The CDC’s new guidelines on COVID-19 risk and masking send confounding signals

When the Centers for Disease Control and Prevention recently unveiled updated COVID-19 guidelines that relaxed masking recommendations, some people no doubt sighed in relief and thought it was about time.

People have become increasingly comfortable being out shopping, attending live events, or meeting up with friends at restaurants. And many are ready to cast aside their masks.

Still, a recent KFF poll pointed to an underlying tension. Just as a large swath of the American public, 62%, said that the worst of the pandemic was behind us, nearly half were worried about easing COVID-related restrictions — like indoor masking — too soon. The poll, conducted in February, found that 49% of adults were either "very worried" or "somewhat worried" that lifting pandemic restrictions would cause more virus-related deaths in their communities. About 50% were "not too worried" or "not at all worried" that death tolls would rise in their communities.

The CDC’s move triggered some of the same mixed feelings from the public that the poll uncovered and laid bare a split within the health care community.

On the one hand, there's applause.

The CDC’s protocol change is an indicator that the nation is approaching a "transition from the pandemic phase to an endemic phase," said Dr. Georges Benjamin, executive director of the American Public Health Association. Rather than pushing messages of prevention, Benjamin said, the agency is changing its focus to monitoring for spikes of infection.

On the other hand, there are criticism and worry, too.

"When I hear about relaxing regulations," said Dr. Benjamin Neuman, a Texas A&M University professor and chief virologist at its Global Health Research Complex, "it sounds a lot like people giving up. And we’re not there yet, and it’s a little bit heartbreaking and a little bit hair-pulling."

Before the update, the CDC considered a community at substantial or high risk if it had had an infection rate of 50 or more new cases for every 100,000 residents in the previous week.

According to the agency’s new community-based guidance, risk levels can be low, medium, or high and are determined by looking — over a seven-day period — at three factors: the number of new COVID-19 cases in an area, the share of hospital beds being used, and hospital admissions.

This change had a profound impact on how COVID-19 risk was measured across the country. For example, the day before the CDC announced the new guidelines, 95% of the nation’s counties were considered areas of substantial or high risk. Now, just 14% of counties fall into the high risk category, according to the agency.

The CDC doesn’t make specific mask recommendations for areas at low risk. For areas classified as medium risk, people who have other health problems or are immunocompromised are urged to speak to their health care provider about whether they should mask up and take other precautions. In areas deemed to be high risk, residents are urged to wear masks in indoor public spaces.

"This more stratified approach with this combination of those factors gives us a better level of understanding of COVID-19’s impact on our communities," said Keri Althoff, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health. "Specifically, the impact of severe disease and death."

But people shouldn’t get rid of their masks yet, she said. Even as the nation’s infection rates fall, the virus continues to spread on a global scale. "We have to fully recognize that there are so many people on this earth who are unvaccinated internationally, and this is where the variants come from," Althoff said.

The same week the CDC rolled out its new guidelines, it reported a national seven-day average of about 71,000 new COVID-19 cases, along with 5,400 hospital admissions. Around 2,000 people were dying because of the disease every day.

It’s numbers like these that led some public health experts to question the CDC’s timing.

"I think we have prematurely opened and prematurely unmasked so many times at this point, followed by remasking and reclosing and just seeing our hospitals absolutely swamped, that I don’t really trust this," said Texas A&M’s Neuman.

There have been "too many times," he said, when the CDC has put down its guard and the virus came back stronger. "We’re basically taking our foot off the accelerator in terms of what we’re doing to slow down the virus, and that just means that there will be more virus going around and it’s going to keep swirling around," he said.

The CDC’s goal for easing mask mandates, Neuman speculated, was to create regulations that are more appealing and easier for people to abide by, because "it’s hard to sell prudence as something really attractive." Plus, public health officials need to have a program that the entire country can follow, he said. The battle against the virus can’t be won with policies "that people follow in blue states but not in red states," he added, "because the virus is very much a collective risk."

There also are questions about how effective the new approach is at signaling when risk is increasing.

Joshua Salomon, a professor of health policy at Stanford University’s medical school, said that although the CDC designed its new guidance to incorporate a stronger indicator of surges, it has "a very late trigger."

Salomon, along with Alyssa Bilinski, an assistant professor of health policy at Brown University, looked into the delta and omicron surges and found that a rough rule of thumb during that period was that 21 days after most states rose to the high risk level, the death rate hit three people for every million. That equals about 1,000 deaths a day at a national level.

The updated CDC guidance "is intended to provide a sort of warning that states are entering a period in which severe outcomes are expected," he said. But the new approach would not sound that alarm until death rates were already reaching that "quite high" mark.

Others, though, point to another set of numbers. They say that with 65% of Americans fully vaccinated and 44% boosted as of March 8, relaxing COVID-19 protocols is the right decision.

The new strategy is forward-looking and continues to measure and track the virus’s spread, said the APHA’s Benjamin. "It allows a way to scale up and scale back the response."

Since the guidelines are based on seven-day averages, he added, they are a good way to monitor communities’ risk levels and gauge which set of mandates are appropriate. "So if a community goes from green to yellow to red," he said, referring to the CDC’s color-coded map that tracks counties’ COVID-19 levels, "that community will then need to modify its practices based on the prevalence of disease there."

The guidelines, Benjamin said, are "scientifically sound, they’re practical." Over time, he added, more communities will move into the low and moderate categories. "The truth of the matter is that you just cannot keep people in the emergency state forever," he continued. "And this is never going to get to zero risk. … [COVID’s] going to be around, and so we’re going to have to learn to live with it."

The CDC’s relaxed recommendations do not prevent anyone from wearing a mask. But for millions of Americans who are immunocompromised or too young to receive a vaccine, less masking means a loss of a line of defense for their health in public spaces.

Children younger than 5 are not eligible to receive a vaccine yet, and people who are immunocompromised and are susceptible to more severe cases of the disease include cancer patients undergoing active treatment and organ transplant recipients. People living with chronic illnesses or disabilities are also vulnerable.

"You only have control of so much," Neuman said. "And if you’re exposed to enough of the virus and you’re doing all the right things, you can still sometimes end up with a bad result."

Masks are most effective when everyone in a room is wearing one, Neuman added, but the new mandate is similar "to victim blaming — basically saying, ‘You have a problem and so here’s the extra burden to go with your problem.’"