Opinion | Should We Bring Masks Back Into the Classroom?

Influenza and respiratory syncytial virus (RSV) infections have skyrocketed this year relative to previous years, with infections from both viruses occurring earlier and increasing faster than any cold and flu season in recent history. Over the past couple of months, many pediatric hospitals have reported running out of beds necessary to treat severe influenza, RSV, and SARS-CoV-2 infection. The surge in respiratory virus infection has also caused problems for working families. More than 100,000 Americans missed work in October to take care of their sick kids. This is an all-time high, according to data from the U.S. Bureau of Labor Statistics. Families are struggling to keep their kids in school while many schools have closed due to the increase in illnesses.

In the school setting, masks can help slow the spread of viral respiratory infections. Masks work both as source control, limiting the amount of virus in the air from those infected, and as exposure control, limiting the amount of virus inhaled by someone healthy. During the 2020-2021 school year, when schools mandated masks and encouraged physical distancing, influenza and RSV infections were virtually non-existent. Reintroducing masks in places of high exposure, such as schools, is a simple and effective method of reducing infection from various pathogens in both children and adults. The recent report, “Lifting Universal Masking in Schools – COVID-19 Incidence Among Students and Staff,” offers real-world evidence on the correlation between masking and reduced incidence of COVID-19 in schools. While variable conditions — from the type of mask to a school’s ventilation system — can change the calculus for different schools, the benefits of masking are clear. Indeed, our understanding of the benefits of masking is nothing new: masks have been a required part of personal protection equipment (PPE) in many hospital settings for decades due to their ability to protect healthcare workers from infectious viruses.

While some have expressed concern that masking in schools may impede learning, psychologists have found that masks do not impede language development in the classroom setting or development of facial recognition skills. Additionally, a January 2022 study found that over a 1-year study period, schools that required masks were 14% less likely to experience school closure. With the understanding that a critical part of childhood development is the learning and socialization that takes place in school, keeping kids healthy and schools open needs to be a priority.

In examining the possible reintroduction of masks in schools to slow the surge in respiratory infections, we also need to consider what’s driving these cases. Many media articles have attempted to link the recent viral respiratory surge to “immunity debt.” This term was coined in a 2021 paper and was not discussed in the medical literature previously. It asserts that “The reduction of infectious contacts secondary to hygiene measures imposed by the pandemic may have led to a decreased immune training in children and possibly to a greater susceptibility to infections in children.” This hypothesis has led many to believe that COVID-19 mitigation strategies, such as mask-wearing and physical distancing, has somehow weakened children’s immune systems. However, there is limited scientific evidence that such a phenomenon exists and debate is ongoing among healthcare professionals. In fact, in Sweden, where widespread mask mandates were not implemented, there was an unusual surge of RSV cases in the fall of 2021, prompting health officials to recommend keeping older children at home if they had infant siblings. The same logic applies in the U.S., where masking was less prevalent in some parts of the country than others, yet the current spikes in pediatric infections aren’t unique to the regions with stricter masking mandates.

So, what might be causing this surge? Patterns of respiratory disease have significantly shifted during the COVID-19 pandemic. This shift is historic. According to the CDC, the peak of the influenza season is most often between December and March. Prior to 2020, RSV onset was predictable, most often starting in mid-October and lasting until May. However, RSV circulation started to rise in the spring of 2021 and peaked in July. Recently, RSV started to rise in September, making the 2022-23 RSV surge unusual. In the U.S., our hospital systems are ill-equipped to care for the huge number of respiratory virus infections from this unusual co-circulating trifecta of COVID-19, influenza, and RSV.

Addressing the surge in respiratory viral infections as quickly as possible is in the best interest of children. The already impacted healthcare system will struggle and perhaps simply run out of staffed beds for critical care if the high rate of severe infections continues to increase in the winter months. There is, however, one well studied, simple solution: Bring back masks in the classroom.

Zachary Rubin, MD, is a pediatrician specializing in allergy and immunology. Melanie Matheu, PhD, is a scientist and the founder of Prellis Biologics, a bioprinting technology company working to recreate tissues and organs for transplantation.