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.”
Dr Henderson recently co-authored an editorial in favor of keeping masks in health care settings while the pandemic wears on.23 The editorial outlines several points in support of masking in health care settings, including the relative lack of any respiratory infections when masking was prevalent in community and health care settings.24
The editorial also addresses presenteeism, which is when health care professionals come into work sick, knowingly or otherwise.23
“One of the reasons that COVID-19 was such a problem for society and for our country in particular, was that asymptomatic spread was underappreciated at the start,” Dr Henderson said. “Masks are highly effective as source control whether someone feels sick or not.”
Before Dr Henderson’s editorial was published, an editorial by Shenoy et al had argued that universal masking in health care was no longer necessary.25 The authors wrote that masks were no longer needed due to low rates of SARS-CoV-2 infections, hospitalizations, and deaths. As noted previously, however, data on infections, hospitalizations, and deaths are limited.8-14
Shenoy et al also wrote that masks are no longer needed due to the availability of COVID-19 treatments.25 At present, there are 4 therapies approved or authorized to treat patients with COVID-19 in the US — remdesivir (Veklury), baricitinib (Olumiant), tocilizumab (Actemra), and nirmatrelvir/ritonavir (Paxlovid).26 However, these treatments are not appropriate for all patients with COVID-19, and accessing the treatments has proven difficult for some patients.26-28
Shenoy et al also cited relatively high levels of prior immunity from vaccines, infections, or both as a reason why universal masking is no longer needed in health care settings.25 However, research has suggested that prior SARS-CoV-2 infection does not provide lasting immunity.29-31 Studies have also suggested that COVID-19 vaccines do not provide lasting protection against COVID-19 or severe outcomes, especially as new SARS-CoV-2 variants continue to emerge.32-34
Multiple studies have suggested that the risk of breakthrough SARS-CoV-2 infections is particularly high in cancer patients, and cancer patients have a higher risk of poor COVID-19 outcomes, including death.35-42
Risk Mitigation for Patients With Cancer
Advocacy groups, such as Action for Care and Equity and COVID Advocacy Initiative, have been pushing for a return to universal masking in health care settings, but those calls have largely been ignored.
“Many people are acting as though there’s very little COVID-19 out there,” said Michael Hoerger, PhD, a clinical health psychologist and associate professor of psychology, psychiatry, and oncology at Tulane University in New Orleans, Louisiana.
“And it’s really not true, which is very challenging for somebody with a serious illness who is no longer getting much protection from others in the community and is largely having to fend for themselves with risk mitigation.”
Dr Hoerger was recently awarded a grant for a pilot project to help patients with cancer avoid COVID-19 in New Orleans. The strategy includes providing patients with educational resources about how to reduce the risk of transmission as well as giving them high-quality masks, air purifiers, and rapid tests.
“There is this prevailing dogma from the start of the pandemic that COVID-19 was mainly spread through droplets from coughs and sneezes and that people would get COVID-19 by touching contaminated surfaces,” Dr Hoerger said.
“People were told to wash their hands, wipe down surfaces, and use hand sanitizer. Now, it’s very clear that COVID-19 spreads predominantly through the air, and when people understand that, it really reshapes the types of precautions they should be using.”
“I think COVID-19 is likely to be a part of our lives for years and decades to come and may take its place alongside the other viruses that we worry about all the time in health care settings,” Dr Henderson said. “Hospitals must try to develop strategies that provide the safest possible environment and don’t compromise patient care.”
Disclosures: None of the interviewees have any relevant conflicts of interest.
References
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