Experts who advise the US Centers for Disease Control and Prevention on its hospital infection control guidelines have voted to recommend that health care providers wear masks during routine care for patients who are thought to be contagious, including for patients with endemic, or regularly occurring, respiratory infections.
This draft recommendation does not specify what kind of mask to wear — either looser-fitting surgical masks or more fitted and tightly woven N95 respirators. The decision frustrated some advocates for frontline health care workers and immune-compromised patients who wanted to see a strong recommendation for the use of N95s in all patient-care situations.
The CDC’s Healthcare Infection Control Practices Advisory Committee, known as HICPAC, did recommend the use of N95s in cases where patients are infected with new or emerging pathogens for which vaccines and treatments are not available. N95s were also recommended for situations where patients may have infections that are known to spread efficiently through the air over long distances, such as measles.
Jane Thomason, lead industrial hygienist for National Nurses United, the largest nursing union in the US, said the draft inappropriately treats surgical and medical masks as personal protective equipment, or PPE, and respiratory protection.
“A surgical or medical mask does not provide protection against inhalation of infectious aerosols,” Thomason wrote in a statement to CNN on HICPAC’s draft recommendations. “NNU urges CDC to fully recognize the science on aerosol transmission of infectious diseases and respiratory protection (including N95s, powered air purifying respirators, and elastomeric respirators) in creating infection prevention guidance,” Thomason wrote.
Guidelines aren’t yet final
The masking recommendation is just one of a suite of draft recommendations for the control of infections in health care settings that was voted on at the meeting, but it is one of the most contentious.
That recommendations are not final. They will next go to the CDC for its sign-off. Once the CDC approves, the draft recommendation will be published in the Federal Register and members of the public have 60 days to comment. After the comment period ends, HICPAC will review the comments and may tweak its draft guidelines and vote on them again. Final versions of the guidelines aren’t expected until 2024.
The guidelines aren’t mandatory, but many hospitals hew to them. They’re also used as the basis of standards made by other agencies like the Occupational Safety and Health Administration, which defers to CDC when it comes to infectious disease. The last time the guidelines were updated was 2007.
In July, NNU drafted a letter to CDC Director Dr. Mandy Cohen voicing its concern that the new guidelines, if implemented as drafted at the time, would significantly weaken protections for health care workers. Thousands of health care workers died during the Covid-19 pandemic and others have been disabled by long Covid.
NNU’s Thomason fears that if the new guidelines walk back protections for health care workers, the US could see a similar catastrophe during the next pandemic.
“What they are working on … it’s going to impact patients and health care workers in so many different places. It’s going to determine whether some of them live or die, quite honestly,” Thomason said.
The advisory committee set out to simplify and update the older document, which is more than 200 pages long. To guide the updates, it relied on new reviews of the medical literature conducted by the CDC. One of those reviews concluded that surgical masks were just as effective at preventing respiratory infections as N95s, raising alarm with patients and advocates for frontline health care workers. The committee’s draft guideline also appeared to walk back other infection control measures for pandemic causing respiratory viruses, advising that keeping patients in airborne infection isolation rooms was “not routinely recommended.”
HICPAC was praised by some at the meeting for clarifying that germs spread through the air, rather than through droplets that transmit only at close range, which had been the dogma of infectious disease transmission before Covid-19 proved that notion wrong.
However, NNU and other organizations said that while the documents seemed to update the mode of spread, they still didn’t appropriately address the problem of airborne germs. Critics, including groups such as the People’s CDC, have also been concerned that the draft guidelines only obliquely mention ventilation or strategies to clean indoor air like air filtration or UV light.
“HICPAC’s draft is permissive and weak and seeks not just to maintain existing practice — which has been shown to be inadequately protective — but even rolls back the use of some important measures, such as airborne infection isolation rooms,” NNU President Zenei Triunfo-Cortez said in a statement on Friday. “This draft guidance will only further degrade the already dangerous working conditions of nurses and other health care workers and further contribute to high rates of moral distress, which will only serve to drive more nurses away from the bedside and further deepen the staffing crisis in health care.”
Patients speak up
During public comment periods on Thursday and Friday, HICPAC heard from several patients with long Covid or conditions that lower their immune function that they did not feel safe accessing health care because they couldn’t be sure their providers would wear protective masks when treating them.
Christine Braile said she was commenting on behalf of her 16-year-old son, who has a condition that weakens his immunity called primary immune deficiency. She said he is now living with long Covid after catching the infection from a home infusion nurse who did not mask properly.
“Loosening the patient protections for respiratory diseases, especially Covid will only hurt patients and further decimate staffing levels,” Braile told the committee.
“Respirators, ventilation, and air filtration and UV are all needed to safeguard at-risk patients like my son.”
Other commenters voiced similar concerns.
“I am deeply afraid of being in a situation where avoiding health care is not an option,” said Seifer Almasy, who spoke as a member of the public. He said he was recently in that situation when he decided he couldn’t put off getting his updated Covid-19 and influenza vaccines. He said he made 34 phone calls and was on hold for more than four hours to find a provider that would wear an N95 while giving him his vaccines.
“HICPAC must recommend clear, robust and authoritative precautions against the airborne transmission of pathogens. Anything less is malpractice and will do harm,” Almasy said.
Many urged HICPAC to delay its vote until it could get input from vulnerable patients and experts in worker protections and aerosol scientists.
All nine voting members of the committee approved the recommendations considered at this meeting.
However, one of the 22 non-voting members expressed concerns about the committee’s process.
“We share many of the ongoing concerns that have been raised by folks that are in the public comment period today,” said Paul Conway, chair of policy and global affairs of the American Association of Kidney Patients, and a liaison member of HICPAC.
Conway noted that if the CDC wanted to strengthen its engagement with the public, there were available models for “substantive engagement of people with lived experiences,” through the World Health Organization, the Veterans Affairs Administration, and the US Food and Drug Administration.
The CDC says members of the public will be given a chance to comment on the guidelines.
“The advisory committee has not introduced any binding recommendations, but is instead kicking off a process that includes a transparent, lengthy public comment period,” a spokesperson said.
Push for transparency
Still, Thomason and National Nurses United have already filed an open records request for the meeting summaries of the work group that’s developing the new guidelines.
“You can see from the very first meeting, there’s this orientation towards flexibility and feasibility, this orientation towards like, what is it going to cost employers really over and above protecting health care workers and patients. They are really focused on kind of those business concerns,” she said.
Three of the CDC committee representatives were among the authors of a June editorial in the Annals of Internal Medicine that argued against universal masking in health care settings to protect against Covid-19. The editorial said masking impedes communication and increases “cognitive load” for health care workers and patients, who have to make an extra effort to listen without the benefit of lip reading or facial expressions.
“We have achieved major advancements in the prevention and management of SARS-CoV-2 since the pathogen was initially identified in 2019,” the editorial said. “In recognition of these achievements, the time has come to deimplement policies that are not appropriate for an endemic pathogen when the expected benefits of such policies are low. Universal masking in health care is a policy whose time has come and gone … for now.”
The CDC had already heard some complaints and concerns about the draft guidelines.
In October, Dr. Michael Bell, deputy director of CDC’s Division of Healthcare Quality Promotion and Cohen, the CDC director, listened to concerns about the early evidence review from several experts in airborne transmission of infectious disease and worker protections. Bell said because this session was not a public meeting, they couldn’t engage in dialogue with the experts, but he promised to take the comments back to the HICPAC. The minutes of the meeting were posted online.
Dr. David Michaels, an epidemiologist and professor at the George Washington University School of Public Health, said the new guidelines should have benefited from all the knowledge about the transmission of respiratory infections gleaned during the pandemic. Instead, he said, “this is going backwards.”
The conclusion of the evidence review that surgical masks work as well as N95 masks contradicts the findings of a 2022 study by researchers at the University of California at Berkeley and the California Department of Public Health that showed people who said they consistently wore N95 masks in public settings were less likely to test positive for Covid-19 compared with those who wore surgical or cloth masks.
“I think what’s happened here is the members of this committee came to us with prejudgment on how infection control should be applied,” said Michaels, who was part of a group of experts that addressed HICPAC with its concerns about the draft during an October listening session.
“This committee has no members who have expertise in worker protection, or in aerosol science,” said Michaels, who is also the former head of the Occupational Safety and Health Administration. “And so their view of infection control is a hospital-based view and hasn’t changed in decades.”
The Society for Healthcare Epidemiology of America said in a statement that it continued to support HICPAC and its work.
“We believe that healthcare epidemiologists are uniquely qualified to lead HICPAC efforts given our specialized training, knowledge and professional experience in the prevention of infectious disease transmission in healthcare settings,” the statement said.
Correction: A previous version of this article misattributed a statement by the Society for Healthcare Epidemiology of America.
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