Face masks may return amid holiday ‘tripledemic’ of covid, flu and RSV

With three highly contagious respiratory viruses sickening adults and children around the country and holiday gatherings just weeks away, public health officials are beginning to talk about face masks again.

While mask mandates are unlikely in most parts of the country, health experts are renewing recommendations to wear a high-quality medical mask on public transportation, in airports and on planes, while shopping and in other crowded public spaces.

What’s notable is that the mask recommendations this time aren’t just about avoiding the coronavirus. Masks are advised to protect against what is being called the “tripledemic” – a confluence of influenza, coronavirus and respiratory syncytial virus (RSV) that already is straining hospitals and forcing parents to miss work in record numbers.

As the country heads into its third pandemic winter, covid-19 cases are on the rise, and the 2022-23 flu season is shaping up to be the worst in a decade – there have already been 4,500 deaths from flu, including 14 children, according to the Centers for Disease Control and Prevention.

With such a heavy burden of illness straining the health-care system, it may be hard to believe that something as simple as a face mask could make a meaningful difference. But health experts say a quality medical mask – such as an, KN95, or KF94 – remains a highly effective line of defense, especially when combined with vaccination, hand washing, better ventilation and avoiding crowds.

“Masks will help reduce your risk of all respiratory viruses not just covid,” said Jay K. Varma, an internal medicine physician, epidemiologist and professor of population health sciences at Weill Cornell Medical College. “They have to be the right quality masks worn consistently and correctly. Even a very small percentage increase in mask-wearing when multiplied by a large population can have a big impact.”

We talked to several public health experts about why a face mask may be your best holiday accessory this winter. Here’s what they had to say.

_ Why are we talking about masks again?

Rochelle Walensky, the CDC director, noted earlier this week that the agency encourages everyone “to wear a high quality, well-fitting mask to help prevent the spread of respiratory illness,” particularly on public transportation and during airport travel. Masking is especially important in counties with high covid-19 community levels, she said.

Walensky said in an interview Wednesday that while the CDC’s mask guidance is “largely based” on the coronavirus, and not flu and RSV, “it is the case that the mask works against those as well.”

“If you have these other things circulating as well, and you want to protect yourself against other respiratory diseases, then the mask will help you,” she said.

While the CDC is not a regulatory agency and does not impose mask mandates, its recommendations have been influential in shaping whether local governments, schools and institutions require masks.

Public health advocates said they were pleased to hear Walensky talk about masks, an issue that was politicized throughout the pandemic and a subject about which the CDC has been notably silent of late.

“It’s good she brought it up,” said Eric Topol, a professor of molecular medicine at Scripps Research. “We had a really good reason to wear a mask with covid, and now we have even more of a reason. It’s a three-fer – you get protection from flu, RSV and certainly from covid.”

California state epidemiologist Erica Pan in an interview last week urged people to consider masking, especially to limit the spread of RSV since infants cannot mask.

“I also recommend people who are elderly or have medical problems to really be masking indoors,” Pan said. “Flu, of course, also hits the elderly the hardest as well.”

_ Are masks mandates coming back?

Only a few communities are reconsidering mask mandates, especially if the CDC identifies them as having high levels of covid. The most notable is Los Angeles County, which the CDC considers to have medium covid levels, where cases are spiking and hospital admissions are rising. If the share of hospital beds used by coronavirus positive patients rises from 6.4 percent (as of Saturday) to 10 percent, that could trigger a new indoor mask mandate that could go into effect by early January, the Los Angeles Times has reported.

The Sacramento City Unified School District has warned it would require masks indoors if the CDC designates Sacramento County as having a high covid community level.

The CDC in February announced a new system of covid community levels that would tie masking recommendations to metrics illustrating the strain of covid on hospitals rather than the prevalence of infections. The system isn’t designed to track levels of other respiratory viruses.

Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, said most public health authorities are not considering bringing back mask mandates because they are following the CDC approach, which recommends mask-wearing once community levels of covid are high. He noted that tracking community levels of covid doesn’t capture the broader toll of respiratory viruses.

“If you lumped RSV, influenza and covid together and started doing community indicators that the CDC is doing for covid right now, there would be a lot more places going into orange and red zones,” Plescia said. “Maybe the American public is done with mask-wearing, but you do wonder can you get a place where you can say things are getting bad right now, we need people to wear masks in public settings.”

New York Gov. Kathy Hochul (D) held a news conference Wednesday about respiratory viruses in which she urged constituents to get vaccinated and to get tested, but did not emphasize masking.

“We’ve gone through a period where people are tired of being told what to do, but we in public health are now emphasizing that people can take decisions on their own and take decisions that are protected: Get vaccinated. Consider wearing a mask in public indoor spaces,” New York Health Commissioner Mary Bassett said in response to a reporter’s question about the tepid tone on masking. “There’s a limit to how much we can legislate people’s behavior.”

_ When should I wear a mask?

Mask-wearing is a personal decision affected by your health risks and whether you spend time with a vulnerable person. It makes sense to wear a mask in crowded spaces where you don’t know the vaccination status of others, such as subways, buses, trains and planes.

Masking is a good idea in public places where you’re spending more than a few minutes – such as a grocery store, shopping mall or physician’s office. Some people may opt to wear a mask at work all the time – or only when gathering in small enclosed meeting rooms.

You should also wear a mask if you’re caring for a sick person or have respiratory symptoms, even if you test negative for the coronavirus. Anyone who has cold or respiratory symptoms should not go to work or social events until the symptoms end.

“If you are choosing to go into large crowds, places where transmission of infectious diseases might occur readily, it may be time to break out your mask and wear it,” said Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association. “You may not wish to wear them all of the time, but certainly when you are at a higher risk of exposure or are about to have a visit with an elderly parent or grandparent.”

_ What’s the evidence that masks really work?

A study that looked at mask use in California found that people who reported always wearing a cloth mask in indoor public spaces last year were 56 percent less likely to test positive for the coronavirus compared with people who did not wear masks. The protection grew to 66 percent for those who consistently wore surgical masks and to 83 percent for those wearing N95 or KN95 masks.

“We know that masking works,” said Marjorie Bessel, chief clinical officer of Banner Health, the largest hospital network in Arizona. “And we know that you can mask when you see these surges for a couple of weeks and that can have significant impact on the individual risk of becoming ill.”

Most of the mask research is on reducing risk for the coronavirus, but the evidence suggests masks will also be effective at blocking other respiratory viruses, said Linsey Marr, a virus transmission expert and professor of civil and environmental engineering at Virginia Tech. Marr noted that masks work by trapping viral particles, and influenza and coronavirus are similar in size.

Marr said she doesn’t wear masks all the time, but she’s keeping an eye on local cases of covid and respiratory illness. She noted that the few weeks after students and co-workers return from holiday travel will be a good time to mask up.

“I wore one on a bus today, it was pretty crowded,” Marr said. “I still wear them on airplanes and will wear them on holiday trips. I don’t want to ruin my vacation, and if I’m meeting my parents, I don’t want to bring whatever virus to them and be sick for the week when we’re trying to enjoy each other’s company.”

_ What kind of mask should I wear?

Look for a high-quality medical mask made with layers of high-tech filtering material that trap at least 94 to 95 percent of the most risky particles. Masks that qualify include N95s, KN95s and KF94s.

Masks come in different shapes and sizes, including flat-fold, duck bill and cup-style masks. Look for one that is comfortable, that molds around your nose and fits snugly against your face.

_ How do I avoid counterfeit masks?

The CDC has a guide for spotting fake N95s. Check for head straps. If your N95 has ear loops, it probably is a fake. A real N95 will be stamped with “NIOSH,” the company name and other text. The CDC has an infographic to show you what to look for.

The KN95 is made to meet Chinese standards for medical masks. It has ear loops and should also be stamped with the manufacturer’s name, model and the quality control number “GB2626-2019.” The CDC has additional guidance for spotting counterfeit KN95s.

The KF94 is made in Korea, where counterfeits are less of a problem. Check the packaging. A real KF94 will be stamped made in Korea, and come in flat individual packages that are glossy and have a textured border.