ROCHESTER, Minn. — It's all about our low vaccination rates.

If Americans in areas with low COVID-19 vaccination rates were to get the shots, the confusing reappearance this week of universal masking advisories would go away.

"Vaccination," as Mayo Clinic vaccinologist Dr. Greg Poland put it on a media call Wednesday, Aug. 4, "is ultimately our way out of this."

It's the starting point, anyway, to a confusing turn of events regarding the necessity of face coverings for people who have been vaccinated.

(Apart from the advice to get vaccinated, the unvaccinated have always been advised to wear masks in public settings.)

Newsletter signup for email alerts

The new shift in Centers for Disease Control and Prevention advice, dropped late last month into the summer of freedom like a storm system out of Canada, occurred on July 27, as the agency unexpectedly revised its guidelines to the vaccinated.

Where the agency had stated since May that the vaccinated could go about their lives without face coverings or distancing, it now exhorted them to “wear a mask indoors in public if you are in an area of substantial or high transmission.”

"There's no question there's airborne transmission here," says Dr. Greg Poland, a Mayo Clinic physician and director of the clinic's Vaccine Research Group.
"There's no question there's airborne transmission here," says Dr. Greg Poland, a Mayo Clinic physician and director of the clinic's Vaccine Research Group.

The data justifying this change was released three days later, and it identified a 469-person outbreak in eastern Massachusetts, with 74% of those being vaccinated persons, 90% of whom were carrying the delta variant.

The CDC concluded from the outbreak that "jurisdictions might consider ... universal masking in indoor public settings," even advising jurisdictions without substantial or high COVID-19 transmission to do so "regardless of vaccination status."

The machinery of official COVID-19 mitigation policy now moving in reverse, the new advice was officially amplified in the region on Wednesday, as an array of area health officials and clinicians chimed in with their own endorsements.

The Minnesota Department of Health now advises "everyone, both fully vaccinated and unvaccinated, wear a mask" in public indoor settings if they live "in areas with substantial or high transmission."

MDH has extended this advice to "schools, health care settings, homeless shelters, and correctional facilities," posing a dilemma for school districts who had hoped to let teens who are vaccinated to forego masks.

For those wondering if they live in a community needing universal masking, the MDH offers a map on the CDC COVID Data Tracker.

The Minnesota Medical Association has echoed this appeal for universal masking in schools. As of Wednesday it urges "all students, teachers, staff, and visitors in K-12 school buildings to wear masks indoors regardless of vaccination status."

But the reasoning for these changes differ according to the organization.

According to the CDC, universal masking is designed "to maximize protection (for the vaccinated) from the delta variant and prevent possibly spreading it to others."

According to the MDH, "with the delta variant, fully vaccinated people may be able to pass the disease to others."

For the Minnesota Medical Association, universal masking offers a way to protect "those who cannot yet be vaccinated or who remain at higher risk because of immune-compromised status or other conditions."

If the reasoning for these changes seem variable and carefully worded, it's because there is no solid information at this time on the likelihood of breakthrough infections — or transmission by the vaccinated.

As a result, health officials are in the unusual position of touting the effectiveness of the vaccine at preventing illness, while asserting its ineffectiveness at stemming spread.

Dr. Nipunie Rajapakse
Dr. Nipunie Rajapakse

"Breakthrough infections in vaccinated individuals — it's really important to emphasize, despite the attention these are getting, that they are rare events," said Mayo pediatrician Dr. Nipunie Rajapakse at the Wednesday news conference.

"When they do occur among vaccinated people, usually those individuals will have no symptoms or very mild symptoms. So the vaccine is doing what it is meant to be doing, which is to keep people out of the hospital or from dying of the infection."

The study used by the CDC to inform its new position concluded that the viral load in vaccinated and unvaccinated persons was the same. Critics have asserted it used an indirect measure to make this determination.

An additional criticism of this primary paper behind universal masking is that the location for the outbreak was Provincetown, Massachusetts, a legendary party town during a week of festivities that would not reflect ordinary transmission circumstances.

Unknowns aside, the delta variant of COVID-19 is indisputably the prevailing version of COVID-19 within the U.S. today, and indisputably more contagious.

Given this new infectiousness, experts believe the ability for the unvaccinated to evade the virus is less likely than ever, if possibly no worse as an illness.

"We have not seen it (the delta variant) causing symptoms that are different in children," Rajapakse said. "We are trying to understand if the severity of the illness is more or not."

In short, while the new COVID-19 may not make unvaccinated people more sick, it will likely make more of them sick.

Whether having the vaccinated wear masks will slow that process is not known.

"We know that our preventive measures for COVID-19 work best when they are used in combination," the pediatrician offered. "There's no one measure that's going to be 100% protective for everyone. That's why using multiple things, vaccination with masking with handwashing with physical distancing, really creates the safest environment in any setting where you have people gathering indoors in proximity for a long period of time."

"You need to leverage as many of those things as possible," she added. "Because in combination they are going to be more effective than on their own."

Poland endorsed "this layering of opportunities to mitigate risk in order to keep people safe."

The result is a rising expectation that the vaccinated begin seeking something closer to 100 % protection, all for the uncertain benefit of the unvaccinated.