CDC Work Group is focused on weakening protections for health care workers and patients to create more flexibility for employers to prioritize profits

IP Work Group meeting summaries

1. The Work Group discussed “factors other than transmission” that should determine use of respirators, including “proportion of population at risk, impact on health systems, availability of effective diagnosis and treatment, and the availability of effective vaccines.”
2. As of July 2022, the draft guidance updates included a section on reuse and extended use of respirators for crisis and contingency periods. Reuse and extended use of single-use respirators undermines protection for health care workers.ⁱ
3. The Work Group was explicit that their drafts constitute a “minimum requirement for protection” and considered adding an explanation “that a person could voluntarily choose to do more than required (e.g., wear a non-fit tested respirator). A healthcare worker who is immunocompromised may choose a higher level of protection than recommended.”

For example:

1. On May 24, 2022, the Work Group held a discussion where some members expressed concern about requiring respirators for SARS-CoV-2. Members of the Work Group stated that “Due to the shortage of respirators during the pandemic, isolation masks were often used. There was no notable difference in the rate of infection of healthcare workers in their facilities.”  
2. On September 15, 2022, there was a discussion about the criteria that should be used for “when a pathogen, such as SARS-CoV-2, can be downgraded….”

This, despite the fact that the Work Group is comprised almost exclusively of infection prevention program managers at large health care corporations and is missing multiple areas of expertise.

The Work Group fails to incorporate input from the range of experts necessary to develop robust, strong, science-based infection control guidance, including direct care health care workers and their unions, aerosol scientists, ventilation engineers, experts in respiratory protection, and other occupational health and safety experts. For example:

1. The Work Group meeting summaries contain no record of a review of evidence regarding ventilation for control of infectious disease transmission. Instead, the Work Group has opted to maintain the current dichotomy where only “airborne” pathogens (e.g., measles and tuberculosis) require airborne infection isolation rooms and all other aerosol transmitted pathogens (e.g., influenza, coronaviruses, etc.) do not.
2. To decide on respiratory transmission-based precaution recommendations for seasonal coronavirus, seasonal influenza, and pandemic influenza/pandemic Covid-19, the Work Group took a vote with 9 of 11 members present. Work Group members were instructed to select their “minimum recommendation for (a) respiratory protection [choose among standard precautions vs. med/surg facemask vs. ASTM Performance Plus facemask vs. N95 respirator], and (b) eye protection [standard precautions vs. mandatory] ….” The scientific data on aerosol transmission of multiple infectious diseases does not appear to have been reviewed in detail by the Work Group, based upon these meeting summaries.
3. Members of the Work Group conducted an informal survey at their institutions to solicit feedback on the proposed use of masks and eye protection.
4. The Work Group recognized that there is insufficient evidence on Enhanced Barrier Precautions—a proposal to limit use of PPE to specific “high risk” tasks while removing patients from complete isolation for many common pathogens, many of which are highly contagious and can cause serious complications—but the Work Group proceeded to propose Enhanced Barrier Precautions for use in nursing homes to the full HICPAC in June 2023. The Work Group also discussed the possible future application of Enhanced Barrier Precautions to acute care settings. 

This set of documents provides the fullest view of the CDC’s evidence review to date; however, key information is still missing. Issues with the evidence review include:

1. The evidence review does not describe the methodology used by CDC staff to find and select papers, nor does it detail the inclusion or exclusion criteria used. However, in the June 9, 2022 Work Group meeting, Erin Stone reported that they selected most cited references from systematic literature reviews to include in their review. This method of selecting studies creates an echo chamber whereby critical evidence is left out.
2. The evidence review included 13 studies (five randomized control trials (RCTs), five case-control studies, and five cohort studies) and concluded “no difference in the effectiveness of surgical/medical masks or N95s to prevent transmission of laboratory-confirmed viral illnesses from patients to healthcare personnel.” But it is unclear why CDC staff excluded entire bodies of evidence indicating clearly that fit-tested NIOSH-certified N95 respirators provide protection against inhalation of hazardous exposures.^ii,iii,iv,v
3. The evidence review examined 29 studies looking at adverse impacts of N95 vs surgical/medical face mask use and found higher frequency of certain adverse events (e.g., difficulty breathing, headaches, and dizziness) but no difference in vital signs (e.g., SpO2, heart rate) or dermatitis among health care workers wearing N95s compared to surgical mask users. But the evidence review failed to take into account the adverse impacts of infections caused by not having sufficient protections, e.g., long Covid, long-term impacts from other viral infections, missed work, and onward transmission to co-workers, families, and communities.

Specifically:

1. In a discussion about how Standard Precautions and other infection control Core Practices are not always followed, Work Group members responded that “the answer may be to limit certain precautions to the highest priority pathogens; they will be easier to enforce if there are fewer patients on them.”  
2. The Work Group demonstrated a consistent orientation that vaccines by themselves constituted sufficient protection. For example, members discussed only using source control for seasonal flu during a year when the vaccine is not as effective. Members of the Work Group also stated that they believe varicella immune staff could enter the room of a varicella patient without wearing a respirator.
3. The Work Group has explicitly sought to “decouple” the use of N95 respirators from the use of negative pressure ventilation/airborne infection isolation rooms without first establishing an evidence base showing that this would be protective.  
4. The Work Group has consistently failed to distinguish between an N95 respirator and other types of masks (e.g., KN95s, ASTM barrier face coverings, surgical/medical masks), despite the fact that NIOSH is clear that other types of masks are not considered respiratory protection. The Work Group has even discussed the use of non-fit tested respirators, which they recognized would violate OSHA’s Respiratory Protection Program Standard.
5. As far back as May 2022, Work Group members stated that source control and indoor air handling need to be incorporated into the updated guidance. However, as of March 2023, Dr. Mike Bell, CDC staff, has reported that ventilation will not be included in the updated guidance.

The Work Group remains focused on dividing transmission by air based on distance—long vs short range—despite having explicitly recognized the fact that scientific evidence is clear that transmission by air occurs along a continuum and that other factors contribute to transmission risk (e.g., dose and time).