When should you still wear a mask?

We’ve entered a new phase in our relationship with COVID-19. Levels of the SARS-CoV-2 virus that causes the disease have waned, the state has ended its mask mandate for schools and the federal government has shifted its focus from vaccination, masks and isolation toward testing and treatment. Most people can now go maskless in many situations.

The decision to wear a mask or not also has shifted from broad rules to the individual and their local community, though Massachusetts still requires them in health facilities and on public transportation. The federal Centers for Disease Control now offers pandemic guidance based upon the level of COVID-19 in your county: low, medium or high. You can check a county’s level with the CDC Data Tracker tool.

Barnstable County’s COVID-19 rates are low, for which the CDC recommends residents be fully vaccinated and get tested if you have COVID symptoms. Masks should be worn if you are exposed to someone with COVID, have symptoms or test positive.

“At the end of the day, it comes down to common sense,” said Karen Monaghan, MD, a hospitalist at Cape Cod Hospital in Hyannis.

The country is in a different place than it was at the beginning of the pandemic, she said. We’ve learned more about the virus and the disease it causes, and we’ve developed effective vaccines and anti-viral medications.

“Masks alone aren’t the be-all and end-all,” Dr. Monaghan said. Rather, she said, they are part of a multi-layered approach to decrease the risk of infection and severe disease. “Vaccination against COVID-19 is still the number one way to prevent severe disease and death.”

Because the virus spreads via the air, chances of transmission are higher in crowds and enclosed spaces with poor ventilation. Knowing that, people can decide whether they might want to don a mask before entering such situations. If they have conditions that put them at higher risk of severe illness from COVID, they may wish to wear a mask or avoid such places, she said. According to the CDC, these health conditions include:

• Age 65 or older. Over 81 percent of COVID-related deaths occurred in this age group.
• Weakened immune system, which can be caused by cancer treatment, long-term use of corticosteroids, other medicines and diseases.
• Cancer.
• Heart disease, stroke and cerebrovascular disease.
• Obesity, risk of severe COVID increases with excess pounds. More than 30 percent of adult Americans are obese, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
• Inadequate physical activity.
• Pregnancy.
• Diabetes, both type 1 and type 2.
• Some disabilities, such as Attention Deficit/Hyperactivity Disorder (ADHD), Down syndrome, cerebral palsy, spinal injuries and intellectual and developmental disabilities.
• Dementia and neurological conditions.
• Tobacco smoking, both current and past.
• Alcohol and drug abuse.
• Chronic lung, kidney or liver disease.
• Respiratory illnesses, such as tuberculosis.
• HIV infection.
• Organ transplants.
• Inherited blood diseases, such as sickle cell disease and thalassemia.
• Cystic fibrosis.

“Losing weight is something helpful in decreasing your risk of severe COVID,” Dr. Monaghan said. “In the U.S., I don’t think we heard a lot about that.”

Risk Tolerance

Part of the decision-making process of whether to mask or not depends upon the risk tolerance of the person who has one or more of these conditions, Dr. Monaghan said. She cited her own experience visiting an uncle who has ALS (amyotrophic lateral sclerosis, a progressive disease of the brain and spinal cord).

“I tested before visiting him because I didn’t want to give it to him,” she said. “We had windows open, kept distanced. We were both vaccinated and boosted.”

Having taken those precautions, and given levels of virus in the community at that time were very low, both felt comfortable not wearing masks, Dr. Monaghan said. It allowed them to fully see each other’s facial expressions, an important part of social interaction, she noted.

Now that rapid tests for infection are readily available, “it’s not unreasonable to do an antigen test if going to visit someone who is immunocompromised,” Dr. Monaghan said.

Common sense indicates that “if the grandchildren are sick with cold or viral symptoms, parents shouldn’t bring them” to visit elderly grandparents and should wait a few days, she added.

The SARS-CoV-2 virus can spread far in poorly ventilated areas because it’s carried in a fine mist or aerosol when an infected person exhales, which is why loose fitting or cloth masks aren’t as effective as N95 respirators. But all masks offer some degree of protection, and Dr. Monaghan said social distancing and masking during the pandemic greatly reduced cases of influenza.

“Flu was barely visible last year,” she said, and has been “very mild” this season.

She urged people to get both flu and COVID vaccinations, and said mask wearing to avoid flu and other respiratory infections might be a smart practice to continue during cold and flu seasons, especially for at-risk individuals.

“We should support people who choose to mask,” she said.