Eleven weeks ago, when more than 1 million Americans a day were getting vaccinated and COVID-19 case counts were low, the Centers for Disease Control and Prevention announced that most fully vaccinated people no longer needed to wear masks inside, even in crowded spaces.
Daniel Salmon, director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health called it “one of the biggest missed opportunities we had."
The hope was to entice people to get the shot, but the new directive lacked rules to penalize them if they didn't.
“There was no enforcement provision. Where I live, everyone just stopped wearing masks and social distancing," Salmon said. "They didn’t follow the CDC recommendations, they just thought, ‘Oh, I don’t have to wear a mask anymore.’”
In May it seemed as if the pandemic were being beaten back. But in the past two weeks, COVID-19 cases have increased 171%. The death rate is up 19% over the week before. Breakthrough infections are making the news, hitting sports teams and politicians.
At the same time, vaccination has slowed. About 516,000 people a day are getting vaccinated, down 85% from the peak in April. And while there are some signs the latest surge in infections among the unvaccinated may prompt some to roll up their sleeves, just over 56% of people in the United States have gotten at least one COVID-19 shot.
Yet the message from the federal government hasn't changed: Get vaccinated. If you're not vaccinated, wear a mask.
Increasingly, that message feels as it it's not enough. With guidance from the CDC remaining unchanged, local governments and individuals are taking their own steps to protect themselves and others.
Los Angeles County and other municipalities are requiring everyone to wear masks indoors. St. Louis announced that beginning Monday, everyone 5 and older must wear masks indoors, vaccinated or unvaccinated. The American Academy of Pediatrics is recommending universal masking in schools.
In San Francisco, which already plans to require that all city workers be vaccinated, the city and businesses are discussing whether to require proof of vaccination to get into bars. Some gyms already require it.
"Things are moving so fast with delta," said Jeff Cretan, communication director for San Francisco Mayor London Breed. "What today seems impossible might seem inevitable a week from now. We just don’t know yet."
Needing ID and a vaccination card to hit a bar might be the push younger people need to get vaccinated while also protecting the people who work there. It's that kind of calculation San Francisco nightlife establishments are contemplating.
It has worked in other countries. Last week, more than 1.7 million people in France made vaccine appointments after the president announced proof of vaccination would be necessary to enter restaurants, cinemas and theaters as well as to board long-distance trains and planes.
Another option might be to link masking to local levels of hospitalization for COVID-19, said Dr. Monica Gandhi, an infectious disease specialist at the University of California, San Francisco.
"Israel has termed this a “soft suppression” strategy to help curb transmission without more extensive restrictions during the time of the delta variant," she said.
Such an approach would normalize mask-wearing, give local governments a clear goal line and allow businesses to follow a government guideline rather than simply setting their own rules, which could provide some cover with unruly customers.
"This fits with the CDC guidance, which is clear that local regions should have discretion in reinstituting mask guidelines for the vaccinated," Gandhi said.
Should the fully vaccinated wear masks?
When pressed by reporters Thursday whether the agency would recommend masking for vaccinated people in light of the current case surge, Director Rochelle Walensky said it's optional.
"If you're vaccinated, you have exceptional levels of protection from that vaccine. You may choose to add an extra layer of protection by putting on your mask," she said. "That's a very individual choice that has been consistent with our CDC guidance since we put it out."
Talk to health experts, however, and almost all are choosing to mask up – and they recommend others who have been vaccinated do so, too.
"I never stopped, personally, even when they lifted things in June," said Dr. Otto Yang, a professor of medicine and chief of infectious disease at the David Geffen School of Medicine at UCLA.
"Masking remains one of the important tools we have. It’s a very minor inconvenience for a potentially significant benefit."
"I'm Mr. Conservative, or so my wife tells me," said Dr. William Schaffner, a professor and infectious disease expert at the Vanderbilt University School of Medicine in Nashville, Tennessee. "When I go to the grocery store, I wear a mask. I know it's dorky, but beyond that it's not a big deal. It's part of my life."
Though people who are fully vaccinated are well-protected against severe illness or death from COVID-19, a small percentage of them can still get a mild case, sometimes so mild they don't even know they have it.
That's another reason to wear a mask, said Dr. Alpesh Patel, chief epidemiologist for the Will County Health Department in Illinois. His elderly father lives with him.
"Though my family is fully vaccinated, when we go out into public places and stores we mask ourselves," he said.
They wear masks to make sure they don't bring the coronavirus back home. It might not hurt younger members of his family, but it could hurt his dad.
Priya Duggal is an epidemiologist at the Johns Hopkins Bloomberg School of Public Health who studies children suffering from post-COVID-19 conditions. As children under 12 can't yet be vaccinated, she is surprised by the resistance among some to kids wearing a mask.
"The number is small, but some children have long-term symptoms. And we can't predict who those children will be," Duggal said. "As a mother, I know that most parents would do anything to protect their children. It’s a relatively small ask for something that could potentially save lives."
Contact Elizabeth Weise at firstname.lastname@example.org
This article originally appeared on USA TODAY: Amid COVID cases surges, should the vaccinated be wearing a mask?