Answering patient questions on mask

There have been stay-at-home orders, recommendations for practicing physical distancing and wearing masks as well as ongoing urging to get vaccinated and boosted against COVID-19. Yet, after more than two years of following this guidance, many people have grown tired and frustrated.

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This pandemic fatigue has led some to throw caution into the wind to find some sense of normalcy again. As many people search for a new normal and feel fatigued at this stage of the COVID-19 pandemic, it is still important to know the benefits of masking, recognizing that N95, KN95 and KF94 respirators provide the highest level of protection. A family physician sets out to clear things up about the importance of correctly wearing a mask or respirator to protect you and the people around you.

AMA member Jennifer J. Bryan, MD, a family physician in Flowood, Mississippi and a delegate in the AMA House of Delegates for the Mississippi State Medical Association, took time to discuss what patients need to know about the importance of masking at this stage of the COVID-19 pandemic.

Masks are still an important tool in 2022, even though we have vaccines and therapeutics that were not available for COVID-19 in 2020, said Dr. Bryan, adding that "masks are just one part of our armamentarium against the virus."

This is especially true when you are indoors in a poorly ventilated space with a lot of people—masking provides protection to you and the people who are around you. For example, when using mass transit such as airplanes, buses or subways, masking protects people themselves and those around them. Masks also help keep travel and public transportation safer for everyone. Wearing a high-quality mask or respirator is most beneficial in crowded or poorly ventilated locations.

In addition to being up to date with recommended COVID-19 vaccinations, consistently wearing a comfortable, well-fitting face mask or respirator in indoor public settings provides protection against getting infected with SARS-CoV-2.

"When you're judging COVID-19 community levels, there are multiple tools that you can use," said Dr. Bryan, adding that you can start on the website for the Centers for Disease Control and Prevention (CDC).

"But your state health department really maintains their finger on the pulse in the communities of exactly what's going on, even down to the county and community level within the counties," she said. "In Mississippi—and in other states—there is a color-coded system for the community level, so we look for that and it helps guide how we interact—the higher the COVID-19 community level, the more precautions we take."

For example, the CDC uses the colors green, yellow and orange for COVID-19 community levels, which refer to the measures of the impact of COVID-19 in terms of hospitalizations and health care system strain. Green means there are low levels while yellow is medium and orange is high. According to the CDC, at a low COVID-19 community level, people may choose to mask at any time. Masks are recommended in indoor public transportation settings and may be required in other places by local or state authorities.

At a medium COVID-19 community level, the CDC recommends that if you are at high risk for getting very sick, you should wear a high-quality mask or respirator. If you have household or social contact with someone at high risk for getting very sick, consider wearing a mask when indoors with them.

For a high COVID-19 community level, the CDC recommends wearing a high-quality mask or respirator. If you are high risk for getting very sick, you should consider avoiding non-essential indoor activities in public where you could be exposed.

"At the beginning of the pandemic when we were in the bandanas-and-homemade-masks stage, our patients were so wonderful at making the homemade masks and we were glad to have them because we found ourselves without personal protective equipment," she said. "So, choose an N95 or KN95 mask—those are great if you have them, especially if your loved one is at significant risk for severe illness due to immunosuppression or underlying medical conditions."

Surgical masks provide the next highest level of protection and cloth masks provide less protection.

In fact, N95 and KN95 masks were found to be 48% more effective than surgical or cloth masks, according to a CDC study. Wearing an N95 or KN95 mask reduces the odds of testing positive for SARS-CoV-2 by 83%. This is compared with 66% for surgical masks and 56% for cloth masks, further pushing the need to swap out such face coverings for an N95 or KN95 mask for protection from SARS-CoV-2.

"We were living in unique times in 2020 and we had division a lot on masks, about how we need to see each other's faces and we need to interact—the psychosocial piece as opposed to the infectious risk," said Dr. Bryan. "It's always been about weighing your risks—what is acceptable and reasonable risk and what is not."

"In 2020, the infectious risk of such a serious virus with no tools outweighed the psychosocial impact that we knew was there, but it was something worth temporarily dealing with to get through a serious situation that we had no tools to combat it with," she said.

But in 2022, we are dealing with COVID-19 variants that seem to be causing fewer deaths and hospitalization than previous variants, an indication that these variants may be less severe, but also negatively impacting our growing population immunity against the virus.

"I tell people: You’re not a failure even with your best efforts because at some point, you’re likely to get this virus," Dr. Bryan said. "Some people are afraid when they test positive because they have been trying so hard, but it's hard not to get BA.5—it's so contagious."

There is also the risk of long COVID or post-COVID conditions, which can include a wide range of ongoing health problems that can last for weeks, months or longer. While long COVID is foundbmore often in people who had severe illness, it can impact anyone who has been infected with SARS-CoV-2, even people who had mild illness or no symptoms.

"It's the spectrum of how we interact, and we hope that as time goes by, we’ll be able to make those judgment calls a little easier and understand that every decision is an individual one and there are a lot of different things that go into that," she explained.

"Many viruses that we have lived with for years were once ancient pandemics as we are living through the natural evolution of this type of virus," said Dr. Bryan. "It's getting more contagious, but it's also getting—thankfully—milder in the outcomes as it affects patients."

"As it affects a lot more people, you’re still seeing a significant number of hospitalizations and death," she said. "But it does make a lot of sense for an immunocompromised person to mask when they are around others."

People who are at higher risk for severe illness include those who are older, have certain medical conditions and are pregnant or recently were pregnant. Some of those medical conditions include cancer, chronic kidney, liver and lung diseases, cystic fibrosis, dementia or other neurological conditions, type 1 and type 2 diabetes, heart conditions, HIV infection, mental health conditions, obesity, physical inactivity, sickle cell disease, current or former smoker, stroke or cerebrovascular disease, solid organ or blood stem cell transplant, substance use disorders, tuberculosis and disabilities such as cerebral palsy and down syndrome.

For those people who are at an increased risk—and those who live with or visit them—wearing a mask or respirator that provides them with greater protection is important.

"Back in the South this summer in the middle of the Omicron BA.5 subvariant, we had a heat wave and people rushed inside to cool off in the air conditioning, and we had a surge in cases," said Dr. Bryan. "So, the weather can certainly affect what we do in both extremes of heat and cold."

"That's why we generally spread respiratory illnesses during the cold or winter months—because we are inside and we are sharing air," she said. "If there is a new variant that comes out and our immune system is not quite primed for it, then you may see what we just went through with BA.5 this year, but one would hope that it is less severe."

It is important to emphasize that masking indoors is the best way to protect yourself and those around you.

"In general, if you are sick, stay home, but in health care settings, the risk is different to physicians and our other health care colleagues because we come in contact with sicker people," said Dr. Bryan.

This is "because the infectious risk is increased and we want to protect patients as well," she said, noting that "we’ve also got lots of immunocompromised patients around, so masking is important."

"There is a significant amount of protection provided by masks even at the level of surgical masks and certainly increased within N95s," said Dr. Bryan. "But if you are in a room of people—and we know that COVID-19 is transmitted primarily in droplets or aerosol particles—and you have a mask on, the droplets are less likely to get through that mask.

"The mask really cuts down tremendously on that type of respiratory transmission," she added. "Now consider other factors like if you are vaccinated. If you are vaccinated, boosted and masked, you have significant protection there, particularly if you are immunocompetent."

If you are immunocompromised, it is important to properly wear a high-quality mask or respirator and remain up to date on COVID-19 vaccinates and boosters.

"There is also "Evusheld for our higher risk patients with the six-month protection going forward," Dr. Bryan said. "It is an antibody product, and all those things afford protection that make that situation either riskier or less risky."

Dr. Bryan added, "there's no place for mask-shaming anywhere."

It's a person's "decision to wear a mask, and it should be honored—we don't know who they’re protecting at home or what their own health condition is."

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