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Hospital approaches to universal masking after public health “unmasking” guidance

Published online by Cambridge University Press:  22 March 2023

Graham M. SnyderOpen the ORCID record for Graham M. Snyder[Opens in a new window],
Catherine L. PassarettiOpen the ORCID record for Catherine L. Passaretti[Opens in a new window] and
Michael P. Stevens
Graham M. Snyder*
Affiliation:
Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Catherine L. Passaretti
Affiliation:
Center for the Study of Microbial Ecology and Emerging Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USADivision of Infectious Diseases, Atrium Health, Charlotte, NC, USA
Michael P. Stevens
Affiliation:
Division of Infectious Diseases, West Virginia University School of Medicine, Morgantown, WV, USA
*
Author for correspondence: Graham M. Snyder, E-mail: snydergm3@upmc.edu
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Abstract

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Type
Research Brief
Information
Infection Control & Hospital Epidemiology , Volume 44 , Issue 5 , May 2023, pp. 845 - 846
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Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

The Centers for Disease Control and Prevention (CDC) released updated guidance for the control and prevention of coronavirus disease 2019 (COVID-19) for healthcare personnel (HCP) and facilities on September 23, 2022. This major update allows facilities to opt out of universal source control use by HCP providing care in counties where the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission level is not high.1 The CDC notes that this guidance does not apply to HCP caring for patients who have or are under evaluation for COVID-19, who have had recent close contact with someone with COVID-19 within 10 days, or are in a facility experiencing a COVID-19 outbreak; the guidelines also noted that facilities could choose not to opt out of source control when HCP are caring for immunocompromised people.1

Masking within healthcare facilities has been an evidence-based mainstay of COVID-19 risk mitigation.2 In addition to continually emerging SARS-CoV-2 variants, increases in seasonal respiratory viruses including influenza are expected for the 2022–2023 season.Reference Ali, Lau and Shan3 We hypothesized that acute-care hospitals may adopt approaches divergent from the new CDC masking guidance given these and other concerns.

Methods

We surveyed healthcare epidemiologists in the United States following release of the updated CDC healthcare COVID-19 guidance to understand their facilities’ planned approach to universal masking and unmasking outside of patient care areas. The survey also explored the rationale for maintaining universal masking.

The full survey is included in the Supplementary Materials (online). From participants in an informal e-mail–based list serve, we invited one representative from each US-based, nonfederal, acute-care hospital or health system. Deidentified study data were collected using REDCap (Research Electronic Data Capture) hosted at the University of Pittsburgh Medical Center.Reference Harris, Taylor, Thielke, Payne, Gonzalez and Conde4 This project was granted approval as a quality improvement study by the UPMC Quality Improvement Review Committee (project no. 4111).

Results

Among 44 healthcare epidemiologists invited to participate, the 34 respondents (response rate, 77.3%) represented health systems from diverse US regions (Supplementary Materials online). Most worked for health systems with multiple acute-care hospitals (n = 26, 76.5%) or facilities with ≥500 beds (n = 6, 17.6%).

Overall, 33 respondents (97.1%) reported that their facility has no immediate plans to discontinue universal masking, and 1 respondent (2.9%) reported their facility had discontinued, or planned to discontinue, universal masking if or when community transmission levels of COVID-19 were not high. No respondents reported that their facility had discontinued or would discontinue universal masking regardless of community transmission levels. Preventing non– SARS-CoV-2 seasonal respiratory viruses (90.9% of respondents) and impact on employee staffing capacity (72.7% of respondents) were the most cited reasons for continuing universal masking regardless of county-specific SARS-CoV-2 transmission levels (Table 1). The “other” reasons described by 7 facilities include several themes: standardizing approach across facilities; the operational challenges of variable or changing masking policies between facilities, within a facility, or as community transmission levels change; and the presence of high-risk individuals (Supplementary Materials online). Also, 7 respondents specifically cited inaccessibility to patients (or visitors) as defining locations where unmasking is permitted in patient care areas (Supplementary Materials online).

Table 1.

Healthcare Epidemiologist Responses to the Survey Question “What Reasons Informed Your Facility’s Decision to Maintain Universal Masking?”

Note: Respondents could choose >1 reason; therefore, percentages may total >100%.

Discussion

In this survey of US hospital epidemiologists primarily representing large, acute-care facilities and multifacility health systems, 97% reported no plans to discontinue universal masking allowed for by the most recent CDC COVID-19 healthcare guidance. Their reasons ranged from risk of respiratory viral spread to healthcare staffing mitigation to facility operational concerns.

Healthcare facilities are tasked with synthesizing CDC recommendations in the context of other respiratory viral illnesses and healthcare worker burnout and staffing shortages. Our survey revealed significant concerns about operationalizing the updated recommendations. Updated masking guidance is tied to county-specific COVID-19 levels with the potential that masking guidance could change week to week. Hospitals within broader health systems must reconcile guidance that may vary depending on geography. Once-weekly reporting of COVID-19 levels may lead to delays in re-escalating universal masking when COVID-19 activity increases. Within-facility SARS-CoV-2 spread among unmasked patients and employees would trigger re-escalation of universal masking may not be detected in real time and potentially result in harm. These factors are consistent with the rationale supporting the Association for Professionals in Infection Control and Epidemiology (APIC) statement against de-escalating universal masking on October 3.5

Our survey had several limitations. Participants in the listserv are self-selected; therefore, these results do not provide a systematic representation of US healthcare facilities. The survey also represents a temporal snapshot immediately following release of the new CDC guidance. This survey was not designed to reflect the merits and risks of masking.

The CDC updated guidance allowing de-escalation of universal masking in healthcare settings based on county-specific COVID-19 transmission represents a major change. The overwhelming majority of healthcare epidemiologists in our survey do not currently agree with adopting this new guidance, and survey respondents relied on scientific evidence of mask effectiveness and transmission patterns in their facility. Clear public health communication relying on robust data is essential to inform infection prevention approaches in acute-care settings.Reference Ng, Lim and Boa6,Reference Loeb, Bartholomew and Hashmi7 Based on our survey results and the APIC position statement, it may be prudent for facilities to wait to consider implementing the new guidance until the Spring of 2023.

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2023.9

Acknowledgments

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

G.M.S. reports that he is a consultant for Infectious Diseases Connect. C.L.P. and M.P.S. report no conflicts of interest relevant to this article.

References

Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Published September 23, 2022. Accessed September 28, 2022.Google Scholar
Science brief: Community use of masks to control the spread of SARS-CoV-2. Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html. Published December 6, 2021. Accessed September 30, 2022.Google Scholar
Ali, ST, Lau, YC, Shan, S, et al. Prediction of upcoming global infection burden of influenza seasons after relaxation of public health and social measures during the COVID-19 pandemic: a modelling study. Lancet Glob Health 2022;10:e1612–e1622.CrossRefGoogle ScholarPubMed
Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381.CrossRefGoogle ScholarPubMed
APIC urges IPs to continue universal masking in patient care areas. Association for Professionals in Infection Control and Epidemiology (APIC) website. https://apic.org/news/apic-urges-ips-to-continue-universal-masking-in-patient-care-areas/. Published October 3, 2022. Accessed October 17, 2022.Google Scholar
Ng, CYH, Lim, NA, Boa, LXY, et al. Mitigating SARS-CoV-2 transmission in hospitals: a systematic literature review. Pub Health Rev 2022;43:1604572.CrossRefGoogle ScholarPubMed
Loeb, M, Bartholomew, A, Hashmi, M, et al. Medical masks versus N95 respirators for preventing COVID-19 among healthcare workers: a randomized trial. Ann Intern Med 2022;175:1629–1638.CrossRefGoogle ScholarPubMed
Figure 0

Table 1.Healthcare Epidemiologist Responses to the Survey Question “What Reasons Informed Your Facility’s Decision to Maintain Universal Masking?”

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