Ideas and Opinions22 August 2023

Lessons From the COVID-19 Pandemic: Updating Our Approach to Masking in Health Care Facilities

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    The COVID-19 pandemic has upended societal norms and changed the way we view the health risks associated with respiratory viral infections. Although extensive research has helped elucidate the transmission dynamics of SARS-CoV-2 and expanded our understanding of COVID-19–associated health complications, much remains to be learned, especially with regard to long-term sequelae of infection. In health care, universal masking was implemented as a key source control measure to reduce risk for nosocomial SARS-CoV-2 transmission among patients and health care workers (HCWs), based on the available evidence that masking could reduce risk for respiratory viral transmission (1). The end of the COVID-19 emergency declarations by the World Health Organization and the U.S. federal government has prompted discussions about the future of masking in health care settings (2, 3) as COVID-19 is increasingly viewed as an established and ongoing health issue. In our view, the ongoing disease burden among persons at highest risk for severe COVID-19, the large proportion of transmission from asymptomatic and presymptomatic cases, uncertainty about the future course of the pandemic (4), and the effects of post–COVID-19 conditions merit integration of lessons learned from the pandemic into health care precautions and policies.

    Although rates of severe COVID-19 have decreased because of increasing community immunity and access to medical countermeasures, severe outcomes attributable to COVID-19 are still occurring. Deaths disproportionately affect older persons (5), those with underlying comorbidities, and those experiencing long-standing inequities in care. Furthermore, we are only just beginning to understand and measure the postacute and long-term ramifications of SARS-CoV-2 infections, even among persons with asymptomatic or mild acute illness. In health care settings, COVID-19 can lead to infection and greater morbidity and mortality due to the presence of many people who are at high risk because of age and underlying conditions. Many facilities include units for patients at the highest risk, such as transplant, oncology, and geriatric patients; however, high-risk patients are scattered throughout hospitals, and facilities have a responsibility to promote widespread safety measures to limit the spread of hospital-acquired infections. People in the general community no longer take the same precautions they did at the height of the pandemic and have returned to normal activities despite ongoing circulation of SARS-CoV-2 and other endemic respiratory viruses. This provides further rationale to integrate precautions, such as masking, as part of general practice to protect patients, especially those who are most vulnerable to severe disease (6). Masking also remains an important mitigation measure to protect the health of our health care workforce, including those who are at high risk for severe disease. Preventing HCW infection is vitally important in maintaining the capacity of an already severely strained health care system.

    In a recent article, Shenoy and colleagues (2) proposed a transition back to prepandemic approaches to mitigating health care–associated respiratory viral infections by using Standard Precautions and Transmission-Based Precautions in health care settings. This recommendation assumes that our prepandemic approach to preventing hospital-acquired respiratory viral infections was adequate. In fact, it is likely that before the pandemic, we vastly underappreciated the degree of harm caused by hospital-acquired respiratory viral infections that were preventable by masking among patients and HCWs (7). Prior policies focused exclusively on limiting health care–associated infections from identified ill patients to HCWs. As Palmore and Henderson highlight (3), the lessons learned from the COVID-19 pandemic have led to a greater appreciation of asymptomatic, presymptomatic, and pauci-symptomatic transmission of SARS-CoV-2 and other endemic respiratory viruses (8). Prior policies assumed that patients with active infection are identified, tested, and isolated appropriately. Yet it is estimated that asymptomatic and presymptomatic cases account for the majority of SARS-CoV-2 spread (9). These findings mean that it is not possible to consistently identify patients and HCWs who are capable of transmitting virus, especially as hospitals discontinue universal SARS-CoV-2 admission testing. We also recognize that nonrespiratory symptoms and diagnoses (10) may further delay identification of ill persons and may require a clinician to suspect and then place patients on traditional transmission-based precautions.

    Palmore and Henderson accurately highlight the considerable effort that went into shifting HCW culture away from coming to work sick as an important pandemic-era change. Despite these efforts, a large proportion of HCWs with symptomatic COVID-19 (11) still come to work. This may increase further as people transition to an “endemic mindset” and workplace culture shifts back to prepandemic habits of presenteeism and limited sick leave allowances. However, the future course of the pandemic remains unpredictable (4). Testing is now less available, testing behaviors are changing, and there is less awareness of local transmission levels. People (including HCWs) may be less likely to test despite high-risk exposures or compatible symptoms. In addition, we do not have metrics to measure and incorporate the current burden of post–COVID-19 conditions into community risk assessments. Furthermore, health care staffing shortages continue across the nation, and our local experiences suggest that prepandemic sick leave policies for HCWs remain unchanged.

    We acknowledge that the point raised about communication challenges associated with mask wearing is important for a subset of patients and providers. However, we would advocate for a shared decision-making approach that considers the implicit power dynamics of the patient–provider relationship as well as the overall health costs and risks for individual patients. If we accept the benefits of increased mask wearing in clinical settings, we should find ways to adapt to this new reality rather than accepting unnecessary risks to patient and provider health. Perhaps rather than removing masks to improve rapport building and enhance perceived empathy, we could find ways to improve masked communication. We should also strive to avoid placing the burden of advocating for patient safety solely on our patients by enacting policies that require them to request that their providers wear a mask when they believe it is appropriate. Doing so also increases the probability of inequitable access to requests to mask based on language proficiency and other barriers to communication.

    As health care systems navigate this next phase of the pandemic, different approaches could be considered that place patient safety first and integrate masking as part of routine health care policies. We agree with Palmore and Henderson that policies could take different approaches; masking could be implemented 1) across health care spaces year-round; 2) in targeted settings, such as transplant, oncology, and geriatric units, where risk is highest for those patient populations (although this is less desirable because high-risk patients in most hospitals may be found in a variety of health care settings); 3) in specified months during the local respiratory viral season; or 4) when community burden of respiratory viruses approaches a critical threshold, although appropriate metrics will need to be defined. In Washington State, regional health care organizations issued a joint consensus (12) to extend universal masking in patient care spaces of health care facilities, with plans to update this policy through a regional approach to masking as the pandemic continues to evolve and integrate into the endemic respiratory viral milieu. By developing a cross-systems health care masking agreement, facilities addressed patient safety through a collaborative and supportive approach that can take into account regional variations in community respiratory viral burden. Given the considerable variation in health care settings and patient risk profiles that the facilities in the region serve, individual facilities were given the flexibility to tailor policies to their own unique spaces, such as determining what constitutes public or patient care spaces.

    Our appreciation and understanding of both patient and health care system impacts associated with SARS-CoV-2 and other respiratory viruses have been reshaped as a result of the COVID-19 pandemic. We should be mindful of continuing areas of uncertainty while integrating the lessons learned into our hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal prepandemic behaviors.



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    Ron Pearson22 August 2023
    Mask types

    The authors Make a coherent case for masking, but provide no guidance or opinions regarding the types of masks that they would recommend. There is ample evidence that a simple tri fold mask provides very little protection relative to a well fitted N95 or KN95 respirator.

    Eric J. Chow, John B. Lynch, Danielle M. Zerr, Francis X. Riedo, Mary Fairchok, Steven A. Pergam, Christopher S. Baliga, John Pauk, James Lewis, Jeffrey S. Duchin6 September 2023
    Author response to Pearson

    We thank Mr. Pearson for elevating the importance of the quality of respiratory protection in the reduction of infection risk. We agree that use of a respirator offers a higher level of protection against COVID-19, but still would contend in settings where respirators are not worn, the universal wearing of surgical masks for both source control and protection can reduce the risk of transmission of COVID-19 and other respiratory viruses (1). Our opinion is that during periods of universal masking, health care facilities should provide N-95 respirators and support fit testing for any healthcare worker (HCW) using the highest level of protection. For persons, for whom prolonged wearing of an N-95 for a universal masking approach is not tolerable or practical, a more acceptable approach of allowing a choice between a respirator or other level 3 or higher mask can still result in an overall risk reduction in a facility (2). Of course, when caring for a patient with suspected or known COVID-19, respirator level of protection is always required (3). Additionally, universal masking should be part of a multi-pronged strategy to reduce risk of respiratory viral transmission in patient care settings: optimizing indoor air quality through ventilation and filtration, ensuring HCWs are up to date with recommended vaccinations and supportive sick leave policies are in place, and implementing symptom screening protocols to identify patients, visitors, and HCWs who may have active respiratory virus infection.


    1. Andrejko KL, Pry JM, Myers JF, Fukui N, DeGuzman JL, Openshaw J, et al. Effectiveness of Face Mask or Respirator Use in Indoor Public Settings for Prevention of SARS-CoV-2 Infection - California, February-December 2021. MMWR Morb Mortal Wkly Rep. 2022;71(6):212-6.
    2. Ueki H, Furusawa Y, Iwatsuki-Horimoto K, Imai M, Kabata H, Nishimura H, et al. Effectiveness of Face Masks in Preventing Airborne Transmission of SARS-CoV-2. mSphere. 2020;5(5).
    3. 2023;Pages on August 29 2023.