Q&A: Clearing up the mask confusion

Keene physician offers context to ever-changing guidance
Keene Mask Protest

Protesters at an August 2020 anti-mask rally in Keene.(Michael Moore-The Keene Senitnel)

The best protection against serious illness, hospitalization, and asymptomatic transmission during the Covid-19 pandemic continues to be getting fully vaccinated. But with the state’s vaccination rate seemingly stuck at 54 percent, masks look to be with us for at least the next several months.

We asked Dr. Aalok Khole, an infectious disease expert at Cheshire Medical Center in Keene, to help decipher the Centers for Disease Control and Prevention’s ever-changing masking guidance, when we can put masks away for good, and whether you really need a KN95 mask. He knows we’d rather not be having this conversation 18 months into Covid-19, but he also thinks we have to.

“For sure, you’ve got to think about yourself,” Khole said. “But you’ve also got to … think about the others around you, which may be your friends, your family, and other community members. We’re truly all in this together. And it’s individual actions that’s going to help us get out.”

Initially, we were told not to mask. Then masks were recommended only for health care workers. That guidance has changed several times. Now, even the vaccinated are supposed to mask. Why all the changes?

The short answer? Learning curve.

Prior to Covid-19, asymptomatic transmission – a significant challenge in managing this pandemic – did not exist, Khole said. So, infectious disease experts initially recommended what had always been the best defense against viruses: Those with Covid-19 symptoms were told to stay home or mask.

“We were all going by data, which said there is no data to support (masking) for everyone,” Khole said. “And as we got to know more, we said, OK we need to think about this in a different way.”

That new understanding collided with a dangerously limited supply of all personal protective equipment, masks included. Health care workers were prioritized because the surge in cases, hospitalizations, and deaths made clear we needed them to keep safe and working

That increased understanding of science prompted new masking guidance. States adopted mask mandates and shut down non-essential businesses to mitigate spread.

Those restrictions were gradually lifted in the spring of 2021 with the arrival of the vaccine. As vaccination rates climbed, mask mandates disappeared, and by summer, in most settings, only the unvaccinated were advised to mask.

“What we saw was that once people are vaccinated … the risk of them getting infected is lesser, and their ability to shed virus for prolonged durations also decreases,” Khole said. “That’s where CDC changed its guidance.”

That guidance changed again with the arrival of the highly contagious Delta variant, and more specifically, the Provincetown, Mass., outbreak in July, where more than 300 people who tested positive were fully vaccinated.

Experts noted at the time that the vaccine prevented almost all of them from being hospitalized, but the high number of “breakthrough” cases led the CDC to recommend masks for all people in all settings because it was the safest approach.

“That’s why it’s gone back and forth and led to this confusion,” Khole said. “But it’s always been driven by science.”

Even guidance on masks became confusing, with health care experts initially saying cloth masks were ineffective. What kind of mask should we be wearing?

“I think the blanket rule to follow is, use something which ensures two things: fit and filterability,” Khole said. And one mask, not two, is sufficient.

Homemade cloth masks were discouraged, Khole said, because they had not been tested or standardized, both disqualifiers in the healthcare world. That changed as evidence demonstrated a cloth mask’s ability to significantly reduce the transmission of respiratory droplets.

To be useful, cloth masks must have at least two layers to be effective, which is why single-layer neck gaiters are not recommended. Masks should have an internal piece that can be pinched around your nose and fit snugly, without gaps around your chin and cheeks.

There is no need to get an N95 or KN95 mask, which differ mainly in that the first is the American standard and the latter is the Chinese standard, Khole said. And it may actually be counterproductive to do so because the CDC estimates that 60 percent of N95 masks on the market today are counterfeit. (If you do opt for an N95 mask, the CDC keeps a list of approved manufacturers on its website.)

“In times of distress, rumors fly around … and there’s this heightened level of anxiety, everyone thinks N95 is better,” Khole said. “Again, I think what we’ve learned is, keep it simple. Fit, filterability, continue distancing and hygiene, and stay away from anyone if you’re sick or if they’re sick. I think that goes a long way.”

Does my mask protect others only or does it protect me too? This messaging has also changed over time.

“It does both,” Khole said. “The primary reason was to protect others from you potentially shedding and not knowing about it (because you are asymptomatic).” But it’s also protecting you from someone else who may be around you and shedding virus.

Are there some health conditions where you would recommend not wearing a mask?

No, Khole said, but there may be other reasons and circumstances that dictate different mask use. The CDC recommends clear masks for people who need to see words spoken, such as people with autism or other disabilities, those who are deaf, and students learning to read or speak a new language.

Parents in this state have filed lawsuits against mask mandates, alleging they are unsafe, even harmful, for children. Is there any truth to this?

“There’s no data or science that is saying that,” Khole said. “I think one of the issues we are battling in this pandemic is misinformation. And I think, whether it be social media or just any other resource that they’re getting this news from, tends to dominate what they hear.”

When can we stop wearing masks, and how do we get there?

“It’s not like one fine day we wake up and say, Covid-19’s done,” Khole said. “It’s going to linger on for years, but we need to get to a point where people can function normally in their lives.” That path there starts with vaccination, he said.

Natural immunity from getting Covid-19 provides some protection, but it comes with risks of serious illness, even death, and it doesn’t last as long as immunity provided by vaccination, Khole said.

Can you foresee continued use of masks, even after we slow Covid-19 transmission rates?

Possibly, Khole said, but by choice, not mandate.

During last year’s flu season, when everyone was masking, the hospital did not have a single patient test positive for influenza, even with widespread testing. Colleagues who have severe allergies told Khole they did not suffer their usual symptoms because they were masking.

“If we’re able to reduce the morbidity and mortality associated with other respiratory viruses that haunt us usually September to March and we know what works, then why not?” Khole said. “However, it’s going to be a big step to move in that direction, to convince people, but it’s not unheard of.”

Glasses and masks are not a good combination. Any secrets for eliminating fogged lenses?

Not much good news here.

Khole has tried the anti-fog spray and didn’t find it helpful. Closing any gaps between your mask and your face is the best bet, he said.

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