Since most kids have already returned to school for the fall 2021-22 academic year and the highly infectious Delta variant is now dominant in the Bay Area and beyond, I have pulled together our guidance regarding whether and how long to isolate or quarantine, which are actually two different things.
My goal is to simplify the confusing, sometimes misleading and frequently changing directives and reports related to COVID exposure, illness and isolation/quarantine which will undoubtedly be useful during the ensuing weeks/months. And, because of the dynamic nature of this pandemic and the public health recommendations therein, these guidelines are subject to change. Don’t miss the important information below regarding what to do if you/your children are COVID-exposed.
By now you all know the Delta variant is significantly more transmissible than earlier COVID variants. Those who become infected, symptomatic or not, and vaccinated or not, can have viral loads from Delta which are up to 1,000 times higher in noses and throats compared to the original form of the virus (from early 2020). Because of this, we likely all know some vaccinated individuals who have had “breakthrough” infections. Most infectious disease experts now believe that vaccinated individuals can spread COVID to others, though their ability to shed and spread virus is likely shortened compared to the unvaccinated, and the risk of severe illness, hospitalization and death remains far lower than in the unvaccinated.
I believe therefore that the prudent thing to do is to take precautions including wearing masks 100% indoors and even outdoors when among crowds (say at a farmer’s market, a sports game, or in a busy park setting). Per Dr. Bob Wachter, Chair of the Department of Medicine at the University of California, San Francisco, double masking is now the rule he has adopted for going to the grocery store, and he no longer eats indoors at restaurants. “The right way to approach this is as if it were a new virus and question all your assumptions” he stated. For what it’s worth, when I do visit my favorite restaurants I only eat outdoors, and I prefer to use Instacart to deliver my groceries — simply to decrease the number of exposure risks.
I’m hopeful that with proper ventilation and HEPA filtration at our schools, well fitting masks, and vaccinated teachers (and other staff) working at schools, the return to in person education will be successful, as we all know how vital this is. According to Eric Topol, MD this combination of measures has the power to decrease viral aerosols in schools more than 30-fold. This likely contributed to the California Department of Public Health (CDPH) modified guidelines for children in school. See discussion below.**
For those of you wondering when emergency use authorization (EUA) for kids under 12 years may occur, I believe we could see EUA by the end of October 2021 for those 5 to 11 years of age. Also, the FDA just announced (08/23/21) its full approval of the Pfizer vaccine. I also expect that official FDA approval for the Moderna vaccine will quickly follow.
Fortunately, just as with prior variants, Delta does seem to largely spare children from serious illness: 1% of children infected end up hospitalized and there is a 0.01% mortality rate. Most kids who become infected recover in less than a week. While it’s too soon to know about long COVID in the pediatric population post Delta, in general rates of “long haul” have been reported as lower than in adults: 2-15% is the range I’ve seen.
Well established risk factors for COVID include low vitamin D3, so as fall/winter approach, make sure to supplement. I still stand behind nasal washes as a low tech intervention/preventive that could decrease viral load (which correlates with disease severity and mortality) and help keep us all healthy. As a reminder, here are my recommendations for nasal washes and staying fortified during this COVID time.
IMPORTANT INFORMATION ABOUT COVID EXPOSURES AND COVID TESTING
GENERAL
Any child or adult with symptoms (cough, runny nose, vomiting/diarrhea, headache, fever, loss of taste/smell, fatigue) with/without exposure to COVID and regardless of vaccination status needs to isolate at home until the results of COVID testing are known and advice has been given or action taken re: those results.
Any unvaccinated child/adult without symptoms but with a known direct exposure to COVID outside of school/daycare needs to immediately quarantine at home and call us (or your doctor). In this scenario, testing will be necessary and PCR testing should be done no earlier than 5-7 days after the last exposure, with the day of exposure = day 0. Testing too early post exposure has a higher likelihood of resulting in a false negative. Rapid antigen testing is not appropriate in all cases for asymptomatic individuals as the false negative rates are often too high to be useful. Rapid antigen testing, however, may be used in certain group settings like schools and nursing homes, per public health guidelines.
For fully vaccinated people with a close COVID-positive contact it is recommended to be tested at 3-5 days FOLLOWING the known COVID exposure. For the unvaccinated, testing is recommended on day 5-7.
Unvaccinated school age kids who are COVID exposed or infected while masked at school may be subject to modified guidelines. [See below for more detail.**]
SYMPTOMATIC PATIENT WITH NEGATIVE PCR TEST RESULTS AND NO KNOWN COVID EXPOSURE
- Return to school, daycare, work, group activities, etc. after symptoms have improved and patient is fever-free for at least 24 hours (without the use of ibuprofen or acetaminophen). This assumes the PCR test was properly administered by a third party technician or medical professional.
EXPOSURE TO COVID AND NOT VACCINATED
- Home quarantine is necessary for unvaccinated individuals after a known exposure to COVID. Person must stay home until symptom free for 10 days after last exposure OR no symptoms for 7 days after last exposure AND tested negative at least 5 days after last exposure. [See the modified quarantine alternative guidelines below for kids who have been exposed while masked in school.**]
- If the unvaccinated individual develops symptoms (e.g., cough, fever, fatigue, muscle aches, headaches, loss of smell or taste, vomiting/diarrhea) at any time within a 14 days window post exposure, please contact us or a doctor to arrange repeat testing (even if a negative test result was already obtained earlier in these 14 days). If the test is negative, a 14 day quarantine will need to be observed (after the last exposure). If the test is positive, all of the following need to be satisfied before leaving home isolation:
- 10 days have passed since symptom(s) started, and
- No fever has developed in the last 24 hours, without taking medicine for fever, and
- Symptoms are getting better. Loss of taste or smell can last for weeks to months so if that isn’t improving but other symptoms are, it’s OK to end the isolation.
EXPOSURE TO COVID AND VACCINATED
- Fully vaccinated people are not required to quarantine at home after a known COVID exposure. They need to mask carefully and consistently for 14 days. Because symptoms could begin within a 2 week period, it is recommended to watch for symptoms and if they develop in that window, get tested again. In this case, if the results are positive, all of the following need to be satisfied before leaving home isolation:
- 10 days have passed since your symptom(s) started, and
- No fever has developed in the last 24 hours, without taking medicine for fever, and
- Symptoms are getting better. Loss of taste or smell can last for weeks to months so if that isn’t improving but other symptoms are, it’s OK to end the isolation.
**MODIFIED QUARANTINE ALTERNATIVE (AS RECOMMENDED BY THE CDPH):
- Unvaccinated students who are exposed while masked (both parties) at school and are asymptomatic, are allowed to continue in the classroom but must test twice weekly and abstain from ALL extracurricular activities including sports. This modified standard can be considered in circumstances where parents desire to have their child continue in the classroom, but ONLY if they are asymptomatic. Masking MUST continue and they MUST undergo at least twice weekly testing during the 10 day modified quarantine.
- If a student in the modified quarantine develops symptoms or tests positive, they must isolate per the above.
- The child must otherwise stay home, i.e. they may not engage in activities outside the home, except school.
- The new guidelines also apply to teachers and school staff.
WITH ANY KNOWN EXPOSURE OR COVID POSITIVE FAMILY MEMBER, ALL HOUSEHOLD CONTACTS SHOULD DO THEIR BEST TO MASK AT HOME AND BEGIN NASAL WASHES IMMEDIATELY (WITH XYLITOL NASAL SPRAY, BRIOTECH OR AN IODINE SOLUTION) IN AN EFFORT TO DECREASE/MINIMIZE VIRAL LOAD.