News surfaced last week suggesting a potential shift in from the CDC. The planned guidance, which is expected to be released this spring for public comment, indicates a significant switch in how COVID-19 is conceptualized. The guidance would bring COVID-19 into line with how other common respiratory viruses are managed: with isolation recommended until the individual has mild and improving symptoms, and is fever-free (without pharmaceutical aid) for 24 hours.
With the news of the proposed guidance, many voices rose up to immediately attack the proposed guidance as a capitulation and not evidence-based. This was similar to the refrain from opponents when the federal or state governments dropped or loosened mask requirements or guidance.
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Indeed, I welcome the proposed guidance change because it reflects the progress that has been made in the management of COVID-19. When evaluating this guidance, it is critical to understand that SARS-CoV-2, the cause of COVID-19, is situated among the myriad respiratory viruses that infect humans.
SARS-CoV-2, a virus unknown to humans before 2019, naturally began its foray into our species unopposed by diagnostic tests, antivirals, vaccinations, and knowledge. Today, in 2024, there are more tools for monitoring and managing COVID-19 than for any other respiratory virus: spanning from home tests, to wastewater monitoring, to potent antivirals, to highly effective vaccines, to a wealth of clinical guidance to manage cases and mitigate complications. All of these medical countermeasures are coupled with a high degree of immunity in the population from prior infections, vaccinations, and combinations of both. In short, the entire context of COVID-19 has changed for the better.
No longer are hospitals worried about capacity due to huge COVID surges -- cases may ebb and flow in the community and new variants appear, but no longer are these phenomena coupled to hospitals in crisis. While the raw numbers of hospital admissions and invasive mechanical ventilation or death were higher for COVID than for both respiratory syncytial virus (RSV) and the flu in 2022-2023, rates of ventilation or death were statistically no different for older adults hospitalized for either RSV or COVID (13.5% vs 10.2%), recent CDC data showed, both higher than for flu (7%). Furthermore, the highest rates of oxygen therapy and ICU admission in the study were among those with RSV (a virus for which no antiviral exists).
What is most baffling to me is that those who are critical of the proposed guidance change seemingly ignore the fact that most countries have already moved to this new paradigm without any evidence of major untoward impacts. Indeed, even -- two states not known for cavalier attitudes regarding COVID-19 mitigation -- have done the same. These states also advise that asymptomatic patients do not need to isolate at all; masking for 10 days is deemed sufficient. This is despite the fact that contagiousness remains in some individuals, even with improved clinical symptoms and a fever-free status.
What the new guidance reflects is that COVID-19, with the wealth of tools that were created to combat it, cannot be singled out from the pack of respiratory viruses (most of which we have zero countermeasures for) for special treatment in perpetuity.
When our ancestors chose to live among each other in cities and villages, it brought many advantages, but there was also the tradeoff of flourishing communicable diseases, as population density and attendant social interactions increased. Among these communicable diseases were respiratory virus infections, which I believe people implicitly consent to when they live among and interact with each other.
While certain respiratory viruses are above that consent threshold -- and COVID-19 was above that threshold for some time -- many are not. COVID no longer is. What that means is that it will remain important for those at high risk for severe COVID, severe RSV, and severe influenza -- or anyone who really wants to avoid infection – to keep in mind that these viruses are ever-present where there are people. They must also remember that humans have the tools to minimize their impact via masks, tests, vaccines, and antivirals; these are readily available if an individual's risk calculation favors employing them. COVID-19 hospitalizations and deaths are preventable with prompt antiviral use coupled with high-risk individuals staying up-to-date on vaccination.
COVID-19 guidance has long needed to embrace the paradigm of harm reduction as it does for sexually transmitted infections, injection drug use, and many other endeavors humans choose to engage in that have a non-zero risk. COVID-19 was always destined to be an endemic respiratory virus for which repeated infection would become a fact of life for humans. This is not capitulation but an embracing of the biology of the virus. Abstinence-only guidance -- as reflected by current guidelines that do not reflect the almost science fiction-like progress made against COVID-19 -- no longer has any place.
is a senior scholar at the Johns Hopkins Center for Health Security, and a practicing infectious disease, critical care, and emergency physician in Pittsburgh.
Disclosures
Adalja is currently a consultant, speaker, and/or advisory board member for GSK, Shionogi, and BD.