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  • Writer's pictureDr. Bow Tie

Masks in Schools (With Some Help From Dr. Chang)

Updated: Sep 6, 2021

Both my hometown in northwestern Pennsylvania and my current city in Western New York have entered "high-transmission" levels of spread of COVID-19. We’re still doing better than much of the rest of the country, where many of my colleagues are seeing worse numbers and hospitalizations even compared to a year ago, but things could still worsen here. In addition, students are returning to school now and/or soon. As transmission has increased, mask mandates are back in schools, and maybe beyond.

I can't tell you how to feel about it, but I, for one, am grateful for the protection of children that I know and do not know. There is a pervasive myth that children are unaffected by COVID-19, but Delta variant has shown us just how wrong that is. Children are being hospitalized at higher rates than ever before, and dying, too. And no, we cannot chalk this up to "some kids will die every year no matter what." These deaths are PREVENTABLE.

The body of evidence shows handily that masks work (article with references in the comments). People love to look at videos of lone doctors standing at a podium claiming otherwise, but either those lone folks have few or poor studies to back it up, or their results cannot be reproduced (which is pretty important in scientific research).

Further, where schools have restarted we have already seen exposures resulting in temporary quarantines or virtual school - which again, could be prevented! So everyone in schools, from students to staff should wear masks. Ventilation is also key along with spacing.

None of these are 100% effective - we know this. No one has ever said otherwise. But they are layers of protection against COVID-19 exposure and infection. People will ask about COVID being airborne (vs. spread solely through droplets), but again, we have seen that even cloth/surgical masking does help in real-life situations.


Parents, you should also come up with a plan in case you need to go virtual/keep kids quarantined. If you or your family has had an exposure or especially if they show symptoms, YOU SHOULD NOT SEND THEM TO SCHOOL. Discuss it with your pediatrician or family doctor or the Department of Health if there is a possibility, and if they are exposed, find a way to keep them at home and avoid exposing other children. There are already so many stories I've seen of kids whose parents called their doctors for COVID testing after multiple days of symptoms - that's exposure every day. The same goes for teachers - school districts MUST allow for sick/quarantine leave. Below is a recent CDC MMWR of a teacher who exposed her students to her COVID-19 infection, yielding multiple positives. Maybe not all of them were serious infections, but who knows who else may have been affected?


It's Labor Day Weekend. I work all weekend, and that's okay. If you're going out to parties, concerts, whatever...please be wary. If you're going to be among close friends who are vaccinated, especially in an open area, great - mask off and have fun. But if you're in a crowded area, indoors or outdoors, and you don't know everyone's vaccination status, then you should wear a mask to prevent spread, especially if you have children. Stay out of my hospitals, and keep your kids from having to go next door to the children's hospital.


And please, for the protection of yourselves, your families, and everyone's children, if you're 12 years old or older, get vaccinated. A majority of the hospitalizations and deaths happening right now are preventable. Let’s prevent them.

* * *

After I posted this, someone quickly responded with "Show the numbers, Joe!" and mentioned the AAP's statistics on children, which state that mortality is 0.03% among children cases; he also stated how tired he was of "fearmongering." To which I responded: "Yes, that number is nice and small, but it’s still 1400 preventable dead children. That, to me, is too many. It’s not fearmongering to wear a seatbelt, stay within traffic lanes, and obey traffic laws - similarly it’s not fearmongering to prevent the spread of infection with masks, desk spacing, ventilation, and vaccinations.

That 0.03% also does not include the kids traumatized by hospitalizations or who may survive but develop post-acute sequelae of COVID-19 (PAS-C, or “long COVID”), which is a much, much larger number which could also be prevented."


That person also brought up an article discussing the UK's lack of mask restrictions. My old friend/classmate and physician scientist Dr. Arthur Chang chimed in: "Taking your question / inquiry by what I think you're asking since the article spends a lot of time talking about what they do *instead* of masks. But feel free to correct me if I'm misunderstanding. Let's break down a lot of components to your statement.

First off, it's the UK (and to some degree England and not even the whole UK) and not Europe so to be precise about your statement there are differences in strategy between the UK and various countries in Europe. As you can imagine there are also differences within European countries as well so I will admit the following is somewhat of a generalization from their socieites. The Association of Schools of Public Health in the European Region and the European Academy of Paediatrics put out a position a few months ago that masks can be helpful, but are not to be viewed as a perfect panacea (no one is suggesting masks are a perfect panacea even in the US). https://www.frontiersin.org/.../10.../fped.2021.580150/full

Regarding the UK, which is what your article highlights, they have adopted a more aggressive test and quarantine strategy in lieu of masking. So it's not mandated but what is mandated is twice weekly testing and 10 day quarantines and aggressive contact tracing. The study the NYTimes article points out is showing that test based strategy for isolation was noninferior to a automatic isolation by contact tracing. So the current going forward strategy based on their late spring experience with delta (we'll get to that in a second) is to test regularly, and test more often in the case of a positive, and isolate for 10 days in England. Other parts of the UK (Scotland, Wales, and northern Ireland) have some other differences in their local protocol. The BBC summarizes the current state here (https://www.bbc.com/news/education-51643556)

Regarding the statement about studies and transmission with schools. That's not necessarily the case and a lot of nuance is required in interpreting the English/UK/ or even European data. So sticking with England, since that's the article you linked. One can judge the data a few different ways. So transmission / cases did increase with the delta era even with the current English strategy. However then it took a dip. There's a variety of reason for that. One, delta hit earlier in the UK than it did with the US so it's a little trickier comparing the effects of school. two, once schools ended for summer break transmission dropped in kids. There is debate with this data because the dip started before schools let up, but it was more obvious after schools did. Obviously if people aren't congregated in school we'd expect transmission among kids to be lower. 3) the issue for most of Europe (and especially the UK) that makes comparisons with the US more challenging is there was not nearly as much vaccine hesitancy as we have. Particularly in the UK, they also had a decent supply of vaccines that their European colleagues struggled somewhat with.

The short of it is that, for the US, it's not really an apples to apples comparison. That's not to say that we can't draw lessons from their experience. But particularly when it comes to numbers in their kids it's really hard to say what impact the no mask things had compared to the other factors at play that also contribute to the numbers.

I think the easiest thing to take away from looking at other countries in general is that a lot of things can help and a lot of things can hurt and we can see what happens with changes within a respective country. If you haven't heard about the "swiss cheese" model of mitigation this is a good example of this. England has elected to be very aggressive with testing and isolation and they had an OK time with that so perhaps them relaxing on masks didn't impact that as much precisely because they had other strategies in place.

So for the US, we don't have that kind of aggressive testing or tracing. We're experiencing the delta wave way later than they did and now we're adding school into the mix (compared to the UK where they were "taking school out of the mix"). So personally I don't think it's unreasonable increase the importance of masks for our circumstances.

I'd also make the case that the proper comparison looking at other countries is to add /remove masks from their mix and see what happens. If we looked at England (hypothetically) with what they're doing now and add mask wearing in. I'd imagine they might have a decrease in cases among kids. Now it's reasonable to ask, for them, is that decrease worth it? That's a separate question, but we aren't England / UK / Europe. Our circumstances are different and we have to make comparisons with other countries with that in mind."


And then he added this, which is incredibly important: "One other thing I wanted to add in general is that taking this one big old step back because I think we forget the context for this is we can talk about numbers but that also is missing another aspect to this which was more commonly discussed earlier in the pandemic, but hospital capacity.

Earlier in the pandemic pediatric hospitals suffered the opposite problem because we were very aggressive with lockdown we decrease the number of general infections in kids (RSV in particular). We are having a massive surge of RSV and the fear is when you add COVID on top of it we will face the issue that the south / adult hospitals faced which is a capacity one. Several children hospitals are at capacity already and even in the north the RSV wave has hit us. My concern is adding even a small COVID wave in kids will push us over the brink.

NPR has highlighted this problem in an article today. https://www.npr.org/.../childrens-hospitals-coronavirus...

Like what we saw with adults, focusing only [on] COVID is misleading. Once hospitals are full, all care will suffer. Here's an example of it happening in Texas of a person with a treatable condition dying because their region was overwhelmed. For kids specifically, I know of kids with cancer who's admissions are being delayed because their hospital is full with RSV and now COVID.

I would encourage people approach the questions of masks and restrictions with a more community-minded framing. ’How many people will I help by doing ____’."


Arthur remains a gem.

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