Many US hospitals have lifted mask mandates, and, in some cases, this has led to COVID-19 outbreaks.1-3
City of Hope in Duarte, California, has maintained masking requirements, and this has prevented hospital-acquired COVID-19 there entirely, according to Vijay Trisal, MD, chief medical officer at City of Hope.
“Our policies enabled us to achieve zero nosocomial infections, zero outbreaks,” Dr Trisal said. “In a cancer hospital, that is critically important. We have no imminent plans to change our current policies.”
Other health systems with cancer centers, such as Mass General Brigham in Boston and Seattle Children’s Hospital in Washington, have lifted or loosened masking requirements, despite patient and caregiver concerns.4,5
Fearing the Place That Should Protect Their Health
Christine Mitchell, a public health researcher in Massachusetts, is a caregiver to her father, who was recently diagnosed with stage III colorectal cancer. Mitchell said nearly everyone at Mass General Cancer Center, where her father is treated, has gone mask-free since the mandate was lifted there.
Mitchell recently wrote an article lamenting the lack of masking requirements at Mass General Brigham.6 In particular, Mitchell took issue with a statement on the health system’s website that said patients are not allowed to ask a health care provider to wear a mask.
Mass General Brigham ultimately changed that statement due to public outcry, but the overall policy did not change.7 The website now reads, “Patients can ask, but providers determine when and if masking in a particular situation is clinically necessary.”
Mitchell is concerned about this policy for her father but also for herself, as she has Marfan syndrome.
“It’s very jarring to have so much fear about going to a place that I am going to protect my health or my father’s going to get treatment and being fearful that it’s actually endangering our health,” Mitchell said. “It’s just a whole added layer of anxiety every time he has to go to the hospital.”
Another concerned caregiver is Becca Peter. Her son, Eddie, was diagnosed with a brain tumor last year and is receiving end-of-life care at Seattle Children’s Hospital.
“The hospital is still requiring providers to mask when providing patient care, but no one has to mask at other times, even if they are symptomatic,” Peter said. “This has been an incredibly disappointing change. When I have had conversations with staff about the changes to hospital policy, most have expressed that they will keep masking on the floor, even when not required, and they are concerned about the lack of mandate for symptomatic people, especially in the emergency room waiting area.”
“I do not anticipate Eddie will ever leave this hospital room alive, so this does not impact him directly, but I have a lot of concern for Seattle Children’s Hospital families moving forward,” Peter said.
At City of Hope, patients and visitors have responded positively to the ongoing masking requirements, according to Dr Trisal.
“I would say less than half a percent of people have asked us why they have to still mask at the hospital,” he said. “Sometimes, they ask because other health care facilities they attend no longer require masking, but we have a uniquely vulnerable patient population. We look after severely immunocompromised patients.”
City of Hope has adjusted its policies somewhat since earlier in the pandemic. Staff are no longer required to mask in non-clinical areas, such as offices where patients are not present. Other mitigation measures, such as face shields and N95 masks for staff, are no longer broadly required. However, surgical masks are required wherever patients are present.
“Any patient, visitor, or staff member that is coming into areas where there are patients or there may be patients are expected and mandated to wear a surgical mask,” Dr Trisal said. He noted that this includes common areas such as entrances and elevators and the connected hotel where patients and caregivers frequently stay during visits.
At MD Anderson Cancer Center in Houston, Texas, the current masking policies are similar to City of Hope’s, but MD Anderson has plans to remove some requirements next week. Masks will no longer be required when entering the hospital or when moving around it. Masks will be required in clinical areas where there are direct patient-staff interactions and when patients are being admitted for care but not on patients when in their rooms and other inpatient areas.
“We still worry about our patients getting COVID-19,” said Roy Chemaly, MD, chief infection control officer at MD Anderson. “We are still seeing patients admitted with COVID-19…, so we need to keep some masking; for example, when staff are in contact with patients for a long period of time providing care, doing procedures.”
“Before we make any decisions for de-escalation, we look at data and metrics related to COVID-19, such as hospitalizations, severe infections, what the situation is nationally, regionally, locally and within the hospital,” Dr Chemaly said. “Over the past 3 years, we have had many protocols in place to protect our patients, but we’ve reached a point where we can safely remove some of these restrictions and alleviate the burden on patients and staff. But we’re doing it step-by step based on data.”
An issue with relying on the current data to make decisions about mitigations is that COVID-19 cases, hospitalizations, and deaths have become difficult to quantify. The US Centers for Disease Control and Prevention (CDC) stopped tracking COVID-19 cases after the public health emergency was lifted.8 Wastewater data can provide some insights regarding SARS-CoV-2 infections, but these data are not available everywhere.9
The CDC does track COVID-19 hospitalizations and deaths, but there are limitations to those data as well. Hospitals have decreased COVID-19 testing, they are no longer required to report data daily, and aggregate death counts were replaced by provisional death certificate data from the National Vital Statistics System.8,10-14 According to the CDC, death data may lag by 8 weeks or more.14
The Masking Debate
Since mask mandates were first implemented early in the pandemic, people have debated whether masks can prevent transmission of SARS-CoV-2.
Multiple studies have suggested they can — particularly when people wear well-fitted masks such as N95s and elastomeric respirators — but some researchers have said more evidence is needed to support that conclusion.15-20
A Cochrane review published earlier this year was widely misinterpreted as suggesting that masks do not protect people from SARS-CoV-2 infection.21,22 In reality, the review authors said there is not enough evidence to make any definitive conclusions about whether masks can prevent COVID-19.
“The reason for the lack of convincing evidence is really straightforward: it’s a really difficult trial to run,” said David Henderson, MD, an epidemiologist and previous deputy director for clinical care at the National Institutes of Health Clinical Center in Bethesda, Maryland, until 2019.
“In some of the better studies, the people in the mask-wearing category wore masks around 60% of the time, and those in the no-mask category wore them 10%-15% of the time, so it makes the data very messy.”