— New guidance to focus more on risk of severe disease versus cases alone

by Molly Walker

After much speculation, CDC unveiled its new criteria on Friday for masking throughout communities based on healthcare indicators, where only 30% of the country would currently be recommended to wear a mask.

These metrics are a combination of new hospital admissions, hospital bed utilization for COVID patients, as well as incidence of cases in a community, combined to indicate either a low risk (green), medium risk (yellow), or high risk (orange) of severe disease in a particular county.

By the most current CDC data, this means that only 28.2% of the population lives in a high-risk county, though 37.3% of U.S. counties would be classified as high-risk. About 40% of counties are classified as medium risk (containing 42% of the nation’s population), while 23% are classified as low risk (29.5% of the population).

“We wanted to make sure we were focusing on severe disease [to] prevent hospitals from being overwhelmed,” said CDC Director Rochelle Walensky, MD, in a briefing with reporters. “We want to give people a break from things like mask-wearing when [COVID] levels are low and have the ability to reach for them again … in the future.”

Indeed, masking is nowhere to be found on the public health guidance for low-risk counties, only vaccination, boosting, and testing. In the medium-risk counties, individuals at high risk of severe disease should talk to their healthcare providers about wearing a mask. Mask-wearing indoors is recommended for high-risk counties.

Walensky said that this framework was “rigorously evaluated” by a variety of experts and was shown to predict risk of severe disease in a community, including hospitalizations, ICU stays, and deaths 3 to 6 weeks into the future.

She also clarified that hospitalizations will be counted as those patients “with” COVID, not just those hospitalized “for” COVID, because of the more intensive care that patient requires.

“Anybody in a hospital bed with COVID, regardless of their reason for admission” is going to “require an isolation bed, require PPE, require a higher staff ratio,” Walensky said.

She also added that many jurisdictions do not note the difference between patients coming in “with” COVID or “for” COVID, and not every hospital is going to “screen a patient for COVID when they walk in the door.”

Vaccination rates were not part of this metric, and when asked why by a reporter, Walensky responded that the focus of the new metric was strain on the healthcare system, and while “vaccination rates fall on the causal pathway for risk of severe disease,” they are “part of the equation,” but are not used as an indicator.

Walensky added that anyone with symptoms, a positive test or exposure to COVID should wear a mask, and people may choose to mask at any time. She said that CDC would keep this metric updated on a county level “for the foreseeable future.”

Masking in schools was only recommended for those in high-risk counties, and when asked why, Greta Massetti, PhD, of CDC’s COVID-19 Response Incident Management Team, responded that illness in children tended to be milder, and prior multi-layered prevention strategies proved transmission can be stopped in schools if implemented.

“Children are at lower risk of severe illness, [so] schools can be a safe place for children,” she said.

In addition, Walensky noted this new guidance does not apply to masking on transportation, such as airplanes. Those mandates are set to expire in mid-March, but Walensky said they will be revisited before then.

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