This story is being republished under a special NJ News Commons content-sharing agreement related to COVID-19 coverage. Link to story: app.com/story/news/coronavirus/2021/08/17/nj-covid-best-masks-kids-school-n-95-kn-95/5561653001/

With students set to head to classrooms next month, Gov. Phil Murphy has announced that everyone in school—students, teachers, staff and visitors—must wear a mask. In the absence of vaccines for children younger than 12, it is the best strategy to prevent the spread of COVID among those gathered for learning indoors, experts say.

The highly transmissible delta variant combined with low vaccination rates among those 12 and older have caused infections among children to soar, particularly in states such as Florida and Texas that prohibit school mask mandates. Pediatric ICUs are full, and the number of children hospitalized has increased to its highest levels since the pandemic began.

In New Jersey, “we continue to see an increase in hospitalizations, particularly among those under 18,” Health Commissioner Judy Persichilli said. As of August 18, 833 people, adults and children, were in hospitals statewide, with 157 in intensive care. That included 13 hospitalized children, of whom seven were in intensive care.

Nearly 115,000 children have tested positive since the pandemic began, and seven have died.

Universal masking has been shown to reduce the rate of transmission of COVID. It protects both the wearer and people nearby. When combined with other precautions distancing, hand-washing, screening out those who have symptoms and staying home when sick—it can make schools safer and save lives, experts say.

In North Carolina, scientists at two universities worked with school districts to implement research findings about COVID to make schools safer. A study of a million children in North Carolina schools where masking was required found that 7,000 children and adults became infected with the coronavirus and attended school while infected. Some 40,000 were quarantined.

But only 363 additional children and adults acquired the virus via in-school contacts, researchers at Duke University and the University of North Carolina at Chapel Hill wrote. That was a lower rate of transmission than in the surrounding communities. Most of the spread occurred among very young children or those with significant special needs, or while eating, they found.

“Although vaccination is the best way to prevent COVID-19, universal masking is a close second,” wrote Kanecia Zimmerman and Danny Benjamin Jr., two of the researchers. “With masking in place, in-school learning is safe and more effective than remote instruction, regardless of community rates of infection.”

The federal Centers for Disease Control and Prevention made the same recommendation in its guidance for school reopening.

“Mask use and physical distancing are two key prevention strategies for reducing SARS-CoV-2 transmission,” CDC Director Rochelle Walensky told Congress last month, speaking about school safety, “but a layered approach that uses several strategies will provide the greatest level of protection.”

No single strategy offers perfect protection. But like slices of Swiss cheese stacked on top of one another, a combination of several strategies together can help prevent COVID from getting through the holes of each.

Face coverings will still need to be worn by school children while aboard buses this fall.

Most children, in fact, have adapted easily to wearing masks, teachers and school nurses say.

“They understand germs,” said Robin Colgan, a certified school nurse in Camden and author of “The Relentless School Nurse” blog. “They want to help out. They want to feel part of the solution.”

The state mandate provides an opportunity, she said. Rather than politicize the public-health message, “This could be such a life lesson about caring for others in a narcissistic world. We all need to work together to keep others safe.”

Here are answers to some common questions about masks and schools.

What’s the best mask for kids?

“The best mask is one that they will wear,” said Dr. Katherine Clouser, a pediatric infectious disease specialist at Hackensack University Medical Center.

Parents should be pragmatic, experts say.

“A mask that’s worn is more helpful than a mask that’s not worn. And a mask that fits and is worn may be more useful than a mask that doesn’t fit, even if the type of mask is less effective,” said Dr. Lawrence C. Kleinman, a professor of pediatrics at Rutgers Robert Wood Johnson Medical School.

Neither the CDC nor the state Department of Health has given specific guidance as to what type of mask should be worn in schools. Nor do most school staff want to serve as “mask police.” So it’s up to parents.

N95s, which filter 95% of particles, are the standard for health care workers. KN95s are the Chinese equivalent of N95s and are more readily available to the public. Manufacturers have started making them in children’s sizes, with colors and designs to appeal to kids.

The masks should fit snugly on the face, without leaving gaps. Some children may find them uncomfortably warm. “They are probably the most difficult to keep on kids,” said Dr. Puthenmadam Radhakrishnan, a Ewing pediatrician on the executive council of the New Jersey chapter of the American Academy of Pediatrics.

Surgical masks are the next-best option. Made of three layers of paper and pleated to expand, they do not fit as snugly. The embedded wire at the top should be shaped to fit the nose of the wearer.

“Surgical masks are good, relatively comfortable, designed to be worn for many hours and come in different sizes,” said Dr. Stanley Weiss, an infectious disease specialist and epidemiologist at Rutgers Robert Wood Johnson Medical School.

Cloth masks and gators are least effective, experts say. A cloth mask is a barrier that “will protect kids from spitting and spreading droplets,” said Radhakrishnan, “but it won’t necessarily filter particles in the air,” thus offering less protection against the coronavirus’s primary means of transmission.

Colgan, the school nurse, finds cloth masks unacceptable. “And certainly not a gator—that’s only one layer,” she said.

If your child insists on using a cloth mask, make sure it has more than one layer of cloth. Cotton is better than synthetic fabric—not as hot, and less likely to provoke an allergic reaction. And “make sure you’re cleaning them frequently,” said Clouser, at least every couple days and preferably more often.

What about the fit of the masks?

Just as kids’ clothing comes in different sizes from adults’, so also with masks. “One size doesn’t fit everyone,” said Weiss. “People have different faces as well as different sizes.

“If it’s not fitting well, you have to get a different mask,” he said. The goal is for all the air the child breathes in or out to pass through the mask.

Finding the right mask can be a process of trial and error. If the mask falls below your nose, it doesn’t fit well. Ditto if it fogs up your glasses.

Health care workers, who must be fit-tested for their N95 masks, are challenged while wearing the mask by a spray of a sweet-smelling aerosol with particles of a certain size. If the health worker smells it, the mask doesn’t fit properly.

While this procedure can’t be used for everyone, parents should look for gaps around the nose or at the sides to make sure that air isn’t escaping.

How often should masks be changed?

If the mask gets wet or soiled, if the ear loops stretch or break, throw it away and use another. Cloth masks should be washed — preferably every day.

On school days, “They definitely need to bring spares,” said Colgan. Most schools will have extra surgical masks available.

What about gym class?

Murphy’s mandate announcement allowed exceptions to the mask requirement “when the individual is engaged in high-intensity aerobic or anaerobic activity [and] when a student is participating in high-intensity physical activities during a physical education class in a well-ventilated location and able to maintain a physical distance of six feet from all other individuals.”

Most pediatricians said the masks should be worn during indoor physical education or athletic activities.

“I’m very concerned about having kids in gym if they’re not wearing well-fitting masks,” said Weiss, who said he also worries about the spectators at indoor school sports events. Airborne virus particles can spread from an infected person to others nearby, a risk that increases with the highly transmissible delta variant.

“I think in gym class they should be wearing it,” Kleinman said. “They’re panting, breathing heavily.”

If the activity is not indoors, that’s different. “If you’re in an outdoor environment — where you are not breathing air exhaled by someone else — that’s fine,” he said.

How about lunchtime?

Obviously, it is impossible to eat or drink with a mask on. But eating together can be a high-risk activity for the spread of coronavirus.

In North Carolina schools, administrators came up with these protocols in consultation with their scientific advisers:

• Students ate outdoors, when possible.

• They sat 6 feet apart.

• They completed all the meal preparation, such as opening milk cartons, before removing their masks.

• They limited time with the mask off to eat to 15 minutes.

• No talking was allowed while eating with the masks off.

What other risk-reduction strategies should parents ask for?

Most school buildings need significant improvements in their air ventilation systems so that indoor air is exchanged for fresh outdoor air more frequently, Weiss said. More research is needed to define the standards for filtration and air cleaning systems, such as ultraviolet light, he said.

But for now, getting fresh air into classrooms and venting indoor air safely to the outdoors is an important goal. “Parents should demand that schools address their heating and ventilation systems,” he said.