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In public setting: Wear mask/face coverings WHENEVER indoors in a public space, WHENEVER traveling or at a transportation hub, or when outdoors and ≥6-ft social distancing not possible, per CDC.1 At home: Wear masks if household member is infected or has had recent potential COVID-19 exposure (eg, known close contact or potential work-related exposure [incl high-risk jobs such as meatpacking, agricultural processing], crowded public settings, travel, or nonhousehold members are present in your house), per CDC,1 AAP2.
Counsel pts that evidence shows that double-masking, or otherwise achieving a tighter mask fit, provides greater protection against the spread of SARS-CoV-2, per CDC.1 Exposure to potentially infectious aerosols decreased by about 95% in lab tests when either of these methods was followed. Masking (to a lesser extent) also offers protection to the mask wearer1,3 - Double-masking: Wear a cloth mask over a medical procedure (surgical) mask
- Optimal tight mask fit: Knot the ear loops of medical masks (where they attach to the mask), then tuck in and flatten the extra material close to the face
- Other effective options to improve fit: use of mask fitter, nylon covering over mask
- Don’t base mask-wearing on presence/absence of sx--about 50% of COVID-19 transmission is from asymptomatic people
- Don’t rely on masks in settings where they could become wet (in ocean/lake/pool), as wet masks may impair breathing; cloth face coverings are recommended at poolside/on beach; in water, social distance instead1
- In cold weather: Be prepared to change a mask when it becomes wet; have 1 or more replacement masks ready; if a reusable mask becomes wet, put it in a sealed plastic bag until it can be washed; scarves & other headwear such as ski masks & balaclavas can be worn over a mask but aren’t suitable for use as masks
- Mask/face coverings required when boarding, disembarking, or traveling on airplanes, ships, ferries, trains, subways, buses, taxis, & ride-shares
- Mask/face coverings also required at transportation hubs such as airports, bus or ferry terminals, train & subway stations, & seaports
- Conditions warranting in-home mask-wearing by contacts: Wear masks in presence of known/suspected COVID-19 pts.1 AAP notes particular value of home mask-wearing around “medically fragile” or “at-risk” pts2
- Be ready to address possible mask misconceptions. There’s no scientific evidence that non-N95 mask wearing causes low O2 levels or weakens the immune system4
Consider mask/face-covering type1 - Multi-layered (2 or 3 fabric layers) superior to single-layer fabric mask
- Don’t use masks w/ exhale valve/vent, as they don’t prevent transmission from the wearer to others
- Don’t use face shield alone nor goggles alone as a substitute for a mask
- Reserve N95, surgical masks, and respirators for health care workers
- Clear masks or cloth masks w/ clear plastic panel can be used as an alternative for people who interact w/ people who are deaf/hard of hearing, young children or students learning to read, students learning a new language, people w/ disabilities, people who need to see the proper shape of the mouth (eg, singers)
Clinicians can issue medically necessary mask exemptions at their discretion; exemptions are considered a disability modification under the Americans With Disabilities Act and afford pts federal & state legal protections;5 be prepared to reasonably question new/unsubstantiated claims of disability, as many employers now require mask-wearing Medical exceptions or alternatives to mask/face-covering - Resp condition exceptions: Anyone who has trouble breathing, per CDC;1 pts w/ normal lungs and even those w/ underlying chronic lung dz should be able to wear a non-N95 facial covering w/o impact to O2 or CO2 levels, per ACCP;5 some experts argue that pts w/ chronic pulmonary dz may have more compelling reasons to wear masks than to not;3 weigh pt’s concerns vs societal need to mitigate virus spread when considering medical exemption;3,5 reassure pts re: safety of face coverings & encourage trying a variety of face-covering options to improve tolerability4,5
- Physical ability exceptions: Anyone who is unconscious, incapacitated, or otherwise unable to remove mask/face covering on their own shouldn't wear one, per CDC;1 some facial deformities may be incompatible w/ masking3
- Occupational hazard exceptions: Any setting where masks may increase risk of heat-related illness (eg, heat stroke, heat exhaustion, heat cramps, or heat rashes), or may cause safety concerns (eg, straps may be caught in machinery): Consult w/ occupational safety health professional to determine appropriate mask. Outdoor workers & those in hot environments include: firefighters, bakery workers, farmers, construction workers, miners, boiler room workers, factory workers. Heat stress risk seen esp in ≥65 yo, overweight, heart dz/HTN pts, or pts on meds that may impact reaction to extreme heat. Outdoor workers should prioritize mask use when in close contact w/ others1
- High-intensity activities: Anyone engaged in high-intensity activities that affect breathing (eg, running) should choose setting where social distancing & good air exchange possible (eg, outdoors)1
- School athletes: AAP advises against face coverings for athletes engaged in activities wherein the cloth face covering could get caught, impair vision, or cause heat illness; remind athletes not to touch front of their face coverings; remove using straps when possible. Wash cloth face coverings in hot water & reuse only after cleaning6
- Deaf or hearing-impaired pts & those who interact w/ them: Those who rely on lipreading to communicate may wear clear masks or hooded face shields, or use written communications1
- Pts w/ intellectual & developmental disabilities, mental health conditions, other sensory-processing sensitivities: Provide mask-wearing advice on case-by-case basis1
When traveling by public transportation or at a transportation hub, people can temporarily remove their masks: - While eating, drinking, or taking medication for brief periods of time
- While communicating, for brief periods of time, w/ hearing-impaired persons when the ability to see the mouth is essential for communication
- If, on an aircraft, wearing of O2 masks is needed because of loss of cabin pressure or other event affecting aircraft ventilation
- If unconscious (for reasons other than sleeping), incapacitated, unable to be awakened, or otherwise unable to remove the mask w/o assistance; or
- To verify ID (eg, TSA screening or when asked to do so by ticket/gate agent/law enforcement)
If pt can’t tolerate a mask or isn't willing to wear one for any reason:3 - Emphasize importance of 6-ft social distancing and avoidance of indoor spaces as risk-reducing measures
- If underlying pulmonary dz, reasonable to recommend shelter in place
Footnotes 1 CDC 2020. Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020. MMWR. 12/4/20. Accessed 2/2/21
Considerations for Wearing Masks. Updated 12/18/20. Accessed 2/2/21
Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2. Updated 11/20/20. Accessed 2/2/21
Requirement for Face Masks on Public Transportation Conveyances and at Transportation Hubs. Updated 1/29/21. Accessed 2/2/21
Maximizing Fit for Cloth and Medical Procedure Masks to Improve Performance and Reduce SARS-CoV-2 Transmission and Exposure, 2021. MMWR. 2/10/21. Accessed 2/11/21
Your Guide to Masks. Updated 2/22/21. Accessed 3/5/21
2 AAP 2020. Cloth Face Coverings. Updated 8/12/20. Accessed 8/21/20
3 Dorfman D, et al. Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians. Insights | COVID-19. JAMA. Published online 7/10/20. Full-text article
4 Hill DG, MD. American Lung Association 2020. Each Breath Blog. From the Frontlines: The Truth About Masks and COVID-19. Published online 6/18/20. Accessed 9/4/20
5 ACCP 2020. American College of Chest Physicians, American Lung Association, American Thoracic Society and COPD Foundation. Joint Statement on Importance of Patients With Chronic Lung Disease Wearing Facial Coverings During COVID-19 Pandemic. Published online 7/17/20. Accessed 8/21/20
6 AAP 2020. Returning to Sports During Pandemic: What Pediatricians Should Know. AAP News. Published online 7/22/20. Accessed 8/24/20
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In public settings (eg, child care, school, playground, park, grocery store, clinic): Wear mask/face coverings WHENEVER indoors in a public space, WHENEVER traveling or at transportation hub, or when outdoors and ≥6-ft social distancing not possible, per CDC.1 At home: Wear masks if household member is infected or has had recent potential COVID-19 exposure (eg, known close contact or potential work-related exposure, crowded public settings, travel, or nonhousehold members are present in your house), per CDC,1 AAP2,3 Counsel parents that cloth face coverings can be safely worn by all children ≥2 yo, incl the vast majority of children w/ underlying health conditions, w/ rare exceptions, per AAP2; WHO recommends masks for >5 yo.4 Evidence shows masks not only protect children;1 they significantly reduce spread of COVID & other resp infxns in schools, community settings, & homes2 Consider the following: - Counsel parents to be sure the mask fits snugly over the nose, mouth & under the chin of children & that there are no gaps around the sides
- Choose masks that have 2 or more layers of washable, breathable fabric & that have a nose wire to prevent air from leaking out of the top of the mask
- Don’t base mask-wearing on presence/absence of sx--about 50% of COVID-19 transmission is from asymptomatic people
- Safety precautions in young children: Find a mask that is made for children to help ensure a proper fit; make sure mask has no choking or strangulation hazards; don’t wear when eating or drinking; instruct children to wash hands before/after wearing mask & avoid touching it once on; when taking mask off, do so from behind to avoid touching front of the face; wash & completely dry cloth face coverings after each wearing5
- Young children (eg, preschool or early elementary age) may be unable to wear a mask properly, particularly for an extended period of time; if so, prioritize mask-wearing for when it’s difficult to keep 6ft from others (carpool drop-off/pickup, school lines); advise parents to ensure proper mask size & fit and to remind children of proper mask-wearing;1 if child scared to wear face covering: demo in mirror, put on favorite stuffed animal, or personalize w/ decorations5
- Don’t rely on masks in settings where they could become wet (in ocean/lake/pool), as wet masks may impair breathing; cloth face coverings are recommended at poolside/on beach; in water, social distance instead1
- In cold weather: Be prepared to change a mask when it becomes wet; have 1 or more replacement masks ready; if a reusable mask becomes wet, put it in a sealed plastic bag until it can be washed; scarves & other headwear such as ski masks & balaclavas can be worn over a mask but aren’t suitable for use as masks
- Mask/face coverings required when boarding, disembarking, or traveling on airplanes, ships, ferries, trains, subways, buses, taxis, & ride-shares
- Mask/face coverings also required at transportation hubs such as airports, bus or ferry terminals, train & subway stations, & seaports
- Conditions warranting in-home mask-wearing by contacts: Wear masks in presence of known/suspected COVID-19 pts.1 AAP notes particular value of home mask-wearing around “medically fragile” or “at-risk” pts2
- Explain that use of cloth face-coverings at home may be beneficial in helping children become accustomed to use in school2
- Be ready to address possible mask misconceptions. Evidence shows that breathable cloth masks can be safely worn for an extended period of time (eg, the school day or at child care) & will not cause hypoxemia/hypercapnia, won’t interfere w/ children’s lung development, won’t weaken immune systems, nor affect ability to focus in school3
- Ascertain that children practice basic infxn control practices (hand washing & physical distancing)2
Consider mask/face-covering type1 - Multi-layered (2 or 3 fabric layers) superior to single-layer fabric mask
- Tightly woven (ie, light won’t pass through when held up to light source) such as cotton & cotton blends are most effective fabrics for cloth masks
- Don’t use masks w/ exhale valve/vent as they don’t prevent transmission from the wearer to others
- Don’t use face shield alone nor goggles alone as a substitute for a mask
- Reserve N95s and respirators for health care workers
- Clear masks or cloth masks w/ clear plastic panel can be used as an alternative for people who interact w/ people who are deaf/hard of hearing, young children or students learning to read, students learning a new language, people w/ disabilities, people who need to see the proper shape of the mouth (eg, singers)
Medical exceptions or alternatives to mask/face-covering - Resp condition exceptions: Anyone who has trouble breathing, per CDC;1 pts w/ NL lungs & even those w/ underlying chronic lung dz should be able to wear a non-N95 face covering w/o impact to O2 or CO2 levels, per ACCP;6 allergies/asthma shouldn’t be reason to avoid masks (except if experiencing active asthma sx); some experts argue that pts w/ chronic pulmonary dz may have more compelling reasons to wear masks vs not;7 weigh pt’s concerns vs societal need to mitigate virus spread as part of decision to provide medical exemption;6,7 reassure pts re: safety of face coverings & encourage trying a variety of face-covering options to improve tolerability6
- Physical ability exceptions: Anyone who is unconscious, incapacitated, or otherwise unable to remove a mask/face covering on their own shouldn't wear one, per CDC1
- Intellectual/developmental disabilities, behavioral/mental health conditions, other sensory-processing sensitivities:1 Children w/ cognitive impairments may have a hard time tolerating a face mask & extra precautions may be needed; provide mask-wearing advice on case-by-case basis.3 Children w/ anxiety: Counsel parents to model appropriate mask wearing & provide factual, reality-based info about COVID-19. Certain rare conditions may make mask wearing unsafe for children: developmental delays, limited physical mobility, severe autism; structural abnormalities of the face/head/neck may be incompatible w/ masking (though some of these children may be able to wear bandanna-style coverings)7
- High-intensity activities: Anyone engaged in high-intensity activities that affect breathing (eg, running) should choose setting where social distancing & good air exchange possible (eg, outdoors)1
- School athletes: AAP advises against face coverings for athletes engaged in activities where the cloth face covering could get caught, impair vision, or cause heat illness; remind athletes not to touch front of face coverings; remove using straps when possible. Wash cloth face coverings in hot water & reuse only after cleaning8
- Deaf or hearing-impaired pts & those who interact w/ them: Those who rely on lipreading to communicate may wear clear masks or hooded face shields, or use written communications1
When traveling by public transportation or at a transportation hub, people can temporarily remove their masks: - While eating, drinking, or taking medication for brief periods of time
- While communicating, for brief periods of time, w/ hearing-impaired persons when the ability to see the mouth is essential for communication
- If, on an aircraft, wearing of O2 masks is needed because of loss of cabin pressure or other event affecting aircraft ventilation
- If unconscious (for reasons other than sleeping), incapacitated, unable to be awakened, or otherwise unable to remove the mask w/o assistance; or
- To verify ID (eg, TSA screening or when asked to do so by ticket/gate agent/law enforcement)
If pt can’t tolerate a mask or isn't willing to wear one for any reason:7 - Emphasize importance of 6-ft social distancing and avoidance of indoor spaces as risk-reducing measures
- If underlying pulmonary dz: reasonable to recommend shelter in place
Footnotes 1 CDC 2020. CDC 2020. Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020. MMWR. 12/4/20. Accessed 2/2/21
Considerations for Wearing Masks. Updated 12/18/20. Accessed 2/2/21
Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2. Updated 11/20/20. Accessed 2/2/21
Requirement for Face Masks on Public Transportation Conveyances and at Transportation Hubs. Updated 1/29/21. Accessed 2/2/21
Maximizing Fit for Cloth and Medical Procedure Masks to Improve Performance and Reduce SARS-CoV-2 Transmission and Exposure, 2021. MMWR. 2/10/21. Accessed 2/11/21
Your Guide to Masks. Updated 2/22/21. Accessed 3/5/21
2 AAP 2020. Cloth Face Coverings. Updated 8/12/20. Accessed 8/21/20
3 AAP 2020. KW Dickinson, MD, MPH and TW Guilbert, MD, MS, FAAP. healthychildren.org. Mask Mythbusters: 5 Common Misconceptions About Kids & Cloth Face Coverings. American Academy of Pediatrics Section on Pulmonary and Sleep Medicine. Updated 8/18/20. Accessed 8/21/20
4 WHO/UNICEF 2020. Advice on the Use of Masks for Children in the Community in the Context of COVID-19. Annex to the Advice on the Use of Masks in the Context of COVID-19. World Health Organization/United Nations Children’s Fund. Updated 8/21/20. Accessed 8/25/20
WHO recommends against face masks for children <5 yo in a community setting and cautions that children 2-5 yo who do wear masks be directly watched and supervised by adults to ensure compliance, esp when masks are to be worn for a longer period.
Based on a “do-no-harm” approach, this recommendation takes into account:
• childhood developmental milestones
• compliance challenges
• autonomy required to use a mask properly
5 AAP 2020. healthychildren.org. Cloth Face Coverings for Children During COVID-19. American Academy of Pediatrics. Updated 8/13/20. Accessed 8/21/20
6 ACCP 2020. American College of Chest Physicians, American Lung Association, American Thoracic Society and COPD Foundation. Joint Statement on Importance of Patients With Chronic Lung Disease Wearing Facial Coverings During COVID-19 Pandemic. Published online 7/17/20. Accessed 8/21/20
7 Dorfman D, et al. Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians. Insights | COVID-19. JAMA. Published online 7/10/20. Full-text article
8 AAP 2020. Returning to Sports During Pandemic: What Pediatricians Should Know. AAP News. Published online 7/22/20. Accessed 8/24/20
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Masks/face coverings shouldn't be worn by children <2 yo due to risk of suffocation, per CDC,1 AAP;2,3 protect children <2 yo via physical distancing & by encouraging those near the child to wear cloth face coverings1,3
Footnotes 1 CDC 2020. CDC 2020. Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020. MMWR. 12/4/20. Accessed 2/2/21
Considerations for Wearing Masks. Updated 12/18/20. Accessed 2/2/21
Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2. Updated 11/20/20. Accessed 2/2/21
Requirement for Face Masks on Public Transportation Conveyances and at Transportation Hubs. Updated 1/29/21. Accessed 2/2/21
Maximizing Fit for Cloth and Medical Procedure Masks to Improve Performance and Reduce SARS-CoV-2 Transmission and Exposure, 2021. MMWR. 2/10/21. Accessed 2/11/21
2 AAP 2020. Cloth Face Coverings. Updated 08/12/20. Accessed 8/21/20
3 AAP 2020. healthychildren.org. Cloth Face Coverings for Children During COVID-19. American Academy of Pediatrics. Updated 8/13/20. Accessed 8/21/20
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