Time to rethink how we deal with positive Covid cases

Damn, Katherine Wu’s Covid articles in the Atlantic have been so damn good.  Really, really appreciated the key point of this one.  A huge part of some return of normalcy is not making it so damn onerous (health effects aside) to have a positive Covid case.  Yes, of course we should expect people to take actions to mitigate spread, but, within reason and properly informed by science!

One idea involves letting some immunized people test out of confinement, a protocol that universities such as Cornell are already tentatively putting in place. The coronavirus transmission window is thought to be rather brief for most people, peaking around the time symptoms start (if they do at all) and slamming shut in the few days after; vaccines appear to trim that period further down. “It’s clear that vaccination will reduce infectiousness,” Ajay Sethi, an epidemiologist at the University of Wisconsin at Madison, told me. And fully vaccinated folks who repeatedly test negative “are probably not a risk to anybody anymore,” Angela Rasmussen, a virologist at the University of Saskatchewan, told me.

The idea of a truncated isolation might sound dicey, especially as cases once again rise worldwide, and a new variant of concern blazes across the globe. But SARS-CoV-2 isn’t going anywhere; our strongest next moves will involve sustainable policies that help us both combat the pathogen and coexist with it. If we must deal with breakthroughs, the least we can do is make them more bearable…

The goal of a cautious isolation is, of course, to keep sick people from spreading the virus; getting the timing wrong can be disastrous. But we’ve known for many months that the COVID-19 vaccines train immune cells to more swiftly sweep the virus out. Even the CDC acknowledges in its guidance on isolation that “fully vaccinated people are likely infectious for less time than unvaccinated people.”

In the unvaccinated, “it’s clear that the majority of transmission happens early on,” says Müge Çevik, a medical virologist at the University of St. Andrews, in the United Kingdom. The contagious period seems even more limitedin theimmunized. Scientists scouring airways for scraps of virus genetic material have found that vaccinated individualsseem to evict SARS-CoV-2 far faster than those who haven’t gotten their shots; the immunized may carry a lot of virus initially, but it disappears quickly. That’s true even for Delta and other hyper-transmissible variants, which can rapidly xerox themselves into armies, and may linger for longer than other versions of SARS-CoV-2. Most post-vaccination infections are also asymptomatic or rather mild—cases that, generally speaking, appear to be less contagious…

A lot of this is common knowledge by now among the experts who design our policies. And yet, American guidelines have not substantially shifted since two summers ago—when, in July of 2020, the CDC said most people should no longer be using tests to determine when to leave isolation. Instead, they could exit 10 days after the start of symptoms or the first positive test result, provided that they no longer felt sick. (People who are seriously ill or immunocompromised might shed the virus for much longer, though, and could require isolation of 20 days or more.) That change happened 17 months ago, at a time when vaccines weren’t authorized, tests were absurdly scarce or slow, and the best option was to estimate how long folks might shed, and tell them to hide away for about that length of time… [bold is mine; italics in original]

Things are very different now. Three super-effective vaccines have been greenlit for use in the United States, and hundreds of millions of Americans are doubly or triply dosed. Tests are faster and more available. And we know a lot more about how and when the virus spreads. The CDC has even been emboldened to modify its rules on quarantining after an exposure to a COVID caseThe policy used to be 14 days of solitude for everyone. Now vaccinated people don’t have to quarantine at all. Even the unvaccinated can peace out at 10 days, or even seven, if they produce a negative test—a change that went into effect in December 2020.

I asked the CDC if it would consider amending its isolation policies for the fully vaccinated. Jasmine Reed, an agency spokesperson, said only that “any changes to shortening isolation or quarantine guidance will be made based on science and research.” But nothing in the current recommendations on ending isolation yet reflects how vaccination has changed the game…

Sorting through these questions, though, means moving on from policies designed for a pre-inoculation world. “Are we isolating people because they represent a risk?” Koretzky said. “Or because it’s protocol?” The point, after all, is flexibility. As experts finagle the details, Saskia Popescu, an infection-prevention expert at George Mason University, recommends a compromise: “No symptoms? No shedding? Take them out of isolation, but also, wear a mask.”

Tackling the isolation issue could be a bellwether for more change. Post-vaccination infections will keep happening. “That’s inevitable,” Sethi, of the University of Wisconsin, told me. And every case still poses a potential threat to the person who’s caught the virus, and the people around them. The world will need to find the right policies around masking, vaccination, testing, and support for those in isolation to keep cases in check in a sustainable way…

We haven’t yet found a middle ground between catastrophizing post-vaccination infections and trivializing them. “We have to make it clear to people that getting COVID unvaccinated is really bad,” Ashish Jha, the dean of Brown University’s School of Public Health, told me. “But in a vaccinated population? We can think about it very, very differently.” Perhaps acknowledging how vaccines transform our experience of COVID, and using that info to guide decision making, is a first step toward carving out that in-between space.

Very good stuff.  It’s long past time to update protocols that come from a time before any vaccines and when we understood viral spread much less well.  And, sadly, Covid will not go away entirely so we really need to find ways to live with it that are not overly and needlessly burdensome on individuals and household.

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