A growing number of public-health experts are urging the Centers for Disease Control and Prevention to recommend that even fully vaccinated people wear masks in public amid the resurgence of virus cases fed by the delta variant.
Doctors, including former Surgeon General Jerome Adams, say the CDC acted prematurely in May when it announced that fully inoculated Americans would no longer need to wear masks in most situations. That move was broadly seen as part of efforts to incentivize people to get the shots.
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Adams said the different rules for the vaccinated and unvaccinated and the impression that Americans could let down their guard sowed confusion that has led to a higher rate of infections.
"The execution was poor, and the results speak for themselves," Adams, who currently practices anesthesia in Indianapolis, said in an email interview. "Low mask usage, slowed vaccination rates and exploding cases."
Covid-19 fatalities in the U.S. surged 48% over the past week to a daily average of 239, and hospitalizations are on the rise as the more transmittable version of the virus spreads rapidly. The CDC says the delta variant now makes up 83% of all sequenced covid-19 cases in the U.S., up from 50% at the beginning of the month.
Unvaccinated people account for 99.5% of covid-19 deaths in the U.S. and 97% of hospitalizations. Although the vaccines are highly effective against the virus, there is still a small risk that vaccinated people will get sick.
There's also a risk that fully vaccinated people will spread the disease to the unvaccinated, including to children who aren't yet eligible for the vaccine. That's why, despite being fully vaccinated, people may want to take extra precautions by wearing masks indoors or in crowded areas.
"There has definitely been a shift in terms of perception of the virus, especially among those who are vaccinated," said Krystal Pollitt, an assistant professor of epidemiology at the Yale School of Public Health. "It's important for the vaccinated to continue masking, especially in places that have lower rates of vaccinations."
CDC Director Rochelle Walensky said Thursday that the organization was sticking with its recommendations that fully vaccinated people don't usually need masks, while allowing that wearing one may have some advantages.
"Communities and individuals need to make the decisions that are right for them based on what's going on in their local areas," she said. "You get exceptional protection from the vaccines, but you have the opportunity to make a personal choice to add extra layers of protection if you so choose."
The highly transmissible delta variant has prompted many countries to rethink their public-health strategies against covid-19.
Last month, Israel lifted most of its restrictions, but days later reinstated the requirement to wear masks indoors. On the other hand, England lifted all of its lockdown restrictions Monday, just as the U.K. saw the world's biggest increase in infections.
The U.S. is the only country in the world that has different mask rules for vaccinated and unvaccinated people, a framework that's difficult to enforce, according to Monica Gandhi, an infectious-disease expert at the University of California-San Francisco.
"This has led to a lot of confusion," she said.
Gandhi suggests that the CDC use metrics such as hospitalization rates to set its recommendations, and said that mask wearing indoors and in public spaces needs to be normalized in areas where infections are widespread.
MASK MANDATES
Facing a resurgence in coronavirus cases and hospitalizations, St. Louis on Friday became the latest major U.S. city to revive its mask mandate, joining Los Angeles in requiring face coverings indoors.
The mandate takes effect Monday and will apply to everyone, even vaccinated people, in indoor public places and on public transportation. It comes a little more than two months after the city lifted the rules, which had been in place since last summer.
Officials said the move was designed to combat the spread of the hyper-transmissible delta variant. The situation is particularly dire in Missouri, where vaccinations have lagged and the case rate among the unvaccinated is now as high as it was near the state's peak of infections in January.
"If our region doesn't work together to protect one another, we could see spikes that overwhelm our hospital and public health systems," Fredrick Echols, acting director of health for St. Louis, said in a statement. "The City and County health departments are taking this joint step to save lives."
Similar moves are being discussed around the country, from the Bay Area to Manhattan, and there's been a steady drumbeat of comments from health officials lately advising the public that a return to masking may be around the corner.
"We certainly are seeing a surge in cases with the delta variant, which is now dominating in this country," White House medical adviser Anthony Fauci told Fox News on Friday. "So it's quite understandable why local authorities are now saying, 'Good that you're vaccinated, but in a situation where you have people indoors, particularly crowded, you should wear a mask.'"
But the renewed push for masking is prompting a wave of backlash and reigniting debate that raged last year over how to combat the pandemic.
In Los Angeles County, some local leaders are seething over the requirement to wear masks indoors, saying the top-down approach only creates confusion in the sprawling urban area, where circumstances differ from one community to the next. Some officials have gone so far as to demand resignations and threaten to cut ties and form their own public health departments over the mandate, which took effect last weekend.
In Arkansas, where cases are spiking and vaccination rates are among the lowest in the country, Gov. Asa Hutchinson, a Republican, says a statewide ban on mandates passed by the Legislature this spring will remain in place.
"Arkansas [is] a state where we have a prohibition on mask mandates. We don't have vaccination mandates either, which is typical of a Southern independent, rural state," he said at a summit in Washington last week. "Culturally that's not where we are."
Sarah Sanders, the Republican former White House press secretary who is running in the election to succeed Hutchinson, has also vowed to preserve the bans. "We believe in personal freedom and responsibility. It's one of the key cornerstones, frankly, of our country," she told Fox News last week.
In St. Louis, the announcement of the mandate Friday immediately drew a rebuke from Missouri Attorney General Eric Schmitt, a Republican, who said he planned to go to court to block it.
"The citizens of St. Louis and St. Louis County are not subjects -- they are free people," Schmitt, who is running for U.S. Senate, tweeted from his campaign account Friday. He added: "If the last six months have taught us anything it's that when it comes to expansive, authoritative executive action we have to fight back with everything we've got -- all the time."
For now, many other cities have stopped short of requiring masks, instead opting for guidelines and recommendations intended to nudge their populations in the right direction. Even those who want to order masking may be barred from doing so by legislation banning the mandates.
KINDS OF MASKS
Some experts say the recommendations should specify the kind of masks people should be using.
"Delta is so contagious that when we talk about masks, I don't think we should just talk about masks," Scott Gottlieb, former commissioner of the Food and Drug Administration, said during a recent appearance on CBS's "Face the Nation." "I think we should be talking about high-quality masks," such as N95 respirators.
"It's a fantastic idea at this point in time to move toward higher-quality masks," especially if you're unvaccinated or otherwise vulnerable to severe disease, said Chris Cappa, an environmental engineer and professor at the University of California at Davis. And for fully vaccinated individuals who may still be at risk of breakthrough infections, he noted, "the delta variant is a good reminder that we shouldn't necessarily quit wearing masks when we're in environments that might be prone to transmission."
Not all masks are created equal. The efficacy of a mask is based on its material and fit. Medical-grade respirators, such as N95 masks, can provide greater protection from infectious coronavirus particles than surgical masks or cloth masks, said Linsey Marr, an aerosol expert at Virginia Tech who studies airborne virus transmission.
And because the delta variant is much more easily transmissible than previously circulating strains of the coronavirus, "we really need highly protective masks along with everything else," Marr said.
"Where a simple cloth mask was helpful before, it's not helpful enough now," particularly for people who remain unvaccinated.
The woven material of many cloth masks isn't as effective at filtering particles as the nonwoven, melt-blown polypropylene used to make surgical masks and respirators, Marr said. And properly worn N95s have a leg up on standard surgical masks because they are designed to fit snugly to the face -- which allows them to filter at least 95% of airborne particulates.
"A surgical mask is just a rectangle, and you're trying to pull it to your face," she said. "Obviously, our faces aren't in the shape of a flat rectangle, so you inevitably end up with lots of leaks."
But, Marr noted, it's important to be wary of counterfeit respirators. The CDC has an online guide with lists of N95 masks approved by the National Institute for Occupational Safety and Health, and tips for spotting counterfeit ones.
KN95 masks, which are manufactured in China and can be equivalent to N95s in effectiveness, have not gone through the National Institute for Occupational Safety and Health approval process. But the FDA had authorized some KN95s for emergency use by health-care workers when there was a shortage of N95 masks during the pandemic.
While someone can refer to that list to find effective and not counterfeit KN95 masks, Cappa said he would still recommend a National Institute for Occupational Safety and Health-approved N95. "I can have higher confidence that it is high quality," he said, and "the ability and ease to get N95s has gone way up."
It's also critical to wear N95s properly, experts said: There should be no gaps between the edges of the mask and the face. To test the seal, Marr suggested a person cup his hands around it to hold the edges down. If breathing becomes noticeably more difficult, that's a sign that the mask likely isn't well-fitted. People who wear glasses can also gauge if their masks are leaky by how much their lenses fog up, Cappa said.
Unlike cloth masks, N95s can't be washed, so people should pay attention to the state of their masks. Gandhi said she typically swaps out an N95 every three days as long as it doesn't become soiled. Between uses experts suggested letting masks air out, preferably in the sun. If there's any visible signs of wear and tear, it's time to get a fresh one.
When handling a mask, a person should try to avoid touching the front and make sure to wash or sanitize their hands after, Marr said.
Information for this article was contributed by Derek Hawkins and Allyson Chiu of The Associated Press.