Keeping kids with contagious Covid home helps communities. We still need to support parents to make that possible.
My four-year-old daughter got Covid-19 last month. After avoiding it for two-and-a-half years, and a few days shy of receiving her 2nd dose of the Moderna vaccine, her number came up. She felt fairly crummy for several days and then bounced back. By day 4 and 5, she was asymptomatic.
Could we have ended her isolation on day 5? Maybe yes, maybe no. Current CDC guidelines offer two options. For those without adequate access to at-home rapid tests, the guidelines state that a then-asymptomatic person could have returned to normal activities after day 5, wearing a mask until day 10. For those with access to enough at-home tests, the guidelines state that she should have stayed home until she tested negative on her at-home rapid tests (as these tests are good proxies for contagiousness).
We chose—we had the privilege and resources—the second option. That meant keeping our daughter and ourselves home through day 8 (four very long extra days), when she finally tested negative. Now, it’s important to recognize that in order to make this choice, both my spouse and I had to have the ability to stay home with our infected daughter and her baby sister (that was the only way we could safely keep them apart). We also had to have an adequate number of tests, both to test our daughter and ourselves frequently. For everyone to be able to choose the CDC’s “test to exit” isolation strategy option, there would need to be policies that guarantee paid sick leave for caregivers (or adult Covid-19 patients) and more free tests than are currently offered by the federal government.
After doing the math, it’s clear that the CDC’s “test to exit” strategy (i.e., isolating until testing negative on at-home rapid tests) is currently the better of its two isolation policies, on a societal level. While keeping our daughter and ourselves home four extra days was painful, there was actually a net benefit to our community. Let’s go through why.
Imagine we had not tested our infected child after day 5 and allowed her to return to in-person indoor activities at that point. Even with masking, she quite possibly would have spread the virus to at least one other person (masks help but are imperfect, especially since kids her age don’t wear N95 masks). Leaving aside any physical harm this could have caused the next person, if she had spread Covid to another pre-schooler, the disruption caused to that child’s family would have been, to us, regrettable.
By keeping our child home for 4 more days until her rapid test was negative, we added 12 “person-days” of at-home time to our experience with Covid. In other words, to eliminate the chance of her spreading the virus to others outside of our home later in her illness, 3 of us had to isolate for 4 more days (3 people x 4 days=12 person-days); I’m not counting the infant in my math here). Now, if we had not done this and she had spread Covid-19 to a classmate, a family resembling ours with a parallel experience to ours would’ve been cost at least 15 person-days (i.e., 3 people x 5 days, if they used the no-test option) and maybe 24 person-days or more (i.e., 3 people x 8 days, if they used the “test to exit” option) of isolation/at-home childcare. So, by choosing the CDC’s “test to exit” option, the 3 of us collectively isolated or stayed home for 12 extra person-days, for a total of 24 person-days at home.
But those additional 12 person-days at home saved just one other family at least 15 person-days at home, and perhaps many more. (If our daughter had spread Covid to more than one person, the at-home days we “caused” others would have really started piling up.) Indeed, in the absence of enough tests, we would have followed the CDC’s alternate recommendation, and would have isolated/stayed home for a total of just 15 person-days (3 people x 5 days). However, we then would have cost the next infected family abiding by the same approach 15 person-days of this misery—and, again, that’s if our daughter spread it to just one other child. Under the CDC’s “no-test to exit” approach, our daughter’s infection would have cost two families (ours and the next) 30-person-days of isolation/at-home time (15+15) instead of 24 (24 for us, 0 for anyone else), assuming the next family also used the CDC’s no-test to exit strategy.
But what if our daughter had spread it to 2, 3, or, 4 kids (not unlikely given how contagious these variants are, even later in the infection)? By being able and willing to stay home longer, we helped our community. In the aggregate (assuming our daughter would have infected at least one other child if she went back to indoor activities while possibly still contagious during those last few days), by increasing our own at-home days, we decreased the total at-home days due to Covid in our community. That’s a good thing, but even that’s a best-case scenario. We very well could have contributed to the spread of disease to a child who might have experienced a worse outcome or spread it to a higher-risk relative far more likely to end up gravely ill.
It strikes me that if we had followed the CDC’s guidelines for people without access to tests, it would have made things worse for our community overall, albeit maybe a little less painful for ourselves by hastening a return to normal. But the CDC’s job is to think at the population level. And it’s the government’s job to ensure that people can afford to do the best thing (read: guaranteed paid sick leave for parents, for example). In my view, the current CDC guidance and public policies inadequately support parents and communities, leading both to more illness and more days of disruption. It would be one thing if the guidance balanced these concerns. But as long as the reproductive number of Covid-19 remains at or above 1 (meaning that the average infected person is expected to spread the virus to at least one other person) during the post-CDC-recommended isolation period, the current policy is poised to backfire on a systemic level, even through the lens of days of disruption, let alone in terms of improving public health.
New Covid quarantine and isolation guidance is expected to be released soon. But it’s anticipated that the CDC will not make changes that further help control the spread of Covid-19 in schools and other public places. I do think the time has come to sunset most quarantine guidelines (i.e., staying home after an exposure to a Covid-19-positive person). People are constantly and continuously exposed to the virus and its unreasonable to punish those who realize or are informed of this. Instead, people with high-risk exposures (e.g., an infection in the home) should test themselves daily for a certain number of days. (Again, we still need more tests.) But whenever we can feasibly keep contagious people out of circulation (i.e., isolation) for a few extra days, the net benefit to society remains clear. Until this virus truly is just another cold—and despite great leaps towards this, we are not there yet—it’s a mistake to act like it is.
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Special thanks to Dr. Rick Bright, Dr. Craig Spencer, and Dr. Kaveh Hoda for feedback.