As masks are shed, a routine visit to a medical office can pose Covid risks for some patients

In May, Sarah Fama had to get blood work done before refilling a prescription for an autoimmune disorder. Because her condition put her at high risk for Covid-19, and she lives with her parents, both in their 80s, she checked the lab’s website, which stated that masks were required inside. When she arrived, she was reassured by a sign on the door that said the same thing.

But when Fama, 48, opened the door, she was greeted by an unmasked employee behind a glass partition. A patient in the waiting area was also maskless. And the technician who took Fama’s blood came into the room with a mask below her chin, before eventually pulling it over her mouth and nose.

“I was just floored to see medical providers doing that,” she said. “I’ve been trying to do everything to keep me and my parents safe and it just makes you feel like you don’t matter.”

For tens of millions of Americans who are at high risk of severe outcomes from Covid-19, or live with such people — either from age, underlying medical conditions, or immunodeficiency — not much has changed since the spring of 2020. They’re still mostly hunkering down at home. They don’t go out to eat or see a movie or take in a concert. Often the only exception they make is a visit to the doctor’s office.

But as the third pandemic fall looms ahead, with mask mandates dropped and isolation requirements relaxed, many high-risk individuals are increasingly anxious about contracting Covid while accessing necessary routine health care.

“Even in clinics where the job is to provide care for people who are really high risk, you can’t even feel safe somewhere like that,” said Amanda, a kidney transplant recipient in Georgia who described visiting a nephrology clinic this summer where staff were unmasked in the waiting room. Evusheld has made it possible for her to do things like attend doctor’s visits, but she’s still terrified of catching Covid because it could damage her donated organ. She asked that her last name not be shared for fear of losing access to care. “It just feels like we’re more and more on our own,” she added.

Patients are especially miffed by the lax Covid protections they’ve experienced in medical offices because the science on the risks of respiratory infection transmission in outpatient settings is far from settled.

“It’s an important issue that people aren’t talking about,” said Michael Barnett, an associate professor of health policy and management at the Harvard T.H. Chan School of Public Health and a primary care physician at Brigham and Women’s Hospital. “There just isn’t a ton of research on it.”

Health care-acquired infections are more frequently studied in hospitals because that’s where most infection control researchers work, and because patients there tend to stay longer, increasing their risk of spreading or catching something. Most states also have laws requiring hospitals to report health care-acquired infections, making them easier to track. The same is not true for outpatient settings, where the brief interaction time — patient visits typically last between 10 minutes and a few hours — is believed to make them relatively low-risk.

But transmission risk of respiratory infections is not just about exposure time. It’s also about the size of the space and the amount of fresh air moving in and out to dilute the clouds of virus-containing particles a contagious person is emitting while they cough, sneeze, speak, and breathe.

Hospital rooms are required to have a minimum of eight air changes per hour. The Centers for Disease Control and Prevention has recommended that patients with suspected or confirmed Covid-19 be placed in isolation rooms with at least 12 air changes per hour. By contrast, clinic exam rooms and treatment rooms only have to have four and six air changes per hour, respectively. And if they’re located in office buildings that house other kinds of businesses or shopping centers they can be classified as office space, not health care buildings, meaning they don’t have to adhere to those ventilation standards.

A study conducted by researchers at the University of Texas Health Science Center and published last year in the American Journal of Infection Control measured ventilation in 105 clinic rooms in offices. It found that 10% of them didn’t meet minimum requirements for general exam rooms, 40% didn’t meet requirements for treatment rooms, and over 80% would not meet the higher standards required for aerosol-generating procedures and minor surgeries. Such spaces “may inadvertently increase the risk to workers and the potential spread of the disease within the clinic,” the authors wrote.

But there’s still not much data that can put hard numbers to what those increased risks might be.

In one of the few studies comparing the risk of SARS-CoV-2 transmission in inpatient versus outpatient settings, researchers at a Veterans Affairs health care system in Ohio used whole-genome sequencing to conduct contact-tracing investigations of 14 Covid clusters from the first year of the pandemic. They were surprised to find that seven of the outbreaks could be traced back to community-based outpatient clinics. Most of the transmission events happened between co-workers. In two cases, health care personnel spread the coronavirus to patients — one in a physical therapy office and the other in a non-Covid hospital ward.

“Clearly from our study there is a lot of transmission among personnel working in outpatient settings,” said Curtis Donskey, an infectious disease physician and hospital epidemiologist who led the investigations. “And there’s always the potential that they could transmit Covid to patients they’re seeing there, but thankfully that seems to be relatively infrequent.”

One of the reasons for that, Donskey believes, is a universal masking policy that was in place for all patients, health care workers, and staff at the time of his study. But what happens when those policies are dropped or not well-enforced? An analysis conducted by Barnett and his colleagues at Harvard Medical School of electronic health records from the mask-free years immediately preceding the arrival of Covid-19 sheds some light here.

In a study published last year, the researchers examined rates of potential airborne disease transmission in clinical office settings by combing through reams of de-identified scheduling and billing data from Athenahealth representing more than 100 million primary care visits from 2016 to 2017. They found that people who had appointments after patients diagnosed with influenza-like illness were 30% more likely to return with a similar illness within the next two weeks, compared to non-exposed patients seen earlier in the day. They didn’t see the same pattern for non-respiratory ailments like urinary tract infections and back pain.

“What I came away with is that there are relatively straightforward things that are not particularly costly that could be done in most clinical office settings that could interrupt common chains of respiratory infection transmission,” said Barnett. First, low-risk patients with respiratory symptoms should be offered virtual visits by default. Anyone who does come for an in-person appointment should be masked and quickly taken into an exam room to minimize time spent waiting around others. “With that combination we could probably drastically reduce the potential of people getting sick from each other inside an outpatient office,” Barnett said.

While his team has not repeated the analysis for 2020 or 2021, other studies have pointed to the profound impact Covid measures had on driving back other respiratory diseases. The past two winters were among the mildest influenza seasons on record. Respiratory syncytial virus, or RSV, which in a normal winter puts nearly 60,000 children under the age of 5 in the hospital, vanished. Common colds? Almost nonexistent.

To Barnett, Covid revealed just how big a difference it could make if primary care providers followed these kinds of infection prevention and control practices for all respiratory infections — but he’s not sure whether they’ll be a lasting fixture of whatever comes after this phase of the pandemic.

“Honestly, it’s not something that a lot of outpatient offices want to think about. Most medical professionals recognize it’s obvious that masks make a difference even if they’re not perfect. But it’s still a hassle and a big culture change,” Barnett said. “Prior to Covid, people didn’t wear masks in America, because as a nation we haven’t historically weighed the risk of contracting respiratory viruses all that heavily. We just accepted all that misery as a way of life. Before the pandemic, I wouldn’t have even known where to find a surgical mask.”

Immunocompromised individuals, on the other hand, have been stocking up on masks and hand sanitizer since long before the pandemic, said Loriana Hernandez-Aldama. “I’ve been wearing masks and wiping down shopping carts since 2014,” she said.

That’s when Hernandez-Aldama was diagnosed with leukemia. For close to a year she received chemotherapy in the hospital — her doctors told her that her devastated immune system wouldn’t survive living at home with her 2-year-old son — before she was able to get a bone marrow transplant. She later survived a bout with breast cancer, and now runs a non-profit called Armor Up for Life, which educates cancer patients from underserved communities about how to navigate the health care system and advocate for themselves.

She’s approached unmasked or poorly masked people in waiting rooms to ask them to fully cover their faces — most recently a few months ago while waiting in a radiology department for a scan for her sister, who’s currently in treatment for breast cancer. But she recognizes that this might be difficult for people in rural communities where masking is less prevalent and health care options are limited. She recommends explaining your situation to the staff at the counter, and politely asking them to enforce the clinic’s masking policy.

“People say it’s a political issue, but it never has been for me,” said Hernandez-Aldama. “I want people to understand that our battle is ongoing and it never ends. So please be considerate of what we’re going through. And remember that my story could someday be your story.”

A Labcorp spokesperson told STAT that all employees at Patient Service Centers like the one Fama visited are required to wear masks. For patients, masks are encouraged but not required. “Labcorp also offers the Wait Where You’re Comfortable Program for patients who would prefer to wait in their vehicles or a nearby location until their appointment,” the spokesperson said.

For high-risk individuals navigating the health care system this fall and winter, investing in well-fitting N95 masks is another important step to take, said Don Milton, an aerobiologist at the University of Maryland.

His lab has been studying the behavior of SARS-CoV-2 in small, inhalable particles that can stay suspended for hours. In a recent study, not yet peer-reviewed, he and his colleagues reported that newer variants of the coronavirus are getting better at cramming more viral copies into these smallest particles, known as aerosols.

“We’re seeing it evolving toward aerosol shedding comparable to what’s been previously observed with influenza,” said Milton. Pre-pandemic studies conducted by scientists at the National Institute for Occupational Safety and Health detected airborne particles containing influenza and respiratory syncytial virus, or RSV, in the air of an urgent care medical clinic and a hospital emergency department waiting room. “We know SARS-CoV-2 will be in the air in these places this fall and winter, so it’ll be really important for vulnerable people to limit their exposure by adding the protection of tight-fitting respirator-style masks,” Milton said.

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