Mask mandates are returning to some hospitals. Should they be there to stay?

Remember back in spring 2020, when severe personal protective equipment shortages plagued hospitals across the country? Healthcare providers on the frontlines reused dirty masks or tried cleansing them with solar power as they posted heartbreaking photos of their faces nearly bruised from the pressure of wearing an N95 for hours on end. Some who expected they would be infected even rented out separate apartments to keep their own families safe from contamination.

Eventually, global supply chains beefed up the production of masks and other protective gear, vaccines were developed and released, which combined with natural immunity massively reduced the number of COVID-19 hospitalizations and deaths. In May 2023, the Centers for Disease Control and Prevention (CDC) rolled back some of its transmission prevention rules, recommending hospitals reinstate mask mandates as community transmission rises, but ultimately leaving it up to individual hospitals to decide when and how that process unravels while also removing universal testing requirements for patients and hospital staff. 

With COVID-19 cases steadily rising since June, and the EG.5 mutation (nicknamed "Eris") contributing to a large portion of the spread, at least 18 hospitals nationwide have made headlines for bringing back mask mandates — but a federally mandated measure has yet to be put in place. While the chance of severe disease is reduced for those who have been vaccinated or who have already had a COVID infection, doctors are concerned about vulnerable patients in hospitals, which are by nature meeting points for all sorts of disease-causing pathogens, not just SARS-CoV-2, the virus that causes COVID. Hospitals are also at elevated risk of things like long COVID, which can occur even in the vaccinated, young and otherwise healthy.

"Our elderly relatives, people with serious illnesses — these are the only places they can go to get care when they are in the worst shape of their lives," said Dr. Theodore Pak, an infectious diseases fellow, who has seen hundreds of COVID-19 patients at the hospitals he practices at in Boston, Massachusetts. 

"We may give somebody a powerful medication that takes away their entire immune system and then in order to get medical care, they have to go to a hospital where they sit next to people that are unmasked that could give them a disease that could kill them," Pak told Salon in a phone interview. "We don't really think about that or weigh that risk anymore."

President Joe Biden declared the pandemic "over" in September 2022, but COVID-19 was the fourth leading cause of death that year. In 2023, it's still the seventh leading cause of death. Although a new batch of no-cost vaccines became available last month, the jury's still out on how many Americans will actually take them, especially due to hiccups in the rollout.

Despite solid evidence that masking works to reduce the spread of COVID-19, recent mask mandates in schools or other settings have been controversial, continuing the politicization that has delayed pandemic response throughout. When a security guard enforced a mask mandate in Rochester, New York in February 2022, he was criminally charged. Mask mandates in hospitals are no exception, with a hospital system in West Virginia facing backlash when it reinstated its mask mandate in January 2023 and some doctors arguing that the time for universal masking in hospitals has come and gone.

But other doctors are urging hospitals to put safety first. Research shows that when community COVID-19 transmission increases, it translates to an outsized COVID-19 spread in hospitals. One study of hospitals in England and Scotland found COVID-19 cases that originated in the hospital jumped 41% after they stopped universal testing upon admission. Another study in JAMA Oncology found more patients with cancer died from COVID during the winter Omicron wave than prior waves, which the authors linked partially to "the relaxation of policies to prevent SARS-CoV-2 transmission."

Many healthcare providers on the frontlines warn that loosening protective measures in hospitals can increase infections from not just COVID-19 but also flu and other viruses. In one study within Brigham and Women's Hospital, COVID-19 protocols cut the spread of the season's other two major viruses, flu and respiratory syncytial virus (RSV), by 50%. Another study published today found pandemic protocols at the University of Texas MD Anderson Cancer Center reduced respiratory viral infections among vulnerable patients.

"It's one thing for us to be over the pandemic in general society, shopping malls and whatever other settings," Pak said. "But to me, hospitals, nursing homes and healthcare facilities are different places from a moral perspective."

Not only have hospitals stopped universally testing inpatients for COVID-19, but the entire system to test and treat COVID has been dismantled outside of hospital systems, as PCR and rapid tests become less available and more expensive, said Dr. Lara Jirmanus, a primary care physician and clinical instructor at Harvard Medical School. As a result, public health agencies are having to rely on hospitalizations and wastewater data, which is available in fewer than half of U.S. counties, to gauge the level of the pandemic. However, hospitalizations are a delayed metric for tracking the spread of disease that by nature puts health care workers and vulnerable patients at the frontlines.

Want more health and science stories in your inbox? Subscribe to Salon's weekly newsletter Lab Notes.

"With the end of the public health emergency, the CDC also stopped asking hospitals to report how many patients have hospital-onset COVID, so we don't even have any way of measuring the serious impact, the damage we ourselves in the healthcare sector are doing to people by exposing them to COVID," Jirmanus told Salon in a phone interview. "How are we supposed to assess the impact of a policy, if we have gotten rid of the evidence?"

In Canada, safety protocols are mandated by the provincial Ministry of Health. Dr. Paul Winston, a physiatrist in British Columbia, said on one hand that leads to some tension because hospitals don't have a choice on whether to instate a mask policy or not. On the other hand, it does protect healthcare workers from violence or conflict, which they face in the U.S. when the onus of these mandates is left to them.

"It does take away the stress," Winston told Salon in a phone interview. "You can just say, 'Look, it's now the rule. You have to mask in my clinical office.'"

The CDC is currently revising its 2007 isolation precaution guidelines for healthcare facilities, but the agency has been criticized for further weakening protective measures. National Nurses United said in a letter addressed to the agency that the workgroup that convened to discuss the revisions was "developed without input from many important stakeholders, including frontline personnel."

The agency is working to get expert opinions on the guidance before finalizing a draft and a spokesperson told Salon that a response would be issued "very soon."

Dr. Andrew Wang, a health equity researcher at Northwestern University Feinberg School of Medicine, says at the end of the day, the responsibility shouldn't be on patients, who may already be sick and vulnerable in hospitals, to mitigate the spread of COVID-19. Instead, it's up to health leaders to establish standard practices for everyone to follow, he added.

"It's the health care policymakers and leaders who are ultimately accountable for downplaying the risks of COVID in health settings," Wang told Salon in a phone call.