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Consensus Guidance on Face Coverings

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Updated February 7, 2022

The AAMC has updated its guidance on face coverings following the latest recommendations issued by the Centers for Disease Control and Prevention (CDC).

While America’s health care workforce has played a critical role since coronavirus infected its first patient in the United States in early 2020, physicians and scientists alone can’t save American lives from being lost to COVID-19. We need a comprehensive, coordinated national response to the pandemic, which the AAMC has previously described.

To reduce risk, fully vaccinated individuals are encouraged to continue wearing face masks in higher risk settings until a high percentage of the population in their community is vaccinated or community transmission is sufficiently low.1 Examples of these settings include grocery stores, gyms, movie theaters, and other crowded settings where the vaccination status of others is not known. Fully vaccinated individuals should also consider wearing a mask outdoors when in crowded settings such as concerts, sporting events, and other mass gatherings where not everyone may be vaccinated. Fully vaccinated and boosted individuals can visit indoors with other small groups of fully vaccinated and boosted individuals without a mask with minimal (though not zero) risk.

It is important to note that guidance from the CDC does not override mask orders issued by states, counties, or cities. It is the responsibility of every community to keep citizens safe, and mask requirements can vary in different parts of the country. There are times when, for the safety of others, everyone should wear masks. Business owners, public agencies, or other entities may, at their discretion, require all individuals to wear a mask when inside an establishment.

Prior guidance for unvaccinated individuals remains unchanged except that even unvaccinated people can be outdoors without a mask, unless in a crowded outdoor setting like a concert or sports event.

Wearing a mask is one step everyone can take to provide additional protection for themselves, their family, and their community in situations with elevated risk of infection. Clinicians and others working with patients wear masks and require all visitors to clinical sites to do the same regardless of their suspected COVID-19 status. A mask is not always comfortable and previously had not been a part of everyday life in the United States, but science shows that the benefits outweigh the discomfort, particularly when indoors with others whose vaccination status is unknown. While mask mandates have been issued in areas of appropriate jurisdiction, we are asking that state and local leaders — and all Americans — generally encourage those who are vaccinated and in areas of substantial or high transmission and those who remain unvaccinated wear masks indoors, as well as when in close proximity to others in crowded outdoor settings. While vaccinations are safe and highly effective at preventing serious disease, they are not 100% effective in preventing infection particularly with some variants.2 Risk of infection is significantly greater for those individuals who are immunocompromised.

Face coverings are critical for slowing the spread of the coronavirus, particularly indoors, while vaccination in this country and others remained uneven and variants of COVID-19 continue to spread. The medical community’s understanding of this virus has grown and evolved since March 2020, when efforts to slow the spread were first introduced. While we still have more to learn, our understanding of effective practices for prevention has grown tremendously. Initial evidence of the effectiveness of face coverings was substantiated through studies conducted early in the pandemic, and continued evidence strongly supports face coverings as a way to decrease transmission. An early study by the CDC followed up with 139 clients of COVID-19-positive hair stylists and found no symptomatic secondary cases; both parties had worn masks during their appointments.3 A study in Health Affairs examined the natural experiment of states’ mask mandates on community spread of COVID-19. The study estimated that, by late May 2020, between 230,000 and 450,000 potential COVID-19 cases were averted by the imposition of state mask mandates.4

Reinforcing the importance of prevention measures beyond monitoring symptoms and sufficient testing, including wearing face coverings in some settings, while accelerating the acceptance of vaccines is essential. Evidence shows that individuals can unknowingly spread the coronavirus because they may be infected and still asymptomatic, are not yet manifesting their symptoms, or have mild symptoms. Wearing a face covering is one step most people can take to protect themselves, their loved ones, and those most vulnerable in their community.

The latest research reinforces that well-fitting masks can help reduce the risk of virus transmission between individuals, allowing longer exposure while minimizing risk. Although almost any face covering which is available to you and that fits you well will provide you some protection, some face coverings are more effective at reducing transmission. Well-fitting National Institute for Occupational Safety and Health- (NIOSH) approved respirators have specific quality requirements and offer the most protection. Well-fitting KN95 and N95 respirators tend to work better than single disposable surgical masks.5 Wearing well-fitting, multilayer cloth masks or “double masking”6 will also provide some protection although less than respirators.5 Any medical-grade mask purchases can be checked against the Food and Drug Administration’s (FDA) list of approved masks to see if they are authorized. As knowledge grows about the virus, its methods of spread and transmission, and the effectiveness of vaccines, these guidelines will be regularly reevaluated and updated.

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Do’s

  • DO take a face mask with you when entering a public setting. Before you leave your home, check that you have your wallet, keys, phone, and mask. 
  • DO cover your mouth and nose with a face mask to stop the spread of coronavirus.
  • DO consider wearing a KN95, N95, or equivalent FDA- or NIOSH-approved mask in indoor settings where the vaccination status of those around you is unknown. 
  • DO wear a cloth mask with at least two layers (three layers when possible) over a surgical  mask or with a filter insert if a KN95 or N95 is not available to you.
  • DO wear a well-fitted face covering with no gaps around your nose and chin. If using a surgical  mask, minimize any gaps by knotting the ear loops and tucking and flattening any extra mask material.7
  • DO wear a mask with a nose wire.
  • DO double-check any medical-grade mask purchases against the FDA’s list of approved masks.
  • DO wear a face mask indoors around people who are not members of your household when transmission levels are high in  your community, even if you are fully vaccinated and boosted. 
  • DO wear a mask outdoors when you expect to be in a crowded setting. 
  • DO roll down the window of a car when sharing a ride or traveling with others who are not members of your household if you or others are unvaccinated.
  • DO change   your masks regularly. Masks can be placed in a plastic bag when not in use. Stop wearing a mask when it no longer fits you properly or becomes wet, dirty, or damaged. 

Don’ts

  • DON’T forget to wear a face covering and stop the spread. Protect yourself and others.
  • DON’T leave your home without a face mask.
  • DON’T wear your  face covering under your nose.
  • DON’T share your mask with others.
  • DON’T combine two disposable masks.

If You Are Fully Vaccinated

  • Fully vaccinated and boosted individuals can safely be outside without a mask except when at mass gatherings where people are more likely to spread viral particles in close proximity (e.g., concerts, rallies, sporting events).
  • We recommend wearing masks indoors (even if you are vaccinated) if the vaccination status of others is unknown, especially if transmission levels in your area remain high. Examples of these indoor settings include grocery stores, gyms, and particularly settings with large crowds like concerts, rallies, and sporting events.

Consensus Guidance on Face Coverings

In regions where community spread is significant and/or not falling significantly, wearing face coverings indoors should be mandatory. The following practices are recommended:

  • Well-fitted face coverings that minimize gaps around the nose and chin are important.
  • A KN95 or N95 will provide the highest level of protection when worn correctly. These masks should form a seal to work properly. These masks are disposable and should be rotated frequently if possible and thrown away when they are dirty, damaged, or difficult to breathe through.5 Individuals can use resources from the CDC to identify NIOSH-approved respirators. 
  • If the highest quality masks are unavailable or are not well tolerated by the wearer, protection can be provided by wearing high-quality, well-fitting cloth masks with multiple layers of fabric over a surgical mask or with a filter insert. 

Indoors

  • The CDC recommends that all people two years of age and older wear a mask in indoor public places. This applies to anyone not fully vaccinated and those who are fully vaccinated and boosted and in an area with substantial or high transmission.1
  • The use of face coverings is critically important indoors for unvaccinated individuals, as compared to outdoors. Superspreader events, in which an infected individual causes many subsequent infections, are likely to occur indoors.8
  • All businesses open to the public, no matter how limited, may insist all customers be masked while indoors.
  • Wear face coverings when indoors, even when six feet apart, if not with household members (unless you are fully vaccinated and boosted or you are only in the room with members of one other household). Some studies suggest that smaller droplets, known as aerosols, can remain in the air longer, though how long is not yet known.9

Outdoors

  • Face coverings are unnecessary outside (in nonenclosed spaces) for vaccinated and unvaccinated individuals, unless in a crowded area such as a concert or sporting event.1

State and local officials should support the distribution of masks for people experiencing homelessness, people who are incarcerated, and other vulnerable populations.

As the level of coronavirus community spread reaches sufficiently low levels, face coverings may become optional for everyone. Low levels can be defined as low regional spread, no national hot spots that could seed the local ecosystem, and adequate contact tracing so all contacts of infected individuals can be identified and quarantined.

Face coverings are only one measure to prevent the spread of infection. Vaccinations are critical to our safety, and frequent hand-washing and social distancing practices should be employed until more people are fully vaccinated.

If all Americans work together, we can protect our communities and continue reopening our schools and economy. Please join health care leaders in encouraging your family, friends, and community to get vaccinated and to at least wear a well-fitted face covering every time they come within six feet of someone outside their household.

Acknowledgments

Acknowledgments

The AAMC Research and Action Institute appreciates the expertise of the following individuals in developing this guidance:
Atul Grover, MD, PhD, executive director, AAMC Research and Action Institute
Ross McKinney Jr., MD, chief scientific officer, AAMC
Sheila Burke, MPA, RN, adjunct lecturer in public policy, Harvard Kennedy School
Ashish Jha, MD, MPH, dean, Brown University School of Public Health; professor of health services, policy, and practice
Megan Ranney, MD, MPH, academic dean, Brown University School of Public Health, director of Brown-Lifespan Center for Digital Health, Warren Alpert Foundation professor of emergency medicine, professor of behavioral and social sciences and health services, policy, and practice

The AAMC also thanks the following individuals for helping to develop this document:
Laura Pincus, MHA, manager, strategy and planning, AAMC Research and Action Institute
Amanda Field, PhD, former senior science policy specialist, AAMC

References

  1. Centers for Disease Control and Prevention. Your guide to masks. Updated Jan. 21, 2022. Accessed Jan. 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html
  2. Pilishvili T, Fleming-Dutra KE, Farrar JL, et al. Interim estimates of vaccine effectiveness of Pfizer-BioNTech and Moderna COVID-19 vaccines among health care personnel — 33 U.S. Sites, January–March 2021. MMWR Morb Mortal Wkly Rep. ePub: 14 May 2021. doi: 10.15585/mmwr.mm7020e2
  3. Hendrix MJ, Walde C, Findley K, Trotman R. Absence of apparent transmission of SARS-CoV-2 from two stylists after exposure at a hair salon with a universal face covering policy — Springfield, Missouri, May 2020. MMWR Morb Mortal Wkly Rep. 2020;69:930-932. doi: 10.15585/mmwr.mm6928e2
  4. Lyu W, Wehby G. Community use of face masks and COVID-19: evidence from a natural experiments of state mandates in the US [published online ahead of print June 16, 2020]. Health Aff. doi: 10.1377/hlthaff.2020.00818
  5. Centers for Disease Control and Prevention. Types of masks and respirators. Updated January 21, 2022. Accessed January 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html
  6. Brooks JT, Beezhold DH, Noti JD, et al. Maximizing fit for cloth and medical procedure masks to improve performance and reduce SARS-CoV-2 transmission and exposure. 2021. MMWR Morb Mortal Wkly Rep. 2021;70:254–257. doi: 10.15585/mmwr.mm7007e1
  7. Centers for Disease Control and Prevention. Improve how your mask protects you. Updated April. 6, 2021. Accessed Jan. 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/your-health/effective-masks.html
  8. Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 attack rate following exposure at a choir practice — Skagit County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:606-610. doi: 10.15585/mmwr.mm6919e6
  9. Prather KA, Wang CC, Schooley RT. Reducing transmission of SARS-CoV-2. Science. 2020;368(6498):1422-1424. doi: 10.1126/science.abc6197 

This is a publication of the AAMC (Association of American Medical Colleges). The AAMC serves and leads the academic medicine community to improve the health of all. The AAMC Research and Action Institute builds upon a long-standing AAMC strength of conducting and disseminating cogent research and analyses and informing and transforming practice and policy in U.S. health care. Learn more at aamc.org.

© 2022 Association of American Medical Colleges. May be reproduced and distributed with attribution for educational or noncommercial purposes only.