The Berkeley Unified School District (BUSD) in the SF Bay Area where we live, announced on Tuesday that it was planning on “transitioning all students and staff” to KN95 respirators. If worn properly, such respirators filter 95 percent of particles the size of those that carry the SARS-CoV-2 virus. The BUSD has proposed this measure as a means to slow the spread of COVID-19 and keep schools open. These respirators would be required for the entire school day, including outdoors during gym and recess.
Unfortunately, the effectiveness of respirators is vastly overestimated, and there is scant evidence that they stop community transmission. Moreover, NIOSH-approved respirators are tight, uncomfortable, and can impede breathing. OSHA requires both fit testing and a medical evaluation before workers can wear them. We’ve all seen images of health care workers with bruised faces from properly worn respirators.
The truth is, the burdens of these masks outweigh their benefits for kids. We need to consider more effective, less harmful interventions as we come together to keep schools open and safe.
We know masks have become a highly contentious issue. But as a physician with a PhD in computational mathematics and a professor of data science, we have read the studies on this topic. We both have children and want them to be safe. But we also don’t want them burdened with measures that won’t help protect them or their peers. And mandating respirators on kids is out of step with CDC guidance and international norms.
What is the evidence for respirators stopping the spread of covid19? Studies on Influenza provide guidance. Though respirators provide better filtration in perfect laboratory conditions, people who wear them are just as likely to catch flu whether they are wearing a surgical mask or a respirator. Though respirators have higher filtration capabilities, a Cochrane review and an independent metanalysis both revealed there were not clear differences between the effectiveness of surgical masks and respirators in preventing infections like Influenza. The Influenza virus and SARS-CoV-2 virus are of comparable size and rates of transmission of infection between close contacts are similar.
Meanwhile, countries that have mandated respirators have not stopped the spread of COVID-19, even during surges. Portions of Germany — Bavaria and Berlin — and all of Austria have both had long standing mandates from early 2021 and are still facing tremendous surges this winter that outpace all previous waves.
If N95s filter so well, why are respirators an ineffective intervention? Because masking is a behavioral intervention as much as a physical one. For respirators to work, they must be well fitting, must be tested by OSHA, and must be used for only short time windows as their effectiveness diminishes as they get wet from breathing.
Fit requirements and comfort issues are untenable in children who have small faces and are required to wear masks for six or more hours each day. For these reasons, NIOSH specifically states that children should not use respirators, and there are no respirators that are approved for children. These views are shared by the California Department of public health. Concerns about impaired breathing and improper use outweigh potential benefits. There are no studies on the effectiveness of respirators on children because they are not approved for pediatric use.
Leaving respirators aside for a moment, many organizations concerned with the health of children do not recommend masking young ones at all. The World Health Organization recommends against mask wearing for children 5 and under and recommends a “risk-based approach” in their use by children between 6 and 11 that take into account a “child’s capacity to comply with appropriate use of masks and availability of appropriate adult supervision. ” The European Center for Disease Control flatly recommends against mask use by children under 12.
Respirators are not necessary to protect children from COVID-19 because of the astoundingly low risk COVID-19 presents to them. It’s always scary as a parent to face an invisible threat, but we have over two years of global data on this topic. The risks children face from COVID-19 continue to be overshadowed by other infectious risks. Some parents may consider the various risks and decide that they may want to find good respiratory protection for their children. But given the absence of evidence of benefit, and given the existing well-documented harms, the precautionary principle tells us that we cannot require respirators for all children.
Though we shouldn’t be panicked about danger, there are still helpful things we can do at this stage of the pandemic. We should focus our time and energy on interventions that can help during this current Omicron surge. Because California is blessed with nice weather, even in winter, we can open windows and shift some school activity outdoors during times of high community transmission. We have excellent vaccines that can protect people against severe disease, including hospitalization and deaths. We should ensure that all vulnerable teachers are vaccinated and boosted, as well as all seniors and others in our communities. And we can use the state of emergency declared by the state to allow parents to volunteer to be substitute teachers to alleviate staffing shortages.
These interventions can be done today, and focusing our efforts there can keep our schools open and flourishing. But compelling children to wear respirators designed and intended for specialized professionals is not the appropriate route to protecting kids or the community.
Update: After this Op-Ed was published, BUSD sent an email to the community retracting the assertion that they plan to “transition all students and staff” to KN95 respirators. They have confirmed that KN95 respirators will be optional.
Ram Duriseti is a Clinical Associate Professor of Emergency Medicine at Stanford. Benjamin Recht is a Professor of Electrical Engineering and Computer Sciences at the University of California, Berkeley where he researches and teaches data science and machine learning.
The views in this article are the writers’ own.