Original Version delivered via email August 30, 2021
Edited/Updated Version as of September 30, 2021 (copies to also be sent to mayors within Maricopa County)
Dear Maricopa County Board of Supervisors:
On September 27, 2021 the Superior Court of Maricopa County ruled in favor of the Arizona School Boards Association, et, al., finding Sections, 12, 21, and 50 of HB2898; Sections 12 and 13 of SB1824; Section 2 of SB1825; and SB1819 unconstitutional for violating the title and/or subject matter requirements of the Arizona Constitution, Art. IV, pt. 2, §13, and they are therefore void and unenforceable. As a result, cities and counties are free to implement laws to protect residents as they see fit.
Therefore, we, the undersigned licensed physicians, healthcare workers, and public health professionals, all of whom live/work in Maricopa County, are writing once again to implore you to adopt a Maricopa County Resolution requiring universal indoor masking in K-12 schools within county boundaries. ARS 15-342.05 (banning masks in public and charter schools) has been ruled void and unenforceable. County-wide urgent action is needed to help keep Maricopa County’s children and vulnerable individuals safe from COVID-19 and its potential long-term effects. The decision should not be left to individual school boards or districts, as this will only worsen the inequity in COVID impact and outcomes. Further, schools do not exist in a vacuum, and universal masking in all K-12 schools will help bring down community rates throughout the county.
Unfortunately, the highly contagious Delta variant is continuing to circulate widely in Arizona, and our state remains in the grip of another COVID-19 surge – 81,660 new cases and 1,200 deaths were reported in the month of September alone. Arizona will likely cross the 20,000 deaths threshold in the next one to two days. There also has been a drastic increase in pediatric infections and hospitalizations in our state and all across the country. The American Academy of Pediatrics and Children’s Hospital Association reported that for the week ending 9/23/21, children represented 26.7% of the weekly reported COVID cases in the United States, and Arizona children are disproportionately impacted because of the lack of universal masking in schools. Arizona is one of only 12 states with 150,000+ cumulative child cases of COVID-19, and it is one of only 14 states that has a cumulative pediatric case rate of more than 10,000 cases per 100,000 children. As of 8/12/21, Arizona had the highest percentage of child cases (compared with cumulative cases) in the entire country, at 20.9%. As of 9/23/21, this percentage has fallen below 20% because of increasing infections in adults, but Arizona still remains one of only 14 states with children accounting for 18% or more of cumulative COVID cases and has the highest cumulative COVID-related pediatric hospitalizations in the entire country, at more than 2,800. Furthermore, Arizona has the second most child deaths from COVID (39) in the country, second only to Texas (79) which has nearly 4.5 times the child population as Arizona does.
The data is equally concerning here in Maricopa County, where the percent positivity remains 11% (high community transmission). There are currently 219 active school outbreaks in the county as of 9/27/21. In the briefing provided by Dr. Rebecca Sunenshine on 8/30/21, she reported that schools without a mask requirement are twice as likely to have a COVID-19 outbreak in students/staff compared with schools who do require universal masking. As of that briefing, 27.3% of COVID cases in Maricopa county are in children (more than one in four). This is a level we have never before seen in this pandemic. 16.5% of new COVID cases in the county (one in six) are in children too young to be eligible for vaccination. Children account for 6% of all COVID-related hospitalizations in Maricopa County, with 120 children hospitalized for COVID-19 in August alone. Even more alarming, the number of pediatric COVID-related hospitalizations is doubling monthly, per Dr. Sunenshine. Reports from Phoenix Children's Hospital that the Pediatric Intensive Care Unit and overflow areas are completely full, with ICU holds boarding in the Emergency Department, are incredibly alarming. Similarly concerning are additional reports that Emergency Departments and inpatient beds all across the state are overwhelmed by the large volume of patients (both pediatric and adult) seeking medical attention and requiring inpatient hospitalization, with delays in ability to transfer patients from smaller community hospitals to tertiary care centers for subspecialty expertise and higher level of care. Action is urgently needed to curb COVID transmission, in both adults and children.
The dramatic increase in pediatric COVID infections directly corresponds to schools reopening without mask mandates or the ability to provide the same level of physical distancing as last year. Of the 665 school COVID-19 outbreaks in Maricopa County since August 2020, 33% (219) of these have occurred within the past 28 days (“active outbreaks”). The number of school outbreaks in Maricopa County have more than doubled each week since schools reopened in July. As of the date of Dr. Sunenshine's presentation, there were three times as many school outbreaks as were present during the previous peak in February 2021. Furthermore, the recent study of 999 Arizona schools published by the CDC’s MMWR on 9/24/21 looked at Maricopa and Pima county schools and found that schools that did not require masks were 3.5 times more likely to have a COVID outbreak.
Ill children, their siblings, and exposed classmates and teachers are unable to effectively learn (or teach) in-person as long as these repeated outbreaks keep occurring. Furthermore, schools do not exist in a vacuum – infected children, who may themselves be low risk, bring the virus home and infect more vulnerable adults who can and do develop severe illness. All of this further overwhelms an already depleted, overwhelmed, and fatigued healthcare system and its healthcare workers, who have very little left in the tank after the never-ending onslaught of the past 19 months.
The science around masking is settled: masks work to significantly reduce disease transmission, especially when implemented universally, and they are safe. Universal indoor masking is a critical component of a broader enforced layered mitigation policy, and is specifically endorsed for K-12 schools by public health agencies and physician organizations, both national and local:
The Centers for Disease Control and Prevention (CDC)
writes that “due to the circulating and highly contagious Delta variant, CDC recommends universal indoor masking by all students (age 2 and older), staff, teachers, and visitors to K-12 schools, regardless of vaccination status. In addition to universal indoor masking, CDC recommends schools maintain at least 3 feet of physical distance between students within classrooms to reduce transmission risk. When it is not possible to maintain a physical distance of at least 3 feet, such as when schools cannot fully re-open while maintaining these distances, it is especially important to layer multiple other prevention strategies, such as screening testing.” 
The American Academy of Pediatrics (AAP)
recommends “that everyone older than age 2 wear masks, regardless of vaccination status. The AAP also amplifies the Centers for Disease Control and Prevention’s recommendations for building ventilation, testing, quarantining, cleaning and disinfection.” 
The American Academy of Family Physicians (AAFP)
released a statement that "The American Academy of Family Physicians supports the CDC’s updated guidance for COVID-19 prevention in the U.S., including universal masking in K-12 schools. Vaccination is currently the leading public health strategy to end the COVID-19 pandemic. To that end, the AAFP urges everyone who is eligible to get vaccinated. However, as many children are not yet eligible for COVID-19 vaccination and some adults are unable to get vaccinated, the updated guidance emphasizes indoor masking in public to mitigate the spread of the virus. Family physicians strongly urge businesses, institutions, and schools to follow the CDC’s guidance. Wearing a face mask has been proven to reduce the viral spread of COVID-19." 
The American College of Physicians (ACP)
released a statement on 8/13/21 recommending that “masks should be required in schools as part of a comprehensive public health strategy to help reduce the spread of COVID-19.” Furthermore, a policy statement from the ACP in January 2021 recommended that “governors require the wearing of masks in public facilities in their respective states, including schools.”
The Arizona Chapter of the American Academy of Pediatrics (AzAAP)
released a statment on 7/26/21 which states "All students greater than 2 years old and all school staff should wear face masks indoors at school (unless medical or developmental conditions prohibit use). A significant portion of the student population is not yet eligible for vaccination. Recognizing requirements from the state government, the AzAAP continues to recommend all students and staff continue to wear masks indoors. The vaccine status of students, teachers, and staff is difficult to monitor. Therefore, universal masking is the best and most effective strategy to create consistent messages, expectations, enforcement, and compliance without the added burden of needing to monitor vaccination status." 
The Arizona Academy of Family Physicians (AzAFP)
states "All students greater than 2 years old, school staff, volunteers and visitors should wear face masks while indoors at school, unless medical or developmental conditions prohibit mask use. This is a proven strategy to keep students and teachers as safe as possible while away from their homes." 
The Arizona Chapter of the American College of Physicians (ACP-AZ)
released a statement advising state leaders to allow schools to follow the guidance from the CDC and ADHS. ACP-AZ also stated “We recommend the following strategies be implemented and sustained during this period of increased transmission and hospitalization risk: All students greater than 2 years old, schools staff, volunteers and visitors should wear face masks while indoors at school unless medical or developmental conditions prohibit mask use. This will protect students who are not eligible to receive a vaccine and allow many parents to feel more comfortable sending their students to school.”
The Arizona Medical Association (ArMA)
on 7/16/21 stated "On behalf of the Arizona medical community, ArMA advises that schools and education leaders follow federal, state, and local health authorities’ guidelines on current measures to prevent and respond to COVID-19. The Centers for Disease Control and Prevention (CDC) recently issued updated guidance for COVID-19 prevention in K-12 schools and that guidance included: Masks should be worn indoors by all individuals (age 2 and older) who are not fully vaccinated." 
The science and data regarding the safety and efficacy of mask use to prevent the spread of the SARS-CoV-2 virus is clear and not up for debate:
study published in Mayo Clinic Proceedings in July 2021 evaluating the effectiveness of masks
resulted in these findings: “Compared with a baseline of 1-foot separation with no masks employed, particle count was reduced by 84% at 3 feet of separation and 97% at 6 feet. A modest decrease in particle count was observed when only the receiver was masked. The most substantial exposure reduction occurred when the aerosol source was masked (or both parties were masked). When both the source and target were masked, particle count was reduced by more than 99.5% of baseline, regardless of separation distance or which type of mask was employed. These results support the principle of layered protection to mitigate transmission of SARS-CoV-2, the virus causing COVID-19, and other respiratory viruses and emphasize the importance of controlling the spread of aerosol at its source. The combination of masking and distancing reduced the exposure to exhaled particulates more than any individual measure. Combined measures remain the most effective way to combat the spread of respiratory infection.” 
review article in the Journal of the American Medical Association (JAMA)
published in February 2021 notes "Community mask wearing substantially reduces transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2 ways. First, masks prevent infected persons from exposing others to SARS-CoV-2 by blocking exhalation of virus-containing droplets into the air (termed source control). This aspect of mask wearing is especially important because it is estimated that at least 50% or more of transmissions are from persons who never develop symptoms or those who are in the presymptomatic phase of COVID-19 illness. ... Second, masks protect uninfected wearers. ... However, the observed effectiveness of cloth masks to protect the wearer is lower than their effectiveness for source control." 
same review article in JAMA
also notes "children aged 7 to 13 years have been shown to be able to make accurate inferences about the emotions of others with partially covered faces, and the US Food and Drug Administration recently approved a transparent surgical mask that may be useful in such circumstances. Concerns about reduced oxygen saturation and carbon dioxide retention when wearing a mask have not been supported by available data." 
A systematic review published by
PNAS (Proceedings of the National Academy of Sciences of the United States of America)
similarly demonstrated that “The preponderance of evidence indicates that mask wearing reduces transmissibility per contact … in both laboratory and clinical contexts. Public mask wearing is most effective at reducing spread of the virus when compliance is high.” 
Reuters has also published three separate fact check articles
reviewing the safety of mask-wearing in children. [18,19,20]
It is unfortunate that mask-wearing and mask mandates have become unnecessarily politicized. Public health should never be politicized. COVID-19 is not political. It won’t vote, it won’t speak, and it won’t protest. COVID-19 will infect at any opportunity and has proven that it is not going anywhere without strict and universal mitigation. Furthermore, all of Arizona’s children and teachers have a right to safe schools, not just the ones at schools courageous enough to make the difficult decisions. Similarly, all schools have a legal obligation via in loco parentis to ensure the safety of their students, to anticipate foreseeable dangers and take responsible steps to protect students from that foreseeable danger.[21,22,23]. This means rigorously following the clear recommendations from the CDC, ADHS, MCDPH, AAP, AAFP, ACP, AzAAP, AzAFP, ACP-AZ, and ArMA - all of whom urge universal masking indoors in K-12 schools.
Maricopa County has a duty to protect the health of the community under Arizona law and the legal authority to do so. ARS 15-342.05 is unconstitutional, void, and unenforceable -- ARS 36-624 (described below) gives local governments and public health agencies have legal authority to lead the response to public health emergencies.
A.R.S. 36-624 states, “When a county health department or public health services district is apprised that infectious or contagious disease exists within its jurisdiction, it shall immediately make an investigation. If the investigation discloses that the disease does exist, the county health department or public health services district may adopt quarantine and sanitary measures consistent with department rules and sections 36-788 and 36-789 to prevent the spread of the disease. The county health department or public health services district shall immediately notify the department of health services of the existence and nature of the disease and measures taken concerning it.”
The Maricopa County Board of Supervisors has the authority to adopt a Resolution requiring universal indoor masking in K-12 schools. This mandate is necessary to prevent the spread of disease and to protect public safety and welfare, in particular to mitigate the spread of COVID-19 and provide essential protections to Maricopa County residents, including but not limited to those who are most vulnerable to infection, namely all children under 12 years old, including but not limited to those who are most vulnerable to infection, namely all children under 12 years old, while still preserving the availability of essential services (such as hospital resources and safe schools). It is clear that entrusting this decision to individual schools and districts has not been effective and is worsening inequity. In July and August 2021, Maricopa and Pima County schools that did not require masks were 3.5 times more likely to have a COVID outbreak than schools who did require masks.
Please fulfill your legal duty and moral obligation to the people and children of Maricopa County by adopting a Maricopa County Resolution in accordance with clear public health guidance requiring universal indoor masking in K-12 schools, to support safe learning in the classroom. We implore you to do so urgently and effective immediately, as the rapid spread of the Delta variant means that each day this is delayed results in thousands more individuals becoming infected. Thank you.
The undersigned licensed Arizona physicians, healthcare workers, and public health professionals
 ADHS COVID dashboard: www.azdhs.gov/covid19/data/index.php#confirmed-by-day and https://www.azdhs.gov/covid19/data/index.php
 https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/ - Version 9/23/21.
 Children and COVID-19: State Data Report. A joint report from the American Academy of Pediatrics and the Children’s Hospital Association. Version 8/12/21.
 Maricopa County Department of Public Health COVID-19 Data Dashboard
 August 30, 2021 Maricopa County Board of Supervisors Meeting
 Jehn M, McCullough JM, Dale AP, et al. Association Between K–12 School Mask Policies and School-Associated COVID-19 Outbreaks — Maricopa and Pima Counties, Arizona, July–August 2021. MMWR Morb Mortal Wkly Rep. ePub: 24 September 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7039el
 American College of Physicians (ACP) Statement on Masks in Schools, 8/13/2021
 Arizona Chapter of the American Academy of Pediatrics (AzAAP) Recommendations for K-12 School Reopening
 Arizona Chapter of the American College of Physicians (ACP-AZ) Statement on COVID-19 in Arizona
 Tomshine JR et al. Combined effects of Masking and distance on aerosol exposure potential. Mayo Clinic Proceedings. 2021;96(7):1792-1800. https://doi.org/10.1016/j.mayocp.2021.05.007
 Brooks JT and Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2. JAMA. 2021:325(10);998-999. https://doi.org/10.1001/jama.2021.1505
 Howard et al. An evidence review of face masks against COVID-19. PNAS. 2021:118(4); e2014564118. https://doi.org/10.1073/pnas.2014564118