The arrival of Omicron, the latest and most transmissible COVID-19 variant to date, underscores the tremendous need for updated COVID-19 policy in the U.S. We always knew it would be difficult to contain a highly transmissible respiratory virus before Omicron. The arrival of the Delta variant forced us to abandon our goal of “herd immunity.” With the arrival of Omicron, a more appropriate goal of protecting those at risk of severe breakthrough infections is now in order. A new framework in light of Omicron will help move us beyond the continuous cycle of removing and reinstating COVID restrictions based on metrics that are no longer clinically relevant.
Highly transmissible variants, such as Delta and Omicron, will lead to high numbers of asymptomatic or mild infections among the vaccinated. These breakthrough infections should not be considered “vaccine failures”. Instead, they should be recognized as the hallmark of highly effective vaccines that are operating precisely as intended—to prevent serious illness or death. Reassuringly, recent data shows that those who receive two doses of vaccine and were then infected were no more likely to report long COVID-19 symptoms than individuals without previous SARS-CoV-2 infection.
We must ensure that Americans understand this is a very different time than March 2020, especially in highly vaccinated regions. Instead, these very same regions are again closing schools. A strategy of examining who is at risk of severe breakthroughs and protecting that population at all costs will help us make this critical transition.
What strategies make sense at this stage of the pandemic?
This new strategy means using different metrics as the basis for COVID-19 restrictions. In a vaccinated population, the relationship between case counts and hospitalizations has been uncoupled. Because so many vaccinated individuals may test positive for COVID-19 with few or no symptoms, the number of infections in a community no longer predicts the number of hospitalizations or deaths. This uncoupling means that we should no longer focus on the number of COVID-19 infections as predictive of the need for lockdowns, physical distancing, or mask use. Instead, we could follow the path of Singapore which changed their metrics from cases to hospitalizations in September for both protecting the country’s population and to avoid unnecessary harm to the economy, which in turn, has a direct impact on health. A similar path was recently embraced in Marin County, California. If public health officials tie policies to hospitalizations, not cases, the media’s obsession with case counting will likely abate and help refocus attention on serious illness alone, as spelled out here. With this sharper focus, our time can be better spent on vaccinating the unvaccinated and boosting as soon as possible the most vulnerable, such as residents of nursing homes, persons over age 65, and those with chronic health issues. However, this new strategy highlights the need for the CDC to increase its tracking and reporting of severe breakthrough infections by the health status of individuals so that the most vulnerable can be rapidly identified and prioritized for life saving treatment, such as Paxlovid and other powerful antiviral therapies.
Retirement of Blanket Mask Mandates
Protecting those at risk of severe breakthroughs also means the end of blanket mask mandates. Our adult population has had access to highly effective vaccines for almost a year, and more recently, all children ages 5 and older became eligible for vaccination. Use of N95, KN95, KF94, FFP2, or even double masking, should be encouraged among select high-risk populations, but perpetual masking of entire populations is not sustainable or necessary. Our children, the demographic group at lowest risk of serious COVID-19 illness, continue to endure more hours of uninterrupted masking than higher risk adults. This strategy would mean making child masking optional at 12 weeks after the last school-age child became eligible for vaccination.
Rational Testing Policies
We need to retire the policy of school closures and the cancellation of school sporting events based on asymptomatic testing. While testing and quarantines may have been rationalized as reasonable strategies prior to the availability of vaccines, these disruptions can no longer be justified as having any direct impact on lowering the risk of life-threatening illness among the lives of those subject to the disruptions, namely students, athletes, or even spectators.
Although schools reopened in 2021, parents and students continue to suffer from educational loss and work disruption due to school testing policies and quarantines. The CDC has recently endorsed test to stay as a safe and reasonable policy for keeping kids in school and minimizing educational disruption. This policy should quickly become the norm until school-based testing is completely phased out. Similarly, testing protocols should be updated for all places of work, shortening the period of isolation following infection. Returning to work (or school) as soon as a rapid test is negative, reflecting when COVID-19 is no longer transmissible, is more appropriate than the outdated 7 day period (with a negative test) of isolation.
Nuanced Booster Policies and Spacing
This updated roadmap also includes modification of vaccination policies to better reflect our nuanced understanding of vaccine efficacy and population risk. Our widespread promotion of booster vaccination for all individuals over age 16 should ensure we target those most vulnerable to serious breakthrough infections first, which would include mass booster campaigns in nursing homes and among those in care for chronic diseases. The spacing out of vaccine doses in young men and careful attention to any adverse events from boosting men under age 30, should be put into practice without concern for decreasing vaccine uptake.
This new roadmap will also give recognition to natural immunity from prior infection when implementing vaccine mandates (such as recommending 1 dose after natural infection to boost immunity but minimize side effects). This policy would increase public trust, particularly among more vaccine hesitant communities, as a more accurate reflection of the evidence to date.
Finally, this new roadmap reframes our policy towards harm reduction, and away from zero COVID policies. Policies such as travel bans are ineffective in decreasing transmission and are fundamentally inequitable, punishing other countries for laudable practices such as data sharing. Getting Paxlovid authorized tells our unvaccinated we want to provide compassionate care to this group. And finally, promoting booster doses for young healthy adults over an equitable global distribution of vaccines is counterproductive for suppressing the emergence of variants and runs contrary to the notion the all humans are of equal value.
We encourage the Biden Administration to take a rational approach to the COVID-19 pandemic on the eve of 2022. President Biden said in his speech on December 21 that the administration will renew efforts to increase access to rapid testing and expand the surge capacity of hospitals in areas of low vaccination, both important and welcome commitments. In addition to meeting these immediate practical needs of the pandemic, we hope that the administration will recognize that it is time to reframe our approach, moving beyond case counts and community-based restrictions and revising policies specifically aimed at protecting vulnerable populations and assuring that our nation’s children will stay in school. We hope this new roadmap will allow a sensible, science-based approach to the next phase of our response.
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