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COVID-19 and Masks: Doctor, May I Be Excused?

holding up face mask

Aug. 13, 2020 -- As mask mandates have increased, some people are looking for a way around the rules by asking doctors for medical excuses to opt out of wearing one.

In the last 2 months, at least 10 patients have asked Constantine George, MD, for a written medical exemption so they won't have to wear a mask in public. George, the chief medical officer of Vedius, an app for a travelers' concierge medical service in Las Vegas, turned them all down.

Elena Christofides, MD, an endocrinologist in Columbus, OH, has also refused patients’ requests for exemptions.

"It's very rare for someone to need an exemption," says Albert Rizzo, MD, chief medical officer for the American Lung Association and a lung specialist at ChristianaCare Health System in Newark, DE.

The opposition is sometimes strong. Recently, a video of Lenka Koloma of Laguna Niguel, CA, who founded the anti-mask Freedom to Breathe Agency, went viral. She was in a California supermarket, mask-less, telling an employee she was breaking the law by requiring patrons to wear masks.

"People need oxygen," she says. "That alone is a medical condition." Her web page has a "Face Mask Exempt Card" that cites the Americans with Disabilities Act and posts a Department of Justice ADA violation reporting number. The DOJ issued a statement calling the cards fraudulent.

Figuring out if a patient's request to opt out of wearing a mask is legitimate is a ''new frontier" for doctors, says Mical Raz, MD, a professor in public policy and health at the University of Rochester, and a hospitalist at the university medical center.

Should Some People Skip Masks?

Experts say there are very few medical reasons for people to skip masks. "If you look at the research, patients with COPD, those with reactive airway, even those can breathe through a mask," George says. Requests for exemptions due to medical reasons are usually without basis, he says. "Obviously, if someone is incapacitated, for example, with mental health issues, that's case by case."

Christofides says one of her patients cited anxiety and the other cited headaches as reasons not to wear a mask. "I told the one who asked for anxiety [reasons] that she could wear ones that were less tight." The patient with headaches told Christofides that she had a buildup of carbon dioxide in the mask due to industrial exposure. Baloney, Christofides told her.

Rizzo says one rare example of someone who can’t wear a mask might be a patient with an advanced lung condition so severe, they need extra oxygen. "These are the extreme patients where any change in oxygen and carbon dioxide could make a difference," he says. But "that's also the population that shouldn't be going out in the first place."

Raz co-wrote a commentary about mask exemptions, saying doctors are faced with difficult decisions and must keep a delicate balance between public health and individual disability needs. "Inappropriate medical exemptions may inadvertently hasten viral spread and threaten public health," she writes.

In an interview, she says that some people do have a hard time tolerating a mask. "Probably the most common reasons are mental health issues, such as anxiety, panic and PTSD, and children with sensory processing disorders (making them oversensitive to their environment). I think there are very few pulmonary reasons."

CDC, Professional Organization Guidelines

The CDC says people should wear masks in public and when around people who don’t live in the same household. Beyond that, it simply says masks should not be worn by children under age 2, ''or anyone who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the mask without assistance."

In mid-July, four professional organizations released a statement in response to the CDC recommendation for facial coverings. Jointly issued by the American College of Chest Physicians, the American Lung Association, the American Thoracic Society and the COPD Foundation, it states in part that people with normal lungs and ''even many individuals with underlying chronic lung disease should be able to wear a non-N95 facial covering without affecting their oxygen or carbon dioxide levels."

It acknowledges that some people will seek an exemption and doctors must weigh the patient's concerns against the need to stop the spread of the virus. "In some instances, physician reassurance regarding the safety of the facial coverings may be all that is needed," it states.

Addressing the Excuses

Here are some of the common medical reasons people give for not being able to tolerate a mask:

  • Claustrophobia or anxiety. Raz and others suggests a "desensitizing" period, wearing the mask for longer and longer periods of time to get used to it. Parents could suggest kids wear a mask when doing something they like, such as watching television, so they equate it with something pleasant. Switching to a different kind of mask or one that fits better could also help.
  • Masks cause Legionnaires' disease. Not true, experts say. Legionnaires' is a severe form of pneumonia, the result of inhaling tiny water droplets with legionella bacteria.
  • It's difficult to read lips. People can buy masks with a clear window that makes their mouth and lips visible.
  • Trouble breathing. Brief periods of mask use won't have a bad effect on oxygen levels for most people.

"There is not an inherent right to be out in a pandemic with an unmasked face," Raz says. But ''you are entitled to an accommodation." That might be using curbside pickup for food and medication, she says. That requires much less time wearing a mask than entering a store would.

There are no ''boilerplate" cards or letters to excuse people provided by the four organizations that addressed the issue, Rizzo says. If he were to write a letter asking for an exemption, he would personalize it for an individual patient's medical condition. As to whether a state would honor it, he cannot say. The states have a patchwork of recommendations, he says, making it difficult to say.

Rizzo tells lung disease patients who are able to go out that wearing a mask for 15 to 20 minutes to do an errand won't harm their oxygen levels. And he reminds them that having an exemption, in the form of a doctor's letter, may bring more problems. "Even with an exemption, someone may confront them" for their lack of a face covering, he says. People with COPD have a higher risk of getting a severe illness from COVID-19, according to the CDC.

WebMD Health News Reviewed by Neha Pathak, MD on August 13, 2020

Sources

Constantine George, MD, chief medical officer, Vedius, Las Vegas.

Elena Christofides, MD, endocrinologist, Columbus, OH.

Lenka Koloma, founder, Freedom to Breathe Agency, Laguna Niguel, CA.

Albert Rizzo, MD, chief medical officer, American Lung Association; lung specialist, ChristianaCare Health System, Newark, DE.

Mical Raz, MD, PhD, Charles E. and Dale L. Phelps professor in public policy and health, University of Rochester hospitalist, University of Rochester Medical Center.

CDC: "How to Wear Masks."

JAMA Health Forum: "Mask Exemptions During the COVID-19 Pandemic -- A New Frontier for Clinicians."

U.S. Department of Justice: "COVID-19 Alert: Fraudulent Facemask Flyers."

Masks4All: "What U.S. States Require Masks in Public?"

CDC: “People With Certain Medical Conditions.”

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