Mask use associated with fewer school and daycare closures, study finds
Managing this phase of the Covid-19 pandemic is about tradeoffs. If masking decreases school closures, so be it.
Whether to keep school and childcare programs open during the pandemic has been a lightning rod issue. I’ve long believed that with frequent testing, mask use, proper ventilation, and other community mitigation efforts, in-person schooling and childcare could continue in most circumstances, even during Covid-19 outbreaks. I’ve also argued that closures due to Covid-19 could be safely avoided or safely shortened by using rapid testing. In other words, Inside Medicine readers have probably figured out that extremists in both camps have often been wrong in their assessment of school safety during the pandemic. Naturally, I’ve eagerly awaited data on whether masking kids during the pandemic, especially those under age 5, was associated with decreased school or childcare closures.
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A new study appearing in JAMA Network Open studied that exact question. Researchers found that school and childcare programs that used masks had markedly fewer closures related to Covid-19 than those that did not, even after controlling for other variables. The study covered the initial outbreak of the pandemic in the United States and after, through June 2021. Programs that maintained masking for the entire study period reported 14% lower rates of closure than ones that did not. Researchers also looked at whether masking only the kids (46% of whom were ages 3-5), only the adults, or both made a difference. Masking both kids and adults was associated with fewer closures, while masking only the kids or only the adults appeared insufficient.
This makes sense given what we know about mask use in schools. For most of the pandemic, admittedly low-quality masks have been used by the public, especially in kids, for whom high-grade masks are not generally available. The less effective the mask, the more people must wear them to maximize the group’s benefit. That means that those who can mask should do so, especially in schools, so that the children who absolutely can’t wear masks—due to legitimate medical or psychological problems—are protected by the others.
That the new study found masking to be associated with fewer school closures was not the only good news. (Indeed, if we are going to mask our kids, at least let it be effective!) This study also provides justification to cease-and-desist on a bunch of other inconveniences that were assessed and found to have had no correlation with fewer school closures, including daily symptom checklists (wow, are these annoying), staggered arrival and departure times (inconvenient), outdoor drop-off and pick-up (meh). None of these practices had any effect on school closures due to Covid outbreaks. That’s great because it means we can and should drop them. If they don’t help, what’s the point? Also, a catalog of unnecessary tasks like these may seem like tiny asks (and small potatoes), but they add up to genuine and earned resentment among the public. Maybe if we don’t insist on a lengthy checklist of daily ineffective rituals, people will do the things that do help. Hygiene theater is annoying. But more importantly, it undermines our credibility when we come with requests that do make a difference. It’s fine for us to change with the evidence. I’d be worried if we didn’t.
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To me, one of the strangest squabbles during the pandemic has been around masking. Masks don’t prevent all infections, though they clearly prevent some. For most of the population, masks amount to a nuisance. I certainly don’t enjoy having to wear them at work or in indoor public settings.
But let’s face it, masks are not the scourge that some unhinged activists would have you believe. My own child started wearing a mask to preschool in the fall of 2021, as have all the kids in the school ages 3 and up. No incidents. No problems. Nevertheless, I’ve literally been accused online (though probably by bots) of child abuse because we allow our 3-year-old to go to preschool in a mask.
Kids seem to do well with masks in school, for the most part. If masking decreases school closures during major outbreaks, then they are helping kids.
Are masks harmful to kids, especially ones under the age of 5? This was always a valid, if an overblown, concern. Biologically, there is no known harm (the most infamous study claiming that was retracted in disgrace, but not before nearly 1 million people read it, making it one of the most read articles in the history of JAMA Pediatrics, despite being online for just 17 days).
But what about child development? The fact is, there are no serious studies suggesting that intermittent masking—which is what masking at school amounts to—confers any serious or lasting effect on child development. Knowing that this fear is what they’d be up against, the authors of the study I’ve been discussing here wisely devoted a paragraph to the topic late in their paper. Because it was so well written, I am reproducing it below, rather than summarizing it (I’ve added hyperlinks to other studies they cited to their prose):
"Concerns have been raised regarding the potential for social and developmental delays when younger children wear a face mask for prolonged periods because of lack of recognition of emotional cues. Notably, these are point-in-time studies, and how quickly children adapt and recognize other emotional cues, such as body language, is not known. Evidence suggests that school-age children can identify most emotions in masked faces. Two-year-old children recognize spoken words better through an opaque mask compared with a clear face shield, suggesting verbal communication to infants is not harmed by face masks. We are unaware of published research on the long-term effects, if any, on intermittent masking. For medical care, most children 4 to 10 years of age did not prefer unmasked health care professionals to masked health care professionals and did not fear health care professionals with masks."
–Murray and colleagues, JAMA Network Open, January 27, 2022.
Nevertheless, mask panic persists, data be damned. Anti-maskers are all-too eager to blame masks (and not the virus itself, oddly) for any and all manner of evil befalling our children during the pandemic. A recent opinion in the Washington Post calling for optional masking in kids old enough to wear highly effective N95 masks (which does not include young children) whined that children have been taught that they might spread Covid-19 to their parents, which, they argue, had caused kids to internalize the harmful message that they are nothing but dangerous disease vectors, and a health threat to their own families. This, they propose, has damaged youth mental health. With over a 140,000 US children (or 1 in 500, with disproportionately high rates in minority populations) having lost a parent, custodial grandparent, or grandparent caregiver to Covid-19, my larger concern isn’t that kids have been made to feel badly for having spread Covid-19 to a loved-one who dies—though indeed we should combat such stigma and blame. My concern is that that awful message appears to have been correct in some instances. Instead of sweeping this all under the rug, as these writers would have us do, pretending the problem doesn’t exist—and trust me, the kids can piece it all together without our help—let’s maybe try to do something about this.
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In-school masking is a simple intervention which should be gated to community case counts (or enacted when a school outbreak is detected). We should not do this permanently and our policies should not be one-way streets. We can mask kids temporarily during significant outbreaks, and not mask them the rest of the time, when the risks are literally orders of magnitude lower than they are right now with Omicron still rampant.
Alas, zealots have trouble with nuance. Nowhere has this been more apparent than in the school and mask debate. At the extremes, some zealots would have schools stay open without masks, without testing, without nuthin’, heedless of how bad an outbreak has become. As I’ve said before, if we try to ignore SARS-CoV-2, the virus eventually makes the decisions for us. Ignoring the virus will not make it go away. It just means its presence gets detected too late to control it, forcing schools to close, and a few children to become gravely ill or die.
The evidence is mounting: masking helps keep schools open and that helps kids. That’s a worthy trade-off, in my mind. Sure, in a post-pandemic world, we’ll be able to keep schools open without routinely masking anyone. But for as long as the pandemic rages on, we will face choices like this one: masks or more school closures? If throwing a mask on my kid keeps her in school more of the time, I’ll take it.
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