Can ‘Strategic Masking’ Protect Against COVID-19, Flu, and RSV?

It can feel lonely when you’re the only person wearing a mask in the grocery store, an office meeting, or wherever you gather with other people. You may wonder if wearing a mask to protect against COVID-19 is even worth doing, as many of those who have gotten the virus recently have been reporting mild symptoms.

But the coronavirus is still infecting people. This summer brought an uptick in COVID-19 cases, hospitalizations, and deaths, and a winter spike is also possible, based on the virus’s seasonal behavior in previous years. There are also two new Omicron subvariants, EG.5 (Eris) and BA.2.86 (Pirola), which may be more transmissible than their predecessors.

And SARS-CoV-2, the virus that causes COVID-19, isn’t the only highly contagious virus that makes people sick. Flu and respiratory syncytial virus (RSV) have also overwhelmed hospitals in previous years. Together, the three diseases—and the uptick in cases of each simultaneously during fall and winter—have become known as a ‘tripledemic.’

Across the U.S., there has been a smattering of new mask mandates in schools, businesses, and other places in response to recent COVID-19 surges; however, infections and hospitalizations are still lower than in previous years, and no one expects the country to go back to widespread masking, which means that people will have to decide how to best protect themselves.

“People can make their own choices about wearing masks to protect against COVID-19 and other respiratory diseases now,” says Karen Jubanyik, MD, a Yale Medicine emergency medicine specialist who has cared for patients with COVID-19.

As a result, some people are adopting what's called "strategic masking"—wearing a mask when and where it might matter the most. While most people don’t want—or need—to wear a mask all the time, “It makes good sense to be strategic about it,” Dr. Jubanyik says. Individual risk for infection, the need to protect loved ones who are at high risk, personal risk tolerance, and the degree to which viruses are circulating in a given area are all factors to be taken into account.

Yale Medicine experts offer some recommendations to help address any confusion about when you might want to consider wearing a mask.

If you are at high risk for severe disease from COVID-19 (see more on that below), it would be smart to wear a mask in public indoor spaces, especially if the coronavirus is circulating in your area, says Dr. Jubanyik.

To assess the situation in your county, you can check the Centers for Disease Control and Prevention (CDC)’s COVID-19 hospital admissions by county, which provides information on whether hospital admissions are low, medium, or high in your area.

Everyone’s situation is different. If you are at high risk for severe disease, the CDC recommends talking to your health care provider about whether you and the people around you should wear a mask or respirator (see more on that below) when hospital admissions for COVID-19 are at a medium or high level.

You are at higher risk than other people for a severe outcome from COVID-19 if:

• You are age 50 or older, with the risk increasing with age (more than 81% of COVID-19 deaths are in those ages 65 and older—that’s 97 times higher than deaths among people ages 18 to 29 years).
• You are any age with certain medical conditions, such as heart disease, diabetes, or obesity.
• You are pregnant.
• You live in a long-term care facility.
• You face barriers to accessing health care, including lack of health insurance, transportation, childcare, or the ability to take time off from work. (These factors have contributed to racial, ethnic, and socioeconomic disparities in some cases of severe COVID-19.)

Everyone, including young, healthy people, might consider wearing a mask in some situations if they live in a geographical area where the virus is spreading.

Even if your personal risk is not high, you might want to wear a mask in more situations than usual to avoid infection and protect loved ones—you won’t always know if you have been exposed, and you have the potential to spread the virus even if you don’t have symptoms.

Wearing a mask may be a personal choice when visiting a doctor or a hospital. Not all medical centers require masks now, although some that abandoned mask mandates are discussing bringing them back in response to the recent uptick in COVID-19 cases.

Authors of an article published in July in the New England Journal of Medicine said that while COVID-19 vaccines and treatments have helped to reduce hospitalizations and deaths from the disease, extra care may be needed in hospitals, where acute illness makes patients especially vulnerable to COVID-19.

Wearing masks in this setting could help protect you and others from viruses that can also exacerbate any underlying conditions, causing such problems as lung disease flares, arrhythmias, and even death, according to the article.

A mask may seem obvious in some situations; others will involve a judgment call. An activity that seems low-risk for one person may be anxiety-ridden for another. In the latter situation, people should do what makes them feel the most comfortable, Dr. Jubanyik explains.

Some examples:

• Shopping: Decide whether to wear a mask based on the store size and foot traffic. “If you're walking into a big department store where the ceilings are extraordinarily high and you’re not standing close to anyone for a long period of time, there may not be a lot of benefit to wearing a mask,” Dr. Jubanyik says. “But in a small, crowded gift shop during the holiday season—or in any small, crowded space without adequate ventilation—a mask can help protect against infection.”
• Eating in a restaurant: Obviously, you can’t wear a mask while you are eating. If you want to dine out but have concerns, choose your restaurant accordingly. Eating outside is safer than eating indoors; eating indoors is safer when the ventilation is good and the tables are spread out, explains Yale Medicine infectious diseases specialist Scott Roberts, MD, who has been eating in restaurants occasionally. “Will I make that same decision in December or January? I'm not sure. I'd have to see the case numbers,” he says, adding that a winter uptick in cases could cause him to take a break from dining out.
• Traveling: Respiratory infections, including COVID-19, flu, and the common cold, are the leading reasons returning travelers seek medical care, according to the CDC. Dr. Jubanyik carries and shares extra masks while traveling on planes, and advises that people also consider masking on trains, buses, and other forms of public transportation.
• Church services: For many people, including older adults and others at risk of severe disease and death from COVID-19, going to a place of worship provides an important sense of community that was disrupted during the pandemic, Dr. Jubanyik says. Church was considered a high-risk venue because it usually welcomes a large group into an enclosed space, has loud talking and singing, and involves being in close proximity to others for a prolonged period of time. “So, if you plan to attend church services, I would advise wearing a mask and making sure you're vaccinated,” she says.
• Important events and holidays: If you have an event coming up, such as a wedding, vacation, or holiday gathering that you have been planning for a while, wearing a mask in the preceding weeks can help lower your risk of infection and give you a better chance of being healthy when it comes up. “It might be smart to mask up in the days ahead of the big event—at least in the higher-risk situations, such as in a crowded room or on public transit,” Dr. Jubanyik says. “It’s also worth considering that many people have reported testing positive for COVID-19 after getting together with family or friends for the first time in a while and spending time together in closed spaces.”
• For kids in school: Some schools put mask mandates back in place, but for the most part, it’s still a personal choice, says Magna Dias, MD, a Yale Medicine pediatrician. She is, however, concerned about situations where kids have been bullied for wearing masks in school. “If there is an immunocompromised child, we would recommend they wear a mask and ask other people to be kind to them. I think that's an important message,” she says.
  
  Otherwise, in crowded situations in places where the rate of COVID-19 is high, she offers the same recommendations for kids as she would for adults, which is to wear a mask. “However, it’s harder for kids younger than 5 to wear a mask, so unless there's a high-risk situation, I wouldn't recommend making those children mask,” she says.
  
  While most children infected with the SARS-CoV-2 virus experience mild symptoms or no symptoms at all, underlying medical conditions, having more than one pre-existing condition, and age (especially infancy) may put them at higher risk for severe illness, according to the CDC. Plus, there is the risk of developing Long COVID, a potentially serious condition in which COVID-19 symptoms persist for weeks, months, and even years after the initial infection.

The length of time that you expect to be in a “high-risk” situation, such as a crowded room, matters. Contact for longer than 15 minutes with a person who has COVID-19 is more likely to result in transmission than two minutes of contact, according to the CDC. “Many people are infected in social settings and in households when people are indoors, in close contact, and without masks,” Dr. Jubanyik says.

A study led by Yale School of Public Health scientists published in August in Nature Communications documented a long-held belief that high levels of exposure to the coronavirus may reduce or overcome the protection provided by vaccination and/or prior infection. Akiko Iwasaki, PhD, a Yale immunobiologist (who did not participate in the study), commented in Nature that the findings suggest that masking and improved ventilation, among other mitigation measures, could help reduce chances of infection, even among people who are vaccinated.

The CDC provides specifics on the types of masks and respirators that can prevent the transmission of SARS-CoV-2. They describe mask options that offer varying levels of protection, from well-fitting disposable surgical masks to KN95s to National Institute for Occupational Safety & Health (NIOSH)-approved respirators (including N95s), with the latter providing the highest level of protection. They advise wearing the most protective mask you can that fits well and that you will wear consistently.

Whether you wear them strategically or all the time, masks can reduce your risk of getting infected, but they aren’t perfect. “If you are the only person in a crowded room wearing one, you’ll get less protection than you would if everyone wore one,” says Dr. Roberts.

That’s why masking should be one strategy among many to protect against respiratory infections, especially this winter when SARS-CoV-2, flu, and RSV are expected to be circulating simultaneously.

The first line of defense is vaccination, Dr. Roberts says. This fall, in addition to the annual flu vaccine, there is an updated COVID-19 booster shot, approved by the FDA and CDC in early September for everyone ages 6 months and older. There also are new preventive options for RSV, such as vaccines for older people, and RSV treatments for young children, such as a monoclonal antibody for infants and toddlers and a vaccine given to pregnant women to provide antibodies that will protect their newborn infants from birth to 6 months.

Staying away from sick people, maintaining a six-foot distance from other people, avoiding crowded indoor places, washing your hands properly, and seeking out good air filtration are also things that make a difference, Dr. Roberts says.

And while the protection provided by wearing a mask isn’t 100%, it’s certainly better than zero, he adds. “I plan to mask strategically, and if the COVID-19 numbers rise, I'll probably mask everywhere,” he says.