We Need to Talk About an Off-Ramp for Masking at School

Mandatory masking at schools has been among the biggest issues in the country over the past few months, with instances of mask opponents berating and threatening school board meeting attendees. The topic has become highly politicized, and it’s sure to get even more contentious now that the Food and Drug Administration has authorized the emergency use of the Pfizer-BioNTech vaccine for children ages 5 to 11.

Linsey Marr, an engineering professor at Virginia Tech who studies the airborne transmission of viruses, said that when she tweeted about a potential timeline for lifting of masking rules once 5- to 11-year-olds start getting Covid vaccines, she was flooded with replies from all sides.

“I’m almost afraid to talk about it, because people have such differing and strong opinions on this topic,” she told me. “I put my thoughts out there, because we need to figure this out. The vaccine should change things for us, and we don’t want kids to wear masks in school indefinitely.”

Some folks replying to Marr were adamant about the need for masks in schools as long as Covid is with us, especially to protect immunocompromised children and children under 5, who still won’t be able to get vaccinated. But that argument might assume that there are no downsides to children wearing masks all day, every day, indefinitely, which is something we can’t say with certainty.

The Covid pandemic is mostly unprecedented in our lives, and “we don’t have the data on what two years of masking children in an early learning environment has to do with their socio-emotional development,” said David Rubin, the director of PolicyLab at Children’s Hospital of Philadelphia and a professor of pediatrics at Penn’s Perelman School of Medicine.

It’s worth noting that the World Health Organization’s website says, “In general, children ages 5 and under should not be required to wear masks.” That contrasts with guidance from the Centers for Disease Control and Prevention that “masks should be worn indoors by all individuals (ages 2 and older) who are not fully vaccinated.” (It’s easy to see why people find this all very confusing.) Additionally, there’s concern that children with speech difficulties, or who have autism or sensory challenges, may be hurt by all-day mask wearing.

Because the masking issue has been so divisive, I fear we haven’t been able to have a practical, nuanced and data-driven conversation about what a good masking policy would look like now that nearly all school-age kids can soon be vaccinated. In some big cities and blue states, kids are wearing masks constantly, including outdoors, even though, as The New York Times’s David Leonhardt reported in May, the science indicates that “masks make a huge difference indoors and rarely matter outdoors.” Some red states, meanwhile, prevent schools from requiring masks. None of this makes sense.

To get a feel for what an off-ramp for in-school masking could look like, I interviewed 11 experts over the past week, including pediatricians, infectious disease specialists and environmental scientists who specialize in indoor transmission. It became clear that this issue won’t get sorted out easily, because these experts weren’t always unanimous.

But it’s time to start a serious discussion about taking off masks since it will take time to institute policies after communities — hopefully — come to some degree of consensus. Maybe the carrot of mask-free schools will inspire some more hesitant families to get their children vaccinated.

At this point, only about a third of parents say they’ll get their 5 to 11-year-olds vaccinated as soon as possible, with about a third saying they’ll wait and see, and a third saying they won’t, or will vaccinate only if it’s mandated, according to September figures from the Kaiser Family Foundation’s Covid-19 Vaccine Monitor. As one commenter on a Times Opinion guest essay put it, “Literally the only thing motivating me to get my kid vaccinated is removing mask mandates.”

First, we should talk about where there is widespread agreement among experts: Every person I spoke to said children 5 and up should get the vaccine. The other point of significant agreement was that masks can be useful tools in our Covid prevention kit, along with measures like proper ventilation and widely available rapid testing.

Out of these 11 experts, two felt it was too soon to start talking about removing masks. “We will need to see the level of vaccine uptake in kids to have a more informed conversation about masking in youth-based groups and organizations,” said Nia Heard-Garris, an assistant professor of pediatrics at Northwestern University and a pediatrician at the Lurie Children’s Hospital of Chicago.

Of the nine others, there were a range of responses, which I’ll place into two major buckets.

Set a Date

Monica Gandhi, a professor of medicine at the University of California, San Francisco, and associate chief of its infectious disease division, said in an email that with vaccine authorization for children 5 to 11, “it makes most sense to me to lift mask mandates in schools (and for adults) once children have the ability to get both doses of the vaccine” — which, in an ideal world, likely means around eight weeks after shots become widely available. Gandhi said, “I am a firm believer in positive motivation and messaging and think making this metric explicit will convince more parents to vaccinate their children.”

Marr, the engineering professor, tweeted that two weeks after school restarts in January should be the earliest date under consideration, because children may pick up the usual non-Covid bugs during the holidays. She also said that she liked the idea of data-driven mask policies based on the level of virus spread in communities. Some experts, like Aaron Carroll, a professor of pediatrics and the chief health officer at Indiana University, was wary of setting specific dates, in case another highly infectious variant like Delta hits. Which brings me to …

Create Unmasking Metrics, and Make Them Local

Many experts I spoke to mentioned Nevada as a model for how schools might think about creating off-ramp policies for masks. What’s nice about the state’s policy for indoor masking is it also provides a ramp back on if there are Covid surges — “an on-and-off switch based on local transmission rates,” as Boston University’s Julia Raifman and Alexandra Skinner described it.

The state uses the C.D.C.’s Covid-19 County Check Tool to assess whether there is low, moderate, substantial or high transmission. If there is substantial or high transmission in a county, masks are required in indoor public spaces. If there is low or moderate transmission, masks can come off. (Experts don’t agree about what level of community transmission should prompt a move toward unmasking in schools — some think the level can be higher than in the broader community because Covid-related illness in children tends to be less severe; others think the level would have to be lower because many schools have outdated HVAC systems.)

“Something that is important about mask policies is that they are the opposite of lockdowns,” said Raifman, an assistant professor of public health. Masking helps reduce the amount of Covid in shared air, and it allows kids to avoid remote learning, something that just about all of us agree we’ve had enough of.

Another appealing aspect of using local transmission levels to assess the need for masks at school is that it applies to all children, regardless of vaccine status. “I like the link to cases and not to vaccination,” because there are such large inequities related to vaccine status, Raifman said, and removing mask policies during periods of high transmission “just concentrates the risk” among these under-vaccinated communities.

The Need for Some Measure of Certainty

Whatever individual communities and states decide about what makes sense for them, part of the reason it’s necessary to talk about concrete benchmarks for unmasking is because the pandemic has created, for some, deep uncertainty. As the American Psychological Association reports, its new survey finds that “decision-making fatigue is having a disproportionate impact on parents.” “Almost half of parents reported that sometimes they are so stressed about the coronavirus pandemic that they struggle to make basic decisions (e.g., what to wear, what to eat)” — compared to just 24 percent of non-parents who feel this stressed.

Moving the conversation on masking at school forward, no matter how complicated it is, may give these stressed parents hope for a more certain future. My hope is that we can start to approach these discussions with less rancor and more empathy, and acknowledge that often there is no absolute right answer.

“Everyone thinks science is yes or no,” said Yvonne A. Maldonado, chief of Stanford Medicine’s division of pediatric infectious diseases. “Science is constantly evolving. The only thing that’s certain in this world is death and taxes. People think we have a crystal ball, but we are using the data to do the best we can do today.”

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