California Healthcare mask mandate ends

Miller Report for the Week of April 3rd, 2023; by William Miller, MD

The California Department of Public Health (CDPH) mask mandate for healthcare facilities is no longer in effect as of today, Monday, April 3rd. However, you might discover that there are some facilities and counties that still require you to mask up. Let’s look at this in some detail.

An official press release on March 3rd, 2023, announced that CDPH would no longer require masking in healthcare settings as well as dropping the requirement that healthcare workers be vaccinated against COVID (federal guidelines still require at least the initial vaccination). The press release states, “Beginning April 3, masks will no longer be required in indoor high-risk and health care settings. This includes health care, long-term care, and correctional facilities, as well as homeless, emergency, and warming and cooling centers. This change takes effect on Monday, April 3 to allow local health departments and individual healthcare facilities to develop and implement plans customized to their needs and local conditions to continue to protect Californians through the end of the winter virus season.”

This was accompanied by new guidelines that stressed that moving forward, CDPH would only be making recommendations regarding masking and no longer institute requirements. The guidelines for healthcare facilities will be based on community levels of COVID transmission. In areas of LOW case rates, the guidelines state, “wearing a mask should be considered,” in MEDIUM community spread, “wearing a mask is recommended,” and in communities experiencing HIGH levels of community spread “wearing a mask is strongly recommended.” The guidelines leave it up to each county and facility to determine their own policies based on these recommendations.

Almost half of the states rescinded their mask mandates in March 2021. As a result, we have two years of experience, including during some of the more aggressive variants such as Delta, to examine the question, “Did the presence or absence of a public health mask mandate make a difference?” Studies have come down on both sides of the argument, with some supporting that COVID cases went up in those areas after mask mandates were removed and other studies that show that the presence or absence of mask mandates did not affect case rates. This is a different question than whether masks prevent the transmission of viral illnesses on an individual level. There have been multiple studies looking at the efficacy of masks in preventing the spread of several other viral illnesses, including influenza.

When science literature on a topic is filled with conflicting results, it is sometimes because there is no overwhelming benefit. In other words, if there were a very strong, overriding benefit, then one would expect that benefit to rise up and not remain mired in ambiguity. There is also the possibility that there is a benefit, just one that is more difficult to tease out. Another possibility is that a study may be poorly designed, and therefore the results are difficult to interpret. When studies vary in results, we can perform what is known as a meta-analysis, where the studies are combined into one large analysis. From Wikipedia, “A meta-analysis is a statistical analysis that combines the results of multiple scientific studies … to derive a pooled estimate closest to the unknown common truth…” Such a meta-analysis was performed recently by the Cochrane Group, a highly respected, international not-for-profit organization that performs analysis of the scientific body of healthcare knowledge for the purpose of helping to guide healthcare decisions. They published their results on January 30th, 2023. The conclusion has received tremendous attention in social media. I will dedicate the next Miller Report to going into their analysis, its findings, and limitations in more detail. Suffice it to say at this point that the conclusion was that, based on current studies, there is no strong evidence to support the benefit of masking mandates as an instrument of public health curbing viral respiratory pandemics. There is evidence that an individual may benefit from wearing a mask, but no evidence on a societal level based on the accumulated results of the studies which have been done so far.

As of this writing, here is a breakdown of healthcare mask mandates for the 50 states and the District of Columbia (DC). Thirty-eight states have no requirements of masks; most of these rescinded their mandates early on or never had a mandate. Six states have mandates that are expiring or being rescinded this month; they are California, Connecticut, North Carolina, Oregon, and Washington. Two states have mandatory masking in limited healthcare settings; Indiana in state-run hospitals only and Colorado in nursing homes only. Three still require masking in hospitals and other healthcare settings; they are Delaware, Massachusetts, and DC. Ten states have laws, governor orders, or state supreme court decisions that either specifically ban or severely limit masking mandates; they are Arizona, Arkansas, Florida, Georgia, Iowa, Montana, Tennessee, Texas, Utah, and Wisconsin. Lastly, two states, Ohio and Rhode Island, have requirements that vary on local transmission rates.

There has been some confusion around the coordination of guidelines between various government agencies. CAL-OSHA responded to the CDPH change in guidelines, stating on its website, “Employers must provide face coverings and ensure they are worn by employees when CDPH requires their use.” (italics added for emphasis) Thus, if CDPH is not requiring masking, then CAL-OSHA is deferring to CDPH and not requiring them either. The federal OSHA, under the US Department of Labor, has not updated its COVID guidelines since December 27, 2021. These require healthcare facilities to ensure that employees wear a mask in accordance with CDC’s “Guidelines for Isolation Precautions,” which is something that all hospitals already do when dealing with patients who are placed in isolation due to communicable diseases.

In my opinion, it is reasonable for federal, state, and local health officials to continue to relax masking requirements as the pandemic is clearly not as severe as it initially was, the benefit of such mandates is unclear, and we, as a democratic society, are moving towards returning to some sense of normalcy. While I commend CDPH for joining the other 38 states in the Union who have already rolled back their masking mandates, it perhaps was less helpful to then leave the decision up to county health officers and local hospital leadership to try to decide what their own response will be. This has continued the confusion of inconsistency that we have seen since the beginning of COVID. For example, Alameda, Contra Costa, and Los Angeles counties have announced that they will continue local masking orders, and San Francisco County remains on the fence. Additionally, for CDPH to continue to have a tiered set of guidelines based on the severity of transmission only adds to the complexity of what could otherwise be simple guidelines, another challenge that we have experienced throughout the pandemic. Again, in my opinion, we would have all been better off if CDPH had simply fully revoked the masking mandate by saying, “Masks are no longer required,” and leave at that.

Note: After taking a two-month break from writing the Miller Report, I am back. Moving forward, I plan to produce it every first and third Monday of each month. You can access all previous Miller Reports online at www. WMillerMD.com.

Dr. Miller is a practicing hospitalist and the Chief of Staff at Adventist Health Mendocino Coast Hospital in Ft. Bragg, California. The views shared in this weekly column are those of the author and do not necessarily represent those of the publisher or of Adventist Health.