Few public places or businesses require masking any more in Hawaii due to the COVID-19 pandemic, but most major hospitals and health care settings still do.

Although Hawaii has no statewide mandate or federal rules that require masks, most hospitals and health clinics are independently requiring them for their clinical settings where patients are seen.

“In our last meeting with all our chief medical officers, overwhelmingly, hospitals at least in the clinical areas, are still requiring masking of all staff, patients, and contractors,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, a nonprofit trade group. “Every clinical setting, whether it’s long-term care or hospitals — any place with direct patient care, masks are still being required.”

This has been agreed upon as still appropriate, according to Raethel, and as a community standard, regardless of mandates.

The Queen’s Health System, however, has eased some requirements as COVID-19 trends decline.

Queen’s still requires masking in all patient care areas, including patient floors, waiting rooms and procedural spaces, but no longer requires masks outdoors or in buildings where patient care is not provided.

The thermometers used for temperature screening will be removed from entrances, Queen’s said, expediting entry into facilities. Patients are also now allowed four visitors a day, including two at a time when previously only one was allowed at a time.

“With the statewide COVID-19 case counts on a downward trend and, for the moment, with hospitalizations stable and much less severe than during other stages of the pandemic, The Queen’s Health System is titrating back on some of the restrictions deployed across our hospitals and clinics to better serve our patients and staff,” said Darlena Chadwick, The Queen’s Health System chief operating officer, in a statement.

Also, unvaccinated staff at Queen’s are no longer required to perform weekly COVID-19 surveillance tests, but must wear an N95 mask or equivalent in all clinical buildings.

“Our highest priority continues to be the safety of our patients, visitors, and staff,” said Chadwick. “With the decreased prevalence of COVID in our hospitals and in our community, we hope these updates will enhance our patient, visitor and caregiver experience here at Queen’s.”

At Kaiser Permanente in Hawaii, masks are required at all facilities at all times for everyone age 2 and older. That includes physicians, staff, patients, and visitors age 2 and up.

Most nursing homes also continue to require masking to protect their residents, according to Wesley Lo, CEO of Hale Makua Health Services.

The state Department of Health said it continues, along with the Centers for Disease Control and Prevention, to recommend mask use by those at increased risk for severe illness while indoors in public spaces and for all people in health care facilities, particularly when community transmission is high.

CDC this week listed the community transmission for all four major Hawaii counties as low.

Average case counts in the state continued to decline, with DOH on Wednesday reporting a daily average of 70 new COVID-19 cases per day, down from 89 per day on Feb. 15. The state’s average positivity rate fell to 4.4% compared with 4.7% on Feb. 15.

All metrics indicate a continuing downward trend, with the number of COVID-19 patients also declining to 37 per day this past week, compared with 47 per day the previous week, according to data from HAH.

DOH also reported 12 more deaths, bringing Hawaii’s COVID-19 death toll to 1,834.

New York state on Feb. 12 ended its requirement that masks be worn in health care settings such as hospitals and nursing homes, leaving the decision up to each to make their own policies. New York was one of the few states left with such policies in place.

Advocacy group Mandate Masks NY opposed the decision, saying it puts “all New Yorkers at risk, particularly people who are at higher risk and the most vulnerable.”

“This decision will lead to more unsafe medical settings and more people postponing needed medical care, particularly people who are at higher risk such as those who are immunocompromised, disabled, or elderly,” said the group. “It is unacceptable to make medical care inaccessible, especially for the most vulnerable amongst us.”

Oahu resident Bonnie Chan, who suffers from long COVID, is relieved most hospitals in Hawaii will still require masks.

Chan, who is still struggling with symptoms after getting COVID in the summer of 2021, said she would like staff at health care settings to wear masks for patients with poor immune systems or respiratory diseases, as well as in the emergency department.

“In health care settings, I would like staff to wear masks,” she wrote in an email. “If the hospital has really high quality air purifiers, especially ones that filter the COVID viruses and the air is purified everywhere in the hospital, then and only then can I see health care settings doing away with masking.”

Still, because there are still many questions and no proven treatments for long COVID, she supports mitigation measures that limit exposure to the coronavirus.

The debate over masks intensified in the wake of a recently published Cochrane review to determine how effective masks were in preventing respiratory diseases.

The report, which is a meta-analysis of multiple studies, concluded “there is uncertainty about the effects of face masks” and that the pooled results of randomized controlled trials “did not show a clear reduction in respiratory viral infection” with the use of medical or surgical masks.

But the authors also concluded the high risk of bias in the trials, relatively low adherence, and other factors “hampers drawing firm conclusions.”

Epidemiologist Katelyn Jetelina said there is no simple, one-word answer to whether masks work, and that the Cochrane analysis was limited because it looked at studies combining different viruses in a wide range of settings.

“On top of the limitations described above, keep in mind that ‘no evidence of a difference’ is different from ‘evidence of no difference,’ she wrote in her weekly newsletter. “Don’t use an inconclusive Cochrane review to reject the value of masks, or any other intervention for that matter.”

DeWolfe Miller, epidemiologist and professor emeritus at the University of Hawaii, said he recommends people continue masking, especially in crowded areas.

“Respiratory viruses are going to be captured by a mask because of their physical properties,” he said. “You’re going to capture orders of magnitude of reduction in viral load and viral exposure, and you’re going to keep it from going out of you and from going into you. It’s blocking it.”