Carolyn Smith, M.D.

08/12/2021

Q: Will my kids get any protection if they wear a mask, but most other kids are not wearing one? ~Kisha from Arkansas

A: Yes. A well-fitted mask can provide good protection for the wearer (though two-sided masking remains most effective).

While the recent updates to CDC guidance mean more schools are likely to require or encourage masks, different state and local decisions mean this is often something outside of parents' control.

We know it may be hard to expect younger children to continue masking if that’s not the norm around them. But for kids who are willing and able to mask up, they can still reduce their risk (and every little bit counts).

Masking is very effective at “source control”- reducing the outward flow of virus particles from an infectious individual.

But since the pandemic started, we also have new evidence on the “inward” efficiency of masks in blocking particles.

Remember the key features of effective masking: 💥FILTERING and FIT💥.
A U.S. CDC experimental study tested ways to improve mask fit for cloth and medical masks to reduce leakage around the edges.

Using mannequin “headforms” and simulated moderate breathing in a small chamber for 15-minute periods they tested:

1) Cloth mask over a medical mask (double masking)
2) Medical mask with knotted ear loops and tucked in sides.

The experiment was able to test both source control (how well the masks blocked outward coughing) and exposure for the “receiver” breathing in aerosols.

Reductions in “receiver” aerosol exposures:
💥UNKNOTTED MEDICAL MASK: 7.5% reduction
💥KNOTTED/TUCKED MEDICAL MASK: 64.5% reduction
💥DOUBLE MASK: 83% reduction

➡️ These experiments provide evidence that FIT can greatly improve the effectiveness of any mask you are wearing.

➡️ They also suggest that good fit can provide reasonable levels of protection for the wearer even if others are not wearing masks (but note that protection from the loose-fitting mask was low).

🤔 Caveats: While the experiment was designed to mimic conditions for transmission, it did not use real people or real virus (thankfully we are not allowed to such experiments). Thus, these numbers should be interpreted as a good indication of the ability of the masks to block particles of the size that carry SARS-CoV-2, but not precise measures of transmission itself. These experiments might also not mimic being in a classroom for long periods of time with an infectious individual.

While the study described was focused on improving fit of medical masks, masks with good built in filtration and fit such as KN95s are also a good choice.

Nerdy Girl mask ranking:
1️⃣ N95
2️⃣ KF94 (Korea), FFP2 (Europe)
3️⃣ KN95s
4️⃣ Double-mask (cloth mask on top of surgical, OR cloth mask with filter insert)
5️⃣ Surgical/Medical mask
6️⃣ Good fitting cloth mask

Options 1-4 provide both good filtration AND fit; besides the gold standard fitted N95, differences among these will be small so use what’s available & fits you.

Option 5: good filtration but gaps
Option 6: good fit but less filtration

💥RECS FOR KN95 MASKS FOR KIDS💥:
https://www.nbcnews.com/shopping/wellness/best-kids-kn95-masks-n1275419

We know parents are struggling to assess the risk to unvaccinated kids going back to school very soon. There will be so many different local contexts in terms of vaccination coverage, transmission levels, and mitigation measures, that a one-size fits all answer is unlikely. We realize that even when masks are required, things like lunch time introduce added challenges. We're here to try to help parents assess risk and navigate these shades of gray as best we can.

While public health doesn’t work well as an individual-only responsibility, choosing to wear a mask even when others aren’t can still provide you or your child with protection. Social norms matter too, so your child's choice to wear a mask could make it easier for others to do so as well.

🧀 As we've emphasized for many months, each layer of protection is imperfect, but stacked together like swiss cheese they are much stronger.

Children remain at low risk from serious COVID disease. Many schools have improved building ventilation during the pandemic and may employ other mitigation measures like regular testing. If even *some* students continue to wear masks when not required, this still adds another layer to the swiss cheese defenses.


______________________________
Links:
Recs for KN95 masks for kids:
https://www.nbcnews.com/shopping/wellness/best-kids-kn95-masks-n1275419?

Previous DP posts on masks:
https://dearpandemic.org/which-is-the-best-mask/
https://dearpandemic.org/new-cdc-mask-study/

Video instructions for Knotting medical masks:
https://www.youtube.com/watch?v=2TTg53aAP8Q

CDC Study:
https://www.cdc.gov/mmwr/volumes/70/wr/mm7007e1.htm

Study by Dr. Linsey Marr: "Inward and outward effectiveness of cloth masks, a surgical mask, and a face shield"
https://www.medrxiv.org/content/10.1101/2020.11.18.20233353v1

08/12/2021

Texas, Florida, other states - I'm looking at you

08/09/2021

Adults, if you haven’t been vaccinated for covid, please do so to protect your children, your nieces and nephews, your friends’ children …. ❤️❤️❤️❤️

And please wear your mask. 😷

Our own children’s hospitals in St. Louis are not currently bursting at the seams with Covid. They are very busy with RSV, though…… which affects adults and older kids as a bad cold but causes major breathing issues in babies. And masks stop its transmission. 💪

“Absolutely household infections are the beginning of this pandemic, that is a major driving force in the spread of infections. We see it often within households, parents to children,” a pediatrician said.

08/01/2021

A letter to Missourians hesitant about vaccination while and/or those who are pregnant....from Dr. Kenan Omurtag, MD

🇺🇸 I grew up in Rolla Missouri.
College & med school UMKC. ⁣🦘
St Louis to settle. Missouri made me.

❤️ My partners and I help 3000 people a year pursue their family building goals. Many of those patients are ⁣from Southwest and points in between on I-44.⁣

I want to again attempt to dispel myths for those and :

1️⃣ does not cause female infertility or sterility. Nor. Will. It. The threat ⁣of is a common trope used by opponents of vaccination. The vaccine will NOT cause . ⁣Period.

2️⃣ COVID Vaccination in the first trimester does not increase risk of . Data summarized above demonstrated that the miscarriage rate among those ⁣vaccinated in the first trimester is ~13%. The baseline miscarriage rate among any pregnant person is 15-20%.
(A reminder that is not uncommon with 1:4 women of reproductive ⁣age experiencing a miscarriage in their lifetime)
💯Getting vaccinated does NOT increase the risk of miscarriage. ⁣

3️⃣ Patients should be encouraged to vaccinate prior to . If you are in the middle of , ⁣there is no medical contraindication to the vaccine. You can get it. There are no signs that vaccination at any time during attempts at ⁣pregnancy and or fertility treatment are harmful to the pregnancy.⁣

4️⃣ COVID Vaccination does not cause problems with ***m or .

5️⃣ Some still harbor concerns about unknown long term risk and unknown adverse outcomes to their child but recall
➡️ the mRNA vaccine platform supplies instructions to build a protein. It does not integrate into the cell nucleus and is gone within 5 hours.
➡️ the reassuring animal data AND ongoing surveillance lead me to conclude that any theoretical risks to the child are greatly outnumbered by the KNOWN benefits that vaccination provides to the individuals: (lower risk of ICU admission, ventilator need and death), resulting child (immunity) and society at large (return to life ⁣without restrictions).⁣

If even ONE person reads this & DECIDES to get vaccinated ⁣
Please . KMOV KSDK News Fox2Now

07/28/2021

I don't know about you all but I have whiplash from following the headlines the last few days about masks locally and nationally. I and some of the other pediatricians recently wrote a letter to the school districts and Archdiocese, about masks for next year. Over 400 physicians in our area signed this letter.

Here are some more of my additional thoughts (which did not make it into the letter because of desire for brevity):

1) We should continue to protect our kids from getting Covid-19 if we can.
Although most initial infections with SARS-CoV-2 are mild in children, some kids have died (more than from a typical flu season). Furthermore, I have seen kids in my own practice suffer long-term disabilities and significant health challenges following initial "mild" infections. Since SARS-CoV-2 is a "new" virus, we have no way of knowing what the long term consequences of covid infection might be on kids' bodies 5, 10, 15 years from now. There are absolutely other viruses, such as measles and polio, that have severe or fatal complications which ensue years after the initial "recovery" from infection. There is clear evidence of long-term brain and lung damage in adults who have had Covid-19.

2) The Delta variant currently spreading in St. Louis is much more contagious.
The Ro, or average number of persons infected by each sick individual without mitigation, was estimated to be 2-3 for the "good old-fashioned 2019 Covid." For the Delta variant, this number is between 5-8. So without masking and mitigation, one sick kid would infect 5-8 others on average. There have been documented cases in Australia and Singapore of transmission involving only a "few breaths". At this time, we should be doubling down on the protective strategies which were proven to work in schools last year... not letting up on the brakes.

3) Masks only work when everyone is wearing them.
What is completely lost with the "masks optional, only if your parents are worried about you catching covid" strategy is that a typical 2-layer cloth or surgical mask provides only modest (30-50%) reduction in the viral particles inhaled by the person wearing it. The same masks provides at least 75% reduction in the viral particles *exhaled* by the person wearing it. So the other kid's mask protects my kid, and my kid's mask protects the other kid. With everyone masked indoors, the chances of covid transmission go way down.

4) Kids should be attending in-person school with the least disruptions possible. Repeated quarantines place stress on families trying to juggle jobs and child care. Covid tests are uncomfortable. Doctor visits for non-Covid illnesses (which are also mitigated by masks) are burdensome for families. Social isolation with remote schooling contributes to anxiety and depression.

5) Last year, masking was a key piece of the Covid mitigation protocols that enabled in-person school to be successful. Even if the St. Louis County "mask mandate" is not in force due to politico-legal machinations, we should go with the science recommended by both the CDC and the American Academy of Pediatrics as well as our local experts on the St. Louis Metropolitan Pandemic Task Force.

I am limiting comments on this post because these opinions are not up for discussion. I just wanted to let you know where I (and my colleagues) stand.

03/03/2021

Q: Manisha from Medford, MA asks what are the rules for family get-togethers with vaccinated adults and unvaccinated kids?

A: We offer a few guiding principles. Severe complications of COVID-19 infection are significantly decreased among the vaccinated but infection risk is not zero. Unvaccinated people remain at risk of infection +/- complications. Determine what is important. Maintain as many risk mitigation strategies as realistic. This is not over yet.

☠️ Vaccination greatly decreases the likelihood of severe illness and death from COVID-19 among the vaccinated. This is fantastic news! Breathe a bit easier knowing the chance of infecting and potentially killing older people who have completed their vaccination series and waited 2-3 weeks is significantly decreased. This is a key benefit for vaccinated individuals.

📉 Vaccination *probably* decreases transmission from vaccinated individuals to unvaccinated individuals but we don’t know how much. It remains possible for a vaccinated person to transmit SARS-CoV-2 to an unvaccinated person even if the vaccinated person never gets sick. Early evidence suggests the risk of transmission among vaccinated individuals is lower, potentially significantly lower, but the level of risk reduction remains unclear.

🤒 Unvaccinated people are still at risk for COVID-19 infection. Unvaccinated kids and adults can get infected, they can get sick, and they can spread infection to others. We have not reached herd immunity status where the virus lacks new hosts to infect. COVID-19 is still with us.

SO WHAT DO I DO?!?

🗓️ Figure out what is essential and make a plan. It’s unrealistic to expect everyone to remain hunkered down until all children are vaccinated. That said, throwing up our hands and giving up on the mitigation measures will hurt individuals we love and society as a whole. We must persevere through the in-between for a while longer.

💉 If you are eligible for vaccination, get it. Vaccination brings down the risk of infection and complications within your crew even if it’s not fail proof.

😷 Stay SMART. Be sure to follow all public health ordinances in place for your location. Layering on the mitigation strategies (SPACE, MASKS, AIR, RESTRICTED NETWORKS, TIME) decreases risk for everyone in the group. If it’s possible to achieve your goals outside, masked, with a select few, over a few hours versus a few days – KEEP THE MITIGATION MEASURES. If a longer and more intimate visit is required, add on quarantine days and asymptomatic testing, especially for unvaccinated people.

🤗 Be realistic with yourself and others. Some will prefer to remain vigilant with all risk mitigation strategies (including delaying the get together for a bit) while others are ready to accept some level of risk. You can control your actions and reactions, but generally not other people. Be honest with what you are comfortable doing. Be transparent with your expectations prior to the event. Be ready to pivot if an agreement can’t be made. Trust and communication are the keys to success.




Related Dear Pandemic Posts

Risk of Transmission among Vaccinated People
https://www.facebook.com/dearpandemic/posts/264966801798641

Holiday Socializing Decision Making
https://dearpandemic.org/communicating-about-holiday-socializing/

File under Families and Infection and Spread

02/16/2021

Hey STL parents, this is the info my office received on the start of covid vaccine trials for younger kids. (Plan is first age 6-11, then 2-6, then babies).
Registering with this link does not commit you to any specific study (there’s a long informed consent process) but it just gives their nurses a heads up so they can contact you when your kids’ age group is available.
I have heard widely varying timelines on when covid-19 vaccines would be available to kids. Maybe this fall, maybe next spring. I’m planning to take a shot (see what I did there 😂) on enrolling my kids in a vaccine study so there’s a chance they will receive it before school starts next year. (Transmission of covid-19 in elementary and older schools has been low so far, but the virus is definitely transmitted in preschools and daycares 😔. The spread of the new, more contagious variants may also change the transmission in school settings.)

01/29/2021

Covid thoughts update:

The vaccine rollout has been frustratingly slow but I feel like there is good news on that front: Sanofi making extra doses of the Pfizer vaccine, and the efficacy data on the Novovax vaccine.

With the vaccines on the horizon and local cases in St. Louis (and nationally) heading downward from the Halloween/Thanksgiving/Christmas surge, I think there’s a conscious or subconscious tendency to let our guard down, take more risks, etc.

Not so, because The Covid Variants (I wish they would call them The Mutants to make them sound more scary) are here. The story of the variants feels to me like 2020, part II. These more contagious strains originated in other countries but have traveled here beneath the radar. Genomic testing for these variants in the USA is way behind, so although we know cases have been detected in the US, we have no idea of the true extent of spread.

These strains of covid are significantly more contagious (easier to catch from a shorter or more casual exposure). England has had a devastating surge due to their variant despite a really “hard” lockdown much stricter than we had last spring.

Better masks (N95 or KN95 type, which are now all widely available for online purchase) or double masks (cloth layered over disposable surgical) might help reduce spread with the variants, especially if everyone did them (link in comments). Vaccine efficacy is reduced with some of these variants, so despite being vaccinated I personally have no intention of letting guard down as far as masking in indoor spaces or outdoors when social distancing is not possible.

Vaccine trials for kids under 12 have not even really been designed yet, so I think there is no realistic chance the younger kids will be vaccinated before school next fall, and school will look similar to this year. 😔😔😔😔😔

The more we allow the virus to spread, the more chances for new mutations to arise. Stay safe, everyone!!

12/27/2020

I love Dr. Osterholm and recommend his podcast highly.

👉 His thoughts on the new, more contagious covid strains in the UK and South Africa are from 11:45 to 25:50 and very much worth 10 minutes of your time.

👉 STAY HOME. DON’T GATHER. This virus isn’t done with us yet. 🦠🦠🦠

The Osterholm Update: COVID-19 podcast is created by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.

12/23/2020

❤️❤️❤️Dr. Fauci❤️❤️❤️

He assured listeners of "The Ten News" that the pandemic will end and life will get back to normal.

12/12/2020

Once again with feeling!!!!

Stay home. Stay safe!

In time, I believe we will look back at this COVID-19 pandemic with a “hindsight is 2020” type of view. How great would it be if you could look back at your own choices in this moment and know, confidently, that you made the right choice? If you could look back and know that you were brave enough to make the unselfish, community-oriented, scientifically-backed decision, even if it happened to be unpopular. As a parent, I want to teach my child these values. I’m sure you do too.

Make the hard decision, my friends.

12/10/2020

Keep wearing those masks and keep distancing. Vaccines are coming but will not be widely available for several months.
Meantime, let’s all do our best to be kind and keep each other safe. You never know who has an at-risk relative at home. ❤️

5 of the deadliest days (from a specific event or cause) in recorded U.S. history have now occurred this month.