On Friday, the Centers for Disease Control and Prevention issued new COVID guidelines, declaring it safe for most healthy people across the country to take off their masks. Beyond simple "on" or "off" recommendations, these guidelines offer a new framework for masking.
Before we cut into the guidance itself, it's worth taking a quick stroll down memory lane. The CDC first reversed its recommendation around masking last May, after the initial demand for vaccinations started to ebb. CDC Director Rochelle Walensky announced new guidance allowing vaccinated people to go without masks in all indoor settings. Hot Vax Summer was on the way!
But it was clear from the jump that the policy guidance was a gamble. I wrote about why in these pages. "On the one hand, [this CDC guidance] could incentivize enough people to finally get their vaccines to get back to life as they once knew it so that all of us can get back to life as we once knew it," I wrote. "On the other, it could backfire — the unvaccinated may free-ride on the policy to forego not just their vaccines, but their masks too. Putting themselves and others at risk in the process, they could perpetuate the pandemic."
At that time, the CDC was, inadvertently, declaring victory over a pandemic whose wiles we were only beginning to fully understand.
As case rates began to quickly tick back up, we came to understand that vaccination may not offer complete protection. That came into full relief after a study was released following a 466-person outbreak at a public gathering in Provincetown, in which more than three in four of those infected had been vaccinated. An analysis of the cycle thresholds — a measure of the viral load and capacity to infect others — among vaccinated people showed that they were similar to unvaccinated people. On that information, Director Walensky announced a reversal of the masking guidelines to recommend universal indoor masking in communities with "substantial or high" rates of transmission. These are the guidelines we've been living with ever since — through delta and omicron.
The CDC's initial gamble failed. The public had seen the U.S.' most important public health agency reverse course again.
Soon after, with the advent of omicron, nearly the entire country was pitched into universal masking territory. Whereas delta was more transmissible, more vaccine evasive, and more severe than previous variants, omicron traded severity for more of the other two features. While maintaining public masking guidelines through the omicron surge was clearly important, omicron posed a unique set of circumstances as it abated: how should the reduction in severity change COVID precautions from here?
This is a loaded question that explodes quickly into a series of other ones. COVID is not gone. But then it will likely never be. So what level of risk are we willing to tolerate? What are the equity implications of any risk at all? What are the risks of another variant that could cause a major outbreak and how do we hedge against them?
States and municipalities began answering these questions quickly, as nearly every single state in the country — red or blue — repealed universal mask mandates.
And that left the CDC increasingly out of step with prevailing sentiment.
The CDC was once bitten, twice shy. They had declared victory and failed before. That's the context in which the CDC introduced its new guidance. Let's cut in.
How the guidelines workRather than recommend masks simply based on the level of COVID transmission, the guidelines stipulate three metrics around which county-by-county decisions should be made. Along with the community transmission rate, the guidelines consider the COVID hospitalization rate and the proportion of hospital beds occupied by COVID patients. Using an algorithm, counties are given a low, medium, or high risk designation, which is updated weekly. In low-risk settings, public indoor masking is not recommended. In high-risk settings, it is. And in medium-risk settings, individuals are recommended to "speak to your healthcare provider."
Let's unpack some of the rationale behind the new guidance. Beyond the risk of infection (COVID case rates) the guidelines consider the severity of cases and the risk to the healthcare system. The severity of symptoms are reflected in the rate of hospitalizations, or the number of new COVID hospitalizations over time. Presumably, if there were a new, more severe variant, the number of hospitalizations would rise, triggering new masking recommendations. The guidelines also aim to protect the healthcare system — which is why the CDC included the proportion of hospital beds in their calculation.
What the guidelines get rightFirst and foremost, these new guidelines meet the pandemic where it is. Cases are down substantially across the country and hospitalization and death rates are plummeting as well. States and municipalities have rushed to downscale their masking requirements.
Some have argued that it's still too early for this kind of action, that they're bowing to political pressure. Thousands are dying every day, they argue. But as I've written in the past, death rates are a lagging indicator that do not reflect the future risk of COVID illness and death considering future trends. We've got to "skate to where the puck is going," not where it is. There's also an under appreciated cost of dissonance between federal guidance and state and local guidance. Continuing to stay out of step with state and local governments who are also, ostensibly, basing their recommendations on "the science," adds to the frustration and mistrust in experts.
The open question I'd ask those who think that the CDC is acting hastily is "if not now, then when?" Most of these critics admit that we'll never get to a "zero COVID" scenario — but they remain uncomfortable with the persistence of the disease. That cognitive dissonance is a recipe for continuing maximal COVID precautions ad infinitum. They worry that scaling back guidelines could allow for yet another surge.
What's critical is that these guidelines allow for masking to be recommended again if that scenario should arise. The CDC has learned its lesson about prematurely declaring victory. Though, as I've written in these pages, omicron has erected a giant immunity barrier between us and the next high-volume variant; there remains the risk that this is not, in fact, the end of the pandemic. The new guidance recognizes that.
In that respect, the new guidelines also reflect some hard-earned humility on the part of the CDC. When Director Walensky first announced that masks could come off in May of 2021, one of the aims was to incentivize more Americans to get vaccinated. This was a fundamental misreading of the motivations of those who were remaining unvaccinated in the first place. The CDC's recommendation that unvaccinated people continue to wear masks simply didn't factor into their choices — if they cared what the CDC guidance was, after all, they would have gotten vaccinated already. Without direct enforcement of a vax-or-mask requirement, what the CDC recommended didn't register.
What the guidelines get wrongThat said, the guidelines have some real flaws. First, though the guidelines do hedge against the risk of another variant or surge, they may not operate quickly enough. Epidemiologist Dr. Ellie Murray wrote a fantastic thread on this.
Her point is that because the CDC's on-ramp to masking is based on hospitalizations, which are a lagging indicator, they may not work fast enough to initiate masking when it's the most effective — to stop all those hospitalizations from happening in the first place. In addition to using hospitalizations as an indicator for severity, the guidance should include an early indicator of potential severity. This could be the change in case counts or test positivity — which occurs quickly and can predict the overall volume of illness a new variant or surge could create.
These guidelines also raise profound equity considerations. Millions of immunocompromised Americans live in constant fear of COVID, even as risks subside. The CDC attempts to address their concerns with the medium risk indicator, in which individuals are told to consult their healthcare provider — ostensibly so that that provider can instruct them to keep wearing a mask. But high-risk individuals deserve a more coordinated effort to protect them.
One approach is to guarantee high-quality masks, delivered at home. Though masking works best in the collective — because it protects the wearer and others they encounter — we've learned that well-fitting N95 masks offer wearers high-quality protection, particularly in settings where case rates and exposure risk are low. However, these masks can be hard to obtain. Making the effort to deliver these to high-risk Americans — frankly to all Americans — would help.
Further, not everyone has access to a primary care physician. You all know my answer here — but that's beyond the scope of this discussion. (Actually, it's really not. But you've heard me tout Medicare for All enough.)
Vaccination remains the most important deterrent to another COVID surge. While the CDC has learned that it has little impact on individuals' choices to get vaccinated, it missed an important opportunity to influence policymakers. Vaccine verification is extremely powerful. After New York City mandated vaccines for its public employees, less than 1% of employees were ultimately dismissed over noncompliance. What's troubling now is that state and local governments are beginning to back down on verification. I would have liked the CDC to include county-level vaccination rates and vaccination verification policy in their algorithm. Not only does this shape the risk of COVID exposure in a given community, but it incentivizes local communities to continue to press the vaccination effort. After all, our best deterrence against another major surge is to vaccinate yet more people.
Yet that would have made the algorithm even bulkier, which is a final challenge to this guidance. Throughout the pandemic the CDC failed to offer simple, clear communication. And while the low, medium, or high risk designations are easy to understand, the system for determining them is not. I hope that the CDC will press hard to explain the algorithm to the public to improve buy-in and understanding.
What now?After nearly two years of this, I understand the worries over taking the masks off now. For me, they come in the form of my 4-year-old little girl, who still isn't old enough for the vaccine. We live in a community that is at "medium" risk, though it will likely fall to low risk soon. Thankfully, everyone in our family is healthy. Sarah and I are relaxing a bit when it comes to small indoor gatherings or eating out in restaurants. We're not going to let the fear of COVID keep us from enjoying the things we've always loved to do. We may still elect to wear our masks in high-traffic indoor places, we may not as cases continue to subside. For us, it's important that we do our part to normalize masks for people who may yet need them — like our daughter.
But the real test of the guidance isn't when masks come off, but if masks ever need to come back on. That's the scenario in which trust in the science and communication behind the guidance will be critical.
Let's hope we never get there.
In that respect, the masking guidelines are potentially less important than several other things the federal government must be doing right now: vaccinating more people both at home and abroad. While the vaccines are not a fail-safe against transmission, they vastly reduce the risk. Perhaps more importantly, they reduce the risk of serious illness and death — and the burden on the healthcare system. But if we want to head the next variant off at the pass, we must continue to manufacture and ship vaccines abroad.