When is it really safe to take off your mask in California?

Customers wait in line to order food inside Grand Central Market in downtown Los Angeles.

Feb. 9, 2022 10:27 AM PT

When is it really safe to take off your mask?

This question is gaining more urgency as the Omicron wave collapses and coronavirus rules ease. Increasing numbers of states and counties are relaxing rules, some much more quickly than others.

Here is what we know:

Caution urged even as rules change

Even as California’s statewide mask order is set to expire next week, a top state health official is still encouraging people to wear masks while transmission rates are up.

“We’re still recommending it while rates are high, and certainly in indoor settings, indoor crowded settings — especially if you don’t know people’s vaccination status,” Dr. Erica Pan, the state epidemiologist and deputy director for the state’s Center for Infectious Diseases, said during a briefing to the California Medical Assn.

Pan’s comments are in line with recommendations from the U.S. Centers for Disease Control and Prevention, which suggests that vaccinated people still wear a mask in indoor public settings when local transmission levels are “high” or “substantial,” the worst two categories in the CDC’s four-level tier system, colored red and orange on the agency’s maps.

Geography differences

Virtually all California counties remain at “high” coronavirus transmission levels, and some will continue local mask mandates even as the state’s two-month-old order expires, citing ongoing high transmission rates.

Most California counties still seeing 'high' coronavirus transmission.

L.A. County health officials have set a goal for lifting an indoor mask mandate when it hits “moderate” coronavirus transmission for two consecutive weeks or when eight weeks have passed since children younger than 5 can get access to the vaccine, thresholds that are expected to be met either in March or April.

Other counties without local mask orders are on track to end mask mandates for vaccinated people in indoor public settings starting Feb. 16, including San Diego, Orange, Riverside and San Bernardino counties.

Unlike some of its neighbors, L.A. County is continuing with its rule that residents wear masks in indoor public spaces, regardless of whether they’ve been vaccinated.

“I will say, unequivocally, that we should not be lifting the masking mandate when we’re reporting thousands and thousands of new cases every day,” Los Angeles County Public Health Director Barbara Ferrer said this week. “That doesn’t make sense to us here at Public Health.”

Ferrer said she was confident that L.A. County will end its indoor mask mandate within months, as long as there are no significantly circulating new variants of concern that threaten the vaccines’ effectiveness.

“From my perspective, there’s no way this is a ‘forever,’” she said. “This has an end point. If nothing else, it’s eight weeks after there’s approval of an early child vaccine, but I think we’re going to get there a lot faster if we continue with the decline. The issue is, the decline continues if the protections are in place that really help us limit transmission. And when we remove a lot of those, as we’ve seen in the past, we tend to see our numbers go back up.”

Some California counties are beginning to repeal vaccination mandates to enter certain businesses. Contra Costa County on Friday said it was lifting its vaccine-or-test requirement for customers of indoor restaurants, bars and gyms. Health officials in the Bay Area’s third-most-populous county said the relaxation of the mandate, which has been in place since August, comes now that 80% of residents are fully vaccinated, and 2 in 5 residents have received a booster shot. By contrast, in Los Angeles County, 69% of residents are fully vaccinated, and 1 in 3 residents has received a booster.

Debate over moving faster

Some elected officials have voiced frustration that L.A. County’s indoor mask rules will not be as lenient as the state’s.

“The state has public health experts that are also advising the governor, and I believe that the recommendation to lift that mandate is based on public health as well,” L.A. County Supervisor Kathryn Barger said. “And so I just find it very frustrating that, once again, we are being the most restrictive.”

But a majority of supervisors have backed Ferrer’s approach.

“It’s pretty clear to me that we do have to have people still wearing masks,” said Supervisor Hilda Solis, whose eastern L.A. County district has been hit hard by the pandemic.

Supervisor Sheila Kuehl said extending the order until cases decline further will help protect front-line workers from facing maskless customers indoors.

“We’ve been wearing masks now for two years. I think that we can probably do it for another month or two,” Kuehl said. “I support the very thoughtful approach that Dr. Ferrer has presented because it actually takes the real data in Los Angeles County into account — not what Sacramento thinks should be sort of a flat number or approach for the whole state.”

Meanwhile, several states besides California, including New York, New Jersey and Delaware, are moving to relax indoor masking rules — some even in schools — though CDC Director Dr. Rochelle Walensky said her agency’s guidance has not yet changed.

The CDC still recommends masking in public indoor settings in areas where community coronavirus transmission is considered “high” or “substantial,” the two worst categories of the agency’s four-tier scale. As of Wednesday morning, virtually the entire country fell under one of those two classifications, including all of California.

“We’re of course taking a close look at this in real time, and we’re evaluating rates of transmission as well as rates of severe outcomes as we look at updating and reviewing our guidance,” Walensky said during a briefing.

However, she added, “we’ve always said that these decisions are going to have to be made at the local level, and the policies at the local level will look at local cases; they’ll look at how local hospitals are doing; they’ll look at local vaccination rates.

“I’m really encouraged that cases are continuing to drop dramatically, hospitalizations are continuing to drop dramatically as people are making these decisions and as we are working on our guidance,” she said.

Masks offer protection

The California Department of Public Health has credited the state’s temporary mask mandate as essential to prevent the state’s winter surge from getting worse. The action “was an important tool to decrease community transmission during the highly infectious Omicron surge,” officials wrote in a memo this week.

“The current hospital census is still over capacity, but the dramatic surge in cases and hospitalizations due to the highly infectious Omicron variant over the last two months has declined significantly,” the memo said. “Californians are also increasingly knowledgeable about how to protect themselves and their loved ones with effective masks when there may be risk of COVID-19 exposure.”

Even a 10% increase in mask-wearing can have an outsized effect in reducing coronavirus transmission, tripling the likelihood of slowing the virus’ spread, the memo said.

While the Omicron variant did not result in hospital illness for many infected people, the enormity of this surge still led to hospitals facing serious strain — far worse than in pre-pandemic times. Even now, hospitals are still being forced to postpone scheduled procedures.

The Omicron surge “still has put our hospitals over the edge,” Pan said. “This has really, really stretched our hospitals and, again, they are improving … but it’s still quite above [a baseline] and quite stretched — with less staffing than we’ve had in prior surges.”

The San Joaquin Valley is still being particularly hard hit, according to state data, with 44% of adult intensive care unit beds filled with coronavirus-positive patients, well above the statewide rate of 34%. In the San Joaquin Valley, just 10% of staffed adult ICU beds are available.

COVID-19 remains far deadlier than the flu. During one of California’s worst recent flu seasons, during the winter of 2017-18, flu made up 5% of all causes of death; during the recent pandemic surges, COVID-19 has comprised anywhere from 15% to 45% of all causes of death.

So even with Omicron being relatively less severe than earlier strains, “we still aren’t back to severity levels that are more similar to flu,” Pan said.

High alert for the unvaccinated

Getting more people vaccinated and boosted remains a top priority, Pan said. Unvaccinated people are 30 times more likely to die from COVID-19, and 15 times more likely to be hospitalized compared to vaccinated people who have received their booster shot.

But more progress can still be done, she said. Only 55% of vaccinated people who are eligible for a booster shot have received one, while 72% of eligible vaccinated seniors have done so.

A particular area of vulnerability are children age 5 to 11. Only one-third of children in this age group are vaccinated with at least one dose of vaccine; by comparison, more than 7 in 10 adolescents age 12 to 17 have received at least one shot.

While COVID-19 is typically less serious in children than adults, the disease is still worrisome for kids, Pan said. COVID-19 causes four times the number of deaths nationally than the flu; for unvaccinated teens, COVID-19 poses a hospitalization risk 11 times higher.

Children 5 to 11 in the poorest neighborhoods are the least likely to be vaccinated — only 1 in 5 of them are, compared with more than 3 in in the wealthiest areas, Pan said.

Children are also at risk for a rare but severe complication associated with COVID-19 known as multisystem inflammatory syndrome in children, which has been reported in more than 800 children in California, half of whom had no underlying conditions. Half of the reported MIS-C cases required ICU care, and eight children have died of this syndrome.

MIS-C cases are disproportionately seen among children in the poorest neighborhoods of California, according to Pan, and disproportionately among Black and Latino children. Among adolescents and teenagers 12 to 17, nearly 90% of MIS-C cases recorded in a recent timeframe were among unvaccinated patients.

California has recorded 51 COVID-19 deaths among children up to age 17; they include 12 infant deaths.