Advance with MUSC Health

Masking: To Do or Not To Do

Joseph Gerald (Jerry) Reves, M.D.
March 12, 2021

Masking: To Do or Not to Do

As this column is submitted three things have just happened. First, on March 5 the CDC published a very complete analysis of the results of mask wearing and on-site restaurant dining in all counties throughout the U.S.[1] On the same date, the Governor of South Carolina lifted the requirement to wear masks in S.C. governmental offices, buildings, and facilities.[2] Most recently, the CDC issued guidance regarding mask wearing by fully vaccinated people.[3] It is not often that public health reports and political decisions are contemporaneous, and it is unfortunate that the Governor’s guidance can be interpreted as being at variance with the national scientific data generated by the CDC.

The New CDC Data

The CDC is moving as fast as it can to help develop policies and recommendations to get the country through this pandemic. The country is living in a time of “major disaster.” One of the goals of the CDC is to examine data to make recommendations on best practices for the country. It is within this framework that investigators at the CDC examined two questions in their March 5 report. The two questions were what effect did mask wearing mandates and restaurant re-openings have on the incidence of new COVID-19 infections and death?

To answer this question the investigators collected data at the county level from all 3,142 counties in every state in the U.S. The data obtained were their government-mandated orders to wear face masks and governmental orders for restaurants to be open or closed. The outcome information was the state health department report of new cases of COVID and deaths from COVID by county. In other words, the new case count and death rate were measured at intervals after mask mandates were put in place and after restaurants were reopened. The period of observation began in March and April and ended December 31, 2020.

The findings of this extensive data analysis revealed that mask mandates were associated with immediate significant decreases in COVID cases and deaths while reopening of the restaurants was associated with a delayed but significant increase in cases and deaths from COVID. Please see the figure below. The conclusion of the CDC investigators was that “universal masking and avoiding nonessential indoor spaces are recommended to mitigate the spread of COVID-19.” It must be noted that the increase seen when not wearing masks was approximately 2% which means that other factors play a role in transmission of the disease. This is why physical distancing, frequent hand washing, and avoiding crowds are still necessary.

Infograph of CDC mask requirements

The S.C. Governor’s Order

Governor Henry McMaster issued executive order 2021-12 that rescinded a previous order requiring everyone in state government offices, buildings, and facilities to wear a face covering. The order furthermore directed “all state agencies to expedite immediately the transition back to normal operations… all non-essential employees and staff to the workplace on a full-time basis.” Furthermore, the order “prohibits any county, municipality, or other political subdivision of the State of South Carolina from closing any location or facility that is occupied or utilized, in whole or in part, by any agency, department, official, or employee of the State.”

Elsewhere in the 18-page executive order were guidelines that “encourage all individuals within the State of South Carolina to wear a face covering,” have restaurants provide 6-foot distance for customers, have all restaurant workers wear face coverings, and have residents and visitors practice social distancing in accordance with CDC and SCDHEC guidance. Additionally, the sale of alcohol is now permitted to individuals in motor vehicles.

The order does not prohibit counties or municipalities from enacting or implementing, modifying, amending, or rescinding narrowly tailored emergency ordinances with regard to face coverings and other mitigation strategies. Thus, counties, municipalities, and private businesses may have more restrictive ordinances and rules than the State to prevent the spread of COVID-19. This practice is permitted. 

What’s a Person to Do?

As of this writing as reported by the Governor in his order, over 1 million South Carolinians have been vaccinated with more getting shots each day. However, S.C. has a population of 5.2 million and it is estimated that herd immunity will not be established in the state until about 3.5 million people are vaccinated or have had the disease. The spread of the virus occurs primarily by inhaling respiratory droplets from infected persons. To stop the spread of the virus masks have been proven in many studies to help reduce transmission, and as the new CDC data show when masks are mandated, spread is reduced. Thus, the preponderance of evidence is that masks should be worn both to protect the wearer from becoming infected and to keep the wearer if infected from spreading the disease to a still very susceptible population.

What’s a Vaccinated Person to Do?

The CDC on March 8 produced new guidance for vaccinated people.[3] If vaccinated, this will protect you from getting very ill and dying from the COVID-19 virus. Fully vaccinated people are those who are two weeks after the Pfizer-BioNTech vaccine or more than two weeks after the Johnson and Johnson vaccine. It is still possible that you can still spread the virus if vaccinated. You will not get seriously ill because your immune system will kill the majority of virus in your body. However, you could spread the virus to others if you have been exposed to it. Therefore, vaccinated individuals like those unvaccinated are urged to continue wearing a mask in public and when around all unvaccinated people, except single families thought to be well. You may be unmasked when visiting with other fully vaccinated people or with young grandchildren. You may refrain from quarantine and testing following known exposure to an infected person if you have no symptoms.

The Bottom Line

We live in a political world that has many forces at play such as economic health as well as individual health. No doubt the Governor wants South Carolinians to be healthy, especially state workers, but he also wants the government to function effectively and the economy to recover with people out and about. It is important to allow local municipalities that keep an eye on local health statistics, to have more restrictive rules if conditions dictate. However, with regard to whether each of us decides to wear a face covering (long for masks) the best medical advice is to continue to do so until we have at least two-thirds of our 5.2 million citizens vaccinated. Fully vaccinated people can unmask when with other fully vaccinated, but in public it is important to continue to mask-up until herd immunity is achieved.

References cited:

1. CDC. Association of State-Issued Mask Mandates and Allowing On-Premises Restaurant Dining with County-Level COVID-19 Case and Death Growth Rates — United States, March 1–December 31, 2020. 2021 [cited 2021 March 8]; Available from:

2. McMaster. Executive Order No. 2021-12. 2021 [cited 2021 March 8 ]; Available from:

3. CDC. Interim Public Health Recommendations for Fully Vaccinated People. 2021 [cited 2021 March 9 ]; Available from:

MUSC Health has earned a "High-Performing Hospital" designation in geriatrics from U.S. News & World Report for 2018-2019

About the Author

Joseph Gerald (Jerry) Reves, M.D.

Keywords: COVID-19, Healthy Aging