This week, if you know someone in healthcare who has been following evidence-based medicine, chances are... they have been more upset than usual. The Center for Disease Control released some new guidelines last week that are frustrating. Now, the following essay is not designed to undermine the CDC, who have done a lot of good work during this pandemic and whose jobs are difficult. Steering a country through the pandemic (when public health has been hamstrung for decades) is no easy task. Still, if you have read some of my other posts, I have had my disagreements with the CDC and their recommendations at times. When they recommended that mask mandates could stop publicly in April-May, when the vaccine rollout had still barely gotten off the ground and conspiracy theories were running rampant, I and many of my colleagues stood there wondering where "disease control" went.
Today I sit here typing in a similar state of frustration. The CDC addressed isolation and quarantine for healthcare workers and now for the general population.
From last week, per the CDC, healthcare workers with COVID-19 (a positive test) who are asymptomatic can return to work after isolating 7 days with a negative test, but that isolation time can be cut further if there are staffing shortages (that caveat will be a focus later in this essay). If they experience a high-risk exposure and have received all recommended vaccine doses including a booster, they do not need to quarantine at home.
This week, the CDC expanded those recommendations to the general population.
If you test positive for COVID-19:
- If asymptomatic: Isolation time is now 5 days, followed by 5 days of wearing a mask.
- If symptomatic: No change in time - 10 days or after symptoms subside with no more fevers or need for fever-reducing medications (whichever comes later).
If you are exposed to someone with COVID-19:
- If unvaccinated OR >2 months from J&J OR >6 months from 2nd mRNA dose WITHOUT a booster/3rd dose:
-- Quarantine for five days and then strict mask use around others for five days.
-- If 5-day quarantine is not feasible, wear a well-fitting mask at all times around others for 10 days after exposure (I recommend a KN95 nowadays, given the increasing contagion of Omicron)
-- No testing requirement
- If you have received your booster/third shot:
-- No quarantine, but wear a well-fitting mask at all times around others for 10 days after exposure
- If exposed and asymptomatic, test at day 5 after exposure
- If symptoms develop, immediately quarantine and test at day 5 to determine whether or not you have COVID
These recommendations are based on the fact that, as I wrote in my previous essay, two-dose vaccine effectiveness has diminished against Omicron (down to ~35%) but the booster/third dose restores effectiveness to >75%. The vaccines ARE STILL WORKING. These are not the first vaccines to require a booster. The CDC (and I) strongly encourage vaccination for everyone 5+ (kids are getting harder than ever by Omicron) and boosters/third doses for everyone 16+. Vaccines still protect us from severe symptomatic disease, hospitalization, and death and if we want to stop more variants, we need to get more vaccines into people.
The rest of this is more about why this is a frustrating change. It's not just me complaining, there are actually are some important factors here. But if you just wanted the recommendations, you can skip to the last two paragraphs and go make sure you #VaccinateAndMitigate with rapid testing, spacing out gatherings, and ventilation if doing so.
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Shortly after the healthcare worker recommendations passed, New York City and New Jersey area hospitals almost immediately shortened it further - healthcare personnel are now REQUIRED there to return to work five days after testing positive as long as they have mild symptoms (with no negative test required). The definition of "mild symptoms" varies, too - working through significant illness, even if it doesn't require hospitalization, can be a significant challenge, especially in healthcare where critical decisions are made every day (I'm not saying other fields aren't like that, too, but these five-day requirements were designed for healthcare workers, and only then were expanded to the general population). Mild disease also still presents a significant risk of PAS-C (“long COVID”).
Of note, it came out that Delta Airlines CEO Ed Bastain actually asked the CDC to shorten quarantine recommendations. Basically, Delta is the boss that tried to get his employees to come in even when not feeling well, and then changed the rules to make it okay. To be honest, the last place we want employer-shortened quarantine rules is in a sealed metal tube in the sky. This is why I can’t fault people for suspecting the CDC of politicizing the pandemic, because while much of their guidance has had to be driven by science…this feels like a political/financial motive. Again, I tell you this not to undermine everything the CDC has said, but to warn you to be wary about relaxing precautions and mitigation measures, especially if you employ people.
We know that this incredibly contagious virus is also extremely variable in how long it keeps someone infectious or symptomatic. Some folks are only contagious for 3 days, some up to 14 days, especially if unvaccinated. Shorter quarantine periods would be a nice thing and we do want to evolve with science, but with something like this, a negative test is absolutely necessary to make sure that the virus is cleared!
If I'm being completely forthright, the other thing that bothers me is the idea of shortening quarantine and then recommending "strict mask use" afterward. Masks work, but if not mandated, too few individuals are willing to wear a mask around a gathering of unmasked people. The peer pressure is hard to resist! Further, a lot of people (not all, but likely a majority) who are choosing not to get vaccinated (and therefore are more likely to spread COVID-19 for longer) are also less likely to wear a mask after their shortened quarantine. The new CDC guidelines put a lot of faith in people, faith that this pandemic has taken away from me.
Epidemiologist Michael Mina wrote a thread in which he points out the CDC's justification: "The change is motivated by science demonstrating...SARS-CoV-2 transmission occurs...generally in the 1-2 days prior to onset of symptoms and the 2-3 days after." Which was true BEFORE Omicron.
He points out that now people test earlier because Omicron symptoms appear even earlier in the disease course, which means people are positive (and likely contagious) for longer. From the beginning I have pointed out that we don't do well enough with testing. Testing should be frequent, widely available, and free. The Biden administration FINALLY has taken it upon themselves to distribute tests to American households...only about a year into their term (and it should have been done under Trump before that). Negative testing should be essential and required if we are shortening the quarantine period.
In the healthcare worker guidelines, even as they were expanded to the general population, it's the caveat that sticks in our collective healthcare craw. "Isolation time can be cut further if there are staffing shortages." Staffing shortages. That's not a healthcare- or science-based reason for cutting isolation time. That is sacrificing healthcare. Specifically, sacrificing healthcare workers (and now pilots and flight attendants and other crew members for Delta, which means other companies will adopt such policies, too, for the wrong reasons).
To add insult to injury, the American Heart Association released new guidelines, too, regarding cardiopulmonary resuscitation (CPR). In the event of a patient suffering cardiac arrest (their heart stopping), everyone knows that CPR should be started immediately. But for years, the most important first step was to make sure the scene is safe. In the hospital, that means protective equipment when required. The AHA recommendations now say "Do not delay chest compressions for provider [personal protective equipment, or] PPE or to place a face covering on the patient."
If you have ever been in the unfortunate circumstance of having to do CPR, you know that this is not safe for the person performing compressions. This is a prime scenario for a high-risk exposure to COVID-19 (after which, conveniently, a third-dose-vaccinated healthcare worker does not have to quarantine but which still presents risk to those around them). When people rightfully complained, the AHA responded, "There are no reports yet of chest compressions alone on COVID-19 positive patients resulting in transmission of the virus." There are also no reports that delaying compressions by 10-15 seconds to get PPE on affects outcomes of CPR, either. It's not realistic and it shows that whoever wrote the guidelines is almost certainly out of touch with how CPR works. I don’t say this to mean that dying patients don’t matter. But we cannot help save others if we get sick and sacrifice ourselves (and our co-workers through potential exposure).
These recommendations have made healthcare workers across the country feel expendable and sacrificial. Throughout the pandemic we have struggled against staffing shortages - we have struggled to do our jobs to the best of our ability among multiple massive surges of patients. Healthcare workers have left in droves. Not because of vaccine mandates (that was only about 1% of healthcare workers, and the mandates remain necessary to protect our patients in a pandemic), but because working conditions in healthcare are the worst they have been in our lifetimes. Experienced doctors, nurses, respiratory therapists, and everyone else have been frustrated at the waves of cases and deaths that have weighed on us so heavily, only to be met with calls for individual resiliency while watching as healthcare organizations barely acknowledge our sacrifices beyond a few words, and pour money into recruitment but not retention.
It may not have felt that way if more steps had been taken to protect healthcare workers - implementing N95 mask mandates and better distribution of PPE in hospitals and healthcare settings, proper restitution for the longer, harder, and more gruesome shifts we have needed to work, and regular and widely-available testing for HCWs and non-HCWs alike (which has been a problem since the very beginning, and it should not be).
Instead we are told that our exposures are an acceptable consequence, and the subsequent increased groups of shortages of HCWs (because several will undoubtedly turn positive and need to isolate; while this is for a short lee time, every person counts in a pandemic) will create even more difficulties in delivering healthcare.
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In the meantime, as we approach New Year's Eve and we warily eye our potential exposures from Christmas, all I can tell you is that you should invest in a higher-quality mask (again, I recommend a KN95 now, which aren't always as fun in terms of pattern, but they are better for safety - and they come in small/kid sizes!) and try to get rapid tests. Don't hoard them, because there aren't enough to go around, but if you're going to be gathering with people, TEST BEFORE YOU GO OUT. Take the 10-15 minutes to do so and then test again a few days after your gathering if possible. Swab your throat/tonsils area, too, in addition to your nostrils - more likely to be accurate that way. Don't be afraid to let others know if you test positive, and don't judge those who do test positive - Omicron is that contagious.
If you have symptoms, DON'T GO AROUND PEOPLE. It is COVID until you prove otherwise. More people I know than ever are testing positive (most mildly so, thanks to vaccines, but not everyone is so lucky), and we must do what we can to prevent spread. Not only does this affect adults, but pediatric hospitalizations are up 395% in New York City according to the Department of Health, and vastly increased in other areas, too. COVID-19 is rapidly ascending to one of the major causes of death for children, and average child deaths HAVE increased this year (this includes kids under 5, who don't have a vaccine yet). PLEASE take precautions, and #VaccinateAndMitigate. I welcome your questions.