As the highly contagious COVID-19 Delta variant sweeps across the country—and many people remain unvaccinated—some experts are advising people to go back to the basics of prevention. For many of us, that now means wearing a mask again even if we’ve had the vaccine.
In late July, the Centers for Disease Control and Prevention (CDC) weighed in with new recommendations that fully vaccinated people go back to wearing masks indoors in public in areas of substantial or high transmission. Right now, this covers much of the country—the CDC map provides regular updates for anyone who wants to check virus activity in their state or county (it breaks it down into four categories: low, moderate, substantial, and high).
The agency has also urged universal masking for teachers, staff, students, and visitors in K-12 schools, regardless of their vaccination status and the intensity of community transmission in their area. That recommendation is in line with one from the American Academy of Pediatrics that all school staff and students over 2 years old should wear masks at school.
The July advisory was a stark turnaround from the CDC’s advice two months earlier that allowed vaccinated people to gather indoors without masks. But that was before the number of cases of people infected with the Delta mutation began to multiply, making it the primary SARS CoV-2 variant in the U.S.
Carlos Oliveira, MD, PhD, a Yale Medicine pediatric infectious diseases specialist, had recommended people hold on to their masks well before Delta became the dominant strain in the United States. “There could be spikes in [coronavirus] transmission for a variety of reasons,” he says. “And there is still a lot we don’t know, especially as the new variants continue to emerge and enter the U.S. It’s still unclear whether these variants will cause more breakthrough infections,” he says, referring to COVID-19 infections occurring in people who are vaccinated against the disease. While experts say such cases have been relatively uncommon and carry a low risk of severe disease, they are still learning about the potential for breakthrough cases with the Delta variant.
Sheela Shenoi, MD, MPH, a Yale Medicine infectious diseases specialist, adds that while the U.S. as a whole has made progress in vaccinations, rates of infections and deaths are still high in other parts of the world where overall vaccination rates are significantly lower. “I hesitate to say that we are approaching a post-COVID world when so many are still being ravaged by this virus,” she says. “If there is anything we should have learned in the past 16 months, it is that we are all interconnected; what happens in one part of the world affects everybody.”
The CDC’s changing mask guidance
The new CDC recommendations pull back from the guidelines the agency announced in May that allowed all fully vaccinated people to resume most activities without wearing masks both indoors and out (while following local, business, and workplace guidelines).
CDC Director Rochelle P. Walensky, MD, PhD, said the May recommendations were made under different conditions, when the Alpha variant was circulating. Since then, the more transmissible Delta variant upped the risks.
The CDC continues to keep restrictions in place for unvaccinated people. They do not need to wear masks in outdoor settings, but are urged to consider wearing one if they are in a crowded outdoor setting and for activities where there may be close contact with others who are not fully vaccinated. And everyone, vaccinated or not, is required to wear a mask on planes, trains, buses, and other forms of public transportation, and indoors in hubs such as airports or stations.
Even when recommendations changed in May, Dr. Shenoi continued to wear her mask inside at stores and at work, partly because she was interacting with people and had no way of knowing whether they were vaccinated. “There's nothing that's ‘safe’—it’s always ‘safer.’ If you are fully vaccinated, it is safer than it was a year ago to be around people without a mask,” she said.
Both Dr. Shenoi and Dr. Oliveira planned to keep wearing masks when out of the house alongside their children, who are too young to be eligible for a vaccine. Dr. Oliveira says his greatest concern is for children exposed to adults who could be infected, since the majority of infected children got COVID-19 after exposure to an infected parent or other adult. He suggests parents do whatever they can to limit a child’s exposure to unvaccinated people. “My advice—if your children can’t get the vaccine by the time school starts—is to make sure they are with immunized people outside of school,” he says. “Try to get everyone in the family who can get the vaccine to get it.”
Karen Jubanyik, MD, a Yale Medicine emergency medicine specialist, stressed the importance of wearing a mask among people who have compromised immune systems, whether they are elderly or taking immuno-suppression medications, or if they are an organ transplant recipient or have a condition such as cancer that affects the immune system. “The vaccinations weren’t well tested in those populations, and we remain concerned that the vaccines might not be as effective in them,” Dr. Jubanyik says.
In keeping with the new CDC recommendations, Dr. Jubanyik also said the decision to wear a mask is important when considering the potential for breakthrough infections and geographic location. The vaccines are highly effective, which is good news for any given person, but across 350 million people in the U.S., that's still a lot of potential infections, she says. “That means you have to know the status of where you are and where you're going. There are pockets in this country and entire other countries where there aren't many people who are fully vaccinated and infection rates are high. I think it is important to realize it could be potentially dangerous to you, as well as other people, to not wear a mask.”
Can your mask protect you from colds and flu?
COVID-19 is not the only reason to reconsider your mask. After a 2020-21 flu season that has been described as one of the mildest ones in memory, some experts are concerned about what the next flu season will bring now that fewer people are practicing social distancing and are more likely to be exposed to germs. Some doctors say they are already seeing colds and other respiratory illnesses rush back.
“More typical viral infections have already started re-emerging,” says Dr. Shenoi. Cases of respiratory syncytial virus (RSV), a common respiratory virus that can be serious in children, immuno-compromised, and older adults, is already ticking upwards in some places in the U.S. “It’s problematic because we are still in the COVID-19 mindset, so anyone who is sneezing or has a runny nose may think they need to get tested for COVID-19,” she says. “It’s particularly hard for parents. Under normal circumstances—before COVID-19—kids would have a sniffle going on from November to March, and we knew to expect that.”
Dr. Jubanyik also urges adults to consider wearing masks during flu season this year if they are at risk for or interact with people who are vulnerable to complications from the flu. “Because the flu hits you all of a sudden—you may feel fine even though you are potentially contagious, then all of a sudden you have a fever of 102,” she says. In fact, Dr. Jubanyik has long worn surgical masks on airplanes during flu season and carried extras to offer people sitting around her. “Usually about half the people take me up on my offer,” she says.
Can a mask help cut down on allergy misery?
Prior to COVID-19, few would consider wearing a mask to limit allergy symptoms. But, “Masks provide significant protection from airborne pollens in people who suffer from allergies,” says Florence Ida Hsu, MD, a Yale Medicine allergist. She says that her patients have found wearing masks while outdoors to be helpful in decreasing seasonal allergy symptoms such as sneezing, runny nose, and nasal congestion.
“I absolutely recommend considering face masks when spending time outdoors, particularly on windy days—as well as wraparound sunglasses to decrease the chances of getting pollen in your eyes,” Dr. Hsu says. “As a side note, pollen in the eyes can lead to nasal symptoms—not just ocular symptoms—since tears carrying allergens can get into the nose through the tear ducts.”
Dr. Jubanyik specifically advises wearing a face mask when you or a neighbor are using a lawnmower or leaf blower. “My husband has significant allergy problems and he finds that wearing a mask when he’s doing yard work is very protective,” she says.
Making a personal choice about masks
Wearing a face mask has been a topic of debate among some Americans; however, masks are part of the culture in some Asian countries, where people wear them to protect from circulating viruses like the flu. The habit took hold after those countries were hit hard by severe acute respiratory syndrome (SARS), which led to more than 8,000 infections and almost 800 deaths in 2002-2003.
Research done this past year in the U.S. shows that masks, worn properly, do offer some level of protection against COVID-19—and this may make masks especially important for people who haven’t had one of the vaccines here. One study from the CDC showed that, within 20 days of the implementation of mask mandates, there were significant declines in COVID-19 case counts and deaths in the areas that made the ruling. This may be especially important information for anyone exposed to Delta—while scientists are still studying the variant, one study found it to spread two to three times faster than the original virus.
There's nothing that's ‘safe’—it’s always ‘safer.’ If you are fully vaccinated, it is safer than it was a year ago to be around people without a mask. Sheela Shenoi, MD, MPH, a Yale Medicine infectious diseases specialist
However, it’s unclear how people will react to new mask mandates here in the U.S., where individualism prevails. “I’m not sure it has sunk in how interconnected we are—that what one person does affects the next person, affects the neighborhood, affects two people down the chain—and all that can have consequences,” Dr. Shenoi says.
At the same time, maybe COVID-19 has led some Americans to think about masks in a new way, Dr. Shenoi adds. “Now that we’ve lived through this, I think masks are much more familiar to us. We know how easy it is—how straightforward it is—to wear a mask. We’ve learned that this is doable.”
Meanwhile, there are still unknowns surrounding COVID-19. Unanswered questions include: What is the potential for more Delta outbreaks and other new variants of the virus? Could masks help in those cases? Should people worry about the rare infections in people who have been vaccinated or partially vaccinated? How long will the vaccines protect us? What will happen when families gather for the holidays?
The decision about continuing to wear a mask may depend not only on such factors as how prevalent the virus is in your geographic locations and whether you are fully vaccinated, but also on how old you are and whether you or someone you live with is immuno-compromised.
“Maybe after another full winter, we can say with more confidence that for COVID-19, the mask can probably go away—if we want it to,” Dr. Oliveira says.