Omicron, Masking, Vaccination, and the Shifting CDC Guidance

Omicron is much more contagious.

Are you confused about the Centers for Disease Control and Prevention’s (CDC’s) ever-changing guidance on COVID-19?

If so, it is not necessarily because they keep altering their recommendations. It’s not because the science is hedging. It’s not even because some nefarious capitalist is demanding reduced isolation time to get their workers back on the assembly lines, or the CDC is yielding to testing component shortages.

The reason the recommendations don’t seem to make sense to a lot of people is fundamental: people were/are not cooperating with the things we know work. If they did, everyone would be vaccinated and would be wearing masks out in public, and we would be in a completely different place.

Let’s review.

Since the beginning of the pandemic, we were informed that asymptomatic people can transmit the virus. Everyone was instructed to wear a well-fitting mask over their nose and mouth and to stay at least six feet away from others. The virus is spread through aerosol and droplets; contain them, and you decrease contagion.

They always told us that the purpose of the vaccine was to decrease or eliminate severe disease, hospitalization, and death; we were always cautioned that being vaccinated didn’t completely protect us from contracting the virus, nor did it prevent vaccinated people from being able to transmit it. That was disappointing, but predicted. We always knew the vaccines were not 100-percent effective. We expected that we would need booster doses.

At the start of the pandemic, we were asked to take mitigation measures – wear a mask, socially distance, frequently wash hands, employ good ventilation. There were regional lockdowns. Those mitigation activities were never intended to expunge the coronavirus from our population. They were meant to keep the virus and disease in check long enough to allow the healthcare system to handle the volume. When a safe, effective vaccine became available, everyone was implored to roll up their sleeves and get the shot, for the sake of ourselves, the young, the immunocompromised, and the medically vulnerable.

We didn’t do what needed to be done.

We were warned that allowing the virus to rage on unimpeded would result in mutations. And it did. First delta arrived, with its wave of deaths, stressing the healthcare system, and now omicron is here, delivering a death blow to our hospitals.

Omicron is much more contagious, and it evades vaccine protection much more than Delta did. Granted, most people who are vaccinated and boosted experience Omicron as mild symptoms. But by sheer numbers, even some vaccinated, boosted, mask-compliant people are contracting omicron and experiencing more than a mild cold. Even though the very sick and dying are overwhelmingly not vaccinated, vaccinated, boosted folks are at risk, too. We also don’t know what the incidence of long-haul COVID from omicron is going to be; long-haul COVID has implications we don’t even understand yet. And another concern is that caregivers and essential workers are being infected and being taken offline for long chunks of time.

Ohio is getting its butt kicked. Last week my husband, who works at the Cleveland Clinic, informed me that 1 in 75 patients admitted in the United States for COVID-19 was in a Cleveland Clinic facility. On that day, there were 1,300 hospitalized patients (plus 200 more in the Florida facility) and 3,200 caregivers out on sick leave. Almost half the patients in the hospital on the floor and in the ICU are COVID-19 patients. Are some of those incidental cases? Yes, some patients are admitted for something else, but test positive. So what? They can still be vectors to give it to someone else. The Clinic statistics show an average of 300 new caregiver cases per day, and some of them are probably being exposed via their incidentally infected patients. There are also numerous patients whose care for non-COVID-related conditions is being delayed. Elective surgeries are being postponed, and there is widespread avoidance of the emergency department for fear of long waits and COVID-19 exposure.

The most recent data on COVID-19 and the omicron variant (which constitutes 95 percent of COVID-19 cases, currently) is that the majority of viral transmission occurs in the 1-2 days prior to symptom onset and 2-3 days after. If you can transmit the virus before you know you have it, THAT is why routine mask wearing is/was recommended. Once you test positive, the recommendation is to isolate for five days, and then if you are asymptomatic or improving, you can go out with a mask on for the next five days.

Quarantining (for known or suspected exposure) is staying at home, away from other people not in your bubble. Isolation (for a known infection) is staying at home in a specific area away from other noninfected inhabitants and using a separate bathroom, if possible.

If you have been exposed and are vaccinated, as much as you can, according to the time frame (e.g., if you were boosted or are still within six months of an mRNA vaccine/two months of the J&J vaccine), you should wear a mask for 10 days and test on Day 5 – or if you develop symptoms (if possible. Tests are not so easy to find in some locales.). If you are exposed and are unvaccinated or not boosted in the recommended time frame, you should quarantine for five days and then wear a mask for the next five days.

What about requiring a negative test prior to being let out of isolation? There is a pretty significant false negative rate. They are marketing antigen tests two in a box. The intention is that if someone suspects they have had a close contact, they are supposed to take the test twice, 24-36 hours apart, if the first result is negative, to make sure they have the opportunity to test positive if they really have the disease. PCR tests can be positive for three months after a COVID-19 infection, but individuals fitting this description are considered non-infectious. If they can’t transmit the infection, who cares if their test is still resulting in a positive?

My opinion is that testing is somewhat helpful, but not the savior nor the villain that some in the media are making it. Since the prevalence of the virus is so high, a positive test predicts the presence of the disease. A negative test is not as useful to me. I still act as though I may have and be capable of spreading the virus, even when I have tested negative. A test samples a moment in time; it is not absolute or enduring. The horse that was testing and contact tracing has long ago left the barn.

Omicron is ubiquitous. At this very moment, my niece in Vermont has it, and my brother-in-law in Michigan and my niece in Missouri just got over it. I bet every single one of you knows someone who has it currently.

It is inevitable that our world has to loosen up. At some point, we are just going to have to accept the risk of going to the gym or theater or store or museum or airplane as being a potential venue for contact and just get on with our lives.

If everyone were to get vaccinated/boosted, the necessary five-day quarantine after exposure would be eliminated. That would mark probably millions of work-hours saved. It might alleviate some of the understaffing issues we are experiencing at restaurants, stores, and medical facilities. Interestingly enough, the CDC guidelines are different for healthcare workers under routine, contingency (shortage), and crisis circumstances. Under crisis conditions, they throw quarantine and isolation out the window. If a healthcare provider needs to work and can work, there are no work restrictions.

The solution would be simple if people would just do the right thing. Don’t make the government have to mandate it; just do it because it is the right thing to do. Wear a mask over your nose and mouth to prevent transmitting COVID to someone else. Wear an N95/KN95 mask to try to prevent yourself from contracting it. Get vaccinated. Get boosted at the recommended intervals. I predict we will need additional boosters; the protection seems to wane, and they may have omicron-specific antigens/mRNA included in the future. We need the rest of the world to get vaccinated as well.

COVID-19 is going to become endemic, and we are going to have to learn to live with it and the variants to come. We are not going to be as lucky with the healthcare provider and hospital staffing shortages that will ensue. I predict that there are dedicated medical folks who are going to exit the healthcare arena in droves when there is a moment to reflect and breathe. People complain about not being able to get an appointment with a dermatologist, otolaryngologist, or gastroenterologist now, but just you wait! It won’t stop at the clinicians, either. This pandemic is going to have staffing repercussions we can’t even anticipate.

All for the lack of a mask, a vaccine, and the will to be a good citizen.

Programming Note:

Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck Tuesdays at 10 Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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