“We have a bunch of rule followers,” said Claire Bengur, the owner of Atlas Salon, which has been in the neighborhood since 2018. “I am so thankful that my salon is in D.C.” She’s been glad to have a mask requirement, she said, because it’s impossible to do clients’ hair without standing close to them.

Bengur is unsure how to feel about Mayor Muriel Bowser’s decision to roll back the mandate. As the covid-19 pandemic has worn on, many Washingtonians have come to view masking as something between a habit and a security blanket. Even when the rule was lifted for about two months starting in May, many people continued to use masks in places like grocery stores. While face coverings will still be required in such as public transit and schools, the District of Columbia will no longer require them in private businesses like Atlas Salon. And that has triggered mixed feelings.

Bengur had been debating whether to continue to ask clients to wear masks because the district gives businesses that option. But at the same time, “there is a certain level of excitement … like I don’t want to wear masks forever.” She ultimately decided to let clients choose for themselves. Bengur and her staff feel more at ease than they did earlier in the pandemic because her salon requires proof of vaccination.

A block away at the H Street Northeast location of Solidcore, a boutique fitness chain that started in the district, CEO Bryan Myers had an it’s-about-time take. “This will be game-changing for our clients’ comfort while working out and the health of our industry,” he said.

On the whole, Washington has been especially cautious when it comes to covid, which has helped the city avoid the worst of the pandemic. Now, the mayor is moving away from ordering protective measures and instead offering recommendations based on vaccination status.

This change can partly be explained by adjustments in the district health department’s goal, which no longer is to reach zero cases. Viewing covid as more of an “endemic” disease — one regularly found in particular populations — Bowser explained her decision this way: “This does not mean that everyone needs to stop wearing their masks. But it does mean that we are shifting the government’s response to providing you risk-based information.” While she’s reserved the right to reinstate the mandate, Bowser has doubled down on her decision. “Quite frankly, I don’t expect many D.C. residents will change their current behavior,” she said Friday during an interview on a

The shift has some residents feeling perplexed, if not nervous, especially given the timing.

Children ages 5 to 11 just became eligible for vaccination, so they are not fully immunized yet, and infections are likely to climb with the holidays coming. Cases . That neighboring Montgomery County reinstated its mask mandate over the weekend leaves some people all the more baffled. A pushing the mayor to reconsider. Meanwhile, the White House, just steps from the mayor’s office, is not lifting its mask requirement, noting that the Centers for Disease Control and Prevention recommends one .

“I’m a little bit iffy about the whole thing,” said Sandra Basanti, co-owner of Pie Shop, which offers fresh pies and live music on H Street.

Basanti has two young children who are not yet fully vaccinated. She’s unsure whether she’ll require customers to wear masks but expects to — at least at first. She’s hesitant because staffers received pushback when Pie Shop became one of the first venues in town to impose a vaccine requirement. She would like to see Washington follow New York City’s example and require proof of vaccination to enter public spaces such as shopping centers, sports arenas and theaters.

“We were just kind of waiting for the city to make that call for us so that we wouldn’t have to fight people on it, and they never did,” said Basanti. “I just don’t want to make the staff feel like they now also have to be the mask police again.”

“Being the mask police sucks,” she added.

The owner of the dive bar across the street agrees. “I’m very exhausted with arguing with people about masks and all the different things,” said Tony Tomelden of the Pug, which will not require patrons to wear masks but will insist that they be vaccinated. “Once a week, at least, there’s some kind of argument with some customer.”

Tomelden worries that talk of endemic covid means leaders are moving on without addressing all the pandemic-induced needs of small businesses beyond masking. “I’m so tired of begging for a break on bills and for grants and that kind of thing, but we’re still not fully recovered,” he said.

Like residents, public health experts are not in agreement on whether the district is acting prematurely.

“It makes sense,” Dr. Lynn Goldman, dean of the Milken Institute School of Public Health at George Washington University, said of the mayor’s decision. She reasoned that, thanks to vaccination, the district has few covid hospitalizations and deaths. “At the same time … we don’t really know how it’s going to go.”

Meanwhile, Dr. David Dowdy, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health, said he generally recommends against easing restrictions at a time like this. “My expectation is that we’re likely to see something of an increase in cases over the winter,” he said, “and then this probably is going to become after that point in time something of an endemic disease.”

“We’ve come this far. It probably is not too difficult to keep our guard up for a couple more months,” he added. “But the flip side of that is we’ve been doing this for a really long time and people are very tired.”

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, sees Washington’s experience as emblematic of what can happen when leaders do not clearly explain their response to covid or why mask mandates are imposed or withdrawn.

Part of the challenge, Osterholm said, is that the explanations are unsatisfying. “We do not understand why surges start or stop,” he said. “Why they start and stop surely can’t be tied to human mitigation strategies. What can be tied to those is how big those surges get.”

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She’s been making the 15-minute drive from work since late September, when Dane County mandated all employees get vaccinated or tested weekly. The testing is free, and she is typically back to work within an hour.

Kostroski is among 10% of county employees who are unvaccinated and get weekly tests. She chose not to get immunized because she thinks the vaccines are too new and she fears side effects.

Kostroski said she doesn’t understand the need for the shots or why vaccinated people are not tested, since they can sometimes also transmit the virus. “I think it’s pointless,” said Kostroski, 34, who has always tested negative. She’s been told by vaccinated colleagues that they feel burdened filling in for people getting tested.

Dane is that require workers to get a covid vaccine or get tested regularly. While some employees complained about the policy, county officials say, it helps keep the workplace safe with modest interruptions. They also say vaccinated workers don’t need testing because they are less likely to get infected and, if they do, are less likely to contract a severe case of covid. But it has been costly, often requiring governments to use federal covid relief dollars they would rather have spent elsewhere.

Some private employers have adopted similar policies. And starting Jan. 4, the Biden administration will require private employers with 100 or more workers to insist on shots or weekly testing.

But opposition to those mandates runs deep among some workers, unions and conservative leaders. More than two dozen Republican state attorneys general sued the administration, arguing the federal government lacks the authority. A federal appeals court agreed with them and temporarily blocked the order, and the case might end up before the Supreme Court.

Still, these early efforts by state and local governments offer insights into what Biden’s rule might mean for the wider private sector as companies deal with setting up and paying for testing and then monitoring the results. The regimen adds more work for government managers even in localities like Dane County, where nearly are at least partly vaccinated.

Nationally, about 81% of adults are at least partly vaccinated against covid, although rates vary widely among states, to the Centers for Disease Control and Prevention.

Jurisdictions run by conservative officials tend to have lower vaccination rates and are unlikely to require vaccinations or testing for workers — meaning experiences to date don’t reflect areas that have had strong opposition to vaccines and other covid requirements.

Local and state governments that have embraced the testing option have done so because it straddles the line between creating a safe work environment and giving reluctant employees a way to opt out of the vaccine without losing their job.

Blaire Bryant, associate legislative director for health at the National Association of Counties, said, “It’s too early to give a definitive answer on how well it’s going, but so far [we have] not heard any major issues.”

Counties are relying on free covid testing in their communities, paying for it through federal covid relief dollars, or having their health insurance companies foot the bill.

Local governments have a smorgasbord of policies on who is subject to the vaccine-or-test requirement and how it’s enforced. For example, all unvaccinated employees of San Diego County, California, who do not work in a health care setting need to provide proof of weekly testing to their supervisor, said spokesperson Michael Workman.

Miami-Dade County’s policy applies only to nonunion workers, or about 9% of its 29,000 employees. About 380 undergo weekly testing. The Florida county is still negotiating with unions about adding the requirement.

Virginia’s Department of Corrections requires unvaccinated employees who work in crowded settings to get tested every three days, and the rest, every seven days. And the expense? It cost the department nearly $7,000 to test 442 staff members over two days in October. The state is tapping federal covid relief funds to pay for the testing.

Securing scarce testing supplies can be difficult. The Virginia State Police had to wait more than a month to start a testing program in part because of delays in delivery.

While the Biden administration hoped its rule would motivate more people to get vaccinated, counties have had mixed results.

Officials in Fairfax County, Virginia, outside Washington, D.C., said they have not seen a significant increase in employees submitting vaccination verification since its mandatory shot policy took effect in October. More than 80% of county employees are vaccinated.

The county distributes and pays for self-administered tests for its 2,300 employees who need them, said spokesperson Dawn Nieters. The cost ranges from $35 for a rapid test to $53 for a PCR test, considered the gold standard for detecting covid.

Mecklenburg County, North Carolina, which includes Charlotte, did see the needle move. Employees there are responsible for getting their own tests. The vaccination rate jumped from 62% to 85% one month after the requirement was implemented in early September.

George Dunlap, chairman of Mecklenburg’s Board of County Commissioners, said he prefers the vaccine-or-test requirement to a vaccine-only mandate because “you have to allow for human behavior that might be different than yours.” But he isn’t sure the policy will encourage any more workers to get vaccinated.

“The people that I know personally who decided to do the testing are still getting testing. They didn’t change their mind about the vaccination,” he said.

Some health experts question the value of testing as a backup and instead favor mandating the shots.

“A vaccine-and/or-testing policy is second best,” said Jeffrey Levi, a professor of health management and policy at George Washington University. “A testing policy catches a problem early. It doesn’t prevent a problem, whereas the vaccination requirement helps to prevent it.”

Marc Elrich, the executive in Montgomery County, Maryland, in suburban Washington, supports a vaccine-only mandate but worries imposing it would result in workers leaving for jobs in neighboring jurisdictions .

“I wish the federal government would impose a [vaccine-only] mandate, because if the feds were to do it, there wouldn’t be any job portability,” said Elrich. “I wouldn’t have to deal with an employee’s ability to go from, particularly in this region, Montgomery County Police Department to pretty much every other police department around here.”

Robb Pitts, who chairs the Fulton County Board of Commissioners in Atlanta, would also like to do away with the testing option. “But I don’t think my colleagues would necessarily go along with that,” he said. About a third of county employees have opted for testing instead of vaccination.

“Why did I compromise? Because I felt, well, we had to do something,” Pitts said. “A lot of times, politics is the art of compromise.”

According to Pitts’ office, Fulton County saw its largest increase in vaccinations since May in September, when the vaccine-or-test policy was implemented. The vaccination rate now hovers around 72%.

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“We felt it was very important for patients to have as many tools on hand to help them meet this really onerous law,” said Elizabeth Cardwell, lead clinician at Planned Parenthood of Greater Texas, which has 24 clinics across the northern and central regions of the state and provides care to tens of thousands of people annually.

Most of their patients — who tend to be uninsured and have annual household incomes of less than $25,000 — had not known about SB 8 the first several weeks after implementation, said Cardwell. But once they learned about it, patients seemed to rush to get on birth control, she said.

SB 8 allows private citizens, in Texas or elsewhere, to sue anyone who performs an abortion in the state or who “aided or abetted” someone getting an abortion once fetal cardiac activity is detected. This is generally around six weeks, before most people know they’re pregnant. It’s had a chilling effect in Texas, where access to abortion was already limited.

Medical staffs are doubling down on educating patients about birth control. They recognize the strategy isn’t foolproof but are desperate to prevent unintended pregnancies, nearly half of which end in abortion.

“It’s more important now than it ever has been,” said Cardwell. “I’ve been in abortion care 30-plus years, and my go-to line was ‘You’ve got plenty of time. You don’t have to feel rushed. Talk with your partner. Talk with your family,’” she said. “Now we don’t have that luxury.”

Patients, too, seem to feel a sense of urgency. During September, according to data from Planned Parenthood of Greater Texas, medical staff provided patients with some form of birth control — for example, pill packs, Depo-Provera shots or IUD implant insertions — in more than 3,750 visits, 5% more than in September 2020.

Dr. Jennifer Liedtke, a family physician in West Texas, said she and her nurse practitioners explain SB 8 to every patient who comes to their private practice and saw a 20% increase in requests for long-acting reversible contraceptive methods, known as LARCs, in September.

LARCs, a category that includes intrauterine devices and hormonal implants, have become increasingly appealing because they are 99% effective at preventing pregnancy and last several years. They are also simpler than the pill, which needs to be taken daily, or the vaginal ring, which needs to be changed monthly.

Still, LARCs are not everyone’s preferred method. For example, inserting an IUD can be painful.

A doctor’s office is one of the few opportunities for reliable birth control education. Texas law to teach sex education, and if they do, educators must stress abstinence as the preferred birth control method. Some doctors opt to explain abortion access in the state when naming birth control options.

Liedtke is used to having to explain new laws passed by the Texas legislature. “It happens all the time,” she said. But the controversy surrounding SB 8 confuses patients all the more as the law works its way through the court system with differing , one of which briefly blocked the measure. The U.S. Supreme Court heard related arguments Nov. 1.

“People just don’t understand,” said Liedtke. “It was tied up for 48 hours, so they are like, ‘It’s not a law anymore?’ Well, no, technically it is.”

Not all providers are able to talk freely about abortion access. In 2019, the Trump administration barred providers that participate in the federally funded family planning program, , from mentioning abortion care to patients, even if patients themselves raise questions. In early October, . The change will kick in this month. Planned Parenthood can discuss SB 8 in Texas because Texas affiliates do not receive Title X dollars.

Dr. Lindsey Vasquez of Legacy Community Health, the largest federally qualified health center in Texas and a recipient of Title X dollars, said she and other staff members have not discussed abortion or SB 8 because they also must juggle a variety of other priorities. Legacy’s patients are underserved, she said. live at or below the federal poverty level.

Nearly two years into the covid-19 pandemic, “we’re literally maximizing those visits,” Vasquez said. Their jobs go beyond offering reproductive care. “We’re making sure they have food resources, that they have their housing stable,” she said. “We really are trying to make sure that all of their needs are met because we know for these types of populations — patients that we serve — this may be our only moment that we get to meet them.”

Specialized family planning clinics that receive Title X dollars do have proactive conversations about contraceptive methods, according to Every Body Texas, the Title X grantee for the state.

Discussions of long-acting reversible contraception must be handled with sensitivity because these forms of birth control have a questionable history among certain populations, primarily lower-income patients. , lawmakers in several states, including Texas, introduced bills to offer cash assistance recipients financial incentives to get an implant or mandate insertion for people on government benefits, .

“It’s important for a client to get on the contraceptive method of their choice,” said Mimi Garcia, communications director for Every Body Texas. “Some people will just say, ‘Let’s get everyone on IUDs’ or ‘Let’s get everybody on hormonal implants’ because those are the most effective methods. … That’s not something that’s going to work for [every] individual. … Either they don’t agree with it philosophically or they don’t like how it makes their body feel.”

It’s a nuanced subject for providers to broach, so some suggest starting the conversation by asking the patient about their future.

“The best question to ask is ‘When do you want to have another baby?’” said Liedtke. And then if they say, ‘Oh, gosh, I’m not even sure I want to have more kids’ or ‘Five or six years from now,’ then we start talking LARCs. … But if it’s like, ‘Man, I really want to start trying in a year,’ then I don’t talk to them about putting one of those in.”

The Biden administration expected more demand for birth control in Texas, so Health and Human Services Secretary Xavier Becerra in mid-September that Every Body Texas would receive additional Title X funding, as would local providers experiencing an influx of clients as a result of SB 8.

But providers said improved access to contraception will not blunt the law’s effects. It will not protect patients who want to get pregnant but ultimately decide on abortion because they receive a diagnosis of a serious complication, their relationship status changes, or they lose financial or social support, said Dr. Elissa Serapio, an OB-GYN in the Rio Grande Valley and a fellow with Physicians for Reproductive Health.

“It’s the very best that we can do,” said Cardwell, of Planned Parenthood of Greater Texas. “There’s no 100% effective method of birth control.”

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“We’ve been at funerals all week,” said , a City Council member who represents the neighborhood. “What can we do as a community?”

She was speaking to dozens of people at a vigil site, a tree adorned with teddy bears and candles along a street lined with rowhouses. According to police, the area, known as Brightwood Park, several dozen violent, gun-related crimes over the past year. When Lewis George asked whether the crowd had known anyone who’d been shot, most people raised their hands.

Earlier that day, five council members joined Lewis George in asking Mayor Muriel Bowser for assistance — not in the form of more police, but from the city’s first-ever gun violence prevention director, Linda Harllee Harper.

Harllee Harper knows Brightwood Park, having grown up near the heavily Black and Latino neighborhood, which has recently begun to attract white residents, too. She knows the local stories, both good and bad. Some families have lived there for decades, witnessing generational poverty and government neglect. During the 1990s, parts of it were considered a “” because of rampant drug- and gang-related activity. She still lives in the same ward with her husband and son, who plays basketball at the local recreation center with the children of a recent murder victim.

Her investment in finding a solution is clear. “It’s not a new development,” Harllee Harper told KHN. “My view of gun violence is shaped by how much loss I’ve experienced. I’ve had friends who have been killed and I also have had young people that I have worked with be killed.”

D.C. began 2021 with two crises: the coronavirus pandemic and a gun violence epidemic. To respond to the latter, Bowser advanced plans to draw on lessons learned from the former. She started by creating a position, one that anti-gun violence groups had long requested and became too urgent to ignore: gun violence prevention director. Enter Harllee Harper, who

About three weeks later, the mayor declared a public health emergency over gun violence and created an “emergency operations center” that mirrored the city’s covid-19 response. No part of the U.S. has been from an increase in murders during the pandemic. And in the nation’s capital the murder toll is outpacing last year’s, which reached , a 16-year high. Per capita, that’s about 29 murders per 100,000 residents.

The City Council has directed to support the efforts.

Harllee Harper, 56, started her 20-plus-year career at D.C. Public Schools as a substance abuse prevention and intervention coordinator. Most recently, she was senior deputy director for the D.C. Department of Youth Rehabilitation Services, where she .

“I’ve run programs before, but this was a different level of limelight” than something she would have signed up for on her own, she said.

Nine months into this new role, Harllee Harper’s most powerful tool is the mayor’s initiative, Building Blocks. Drawing on public health strategies to contain the spread of gun violence, it’s designed to treat the immediate symptoms and root causes of community violence.

Its workers operate almost as contact tracers, whose methods have become familiar during the pandemic. They enter targeted communities to form relationships and connect high-risk residents to violence interrupters, who are trained to de-escalate conflict. They also arrange for resources, like drug addiction treatment and housing assistance. The idea is to reach the small number of people who engage in dangerous behavior and invest in them and their neighborhood.

“Hopelessness combined with a gun, combined with substance abuse, is a really bad combination. And I think that’s what we are seeing right now,” said Harllee Harper.

Building Blocks is up and running in about a third of its targeted 151 blocks — 2% of the city — that were connected to 41% of last year’s gunshot-related crimes last year. (Brightwood Park is not on this list but is included in the city’s fall crime prevention initiative run by the police department.)

These diverse neighborhoods are home to people who tend to be poorer and lack access to resources and opportunities. Statistics among covid and murder victims look similar: The same neighborhoods were hit hardest and the vast majority of deaths have befallen Black people.

D.C. stemmed the spread of covid far more efficiently than the nation as a whole, . The city’s crash course on public health during the pandemic could mean it’s better situated to address gun violence. “We can explain certain things through this public health lens and people can understand it a bit better,” said David Muhammad, executive director of the National Institute for Criminal Justice Reform.

He said D.C.’s approach is unique and Harllee Harper’s position is rare. “If you claim to want to reduce gun violence in your city, prove it. Whose full-time job is it in your city to do that? In most cities, it is zero,” he said. “Don’t tell me the police chief. That’s a small portion of their job.”

For the few dozen cities that have some sort of anti-violence czar, the position is relatively new. Richmond, California, is an exception, with an agency dedicated to reducing gun violence since 2008. Richmond’s . By 2013, Richmond went from more than 40 homicides a year to 16, according to Giffords Law Center to Prevent Gun Violence — its lowest number in three decades.

Harllee Harper’s position is housed not within the public safety agency but the city administrator’s office, presumably affording her more authority and oversight of government programs.

And Building Blocks created a mobile app with which its employees can flag requests during walk-throughs of select neighborhoods. An employee could make a request using the city’s “311” service line to repair a streetlight that is out, for example, and the agency responsible would prioritize it because it came from Building Blocks.

There’s no guarantee these interventions will work, though multiple studies have shown positive outcomes of or infrastructure , such as cleaning and transforming vacant lots and abandoned buildings.

But Daniel Webster, director of the Johns Hopkins Center for Gun Violence Prevention and Policy in Baltimore, said it’s important to track successes and failures because efforts like the one Harllee Harper is spearheading don’t “always work in all places” and there are lessons to learn when they don’t.

“We can’t expect the workers to just perform miracles,” said Webster.

While expectations are high, Harllee Harper’s success depends on whether government and business leaders will respond with the same urgency as they did when the health director requested action.

“The biggest hurdle really is getting all of government to buy into a new day and a new way to get things done,” said council member Charles Allen, who chairs a committee that created Harllee Harper’s position. “Bureaucracy is not nimble.”

“My colleagues in the sister agencies across the city, when Building Blocks calls, they are very, very responsive,” said Harllee Harper. “We’re working together to create performance metrics for agencies related to gun violence prevention.”

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The argument that pharmaceutical companies need to charge high prices to invest in research and develop new drugs does little to change that sentiment, according to the new Â鶹ŮÓÅ poll. Most respondents agreed the negotiation strategy is needed because Americans pay more than people in other countries and because companies’ profits are too high.

, in addition to Â鶹ŮÓÅ’s, have found the plan to allow Medicare to negotiate prescription drug prices to be very popular. (KHN is an editorially independent program of Â鶹ŮÓÅ.) The policy has polled favorably for at least the past six years, according to Ashley Kirzinger, associate director of public opinion and survey research at Â鶹ŮÓÅ.

Still, congressional lawmakers on whether to include such a provision in the major reconciliation bill aimed at funding President Joe Biden’s domestic policy agenda and enhancing social programs. Republican lawmakers generally oppose efforts to impose price restraints on prescription drugs. Democrats in the House are pushing a bill that would allow changes in Medicare drug policies, including negotiations of prices for some medications. The bill passed the House last year but has run into opposition this fall. A few moderate Democrats .

The Â鶹ŮÓÅ poll found 83% of the public — including 91% of Democrats, 85% of Independents, 76% of Republicans and 84% of seniors — initially favored the federal government negotiating lower drug prices for both Medicare and private insurance. These opinions were relatively unchanged by the arguments in favor or against the policy, the poll found. Even Republican support remained relatively steady, at 71%, after hearing concerns about how negotiations could upend the pharmaceutical industry. However, the share of Republicans who “strongly” favored the plan dipped from 44% to 28%.

For example, large majorities regardless of party identification and age found the following argument convincing: “Those in favor say negotiation is needed because Americans pay higher prices than people in other countries, many can’t afford their prescriptions, and drug company profits are too high.”

A third, including a slight majority of Republicans 65 or older, found the following argument convincing: “Those opposed say it would have the government too involved and will lead to fewer new drugs being available in the future.”

In addition, 93% — including 90% of Republicans — said that even if prescription prices were lower “drug companies would still make enough money to invest in the research needed to develop new drugs,” while just 6% said “drug companies need to charge high prices in order to fund the innovative research necessary for developing new drugs.”

These findings represent a change from a June which found attitudes changed after hearing assertions that allowing the federal government to negotiate Medicare prescription drug prices could lead to less research and development or limited access to newer prescriptions.

“This [latest] poll did a better job of representing what’s happening in the debate,” said Kirzinger. “The public is hearing both sides of the argument.”

Pharmaceutical companies have spent a lot of money on messaging. PhRMA, the industry’s trade group, ad campaign against legislation to lower drug prices through negotiation. Pharmaceutical companies have spent the most of any single industry on federal lobbying this year and donated sizable sums to House Democrats opposed to the plan, to Open Secrets.

But the Medicare drug-pricing negotiation plan outlined in H.R. 3 (or the “Elijah E. Cummings Lower Drug Costs Now Act”) is estimated to save roughly $500 billion in federal spending for Medicare drugs over 10 years, to a Congressional Budget Office estimate. Many Democrats hope to use the savings to expand coverage in Medicare and Medicaid as they piece together their larger spending plan.

The Â鶹ŮÓÅ poll also found most people have little or no confidence that Biden or Congress will “recommend the right thing” for the country on prescription drug prices. The vast majority expressed the same about drug companies. A slight majority reported confidence in what AARP recommends — .

The Â鶹ŮÓÅ Health Tracking Poll was conducted from Sept. 23 to Oct. 4 among a nationally representative sample of 1,146 adults, including an oversample of adults 65 and older. The margin of sampling error is plus or minus 4 percentage points for the full sample.

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Se trata de un nuevo debate sobre la eficacia del popular cubrebocas de tela, cuyo uso se extendió desde los primeros días de la pandemia, cuando se emitieron las primeras recomendaciones. De hecho, los Centros para el Control y la Prevención de Enfermedades (CDC) las siguen incluyendo en su “”.  

Las máscaras siguen siendo una pieza fundamental en la lucha contra la pandemia, porque las personas con el SARS-CoV-2, el virus que causa covid-19, al inhalar pequeñas partículas de aerosol que permanecen en el ambiente y las gotas respiratorias que se producen al toser y estornudar.

Pero la ciencia está cambiando. La variante delta, que actualmente es la principal en los Estados Unidos, es mucho más contagiosa que el coronavirus original, lo que significa que la carga de virus en el aire es mayor. 

En consecuencia, algunos expertos han revisado sus recomendaciones. “Por la variante delta, probablemente haya que actualizar también las máscaras”, dijo el , y decano de la Escuela de Salud Pública de la Universidad Brown, a principios de este mes. 

¿Qué tipo de cubreboca se debe usar?

Hay confusión. Las orientaciones sobre las máscaras han ido cambiando, y las nuevas investigaciones han modificado el pensamiento convencional.

Primero se dijo que la máscara no era necesaria. Poco después, esta recomendación cambió, pero se aconsejó no comprar las quirúrgicas que utilizan los profesionales de salud por la gran escasez de este tipo de equipos de protección. En su lugar, se recomendó a los estadounidenses que compraran máscaras de tela o que hicieran sus propias versiones. Ahora, la escasez no parece ser un problema tan grande, pero los CDC

A finales de agosto, el doctor Anthony Fauci, el líder médico en enfermedades infecciosas, se negó a recomendar máscaras de mayor calidad. “En lugar de preocuparse por el tipo de máscara, basta con usarla”, de MSNBC. 

¿Qué es lo que pasa? El , experto en enfermedades infecciosas de la Universidad de California en San Francisco, opinó que Fauci intentaba controlar el tema para evitar males mayores. “Parece más importante usar algo con lo que te sientas cómodo y que puedas llevar durante largos periodos de tiempo si vas a un entorno concreto… en lugar de decir que tienes que llevar el estándar de oro en todo momento”, señaló. 

“La base debería ser una máscara quirúrgica”, añadió Chin-Hong. “Es más fácil de colocar. Es barata, aunque no siempre sea respetuosa con el medio ambiente”. Chin-Hong sólo se pone una N95 cuando hay incendios forestales. “Incluso en el hospital, uso principalmente una máscara quirúrgica”, aseguró. 

Aunque cree que el gobierno y los funcionarios de salud pública deberían hacer hincapié en el uso de máscaras quirúrgicas, Chin-Hong dijo que las máscaras de tela pueden ofrecer suficiente protección en determinadas circunstancias.

Por ejemplo, una persona totalmente vacunada, probablemente obtendría una protección adecuada llevando un cubrebocas de tela durante breves períodos de tiempo cuando un espacio interior no esté lleno. Mucho depende del contexto, por lo que el doctor propuso estas preguntas para ayudarnos a tomar decisiones: Si vas a entrar en un espacio cerrado, ¿habrá mucha gente en el edificio? ¿Cuánto tiempo vas a estar dentro? ¿Todo el mundo tendrá puesta una máscara? ¿Están, o estás, totalmente vacunados? ¿Eres inmunodeprimido? 

Cuanto más arriesgada sea la situación, más probable es que una máscara de mayor calidad sea la mejor opción. “Nada implica riesgo cero, por lo tanto, se trata de reducir el riesgo”, afirmó Chin-Hong. 

“Está claro que hay que mejorar las máscaras para luchar contra la variante delta, pero eso no significa que quienes no puedan permitirse las N95 no tengan opciones”, indicó Raina MacIntyre, directora del Programa de Investigación en Bioseguridad de la Universidad de Nueva Gales del Sur en Sidney, Australia, que ha realizado muchos estudios sobre las máscaras. 

MacIntyre dijo que es “posible diseñar una máscara de tela de alto rendimiento”. encontró que una máscara de tela en capas puede bloquear eficazmente las gotas. El estudio, publicado en mayo en el Journal of the American Chemical Society, recomienda utilizar un mínimo de tres capas —una combinación de algodón/lino y poliéster/nylon— para lograr el mismo bloqueo de gotas de las máscaras quirúrgicas. 

No sólo es importante la superposición de capas para mejorar la filtración, sino también el ajuste. Una técnica recomendada por los CDC para mejorar el ajuste de una máscara de tela o quirúrgica consiste en . Por lo general, está bien ajustada si se siente que al inhalar y exhalar.  

, publicado en septiembre, reveló que las máscaras quirúrgicas son especialmente eficaces para reducir las infecciones sintomáticas. Este tipo de mascarilla evitó una de cada tres infecciones entre personas de 60 años o más.  

Investigadores de Yale, Stanford y la organización sin fines de lucro GreenVoice realizaron un seguimiento de más de 340,000 adultos, en una zona rural de Bangladesh, durante al menos ocho semanas. Aproximadamente la mitad se beneficiaron de la distribución y promoción gratuita de máscaras. En las aldeas donde esto ocurrió, el uso de máscaras pasó del 13% al 42%. Estas mismas aldeas informaron un menor número de infecciones por covid-19 confirmadas, y una menor incidencia de síntomas relacionados. 

Las aldeas en las que se repartieron máscaras de tela informaron de una reducción del 5% de los síntomas, mientras que las aldeas que recibieron máscaras quirúrgicas informaron de una reducción del 12%.

Cuando un tercio de los adultos con síntomas comúnmente asociados a covid-19 aceptaron hacerse un análisis de sangre, los investigadores descubrieron una reducción del 11% entre los que llevaban máscaras quirúrgicas. Los investigadores no observaron una reducción significativa de las infecciones entre los que llevaban máscaras de tela.

Este estudio se realizó antes de que la variante delta circulara ampliamente en el país. El estudio aún no se ha sometido a una revisión por pares, pero ya han anunciado su metodología y sus resultados. 

“Cuando vi esos resultados, tiré mi máscara de tela”, aseguró , coautor del estudio y profesor de enfermedades infecciosas en la Universidad de Stanford. “Si delta está circulando y tienes que usar una mascarilla, ¿por qué no usas una que los datos te dicen que es buena?”. 

“Encontramos pruebas muy sólidas de que las máscaras quirúrgicas son eficaces”, agregó , economista de Yale que ayudó a dirigir el estudio. “Mi lectura de esto es que las máscaras de tela son probablemente algo efectivas. Mejores que nada”.

Abaluck sospecha que su estudio ofrece pruebas contradictorias sobre las máscaras de tela, porque sólo un tercio de los que reportaron síntomas consintieron en someterse a un análisis de sangre para detectar covid. En otras palabras, el pequeño tamaño de la muestra produjo estimaciones imprecisas. “La interpretación de toda esta constelación de resultados es que las máscaras realmente ayudan. De hecho, reducen la probabilidad de tener covid, y por eso hemos observado menos síntomas”, afirmó. 

han demostrado que el uso comunitario de las máscaras, incluyendo máscaras de tela, reduce la propagación de covid. Los investigadores del estudio de Bangladesh aclararon que esos estudios tenían inconvenientes, y por eso realizaron un ensayo clínico aleatorio.

Por ejemplo, algunos de esos estudios no pudieron observar el efecto independiente de las máscaras en entornos reales porque observaban las consecuencias de los mandatos de uso de máscaras, que a menudo iban acompañados de otras medidas contra covid, como el distanciamiento físico. Sin embargo, coincidieron en la conclusión general: Las personas que usan máscara tienen menos probabilidades de infectarse que las que no.  

“Así es la ciencia. La ciencia evoluciona”, apuntó Luby. “Teníamos pruebas de que obtenemos cierta protección con las máscaras de tela, y ahora tenemos pruebas, más recientes, de que obtenemos mejor protección con las máscaras quirúrgicas”. 

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It’s another salvo in the debate over the effectiveness of the ubiquitous cloth mask, which sprang into fashion when surgical masks and N95s were harder to find in the pandemic’s early days. The Centers for Disease Control and Prevention still promotes cloth face coverings

And masks remain a critical mitigation tool because people with SARS-CoV-2, the virus that causes covid-19, by inhaling small aerosol particles that linger in the air or large respiratory droplets produced in coughs and sneezes.

But the science is changing. Delta, currently the primary variant in the United States, is far more contagious than the original coronavirus, so the density of virus in the air is greater.

Some experts have adjusted their advice proportionally. “Given the delta variant that’s out there, you probably need to upgrade your mask,” , a and dean of the Brown University School of Public Health, said on .

What Type of Mask Should You Wear?

Don’t worry if you are confused. Mask guidance has been mixed since the dawn of the pandemic, and new research has altered conventional thinking. We decided to dig in and sort out the latest developments.

First, people were told masking wasn’t necessary. Soon after, this recommendation changed, but the public was advised against purchasing surgical-style masks used by health professionals because of dire shortages of such protective gear. Americans instead were told to spring for cloth masks or make do-it-yourself versions. Shortages do not appear to be as big a problem now, though the CDC choosing N95 respirators.

As recently as late August, the nation’s top infectious-disease doctor, Dr. Anthony Fauci, declined to recommend higher-quality masks. “Instead of worrying about what kind of mask, just wear a mask,” .

So, what gives? , an expert on infectious diseases at the University of California-San Francisco, said Fauci was taking a harm-reduction approach. “It probably is more important to wear something that you feel comfortable with, and you can wear for long periods of time if you’re going into a particular environment … rather than saying you need to wear the gold standard thing at all times,” he said.

“A baseline should be a surgical mask,” added Chin-Hong. “It’s easier to implement. It’s cheap, albeit not always environmentally friendly.” Personally, he wears only N95s when wildfires are blazing. “Even in the hospital, I’m mainly wearing a surgical mask,” he said.

While he thinks government and public health officials should emphasize wearing surgical masks, Chin-Hong said cloth masks can offer enough protection in certain circumstances. For example, a fully vaccinated person, he said, would likely get adequate protection by wearing a cloth face covering for brief periods indoors when the venue is not at capacity. A lot depends on the context, so he provided these questions to help the decision-making process: If you are going indoors, will the building be especially crowded? How long will you be inside? Will everyone most likely be masked? Are you and others around you fully vaccinated? Are you immunocompromised?

The riskier the situation, the more likely the higher-quality mask is the best option. “Nothing is zero risk, so it’s just a matter of risk reduction,” Chin-Hong said.

“So definitely, masks need to be stepped up to fight delta, but it does not mean those who cannot afford N95s have no options,” said Raina MacIntyre, head of the biosecurity research program at the University of New South Wales in Sydney, Australia, who has conducted many studies on masks.

MacIntyre said it is “possible to design a high-performing cloth mask.” found a layered cloth mask can effectively block droplets. The study, published in May in the journal , recommends using a minimum of three layers — a combination of cotton/linen and polyester/nylon — to resemble the droplet-blocking performance of surgical masks.

Not only is layering important to improve filtration but so is fit. A CDC-recommended technique for improving the fit of either a cloth or surgical mask the sides. A mask is generally a good fit as you inhale and exhale.

What Does the Research Say?

A month found surgical masks especially effective at reducing symptomatic infections. These types of masks prevented 1 in 3 infections among people 60 and older.

Researchers from Yale, Stanford and the nonprofit GreenVoice monitored more than 340,000 adults in rural Bangladesh for at least eight weeks. Roughly half the Bangladeshis received interventions like free mask distribution and promotion. Villages that received interventions saw mask use jump from 13% to 42%. The same villages reported fewer confirmed covid infections and a lower incidence of related symptoms.

Villages where cloth masks were given out reported an 8.5% reduction in symptoms, while villages that received surgical masks reported a 13.6% reduction. When a third of adults with symptoms commonly associated with covid agreed to get their blood tested for the virus, researchers discovered an 11% reduction among those who wore surgical masks. Researchers observed a 5% reduction in infections among those who wore cloth masks. This study was conducted before the delta variant was circulating widely in the country. The study has not yet undergone peer review, but have already heralded its methodology and results.

“When I saw those results, I threw away my cloth mask,” said , a co-author of the study and professor of infectious disease at Stanford University. “If delta is circulating and if you’re going to wear a mask, why don’t you wear one that the data tell you is good?”

“We find very strong evidence that surgical masks are effective,” added , an economist at Yale who helped lead the study. “My read of that is that cloth masks are probably somewhat effective. They are probably better than nothing.”

Abaluck suspects his study offers mixed evidence for cloth masks because only about a third of those who reported symptoms consented to blood testing for covid. In other words, the sample size was too small to observe anything significant. “The most likely interpretation of this whole constellation of results is that [cloth masks] actually do help. They actually do make you less likely to get covid. That’s why we saw fewer symptoms,” he said. A second possibility is that cloth masks prevent other respiratory diseases that have similar symptoms, he said.

found community masking, which includes the use of cloth masks, reduces the spread of covid. The researchers of the Bangladesh study said those studies had drawbacks, which is why they conducted a randomized clinical trial. For example, some of those studies could not observe the independent effect of masks in real-world settings because they looked at the aftermath of mask mandates, which were often coupled with other covid mitigation steps such as physical distancing. However, they agreed with those studies’ overall assessment: People who wear masks are less likely to get infected than people who don’t.

“This is the nature of science. Science evolves,” Luby said. “We had evidence that we get some protection from cloth masks, and we now have newer evidence that we get better protection from surgical masks.”

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The initiative was created for the covid-19 vaccines to complement the Centers for Disease Control and Prevention’s vaccine safety monitoring system. Known as , the registry lets inoculated people report their experiences, including serious suspected side effects, directly to the CDC through smartphones, adding to the data gathered from clinical trials and other safety monitoring systems.

So how does v-safe strengthen the nation’s existing safety checks and how well is it working?

Going in, some public health experts expressed doubts about its effectiveness. But since the tool’s Dec. 13 release, reviews have mostly been positive.

“It’s a really good way to make everybody part of the process,” said Dr. , founder of the Vanderbilt Vaccine Research Program and principal investigator for the .

“There never has been so much scrutiny of vaccines and so much reporting and so much tailored information,” she added.

How Is Vaccine Safety Traditionally Monitored?

The federal government has to monitor the safety of vaccines as well as other pharmaceutical products once they reach the marketplace. For starters, the , jointly run by the CDC and the Food and Drug Administration, since 1990 has served as a repository for reports on health problems that may be side effects of vaccines. Health care providers to , but patients, their family members or caregivers can also submit a report online.

VAERS , which are stripped of personal identifiers and publicly shared in an online database. These reports are not enough to establish a causal relationship between the vaccine and an adverse event, but they offer the agencies, along with scientists and researchers, a chance to identify and investigate unusual patterns.

VAERS helped spot unexpected cases of rare blood clots in several people who received the Johnson & Johnson vaccine. After studying the VAERS reports, the CDC what experts later identified as thrombosis with thrombocytopenia syndrome as a serious but rare health problem associated with the J&J vaccine.

Then there’s the , which uses electronic health data from nine large health care organizations across the country, including various Kaiser Permanente systems on the West Coast and Harvard Pilgrim Health Care in Massachusetts. to Minnesota-based HealthPartners, another participating organization, the VSD network looks at data for 3% of the U.S. population, or roughly 12 million people — everything from medical and pharmacy claims to vital records. reported that analyses are done weekly so signals of adverse events are quickly noted.

What Does V-Safe Add to the Mix?

Launched the day before covid vaccines were first available to the public, v-safe allows the CDC to track people over time to see how they fare.

the U.S. for leaning too heavily on a “passive” system that relies on people reporting issues that may or may not be related to the shots as opposed to “active” surveillance that scans large volumes of electronic health data and compares adverse events in people who receive the vaccine to those who didn’t.

V-safe requires individuals to opt in, with no control group for comparison. But some still view the tool as a step forward.

“It is a little bit more of a proactive monitoring system,” said , an assistant scientist at the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health.

Here’s how it works: People register with the v-safe program on their smartphone or computer after receiving their first vaccine dose. The CDC then sends them daily text messages the first week, and weekly ones for six weeks after that. Additional follow-up texts are sent at the three-, six- and 12-month marks.

Every message includes a brief health survey, always asking: “How are you feeling today?” The first week, participants are asked whether they have experienced symptoms — chills, headache, joint pain or something not listed. They are also asked if they were unable to work or attend school or perform “normal daily activities,” or if they sought a physician’s care.

Over time, the check-ins focus on new or worsening symptoms or health conditions and compare participants’ health before and after vaccination. Participants are also asked whether they have tested positive for covid since the previous survey.

CDC scientists then study responses, looking for patterns of problems that go beyond what the clinical trials predicted. And the data may provide a fuller snapshot of vaccine outcomes because it reflects not only reports of side effects but also of people who had no complaints, said Carcelén.

Even as these investigations proceed, people who reported a problem may not ever hear directly from the CDC, and v-safe is not intended to offer medical advice. The CDC requests and reviews medical records, death certificates and autopsy reports only for serious adverse events, said Martha Sharan, a CDC spokesperson. “If a report is a hoax, it is quickly caught,” she said.

And what has v-safe shown so far? “The findings in normal, regular people that got the vaccine were pretty reflective of what you saw in the clinical trials,” said Vanderbilt’s Edwards. Edwards also served on an independent safety data monitoring committee for the Pfizer-BioNTech vaccine, now branded as Comirnaty.

How Is the V-Safe Data Used?

Unlike VAERS, v-safe data is not published without context. Meaning, no one can just sort through the database and interpret the numbers as they please, data. It is, however, publicly shared through CDC studies and presentations given during meetings held by the CDC’s independent panel of experts, the Advisory Committee on Immunization Practices.

And like VAERS reports, v-safe data is susceptible to misinterpretation. One post that circulated on social media inaccurately said “3,150 persons were paralyzed” based on an ACIP presentation slide. Reuters , saying it is a “misinterpretation of the CDC health events.”

Information gleaned from v-safe has been used in several safety analyses, . That analysis, published Aug. 6, found that serious adverse events are rare among adolescents, partly based on v-safe surveys from tens of thousands of people ages 12 to 17. The analysis also found that a minority reported being unable to perform “normal daily activities” the day after receiving a second dose.

V-safe has perhaps been most helpful at providing real-world evidence that the covid-19 vaccines are safe during pregnancy. This is important because there was little information on how the vaccines affected pregnancy when they were first authorized, said Dr. Dana Meaney-Delman, a member of the CDC’s vaccine task force,.

Pregnant women were excluded from the initial clinical trials that led to the emergency use authorization of the Pfizer, Moderna and J&J vaccines, and misinformation was rampant.

Because pregnant health care workers got vaccinated and enrolled in v-safe, Meaney-Delman said, there is more that indicates the benefits of getting vaccinated during pregnancy outweigh any potential risks. Following the publication of an analysis that leaned on v-safe’s vaccine pregnancy registry, the CDC on Aug. 11 that people who are pregnant, lactating or trying to become pregnant get vaccinated against covid.

Currently, uptake is low — as of mid-August,.

Who Is Participating in V-Safe?

More than 9.2 million people have enrolled in v-safe as of Aug. 9, who received at least one dose of a covid vaccine. This seemingly low participation rate is often linked to weak advertising and public education programs about v-safe. Also, a segment of the vaccinated public likely considered it tedious or had privacy concerns. The number also excludes people who do not have smartphones.

Dr. Matthew Laurens, a vaccine researcher at the University of Maryland School of Medicine, considers this an important gap in reporting. — or an estimated — say they do not own a smartphone.

People who line up for an additional vaccine dose — often referred to as a booster but representing the same formula as previously administered — will have another opportunity to sign up for v-safe.

Meanwhile, as nationwide vaccination efforts continue, some v-safe participants said they joined the effort because they wanted to help.

John Beeler, 44, of Atlanta, considered it a “public good.” He reported experiencing tinnitus — a condition that was part of his medical history — after receiving his first Moderna dose. He was never contacted but hopes his report proved helpful. Still, he appreciated being checked on, even via automation.

“Dr. Fauci is not reading my response. But the feeling is there,” said Beeler.

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The teen’s school has a couple of thousand students, and the cafeteria was crowded. Plus outside Austin didn’t require masks, so some students weren’t wearing them. Even her honors biology teacher was maskless.

Daniels said her daughter, who like her is fully vaccinated, is terrified of bringing home the virus because it could infect her 7-year-old sibling, who is too young for a shot.

“She was like, ‘Mama I’m going to pass out,’” said Daniels, a Round Rock Black Parents Association member and former assistant principal in the district.

“Every morning I wake up with knots in my chest, just like, ‘Am I making the right decision, putting myself and my child at risk for my older two to go to school?’” said Daniels, who is immunocompromised. “And my husband was like, ‘Well the option still stands for you to go get an Airbnb and move out’ with my youngest. … Do we sacrifice our savings? It’s so hard.”

After a difficult year or more of virtual learning, parents are eager to have their children back in classrooms. But even as the highly transmissible delta variant surges, school districts like Daniels’ aren’t beefing up protocols to prevent infections. Masks aren’t mandated or enforced, according to teachers, parents and officials in several states. Physical distancing is nearly impossible. To top it off, students exposed to covid may not be required to quarantine despite guidelines from the Centers for Disease Control and Prevention, risking an even more rapid spread among children, the youngest of whom aren’t yet eligible for vaccination.

quarantining up to 14 days for people who have had close contact with an infected person — within 6 feet for at least 15 minutes over a 24-hour period. (It exempts vaccinated people without symptoms.) This summer, the agency drafted an exception for schools: It’s not considered close contact if both the infected and exposed students “correctly and consistently” wore masks. That means an unvaccinated but masked student who was exposed wouldn’t have to quarantine.

But whether school districts follow CDC guidelines is an open question. And, in many cases, counties, states and the CDC don’t issue the same advice.

Even if districts follow CDC guidance, success hinges on whether students consistently wear masks. In Round Rock, for example, quarantine is “ for students and staff members who had close contact with those infected, essentially leaving it up to parents whether to take a child out of school.

“An optional quarantine just doesn’t work,” said Allison Stewart, lead epidemiologist at Williamson County and Cities Health District, which oversees 12 school districts including most Round Rock schools. When not required, “it seems that there’s only a cursory effort to actually identify contacts.” And then only “a cursory effort to quarantine.”

“There is more transmission occurring in a school setting than there is in the community right now,” Stewart said, “which is the exact opposite of what happened last year.”

The nation’s largest school districts are mostly not following the CDC’s close-contact exception for masked students, said , an analyst at the Center on Reinventing Public Education who is tracking state and district policies. The center reviewed 100 large and urban school districts and found that most of them gave students who are fully vaccinated and have close contact with an infected student an exemption from quarantine. Some require covid testing for students to return earlier than recommended, while others exempt those who’ve recently recovered from covid and, assumedly, have antibodies.

“Districts are managing on-the-ground politics,” Dusseault said. “You may find leaders relying less on scientific recommendations and data and more on local preferences” and on “what they’re hearing.”

“We know that masks aren’t perfect,” said , superintendent of the School District of Osceola County in Florida. Fully vaccinated people without symptoms are exempt from quarantine, but require any exposed students to quarantine for four to 10 days, depending on whether they showed symptoms or had a negative test.

“The delta variant is very different,” Pace said. “As much as I hate to quarantine kids, if we don’t quarantine, we risk having to shut a school down, which we absolutely don’t want to do.”

Each school’s decision about who counts as a close contact affects contact tracing, a laborious process officials use to slow the spread of disease. The CDC’s guidance curtails the number of school-based contacts for follow-up. Epidemiologists support the CDC’s approach, said Janet Hamilton, of the Council of State and Territorial Epidemiologists. She added that having clear consequences for not wearing masks seems to resonate with parents: Kids who don’t mask up will miss more school.

“So many parents are interested — and I think rightly so — in having their children have in-person learning,” Hamilton said.

But in Round Rock, protocols are squishy in part because and conflict with federal recommendations. did Round Rock ISD last Thursday — a week into school and after were reported.

Ben Sterling, president of the local teachers union Education Round Rock, said staffers and students alike are not incentivized to follow covid rules, particularly related to quarantine. For staff members, one round of quarantine would use all 10 days of personal and sick leave they get annually. Those days roll over, but Sterling knows of teachers with health issues who haven’t banked any. “The ones who are most vulnerable are going to get hit hardest, as per usual,” he said.

Dusseault said Round Rock’s policy is unusual because it’s optional. But the district is hardly alone — neighboring . Round Rock ISD requires anyone who tests positive for covid or is a probable case to quarantine for 10 days. For close contacts, it’s merely suggested “because parents and students have a right to a free, appropriate public education under the federal law,” said Jenny LaCoste-Caputo, Round Rock ISD’s chief of public affairs and communications.

Leniency about covid safety doesn’t sit well with Natosha Daniels. “I feel sick” about it, she said. “At best, they are, like, caving to this violent group of right-wing parents and, at worst, it’s like a blatant willingness to increase our community spread.”

Quarantine isn’t required for Round Rock employees because they would have to use personal and sick leave, LaCoste-Caputo said. The board of trustees approved covid leave only for staff members who test positive.

It is also “just not having the backing of our state government,” said Amy Weir, president of the Round Rock ISD board of trustees.

The Texas legislature did not fund virtual learning, so school districts are covering the costs themselves. Weir said Round Rock ISD is paying $17.5 million to offer virtual learning for students younger than 12, who cannot get vaccinated. For older students, teachers upload handouts of curated lessons.

On the second day of classes, the middle school where Sterling teaches saw its first case. He and another teacher said the student who tested positive was sometimes maskless and around others without masks. Yet, they said, the school told the families of that child’s classmates that no one was a close contact.

The school, they said, is not requiring seating charts, which would help staff members track student movement, nor do school officials know who is vaccinated or unvaccinated, which factors into the school district’s close-contact definition. It’s all handled on the honor system.

“You’re saying, ‘Choose between going to work and quarantining your child for 10 days,’” Daniels said. “This is the world that we are in — creates these systems that leave parents with no choice.”

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Then delta hit.

Now state and local health departments are trying to build back operations with depleted resources, as covid fatigue among their workers and the public alike complicate those efforts.

“Contact tracing from the start of this pandemic provided us with really kind of invaluable information,” said , a professor of epidemiology at George Washington University. Castel said it’s still “a fundamental part of our response.” As is covid testing, especially for those who are vulnerable or unvaccinated, such as children under age 12. Yet numerous departments now find themselves with fewer contact tracers and less robust programs. Like testing, contact tracing seems to have fallen by the wayside.

Contact tracing is a resource-intensive operation, requiring workers to quickly call people who test positive for a disease and offer medical advice, and then to identify and reach out to anyone with whom the infected people came in close contact. The hope during the pandemic is to prevent spread of the covid virus, and to observe how the virus is changing. The process has been used for decades by public health officials to stop disease transmission.

But many public health departments were overwhelmed by the onslaught of covid. Last winter — before vaccines provided relief — they were unable to stay ahead of the virus through contact tracing. And as case counts dropped by virtue of increased vaccination rates in the spring and early summer, more than a dozen state health departments the workforce, said , a senior scholar and assistant professor at the Johns Hopkins Center for Health Security. The resources were needed for vaccination initiatives and to restart other public health programs.

The situation has grown critical in a number of states during the past month or so as local health officials find themselves once again behind the curve as the delta variant drives up case counts. Resources are already stretched, and the politicization of covid-19 has left these local officials making tough calls regarding whom to trace in places like Missouri and Texas. And some states just don’t have enough personnel to do the job. The army of disease detectives more often than not included temporary staff or civil servants from outside the health department. In Kentucky, is now . The state health department said he has a successor but declined to name them.

The highly contagious delta variant makes the job harder. Cases can stack up quickly. Public health departments, which are chronically understaffed and underfunded, must pick and choose which tools will serve them the best.

“Some places have done a good job at retaining a kind of reserve workforce that they could call back up. And I’m sure that’s coming in handy right now. Other places did not. And they’re probably going to be quickly overwhelmed,” Watson said. “It’s also hard to say because there’s not a lot of public reporting.”

Arkansas, where Republican now says it was an error to sign a law in April banning mask mandates, is , . But the state health department has significantly fewer contact tracers now — 192 compared with 840 in December, when case counts were at the same level, according to the department and data collected by Johns Hopkins.

Danyelle McNeill, an Arkansas health department public information officer, said contractors performing this work have been authorized to increase their staff size. She also said that the agency is triaging cases, prioritizing those who tested positive for or were diagnosed with covid within six days of specimen collection or symptom onset, , and that its vendors are not calling all positive cases the same day they receive lists when infections near 2,000.

In states that have opted to downplay contact tracing, county and city health officials are left to fend for themselves. In hard-hit southwestern Missouri, the flood of cases has overwhelmed a staff already stretched thin, said Springfield-Greene County Health Department Director Katie Towns, so the department pivoted to conducting contact tracing only in cases involving children younger than 12, who aren’t eligible for vaccination, Towns said.

Lisa Cox, a spokesperson for the state health department, said that “local health departments will work to triage and prioritize case investigations and will work with them if assistance is needed.” Her department expects financial support through the federal , but funds have yet to be appropriated. Ultimately, local strategies will come down to priorities. “We’ve made it clear that local jurisdictions need to make decisions locally based on their unique situation.”

The Springfield-Greene County Health Department’s surge capacity has diminished as team members have been redeployed to other health programs, which had been neglected during the pandemic. But even if Towns had unlimited resources, she said, she questions how effective investing it all in contact tracing would be: Covid is rampant and compliance with public health measures has waned. She would likely deploy more people to perform vaccine outreach and distribution.

Kelley Vollmar, executive director of the Jefferson County Health Department in eastern Missouri, said the delta surge is hitting a community polarized against public health efforts. “You have a public who is really not supportive of contact tracing and quarantine, as well as the funding for contact tracing and infrastructure is not there like it was last year,” she said.

In Texas, the Department of State Health Services is “winding down” the contact-tracing program to meet the requirements of the budget. , which takes effect Sept. 1, taxpayer dollars are expressly banned from being used for covid contact tracing. “We will still be doing case investigations and other public health follow up,” said Chris Van Deusen, the state health department’s director of media relations, via email, “but won’t be providing contact tracing for local health departments.” The Texas Education Agency, which oversees primary and secondary education, that schools are not required to conduct contact tracing.

Contact tracing has been clouded by controversy in Texas. Five legislators sued Republican Gov. Greg Abbott and the health department in August 2020 for awarding a contract to conduct the program. “The contract tracing policy has never been established as a policy accepted or supported by the Texas Legislature,” . filed the same month by dozens of Texans alleges that the adoption of contact tracing violates their constitutional right to privacy.

In Texas’ Williamson and Bexar counties, , local health officials are troubled by the lack of statewide tracing.

Williamson County turned to the state health department for help in contact tracing and case investigation as 50 to 100 new cases per day were being reported.

The county health department, which is separate from the county government, also trained more than half its staff to do contact tracing, everyone from clinical staff to press, said Allison Stewart, lead epidemiologist at Williamson County and Cities Health District, but the 65 people, including external staff and volunteers, couldn’t keep up with cases. Some worked seven days a week or 12-hour days, but now the county relies on the state for that work. “We can’t return to those days now, because all the people that we used actually are doing their real jobs,” she said. “We’re trying to figure out right now what the plan is come Sept 1. And it may mean the plan is that we don’t do case investigation or contact tracing.”

“Honestly, we don’t know,” she said.

San Antonio, one of the country’s largest cities and located in Bexar County, has its own contact tracers but leans on the state whenever there is a surge, said Rita Espinoza, the city’s chief of epidemiology. San Antonio is currently relying on the state and thus able to handle the load without backlogs, Espinoza said. She worries about what will happen in the fall, after school starts and there are more opportunities for transmission. The staff is already operating at a reduced capacity of 80 people.

“The specific impacts are unknown, but it may impact efforts to enhance other infectious disease investigations,” said Espinoza.

Florida, where covid has become a political buzzword, is another state where this tension is playing out. Broward County Mayor Steve Geller said he’s asked about contact-tracing capabilities, including how many investigators the state health department has, but he said he’s only ever told, “We’re working on it. It’s under control.” Contact-tracing data is not publicly available, but Republican Gov. Ron DeSantis once contact tracing “has just not worked.”

Geller has not pushed health officials for information, given that “contact tracing doesn’t work well when everyone has covid” and that covid data has become . “I’m not looking to create any new martyrs,” he said.

Midwest correspondent Lauren Weber contributed to this story.

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