By Carolyn Boscia, MD

I’m making morning rounds on the pediatric unit today: First up, 4-year-old twins with a severe asthma flare; next an infant with bronchiolitis on supplemental oxygen; then a dehydrated 3-year-old listless in bed. These children are all hospitalized with viral illness – but none of it is COVID-19. Meanwhile, their sniffling peers fill daycares and classrooms, and my daughter is among them. “Maybe it’s allergies,” I said to myself this morning as I ushered her past the unused COVID test on the kitchen counter.

A week cancelled is a big gamble for a kid who’s feeling fine. I feel a brief pang of mom guilt, along with clinical concern that decision-making around how to handle sick kids is being unduly influenced by the threat of quarantine, which is no longer serving anyone’s best interests.

Despite declaring the end of the COVID public health emergency, the CDC still recommends a minimum of 5 days isolation for COVID-positive individuals. This prescription has a huge trickle-down impact on our collective freedoms: to attend school, earn a living, and congregate with loved ones. It made sense during an emerging pandemic. But in the post-vaccine era, the threat of a COVID quarantine does more harm than good: It discourages testing, and creates a disregard for reasonable precautions around other viral illness.

COVID infection risk today looks very different than it did in 2020. Most cases are mild to moderate in severity, and those hospitalized are predominantly older and unimmunized or immunocompromised—the same people most vulnerable to the flu and other viral respiratory illnesses. Long COVID is concerning, but most Americans—97 percent—have protective COVID antibodies from prior infection or vaccination. ‘Hybrid immunity,’ drawn from a combination of vaccination and infection, appears to be stronger and longer-lasting than protection from vaccines alone. Fortunately, the case fatality rate of COVID-19 has deceased as it has moved from pandemic to endemic disease.

As infection risks have waned, the negative repercussions of quarantine have accumulated: time off work, job loss, and social disruption carry huge costs. For children, missed school and isolation raise mental health concerns. The CDC has done a good job of recognizing these side effects. But over time, the side effects have become primary problems. Quarantine interferes with many people’s ability to meet basic needs, preserve daily routines, and protect mental health, all core values of civic life.

After three years’ worth of constantly shifting risk-benefit calculations, families are suffering decision fatigue around how to handle viral illness. Many are no longer willing or able to prioritize a week of isolation above other important priorities. Many recognize that the costs outweigh the benefits. Without a general collective belief in the importance of quarantine for the common good, quarantining becomes an exercise in futility. If ten COVID-positive children all test and isolate, the virus may be contained. But if only two test and isolate, and the remaining eight go to school, COVID will spread the same as if nobody had isolated at all. Partial quarantine simply means missed learning and increased household strain for the two children who stayed home.

People intuitively sense the futility of patchy community-wide quarantine adherence; in this context, the only thing quarantine achieves is a weeklong logistical nightmare. This can be avoided by adopting a “don’t test, don’t tell” mentality. I am a pro-vaccine and COVID-conscious pediatrician. But if my daughter has a mild cold alongside many classmates, why test her for COVID and risk missing school and work while her classmates continue swapping germs? Her absence has no impact on the classroom petri dish, but a major impact on our family’s wellbeing.

Would I test her if there were no isolation requirements? Probably. I would keep her home a bit longer than for a “maybe-it’s-allergies” stuffy nose; I would notify any immunocompromised contacts and be better able to protect vulnerable community members; I would be better-informed when planning the timing of her booster shot. I might even test my healthy kids electively before socializing with particularly vulnerable or COVID-conscious people. But with a weeklong life-pause on the line, elective testing isn’t really a viable option. Paradoxically, the CDC’s continued restrictive approach here is increasing the number of COVID-positive (untested) people in school and in the community. And for those who do remain at elevated risk for severe disease, due to immunocompromise or other factors, isolation guidelines put forward an illusion of protection that doesn’t match the current epidemiology of COVID infection: It’s out there, much of it untested and undetected.

Moreover, the 5-day isolation recommendation singles out COVID as “the dangerous” virus, implying, to a weary public, a free pass for non-COVID viral illness. Single pink line? Tylenol, Motrin, backpack, lunchbox, out the door! When COVID isolation has exhausted all of a family’s reserves, loose handling of non-COVID sick kids ensues. This risks a repeat of last year’s dreadful viral respiratory season, when the sickest patients I saw in the hospital had metapneumovirus, RSV, rhinovirus, and flu. It puts vulnerable community members, children and adults alike, at real risk from a barrage of unchecked non-COVID viral illness.

It’s time to re-ground ourselves on conventional standards for contagiousness: Stay home when you’re sick. Return to public life when fever-free for a day, and overall feeling improved. Usually, this will take less than five days; sometimes it might take longer. COVID is not actually contagious for longer than other common respiratory viruses, and its contagiousness probably depends more on the frequency of high-velocity unprotected coughs and sneezes than on whether someone is on day four versus day six of illness.

The CDC’s guidelines have had to evolve alongside the COVID pandemic. At the end of 2021, the recommended 10-day isolation period was cut in half to 5 days. Now as we near the end of 2023, it’s once again time for a change. Quarantine guidelines offer only illusory protection and perpetuate harmful levels of stress. Instead, the CDC should prioritize still-impactful measures: vaccination, reasonable viral respiratory precautions, and a bolstered social safety net that enables people to care for sick loved ones without overly burdensome consequences. A restrictive approach, outside the bounds of a public health crisis, raises questions about the scope of the CDC’s regulatory authority in our daily lives, and risks losing public trust and buy-in to that authority for future health challenges. It’s time to move away from quarantine, and towards common-sense precautions. COVID-19 is no longer the predominant threat to our public health.

Carolyn Boscia is an internal medicine physician.