Should Healthcare Workers Wear Masks?

I’m at an age where I see doctors frequently enough that I noticed that the masks are gone. Will a surge in influenza or COVID this fall and winter bring masks back for all, or has COVID given us something other than a one-size-fits-all approach?

A more strategic approach comes from a recent New England Journal of Medicine article. The authors note that discontinuing the use of masks outside of healthcare “settings” is understandable given the rising immunity to COVID in the community, either from infection, vaccination, or both, and the apparent diminishing severity of the illness the newest variants create. But, having said that, they believe, and I agree, that healthcare is a special case. Why might that be?

First, the population within hospitals, especially on the medical floors, differs significantly from the general population. The reason should be obvious, our sickest patients are hospitalized; those with lesser problems are cared for as outpatients. And in a growing number of instances, those hospitalized patients are our elderly frail, the immunocompromised, and those with multiple comorbidities – the fodder for the ravages of COVID and, frankly, other airborne illnesses.

Second, hospital-acquired infection, nosocomial infections, occur despite our best efforts. One study suggests nosocomial pneumonia is seen in 0.02% of all hospitalized patients and that percentage is increased in those already at risk for complications from further respiratory problems. When all hospital staff wears masks, the transmission of influenza nosocomial infections has been shown to decrease by nearly 50% and the mortality of those infections by nearly 85%. While some might say that the overall incidence of nosocomial pneumonia of 0.02% is too low to be of concern, using masks, a simple intervention, has a powerful effect. Someday, nearly all of us will fall into those high-risk groups.

The reality is that healthcare workers are all too human and that blanket rules for wearing masks are too draconian. The authors note that symptomatic workers came to work even at the height of the pandemic; “’ presenteeism’ (coming to work despite feeling sick) remains common.” In place of a single arbitrary rule, the authors make the following suggestion:

“We believe the solution is to apply masking requirements judiciously by tying them to levels of virus transmission in the community, the activities that workers are engaged in at a particular time, and individual patients’ risk of severe disease.”

It makes good sense that our precautions are tied to the rising and falling virus transmission; transmission is the one number accounting for all of our activities, defenses, and susceptibilities. Using that as the biomarker of concern comes with two caveats related to those around you. The risk for patients undergoing elective surgery is far different than the risk of transmitting a nosocomial infection to those undergoing transplantation or those in the intensive care unit. Masks might also find a home in the Emergency Department because you never really know what contagious diseases may walk in the door. Working in situations that do not entail patients at risk, ambulatory care centers or offices do not necessarily need masks.

Their recommendation could as easily apply to the population outside of the hospital. We should consider masking based on transmission rates and the risks to ourselves and those we interact with. We developed an ability to have near real-time data on transmission during the pandemic. And those who considered themselves most at risk altered their behavior to include wearing masks. The great leap of faith was assessing the risk to those around us. In some instances, our assessments were incorrect, and we brought a potentially lethal problem to those around us. Perhaps as we come into the fall and the value of masking rises, we might use the following guidance for the public; Do unto others as you will have them do unto you.  


Source: Strategic Masking to Protect Patients from All Respiratory Viral Infections New England Journal of Medicine DOI: 10.1056/NEJMp2306223