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Guidance For the Use of Masks

Background

California has used science to guide our health protection strategies throughout the pandemic. Data show that because of these strategies, we have saved lives. This is due in large part to the collective efforts of Californians to get vaccinated, get boosted, and wear masks indoors.

A universal indoor masking requirement was reinstated on December 15, 2021, to add a layer of mitigation as the Omicron variant, a Variant of Concern as labeled by the World Health Organization, increased in prevalence across California, the United States, and the world and spread much more easily than the original SARS-CoV-2 virus and the Delta variant. Implementing the universal masking requirement in all indoor public settings during the winter season was an important tool to decrease community transmission and protect critical healthcare system capacity during the highly infectious Omicron surge. Since the peak in case rates during the Omicron surge in early January 2022, the dramatic surge in cases and hospitalizations due to the highly infectious Omicron variant has declined significantly. Californians have also become increasingly knowledgeable about how to protect themselves and their loved ones with effective masks when they may be at risk of COVID-19 exposure or transmission. Accordingly, CDPH amended this masking guidance to allow the universal indoor masking requirement to expire on February 15, 2022 as scheduled.

On March 1, 2022, the requirement for unvaccinated persons to mask in indoor public settings and businesses was replaced by a strong recommendation that all persons, regardless of vaccine status, mask in indoor public settings and businesses (examples: retail, restaurants, theaters, family entertainment centers, meetings, state and local government offices serving the public). Additionally, after March 11, 2022, the universal masking requirement for K-12 and Childcare settings terminated.

On April 20, 2022, the universal masking requirement on public transit and in transit hubs was replaced by strong recommendations that individuals in these settings continue to mask while on public transit and indoors in transit hubs to continue protecting our most vulnerable and those communities disproportionately impacted by COVID-19. 

Masking recommendations in general community settings, including public transit and transit hubs:

Earlier this year, California announced the release of the state's SMARTER Plan, the next phase of California's COVID-19 response. While state and local leaders must continue to prepare for the future, California's path forward will be predicated on individual, smarter actions, that will collectively yield better outcomes for our neighborhoods, communities, and state. Consistent with the SMARTER Plan, California is shifting its masking recommendations to a framework intended to provide information and recommendations that each Californian should consider based on the unique circumstances happening within their own community and county. 

The levels included in this framework are based on CDC COVID-19 Community Levels released in March 2022 as well as consideration of metrics based on California's historical data.

Persons should use information about the current COVID-19 Community Levels (CCLs) in their county to decide which prevention behaviors to use and when (at all times or at specific times), based on their own risk for severe illness and that of members of their household, their risk tolerance, and setting-specific factors. CCLs are based on hospitalization rates, hospital bed occupancy, and COVID-19 incidence during the preceding period.  At all CCLs (low, medium, and high), CDPH continues to strongly recommend that all persons:

• Stay up to date with COVID-19 vaccination, including all primary series doses and boosters.
  
• If you've been exposed, wear a mask for 10 days.
  
• Stay home when sick and know what to do if you have been infected with COVID-19, including seeking treatment early.
• Test if you are sick or have been exposed to someone with COVID-19.
  
• Improve ventilation and air quality in their setting.
  
• Wash hands regularly.
• Sign up for CA Notify to receive alerts when you have been in close contact with someone who tests positive for COVID-19.
  

Despite what level your community may be in, masks that offer the best fit and filtration (e.g., N95s, KN95s, KF94s), are highly recommended, and remain a critical component of our multi-layered approach for protection against COVID-19 infection. A series of cross-sectional surveys in the U.S. suggested that a 10% increase in self-reported mask wearing tripled the likelihood of slowing community transmission.[1] Our recently published case-control study conducted in California from February 18 to December 1, 2021 demonstrated that consistently wearing a face mask or respirator in indoor public settings reduces the risk of acquiring SARS-CoV-2 infection.[2] . Masks also remain a critical component for protecting those that are most vulnerable in our communities, including the unvaccinated, the immunocompromised, or those at risk for severe disease and illness.

*Those that are vulnerable include the unvaccinated, those that are immunocompromised, have certain disabilities, or have underlying health conditions, and those at risk of severe illness of death if they are infected with COVID-19.  Such persons should consider taking extra precautions.

Vaccination continues to remain the ultimate exit strategy out of the COVID-19 pandemic. While the percentage of Californians fully vaccinated and boosted continues to increase, we continue to have areas of the state where vaccine coverage is low, putting individuals and communities at greater risk for COVID-19. As a state, we need to remain vigilant.

Masking Requirements in Specified High-Risk Settings

The CDC COVID-19 Community Levels can also be used to define the level of recommended mitigation strategies for certain settings.

Accordingly, CDPH is updating its masking requirements in specified high-risk settings, consistent with current CDC recommendations. These changes are effective September 23, 2022.  CDC has noted that CDC COVID-19 Community Levels  do not apply in healthcare settings, such as hospitals and skilled nursing facilities. CDPH will continue to monitor the science and current CDC recommendations to ensure we continue protecting our most vulnerable populations and the workforce that delivers critical services in these settings.

In the following healthcare and long-term care indoor settings, masks are required for all individuals regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended.

• Healthcare Settings
• Long Term Care Settings & Adult and Senior Care Facilities
  

In the following non-healthcare indoor settings, facilities may use the CDC COVID-19 Community Levels to determine the level of masking requirements within their facility. 

• Homeless shelters[3], Emergency shelters[4] and cooling and heating centers[5]
  
• State and local correctional facilities and detention centers[6]
  

1)    When the COVID-19 Community Level is low, masking may be optional:

1. Only in non-clinical areas (such as in housing units, communal dining areas, visitation areas, and in administrative areas where only staff may have access), and
2. When there have been no outbreaks (defined as three suspected, probable, or confirmed COVID-19 cases within a 14-day period among epidemiologically linked residents and/or staff) in the entire facility or within separated, closed subunits that do not allow for mixing of those residents or staff with the general population.

Facilities should make surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit available at all times to any residents and staff who would like to use them based on their personal preference.

2)    When the COVID-19 Community Level is medium or high, facilities must maintain or reinstate universal masking requirements for all staff and residents, regardless if there are no outbreaks within the facility.   

Universal masking of all staff and residents, regardless of vaccination status and Community Level, is required in all clinical areas (or when any healthcare is being delivered), including isolation and quarantine areas, or any other areas that are covered by other specified high-risk settings. 

*In certain healthcare situations or settings surgical masks (or higher filtration masks) are required. In workplaces, employers and employees are subject to either the Cal/OSHA COVID-19 Prevention Non-Emergency Regulations or the Cal/OSHA Aerosol Transmissible Diseases (ATD) PDF Standard and should consult those regulations for additional applicable requirements.

Additional Masking Requirements

Finally, CDPH is maintaining the requirement that businesses and venue operators, including K-12 school and childcare settings, must allow any individual to wear a mask if they desire to.

In workplaces, employers and employees are su​​​​bject to either the Cal/OSHA COVID-19 Prevention Non-Emergency Regulations​​​ or the Cal/OSHA Aerosol Transmissible Diseases (ATD) PDF Standard and should consult those regulations for additional applicable requirements.

Local health jurisdictions and entities may continue to implement additional requirements that go beyond this statewide guidance based on local circumstances.

These requirements and recommendations will continue to be updated as CDPH continues to assess conditions on an ongoing basis.

For additional information on the most effective types of masks and ensuring a well-fitted mask for adults, individuals should refer to CDPH Get the Most out of Masking and see CDPH Masking Guidance Frequently Asked Questions. For additional information on the most effective types of masks and ensuring a well-fitted mask for children, individuals should refer to CDPH Masks for Kids: Tips and Resources.

Guidance for Businesses, Venue Operators or Hosts

When CDC COVID-19 Community levels are medium or high, businesses, venue operators or hosts should consider:

• Providing information to all patrons, guests and attendees regarding masking recommendations for all persons, regardless of vaccine status.
• Providing information to all patrons, guests and attendees to consider better fit and filtration for masks [Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are recommended over cloth masks].
• Requiring all patrons to wear masks, especially when risk in the community may be high, or if those being served are at high-risk for severe disease or illness.
• Requiring attendees who do not provide proof of vaccination to enter indoor Mega Events to continue masking during the event, especially when not actively eating or drinking.

No person can be prevented from wearing a mask as a condition of participation in an activity or entry into a business.

Exemptions to masks requirements

The following individuals are exempt from wearing masks at all times:

• Persons younger than two years old. Very young children must not wear a mask because of the risk of suffocation.
• Persons with a medical condition, mental health condition, or disability that prevents wearing a mask. This includes persons with a medical condition for whom wearing a mask could obstruct breathing or who are unconscious, incapacitated, or otherwise unable to remove a mask without assistance.
• Persons who are hearing impaired, or communicating with a person who is hearing impaired, where the ability to see the mouth is essential for communication.
• Persons for whom wearing a mask would create a risk to the person related to their work, as determined by local, state, or federal regulators or workplace safety guidelines.
  

[1] Rader B, White LF, Burns MR, et al. Mask-wearing and control of SARS-CoV-2 transmission in the USA: a cross-sectional study. The Lancet Digital Health. 2021;3(3):e148–e157.

[2] Andrejko KL, Pry JM, Myers JF, et al. Effectiveness of Face Mask or Respirator Use in Indoor Public Settings for Prevention of SARS-CoV-2 Infection — California, February–December 2021. MMWR Morb Mortal Wkly Rep. ePub: 4 February 2022

[3] CDC Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19)

[4] CDC's Interim Guidance for General Population Disaster Shelters During the COVID-19 Pandemic

[5] CDC COVID-19 and Cooling Centers

[6] CDC Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities

Originally published on November 16, 2020