A reaction to the CDC guidance
Yesterday, the CDC released much anticipated guidance for COVID-19. In all, the guidance is much more “relaxed,” as headlines are detailing. It’s difficult to organize my million thoughts, but here are a few:
1. Goal. I appreciated that the CDC clearly defined their goal: reduce severe disease. Some may not agree with it, but we finally have clarity on what the CDC is actually trying to control and prevent.
On one hand, this goal makes sense. Cases are clearly decoupling from hospitalizations, and we are in a different place than before. The risk of long COVID is also changing, thanks to vaccinations and less severe Omicron.
On the other hand, the decoupling effect is not perfect, especially for high-risk groups. This was clearly reflected in Portugal during the BA.5 wave. (They have one of the highest vaccination rates in the world, but reported significant excess death among those over 65.) Vaccines are not perfect, especially with a highly transmissible variant finding vulnerable pockets.
Can we really only focus on severe disease without focusing on transmission? Maybe. If reducing severe disease is our goal, we cannot believe that 450 deaths per day is the best we can do. And I don’t think the CDC thinks this. But, we need a comprehensive plan to understand who is dying today and, more importantly, why: If they didn’t take Paxlovid, why? If they aren’t vaccinated, why? If they aren’t boosted, why? If they did everything right, how were they infected? Once we have these answers, we can create targeted approaches, like antivirals that people on medication can take, to reduce severe disease, even given the current climate.
2. Up to date. I absolutely agree with the new language around vaccination. Before, “fully vaccinated” was used to describe the primary series. However, it’s abundantly clear that we need a booster, if not several. Using the language “up-to-date” allows for flexibility around our science and understanding, while also making it clear that if you don’t have a booster, you are at risk.
3. Individual vs. population. The CDC continues to go down the path of individualization. In other words, people need to make their own decisions. This is a very medical perspective. This is a very American perspective. This is not a population health perspective. This will leave people behind.
4. Protecting self. If we continue down the path of individualized health, we need to provide evidence-based guidance for people who want to protect themselves. I was disappointed to see this guidance doubled down on the following:
Leave isolation after 5 days. We see strong evidence (here, here) that an Omicron infection lasts, on average, 8-10 days. Peak infectiousness is around day 4/5, as demonstrated from an FDA study released earlier this week. While the guidance did state to wear a mask after 5 days and/or avoid high-risk people, this narrative has already been lost.
(Michael Mina Twitter) Remove test-to-exit. I was disappointed to see test-to-exit removed. Antigen tests are the *only* tool we have tell whether or not they are infectious. People need to know this, and they need to leverage this tool. If not enough free antigen tests are available for this policy, we need to fix this.
Community Levels map to mask. This map tells us when to take collective action so hospitals don’t surge. This does not tell us when to wear a mask for individual protection due to high transmission. If we are trying to prevent severe disease, those at most risk should know when they are at risk for infection.
5. Larger policy picture. What has been eating at me the most, all week, is around national health policy itself. How much should the CDC meet people where they are vs. how much should the CDC set the standard?
One epidemiologist drew parallels to the food pyramid. A lot of people don’t actually follow the food pyramid, but that doesn’t mean the CDC should shy away from striving for better. Unfortunately, unlike the food pyramid, COVID-19 has been incredibly politized and polarized. And, as much as I hate it, the CDC is not independent of politics. In fact, they are funded through Congress. So, public health policy is not solely based on science.
Unfortunately, this creates a dangerous feedback loop: CDC tries to meet people where they are by saying isolate for 5 days. But then an employer uses this guidance to require employees to be back after 5 days. This forces people who want to stay home but can’t. Then, this drives inequities. Those who have high-wage jobs can stay at home (or continue to work from home), while people with low-wage jobs don’t have this option.
How do we get out of this politics-health loop? This is an important question, not just with COVID-19 but with other public health problems like gun violence. I don’t have an answer. I don’t know if anyone does, which keeps me up at night.
What does this guidance mean for me?
This changes nothing for me and my family. We will continue to ride the waves based on transmission in the community. There are three reasons I do this:
I just don’t want to get sick. (I just don’t have the time with two toddlers running around and a career.)
I don’t want to get long COVID-19. Many of my friends have it, and it is debilitating and absolutely nasty. To me, the risk to adults is still high enough for action.
Protect the most vulnerable around me, like grandparents.
This does not mean that I constantly worry. It also doesn’t mean I make perfect decisions. But it does mean that I integrate pandemic tools in my life to reduce risk. For example, my entire family is up to date on vaccines, including my little ones under 5. I still wear a mask in public indoor spaces. If I forget a mask and the store isn’t busy, I don’t turn around. If it’s Costco on a Saturday, though, I turn around and grab my mask. I still wear a mask at the airport. My toddlers do not wear masks at daycare, but we encourage it if traveling on public transit. If they were older, I would encourage it at schools fully knowing that they would probably take it off with friends. I think that’s okay. I’m going to a wedding this weekend and will not wear a mask, but we are antigen testing. We also continue to take antigen tests before seeing grandparents. My girls absolutely hate it, but it’s nothing a lollipop can’t fix.
As I’ve written before, we are in a very strange phase of the pandemic: somewhere between endemic and a full blown emergency. If you’re confused on what to do, know that we are all confused and just trying to do our best. Give yourself and others grace through this time.
Have a wonderful weekend, YLE
“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, biostatistician, wife, and mom of two little girls. During the day she works at a nonpartisan health policy think tank, and at night she writes this newsletter. Her main goal is to “translate” the ever-evolving public health science so that people will be well equipped to make evidence-based decisions. This newsletter is free thanks to the generous support of fellow YLE community members. To support the effort, please subscribe here:
God, I needed someone to say this, and you say it so well. Carefully and clearly. The CDC's guidance is quintessentially "American" in its focus on individual preference and, sadly, in its choice of what's palatable (5 days) over what is actually in the data (the infectious period is longer than that). Finally, for those of us at medical high risk -- a non-trivial 9-15 million people, depending on which definition you select -- the latest guidance conveys that the CDC, like many in this country just... doesn't... care. Doesn't see our lives as worth protecting. It's a bitter reality.
As a high risk person and as a family doc I thank you for your practical explanation of the CDC guidance and recommendations for continuing individual risk reduction. However, I regret that out of kindness or professionalism or diplomacy, your list of the shortcoming in the CDC guidance does not explicitly call them out for abandoning the basic foundation of equitable population protection inherent in public health values to emphasize individual guidance. They continue to leave high risk people, the uninsured, those in medical deserts, those who have experienced discrimination unprotected. They put out guidance (out of isolation in 5 days) not based on good science. We are watching the destruction of the system of public health as a public resource.