NIH required immunocompromised woman to remove her N95, highlighting CDC’s conflicting mask guidance

Health care facilities around the country are juggling conflicting recommendations from the Centers for Disease Control and Prevention about N95 masks more than two years into the pandemic.

The confusion is so widespread that the industry’s preeminent trade association said it isn’t sure what to advise hospitals. America’s hospital regulator is seeking patients’ complaints related to unsafe masking. And despite scientific consensus, including from the CDC, that N95s provide some of the best defense against Covid-19, some health care facilities are opting not to mandate them, defaulting to surgical masks for workers and patients.

The CDC on its website says people shouldn’t wear masks that are soiled or damaged and some hospitals have used this to ask patients to replace their N95 with a less protective hospital-provided mask or to layer it over their N95. But the CDC also says patients and visitors should not be asked to remove an N95 and that other masks shouldn’t be layered over because it can affect the fit, rendering the N95 less protective.

Last month, POLITICO reported that hospitals around the country were requiring patients and visitors to remove N95s and replace them with inferior surgical masks. The CDC then updated its guidance, allowing patients to wear protective masks like N95s, and the Centers for Medicare and Medicaid Services began seeking patient complaints about the practice.

CDC spokesperson Kristen Nordlund said Monday the agency isn’t changing its guidance, though it recommends people visiting health care facilities use the most protective mask that fits well.

The changing recommendations and inconsistent guidance leave patients — and occasionally medical facilities — confounded over how best to keep the virus from spreading. And it exacerbates a hodgepodge system where rules over masks can vary from place to place, or day to day, even in settings that care for America’s most vulnerable.

“The guidance is just very confusing,” said Mia Ives-Rublee, a disability advocate at liberal think tank Center for American Progress who has pushed for a more protective standard. It’s “concerning that we are at Year 3 and we have not done better at messaging.”

Michelle Fried Galvanek told POLITICO that when she brought her daughter to the National Institutes of Health’s Bethesda, Md. campus in February to partake in a research study related to Covid-19, staff told them to replace their N95s with surgical masks.

Fried Galvanek said she has two autoimmune conditions and that the policy put her and her daughter at risk of catching Covid-19 during their hourslong visit.

“Maddening,” she said. “If I only had a surgical mask, I would not care about wearing theirs. It was the fact that we had to replace our more protective masks with their less protective ones.”

Vulnerable people visit the NIH daily, often to take part in research at the NIH’s Clinical Center, which in its 70-plus year history has developed chemotherapy for cancer and the first treatment of AIDS. The center has more than 1,600 studies ongoing with patients coming from all 50 states and around the world, according to its website.

The NIH’s Clinical Center, where the pair visited, says on its website that visitors must wear the center’s “medical grade mask.” Amanda Fine, an agency spokesperson, said Fried Galvanek, who is a health care attorney at a lobbying firm, and her daughter should have been permitted to keep on their N95s on condition they layered a clinic-provided surgical mask on top.

Fine, the spokesperson, said NIH was following the CDC guidance that states masks shouldn’t be worn if soiled or damaged.

NIH requires all visitors to wear the agency’s surgical masks, she said, “because we do not have the ability to assess the quality of the mask for all people entering.”

She wouldn’t say why the NIH chose to favor that interpretation of CDC’s guidance over the recommendation to not layer anything on top of an N95, but said the NIH’s Covid policies are so effective that “no cases of patient transmission have occurred.”

Fine also said surgical masks are sufficiently protective. CDC Director Rochelle Walensky has said the same.

The CDC, on its website, says those masks are the least effective, and that N95s are much more so, providing “the highest level of protection” while containing “your respiratory droplets and particles so you do not expose others.”

Mass General Brigham, the Boston-area hospital system, which POLITICO found required patients to remove their N95, now requires patients to layer surgical masks over their N95s, despite the CDC’s warning that doing so could make the N95s less protective.

Mass General made no changes to its policies after the CDC’s update last week because it believes it is compliant with public health guidance, said Jennifer Street, a hospital spokesperson. When POLITICO pointed to the discrepancy with CDC guidance that advises against layering, she declined to comment.

In another indication of the confusing recommendations, the trade group that oversees most of the nation’s hospitals, the American Hospital Association, isn’t sure how to interpret the CDC’s guidance. “We recommend you check with the CDC,” said Colin Milligan, the group’s spokesperson.

Many facilities, including the NIH, point to guidance from the CDC, which says surgical masks are sufficient against Covid, but public health experts and patient advocates say that more than two years into the pandemic, N95s should be the standard for everybody, especially in health care.

Don Milton, an occupational health specialist at the University of Maryland, says surgical masks are about as protective as cloth masks and that health facilities should be distributing free N95s, as pharmacies recently started doing in a U.S. government program. National grocery chain Sam’s Club has too.

“If Sam’s Club can give out N95s, why can’t hospitals give out N95s?” he said.

Researchers estimate N95s leak around 20 percent of air around the edges compared to 50 percent for surgical masks. N95s can leak less — close to 10 percent — if they are fit-tested, a process that some health care workers undergo but which isn’t necessary to get high-level protection. A 2020 paper authored by Walensky, who now runs the CDC, noted that a suboptimal fit still produced a filtration efficiency of more than 90 percent.

Health facilities, like all indoor spaces, have facilitated Covid transmission throughout the pandemic. A record number of hospitalized patients in the U.S. were infected with Covid during the Omicron wave. Hospital staff and visitors often wear surgical masks — in accordance with CDC guidelines — but such masks put people at higher risk of catching Covid, according to studies, including ones done by the CDC. Michael Osterholm, an infectious disease expert who advises the Biden administration, earlier told POLITICO that he had “no doubt” such sub-par masks contributed to the transmission.

Many people are several months from their last Covid vaccine shot, and while those shots remain highly protective for most against severe disease, they don’t prevent infection. Healthy as well as immunocompromised people rely on N95s to stop infections.

“I get that they want to send the message that any mask is better than no mask, but why not just recommend the one that’s most protective?” said Fried Galvanek, the woman who had to swap into a surgical mask at the NIH.

Fried Galvanek said the opportunity to meet top government scientists had been a source of excitement for her daughter, but the visit left her befuddled. “[What] do these people not understand about masks?” her daughter asked at the time.

“I didn’t have a good answer,” Fried Galvanek recalled. “I think it hurt their credibility for her.”