Today’s mini-blog is to address the CDC’s new guidance regarding isolation/quarantine and give you a glimpse of what is coming in the weeks ahead. Spoiler alert: The horse is out of the barn.  It’s about to get as ugly as you ever dreamed.  But it may not be all that bad.  Confused?  Got your attention?  And away we go….

A quick studio cut from The Tubes off their 1980 album The Completion Backwards Principle.   

The Completion Backward Principle

Over the last couple of weeks, the Omicron variant has taken hold in the United States.  Case rates are absolutely soaring.  In our tiny neck of the woods, we have gone from calling 5 positive swabs for Covid a “crazy day”  to not having swabbed less than 20 positive daily for the last couple of weeks.  And that is despite turning many folks away due to lack of capacity here. One bright spot with the kids here – all milder infections, a bad cold essentially.  Just a ton of them.

In the face of this onslaught, the CDC last week relaxed isolation/quarantine guidelines for everyone who has the misfortune of contracting Covid.  Seem backwards to you?  At first glance, perhaps yes.  Perhaps genius.  Time will tell.  No new data was released to support the change in guidance, so here is hoping they did some real good modeling of the effects of their decision and are not relying on the confidence that comes with passing off ass-pennies.*

*Any connection between ass-pennies, jackasses, or particular party affiliation with the jackass logo is not intended.  On the topic of items passed through one’s colon, and to even out the animal logo/political party commentary, it should be noted that coffee beans that pass through the intestines of elephants are considered a delicacy.  Really.  Couldn’t make this up if I tried.

CDC Guidance

The CDC this past week issued updated guidance on isolation and quarantine to lower the duration of both from ten days to five days with a few caveats.  Of note, little distinction was made regarding vaccination status.  Presumably, this is because there are a lot of breakthrough cases among the vaccinated and sorting out the issue of boosted vs. not boosted and timing of such is likely beyond anything they have studied.

The Party Line Reasoning

Per the CDC press release, the rationale behind lowering the duration of isolation/quarantine is based on data demonstrating the majority of cases are contagious for a couple of days before and a couple of days after the onset of symptoms.  No new actual numbers were released to support the statement.  Worth noting the statement is nothing different that has been suspected and stated for quite some time.  The stated objective is to try to not disrupt everyone’s lives to the extent that they have been with the longer isolation/quarantine, as it has significant negative effects on education and the workforce.*

*Not to mention the NYE run of Phish shows at MSG was canceled. 

What Is The Likely Consequence of the Decision?

The consequence of the CDC decision is that there will be, by definition, many contagious folks released from isolation/quarantine while contagious.  This is for two reasons.  First, “most” does not equal “all.”  While the percentage still contagious after four days may be less than three; when a ton of cases are out there, it starts to add up.  Second, people lie.  A lot.   Folks claiming they were already with symptoms for two days at time of testing will be released to the public while still at peak contagion.  And that begets the next question…..does it really even matter any more?

Isolation and Quarantine

General Premise and Optimal Conditions

The general premise is obvious – if you keep folks capable of spreading an illness away from others, you can stop the spread of the illness.

With that premise in mind, isolation and quarantine can be very effective tools to mitigate the spread of infection.  As with many tools, there are optimal conditions and then there are real life conditions. Isolation and quarantine work best when only the symptomatic individual is contagious and easily identified.  This enables them to be placed in isolation, along with contacts quarantined based on quick contact tracing before they are contagious themselves.  Other infectious parameters also have significant impact on the effectiveness of isolation and quarantine.  First, isolation and quarantine are more effective when case loads are low in a community.  Second, they are more effective when the transmissibility of a virus is lower.  I could not find reference data, but in this case, it is really common sense – less people that are less contagious get less people sick, and thus rounding them up is simplified.

Of course little in this world runs under optimal conditions…..

How Are the Current Conditions Amenable to Isolation and Quarantine?

Is “not amenable” a clear enough answer? When 1/4 of the population is running around with a highly contagious virus at any given time, isolation and quarantine are no longer effective strategies.  It’s like catching a falling knife.  Doesn’t work for investors either.

Based on the prior sections optimal conditions, we currently meet none of them.  The current case load as aforementioned is very high.  In addition, this virus variant is highly contagious, and is such a couple of days before the onset of symptoms.  By the time someone has shown symptoms, they have shared the infection with many others, unless they have been isolating habitually (and there are many out there doing such).

A happy birthday in advance David!  Can’t believe it has been five years already.

Crystal Ball Time

Caseloads exploding?  Isolation/Quarantine not effective?  What are you implying doc?

I am implying that you are about to witness the 2022 equivalent of a “chicken pox party.”  Nearly 7,000 cases were identified in Suffolk County yesterday.  That number could well hit 20,000 per day over the next couple of weeks.

Alas though, it is not about the number of cases.  As I have been saying since early on, it is about our resources to manage the cases.  Primary among them are hospitals.  You cannot get into a general pediatric office to assess cold symptoms and determine whether they are caused by Covid?  Nobody gets harmed in a medical sense.  You cannot get seen in an ED for a legitimate illness due to capacity issues?  There you have a real problem.  And people do get hurt.  Some pain is permanent.

Our hospital census is increasing at this time.  Fairly quickly at that.  But we still have capacity.  We have managed twice the overall number of current hospitalizations during this pandemic already.

How does this story end?  There are two major ways I see this ending as January winds down.  First, this variant remains less severe than prior variants and we load up our hospitals to near capacity again while we finally achieve herd immunity.  That, my friends, would be the end of the pandemic.  Second, we overwhelm the hospitals, tons of folks start dying again, and we find ourselves in another lockdown.  I am sure there is some gray area to be found, though I am not seeing it from my vantage point.

What Next Dr. Bundle of Joy?

My gut keeps telling me that we are going to get tested to the point of caving over the next few weeks.  I am praying in my own special pastafarian way that our elected officials have been preparing appropriately.   They will need to have the ability to increase typical hospital capacity.  Hopefully there are crews, supplies, and equipment available to help locations as the game of Whack-A-Mole begins.  If we weather this storm, and I don’t think there is another choice at this point, we may actually have something to all celebrate in a few weeks.

A Few Suggestions

For Our Elected Officials

Please use whatever powers you possess to work with manufacturers to make Paxlovid and the monoclonal antibody therapies available to as many high risk patients as is possible in the immediate term.  With sufficient supply of the medication, we can minimize the hospitalizations and deaths over the next few weeks.  Easier said than done I am sure.  But we are a nation with immense resources.  We should be able to do this.

Please focus on our high risk populations.  Stop worrying about the schmuck in the deli who is yelling at the counterperson about wearing a mask.  Focus on keeping our nursing homes safe.  Find ways to enable our elderly to cocoon for a few weeks and stay the heck out of that deli with the yelling schmuck.  Give them free food delivery and supply drop off.  Gotta be cheaper than another bail out.

I honestly don’t envy any government official’s job at this time.  But there is impact to be made, and this is the life they chose.  Let’s hope we chose wisely with our elections.  This is why we vote by the way.

For Our Media

Cut the crap with non-objective reporting and sensationalization.  We do not need people panicking every day.  If all you report are numbers skewed to scare, things are going to get far uglier than necessary.  As an example: “Deaths among people with XYZ increased 300% in one week” sounds scary.  But it is not, if it involved three deaths rather than one in the entire country.

For Our Schools

Stop torturing the kids.  They are not the problem.  They have not been since the start of this.  Do not send them home to learn remotely, unless they either choose to or there is a lockdown.  Yes, that is the second time I mentioned that word.  Wanna focus on something?  Get the adults in the building to get a vaccine. Educated people making uneducated decisions.

For The Rest of the Peeps Out There

Haven’t gotten vaccinated yet?  Stop messing around.  Billions of doses served.  Keeps you from dying if you catch Covid.  And you are gonna catch it now.

Over 90% of those in the hospital did not get vaccinated.

Over 90% of those in the hospital did not get vaccinated.

Over 90% of those in the hospital did not get vaccinated.

Over 90% of those in the hospital did not get vaccinated.

Over 90% of those in the hospital did not get vaccinated.

Parting Thoughts

Sorry if the tone today was not among the most encouraging.  I urge you to focus on the positives.  We are coming to a conclusion.  This variant appears weaker and we have some therapies that work.

It has to get worse though before it goes away.  Our nation’s willingness for preventative measures has dictated that.  Please watch out for your elders and high risk individuals  the next few weeks.  Do not take a chance of giving them your “cold.”  You didn’t just develop new allergies.  Or a sinus infection.  You likely have Covid.  Your “cold” is their ticket to the great beyond.

And for the last time today, please get vaccinated.  It’s part of the overall solution.

Happy New Year!  May you and your families remain healthy and looking forward to seeing y’all on the other side of this pandemic.  Buckle up though, it’s gonna be a bumpy ride the next few weeks.

Parting Thoughts Part 2

I lied.  Just for good measure:

Go Get Vaccinated!

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.