Leana S. Wen: How the CDC’s isolation guidance can still protect the most vulnerable

Officials at the Centers for Disease Control and Prevention would be right to rework the federal isolation guidance for people with COVID-19, as they are reportedly considering doing. The change is long overdue and could refocus the agency’s recommendations on protecting the most vulnerable.

The current guidance, which hasn’t been updated since December 2021, is both too restrictive and not protective enough. It states that most people who test positive for COVID should stay away from others for five days following the onset of symptoms. For the five days after that, they can be in public if they wear masks.

Many misinterpret the guidance, which requires no testing to exit isolation, as saying they are no longer infectious after five days. This is not true. A 2022 Lancet study found that 65% of infected people still shed the virus after Day 5. If they stop isolating around vulnerable family members so soon, they would be putting their loved ones at risk.

The CDC can and should make the guidance clearer and more specific. It can do this by providing three different sets of recommendations – based on people’s risk factors and the vulnerability of those in their households.

The first recommendation would be for those at high risk for severe illness because of advanced age or underlying medical conditions. These individuals should test as soon as they experience COVID symptoms. If they are negative, they should test at least once more over the next few days. If they are diagnosed with COVID, they should begin antiviral treatment as soon as possible. (And, of course, these individuals should be up to date with the coronavirus vaccine. Shockingly, only 40% of nursing home residents have had the latest shot.)

How long these individuals should isolate depends on whether they are around others who are also at high risk. Those living in nursing homes or with other high-risk individuals, for instance, should have stricter precautions than those living with young and healthy people. In the former situation, the CDC should advise people to stay away from other vulnerable people until they test negative.

The second set of recommendations would be for people who are not high-risk themselves but live or work in close contact with those who are. The guidance should state that they must take precautions around high-risk individuals for as long as they are infectious.

Health care workers who test positive, for example, should stay home in the early days of their illness when they are most likely to pass the virus to others.

To meet staffing needs, they probably can’t wait until they test negative to go to work, but they should mask at all times around patients and other staff.

Similarly, a child who has COVID should not be around their immunocompromised grandparent until symptoms have resolved and the child is no longer testing positive.

But that is not the same length of time the child has to stay home from school. And this brings us to the third set of guidelines: for individuals who are not at high risk themselves and not in close contact with vulnerable people.

In this regard, the CDC has to adapt to reality. This group should be given the same advice for COVID that they receive for other respiratory viruses: Don’t be around others when you have symptoms.

This has already been the norm for much of the United States. Anne Zink, Alaska’s chief medical officer, told me during an interview that she is not aware of a single school in her state that is still requiring five days of isolation for infected students.

“The schools have moved beyond it,” she said. “They’ve said we have to prioritize kids being in school.”

This would be a crucial change in the CDC’s guidance. Many people avoid testing because they don’t want to have to isolate. This alteration would specify that a positive test doesn’t mean they need to stay home from work or school, but that they should avoid close contact with vulnerable loved ones. Research shows that prolonged contact of an hour or more constitutes the majority of COVID infections, so additional caution around high-risk household members and friends can save lives.

I would add that anyone planning to visit a relative in a nursing home or have dinner with a high-risk friend should take a rapid test the day of. If it’s positive, don’t go. If you are infected with COVID and live with a vulnerable person, stay away from them until you test negative.

In anticipation of the CDC easing its guidelines, advocates expressed concerns that COVID remains deadly for immunocompromised individuals and others. They are right; the United States has not done enough to help the most vulnerable. We need to do a lot more to target vaccinations and treatments to high-risk patients. Universal masking should remain in cancer centers, dialysis clinics and other settings frequented by vulnerable people. And there should be more investment into researching and treating long COVID.

But continuing the current confusing and impractical isolation guidance is not the answer. The CDC should align its recommendations with the reality of what Americans are still willing to do four years into COVID-19 while also safeguarding those at highest risk. Both are possible.

Leana S. Wen is a professor at George Washington University’s Milken Institute School of Public Health and author of the book “Lifelines: A Doctor’s Journey in the Fight for Public Health.” Previously, she served as Baltimore’s health commissioner.