A new commentary from infectious disease experts at George Washington University School of Medicine and the National Institutes of Health (NIH) says that for patient safety, the use of masks should continue in healthcare settings. This message conflicts with a recent commentary from authors at 8 US institutions suggesting that the time for universal masking is over. The commentary is published in Annals of Internal Medicine .
Experts say it’s not time to remove masks in healthcare settings yet
Masking has been a controversial mitigation strategy during the COVID-19 pandemic because high-quality evidence of effectiveness is lacking and because the issue has become highly politicized. Regardless, real-world experience demonstrates the effectiveness of mask-wearing in clinical settings where data shows that patient-to-staff and staff-to-patient transmission, when both are masked, is rare. With healthcare personnel reporting being forced to report to work even when they themselves are sick, the argument for wearing masks becomes even more compelling.
Those without symptoms can also transmit respiratory viruses, particularly SARS-CoV-2. While the Omicron strain has been milder, the infection could still cause severe or life-threatening illness or prolonged illness if transmitted to at-risk patients, such as the elderly or immunocompromised. With risks still looming, now doesn’t seem like the time to take off masks in the healthcare setting. Instead, the authors strongly advocate the continued use of masks for infection prevention.
Fragment of the statement
Laboratory studies have done what clinical research has not and shown that surgical masks, and to a greater extent, filtering facepiece respirators, are effective in limiting the spread of aerosols and droplets from people infected with influenza, coronavirus and other respiratory viruses.
Although they are not 100% effective, they substantially reduce the amounts of virus expelled when coughing or talking, thus mitigating the risk.
Real-world experience shows the effectiveness of wearing masks in clinical settings. Thanks in large part to the universal use of masks and other personal protective equipment, healthcare personnel have been at much higher risk of contracting COVID-19 from the community than from occupational exposures. Transmission from patient to staff and from staff to patient when both are masked occurs, but is rare.
One compelling reason to continue mask-wearing in healthcare is presenteeism , a behavior that long preceded the pandemic and will likely endure longer. Healthcare personnel are known to come to work when they are sick. In studies conducted during the pandemic, between half and two-thirds of healthcare personnel reported working with symptoms of respiratory illness (5). Presenteeism has been well documented in healthcare-associated respiratory viral outbreaks (6), with various reasons given, including an unwillingness to impose burdens on colleagues, the belief that some respiratory infections may be trivial, fear of retaliation for absenteeism, a moral imperative to provide patient care, and, for those in some roles, the lack of paid sick leave. We can find no reason to believe that these traditional behaviors will change if the masks are removed.
Presymptomatic transmission of respiratory viruses, particularly SARS-CoV-2, provides additional reasons for the continued use of masking in clinical settings. Those who are vaccinated against influenza or SARS-CoV-2 may experience mild symptoms that are often downplayed or mistaken for non-infectious. Additionally, up to one-third of Omicron infections are asymptomatic but could nevertheless cause serious or life-threatening illness or prolonged illness if transmitted to immunologically vulnerable patients. Hospitals caring for elderly and immunocompromised patients, such as oncology patients and organ and stem cell transplant recipients, face challenges in reducing measures that protect these patient populations.
The use of masks in the clinical setting should continue to be studied for both benefits and adverse consequences. The more specific pitfalls of masks, such as preventing communication and negatively affecting empathy, should become input for engineers and developers to improve or redesign masks to avoid these problems.
Overall, despite the limitations of existing masks, healthcare institutions performed reasonably well during the pandemic. Some have argued that maintaining universal masking is not practical for patient care. During the early HIV/AIDS epidemic, some doctors said they simply could not, for a number of reasons, wear gloves even when situations were associated with possible exposure to blood or bloody body fluids. Healthcare personnel have adapted to this requirement and the use of gloves in such situations has now become the standard of care and is widely accepted as part of standard precautions.
We are amazed by the broad effectiveness of masks for source control and protection during the pandemic and consider this a major lesson learned with lasting value as a patient safety measure in healthcare. A surprising finding was the notable reduction in healthcare-associated transmission of virtually all respiratory viruses, not just SARS-CoV-2, at our institutions and others. Although not all of our colleagues agree with our approach, a survey of hospital epidemiologists across the country suggests that, in the fall and winter of 2022, approximately 97% of hospital epidemiologists surveyed were not eager to eliminate masks in its facilities (10). Perhaps that sentiment has changed in the past 4 months, but support from many infection prevention experts for the use of masks for broad prevention of respiratory virus transmission, and not just SARS-CoV-2, suggests that many others share this opinion.
In our eagerness to return to a look and feel of normal, and as institutions decide which mitigation strategies to discontinue, we strongly recommend not dismissing this important lesson learned for the sake of our patients’ safety .
