As the ups and downs of the pandemic continue, how can we wrap our minds around the future?

The Arc of a Year

Life as we know it has changed over the past year. I remember coming into the hospital around the Christmas holidays of 2019 and reading about the novel Coronavirus in Wuhan and how it was lethal for the elderly. Come January 2020, the Infectious Diseases community was validating these reports, and some were starting to get really nervous. Do you remember February 2020, when the talk of shutting down borders became a possibility? Everyone, within and outside of medicine, scrambled to understand the actual threat, and what could or could not be done to prevent disaster. 

The most notorious date for me, as a parent, was March 13, 2020, when the Governor in our state (Michigan) passed the emergency order to close schools. For most parents, the 3 to 4 months that followed was a haze of virtual education, working from home, and locking down life as we knew it. I still have a bit of PTSD when I relive those memories--ones marked by fear, isolation, grief, and lack of clarity about the future. Then summer came, with hopes of at least the opportunity to venture out from our home, feeling the promise of fresh air, sun, and being able to see some of those we love (even if not necessarily touching those loved ones). We even escaped to a city that seemed to have squashed COVID-19, and although our kids behaved like caged animals set free, we felt a little wave of relief. At that time, Americans were still pretty skeptical about the effectiveness of masks, and many felt the mask mandates to be either overkill or a joke of an intervention. As we cautiously traveled this summer, we donned our masks, hoping they would be helpful and that we wouldn’t inadvertently spread or catch COVID-19 while traveling.

Late summer into early fall of 2020 was marked by hopes and doubts of returning to in-person education. For many parents, there was delight in seeing that many school districts made near-heroic efforts to get our youngest kids back into the classroom, with surprising success (it wasn’t perfect, but it was progress). We learned that it was possible, even though life and school looked different from the year before. The resilience and flexibility of kids across the country continued to shine through. We saw them adapt and even play competitive sports with masks on (again, not perfect, but progress). Masks became the norm for our kids and their classmates, and my husband and I made it through, week after week, without our kids getting sick or needing to be quarantined. Were these masks magic?

Next came late fall 2020. We watched with anxiety while most states were “wide open” and COVID-19 cases started to climb. By mid-October, anxiety was at a high for my region, the Midwest. By November, the worst fears were realized, we were in a COVID crisis. It wasn’t until strict guidance from our state health department really put a dent in the behaviors that were propelling a surge of cases in our state. While never easy, we saw our kids accept… and even at times understand… why the things that made them happiest had to be put on the back burner. Fortunately for our school-aged kids, many elementary schools were able to stay open. Despite surging cases in the US, we saw very infrequent cases of “secondary transmission” within schools—meaning that even if a child or educator came to school and was found to be COVID-19 positive, it very rarely resulted in another contact within the school contracting the virus. Keeping elementary schools open and operational during the pandemic’s peak for many states was truly an incredible feat! We felt an enormous appreciation for all the effort that teachers and administrators put into keeping our kids masked which in retrospect undoubtedly kept our schools open.

Then came January and February, when we felt like we were out of the scariest phase of the pandemic. As more of the public was getting vaccinated, we started to feel that glimmer of hope in returning to normalcy. Unfortunately we’re now riding the wave of another surge of COVID-19 in Michigan, and we’re all trying to make sense of the big rise of cases in a younger demographic, and… cope. So here we are, trying to think about how long this will last--how long COULD this last, and what we can do to prepare for the likely future.

What Have We Learned?

As I reflect back on the past year, there were many lessons learned; many things that are so commonplace now, they’re barely worth mentioning: staying home when you don’t feel well… washing your hands (not just after you use the bathroom); social distancing, or should I say physical distancing; optimize ventilation; avoid large groups; WEAR A MASK. Why do I put so much emphasis on the mask-wearing?

There is now a mountain of data that supports how incredibly important the widespread adoption of mask-wearing has slowed the otherwise efficient spread of SARS-CoV-2. And this is NOT to say that all the other mitigation strategies aren’t incredibly important. But mask-wearing stands out as THE intervention that has the most bang for the buck. Yes, we could get very technical about the different types of masks and the dynamics of the novel variants...but let me walk you through what data can tell us from the real world in the COVID-19 pandemic. And for simplicity, when I say “mask” I mean a surgical mask, or a double-layered fabric mask recommended by the CDC.

Success Stories of Masks

We love to go to science for burning questions that affect health. When most of us think about “science” we envision lab technicians in white coats, using pipettes and Petri dishes, doing cellular or animal experiments. While this is part of science, this vision of science has not been what has helped us navigate the ever-changing landscape of the COVID-19 pandemic—ESPECIALLY when it comes to human behaviors and the pace of the pandemic. Some of the most compelling data about mitigation strategies for COVID-19 have come from “real-world” or natural experiments, which are fancy terms for: studying what is already actually happening. These real-world experiences have been some of the most transformative in my understanding of the COVID-19 transmission dynamics, including the utility of mask-wearing.

Natural Experiments of Mask-Wearing

This summer there was a compelling publication that detailed the impact of masks in a salon in Missouri. Two hair stylists unfortunately tested positive for COVID-19 after they had been working. Both of these hair stylists had worn a double-layered cotton face covering or a surgical mask while working with clients; and by the nature of their work, they were in close proximity and touching their clients for extended periods of time. The stylist infected the people they lived with and co-workers (whom they mingled with, mask-free, in break rooms) but not a single exposed client was infected with SARS-CoV-2.

A couple other natural experiments are nice to show in contrast to one another, as outlined a Nature news feature. At Black Lives Matters protests in the US in the summer of 2020, most attendees wore masks, and these events were held outside. These BLM events did not correlate with spikes in infections. Contrast this finding with late June 2020 summer camps in Georgia, where children who attended were not required to wear masks; the virus “ran rampant” in these camps. These experiences are not directly comparable, most importantly because the summer camp participants slept in cabins with other attendees. It is very compelling that the BLM protests were on a much larger scale, yet these masked events did not lead to the outbreak that unmasked Georgia camps did.

When zooming WAY out to the population level, in August 2020 we learned about the risk of death from COVID-19 varied depending on government mandates for mask-wearing. One study by Howard and his team surveyed 200 countries over the first 5 months of the pandemic. In countries with mask mandates, compared to those without mask mandates, the weekly increases in per-capita mortality was FOUR TIMES LOWER!

This study supports that wearing masks reduces the chances of catching SARS-CoV-2, as well as reducing the likelihood of  passing it on to others. Other studies have mathematically modeled the reduction in deaths by mask-wearing in the US, with estimates that hundreds of thousands of lives have been saved by mask mandates in our country. But another important detail about masks is supported by these population-based studies, as well as a phenomenon supported by other scientific data: something called the “inoculum effect.” 

The Inoculum Effect

We think of illness in very binary terms at times: you either have something, or you don’t. However, what the inoculum effect shows us that it is NOT just whether you have COVID-19 or not, but HOW MUCH of the virus you’re infected with. A perspective article from the COVID-19 era summarizes research on the inoculum effect of the novel coronavirus as well as other viruses (from herpes to hepatitis B). The bottom line? When humans and animals are infected with a smaller dose of a viral inoculum (a.k.a. the dose of virus), they experience a milder or even an asymptomatic infection. Conversely, when infected with a large viral inoculum, the body produces a much more intense inflammatory response, which often results in more severe clinical symptoms. When you’re wearing a mask, you may not be 100% protected from contracting COVID-19. But if you wear a mask, you’re much more likely to take in a lower dose of virus, resulting in a milder infection… or no obvious infection at all! 

There are other trends we’ve seen in different parts of the country that tell me that mask-wearing has been incredibly impactful, especially as other mitigation strategies have gotten more lax. In my state, for example, in mid-November 2020, our state health department prohibited many activities that were often associated with inconsistent or absent mask-wearing. Of these, the most salient in my opinion was closing restaurants, which made it much more difficult to dine with people who live outside your household. I think this a very salient intervention because to eat you need to…. remove your mask. This frustrating but necessary sustained intervention (and yes, several other venues and activities were also prohibited) led to steady decreases in COVID-19 cases in my state.

A Safety Net Despite Lack of Certainty

We’ve certainly made progress with the pandemic, with decreases in viral transmission in most parts of the country for most of the summer of 2021. However, with the 2021-2022 school year on the horizon, there is much uncertainty of how the next year will unfold. As of today, there are consistent data and trends indicating that we are heading into the next surge of COVID-19 in the US, spurred on by the even more contagious Delta variant. We are currently witnessing that those who are unvaccinated (both old and young) are getting infected with SARS-CoV-2, and efficiently spreading it to others. While the most widespread vaccines in the US (the mRNA vaccines produced by Pfizer and Moderna) have very good protection against the Delta variant, we are finding that this variant is occasionally causing infections in those who have been vaccinated against COVID-19. With these emerging variants, increasing access to vaccines, and the much-anticipated data on how immunity (from natural infection and vaccination) will prevent transmission of this virus, it is simply impossible to predict how all of these, as well as unforeseen factors, will continue to shape the arc of the pandemic. 

However, we DO know that this coming school year has a few salient facts:

1. Children less than 12 have no access to COVID-19 vaccines yet, and will be at high risk of catching and spreading COVID-19 if no mitigation strategies are used in school.
2. Only ~30% of adolescents aged 12-17 years have been fully vaccinated against COVID-19; this percentage is not nearly high enough to keep the virus at bay in schools. 
3. Not all adults working in schools are vaccinated against COVID-19.

We also DO know that universal mask-wearing in schools is an inexpensive, widely available, and effective means of curbing the spread of SARS-CoV-2 and preventing COVID-19 from causing people to get hospitalized or die. While I can’t predict the future, I do think that masks will be part of our lives for the foreseeable future, and most importantly, are extremely important for this coming school year. The organization charged with promoting the health and wellbeing of children, the American Academy of Pediatrics (AAP), comprehensively evaluated the existing science on this topic, and recently published guidance on universal mask use in K-12 educational environments for this coming school year, and the CDC came into step with the AAP in short order. As a parent and a physician, I am relieved for this guidance heading into this uncertain school year, for the health of our children and communities. And frankly, I’m happy that we have this tool to protect our communities through the end of this pandemic.  

And as I heard one infectious diseases physician say on a podcast this Spring: mask-wearing is also a symbol. A symbol that I’m here with you, and I care about you. Protect yourself and protect others by continuing to wear a mask. 

Written by Rosey Olivero, MD

CSO and Co-Founder of Inspired Biometrics
7/30/21