Fewer and fewer are wearing a mask. Why? And is this wise?

Filed Under: Costs, Patients, Providers

doctor wearing mask

It seems like overnight: The practice of wearing a mask has changed

I went to a memorial in New York City recently at which maybe 6 people of the 125 or so were masked. My social media feeds are full of pictures of unmasked people.

A colleague went to a party at a bar in Coney Island where she was the only person masked. (People sought to make her feel better by saying they should probably be masked too.)

My friends who are traveling are telling me few people are masking — in airports, airplanes, stores, wherever.

The Broadway League announced this week that it was putting into effect a mask-optional policy for all theaters, beginning July 1.

“Last week, six out of the 11 cast members of the acclaimed Tracy Letts play, ‘The Minutes,’ were out sick,” Ginia Bellafante wrote in The Times. “One of them, Blair Brown, now in her 70s, has been especially cautious over the past two years, staying away from restaurants and public transportation. She did not understand how the League would periodically reassess the need for masks — which it has committed to doing — considering that there is no system for tracking transmission in theaters.”

Airlines that dropped masking rules this spring found that they  had to cancel flights because of Covid-related staffing shortages, CBS News reported.

We often hear from people who aren’t masked that they are vaccinated and even boosted. Yet we all know that vaccines don’t prevent illness — they reduce serious illness and death, but they don’t erase serious illness and death. So vaccines should be used in concert with other tools: Masking, distancing, outdoors meetings, good ventilation and other common-sense practices like handwashing.

We also hear frequently “I already had it” or “everybody’s going to get it anyway,” which we find to be utterly senseless and depressing. Previous infection does not prevent subsequent infections.

Mask mandates have changed over time — first masks were supposedly not good, then suddenly they were good, then they were required in certain places. And then mask mandates were selectively applied and relaxed. The public health messaging on this has not been consistent. The topic has been highly politicized,

So why should we continue to mask?

The science on reinfections and wearing a mask

What are the science-based arguments? Well, for one, masking can be a protection against infection or re-infection. Vaccines are not a guarantee of good health.

Chart of covid re-infections

A new report on Covid reinfections is quite concerning,” Eric Topol writes on his Substack. “It’s currently a preprint but these same authors with access to the US largest healthcare system, the Veteran Affairs, have published numerous eye-opening studies during the pandemic, in leading peer-review journals, on topics which include Long Covid cardiovascular outcomes, diabetes, breakthrough infections, the toll on mental health, and kidney disease. I have not previously seen any substantive differences from their preprints compared with the final publications. So with that context let’s look at their findings from >250,000 people with 1 infection, ~39,000 people with 2 or more infections, and nearly 5.4 million uninfected controls. It’s the first study to characterize the risks of reinfection.

“The first finding is the comparison of people with reinfections vs those with only 1 infection. Note the doubling of all-cause mortality, cardiovascular, and lung adverse outcomes, 3-fold risk of hospitalization, and impact on other health domains. The absolute excess burden is shown on the right panel.

He also noted the “dose-response” effect of multiple reinfections. “By that I mean with additional episodes of Covid, for every outcome there was a stepwise increased risk, both relative (left panel) and absolute (right panel).”

What is the cause of the rising re-infection rate? “Obviously these findings are worrisome since reinfection was quite rare before the Omicron wave hit, at 1% or less through the Delta variant wave,” he writes. “But now reinfections have become much more common. Why? The Omicron BA.2, BA.2.12.1, BA.4, and BA.5 have progressively increased immune escape and there is limited cross-immunity with BA.1, the Omicron version that about half of Americans got infected with early in 2022.”

Viruses lurking in the body, causing problems years later

The prevalence of long Covid — and the idea that a mask can prevent you from getting long Covid — is another reason to mask. An increasing body of research is linking long Covid to a resurgence of a previously existing disease: Lyme disease, for example, or Epstein-Barr virus (EBV), which causes mononucleosis in a certain percentage of people.

“Although the mechanisms of SARS-CoV-2 are different from those of true latent viruses – the coronavirus might not stick around in the body as long as or in the same ways as, say, EBV – scientists are looking at reactivation of latent viruses, and other existing post-infection syndromes, for answers about long-haul COVID-19,” Melina Walling writes for The Arizona Republic.

“Dr. Janko Nikolich-Žugich, the head of the immunobiology department at the University of Arizona and co-director of the Arizona Center on Aging, said he and other researchers are interested in examining the relationship between long COVID and latent viruses because it is ‘probably the interplay between the host and the viruses that will determine why one person got (long COVID) and the other person just sailed through,’ he said.”

Other mechanisms for long Covid are also under study, Walling writes. Amy Proal, a microbiologist at the PolyBio Research Foundation, discussed “potential biological factors contributing to long COVID, including latent virus reactivation and dysregulation of the microbiome,” she writes. “According to Proal, the condition may very well represent a continuum of different effects within the body.

‘In one person, for example, a reservoir of SARS-CoV-2 may lurk in the intestinal tissue, sending inflammatory signals to the brain and resulting in sickness, nausea or other nervous system symptoms.

“But in another person, the coronavirus could have been cleared from the body, and yet it may have also caused a reactivation of Epstein-Barr virus in the process and disrupted the microbiome – eventually resulting in those same or similar sickness, nausea and nervous system symptoms.”

EBV has also recently been linked to multiple sclerosis.

Reinfection is not trivial

Commenting on this on Twitter, Dr. Deepti Gurdasani, an epidemiologist, wrote: “So, the idea that ‘infection is inevitable, so what’s the point?’ seems deeply flawed, given every single dose increases risk of dying, being hospitalised, or having an organ system affected significantly and substantially.”

We don’t know what the actual current infection rate is — because of the surge in home tests, which are generally not reported consistently to central health repositories. We also don’t know what new variants are on the horizon, so we need to look at what current variants of Covid are doing in other countries.

BA.4 and BA.5 are spreading fast in other nations. In Portugal, for example, a highly vaccinated nation, those variants are surging to press the nation’s death rate from all causes to the highest level since the vaccine campaign began, writes Katelyn Jetelina, an epidemiologist who writes on Substack.

This Financial Times graphic measures hospitalizations, with the BA.4 and BA.5 in bright red on the far right.

chart of covid infection rates

Ba.4 and BA.5 now make up 35 percent of U.S. infections, Jetelina writes.

Vaccines are the first line of defense against serious illness and death, Jetelina writes, but the bottom line is this: “This virus continues to mutate to escape our first line of defense causing (re)infections. If you don’t want to get sick, it’s time to leverage other layers of protection, like masking. Thankfully, other immune system mechanisms continue to work to reduce severe disease. The transmissibility of the virus is causing upswings of hospitalizations and deaths among the most vulnerable of our populations.”