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A CDC advisory committee voted unanimously on Friday to approve , though some critics charge the recommendations don't go far enough and ignore lessons from the COVID-19 pandemic.

At the heart of the controversy is a new "air" category for pathogen transmission, and three levels of air precautions based on how transmissible a respiratory pathogen is: "routine," "special," or "extended."

The lowest level "routine" air precautions are to be used with "common, often endemic, respiratory pathogens that spread predominantly over short distances" and "for which individuals and their communities are likely to have some degree of immunity," according to the guidance.

The guidelines, drafted by CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC), recommend that masks be worn at this level of transmission. This can include surgical masks, though healthcare workers may "choose voluntarily" to wear a higher level of protection.

Critics have argued that surgical masks would offer inadequate protection in this scenario.

Zenei Triunfo-Cortez, RN, president of National Nurses United (NNU), called the draft guidance "permissive and weak" in a statement following the meeting.

"This draft guidance will only further degrade the already dangerous working conditions of nurses and other healthcare workers," she said.

Several groups -- including NNU, Cal/OSHA, the People's CDC, and Project N95 -- have rallied opposition to the draft guidance, which updates recommendations from 2007. Ever since HICPAC presented the evidence review for the guidance in June, these groups have charged that it doesn't go far enough to adequately protect healthcare workers and patients. They've organized public commentary and have urged the CDC to incorporate stronger protections into the guidelines.

That evidence review that there's no difference in seasonal respiratory virus infection rates for healthcare workers whether they use N95 or surgical masks during routine patient care.

In an email, a CDC spokesperson told MedPage Today that "Additional analyses have been performed to address feedback that has been received since the initial presentation [of the evidence review] in June 2023. The evidence reviews have been posted on the HICPAC website to ensure full transparency and to allow for more in depth review by stakeholders."

HICPAC members said during Friday's meeting that the first part of the guidance is written to be "pathogen agnostic." A second part on infection control protocols for individual pathogens -- including viruses like COVID-19 -- is expected to be completed next year, with sections updated piecemeal until that time.

The CDC spokesperson said in the email that the agency "will conduct additional pathogen-specific reviews" for this section.

NNU and the People's CDC have voiced some of the loudest opposition to the draft guidance. Andrew Wang, PhD, MPH, a researcher at Northwestern University's Feinberg School of Medicine representing the People's CDC, wrote in an email to MedPage Today that HICPAC "failed to establish ... a NIOSH-approved N95 or higher-level as the minimal standard as a routine air precaution. [I]nstead, they relegated this effective layer of protection to only 'special' or 'extended' air precautions."

"Special" air precautions apply when patients have a "new or emerging" respiratory pathogen that is not observed to spread across long distances, and for which infections "generally leads to more than mild illness," the guidance states. An N95 mask or higher level respirator is recommended in this case, and in the "extended" transmission scenario.

NNU and others have also charged that HICPAC boxes out meaningful impact from stakeholders, for instance by posting the draft guidance the morning of the meeting and cutting off public commentary at 45 minutes, despite receiving 600 pages of comments, according to the People's CDC.

HICPAC's voting members are largely infection control and epidemiology experts, but critics have said the committee's makeup privileges the perspectives of health employers. Administrators have an interest in keeping costs down, they say, which runs contrary to implementing protections for workers and patients. Five of the eight members listed work for hospitals or health systems.

During the public comment section of the meeting, speakers told stories of family members contracting COVID-19 or other infections from healthcare visits, and facing healthcare providers who refused to wear N95 masks.

"Why is it that I have to continuously ask about safety precautions when I need healthcare?" one commenter asked. "I'm continuously hit with the canned answer from healthcare providers saying that oh, they follow the recommendations and guidelines. ... The whole point of healthcare is to stop disease."

Eric Berg, MPH, deputy chief of health at Cal/OSHA, said during the public comment session, "We know from extensive studies from NIOSH and many others that only respirators can protect against fine and ultra fine particles that can carry certain airborne infectious pathogens." Worker protections in California prevail over CDC guidance, he added, which may not be true elsewhere.

Critics also raised concerns about ventilation recommendations they said were too vague. A former non-voting "liaison representative" at the HICPAC meeting, from the Patient Safety Action Network, called the language "a little soft."

In its email, the CDC said that the draft guidance "includes information on the importance of indoor air quality and air handling to prevent infections; however, details on the implementation of interventions to improve ventilation are covered far more completely in other guidance from CDC and other organizations."

The draft guidance will now be submitted to the CDC for review and approval, followed by a 60-day period of public comment. CDC and HICPAC then "review and respond" to comments, followed by several more reviews.

Correction: Andrew Wang, PhD, MPH, is a researcher at Northwestern University's Feinberg School of Medicine, not a student.

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