Winter is back, and so are warnings from “experts” for Americans to don masks. A resurgence of influenza (flu) and respiratory syncytial virus (RSV)—respiratory illnesses that took a holiday during the Covid-19 pandemic, when various measures limited person-to-person contact and spread of disease—is allegedly combining with new Covid cases into a so-called tripledemic, leading academics and public-health officials to advise masking. An advisory from the New York City health commissioner instructs that “everyone . . . should wear a mask” at all times when indoors and when in a crowded outdoor setting. While the advisory says that “higher-quality masks, such as KN95 and KF94 masks and N95 respirators, can offer an additional layer of protection,” it does not otherwise distinguish between types of masks or discourage cloth masks. And Los Angeles County is, again, encouraging people to wear masks in indoor public spaces.
Can mask mandates be far behind? Let’s hope not. The need for masks is far from clear, and mandates could be counterproductive.
Despite the hype, these three viral diseases are not surging simultaneously. RSV cases and hospitalization rates rose and peaked far earlier this year than normal but have been declining for the past month. Covid-19 cases, hospitalizations, and deaths had been down for months, only rising recently to relatively low levels. And the flu season—which typically runs from October to April, peaking in February—is, like RSV, happening much earlier than usual.
While this flu season currently appears severe, it may not be out of the ordinary. Center for Disease Control and Prevention (CDC) estimates of the flu burden so far show at least 15 million flu illnesses, 150,000 flu hospitalizations, and 9,300 flu deaths. To put that in context, in the ten full flu seasons between 2010–2011 and 2019–2020, flu illnesses ranged from 9 million to 41 million, flu hospitalizations ranged from 140,000 to 710,000, and flu deaths ranged from 12,000 to 52,000. Unless the season takes a severe turn, this year’s influenza metrics should fall within normal ranges.
As is usually the case, the elderly, very young, and sick are most affected this year. People aged 65 and older account for 41 percent of flu hospitalizations. Among hospitalized adults, 97 percent had at least one underlying medical condition (hypertension, cardiovascular disease, metabolic disorder, or obesity). Seventy-one percent of hospitalized children had at least one underlying medical condition (asthma, obesity, or neurologic disorders). Children account for the highest percentage of outpatient visits for influenza, yet the total influenza-associated pediatric deaths reported so far this season is 30, compared with the last normal full-season total of 199. Seasonal flu activity remains high but appears to be declining: hospitalizations peaked two weeks ago and have been decreasing since.
The bottom line is that every winter brings an uptick in respiratory illnesses. This year, Covid is part of that mix. But the current surge does not warrant the return of pandemic-era controls. Such measures are not only unnecessary but would also likely prove ineffective.
Take masks. A pre-Covid systemic review of interventions to combat the spread of respiratory viral diseases, conducted by the highly regarded Cochrane Library, found that medical and surgical mask-wearing made little to no difference to the outcome of influenza or influenza-like illnesses, compared with not wearing a mask. Subsequently, a review of the literature found just two randomized controlled clinical trials of the effectiveness of masking in Covid-19. The first reported a tiny, statistically insignificant benefit. The second found small, marginally statistically significant reductions in viral transmission for surgical masks but not for cloth masks. Thirteen of 14 randomized trials examining mask-wearing in non-Covid respiratory infections failed to find a statistically significant benefit. Nearly all the evidence in favor of masks comes from observational studies that suffer from methodological problems; evidence for the cloth masks that many people use is essentially nonexistent.
A re-imposition of mask mandates would likely happen first in schools. These were the last mandates to be lifted, and teachers’ unions have been vocal in pushing for them. Yet scant evidence supports school masking. Sweden, which kept schools open without mask mandates, found little evidence of in-school disease transmission, either between students or between children and adults. Staff-to-staff transmission between adults, and adult transmission outside of school, are far more common than transmission from students.
A study of hospital admissions during the first two months of the pandemic (mid-March to mid-May) in the Stockholm area found that pediatric admissions accounted for a tiny portion (0.7 percent) of the total admissions due to Covid‐19 and that more than half of the children admitted with a primary diagnosis of Covid‐19 were less than one year of age and hence were not in school. Another study of severe Covid-19, as defined by intensive care unit (ICU) admissions nationwide among Swedish children aged one to 16 and their teachers during the pandemic’s initial four months, found a low incidence of severe Covid among schoolchildren. There were just 15 pediatric ICU admissions, four of whom had pre-existing chronic medical conditions, and zero children died. Swedish teachers saw no increase in age- and sex-adjusted relative risk of ICU admission compared with other occupations.
Even if school transmission occurs, severe Covid illness is extremely rare in children. Just one-tenth of 1 percent of all U.S. Covid-19 deaths—1,390—during the pandemic to date have been among minors. And nearly all the severe Covid cases and deaths in kids are associated with underlying medical conditions. The risk for healthy children—the overwhelming majority of kids—is practically nonexistent.
Moreover, school masking carries a cost. Children with and without hearing impairment have been found to have impaired word identification in settings with mask wearing. And face masks also appear to interfere with social communications by impairing the recognition of emotions.
The pandemic has already imposed severe educational, psychosocial, and economic harms on our children. Now is not the time to make matters worse. The past three years have warped the way we approach public health. Authorities tended to shoot first and ask questions later, imposing restrictions and mandates without undertaking serious cost–benefit analyses. That approach was a mistake and should not be repeated.
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