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COVID Isolation Should Not Be 'One Size Fits All'
Quarantine and isolation periods should be individually tailored, by Amesh Adalja, MD January 7, 2022.
In medicine we are often reminded that patients are never identical to textbook examples, guidelines are not dogma, and one-size-fits-all solutions never work. Precision medicine -- individualized care integrated with the unique circumstances and characteristics of a patient -- has increasingly been shown to be the optimal approach.
The U.S. has recently been dealing with the implications of one of these one-size-fits-all recommendations: the minimum isolation period used for all who test positive for COVID-19. This recommendation does not take into account the idiosyncrasies and variations in contagiousness that differ from person to person based on such factors as their immune system and their vaccination status. Early in the pandemic, we adopted a 10-day isolation period because it was crucial for public health and to protect healthcare systems. But as more data has been collected, case contact investigations show that the bulk of transmission occurs in the first half of one's illness with infectivity tapering towards the end of the 10-day period. This became even more apparent looking at the viral load kinetics and antigen positivity duration in those with infection post-vaccination.
A 10-day isolation period is not benign and is extremely disruptive to patients and society, especially if illness is asymptomatic or mild. Part of acclimating to a world in which COVID-19 is ever-present involves minimizing the disruption it causes to individual lives and organizations. The long isolation period caused many people to avoid testing and others to discontinue isolation early. Thus, many of us in medicine and public health were clamoring for a precision-guided isolation period -- one that was not too long but achieved the purpose of preventing significant viral transmission.
There are several different approaches CDC could take to truncate the isolation period. For example, the agency could articulate the goal of blocking the bulk of transmission (but not all) and then halve the isolation period -- this is similar to what the CDC actually did in late December. Alternatively, the agency could advise people to use rapid antigen tests as a correlate for infectivity -- there are data suggesting that this works -- to individually tailor isolation periods. Isolation periods would then be of varied length, depending on the individual involved. In fact, this is what I have been recommending to patients and others who ask my advice. This approach is similar to influenza: we use a clinical method of ending isolation 24 hours after fever has abated.
While I agree with the spirit of the revisions to the CDC isolation guidance, its execution and delivery have been unforced errors that rightly merit criticism. If the CDC had announced the changes within a conceptual framework of harm reduction weeks or months ago -- and not in the face of Omicron breakthrough infections, employer concerns, and massive shortages of home tests -- it would not have faced the opposition it has garnered. They could have more strongly emphasized how such guidance was not meant to be perfect, but to be impactful and congruent with the approach to other respiratory viruses. Instead, they initially failed to include testing in the recommendation and, in turn, cast doubt on the ability of rapid antigen tests to provide meaningful information on contagiousness. Then, in response to widespread criticism, the agency reversed that position and added testing into the guidance. However, the addition of testing was done in a confusing and, to me, inexplicable, manner. The guidance currently reads, if you "want" to test, test on day 5 but then isolate for the remaining 5 days if you still test positive -- a surefire way to make no one "want" to test. Those testing negative on day 5 can end isolation, but masking until day 10 is still recommended at home and in public. This back-and-forth is why so many people have lost confidence in the CDC; the agency we're supposed to be able to rely on as the gold standard.
The overarching goal of COVID-19 health recommendations has to be to reduce the harm caused by the virus, knowing that with an endemic viral illness there will always be a baseline number of cases, hospitalizations, and deaths. We cannot drive risk to zero. We need a harm-reduction framing of isolation periods that explicitly acknowledges that the goal is to block the bulk of -- but not all -- transmission events. This intent must be publicly acknowledged. This is how the guidance, which we desperately need as we try to calculate risk in a world laden with COVID-19, can be salvaged.
Amesh Adalja, MD, is a senior scholar at the Johns Hopkins Center for Health Security, an adjunct assistant professor at the Johns Hopkins Bloomberg School of Public Health, and an affiliate of the Johns Hopkins Center for Global Health.
This One Size fits all approach is an anathema in the everyday practice of medicine where personalized care is fostered and the Choosing Wisely approach to developing treatment plans that promote share decisions where is to ameliorate and achieve remission with persons presenting with MDD or Cardiovascular disease or Low back pain or SUD or Type II DM with persistent high A1C or difficult to control Hyperlipidemia. The use of one size fits all strategy by CDC without adequate caveats and specifications in their guidelines to inform HC professionals and guide the general public is likely to cast a big shadow on the credibility of the CDC as an entity in charge of promoting best practices for safeguarding our health and bring significant disrepute from many directions including well regarded professional- in Health care and Epidemiology as well the general public who have posted numerous satirical memes about the CDC. The CDC director statements about the high mortality rates among persons with multiple medical disorders in an interview has evoked a strong and well deserved 'My disabled life is worthy': Hashtag. My website has related posts ;velandymanoharmd.com.
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Posted on MedPage 01 11 22 Avyukt!Neha#9
Good afternoon Dr Adelja. I am very glad you shared this public engagement and empowering prescription to protect our colleagues, neighbors, friends, and fellow Americans which is based on well-established traditional approach to managing health risks and achieve fitness and wellbeing by partnering with the person we seek to restore to health to enhance their capacity to personally take charge of the tasks that must be achieved. The best way is to provide the information they need to know and understand well to make health promotion a doable and staying safe in the face of this surging Covid-19 pandemic themselves and helping others to stay safe much like the Airlines recommend first put your own oxygen mask on and then assist your child or other to put their masks on just as you would with the life vests to keep you and others safe. Staying Safe and helping others to stay safe are the key components of a practical effective Public health Initiative the data you have provided and the method of supporting shared decision making as the core process to defeat the spread of the Omicron Variant of SARS Covid2 virus. I would like to share these links that I have found useful.. 1.Managing Risks of Omicron Variant in Community - Issues with CDC Guidelines 2.COVID19-Can You Leave Isolation After 5 Days? 3.COVID19-Risk of COVID19 Death is Nearly 4X Higher in Schizophrenics.4.COVID19-Five Reports on Issues with CDC Recommendations on 12/27/2021 5. 'My disabled life is worthy': Hashtag Rochelle Walensky inspired with horrible interview 6. https://www.pbs.org/video/covid-confusion-1641854573/ AMA President is explaining the reason for rebutting the Guidelines. I totally concur with your approach to discourage a one-size-fits- all approach and provide accurate understandable data to empower individuals make self-affirming, lifesaving and health promoting decisions to keep themselves safe and help others to stay safe to help rebuild families and communities together with similarly informed persons in every state irrespective of their political allegiances. I am grateful to this very Timely needed discussion you have initiated in the midst of much rancor, heat and smoke after the CDC released their one size fits all guidelines about isolation, quarantine, and antigen testing on Dec 27. My links address these issues.,
Velandy Manohar, MD., Distinguished Life Fellow, Am. Psychiatric Assoc. there are more posts on my website velandymanoharmd.com