Lifting Mask Requirements in Nonclinical Workspaces in Healthcare Facilities

This guest post was written by Jorge Salinas, MD, Hospital Epidemiologist at the University of Iowa Hospitals & Clinics. 

The COVID-19 epidemiologic situation in the United States has improved tremendously. The Centers for Disease Control and Prevention (CDC) recently modelled that the United States will continue seeing a decreasing incidence in coming months. There is also increasing recognition that vaccines are protective against infection and transmission. Because of these factors, an updated CDC guidance for settings other than healthcare facilities states that fully vaccinated people may attend indoor gatherings without wearing a mask. These indoor locations include restaurants, bars, gyms, movie theaters, and full-capacity worship services. They even allow singing in an indoor chorus. This qualitative jump has —of course— been received with skepticism by many members of the public including some public health practitioners. 

Some of the reasons for the criticism arise from 1) how difficult it is to determine if unmasked persons are in fact vaccinated, 2) the low vaccine uptake in some localities, and 3) the relatively high incidence in these communities. These are adequate indicators that should influence de-escalation of universal mask requirements in the community. However, confirming the vaccination status of people in public indoor spaces represents the hardest challenge to overcome. We may be able to bypass it by assuring that high vaccination levels and a low incidence have been achieved in the community. If these principles hold true for the community, I believe they are true for some areas in healthcare settings too. Healthcare facilities (Hospitals, nursing homes, long-term care facilities) have several factors that make them special such as caring for vulnerable people: elderly, ill, or immunosuppressed patients. However, healthcare facilities have better administrative and engineering controls than community settings, namely, higher vaccination rates and air handling. Healthcare facilities also have several spaces, some of which, host only healthcare workers while other areas have visitors and patients. 

The latest CDC recommendation for COVID-19 infection prevention and control in healthcare facilities from April 2021 states that “In general, fully vaccinated HCP should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing”. This recommendation acknowledges that the COVID-19 vaccines approved in the United States are quite good at preventing both infection and transmission. However, the same guidance states that “If unvaccinated HCP are present, everyone should wear source control and unvaccinated HCP should physically distance from others”. Because of the astonishing protection derived from vaccination, healthcare workers may be able to have maskless meetings and lift mask requirements in shared workspaces and gatherings even if the vaccination status of each individual worker is not known. To achieve that safely, healthcare facilities will need to ensure high vaccine acceptance rates among healthcare workers (e.g., >70%), vaccination among those eligible in the public is high (e.g., >50%), and community incidence is low (e.g., <10/100,000 population). Facilities should require that healthcare workers who were not vaccinated continue wearing masks. 

As the incidence of COVID-19 continues to decline and vaccination rates go up, further de-implementation will also need to be considered in the future: for example, lifting mask requirements in hallways and waiting areas for healthcare workers, visitors, and patients. Lastly, mask wearing when providing patient care will also need to be evaluated. Many societal milestones will need to be met before these next de-implementation phases.

As with other de-implementation efforts, it will be important to have adequate surveillance in place to detect if this change is associated with increases in transmission.  Other factors such as potential future increases in community incidence either because of emerging variants of concern or waning immunity are also possible but not very likely in the short term.

Throughout the pandemic, everyone in charge of national, local public health, as well as healthcare epidemiologists/infection prevention professionals have made decisions with incomplete information and risking the possibility of being wrong. We must, however, not let our fear of being wrong keep us from implementing —or de-implementing — measures when the epidemiologic parameters support it.