Masking Rollbacks May Create More Disruptions For Our Kids, Experts Say
What happens in schools when mask mandates are lifted?
With Omicron now receding, Covid-19 policies are changing rapidly. Case levels are low in many places, and vaccines are proving effective at preventing severe outcomes, but with mask mandates and other mitigation measures ending, it can be hard for parents and families to understand how the new policies will affect them — and what might play out in their kids’ schools.
On Friday, the Centers for Disease Control and Prevention unveiled new guidance for Covid-19 risk assessment that’s based on county case rates and hospitalization. Instead of community-wide mandates, the new guidance focuses on people managing their own risk. Notably, the CDC also no longer recommends universal masking in schools, except during what they define as “high” levels of Covid-19.
After the announcement, the governors of New York, Oregon, California, and Washington all set expiration dates for their school masking requirements. That leaves only one state that still requires masking in schools — Hawaii.
The effects of removing masks won’t be fully understood for several weeks as the new policies go into effect. But as a new model shows, increased school disruptions are a very real possibility, even at levels the CDC considers “low.”
What role do masks really play in keeping us safe right now?
This isn’t an easy question to answer, and there are conflicting studies on how much masking reduces Covid-19 transmission. But masking is one layer of a so-called “Swiss cheese” policy, says Daniele Lantagne, a professor of community health and civil and environmental engineering at Tufts University. Different mitigation measures like masking, quarantining, testing, good ventilation, and vaccination layer over each other, ideally so the holes in each layer don’t line up. Some mitigation measures (like vaccination) provide greater absolute benefits, but it can be difficult to disentangle the effects of one mitigation measure (like testing and quarantines) from the others alongside it (like masks).
Removing this one part of the system could cause other disruptions. Aside from potentially increasing in-school transmission of Covid-19, widespread mask wearing also underpins shorter quarantine policies, which means less missed school.
“It's OK as cases go down, to remove mitigations,” says Lantagne. Mitigation measures that are removed, like masks, may need to be restarted if local conditions deteriorate.
Many states have made masks optional for students for months, but tracking the outcome of these policy changes is difficult. Individual districts may require masks even when state governments don’t, and even in schools without mask requirements, many students may still wear them. Places that have made masks optional have also made other changes, says Andrea Ciaranello, an associate professor of medicine at Harvard Medical School, like ending contact tracing, testing, and quarantines. As a result, there’s a lack of data that could clarify the likely outcomes from removing masks.
Often, it’s not clear what metrics are driving policies. Without clear policies and guidance about the conditions that do require masks, removing them can feel unpredictable and haphazard instead of liberating.
‘There’s nothing magical about schools in terms of Covid transmission.’
Corisa, an elementary educator in north New Jersey who asked to use only her first name, says she’s happy to wear masks when necessary but feels they make it harder to connect with her students. While she’s “thrilled” about the upcoming end of mask requirements, she says the development feels arbitrary. “What metrics are even being used to say that it's OK all of a sudden, to not wear masks?” Corisa says, adding that clear metrics would also allow educators to have confidence that masks would return if necessary.
A new modeling study published in January suggests that schools that go without masking should prepare for in-school transmission. For the study published in JAMA Open Network, a team of doctors and public experts created a model based on typical elementary school. Only when cases were exceptionally low could masks be removed without increasing cases in the school community.
The study’s thresholds were well below what the CDC counts as a “low” level of Covid-19 in a community.
“There’s nothing magical about schools in terms of Covid transmission,” says Ciaranello, one of the study’s authors. Ciaranello says that removing mask makes other mitigation measures — ventilation, hygiene, access to tests, staying home when sick, masking when returning from isolation — even more important.
“People are having a lot of conversations about what the mitigation should be,” says Ciaranello, “without being really explicit about what the goals are.”
The potential for more quarantines
Goals are important when it comes to maintaining consistent in-person schooling for students, says Ciaranello. Previously, the CDC stated that masked interactions in school did not meet the definition of a close contact, and therefore such kids didn’t need to quarantine. But the public health agency hasn’t updated its guidance for K-12 schools and early childhood education centers since rescinding the recommendation for masking in schools.
Based on her team’s model, Ciaranello says schools that remove masks should expect an increase in in-school transmission and exposures, as well as more cases in the school community. This will likely be true except in communities with very low case rates that also have high vaccination rates.
Corisa says there hasn’t yet been any guidance about how the end of masking will interact with quarantine policies in her school. Teachers like her, she says, would be unlikely to support the end of masking if it meant more students were at home quarantining.
“For us, the most important thing is having the kids in the building every day,” Corisa says.
Lantagne agrees that it was important to fix quarantine policies before moving on to masks.
The CDC has previously endorsed a test-to-stay policy for school and child care settings as an alternative to quarantines, though it’s not clear if this stance will change post-masks in schools. Lantagne also highlights the potential for test-if-symptomatic policies, a related option.
In a test-to-stay policy, exposed children can continue to come to school if they are testing negative on rapid antigen tests at regular intervals. Tests are given to all children regardless of symptoms. Under a test-if-symptomatic policy, exposed children are only tested if they develop symptoms. This can save resources while still catching infections, Lantagne says. The experience of Somerville, Massachusetts, shows the stark math underlying the switch. Out of 8,000 tests performed on 1,600 students, Lantagane says, there were only 13 positives. That community, like the rest of the state, has now moved to a test-if-symptomatic policy. The data was collected when masks were required.
The same rationale underlies both policies: that in-school transmission rates among masked students have been so low that quarantines do not prevent enough new infections to be worth the learning loss they create.
Lantagne says that only after ending quarantines, provided there was low community transmission, would she advocate for ending masking rules for older kids.
The role of vaccinations
Lantagne says she considers vaccination “a crucial piece of Swiss cheese” that allows other mitigation measures to be removed faster but does not favor hard vaccination thresholds. “I do think if we start setting targets related to vaccination at high levels,” she says, “we'll see differences across class and race groups in the United States that I think will lead to inequity.”
In contrast, Dr. Monica Gandhi, a professor of medicine at the University of California, San Francisco, says she would not recommend ending school masking until the state or region’s vaccination rate hits 70% and hospitalizations fall below a rate of 10 per 100,000 people each day. (To compare, the new CDC guidelines give communities a “low” level rating when they have seven-day case rates below 200 per 100,000 people, fewer than 10 new hospitalizations per 100,000 people, and less than 10% of inpatient beds occupied by Covid-19 patients. The new guidelines do not include vaccination rates.)
Even with the CDC’s updated labeling, huge swaths of the country are still considered to have “medium” or “high” levels of Covid-19. Communities with “high” levels should adopt universal masking in schools, the agency said.
Against this backdrop of mask rollbacks, there are calls for a more data-driven and nuanced approach to Covid management. Urgency of Equity is a group of public health experts advocating for an evidence-based approach to managing the pandemic that foregrounds equity.
“We can have really good conversations about tradeoffs,” says Julia Raifman, an assistant professor at Boston University’s School of Public Health and part of Urgency of Equity. “We can only get through this together.”
Raifman says that it’s important to discuss the range of harms Covid-19 has wreaked on kids. Estimates suggest that more than 140,000 children have had a primary caregiver die of Covid-19, with the highest rates concentrated among Black, Hispanic, and Indigenous children. About 1,339 kids have died from Covid-19 to date. “In public health, I look at the absolute numbers,” says Raifman. “It’s something we could have prevented.”
After two years, sadly, we still haven’t learned that data can help us make informed decisions. The effects of mask rollbacks will become clearer over time. Unfortunately, as states stop contact tracing and collecting data, it can become difficult to monitor the effects of mitigation policy changes. If the Omicron surge is any indication, school districts may be likely to reinstate mask requirements if conditions worsen. And if they don’t, the consequences of future surges — teacher and student absences, bus driver shortages, needing to fall back to remote learning, will be felt even more acutely.
This article has been updated with a correction to the number of pediatric deaths from Covid; it is 1,339, not “more than 1,400” as we originally reported. The overcount was due to a coding error by the CDC, which has since updated its findings with the revised numbers.