Industry Voices—As healthcare's labor shortages worsen, masking remains critical

Hospitals are experiencing critical workforce deficiencies. This is a worldwide problem as stressed by WHO Director-General Tedros Adhanom Ghebreyesus, Ph.D., that “millions of health and care workers were infected (with SARS-CoV-2), thousands died and many of them are simply exhausted from overwork.”

And the single largest cause of disruption in healthcare delivery in high- and low-income countries is the shortage of healthcare workers. According to a June 2022 American Hospital Association report, America will have a shortage of 124,000 by 2033 and, due to nursing attrition, will need to replace 200,000 nurses per year.

Staffing shortages have created healthcare worker burnout and skyrocketed hiring prices. A vicious feedback loop ensued.

We must rethink our approach to staff retention. Breaking and reversing this loop may be as simple as upgrading the quality of facial masks and healthcare facility ventilation. The importance of keeping workers safe and eliminating absenteeism due to illness cannot be overstated. 

During the pandemic, nurses were 44% more likely and physicians 33% more likely to become infected with SARS-CoV-2 compared to other occupations. COVID-19 illnesses are not over, and future pandemics are looming. New XBB variants are causing recurrent infections and increasing hospitalizations in India (XBB.1.6) and the U.K. (XBB.1.5 and XBB.1.9). Both countries have a population with an extremely high degree of natural immunity. The U.S. should not assume it can escape these variants; the XBB.1.9 is rapidly increasing in our population where an estimated 94% has already been previously infected with SARS-CoV-2.

Concerns over the emergence of new pathogens were heightened by a recent report from the Shanghai Institute of Infectious Disease and Biosecurity which details the possibility of a recombinant virus comprised of MERS-CoV and SARS-CoV-2. Such a virus would be expected to be both highly infectious and lethal. Because of the lack of international restrictions on gain-of-function research, this virus may already exist in a biomedical laboratory. Almost any pathogen can become airborne by an aerosolizing procedure. These pathogens include bacteria that are almost a hundred-fold smaller than the size required for aerosolization.

However, a truly “airborne” pathogen does not require a procedure to spread, it can be spread by simply talking and breathing. This is the case with SARS-CoV-2. The first line of defense against airborne diseases is the provision of masks to healthcare workers which will block aerosolized pathogens. Surgical masks should not be used. As their name implies, these masks should be reserved for procedures with the goal of blocking the spread of large droplets from the surgeon to the patient.

Surgical masks provide a degree of protection but are far from adequate for frequent and high levels of viral exposure. N95 masks or respirators work by a combination of filtration and electrostatic attraction of particles. The technology was developed at the University of Tennessee in the mid-1990s by Peter Tsai, Ph.D., a Taiwanese American researcher.

The efficacy of N95 masks in filtering aerosolized particles, including viruses, has not been questioned previous to the COVID-19 pandemic. Current resistance to the usage of all types of masks was recently bolstered by a recent Cochrane meta-analysis that failed to find evidence that masks prevented respiratory disease. However, it is ethically difficult to conduct controlled masking studies, and as noted in the Cochrane review, “Relatively low numbers of people followed the guidance about wearing masks.”

This, along with the fact that the vast majority of the studies involved influenza or influenzalike illness which can also be spread by surfaces and aerosols, mitigates the benefit of surgical masks. Only two studies in the meta-analysis dealt with SARS-CoV-2. They were studies on masking compliance and they both showed a positive effect, one reaching statistical significance.

The Yale and Stanford study in Bangladesh was well-controlled and demonstrated the positive effect of wearing surgical masks.  If N95 masks were used and compliance was higher, one would expect an even greater benefit. The Cochrane meta-analysis also analyzed five studies and concluded that N95 masks did not provide a benefit over surgical masks, but all of these studies analyzed influenzalike illnesses, not COVID-19. In addition, the studies had low compliance in mask wearing and many reported non-continuous use.

Thus, it is not surprising that a benefit was not detected. Despite these problems, two of the studies demonstrated an added benefit of N95 masks.

The Cochrane meta-analysis also stated, “The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect.“ Unfortunately, the Cochrane findings have been portrayed in disinformation regarding masks’ efficacy in stopping the spread of SARS-CoV-2.

Tom Jefferson, the lead author, stated in a news interview with Maryanne Demasi that “There’s still no evidence that masks are effective during a pandemic” and that N95 masks make “no difference.” Most authorities disagree with these statements.

The editor-in-chief of the Cochrane Library, Karla Soares-Weiser, stated “Many commentators have claimed that a recently-updated Cochrane Review shows that 'masks don't work', which is an inaccurate and misleading interpretation.”

Several other researchers have found masks effective in reducing the spread of SARS-CoV-2. Stella Talic, et al., reported in the British Medical Journal a systematic review, and meta-analysis involving six studies, and concluded that masks reduce SARS-CoV-2 infections by almost 50%. In the Massachusetts school system, the lifting of mask mandates resulted in an additional 44.9 infections per 1000 students, accounting for 29% of all infections in the school districts at that time.

Thus, N95 masks are one of the keys to the optimal maintenance of a healthy healthcare workforce. The expense of these masks pales in comparison to the expenses paid by hospitals to hire agency replacement workers. The benefits of high-quality masks extend far beyond SARS-CoV-2, since they will help prevent illnesses from other common airborne pathogens, decreasing sick leave and allowing the facility to maintain the provision of high-quality services. 

Kevin Kavanagh, M.D., is the founder and president of the patient advocacy group Health Watch USA.