James Augustine, MD, FACEP
February 15, 2022
The IAFC Coronavirus Task Force has been looking into the future and attempting to plan for a reduction in COVID burden in the communities we serve. This can then be matched to the stepdown of mask guidelines for the service.
As of the second week of February, almost all states and provinces are in downward numbers of COVID cases and hospitalizations. There are significant regional variations, and it is critical for fire service leaders to understand hospital shortages of service. But these appear to be past their peak in many areas. All positive indicators.
Critical to our ability to return to restoration of normal public safety services, the so called “off-ramp strategies”, is how and when to modify mask guidelines for public safety service members. Many departments are at a point where masks are being used at most times when in the presence of others.
There can now be consideration of reducing mask use, based on local data, in sequential steps. Each of these steps could be considered for all staff or targeted for those members that have provided evidence of having up to date COVID vaccination status. That is the current preferred language from the Centers for Disease Control and Prevention (CDC).
Consider these steps
1. Reduce requirement for masking in common areas of the station and in vehicles.
Trigger: Significant decrease in community spread. Prior guidance from the CDC recommended indoor masking for communities logging either an average of 50 COVID cases per 100,000 residents, or a test positivity rate of at least 8%. There has been no change in that guidance. As of last week, 99.9% of U.S. counties met the criteria for indoor masking.
Official CDC guidance is here:
The CDC determines an area's level of virus transmissibility based on the average number of cases relative to a county's population and the COVID test positivity rate. If two indicators suggest different transmission levels, the higher level is selected.
• Low transmission: fewer than 10 new cases per 100,000 and less than 5% positive test rate,
• Moderate transmission: 10-49.99 new cases per 100,000, 5-7.99% positive test rate,
• Substantial transmission: 50-100 new cases per 100,000, 8-9.99% positivity rate, and
• High transmission: 100 or more new cases per 100,000, 10% or higher positivity rate. Masks are recommended in areas with substantial or high transmission.
The CDC developed these triggers as “on-ramp” strategies, when COVID is moving into a region and caseloads are going up, and there are plenty of potential patients for the disease to strike. But these triggers do not apply as easily when case rates are headed down quickly, as they are now. That is when an “off-ramp” strategy has to be applied. This strategy is a reflection that herd immunity is at very high levels from both vaccination and occurrence of the disease. And must occur when other variants of the disease are not poised to enter the population.
Considering the rapid decreases, a better trigger, or off-ramp strategy, might be:
• When case rates have decreased more than 50%,
• When cases are decreasing more than 50% among members,
• When no new variants are being reported,
• When hospital systems in the community are not operating at crisis level,
• When personnel are following department guidance to “Not come to work if ill”, and
• Potential of allowing vaccinated personnel to be relieved of mask requirements first.
At this stage, members will still:
• Wear N95 or better protection for all patient encounters.
• Wear masks in public settings and while doing educational programs in enclosed areas, and in public settings where there is concern about ongoing spread (nursing homes where cases are still occurring).
2. Reduce requirement for masking in public, while doing education programs, and in patient encounters involving patients who are not ill.
Considering further rapid decreases, a trigger might be:
• When community case rates have decreased more than 75%,
• When cases are decreasing more than 75% among members,
• When no new variants are being reported,
• When hospital systems in the community are not operating at crisis level, and
• Potential of allowing vaccinated personnel to be relieved of mask requirements first.
At this stage, members will still:
• Wear N95 or better protection for all patient encounters where the patient, or patient family members, are ill.
• Wear masks in public settings in enclosed places where there is concern about ongoing spread (nursing homes where cases are still occurring).
3. Reduce requirement for masking in all circumstances where there is no indication of a respiratory or infectious illness.
Considering further rapid decreases, a trigger might be:
• When community case rates have decreased to a very low level of spread,
• When cases are decreasing to a very low level among members,
• When no new variants are being reported,
• When hospital systems in the community are operating at a normal level of service,
• When occasional outbreaks are reported in congregate care sites, and
• Potential of allowing vaccinated personnel to be relieved of mask requirements first.
At this stage, further cases are falling. Members will still:
• Wear N95 or better protection for all patient encounters where the patient, or patient family members, are ill with infectious or respiratory symptoms.
• Wear masks in public settings in enclosed places where there is the known presence of ongoing spread (nursing homes where cases are occurring).
4. Masking requirement when there is indication of an infectious respiratory disease or illness (meningitis, tuberculosis (TB)). This is the baseline level of protection, with the use of respiratory PPE for circumstances where patients can expose emergency personnel to a dangerous illness.
At this baseline level of operations, members will still:
• Wear N95 or better protection for all patient encounters where the patient is likely ill with infectious or respiratory symptoms.
• Wear masks in public settings in enclosed places where there is the known presence of ongoing spread (the TB hotel).
Summary of off-ramp strategy for mask use
The current wave of COVID, attributable to the Omicron variant, is decreasing across North America. This can be matched to an off-ramp strategy to stepdown the mask guidelines for public safety providers. Off-ramp strategies require different considerations than on-ramp strategies, based on risks to exposed personnel. Now is the time to develop a safe departmental strategy of reduced mask use, based on local data, in sequential steps. Each of these steps could be considered for all staff or targeted for those members that have provided evidence of having up to date COVID vaccination status.
Dr. Augustine is a member of the IAFC’s Coronavirus Task Force.