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Does it still make sense for vaccinated people with Covid-19 to isolate for 10 days?

Omicron — and short-staffed hospitals — could force the US to rethink isolation rules.

Katie Lucey administers a Covid-19 test on her son at a PCR and Rapid Antigen pop-up testing site on Wall Street in New York City on December 16.
Ted Shaffrey/AP
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

A lot of people are going to contract the new omicron variant in the coming weeks. Some of them will feel sick and, as has always been the case, those people should isolate themselves. Others may be identified through regimented testing for work, school, or travel, and have no symptoms at all.

Right now, all of those people who test positive for Covid-19 — symptomatic or not, vaccinated or not — are urged to isolate themselves for 10 full days. Some public health experts are asking: Does that still make sense?

The forthcoming omicron wave won’t be the same as the ones that preceded it. More than 60 percent of America’s population is vaccinated, and the coronavirus itself is also different: The early evidence suggests with the omicron variant, people might recover and clear the virus from their bodies faster, especially if they’re vaccinated, and they may therefore be contagious for a shorter period of time.

The CDC guidance for when and how long fully vaccinated Americans should isolate was last updated in October. It still recommends that if a person, vaccinated or not, tests positive for Covid-19, they should isolate for 10 days, staying home, keeping away from anybody else who lives in their house, using a different bathroom, and wearing a mask as much as possible. (For vaccinated people who think they may have been exposed to Covid but aren’t sure, the guidance is not to isolate but to get tested after several days.)

Some experts argue it’s time to consider shortening the isolation window after a positive test or even changing the guidance to rely more on test results and less on timing.

The stakes are high. A 10-day quarantine for a child in school or somebody with a job that can’t be done remotely can be a major inconvenience. The CDC is already relaxing its guidance for schoolchildren, saying those who have been exposed to somebody with Covid-19 can continue to attend classes as long as they continue to test negative. But some of these experts are urging a broader reassessment of similar recommendations for people who contract the virus.

The length of quarantine windows could also determine whether or not US hospitals have the staff to handle the surge of Covid-19 patients expected as omicron sweeps across the country in the coming weeks and months.

The preliminary data out of South Africa indicates that people who are hospitalized with omicron are staying in the hospital for a shorter period of time. That may mean the virus is now clearing the body more quickly, said Monica Gandhi, an infectious-diseases researcher at the University of California San Francisco.

It’s too soon to be certain about that. But if this pattern does hold up, that would be a reason to reevaluate the recommendations.

“We have to keep on reevaluating if isolation can be shortened,” Gandhi said, “as we transition to a society where there will be a lot of omicron exposure, given how infectious it is, but hopefully continued protection against severe disease due to cellular immunity.”

Rapid tests should, in theory, also make it easier to revise the isolation protocols. Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security, said the evidence suggests vaccinated people with a breakthrough infection are contagious for less than the current 10-day isolation window. He would like to change the protocols so that vaccinated people who test positive continue to take rapid at-home tests.

Once they test negative, as long as they feel healthy, he said, they shouldn’t need to isolate.

“One thing we could do today is to start saying, ‘Use those home tests when you have a breakthrough,’” he sad. “‘When you’re negative and you feel good, go back to your life.’”

Rapid at-home tests could then serve as a kind of contagiousness test, replacing a strict time-based guideline to let people know when to start and stop isolating. Even small adjustments could help: As Adalja put it to me, being able to return to normal life after nine days instead of 10 can make a real difference.

Other experts agree that it could make sense to reduce isolation periods for fully vaccinated people who aren’t experiencing symptoms. But it takes time to get the sturdiest empirical foundation for these policy changes.

“We will not have the evidence base on which to assess the impact of changes in these protocols for week or months and omicron will be on us before that,” Bill Hanage, an epidemiologist at Harvard University, said.

So we are working with imperfect information at a critical point in the pandemic: It’s imperative to constrain spread as much as possible, but there’s also a risk in asking health care workers to quarantine for too long when hospitals are expecting a swell of Covid-19 patients.

The current isolation guidelines pose a staffing challenge to hospitals

We don’t know how many people have been strictly following the CDC’s guidance after they test positive. But hospitals do with their staffs.

Right now, hospitals are typically asking their staff members who test positive to quarantine for the full 10 days — and they are already seeing positive tests skyrocket, even with omicron still accounting for only a fraction of US cases, according to the available data.

Houston Methodist Hospital saw the number of positive tests among its staff members grow from 46 the week of December 6 to 200 the following week.

“We must follow the CDC and OSHA guidelines, which require the 10 days of quarantine,” Stefanie Asin, a spokesperson for Houston Methodist, said in an email. “If they change the guidelines, we will follow suit with our own policies.”

This is another way the omicron variant could push the health system into crisis.

Even if the variant does tend to cause milder illness on average, as some early indications suggest, a certain percentage of infected people, especially unvaccinated people, is going to end up getting really sick. The bigger the denominator (infected people) gets, the bigger the numerator (hospitalized patients) will too. The more hospitalizations we see, the more deaths will be added to the 800,000 American lives lost so far and the higher the risk that there will not be beds or nurses for people who come to a hospital with non-Covid medical emergencies.

The crunch will be even more acute if a wave of sick patients hits hospitals where doctors, nurses, and staff are sidelined for days with mild or asymptomatic cases. Omicron appears adept at evading immunity from vaccines and causing mild or asymptomatic breakthrough infections for some people, though the vaccines still provide strong protection against severe illness. But that change in the virus could lead to a lot of nurses and doctors testing positive — and being required to quarantine, even if they don’t have symptoms or if they feel better quickly.

As hospitals have said throughout the pandemic, staffing is as much of a constraint on their ability to deliver care as physical beds or supplies. Before omicron hit, nearly 99 percent of rural hospitals already said in a recent survey that they were experiencing a staffing shortage; 96 percent said they are having trouble finding nurses specifically. These hospitals tend to be in communities with lower vaccination rates, where the need for care is expected to explode as omicron takes over.

Even though the CDC recommendations are thus far unchanged, isolation protocols in some industries are already starting to change ahead of the omicron wave.

The NFL announced this week, after a rash of positive tests that put several of the coming weekend’s games in jeopardy, that it would relax its isolation policies for vaccinated players who test positive. Instead of requiring them to return two separate negative tests taken 24 hours apart, those players no longer need to wait a full day between tests. Any two negative tests are sufficient to allow a player to return to practice and games. (At the same time, the league is also reinstating mask requirements and is putting restrictions on what players and coaches can do outside team facilities, steps not widely seen outside of the NFL.)

This kind of transition is necessary, Adalja argued. We are moving from a reality in which Covid-19 is a world-altering public health emergency to one in which it is one of many viruses circulating and infecting people all the time. In the first scenario, blanket one-size-fits-all guidelines had value.

But as we move into the second, individual cases should be treated individually, he said. A vaccinated person with no symptoms is not the same as somebody who isn’t vaccinated and feeling sick. There should be a protocol that allows the former to return to life as soon as possible, while giving the latter a way to know when they can do the same.

There’s one big hurdle: Ending quarantines based on test results depends on tests being available and on people being willing to take them. Some people might not because testing every day at current rates could get expensive. The Biden White House sought to ease the cost burden for tests with its plan to have people submit their receipts to their insurer for reimbursement, but that could prove too cumbersome for many people to follow through.

In the years to come, as the coronavirus continues to circulate without, it is hoped, causing massive waves of hospitalization and death, this guidance will be less necessary; the CDC will offer its recommendations and people will decide whether to heed them.

That’s already how we handle flu and other seasonal illnesses, and it’s likely it will eventually be true of Covid-19 too. “Precision medicine is when we craft recommendations based on individual characteristics,” Adalja said. “As this becomes more endemic and managed by individual physicians, you will see naturally a move toward precision medicine.”

For individuals, that transition may happen over years. But for hospitals anticipating an imminent surge of omicron patients, considering a new policy for isolation is urgent. They’ll need all hands on deck to care for their patients.