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It’s a true Goldilocks debate: A week after the Centers for Disease Control and Prevention (CDC) updated its COVID-19 isolation and quarantine guidelines — lowering isolation time — healthcare experts continue to debate the changes, with some calling them suitable, some saying they’re “reckless,” and at least one expert saying they’re “right in the middle.”
The controversy may lead to more updates. On Sunday, Anthony Fauci, MD, President Joe Biden’s chief medical adviser, said on CNN’s State of the Union that he anticipates further clarification of the guidelines soon.
Sparking the most debate: infected people are not told to test before leaving isolation, the vaccinated and unvaccinated who are exposed are given some of the same advice, and the mask advice is not specific enough.
As issued on December 27, the guidelines for the general public recommend:
Anyone who tests positive should stay home and isolate for 5 days (instead of 10) and if the person has no symptoms or the symptoms resolve after 5 days, leaving the house is okay. A mask should be worn around others for 5 more days. In the event of a fever, the person must stay home until it resolves.
If someone is exposed to someone infected with COVID-19 and they have been boosted, finished the primary series of either the Pfizer or Moderna vaccine within the past 6 months, or finished the primary series of the Johnson & Johnson vaccine within the past 2 months, they should wear a mask around others for 10 days and, if possible, test on day 5. However, if symptoms develop, they should get a test and stay home.
If someone is exposed to someone infected with COVID-19 and they are unvaccinated or are more than 6 months out from their second dose of the Pfizer or Moderna vaccine (or more than 2 months after the J&J vaccine) and not boosted, they should quarantine for 5 days and then wear a mask for 5 more days. If quarantine is impossible, a mask should be worn for 10 days. A test on day 5 is suggested if possible. If symptoms occur, the person should quarantine and test.
On social media and in interviews with Medscape Medical News, public health experts expressed an array of opinions.
A tweet from Eric Topol, MD, editor-in-chief of Medscape, posted the day after the new guidelines came out, had an empty box and this: “The data that support the new @CDCgov 5 day isolation period without a negative test.”
In a tweet on Sunday, Ashish K. Jha, MD, MPH, dean of the Brown University School of Public Health, said: “Hearing that CDC considering adding testing to isolation guidelines. That would be great. I’ve been arguing for a while that serial negative antigen tests provide a lot of confidence that someone is not contagious.”
Michael Mina, MD, PhD, chief science officer of eMed, a digital point-of-care platform enabling at-home diagnostic testing, tweeted: “CDC’s new guidance to drop isolation of positives to 5 days without a negative test is reckless. Some [people] stay infectious 3 days, some 12. I absolutely don’t want to sit next to someone who turned [positive] 5 days ago and hasn’t tested Neg. Test Neg to leave isolation early is just smart.”
Paul Offit, MD, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and an infectious disease specialist, disagrees. Typically, he said, an infected person sheds virus for 7 days.
“If you are asymptomatic, the chances that you are shedding a significant amount of virus is very, very small,” he told Medscape.
Under Debate
Testing: While many public health experts say a recommendation to test before leaving isolation is needed, CDC Director Rochelle Walensky, MD, explained testing was not recommended before leaving isolation because PCR testing can stay positive up to 12 weeks after a person is first infected with COVID-19.
Asked why there was not a recommendation for a rapid antigen test before leaving isolation, Walensky told CNN that it is not known how these tests perform at the end of infection and that the tests are not US Food and Drug Administration-authorized for that purpose.
And while the guidelines suggest that those exposed — whether they are boosted, vaccinated, or not — should test on day 5 if possible, that recommendation should be stronger, some said. “At the very least recommend a test in those who can get it done,” said Topol.
However, making that recommendation is difficult when experts know how difficult it is for people to obtain tests now, William Schaffner, MD, professor of preventive medicine and an infectious disease specialist at Vanderbilt University, Nashville, told Medscape.
“I am sure this was intensely debated,” Schaffner said of the recommendation on testing.
Vaccination Status Categories: Amesh Adalja, MD, senior scholar at the Johns Hopkins Center for Health Security, Baltimore, Maryland, questioned the scientific basis behind treating the fully vaccinated (with two mRNA or one J&J vaccine) who are exposed ”as the equivalent of the unvaccinated when it comes to the quarantine requirement since the fully vaccinated are protected against what matters.”
Topol agreed. Guidelines “should be different for vaccinated vs unvaccinated.”
The recommendations for the exposed should definitely be simpler, Offit said. “I think it would be much simpler to just say, ‘If you are exposed, mask for 10 days,’ ” regardless of vaccination status.
Masks: The guidelines should also be more specific about the type of masks, Topol said. They should spell out that the masks need to be N95 or KN95, he said.
Science-Driven or Economy-Driven? Were the guidelines changed due more to concerns about the economy than to scientific information about infection and transmission? “It was,” Topol said.
Adalja sees it differently. “While it is true that this updated guidance will help the economy, it is based on a scientific foundation and should have been issued much earlier than it was.”
Tough Decisions
The agency is walking a tightrope, Schaffner said, adding that he is in general agreement with what the CDC is trying to do. “The tightrope is between the public health ideal and trying to determine what will be acceptable,” he said.
The revised guidelines are more practical than before, others said. “The goal is harm reduction and many people just don’t do any isolation if they are faced with a 10-day period,” Adalja said.
Before issuing the new guidance, the CDC looked at the accumulating science and also took into account stresses on the healthcare system and other factors, Schaffner said. “Is it perfect?” Schaffner said of the new guideline. “No. Is it carefree? No. It’s right in the middle.”
Schaffner does think the messages about the new recommendations and how they were decided upon could have been communicated better, and in a more understandable manner. Some experts, for instance, led with the economy and the need for people to return to work and school when explaining the guidelines and then brought up the science behind the revisions.
That order should have been reversed, Schaffner said.
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