feature article about covid 19 pandemic

“So, we shifted, we’ve been several times in a contingency plan mode and then again in non-contingency mode. So, we’ve had the principle that when we need an elevated alert level, we raise our alertness and as soon as the situation allows, we drop it again back to normal.” (informant 6, director of joint municipal authority)

Although the abovementioned example reflects the general need to adapt during the crisis mode of the first year of COVID-19 in Finland, we identified three sub-themes of adaptability. These were: leading the workforce, knowledge and sensemaking, and collaboration form the basis of primary healthcare organisations’ adaptability. These sub-themes of leading towards adaptability are addressed in the next sections.

The leaders identified the healthcare workforce as a crucial resource and a key actor to achieve resilient responses. One way of ensuring an adequate workforce was the reallocation of staff, which was carried out also across sectoral boundaries at the municipal level. The reallocation generated the need to introduce new tasks and to ensure continuous support for the employees in the changing working environment. Mostly the experiences were positive, as described by one of the interviewees:

“But I have to say that from the viewpoint of the whole city, for example the staff from cultural services like libraries, museums, the city orchestra, and from other places, they have been ready to come and do really different kinds of jobs on a short notice when their operations were closed (due to COVID-19). It has in a sense opened the eyes of some in those sectors but also in social and healthcare services that we don’t have to limit ourselves solely to the workforce representing social and health care. That it is worth taking a broader perspective in crises, looking at the resources society has to offer.” (informant 5, head of social and health services (municipality))

The high morale and motivation of the workforce during the first months of the pandemic was praised, and some organisations even experienced reduced absenteeism. However, the leaders also questioned whether the support for the employees was sufficient. They acknowledged that the organisations had not prepared well enough for the strain on workforce, and that measures to support the employees were not included in the contingency plans of their organisations. All this was further emphasised as the pandemic and thus extraordinary circumstances were prolonged. One of the informants noted:

“But people get tired when the situation lasts for a long time, that’s for sure. It happens to the leaders, to the managers, and to everyone who is involved. We are trying to implement a COVID exit at this stage, so that people can have their vacations, and that they get feedback on their work, and all. It is a big question.” (informant 4, director of joint municipal authority)

In sum, the leaders acknowledged the importance of a motivated workforce for resilience in healthcare. Simultaneously, they considered that the personnel had not always been supported well enough and were concerned about the long-term effects of the pandemic and various other stresses on the workforce.

Knowledge construction and sensemaking

Collecting, combining, and analysing information from different sources are a cornerstone for resilience in healthcare. A common view amongst the interviewees was that the staff competencies and knowledge accumulated prior to the crisis were pivotal, especially at the beginning of the pandemic. Different preparedness activities, such as contingency planning, exercises, and simulations, which are organised regularly, were regarded helpful although examples of insufficient preparedness or experience were cited as well:

“Somehow at this moment I think even more, if we talk about preparedness planning, that working on different scenarios should have been done more, that before this situation sketching, outlining scenarios could have been made. Now we have been leaning on the experiences from previous pandemics a bit too much and it would probably have been useful to carry out more planning and preparations with other actors.” (informant 5, head of social and health services (municipality))

As stated by the interviewees, knowledge management including analysing information was seen as central in crisis governance and thus accessible, although often incomplete, information was described as a foundation for decision-making. One of the interviewees noted:

“It has been really successful in the sense that the situational awareness that we have at hand at any time, it’s been accessible as frequently as daily or several times a day. Each time we went through the situation and after that we could propose if something needed to be done or not. I don’t remember any occasion that something that was well argued hadn’t been carried out.” (informant 7, director of health services (joint municipal authority))

Collecting and combining information was also seen as important for learning from the previous phases of the pandemic and preparing for the next phase. Sharing information, analysing and sensemaking tasks were often carried out in different groups or networks which are discussed under the next theme.

Collaboration

New collaborative practices were introduced during the pandemic to enforce coordination and pandemic governance. These included the creation of new expert groups, but also complementing existing ones or adding to the frequency of regular meetings. Communication through these groups often functioned to combine stakeholder views and sensemaking. One of the interviewees explained this as follows:

“We’ve been aware of their (the local hospital district) situation at all times, and they’ve been aware of ours. Together, we resolved issues such as where to set up the infection wards and how the patient flows would be organised. This still goes on. We meet two times per week and keep each other on track.” (informant 4, director of joint municipal authority)

Trust and prior familiarity between stakeholders appeared as facilitators for collaboration during the pandemic. Representatives from organisations with integrated social and healthcare services estimated that pandemic governance was more effective since both sectors “sat around the same table” and were under the command of the same leader, which exemplifies one structure that promoted collaboration between sectors. The clarity of stakeholder roles and responsibilities was an important benefit, enabling timely and effective organisational responses. However, the interviewees expressed that this clarity was often missing, thus, undermining the ability to adapt quickly to the new situation.

In addition to collaboration between the sectors of the same organisation, collaborative groups and networks played an important role in pandemic governance on the regional level (i.e., collaboration between municipalities and between municipalities and other key organisations such as hospital districts). The foremost aim of inter-organisational collaboration was to find a consensus on decisions to be made throughout the region. One of the informants described the collaboration:

“First, between our people, and then with the municipal leaders and leaders of the education sector, we communicate about what we think of any issue at hand. Then, it may be that they think in one way and we in another, but we don’t go with that mindset to the meeting, we work out our opinion and then we want to hear what THL (Finnish institute for health and welfare) thinks. But the starting point in these COVID-coordination groups is that from THL’s point of view they too want to know what the region’s opinion is. And then it’s good that the region has an opinion. We can discuss that ”we have these viewpoints, but this is our solution.” (informant 11, director of health services (joint municipal authority))

In a large-scale health crisis such as COVID-19, municipalities and local health systems were naturally part of a larger system for pandemic governance. This increased the demand for leaders to participate in several networks. Different mentions on collaboration were notably frequent in the interview data underlining its significant role in the leaders’ work during the pandemic.

Embedding a holistic approach

The leaders described their view of the crisis and population in many ways that emphasised their holistic approach to the situation. They underlined the need to have a comprehensive picture of the diverse population needs and the effects of the crisis on the population and services. The overall well-being of the population can be interpreted as the evident purpose of resilient responses and activities to maintain population trust. This includes adequate services and clear public communication, which were considered critical by the interviewees as explained here:

”Regardless of the situation, we discuss issues beyond healthcare. I think that an integrated healthcare and social service organisation like this is very fruitful, because in the same steering group we can always look at the situation from the viewpoint of child welfare to intensive care. It’s a broad perspective, and it enables us to discuss a wider array of issues than one would if you only look at it from the angle of healthcare.” (informant 6, director of joint municipal authority)

Balancing the multifaceted needs of the population and the realities of service production, such as financing and availability of workforce, were recurring themes in the interviews, often declared as insufficiently managed. Some services were scaled back during the first months of the pandemic to secure the capacity in other parts of the health system. However, the informants felt that these adaptations could not be prolonged as the pandemic went on and they also reprehended some other societal mitigation measures, such as school closures, as they held the potential to aggravate citizens’ overall wellbeing. As one of the informants reflected:

“I think this is a good lesson, an observation, for us that if everyone just does their business, then this thing will not work out. So, we need to recognise the pressures and situations that arise when the health authority decides or recommends something, that what kind of a chain starts from there and how that will be handled. For me the acknowledgement and understanding of these cascading impacts has been an essential observation. They are highlighted in this situation and it’s something that we all have probably learnt.” (informant 13, city manager)

This balancing is an important task for leaders, in order to ensure both sufficient adaptability and stability. Embedding the holistic approach is reflected in the three categories: the purpose of resilience (' resilience for what' ), the immaterial resources of resilience (e.g., financing and understanding the multifaceted effects of the crisis), and processes of resilience (e.g., building a holistic view of the service needs) all aiming at supporting the wellbeing of the population.

Embracing uncertainty

The final theme covers uncertainty as characteristic to the local level health services and leadership. The interviewees stated that the key persons should be able to make decisions and work effectively during uncertain times. This seemed to have succeeded well with very few exceptions. Every crisis or shock was acknowledged to be of a different kind and only partial preparation for the next one is possible since no one has the certainty as to what the next crisis will be. Multiple shocks and cumulative stresses, such as questions of workforce availability and the future health and social services reform taking place as of January 2023, were also mentioned. Functioning as an interpreter of uncertain situations is a principal endeavour for leadership, and the interviewees believed leaders to be more apt at this skill than front-line workers. One of the informants illustrated this as follows:

“It can be easier for senior level leaders to live under uncertainty and to put up with the world turning into 24/7 reality. But I think we should have thought more about the staff coping on that level. It doesn’t help much if you’re told that this is what it’s like now and let’s just work it out when there are so many uncertainties out there. When you’re in a leading position you possibly better tolerate the uncertainty and that you don’t know what tomorrow brings. But it’s so important for people to know about their days off and holidays and what they’re allowed to do." (informant 10, head of social and health services (municipality))

The undoubtedly significant role of instability was stressed by the leaders on many occasions, such as in relation to preparedness plans, the epidemiological situation, national instructions, and the sufficiency of workforce. However, the interviewees also listed several uncertainties that were present before the pandemic started and portrayed the constant change as a prevailing circumstance in their operational environment. The leaders would like the workforce to be able to adapt to continuous change. Hence, it can be interpreted that “living with uncertainty” instead of just tolerating it, is an important part of resilience in primary healthcare.

In this study we analysed the interpretations of the leaders at the local health system level on the changes in their operational environment during the COVID-19-pandemic and, furthermore, how these interpretations reflected aspects of resilience in healthcare. We detected that leading towards organisational adaptability, embedding a holistic approach in operations, and embracing uncertainty are essential aspects of building resilience in healthcare. Our results also highlighted the importance of considering absent or insufficient components of resilience in healthcare in operationalising the concept. Wiig et al. [ 8 ] have defined resilience in their study context as “the capacity to adapt to challenges and changes at different system levels, to maintain high quality care”. In the light of our data and analysis, resilience in primary healthcare expands to signify a capacity to adapt to unforeseen events and changes at different system and organisational levels, and in different sectors regardless of uncertainties, to maintain services to answer to population needs and to support the population’s overall wellbeing.

Local governance has been identified as an important part of resilience in healthcare and for the pandemic response [ 6 , 46 , 47 ]. The Finnish decentralised and publicly funded healthcare system serves as an example of the role of local governance in the context of the pandemic response, which can generally be regarded as one of the strengths of Finland’s pandemic response [ 43 ]. This paper contributes to the literature of resilience in healthcare by studying how resilience is interpreted by leaders at the local health system level, which, in turn, increases the understanding of how to strengthen health system resilience overall [ 48 ].

In the context of primary healthcare, the need for horizontal and vertical collaboration are accentuated especially during a crisis—our interviewees participated in several collaborative groups with stakeholders on different health system levels. Those participants who represented joint municipal authorities in our study worked in the type of organisations where different levels of healthcare and social services are integrated. These participants declared clearly to be in favour of an integrated structure as it facilitated collaboration between sectors and health system levels. The same structure of organisation has been formed in other Finnish regions as well as part of a major health and social services reform from January 2023 on. While these participants’ notions supported the integration of healthcare and social services in Finland, it is important to bear in mind that the benefits of local governance should not be lost when services are being centralised. Equal attention should be paid to ensure that primary healthcare is recognised as playing a key role in preventive functions and public health interventions [ 6 ].

Leadership is a critical building block of health systems and pivotal in supporting resilience in healthcare, yet it is rarely explicitly centred in resilience studies [ 6 , 13 ]. Several frameworks portray resilience as a process or a collection of capacities or capabilities incorporating a considerable degree of dynamics and interdependencies [ 1 , 10 , 49 ]. According to our results, leaders responsible for local health systems played an active role in building resilience during the COVID-19 pandemic in Finland. Our analysis complements the notion that different components and aspects of resilience are not only strongly interdependent, but also entwined [ 10 , 37 ]. The results support the findings by Lyng et al. [ 34 ] who articulate that resilience in healthcare requires a holistic awareness of a wide array of resilience capacities, which have to be maintained simultaneously, instead of concentrating on just a few of them. The presence of the future health and social services reform in Finland also caused considerable cumulative stress and uncertainty in the healthcare organisations and put pressure especially on the leaders.

The non-linearity of the chain of events triggered by the COVID-19 pandemic is another evident observation derived from the data. The results illustrate how steps were taken back and forth during the pandemic in healthcare organisations, and the crisis held unexpected events within itself, such as pandemic waves and challenges of healthcare workforce availability. The stages of the resilience process (anticipation, coping, and adaptation) could not be clearly separated in the data, as Duchek also presents in her conceptualisation [ 10 ].

As the present study also illustrated, the need to embrace uncertainty is pronounced during crises and in complex surroundings such as local health systems and primary healthcare [ 26 , 50 ]. In order to nurture resilience in healthcare, the interviewees adopted a holistic approach and described attempting to incorporate uncertainty as an existential orientation of the system they were leading. They also used several means of promoting adaptability by leading the workforce, striving for sensemaking of the knowledge that was gathered, and collaborating in various networks. These endeavours reflect leadership focussing on complexity, also referred to as complexity leadership, in which the leader’s role is more about building connections for emergent adaptability, as well as sensing opportunities and challenges than trying to control the “messiness” of the complexity [ 26 , 51 ].

Furthermore, our results illustrated how the interviewees reported insufficiency or absence of several aspects in their organisational environment that restricted or challenged their ability to respond to the crisis, such as scant resources, inability to support the workforce, insufficient information flows and the deficient quality of preparedness plans. We interpreted these as representations of missing parts of resilience in healthcare. Based on this finding, we argue that acknowledging the missing aspects of resilience is as crucial from the perspective of a comprehensive crisis response as an awareness of those aspects of resilience that are present. In this study we concluded a fifth category of ‘insufficient or absent components of resilience’ to our analysis in addition to the core questions introduced by Wiig et al. [ 8 ] answering the question ‘What does the healthcare organisation’s resilience lack?’. However, the insufficient or absent components of resilience in healthcare that we were able to identify were the same as those that the informants identified as present components. Thus, we suggest that the aspect of possibly absent or insufficient components of resilience in healthcare be actively considered in study designs of future research. It is noteworthy that our results represent only those insufficient components of resilience that were explicitly identified by the interviewees. Therefore, it is an important task for further studies to continue to investigate other potential shortcomings of crises responses that could be identified by using alternative data collection methods and research designs. The interviewee selection may also have affected the identification of lacking components. The resources or capabilities that have not been identified should be of high interest for both scholars and the leaders of health systems and healthcare organisations in the tasks of anticipation and learning and will likely require multimethodological approaches, including observational studies in healthcare settings [ 52 , 53 ].

Limitations

Our data consisted of 14 interviews which were utilised to conceptualise leaders’ experiences of resilience in healthcare in the context of local health systems and primary healthcare in Finland. Primary healthcare and public health crises, as well as leadership and resilience, are complex issues with an abundance of variance in different contexts. However, our study protocol addressed this pitfall by including interviewees from four different regions and, at least in the Finnish context, the findings were analogous.

Because of the relatively limited number of participants in the study, generalisations of findings must be made with caution. Nonetheless, the study provided a deeper understanding of leaders’ perceptions of resilience in a local health system setting, as well as conceptual considerations of resilience in healthcare, which can be used in further research. Furthermore, it is important to note that assessing the extent of the achieved resilience in healthcare is beyond the scope of this study, and therefore remains an important research task for further studies [ 54 ]. The themes of the semi-structured interviews naturally had an impact on the contents of our data. For example, questions on preparedness and workforce were asked which might have led the interviewees to contemplate these aspects more carefully and therefore also to identify the shortcomings in these sectors. A study protocol with a more open narrative inquiry could confirm or challenge the results of this study.

Implications

The practical implications of this study arise from the finding that different aspects of resilience in healthcare, leadership roles, and stages of the crisis cannot be separated, nor lines strictly drawn between their components. Before, during, and after a crisis, leaders should think and act with a broad mindset, which can be facilitated by inviting other members of the organisation as well as other stakeholders to sensemaking discussions to build a comprehensive understanding of the operational environment and pressures directed to the organisation. Health workforce and their low turn-over rate, along with other resources that support resilience, are key in achieving agility of the organisation and ensuring the continuance of services for the population. Future research should ensure that resilience is explored with a broad view, also investigating whether same issues are of importance in leadership and managerial tasks in everyday resilience as in resilience triggered by exceptional shocks.

In Finland, the Ministry of Social Affairs and Health has provided guidance for operators in the healthcare and social welfare sectors for preparedness planning and continuity management in 2019 [ 55 ]. The guidance aimed at providing practical instructions for developing preparedness plans at the operational level. However, based on our results, although preparedness plans were made, they were not in all respects feasible for the COVID-19 pandemic. For instance, inter-organisational collaboration and scenario work played a much larger role during the pandemic than had been taken into consideration in the preparedness plans, and workforce issues had scarcely been addressed. Thus, there is an essential need for developing the national guidance for preparedness planning at operational level and providing practical instructions for primary healthcare leaders. For example, the results of this study emphasise the importance of planning how the workforce will be supported during crises, especially long-lasting ones.

The findings of this study accentuate the importance of a holistic approach and ability to work under uncertain conditions at the local level of a health system and in primary healthcare in particular, especially during a crisis. This broad and multifaceted mindset seemed to be intrinsic to the study participants who were leaders responsible for local health systems in Finland. It is apparent that leaders are in a key position in building and maintaining resilience before, during, and after a crisis. Complexity leadership can provide beneficial approaches to both leaders and researchers in operationalising resilience in healthcare. Our findings confirm that the governance of unexpected events should accommodate different aspects, such as the workforce and other resources as well as processes that support resilience and stages of a crisis simultaneously. This entwinement should be emphasised in research and policy recommendations. Simplifying the complex nature of resilience in healthcare should be avoided.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to European provisions on data protection, of which the interviewees were assured.

Abbreviations

Complex adaptive system

Finnish institute for health and welfare

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Acknowledgements

We wish to thank all the interviewees for providing a rich data set with valuable insights.

Open access funding provided by Tampere University including Tampere University Hospital, Tampere University of Applied Sciences (TUNI). This study was conducted as part of the “Resilience, crisis preparedness and security of supply of the Finnish health system RECPHEALS” research project. RECPHEALS project is funded by Academy of Finland, Grant nr 340501 and Grant nr 340503, and Strategic Research Council, Academy of Finland, Grant nr 345300.

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Soila Karreinen, Henna Paananen, Marjaana Viita-aho & Liina-Kaisa Tynkkynen

Welfare State Research and Reform, Finnish Institute for Health and Welfare, Helsinki, Finland

Laura Kihlström, Kristiina Janhonen, Moona Huhtakangas & Liina-Kaisa Tynkkynen

Cultural, Behavioral & Media Insights Centre, Finnish Institute for Health and Welfare, Helsinki, Finland

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LKT, MV and to a smaller degree SK and MH participated in the data gathering, together with other members of the RECPHEALS project. LKT was the PI of the project. SK planned and designed this study. SK performed the data analysis whilst LK, HP, and LKT provided advice on the process. The first and final drafts of the manuscript were written by the lead author (SK). The manuscript was commented on and edited by all other authors at different stages of the writing process. All authors have proofread and approved the final version. All authors had access to the dataset.

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Karreinen, S., Paananen, H., Kihlström, L. et al. Living through uncertainty: a qualitative study on leadership and resilience in primary healthcare during COVID-19. BMC Health Serv Res 23 , 233 (2023). https://doi.org/10.1186/s12913-023-09223-y

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DOI : https://doi.org/10.1186/s12913-023-09223-y

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Oregon sees COVID-19 receding, but pandemic lingers

The good news: COVID-19 information in Oregon has been mostly upbeat in recent weeks. Oregon case numbers are improving, hospitalization rates are dropping, and the winter triple threat of COVID-19, flu and RSV have been retreating.

“A welcome sign,” wrote Sen. Michael Dembrow, D-Portland, whose weekly newsletter has delved deeply into the pandemic in Oregon over the past two years.

Not so good news: Astoria, Medford, Sunriver, Forest Grove, Grants Pass, Hillsboro and Port Orford were showing “sustained increases” in the presence of omicron in local wastewater according to Oregon Health Authority tests.

With the rise of home COVID-19 test kits, the percentage of positive cases that get reported to health officials isn’t as strong an indicator of current trends, OHA has said.

Epidemiologists have leaned on sewers and septic tanks to tell a more accurate story. Data compiled by testing sewage water indicates how prevalent the virus has become in nearby homes, schools and businesses.

Getting better is good enough Statewide, the trends were enough for OHA to announce hospitals and other health facilities could choose to no longer require masks on their premises.

Dr. Dean Sidelinger, the Oregon health officer, said data showed COVID-19 test positivity rates at 10% and falling. Influenza test positivity is 1.2%, while Respiratory Syncytial Virus — known by its acronym RSV — had test positivity at or under 3.5%.

But there is daily evidence that COVID-19 is still very much among the population in the form of more contagious but less virulent infections from omicron subvariants.

The Johns Hopkins Coronavirus Resource Center reported this week that there have been 676 million cases worldwide, and more than 6.87 million deaths. The United States has had 103.6 million cases and 1.12 million deaths.

Rising wastewater numbers could be a harbinger of a wider spread, or an anomaly, Sidelinger said.

“So it’s possible that we may well see the numbers rise again in the coming weeks,” Sidelinger said. “However, the combination of vaccines and prior infections seems to be keeping Oregonians from being sick enough to need serious treatment.”

Mix of familiar and new names at OHA Sidelinger remains the main holdover on the state’s team monitoring COVID-19. While Dr. Steven Graven and his virus forecasting team at Oregon Health & Science University also remain, both the OHA and OHSU reports on the status of the virus have become less frequent.

New Gov. Tina Kotek asked for and received the resignation of Oregon Health Authority Director Pat Allen, who has taken a public health position with the state of New Mexico.

Kotek on Tuesday had to announce the second interim OHA director since she was sworn in as governor on Jan. 9.

David Baden, OHA’s chief financial officer, will take over for the previous interim director, James Schroeder, who resigned after only about two months on the job.

Schroeder is the former CEO of Health Share Oregon, the state’s biggest Medicaid insurer. Kotek’s office said the governor had not sought Schroeder’s resignation.

Baden was responsible for helping bring over 2,000 staff members to Oregon, Kotek said. He also oversaw a successful vaccine-distribution program, even if the level of anti-vaccination sentiment in many areas saw inoculations slow, then stall.

The announcement on Baden noted that Oregon had the second-lowest COVID-19 case rate and eighth-lowest death rate in the nation.

Oregon has reported 961,523 positive cases since February 2020, resulting in 9,361 cases. There are currently 232 patients with COVID-19 in state hospitals.

Oregon ranks 18th in the nation in terms of hospitalizations with COVID-19, with a daily average of 338 cases over the past two weeks. But the numbers are dropping. The state is in the middle of the pack on vaccinations, with a report of 71% considered fully vaccinated.

Masks are still a good way to avoid becoming infected — Oregon reported 2,025 new cases over the past week.

OHA underlined that it issued the mask order a month ahead of time to give managers, workers and facilities involved in health care time to prepare for the change — and opt out of the rules if they wish. Individual medical care facilities could continue to require masks past April 3. Individual health care workers can make the decision to continue to wear masks. It is not a “no masks” mandate.

The new policy covers hospitals, mobile clinics, ambulances, outpatient facilities, dental offices, urgent care centers, counseling offices, school-based health centers, and complementary and alternative medicine locations.

The trend is likely for fewer restrictions around COVID-19 if overall numbers stay low. There are no plans for going back to mandatory statewide restrictions on the statewide level, OHA has said.

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(2) comments.

No, masks don't help, but let's deny the lack of science showing they work, to keep this myth alive. Also, the public is far ahead of our political health care leaders as to when the pandemic was over.

Out of interest, who/what is the source of your information that there is no scientific evidence that masks are effective? Here is what I am seeing – I am happy to send you the citations if requested:

1) A large, well-designed cluster-randomized trial in Bangladesh in late 2020 found that surgical or cloth mask distribution, role-modeling, and active mask promotion tripled mask use to 42.3% in intervention villages compared to 13.3% in comparison villages. In villages receiving mask interventions, symptomatic seroprevalence of SARS-CoV-2 was statistically significantly reduced by approximately 9% relative to comparison villages. In villages randomized to receive surgical masks, symptomatic seroprevalence of SARS-CoV-2 was statistically significantly lower (relative reduction 11.1% overall). The results of this study show that even modest increases in community use of masks can effectively reduce symptomatic SARS-CoV-2 infections (COVID-19).

2) A study of an outbreak aboard the USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk of infection.

3) A study examining SARS-CoV-2 secondary attack rates among eight public K-12 school districts in Massachusetts (70 schools with >33,000 enrolled students) during the 2020–21 school year found an unadjusted secondary attack rate of 11.7% for unmasked versus 1.7% for masked interactions.

4) During July 15–August 31, 2021, when Delta was the predominant strain circulating in the U.S., about one in five K–12 public non-charter schools open for in-person learning in Maricopa and Pima Counties, Arizona, experienced a school-associated outbreak. Outbreaks were three and a half times more likely (adjusted odds ratio 3.5, 95% confidence interval 1.8-6.6) in schools without mask mandates.

5) In a nationwide analysis of data collected during July 1-September 4, 2021, U.S. counties without school mask requirements experienced larger increases in pediatric COVID-19 case rates (18.53 per 100,000 per day more cases) after the start of school compared with counties with school mask requirements.

6) An investigation of a high-exposure event in the U.S., in which 2 symptomatically ill hair stylists interacted for an average of 15 minutes with each of 139 clients during an 8-day period, found that none of the 67 clients who subsequently consented to an interview and testing developed infection. The stylists and all clients universally wore masks in the salon as required by local ordinance and company policy at the time.

7) Investigations involving infected passengers aboard flights longer than 10 hours strongly suggest that masking prevented in-flight transmissions, as demonstrated by the absence of infection developing in other passengers and crew in the 14 days following exposure.

8) Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis of 172 various study designs, which included 25,697 patients with SARS-CoV-2, SARS, or MERS, concluded masks were effective in preventing transmission of respiratory viruses

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