When Is a Mask Mandate Not a Mask Mandate?

Michael A. Sharma, PA-C


May 11, 2022

Let's start where most people agree: If an effective barrier to SARS-CoV-2 stays between an infected person and an uninfected person, the uninfected person is unlikely to become infected.

Speaking of "barriers," on April 18, US District Judge Kathryn Kimball Mizelle ruled that the 2021 CDC travel mask mandate was unlawful. I was hoping the mandate would expire quietly of old age on May 3 as expected.

Now, with this judge's ruling, the issue of mandating masking while traveling has been figuratively upgraded to "full code" status. It's not going to pass away without a fight, involving legal maneuvering and political grandstanding instead of epinephrine and chest compressions. Indeed, on May 3, the CDC reissued a recommendation on the importance of masking during travel.

People used to be more motivated to mask. So motivated, in fact, that a gentleman once ran into our emergency department lobby, grabbed a box of our masks, and fled back into the night air before you could even say "bebtelovimab." Those days are long gone for many.

Maybe they feel that masks add little protection from severe COVID-19 over their baseline health, their level of immunity after vaccination and/or infection, and therapeutics. With motivation waning, perhaps a travel mask mandate could help stop the spread of SARS-CoV-2?

Let's quickly look at the state of evidence for masking in transportation. Epidemiologist and biostatistician Katelyn Jetelina, PhD, MPH, wrote a Substack post about SARS-CoV-2 transmission on planes after the mandate was revoked. She noted: "Because randomized control[led] trials are not feasible, we've had to rely on descriptive and modeling studies to assess the impact of masks on planes."

It's true that randomizing individuals on a particular flight to different masking groups would not generate the evidence needed to support mass masking on planes. There are other types of studies, such as a cluster randomized trial (CRT), where entire planes could be randomized to control groups or trial groups. This kind of study would be appropriate and generate better-quality evidence than retrospective studies and models.

NIH Collaboratory notes that CRTs are "better able to evaluate whether a… practice-wide, hospital-wide, or system-wide change is affecting patient outcomes." Sounds perfect.

Are such studies feasible? Billions of dollars have been granted by the federal government to scientists for COVID-19 research. The government gave additional billions to private industry to enable COVID-19 vaccines and therapeutics quickly getting to market. Study methodology, funding, and precedent of public-private partnership exist. Yes, higher-quality studies are feasible.

Jetelina goes on to describe the studies from 2020 that supposedly support masking on planes. Even if these studies were accurate in a time when many models failed, the models describe an entirely different landscape from today. They don't account for the changes of SARS-CoV-2 spread from increased community immunity from vaccination and infection or the high infectivity of Omicron.

Let's consider the types of masks that were mandated. The CDC's mask guidance said that adequate masks could be homemade, cloth, and didn't even need to be masks; some gaiters were acceptable. However, concerns about poor mask quality have been rising.

Michael Osterholm, PhD, MPH, and his team at the Center for Infectious Disease Research and Policy at the University of Minnesota have been advocating for widespread use of higher-quality respiratory protection like N95s and how they provide so much more protection than cloth or surgical masks. N95-equivalent masks are more available now than ever.

Now we come to what behaviors were mandated. From the text of the mandate, there were many exceptions, including "while eating, drinking, or taking medication, for brief periods; while communicating with a person who is hearing impaired when the ability to see the mouth is essential; . . . if unconscious (for reasons other than sleeping), incapacitated, unable to be awakened."

In addition, "People who are experiencing difficulty breathing or shortness of breath or are feeling winded may remove the mask temporarily."

Basically, if people don't want to mask, the mandate handed them multiple ways not to mask. On planes, you don't even have to remember to bring your own food anymore, like you did earlier in the pandemic on some airlines. Flight attendants come to your seat and ask you what you would like from their cart, which would lead to you unmasking to eat. There was no standard to qualify as hearing impaired or short of breath. And if someone didn't want to pantomime any of those behaviors, they could just roll over and be "unable to be awakened" instead. Nighty night!

The combination of low-quality masking and multiple exemptions to masking was described by Osterholm in an ABC News interview as "closing only three of the five screen doors on your submarine."

I do believe that many people in favor of the travel mask mandate are concerned about the medically vulnerable. Earlier, we probably agreed about the importance of effectiveness. "What happens in airplanes today is really more just 'check a box.' It is not effective," said Osterholm.

How many medically vulnerable people during this pandemic accidentally caught SARS-CoV-2 while they were performing unproven or ineffective interventions, like spacing themselves 6 feet apart from others or wearing low-quality masks ineffectively, interventions that they were told were supposed to protect them? They should be the most upset about the lack of scientific and journalistic curiosity about masking during travel. If we're really concerned about the medically vulnerable, let's expend the effort to see if what we're doing actually works.

Could a better travel mask mandate, one that required high-quality respiratory protection and more strongly restricted exceptions to masking, decrease the spread of COVID-19? It might. The science should be followed; right now, it points to the need for more rigorous trials and higher-quality evidence.

"Structured prospective studies to quantitate transmission risk on flight with rigid masking protocols are now most pressing," said the authors of a 2020 review of mask evidence quoted by Jetelina. A mandate propped up by theoretical evidence that doesn't actually require you to do the action it's supposed to mandate is so 2021. It's not a mandate at all. The year is 2022. It's time to get to work on understanding and implementing effective barriers to spreading SARS-CoV-2.

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About Michael Sharma
Michael A. Sharma, PA-C, is a practicing emergency medicine and urgent care PA in the Dallas, Texas, area. He is the co-host of The 2 View: Emergency Medicine PAs & NPs podcast with NP Martha Roberts. Mike is a US Army veteran, including a deployment to Afghanistan as a trauma team leader at a NATO Role 1 aid station. He has lectured and taught hands-on workshops internationally and nationally on emergency medicine topics to a variety of clinicians. Follow Mike on Twitter, Facebook, and Instagram.


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