“This is the moment” to discount a positive Covid test (after 5 days) (i)

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This week’s big controversy concerns the CDC’s deciding to cut recommended days for isolation for people infected with Covid. CDC director Walensky was all over the news explaining that this “was the moment” for a cut, given the whopping number of new Covid cases (over 400,000 on Dec. 28, exceeding the previous record which was in the 300,000’s).

“In the context of the fact that we were going to have so many more cases — many of those would be asymptomatic or mildly symptomatic — people would feel well enough to be at work, they would not necessarily tolerate being home, and that they may not comply with being home, this was the moment that we needed to make that decision,” Walensky told CNN.

The CDC had already explained last week that “health care workers’ isolation period could be cut to five days, or even fewer, in the event of severe staffing shortages at U.S. hospitals”.

Then, on Monday, the CDC announced that individuals who test positive for Covid-19 and are asymptomatic need to isolate for only five days, not 10 days, citing increasing evidence that people are most infectious in the initial days after developing symptoms.

What’s really causing alarm among many health experts is that the new policy has no requirement for a negative test result, with a rapid test, before ending isolation. Even if you test positive on day 5, the CDC says, you can go about your business. So long as you’re asymptomatic or mildly symptomatic or your “symptoms are resolving” and you wear a mask. I don’t suppose the new looser guidance would result in any pressure being put on a pilot or other worker to get back to work even with some mild brain fog or coughing that seemed to be resolving.[1]

“It’s frankly reckless to proceed like this,” Eric Topol, founder and director of the Scripps Research Translational Institute, told The Associated Press on Tuesday. “Using a rapid test or some type of test to validate that the person isn’t infectious is vital.”

Similarly, Michael Mina tweeted:

“CDC’s new guidance to drop isolation of positives to 5 days without a negative test is reckless, …I absolutely don’t want to sit next to someone who turned [positive] five days ago and hasn’t tested [negative].”

Incredibly, Walensky denies that removing the requirement to test negative was driven by the obvious dearth of rapid tests, as anyone who has tried to buy them recently knows. (We’ve seen the same denial earlier in the pandemic in defending the CDC’s not recommending high quality masks. See this post.) “This really had nothing to do with supply”, she avers. Really? And health officials wonder why the general public has a hard time believing our agencies are being honest with them.

Instead, she says the reason is that the CDC does not know if rapid tests “predict whether you’re transmissible during the end of disease.”[2]

“If you got a rapid test at five days and it was negative — we weren’t convinced that you weren’t still transmissible — we didn’t want to leave a false sense of security. We still wanted you to wear the mask,” Walensky told CNN.

“And if it was positive — we still know the maximum amount of transmission was behind you — we still wanted you to wear a mask,” she added.

What? If you were still in isolation you wouldn’t be out and about with only a mask to protect those around you.

“And given that we were not going to change our recommendations based on the result of that rapid test, we opted not to include it.”

But the whole question is whether the CDC ought to have a policy recommendation based on the result of the rapid test, and whether a positive result ought to block someone with Covid from ending isolation. The rest of the world, while also cutting isolation days, is requiring negative results on rapid tests before ending isolation entirely.

It’s weird that they can talk about mandating vaccines (for an out-of-date virus) on domestic flights, as we hear this week, while allowing Covid positives on board. (And this is with the rapid tests, not the PCR tests which can take a longer time to turn negative.)

Ashish Jha, the dean of Brown’s school of public health, calls them “contagiousness tests”: [Rapid Covid tests] won’t detect every speck of virus that their PCR counterparts are attuned to do, but they can detect the important part—if someone is producing enough of the virus that they’re likely to spread it. (link)

Walensky should be asked: Would you go visit your elderly relative after a positive Covid test on day 5 of isolation? The answer would be informative. This would have been the moment to come out and tell it like it is: “look, we have to cut isolation days, despite the low but still very real risk of being contagious in days 6-10, in order to avoid the break-down of essential services, putting airlines out of business, etc. etc. particularly given the low rates of hospitalization and death nowadays. And we can’t recommend getting a negative test first because we’d be recommending something many people could not carry out, since there’s a nationwide shortage of test kits”. That would have garnered more trust, and resulted in better outcomes, than their obfuscating about the risks. Papering them over prevents people—both with and without Covid– from deciding what precautions to take in various different contexts. In some contexts, they might prefer to err on the side of caution and isolate until getting a negative test result–at least where feasible. Instead the message is, there’s really no need to. (Fauci handled this issue a bit more frankly, it seems.)

And why is there a drastic shortage of rapid tests when everyone knew about Omicron’s transmissibility rate a month ago? Walensky’s whole defense seems aimed at shielding from blame those who should have been ramping up availability of tests. (And don’t get me started on the promise we’ll all be able to order them from the government some time next month.)

In typical Walensky fashion, she argues that since people already disobey the more onerous recommendations, they need to be lowered. Of course, it’s precisely the kind of disingenuous defenses from our health experts that has people ignoring them to begin with. This will add to that bad record. Even if it’s true that many people disobey CDC recommendations, it does not mean that those recommendations won’t figure into their calculations as to how to behave when it counts. So maybe, as Walensky says, people with Covid, but with slight symptoms, won’t tolerate staying home from work for 7 or 10 days. But they might well balk at visiting with relatives at risk of serious disease. Likewise, people might balk at letting their kids ride in a car with someone who tested positive this morning, who had already isolated 5 days. But with this new CDC recommendation, people are effectively told the new data indicate it’s OK, (mixed in with a muddled message that it might actually be staff shortages, scarcity, and influence of airline CEOs). CDC should instead raise an alert, such as: “given the new lowering of requirements, you may want to ask if a person has tested negative, and take extreme precautions if they say no”. Wearing a mask (any mask?) does not suffice, and notice there is no call for a high quality mask. (See this post on hi-fi masks.)To those with Covid they might have said “If you have no symptoms, or they’re slight, and there are staff shortages, go to work, but we recommend–especially if you’re still testing positive–you hold off being with people at high risk of severe disease for the full 10 days, and please honestly inform those around you of your status.

Share your thoughts in the comments.

[1] Note Delta Airlines new policy in response to the new CDC guidance is to give pilots 5 days of sick pay, saying nothing about requiring improvement even to be expected to return to work:

The airline’s new policy, dated Tuesday, provides five days of paid leave for workers who test positive for the coronavirus to isolate, according to an internal communication to company leaders obtained by The New York Times. And it encourages, but does not require, a Covid test to go back to work, going a step further than the C.D.C. guidance, which does not include a recommendation for additional testing. Delta’s new protocols make no mention of whether returning employees should have improving symptoms, as suggested by the C.D.C.

link is here

[2] We also don’t know if levels of neutralizing antibodies predict immunity, yet those waning levels are the basis for the call for boosters.