The guidelines’ chief innovation is to combine case levels with hospitalization figures — those related to hospital admissions as well as occupancy levels of staffed beds — rather than using case numbers alone. Under the old guidelines, a 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 that for the recommendation to kick in. (At lowercase rates, high hospitalization numbers can also trigger masking recommendations.)
While it is true that whether hospitals are under stress is an important public health consideration, there is much about this approach that could be improved. The virus may be with us for years, repeatedly causing severe illness, long covid, deaths, and social and health-care disruption, with a high and inequitable cumulative toll. A sounder public health strategy, therefore, would be one tailored to respond more quickly and effectively to surges.
A recommendation for universal masking (as well as increases in supplies of masks and tests) 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, a one-week delay in implementing control measures could lead to twice as many cases as well as preventable hospitalizations and deaths.
Masks are far more powerful as a public health tool implemented through mandates than as an individual protective measure, as reports in the CDC’s morbidity and mortality weekly report document. 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 they should lead in answering. (Meanwhile, mask mandates in surges are less unpopular than a vocal minority opposed to them make them seem. According to a recent Washington Post-ABC News poll, 58 percent of 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). The exception tacitly acknowledges that in settings where it’s really important that people not get infected, the new guidelines are inappropriate.
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 risk of severe illness or death. As for schools: So far, the coronavirus has tended to produce less-severe symptoms in children than in adults, but there have been 1,500 child deaths due to covid in the United States, with 500 of those since Jan. 1. 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 U.S. 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 work because of covid-19 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 given the reduction in masking that will accompany these new guidelines, 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 they would prepare to masks and tests available in every high exposure setting at the start of every surge, with a focus on ensuring that distribution focuses first on the highest exposure communities, occupations, and individuals. Previous distribution efforts have often overlooked Black and Latino neighborhoods, for example, despite high rates of covid-19 in those populations.
The new “test and treat program” is also promising: The Biden administration has said a positive test at a drugstore or health clinic will lead directly to the prescription of the antiviral drug. But that plan requires a mass communications campaign, in several languages, to inform the public about the importance of early diagnosis and treatment. It should also not be used as 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 impacts and higher risk of cardiac events.
This period of lower transmission is something to be thankful for, but we cannot expect the current 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 reflect the agency’s mandate, as reflected in its name. That mandate is not to keep hospitalization rates manageable or to balance political goals with the public health. It is to control and prevent disease.
