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tates that recently announced plans to lift either indoor or school mask mandates have at least two things in common: Hospitalization rates are on the decline, and all except one have a larger share of fully vaccinated residents than the national average.
Most of the governors in those states have linked these metrics to their moves to lift some COVID-19 mitigation measures. That's raising questions about whether these metrics should play a larger role in mitigation decisions nationwide — more than COVID-19 case counts.
Meanwhile, shifts to phase out state mask mandates conflict with the U.S. Centers for Disease Control and Prevention's guidance to continue wearing masks in areas with "high" or "substantial" COVID-19 transmission, which includes about 99% of U.S. counties. The agency is working to review and possibly update its guidance on mask-wearing, but for now, states appear to be outpacing the White House in planning for a post-omicron period.
High levels of vaccination, low levels of hospitalization
Although many indoor mask mandates are implemented at the city and county level, six states still have mandates in place: California, Hawaii, Illinois, New Mexico, Oregon and Washington.
A growing number of states — the majority with Democratic governors — have planned to end their indoor or school mask mandates in the coming weeks, including California, Connecticut, Delaware, Illinois, Massachusetts, Nevada, New Jersey, New York, Oregon and Rhode Island.
Many of these states were early adopters of strict COVID-19 safety measures, and vaccination rates in all but one have climbed above the national average. In the United States as a whole, 64.3% of the population is fully vaccinated, as of Thursday.
The share of fully vaccinated people in each of those states, according to the latest data from the U.S. Centers for Disease Control and Prevention, is:
66.8% in Delaware and Illinois
68.2% in Oregon
69.6% in California
73.5% in New Jersey
74.8% in New York
77% in Massachusetts
77.2% in Connecticut
79.7% in Rhode Island
Only one state that recently rolled back its mask mandate had a percentage of people fully vaccinated that was less than the national average: Nevada, with 59%.
Vermont and Rhode Island are tied for the highest vaccination rates in the country, with 79.7% of their population fully vaccinated against COVID-19 as of Thursday.
"Vermont has not had any statewide, mandatory mitigation measures in place since June, when we became the first state to vaccinate 80% of our eligible population," Jason Maulucci, press secretary for the Office of Gov. Phil Scott, wrote in an email to CNN on Thursday.
"Since then, we continue to be the national leader in many vaccination categories, including percentage of the full population vaccinated, percentage of the pediatric population vaccinated (by far), and for booster shots rates," Maulucci wrote. "As a result, even through the delta and omicron waves when our cases were elevated, Vermont's hospitalization rate has consistently been one of, if not the lowest, in the nation."
Students here line up to enter Christa McAuliffe School in Jersey City, New Jersey, April 29, 2021.As states plan to lift school mask mandates, CDC remains vague on updating its guidance
In Rhode Island, where indoor mask mandates and proof of vaccination protocols will be lifted Friday, infection rates declined about 94% since January. "We're the second most vaccinated state in the country. Right now, we're the third most boosted state in the country," Rhode Island Gov. Dan McKee told CNN Thursday, seeming to put more emphasis on vaccination rates than community transmission.
Even though the state has high levels of community transmission right now, "we know that the trends are really moving very sharply in the other direction," McKee said. "I think we've done the right thing for Rhode Island."
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On the international stage, Denmark was the first European country to eliminate mask mandates, vaccine passports, isolation protocols "and all the rest," but the country is different from the United States "in a few important ways," Andy Slavitt, former senior adviser to the Biden administration's COVID-19 Response Coordinator and former acting administrator of the Centers for Medicare and Medicaid Services, wrote in a series of Twitter posts Thursday.
They have 81% of their population double vaccinated and 61% boosted, as well as universal health coverage, manageable intensive care units and "a top flight surveillance capability," Slavitt tweeted. "The U.S. doesn't have enough people vaccinated, has full hospitals, has huge access challenges, massive inequality."
But on the local level, "you don't have to look far" in the U.S. to see state governors following a path similar to Denmark's, Slavitt added.
"These are responsible governors with states that have done a good job managing the pandemic," he tweeted. "They have higher vax rates than in most of the country and the cultural fights over masks are at a relative minimum."
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Moving beyond community transmission
In the CDC's guidance to keep masking in communities with "high" or "substantial" COVID-19 transmission, the agency defines substantial transmission in a given area as fewer than 50 to 100 new cases per 100,000 people in the past week and at least 8% but less than 10% test positivity during the past week. High transmission is at least 100 new cases per 100,000 people in the past week and 10% or greater percentage of positive tests.
With the rising use of at-home tests and the spread of the highly transmissible omicron variant, it might be time to shift COVID-19 measurements from case counts and test positivity to metrics on serious illness and death, Lori Tremmel Freeman, chief executive officer of the National Association of County and City Health Officials, told CNN on Wednesday.
"When you think about what the local and county health departments face in local decision-making and the metrics that are in place on current case rates and test positivity, those are community leading indicators that were defined a long time ago," Freeman said.
"What's changing over time is our ongoing ability to keep track of those things with the omicron surge entering the picture and the expansion of at-home tests, paired with people in various stages of mitigation efforts across the country," she said. "I don't know how much longer the current community indicators may remain useful, and then what we're hearing from the ground is just overall public fatigue with the pandemic and mask-wearing and mitigation strategies."
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From East Coast to West Coast
Some U.S. states never had mask mandates, and a few went so far as to ban mask mandates in schools — and they continue to face high hospitalization rates and low vaccination uptake.
The approach was different in the states that recently announced mandate changes.
When New Jersey Gov. Phil Murphy announced Monday that the state's universal mask mandate in schools will lift March 7, he noted that the decision was based on "significant" declines in multiple statewide COVID-19 metrics.
"Our case count, hospitalizations, the spot positivity rate, the rate of transmission are all dropping like a rock," Murphy told CNN on Monday.
"We've adhered overwhelmingly with the CDC guidance. The reason why we're making this step today is our reality in New Jersey," Murphy said. "We are now in a dramatically different place than the norm right now across the country, which is why we feel like we can decouple and take this step."
In New York, Gov. Kathy Hochul said in a briefing Wednesday that "overall cases are down, positivity rates down, hospitalizations are down, cases per 100,000 are down, and new admissions are down," and "vaccines and boosters are up, and our hospital capacity is up," leading to lift of the statewide indoor business mask-or-vaccine requirement starting Thursday. She called the data "a beautiful picture."
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In Oregon, the state plans to remove general mask requirements for indoor public places no later than March 31, health officials announced Monday, and mask requirements for schools will lift March 31.
State officials pointed to hospitalization data as the reasoning behind their plan.
By late March, public health specialists predict that about 400 or fewer Oregonians would be hospitalized with COVID-19 — the level of hospitalizations the state experienced before the omicron variant began to spread, according to the Oregon Health Authority.
However, state health officials emphasized that people in Oregon need to keep mask requirements in place for now as COVID-19 hospitalizations crest and the health care system strains to treat high numbers of severely ill patients.
"The evidence from Oregon and around the country is clear: masks save lives by slowing the spread of COVID-19," Dr. Dean Sidelinger, health officer and state epidemiologist, said in a news release Monday.
"We should see COVID-19 hospitalizations drop by the end of March because so many Oregonians are wearing masks and taking other steps to protect themselves and each other, such as getting a booster shot or vaccinating their children. At that point, it will be safer to lift mask requirements."
Surgeon General Dr. Vivek Murthy InterviewSurgeon general says US should adjust COVID-19 restrictions depending on current situation
In California, Gov. Gavin Newsom touted the state's stabilizing hospitalization rates as a contributing factor to planning for lifting mask mandates.
California's "case rate has decreased by 65% since our omicron peak. Our hospitalizations have stabilized across the state," Newsom posted to Twitter on Monday. The state now plans to expire its indoor mask requirement on Tuesday.
In an emailed statement to CNN on Wednesday, the California Department of Public Health also noted that "COVID-19 cases and the rate of community transmission have steadily decreased statewide since early January, and hospitalizations are either plateauing or declining in most regions of the state."
Public health experts and infectious disease specialists remain split on whether these states are jumping the gun or are smart to set these plans ahead of time.
"These periods of transition are always the most challenging," Dr. Richard Besser, a former acting director of the CDC, told CNN on Wednesday.
"If you listen to public health experts, to infectious disease experts, you don't see uniformity of opinion. You see quite a number of different opinions there in terms of, is this the right time to try and remove some of the public health measures that are in place?" Besser said. "Politicians, our elected officials, have to weigh all of those factors when they're coming forward with their recommendations. It's a messy playing field right now. I think it would be wrong for any governor to ban mandates."
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White House thinking about life after the pandemic
Decisions to lift statewide mask mandates came after some state leaders pressed President Joe Biden and his administration at the White House last week for clearer guidelines on how to transition out of the current pandemic and into an endemic phase with the coronavirus.
Endemic means a disease has a constant presence in a population but is not overwhelming health systems or affecting an alarmingly large number of people, as typically seen in a pandemic.
Biden and his administration's public health team have been canvassing outside health experts and others for weeks on how to best transition to a new phase of the pandemic.
Sources told CNN that the administration's top health officials are assessing in real time how to handle federal guidance on mitigation steps like masking, and there is an internal recognition that the U.S. is entering a new phase.
A key component of the discussion has been what metrics will now determine when communities need to implement safety measures, like masking. In previous phases of the pandemic, the focus has been on case numbers, but now, hospital capacity, hospitalization rates and death rates are all considered major factors.
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One administration official described this as a "significant undertaking," given that officials are identifying a new national framework for public health guidance.
"We want to be deliberate about it and ensure we both implement right decisions but also can communicate it clearly to a diverse country, where one state may look different than another," the official said.
The CDC also has been reviewing its guidance on mitigation measures, Dr. Rochelle Walensky, director of the agency, said in a virtual White House briefing Wednesday.
"We certainly understand the need and desire to be flexible," Walensky said. "Cases and hospitalizations are falling. This is, of course, encouraging, and that leads us, of course, to look at all of our guidance. At this time, we continue to recommend masking in areas of high and substantial transmission. That's much of the public right now."
When pressed by CNN about whether Americans should follow guidance from the CDC or that of governors, Walensky said that such mitigation decisions would continue to be made "at the local level."
"They — as I understand it, in many of these decisions — are using a phased approach. Not all of these decisions are being made to stop things tomorrow, but they're looking at a phased approach. And so, what I would say is, again, they have to be done at the local level," Walensky said, adding that she was "really encouraged" by the ongoing decline in U.S. cases and hospitalizations and the CDC continues "working on our guidance" with respect to masks.
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