ID Experts Urge Healthcare to Shed Universal Masking

The time for COVID-inspired universal masking in healthcare "has come and gone," even if only for now, infectious disease specialists argued in Annals of Internal Medicine.

Expanded use of facemasks -- for clinicians, staff, patients, and visitors -- was implemented as a "critical protective measure" during the pandemic, but it was done so in the context of no population immunity, limited testing capacity, and no vaccines and therapeutics, wrote Erica Shenoy, MD, PhD, of Harvard Medical School and Mass General Brigham in Boston, and colleagues in an editorial.

Yet "despite the evolution of the pandemic and transition to endemicity," healthcare facilities are among the last places with widespread masking requirements, even after such mandates were lifted by state and local authorities, according to the group.

"Our goal was to outline the rationale for universal mask use in healthcare settings earlier in the pandemic, why we should end it now, and what conditions in the future might prompt a discussion on bringing it back with either more widespread masking, or perhaps targeted masking," Shenoy told MedPage Today via email.

"While the Annals is read by a healthcare audience, we believe that the assessment we have put forth articulates to all audiences the conceptual approach to the use of masking (and other infection-prevention interventions) in the context of changing circumstances, and to emphasize how important it is to have evidence-based public policy that adapts," she added.

Indeed, Shenoy and colleagues acknowledged that masking requirements in healthcare have continued longer than those in the community, "because these settings have a higher proportion of individuals at high risk for complications of infection."

"However," they added, "the context and conditions of the pandemic have changed dramatically and favorably since masking requirements in healthcare were initially adopted, and evidence-based public health policy should also adapt in response."

COVID-19's burden has eased, they stated, with both the World Health Organization and the U.S. government moving to end related public health emergencies.

Shenoy's group also pointed to a type of cost-benefit analysis.

They said that holding on to masking requirements for healthcare personnel during all direct clinical encounters "may marginally reduce" transmission risk for personnel to patients and vice versa, but "potential incremental benefits ... need to be weighed against increasingly recognized costs." For instance, masking impedes communication and is a barrier that unequally affects different patient populations. They noted that patients for whom English is not their preferred language, and for patients who are hard of hearing, there could be disproportionate challenges tied to universal masking.

Additionally, an increase in listening effort prompted by masking is "associated with increased cognitive load for patients and clinicians," they said, and masks obscure facial expression, which can contribute to feelings of isolation and negatively affect human connection, trust, and perception of empathy.

Shenoy and colleagues advocated for healthcare professionals to manage SARS-CoV-2 as they do other endemic respiratory viruses with standard precautions, such as:

• Use a mask and eye protection when engaging in actions that could generate splashes or sprays to the face, regardless of a patient's symptoms
• Require masks for individuals with respiratory symptoms as a means of source control
• Implement transmission-based precautions (e.g., personal protective equipment) when caring for patients with suspected or confirmed respiratory infection

The authors also said that other pandemic-era strategies like asymptomatic testing and resource-intensive contact tracing should be reconsidered as well.

Shenoy told MedPage Today that "there will most certainly be differing opinions across healthcare on this topic. However, I believe that most experts in the field will agree that the conditions of the pandemic have changed dramatically and favorably, and we hope that the conceptual approach to adapting our responses and interventions to the current conditions will resonate with colleagues from all perspectives."

And Shenoy and colleagues pointed out that masking policies "remain an important infection-prevention strategy," so educating healthcare professionals, patients, and others regarding ongoing policy changes will be essential.

"Future pandemics or significant localized outbreaks may justify more widespread or targeted masking policies, respectively, as part of a bundled response," they said. "High-quality epidemiologic data with frequent updates and regular reevaluation are needed to inform scale-up or scale-down decisions."

The group called for "focused research to quantify the incremental value of interventions under various epidemiologic circumstances and to support the development of a learning healthcare system. This is essential to allow active and ongoing local reassessment of utility to ensure requirements are not maintained longer than necessary and are reinstated when needed."

They added that more data on transmission risk across respiratory viruses, and intensity of exposures during asymptomatic, presymptomatic, and symptomatic stages, will help inform future policy.

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