Workplace Transition to Endemic COVID-19 Illness in 2022

By Wei-Shin Lai, M.D. January 26, 2022

Two full years into the COVID-19 pandemic, we have reached a turning point. Having survived the original strain, alpha, delta, and now omicron, most of us have either had the illness or vaccinations. Over 80% of the population in the US have some level of immunity. I am NOT about to suggest that we have reached some sort of herd immunity and thus can stop distancing behaviors. Combining multiple mitigation measures such as wearing masks indoors, minimizing large gatherings, and increasing ventilation are all still important. But we SHOULD change how we approach isolation, quarantine, and testing, as the disease and transmission process has now fundamentally changed.

Vaccines and Prior Illness Shift Immune Response

In the beginning of the pandemic, the world was introduced to a brand new virus. No one's immune systems had ever seen the virus. When it replicated in a person's nose and lungs, it met very little immediate resistance. The virus would reach very high concentrations and be expelled into the air around us when we talk, cough, or sneeze. After a few days, our immune systems would begin to acknowledge the virus and mount an attack. Our bodies divert energy from routine functions to fighting the virus, building up white blood cell troops, making us tired. As the war between the immune system and virus ramps up, our immune system destroys diseased cells, sends high alert messages throughout the body, and sustains heavy white blood cell casualties, causing fevers and achiness. Most of our illness symptoms are actually caused by our immune system's process to combat the virus. It took time - 5 days - for our immune systems to begin to mount a response strong enough to cause typical illness symptoms. Meanwhile, the virus was multiplying with minimal interference since the beginning. That's why we were contagious 2 days before symptoms even started.

"Average COVID-19 Timeline for People Without Prior Immunity" AcousticSheep LLC Ⓒ January 26, 2022

This chart shows the timeline of when we were sick compared with likely test results or contagiousness for a non-immune person. When the pandemic started, none of us had any immunity, so we followed this timeline of being contagious before symptoms began.

Now that over 80% of us have vaccine or disease-acquired immunity, the disease process and timeline changes. When exposed to the virus, our immune systems are now already somewhat familiar with the virus. The immune system's memory cells immediately detect familiar enemy virus and know which weapons work best. The immune system quickly diverts our energy to building weapon factories, making us tired about 2-3 days after exposure. It also sends out red alert signals all over the body to activate all remote troops. That causes our fevers and achiness. Before our weapons factories reach full speed, virus replication wins for a few days. The virus multiplies in our nose and upper airways, expelled as tiny aerosol particles as we laugh, sing, or eat, but at lower concentrations. After that, our immune system soundly defeats the virus, and we are no longer contagious. Note that we become maximally contagious shortly after symptoms start.

You may have heard from a friend who was exposed to the omicron variant and started with symptoms in 2-3 days. It seems to affect a person much sooner than the 5 days it took at the beginning of the pandemic. This phenomenon is actually because the friend had prior immunity and was able to mount a faster response, causing symptoms to manifest earlier. This friend may also have tested negative at day 2 into their symptoms but ended up testing positive when they retested at day 5. This is also explained by the prior immunity phenomenon. Their immune system was mounting an early response making them feel sick, but the virus hadn't actually replicated enough to be detectable just yet. The virus hasn't actually changed that significantly. It's really our body's ability to respond to it has changed, now that so many of us have prior immunity.

This chart shows the timeline of how a vaccinated or previously-ill person responds to a COVID-19 infection, along with when they will likely test positive and when they are contagious.

Being contagious before symptoms versus being contagious after symptoms fundamentally changes quarantine and isolation guidance. Before, people were contagious before they knew they were sick. Close contacts had to be quarantined to watch for illness. Now, if sick people strictly isolate as soon as symptoms begin, they are less likely to pass the disease on to other people, since they are most contagious after they know they are sick. Contact tracing becomes less important, and the focus turns to proper isolation. Quarantines and contact tracing still play a role, but staying home when sick should be obvious. We should isolate when symptoms begin and stop isolating when we are no longer contagious to other people.

Role of Rapid Versus PCR Testing

One good way to determine contagiousness is with rapid testing. These are the 15-minute, over-the-counter tests you can do at home. Previously, we thought that the tests were only 60% accurate at detecting positive cases. This was based on comparing the rapid test to PCR results. But more recent research shows that the rapid tests are actually incredibly accurate when a person is actively shedding a lot of virus. It takes a lot of virus to turn the rapid test positive. When a person sheds less virus, the quick test may be negative. PCR tests will detect the smallest trace of virus, even long after it's dead and unable to cause illness. PCR tests stay positive for 24 days on average and up to 90 days. However, a person is really only contagious in the short window between super high virus replication and before our immune system ramps up to neutralize the virus. Once our immune system antibodies overpower the virus, we are no longer contagious. Viral shedding decreases from our nose, and the rapid tests can no longer detect the signal.

In other words, PCR tests tell us whether or not there is virus in our nose. Rapid tests show how much. Rapid tests are positive when there is a lot and are negative when there is less. Thus, rapid tests are a great proxy for telling us whether or not we are contagious. PCR is great for telling us whether we have or had the disease. Both types of tests play an important role in disease management, but they are useful for different purposes.

PCR tests tell us whether or not we have COVID-19.

Rapid antigen tests tell us if we are contagious.

In theory, if everyone stayed home when sick, the pandemic would be over soon. In practice, it's never simple. Many people have no symptoms at all. Everyone's illness timelines vary greatly. About 30% of children have no immunity yet. Isolation is impossible for young children. Not everyone has adequate immunity. Risk factors influence risk tolerance. So we still need guidelines for isolation, quarantines, and contact management. Population-based guidelines have to consider transmission patterns and likelihood of adherence to potentially complex rules. New guidelines should balance biology with flexibility. As the pandemic progresses, we learn how to live with the virus with less disruption.

Testing pro-tips:

• When performing the 15 second nasal swab, you need to touch as much of the lining of your nose as possible. The goal is to pick up a few cells and the fresh secretions from the nasal wall lining.
• Be sure to swab both nostrils.
• Don't aim too far up the nose. That's more painful. You can insert the swab parallel to how you would imagine swabbing the throat.
• Old crusty mucus is actually not helpful. Consider blowing your nose before swabbing.
• Aiming the swab at the outside portion of the nose rather than the inside portion may reduce the chance of nose bleeds. The blood vessels along the nasal septum bleed easier than other parts of the nose.
• There have been some reports of people swabbing the throat with the rapid tests. Since no large-scale formal studies are available on this yet, this technique is questionable. If you want to try this, wait 30 minutes after eating, drinking, or brushing your teeth. Swab the throat first. Then swab both nostrils. Swabbing the throat alone is not recommended.

At AcousticSheep LLC, over 95% of us have prior immunity (either through vaccination or disease). Two families have children who are too young to be vaccinated. 33% of us have risk factors for more severe disease. We have some flexibility with working from home and plenty of space for distanced, low-risk, in-person indoor work. As a former doctor, it's important for me to do no harm, and I am proud that we have had no workplace-related infections for two years. Our new COVID-19 guidelines should carry us through this next phase of the pandemic, where we adapt the latest science to working effectively and safely together.

Here are some of the things we are doing:

• We have minimized the amount of shared equipment and office space.
• Some people work from home while others work in-person a few days a week to strategically overlap with certain colleagues.
• When local transmission peaks, we keep essential team members who can cover each other separated so that there should always be one team that can do the essential in-person duties if the other group needs to quarantine at home.
• We have online meetings, even when some of us are in the office.
• We make it clear to employees that their health and safety always come first, so they never feel pressured to work when ill.
• We continue to wear masks when around others indoors. When in a room by oneself, it is okay to unmask.
• Our HVAC system is designed and set for over 4 air exchanges per hour.
• Meals can be taken in private rooms or areas, very well distanced from each other.
• We use an extensive array of digital tools for communication and collaboration.

Here are definitions of important terms. Some definitions differ from official versions.

Definitions

Isolation:

Staying away from other people when sick or testing positive for COVID-19.

Quarantine:
Staying away from other people when exposed to COVID-19 but not yet ill.

PCR:
Polymerase chain reaction tests detect short sequences of genetic material from COVID-19. It can also be called NAAT (nucleic acid amplification test), and TMA (transcription mediated amplification.

Rapid test:
Usually a 15 minute test you can buy over-the-counter and perform at home, a rapid test can also be called an antigen test or lateral flow test (LFT). Examples include BinaxNOW, iHealth, or CareStart.

Close Contact (This definition is different from the official or typical definition.):
Someone who was within 6 feet of you for 15 minutes over the course of a day, if neither of you were wearing a tightly fitted N95, KN95, or KF94 mask.

Prior immunity (This definition is different from the official or typical definition.):
A person has prior immunity if they have had COVID-19 illness, received a positive PCR test, confirmed COVID-19 antibodies through blood testing, or received a second dose (or more) of any COVID-19 vaccine in the past 12 months.

Confirmed case (This definition is different from the official or typical definition.):
When a person begins with symptoms or tests positive is when a case is considered active.

In mild or asymptomatic illness, they stop being an active case 10 days after symptoms or testing positive. Alternatively, if a person has two consecutive negative rapid tests 24 hours apart, at least 6 days from the start of symptoms or a positive test, they are no longer active after the second negative rapid test on day 7.

For example, Ida starts to feel tired Monday, August 1. She has some sinus congestion on Tuesday and tests positive on a rapid test. By Thursday, she starts to feel better. She takes a rapid test on Saturday, August 6, and it is negative. On Sunday, she takes another test, and it is also negative. She is considered an active case from Monday to Sunday. She leaves isolation on Sunday, August 7. Note that this is longer than the current CDC recommendation and uses two rapid tests.

Flowchart - Can I Report to Work?

We are a small, privately-owned business. As a private business, we can set our own rules for dealing with the pandemic, as long as it's lawful. This is our new flowchart showing when a person can come to work in person. Our company has high immunity rates, high ability to socially distance, a slightly younger worker demographic, and a relatively low percentage of higher-risk individuals. This is more careful than the current CDC recommendation, so if you are looking for a safer reopening plan for the workplace, this offers more protection from the omicron variant. Please note that kids have lower levels of immunity at this time and higher rates of asymptomatic disease, so this flowchart does not work for schools.

Here are some possible questions or scenarios:

• Even if you do not have your day 5 PCR results back, if your day 6 and day 7 rapid test results are both negative, then you may return to work on day 7.
• If you have no results back by day 10, you may return to work as long as you are feeling better with no fever in the past 24 hours.
• If you happen to have a positive rapid test on day 10, you may still return to work as long as you are feeling better with no fever in the past 24 hours.
• If it's after day 10 and you still feel poorly even without a fever, stay home.
• You get a PCR test and a rapid test on the same day. The PCR test is positive, but the rapid test is negative. The PCR would indicate that you have or have had the virus recently. The rapid test would show that the virus level in your nose was not very high at that time of the test. This is expected to occur early in the illness and late in the illness.
• You get a PCR test and a rapid test on the same day. The rapid test is positive, but your PCR test is negative. This is unusual and can mean that the rapid test positive was a false positive (less likely - less than 5%) or that your PCR swab was not performed optimally (more likely - up to 20%). If you have symptoms or were a close contact to a positive case, then assume that you are positive.
• If you have every reason to believe that you had COVID-19 but your PCR and rapid tests were negative, your doctor can order a COVID-19 nucleocapsid antibody test to look for prior infection. This requires an appointment. Since this test can be positive for life, it can be difficult to know if this turned positive with a recent infection or an infection from long ago. It can be checked as early as day 14 of illness but is more reliable after day 21. This test is not useful for disease or public health management, but it can satisfy your curiosity, help you schedule future vaccinations, or aid in long COVID symptom management.

At this time, the omicron BA.1 variant has just swept through our area. Case rates are falling, but deaths are still at a peak. I am waiting for the omicron BA.2 "stealth" variant to bump up cases over the next few weeks. Current estimates are that 50% of Americans will have caught the omicron variant this winter. While the future of variants is uncertain, we can be certain that many of us now have some level of immunity. Future variants will need to mutate enough to surmount our collective immunity to spread effectively. That will require many new mutations which takes time.

When COVID-19 becomes endemic, we won't have overwhelmed hospitals. We can eat indoors safely, gather with friends and family, travel, and attend big events. We would still be considerate people and stay home when we are sick so we don't spread it to others. Schools can get back to normal, and we won't have to wear masks. COVID-19 variants will spread, but they won't cause massive problems. Eventually, we will learn to live with it like we live with the flu. The flu causes a few nursing homes and schools to quarantine for a few days in a bad year. If one hospital gets too busy, there are plenty of other hospitals to offload the burden.

Seeing how things are on the ground currently, we are not close to endemicity. Officials from local hospitals are urging social distancing precautions because they are at capacity. My child's class's substitute teacher's substitute had a substitute. My child's previous school won't reopen next year. The dominos are still falling, so we still need to take precautions.

We are one step closer, however, having reached a high level of existing immunity in the general population. It is one step to transitioning to endemic disease. Other steps may involve better vaccines, such as one that doesn't have as much immune escape with new variants. Younger children need vaccine access too. The new oral medications for people who catch COVID-19 help tremendously as well, but we need a higher supply. Finally, the entire world will need to reach high levels of immunity through disease or vaccination to end the pandemic. Until then, we continue to do our part in being careful to avoid catching and spreading COVID-19.