The new CDC "No Quarantine" recommendations: Do they increase your risk? (Spoiler: Yes)

Recently, the Centers for Disease Control and Prevention (CDC) revised its COVID-19 recommendations to eliminate the quarantine for infected people. Previously this had been reduced from 10 to 5 days. It is now not recommended at all, although masking for 5-10 days is still recommended after being infected, and there are suggestions -- “strategies that people may want to consider in order to reduce their risk” – such as avoiding crowded areas and maintaining a distance from others.

‘“We know that Covid-19 is here to stay,” Greta Massetti, a C.D.C. epidemiologist, said at a news briefing on Thursday,’ which about sums up their perspective. It is apparently their justification for the (lack of) safety recommendations and precautions. The author of the article notes that the loosening of the guidelines free ‘schools and businesses from the onus of requiring unvaccinated people exposed to the virus to quarantine at home.’

As far as that author (Emily Anthes) and the editors are concerned, there seems to be universal approval of this change from the medical and epidemiologic community, at least based upon those that are quoted in the article:

‘“I think they are attempting to meet up with the reality that everyone in the public is pretty much done with this pandemic,” said Michael T. Osterholm, an infectious disease expert at the University of Minnesota’; 

‘“I think this a welcome change,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “It actually shows how far we’ve come”’ ;

‘“This really will help to minimize the impact of Covid-19 on education,” said Christina Ramirez, a biostatistician at the University of California, Los Angeles.’

One commentator, ‘Mercedes Carnethon, an epidemiologist at the Northwestern University Feinberg School of Medicine, said that she did not view the changes, even the elimination of quarantines in favor of 10 days of masking, as a loosening of the agency’s guidance.’

Dr. Carnethon continues ‘“We certainly know that wearing a high-quality mask is going to provide some of the strongest protection against spreading it to somebody else, and quarantine is logistically burdensome. That could be seen as a relaxing of guidelines, but I think it’s a much more appropriate and targeted solution.” Except, of course, that the CDC is not recommending that we mask in public areas. Whoops.

Ross Douthat, NY Times Op-Ed columnist, writes (Aug 13, 2022) that “The CDC continues to lead from behind”. His take is essentially that “everyone” has already been doing (or not doing) the things that the CDC is now recommending (or not recommending). I would agree that that is true (at least in the US), but to me it suggests that the recommendations are driven politically, not by “the science”.  Certainly it has been “an onus” for schools and businesses to comply with the recommendations (often conflicting) from different governmental agencies and others to protect their students, staffs, and customers. People do not like having to wear a mask in public, even in crowded indoor spaces, nor having to distance, nor staying home and quarantining and missing school or work. Or, even missing social interactions, from casual to parties. If CDC is “leading from behind”, making recommendations that much of the population has already been implementing, then this new step will encourage those who have already been doing so to further relax their carefulness. They may do so from a desire to get an education, make a living, interact with family and friends, or to party and use drugs or have wild sex, but these are, essentially, quantitative and not qualitative, differences. The fact that the article in the Times could not (or at least did not) find any countervailing views from epidemiologists, scientists, physicians, and other experts further endorses the “opening up” that people want. It is political in that having restrictive requirements is generally unpopular and could lose votes for politicians.

The only problem, of course, is that COVID is still out there and we are still at risk. What we are at risk for varies a lot, depending upon who we are, from “mild” illness (usually not so mild!) to severe illness to hospitalization, to death. The people who are most at risk are those who are immune compromised, either because of age, or illness, or (my favorite) the drugs that they are taking to treat illness, including the drugs widely advertised on television for cancer and rheumatic diseases. Plus anyone, of any age or prior health status, can get “long COVID”, with persisting symptoms that can be very severe and debilitating.

The World Health Organization observes that “7.9 billion people” (the world’s population) are still at risk for COVID, and that thousands are still dying every week. This poster makes those points, and also that new variants continue to emerge and can quickly become dominant. It also recommends things like keeping your distance and wearing a mask, abandoned by most Americans.

 

Of course, the risk of COVID also varies from country to country, which could justify why WHO and CDC have different recommendations. After all, in some countries there is greater risk than in others, and the struggle is just to keep their people alive. This might be reassuring to Americans if it were not for the fact that the US is one of those, remaining the leader in deaths.

(https://ourworldindata.org/coronavirus)

 

One of the key determinants of how a society functions is the balance between the rights of an individual to do what they want and the benefit to and protection of society. In the US, we have always tended toward the individual, but public health laws, regulations, rules, and recommendations are based upon the benefit to society. This makes sense because infectious diseases do not limit themselves to only those people who have consciously and willingly made the decision to take the risk of acquiring them. They also affect those who, absent governmental requirements to protect them, are forced to come to work and risk being infected or lose their livelihood, and those who are old or sick but come into contact (even in families) with those who have acquired infection because protecting themselves was just too much trouble.

The logic is flawed; what if laws against killing and stealing were made recommendations to be adopted by those who wished to be cautious? It would not just affect those who made the decision to not adopt them. Sure, we have people killing and stealing and being killed and being robbed despite the laws against it, but those laws protect us far more than a general recommendation that folks not kill or steal would. So too it is with the virus; if you go shopping and few others are wearing a mask despite rules or recommendations that they do, you are at risk. If those rules are repealed and the recommendations rescinded, then more and more people will think they are safe not doing so.

Vaccines are good and protect a lot. They do not by any means eliminate the danger. The changes in recommendations mean the politicians to whom CDC answers will be more popular, and be more likely to get re-elected.

And that more people will die.

Where has all the caution gone? COVID infection is still common!

Most infections diseases in people get passed from one person to another, although sometimes animals and insects are the vectors. More rarely (as in the case of COVID-19) an ‘enzootic’ infection (one that resides in animals) can ‘make the jump’ to people, although after that the transmission continues to be primarily person-to-person. If there is an outbreak of an infection it can spread rapidly among ‘susceptibles’ (people who do not have immunity through either prior exposure to the infection or from vaccination against it), particularly in crowded conditions.

Many of us are aware of this from our children. In winter, young children in school and day-care bring home infections that can make them sick and often infect other members of the family. Luckily, most of these are minor and transient (the ‘common cold’), but in the past included many serious and potentially fatal diseases such as polio, measles, mumps, whooping cough, rubella, diphtheria, Hemophilus influenza, chickenpox, and others. The frequency of these diseases has gone down dramatically as a result of vaccines that have been incredibly effective. Outbreaks still occur in places and populations where an insufficient percent of the children have been vaccinated to result in ‘herd immunity’. In the US, this is, sadly, most common not in communities which do not have access to vaccinations, but in which large numbers of people have, for whatever their reasons, chosen to forego vaccination for their children.

 

Dave Caverly, Speedbumps

 

The way that outbreaks of any infectious disease, from colds to influenza to chickenpox to sexually-acquired infections to COVID-19, occurs depends upon the route through which that organism is transmitted – sometimes by respiratory droplets (cold, COVID, pneumonic plague, polio), sometimes through fecal-oral contamination (think young children), sometimes through sexual contact involving exposure to blood or other body fluids, sometimes by more than one of these. Respiratory transmission is particularly great in crowded indoor environments, such as schools, concerts, restaurants, clubs, and family gatherings. And gyms, where people working out are breathing heavily. And singing (such as the karaoke sessions enjoyed by the NY State judges before many came down with COVID). Sexual transmission is, of course, less likely to be incidental and requires close and often prolonged contact.

But there is a similarity. This is that we are at risk for exposure not only from symptomatic individuals with whom we have contact, but often from those who are not, or not yet, symptomatic but who have been infected by someone else. In the case of sexually acquired infections, the idea that when you have sex with someone you are not only having sex with them, but potentially anyone else they have had sex with, or the people those people had sex with. Monogamy, is of course, protective, provided, of course, that it is actually practiced. It does not necessarily take many outside episodes to introduce an infectious disease.

In the case of COVID, we are not talking about sex, but about high-risk exposures. And also about what we assume should have been low-risk exposures but were to people who themselves may have taken greater risks. You may be pretty careful, not go out much, wear your mask if you are indoors with groups of people that you do not know, but be less careful if you are with close family members, especially those in your home. But just as a child can bring home a cold from daycare, or a sexual partner can bring home an STI from a relationship that you did not know they had, a family member can bring home COVID from a concert, club, restaurant, airport, social gathering, or other event in which others, who you (and maybe they) do not know were infected, unvaccinated, unmasked. If you happen to be more vulnerable: older, sicker, immunocompromised, and especially (because this is usually fixable) unvaccinated, the outcome can be not just infection but hospitalization and even death.

Minority communities have higher rates of all of these problems – infection, hospitalization, and death. Some of this can be tied to greater prevalence of chronic disease, some could possibly be lower rates of vaccination, and much may be related to having a higher rate of low-income and jobs that require actual presence and cannot be done from home by ‘Zooming it in’. It can also be true that poorer families may be more likely to have multiple generations living in the home, with various sources of infection (school, work, social activities) increasing the likelihood of COVID being brought into the home and infecting family members who are more at-risk.

Most of us want to see and interact with our family members. But if those family members have contracted infection, whether by “choice” (adopting higher-risk behaviors, not wearing masks, especially not being vaccinated) or by bad luck despite taking precautions, seeing them puts us at greater risk. Some of that risk may be unavoidable, but some can definitely be mitigated. COVID is NOT gone, but people are taking more and more risks, including me. I returned from a trip to Europe a few days ago, and while I wore an N-95 mask on the plane and in the airports, it was risky (the line for passport check in the Madrid airport crowded despite ironic signs on the floor asking people to maintain a 2-meter distance, between which were many people, was surely a potential super-spreader event). But I seem to be one of the few people worried about it. In the gym, no one else is wearing a mask, even as they huff and puff on machines which definitely increases the likelihood of spread, and I take no reassurance from their carefully wiping them down, since this is not really how COVID is spread. The front desk has even taken down the plastic barrier that has long been in place.

If all this were occurring because the rate of infections, and thus hospitalization and death, were down, this could be a good sign. Unfortunately, it is not. A recent headline in my local paper, the Arizona Star, on June 3, 2022 is “AZ COVID numbers continue to rise”, and daily published an update on number of cases. Yes, vaccination has definitely reduced the rate of hospitalization and death among those who have been infected, but the greater the number of infections the greater the risk of those really bad outcomes.

Death is now less likely, at least among the vaccinated. Be vaccinated. But COVID is still there, and in many places cases are increasing. Continue to exercise caution, and try to not take unnecessary risks.

 

Jane Brody, Dietary fat and carbohydrate, Vitamin D and really assessing the evidence

I admit that, as I write this, it is hard to think of anything else as important when Vladimir Putin has invaded Ukraine in an action that, in addition to its obvious direct impact on that country, had led to as great a threat to nuclear war and human extinction as we have seen in two generations. That a deranged power-mad autocrat can do this is even more terrifying when we look at the number of psycho autocrats that have gained power in the world, including recently (and hopefully not in the future) in the US. But I am not going to write about it, for three reasons:

--It is not the topic of this blog, which is Medicine and Social Justice

--There remain a lot of things that urgently need discussion in regard to American healthcare, mired as it is not only in the evils of for-profit capitalism but incredible inefficiency and incompetence, and

--These issues actually matter on a day-to-day, week-to-week, year-to-year basis for the American people.

First, I will start a good thing, or at least a mixed one. The less-good part is that Jane Brody, the health columnist in the New York Times, has written her last column. The good part is lauding her for the incredible contributions she has made to our understanding of the issues of our health over the decades (since 1976) that she has been writing it. We all have (or should have) learned much from her, about diet, and exercise, and dealing with illness and even death. In her last column she points out some areas where her advice has been incorrect, based on the science of the time, when new evidence has disproven it. I believe that an ability to acknowledge that you were wrong, whether because (as usually true for her) the scientific knowledge has changed, or because you wanted to believe something and so were previously unwilling to actually examine the evidence adequately. A particular area of health that she has been associated with is diet (she has written several cookbooks), and this is the area in which her admission of error is most incomplete and thus disappointing. While she notes that ‘One of the most significant shifts has concerned dietary fats,’ her emphasis is on how the recommendations in the ‘70s to shift away from animal fats missed the dangers of vegetable-based trans fats. She cautiously says ‘But time will tell whether specific dietary fats, or the much vaunted Mediterranean diet currently embraced by many doctors, will fall prey to future findings.’ 

But that’s it. There is no mention whatever of the problems with carbohydrates in the diet, particularly simple carbohydrates like sugars, on people’s health. This is a major lapse. Without getting into a discussion about the benefits of a very-low-overall carbohydrate diet (e.g., Atkins, paleo, etc.), there can be no question that large amounts of sugar (and possibly even small amounts of sugar) in the diet is deleterious, non-nutritious, and causes not only obesity but a great many other health problems, and that no reasonable diet today can fail to feature this fact. Moreover, it completely avoids the evidence that the campaign against dietary fat, carried on by organizations such as the American Dietetic Association (now the Academy of Dietetic and Nutrition, AND) and many others, for decades was funded by the sugar industry and the manufacturers of high-sugar foods such as soda pop (addressed in several blog posts, including Gangster capitalism and our health: In the US and in the World Jan1, 2019, The AAFP, Coca-Cola, and Ethics: Serving the public interest? Aug 20, 2010, and others). The lack of any mention of this in Ms. Brody’s column is concerning; does she still believe that fat is a bigger dietary problem that sugar? This is not an academic question; go to your grocery store and look at the labels on “low fat” or “fat free” products and see what is in them. My personal favorite is “fat-free half-and-half”, which is almost an oxymoron because fat is the basis of half-and-half: half whole milk (4% fat) and half cream (about 20%) for a total of about 12%. How can half-and-half be fat free? Read the label! It is full of sugars. Indeed, almost all foods with such labels are high in calories an high in carbohydrates, especially sugar (commonly in the form of ‘high-fructose corn syrup’).

Another undying health claim, promoted by some doctors and many non-medical professionals and non-scientists for several decades is vitamin D (not an issue which Ms. Brody, in this final column, addresses). Fifteen years ago, endocrinologists were promoting vitamin D deficiency as a major endemic problem, claiming deficiency at blood levels then (and now) considered normal. While most have backed away from the idea that it is a panacea, some have not and fed an ongoing commitment to taking more of this vitamin, an idea that flourishes on, of course, the Internet. With the onset of the COVID-19 pandemic, enthusiasts have found this to be the newest “indication” for it (Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems, Jan 28, 2021). In an excellent – and brief and easy to read --Commentary on Medscape® (Feb 17, 2022), John Mandrola asks ‘Why Is Vitamin D Hype So Impervious to Evidence?’. His emphasis is on critical appraisal of the scientific research, on the quality, breadth, and significance of the studies done. He emphasizes that there are many, many randomized controlled trials that do not show that taking Vitamin D decreases the risk of any condition (other than true vitamin D deficiency, which occurs at quite low levels.) Among the many important points he makes is that association (many people with chronic disease have lower vitamin D levels) does not show causation (it was the low vitamin D levels that caused the disease), because often ill-health causes the lower levels, and still less that administration of vitamin D will cure it. Indeed, he discusses the many large, well-designed studies that prove that it does not.

So why is this issue so impervious to evidence? The answer, it appears, is rooted more in psychology than science, in how people choose to believe what they believe and seek out evidence that supports it (if, indeed, they seek evidence at all). There are always experts who espouse their (and almost any) position. Even when they are a small minority, there are 330 million Americans and 8 billion people in the world, so a small minority can be a lot of people. Almost all people (scientists are a very small minority) do not have the training or the skill to read and assess the scientific literature, and it is uncommon that they even try. Instead, they seek (or have sent to them) articles by people that seem to be reputable that support their position. Mandrola focuses also on how even scientific papers engage in “spin”, pointing out how often they emphasize minor, secondary, and non-significant results even when the main point that they were trying to prove (that vitamin D cures or prevents something) is not shown by their research. Indeed, such minor things are pounced on by a public that wants to see what isn’t there; he gives this example:

the authors of the VITAL trial, which found that vitamin D supplements had no effect on the primary endpoint of invasive cancer or cardiovascular disease, published a secondary analysis of the trial looking at a different endpoint: a composite incidence of metastatic and fatal invasive total cancer. They reported a 0.4% lower rate for the vitamin D group, a difference that barely made statistical significance at a P value of .04. 

But everyone [he says; I think he means physicians and scientists] knows the dangers of reanalyzing data with a new endpoint after you have seen the data. What's more, even if this were a reasonable post hoc analysis, the results are neither clinically meaningful nor statistically robust.  Yet the fatally flawed paper has been viewed 60,000 times and picked up by 48 news outlets. [emphasis mine].

Think about that. It is not what is proven to be true that gets the most coverage, it is what is most provocative. And clearly, this is not just about vitamin D. COVID and the COVID vaccines are common and prevalent examples of people choosing to believe something and then picking and choosing research that supports it; they even call this “doing their own research”. Some of this is the result of religious-like devotion to a position or point of view, some is purposely malicious, some is conspiracy theory, and some is honestly being overwhelmed by data that they do not understand. But it sure can be very dangerous. You deciding that COVID is not a risk anymore (if ever) and you don’t need to be vaccinated and don’t need to wear a mask is dangerous to me!

If over 95% of climate scientists agree that human activity, especially the burning of fossil fuels, is the cause of global warming, but many people do not believe it, why would we think the kinds of foods we eat, the benefits (or not) of taking high doses of a vitamin, the risk of a pandemic virus, the benefit of vaccination, would not be controversial? I would like to agree with Dr. Mandrola that there is hope, but I am sometimes not sure.

In the meantime, get vaccinated, eat very little sugar, and do not overdose on vitamin D, which can absolutely happen.