Liv Grace suffered three chest infections over the course of four months. Each occurred after a visit to a medical provider in the Bay Area.
MX. Grace, 36, a writer who uses those pronouns, was infected with respiratory syncytial virus in December, which led to pneumonia, after being treated by a nurse in a surgical mask who complained that her children were sick with the virus.
MX. Grace contracted Covid after visiting a cancer center for an IV in February. And then there was the pale, coughing phlebotomist who drew blood in April, just before they came down with Covid again.
MX. Grace was born with a rare immune deficiency linked to lupus and is on a drug that depletes the cells that produce antibodies. The combination makes the body unable to ward off pathogens or recover quickly from infections.
Since the start of the pandemic, Mx. Grace has rarely ventured anywhere other than health care facilities. But hospitals, by their very nature, are often hotbeds of disease, including Covid-19, even when community rates are relatively low.
“People like me, who are at very high risk and very susceptible, are still going to get sick if we are in a virus soup,” says Mx. Grace said.
Facing a potential surge of coronavirus infections this fall and winter, relatively few hospitals — especially in New York, Massachusetts and California — have reinstated mask mandates for patients and staff members. The vast majority don’t, and almost no one needs them for visitors.
On Thursday, several Bay Area counties had announced mask mandates effective Nov. 1 for staff members at health care facilities that treat high-risk patients, including infusion centers.
The order does not apply to facilities in Berkeley, including the Alta Bates Summit Center – part of the Sutter Health network – where Mx. Grace was treated.
“We continue to monitor the impact of Covid-19 in our communities and are working with state and local health departments to ensure any additional masking and public health requirements are included in our policies,” a Sutter Health spokeswoman said in a statement.
Opinion is sharply divided among patients, healthcare workers and public health experts on whether and when to institute mask mandates in hospitals.
Brigham and Women’s Hospital, which is part of the Mass General Brigham system, currently only requires masks in inpatient settings. Yet some of its own experts disagree with the policy.
Hospitals have an ethical obligation to prevent patients from becoming infected on site, regardless of what they might do elsewhere, said Dr. Michael Klompas, hospital epidemiologist at Brigham and Women’s.
“That’s their prerogative,” he said of patients taking risks outside the health care system. “But in our hospital we have to protect them.”
In August, Dr. Klompas and his colleagues published a paper showing that masking and screening for Covid at Brigham and Women’s also reduced flu and RSV infections by about 50 percent.
The Centers for Disease Control and Prevention recommends that hospitals implement masks when rates of respiratory infections rise, especially in emergency rooms and emergency rooms, or when treating high-risk patients.
But the guidelines do not specify what the benchmarks should be, leaving each hospital to choose its own criteria.
Ideally, every patient would be given a mask upon arrival at the emergency room or urgent care and asked to wear it, regardless of symptoms, said Saskia Popescu, an infection control expert at the University of Maryland.
But hospitals must also take into account the resistance to masking in large parts of the population. “Now that we’re not in this emerging state with Covid, I think that’s going to be the biggest challenge, especially because masks have been so politicized,” she said.
As a result, patients with Covid are sitting in the emergency rooms of many hospitals — such as Banner-University Medical Center Tucson, in Arizona, and Kaiser Permanente Sunnyside Medical Center, outside Portland, Oregon — alongside older adults, pregnant women and people with conditions such as diabetes which puts them at high risk if they become infected.
A very small number of hospitals that treat primarily immunocompromised patients, such as City of Hope, a cancer treatment center in Los Angeles, have maintained universal masking. But some of the country’s most prestigious hospital systems don’t require masks, even in their cancer centers, where severely immunocompromised patients like Mx. Grace gets IVs.
“Just do whatever you want — that’s essentially what the CDC guidelines say right now in terms of universal masking,” said Jane Thomason, chief industrial hygienist for National Nurses United, which represents nearly 225,000 registered nurses.
The guidelines give hospitals “permission to prioritize profits over the protection of nurses and patients,” Ms. Thomason said. The union has called for stronger protections, including the use of N95 respirators, to protect healthcare workers, patients and visitors.
A recent study found that more cancer patients died of Covid during the Omicron peak than during the first winter wave, partly because people around them stopped taking precautions.
But partial masking — for example, only in units with high-risk patients — can still put patients at risk, said Dr. Eric Chow, chief of communicable diseases at Public Health – Seattle & King County, in Washington state. High-risk people “are spread throughout the hospital,” he said. “They are not necessarily limited to one specific space.”
Until Thursday, hospitals in the Emory Healthcare system required staff members to wear masks only when interacting with inpatients. It also now requires masks for staff members who work in high-risk environments, such as cancer centers.
Emory’s Winship Cancer Center in Atlanta changed its policy “based on the currently increasing prevalence of and hospitalizations due to Covid-19 and other respiratory illnesses in the community,” Andrea Clement, the institute’s deputy director of public relations, said in a statement.
Employees are now required to wear masks wherever they may encounter patients, including lobbies, elevators and stairwells. Masking for patients and visitors is “encouraged” but not required.
Mass. General Brigham is evaluating new criteria for reintroducing masking, such as the proportion of people in emergency rooms with respiratory illnesses, admissions for such illnesses and wastewater data, said Dr. Erica Shenoy, the hospital’s chief of infection control.
In June, Dr. Shenoy and her colleagues in the journal Annals of Internal Medicine that the time for universal masking had passed, in part because most interactions between patients and healthcare workers are short-lived.
In response to criticism from scientists, they later cited results from an unpublished study showing that only 9 percent of people without symptoms were carriers of the contagious coronavirus.
“The fact is that the conditions for Covid have changed dramatically,” said Dr. Shenoy in an interview. “From a policy perspective, it is important to have an open mind and be able to reflect and revise our policies as we go.”
But several experts, including Dr. Klompas, said this stance underestimated the long-term effects of other respiratory infections, such as influenza and RSV.
Respiratory viruses can unmask or worsen chronic conditions of the heart, lungs or kidneys and cause autoimmune diseases. “It’s much bigger than just the actual infection,” said Dr. Klompas.
The CDC’s infection control guidelines date back to 2007 and are being revised by an advisory committee. The process has been fraught with controversy: Critics fear the recommendations will be too modest to protect patients and staff. (Dr. Shenoy is one of eight committee members, and co-author of the June editorial, Dr. Sharon Wright, is the co-chair.)
In July, National Nurses United presented a petition to Dr. Mandy Cohen, the CDC director, which was signed by hundreds of health care, virology and infection control experts, and dozens of unions and public health organizations.
The petition criticized the infection control committee for lacking diversity of expertise and opaque decision-making. The committee appeared to be unaware of how the coronavirus spreads indoors, and the need for N95 or similar respirators that effectively block virus particles, the petition said.
The advisers were scheduled to vote on the changes at a meeting in August, but postponed the vote until November. During a public comment period at an August meeting, several people, including Mx. Grace expressed her dismay at the draft guidelines, which they said were inadequate and put their lives at risk.
The repeated infections have taken their toll on Mx. Grace causes more frequent migraines and brain attacks, making them afraid to seek help even when they need it.
Before the pandemic, hospitals were less dangerous because staff members often wore masks, and people in waiting rooms and elevators likely didn’t get sick until late fall or winter, MX. Grace said.
“It was still scary,” says Mx. Grace said. But there was no “negative attitude toward asking for more precautions.”
