Update Aug. 19: This story has been updated to include information about a Douglas County School District policy that states that the district will follow the guidance of local and state public health agencies.

In a much-anticipated decision, the local public health agency for Adams, Arapahoe and Douglas counties decided it will require masks for all children aged 2 to 11 years old — and all the individuals working or interacting with those children — in all indoor school and child-care settings in the three counties as a COVID-19 safety measure.

In its decision, the Tri-County Health Department cited the absence of an approved coronavirus vaccine for children under the age of 12 years.

The spread of the coronavirus, exacerbated by the Delta variant, continues throughout Tri-County Health’s jurisdiction and has been increasing for nearly six weeks, the agency wrote in a document explaining its reasons for issuing the public health order requiring masks.

Transmission of COVID-19 in school settings would pose "considerable risk" to family and others outside of the child care and school settings, especially for
those at higher risk of complications from COVID-19, the agency wrote.

Douglas County commissioners told Colorado Community Media shortly after the decision that they plan to opt out of the order. The county has opted out of other Tri-County Health orders over the course of the pandemic.

Tri-County Health’s intent is for any school, school district or child-care facility to understand that they can implement the mask order even if the board of county commissioners in their county opts out, according to Jennifer Ludwig, deputy director of Tri-County Health. School districts, schools and child-care facilities aren't required to follow the mask order if their county opts out, but they can choose to do so.

“If a county opts out, school districts, schools, and child cares within that county will be strongly encouraged to adopt the requirements of the order as their district (or) school (or) child care policy,” said Mellissa Sager, the policy and public affairs officer for Tri-County Health.

School districts and municipalities cannot opt out on their own, according to Sager. A board of county commissioners — a county’s elected leaders — can opt the entire county out of the order or opt out a part of the county, such as when Arapahoe County opted out the portion of the county east of Watkins Road from Tri-County Health’s earlier 2020 mask order that applied to public spaces in general.

Tri-County Health policy allows counties to opt out of public health orders, but “if a county exercises that right, it does not preclude any school, school district or child care facility from following this public health order,” the new action from Tri-County says. The order takes effect Aug. 23.

Douglas County School District Superintendent Corey Wise has said the district must follow the health order, regardless of whether county commissioners opt out. In a letter to the community, he cited district policy that states Douglas County Schools will follow the guidance of local and state public health agencies in responding to common communicable disease.

Colorado Community Media has asked the district for further clarification about how it interprets the health order in conjunction with district policy.

Douglas County School District on Aug. 17 officially announced it will begin requiring masks for students in preschool through sixth grade inside its school buildings, as well as for staff who work with that age group. 

The school district reiterated its newly announced rule in an Aug. 20 letter to the community. Douglas County commissioners unanimously approved a decision to opt out of the mask order during an Aug. 19 meeting.

Mask decision in spotlight

Some in the community have expressed skepticism about masks, but the “evidence we have compiled suggests that the benefits of mask-wearing outweigh the risks,” Kaia Gallagher, president of the Tri-County board of health, said during the Aug. 17 meeting where the board voted on a mask order. Masks limit the potential for a need to switch from in-person to remote classes, Gallagher argued.

Tri-County’s board of health is the policy-making body for the agency, composed of nine members — three each from Adams, Arapahoe and Douglas counties.

Tri-County had received more than 10,000 responses on a survey regarding whether to issue a mask mandate, according to numbers announced during an earlier meeting on Aug. 16, where the board heard comments from the public about whether people wanted a mask order.

More than 900 people signed up to speak for the Aug. 16 meeting. Tri-County Health limited the comments to about 90 minutes, so a small fraction of the total got to make comments. The number registered to view the Aug. 16 meeting over Zoom was 3,554, according to Becky O’Guin, spokesperson for Tri-County Health.

It was unclear from the public comment whether more of the potential speakers were for or against a mask order — Tri-County alternated between speakers who were pro- and anti-mask-mandate.

By the survey results, 62% of respondents in the three-county region did not support masking in schools, 8% supported masking in indoor settings where there is a presence of anyone 11 or younger, and 31% supported masking in all indoor school settings. The survey was open from Aug. 13 to Aug 16.

The survey "was not scientific — it was not random," Gallagher said. "It was a listing of the opinions of the (people) who had very strong ideas about, both for and against, whether there should be a mask mandate in schools." 

Tri-County based its mask decision on data and “the advice of numerous health experts such as the Colorado Chapter of the American Academy of Pediatrics,” the health agency said in a news release.

Thomas Fawell, a board member, argued that expert recommendations on mask policy are based on what appear to be “regional problems” — he mentioned Florida and Texas — in areas of highly unvaccinated populations.

“And while we do have an increase in cases, which puts us in what they’ve termed ‘high transmission,’ our cases and our transmissions don’t equal hospitalizations or deaths,” Fawell said.

Fawell ultimately voted for the mask mandate for children ages 2 to 11.

Tri-County’s decision comes as Colorado finds itself in its fifth wave of COVID-19 cases and hospitalizations.

Statewide hospitalizations have spiked in the last few weeks, jumping from 266 confirmed COVID-19 patients on July 22 to 566 on Aug. 16. Daily deaths among those with COVID-19 in the past several weeks continued to outpace the recent lows seen in March, at times breaking into double digits.

Tri-County’s board also considered issuing an order requiring masks for all individuals in all indoor school and child care settings — regardless of age — but that motion failed on a 4-4 vote.

Zachary Nannestad abstained from voting because he is employed by one of the school districts that would be affected by the vote, Nannestad said. The Douglas County School District lists Nannestad as its operations manager for environmental health.

The vote for the mask order for those aged 2 to 11 — and the individuals who interact with them — passed with on a 6-2 vote, with Nannestad abstaining. Board members Linda Fielding and Kim Muramoto voted no. Nannestad, Fielding and Muramato are the three board members from Douglas County.

Individuals who "cannot medically tolerate" a mask are exempt from the order. The order also lists exceptions that apply during certain activities and situations.

Health and masks

Responding to the community’s concerns about mask-wearing, Fawell said during the Aug. 17 meeting: “There’s no significant health effects of wearing a mask. Having spent 35 years in surgery, I can attest to that.

“I can’t attest to whether wearing a mask is a psychological problem or a learning problem,” Fawell said.

Board members Fielding and Muramoto expressed reservations with issuing a mask mandate, citing concerns about suicide and mental health among youth.

“How are we going to protect people the most?” Muramoto said, noting that wearing masks doesn’t entirely prevent transmission of COVID-19.

Children’s Hospital Colorado declared what it termed a “state of emergency” in May regarding youth mental health, which Muramoto appeared to reference.

Julie Mullica, a board member, said she has a child who was a kindergartner who struggled with online school during the pandemic. “Every day ended in tears,” she said.

“At the end of the day, it wasn’t a mask that hurt my child — it was them not being in school,” Mullica said. She argued that “the best thing we can do for our kids” is keep consistency in school and avoid “shuffling kids” between online and in-person classes.

John Douglas, the executive director of Tri-County Health, has said he hoped a mask order would cut down on coronavirus infections that result in students needing to miss school.

Mental health concerns

A few parents in Tri-County’s Aug. 16 meeting raised concerns about mental health, including suicide, amid the pandemic.

The picture of mental health in general during the pandemic is complicated: Researchers haven’t clearly linked recent suicides to the pandemic, but pediatric mental health experts are expressing concern, a July 8 article in Yale Medicine said.

Headlines that call attention to the pandemic’s effect on mental health are common. And while “no suicide rate, whether high or low, rising or falling, is acceptable,” says an article in the BMJ (under the British Medical Association), numbers from several countries suggest that suicide rates have not risen. The article, published in March, noted that the findings may change over time.

“How do we square the evidence on suicide with what surveys and calls to charities are telling us, that the pandemic has made our mental health worse? How can both be true?” the article says. “Perhaps as well as risks, there have been protections. We may have been more careful in lockdown to stay in touch, more alert to warning signs. In the face of a crisis, there may have been a greater sense of community, of getting through it together.”

The text of Tri-County Health's order also addressed the topic of mental health. It reads: "And while the mental health impact of the COVID-19 pandemic on children is clear, Children’s Hospital Colorado clarified that mask wearing has not been linked to mental health problems in children or any other group and did not contribute to their declared ‘state of emergency’ for pediatric mental health."

Elizabeth Whitehead, a spokesperson for Children's Hospital Colorado, confirmed the accuracy of that statement.

“There is currently no scientific evidence to support this potential concern” about masks and mental health, Jenna Glover, a child and adolescent psychologist, said in a Children's Hospital Colorado frequently-asked-questions page about masks and kids.

Reporting from The Atlantic has also called into question the idea that there has been a “broad, pandemic-driven suicide crisis among teens,” criticizing the way news outlets have reported certain statistics. See that story here.

Disease spread by kids is factor

Two weeks after Tri-County initially stopped short of requiring masks in schools, the agency announced on Aug. 12 that it planned to consider issuing some type of mask order for students. During Tri-County’s meeting on Aug. 16, pro- and anti-mask Coloradans dug in their heels and found little common ground.

What wasn’t often mentioned during the discussion was the issue of whether — and to what degree — kids could contribute to COVID-19 spread in the community.

Most children who become infected with COVID-19 have no symptoms, or they have milder symptoms such as low-grade fever, fatigue and cough, according to a Harvard Medical School article.

“Early studies suggested that children do not contribute much to the spread of coronavirus,” the Aug. 13 article says. “But more recent studies raise concerns that children could be capable of spreading the infection.”

The federal Centers for Disease Control and Prevention website goes further, writing: “Outbreaks among adolescents attending camps, sports events, and schools have demonstrated that adolescents can transmit (the virus) to others.

“Studies that have examined secondary infection risk from children and adolescents to household contacts who are rapidly, frequently, and systematically tested demonstrate that transmission does occur,” the CDC’s page says.

“Transmission of COVID-19, exacerbated by the more transmissible delta variant, is highly likely in the school setting without high levels of mask wearing,” Douglas, director of Tri-County Health, wrote in an Aug. 13 letter.

For a look at data and claims about the effectiveness of masks, see Colorado Community Media’s previous story on Tri-County’s Aug. 16 meeting here.

Reporters Jessica Gibbs and Elliott Wenzler contributed to this story.

Clarification: A Tri-County Health Department official said during the Aug. 16 board of health meeting that "nearly 2,000 people" had signed up to speak in that meeting. Tri-County Health later clarified that 913 people signed up to speak, and the number registered to view the meeting over Zoom was 3,554.