tag:theconversation.com,2011:/fr/topics/mask-wearing-87192/articlesMask wearing – The Conversation2023-08-25T10:21:10Ztag:theconversation.com,2011:article/2118402023-08-25T10:21:10Z2023-08-25T10:21:10ZCOVID: should we start wearing masks again?<p>One thing that can be guaranteed about COVID is that evolution will provide us with a more or less constant stream of new coronavirus variants, some of which will be more successful at infecting people. Talk of mutations sounds scary and it can lead to serious problems, but it would be a mistake to think that it’s always the case.</p>
<p><a href="https://www.nature.com/articles/d41586-023-02656-9">BA.2.86</a> (nicknamed pirola) is one such new variant that has aroused concern from some doctors and scientists because of the high number of mutations in its spike protein, the molecule on the virus surface that acts like a key for it to unlock and enter our cells. It’s also the target for the vaccines, so changes in the spike might mean changes in the way the virus behaves, perhaps significantly. </p>
<p>But as things stand, we don’t have good data to be certain about this. It’s this worry that there may be a new wave of infections that has got some people <a href="https://www.dailymail.co.uk/health/article-12410235/Gloomy-scientists-call-people-start-wearing-Covid-masks-sound-alarm-new-variant-BA-6-lot-new-mutations.html">talking</a> about the need to reintroduce measures that control viral spread.</p>
<p>At the start of the pandemic, one of the most persistent <a href="https://twitter.com/SkyNews/status/1235105792795136002">questions</a> asked was whether people should protect themselves and others by wearing some form of face covering. Initially, the prevailing opinion was that public use would not be <a href="https://www.independent.co.uk/news/uk/home-news/coronavirus-uk-news-professor-chris-whitty-no-masks-advice-a9374086.html">effective</a>. </p>
<h2>Loud calls for face coverings</h2>
<p>Government medical advisers in London and Edinburgh repeatedly assured the daily press conferences of this, only for <a href="https://news.sky.com/story/coronavirus-face-coverings-useful-when-uk-lockdown-is-eased-says-boris-johnson-11981298">politicians</a> to lead the way in changing that advice while their advisers looked on. Now that the threat of COVID has largely receded, whenever infection numbers start to climb there are loud <a href="https://www.independent.co.uk/news/health/covid-face-masks-arcturus-vaccine-b2329693.html">calls</a> to instruct people to wear face coverings again. </p>
<p>The issue of masks, which in reality should be taken as shorthand for face coverings of all sorts, is one that too often creates more heat than light. There have been <a href="https://fullfact.org/health/danish-mask-wearing-spectator/">overstated</a> claims of their effect and unwarranted claims of proof of <a href="https://fullfact.org/health/danish-mask-wearing-spectator/">ineffectiveness</a>. </p>
<p>The picture is complicated by the lack of comprehensive, well-designed studies. Sometimes a study size is too small, meaning that slight but real differences might be difficult to see, or the actual adherence to wearing a mask is too low. If people only wear them sometimes, it could be difficult to observe an effect.</p>
<p>Compelling people to change their behaviour to reduce the number of COVID infections might not be without some sort of cost in terms of public confidence. During the pandemic, a school of thought arose that the public doesn’t really take any notice until they see TV pictures of people struggling to breathe being admitted to hospital. A lack of such urgency might mean compliance would therefore be poor and enforcement weak or non-existent. </p>
<p>When introduced in the UK in the spring of <a href="https://www.theguardian.com/uk-news/2020/apr/28/sturgeon-urges-scots-to-wear-coronavirus-face-masks-for-shopping-and-travel">2020</a>, the instruction to cover our faces was part of a larger, more wide-ranging package of measures that, combined, did not prevent subsequent waves of infections and lockdowns. That being the case, it seems unlikely that masking on its own, without other measures, would have much effect, if any. </p>
<p>Coupled with the inevitable questioning of why it is necessary, any failure of masks to control infections when deployed as a sole measure could seriously jeopardise people’s willingness to comply with their use should a serious wave of respiratory infections occur that puts significant numbers of people in hospital and in which masks form part of a multi-component set of infection control measures. </p>
<p>As things stand, the chances of any reintroduction of significant multi-layered infection controls are virtually zero. A general election is due in the UK before the end of 2024, and it would take a very serious emergency of the type we saw at the height of the pandemic to make the government even contemplate it.</p>
<p>BA.2.86 has spread globally and we don’t know how many people it has infected. If it has spread widely, it seems to have put only a handful of people in <a href="https://www.dailymail.co.uk/health/article-12420697/Real-deal-Covid-variant-Britain-Patient-hospitalised-London-heavily-mutated-BA-X-strain-experts-think-caught-UK.html">hospital</a>, indicating that immunity derived from vaccines and previous infections is still protecting us against serious, life-threatening COVID.</p><img src="https://counter.theconversation.com/content/211840/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Clarke has received funding from the British Heart Foundation and the Defence Science & Technology Laboratory.</span></em></p>Some experts are calling for a return to masking as new variants emerge.Simon Clarke, Associate Professor in Cellular Microbiology, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1965702022-12-19T19:01:08Z2022-12-19T19:01:08ZWith COVID on the rise again, here are some simple steps to help us socialise safely during the holidays<figure><img src="https://images.theconversation.com/files/501784/original/file-20221219-26-e59g6c.jpg?ixlib=rb-1.1.0&rect=0%2C431%2C5760%2C2914&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Pressmaster</span></span></figcaption></figure><p>New Zealand’s third wave of COVID infections will likely reach its peak during the holiday period and stretch well into 2023. </p>
<p>The risk of infection is now the highest since June 2022 and continues to rise, driven by new, immune-evasive variants and the social mixing that comes with reduced pandemic controls, end-of-year events and holidays. </p>
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<p>Reported cases have risen almost five-fold from a low point of about 1,300 a day in September to <a href="https://www.rnz.co.nz/news/in-depth/450874/covid-19-data-visualisations-nz-in-numbers">more than 6,000 a day now</a>. Because of declining testing and reporting, the true number of infections is likely <a href="https://www.stuff.co.nz/national/explained/130538183/explainer-how-many-covid19-infections-really-are-out-there">two to three times higher</a>. Hospitalisations are also at their <a href="https://www.rnz.co.nz/news/in-depth/450874/covid-19-data-visualisations-nz-in-numbers">highest level since August</a> and are rising quickly. </p>
<p>The risk of being exposed to the virus has increased markedly in all social settings. For example, in a small gathering of ten people, the probability that one or more of the people attending has the virus has increased from 2-3% to more like 15% currently, and is likely to peak at around 20%. </p>
<p>For large gatherings of 100 people, this risk has risen from about 20% to more than 70%. </p>
<p>The main message is that multiple meetings with different people add up to a lot of potential exposure to this virus, and the risk rises with the number of people and the prevalence of infection (as illustrated by this <a href="https://public.flourish.studio/visualisation/10573093/">infographic</a>). This combination is making the pre-Christmas period particularly high risk for New Zealanders.</p>
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Read more:
<a href="https://theconversation.com/with-a-covid-variant-soup-looming-new-zealand-urgently-needs-another-round-of-vaccine-boosters-193616">With a COVID 'variant soup' looming, New Zealand urgently needs another round of vaccine boosters</a>
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<h2>Risk management</h2>
<p>The good news is that despite widespread COVID infection there are simple ways you can protect yourself and others. A good first step is to recognise that all of us are vulnerable, even if we have been infected previously. </p>
<p>We estimate that more than half of current infections are reinfections, with the <a href="https://covid19.govt.nz/testing-and-isolation/if-you-have-covid-19/after-you-have-had-covid-19">risk starting within a few weeks</a> of each infection and increasing over time. </p>
<p>The most effective way to protect yourself from severe illness is being up to date with vaccines and boosters. A large number of eligible New Zealanders have <a href="https://www.rnz.co.nz/news/national/480692/covid-19-boosters-flatlining-as-case-numbers-surge-across-country">still not had their third and fourth doses</a>. </p>
<p>Anyone who has not been infected in the past three months should check whether they are <a href="https://www.health.govt.nz/covid-19-novel-coronavirus/covid-19-vaccines/covid-19-vaccine-boosters">eligible for a booster</a>.</p>
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<p>After that, it is important to recognise that COVID transmits most effectively in <a href="https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-how-is-it-transmitted">crowded, close-contact, confined indoor environments </a>. Try to avoid these situations. But if you are in packed shopping malls, on buses or planes, <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7106e1.htm">wear a respirator style mask</a> (N95, KN95, P2, FFP2). </p>
<p>Such masks provide good protection for the wearer and those around them. They can reduce the risk of transmission by <a href="https://www.pnas.org/doi/full/10.1073/pnas.2110117118">more than 200-fold</a> if both you and the people you are interacting with are wearing them. </p>
<p>When organising events or gatherings, remember that <a href="https://blogs.otago.ac.nz/pubhealthexpert/ventilation-in-nz-schools-during-the-omicron-wave-results-from-a-preliminary-study/">good ventilation is key</a> to preventing transmission. Outdoors is best, but indoors can be relatively safe if well ventilated and not crowded. To add an extra layer of protection, especially when meeting vulnerable people, everyone can take a Rapid Antigen Test (RAT) before attending. </p>
<p>Te Pūnaha Matatini provides useful <a href="https://www.tepunahamatatini.ac.nz/our-values/safe-covid-19-events/">guidelines for organising safe events</a>. </p>
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Read more:
<a href="https://theconversation.com/were-entering-a-new-phase-of-covid-where-we-each-have-to-assess-and-mitigate-our-own-risk-but-how-195912">We're entering a new phase of COVID, where we each have to assess and mitigate our own risk. But how?</a>
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<p>If you do get sick, it is <a href="https://covid19.govt.nz/testing-and-isolation/if-you-have-covid-19/">vital to self-isolate</a> and not go to work and social events for a minimum of seven days. RATs are still free, widely available and useful for showing when you are infectious. It can take a few days after the start of an infection to test positive on a RAT so <a href="https://www.fda.gov/medical-devices/safety-communications/home-covid-19-antigen-tests-take-steps-reduce-your-risk-false-negative-results-fda-safety">continue to test</a> after developing symptoms, or after a possible exposure event, even if you initially test negative. </p>
<p>It is also valuable to <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00226-0/fulltext">test at the end of the seven-day isolation period</a> to check that you are no longer positive and potentially infectious to those around you. </p>
<p>Risk management is a partnership between individuals, their families, employers, venue operators, businesses and other organisations. The other partner is the government, which has a vital role in <a href="https://www.nzherald.co.nz/nz/reintroduction-of-covid-response-measures-urged-amid-third-wave/CDE3UISIZFHO3JRGMH3VWEFJJA/">coordinating and guiding the public health response</a>. </p>
<h2>The future</h2>
<p>After three years, COVID remains a pandemic. It has not yet transitioned to being a predictable endemic infection. </p>
<p><a href="https://esr2.cwp.govt.nz/assets/HEALTH-CONTENT/COVID-Genomics-Insights-Dashboard-CGID/CGID_29_Report.pdf">Genomic surveillance</a> shows a succession of new subvariants replacing those that came before because of their improved ability to evade our immunity. In the last week, BA.5, which has been dominant for more than six months, has been replaced by a collection of BA.2.75 subvariants as the most common in New Zealand. </p>
<p>Ongoing viral evolution and waning immunity means people are being infected multiple times in a single year. Each infection carries a risk of <a href="https://www.nature.com/articles/s41591-022-02051-3">serious illness and long COVID</a>.</p>
<p>The World Health Organization <a href="https://healthpolicy-watch.news/who-director-general-covid-global-health-emergency-can-be-declared-over-in-2023/">suggests</a> the pandemic may cease to be a public health emergency of international concern next year. Regardless of its designation, it is likely to continue as a major health threat. </p>
<p>It has become the <a href="https://www.rnz.co.nz/news/national/480620/covid-19-vs-the-flu-death-rates-compared">second leading cause of death</a> in New Zealand this year (after ischaemic heart disease). Potentially, its largest health impact may be as a <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00491-6/fulltext">cause of long-term illness and disability</a> through long COVID. We still need measures to minimise both infections and severe outcomes.</p>
<p>Socialising with whānau, friends and colleagues is a highlight of the holiday season and vital for our health, wellbeing and enjoyment of life. At the same time, relatively small adjustments in how we do these things can help us enjoy the holiday period in relative safety.</p><img src="https://counter.theconversation.com/content/196570/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker's employer receives funding for his research on Covid-19 and other infectious diseases from the Health Research Council of New Zealand (HRC) and the New Zealand Ministry of Health.</span></em></p><p class="fine-print"><em><span>David Welch has received funding from HRC, MBIE, and ESR for Covid-19 modeling and genomic analysis.</span></em></p><p class="fine-print"><em><span>Dion O'Neale's employer receives funding from the Health Research Council of New Zealand and from the New Zealand Ministry of Health for his research on COVID-19 modelling and the equity impacts of contagion modelling. </span></em></p>The pre-Christmas period puts New Zealanders at high risk of exposure to COVID. Even at small gatherings of ten people, the probability someone has the virus has increased from 2-3% to about 15%.Michael Baker, Professor of Public Health, University of OtagoDavid Welch, Senior Lecturer, University of Auckland, Waipapa Taumata RauDion O'Neale, Project Lead - COVID Modeling Aotearoa; Senior Lecturer - Department of Physics, University of Auckland; Principal Investigator - Te Pūnaha Matatini, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907372022-09-16T02:48:21Z2022-09-16T02:48:21ZNew Zealand’s new cut-down COVID response is a missed opportunity – here are 5 ways to improve it<figure><img src="https://images.theconversation.com/files/484980/original/file-20220915-39553-2i5gqn.jpg?ixlib=rb-1.1.0&rect=0%2C125%2C5247%2C3165&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Phil Walter/Getty Images</span></span></figcaption></figure><p>New Zealand’s decision to end most COVID health measures is welcome, as it removes controls that are in most cases no longer essential. But the new <a href="https://covid19.govt.nz/next-phase-of-our-covid-19-response/">COVID management phase</a> looks like a short-term reaction to declining case numbers rather than a longer-term strategy.</p>
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<p>New Zealand has achieved one of the <a href="https://blogs.otago.ac.nz/pubhealthexpert/the-covid-19-experience-in-aotearoa-new-zealand-and-other-comparable-high-income-jurisdictions-and-implications-for-managing-the-next-pandemic-phase/">best health outcomes of any country</a> by taking decisive action from the start of the pandemic. </p>
<p>We argue now is the time to build on that success with a strong, science-informed strategy to get us through the next pandemic stages and lift our resilience against future emerging infectious disease threats.</p>
<p>Such a strategy would need to provide a robust plan for managing the two most likely pandemic scenarios – new variants and endemic disease.</p>
<p>The most probable scenario is that SARS-CoV-2, the virus that causes COVID-19, will continue to evolve new variants that evade immunity from prior infection or vaccination, triggering new waves. Any new variant <a href="https://www.nature.com/articles/s41579-022-00722-z">could be more or less severe</a> than Omicron. </p>
<p>The government has previously identified the need for a <a href="https://www.health.govt.nz/covid-19-novel-coronavirus/covid-19-response-planning/variants-concern-framework-summary">strategy to manage this scenario</a>, which would require rapid risk assessment of new threats and increased controls if needed.</p>
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<a href="https://theconversation.com/with-most-mandatory-public-health-measures-gone-is-new-zealand-well-prepared-for-the-next-covid-wave-190528">With most mandatory public health measures gone, is New Zealand well prepared for the next COVID wave?</a>
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<p>COVID is also likely to eventually become a more stable and predictable endemic disease, perhaps somewhat like seasonal influenza but with <a href="https://theconversation.com/imagining-covid-is-like-the-flu-is-cutting-thousands-of-lives-short-its-time-to-wake-up-190545">more severe consequences</a> that are still emerging. </p>
<p>Endemic does not necessarily mean <a href="https://www.nature.com/articles/d41586-022-00155-x">mild</a>. The world’s biggest infectious disease killers, including tuberculosis, HIV/AIDS and malaria, are all endemic. A long-term strategy should aim to minimise health burdens (serious illness, death and <a href="https://blogs.otago.ac.nz/pubhealthexpert/long-covid-century-old-lessons-we-still-have-not-learned/">long-term disability</a>) and health inequities.</p>
<p>Unfortunately, New Zealand’s new approach does not provide a robust response to either of these scenarios. </p>
<h2>Defences against likely pandemic threats</h2>
<p>New Zealand already has well-established tools for assessing and communicating the risk associated with many other hazards such as fires and storms. Why not do the same for COVID and potentially other serious respiratory infections?</p>
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<img alt="Sign for fire danger" src="https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484983/original/file-20220916-48379-6nr6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Why not treat pandemic risk like we do fire danger updates?</span>
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<p>We propose five changes to fill gaps in the new COVID management approach while at the same time minimising disruptions.</p>
<p><strong>1. Develop an updated alert level system for COVID variants</strong></p>
<p>The government could use this relatively low point in the number of COVID cases to develop a robust framework to provide a simple way for <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(21)00115-2/fulltext">describing the level of risk</a> and a proportionate response at each level. </p>
<p>Before COVID, New Zealand’s <a href="https://www.health.govt.nz/publication/new-zealand-influenza-pandemic-plan-framework-action">pandemic plan</a> was based on mitigation. This meant accepting pandemics would wash over the country and the best we could do was to minimise healthcare system overload. Now we know we can potentially <a href="https://www.bmj.com/content/371/bmj.m4907">stop any respiratory disease pandemic</a>. </p>
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<img alt="Two masked women hugging at the airport" src="https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484981/original/file-20220916-48413-6nr6ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">New Zealand has scrapped vaccination requirements and mandated testing for international arrivals.</span>
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<p><strong>2. Reinforce the critical importance of borders for biosecurity</strong></p>
<p>We need an evidence-informed strategy for our borders to manage potentially more dangerous variants and other future pandemics. </p>
<p>The government has now removed vaccination requirements and mandated testing for visitors. As case numbers fall, arriving travellers will likely become an increasingly important source of new infections. </p>
<p>The end of routine testing on arrival limits our ability to collect viral samples for <a href="https://theconversation.com/as-new-zealands-omicron-infections-rise-rapidly-genome-surveillance-is-shifting-gears-177441">whole genome sequencing</a> and leaves a gap in our surveillance system. Long-term benefits of improved border control would include a reduced risk of importing other outbreak-prone diseases such as <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/global-importation-and-population-risk-factors-for-measles-in-new-zealand-a-case-study-for-highly-immunized-populations/AA7A61E06F421945937D0BCB01DD11A8">measles</a> or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262147/">more serious, bioengineered pandemics</a>.</p>
<p><strong>3. Reinforce self-isolation as a key infection control tool</strong></p>
<p>Fortunately, the government has retained mandatory isolation for people who test positive for COVID. It is fundamental to disease control that sick people stay home. Keeping isolation to a minimum of seven days is also wise, as even then about a <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00226-0/fulltext">quarter of people are still infectious</a>. </p>
<p>Nevertheless, adding a <a href="https://cpb-ap-se2.wpmucdn.com/blogs.auckland.ac.nz/dist/c/828/files/2022/08/quantifying-the-impact-of-isolation-period.pdf">test-to-release</a> requirement would improve the effectiveness of this strategy and reduce the isolation period to five days for some. </p>
<p>Making these measures work well requires a great deal more public education and support, particularly around health, social and work support. This could be a major legacy benefit of this pandemic, particularly if it also helps to reduce the spread of other respiratory diseases such as <a href="https://www.cdc.gov/flu/business/stay-home-when-sick.htm">influenza</a>.</p>
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Read more:
<a href="https://theconversation.com/cutting-covid-isolation-and-mask-mandates-will-mean-more-damage-to-business-and-health-in-the-long-run-189862">Cutting COVID isolation and mask mandates will mean more damage to business and health in the long run</a>
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<p><strong>4. Establish requirements for masks and ventilation</strong></p>
<p>Masks still have to be worn in healthcare and aged-care settings. Masks work best in such high-risk environments when <a href="https://www.pnas.org/doi/10.1073/pnas.2110117118">everyone is using them</a>. But we need systematic criteria to identify other confined, crowded and close-contact environments with a high risk of infection. </p>
<p>On that basis, public transport would be an important environment for universal mask use and <a href="https://blogs.otago.ac.nz/pubhealthexpert/monitoring-co2-indoors-for-improving-ventilation-as-a-covid-19-control-tool/">ventilation improvements</a>, particularly <a href="https://doi.org/10.26686/pq.v18i1.7500">during winter</a>. An evidence-based mask and ventilation policy would be another major legacy benefit of the current pandemic.</p>
<figure class="align-center ">
<img alt="Masked people on a bus" src="https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484982/original/file-20220916-19-y1jkal.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ongoing mask use and better ventilation should be considered for public transport.</span>
<span class="attribution"><span class="source">Getty Images</span></span>
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</figure>
<p><strong>5. Establish vaccination as the norm for healthcare and essential services</strong> </p>
<p>The government has now removed all vaccine mandates. However, there are several reasons why <a href="https://www.cdc.gov/vaccines/adults/reasons-to-vaccinate.html">healthcare</a> and other essential workers should be vaccinated against COVID and other serious infectious diseases. It should be a basic occupational health and safety necessity, just like some groups are required to wear personal protective equipment. </p>
<p>One legacy benefit of the pandemic should be a wider discussion about how to appropriately establish vaccination as a requirement for key occupational groups.</p>
<p>The inconvenient truth is that the pandemic has not gone away and future pandemics remain a risk. Even if COVID becomes a more predictable endemic disease, we still need to minimise serious illness, particularly for the most vulnerable.</p><img src="https://counter.theconversation.com/content/190737/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker receives funding from the Health Research Council for research on Covid-19. </span></em></p><p class="fine-print"><em><span>Nick Wilson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Zealand has done better than most countries by taking decisive action at the start of the COVID pandemic. Now is the time to build on this with a science-based strategy to manage the next stages.Michael Baker, Professor of Public Health, University of OtagoNick Wilson, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1797462022-03-22T23:23:45Z2022-03-22T23:23:45ZAs New Zealand relaxes restrictions, here’s what we can still do to limit COVID infections<figure><img src="https://images.theconversation.com/files/453703/original/file-20220322-21-mfo752.jpg?ixlib=rb-1.1.0&rect=18%2C138%2C4007%2C2879&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Phil Walter/Getty Images</span></span></figcaption></figure><p>New Zealanders are about to enjoy cautiously relaxed COVID restrictions under the country’s <a href="https://covid19.govt.nz/traffic-lights/covid-19-protection-framework/">COVID-19 Protection Framework</a>, starting from this weekend.</p>
<p>Prime Minister Jacinda Ardern announced the relaxations today, signalling the end “for now” of vaccine passes, QR codes and vaccine mandates in the education, police and defence sectors from April 4. </p>
<p>Mandates will still apply for health, aged-care, corrections and border control workers, pending more official advice. Settings within the traffic light system have also been revised, but the country remains at the red level and indoor mask use is still required.</p>
<p>New Zealand’s vaccine pass system was designed when we were in the middle of the vaccine rollout, only about one in 400 New Zealanders had had COVID-19, and nobody had even heard of Omicron. </p>
<p>At that time, unvaccinated people had a <a href="https://theconversation.com/your-unvaccinated-friend-is-roughly-20-times-more-likely-to-give-you-covid-170448">much higher risk</a> of catching the virus and spreading it to others. </p>
<p>For this reason, vaccine passes were an important part of safely relaxing the Auckland lockdown. They helped us enjoy a summer with very low case numbers and minimal restrictions. Crucially, this meant we avoided the dual Delta-Omicron epidemic that significantly added to the health burden in places such as <a href="https://www.stuff.co.nz/national/explained/127440590/covid19-the-nsw-omicron-outbreak-is-not-what-you-think">New South Wales</a>. </p>
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<p>The situation we face today is very different. Vaccines remain highly effective at preventing severe illness but aren’t as good at stopping people catching Omicron. And the protection they do provide against infection wanes fairly quickly. </p>
<p>At the same time, increasing numbers of people have some temporary immunity as a result of having had the virus. This means vaccine passes are far less effective as a public health intervention now than they were a few months ago. </p>
<p>But as vaccine passes are phased out, it is important to consider what measures we can use to reduce transmission.</p>
<h2>Vaccines still work</h2>
<p>Vaccines are still highly effective at preventing severe illness and death from COVID-19. Like New Zealand, Hong Kong is now experiencing a major Omicron wave after initially following an elimination strategy. But in the last two months, Hong Kong has had close to 4,000 deaths per five million people compared to New Zealand’s 130. </p>
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<p>Why such a big difference? Vaccines. Hong Kong has much <a href="https://www.ft.com/content/6e610cac-400b-4843-a07b-7d870e8635a3">lower vaccine coverage in older groups</a> than New Zealand does. </p>
<p>But it’s clear vaccines are less effective at preventing infection with Omicron. The <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1061532/Vaccine_surveillance_report_-_week_11.pdf">UK Health Security Agency</a> estimates the effectiveness of two doses of the Pfizer vaccine against symptomatic COVID-19 drops to just 10% after about 25 weeks following the second dose. This jumps to 65% after a booster but also wanes quite quickly to around 40% 15 weeks later.</p>
<p>The proportion of unvaccinated people testing positive is <a href="https://www.newsroom.co.nz/tracking-omicron-in-new-zealand-latest-charts-and-data">not that different</a> from fully vaccinated people. So if you go to a cafe, a hairdressers or a bar, whether or not there are unvaccinated people there makes little difference to your risk of catching the virus.</p>
<p>Other risk factors are more important: are people wearing masks, is it crowded, is the venue well ventilated or outdoors, are people staying away if they have symptoms? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/most-covid-patients-in-nzs-omicron-outbreak-are-vaccinated-but-thats-no-reason-to-doubt-vaccine-benefits-179648">Most COVID patients in NZ's Omicron outbreak are vaccinated, but that's no reason to doubt vaccine benefits</a>
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</em>
</p>
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<h2>We still need public health measures to mitigate COVID</h2>
<p>The <a href="https://theconversation.com/to-be-truly-ethical-vaccine-mandates-must-be-about-more-than-just-lifting-jab-rates-169612">limitations</a> the vaccine pass system has placed on people’s freedoms are much harder to justify now. But that doesn’t mean we can end all vaccination requirements or remove all public health measures.</p>
<p>COVID-19 is an airborne disease but a comparison with diseases spread through contaminated water is useful. The spread of cholera from contaminated water is one of the earliest examples of an <a href="https://www.ph.ucla.edu/epi/snow/snowcricketarticle.html">effective public health response</a> to an infectious disease. </p>
<p>The first response was a “boil water” notice, the equivalent of mask wearing to prevent the spread of infections. Longer-term measures involve systemic changes, such as infrastructure for clean water or, in the case of COVID, infrastructure for <a href="https://www.reuters.com/world/europe/italian-study-shows-ventilation-can-cut-school-covid-cases-by-82-2022-03-22/">clean air</a> through ventilation and filtration. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-catching-omicron-is-not-inevitable-heres-why-we-should-all-still-avoid-the-virus-178276">No, catching Omicron is not 'inevitable' – here's why we should all still avoid the virus</a>
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<p>The time to remove boil-water notices is not when case numbers are peaking, or even when they are back at half of their peak level. It is when there are sufficient systemic changes in place to keep people safe.</p>
<p>Similarly, isolation periods are intended to stop people from infecting others. For Omicron, studies suggest half of all cases were still <a href="https://dash.harvard.edu/handle/1/37370587">infectious on day five</a> and the infectious period may be as long as ten days. Given wider availability of rapid antigen tests, we could introduce a test-to-return policy to require a negative test before people leave isolation. </p>
<h2>Some vaccine mandates remain</h2>
<p>People working in specific high-risk situations, like healthcare and aged residential care, will still be required to be up to date with their vaccinations to protect the vulnerable people they work with. </p>
<p>We are currently in the middle of a major Omicron wave, with hospitalisations and deaths at record levels. At least as many people will get infected on the way down from the peak as on the way up. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/evidence-supports-mandatory-covid-vaccination-for-aged-care-workers-but-we-need-to-make-it-easier-too-163569">Evidence supports mandatory COVID vaccination for aged-care workers. But we need to make it easier too</a>
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<hr>
<p>And even when this wave subsides, COVID-19 isn’t going to go away. It’s likely we will continue to see daily case numbers in the thousands for some time. Added to other respiratory illnesses like influenza and RSV, this could cause significant strain on healthcare over the winter months. </p>
<p>Altogether, this means we still need <a href="https://blogs.otago.ac.nz/pubhealthexpert/covid-19-hospitalisations-now-peaking-in-aotearoa-nz-but-key-covid-19-control-measures-still-need-to-be-maintained/">a set of sustainable mitigations</a> to reduce transmission and the health impacts of the virus. This includes strategies to address <a href="https://www.stuff.co.nz/pou-tiaki/300482666/government-breached-treaty-principles-in-covid19-response-waitangi-tribunal-finds">vaccine inequity</a> and increase booster uptake, mask use when cases are high, better ventilation and adequate financial support for people to take time off work when they are sick. </p>
<p>COVID vaccine passes have outlived their usefulness at least for now. But COVID-19 is going to be with us for the forseeable future.</p><img src="https://counter.theconversation.com/content/179746/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Plank is affiliated with the University of Canterbury and is funded by the New Zealand Government for mathematical modelling of Covid-19.</span></em></p><p class="fine-print"><em><span>Dion O'Neale receives funding from the NZ Department of Prime Minister and Cabinet for providing modelling and analysis related to COVID-19 and from the NZ Health Research Council for research on modeling and equity impacts of COVID-19 in Aotearoa. He is affiliated with COVID Modelling Aotearoa, The University of Auckland, and Te Pūnaha Matatini. </span></em></p><p class="fine-print"><em><span>Emily Harvey receives funding from the NZ Department of Prime Minister and Cabinet for providing modelling and analysis related to COVID-19 and from the NZ Health Research Council for research on modeling and equity impacts of COVID-19 in Aotearoa. She is affiliated with COVID-19 Modelling Aotearoa, ME Research, Te Pūnaha Matatini, and the University of Auckland.</span></em></p>Vaccine passes have outlived their usefulness, at least for now. But as New Zealand’s Omicron wave begins to subside, other public health measures remain vitally important.Michael Plank, Professor in Applied Mathematics, University of CanterburyDion O'Neale, Project Lead - COVID Modeling Aotearoa; Senior Lecturer - Department of Physics, University of Auckland; Principal Investigator - Te Pūnaha Matatini, University of Auckland, Waipapa Taumata RauEmily Harvey, Principal Investigator, Te Pūnaha Matatini, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1782762022-03-08T18:10:35Z2022-03-08T18:10:35ZNo, catching Omicron is not ‘inevitable’ – here’s why we should all still avoid the virus<figure><img src="https://images.theconversation.com/files/450554/original/file-20220308-51485-izb4i3.jpg?ixlib=rb-1.1.0&rect=0%2C30%2C5024%2C2870&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Fiona Goodall/Getty Images</span></span></figcaption></figure><p>Aotearoa New Zealand has entered new COVID territory, characterised by <a href="https://www.health.govt.nz/covid-19-novel-coronavirus/covid-19-data-and-statistics/covid-19-vaccine-data#total-vaccinations">high vaccination rates</a> but also the rapid spread of the Omicron variant and <a href="https://www.health.govt.nz/news-media/news-items/23894-community-cases-757-hospital-16-icu">rising numbers of hospitalisations</a>. </p>
<p>As we approach the peak of this wave, some have suggested it would be better to drop remaining public health measures, let the infection rip through our population and accept nearly all of us will get infected very soon. This is unwise for many reasons. </p>
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<p>First, simple measures we can all take will ensure that even in this big wave of infections, most of us can still avoid getting infected. Even if you share a household with an infected person, <a href="https://www.medrxiv.org/content/10.1101/2022.02.15.22271001v1">international</a> <a href="https://www.medrxiv.org/content/10.1101/2021.12.27.21268278v1.full">studies</a> show the risk of catching the virus is somewhere between 15% and 50%. </p>
<p>Second, not all infections are equal. </p>
<p>The Delta variant is still circulating and we can’t presume all infections are Omicron. While less virulent than Delta, Omicron can nevertheless cause severe disease and death, particularly among the unvaccinated who make up 3% of the vaccine-eligible population but <a href="https://www.health.govt.nz/news-media/news-items/23894-community-cases-757-hospital-16-icu">19.4% of hospitalisations</a>. </p>
<p>There are still many vulnerable people in the community we can protect by limiting the spread of the virus and ensuring they are less likely to encounter it. </p>
<p>Another reason to limit potentially infectious contact is that infection is more likely if an individual is exposed to a higher initial dose of the virus. An infection avoided or delayed is always a win as we move closer to even more effective vaccines and improved medical treatments for COVID.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-does-omicron-compare-with-delta-heres-what-we-know-about-infectiousness-symptoms-severity-and-vaccine-protection-172963">How does Omicron compare with Delta? Here's what we know about infectiousness, symptoms, severity and vaccine protection</a>
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<hr>
<h2>Why outbreaks come in waves</h2>
<p>The reason we get large wave-like outbreaks that rise and fall quickly is because the virus becomes less able to find people to infect as the outbreak progresses. Crucially, this happens before everyone is infected. </p>
<p>This is related to the R number epidemiologists talk about. R0 is the average number of people an infectious person infects at the start of an outbreak. When R is greater than one, the number of cases increases, when it is below one, it decreases. </p>
<p>As the outbreak proceeds, more and more people get infected and recover. They cannot immediately be reinfected. For example, if R is 2 at the start of an outbreak, meaning each case on average transmits to two others, by the time half of the population has been infected and has recovered, the virus will only transmit to one other. </p>
<p>That is because it “tries” to infect two people but finds that, on average, one has already recovered and cannot be reinfected. In this example, the R number is now effectively 1 and infections will start to fall. </p>
<h2>Omicron’s rapid spread</h2>
<p>Despite New Zealand’s high vaccination rates, Omicron is spreading quickly here, as it has in other countries. There are many elements to this. </p>
<p>Omicron is good at avoiding immunity generated by vaccination and previous infection. We have very high rates of first and second doses, but fewer than 60% have received boosters, and we have a very short history of exposure to natural infection. </p>
<p>These characteristics make us prone to a rapid and large outbreak of Omicron. Further, vaccinations, including boosters, are very good at preventing illness, hospitalisation and death, but they don’t prevent infection and transmission quite as well. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nzs-confirmed-covid-case-numbers-are-rising-fast-but-total-infections-are-likely-much-higher-heres-why-177901">NZ's confirmed COVID case numbers are rising fast, but total infections are likely much higher – here's why</a>
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</p>
<hr>
<p>This means that even in a highly vaccinated population, you can still get high levels of transmission and infection, but the rates of illness and severe complications will be much lower. </p>
<p>Relaxation of public health measures and the impact of superspreader events may also be contributing to the current picture. Importantly, while the number of infections has increased dramatically with Omicron, the proportion of these that result in severe complications is much lower than during the earlier Delta outbreak.</p>
<h2>Our behaviour helps determine the size of the wave</h2>
<p>The earlier cases start to fall, the smaller the overall outbreak will be. If R is 2 at the start of an outbreak, a basic model says around 80% of the population will be infected. If the initial R number can be reduced to 1.5, only 58% of the population get infected. </p>
<figure class="align-center ">
<img alt="A graph showing the percentage of the population infected over the course of a closed outbreak for different values of R0." src="https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=489&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=489&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=489&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=614&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=614&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450529/original/file-20220307-126059-137z59g.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=614&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The percentage of the population infected over the course of a closed outbreak for different values of R0.</span>
<span class="attribution"><span class="source">Calculated using the method described by Ottar N. Bjørnstad in Epidemics: Models and Data Using R</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Luckily we exert some control over the R number. Measures like mask wearing, good use of ventilation, self-isolation when symptomatic or after a positive test, vaccination, and avoiding crowded indoor areas all work to reduce R and the total number of people who will get infected. <a href="https://www.covid19modelling.ac.nz/a-preliminary-assessment-of-the-potential-impact-of-the-omicron-variant/">Local modeling suggests</a> that depending on how well we adopt these measures, somewhere between 25% and 60% of the population are likely to be infected in this outbreak.</p>
<p>Even when sharing the same household as a case, it is not inevitable everyone else will get infected. Studies from the <a href="https://www.medrxiv.org/content/10.1101/2022.02.15.22271001v1">UK</a>, <a href="https://www.medrxiv.org/content/10.1101/2021.12.27.21268278v1.full">Denmark</a> and <a href="https://wwwnc.cdc.gov/eid/article/28/3/21-2607_article">South Korea</a> have all looked at the probability of susceptible people in the same household as a positive case getting infected. </p>
<p>They found with Omicron, this probability is somewhere between 15% and 50%. In other words, you still have a better than even chance of avoiding infection through your infectious housemate. </p>
<p>All the measures that work generally to reduce spread also work within a household. Mask up inside, get air flowing through, where possible move the infected household member into their own bedroom and bathroom, and practice good basic hygiene.</p>
<p>The relationship between the initial exposure dose, infection and disease severity is a property of many infectious diseases, including respiratory diseases in humans and other animals. </p>
<p>A recent <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab903/6397523">review</a> concluded that while there is good evidence of a direct relationship between the SARS-CoV-2 virus dose and infection in humans, evidence for a link between dose and severity is lacking, despite some evidence from <a href="https://doi.org/10.1371/journal.ppat.1009865">animal models</a>. </p>
<p>COVID severity is most likely driven by factors other than the initial exposure dose. These include the virus variant and host factors such as age or the presence of some pre-existing health conditions. </p>
<p>All the standard public and personal health measures will help us avoid getting infected and reduce transmission to the more vulnerable, thereby reducing the number of people with severe illnesses.</p><img src="https://counter.theconversation.com/content/178276/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Welch has received funding from MBIE, MoH and HRC.</span></em></p><p class="fine-print"><em><span>Nigel French is affiliated with Massey University and has received funding from MBIE and HRC. </span></em></p>As Omicron cases soar in New Zealand, most people can still avoid getting infected. Even if you share a household with an infected person, catching the virus is not at all inevitable.David Welch, Senior Lecturer, University of Auckland, Waipapa Taumata RauNigel French, Professor of Food Safety and Veterinary Public Health, Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1771342022-02-27T23:11:12Z2022-02-27T23:11:12ZTwo years on from the first COVID case, New Zealand’s successful pandemic response still faces major challenges<figure><img src="https://images.theconversation.com/files/448758/original/file-20220227-32564-1ai6b20.jpg?ixlib=rb-1.1.0&rect=63%2C165%2C5207%2C3287&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Fiona Goodall/Getty Images</span></span></figcaption></figure><p>Two years ago today, the first confirmed case of COVID-19 was reported in Aotearoa New Zealand. Few of us could have imagined the huge impact this pandemic would still be having two years later.</p>
<p>As New Zealand enters its third year of the pandemic, we are facing widespread community transmission as an epidemic wave of the Omicron variant sweeps across the country. A majority of New Zealanders <a href="https://cpb-ap-se2.wpmucdn.com/blogs.auckland.ac.nz/dist/c/828/files/2021/07/omicron-preliminary.pdf">may become infected</a> in coming months, but many with few or no symptoms. </p>
<p>Australian experience suggests we might see a peak of around <a href="https://blogs.otago.ac.nz/pubhealthexpert/covid-19-hospitalisation-peaks-in-australian-states-since-omicron-emerged-potential-relevance-to-aotearoa-nz/">1,100 people with COVID-19 in hospitals</a> during March and April.</p>
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<p>We have previously written about the challenges apparent after <a href="https://theconversation.com/6-months-after-new-zealands-first-covid-19-case-its-time-for-a-more-strategic-approach-144936">six months</a> and <a href="https://theconversation.com/a-year-on-from-the-arrival-of-covid-19-in-nz-5-lessons-for-2021-and-beyond-155367">one year</a> of the pandemic. Today, we examine what we’ve learned — the major challenges that have persisted or emerged and how New Zealand can manage them to achieve the best possible outcomes.</p>
<h2>Shifting strategies</h2>
<p>New Zealand has demonstrated the benefits of a science-informed response with a <a href="https://www.bmj.com/content/371/bmj.m4907">strong strategic focus</a>. During the first year of the pandemic when there were no vaccines available, the <a href="https://journal.nzma.org.nz/journal-articles/new-zealands-elimination-strategy-for-the-covid-19-pandemic-and-what-is-required-to-make-it-work">elimination strategy</a> protected people and the economy. </p>
<p>Following the emergence of the Delta variant, <a href="https://journal.nzma.org.nz/journal-articles/the-next-phase-in-aotearoa-new-zealands-covid-19-response-tight-suppression-may-be-optimal-for-health-equity-and-wellbeing-in-the-months-ahead">tight suppression</a> was also highly effective. Now, with the growing surge driven by the Omicron variant, New Zealand has been forced to shift to a <a href="https://blogs.otago.ac.nz/pubhealthexpert/preparing-for-omicron-a-proactive-government-response-is-urgently-needed-to-minimise-harms/">mitigation strategy</a>.</p>
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Read more:
<a href="https://theconversation.com/nzs-confirmed-covid-case-numbers-are-rising-fast-but-total-infections-are-likely-much-higher-heres-why-177901">NZ's confirmed COVID case numbers are rising fast, but total infections are likely much higher – here's why</a>
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<p>New Zealand’s strategic approach has supported the country in achieving some of the world’s <a href="https://blogs.otago.ac.nz/pubhealthexpert/mortality-declines-in-aotearoa-nz-during-the-first-two-years-of-the-covid-19-pandemic/">lowest COVID-19 mortality rates and increased life expectancy</a>. New Zealand has also had a relatively small amount of time in lockdown and comparatively <a href="https://www.oecd.org/economy/new-zealand-economic-snapshot/">good economic performance</a>.</p>
<p>To achieve these successes, New Zealand has had to deliver major public health interventions very rapidly and their limitations have become apparent over time. </p>
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<p>Border quarantine is <a href="https://www.mja.com.au/journal/2021/215/7/failures-quarantine-systems-preventing-covid-19-outbreaks-australia-and-new">difficult to maintain</a> if not done well and creates <a href="https://www.nzherald.co.nz/nz/its-a-case-of-wait-and-see-grounded-kiwis-wrap-up-two-day-bid-for-judicial-review/X43JEMEEEL47I7JBPHTZIBJPFI/">severe consequences for some</a>. The vaccine rollout has been <a href="https://www.bmj.com/content/376/bmj.o180">highly inequitable</a>. Mandates for vaccine and mask use have been divisive and <a href="https://www.theguardian.com/world/2022/feb/09/lets-remember-why-we-are-here-new-zealand-anti-vax-protest-splinters-into-jibes-and-jabs">sometimes vigorously opposed</a> by a vocal minority.</p>
<h2>Challenges and opportunities ahead</h2>
<p>The experience of the last two years highlights five major opportunities to enhance New Zealand’s pandemic response and achieve lasting benefits for our ability to manage other major public health threats.</p>
<p><strong>1. Taking a precautionary approach in the face of uncertainty</strong></p>
<p>Possibly the biggest challenge has been the changing nature of the pandemic threat itself. The virus <a href="https://www.nature.com/articles/s41586-021-03792-w">continues to evolve</a> and new variants of concern with increased infectiousness have emerged. We do not know whether future variants will be <a href="https://www.theguardian.com/world/2022/jan/11/will-covid-19-become-less-dangerous-as-it-evolves">more or less virulent</a>. </p>
<p>Omicron shows a <a href="https://www.nature.com/articles/d41586-022-00438-3">high capacity for reinfection</a> which will need to be managed if this variant remains dominant. Optimistically, we may see the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00100-3/fulltext?s=09">end of the pandemic</a> though not the end of COVID-19. The full population impact of <a href="https://www.nature.com/articles/d41586-020-02598-6">post-acute illness</a> (long COVID) is not yet known and evidence about <a href="https://www.nature.com/articles/d41586-022-00177-5">prevention</a> and management is still at an early stage.</p>
<p><strong>2. Enhancing equity and better protecting the most vulnerable</strong></p>
<p>The move to mitigation (from elimination and suppression) shifts protection away from the collective, population-level focus to individual measures like vaccination, mask use and self-isolation. </p>
<p>Despite a strongly stated commitment to equity, Māori and Pasifika have <a href="https://thespinoff.co.nz/business/23-02-2022/the-spinoff-covid-tracker-the-live-graphs-that-tell-the-story-of-delta-in-aotearoa">lower vaccine and booster coverage rates</a>. They are also <a href="https://www.health.govt.nz/covid-19-novel-coronavirus/covid-19-data-and-statistics">over-represented among COVID-19 cases and hospitalisations</a>. </p>
<p>Mitigation aims to flatten the epidemic curve to protect the healthcare system from being overwhelmed. During such periods, there is potential for the most vulnerable (people who are Māori, Pasifika, low-income, living with other illnesses and disabilities) to miss out on care. </p>
<p>There are multiple ways of improving equity in the response. These include greater support for Māori and Pasifika <a href="https://www.waitangitribunal.govt.nz/assets/Documents/Publications/Covid-Priority-W.pdf">health providers</a>, further efforts to <a href="https://www.newsroom.co.nz/ideasroom/eliminating-maori-inequities-in-covid-19-outcomes">raise vaccine coverage for Māori</a> in particular, policies to <a href="https://www.stuff.co.nz/business/125804726/sick-leave-increase-what-you-need-to-know">support sick workers staying at home</a> and a <a href="https://blogs.otago.ac.nz/pubhealthexpert/making-the-most-of-masks/">national mask strategy</a> that makes effective masks freely available.</p>
<p>We also need a stronger focus on protecting children’s health and well-being, including a pivot to a whānau-centred approach and efforts to reduce transmission in <a href="https://blogs.otago.ac.nz/pubhealthexpert/tag/ventilation-schools/">schools</a> and <a href="https://blogs.otago.ac.nz/pubhealthexpert/strengthening-omicron-mitigation-strategies-in-early-childhood-education-settings/">early childhood education</a>.</p>
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Read more:
<a href="https://theconversation.com/to-protect-children-during-aotearoas-omicron-outbreak-we-need-to-consider-their-families-not-just-schools-176458">To protect children during Aotearoa's Omicron outbreak, we need to consider their families, not just schools</a>
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<p><strong>3. Improving communication, policy responsiveness and trust</strong></p>
<p>Pandemics are different from other public health emergencies because the behaviour of individuals directly affects the level of risk for the wider population. Inevitably, after two years, the response has become more contested and social cohesion has weakened. Some of this shift appears fuelled by the global pandemic of <a href="https://www.theguardian.com/world/2022/feb/26/so-many-rabbit-holes-even-in-trusting-new-zealand-protests-show-fringe-beliefs-can-flourish">disinformation</a>.</p>
<p>The New Zealand government can enhance public trust by showing that the response is risk-based, for example by phasing out travel restrictions and border isolation requirements now that Omicron infection is widespread. Some mandates are needed for critical public health interventions but require continuing review to ensure they are proportionate. </p>
<p>Trust and <a href="https://informedfutures.org/social-cohesion/">social cohesion</a> will also be improved by maximising transparency around the pandemic response, with clear statements about the rationale and level of risk, supported with evidence and local surveillance data presented in meaningful ways. We also need <a href="https://www.newsroom.co.nz/cracking-the-misinformation-code">specific strategies</a> to reduce misinformation and disinformation on social media.</p>
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<img alt="Tent and sign from an anti-mandate protest." src="https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448759/original/file-20220227-95880-851xvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Anti-mandates protests have been partly fuelled by misinformation.</span>
<span class="attribution"><span class="source">Adam Bradley/SOPA Images/LightRocket via Getty Images</span></span>
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<p><strong>4. Improving evidence-informed leadership and adaptability</strong></p>
<p>While New Zealand’s science-informed strategic response has been generally successful, it has at times been reactive rather than proactive in rapidly adapting to changes in the pandemic. We need better mechanisms, such as the multi-party <a href="https://www.parliament.nz/en/visit-and-learn/history-and-buildings/special-topics/epidemic-response-committee-covid-19-2020/">epidemic response committee</a> of parliamentarians, and advisory processes that ensure high-level science input into the all-of-government response. This could include the formation of a COVID-19 science council/rōpu. </p>
<p>Other measures include a <a href="https://www.mbie.govt.nz/science-and-technology/science-and-innovation/research-and-data/nzris/covid-19-research-database/">well-resourced research strategy</a> to provide high-quality scientific evidence and an <a href="https://blogs.otago.ac.nz/pubhealthexpert/five-key-reasons-why-nz-should-have-an-official-inquiry-into-the-response-to-the-covid-19-pandemic/">official inquiry</a> to assess the pandemic response and drive wider system improvements.</p>
<p><strong>5. Investing in public health infrastructure</strong></p>
<p>The current <a href="https://dpmc.govt.nz/our-business-units/transition-unit/response-health-and-disability-system-review/information">health sector reforms</a> are an opportunity to establish essential infrastructure, including a Public Health Agency and Māori Health Authority. </p>
<p>Investment in the national immunisation register may help with reversing the recent <a href="https://www.immune.org.nz/sites/default/files/publications/Coverage%20Report%20-%20July%202021.pdf">decline in childhood immunisations</a>. The pandemic also demonstrates that <a href="https://www.newsroom.co.nz/rethinking-rebreathing-how-to-end-the-pandemic">clean indoor air</a> is as essential to health as clean drinking water. </p>
<p>We should learn from other countries that have also delivered effective responses. <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(20)30044-4/fulltext">Taiwan is an example</a> we have previously documented.</p>
<p>In summary, New Zealand is well placed to navigate the pandemic and the Omicron wave successfully. As we enter our third pandemic year, we can improve the effectiveness of our response by maintaining a precautionary approach in the face of uncertainty. We also need to improve equity, communication and trust, and evidence-informed leadership, as well as investing in public health infrastructure. </p>
<p>These improvements will provide legacy benefits that <a href="https://ojs.victoria.ac.nz/pq/article/view/6550/5715">prepare us well for other public health challenges</a> we face.</p><img src="https://counter.theconversation.com/content/177134/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker receives funding from the Health Research Council of New Zealand for infectious disease research.</span></em></p><p class="fine-print"><em><span>Amanda Kvalsvig receives funding from the Health Research Council of New Zealand for infectious diseases research.</span></em></p><p class="fine-print"><em><span>Matire Harwood receives funding from Health Research Council, National Science Challenge - Healthier Lives and Heart Foundation. She is e member of the COVID-TAG. </span></em></p><p class="fine-print"><em><span>Nick Wilson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Now that Omicron infection is widespread, the government could improve trust by phasing out travel restrictions and border isolation and reviewing vaccine mandates to ensure they are proportionate.Michael Baker, Professor of Public Health, University of OtagoAmanda Kvalsvig, Senior Research Fellow, Department of Public Health, University of OtagoMatire Harwood, Associate Professor Department of General Practice and Primary Care, University of Auckland, Waipapa Taumata RauNick Wilson, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1767502022-02-24T16:36:27Z2022-02-24T16:36:27ZChildren struggle more than adults to recognize masked faces<figure><img src="https://images.theconversation.com/files/447669/original/file-20220221-28422-lavtez.jpg?ixlib=rb-1.1.0&rect=23%2C0%2C5161%2C2487&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Public health measures to curb the spread of COVID-19 require face masks in many settings.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Face perception is one of the most important visual abilities for humans. A quick glance at a person’s face provides us with rich and socially relevant information, including race, age, gender and emotional state. </p>
<p>Humans typically process faces as a unified whole instead of relying on specific facial features like eyes, nose or mouth. Scientists refer to this type of processing as “<a href="https://doi.org/10.1177/0956797611401753">holistic processing</a>,” and believe that it is essential to recognizing faces quickly and accurately. </p>
<p>Our research explores how mask wearing — the new reality imposed by the COVID-19 pandemic — changes how children and adults process and perceive faces.</p>
<h2>Facing difficulties</h2>
<p>Scientists have promoted mask-wearing as <a href="https://doi.org/10.1073/pnas.2014564118">one of the most important and effective tools to reduce COVID-19 transmission</a>. Many governments around the world required face masks in public places, especially when physical distancing is less feasible. Wearing a mask became prevalent in diverse social settings including on public transportation, in schools and at sporting events and concerts. </p>
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Read more:
<a href="https://theconversation.com/masking-in-schools-a-doctor-and-covid-19-researcher-explains-how-it-keeps-children-safe-177239">Masking in schools: A doctor and COVID-19 researcher explains how it keeps children safe</a>
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<p>However, because face masks conceal the lower part of the face, <a href="https://doi.org/10.1038/s41598-020-78986-9">our research group was not surprised to find a reduced ability to learn to recognize new faces when they are masked</a>. Notably, we found that when people had difficulty recognizing masked faces, there were changes in how faces were recognized. Masked faces were processed in a less holistic manner, and more in a feature-by-feature way. </p>
<p>Sensitivity to faces appears early in life. In fact, <a href="https://doi.org/10.1111/1467-9280.00179">newborns are already sensitive</a> to the spatial arrangement of a face, and stare more at visual patterns that resemble this organization (two eyes above a nose above a mouth). Despite this early sensitivity, face perception develops slowly, and some studies suggest that this ability is not fully matured even in teenagers. Given that their face processing system is not fully developed, we wondered if children might have even greater difficulties recognizing masked faces compared to adults. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A ridiculously adorable baby looks at their mother" src="https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447702/original/file-20220222-28-1lix8sd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Infants show signs of facial recognition and are drawn to visual representations of how facial features are organized.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Impaired recognition</h2>
<p>To test this question, <a href="https://doi.org/10.1186/s41235-022-00360-2">we conducted a study using a version of the face recognition test used in adults, but specially designed for children</a>. This test includes increasing levels of difficulty: The child participants are presented with photographs of other children’s faces, and they need to choose which face they had seen during the study phase. To make the test more challenging, the faces are presented from different viewpoints, and external cues, like hair, are removed. </p>
<p>We tested 72 children. Half of them completed the regular version of the test, while the other half completed a “masked” version of the test, where the children in the photographs appeared to be wearing masks. Each child completed the test twice, once with faces presented upright and once with faces presented upside down. </p>
<p>Turning a face upside down stops people from processing the faces in a holistic way because the typical spatial organization of the face (two eyes above a nose above a mouth) is distorted. When we try to recognize faces without masks, we are much worse at doing so when the face is upside down. This is because we are no longer able to rely on our natural holistic processing system and, instead, we rely on a weaker feature-based strategy. </p>
<p>We assumed that if participants were just as poor at recognizing upright faces with masks as they were at recognizing upside-down faces with masks, it would mean that these masked faces are no longer being processed in a holistic way.</p>
<p>The results of the study were clear. First, we found that children were impaired in recognizing masked faces. The group of children who completed the masked version showed a 20 per cent reduction in their test score. This was even worse than what we had originally found in adults (15 per cent reduction), suggesting that children might find it even more difficult to recognize faces with masks than adults. </p>
<p>We also found evidence for a smaller “upside-down” effect for masked faces. This finding indicates that children processed the masked faces in a more feature-to-feature fashion, which might explain some of their difficulty in recognizing masked faces.</p>
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<a href="https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A girl wearing a surgical mask hangs upside down in a swing" src="https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447703/original/file-20220222-27005-1qcsa24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">It takes us longer to process upside-down faces because features aren’t where they’re supposed to be.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Children’s recognition cues</h2>
<p>These new findings raise a number of important questions that scientists could address in the future. First, do children learn to use other cues to recognize friends and teachers — for example, by relying on people’s voices or movements? Second, would children become better at recognizing masked faces as they gained more experience with such faces? </p>
<p>This seems likely because previous research found that children’s brains are more adaptable and that experience can shape their visual abilities. Third, do difficulties recognizing masked faces affect children’s ability to communicate with others and form meaningful social relationships? </p>
<p>It is important to emphasize again that masks are one of the most effective tools in our effort to reduce the spread of COVID-19 and keep people safe and healthy. Despite the difficulties that adults and children experience with recognition of masked faces, any decisions about mandatory mask wearing should be informed by public health experts. </p>
<p>At the same time, it’s important to understand how masks may change how children perceive faces so that we can determine whether children are better able to adapt to masks, and which cues or strategies help to improve recognition of masked faces.</p><img src="https://counter.theconversation.com/content/176750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erez Freud receives funding from the Natural Sciences and Engineering Research Council and from the Vision Science to Applications (VISTA) program funded by the Canada First Research Excellence Fund (CFREF, 2016–2023) . </span></em></p><p class="fine-print"><em><span>Shayna Rosenbaum receives funding from the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council (NSERC), and from the Vision Science to Applications (VISTA) program funded by the Canada First Research Excellence Fund (CFREF, 2016–2023) .</span></em></p>We rely on the spatial arrangement of facial features to process faces, and wearing masks interferes with that — especially for children.Erez Freud, Assistant Professor, Psychology, York University, CanadaR. Shayna Rosenbaum, Professor and York Research Chair, Psychology, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1679632021-09-22T12:55:45Z2021-09-22T12:55:45ZEvidence shows that, yes, masks prevent COVID-19 – and surgical masks are the way to go<figure><img src="https://images.theconversation.com/files/422459/original/file-20210921-13-1f55482.jpg?ixlib=rb-1.1.0&rect=113%2C106%2C4937%2C3256&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What type of mask is best?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/single-use-mask-vs-reusable-mask-royalty-free-image/1269406362?adppopup=true"> Brais Seara/Moment via Getty Images</a></span></figcaption></figure><p>Do masks work? And if so, should you reach for an N95, a surgical mask, a cloth mask or a gaiter?</p>
<p>Over the past year and a half, researchers have produced a lot of laboratory, model-based and observational evidence on the effectiveness of masks. For many people it has understandably been hard to keep track of what works and what doesn’t.</p>
<p><a href="https://publichealth.berkeley.edu/people/laura-kwong/">I’m</a> an <a href="https://scholar.google.com/citations?user=rATz6o4AAAAJ&hl=en&oi=ao">assistant professor of environmental health sciences</a>.
I, too, have wondered about the answers to these questions, and earlier this year I led a study that examined the <a href="https://doi.org/10.1021/acsnano.0c10146">research about which materials are best</a>. </p>
<p>Recently, I was part of the largest randomized controlled trial to date testing the <a href="https://www.poverty-action.org/publication/impact-community-masking-covid-19-cluster-randomized-trial-bangladesh">effectiveness of mask-wearing</a>. The study has yet to be peer reviewed but has been <a href="https://www.theatlantic.com/ideas/archive/2021/09/masks-were-working-all-along/619989/">well received</a> by the <a href="https://cm.publichealthontario.ca/-/media/documents/ncov/research/2021/09/synopsis-abaluck-ipa-impact-community-masking.pdf?sc_lang=en&hash=F90079914D3618E32F9233E3CC3F2B5F">medical community</a>. What we found provides gold-standard evidence that confirms previous research: Wearing masks, particularly surgical masks, prevents COVID-19.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/DNeYfUTA11s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Laboratory studies help scientists understand the physics of masks and spread.</span></figcaption>
</figure>
<h2>Lab and observational studies</h2>
<p>People have been <a href="https://www.npr.org/2020/05/13/855405132/the-mask">using masks to protect themselves from contracting diseases</a> since the <a href="https://doi.org/10.1080/01459740.2017.1423072">Manchurian outbreak of plague in 1910</a>.</p>
<p>During the coronavirus pandemic, the focus has been on masks as a way of preventing infected persons from contaminating the air around them – called source control. Recent laboratory evidence supports this idea. In April 2020, researchers showed that people infected with a coronavirus – but not SARS-CoV-2 – exhaled <a href="https://doi.org/10.1038/s41591-020-0843-2">less coronavirus RNA into the air around them if they wore a mask</a>. A number of additional <a href="https://doi.org/10.3389/fmed.2020.00504">laboratory studies</a> have also supported the efficacy of masks.</p>
<p>Out in the real world, many epidemiologists have <a href="https://doi.org/10.1377/hlthaff.2020.00818">examined the impact of masking and mask policies</a> to see if <a href="https://doi.org/10.1016/j.jeconom.2020.09.003">masks help slow the spread of COVID-19</a>. One observational study – meaning it was not a controlled study with people wearing or not wearing masks – published in late 2020 looked at demographics, testing, lockdowns and mask-wearing in 196 countries. The researchers found that after controlling for other factors, countries with cultural norms or policies that supported mask-wearing saw weekly per capita coronavirus mortality increase 16% during outbreaks, compared with a <a href="https://dx.doi.org/10.4269%2Fajtmh.20-1015">62% weekly increase in countries without mask-wearing norms</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man wearing a surgical mask handing a mask to a woman working at a vegetable stand." src="https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422469/original/file-20210921-25-o5o11.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Researchers gave surgical masks to adults in 200 villages in Bangladesh to test whether they reduce COVID-19.</span>
<span class="attribution"><span class="source">Innovations for Poverty Action</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Large-scale randomized mask-wearing</h2>
<p>Laboratory, observational and <a href="https://doi.org/10.1016/j.idm.2020.04.001">modeling</a> <a href="https://doi.org/10.1126/science.abg6296">studies</a>, have <a href="https://doi.org/10.1073/pnas.2014564118">consistently supported the value of many types of masks</a>. But these approaches are not as strong as large-scale randomized controlled trials among the general public, which compare groups after the intervention has been implemented in some randomly selected groups and not implemented in comparison groups. One such study done in Denmark in early 2020 was inconclusive, but it was <a href="https://doi.org/10.7326/m20-6817">relatively small and relied on participants to self-report mask-wearing</a>.</p>
<p>From November 2020 to April 2021, my colleagues Jason Abaluck, Ahmed Mushfiq Mobarak, Stephen P. Luby, Ashley Styczynski and I – in close collaboration with partners in the Bangladeshi government and the research nonprofit <a href="https://www.poverty-action.org/about">Innovations for Poverty Action</a> – conducted a large-scale randomized controlled trial on masking in Bangladesh. Our goals were to learn the best ways to increase mask-wearing without a mandate, understand the effect of mask-wearing on COVID-19, and compare cloth masks and surgical masks. </p>
<p>The study involved 341,126 adults in 600 villages in rural Bangladesh. In 300 villages we did not promote masks, and people continued wearing masks, or not, as they had before. In 200 villages we promoted the use of surgical masks, and in 100 villages we promoted cloth masks, testing <a href="https://www.poverty-action.org/masks">a number of different outreach strategies</a> in each group. </p>
<p>Over the course of eight weeks, our team distributed free masks to each adult in the mask groups at their homes, provided information about the risks of COVID-19 and the value of mask-wearing. We also worked with community and religious leaders to model and promote mask-wearing and hired staff to walk around the village and politely ask people who were not wearing a mask to put one on. Plainclothes staff recorded whether people wore masks properly over their mouth and nose, improperly or not at all. </p>
<p>Both five weeks and nine weeks after starting the study, we collected data from all adults on symptoms of COVID-19 during the study period. If a person reported any symptoms of COVID-19, we took and tested a blood sample for evidence of infection.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman exiting a store with signs showing mask requirements on the door." src="https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422461/original/file-20210921-19-5i09ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Based on current evidence, many places across the U.S. have some form of mask requirements.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakTexas/98acae1926e143b68cb2a82b857361e7/photo?Query=mask%20required%20sign&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=220&currentItemNo=0">AP Photo/LM Otero</a></span>
</figcaption>
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<h2>Mask-wearing reduced COVID-19</h2>
<p>The first question my colleagues and I needed to answer was whether our efforts led to increased mask-wearing. Mask usage more than tripled, from 13% in the group that wasn’t given masks to 42% in the group that was. Interestingly, physical distancing also increased by 5% in the villages where we promoted masks.</p>
<p>In the 300 villages where we distributed any type of mask, we saw a 9% reduction in COVID-19 compared with villages where we did not promote masks. Because of the small number of villages where we promoted cloth masks, we were not able to tell whether cloth or surgical masks were better at reducing COVID-19. </p>
<p>We did have a large enough sample size to determine that in villages where we distributed surgical masks, COVID-19 fell by 12%. In those villages COVID-19 fell by 35% for people 60 years and older and 23% for people 50-60 years old. When looking at COVID-19-like symptoms we found that both surgical and cloth masks resulted in a 12% reduction. </p>
<h2>The body of evidence supports masks</h2>
<p>Before this study there was a lack of gold-standard evidence on the effectiveness of masks to reduce COVID-19 in daily life. Our study provides strong real-world evidence that surgical masks reduce COVID-19, particularly for older adults who face higher rates of death and disability if they get infected. </p>
<p>Policymakers and public health officials now have evidence from laboratories, models, observations and real-world trials that support mask-wearing to reduce respiratory diseases, including COVID-19. Given that COVID-19 can so easily spread from person to person, if more people wear masks the benefits increase.</p>
<p>So next time you are wondering if you should wear a mask, the answer is yes. Cloth masks are likely better than nothing, but high-quality surgical masks or masks with even higher filtration efficiency and better fit – such as KF94s, KN95s and N95s – are the most effective at preventing COVID-19.</p><img src="https://counter.theconversation.com/content/167963/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura (Layla) H. Kwong does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Since the coronavirus first began spreading around the globe, people have debated how effective masks are at preventing COVID-19. A year and a half in, what does the evidence show?Laura (Layla) H. Kwong, Assistant Professor of Environmental Health Sciences, University of California, BerkeleyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1668922021-08-31T05:03:36Z2021-08-31T05:03:36ZWhat are the limits of dissent as NZ locks down, vaccinates and prepares to ‘open up’?<figure><img src="https://images.theconversation.com/files/418538/original/file-20210831-19-xntvxf.jpg?ixlib=rb-1.1.0&rect=68%2C51%2C3716%2C2564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Mark Mitchell - Pool/Getty Images</span></span></figcaption></figure><p>As New Zealand grapples to bring a Delta outbreak under control and to accelerate the vaccination rollout, social cohesion is vital for a successful <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-response-planning/covid-19-elimination-strategy-aotearoa-new-zealand">elimination strategy</a>.</p>
<p>Political consensus on elimination has endured so far. Unlike the anti-mask and anti-vaccination movements elsewhere, most New Zealanders <a href="https://thespinoff.co.nz/politics/25-08-2021/exclusive-poll-seven-out-of-10-back-nz-sticking-with-elimination-strategy/">continue to back</a> the prime minister’s decision to place the country under the strictest lockdown.</p>
<p>But strains on public consensus are beginning to show, with a less-than-ideal parliament, some pushback against lockdowns and agitation to “open up”. </p>
<p>These debates will become more pressing as the government moves towards difficult discussions about an exit strategy and targets for vaccination rates.</p>
<h2>Dissent and debate within parliament</h2>
<p>At the highest level, the country has been let down by all sides. </p>
<p>During last year’s nation-wide lockdown, the prime minister created the <a href="https://www.parliament.nz/en/visit-and-learn/history-and-buildings/special-topics/epidemic-response-committee-covid-19-2020/">epidemic response committee</a>. It reflected a government confident enough to be questioned in public through a parliamentary body it did not control. The opposition was constructive in finding the best ways forward. This was constitutional governance at its best. </p>
<p>This time, all sides of the political spectrum have failed. It began with the decision to suspend the parliamentary sitting, on the advice of the director-general of health. Any such advice should have been given in conjunction with the attorney-general, as it has significant constitutional consequences. </p>
<p>The epidemic response committee was not resuscitated. Following a wave of criticism, the government floated a virtual option. Opposition parties <a href="https://www.stuff.co.nz/national/politics/300393369/covid19-nz-national-and-act-reject-plan-for-virtual-parliament-and-question-time">rejected</a> this, forcing the government to <a href="https://www.rnz.co.nz/national/programmes/morningreport/audio/2018810380/covid-19-socially-distanced-parliament-resumes-sitting-today">recall a truncated parliament</a> with enhanced social distancing rules. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1432165060294504452"}"></div></p>
<p>As a result, very few politicians are in parliament; and smaller parties are <a href="https://www.rnz.co.nz/news/political/450364/resumption-of-parliament-parties-take-a-stand-over-sitting">staying away</a> for health (not constitutional) reasons. This is a poor example of how our country should be governed in at a time of emergency.</p>
<h2>Dissent in the wider community</h2>
<p>Dealing with protests outside parliament during this pandemic is equally difficult. The important point here is that people have rights, but these rights may be subject to reasonable limits. </p>
<p>All New Zealanders have a right to peaceful assembly in public to protest, but this can be curtailed by conditions of where, when and how. Fundamentally, nobody has a right to public protest in the middle of a national lockdown. </p>
<p>Other rights, such as freedom of expression, remain intact, pandemic or not. However, this too is not without limits. For example, advocacy is permissible in a speech about vaccination in a public space, but it <a href="https://www.stuff.co.nz/national/health/coronavirus/300329450/complaints-against-antivax-leaflet-largely-upheld-by-advertising-standards-authority">cannot be misleading</a> or factually incorrect. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/phased-border-reopening-faster-vaccination-be-ready-for-delta-jacinda-ardern-lays-out-nzs-covid-roadmap-165957">Phased border reopening, faster vaccination, be ready for Delta: Jacinda Ardern lays out NZ's COVID roadmap</a>
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<p>The above examples generally relate to situations in which a minority group is trying to influence the majority view. But the debate gets more complex when the majority tries to make smaller groups do things they disagree with. </p>
<h2>Compulsion and harm to others</h2>
<p>Vaccination is likely to bring this issue to a head. The government has released a <a href="https://covid19.govt.nz/assets/reports/Independent-Advisory-Groups/Reconnecting-New-Zealanders-to-the-World/Reconnecting-New-Zealanders-to-the-World-Next-steps.pdf">plan</a> for a phased border opening, based on its elimination strategy. The plan would eventually allow vaccinated travellers from low-risk countries to enter without quarantine.</p>
<p>This will only be possible once a high proportion of New Zealanders is vaccinated. Earlier <a href="https://www.tepunahamatatini.ac.nz/2021/06/30/a-covid-19-vaccination-model-for-aotearoa-new-zealand/">modelling</a> shows that, for the alpha variant of COVID-19, around 80-85% of the population would need to be vaccinated before New Zealand can relax border controls. For the more transmissible Delta strain, the source of New Zealand’s current outbreak, we would need to reach <a href="https://theconversation.com/at-least-four-in-five-new-zealanders-will-have-to-be-vaccinated-before-border-controls-can-be-fully-relaxed-163486">97% of the population</a>.</p>
<p>While Australia and other countries are now discussing how to adapt to an ongoing presence of COVID-19, accepting deaths and hospitalisations, New Zealand so far maintains <a href="https://covid19.govt.nz/assets/reports/Independent-Advisory-Groups/Reconnecting-New-Zealanders-to-the-World/Reconnecting-New-Zealanders-to-the-World-Next-steps.pdf">elimination as a strategy</a> “to stamp out the virus and keep our options open”. </p>
<p>Whatever vaccination target will be necessary, getting there from the current level of 21% of the population fully vaccinated will be a challenge. The government will likely need to use incentives and some degree of compulsion.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-rights-do-nz-children-and-their-parents-have-when-giving-consent-to-be-vaccinated-166495">What rights do NZ children and their parents have when giving consent to be vaccinated?</a>
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<p>Free vaccinations, if delivered conveniently and safely as part of a targeted public health education campaign to overcome vaccine hesitancy, are an effective tool. Lowering the age for vaccinations will also lift the overall percentage of uptake. If all else fails, even <a href="https://theconversation.com/top-economists-in-no-rush-to-offer-cash-incentives-for-vaccination-166560">cash incentives</a> may help to increase voluntary vaccination.</p>
<p>But compulsion might become necessary. While the general rule is that people can refuse medical treatments, in times of emergency this can be trumped and regulations could be introduced to enforce vaccination. This is where we must be careful. The temptation will be to use compulsion or heavy-handed pressure (such as restricting social welfare) against those who choose not to get vaccinated. </p>
<p>So far, the government has only introduced <a href="https://www.legislation.govt.nz/regulation/public/2021/0094/latest/LMS487857.html">law</a> to make it mandatory that certain workers, such as <a href="https://www.beehive.govt.nz/release/govt-makes-covid-19-vaccinations-mandatory-more-border-jobs">those at the border</a>, are vaccinated. This is done to reduce the risk to others, and it is the correct measure to use. </p>
<p>If people choose not to be vaccinated and risk harming others, the government should intervene, explaining the risk the unvaccinated pose, apart from their potential self-harm. It should then pass laws to allow reasonable levels of discrimination against people who refuse the vaccine. </p>
<p>This means if a risk of harm to others can be shown, it may become acceptable to stop unvaccinated people from entering restaurants, but not from buying food from a supermarket (although strict safety measures may be insisted upon). Conversely, if an unvaccinated person risks harming only themselves, the government should let them carry the full consequences of their choice.</p><img src="https://counter.theconversation.com/content/166892/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Gillespie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Zealand continues to pursue an elimination strategy to stamp out community infections with the Delta variant. But it will need incentives and some degree of compulsion to raise vaccination rates.Alexander Gillespie, Professor of Law, University of WaikatoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1647412021-08-18T12:12:25Z2021-08-18T12:12:25ZCorrectional officers are driving the pandemic in prisons<figure><img src="https://images.theconversation.com/files/415045/original/file-20210806-90838-180utg2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2995%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While prison may isolate people from the larger community, it does not isolate them from COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-wearing-protective-masks-leave-the-cook-county-jail-news-photo/1217875901">Scott Olson/Staff/Getty Images News</a></span></figcaption></figure><p>Prisons and jails have hosted some of the <a href="https://www.nytimes.com/interactive/2021/us/covid-cases.html">largest COVID-19 outbreaks in the U.S.</a>, with <a href="https://www.nytimes.com/interactive/2021/us/covid-cases.html">some facilities approaching 4,000 cases</a>. In the U.S., which has some of the highest COVID-19 infection rates in the world, 9 in 100 people have had the virus; in U.S. prisons, <a href="https://www.nytimes.com/interactive/2021/04/10/us/covid-prison-outbreak.html">the rate is 34 out of 100</a>.</p>
<p><a href="https://scholar.google.com/citations?hl=en&user=l3emkpsAAAAJ">I study public health issues around prisons</a>. My colleagues and I set out to <a href="https://doi.org/10.3390/ijerph18136873">understand why COVID-19 infection rates were so high</a> among incarcerated individuals. </p>
<p>Using data from the Federal Bureau of Prisons, we discovered the infection rate among correctional officers drove the infection rate among incarcerated individuals. We also found a three-way relationship between the infection rate of officers, incarcerated individuals and the communities around prisons.</p>
<h2>No stranger to outbreaks</h2>
<p>Prisons, jails and other correctional facilities routinely deal with infectious diseases. <a href="https://doi.org/10.1086/521910">Hepatitis B</a> <a href="https://doi.org/10.1016/j.idc.2018.02.014">and C</a> as well as <a href="https://doi.org/10.2105/AJPH.2016.303423">tuberculosis</a> are all incredibly common in prison populations.</p>
<p>Because of that, prisons have established policies and procedures for handling infectious diseases. Many of those policies are the same as those for preventing the spread of COVID-19 – such as medical isolation of individuals with active infections, increased cleaning and surveillance of the disease. </p>
<p>Public health experts have <a href="https://doi.org/10.1086/521910">encouraged prisons to think about the role of correctional officers in infection spread</a> for years and more recently have warned that <a href="http://dx.doi.org/10.15585/mmwr.mm6919e1">correctional officers are a weak link for COVID-19</a> infections in prisons.</p>
<p>Even though prisons have policies for disease control, many of which include guidelines for correctional officers, <a href="https://doi.org/10.1086/521910">prisons are at a disadvantage</a> in stopping the spread of COVID-19. Current prison conditions – including <a href="https://doi.org/10.1016/j.amepre.2021.01.018">poor ventilation</a>, <a href="https://www.prisonpolicy.org/blog/2020/12/21/overcrowding/">overcrowding</a> and a <a href="https://doi.org/10.1007/s11606-020-05968-y">lack of space for social distancing and isolation</a> – make respiratory diseases like COVID-19 very difficult to control. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Prisoners populate a yard surrounded by razor wire." src="https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415054/original/file-20210806-17-19y86fs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nebraska Department of Correctional Services was forced to declare an overcrowding emergency on July 1, 2020. Capacity in the state’s 10 prisons was at 151%, exceeding the 2015 mandated 140% threshold.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PrisonCrowdingNebraska/581139315b654cf786085fa5d02693bb">AP Photo/Nati Harnik</a></span>
</figcaption>
</figure>
<p>For instance, before the start of the pandemic, the Federal Bureau of Prisons, along with nine state prison systems, has been <a href="https://www.prisonpolicy.org/blog/2020/12/21/overcrowding/">operating at over 100% capacity</a>. During the pandemic, even with massive early release and home confinement programs, <a href="https://www.prisonpolicy.org/blog/2020/12/21/overcrowding/">many states remain at 100% prisoner capacity – or more</a>. </p>
<p>Additionally, U.S. <a href="https://nij.ojp.gov/topics/articles/workforce-issues-corrections">prisons have been facing chronic staffing shortages</a>. In the federal system, the issue is so severe that staff not trained as prison guards – including nurses – <a href="https://www.nbcnews.com/news/us-news/federal-prisons-forced-use-cooks-nurses-guard-inmates-due-staff-n1268138">are being reassigned to guard the prison population</a>. Short staffing makes the daily business of running a prison difficult during the best of times, not to mention during a pandemic. </p>
<p><a href="https://www.bop.gov/coronavirus/overview.jsp#bop_emergency_response">As early as March 2020</a>, many prisons attempted to mitigate these conditions by granting early release and home confinement. Some also blocked all visitors and outside contractors. While <a href="https://madison.com/ct/news/local/govt-and-politics/early-research-shows-fewer-inmates-flattened-covid-19-curve-at-dane-county-jail/article_7fd4ebb9-59fa-56c2-8952-3668f5d61ad2.html">helpful in some cases</a>, ultimately these actions did little to stop outbreaks. </p>
<h2>Responding to COVID-19</h2>
<p>Initially, public health organizations such as the Centers for Disease Control and Prevention <a href="https://www.latimes.com/science/story/2021-07-27/timeline-cdc-mask-guidance-during-covid-19-pandemic">went back and forth on the need for masks</a>. Then mask mandates became a partisan issue. By midsummer 2020, <a href="https://www.prisonpolicy.org/blog/2020/08/14/masks-in-prisons/">30 states mandated masking for correctional officers, prisoners or both</a>. The Bureau of Prisons <a href="https://www.bop.gov/foia/docs//Mandatory_Use_Face_Coverings_for_Staff_08242020.pdf">adopted a masking policy in late August</a>, requiring correctional officers to mask when social distancing was not possible.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Wearing a protective mask and gloves, a correctional officer sanitizes an inmate transport van." src="https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=447&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=447&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=447&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=561&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=561&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415894/original/file-20210812-20-1ixq4w5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=561&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Masking seems to slow the spread in prisons but not halt it.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/wearing-a-protective-mask-and-gloves-elijah-johnson-a-news-photo/1209294310">David L. Ryan/The Boston Globe via Getty Images</a></span>
</figcaption>
</figure>
<p>As the second and third waves of COVID-19 swept through the nation and the federal prison system, the <a href="https://doi.org/10.3390/ijerph18136873">mask mandate made only a small dent</a> in slowing the uptick of infections among prisoners. </p>
<p>Additionally, <a href="https://www.prisonpolicy.org/blog/2021/04/22/vaccinerefusal/">vaccine adoption rates among correctional officers</a> and <a href="https://www.nytimes.com/2021/05/22/us/covid-prison-vaccine.html">incarcerated people</a> are low, weakening this line of defense. Across all states, <a href="https://doi.org/10.1371/journal.pone.0253208">incarcerated people have not been prioritized for the vaccine</a>. Even when the vaccines are available, many incarcerated people are <a href="https://www.nytimes.com/2021/05/22/us/covid-prison-vaccine.html">skeptical about receiving them due to mistrust</a> of prison officials. </p>
<h2>Two-way vectors</h2>
<p>We found the relationship between COVID-19 infections among correctional staff and incarcerated individuals is also shaped by the <a href="https://doi.org/10.3390/ijerph18136873">incidence of COVID-19 in the community</a> surrounding the prison. Because correctional officers move between the prison and the community at the beginning and end of each shift, they can carry COVID-19 between these two spaces. </p>
<p>Even when correctional officers test negative for COVID-19, they can still drive COVID-19 rates both inside and outside the prison via asymptomatic or pre-symptomatic spread. <a href="https://doi.org/10.3390/ijerph18136873">Our data shows</a> that when COVID-19 rates in the outside community get worse, so too do rates among the incarcerated population.</p>
<p>Prison policies aimed at stopping the spread of COVID-19 should be designed with an eye toward controlling the disease in the prison population, among correctional officers and in the community around the prison. </p>
<p>For example, prison systems should be just as concerned with vaccination rates in the communities around prisons as they are with vaccination rates among correctional officers. Both rates will have an impact on the spread of COVID-19 within a prison.</p>
<p>[<em>Over 110,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p><img src="https://counter.theconversation.com/content/164741/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Danielle Wallace received funding from the National Science Foundation, surrounding this work, specifically, Award #2032747, “Estimating the Reciprocal Relationship between COVID-19 Infections of Prisoners and Staff and Infections in the Surrounding Communities.”</span></em></p>New research shows correctional officers are vectors of infection, driving COVID-19 rates both inside prisons and in their communities.Danielle Wallace, Associate Professor of Criminology and Criminal Justice, Arizona State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1650052021-08-05T06:29:59Z2021-08-05T06:29:59ZWhen faces are partially covered, neither people nor algorithms are good at reading emotions<figure><img src="https://images.theconversation.com/files/414452/original/file-20210804-14-bjw0w8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5101%2C3403&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Sergey Tinyakov</span></span></figcaption></figure><p>Artificial systems such as homecare robots or driver-assistance technology are becoming more common, and it’s timely to investigate whether people or algorithms are better at reading emotions, particularly given the added challenge brought on by face coverings.</p>
<p>In our recent <a href="https://psyarxiv.com/mnsyx/">study</a>, we compared how face masks or sunglasses affect our ability to determine different emotions compared with the accuracy of artificial systems. </p>
<figure class="align-center ">
<img alt="Our study used full and partial masks and sunglasses to obscure parts of the face." src="https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=116&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=116&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=116&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=145&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=145&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414016/original/file-20210731-13-wst32o.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=145&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The study used full and partial masks and sunglasses to obscure parts of the face.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We presented images of emotional facial expressions and added two different types of masks — the full mask used by frontline workers and a recently introduced mask with a transparent window to allow lip reading. </p>
<p>Our findings show algorithms and people both struggle when faces are partially obscured. But artificial systems are more likely to misinterpret emotions in unusual ways.</p>
<p>Artificial systems performed significantly better than people in recognising emotions when the face was not covered — 98.48% compared to 82.72% for seven different types of emotion. </p>
<p>But depending on the type of covering, the accuracy for both people and artificial systems varied. For instance, sunglasses obscured fear for people while partial masks helped both people and artificial systems to identify happiness correctly. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-is-increasingly-being-used-to-identify-emotions-heres-whats-at-stake-158809">AI is increasingly being used to identify emotions – here's what's at stake</a>
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<p>Importantly, people classified unknown expressions mainly as neutral, but artificial systems were less systematic. They often incorrectly selected anger for images obscured with a full mask, and either anger, happiness, neutral, or surprise for partially masked expressions.</p>
<h2>Decoding facial expressions</h2>
<p>Our ability to recognise emotion uses the visual system of the brain to interpret what we see. We even have an area of the brain specialised for face recognition, known as the fusiform face area, which helps interpret information revealed by people’s faces. </p>
<p>Together with the context of a particular situation (social interaction, speech and body movement) and our understanding of past behaviours and sympathy towards our own feelings, we can decode how people feel. </p>
<p>A system of <a href="https://www.paulekman.com/facial-action-coding-system/">facial action units</a> has been proposed for decoding emotions based on facial cues. It includes units such as “the cheek raiser” and “the lip corner puller”, which are both considered part of an expression of happiness.</p>
<figure class="align-center ">
<img alt="Study team wearing face masks" src="https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414017/original/file-20210731-17-1e2apxb.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Can you read the researchers’ emotion from their covered faces? Both artificial systems and people are compromised in categorising emotions when faces are obscured.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In contrast, artificial systems analyse pixels from images of a face when categorising emotions. They pass pixel intensity values through a network of filters mimicking the human visual system. </p>
<p>The finding that artificial systems misclassify emotions from partially obscured faces is important. It could lead to unexpected behaviours of robots interacting with people wearing face masks.</p>
<p>Imagine if they misclassify a negative emotion, such as anger or sadness, as a positive emotional expression. The artificial systems would try to interact with a person taking actions on the misguided interpretation they are happy. This could have detrimental effects for the safety of these artificial systems and interacting humans.</p>
<h2>Risks of using algorithms to read emotion</h2>
<p>Our research reiterates that algorithms are susceptible to biases in their judgement. For instance, the performance of artificial systems is greatly affected when it comes to categorising emotion from natural images. Even just the sun’s angle or shade can influence outcomes.</p>
<p>Algorithms can also be racially biased. As previous studies have found, even a small <a href="https://link.springer.com/chapter/10.1007/978-3-030-72699-7_30">change to the colour</a> of the image, which has nothing to do with emotional expressions, can lead to a drop in performance of algorithms used in artificial systems. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/face-masks-and-facial-recognition-will-both-be-common-in-the-future-how-will-they-co-exist-144417">Face masks and facial recognition will both be common in the future. How will they co-exist?</a>
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<hr>
<p>As if that wasn’t enough of a problem, even <a href="https://arxiv.org/abs/1702.02284">small visual perturbations</a>, imperceptible to the human eye, can cause these systems to misidentify an input as something else. </p>
<p>Some of these misclassification issues can be addressed. For instance, <a href="https://ieeexplore.ieee.org/document/9223510">algorithms can be designed</a> to consider emotion-related features such as the shape of the mouth, rather than gleaning information from the colour and intensity of pixels. </p>
<p>Another way to address this is by changing the <a href="https://psyarxiv.com/mnsyx/">training data characteristics</a> — oversampling the training data so that algorithms mimic human behaviour better and make less extreme mistakes when they do misclassify an expression.</p>
<p>But overall, the performance of these systems drops when interpreting images in real-world situations when faces are partially covered. </p>
<p>Although robots may claim higher than human accuracy in emotion recognition for static images of completely visible faces, in real-world situations that we experience every day, their performance is still not human-like.</p><img src="https://counter.theconversation.com/content/165005/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Will Browne receives funding from Science for Technological Innovation, Ministry of Business, Innovation and Employment. </span></em></p><p class="fine-print"><em><span>Harisu Abdullahi Shehu and Hedwig Eisenbarth do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Robots are more likely than people to misclassify emotions when reading faces that are partially covered. This could lead to unexpected behaviours when they interact with people wearing masks.Harisu Abdullahi Shehu, PhD Researcher, Te Herenga Waka — Victoria University of WellingtonHedwig Eisenbarth, Senior Lecturer in Psychology, Te Herenga Waka — Victoria University of WellingtonWill Browne, Professor in Artificial Cognitive Systems, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1634172021-07-22T12:11:04Z2021-07-22T12:11:04ZOur analysis of 7 months of polling data shows friendships, the economy and firsthand experience shaped and reshaped views on COVID-19 risks<figure><img src="https://images.theconversation.com/files/412158/original/file-20210720-23-pkmeor.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C6735%2C3952&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Political leanings and community features predicted support of COVID-19 mitigation measures.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mask-war-royalty-free-image/1257147451">wildpixel/iStock via Getty Images Plus</a></span></figcaption></figure><p>Even though Americans shared the experience of living through a global pandemic, their individual attitudes towards it differed and evolved – sometimes dramatically. </p>
<p><a href="https://scholar.google.com/citations?hl=en&user=Hw_l57UAAAAJ">We</a> <a href="https://scholar.google.com/citations?user=UP31kb4AAAAJ&hl=en">study</a> risk perception. Using public opinion polls and state-level data, we conducted an in-depth analysis of how American attitudes and behaviors changed over the course of the pandemic.</p>
<p>Since the first confirmed COVID-19 case in the U.S., over 33 million Americans have been diagnosed with SARS-CoV-2 and <a href="https://coronavirus.jhu.edu/region/united-states">more than 600,000 have died</a>. We set out to see how attitudes and beliefs correlated with Americans’ risk perceptions, mask wearing and support for other COVID-19 mitigation measures. </p>
<p>Here’s what we discovered.</p>
<h2>Public health and politics are intertwined</h2>
<p>Using statistical modeling, we dug into data from public opinion polls conducted by Pew Research Center, National Opinion Research Center, Democracy Fund and UCLA – as well as our own survey combined with state-level data from the Centers for Disease Control and Prevention and Moody’s Analytics and National Conference of State Legislatures. </p>
<p>In a presidential election year <a href="https://www.pewresearch.org/2021/03/05/a-year-of-u-s-public-opinion-on-the-coronavirus-pandemic/">characterized by intensifying polarization</a>, public health got caught up in politics. </p>
<p>In March 2020, with uncertainty surrounding COVID-19, contrasting cues from political leaders undoubtedly played a crucial role in shaping risk perception of the virus.</p>
<p>Conservatives who had more confidence in President Trump and his team’s handling of COVID-19, <a href="https://doi.org/10.1016/j.socscimed.2020.113235">perceived less risk from the virus</a> compared to conservatives with less confidence in Trump. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three middle-aged women at a rally wearing Trump hats." src="https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410197/original/file-20210707-15-vew72g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Political leaders shaped risk perception.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/with-few-face-masks-and-no-social-distancing-to-reduce-the-news-photo/1282732670">Chip Somodevilla via Getty Images News</a></span>
</figcaption>
</figure>
<p>The powerful influence of political cues persisted. Based on our <a href="https://www.voterstudygroup.org/publication/nationscape-data-set">analysis of a poll conducted in June 2020</a>, Republicans who were in favor of Trump were less supportive of mitigation measures – like canceling gatherings, closing businesses and schools, restricting non-essential travel and fever testing before entering public buildings – <a href="https://doi.org/10.3389/ijph.2021.1604037">compared to Republicans who were less supportive of Trump</a>. </p>
<p>Symmetrically, Democrats who were in favor of then candidate Joe Biden were more supportive of mitigation measures, <a href="https://doi.org/10.3389/ijph.2021.1604037">compared to Democrats who were less supportive of Biden</a>. </p>
<p>By May 2020, national political influence began to be mirrored at the state level. Americans who lived in states with both Democratic governors and legislatures were <a href="https://doi.org/10.1177/08901171211017286">more likely to perceive COVID-19 as a threat</a> and adjust their behaviors and support policy measures to mitigate transmission of the virus. </p>
<h2>Connected communities more likely to slow the spread</h2>
<p>When the pandemic was rapidly spreading in early summer of 2020, the CDC <a href="https://www.cdc.gov/coronavirus/2019-ncov/php/mask-evaluation.html">recommended wearing masks</a>. Americans with more extensive social connections and stronger trust in others were <a href="https://doi.org/10.1016/j.healthplace.2021.102537">more likely to engage in mitigation behaviors</a> such as mask wearing. </p>
<p>Individual behavior is <a href="https://doi.org/10.1016/j.healthplace.2021.102537">influenced by one’s community</a> – such as family, friends and neighbors. As information on the pandemic spread, counties where residents had stronger and closer connections with others started to show a <a href="https://doi.org/10.1371/journal.pone.0245135">slower increase in COVID-19 cases</a>, as people adopted more infection mitigation measures. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Masked riders on the subway" src="https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410198/original/file-20210707-19-vyzcxg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People in areas with greater social connection were more likely to change their behaviors.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/passengers-wear-face-masks-while-traveling-through-the-news-photo/1267735676">Robert Nickelsberg via Getty Images News</a></span>
</figcaption>
</figure>
<p>Also, people with stronger and closer connections with others were <a href="https://doi.org/10.1016/j.healthplace.2021.102537">more likely to act for the common good</a> with the expectation that others would do the same. Trust promoted social coordination, which provided incentive for people to take similar actions such as wearing masks in response to COVID–19. </p>
<h2>COVID-19 survivors less likely to support distancing</h2>
<p>In summer 2020, when COVID-19 continued to infect thousands of Americans a day, the <a href="https://www.cdc.gov/coronavirus/2019-ncov/php/mask-evaluation.html">CDC recommended mitigation measures</a> such as canceling gatherings, closing schools and restricting non-essential travel.</p>
<p>Americans who contracted COVID-19 – or whose family members had been sick with the coronavirus – <a href="https://doi.org/10.3389/ijph.2021.1604037">didn’t necessarily support mitigation measures</a> after their illness. Perhaps acquiring some measure of immunity by surviving COVID-19 lessened their perceived threat. As philosopher Friedrich Nietzsche once said, “<a href="https://en.wikipedia.org/wiki/What_does_not_kill_me_makes_me_stronger">What does not kill me makes me stronger</a>.”</p>
<p>Interestingly, Americans who had coworkers and others in their social circle get COVID-19 were <a href="https://doi.org/10.3389/ijph.2021.1604037">more likely than others to support mitigation measures</a>. It may be those with indirect experience became more anxious about contracting the virus themselves by hearing “horror stories” from others.</p>
<h2>Economic recovery falsely signaled safety</h2>
<p>In late August to early September 2020, Americans from states whose economies had recovered close to pre-pandemic levels <a href="https://doi.org/10.1177/08901171211017286">became less concerned about the pandemic</a> and were more likely to forgo mitigation behaviors. We suspect economic recovery provided people with the impression that a return to normal was around the corner, which helped form a false sense of safety. </p>
<h2>Risk mitigation closely linked to cases and deaths</h2>
<p>COVID-19 case numbers and death rates influenced whether or not people adopted risk mitigation behaviors. Generally speaking, <a href="https://doi.org/10.1177/08901171211017286">more cases</a> and <a href="https://doi.org/10.1016/j.healthplace.2021.102537">deaths</a> influenced people to see the virus as a more urgent threat, which resulted in active mitigation behaviors. </p>
<p>Meanwhile, in places with a low number of confirmed cases or deaths, <a href="https://doi.org/10.1177/08901171211017286">residents were likely to perceive the risk as abstract and distant</a>. Consequently, their motivation to control the transmission of the virus was weak.</p>
<p>Overall, our research shows the combination of timely information with trusting, well-connected communities, is most likely to result in collective risk mitigation behavior. Perhaps these insights can help the U.S. prepare better for the next pandemic.</p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/163417/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Multiple factors determined whether or not individual Americans adopted COVID-19 safety measures, according to statistical analysis of public opinion data.Wanyun Shao, Assistant Professor of Geography, University of AlabamaFeng Hao, Assistant Professor of Sociology, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1647772021-07-21T04:02:21Z2021-07-21T04:02:21Z7 tips for making masks work in the classroom<figure><img src="https://images.theconversation.com/files/412047/original/file-20210720-23-1xbj49l.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3461%2C2299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/education-pandemic-health-concept-group-students-1740217373">Shutterstock</a></span></figcaption></figure><p>With more infectious variants of the COVID-19 virus emerging, teachers and students have been required to wear masks in high school classrooms. It was mandatory in <a href="https://education.nsw.gov.au/covid-19/advice-for-families/schools-in-greater-sydney1#Masks4">Greater Sydney</a> and all of <a href="https://www.coronavirus.vic.gov.au/face-masks">Victoria</a> before the recent switch to remote learning under lockdowns. Mask wearing has also been compulsory in schools overseas, including <a href="https://www.usatoday.com/story/news/education/2021/07/09/masks-schools-covid-cdc-guidance-teachers-students/7922052002/">parts of the US</a>, <a href="https://www.ohscanada.com/features/guide-back-school-rules-across-canada/">Canada</a> and <a href="https://www.thestar.com.my/lifestyle/living/2021/03/07/contradictheory-so-how-safe-are-malaysia039s-newly-re-opened-schools">Malaysia</a>. </p>
<p>The new variants appear to have <a href="https://theconversation.com/is-it-more-infectious-is-it-spreading-in-schools-this-is-what-we-know-about-the-delta-variant-and-kids-163724">increased infection risks</a> for younger people, and most Australians are <a href="https://www.theguardian.com/australia-news/datablog/ng-interactive/2021/jul/19/covid-19-vaccine-rollout-australia-vaccination-rate-progress-how-many-people-vaccinated-percent-tracker-by-state-victoria-vic-nsw-queensland-qld-daily-live-data-stats-updates-total-number-world-ranking-distribution-schedule-tracking-chart-percentage-new-cases-today">not yet fully vaccinated</a>. Until that time, masks may well be one of our best tools to allow a return to face-to-face schooling.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-more-infectious-is-it-spreading-in-schools-this-is-what-we-know-about-the-delta-variant-and-kids-163724">Is it more infectious? Is it spreading in schools? This is what we know about the Delta variant and kids</a>
</strong>
</em>
</p>
<hr>
<p>However, having to wear masks in the classroom may create challenges for teachers and students. Mask-wearing can have negative impacts on all students, although the issues can be greater for students from minority cultures and those with chronic health or disability barriers. </p>
<p>Education is primarily a communication and relational activity. Masks not only hinder the visual communication tools we rely on but can also muffle speech, create discomfort and be psychologically unsettling for some. The word mask is <a href="https://www.etymonline.com/word/mask">thought to come</a> from the Medieval Latin <em>masca</em>, meaning spectre or nightmare.</p>
<p>Most of the barriers to wearing masks can be overcome. By harnessing the benefits of embracing the mask, classrooms can adapt and thrive during the pandemic. Adopting <a href="https://theconversation.com/covid-19s-teaching-challenges-5-tips-from-pediatric-care-for-teachers-wearing-masks-144446">recommended practices</a> for using masks in the classroom will benefit all students.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-19s-teaching-challenges-5-tips-from-pediatric-care-for-teachers-wearing-masks-144446">COVID-19’s teaching challenges: 5 tips from pediatric care for teachers wearing masks</a>
</strong>
</em>
</p>
<hr>
<h2>Use masks properly</h2>
<p>Openly and regularly discuss mask use with all students. Teach and practise <a href="https://escholarship.org/uc/item/83d8c84g">mask etiquette</a> so students understand the need to avoid touching the mask and to touch only the edges if they need to adjust their mask. They may need to do this to maximise comfort and to ensure the mouth and nose are properly covered, protecting the wearer and those around them. </p>
<p>Encourage students to use hand sanitiser, especially after touching the mask. </p>
<p>Remind students to clean reusable masks every day and to dispose of single-use masks.</p>
<figure class="align-center ">
<img alt="School student wearing mask holds out hands for hand sanitiser offered by masked teacher" src="https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412045/original/file-20210720-15-116g4xn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Encouraging students to use hand sanitiser adds to the protection masks provide.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/high-angle-portrait-boy-wearing-mask-1983219791">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rethink-ventilation-for-a-safe-return-to-schools-after-the-covid-19-pandemic-163219">Rethink ventilation for a safe return to schools after the COVID-19 pandemic</a>
</strong>
</em>
</p>
<hr>
<h2>Exaggerate body language and facial expressions</h2>
<p>Young people take many <a href="https://doi.apa.org/doiLanding?doi=10.1037/dev0000750">visual cues from the mouth</a> of the speaker, while adults take more visual cues from the eyes. When wearing masks covering the lower half of the face, teachers and students will naturally become more aware of upper face expressions. </p>
<p>Exaggeration is helpful to communicate clearly while wearing a mask. Teachers should continue to use natural facial expressions like smiling, such as the “<a href="https://www.newscientist.com/definition/duchenne-smile/">Duchenne smile</a>”, but exaggerate eye gestures and eyebrow movements to aid communication. The face has <a href="https://www.smithsonianmag.com/smart-news/human-faces-might-only-express-four-basic-emotions-180949598/">42 individual muscles</a>. We should use them all.</p>
<p>Play with facial expressions when using masks and have students read social cues from the eye movements they can see. Make the development of social and emotional intelligence a game of exploration to promote an <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243708">understanding of psychology</a> and how we react to others. This is merging science and the arts.</p>
<p>Teachers can and should use their whole body to communicate. For example, the teacher can shrug their shoulders when asking a question, or shake or nod their head to communicate a point of view. Exaggerated hand gestures and being near to the students are other helpful strategies. </p>
<figure class="align-center ">
<img alt="Women wearing a mask with wide-eyed expression" src="https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412053/original/file-20210720-15-156d3cq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wearing a mask means we have to express more with our eyes and body language.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/shocked-surprised-woman-wearing-handmade-face-1689043423">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weve-become-used-to-wearing-masks-during-covid-but-does-that-mean-the-habit-will-stick-163971">We've become used to wearing masks during COVID. But does that mean the habit will stick?</a>
</strong>
</em>
</p>
<hr>
<h2>Use your voice</h2>
<p>Although the mask covers the mouth, teachers can generally still be heard through the cloth. The key here is again a form of exaggeration as well as proximity to the student. Teachers can stay close to their listeners, speak more slowly, articulate all sounds clearly and increase volume. </p>
<p>However, teachers must balance vocal volume with projecting the voice. Teachers can practise <a href="https://www.torontospeechtherapy.com/blog/2019/breathing">diaphragmatic breathing</a> to help avoid vocal straining. </p>
<p>Where possible, try to <a href="https://www.tandfonline.com/doi/abs/10.1080/14643154.2018.1442908">rely less on talking for teaching</a>. Use PowerPoint and written communication. Keep language simple and straightforward. </p>
<p>In addition, check with students that they can hear and understand. Pay particular <a href="https://www.nature.com/articles/d41586-020-02823-2">attention to children who are deaf or hard of hearing</a>. Speak with them about the situation and take their advice. </p>
<h2>Embrace technology</h2>
<p>Where possible, use technology such as iPads or IT devices. Choose or make a video clip with subtitles instead of having to speak while wearing a mask. This is particularly important for students who are deaf or hard of hearing. </p>
<p>Use a microphone, carefully placing it near the mouth but not against the mask material.</p>
<h2>Don’t panic</h2>
<p>Masks do allow enough airflow to breathe comfortably. However, remain vigilant to children who do panic or feel claustrophobic when required to wear a mask. These psychological challenges can be made worse when a child has breathing difficulties such as asthma. </p>
<p>Schedule regular quiet breaks throughout the day – even every hour.</p>
<h2>Create a safe space</h2>
<p>Staff should try to include a photograph of themselves on their school ID badge, if wearing one. This can help reassure those who feel isolated and uncomfortable when people are wearing masks. </p>
<p>Children with neurological disabilities, such as autism or dyspraxia, will <a href="https://www.ingentaconnect.com/content/intellect/jaah/2014/00000005/00000003/art00008">not always have the issues</a> some might expect with wearing a mask. Like all children, they just need to know who we are and why we are all wearing masks. </p>
<p>The most important thing is to communicate. Talk with and listen to students, as the best teachers always do. Let them talk about their masks and take ownership of the situation, and then we can move forward with learning. </p>
<figure class="align-center ">
<img alt="Masked teacher explains a point to masked student" src="https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412050/original/file-20210720-25-1k0wckt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Taking the time to talk with individual students and hear what they have to say is most important.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-students-teacher-desks-college-university-1836356941">Shutterstock</a></span>
</figcaption>
</figure>
<p>Following <a href="https://canadacollege.edu/dreamers/docs/Maslows-Hierarchy-of-Needs.pdf">Maslow’s Hierarchy of Needs</a>, children will learn when they know they are safe.</p>
<h2>See it as a opportunity to learn</h2>
<p>The challenges of mask-wearing can be opportunities. Rather than seeing the mask as a burden, see it as an opportunity to teach and have fun. </p>
<p>Incorporate lessons that look at masks in history, from the <a href="https://academicjournals.org/journal/IJSA/article-full-text/144926455266">earliest Greek plays through to Asian theatre</a> and more recent times. Look at superhero movies, look at politics and public protests. Understand medicine and the use of masks throughout history – why we wear them to keep both ourselves and others healthy. </p>
<p>Explore the <a href="https://www.tandfonline.com/doi/abs/10.1080/14452294.2020.1869913">inclusive nature of masks</a> and how they can create acceptance and equity. <a href="https://www.scirp.org/journal/paperinformation.aspx?paperid=100129">Research has found</a> masks allow children to disassociate from identities and see themselves and others from a more empathetic and accepting perspective. </p>
<p>Many societies where people commonly wore masks prior to COVID, in parts of Asia for example, have thrived. Schools are microcosms of society. The mask is not a barrier to learning. A mask should only be a barrier to the spread of the virus, so mask up and enjoy the masquerade.</p><img src="https://counter.theconversation.com/content/164777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jill Duncan is affiliated with Aussie Deaf Kids, Disability Council NSW, Deafness & Education International. </span></em></p><p class="fine-print"><em><span>David Roy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Effective education depends on good communication and relationships, but face masks hinder visual and verbal cues and can be unsettling. So how can teachers and students overcome these issues?David Roy, Lecturer in Education, University of NewcastleJill Duncan, Senior Lecturer, School of Education, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1611662021-05-25T12:13:39Z2021-05-25T12:13:39ZCan people vaccinated against COVID-19 still spread the coronavirus?<figure><img src="https://images.theconversation.com/files/402429/original/file-20210524-19-1pkj1h1.jpg?ixlib=rb-1.1.0&rect=0%2C255%2C4788%2C3447&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaccinated people are well protected from getting sick, but could they inadvertently transmit the coronavirus?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-walk-in-hudson-river-park-on-may-23-2021-in-new-york-news-photo/1319716519">Noam Galai/Getty Images Entertainment via Getty Images</a></span></figcaption></figure><p><strong>Takeaways:</strong></p>
<ul>
<li>Vaccines can be great at preventing you from getting sick, while at the same time not necessarily stopping you from getting infected or spreading the germ.</li>
<li>Preliminary evidence seems to suggest the COVID-19 vaccines make it less likely someone who’s vaccinated will transmit the coronavirus, but the proof is not yet ironclad.</li>
<li>Unvaccinated people should still be diligent about mask-wearing, physical distancing and other precautions against the coronavirus.</li>
</ul>
<hr>
<p>When the U.S. Centers for Disease Control and Prevention <a href="https://www.whitehouse.gov/briefing-room/press-briefings/2021/05/13/press-briefing-by-white-house-covid-19-response-team-and-public-health-officials-36/">changed its guidelines about mask-wearing</a> on May 13, 2021, plenty of Americans were left a little confused. Now anyone who is fully vaccinated can participate in indoor and outdoor activities, large or small, without wearing a mask or physical distancing.</p>
<p>Anthony Fauci, chief medical adviser to President Biden, said the new guideline is “<a href="https://www.cbsnews.com/news/transcript-dr-anthony-fauci-face-the-nation-05-16-2021/">based on the evolution of the science</a>” and “serves as an incentive” for the <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">almost two-thirds of Americans</a> who are not yet fully vaccinated to go ahead and get the shot.</p>
<p>But some people <a href="https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html">cannot be vaccinated</a> because of underlying conditions. Others with weakened immune systems, from cancer or medical treatments, <a href="https://www.medrxiv.org/content/10.1101/2021.03.17.21253131v1">may not be fully protected</a> <a href="https://www.medrxiv.org/content/10.1101/2021.04.06.21254949v1">by their vaccinations</a>. <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use">Children aged 12 to 15 became eligible</a> for the Pfizer-BioNTech vaccine only on May 10, 2021. And <a href="https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html">no COVID-19 vaccines are yet authorized</a> for the nearly <a href="https://www.childstats.gov/americaschildren/tables/pop1.asp">50 million children</a> in the U.S. younger than 12.</p>
<p>As restrictions are lifted and people start to leave their masks at home, some people worry: Can you catch COVID-19 from someone who’s vaccinated?</p>
<h2>Vaccines don’t always prevent infection</h2>
<p>Researchers had hoped to <a href="https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-vaccines-prevent-covid-19">design safe COVID-19 vaccines</a> that would <a href="https://www.fda.gov/media/139638/download">prevent at least half</a> of the people vaccinated from getting COVID-19 symptoms.</p>
<p>Fortunately, the vaccines have <a href="https://doi.org/10.1056/NEJMc2102153">vastly</a> <a href="https://doi.org/10.1016/S0140-6736(21)00947-8">outperformed</a> expectations. For example, <a href="https://doi.org/10.1016/S0140-6736(21)00947-8">in 6.5 million residents of Israel</a>, aged 16 years and older, the Pfizer–BioNTech mRNA COVID-19 vaccine was found to be 95.3% effective after both shots. Within two months, among the 4.7 million fully vaccinated, the detectable infections fell by 30-fold. Similarly in <a href="https://doi.org/10.1056/NEJMc2101927">California</a> and <a href="https://doi.org/10.1056/NEJMc2102153">Texas</a>, only 0.05% of fully vaccinated health care workers tested positive for COVID-19.</p>
<p>Vaccine developers often hope that, in addition to preventing illness, their vaccines will achieve “<a href="https://doi.org/10.1038/srep32973">sterilizing immunity</a>,” where the vaccination blocks the germ from even being able to get into the body at all. This sterilizing immunity means someone who’s vaccinated will neither catch the virus nor transmit it further. For a vaccine to be effective, though, it doesn’t need to prevent the germ from infecting an immunized person. </p>
<p>The <a href="https://www.cdc.gov/vaccines/vpd/polio/index.html">Salk inactivated polio vaccine</a>, for instance, <a href="https://doi.org/10.1016/B978-0-323-04404-2.10092-2">does not completely stop</a> polio virus from growing in the human gut. But it <a href="https://medicine.yale.edu/news/yale-medicine-magazine/breaking-the-back-of-polio/">is extremely effective</a> at preventing the crippling disease because it triggers antibodies that block the virus from infecting the brain and spinal cord. Good <a href="https://doi.org/10.1016/B978-0-323-04404-2.10092-2">vaccines provide effective and durable training</a> for the body’s immune system, so when it actually encounters the disease-causing pathogen, it’s ready to mount an optimum response. </p>
<p>When it comes to COVID-19, immunologists are still figuring out what they call the “<a href="https://doi.org/10.1016/S0140-6736(21)00782-0">correlates of protection</a>,” factors that predict just how protected someone is against the coronavirus. Researchers believe that <a href="https://www.nature.com/articles/s41591-021-01377-8">an optimum amount</a> of “<a href="https://www.sciencedirect.com/topics/neuroscience/neutralizing-antibody">neutralizing antibodies</a>,” the type that not only bind the virus but also prevent it from infecting, are sufficient to fend off <a href="https://doi.org/10.1016/S0140-6736(21)00675-9">repeat infections</a>. Scientists are also still assessing the <a href="https://doi.org/10.1056/NEJMc2032195">durability of immunity</a> that the COVID-19 vaccines are providing and <a href="https://doi.org/10.1101/2021.05.06.21256403">where in the body</a> it’s working. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="stickers given out to people who get vaccinated" src="https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402430/original/file-20210524-19-aq22jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vaccination can mean far fewer infections, but it’s not clear it will stop transmission by those who are vaccinated.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/stickers-are-stacked-up-for-people-receiving-vaccinations-news-photo/1319347246">Ethan Miller/Getty Images News</a></span>
</figcaption>
</figure>
<h2>Can a vaccinated person spread coronavirus?</h2>
<p>Immunologists expect vaccines that protect against viral illnesses to also reduce transmission of the virus after vaccination. But it’s actually tricky to figure out for sure if vaccinated people are not spreading the germ.</p>
<p>COVID-19 poses a particular challenge because people with asymptomatic and pre-symptomatic infections can spread the disease – and insufficient contact tracing and testing mean those without symptoms <a href="https://doi.org/10.1126/science.abf9569">are rarely detected</a>. Some scientists estimate that the number of asymptomatic COVID-19 infections in the overall population <a href="https://doi.org/10.1038/s41467-020-18272-4">could be 3 to 20 times higher</a> than the number of confirmed cases. Research suggests that undocumented cases of COVID-19 in people who either were asymptomatic or experienced very mild disease could be responsible for <a href="https://doi.org/10.1126/science.abb3221">up to 86% of all infections</a>, though other studies <a href="https://doi.org/10.3138/jammi-2020-0030">contradict the high estimates</a>.</p>
<p>In <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7013e3.htm?s_cid=mm7013e3_w">one study</a>, the CDC tested volunteer health care personnel and other front-line workers at eight U.S. locations for SARS-CoV-2 infections weekly for three months, regardless of symptoms or vaccination status. The researchers found that fully immunized participants were 25 times less likely to test positive for COVID-19 than were those who were unvaccinated. Findings like this imply that if vaccinated people are so well protected from getting infected at all, they are <a href="https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html">also unlikely to spread</a> the virus. But without contact tracing to track transmission in a larger population, it’s impossible to know if the assumption is true.</p>
<p>What we know for sure is that if someone does get sick with COVID-19 after vaccination, in what is called a “breakthrough infection,” <a href="https://doi.org/10.1056/NEJMoa2105000">symptoms will be milder</a>. Studies have found that people who tested positive for COVID-19 after getting <a href="https://www.nature.com/articles/s41591-021-01316-7">just their first vaccine dose</a> had <a href="https://www.medrxiv.org/content/10.1101/2021.02.06.21251283v1">lower levels of virus in their bodies</a> than unvaccinated people who tested positive. The researchers believe the decreased viral load hints that vaccinated people who do contract the virus <a href="https://doi.org/10.1016/S1473-3099(20)30985-3">will be less infectious</a> because they will have much less virus that could be spread to others.</p>
<p>A preprint study which has not yet been peer-reviewed suggests that the Moderna mRNA COVID-19 vaccine can produce coronavirus-fighting <a href="https://doi.org/10.1101/2021.05.06.21256403">antibodies in the oral and nasal fluid</a>. Since <a href="https://doi.org/10.1371/journal.ppat.1009037">that’s where SARS-CoV-2 makes its entry</a>, antibodies in the mouth and nose should block the virus from getting into the body, effectively providing “sterilizing immunity.” This would also mean vaccinated people probably wouldn’t spread the virus through respiratory droplets.</p>
<p>These bits of evidence are promising. But without more studies, scientists <a href="https://doi.org/10.1038/d41586-021-00450-z">cannot yet conclude</a> that COVID-19 vaccines really do protect against all transmission. <a href="https://preventcovidu.org/">Studies attempting</a> to directly answer this question through contact tracing are just beginning: Researchers will track COVID-19 infections among vaccinated and unvaccinated volunteers and their close contacts.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="coronavirus precaution signs in multiple languages hang on a fence" src="https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402431/original/file-20210524-13-5jiayj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">CDC guidance still calls for those who are not yet vaccinated to mask up and maintain physical distance.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/wear-a-face-covering-sign-in-three-languages-flushing-news-photo/1310967691">Education Images/Universal Images Group via Getty Images</a></span>
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<h2>Protection and prevention go hand in hand</h2>
<p>Vaccines help slow down the spread of an infectious disease by breaking the chain of infection. Those who are infected eventually have fewer and fewer unprotected people to pass the virus on to. This is how a vaccine increases <a href="https://www.who.int/news-room/q-a-detail/herd-immunity-lockdowns-and-covid-19">herd immunity</a> – susceptible and not-yet-immunized people are surrounded by a “herd” of people who have become immune, thanks to vaccination or previous infection. But studies suggest that, for a combination of biological and <a href="https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/">social reasons</a>, <a href="https://doi.org/10.1016/S1473-3099(21)00143-2">vaccination alone is unlikely</a> to achieve herd immunity against COVID-19 and fully contain the coronavirus.</p>
<p>In fact, vaccination <a href="https://doi.org/10.1146/annurev.publhealth.20.1.211">alone can take a long time</a> to eradicate any disease. Even diseases that are nearly “eliminated” – such as chickenpox, measles and pertussis – <a href="https://doi.org/10.1001/jama.2016.1353">can resurface</a> with waning immunity and declining vaccine rates. </p>
<p>The recent outbreak of infections among the <a href="https://www.npr.org/2021/05/14/996873507/what-to-make-of-the-yankees-outbreak-scientists-say-dont-panic-we-expected-this">vaccinated New York Yankees</a> shows that vaccinated people not only can still get infected, they might also transmit the coronavirus to close contacts. Highly tested groups, such as professional sports teams, spotlight the fact that mild, asymptomatic infections among the vaccinated in the general population might actually be more frequent than reported. A similar <a href="https://www.straitstimes.com/singapore/speed-at-how-changi-airport-covid-19-cluster-grew-is-worrying-says-expert">outbreak in airport workers in Singapore</a> shows that, even among the fully vaccinated, new and more infectious variants can spread fast. </p>
<p>The CDC’s relaxed guidelines on masking are meant to reassure vaccinated people that they are safe from serious illness. And they are. But the picture is less clear-cut for the unvaccinated who interact with them. Until near herd immunity against COVID-19 is achieved, and clear evidence accumulates that vaccinated people do not spread the virus, I and <a href="https://www.nytimes.com/2021/05/13/upshot/epidemiologists-coronavirus-masks.html">many epidemiologists</a> believe it is better to avoid situations where there are chances to get infected. Vaccination coupled with <a href="https://www.pnas.org/content/118/4/e2014564118">continued masking</a> and social distancing is still an effective way to stay safer.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-important">The Conversation’s most important coronavirus headlines, weekly in a science newsletter</a></em>]</p><img src="https://counter.theconversation.com/content/161166/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sanjay Mishra receives funding from the National Cancer Institute through his institution. </span></em></p>The COVID-19 vaccines are a smash success. But that doesn’t mean they keep every vaccinated person completely free of the coronavirus.Sanjay Mishra, Project Coordinator & Staff Scientist, Vanderbilt University Medical Center, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1565512021-03-23T12:33:02Z2021-03-23T12:33:02ZPeople gave up on flu pandemic measures a century ago when they tired of them – and paid a price<figure><img src="https://images.theconversation.com/files/391004/original/file-20210322-21-1ubeke9.jpg?ixlib=rb-1.1.0&rect=0%2C517%2C2700%2C1669&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Armistice Day celebrations on Nov. 11, 1918, worried public health experts as people crowded together in cities across the U.S.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ArmisticeDay1918/4a5c7026339b41feabd1d798f98af262/photo?boardId=d7f2514f50804466b15dfb81ed00d9cd&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=36&currentItemNo=0">AP Photo </a></span></figcaption></figure><p>Picture the United States struggling to deal with a deadly pandemic.</p>
<p>State and local officials enact a slate of social-distancing measures, gathering bans, closure orders and mask mandates in an effort to stem the tide of cases and deaths.</p>
<p>The public responds with widespread compliance mixed with more than a hint of grumbling, pushback and even outright defiance. As the days turn into weeks turn into months, the strictures become harder to tolerate.</p>
<p><a href="https://quod.lib.umich.edu/f/flu/7520flu.0016.257/1/--protest-is-made?rgn=full+text;view=image;q1=Protest+is+Made+by+Theater+Men">Theater and dance hall owners complain</a> about their financial losses.</p>
<p><a href="https://quod.lib.umich.edu/f/flu/9660flu.0001.669/1/--wants-churches-open?rgn=full+text;view=image;q1=Wants+churches+open">Clergy bemoan church closures</a> while offices, factories and in some cases even saloons are allowed to remain open.</p>
<p><a href="https://quod.lib.umich.edu/f/flu/1240flu.0006.421/1/--clash-over-school-order-due-monday?rgn=full+text;view=image;q1=Clash+Over+School+Order+Due+Monday">Officials argue whether children are safer in classrooms</a> or at home.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="men with a streetcar" src="https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=823&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=823&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=823&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1034&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1034&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391006/original/file-20210322-17-1xdndpw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1034&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">No mask, no service on streetcar in 1918.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/precautions-taken-during-spanish-influenza-epidemic-would-news-photo/1223011380">Universal History Archive/Universal Images Group via Getty Images</a></span>
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<p><a href="https://quod.lib.umich.edu/f/flu/1320flu.0009.231/1/--new-cases-of-influenza-at-low-record?rgn=full+text;view=image;q1=New+Cases+of+Influenza+at+Low+Record">Many citizens refuse to don face masks while in public</a>, some complaining that they’re uncomfortable and others arguing that the government has no right to <a href="https://theconversation.com/mask-resistance-during-a-pandemic-isnt-new-in-1918-many-americans-were-slackers-141687">infringe on their civil liberties</a>.</p>
<p>As familiar as it all may sound in 2021, these are real descriptions of the U.S. during the deadly 1918 influenza pandemic. <a href="https://scholar.google.com/citations?user=gzhca9MAAAAJ&hl=en&oi=sra">In my research as a historian of medicine</a>, I’ve seen again and again the many ways our current pandemic has mirrored the one experienced by our forebears a century ago.</p>
<p>As the COVID-19 pandemic enters its second year, many people want to know when life will go back to how it was before the coronavirus. History, of course, isn’t an exact template for what the future holds. But the way Americans emerged from the earlier pandemic could suggest what post-pandemic life will be like this time around.</p>
<h2>Sick and tired, ready for pandemic’s end</h2>
<p>Like COVID-19, the 1918 influenza pandemic hit hard and fast, going from a handful of reported cases in a few cities to a nationwide outbreak within a few weeks. Many communities issued several rounds of various closure orders – corresponding to the ebbs and flows of their epidemics – in an attempt to keep the disease in check.</p>
<p><a href="https://doi.org/10.1001/jama.298.6.644">These social-distancing orders worked</a> to reduce cases and deaths. Just as today, however, they often proved difficult to maintain. By the late autumn, just weeks after the social-distancing orders went into effect, the pandemic seemed to be coming to an end as the number of new infections declined.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="masked typist at work" src="https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391007/original/file-20210322-15-aqbh8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People were ready to be done with masks as soon as it looked like the flu was receding.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/typist-wears-mask-while-working-at-her-office-desk-during-news-photo/108882651?adppopup=true">PhotoQuest/Archive Photos via Getty Images</a></span>
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</figure>
<p>People clamored to return to their normal lives. Businesses pressed officials to be allowed to reopen. Believing the pandemic was over, state and local authorities began rescinding public health edicts. The nation turned its efforts to addressing the devastation influenza had wrought.</p>
<p>For the friends, families and co-workers of the <a href="https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html">hundreds of thousands of Americans who had died</a>, post-pandemic life was filled with sadness and grief. Many of those still recovering from their bouts with the malady required support and care as they recuperated.</p>
<p>At a time when there was no federal or state safety net, charitable organizations sprang into action to provide resources for families who had lost their breadwinners, or <a href="https://quod.lib.umich.edu/f/flu/07z0flu.0000.070/1/--caring-for-little-ones-left-orphans?page=root;rgn=full+text;size=150;view=image;q1=orphan">to take in the countless children left orphaned</a> by the disease.</p>
<p>For the vast majority of Americans, though, life after the pandemic seemed to be a headlong rush to normalcy. Starved for weeks of their nights on the town, sporting events, religious services, classroom interactions and family gatherings, many were eager to return to their old lives.</p>
<p>Taking their cues from officials who had – somewhat prematurely – declared an end to the pandemic, Americans overwhelmingly hurried to return to their pre-pandemic routines. <a href="https://quod.lib.umich.edu/f/flu/7900flu.0004.097/1/--big-increase-in-flu-feared-as-result-of-packed-city-streets?rgn=full+text;view=image;q1=Big+Increase+in+Flu+Feared+as+Result+of+Packed+City+Streets">They packed into movie theaters</a> and dance halls, crowded in stores and shops, and gathered with friends and family.</p>
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<p>Officials had warned the nation that cases and deaths likely would continue for months to come. The burden of public health, however, now rested not on policy but <a href="https://quod.lib.umich.edu/f/flu/2770flu.0007.772/1/--measures-taken-to-again-combat-epidemic-of-flu?page=root;rgn=full+text;size=150;view=image;q1=Measures+Taken+to+Again+Combat+Epidemic+of+Flu">rather on individual responsibility</a>.</p>
<p>Predictably, the pandemic wore on, stretching into a third deadly wave that lasted through the spring of 1919, with a fourth wave hitting in the winter of 1920. Some officials blamed the resurgence on careless Americans. <a href="https://quod.lib.umich.edu/f/flu/6090flu.0000.906/1/--anxious-rumors-about-recurrence-of-influenza-not-sustained?page=root;rgn=full+text;size=150;view=image;q1=Anxious+Rumors+about+Recurrence+of+Influenza+Not+Sustained+by+Facts">Others downplayed the new cases</a> or turned their attention to more routine public health matters, including other diseases, restaurant inspections and sanitation. </p>
<p>Despite the persistence of the pandemic, influenza quickly became old news. Once a regular feature of front pages, reportage rapidly dwindled to small, sporadic clippings buried in the backs of the nation’s newspapers. The nation carried on, inured to the toll the pandemic had taken and the deaths yet to come. People were largely unwilling to return to socially and economically disruptive public health measures.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="masked barber shaves a customer" src="https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391008/original/file-20210322-21-m1jb0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">No matter the era, aspects of daily life go on even during a pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/in-an-unspecified-barbershop-a-man-receives-a-shave-from-a-news-photo/1219167388">Chicago History Museum/Archive Photos via Getty Images</a></span>
</figcaption>
</figure>
<h2>It’s hard to hang in there</h2>
<p>Our predecessors might be forgiven for not staying the course longer. First, the nation was eager <a href="https://chroniclingamerica.loc.gov/lccn/sn83030193/1918-11-07/ed-1/seq-1/#words=Ended+end+End+War+war+Peace+peace">to celebrate</a> the recent <a href="https://chroniclingamerica.loc.gov/lccn/sn83030214/1918-11-11/ed-1/seq-1/#words=over+end+surrendered+Over+war+ENDED+War+armistice+SURRENDERED+End+surrender+WAR+Armistice">end of World War I</a>, an event that perhaps loomed larger in the lives of Americans than even the pandemic.</p>
<p>Second, death from disease was a much larger part of life in the early 20th century, and scourges such as diphtheria, measles, tuberculosis, typhoid, whooping cough, scarlet fever and pneumonia each routinely <a href="https://www.cdc.gov/nchs/data/vsushistorical/mortstatsh_1918.pdf">killed tens of thousands of Americans every year</a>. Moreover, neither the cause nor the epidemiology of influenza was well understood, and many experts remained unconvinced that social distancing measures had any measurable impact.</p>
<p>Finally, there were no effective flu vaccines to rescue the world from the ravages of the disease. In fact, the influenza virus would not be <a href="https://www.cdc.gov/flu/pandemic-resources/pandemic-timeline-1930-and-beyond.htm">discovered for another 15 years, and a safe and effective vaccine</a> was not available for the general population until 1945. Given the limited information they had and the tools at their disposal, Americans perhaps endured the public health restrictions for as long as they reasonably could.</p>
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<p>A century later, and a year into the COVID-19 pandemic, it is understandable that people now are all too eager to return to their old lives. The end of this pandemic inevitably will come, as it has with <a href="https://theconversation.com/how-do-pandemics-end-history-suggests-diseases-fade-but-are-almost-never-truly-gone-146066">every previous one humankind has experienced</a>.</p>
<p>If we have anything to learn from the history of the 1918 influenza pandemic, as well as our experience thus far with COVID-19, however, it is that a premature return to pre-pandemic life risks more cases and more deaths.</p>
<p>And today’s Americans have significant advantages over those of a century ago. We have a much better understanding of virology and epidemiology. We know that <a href="https://www.sciencedaily.com/releases/2020/09/200910110824.htm">social distancing</a> and <a href="https://doi.org/10.1038/d41586-020-02801-8">masking work to help save lives</a>. Most critically, we have multiple safe and effective vaccines that are being deployed, with <a href="https://www.nytimes.com/live/2021/03/18/world/covid-19-coronavirus/us-vaccine-pace-eligible">the pace of vaccinations increasingly weekly</a>.</p>
<p>Sticking with all these coronavirus-fighting factors or easing off on them could mean the difference between a <a href="https://www.statnews.com/2021/03/20/rising-covid19-cases-in-some-states-highlight-precarious-position/">new disease surge</a> and a quicker end to the pandemic. COVID-19 is much more transmissible than influenza, and <a href="https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-cases.html">several troubling SARS-CoV-2 variants are already spreading</a> around the globe. The deadly third wave of influenza in 1919 shows what can happen when people prematurely relax their guard.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/156551/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J. Alexander Navarro does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Americans were tired of social distancing and mask-wearing. At the first hint the virus was receding, people pushed to get life back to normal. Unfortunately another surge of the disease followed.J. Alexander Navarro, Assistant Director of the Center for the History of Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1573122021-03-18T12:19:55Z2021-03-18T12:19:55Z4 steps to reaching Biden’s goal of a July 4th with much greater freedom from COVID-19<figure><img src="https://images.theconversation.com/files/390193/original/file-20210317-19-1xl7yiz.jpg?ixlib=rb-1.1.0&rect=8%2C33%2C5551%2C3667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Holiday gatherings with family and friends before the pandemic seemed so simple.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/group-of-young-adult-friends-dining-al-fresco-on-a-royalty-free-image/1007278168">FatCamera via Getty Images</a></span></figcaption></figure><p>President Joe Biden <a href="https://www.nytimes.com/live/2021/03/11/us/joe-biden-news">set a goal</a> for the U.S. to have COVID-19 under enough control by summer that Americans can celebrate July 4th with family and friends, at least in small gatherings. Important in achieving this goal is another presidential request: that all U.S. adults be made eligible for <a href="https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines">COVID-19 vaccinations</a> by May 1.</p>
<p>We are <a href="https://scholar.google.com/citations?user=ZxSqdKsAAAAJ&hl=en">public</a> <a href="https://scholar.google.com/citations?user=k5_VseQAAAAJ&hl=en">health</a> <a href="https://nyuscholars.nyu.edu/en/persons/cheryl-healton">deans</a> who lead a variety of COVID-19 response efforts and are involved in public policy discussions. At a time when the nation is weary of hearing “no, you can’t,” we believe that <a href="http://doi.org/10.1001/jamahealthforum.2020.0656">thinking</a> <a href="https://doi.org/10.1007/s10461-014-0789-9">in terms of</a> <a href="https://prevention.nih.gov/about-odp/directors-messages/2020/qa-dr-julia-marcus-2020-odp-early-stage-investigator-lecture-awardee">harm reduction</a> – offering safer but not necessarily risk-free alternatives – is <a href="https://blogs.bmj.com/bmj/2020/12/15/harm-reduction-principles-can-help-us-restore-trust-in-public-health-messaging-on-covid-19/">crucial</a>. </p>
<p>Harm reduction strategies are in use <a href="http://doi.org/10.1056/NEJMp1711991">all around you</a>. Seat belts and air bags are perhaps the most widespread harm reduction strategy for a <a href="https://www.cdc.gov/injury/features/global-road-safety/index.html">leading cause of death in the U.S.</a> Designated driver programs represent a harm reduction technique to reduce alcohol-related traffic fatalities. Another well-known example is the use of <a href="https://www.cdc.gov/ssp/syringe-services-programs-factsheet.html">sterile syringe exchange services</a> to help prevent HIV infection among people who inject drugs while also creating an important pathway for them to access client-centered medical and social services. </p>
<p>Central to harm reduction strategies is meeting someone <a href="https://harmreduction.org/about-us/principles-of-harm-reduction/">where they are</a>, without judgment, yet with support and practical pathways for improving health and wellness. It’s <a href="http://doi.org/10.1007/s10461-020-03006-w">relevant today</a>. </p>
<p>Here are four steps we believe are necessary to achieve the president’s Independence Day goal and a major national population health milestone. </p>
<h2>Get the vaccine and help others get vaccinated</h2>
<p><a href="https://www.euro.who.int/en/health-topics/communicable-diseases/hivaids/policy/policy-guidance-for-areas-of-intervention/harm-reduction">Vaccination is a classic harm reduction measure</a> – it may not eliminate risk, but it vastly reduces it.</p>
<p>People can both commit to getting the <a href="https://www.cdc.gov/vaccines/covid-19/index.html">vaccine</a> and to assisting others in the community to get vaccinated. They can volunteer at vaccination events via the <a href="https://mrc.hhs.gov/HomePage">Medical Reserve Corps</a>. Family members can help each other monitor for available vaccine time slots and navigate the sometimes <a href="https://www.nytimes.com/2021/03/12/technology/vaccine-sites-technology-problems-covid.html">challenging systems to get appointments</a>. Businesses and governmental agencies can allow employees <a href="https://www.nbcnewyork.com/news/coronavirus/new-york-gets-vaccine-boost-to-fight-inequity-cvs-adds-more-hubs/2939938/">paid time off</a> to get vaccinated. <a href="https://www.cdc.gov/coronavirus/2019-ncov/communication/toolkits/community-faith-based.html">Faith communities</a> can also encourage people to get vaccinated and provide welcoming sites for doing so.</p>
<p>Role models can make a difference, too. Recently, <a href="https://www.cnn.com/2021/03/11/politics/former-presidents-vaccine-psa/index.html">four former presidents and first ladies</a> got their vaccine injections on camera and implored U.S. residents to do the same. On March 16, former President <a href="https://www.cnn.com/2021/03/16/politics/donald-trump-covid-19-vaccine/index.html">Donald Trump also urged people to get the vaccine</a> in an interview on Fox. We consider this important at a time when <a href="https://thehill.com/policy/healthcare/542814-49-percent-of-gop-men-say-they-wont-get-vaccinated-pbs-poll">nearly half of Republican men</a> say they will not get vaccinated, according to a PBS News Hour/NPR/Marist poll.</p>
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<p>A wide variety of outreach efforts <a href="https://www.nber.org/papers/w25589">for vaccinations</a> are <a href="https://www.nytimes.com/2021/02/07/opinion/covid-black-americans.html">needed to speak to communities</a> with <a href="https://thehill.com/policy/healthcare/542814-49-percent-of-gop-men-say-they-wont-get-vaccinated-pbs-poll">differing outlooks on the pandemic</a>, <a href="http://doi.org/10.1056/NEJMms2025396">differing historical experiences with the medical system</a>, and different experiences in getting access to COVID-19 vaccines. Vaccine delivery strategies must directly address the <a href="https://cph.osu.edu/sites/default/files/docs/covid19inequities/1-Full%20Report.pdf">disparities in racial and ethnic minority communities</a> that are most heavily affected by <a href="http://doi.org/10.1016/j.annepidem.2020.06.010">COVID-related illness</a> but are <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/">not being vaccinated at a similar rate</a>.</p>
<p>Above all, vaccines need to be distributed in the communities where people live, with rollouts aided by <a href="https://cph.osu.edu/sites/default/files/docs/covid19inequities/1-Full%20Report.pdf">trusted systems and community partners</a>.</p>
<p>To quickly reach “<a href="https://khn.org/morning-breakout/herd-immunity-are-we-there-yet-sorry-not-even-close/">herd immunity</a>” – when enough people are immune to the virus through vaccination or infection to substantially disrupt viral transmission – the vast majority of Americans, communities and organizations will need to be engaged in these strategies.</p>
<h2>Wear a mask and keep up social distancing</h2>
<p>Think of masks in a context of opening up social activity, not locking down activity. Everyone needs to commit to continuing to wear a mask, practice physical distancing and keep hands sanitized for just a little while longer.</p>
<p>As the nation races to get everyone vaccinated to stay ahead of the very concerning emerging <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html">variants</a>, we need to <a href="https://doi.org/10.1001/jama.2020.21946">use</a> all <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7010e3.htm">evidence-based tools</a> at our disposal. Every shot in an arm is a step forward. And every instance in which other harm reduction measures are kept in place prevents the nation from taking a step backward.</p>
<p>These harm reduction measures are not meant to continue forever, and one can imagine a day when they will not be needed, at least not to the same degree. As social interactions start to resume, now is the time to encourage practical strategies for continuing their use.</p>
<h2>Be strategic in scheduling events</h2>
<p>As more people are vaccinated, the risk of the virus spreading will fall – but that will still take some time, as currently about 12% of the U.S. population has been fully vaccinated, <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">according to the CDC</a>. How soon the U.S. could <a href="https://www.nytimes.com/interactive/2021/02/20/us/us-herd-immunity-covid.html">reach herd immunity</a> will depend on the speed of vaccine uptake. </p>
<p>To avoid spreading the virus in another wave, people, universities, schools, businesses, community-based organizations and governmental entities can employ “strategic scheduling” of events. This includes limiting relaxation of mask-wearing and social distancing to private settings with other fully vaccinated people for the time being, as the <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html">CDC’s guidelines</a> suggest.</p>
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<p>People can also postpone events, such as in-person school graduations or Memorial Day community picnics, until later in the summer. A spring vacation this year <a href="https://www.nbcnews.com/politics/meet-the-press/fauci-we-re-not-end-zone-yet-covid-spread-n1261052">could have negative individual and collective consequences</a>. Simply scheduling the same trip later in the summer could be both more enjoyable and much safer. </p>
<p>Many of the life events people might like to experience in 2021 may be possible, but perhaps not to their ideal ordering, or at the scale, they crave.</p>
<h2>Try to be patient</h2>
<p>Public health officials have seldom stressed patience as a tool, but in this circumstance, just a bit more patience regarding higher-risk activities could have great public health benefits.</p>
<p>Thought of in risk reduction terms rather than risk elimination terms, individual, school, business and government planning the next few months might help us all engage in strategic scheduling and have just a bit more patience to benefit everyone.</p>
<p>The nation has <a href="https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6">lost over 530,000</a> family members and friends, many of whom <a href="https://www.statnews.com/2021/01/27/vaccinated-health-care-workers-immunity-spend-time-visiting-covid-19-patients/">died alone</a>. Due to the horrible circumstances of this pandemic, we believe we owe it to their memory to minimize any further loss and to find a pathway to continuing our lives in a way that honors their legacy by urgently employing practical and achievable harm reduction strategies. It may appear small, but a midsummer picnic seems like a great way to start to build upon their legacy.</p>
<p><em>This article has been updated with charts showing vaccine distribution and daily COVID-19 cases</em></p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/157312/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The president wants Americans to be able to celebrate Independence Day with small gatherings. What will it take to get the virus under control by then? Three public health school deans explain.David R. Holtgrave, Dean and SUNY Distinguished Professor, University at Albany, State University of New YorkAmy Lauren Fairchild, Dean and Professor, College of Public Health, The Ohio State UniversityCheryl Healton, Director of the NYU Global Institute of Public Health (GIPH), Dean of Global Public Health, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1537052021-03-09T13:35:40Z2021-03-09T13:35:40ZCOVID-19 survivor’s guilt a growing issue as reality of loss settles in<figure><img src="https://images.theconversation.com/files/383903/original/file-20210211-14-ie4dau.jpg?ixlib=rb-1.1.0&rect=44%2C22%2C7304%2C4880&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Millions of Americans may wonder if they inadvertently passed COVID-19 to someone else.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pensive-woman-in-front-of-the-window-royalty-free-image/1129697415?adppopup=true">franckreporter/E+ via Getty Images</a></span></figcaption></figure><p>People are eager to return to normal after a year of coronavirus, but is the U.S. there yet? <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html">Hardly</a>. The ongoing psychological and spiritual damage caused by the pandemic is rising, too. </p>
<p>Guilt and shame are <a href="https://doi.org/10.3389/fpsyg.2020.571828">two prevailing emotions</a> surrounding COVID-19.
This guilt stems in part from the fact that anyone could be a potential carrier of the virus – so anyone, then, could unwittingly pass it to another person. Guilt can also arise when a person looks at the national and global death tolls and <a href="https://www.heart.org/en/news/2021/02/04/surviving-covid-19-survivors-guilt">wonders how they were spared</a>. </p>
<p><a href="https://doi.org/10.1037/tra0000742">Guilt also happens when</a> family members can’t visit loved ones undergoing treatment at a hospital, or when someone with COVID-19 survives but <a href="https://consumer.healthday.com/aha-news-surviving-covid-19-survivors-guilt-2650291047.html">reads about a infected stranger who died</a>. A particular type of response called <a href="https://www.medicalnewstoday.com/articles/325578">survivor’s guilt</a> can occur when people lose loved ones due to a traumatic event, or when they themselves experienced the threat but survived it. </p>
<p>As <a href="https://med.jax.ufl.edu/directory/bio/1164/david-chesire/">a psychologist</a> and a doctor of <a href="https://med.jax.ufl.edu/directory/bio/1141/mark-mcintosh/">emergency medicine</a>, we have personal experience with patients suffering from survivor’s guilt as they watched loved ones succumb to COVID-19. And as the pandemic continues, we expect to see more. </p>
<figure class="align-center ">
<img alt="A doctor and nurse tend to a patient in the hospital." src="https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380595/original/file-20210126-15-1b5xzyc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Determining precisely how someone got COVID-19 is difficult, if not impossible.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctors-caring-for-patient-in-emergency-care-unit-royalty-free-image/1217819947?adppopup=true">Westend61 via Getty Images</a></span>
</figcaption>
</figure>
<h2>Survivor’s guilt is complicated</h2>
<p>Survivor’s guilt can occur whether or not a person caused an event to occur. It can happen to a sole survivor of a plane crash who had nothing to do with the accident, or an intoxicated driver who crashed his car and killed his passenger. Either way, the person feels they were spared an event while others perished, and feelings of grief and anxiety result. Survivor’s guilt can affect <a href="https://doi.org/10.1080/15325024.2018.1507965">up to 90% of survivors</a> of traumatic events. COVID-19 <a href="https://www.nytimes.com/2020/12/06/world/europe/bergamo-italy-coronavirus-covid-19-ptsd.html">survivors in Bergamo, Italy</a>, one of the world’s hardest-hit towns, have experienced this on a widespread basis. Some people have reported a type of survivor guilt when they have <a href="https://www.health.com/condition/infectious-diseases/coronavirus/covid-survivors-guilt">been vaccinated</a>, with many wondering why they have been so fortunate. </p>
<p><a href="https://californiahealthline.org/news/while-los-angeles-county-sets-new-record-for-infections-california-leaders-behavior-sends-mixed-messages/">Conflicting messages</a> from the federal and various state and local governments haven’t helped. Because some leaders have suggested that COVID-19 is <a href="https://www.usatoday.com/story/opinion/2020/11/20/anthony-fauci-covid-us-must-accept-how-dangerous-coronavirus-is-react/3778241001/">no worse than the flu</a>, millions of Americans did not wear masks. By some estimates, not wearing masks <a href="https://www.nytimes.com/2020/10/23/health/covid-deaths.html">could have contributed to 130,000 deaths</a>.</p>
<p>Also, <a href="https://theconversation.com/can-people-spread-the-coronavirus-if-they-dont-have-symptoms-5-questions-answered-about-asymptomatic-covid-19-140531">a person can spread COVID-19</a> without knowing they have the disease. This uncertainty combined with loneliness might have led to social gatherings that weren’t the safest. Perhaps an elderly parent decides to risk illness <a href="https://www.washingtonpost.com/health/im-missing-it-all-grandparents-grieve-over-loss-of-visits-with-grandchildren/2020/05/29/0a9831c2-9fa6-11ea-b5c9-570a91917d8d_story.html">rather than spend the holiday alone</a>. Many parents, including our own, say they want to make the most out of the time they have right now; they cannot bank on being around next year. </p>
<p>In the world of palliative medicine, there is no shortage of examples of patients <a href="https://www.washingtonpost.com/health/im-missing-it-all-grandparents-grieve-over-loss-of-visits-with-grandchildren/2020/05/29/0a9831c2-9fa6-11ea-b5c9-570a91917d8d_story.html">choosing quality of life over quantity</a>, sometimes refusing lifesaving but invasive treatment so they can spend time engaged in activities they might not otherwise be able to enjoy. This is not unusual at any age – it’s not at all uncommon for people to make choices that have potential tremendous costs, from smoking to skydiving. </p>
<p>So is someone who inadvertently passed along COVID-19 at fault? For example, how do we cope with the guilt when we know we passed the virus on to a <a href="https://www.nbcnews.com/news/us-news/i-gave-my-dad-covid-19-survivors-grapple-guilt-infecting-n1207921">family member</a>? Generally people don’t ascribe this kind of blame when they inadvertently pass the flu to someone who gets sick, or perhaps even dies. We do not see countless news stories assigning blame when someone with the common cold does not wear a mask at the grocery store. We believe that people should be forgiving of themselves should they accidentally transmit COVID-19. Self-forgiveness requires recognition we cannot control everything and that our motives were benign. </p>
<figure class="align-center ">
<img alt="A sad woman, looking out the window." src="https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380596/original/file-20210126-17-1y1cwqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Survivor’s guilt can lead to major depression.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sad-woman-looking-out-of-the-window-royalty-free-image/916643676?adppopup=true">EMS-Forster Productions/DigitalVisio via Getty Images</a></span>
</figcaption>
</figure>
<h2>Dealing with survivor’s guilt</h2>
<p>Symptoms of survivor’s guilt include anxiety, depression, headache, nausea, sleeplessness and fatigue. It can lead to post-traumatic stress disorder. Managing survivor’s guilt is an individual process, and what works for one may not work for another. Interventions include deep breathing, meditation, relaxation, exercising, a healthy diet, journaling, adopting a hobby, getting a pet, watching comedies and reaching out – volunteering or engaging with family, friends and co-workers. For some, spirituality and faith are also important.</p>
<p>Nonreligious people may find comfort by connecting directly to nature, where life and death are part of a grand cycle, and nature itself may have a purpose that ordains when one person succumbs while another survives. </p>
<p>As people pass through the grieving process, healing comes by recognizing our interconnectedness to each other. But when the U.S. quarantined, many people lost that most basic and primal coping mechanism. Instead, Americans, sometimes alone, have had to explore existential truths that may have been painful, even devastating. Yet in many ways, the country has already prevailed. Through mourning our losses and suffering heartbreak, our medical, psychological and spiritual well-being remains a strength.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/153705/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What if you passed COVID-19 to someone else? For those living with that guilt, the thought could be devastating.David Chesire, Associate Professor, College of Medicine, University of FloridaMark S. McIntosh, Associate Professor of Emergency Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1564562021-03-07T14:35:47Z2021-03-07T14:35:47ZStates drop COVID-19 mask mandates but still expect people to mask up – will they?<figure><img src="https://images.theconversation.com/files/388141/original/file-20210306-13-19um44d.jpg?ixlib=rb-1.1.0&rect=32%2C0%2C3573%2C2257&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Texas' announced it is ending its COVID-19 restrictions. Its vaccination rate is among the lowest in the U.S., and its case numbers are still high.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/san-jose-hotel-engineering-manager-rocky-ontiveros-wears-a-news-photo/1231493646">Montinique Monroe/Getty Images</a></span></figcaption></figure><p>The <a href="https://open.texas.gov/uploads/files/organization/opentexas/EO-GA-34-opening-Texas-response-to-COVID-disaster-IMAGE-03-02-2021.pdf">governors of Texas</a> and <a href="https://www.sos.ms.gov/content/executiveorders/ExecutiveOrders/1549.pdf">Mississippi</a> announced that they were rescinding their statewide mask mandates and allowing restaurants and other businesses to return to 100% capacity in early March. The moves come while new infection numbers in the U.S. <a href="https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases">are still higher</a> than they were in September and just ahead of school spring breaks, known for large gatherings and crowded bars where the <a href="https://doi.org/10.1016/j.jue.2020.103311">coronavirus can quickly spread</a>.</p>
<p>Along with <a href="https://www.aarp.org/health/healthy-living/info-2020/states-mask-mandates-coronavirus.html#Iowa">Iowa</a>, <a href="https://news.mt.gov/governor-gianforte-issues-new-directives-executive-order">Montana</a> and <a href="https://www.thedickinsonpress.com/news/government-and-politics/6846684-As-statewide-mandate-expires-North-Dakota-cities-hang-onto-mask-requirements">North Dakota</a>, which recently lifted their mask orders, these states are part of an emerging trend of some states bucking national and international public health recommendations. </p>
<p><a href="https://www.cnbc.com/2021/03/04/alabama-gov-ivey-lifts-statewide-covid-mask-mandate-beginning-april-9.html">Alabama</a> and <a href="https://www.sltrib.com/news/2021/03/06/utahs-mask-mandate-will/">Utah</a> plan to end their mask requirements in April. <a href="https://governor.wyo.gov/media/news-releases/2021-news-releases/governor-gordon-announces-removal-of-statewide-mask-requirement-lifts-all">Wyoming</a>’s governor announced on March 8 that he would drop his mask order, too.</p>
<p>Residents and visitors in these states will face a situation where masks are no longer required. Yet, many of the <a href="https://www.dallasnews.com/news/politics/2021/03/04/gov-abbott-ended-texas-mask-mandate-without-input-from-all-his-covid-19-medical-advisors/">same governors lifting the mandates</a> are still urging people to take precautions. </p>
<p>These mixed messages can be confusing. Dropping mask mandates and capacity limits contradicts public health recommendations that were established to <a href="https://www.cdc.gov/coronavirus/2019-ncov/your-health/need-to-know.html">impede the spread of COVID-19</a>. Research shows the public health effect of wearing masks is clear: <a href="http://doi.org/10.1016/j.annepidem.2021.02.006">Mask mandates reduce the spread of COVID-19</a>. </p>
<p>As <a href="https://scholar.google.com/citations?user=G7AWX0QAAAAJ&hl=en">public</a> <a href="https://scholar.google.com/citations?user=me4Q9y4AAAAJ&hl=en">health</a> <a href="https://temag.tamu.edu/directory/walter-t-casey/">researchers</a>, we study how changing policies have affected the trajectory of the pandemic in the U.S. The end of mask mandates and other restrictions poses three important questions about responsibility, safety and public health. </p>
<h2>What does it mean for individual responsibility?</h2>
<p>Hearing from state leaders that there is no longer a mandate to wear a mask, but that individuals should choose to wear masks and remain vigilant, can be confusing.</p>
<p>If the end of stay-at-home orders last summer and <a href="https://doi.org/10.3389/fcomm.2019.00056">resistance</a> to <a href="https://doi.org/10.1016/j.paid.2020.110491">health guidelines</a> over time are any indication of <a href="https://theconversation.com/covid-19-messes-with-texas-what-went-wrong-and-what-other-states-can-learn-as-younger-people-get-sick-141563">what to expect</a>, mask wearing will fall rapidly without a mandate. The <a href="https://www.bloomberg.com/opinion/articles/2020-06-25/coronavirus-in-texas-covid-19-gives-greg-abbott-a-reality-check">result will likely be less compliance</a> with other practices to reduce COVID-19 spread in public places, such as social distancing, and a related uptick in cases.</p>
<figure class="align-center ">
<img alt="Vistors, many without masks, walk the beachfront boardwalk" src="https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Ocean City, Maryland, boardwalk filled up quickly in May 2020 after the town dropped many of its COVID-19-related restrictions. The state now has a mask mandate and doesn’t plan to lift it soon.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-enjoy-the-boardwalk-during-the-memorial-day-holiday-news-photo/1214812758">Alex Edelman/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>This effect may be even stronger when residents’ <a href="https://www.pewresearch.org/politics/2020/06/25/republicans-democrats-move-even-further-apart-in-coronavirus-concerns/">political affiliation is considered</a>, as ending a mask mandate could be viewed as the partisan difference between the belief in working collectively to protect each other and <a href="https://www.nbcnews.com/think/opinion/covid-vaccine-mask-conspiracies-succeed-when-they-appeal-identity-ideology-ncna1251761">the fear that mandates</a> limit individual freedoms. And if <a href="http://doi.org/10.1056/NEJMp2100351">polling</a> about <a href="https://www.cbc.ca/news/canada/toronto/anti-masking-group-tied-to-anti-vaccination-covid-19-1.5661790">vaccine hesitancy</a> is an indicator, when mask mandates are loosened, it is not unreasonable to expect <a href="https://www.vox.com/science-and-health/21546014/mask-mandates-coronavirus-covid-19">mask wearing to be cut in half</a> – <a href="https://www.prnewswire.com/news-releases/83-of-americans-report-that-they-always-wear-a-face-mask-when-out-in-public-according-to-new-state-by-state-survey-findings-from-slickdeals-301164658.html">or decline even more</a>. </p>
<h2>Does it mean that residents of these states are now safer from COVID-19 risks?</h2>
<p>The short answer is “no.” The message that masks are no longer required may lead to a false sense of increased safety from the virus. </p>
<p>Yet, new daily cases and hospitalizations for COVID-19 in the U.S., and particularly in Texas, were <a href="https://coronavirus.jhu.edu/data/state-timeline/new-confirmed-cases/texas">higher on March 1, 2021, than they were on Oct. 1, 2020</a>. Unfortunately, several more-contagious variants of the virus are also now starting to spread – <a href="https://www.houstonchronicle.com/news/houston-texas/health/article/Houston-is-first-city-to-record-all-major-COVID-15990299.php">Houston has had cases of all the major variants</a>. Wearing masks is a known and effective barrier that reinforces the immunity gained from vaccinations or illness recovery and avoid spreading viruses.</p>
<p>While no state is fully vaccinated yet, Texas and Mississippi have an even longer way to go than most. They <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">rank 45th and 44th</a> among states by the percentage of their population fully vaccinated. Vaccinations are also only <a href="https://www.statnews.com/2021/02/10/vaccines-alone-wont-end-pandemic/">one piece</a> of the public health response.</p>
<p>Public health guidance still recommends vaccinated people wear masks, practice social distancing and wash their hands to avoid spreading the coronavirus to those who are not protected. <a href="https://doi.org/10.1186/s40249-020-00759-3">These mitigation efforts have been shown to work</a>, especially when applied consistently and broadly.</p>
<p><iframe id="lFl6N" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/lFl6N/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Several studies have demonstrated a decline in infection rates from having mask mandates in place. A <a href="http://dx.doi.org/10.15585/mmwr.mm7010e3">study released March 5</a> by the Centers for Disease Control and Prevention found that implementing mask mandates had been associated with a drop in the growth of daily COVID-19 cases within 20 days of being implemented, while allowing in-restaurant dining was associated with an increase in daily cases. Another study determined that mask mandates in 15 states and the District of Columbia helped <a href="https://doi.org/10.1377/hlthaff.2020.00818">avoid more than 200,000 cases</a> in April and May 2020.</p>
<p>“With the emergence of more transmissible COVID-19 variants, community mitigation measures are increasingly important as part of a larger strategy to decrease exposure to and reduce transmission of SARS-CoV-2,” the CDC authors wrote. </p>
<h2>Why isn’t there a consistent message?</h2>
<p>Rescinding the mask order also places burdens on businesses to decide which, if any, guidelines to follow. </p>
<p>Not surprisingly, education and health care have generally responded in favor of <a href="https://www.nbcnews.com/news/us-news/texas-doctors-say-gov-greg-abbott-s-decision-scrap-mask-n1259513">continuing to require masks and follow public health guidelines</a>. Some other industries and retailers took the opportunity to <a href="https://www.houstonpublicmedia.org/articles/news/business/2021/03/03/392771/heres-how-retail-chains-are-responding-to-texas-lifting-its-covid-19-mask-mandate/">revise their COVID-19 policies</a>. </p>
<p><iframe id="ylmXy" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ylmXy/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Businesses in some areas <a href="https://www.texastribune.org/2021/03/07/texas-businesses-masks-threats/">have faced</a> <a href="https://www.texastribune.org/2020/05/22/texas-coronavirus-masks/">a backlash</a> for requiring patrons to wear masks when the state did not mandate it. Those that operate in multiple states may also need to address differing mask requirements and balance the public health and business cases for masks. Federal requirements for wearing masks on airplanes and certain other places can further confound business operations when patrons are unclear about the requirements and potential for penalties if they do not comply.</p>
<h2>Past experience shows the value of mandates</h2>
<p>Already, Texas is seeing the result of the state rescinding its mask mandate and gathering restrictions as <a href="https://www.dallasnews.com/news/politics/2021/03/02/tarrant-county-ends-its-mask-mandate-after-texas-gov-greg-abbott-says-statewide-covid-19-orders-will-end-next-week/">municipalities follow suit</a>. </p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>We know from earlier attempts to rely on personal responsibility, <a href="https://www.history.com/news/seat-belt-laws-resistance">like seat belt laws</a>, as well as with <a href="https://www.washingtonpost.com/lifestyle/food/when-it-comes-to-nutrition-were-all-too-eager-to-ignore-the-evidence-heres-why/2020/02/23/d4dd8534-54a8-11ea-9e47-59804be1dcfb_story.html">nutrition</a> choices and <a href="https://www.who.int/bulletin/archives/78(7)902.pdf">tobacco use</a>, that some people <a href="https://doi.org/10.1016/j.glt.2020.06.003">will do the safe thing</a> only if <a href="http://doi.org/10.1016/j.socscimed.2013.10.035">the law requires</a> it. </p>
<p>After all, people tend to follow the maxim that “<a href="https://www.jstor.org/stable/40711861">what isn’t forbidden is permitted</a>.”</p>
<p><em>This story was updated March 9 with Wyoming also planning to lift restrictions.</em></p><img src="https://counter.theconversation.com/content/156456/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The COVID-19 case spike in the summer of 2020 and earlier attempts to rely on personal responsibility, like wearing seat belts, showed that mandates make a difference.Murray J. Côté, Associate Professor of Health Policy and Management, Texas A&M UniversityTiffany A. Radcliff, Associate Dean for Research and Professor of Health Policy and Management, Texas A&M UniversityWalter Thomas Casey II, Associate Professor of Political Science, Texas A&M University-TexarkanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1545642021-02-11T15:06:47Z2021-02-11T15:06:47ZAre two cloth masks better than one for preventing the spread of COVID-19?<figure><img src="https://images.theconversation.com/files/383123/original/file-20210208-21-vgaszv.jpg?ixlib=rb-1.1.0&rect=389%2C71%2C3579%2C2789&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Layering face masks has been suggested as a way to increase protection against COVID-19 variants that may be more transmissible.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Double masking has emerged as a crowd-sourced method for adding extra layers to our masks, using the masks that we have — a response to concerns about the overall direction of the pandemic and the <a href="https://theconversation.com/why-new-covid-19-variants-are-on-the-rise-and-spreading-around-the-world-153530">transmissibility of new COVID-19 variants</a>. </p>
<p>When our group <a href="https://doi.org/10.7326/M20-2567">recommended cloth masks</a> as a worthwhile additional effort to reduce transmission of COVID-19, some of the masks that we had identified in the literature were <a href="https://doi.org/10.1128/jb.83.3.663-667.1962">three-</a> and <a href="https://doi.org/10.1002/bjs.1800621203">four-layer masks</a>: in an experimental setting, they were very effective at blocking particles exhaled by the wearer. </p>
<p>We are a group of epidemiologists and engineers who have been working <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">to summarize what is known</a> about the filtration properties of textiles, to maintain a plain-language website <a href="https://www.clothmasks.ca/">clothmasks.ca</a>, and to create new knowledge about the best textiles to use and the best mask designs.</p>
<p>On the basis of our research review, <a href="https://theconversation.com/covid-19-masks-faqs-how-can-cloth-stop-a-tiny-virus-whats-the-best-fabric-do-they-protect-the-wearer-146822">we recommended two- to four-layer masks</a>, and provided <a href="https://www.clothmasks.ca/how-to-make-a-cloth-mask">a pattern for making a four-layer mask</a>. Four layers is a challenge, though, in terms of design, particularly for the home or artisanal sewer, and few commercial masks have four layers. To sew a four-layer mask, stitching may have to go through eight layers of material after turning seams, multiplied by three for darts or pleats. </p>
<p>The simple action of wearing two multi-layer masks together gets around this problem. It seems to have arisen, like many good ideas, in a number of places at the same time.</p>
<h2>Filtration efficiency</h2>
<figure class="align-right ">
<img alt="Man wearing two cloth face masks" src="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=904&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=904&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=904&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wearing two fabric face masks together improves filtration efficiency.</span>
<span class="attribution"><span class="source">(Catherine Clase)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We summarize the protective function of a mask or mask material in terms of the percentage of small particles that it filters out — the <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">filtration efficiency</a>. Every extra layer worn increases the overall filtration efficiency of the mask, though not in a simple way. This was first <a href="https://www.jstor.org/stable/30082047">shown in a laboratory setting in 1919</a> and confirmed in <a href="https://doi.org/10.1021/acsnano.0c04897">studies conducted in aerosol labs</a> in Chicago and from the <a href="https://doi.org/10.1021/acsnano.0c05025">U.S. National Institute of Standards and Technology</a> during the current pandemic. </p>
<p>Nurses working in the 1919 influenza pandemic double masked, wearing two three-layer gauze masks. During the first SARS outbreak in 2003, health-care workers in China made twelve- to sixteen-layer masks when they ran out of certified personal protective equipment. Studies that included people wearing these masks suggested that <a href="https://doi.org/10.1016/S0140-6736(20)31142-9">they did provide protection for the wearer</a>.</p>
<p>Increasing the filtration efficiency is our goal whether we are trying to achieve source control (my mask protects you, your mask protects me) or protection of the wearer (my mask protects me). <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html">Health Canada recommends</a> a middle layer of non-woven polypropylene in masks to improve filtration efficiency. </p>
<p>We think that this non-woven material, which can be sewn and washed like a textile, is <a href="https://theconversation.com/polypropylene-the-material-now-recommended-for-covid-19-mask-filters-what-it-is-where-to-get-it-149613">likely to be a useful addition</a>. Probably the best way to improve the filtration efficiency of masks is to <a href="https://www.clothmasks.ca/polypropylene">add a layer of polypropylene</a>, either when the mask is made or as a washable filter insert into a pocket masks.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=527&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=527&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=527&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=662&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=662&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=662&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pocket mask with an insert of washable spunbond industry-grade polypropylene.</span>
<span class="attribution"><span class="source">(Jonathan Clase)</span></span>
</figcaption>
</figure>
<p>Wearing two such masks together, or one mask with polypropylene with another that you are less sure about, is likely to be a good way to further improve filtration. You can even layer two masks without polypropylene and place a rectangle of polypropylene between masks. The tension of the outer mask will keep it in place. </p>
<p>The non-standardized community masks that we have bought, made or been given, imperfect and varied though they are, are proving effective at reducing transmission in the pandemic. Studies of mask mandates in <a href="https://doi.org/10.1377/hlthaff.2020.00818">the United States</a>, <a href="https://doi.org/10.3386/w27891">Canada</a> and <a href="https://doi.org/10.1073/pnas.2015954117">Germany</a>, and <a href="https://doi.org/10.4269/ajtmh.20-1015">between-country comparisons</a>, all consistently show associated reductions in transmission when masks are worn. </p>
<p>Improving filtration further is also likely to be a worthwhile goal: modelling studies show that <a href="https://doi.org/10.1016/j.idm.2020.04.001">improving filtration reduces transmission of COVID-19</a>. Adding layers by double masking is a way of using the masks that we already have, possibly to better effect. And we need all the leverage we can find at this point.</p>
<h2>Breathability</h2>
<p>There is an important caveat. Every layer added also affects breathability, or how it feels to wear the mask in term of the effort of breathing. This is important for comfort and helps keep the mask safe for the wearer. </p>
<p>If you feel short of breath in a double mask, it may be too many layers for you. If you are <a href="https://theconversation.com/joggers-and-cyclists-should-wear-masks-if-they-cant-maintain-a-physical-distance-from-pedestrians-153110">exercising in a double mask</a>, be alert for the feeling of breathlessness and monitor how it feels; don’t push yourself further than you normally would.</p>
<figure class="align-center ">
<img alt="Red cloth face masks" src="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More layers provide more protection, but it’s difficult to sew masks with more than three layers. Wearing two multi-layer masks together gets around this problem.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>The other problem with the extra layers is that when breathability decreases, it means that the resistance of the mask to the passage of air has increased. This increases the pressure inside the mask and may cause leaking around the edge. Sometimes the double mask, with two sets of head fastenings, will get around this problem because the fit to the face is more snug and held in place by more points. </p>
<p>But there will be diminishing returns if the breathability is so poor that there is significant airflow around the edges of the mask. The aim is to minimize this completely unfiltered air. You can watch out for this when you add the second mask — does the amount of leakage feel less, or more, than when you wore one of the masks alone? And can you breathe comfortably enough for the task you are planning?</p>
<p>At McMaster’s <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Excellence in Protective Equipment and Materials</a>, our group is working with commercial mask manufacturers, textile experts, quilters and other home sewers to create alternative designs for masks and test them in the laboratory. Until such studies are done, double masking is a creative innovation that is worth trying out with the masks that you have.</p><img src="https://counter.theconversation.com/content/154564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZenec, Vifor Fresenius Medical Care, relypsa, Bayer HealthCare and Boehringer Ingelheim.</span></em></p><p class="fine-print"><em><span>Prof. Charles-François de Lannoy is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article.
Charles has received research funding from the Natural Sciences and Engineering Research Council (NSERC), Canada First Research Excellence Fund (CFREF), Global Water Futures (GWF), Canadian Foundation for Innovation (CFI), Ontario Centres of Excellence (OCE), Southern Ontario Water Consortium (SOWC), MITACS, ECO Canada, the France-Canada Research Fund, McMaster University, and the North American Membrane Society (NAMS). </span></em></p><p class="fine-print"><em><span>Scott Laengert is the recipient of an NSERC scholarship.</span></em></p><p class="fine-print"><em><span>Juan Jesus Carrero and Roberto Pecoits-Filho do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Are two face masks better than one? Adding layers of filtration by double masking is a way of using the masks that we already have, possibly to better effect.Catherine Clase, Physician, epidemiologist, associate professor, McMaster UniversityCharles-Francois de Lannoy, Assistant Professor, Chemical Engineering, McMaster UniversityJuan Jesus Carrero, Professor of Epidemiology, Karolinska InstitutetRoberto Pecoits-Filho, Professor of Medicine, Pontificia Universidade Católica do ParanáScott Laengert, PhD Student, Chemical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1525172021-01-25T13:32:06Z2021-01-25T13:32:06ZYes, customers do like it when waiters and hairdressers wear a mask – especially if it’s black<figure><img src="https://images.theconversation.com/files/379559/original/file-20210119-13-sp5y0v.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C3000%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The authors didn't examine diners' perceptions of polka-dot masks specifically. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakCalifornia/a31f7dcd4bb34e858c9ff38ef0d0b3fd/photo?hpSectionId=879083fa405d449fa332cbf742e7d609&st=hpsection&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=340&Query=restaurant%20AND%20mask&currentItemNo=16">AP Photo/Ringo H.W. Chiu</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Customers perceive a better quality of service, feel less anxious and exhibit more trust in businesses when waiters and other service workers wear a mask, according to a new study we just submitted for peer review. And we found this to be especially true when the mask was black.</p>
<p>We surveyed about 4,500 Americans through <a href="https://www.mturk.com">Amazon’s Mechanical Turk</a>, showing each of them a random picture of a service employee, with or without a mask, in either a grocery store, bank, hair salon, hotel or restaurant. We included photos of men and women who were either Black, white or Asian. Further, the masks were in one of five color schemes: white, black, blue, multi-colored or clear.</p>
<p>We then asked participants to record their impressions of the service workers and subsequent perceptions, emotions and behavior. </p>
<p>We found that customers consistently expected higher quality of service from workers who wore masks compared to employees who weren’t wearing face coverings. We also found that participants tended to become less anxious when they saw a service person with a mask. </p>
<p>Interestingly, we found that the color of the mask worn made a difference. People who wore black masks got the highest ratings, followed by white, multi-colored and blue. The clear mask – even though it allows customers to actually see facial expressions – was rated the lowest by respondents.</p>
<p>While we didn’t ask participants about their political leanings, we did learn where they reside. And we found that those based in the West had the most positive reaction to mask-wearing, followed, in order, by people in the Southwest, Northeast, Southeast and Midwest.</p>
<p>We found no meaningful differences in terms of the respondents’ age, race or educational level. </p>
<figure class="align-center ">
<img alt="Six different images show various people wearing masks of varying colors, including one without a mask." src="https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=335&fit=crop&dpr=1 600w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=335&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=335&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=421&fit=crop&dpr=1 754w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=421&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=421&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">These are six of the pictures that participants in the survey randomly saw.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Why it matters</h2>
<p>President Joe Biden’s <a href="https://www.wsj.com/articles/bidens-first-day-orders-will-include-mask-mandate-blocking-keystone-pipeline-11611136804">first acts as president</a> included requiring masks be worn on all federal property and on <a href="https://www.nytimes.com/live/2021/01/21/world/covid-19-coronavirus?type=styln-live-updates&label=coronavirus%20updates&index=0&action=click&module=Spotlight&pgtype=Homepage#biden-rolls-out-full-scale-wartime-coronavirus-strategy-including-requiring-masks-on-some-planes-trains-and-buses">planes and trains</a>, and <a href="https://www.aarp.org/health/healthy-living/info-2020/retailers-require-face-masks-coronavirus.html">most businesses already expect their employees</a> to wear face coverings while working. While the primary reason for this is to <a href="https://theconversation.com/masks-help-stop-the-spread-of-coronavirus-the-science-is-simple-and-im-one-of-100-experts-urging-governors-to-require-public-mask-wearing-138507">mitigate the spread of the coronavirus</a> and protect workers, little is known about how mask-wearing can affect customer perceptions of service quality. </p>
<p><a href="https://www.theatlantic.com/politics/archive/2020/04/america-asia-face-mask-coronavirus/609283/">Wearing a mask in Asian cultures</a> has been a socially accepted practice for years. In the United States, however, wearing a mask became common only last year as the pandemic worsened in the spring. The practice <a href="https://theconversation.com/masks-and-mandates-how-individual-rights-and-government-regulation-are-both-necessary-for-a-free-society-150819">remains controversial</a> among some people who claim it violates their civil liberties or isn’t actually effective, though health officials have consistently endorsed their use.</p>
<p>Although there have been many reports of <a href="https://www.nytimes.com/2020/06/30/style/mask-america-freedom-coronavirus.html">altercations</a> when workers asked a customer to wear a mask, our research shows most people appreciate it when waiters and hairdressers cover their own faces. </p>
<h2>What’s next</h2>
<p>We plan to also study other effects of wearing masks. For example, are the perceptions of service staff members affected when customers and fellow employees wear a mask or not? What’s the impact on a customer if a mask carries a logo of a company or branding message? Do servers who wear masks receive higher tips?</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/152517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The positive reaction to service workers wearing masks varied by region, with those in the West on the high end and people in the Midwest at the low end.Cihan Cobanoglu, Professor of Hospitality and Tourism, University of South FloridaFaizan Ali, Assistant Professor of Hospitality and Tourism, University of South FloridaKhuraman Shahtakhtinskaya, Financial Analyst and Researcher, University of South FloridaLuana Nanu, Ph.D. Student in Hospitality Management, Auburn UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1483102020-10-26T12:02:03Z2020-10-26T12:02:03ZIn rural America, resentment over COVID-19 shutdowns is colliding with rising case numbers<figure><img src="https://images.theconversation.com/files/365362/original/file-20201025-19-1jktsyq.jpg?ixlib=rb-1.1.0&rect=7%2C662%2C4311%2C2258&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Business restrictions early in the pandemic, when rural towns had few cases, triggered a backlash that haunts them now.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/worker-of-the-aspen-cafe-wears-a-mask-as-she-is-seen-behind-news-photo/1211912309">Johannes Eisele/AFP/Getty Images</a></span></figcaption></figure><p>As COVID-19 spreads through rural America, new <a href="https://www.nytimes.com/2020/10/23/us/covid-worst-day.html">infection numbers are rising</a> to peaks not seen during this pandemic and <a href="https://www.nytimes.com/2020/10/23/us/covid-hospitalizations.html">pushing hospitals to their limits</a>. Many towns are experiencing their first major outbreaks, but that doesn’t mean rural communities had previously been spared the devastating impacts of the pandemic.</p>
<p>Infection rates in rural and frontier communities <a href="https://www.washingtonpost.com/nation/2020/05/24/coronavirus-rural-america-outbreaks/?arc404=true">ebbed and flowed</a> during the first seven months, often showing up in pockets linked to <a href="https://www.wired.com/story/why-meatpacking-plants-have-become-covid-19-hot-spots/">meat packing plants</a>, <a href="https://theconversation.com/failure-to-count-covid-19-nursing-home-deaths-could-dramatically-skew-us-numbers-137212">nursing homes</a> or <a href="https://theconversation.com/what-the-coronavirus-crisis-reveals-about-vulnerable-populations-behind-bars-and-on-the-streets-137455">prisons</a>.</p>
<p>Even if they had no cases, many rural areas were under <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6935a2.htm">statewide public health orders</a> that left businesses closed and events canceled. And that has become part of the problem today. The early compassionate and cohesive community responses to COVID-19 quickly gave way to <a href="https://www.npr.org/2020/05/27/862831144/why-parts-of-rural-america-are-pushing-back-on-coronavirus-restrictions">growing anger and compliance fatigue</a>, especially when some isolated towns didn’t see their first positive cases until summer.</p>
<p>That resentment toward public health recommendations, including mask-wearing, is now on a crash course with rising case numbers in the <a href="https://covidactnow.org/?s=1178286">Mountain West, Midwest and Great Plains</a>. Rural counties have witnessed sharp increases in cases, to the point where over 70% of the nation’s nonmetropolitan counties had <a href="https://dailyyonder.com/welcome-to-the-rural-wave-rural-cases-are-likely-to-keep-climbing/2020/10/23/">earned a “red zone” designation</a>, suggesting local viral spread was out of control. The reality, though, is <a href="http://doi.org/10.1056/NEJMe2029812">COVID-19 has never been “under control” in the U.S</a>.</p>
<p>As professors of family medicine with experience in <a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/30536">rural health policy</a> and <a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/21948">medical practice</a>, we have been studying the barriers rural communities are facing during the pandemic and how they can solve COVID-19-related challenges. </p>
<p>Understanding the drivers of increasing COVID-19 cases in rural places is critical to both curtailing the current surge and limiting flareups in the future.</p>
<p><iframe id="KeWw8" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/KeWw8/11/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Why rural cases are on the rise</h2>
<p>Several factors have contributed to the rise in rural case numbers. </p>
<p>The <a href="https://www.aei.org/politics-and-public-opinion/the-urban-rural-divide-over-the-coronavirus-outbreak/">politicization of the pandemic</a> – and of mask-wearing – has hampered both public health efforts and collaboration among businesses, community organizations and health care entities. Political tensions have given rise to <a href="https://doi.org/10.1016/S2589-7500(20)30084-4">misinformation, reinforced on social media</a>, that can be difficult to turn around. If people aren’t taking protective measures, when COVID-19 does come in, it can easily and quickly spread.</p>
<p>In some communities, the <a href="https://time.com/5831319/coronavirus-rural-america/">resumption of small-town activities</a>, such as school, church and sports events, has led to more infections. Experts have pointed to social gatherings, including the nearly <a href="https://www.washingtonpost.com/health/2020/10/17/sturgis-rally-spread/">500,000-strong Sturgis motorcycle rally</a> in South Dakota in August, as sources of the recent COVID-19 surge in the upper Midwest. </p>
<p>Working from home is also nearly impossible for many rural jobs. <a href="https://www.americanprogress.org/issues/economy/news/2020/03/05/481340/rural-communities-vulnerable-coronavirus/">Paid sick leave may also be difficult to come by</a>, prompting some people to choose between working while sick and isolating at home without pay. <a href="https://www.wired.com/story/why-meatpacking-plants-have-become-covid-19-hot-spots/">Meat and poultry processing plants</a> and other farm industries often employ <a href="https://www.tableau.com/about/blog/2020/4/what-you-need-know-about-covid-19-data-and-rural-america">immigrants</a> whose living and commuting realities can make social distancing difficult. Many rural places are heavily dependent on recreation and <a href="https://www.americancommunities.org/in-americas-second-home-communities-covid-19-poses-special-concerns-now/">service industries</a>. When <a href="https://www.washingtonpost.com/local/trafficandcommuting/thousands-from-coronavirus-hotspots-flocked-to-maryland-and-virginia-as-parts-of-the-states-reopened/2020/05/20/c34172b6-99e7-11ea-89fd-28fb313d1886_story.html">visitors arrive from out of town</a>, they may bring COVID-19 with them.</p>
<figure class="align-center ">
<img alt="A man partially wearing a mask waits for an employment interview in Imperial County, California." src="https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365315/original/file-20201023-23-12ya5rq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Unemployed workers wait to fill out job applications in a region hit hard by the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/faustino-who-is-currently-unemployed-waits-after-filling-news-photo/1258000442">Mario Tama/Getty Images</a></span>
</figcaption>
</figure>
<h2>Local health care is already short-supplied</h2>
<p>Pinpointing COVID-19 outbreaks early and stopping the spread can also be harder in rural areas.</p>
<p><a href="https://doi.org/10.2105/AJPH.2020.305864#_i2">Funding for rural public health departments</a> has long been anemic, crippling their ability to test, share data and conduct contact tracing. Limited resources also constrain education and outreach efforts.</p>
<p><a href="https://www.ivantageindex.com/wp-content/uploads/2020/02/CCRH_Vulnerability-Research_FiNAL-02.14.20.pdf">Many rural hospitals</a> and <a href="https://www.healthaffairs.org/do/10.1377/hblog20200415.293535/full/">primary care practices</a> entered the pandemic in financial trouble and <a href="https://www.astho.org/generickey/GenericKeyDetails.aspx?contentid=22780&folderid=5158&catid=7237">chronically short-staffed</a>. They reside squarely at the <a href="https://www.youtube.com/watch?v=0-FrrAYfY0Q">end of the supply chain</a>, making acquisition of needed personal protective equipment and testing supplies difficult. Rural hospitals have <a href="https://khn.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds/">fewer ICU beds per capita</a> than their urban counterparts. <a href="https://www.fcc.gov/health/maps">Lack of consistent broadband coverage</a> can make access to telehealth difficult, as well. </p>
<p>These factors, compounded by caring for a population that is comparatively <a href="https://www.nihcm.org/categories/rural-health-in-america-how-shifting-populations-leave-people-behind">older, sicker and poorer</a>, leave rural communities extraordinarily vulnerable as cases continue to rise.</p>
<p><iframe id="F9zYa" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/F9zYa/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>How to turn the tide of rising cases</h2>
<p>Intervening now can slow the rate of rise of COVID-19 cases in rural hot spots while simultaneously building a more robust long-term response.</p>
<p>To be most effective, each rural area’s unique demographics, economies and perspectives should be considered as policies are developed.</p>
<p>For example, allowing rural communities to exert control over their reopening and closing decisions based on local disease transmission dynamics would allow them to better balance disease mitigation with economic impacts. Some states allow rural communities with few or no cases <a href="https://www.cpr.org/2020/05/29/a-slap-in-the-face-some-rural-counties-frustrated-with-how-colorado-grants-health-order-waivers/">to apply for waivers</a> from statewide public health orders. These applications generally look at local infection data, containment measures and health care capacity. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p><a href="https://doi.org/10.1111/jrh.12432">Changing the nature of the conversation</a> around COVID-19 in the community can also help in implementing simple, effective measures like mask-wearing. When communications are personal, they may be more accepted. For example, a public service message could remind people that wearing a mask keeps your favorite business open and your grandmother healthy. Framing levels of risk in understandable terms for different types of activities can also help, such as <a href="https://theconversation.com/7-tips-for-staying-safe-as-covid-19-cases-rise-and-colder-weather-heightens-the-risk-146981">how to exercise or socialize safely</a>. Working with trusted local messengers, such as business owners and faith leaders, can help convey evidence-based information.</p>
<figure class="align-center ">
<img alt="A cafe owner wears a protective face mask in Stillwater, Oklahoma." src="https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365316/original/file-20201023-13-i0y3qf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stillwater, Oklahoma, pulled back on requiring people to wear masks in stores last spring after officials said some customers threatened store employees.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/kelly-lyda-owner-of-the-aspen-cafe-stands-in-front-cafe-on-news-photo/1211912339">Johannes Eisele/AFP via Getty</a></span>
</figcaption>
</figure>
<p>Planning is also essential. Communities need to prepare so they can get supplies, testing and treatment when needed; protect the most vulnerable community members; educate the community; and support people in isolation and quarantine. A <a href="https://www.aamc.org/news-insights/rural-and-risk-covid-19">rural regional approach to testing</a> and contact tracing, sharing supplies and <a href="https://www.aha.org/system/files/media/file/2020/08/aha-cs-lincoln-0820.pdf">swapping staff</a> could help bridge some of the gaps. Getting test results closer to home could decrease wait times and courier costs. Sharing resources across health care organizations could also minimize the burden of response.</p>
<h2>3 ways to strengthen systems for the future</h2>
<p>COVID-19 isn’t likely to be the last pandemic rural America will see. Here are three ways to strengthen rural systems for the future.</p>
<ul>
<li><p>By partnering with universities and local and state agencies, communities can incorporate their unique susceptibilities into dynamic <a href="https://www.techwire.net/news/experts-say-state-covid-models-are-inaccurate-in-rural-areas.html">epidemiological models</a> that could better inform local public health and economic decisions.</p></li>
<li><p><a href="https://www.maine.gov/governor/mills/news/governor-mills-introduces-rural-reopening-plan-2020-05-08">Aligning public health and health care</a> measures could help governments better balance pandemic responses and ensure all parts of the community are moving toward the same goal.</p></li>
<li><p>Increasing broadband access and internet speeds in rural and frontier communities could also help. During the pandemic, people everywhere have appreciated the need for <a href="https://journalistsresource.org/studies/society/internet/rural-broadband-coronavirus/">internet connectivity</a> for education, remote work and purchasing goods, as well as virtual health care.</p></li>
</ul><img src="https://counter.theconversation.com/content/148310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Hughes’ work to strengthen rural health infrastructure is funded in part by the ZOMA Foundation. She is also affiliated with the Rural Health Redesign Center Organization.</span></em></p><p class="fine-print"><em><span>Roberto Silva receives funding from the Health Resources and Services Administration (HRSA) of Health and Human Services (HHS). The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.
</span></em></p>Coronavirus cases have risen sharply across the Mountain West, Midwest and plains. Over 70% of nonmetropolitan counties are now “red zones,” suggesting viral spread is out of control.Lauren Hughes, State Policy Director, Farley Health Policy Center; Associate Professor of Family Medicine, University of Colorado Anschutz Medical CampusRoberto Silva, Assistant Professor of Family Medicine, University of Colorado Anschutz Medical Campus, University of Colorado DenverLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1445522020-08-18T03:18:01Z2020-08-18T03:18:01ZMask or no mask? This simple ethical approach can help with your pandemic etiquette<figure><img src="https://images.theconversation.com/files/353280/original/file-20200817-22-1c1hx7u.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5416%2C3597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">www.shutterstock.com'</span></span></figcaption></figure><p>Feeling torn about wearing a mask? Me too. I don’t want to look like I’m virtue signalling or get <a href="https://www.newshub.co.nz/home/new-zealand/2020/08/coronavirus-people-wearing-face-masks-say-they-re-getting-funny-looks-despite-government-s-encouragement.html">funny looks</a>. But I also want to be responsible about public health. I’ve ended up conflicted, wearing a mask one day but not the next. </p>
<p>The statistics suggest this isn’t my dilemma alone. While mask sales have <a href="https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12356065">skyrocketed</a> in New Zealand since COVID-19 reemerged, public mask wearing (even in <a href="https://www.stuff.co.nz/national/health/coronavirus/122431981/coronavirus-few-aucklanders-seem-to-be-wearing-masks-in-public">Auckland</a>) is still the exception.</p>
<p>This is where understanding ethical decision making can be useful. Ethics breaks down values-based decisions, helping us see when our ego is ruling us, and when our rationality is in control. </p>
<p>Ethical analysis can’t make the decision for us, but it can make dealing with ethical decisions clearer and more conscious.</p>
<h2>What kind of person do I want to be?</h2>
<p>Scholars divide the study of ethics into three main branches: virtue, <a href="https://ethics.org.au/ethics-explainer-deontology/">deontological</a> and consequential. All three can us help think about wearing a mask.</p>
<p>Virtue ethics is about developing good character. Our virtues come from our upbringing, experiences and education. We can change them by redefining what sort of person we want to be. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/3-moral-virtues-necessary-for-an-ethical-pandemic-response-and-reopening-140688">3 moral virtues necessary for an ethical pandemic response and reopening</a>
</strong>
</em>
</p>
<hr>
<p>Simple virtue checks include:</p>
<ul>
<li><p>The front page test – would you feel comfortable seeing your behaviour on the nightly news?</p></li>
<li><p>The significant other test – would the important people in your life be proud of you?</p></li>
</ul>
<p>(There are several recently <a href="https://www.rnz.co.nz/news/national/420699/national-mp-hamish-walker-admits-leaking-covid-19-patient-details">disgraced politicians</a> who probably wish they’d run the front page and significant other checks before acting.)</p>
<p>However, virtue ethics are individualistic: values differ by gender, age, culture and other factors. Our ego can help us moderate our behaviour, but it can also convince us we are right just because we sincerely hold a strong moral belief. </p>
<p>The “no win” debates we see on social media often reach a stalemate because people are relying on personal values as their only moral compass.</p>
<p>Also, prioritising reasonableness can result in apathy. While Aristotle praised the “reasonable man” as virtuous, George Bernard Shaw pointed out that “all progress depends on the unreasonable man”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1292387978463961088"}"></div></p>
<p>Currently mask wearers are the exception rather than the rule, and some have even been <a href="https://www.stuff.co.nz/national/health/coronavirus/300083046/coronavirus-kiwis-outside-of-auckland-mocked-laughed-at-for-wearing-face-masks">mocked</a>. Shaw’s approach would suggest the courage to show ethical leadership deserves praise rather than mockery. But we can only make a robust ethical judgement if duties and outcomes are also considered. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-new-zealand-needs-to-focus-on-genome-sequencing-to-trace-the-source-of-its-new-covid-19-outbreak-144402">Why New Zealand needs to focus on genome sequencing to trace the source of its new COVID-19 outbreak</a>
</strong>
</em>
</p>
<hr>
<h2>What are my duties?</h2>
<p>Deontologists try to identify rules for good behaviour that will hold true in every situation. They advise us to obey the law and any codes of conduct or standards that apply to our job or other group membership. </p>
<p>There is currently no law in New Zealand mandating mass masking, so that can’t guide us. But many workplaces have conduct or health and safety codes, which can simplify decision making, and there are clear <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-health-advice-general-public/covid-19-use-masks-community#fmuse">public health recommendations</a>.</p>
<p>Deontology gives clarity – rules define what can be done without penalty – and is less muddy or personal than virtue-based ethics. It can also provide accountability. If we breach the rules of a group, often we can be removed from that group.</p>
<p>On the other hand, deontological ethics is inflexible. Codes and rules can’t cover every situation, can date rapidly, and are usually made reactively. They mostly punish breaches rather than guiding good behaviour. </p>
<p>Nonetheless, considering laws and rules is an important ethical step, alongside thinking about our values and the impact of our actions.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1293677280556769280"}"></div></p>
<h2>What kind of world do I want to live in?</h2>
<p>Consequentialists judge actions by their outcomes: who is affected and how. They aim to maximise benefit and minimise harm. </p>
<p>When weighing consequences, it is useful to ask:</p>
<ul>
<li><p>Would you be happy for your action to affect you in the same way it does others (reversibility)?</p></li>
<li><p>Would the outcome be acceptable if everyone behaved this way (universalisability)?</p></li>
<li><p>What don’t we know today that might be true tomorrow (unknowability)?</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-stand-so-close-to-me-understanding-consent-can-help-with-those-tricky-social-distancing-moments-139293">Don't stand so close to me – understanding consent can help with those tricky social distancing moments</a>
</strong>
</em>
</p>
<hr>
<p>Consequentialists try to act ethically towards all groups of people, not just the group they currently occupy, because they know circumstances can change. If a friend was diagnosed with an unexpected respiratory condition tomorrow, for example, would we be happy with how we behaved today? </p>
<p>But, on their own, consequentialist approaches can be vague and complex. Most usefully, consequentialism adds depth to other approaches.</p>
<h2>Ask yourself these questions</h2>
<p>So, I run all three ethics checks: what values are important to me, what are my duties, and what are the potential impacts of my choice? To help, I can ask other questions: </p>
<ul>
<li><p>What would mum say? (Be compassionate.) </p></li>
<li><p>What does my workplace code of conduct say? (It prioritises <a href="https://maoridictionary.co.nz/search?keywords=manaakitanga">manaakitanga</a> or care for others.) </p></li>
<li><p>What does the reversability test imply? (That I can show solidarity with, and reduce anxiety for, people at risk, even if I am at less risk.)</p></li>
<li><p>If someone I’m in contact with got sick tomorrow, how would I feel about my behaviour today? (I’d rather not be sorry in hindsight.)</p></li>
</ul>
<p>Asking a range of questions from all three ethical angles helps me arrive at an ethically measured decision: that I should be consistently wearing a mask when I go out. And a careful decision is much easier to stick to, even if it means I still get the odd funny look.</p><img src="https://counter.theconversation.com/content/144552/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elspeth Tilley has previously received research funding from the Ministry of Health and the Health Research Council of New Zealand.</span></em></p>Worried about being accused of virtue signalling or getting funny looks for wearing a mask? Here’s how to test your ethics and come to the right decision.Elspeth Tilley, Associate Professor of English (Expressive Arts), Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1436692020-08-16T12:12:34Z2020-08-16T12:12:34ZHow to calmly navigate personal interactions during COVID-19<figure><img src="https://images.theconversation.com/files/352090/original/file-20200811-16-1f33puu.JPG?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C1594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some passengers wear face masks as they commute on the metro in Montréal in July 2020.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span></figcaption></figure><p>Thanks to COVID-19, we’ve slowly built new routines centred on being at home. But as we start to enter various phases of reopening and increased contact, we may feel uncomfortable interacting in person again. </p>
<p>Treating each interaction as a type of micro-negotiation provides a helpful road map for navigating these potentially tricky situations. </p>
<p>What once were automatic interpersonal behaviours now require explicit agreement.</p>
<p>What do you do if someone enters the elevator with you without a mask? </p>
<p>If a friend rushes close to greet you? </p>
<p>If someone stands too closely in line? </p>
<p>What if you are (perhaps unintentionally) the offending party? </p>
<p>These situations are increasingly common and can escalate quickly into full-blown conflicts if not handled carefully. I draw on research on effective negotiations and conflict management to offer concrete suggestions and practical tips for how to ensure everyone walks away happy — and safe. </p>
<p>Overall, treating each interaction as a micro-negotiation first involves a change of mindset. Productive changes to your behaviour will then follow more easily. </p>
<p>It is important to note that many interactions won’t require all the recommendations below. But thinking about each in advance can help you be ready in the moment. A negotiation done well in this case may be one in which you don’t even realize you’ve successfully negotiated until after it’s over. Practice and preparation are key so that these tactics become second nature. </p>
<h2>Prepare and have a plan beforehand</h2>
<p>In negotiations, an important concept is what’s known as BATNA, which stands for the Best Alternative to a Negotiated Agreement. It is what you will do instead if you don’t reach agreement with your negotiation counterpart. </p>
<p>For daily interactions during the pandemic, this means you should have a clear idea in advance of what you will do if a situation gets too uncomfortable. <a href="https://doi.org/10.1006/obhd.1994.1006">Research shows</a> that having a defined, desirable alternative in mind helps negotiators perform better; the psychological comfort of having an attractive backup plan helps you feel more powerful and removes unnecessary stress in the current moment. </p>
<figure class="align-center ">
<img alt="A man wearing a mask cycles past a mural featuring a smiling face in front of a dental office." src="https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352091/original/file-20200811-24-1qr3trj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Don’t bike off in a rage if someone isn’t adhering to safety protocols when you venture out into the world. Have a Plan B in mind.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Rather than storming away in a huff, or escalating a conflict unnecessarily, plan ahead and have explicit options in mind. For example, if mask-wearing doesn’t seem to be enforced in a particular place, know before you leave your home what you will do: you might get takeout from a different restaurant, order groceries for pickup or delivery or simply come back at a different time. </p>
<p>Having your alternative in mind will help you remain calm, knowing that you always have a perfectly acceptable alternative. In fact, <a href="https://doi.org/10.1108/IJCMA-01-2019-0016">research shows</a> that simply feeling that you can handle a tense situation can help you avoid reacting unproductively. </p>
<h2>Respect other perspectives, but be creative</h2>
<p>Although it might seem inconceivable that someone may have a different comfort level in terms of interactions than you do, it’s bound to happen and doesn’t mean the other person is crazy. (In fact, they may be thinking you are the crazy one.)</p>
<p>A more productive approach is to try to understand the other person’s perspective, and how you can satisfy both of your underlying needs in a creative way. <a href="https://www.penguinrandomhouse.ca/books/324551/getting-to-yes-by-roger-fisher-and-william-ury/9780143118756">Separate the position (the behaviour, or the “what” that makes you feel uncomfortable) from the interest (the “why” of the behaviour)</a>. </p>
<p>For example, if you’re not comfortable attending the “small” get-together of friends that somehow grew much larger in number, that’s OK. Simply say so explicitly, but also suggest an alternative that could meet both your and the host’s interests (to connect with an old friend) in a different format (taking a physically distant walk together later in the week). </p>
<figure class="align-center ">
<img alt="A man sits in a circle drawn in chalk in a park, sipping a beer." src="https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352093/original/file-20200811-24-ayjl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not comfortable going to a friend’s party? Suggest a visit in a park instead.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>Remember that respecting the other person doesn’t mean you have to agree with their position. </p>
<p>But by being creative and focusing on deeper, underlying interests rather than more superficial positions, you can keep everyone happy. </p>
<h2>Don’t take it personally, and use threats wisely</h2>
<p>Despite our best intentions, it is likely that some interactions may lead to strong emotions, even anger. </p>
<p>However, rather than reacting angrily to a situation, <a href="https://doi.org/10.1177/1094670519838623">which can backfire</a> depending on how it is received, take a step back and reconsider the situation from an open-minded, problem-solving perspective. </p>
<p>Use the other person’s reactions and emotions as a trigger to help you find out what’s really going on at a deeper level, which <a href="https://doi.org/10.1037/apl0000458">research shows</a> shows can help you reach a more mutually beneficial solution without having to simply give in to the other person’s demands. </p>
<figure class="align-center ">
<img alt="People in lycra, some of it hot pink, do yoga and stretches on asphalt." src="https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=489&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=489&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352094/original/file-20200811-24-darydf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=489&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If this impromptu, mid-pandemic exercise session on Sainte-Catherine Street in Montréal is your worst nightmare, try not to react angrily to it.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>If you feel that you need to resort to ultimatums, do so carefully and purposefully. <a href="https://hbsp.harvard.edu/product/N0412B-PDF-ENG?itemFindingMethod=Other">Research suggests</a> that WISE threats — those that you are <em>willing</em> to enact, that serve your underlying <em>interests</em>, that help the other person <em>save face</em> or maintain their dignity and that are <em>exact</em> rather than vague — are more likely to lead to effective conflict resolution. </p>
<p>Thinking about each interaction you have as a form of micro-negotiation will help you practise a few fairly minor behavioural and mindset changes so that you, and those around you, are more likely to have positive interactions and avoid unnecessary conflict. </p>
<p>It’s important to remember that we’re all navigating uncharted waters, and negotiating what used to be mundane but now feels uncomfortable may not come naturally. However, with conscious practice and an open mind, it’s possible to approach even the most challenging interactions from a productive problem-solving mindset.</p><img src="https://counter.theconversation.com/content/143669/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Rees does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As we venture out into the world during the COVID-19 pandemic, treating each interaction as a type of micro-negotiation provides a helpful road map for navigating potentially tricky situations.Laura Rees, Assistant Professor of Organizational Behaviour, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1439952020-08-14T05:19:49Z2020-08-14T05:19:49ZHow to talk to someone who doesn’t wear a mask, and actually change their mind<figure><img src="https://images.theconversation.com/files/353353/original/file-20200818-20-eo21by.jpg?ixlib=rb-1.1.0&rect=0%2C13%2C1000%2C556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>It could be a brother or sister. It could be a neighbour. It could be a person you work with. We probably all know someone who doesn’t wear a mask in public even though it’s compulsory or recommended where you live.</p>
<p>The media is quick to highlight people who think it’s <a href="https://theconversation.com/living-people-who-are-the-sovereign-citizens-or-sovcits-and-why-do-they-believe-they-have-immunity-from-the-law-143438">their right</a> not to wear a mask, such as <a href="https://twitter.com/search?q=%23Bunningskaren&src=recent_search_click">#bunningskaren</a>, or who <a href="https://7news.com.au/lifestyle/health-wellbeing/victoria-police-officers-head-smashed-into-concrete-by-woman-refusing-to-wear-a-mask-c-1214738">become violent</a> in expressing their objection.</p>
<p>But others can be persuaded, with the right approach.</p>
<p>So how do you know if it’s worth trying to convince someone to wear a mask? And what’s the best way to talk to them if you actually want to make a difference?</p>
<h2>Yelling ‘Mask up!’ at them won’t work</h2>
<p>People vary in how they perceive and tolerate risk, and how physically and psychologically vulnerable they are. So we may need to negotiate accepted behaviours, just as we did <a href="https://jamanetwork.com/channels/health-forum/fullarticle/2766837">with HIV</a>. Many of these conversations might be difficult.</p>
<p>We also need to watch our own emotions don’t cloud the message we want to convey. For instance, when we become <a href="https://theconversation.com/how-to-cut-through-when-talking-to-anti-vaxxers-and-anti-fluoriders-72504">angry, anxious, outraged or fearful</a>, the person we are trying to communicate with might not hear the message we intended.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Worried woman using a smartphone" src="https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352834/original/file-20200813-14-im8ldq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Having one of these conversations while you’re angry or anxious can backfire.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/picture-worried-young-woman-on-phone-489985801">www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>We might want to convey: “I want you to wear a mask when you catch the train to see our father.” But instead, the other person hears the message: “I think you are behaving badly and I’m angry with you.”</p>
<p>Ironically, the pandemic makes this type of miscommunication more likely. When we are stressed or emotional, we are more likely to activate our body’s “fight, flight, freeze” mechanisms. This <a href="https://academic.oup.com/brain/article/137/9/2620/2848178">affects</a> how we communicate and how our communication is received.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-cut-through-when-talking-to-anti-vaxxers-and-anti-fluoriders-72504">How to cut through when talking to anti-vaxxers and anti-fluoriders</a>
</strong>
</em>
</p>
<hr>
<p>If refusing to wear a mask is about maintaining a <a href="https://www.huffingtonpost.com.au/entry/psychology-why-people-refuse-wear-face-masks_l_5efb723cc5b6ca970915bc53">sense of control</a> or is connected to a sense of identity — for example, if someone considers themselves “not someone who fusses” — then telling them to mask up could make them <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1123807">defensive</a>.</p>
<p>Becoming defensive makes people not only <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1123807">less willing</a> to listen, but less <em>able</em> to take in information, and or to appraise it accurately.</p>
<p>As a result, criticising someone’s views — for example, that wearing a mask doesn’t work — may lead them to “switch off” from what you’re saying and stick more firmly to their <a href="https://theconversation.com/parents-decisions-about-vaccination-and-the-art-of-gentle-persuasion-9969">beliefs</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/parents-decisions-about-vaccination-and-the-art-of-gentle-persuasion-9969">Parents' decisions about vaccination and the art of gentle persuasion</a>
</strong>
</em>
</p>
<hr>
<h2>So, what does work?</h2>
<p>To communicate well, we need to <a href="https://www.psychologytoday.com/au/blog/some-assembly-required/201703/how-have-difficult-conversations">prepare</a>. The authors of the book <a href="https://www.bookdepository.com/Crucial-Conversations-Tools-for-Talking-When-Stakes-Are-High-Second-Edition-Kerry-Patterson/9780071771320">Crucial Conversations</a> <a href="https://www.psychologytoday.com/au/blog/crucial-conversations">recommend</a> asking yourself what you want to achieve as an outcome <em>and</em> what you want for the relationship between you.</p>
<p>The goal is to keep the relationship respectful and the lines of communication open, so negotiations can continue as new pandemic circumstances arise.</p>
<p>You won’t completely change someone’s beliefs or actions. A better aim is to negotiate a change in behaviour that <a href="https://www.wnycstudios.org/podcasts/otm/episodes/abstinence-only-coronavirus-guidance-wont-save-us-on-the-media">minimises harm</a>. This might be: “Do as you choose at other times of course, but could we agree that just for now, you wear a mask when you visit Dad?”</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-older-people-more-at-risk-of-coronavirus-133770">Why are older people more at risk of coronavirus?</a>
</strong>
</em>
</p>
<hr>
<h2>Respect, empathy, appeal to values</h2>
<p>Identifying and respecting another person’s <a href="https://www.tandfonline.com/doi/full/10.1080/13669877.2020.1758193">values</a> and finding values in common reduces defensiveness and provides grounds for negotiation.</p>
<p>For instance: “I can see how important it is to you to be sceptical, and I absolutely agree, especially since the evidence changes so often. But since the evidence definitely shows that even some young, healthy people can get seriously ill, could I ask you to wear a mask on our trip?”</p>
<p>Asking someone why they are not wearing a mask, instead of telling them to wear one, is another helpful tool. This is a chance for someone <a href="https://www.tandfonline.com/doi/full/10.1080/10904018.2013.813234">to be heard</a>, which lowers any defensiveness.</p>
<p>There are many reasons why people <a href="https://www.theverge.com/21303553/face-mask-coronavirus-cdc-etiquette-public">don’t wear masks</a>. And <a href="https://hbr.org/1957/09/listening-to-people">hearing someone</a> explain could provide an opportunity to problem-solve (especially if we ask how we can help, and refrain from giving advice).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-easy-to-judge-but-some-people-really-cant-wear-a-mask-143258">It's easy to judge. But some people really can't wear a mask</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.psandman.com/col/empathy.htm">Compassion</a> or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571783/">empathy</a> allows us to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047264/">support another’s position</a> while more strongly <a href="https://business.rice.edu/wisdom/commentary/empathy-about-using-your-brain">maintaining our own</a>. </p>
<p>For example, acknowledgements such as “I can relate! All these controls over our lives make me crazy and a lot of them make no sense” or “I might be wrong, and I might be overreacting”, can help with negotiating “please humour me and wear a mask, just on the train”. </p>
<p><a href="https://www.psychologytoday.com/us/blog/evolution-the-self/201706/feeling-understood-even-more-important-feeling-loved">Empathy</a> can also help preserve the relationship while insisting on a boundary, such as: “Our relationship is so important, I really want to see you, and I hate saying this, but I can’t accept you visiting without a mask, at least until there are fewer cases.”</p>
<h2>How a non-judgemental approach can win people over</h2>
<p>Evidence shows <a href="https://theconversation.com/young-men-are-more-likely-to-believe-covid-19-myths-so-how-do-we-actually-reach-them-143745?">some groups of men</a> — such as younger men, more <a href="https://www.psypost.org/2020/06/political-conservatism-indirectly-linked-to-flouting-coronavirus-safety-measures-via-reduced-trust-in-science-57178">politically conservative</a> <a href="https://theconversation.com/coronavirus-lockdown-fresh-data-on-compliance-and-public-opinion-135872">men</a>, men with lower health literacy, and men who endorse more <a href="https://onlinelibrary.wiley.com/doi/full/10.1348/135910710X485826">traditional notions</a> of masculinity — are among the most likely to <a href="https://psyarxiv.com/tg7vz/">resist wearing a mask</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/young-men-are-more-likely-to-believe-covid-19-myths-so-how-do-we-actually-reach-them-143745">Young men are more likely to believe COVID-19 myths. So how do we actually reach them?</a>
</strong>
</em>
</p>
<hr>
<p>Non-judgemental communication <a href="https://www.menshealth.com/health/a33267635/wont-wear-a-mask-what-to-say/">is as effective</a> with men as with everyone else.</p>
<p>When Harvard professor Julia Marcus <a href="https://www.theatlantic.com/ideas/archive/2020/06/dudes-who-wont-wear-masks/613375/">wrote about</a> male anti-maskers without shaming or judgement, many men contacted her, willing to listen to her views on masks.</p>
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<h2>In a nutshell</h2>
<p>If we are non-judgemental, empathetic, and clear in what we want to achieve, we can rise above counterproductive reactions, such as jumping in to tell someone off or dismissing someone’s concerns.</p>
<p>This allows us to be brave enough to tailor our communication to what the other person is able to hear, and to make it safe for the other person to speak. This is when our communication will actually work.</p><img src="https://counter.theconversation.com/content/143995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Hooker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It might be tempting to yell ‘bloody well wear a mask’, but that will probably make little difference. Research shows there are more constructive ways to get your message across.Claire Hooker, Senior Lecturer and Coordinator, Health and Medical Humanities, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1441242020-08-12T05:38:52Z2020-08-12T05:38:52ZHow do I know if my mask actually works? What about the ‘candle test’?<figure><img src="https://images.theconversation.com/files/352426/original/file-20200812-21-11becbd.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pensive-thoughtful-woman-wearing-protection-handmade-1689043420">Shutterstock</a></span></figcaption></figure><p>With mask wearing in public compulsory in Victoria and recommended in New South Wales, many Australians are buying, wearing or making face masks for the first time.</p>
<p><a href="https://www.theguardian.com/australia-news/2020/aug/06/hundreds-of-types-of-face-masks-withdrawn-from-sale-in-australia-amid-safety-fears">Reports</a> of counterfeit or potentially substandard masks on the market may lead some people to question whether their surgical or cloth mask actually works.</p>
<p>So what can you look out for when buying a mask to make sure it does what it’s supposed to do? </p>
<p>And how can you test one you’ve bought or made?</p>
<h2>What do I look for in a surgical mask?</h2>
<p>Surgical masks (also known as medical masks) are usually made of three or four layers, most commonly polypropylene. </p>
<p>Ideally, they should meet <a href="https://www.tga.gov.au/post-market-review-face-masks-overview">Australian standards</a> for how well they filter and how resistant they are to water.</p>
<p>Only masks the Therapeutic Goods Administration (TGA) approves as medical products (officially known as medical devices) can be used in hospitals.</p>
<p>If a mask meets Australian standards as a medical device, <a href="https://www.tga.gov.au/behind-news/regulation-personal-protective-equipment-and-covid-19">you will see</a> a label on the packaging, plus a code indicating the standards it has met, such as:</p>
<ul>
<li><p>AS/NZS 4381:2015</p></li>
<li><p>ASTM F2101-14 or EN 14683:2014</p></li>
<li><p>ISO 22609 or ASTM F1862/F1862M-13.</p></li>
</ul>
<p>If your surgical mask says “not for medical use”, it doesn’t necessarily mean it’s useless. It just means it has not been submitted to the TGA for approval as a medical device.</p>
<p>If that’s the case, you can assess it using one of the methods below.</p>
<h2>What do I look for in a cloth mask?</h2>
<p>Cloth masks are non-medical devices. But they can be <a href="https://wwwnc.cdc.gov/eid/article/26/10/20-0948_article">designed</a> to be reasonably protective.</p>
<p>If you’re buying one online or making one yourself, check <a href="https://www.bloomberg.com/news/articles/2020-07-23/homemade-face-masks-work-best-with-multiple-layers-study-finds?sref=3ZPWSuyv">how many layers</a> it has. A single-layered mask is better than no covering, but <a href="https://thorax.bmj.com/content/early/2020/07/24/thoraxjnl-2020-215748">two layers</a> are better than one, and three layers are better than two. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext">More than three layers</a> are better still.</p>
<p>Look for a fine weave, high thread count and dense material. Flimsy or see-through material, or material with large gaps, is not adequate because droplets and aerosols can pass through the gaps.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/which-mask-works-best-we-filmed-people-coughing-and-sneezing-to-find-out-143173">Which mask works best? We filmed people coughing and sneezing to find out</a>
</strong>
</em>
</p>
<hr>
<p>For a cloth mask, pure cotton is not a good choice for the outer layer, as it is absorbent. If someone else is coughing and sneezing near you, you want your mask to block those droplets rather than enable them to pass through the mask and infect you. A polyester or cotton-polyester blend is a better choice for this outer layer.</p>
<p>So for cloth masks, <a href="https://www.dhhs.vic.gov.au/sites/default/files/documents/202007/Design%20and%20preparation%20of%20cloth%20mask_0.pdf">aim for</a> at least three layers, including a water-resistant outer layer. The inner layer can be cotton, as that makes it more comfortable to wear, because it will absorb moisture from your breathing.</p>
<p>Check also that your mask fits well around your face. If you have gaps around the edges of your mask, you can breathe in unfiltered, contaminated air. </p>
<p>Look to see if there’s a nose bridge piece or other adjustable edge to help mould the mask around your nose and the top of your cheeks. If your mask is loose-fitting, a <a href="https://www.medrxiv.org/content/10.1101/2020.04.17.20069567v2">nylon stocking</a> over the top can improve the fit and seal. </p>
<p>And remember to wash your cloth mask daily.</p>
<hr>
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<em>
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Read more:
<a href="https://theconversation.com/13-insider-tips-on-how-to-wear-a-mask-without-your-glasses-fogging-up-getting-short-of-breath-or-your-ears-hurting-143001">13 insider tips on how to wear a mask without your glasses fogging up, getting short of breath or your ears hurting</a>
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</em>
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<h2>How can I test my mask at home?</h2>
<p><strong>Test for good filtration and fit</strong></p>
<p>For filtration and fit, you can do some rather <a href="https://makermask.org/diy-mask-tests/">time-consuming experiments</a> at home.</p>
<p>But a much simpler method is the candle test, popularised by US science educator <a href="https://www.billnye.com/">Bill Nye</a>. If you can blow out a candle while wearing your mask, that’s a fail.</p>
<p>It means your mask doesn’t adequately stop the flow of air. If you can blow air out, air can also leak inward just as easily. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/pKk9GFur4Hc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Put on your mask, light a candle, then try to blow out the flame.</span></figcaption>
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<p><strong>Test for water resistance</strong></p>
<p>The virus is carried on water droplets expelled when infected people talk, cough and sneeze. If these droplets land on your mask, you want the outer layer to repel them. </p>
<p>A TGA-approved mask will be water resistant. But <a href="https://makermask.org/diy-mask-tests/">not all</a> other masks are. So you can test a non-approved surgical mask or cloth mask at home. </p>
<p>If a drop of water on the outside surface is absorbed straight away, <a href="https://makermask.org/diy-mask-tests/">that’s a fail</a>. If the drop forms a bead, the mask is water-resistant.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-should-i-clean-my-cloth-mask-143974">How should I clean my cloth mask?</a>
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</em>
</p>
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<p>Whether you go for a surgical mask that’s an approved medical device, an unapproved surgical mask, or a cloth mask, these simple tips should help you assess it before leaving the house.</p>
<p>Masks are a simple method for helping <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext">reduce transmission</a> of the virus that causes COVID-19, alongside physical distancing, hand-washing and other infection control measures. If enough people wear them, they may even help <a href="https://www.sciencedirect.com/science/article/pii/S0025556420300560">avoid a lockdown</a>.</p><img src="https://counter.theconversation.com/content/144124/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC (Principal Research Fellowship and Centre for Research Excellence), the Medical Research Futures Fund (research grant on bushfire smoke and facemasks) and has received funding from Sanofi and Seqirus in the past five years for investigator driven research on influenza. She has consulted for Australian mask manufacturer, Detmold in 2020.</span></em></p>A few simple pointers can help you spot a quality mask from a dud.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.