These are the masks infectious disease experts wear at work and at home
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Last week, the CDC updated its consumer COVID-19 mask guidance to say for the first time that people can wear N95 or KN95 respirators.
Previously, the CDC said these types of masks should be reserved for health care personnel because of supply shortages. The agency continues to say that respirators specifically labeled as “surgical N95s” be reserved for health care settings.
This week, as part of its plan to address the surge of infections caused by the omicron variant, the Biden administration announced that it would distribute 400 million free N95 masks at pharmacies and health centers throughout the U.S.
We asked more than a dozen Infectious Disease News Editorial Board Members and other experts for their thoughts on the CDC’s updated guidance and to tell us what masks they wear at work and in their personal life.
Healio: What do you think of the CDC’s mask guidance?
Peter Chin-Hong, MD, Infectious Disease News Editorial Board Member, professor of medicine and director of the University of California, San Francisco’s transplant infectious disease program: I think it sends sound advice to the public about upping their mask game during omicron times. A hierarchy of masks was clearly explained. However, I wish this was done earlier in the pandemic, and certainly during the early part of omicron we have known for some time that N95s provide superior protection for those in high-risk settings, and not just for health care workers.
Elizabeth Connick, MD, Infectious Disease News Editorial Board Member, professor of medicine and chief of the division of infectious diseases at the University of Arizona College of Medicine: I’m fine with it.
Kathryn M. Edwards, MD, scientific director of the Vanderbilt Vaccine Research Program: I think that it is a good idea to provide better mask guidelines.
Carlos del Rio, MD, Infectious Disease News Editorial Board Member, executive associate dean at Emory University School of Medicine: I think it is good because it grades the different types of masks and gives people options.
Keith S. Kaye, MD, MPH, Infectious Disease News Editorial Board Member, chief of allergy, immunology and infectious disease at Rutgers Robert Wood Johnson Medical School: I think it is confusing from a practical standpoint ⎼⎼ lots of changes over a short period of time.
Kenneth M. Kaye, MD, Infectious Disease News Editorial Board Member, professor of medicine at Harvard Medical School and senior physician at Brigham and Women’s Hospital: N95s have their place, especially for immune suppressed or high-risk individuals (along with other preventive measures). Even if not an N95, I believe high-quality masks along with social distancing are the key to preventing spread in the general population.
Linsey C. Marr, PhD, professor of civil and environmental engineering at Virginia Tech University: Finally! We've always known that N95s provide the best protection, and as we transition from population-wide public health measures to more individual ones, it's important for people to know that some masks are more effective than others.
Jeanne M. Marrazzo, MD, MPH, Infectious Disease News Editorial Board Member, director of the division of infectious diseases at the University of Alabama at Birmingham: The guidance walks a very reasonable line that recognizes not all masks are created equal (clearly, N95 or KN95 work best) but that the best mask is the one that people will wear consistently and in settings where protection is key (poorly ventilated places, crowded places, places with high community prevalence). It’s also backed up by the tangible distribution of N95 masks by the administration announced this week. Hopefully, as a community, we’ll normalize mask wearing at least until we’re out of this omicron surge.
Gitanjali Pai, MD, Infectious Disease News Editorial Board Member, chief medical officer for the Oklahoma State Department of Health: In the wake of the highly contagious omicron variant and its ability to evade immunity to some extent, layered protection becomes important now more than ever. Masks are a very simple yet effective tool to reduce the spread of infection. Despite their limitations, they remain a highly effective tool in our armamentarium as we continue to battle this pandemic. The CDC has released this timely mask guidance, which could help people think through their mask options and decide what best fits them and their situation, thereby helping to reduce the spread of the virus, as well as reduce preventable human suffering, including serious illness and death. It will take us one step closer to stepping out of this pandemic.
Amit Sharma, MD, infectious disease specialist at Geisinger Community Medical Center: The CDC’s mask guidance is scientific and appropriate to the current situation. At this time, we have a highly infectious variant of SARS-CoV-2, and even though the severity is “mild” compared with the previous variant, we have to be mindful of the impact on the vulnerable populations. First, I feel that any mask is better than no mask because masking is a critical public health tool for preventing spread of COVID-19. Second, the CDC has highlighted the importance of a mask “that fits well” and “that can be worn consistently.” Respirators and masks, including N95 masks, offer better protection, but the fit of the mask is extremely important. Finally, consistent wear of a certain mask helps ease the anxiety level of the wearer and helps the individual to make rational informed choices.
Melanie A. Thompson, MD, Infectious Disease News Editorial Board Member, principal investigator at the AIDS Research Consortium of Atlanta: On the one hand, this guidance comes at least a year and a half too late. The supply shortage for N95 masks for health care workers was real in the beginning of the pandemic and the shortages persisted throughout 2020 to some extent, with the American Nurses Association asking the administration to scale up the Defense Production Act (DPA) as late as September 2020. Ongoing shortages for health care workers made it practically impossible to recommend better masking for the general public, even if the political will had been there to do it. On Jan. 21, 2021, one of first acts of President Joe Biden was to use the DPA to scale up production of personal protective equipment, among other items. As supplies for health care workers have increased, the emergence of a delta wave and an even more infectious omicron wave have put the spotlight on the need for better masking for the general population.
On the other hand, the announcement of free N95 masks for the general population finally is a step toward making a new mask guidance implementable. Some criticized CDC Director Rochelle Walensky, MD, MPH, for acknowledging that some people feel that N95/KN95 masks are uncomfortable. Honestly, I hear this every day in the exam room from people who genuinely want to protect themselves, and I think that the recommendation "that you wear the most protective mask you can that fits well and that you will wear consistently” is a compromise that is reality based. I like the new website that educates people about different kinds of masks, along with tips about their use. My sense is that a lot of people will give N95s a try when they are provided for free. It’s overdue, but it’s never too late
Raghavendra Tirupathi, MD, FACP, Infectious Disease News Editorial Board Member, medical director for Keystone Infectious Diseases/HIV, medical director of infection prevention for WellSpan Chambersburg & WellSpan Waynesboro Hospitals, and clinical assistant professor of medicine at Penn State University School of Medicine: Infectious disease doctors have always recommended and advocated for well-fitting masks to reduce transmission of COVID-19. Masks have been one of the several layers of the “Swiss cheese model” of interventions to decrease the risk for one’s acquisition of COVID-19. Well-fitting masks should fit perfectly against the face with no gaps around the nose or mouth. Cloth masks may not be the best with the omicron variant.
The CDC has been extensively criticized historically with respect to its masking recommendations and more so recently with this current recommendation. The CDC's graded recommendation of using the best mask available to a particular person is appropriate, taking into consideration the problems of availability and cost to the general public. We do not want to end up in the same situation as the beginning of the pandemic, where we were struggling with mask availability. Another important caveat to this equation would be emphasis on appropriately using masks in the right situation, including while being indoors and in crowded situations. There is definitely an equity issue with respect to mask availability, which also needs to be addressed. President Biden's plan of shipping at-home COVID-19 test kits should also incorporate shipping high-grade good-quality masks in the near future to address this inequity. The DPA should also be put to good use to increase the production of masks if there is an impending shortage.
Paul A. Volberding, MD, Infectious Disease News Chief Medical Editor, professor emeritus of medicine at the University of California, San Francisco: It feels as if we are making real progress on the issue of masking for COVID-19 prevention. I was personally OK with cloth masks — I'm fully vaccinated and limit social contacts and distance — until the omicron variant appeared. I've now retired those and some low-quality paper masks as well but plan to keep some as reminders of the past 2 years.
Darcy Wooten MD, MS, Infectious Disease News Editorial Board member, associate clinical professor of medicine at the University of California San Diego (UCSD) School of Medicine and associate program director for the UCSD ID fellowship training program: The mask guidance is confusing. I think they are taking a harm reduction approach, which we know works in other areas of ID, such as substance use and STDs. Their point that the best mask is the one that you will wear and that fits well is a key point. An N95 hanging around someone’s chin is obviously useless. They are trying to provide detailed guidance based on a variety of factors, including someone’s risk of getting COVID-19, risk of a bad outcome, vaccination status and setting (indoors for long periods of time vs. not).
The problem is that, from a public health perspective, this is too confusing and there are too many options. If we lived in a different type of society that didn't prioritize autonomy and individualization over altruism and public health, it would be easier to make a more unified and simplified recommendation. I think the CDC is also trying to be as evidence based as they can be, but there is just a limit to the evidence, especially in a rapidly evolving situation. I haven't heard much about supply shortages in my area, which of course would be a concern for health care workers. I also recognize that although someone "may not need" to wear an N95 in public, doing so may decrease anxiety and help them feel better about interacting in society. Although the latter needs to be balanced with evidence and data, there are plenty of areas in medicine where we provide interventions to decrease anxiety without a huge margin of clinical benefit (eg, prescribing PrEP to a seronegative partner whose husband has HIV but is undetectable on ART because the PrEP allows the person to enjoy sex "worry free" and enhances their sexual health in this way).
Healio: What masks are you wearing at work and in your personal life, and has your choice in masks changed since the emergence of the omicron variant?
Chin Hong: At work, I wear a well-fitted surgical mask as baseline. This has not changed during omicron. What has changed during omicron is wearing an N95 when seeing patients, wearing a well-fitted surgical mask in indoor public settings for an hour or less (instead of a cloth mask only) and in public transportation/Uber, and wearing a KN95 when spending more than an hour in a public indoor setting (instead of a cloth mask only). I miss my bespoke fabric designs on my cloth masks but have adapted pretty easily.
Connick: I wear an N95 and goggles when seeing patients of all types. Recently, I have greatly limited unnecessary excursions to stores or other indoor venues. When I do go, I wear a surgical mask and sometimes an N95. If there are a lot of people, I leave.
Edwards: I use N95s in my personal life.
Del Rio: At work, I wear a surgical mask unless I am going to see a patient with COVID-19 or suspected COVID-19 or unclear diagnosis, in which case I use a fitted N95. In my personal life, I have upgraded to a KN95 for air travel or getting on public transportation or Ubers. I personally think that a high-quality mask ⎼⎼ a multilayer one ⎼⎼ that fits well is the best mask one can use.
Keith S. Kaye: I use a surgical face mask standard hospital grade. For suspected or possible COVID, I wear an N95 and surgical mask on top.
Kenneth M. Kaye: Standard surgical masks are what we use at work and when needed in my personal life. I have not made any changes since the emergence of the omicron variant.
Marr: In higher risk situations — those where I'm in a crowded place for a long time, such as traveling by public transit or attending an event where people are seated close together, such as a research group meeting in a small conference room — I wear an N95 (3M Vflex). When passing in and out of my office building and going shopping, I wear a cloth mask with a filter. I am refraining from eating indoors until after the omicron surge is over, unless everyone present has done a rapid test.
Marrazzo: I was taking care of patients on the ID consult service in December when omicron started to overtake delta, and I switched to wearing N95 masks routinely at that time. I was concerned with the high level of infectiousness that I needed to do whatever it took to stay healthy and keep patients safe. I also found that the newer N95 masks — not available early in the pandemic, like 3M’s — were infinitely more comfortable, and it was relatively easy to wear them all day.
Pai: I wear an N95 when needed, but otherwise I have been using a surgical mask and, at times, use multiple layers. The recent guidance has solidified my stance on masks. As we have now known from the beginning of the pandemic, any mask is better than no mask, but the fit and comfort of the mask are also equally important and perhaps even more important than its permeability. A higher grade mask that is not very well tolerated will not be used consistently, rendering it ineffective, and may actually cause harm by giving people a false sense of confidence that they’re being protected.
Sharma: I usually wear a level 3 surgical mask (3M) at work. For grocery shopping trips, I wear a cloth mask that has three layers at least. Cloth masks can be washed daily, and above all, they give me an opportunity to do “hand-washing with soap and water.” With respect to the omicron variant, I would not really change my choice of the masks, but I will ensure that I am mindful of avoiding closed and crowded spaces. I may consider the KN95 for grocery shopping, depending upon the situation.
Thompson: I’m in an outpatient care setting and have ordered our masks from Project N95 since early in the pandemic because they are nonprofit and vet their sources. We require KN95 or N95 masks for all staff. Early in the pandemic, some chose also to wear face shields, but that has fallen away except when doing nasal swabbing or when a patient is actively coughing. Before omicron, some people lapsed into wearing surgical masks while at their desks, but omicron has ended that. Last week, we gave five KN95 masks to each staff member for personal use outside of the office. All of the staff who have had COVID-19 most likely acquired it outside of the office. For personal use, I have worn KN95s for most of the pandemic but recently have added 3M AURA 9205 N95s to my home mask wardrobe as well.
Tirupathi: I also incorporate graded decision-making with respect to the choice of masks, depending on the situation I meant. I would use a 3M N95 surgical respirator mask while in the hospital and especially while in COVID-19-positive patient rooms. Everywhere else, I am using a grade 3 surgical mask at this time. Avoiding crowded places and social distancing while indoors are also paramount, in addition to adequate masking.
Volberding: I am now wearing KN95 masks purchased at a trusted local hardware store and online, hoping they are the real thing. If I were still having direct patient contacts, I would definitely use N95 masks in that setting. Obviously, the national guidance has changed over time, but I believe that has been understandable given how much we've learned since all this began.
Wooten: I don't really go anywhere other than the hospital and home. When I do go somewhere, I use a KN95 mask. I have some that I ordered from Amazon and some from my hospital as well. When I flew on an airplane in mid-December, I wore an N95 mask. My 3-year-old daughter "wears" a KN95 mask to preschool, but it has been challenging to get her to keep her mask on all the time at school. My husband wears a surgical mask when he goes out in public and at work. I've recommended him to wear a KN95 with omicron, but he doesn't listen to me.
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