For Patient Safety, It Is Not Time to Take Off Masks in Health Care Settings

Abstract

As the COVID-19 public health emergency is lifted and the pandemic continues to recede, hospitals must decide how to deescalate mitigation strategies to sustainable states. This commentary advocates continuing universal masking in health care settings.

As the COVID-19 public health emergency is lifted and the pandemic continues to recede, hospitals must decide how to de-escalate mitigation strategies to sustainable states. Decisions about modifying institutional strategies for infection prevention and control are complex and depend on regional and institutional factors. As health care facilities approach this crossroad, we urge their leaders to take stock of what we have learned regarding masking and patient safety.

Masking in the community has been a controversial mitigation strategy during the pandemic, in part because of the dearth of high-quality evidence documenting efficacy and in part because mask wearing has become politicized. Most published studies addressing mask efficacy have methodological flaws, and adherence to mask wearing has been suboptimal in virtually all. Demonstrating that masks work is difficult when they are not worn consistently. Although gold-standard evidence is not available, we argue that, despite the lack of clinical efficacy trials (as with the widely accepted practice of hand hygiene), masking in interactions between patients and health care personnel should continue to receive serious consideration as a patient safety measure.

Laboratory studies have done what clinical research has not and demonstrated that surgical masks—and to a greater extent, filtering facepiece respirators—are effective in limiting the spread of aerosols and droplets from individuals infected with influenza, coronaviruses, and other respiratory viruses (1). Although not 100% effective, they substantially reduce quantities of virus expelled during coughing or talking, thereby mitigating risk (2).

Real-world experience shows the effectiveness of mask wearing in clinical settings. Thanks largely to universal masking and use of other personal protective equipment, health care personnel have been at far greater risk for acquiring COVID-19 from community than occupational exposures (3). Transmission from patient to staff and staff to patient when both are masked does occur but is uncommon (4).

A compelling reason for continuing masking in health care is presenteeism, a behavior that long preceded, and will likely outlast, the pandemic. Health care personnel are notorious for coming to work while ill. In studies conducted during the pandemic, half to two thirds of health care personnel acknowledged working with symptoms of respiratory illness (5). Presenteeism has been well documented in health care–associated respiratory viral outbreaks (6), with various reasons proffered, including an unwillingness to place burdens on colleagues, a belief that some respiratory infections may be trivial, a fear of reprisal for absenteeism, a moral imperative to provide patient care, and, for those in some roles, a lack of paid sick leave. We can find no reason to believe these time-honored behaviors will change if masks come off.

In one of our hospitals, the NIH Clinical Center, we studied presenteeism in detail during the pandemic via contact tracing interviews (NIH Clinical Center. Unpublished data.). Among staff who chose an asymptomatic rather than a symptomatic testing pathway and tested positive, more than 50% subsequently acknowledged having had some symptoms characteristic of COVID-19 at the time of testing. These data underscore the problem of presenteeism and emphasize the appropriateness of masking. Despite the proximity of personnel providing care, no transmission to patients was identified.

Presymptomatic transmission of respiratory viruses, particularly SARS-CoV-2, provides additional grounds for the continued use of masking in clinical contexts (7). Those who are vaccinated against influenza or SARS-CoV-2 may present with mild symptoms that are often minimized or mistaken as noninfectious (6). In addition, up to a third of Omicron infections are asymptomatic (8)—but could nonetheless cause severe or life-threatening disease or prolonged illness if transmitted to immunologically vulnerable patients. Hospitals serving elderly and immunocompromised patients, such as oncology patients and stem-cell and organ transplant recipients, face challenges when deescalating measures that protect these patient populations.

Universal masking may not be the only valid approach. One could envision other reasonable approaches to this issue, based on the clinical setting. Examples include masking only during respiratory virus season, beginning in the fall; masking on wards housing patients at higher risk for serious sequelae of respiratory virus infections; or masking staff and visitors but allowing optional masking for patients (one-way masking). In any event, exposing patients unnecessarily to infections that are preventable by masking seems directly contrary to the principles of patient safety. For all of these reasons, we advocate remaining masked during patient interactions.

Use of masks in the clinical setting should continue to be studied for both benefits and untoward consequences. The most concrete pitfalls of masks, such as impeding communication and negatively affecting empathy, should become fodder for engineers and developers to improve or redesign masks to obviate these issues.

On balance, despite the limitations of existing masks, health care institutions functioned reasonably well during the pandemic. Some have argued that sustaining universal masking is impractical for patient care. During the early HIV/AIDS epidemic, some physicians said they simply could not—for a host of reasons—wear gloves even when situations were associated with likely exposure to blood or bloody body fluids. Health care personnel have adjusted to this requirement, and glove use in such situations has now become the standard of care and is widely accepted as part of standard precautions.

We are struck by the broad efficacy of masks for source control and protection during the pandemic and find this to be one of the major lessons learned with enduring value as a patient safety measure in health care. A striking finding was the remarkable reduction in the health care–associated transmission of virtually all respiratory viruses, not simply SARS-CoV-2, in our institutions and others. Although not all of our colleagues agree with our approach (9), a survey of hospital epidemiologists across the country suggests that, as recently as the fall and winter of 2022, about 97% of surveyed hospital epidemiologists were not eager to eliminate masks in their facilities (10). Perhaps that sentiment has shifted in the past 4 months, but the support of many infection prevention experts for using masks for broad prevention of respiratory virus transmission, and not simply SARS-CoV-2, suggests that many others share this view.

In our enthusiasm to return to the appearance and feeling of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not discarding this important lesson learned for the sake of our patients’ safety.