How Long to Isolate With COVID in 2024? California and the CDC Say That Now Depends on Symptoms

Update Tuesday, March 5:  The Centers for Disease Control and Prevention (CDC) have officially revised their national guidance for how long people with COVID should isolate from others — saying that as of March 1, COVID-positive people can now return to work or regular activities once “symptoms are improving overall” and they’ve been fever-free for at least 24 hours without use of a fever-reducing medication.

Previously, the CDC advised that people who test positive for COVID stay home and isolate from other people for at least five days, regardless of the severity of their symptoms — or whether they had symptoms at all. The CDC says that “depending on the length of symptoms,” the length of time a person now isolates with COVID “could be shorter, the same, or longer than the previous guidance” for the disease.

Once a person’s COVID symptoms are mild and improving “for at least 24 hours,” and any fever has been gone without the aid of medication for that period of time, the CDC says that they “are encouraged to take additional prevention strategies for the next 5 days to curb disease spread, such as taking more steps for cleaner air, enhancing hygiene practices, wearing a well-fitting mask, keeping a distance from others, and/or getting tested for respiratory viruses.”

The CDC’s new guidelines now mostly resemble California’s own updated COVID isolation recommendations, which the state revised back in January. The biggest difference between California’s new guidelines and the CDC’s revised advice is what people who test positive for COVID but do not have symptoms — known as asymptomatic infections — should do when it comes to isolation and avoiding infecting others.

The state says that asymptomatic people with COVID should wear a mask indoors around others for 10 days and avoid higher-risk people for the same duration.  The CDC says that asymptomatic “may be contagious” and should only take “added precautions[s],” including possible masking, for five days.

This 2024 update represents the first time during the pandemic that the CDC has moved away from set periods of isolation for people with COVID. At the outset of the pandemic in 2020, the CDC stipulated a 10-day period of isolation for COVID-positive patients — a period shortened to five days in December 2021. This update was still accompanied by guidance to wear a well-fitted mask for another five days.

The CDC says that this new guidance “brings a unified approach to addressing risks from a range of common respiratory viral illnesses,” bundling guidance on COVID into that for other viruses like flu and RSV as one set of Respiratory Virus Guidance. The webpage that previously contained the CDC’s COVID isolation guidance has now been archived, and the agency’s online COVID information hub contains a note stating that “The content of this page will be updated soon.”

Original story from Jan. 19 continues:

California health officials have updated the state’s official guidance on how long people with COVID-19 should isolate from others — with new recommendations that represent a relaxing of the isolation guidelines still in place from the Centers for Disease Control and Prevention (CDC).

Up until now, the CDC has recommended that people who test positive for COVID-19 stay home and away from other people for at least five days — regardless of whether or not they have symptoms. But on Jan. 9, the California Department of Public Health (CDPH) issued an update that their official recommendations for Californians would now move away from the five-day rule in favor of “instead focus[ing] on clinical symptoms to determine when to end isolation.”

Now, the new guidance for COVID-positive Californians says that they should still stay home until their symptoms improve and wear a mask around others indoors for 10 days. But COVID-positive people without symptoms can leave their homes and be in public, CDPH says — albeit as long as they stay masked for that period.

This big change in state guidance, coming amid a wave of respiratory virus infections around California — and running counter to the CDC’s current advice — might be causing confusion in your household. Keep reading for the breakdown of the new official guidelines for what happens when you test positive, why the state says they’re making this change, and how to think about the risk your positive COVID-19 test poses to others.

What are the official COVID-19 isolation recommendations for Californians now? What’s changed?

CDPH’s new isolation guidelines are focused on whether or not a COVID-positive person has symptoms. (Jump straight to the guidance for people without symptoms.)

The new guidance for COVID-positive Californians who have symptoms:

• Stay home until symptoms improve and any fever has been gone 24 hours without medication
• Wear a mask indoors around others for 10 days
• Avoid higher-risk people for 10 days.

CDPH’s message is clear: You still need to stay home — initially. But now, instead of setting a clear time period like before — five days at home, 10 days masking — CDPH now says that you should judge when you’re safe to leave the house: “until you have not had a fever for 24 hours without using fever-reducing medication AND other COVID-19 symptoms are mild and improving.”

Not everyone gets a fever as one of their COVID-19 symptoms, so what should you do if that’s you? CDPH confirmed via email to KQED that you should “still stay home if sick until symptoms are mild or improving.”

Once your symptoms have improved, CDPH recommends that you “Mask when you are around other people indoors for the 10 days after you become sick.” You should only remove your mask before the 10 days are up “if you have two sequential negative tests at least one day apart,” says the new CDPH guidance. If you have symptoms, Day 0 is the day those started.

CDPH also says to “Avoid contact with people at higher risk for severe COVID-19” for those 10 days. The agency’s definition of higher-risk individuals includes “the elderly, those who live in congregate care facilities, those who have immunocompromising conditions, and that put them at higher risk for serious illness.”

CDPH’s new guidance includes a reminder that you’re potentially infectious with COVID-19 two days before your symptoms start.

The biggest change in CDPH’s guidance: If you test positive for COVID-19 but don’t have symptoms, you should now:

• Wear a mask indoors around others for 10 days
• Avoid higher-risk people for 10 days.

The CDC still says that COVID-positive people should stay home a full five days whether they have symptoms or not. But now, CDPH says that symptom-free people with COVID-19 can leave their homes as long as they follow the guidance above.

Like people with symptoms, you should only remove your mask before the 10 days are up “if you have two sequential negative tests at least one day apart,” the new CDPH guidance says. If you have no symptoms, your Day 0 is the day you tested positive.

CDPH’s new guidance advises that even if you have no symptoms, you’re still potentially infectious with COVID-19 two days before you get a positive test.

The state’s updated isolation protocol applies to schools, and the Oakland Unified School District was one of the first to announce it will be adopting the new recommendations that allow students who test positive for COVID-19 but have no symptoms, to attend school, as long as they wear a mask for 10 days after testing positive. Cal/OSHA has also adopted the new rules for most workplaces around the state (PDF).

Remember, there’s growing evidence that some people take longer to get a positive test on an at-home antigen test. If you have symptoms but have tested negative, don’t assume it means you’re COVID-free. The CDC recommends that you take another antigen test 48 hours later and then test again after another 48 hours. You can also seek out a PCR test, which is more sensitive.

Why is the state making this change when the CDC’s ‘5 day’ guidelines remain unchanged?

CDPH is firm that for California, the time has come to make this change.

“Previous isolation recommendations were implemented to reduce the spread of a virus to which the population had little immunity and had led to large numbers of hospitalizations and deaths that overwhelmed our healthcare systems during the pandemic,” the agency says in the introduction to its new guidelines. “We are now at a different point in time with reduced impacts from COVID-19 compared to prior years due to broad immunity from vaccination and/or natural infection and readily available treatments for infected people.”

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The agency says it’s now recommending these new guidelines “to align with common practice of other respiratory viruses,” and in an email to KQED, elaborated that “a significant proportion of COVID-19 infections are asymptomatic or include minimal symptoms, and many people may be infected with COVID-19 or other respiratory infections and do not test or know what infection they may have.”

Acknowledging that COVID-19 now spreads alongside flu, RSV and other respiratory viruses, CDPH says in its email that this update “incorporates our recommendations into a broader, multi-pronged approach to multiple respiratory viruses.”

But “if you look now at the weekly hospitalizations and deaths … they’re much higher for COVID than they are for flu, like for the flu season,” says Dr. Abraar Karan, an infectious disease physician and researcher at Stanford University. “Late December, we had [around] 6500 [nationwide] recorded deaths for COVID. It was [around] 1500 to 2000 per week.”

“I wouldn’t say that COVID has come down to the level where it’s less pathogenic than the flu per se, just by the numbers,” Karan says.

The state’s COVID-19 dashboards show that hospitalizations and deaths of people with COVID-19 have risen since early November 2023. And when it comes to COVID-19 levels in Bay Area sewage, Stanford University’s WastewaterSCAN team says that those levels of COVID-19 are “high and increasing” right now.

Dr. Peter Chin-Hong, an infectious disease expert at UCSF, says this “new chapter” in the state’s health policy “took us all a bit by surprise.”

“But when you step back and think about it, we’re in a different place in January of 2024 compared to March of 2020,” Chin-Hong says. “There are some things that are changing. It seems dramatic, but there are many things that are not changing in terms of continuing to protect each other.”

CDPH says that in 2024, the agency’s “policies and priorities for intervention are now focused on protecting those most at risk for serious illness while reducing social disruption that is disproportionate to recommendations for the prevention of other endemic respiratory viral infections.” Chin-Hong says that he sees this latest CDPH guidance as “really speaking to workplace and schools,” and especially notes “the impact of the pandemic on kids’ education, particularly in California and in the Bay Area because we probably were shut down more than most places in the country for a long, continuous time.”

“So I think in some ways it might be a response to that and sort of a nervousness around making sure that our kids are really as well prepared for the future as they can be,” Chin-Hong says, “given the fact that we’re going to be seeing these kinds of viruses emerge at least twice a year, we know, for COVID — and at least once a year for many of the other respiratory viruses.”

While Stanford’s Dr. Karan says he has concerns about how much the general public will be able to adhere to mask guidelines and avoid higher-risk people after testing positive, he also says that even before this new guidance, “a lot of people weren’t testing at all — or even if they were testing positive, they probably weren’t following [existing isolation] guidance to 100%.”

“So I think what the health officials were trying to do was to be more practical and more pragmatic and say, ‘Okay, well, people are probably going out anyways if they feel okay — so let’s at least just try to emphasize wearing a mask [and] staying away from others who are higher risk,’” Karan says. “That’s my assumption of what drove this.”

Why does the state now think it’s safe for COVID-positive folks without symptoms to be in public, even if they’re masked?

After almost four years of public health policy at the federal and state levels that’s emphasized “If you’re COVID-positive, stay the heck away from other people,” this new update might seem jarring to you.

There’s also the fact that since 2020, we’ve been told that not only can asymptomatic people be contagious with COVID-19, they might be responsible for fueling a lot of the spread of COVID-19 — because those folks are so often unaware they even have the virus.

“We know that you can be contagious without symptoms,” Karan says. “We also know that symptomatology can increase the risk of transmission. So if you’re coughing and sneezing, you’re probably emitting more viral particles.”

This new California guidance focuses on symptomatic people as posing the most risk to others, noted Karan — hence the continuing recommendation that those people stay home until those symptoms get milder. As for those asymptomatic people, Karan says, CDPH’s take appears to be that if those people wear a mask for 10 days after their positive test, their “risk is going to be pretty low that they’re going to be transmitting over time.”

Karan says it might also be helpful to see this recent change in the context of how isolation recommendations have evolved throughout the pandemic — but also how they haven’t. At the outset, the CDC stipulated a 10-day period of isolation for COVID-positive patients, a period shortened to five days in December 2021. But this update was still accompanied by guidance to wear a well-fitted mask for another five days.

That aspect — wearing a mask for 10 days — is something that’s remained the same in this latest California update, and “the mask part of it is key,” Karan says. “It’s just sort of extending this a little bit to say people who no longer have any symptoms: To people that are either asymptomatic or they’ve been fever-free without medications for 24 hours,” he says. “So they’re adding a contingency.”

What are the concerns over this new guidance — especially when it’s so different from the CDC’s advice?

“I think it will confuse the public,” Karan says.

One big element he’s looking at: As the isolation advice shifts from a clearly set time period — five days, regardless of symptoms — toward monitoring your own symptoms and you deciding when you’re safe to leave the house, will people still remember that crucial next step of wearing a mask for 10 days? And will they have all the necessary information to also follow the other part of CDPH’s new guidance that urges them to stay away from people at higher risk from COVID-19?

Karan says that he worries that “people are going to forget the second and third part of that,” Karan says — and he’s especially concerned that the importance of that well-fitted, high-filtration mask “is going to get lost.”

Karan says he’d also liked to have seen CDPH give the public more information about “the rationale behind why they were doing it,” so that the public could understand that this new guidance wasn’t a green light to go out into the world with COVID-19.

“If they’d said, ‘People that are not symptomatic can be contagious, but it’s less likely, and people without symptoms are likely going to be shedding less virus, so if you wear a high filtration mask, your risk of infecting others is quite low, and that’s why we’re doing it’? I think that would have made a lot of sense,” Karan says.

Chin-Hong also acknowledges the emphasis these new guidelines place on avoiding exposing people who are at higher risk of severe illness and death from COVID-19. “I worry about that population every night I go to sleep,” he says, “and that’s because we’re still seeing 1600 Americans die every week.”

“When I look at the patients who I’m taking care of in the hospital right now, the people who are doing poorly are people who didn’t get the recent vaccines,” Chin-Hong says. “They’re generally older than 75, and they didn’t get access to or take advantage of Paxlovid.”

Calmatters has reported that disability and equity advocates have particularly criticized CDPH’s new guidelines, which they say could increase the risk of infection for Californians most vulnerable to severe illness or death from the virus.

“This policy is not based in science, equity or public health,” Lisa McCorkell, co-founder of the Patient-Led Research Collaborative that studies the impacts of long COVID, told CalMatters. “It devalues the lives of immunocompromised and disabled people and completely ignores the risk of long COVID.”

Michelle Gutierrez Vo, a registered nurse with Kaiser Permanente and a president of the California Nurses Association, echoed these concerns, calling the new guidelines “a step backwards from protecting public health” and “very dangerous.”

“High risk people do not walk around with a flag saying ‘I am high risk,’ so then the people that are COVID-positive can identify them and stay away from them,” said Gutierrez Vo. “It doesn’t work that way.”

“So therefore, if you cannot be selective of who you need to be getting away from, then there just has to be a general understanding or a mandate — which is what we had — to make sure to protect the general public. It is the Department of Public Health’s responsibility to uphold public health, and they are not doing that with this new guidance,” said Gutierrez Vo.

On the risks of long COVID, Gutierrez Vo said that California’s relaxing of isolation protocol “puts everyone in danger.” COVID, she said, “is not like any other respiratory illness. When you have flu and you get over it, it doesn’t have long term effects. When you have RSV, or any other respiratory illness like a viral syndrome, it doesn’t damage your kidney or it doesn’t damage your heart.”

Chin-Hong urged the public to remember the ongoing basics of COVID-19 prevention — seeking out the latest vaccine, wearing a well-fitted mask when necessary, remembering the importance of ventilation indoors and testing for COVID-19 — amid the latest guidance. “Reminding ourselves of those things … should be really front and center,” he says.

This story contains reporting by KQED’s Lesley McClurg.

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This story originally published on Jan. 19