Comment: CDC’s new mask guidance could be too slow to respond

In the event of a surge, its recommendations could delay a response, allowing covid to spread rapidly.

By Julia Raifman and Eleanor Murray / Special To The Washington Post

The Centers for Disease Control and Prevention recently unveiled new guidelines for coronavirus control in the United States, increasing the thresholds of disease that trigger recommendations for mask-wearing. In the blink of an eye, the CDC pivoted from recommending that nearly everyone wear a mask to saying it was necessary for only about 30 precent of Americans.

The guidelines’ chief innovation is to combine case levels with hospitalization figures — those related to hospital admissions as well as availability of staffed beds — rather than using case numbers alone. Under the old guidelines, a coronavirus case rate of 50 per 100,000 in a county was enough to trigger a recommendation that individuals mask indoors; now the case rate must be four times as high for the recommendation to kick in. (At lower case rates, high hospitalization numbers can also trigger masking recommendations.)

While it is true that strain on hospitals is an important public health consideration, there is much about this approach that could be improved. The virus may be with us for years, causing severe illness, long covid, deaths and social and health-care disruption, with a high and inequitable cumulative toll. A sounder public health strategy to address it would be tailored to respond more quickly and effectively to surges.

A recommendation for universal masking should turn on when case counts alone are on the rise, even if they are not yet high. In the context of a highly transmissible variant such as omicron, just a one-week delay in implementing control measures could lead to twice as many cases, as well as to preventable hospitalizations and deaths (which do not follow cases in a 1:1 relationship).

Masks are far more powerful as a public health tool implemented through mandates than as an individual protective measure. But the new guidelines on masking are squarely directed at individuals. Even when transmission is considered “high” under the new formulas, the CDC does not provide clear recommendations for states and municipalities, offering this advice instead: “Consider setting-specific recommendations for prevention strategies based on local factors.” And under what the CDC considers “medium” community spread, the agency tells even immunocompromised people to simply “talk to your health-care provider about whether you need to wear a mask,” punting on the question its officials should lead in answering. (Mask mandates in surges are more popular than the vocal minority opposed to them might suggest. According to a recent Washington Post-ABC News poll, 58 percentof Americans think controlling the spread of the virus remains more important than having no restrictions on behavior.)

At the same time, the CDC recommends that in some settings —notably, hospitals and nursing homes — everyone should mask, regardless of vaccination status, and masking should be particularly emphasized when community transmission is substantial or high under the old standards (50 to 99 cases per 100,000 and 100-plus cases per 100,000, respectively). This exception tacitly acknowledges that in settings where it’s really important that people not get infected, the new guidelines are insufficient.

But hospitals and nursing homes are not the only settings in which vulnerable people need protection, nor should we normalize rates of infection that, until last month, were considered high. Schools and many workplaces are settings with high exposure to shared air, over a long duration, increasing risk of transmission of the coronavirus. These are also spaces that most people can’t choose to avoid; including children and adults with any of several health conditions that increase the risk of severe illness or death. So far, covid has tended to produce less-severe symptoms in children than in adults, but it has still caused nearly 1,400 child deaths in the United States. And there is no guarantee that we will not encounter a future variant that is more severe for children.

Loosening mask guidelines is likely to exacerbate already large disparities in covid-19 by race, ethnicity and income. In January, according to the Census Bureau’s Household Pulse Survey, workers in the lowest income bracket (making less than $25,000) were 3.5 times more likely to report missing a week of work because of covid than workers in the highest income bracket (making more than $100,000).

Preparedness to turn on mask mandates is one key element of reducing the harms of surges, but so are vaccines, tests, ventilation and treatment access. Especially because these new guidelines will mean fewer people wear masks, the CDC ought to redouble efforts to spread the word — in multiple languages — about the importance of vaccination for adults and children, letting them know as well where they can go for walk-in vaccinations. The federal government took a step in the right direction by beginning to make free masks and tests available; ideally, officials would prepare to make masks and tests available in every high-exposure setting at the start of every surge, ensuring that distribution focuses first on the communities, occupations and individuals most at risk. Previous distribution efforts often overlooked Black and Latino neighborhoods, for example, despite high rates of covid-19 in those populations.

The new “test to treat” program is also promising: The Biden administration has said a positive test at a drugstore or clinic will lead directly to the prescription of antiviral drugs. But that plan requires a mass communications campaign, in several languages, to inform the public about the importance of early diagnosis and treatment. And it should not be an excuse to eliminate prudent steps to reduce viral transmission; especially given that even moderate cases of covid-19 can lead to long covid, cognitive effects and higher risk of cardiac events.

This period of lower transmission is something to be thankful for, but we cannot expect the lull in cases to last forever. The United States has a bad record of handling surges, experiencing higher death rates than other high-income countries. The CDC’s new masking guidelines make it more likely that we will repeat that performance, exacerbating inequities in the process. All in all, the CDC’s messaging and policies should better conform to the agency’s mandate, as reflected in its name. That mandate is not to keep hospitalization rates manageable or to balance political goals with public health. It is to control and prevent disease.

Julia Raifman is an assistant professor of health law, policy and medicine at Boston University and leads the covid-19 U.S. State Policy Database. Eleanor Murray is an epidemiologist and assistant professor at the Boston University School of Public Health.

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