(Un)Masking Mask Confusion
Last week, the CDC issued new guidelines regarding mask wearing for those who have completed the COVID19 vaccination. Governor Cuomo has announced that New York State will adopt those recommendations effective Wednesday of this week. For many, this is good news, as we all long to get back to normal activity, take off our face covers, and “re-open” society. But for others, the news is confusing and filled with uncertainty. After all, COVID19 recommendations and regulations seem to change weekly, as mask-wearing guidelines may come from the government, the CDC, Dr Fauci, and other “experts” opining on news programs and the internet.
The coronavirus pandemic has been a terrible experience for all of us. Collectively, we have been traumatized. It is not easy getting over the fears and anxiety that have dominated our conversations and activity over the past 14 months. Many of us have experienced great losses and are not confident that the crisis is slowly but surely resolving. With changing and so much conflicting information and misinformation promulgated in the media, it is difficult to distill facts from speculation and accurate information from fiction.
The CDC recommendations basically state that if you are fully vaccinated, you no longer need to wear a mask outside or inside, nor is physical distancing required in any setting, except when required by the workplace, local laws, or businesses. In addition, domestic travel is permitted without the need for COVID19 testing or quarantine. This means that weddings, graduation ceremonies, and other gatherings are acceptable—so long as you are vaccinated.
Thankfully, the COVID-19 vaccines are incredibly effective, even against some of the new, more virulent coronavirus variants. It is a modern miracle that scientists have developed safe and very effective vaccines in such a short time.
The new CDC guidelines are based upon science–newly published data regarding the effectiveness of the vaccines in preventing COVID19 infections and spread. For example, in the May 6 issue of JAMA, Israeli researchers presented data comparing the incidence of symptomatic and asymptomatic COVID19 infections amongst 6700 vaccinated and unvaccinated health care workers—a high-risk group. While some vaccinated individuals still contracted COVID19, the incidence of symptomatic infection was 30 times lower, and the asymptomatic infection incidence over 6 times lower. Additional studies have indicated that vaccinated individuals, even when contracting COVID19, are more likely to be asymptomatic or have mild disease and the transmission of the virus to others is negligible.
That means if you have completed the vaccination process, you can really dispense with your mask in most situations!
Some stores and businesses are relaxing their requirements for face coverings, but others still expect all entering to wear masks. This will be the case for travel on public transportation or air travel for some time, at least.
Some vaccinated people will choose to continue to wear masks, despite the new guidelines. In some cases, this may be for good reason: people with suppressed immune systems as a consequence of medications, autoimmune disease or cancer, may still face a greater risk of contracting COVID19 and we still do not know if the vaccines are as effective in this group of individuals…and that is fine.
But for most of us, once vaccinated, you can dispense with the mask! If you are going to be near others, especially those who have been vaccinated, you are safe! Even if exposed to an unvaccinated person, your risk remains quite low. Let’s say you are going to an event with a large number of people, many of whom you do not know. If conducted outside, you needn’t worry– the risk is minimal. If indoors, while the risk remains low, you might choose to wear a mask, especially if you suspect that many unvaccinated participants will be present– but even then, the risk remains low because the vaccines protect you.
What about children? Well, the Pfizer vaccine is now FDA EUA authorized for those ages 12 and older. And a similar approval is expected for the Moderna vaccine very soon. Children, in general, do not suffer serious consequences of COVID-19 infection in the vast majority of cases and they transmit the virus much less than adults. But it will take time to vaccinate the kids and more data will be needed before even younger children can be safely vaccinated. But if their parents and teachers are all vaccinated, COVID-19 infections in children will be minimized. Indeed, by September, it will be time to open all the schools and encourage all teachers and school employees to get vaccinated.
For those who have chosen not to be vaccinated, mask-wearing is still a must. You are still at risk of contracting COVID19 and spreading it to others. This means that we must rely on an “honor system” in which we expect that those who are not vaccinated will continue to wear masks. While we cannot necessarily trust that the unvaccinated will respect these guidelines, it is reassuring to know that the vaccines protect those of us immunized from catching the virus from unvaccinated carriers. In other words, you are pretty darn safe in most situations if you have completed the vaccination process.
In our office, we have all been fully vaccinated. We still require that anyone in the waiting areas or public spaces wear masks. But in the examining rooms, if you have been fully vaccinated ( at least 2 weeks following the second shot) then we encourage removal of face coverings in order to normalize interactions.
Still, despite the new guidelines, some people will choose to continue to wear masks. There are a variety of reasons for this, not the least of which is the trauma and anxiety that the pandemic brought to us. We should respect an individual’s choice to continue to wear a mask if they feel more comfortable. But we do need to start normalizing human interaction and return (mostly) to pre-pandemic functioning—and listen to the science.
On the other hand, if you have chosen not to get vaccinated, it is expected that you will continue to face cover. If you do not care about your own risk, that is your choice, but putting others at risk is not and we all have a responsibility to our neighbors.
The rate of new COVID-19 infection has been going down dramatically in recent weeks and the death rates have also greatly diminished. In large part , this is due to the vaccination program, in which about half of the adult US population have received at least 1 dose. Other factors, such as the warmer weather, as people spend more time outside, contribute ( the spread of COVID-19 is an indoor phenomenon and simply does not occur in outside settings).
But the goal of herd immunity seems unlikely at this point since it is estimated that over 70% of the world population must be vaccinated for this to occur. Right now, that looks like an unrealistic prospect. Instead, COVID-19 will probably be endemic, meaning that it will continue to be around and vary in prevalence, with episodic outbreaks in certain settings. So, we will need to maintain our immunity. We will learn over time how long primary vaccination works and whether and how frequently we will need boosters.
A word for those who remain vaccine-hesitant:
As of this writing, over 260 million doses of COVID-19 vaccines have been administered in the US and over 1.37 billion doses have been given worldwide. So, quite a lot has been learned. While we may hear about adverse reactions in the media, the actual risk of a serious reaction to any of the available vaccines is extraordinarily low. For example, concerns were raised about the Johnson and Johnson vaccine due to reports of potentially fatal blood clots following vaccine administration. But there were only 6 cases out of over 7 million persons vaccinated! A risk of under one in a million is much lower, for example than the risk of a blood clot while on birth control pills ( 1 in 10,000)– widely used by millions of young women!
There are indeed serious vaccine reactions that may occur, but these are quite rare. Vaccines that we have become accustomed to, such as MMR. tetanus, polio, influenza, pneumonia, and hepatitis vaccines all are associated with rare, but potentially serious adverse reactions. Oral polio vaccine, for example, may cause paralytic poliomyelitis in 3 persons per million doses given.
The important point about serious adverse reactions from vaccines is that they all occur within 2 weeks of receiving the inoculation. There simply are no instances in which adverse reactions developed months or years after any vaccination. As such, there is simply no reason to think that would be the case with the COVID-19 vaccines.
The amazing speed with which scientists and pharmaceutical companies developed safe and effective COVID-19 vaccines is remarkable. Some people have raised concern that vaccine development in the past takes as long as ten years. Thus, they fear that the unusually rapid development of COVID19 vaccines is worrisome and has not allowed sufficient time to ensure safety. But the coronavirus pandemic is like no other we have experienced in our lives. Thousands of scientists all over the world, supported by billions of dollars from government and private support have been simultaneously working on solutions to the crisis. This is not the case with other infectious diseases. The amount of “personpower” focused upon COVID-19 vaccinations is so great that effective solutions were achieved most rapidly, without taking shortcuts that might impact patient safety.
Recent data on COVID-19 vaccines in pregnancy indicate not only excellent safety, but effective immune responses that even protect the newborn infant!
Many have raised concerns about our patients with autoimmune diseases or who may be on immunosuppressive medications. Covid-19 vaccines in this population have not been shown to result in any adverse reactions that differ from the general population. A greater concern is whether the vaccines will prove as effective in this group of people. A less robust immune response has been observed with some other vaccines, such as flu and pneumonia, and also may depend upon which specific medications are in use. We will learn more answers to these questions over time. For our patients in this circumstance, I recommend the following: continue to wear masks when in public places, though this is not necessary outdoors or indoors in small groups with others who have been vaccinated. We can also measure your vaccine response with a blood test. If your COVID19 antibodies are present, then you may act as other vaccinated people.
Finally, I would like to address another concern that I have heard from vaccine-hesitant people.
Since the Pfizer and Moderna vaccines use mRNA to induce the immune response, some worry that this “changes” our DNA or may have a permanent impact on our genes. This is simply untrue and impossible. The body does not have the capacity to convert RNA into DNA. Moreover, mRNA has no ability to enter into the nucleus of our cells, where the DNA resides. The mRNA allows for the translation ( production) of coronavirus spike protein by our cells, which in turn recognize a foreign protein and mount an immune response and produce antibodies against it.
In the case of the Johnson and Johnson vaccine, a benign virus is introduced which does contain DNA, which codes for the spike protein. The virus cannot replicate and thus causes no problem in the host. The DNA is inserted into the nucleus, where it is transcribed into mRNA and then produces spike protein in a similar fashion to the Pfizer and Moderna vaccines. The piece of DNA which enters the cell cannot become a part of our own DNA because there are complex biologic mechanisms by which insertion into the genome is required and our cells do not have the capacity to do this. As such, our DNA remains unaffected.