Universal masking in school work.  New data shows just how well

In many schools in the US – in line with trends across the country-the only masks seen lately were those of Halloween costumes. Mask requirements were generally dropped in the spring of 2022 when the first wave of Omicron subsided and The CDC has changed its recommendations on masking, replacing universal masking with masking driven by high case and hospitalization rates. Since then even when Masking is recommended by the CDC given a high category for the community level, schools and other indoor facilities have rarely reinstated the requirement. Keeping children healthy and learning is uppermost in the minds of parents and educators. But clearly the persistent central question is a simple one: Do universal school masking requirements actually work?

A a new study in the New England Journal of Medicine throws some light on this matter. The authors examined cases of COVID-19 in Boston-area districts following the Massachusetts Department of Elementary and Secondary Education (DESE) repealed mask-wearing requirements in schools across the country in February 2022, in accordance with CDC guidelines. What followed was a natural experiment in the impact of mask requirements, as school districts removed the requirement at different points in time or did not remove it at all. Two school districts (Boston and nearby Chelsea) maintained the requirement throughout the study period.

The authors found that COVID-19 rates were similar among districts before the mask requirement was lifted, then diverged rapidly, with higher case rates in districts immediately after the mask requirement was lifted. Approximately 12,000 cases, or 30% of all cases during the study period, were due to the lifting of the mask requirement. The resulting illnesses led to a significant loss of personal school days – an estimated minimum of 17,500 days of absence from school for students and 6,500 days of absence for staff – arguing for masks as a critical component to optimizing learning.

An important finding of the study is that school districts that maintain a mask requirement are more likely to have school buildings in poor condition, overcrowded classrooms, and a higher proportion of people more vulnerable to adverse health outcomes, including those with disabilities, than more affluent neighborhoods that raised mask requirements. All other things being equal, the risk of transmission of SARS-CoV-2 is higher in buildings with insufficient ventilation and filtration and with more people in smaller spaces, so the need for protective measures such as masks is greater in schools with lower resources. The importance of this protection was further heightened as other mitigation measures, including contact tracing, physical distancing, COVID testing and quarantine of close contacts, were lifted at the same time.

Wealthier communities may feel they can expose more easily because of the lower risk of transmission and because of higher vaccination rates. The study suggests that this perception is incorrect, as cases increased significantly among schools that removed mask requirements, despite the fact that many were better-resourced schools structurally better prepared to avoid and mitigate disease. Although the study did not capture the wider contribution to community transmission, excess cases tend to place a disproportionate burden on the health and financial well-being of less well-off community members. Therefore, allowing wealthier communities to drive decision-making around mask requirements is not only unfair, but threatens to widen it.

Fixing the inequity requires giving under-resourced schools a central voice in policy decision-making and making tangible and immediate investments in those schools to make them safer. Apart from investing in the schools themselves, which will have multiple benefits for learning and health after COVID-19additional measures to protect students, staff and their families include sick leave and other structural benefits that help increase vaccination and revaccination rates and equitable access to health care.

Overall, there are some who will be quick to dismiss the new study’s findings, arguing that masks do not work to reduce the transmission of SARS-CoV-2. The evidence is clear on this point. Masks can block and filter the aerosols that carry SARS-CoV-2and better masks work better; this study supports previous evidence that mask policies in communities prevent transmission by providing data specifically on policies in school settings. Although there are challenges for schools, including mask compliance, the lack of N95s designed for young children, and the need to remove masks at lunchtime, there are many high-quality masks (such as KF94 or KN95) which work well for children and are extremely comfortable. The study by Cowger and colleagues did not have information on the types of masks worn in the Boston area, but in multiple school districts communicated the importance of higher quality masks to combat more portable options and made these masks freely available to students.

So what should we make of the new information provided by this study? As a school nurse, environmental health researcher, and emergency medicine physician, we find this information compelling and important for action. Right now, pediatric practices and hospitals are overcrowded with COVID-19, RSV, flu, and many other respiratory viruses, and winter and the holiday season (when things usually get a lot worse) are right around the corner. Student and staff absences are increasing at the beginning of this school year, the fourth academic year affected by COVID, but the first without consistent protective measures. The exit ramps were clear once universal masking was over; these are the ramps that are not accessible or fair.

Although the “mild” illness has provided the rationale for low concern about COVID among children, the sheer numbers in the winter spike will mean an increased burden on the health care system and many more cases of serious complications such as long covid, among children. Now is the time for schools to develop specific disease mitigation plans. Short-term mask requirements based on clear indicators and targets and with the provision of high-quality masks to families can make a big difference. This will keep children and staff in school and parents at work.

The strategic use of masks should be seen as a primary means of increasing learning – not the other way around – because children cannot learn when they are sick at home, in the hospital, or when their instructors are sick. Any strategy must also include suitable accommodation, including routine masking, regardless of CDC community level, for students at high risk for severe COVID-19 due to immunocompromise or other conditions. This approach can be widely used by any organization that wishes to improve worker protection, play a role in limiting community transmission, and ensure that public spaces are accessible to all.

The new study by Cowger and colleagues confirms this we have the tools to protect both the health of our students and their learning. Now is the time to really use them, but are decision makers in schools and in local, state and federal government paying attention?

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