Tennessee Healthcare Professionals' Response to Governor Bill Lee re: Mask Mandate in Schools

August 17, 2021

To Governor Bill Lee and Tennessee State Leadership:

Physicians, Advance Practice Providers, Nurses, and Healthcare Professionals across the state of Tennessee stand in solidarity with our colleagues in Florida, South Carolina, North Carolina, and Texas who have petitioned their state governments to remove mandates that restrict appropriate and necessary public health safety measures.

Over the past 18 months, we have been battling a deadly COVID-19 pandemic that has killed more than 620,000 Americans. We have done everything in our power to protect the public and provide care to the best of our abilities.

Unfortunately, the Delta variant is currently surging in our state, straining our healthcare system beyond its capacity. As of August 13, 2021, fewer than 4 out of 10 people in the state of Tennessee are fully vaccinated against COVID-19. The positivity rate in Tennessee is greater than 17%. Health officials have stated that positivity rates less than 5% are needed to slow the spread of the Delta variant; unfortunately, our positivity rate is on a rising trajectory. Over the past week, we have seen an average of more than 3,000 new cases of COVID-19 diagnosed daily, with numbers rising steeply. More than 2,000 patients are currently hospitalized in Tennessee with serious COVID-19 illness, with positive net hospitalizations continuing to rise each day. Many intensive care units across the state are already at capacity – yet we remain weeks away from our projected peak surge.

Despite these grim data, on August 16, 2021, Tennessee Governor Bill Lee signed an Executive Order preventing local school leadership from implementing a mask mandate – effectively blocking educators from using proven public health mitigation strategies to curb the spread of this deadly pandemic. To justify this Executive Order, Governor Lee stated: “Our hospitals are struggling under the weight of COVID, but those hospital beds are filled with adults. Requiring parents to make their children wear masks to solve an adult problem is, in my view, the wrong approach.”

As trained healthcare providers, we strongly oppose Governor Lee’s Executive Order. Scientific evidence demonstrates that masks can decrease the spread of COVID-19. Scientific evidence demonstrates that children can be infected with COVID-19 and that children can spread the infection to adults. When community members – both adults and children – wear masks in the context of group settings, this action has the potential to decrease community spread of COVID-19. Decreasing the spread of COVID-19 allows us to flatten the curve, enabling our healthcare system to provide higher quality care to sick adults and children alike.

We know that children under 12 years old remain vulnerable to the Delta variant because they are ineligible for vaccination. The Delta variant is significantly more contagious than the original COVID-19 virus, resulting in more children becoming infected. Although only a small percentage of infected children may become seriously ill from acute COVID-19 infection or multi-system inflammatory syndrome in children (MIS-C), as higher numbers of children become exposed to COVID-19 in our communities, we will necessarily see more cases of children hospitalized with critical illness.

The American Academy of Pediatrics and the Children’s Hospital Association are collaborating to share all publicly available data on pediatric COVID-19 cases. In the early summer, COVID-19 cases in children were decreasing; unfortunately, with the advent of the Delta variant, cases in children have been steadily rising since July. Since the pandemic began, children represented ~14% of total cumulated cases. For the week ending on August 12, 2021, children comprised ~18% of reported weekly COVID-19 cases – a significant increase. In the last week alone, more than 120,000 new COVID-19 cases were diagnosed in children, and the numbers are continuing to rise.

According to data from the U.S. Department of Health and Human Services, as of August 14, 2021, the number of children hospitalized with serious COVID-19 infection in the U.S. reached a record high at nearly 2,000. Children currently comprise ~2.4% of all hospitalized COVID-19 patients, and these numbers are rising at an alarming rate that is outpacing the capacity of pediatric hospitals to provide care, requiring hospitals to divert critically ill children to out-of-state hospitals to find an available bed.

For these reasons – i.e., 1) to decrease spread of infection within communities; 2) to flatten the curve to enable hospitals to provide adequate patient care; and 3) to protect the health of children – the nation’s leading pediatricians and public health experts strongly urge that all individuals in schools wear masks. There is no more reputable, esteemed national governing body for the health and safety of children in the U.S. than the American Academy of Pediatrics (AAP). The AAP is a non-partisan entity, comprised of the nation's top physicians and scientists with expertise in pediatric health and wellbeing. The AAP has unequivocally stated that all children, teachers, and school staff should be masked in schools during the upcoming year. The CDC also aligns fully with the recommendations of the AAP, strongly recommending universal masking for all teachers, staff, students, and visitors in schools, regardless of vaccination status, age, or local rates of community transmission of the virus.

Data strongly suggest that, without requiring masks, it will be difficult for schools to remain open as the Delta variant surges across our region. In his statement, Governor Lee said, “While we deal with this issue, it remains important that we keep our schools open and in person as we’ve seen the devastating loss of progress our kids have had academically when schools were remote or closed.” We agree with Governor Lee that we must do everything possible to try to keep schools open. Without access to vaccines, the only available protections for school-age children are masking and social distancing. Recent models designed by researchers in North Carolina demonstrated that, in an elementary school setting that doesn’t require masks, 75% of students are likely to be infected with COVID-19 within 2 months. We must heed lessons from neighboring states like Arkansas, which blocked mask mandates and, within days of schools opening, were forced to shut down an entire school district due to a massive COVID-19 outbreak resulting in >800 people in quarantine.

As healthcare professionals, we emphasize that no data exist to suggest that wearing masks causes physical harm to children. Claims about risks from CO2 exposure have been repeatedly debunked as untrue. Masks are an imperfect barrier to COVID-19, but they have been conclusively shown to decrease spread. This is crucial in the context of the Delta variant, which is much more contagious than the original strain. During the past year, flu rates were down 98% (1/50th of the normal rate of flu hospitalizations), despite fewer flu vaccinations administered - and this is entirely due to masking and social distancing. Masks are not convenient and they are not perfect, but they absolutely work to decrease viral spread, and they do not cause harm.

A few months ago, the U.S. was averaging approximately 10,000 new cases of COVID-19 per day. With the current Delta variant, we are on track to hit 200,000 new cases per day in the coming months. The implications of this 20-fold increase in daily cases are sobering. The more people who get infected, the higher the odds are that the virus will spread widely and have opportunity to mutate into another more contagious and deadlier variant.

Every person has the ability and the responsibility to try to curb the spread of COVID-19 to prevent the development of a new, worse strain of the virus. We understand and empathize with the desire not to “back track.” Wearing masks isn’t back tracking - it’s the practical, necessary response to an acute, critical situation – and our best chance at decreasing spread of infection, protecting the health and safety of children and community members, and keeping schools open.

We ask for your courageous leadership as we navigate this season of an evolving pandemic that continues to rage – globally and at our front door. We ask you to respect the scientists and researchers and physicians in the AAP and CDC who recommend a mask mandate in schools to protect children, families, and communities in the context of an ongoing deadly pandemic.

We urge Governor Lee and our elected leaders to listen to the healthcare professionals of Tennessee. An Executive Order that allows parents to “opt out” of masks threatens the public health of entire communities and our state at large. Please allow our local health departments to guide school boards in mandating masks when local spread is high. Please trust our expert recommendations as we strive to protect the health and wellbeing of the people of Tennessee.

Sincerely,