for organizations during public health emergencies, and with COVID-19, Watson has been assisting organizations in making decisions about mitigation measures in their community or at their facility. She has also been working with the World Health Organization to develop decision support tools around COVID-19 and seasonal influenza.

Watson, an assistant professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health, recently discussed the present and future of masking while offering practical risk-assessment tips for getting comfortable with our on again, off again relationship with masking.

Many of us are suffering from decision fatigue around COVID-19. We want answers for things that we don't have answers to yet, such as how quickly and widely will the delta variant spread, and should we be going back to universal masking. What are some of the tools that can help us make decisions?

I work to help decision-making easier and more accurate for leaders involved in public health, and it's about providing frameworks that make decision-making more clear. This works for individuals, too. First, define the problem that you're facing. Think specifically about what the problem is and how you're interested in approaching it. Second, define what your values are. What is most important to you in terms of COVID? It could be making sure that you protect the medically vulnerable people in your family, or making sure you never get the virus. Or it could be going about your business and your life as normally as possible while trying to have some level of safety. Next, do some basic risk assessment. What does the science show now and what is the CDC guidance? From there, come up with a few different options for your decisions, and weigh the pros and cons. You can then make a more fully informed decision that isn't just going off of instinct but incorporates information and science and also the realities of your life. This isn't how we usually make decisions. We're usually more off the cuff. But with COVID, in particular, this is a helpful approach.

I think we're also used to making a decision and being done, but COVID is forcing us to continually reassess.

One key component of decision-making is acknowledging and accounting for uncertainty. And we have had so much uncertainty over the past 18 months. You have to acknowledge that and deal with it. It's also hard because you get anchored on one specific approach and it can be difficult to make a change in your thinking after that.

Crystal Watson

Image caption: Crystal Watson

Studies have shown that vaccinated people appear to be protected from grave illness, but we're still seeing breakthrough cases. Should vaccinated people be wearing masks again?

The CDC is saying that there may be more transmission from vaccinated people than we previously thought. It's good that universal masking is coming back in health care facilities where medical personnel have a lot more exposure. I feel good about the CDC guidance, which says that in areas where delta is on the rise and we still have fairly low levels of vaccination, that extra level of protection of a mask can really reduce the transmission and blunt the peak of these curves. We have seen more and more data about mask-wearing and its effectiveness in helping reduce transmission. So, yeah, I think people in the areas where the transmission is high should probably think about wearing masks indoors in public, whether they're vaccinated or not. That may change over time. Hopefully delta will be gone or will be much reduced soon, and we can go back to not having masks indoors for everyone.

That's an interesting point: As COVID continues to mutate and run its course, it just might be that there are these shorter moments of time where masks are important again.

This is what I like about the CDC guidance. The recommendation is that if you are vaccinated and you are in areas where there is high or substantial transmission for the average person, then wear a mask. They also recommend it for people who are immunocompromised or have increased risk of severe disease. Also, if you have someone who's not vaccinated at home, or if someone at home is medically vulnerable, then you might still want to wear a mask in public, even if you're not in a high-transmission area, to give them that extra protection.

With schools beginning to open in person across the country, some states are leaving the masking choice up to parents. Is that wise?

Because most children are not able to be vaccinated right now, it's important that there is universal masking in schools for the time being. We've seen data from CDC that if schools are taking the precautions that they recommend, returning to school even during the pandemic is relatively safe. Even though kids are at lower risk of developing severe illness and dying from COVID, the more kids who are infected, the more deaths in children we will face. We also see that schools can drive community transmission. The safer we keep our schools, the safer we keep our surrounding communities. I know parents are facing really tough choices right now sending kids back to school. If every school had universal masking, we would be much better off.

"If we're in the middle of cold and flu season and I'm going somewhere that's really crowded, I would probably elect to wear a mask."
Crystal Watson
Senior scholar, Center for Health Security

Is your sense that parents who are epidemiologists are going to have their children wear masks?

It comes down to risk perception in any individual, and we don't all have the exact same risk perception about COVID-19, but I personally would like to avoid having my son be infected, so we mask.

With the delta variant so transmissible, do we need to reconsider what type of mask we wear?

The better the mask, the more protected you are. If you can wear a medical grade mask, that's a great precaution, but it's hard to wear an N95 for long stretches. If you're a kid sitting in a classroom, that would be a tough thing to ask all day. Wearing a well-fitted mask is important and if it's cotton, you want it to have multiple layers and make sure that there aren't any gaps in the sides or around the nose.

A lot of us have gotten casual with our masks. Do we need to consider mask hygiene with a higher viral load variant like delta?

We need to remind ourselves about mask hygiene, like trying to wash your cloth mask frequently as well as dispose of disposable masks after use. Try to handle them as little as possible. Make sure you're not touching the surface of the mask so that you're not transferring any potential viral particles to your hands. And washing your hands after you've handled your mask is really important still.

I know some people who never got a cold or the flu because they wore masks last season. Do you think people might start wearing masks more during normal cold and flu season now that they've seen the potential benefit?

We'll probably see some of that. If we're in the middle of cold and flu season and I'm going somewhere that's really crowded, I would probably elect to wear a mask. I also hope it's not just masks, and that people will be more diligent about getting the flu vaccine in the future. It's not a perfect vaccine, we know vaccines are not perfect, but it will give significant protection to people especially from severe illness and death.