It’s time to think outside the mask mandate

The pandemic is different than it used to be — but we’re still fighting about masks.

Vaccines that keep most Covid-19 cases from leading to hospitalization are now widely available, and many of those at highest risk have access to treatments to prevent severe illness. Nevertheless, public attention and policy are still focused on mask mandates, like the one Philadelphia reinstated on April 11.

Should it be? While these kinds of measures still have a role to play, they are arguably less important now than they used to be, said Jennifer Nuzzo, an epidemiologist recently tasked with creating a new Center for Pandemic Preparedness and Response at Brown University’s public health school. The state of the pandemic has changed, and public health authorities now have enough tools to take a more pragmatic and focused approach, Nuzzo argues — but our policies and public health approaches have not caught up to reality.

In our conversation, she outlined four areas where our thinking on the pandemic could use a reset. She calls for a better understanding of what masks can and cannot do; clarity on what testing really tells us; a pivot away from emergency measures and toward longer-term efforts to ensure equitable testing, vaccination, and treatment; and renewed focus on locally relevant data gathering.

Overall, Nuzzo wants Americans to better understand the breadth of tools that health departments, institutions, and individuals have at their disposal when Covid-19 cases rise — and why different tools might be better than others at getting us through this new phase of the pandemic. None of her favored approaches involve enforceable mandates, but they do require empowering public health departments to choose different tools for a different time.

This conversation has been edited for length and clarity.

Masking is neither the only nor the best preventive approach

Keren Landman

How are the goals of public health different now than they were earlier in the pandemic?

Jennifer Nuzzo

Our goal now is not to prevent transmission or even necessarily try to flatten transmission. It’s to keep people out of the hospital and prevent deaths. We need to keep our hospitals from being overwhelmed so they can continue to provide lifesaving care, not just for Covid patients but for every other thing that could bring someone to the hospital.

Keren Landman

During a big wave of infections, ensuring hospitals aren’t overwhelmed requires health departments to implement lots of preventive interventions, right?

Jennifer Nuzzo

Yes, but a lot of attention has been on whether or not people need to mask. That’s not the only intervention we have, and it’s not even the best intervention.

Look at South Korea and Hong Kong. They still had tremendous omicron waves despite very high compliance with public masking. I’m not opposed to masks by any means; I think they’re an important tool. But I think sometimes we’re overstating how much of an impact they actually have.

I also think public health mandates should be used sparingly and only when there’s no alternative — we could be doing more mask recommendations rather than mandates.

Wang Ying/Xinhua via Getty Images

Some people might have a mental model of “we’re gonna bring out the masks every single time we have a surge.” I don’t have a problem with that; it’s just hard for me to imagine societies are going to accept that.

I’m not sure masks are our most protective tool right now. Many of the people who are not wearing masks have already had Covid, so they’re like, “I’ve been vaccinated, I already had it — how much longer do you want me to do this for?” And it’s kind of hard to say, “No, you absolutely must wear it.”

I just think there are other, more important interventions than masking.

Keren Landman

Like what?

Jennifer Nuzzo

Look at how similar omicron waves played out in places like South Korea and Hong Kong, places that have had very high mask use in social settings and public spaces. Both countries just had this tidal wave of cases. It gives me humility in terms of what we can do to really prevent transmission.

But there was a big difference between Hong Kong and South Korea in that South Korea had a surge of cases with very little hospitalization and death. [Hong Kong saw high numbers of deaths among older residents.]

What did Hong Kong not have? High vaccine coverage. Only around 50 percent of their elderly and about 20 percent of their nursing home residents were vaccinated. That is a recipe for an explosion of severe illness — and that’s why they saw overwhelmed hospitals, because the people most likely to wind up hospitalized were not given the full protection they needed to prevent that from happening.

So, sure, we may need to use masks again. But above all, we need to make sure we get eligible people vaccinated — and, in particular, boosters for older people.

Will Lester/MediaNews Group/Inland Valley Daily Bulletin via Getty Images

Testing no longer provides a good snapshot of the pandemic

Keren Landman

What proactive actions should public health authorities be taking right now?

Jennifer Nuzzo

There’s a lot of other prevention stuff that we should be doing, and I feel like that gets lost in the culture war that we’ve waged around masks.

We are at a point where our surveillance [i.e., disease detection system] is far worse than it’s ever been, which matters not necessarily because we’re trying to prevent all cases, but because we want to spot changes in transmission dynamics early to prepare for a surge in hospitalizations. And that is harder now.

Rapid tests are great, but we capture none of their positives in our surveillance, so we have no idea how many infections are occurring in people’s homes.

There are economic disincentives to test [such as having to take off work in the case of a positive result] unless you’re sick enough to be hospitalized. Additionally, hospitalized people often have incidental Covid-19 infections. So our surveillance data is becoming biased toward severe cases.

One thing we could do is conduct anonymized population representative sampling to try to understand the demographics of who’s getting infected. That would help us understand the characteristics of the people transmitting and catching the virus at any given moment.

Keren Landman

You haven’t brought up wastewater monitoring or syndromic surveillance [tracking trends in health care seeking for flu-like symptoms]. How should we be using those tools right now?

Jennifer Nuzzo

Those tools don’t really give you the specific information to pinpoint where cases are rising and what populations are at risk — they’re very blunt indicators that something may be happening.

If you’re working in a public health department and you see these signal increases, that alone doesn’t tell you what to do. But you can use these data to say, “Hey, community, take additional precautions, because you have a higher probability of coming in contact with the virus.”

Between these waves, we should be using the quiet times to do the hard stuff, which is trying to vaccinate people, engaging with community groups, finding the homebound, trying to understand vaccine hesitancy, and talking to parents of kids about vaccination.

Lockdowns and mask mandates are short-term emergency measures. Right now we need equitable testing, vaccines, and treatments.

Keren Landman

Do you think mandates or other temporary measures are sensible approaches at this stage?

Jennifer Nuzzo

My worldview is that these other non-pharmaceutical interventions — masks, canceling things, and closing things — they’re really great when we’re in an acute emergency and we’ve got to buy ourselves some time. They’re a pause button; they don’t eliminate the virus, they just reduce the probability of exposure to it. But if we’re going to hit the pause button, what are we buying time for?

Not everybody has access to the things they need to follow these rules, the biggest one being the ability to work from home. Income is actually an important criterion associated with ability to comply with safety recommendations.

Public health departments have the option of reacting in a more targeted way, and that’s really what I hope for. At this stage, we have so many more tools. Mask mandates and shutdowns are really broad things that don’t particularly target the populations that are most at risk.

Keren Landman

What are some of those other tools?

Jennifer Nuzzo

Getting more rapid tests out into the community is important, particularly in low-access places. We started with mostly government-funded testing sites, but the private sector’s involvement in testing has created inequities. The urgent care centers and pharmacies where a lot of those are located don’t exist in certain communities.

Joe Raedle/Getty Images

It frustrates me that our approach to expanding rapid testing was internet-based. That also created inequities because not everybody has the ability and the resources to do that.

We haven’t done enough to make treatment more available — we need to work out the whole Paxlovid access issue. It’s still really, really hard for people to know if they qualify and where to get it, and clinicians don’t know how to give it. Improving that is absolutely something we can and should be doing. ... During a surge, test-to-treat programs are important.

We need more reliable sources of pandemic data, and more research

Keren Landman

Are there other tools that are underrecognized on the list of things health departments can or should do as rates tick up?

Jennifer Nuzzo

First of all, it really, really, really frustrates me that we don’t have a better understanding of where Covid is transmitting. I really want us to be investigating cases and doing mini- epidemiology studies — focused outbreak investigations to better understand how Covid-19 is spreading now, and how can we best try to limit that from happening.

Not doing contact tracing universally is understandable. The goals are different: Contact tracing is also aimed at tamping down cases. We wouldn’t have to do contact tracing for all cases, because instead of trying to stop transmission, we would be trying to better understand transmission dynamics.

I’d love health departments to do case control studies [which compare characteristics of infected cases and uninfected controls] to understand who is and isn’t catching Covid. That may prompt some understanding about what types of activities and exposures are most likely to result in infections. If you found that, locally, cases were rising in 2- to 5-year-olds, you would take a different measure to address that than you would if cases were rising in nursing homes.

I also wish we were doing more genomic epidemiology to understand who’s giving the virus to whom — but that’s something that you can’t start up in the midst of a surge, because it takes resources.

Keren Landman

I’m not sure if public health departments have the resources for a lot of these things.

Jennifer Nuzzo

I wouldn’t have asked them to do this at the end of December [during the omicron BA.1 surge] But now, there should be more bandwidth in the system to be able to do this. If there isn’t, that means we have no system.

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