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San Francisco and six other Bay Area counties announced Monday that they are reinstating a mask mandate for all indoor public settings as COVID-19 infections surge because of the highly contagious delta variant.

The new mandate applies to everyone, regardless of their vaccination status, and takes effect on Tuesday in San Francisco, Alameda, Contra Costa, Marin, San Mateo, Santa Clara and Sonoma counties, as well as the city of Berkeley.

In a news conference announcing the new orders, Bay Areafor health officers also recommended that people gather outdoors if they have that option.

“It is unfortunate we have to do this at this point in the pandemic. None of us wanted to be here,” said Dr. George Han, deputy health officer for Santa Clara County. “But the virus has changed.”

The delta variant accounts for 95% of new coronavirus cases in the region, said Sundari Mase, the interim health officer for Sonoma County, which is north of San Francisco.

“We are facing a much more aggressive and contagious opponent right now,” she said.

The vast majority of new cases and hospitalizations are among unvaccinated people, but the Bay Area mandate affects all people because there has been an increase in the number of vaccinated people testing positive and evidence that vaccinated people can transmit the virus.

Mase and the other health officials said the relatively low number of vaccinated people who are hospitalized now are primarily elderly or those with significant underlying health conditions.

In line with guidance from the U.S. Centers for Disease Control, California last week recommended that everyone wear masks indoors regardless of vaccination status, but officials stopped short of requiring it.

Indoor mask mandates are already in effect in Los Angeles, Yolo and Sacramento counties. In a major retreat in the Deep South, Louisiana, with one of the lowest vaccination rates in the nation, also reinstated a mask mandate Monday, going a step further to include schools and colleges.

The San Francisco Bay Area’s health officers were the first in the nation to announce a shutdown at the start of the pandemic in March 2020.

The region collectively leads the state in vaccination rates, with over 60% of residents fully vaccinated. Marin County, north of San Francisco, has the highest rate, with about 73% of its residents vaccinated.

California has experienced a steady rise in virus cases since the state fully reopened its economy on June 15 and did away with indoor and outdoor capacity limits and social distancing.

The Bay Area health officers said they took action Monday because of troubling numbers of hospitalizations and that they will consider easing the new restrictions when those rates go down.

“We are alarmed at the rate at which COVID patients are filling our community hospital beds,” said Chris Farnitano, health officer for Contra Costa County, where the number of hospitalized patients has doubled in the past 10 days and increased by more than 400% in July.

He urged unvaccinated people to get the shots and said indoor gatherings presents the highest virus spread risk.

“If you are unvaccinated I would strongly advise against higher-risk indoor activities — like eating in an indoor restaurant, going to exercise in a gym, going to a movie theater,” Farnitano said.

Indoor restaurant dining will still be allowed, although people will have to keep masks on when they are not eating or drinking.

In other public settings like gyms and movie theaters, face coverings must be worn, though enforcement will vary depending on location.

In Santa Clara County, businesses will be required to enforce the mask mandate and residents can submit complaints on the health department’s website, Han said.

In the city of Berkeley, which is in Alameda County but has its own public health department, businesses will be required under the new order to have signs indicating that masks are required indoors, said Lisa Hernandez, the city’s health officer.

San Francisco does not plan to enforce its new order but will rely on the tendency of residents “to follow the science and the data,” said Naveena Bobba, the city’s deputy director of health.

The Kaiser Permanente health care business joined other U.S. employers and public health departments Monday in making COVID-19 vaccines mandatory for an estimated 239,000 employees and physicians.

The Oakland-based health care and health plan provider said nearly 78% of its employees and more than 95% of physicians are fully vaccinated.