Guidelines

To top it all off, the guidelines themselves are still complicated - Philip Kiefer

Guidelines

image by: Henry Payne
     

 

For nearly two years, American officials have changed recommendations on how to manage the coronavirus... Infected people, who had long been told to isolate for at least 10 days, now have to isolate for only five days if they feel fine, regardless of vaccination status. On one level, this decision by the Centers for Disease Control and Prevention is a welcome nod to science and practicality because many people aren’t infectious for such a long period.

But the change doesn’t grapple effectively with the reality that the fully vaccinated and boostered and the unvaccinated are living in two different worlds. The C.D.C. guidelines still rely on a mostly one-size-fits-all approach and ignore the use of antigen testing to make distinctions between the relative safety and danger of both groups.

When the pandemic began, there were no vaccines, so we all lived in a world where everyone was at the same high risk. The C.D.C. therefore recommended that people who became infected shelter in place for 10 days because evidence pointed to the fact that they could be infectious for quite some time. The C.D.C. also argued that those who were credibly exposed but not yet sick quarantine for 14 days, because it could take that long for them to become infected and infectious.

When vaccinations became widespread, however, the calculus changed. Those who were immunized were less likely to become infected and less likely to be as infectious. Because of this, the C.D.C. said this year that immunized people did not need to quarantine if exposed so long as they remained asymptomatic, although it recommended such people test a few days after exposure to be sure they were safe.

New recommendations go even further. They say that as long as people who test positive for the coronavirus are asymptomatic, they need isolate for only five days — regardless of whether they are vaccinated, boostered or unvaccinated.

The recommendations also changed for quarantine, which is what uninfected people do if they are exposed. If they are boostered appropriately, they need be careful only for the next 10 days (i.e., wear a mask when around others). If they are unvaccinated or in need of a booster, they now need quarantine only for five days if they never become symptomatic and then be careful the next five. The recommendations also say that if for such people — even if unvaccinated — a quarantine “is not feasible,” they can just mask for 10 days. (The C.D.C. also recommends, if possible, getting tested five days after the exposure, whether or not a person is vaccinated and boostered.)

These numbers are mostly averages — sometimes best guesses — as to how people respond when exposed or infected. They’re also pretty much equally applied to the fully vaccinated and unvaccinated alike, as if those two populations were the same.

This is puzzling. Covid itself hasn’t changed that much for those who are unvaccinated. If they get infected, there’s no reason to believe they shouldn’t still follow the original guidelines and isolate for 10 days. This is a very infectious disease, and they are at risk not only to themselves but also to those around them. Hospitals are still full of unvaccinated people, and nothing had led us to believe that the danger is gone for them.

However, vaccinated people, especially boostered people, are at very low risk for bad outcomes, less likely to get infected if exposed and less likely to be infectious for longer periods.

It seems that even at this late date, the C.D.C. is trying to appease everyone and therefore is pleasing no one.

What would be better is a more evidence-driven approach. Antigen testing provides us a means to see whether people remain infected, and perhaps infectious, over time. My 17-year-old son, who is boostered, felt congested last week. Being responsible, we tested him at home with an antigen test, and he was positive.

The next day, though, he felt fine. Same with the day after. We tested him again, and he was negative. We tested him one day later, and he was still negative.

Of course, all this was possible because we bought a bunch of antigen tests a few weeks ago in case that happened. There’s a nationwide shortage of such tests, and they’re priced out of reach for too many Americans.

Based on his two negative tests, I would argue that at this time, my son is no longer infectious. He’s asymptomatic, he’s boostered, and he has repeatedly tested negative on antigen tests. That’s why his isolation should end, not because of a one-size-fits-all rule that treats all people and all infections the same.

If, however, he had tested positive for more than five days, even if he was feeling fine, he might still be infectious. How would we know? Many people may feel pressured by jobs or obligations to ignore symptoms and get back to work or life before it’s safe. They may minimize lingering symptoms as five-day isolations become the norm. And the unvaccinated may never quarantine because it “is not feasible” for them to do so. All of these scenarios would be acceptable under the new C.D.C. guidelines, but they all potentially present a risk of spreading coronavirus infections.

Covid-19 is becoming endemic. We are even seeing more and more people who are boostered getting infected. We cannot keep asking people to isolate for mandatory periods in the hope that Covid will go away. We have to find ways for living with the coronavirus, in which we recognize that for many, it is a mild infection from which they quickly recover. For others, Covid is a serious illness for which precaution is warranted. The biggest difference between those groups is immunization.

The C.D.C. should develop further guidelines, right now, that allow for those who are vaccinated and boostered to leave isolation as soon as possible after they have gotten negative results repeatedly with antigen tests. The government should do everything possible to make such antigen tests freely and easily available. The Biden administration’s efforts are necessary but not sufficient. They need to go much further and much faster.

Such guidelines would provide another incentive for people to be fully vaccinated. They also might get more people who are avoiding testing because they fear a mandatory lockdown to test, because the implications of a positive test aren’t as severe.

They would also provide us a means to transition to a way of thinking that recognizes that Covid is here to stay and that we need to find a way to live with it. Our previous plans were based on an illness that could be controlled by testing, contact tracing, quarantine and isolation, along with vaccination.

Omicron may not be so controlled; it appears to be very, very possible to prevent serious illness and death with vaccination, but it may not be possible to prevent transient infections, even with masking. If that’s the case, we need to redouble our focus on the former and accept the latter. Infectious people need to isolate as long as they are infectious, no longer and no less, and we need more accurate means to make those judgments.

Covid is changing right before our eyes. We need to adapt along with it.

Source: Aaron E. Carroll, The C.D.C. Has New Covid Guidelines. This Is What It Got Wrong, The New York Times, December 28, 2021.

As of January 4, 2022 the guidelines now say that an individual who “has access to a test and wants to test” at the end of the isolation period may do so, but stops short of a recommendation to test.

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Last Updated : Sunday, January 9, 2022