Isolation policies haven’t stopped Covid’s worst outcomes. Other, better policies might.
Today, the Centers for Disease Control and Prevention (CDC) changed its Covid-19 guidance in a big way: People infected with the virus, or with other respiratory viruses, no longer need to isolate for five days before going back to work or school, the agency said.
Instead, the agency advises that people can leave home if they’ve been fever-free for at least 24 hours (without fever-reducing medicine like ibuprofen or acetaminophen) and have improving symptoms.
The new guidance does encourage people to take extra steps to prevent spreading their infections to others once they’ve resumed their usual activities, like getting immunized against preventable infections (which include Covid-19, flu, and RSV), washing hands frequently, coughing and sneezing into elbows, and using air-filtering and ventilation strategies — all of which are considered core strategies under the new recommendations. Meanwhile, masking, keeping a distance from others, and testing are in a lower-urgency “additional recommendations” category.
“It’s a reasonable move,” said Aaron Glatt, an infectious disease doctor and hospital epidemiologist at Mount Sinai South Nassau Hospital on Long Island. “When you’re doing public health, you have to look at what is going to be listened to, and what is doable.”
Guidelines that adhere to the highest standards of infection control might please purists in public health who don’t have to make policies for the real world. However, guidelines that seem to acknowledge that workers often don’t have paid sick leave and emergency child care, and that social interactions are important to folks, are more likely not only to be followed but to engender trust in public health authorities.
This change likely won’t increase exposure risk for the people most vulnerable to severe Covid-19
It’s important to note that the new recommendations are aimed toward the broader community and the people who live, work, and go to school in it — not toward hospitals, nursing homes, and other facilities whose residents are both less socially mobile and more vulnerable to the virus’s worst effects.
That means the people who are at higher risk of getting severely ill or dying if they get infected — people who are older and sicker at baseline — are subject to different, more conservative guidelines. Which makes sense, said Glatt: “It’s not the same approach in a 4-year-old kid as it is in a nursing home. It shouldn’t be.”
Covid-19 hospitalization rates among adults 65 and over are at least four times what they are in other age groups, and rates are particularly high among adults 75 and over, according to the CDC. In a study published in October, the agency reported that those 65 and older constituted nearly 90 percent of Covid-19 deaths in hospitals.
The older adults getting hospitalized and dying with Covid-19 now are not the otherwise well people with active work and social lives who were getting severely ill earlier in the pandemic, said Shira Doron, an infectious disease doctor and hospital epidemiologist at Tufts Medicine in Boston. They’re people with severe underlying illness and compromised immune systems — and for many, it’s not even clear Covid-19 is what’s causing their decline. “I’m really struck by how totally different the Covid inpatient population — even the Covid death population that I’m seeing — is from 2020, or even 2021,” she said.
It’s hard to tell exactly how many of the worst-affected adults are infected in facilities like hospitals and nursing homes — in other words, how many of them would be relatively unaffected by a revised set of guidelines. It’s also hard to tell how many older adults, aware of their higher risk, take more measures to protect themselves in public, like wearing masks and gathering outdoors.
However, it’s worth noting the experiences of states that have already loosened recommendations. Since Oregon loosened its guidelines in May 2023, the state has not seen unusual increases in transmission or severity; California made similar changes in January 2024. In revising their recommendations, state officials hoped to reduce the burdens on workers without sick leave and reduce disruptions on schools and workplaces, according to reporting in the Washington Post.
Doron said the reason loosened isolation guidelines haven’t led to mayhem in Oregon — nor in Europe, where the recommendations began to loosen two years ago — is because isolation never did much to reduce transmission to begin with. “This has nothing to do with the science of contagiousness and the duration of contagiousness. It has to do with [the fact that] it wasn’t working anyway,” she said.
Leaning away from what doesn’t work to reduce the virus’s impact — and toward what does work — is a smarter way forward, she said.
Revising testing guidelines would free up resources for interventions that actually work
Isolation guidelines haven’t been effective in mitigating Covid-19 harms because so many people simply do what they want, regardless of whether they’re sick — and they may avoid reporting symptoms to avoid being forced to comply with an isolation policy.
Imagine a workplace or school policy adheres to the current CDC guidelines, which recommend that people who test positive for Covid-19 infection stay home for at least five days. That policy creates a “perverse incentive” for some people who have symptoms to avoid getting tested, Doron said, because they don’t want to miss school, work, or a social event. Because so many people don’t have paid sick time, acknowledging even mild symptoms can lead to real financial losses when it means missing a week of work.
At the same time, because these guidelines build testing into their protocols, they lead lots of other people — and the federal government — to spend money on at-home tests, which are often inaccurate early in infection. That’s a waste of resources that could save more lives if they were instead spent on providing tests to people likeliest to benefit from Paxlovid and getting them treated, said Doron.
“You should only be testing when it will change something, and that should be because you need Paxlovid or an antiviral,” Doron said. (Clarity and greater focus on who qualifies for Paxlovid would also be helpful, she said — current CDC recommendations are too broad.)
The updated guidelines clarify that testing is most useful for making choices about prevention or treatment — “even better than what I was expecting,” said Doron.
In the long term, CDC guidelines should normalize being considerate
While the CDC’s guidelines are recommendations, not requirements, employers and state and local health departments often use them to guide their own policies.
In February, before the guidelines had been published, Jay Varma, an epidemiologist and biotechnology executive with extensive experience in state and federal public health practice, said one area where a new set of guidelines could make a big difference is in elevating and normalizing masking. He hoped the new recommendations would lean heavily into putting forth masking in public as a matter of routine for people who leave home as soon as they feel well.
“CDC should be thinking of this as a decades-long effort to promote cultural acceptance that being in public with a mask is similar to washing your hands, wearing a condom, or smoking outdoors: It’s a form of politeness and consideration for others,” Varma wrote in an email to Vox.
After all, in the long term, it’s a lot easier to change social norms around masking than it is to get people used to giving up their social lives for days or weeks at a time.
After the guidelines were released on Friday, Varma wrote on Threads that public health officials should’ve advised individuals “that you don’t only use ventilation, hygiene, masks ‘when you’re home sick’ but when also you in public for at least 5 days after symptoms resolving.” He also wrote that organizations should improve ventilation and make N95 masks and antigen tests more broadly available to staff and visitors.
It would also be helpful for public health officials to encourage people to factor in who gets exposed if they leave isolation soon after a Covid diagnosis, said Glatt. The revised guidelines do note that it’s especially important to use prevention strategies when you’ll be around people who have risk factors for severe illness — for example, if they take high-dose immunosuppressive medications, are either older adults or young children, or are pregnant.
Update, March 1, 5:40 pm ET: This story, originally published on February 14, has been updated to note the CDC’s revised guidelines on respiratory virus prevention.
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