The masks are off in Boise area — but CDC’s ‘significant departure’ raises questions
As the omicron wave subsided in the U.S., the Centers for Disease Control and Prevention moved to ease pandemic recommendations, declaring that many people in large portions of the country, including Idaho, don’t need to wear masks for the time being.
But along with the changing recommendations came a major shift in how COVID-19 risks were calculated and addressed, and the move has left some physicians and public health experts questioning the shift.
“This continues on in a series of disappointments for me that the CDC has not been more clear in their communication … and hasn’t taken a little bit more regard for protecting those among us who are particularly vulnerable,” Dr. David Pate, the former president of St. Luke’s Health System and a member of the Governor’s Coronavirus Working Group, told the Idaho Statesman.
The CDC’s previous guidance was focused on stopping transmission — keeping as many people as possible from getting infected — but the new recommendations are closer to a “live with it” philosophy, Pate said.
The new guidelines, announced at the end of February, added metrics to the equation beyond case levels and test positivity rates — known together as transmission levels. Those include the number of recent COVID-19 hospitalizations per capita as well as what percent of staffed hospital beds are occupied by COVID-19 patients.
Analyses performed by the CDC have found that the new county-by-county metrics do a better job at predicting strain on health systems and deaths three weeks out.
In recent months, many health experts warned that a lack of surveillance testing — which aims to capture a proportional sample of the population — combined with the prevalence of at-home tests, which are not recorded in state or national data sets, may be skewing transmission rates.
That could mean the additional metrics will provide a more accurate picture of a community’s COVID-19 status.
“If you do a lot of precise calculations on imprecise data, where are you?” Dr. Sky Blue, a physician at Sawtooth Epidemiology who specializes in infectious diseases and epidemiology, told the Statesman.
But the CDC’s new calculations have also shifted the goalposts on transmission risk by allowing much higher community infection levels before suggesting that residents take precautions.
For much of the pandemic, the CDC recommended that Americans wear masks when there were 50 or more cases per 100,000 people in a given county. Now, the acceptable level is four times that, at 200 per-capita cases, before universal indoor mask recommendations kick in.
Furthermore, transmission rates in a community can be much higher than that as long as patient levels at local hospitals are below certain benchmarks, as is the case in Ada County.
COVID-19 data and risk factors for CDC
For a U.S. county to be in the “low” or “medium” risk category, when universal masking is not recommended, new COVID-19 hospital admissions over the prior seven-day period per 100,000 residents have to be less than 10, while the amount of staffed inpatient hospital beds occupied by COVID-19 patients has to be less than 10%, according to the guidelines.
In Ada County, those figures are 7.4 and 9.7%, respectively, according to CDC data posted last Thursday.
But the current number of COVID-19 cases per 100,000 residents is 1,174, or nearly six times the 200 per-capita rate. It is only because the hospital metrics are below the thresholds that Idaho’s most populous county is at “medium” rather than “high” risk.
“This is a very significant departure from our previous approach,” Pate said.
The CDC’s priorities have become limiting severe illness and death, rather than restricting transmission.
“They’ve decoupled health systems risk from transmission risk, but I don’t think that they’ve clearly communicated that that’s what’s been done,” said Jennifer Johnson-Leung, an associate professor of mathematics at the University of Idaho who leads the Idaho Pandemic Modeling Group at the university.
Complicating the situation is the statistics, which the CDC pulls from each state. On March 1, Dr. Kathryn Turner, the deputy state epidemiologist who oversees the Idaho Department of Health and Welfare data project, said a large backlog was skewing the CDC’s numbers. “I don’t think they’re looking at the right data,” she said.
Pate said the shift in focus can leave millions of immunocompromised people in the lurch.
“If we’re not going to take broad public health measures to protect everybody,” he said, “at least give those people who are at higher risk — who do want to take precautions, who are concerned about some of the long-term effects of COVID — give them your best advice about how to protect (themselves).”
When a county is at medium risk, the CDC says high-risk Americans should “talk to your health care provider about whether you need to wear a mask.”
“You can translate that as, ‘The CDC isn’t giving advice for you,’ ” Pate said, pointing out that lots of people don’t have doctors, or would have to pay money for a doctor’s visit, while getting to the doctor can entail complicated logistics.
“That’s not a great solution for them,” he said. “There are ways to live with the virus, yet also protect people that are very vulnerable.”
The CDC’s guidance, of course, is just that. It issues recommendations, not mandates, and many Idahoans have not been following mask recommendations for months or all through the pandemic. Plus, differences in the quality of various masks and whether people wear them correctly also affects their impact.
“I think (the CDC) did a good job by coming up with a scientifically more rigorous measure of community burden,” Blue said. “However, the recommendations for a response when that burden is at ‘medium’ and ‘high’ may not have a significant impact.”
He added: “We should enjoy the fact that CDC is suggesting that in a lot of situations it’s safe now to come off of those precautions … but what I’d also say is as you enjoy this, you should have individuals think about and be prepared to toggle back the other way if we see a new variant or the situation change.”
So, should you keep your mask on?
With mask recommendations changed, lingering mandates have been lifted, too. The city of Boise ended its indoor mask rules last week, with Mayor Lauren McLean citing the CDC’s new guidance, and the Boise School District decided to lift its mask mandate effective Tuesday.
But some public health officials have said they will continue to use caution. Blue said he will keep wearing masks to protect himself in high-risk situations, such as in poorly ventilated or crowded areas, and to protect others in places such as grocery stores, banks and pharmacies.
Blue also said that while the region’s risk category is medium or low, he would feel comfortable going to a restaurant that isn’t packed and taking his mask off.
He also was careful to note that the new CDC masking guidelines should not apply to health care settings, where masks help protect workers and vulnerable people visiting the doctor.
Pate said he will keep making “situational assessments” about masking. He said he is fully vaccinated and is not primarily concerned about dying from COVID-19, but is worried about “one of the other things COVID does to you.”
Health and Welfare has previously reported that people who are vaccinated and boosted are 11 times less likely to be hospitalized and 20 times less likely to die of COVID-19 than unvaccinated people.
Around 46% of Idaho’s 5-and-older population remains unvaccinated, according to Health and Welfare. Even when COVID-19 community levels are in the “low” category, the CDC recommends that Americans stay up to date with COVID-19 vaccines to protect against severe illness and death.
Pate said he would “probably always” wear masks while on airplanes — they still are required for air travel — but that if he’s gathering with friends whom he knows are vaccinated, and disease transmission is low in the area, he would be unlikely to wear a face covering.
The CDC guidance includes that people with COVID-19 symptoms, a positive test or recent exposure to someone with the disease should wear a mask regardless of the level in their community.
