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Before President Biden emerged from coronavirus isolation on Wednesday, he made sure he was no longer contagious. He received negative tests Tuesday night and Wednesday morning. Testing at all meant Biden was going beyond the Centers for Disease Control and Prevention’s instructions to come out of isolation.
CDC has built this guidance around a timeline, a prescribed minimum number of days of isolation, rather than the direct, personalized evidence of virus clearance that rapid antigen tests provide. But the usefulness of those tests was highlighted again on Saturday when Biden, who had taken the antiviral during his illness, tested positive again and returned to isolation at the White House residence.
More than 2 1/2 years into the pandemic, and with a highly contagious version of the virus circulating, the CDC’s guidelines for what to do when you get sick and when to return to public life continue to generate as much confusion as clarity. This is a reflection of the changing nature of the virus, the inherent unpredictability of an infection and the demands and expectations of work and family life.
With new research showing that people are often infectious for more than five days, the CDC’s guidance has drawn criticism from some infectious disease experts. The Biden Protocol considers many of them to be the right way, because it is empirical evidence that a person is not shedding viruses.
The CDC does not explicitly recommend a negative test for patients who want to resume activities. He describes this test, which offers a direct, if imperfect, measure of contagiousness as optional. The guidance states that a patient should be isolated for at least five days. (Day 1 is the day after your symptoms develop or your test is collected.) Patients who complete isolation should continue to wear an appropriate mask around others at home or in public until the day 10.
“Given that a substantial proportion of people have a positive rapid test after 5 days, I believe that an updated recommendation should include people who have a negative rapid test before coming out of isolation for COVID,” said Tom Inglesby, director of the Johns Hopkins Center. for health security, who was the Biden administration’s top adviser on tests from December to April.
Rapid tests are widely available, and “there is new science and practical experience with this virus since December, when isolation guidance was issued,” Inglesby said in an email.
People who are asked to return to work after five days of being sick with covid, even if they still test positive, “shouldn’t,” Inglesby said. “It is exposing others in the work environment to the risk of spreading COVID. CDC guidance on this would be valuable.”
The test to return should be the standard across the country
Good enough for POTUS = good enough for everyone https://t.co/k3B8DkT9ZR
— Anand Swaminathan MD MPH 🏳️🌈🇺🇦 (@EMSwami) July 27, 2022
Biden has used his brief bout with the coronavirus as a sign that the administration is on top of the pandemic and has taken the right steps by relying on vaccines, tests and new antiviral drugs to lower the death rate. But across the country, hundreds of thousands of people a day become infected with the omicron BA.5 subvariant—the exact number is impossible to know—and have a common and urgent need to know when they are no longer contagious.
The CDC’s guidance has been under internal review in recent months. A renewed set of recommendations is expected to come out in the coming weeks, according to three administration officials and advisers who spoke on condition of anonymity to describe sensitive internal discussions. A draft of the updated guidance does not include any requirements at this time test negative before leaving isolation, they said.
Existing CDC guidance says patients can end isolation five days after the first day of symptoms, as long as their symptoms have improved and they have been fever-free for at least 24 hours without fever-reducing medication. The CDC encourages people who become very ill or have a weakened immune system to self-isolate for 10 days.
This leaves a negative test result as optional.
Robert Wachter, a professor of medicine at the University of California, San Francisco, said people can easily misinterpret the CDC’s five-day guideline as a personal guarantee of not being contagious.
“Unfortunately, people hear ‘five days’ and think, ‘Oh, I must not be infectious,'” Wachter said. “This is wrong.”
A recent study in the New England Journal of Medicine looked at how long people could clear viruses that could be grown in a lab — the best test of infection. The result: People clear this virus for eight days, on average, before testing negative.
The CDC guidance “makes no sense,” said Andrew Noymer, an epidemiologist at the University of California, Irvine. “They’re telling people to go back to work while they’re still contagious, basically.”
Wachter suggests people test negative before going out in public.
“The antigen test turns out to be a very good test of ‘you’re infectious,'” Wachter said. “If they still test positive on day 6, 7 or 8, I don’t want to be huddled in a room without a mask.”
Officials familiar with covid policymaking say the administration needs to consider human behavior — what people can and will do in their daily lives to limit the transmission of the virus.
The administration’s decision not to push hard for a negative test before ending isolation reflects an awareness that not everyone has access to testing or can extend time away from work, school, the care or other tasks.
When CDC Director Rochelle Walensky was asked recently why the agency doesn’t recommend that all Americans use successive negative tests to come out of isolation, as Biden did, she said the president was in a special category.
The president received several rapid tests because he was being monitored for a Paxlovid “rebound” infection, which can occur days after initially testing negative. Biden tested negative Thursday and Friday morning before a positive result Saturday morning indicated the rebound and put him back in isolation, White House physician Kevin C. O’Connor said in a letter. “Not surprisingly,” Biden tested positive again Sunday, O’Connor said.
Walensky said during an interview with the Washington Post Live that “I think we can all agree that the president’s protocols probably go beyond and have the resources to go beyond what every American is capable of and has the ability to do”.
“As we roll out our CDC guidance, we need to make it relevant, doable and followed by Americans,” he said, noting that some communities have fewer resources and greater labor constraints.
He also noted that the guidance gives people the option to do a quick test before ending isolation.
CDC Director Rochelle Walensky commented on President Biden’s covid protocols on July 22. (Video: Washington Post Live)
The five-day isolation period reflects an approximation of when people are most likely to be infectious. But these are averages, covering broad populations.
A positive result on a rapid antigen test, often called a home test, is the best indicator of how much virus is present and how likely you are to infect someone, said Michael Mina, a former infectious disease epidemiologist and immunologist. from Harvard University. who is an expert in rapid tests. Rapid antigen tests look for specific viral proteins to detect infection. Mina is the scientific director of a telehealth company that uses rapid tests, including covid, to link patients to care.
“If you still have enough virus to see it on a quick test, you know you’re still contagious,” Mina said.
The California Department of Public Health, for example, requires a negative test on the fifth day after the first positive test, or later, to leave isolation.
Policy makers could help patients by publishing ‘clearer guidelines on the use of antigen tests’ leaving isolation, as in Biden’s case, said Amy Barczak, an infectious disease expert at Massachusetts General Hospital. Their research suggests that a quarter of people infected with an omicron variant could still be infectious after eight days.
The CDC guidance dates to the wave of illnesses caused by the omicron variant that began in December and sickened tens of millions of people in a matter of weeks, causing the cancellation of thousands of commercial airline flights daily and causing shortage of personnel in all sectors of the economy. Under immense pressure to keep essential services open, and amid signs that the omicron was less likely to cause serious illness in a largely vaccinated population, the CDC shortened the recommended isolation period from 10 to five days.
Rapid tests were scarce at the time, but then the federal government expanded its acquisition of tests, with millions now available. Since this spring, Americans have been able to go to a government website, covid.gov, order free rapid antigen tests and have them sent to their homes. At drugstores and online retailers, a two-test package generally costs about $25, depending on location. Private insurance is supposed to cover home test purchases.
Some elements of the CDC guidance can be confusing.
The CDC says that people who decide to take a coronavirus test after day 5 and get a positive result should extend their isolation to 10 days. But the agency doesn’t directly recommend testing after day 5. The guidance as written says you can indeed test after five days, but be prepared to manage the result. People for whom isolation is a hardship may see no incentive to find out if they are still losing…