Respiratory Virus Guidance Update Frequently Asked Questions

1. What new evidence has led to this updated Respiratory Virus Guidance?

We have more and better tools and protection to fight serious respiratory illness.

• Effective vaccines against all three major viruses are now widely available:
  • COVID-19 vaccines cut the risk of severe disease in half. Over 95% of hospitalized adults were not up-to-date with their COVID-vaccine in fall 2023.
  • Flu vaccines also cut the risk of severe disease by nearly half.
  • For the first time, in fall 2023, we had an immunization against respiratory syncytial virus (RSV) for older adults, pregnant people, and young children.
• Effective treatments are also widely available:
  • Paxlovid cuts the risk of hospitalization due to COVID-19 by over half and the risk of death by even more (75%).
  • Treatment of flu with antiviral medications can lessen symptoms and shorten the time you are sick by about a day. Starting antiviral treatment shortly after symptoms begin can also help reduce some flu complications.
• Population immunity to COVID-19 is high:
  • More than 98% of the U.S. population now has some protective immunity against COVID-19 from vaccination, prior infection, or both.

As a result, far fewer people are getting seriously ill from COVID-19.

• Fewer hospitalizations and deaths:
  • Weekly hospital admissions for COVID-19 are down more than 75% from the peak of the initial Omicron wave in January 2022. Deaths are also down by more than 90%. In 2022, COVID-19 accounted for more than 245,000 deaths. Last year, that number was around 76,000.
• Fewer complications
  • Complications like multisystem inflammatory syndrome in children (MIS-C) are now also less common, and prevalence of Long COVID is also going down.

While COVID-19 still poses a significant health threat to people at higher risk, its health impacts are now similar to other respiratory viruses, like flu, which are also important causes of illness and death, especially for people at higher risk. As a result, this is the right time to issue unified Respiratory Virus Guidance, rather than additional guidance for each specific virus. This Respiratory Virus Guidance update brings a unified, practical approach to protecting against a range of common respiratory viral illnesses so that people can protect themselves and loved ones from these illnesses.

These viruses share similar routes of transmission, symptoms, and prevention strategies. Although COVID-19 is starting to look like other respiratory viruses, like flu, when we look at the number of hospitalizations and deaths, it continues to differ in important ways, such as Long COVID. Flu, COVID-19, and RSV continue to be significant health burdens, especially to people at higher risk, and require ongoing actionable prevention strategies such as those recommended in our updated Respiratory Virus Guidance. This updated guidance continues to protect those most at risk, and evidence shows it will not significantly increase severe disease related to COVID-19 or other respiratory viruses.

Notably, states (California, Oregon) and countries (Australia, Canada, Denmark, France, and Norway) that have changed their recommended isolation times have not seen increased hospitalizations or deaths related to COVID-19.

CDC will continue to evaluate the available evidence, including public health and clinical trends, virology, behavioral science, and social practices, to ensure the recommendations in the guidance provide the intended protection.

2. Why is the focus of the guidance on COVID-19, flu, and RSV? There are many respiratory viruses. Is there a plan to include others?

COVID-19, flu, and RSV are very common respiratory viruses that cause significant amounts of disease, especially in the fall and winter season. We also have immunizations and treatments that help prevent severe outcomes of these viruses. As such, these are key examples we have highlighted, but the Respiratory Virus Guidance covers most common respiratory viral illnesses. It should not replace specific guidance for viruses that transmit through the air and require special control measures, such as measles. However, the recommendation in this guidance may still help reduce spread of various other types of infections. The guidance may not apply in certain outbreak situations when more specific guidance may be needed. In addition, CDC offers separate, specific guidance for healthcare settings (COVID-19, flu, and general infection prevention and control) and Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that is not currently changing.

3. Why has CDC changed the "isolation" period for COVID-19?

Prior Guidance: The previous COVID-19 guidance recommended a minimum isolation period of 5 days plus a period of post-isolation precautions. It was created during the public health emergency, at a time when we had lower population immunity, fewer tools to combat respiratory viruses, and higher rates of severe illness, including hospitalizations and deaths.

Updated Guidance: The updated Respiratory Virus Guidance recommends that people stay home and away from others until at least 24 hours after both their symptoms are getting better overall, and they have not had a fever (and are not using fever-reducing medication). Note that depending on the length of symptoms, this period could be shorter, the same, or longer than the previous guidance for COVID-19.

It is important to note that the guidance doesn't end with staying home and away from others when sick. The guidance encourages added precaution over the next five days after time at home, away from others, is over. Since some people remain contagious beyond the "stay-at-home" period, a period of added precaution using prevention strategies, 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 can lower the chance of spreading respiratory viruses to others.

We considered multiple options for adjusting isolation guidance at different lengths of time. In addition to fewer people getting seriously ill from COVID-19 and having better tools to fight serious illness, CDC considered other factors such as the personal and societal costs of extended isolation. We also considered the timing of when people are most likely to spread the virus (a few days before and after symptoms appear). The updated guidance is easy-to-understand, practical, and evidence-based, as well as more aligned with long-standing recommendations for other respiratory illnesses.

CDC offers separate, specific guidance for healthcare settings (COVID-19, flu, and general infection prevention and control) and Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that is not currently changing.

4. Why are the updated recommendations about ending the "stay home" period based on symptoms and not testing?

The updated Respiratory Virus Guidance recommends that people stay home and away from others until at least 24 hours after both their symptoms are getting better overall, and they have not had a fever (and are not using fever-reducing medication).

It is important to note that the updated guidance states that testing is an option during the 5 days of additional precautions following the "stay home" period. While COVID-19 at-home testing can give a rough approximation of whether a person is still infectious, at-home testing for other respiratory viruses is not widely available. CDC guidance throughout the pandemic recognized that repeated testing through the course of illness is not practical for many people.

Several factors were considered in updating this recommendation:

• The severity of certain symptoms for COVID-19 and flu, most prominently fever, correlates to some extent with duration of viral shedding—an indicator of contagiousness. In other words, as symptoms improve, especially fever, infectiousness tends to go down in most people.
• Regardless of which respiratory virus is the cause, symptoms are a simple indicator for determining when to act.
• The total number of days of precautions when sick, that is, a period of staying home and away from others plus 5 days of additional actions, covers the period during which most people are still infectious.
• Most people do not know what virus is causing their infection, and at-home tests (antigen tests) are only widely available for COVID-19.
• This recommendation is similar to longstanding public health practice based on symptoms for flu and other respiratory viruses.

5. How does the guidance work for people with higher risk for severe illness from respiratory viruses?

Some people have risk factors that put them at increased risk for severe illness from respiratory viruses and the Respiratory Virus Guidance includes important considerations and protections for these populations. Examples of groups of people at higher risk can include, but are not limited to:

• Older adults whose immune systems tend to not work as well and are more likely to have underlying health conditions. Recommendations include vaccines that can protect older adults (additional dose of the COVID-19 vaccine, the high dose or adjuvanted flu vaccine, and the RSV vaccine for older adults), and flu and COVID-19 treatments that are recommended for all older adults.
• Young children have immune systems that are still developing and small airways. Recommendations include maternal immunization to protect very young infants, nirsevimab to protect against RSV, and treatment considerations based on age.
• People with weakened immune systems can have lower defenses against infections and their bodies may have a harder time building lasting protection from immunization or prior infection. Recommendations include options for receiving additional COVID-19 vaccines and guidance on which types of flu vaccines to use, as well as information about flu and COVID-19 treatments that are recommended for people with immunocompromise. Since it may take people with weakened immune systems longer to recover from respiratory viruses, this may influence choices on precautions after returning to normal activities following time at home sick.
• People with disabilities are more likely to have underlying medical conditions, live in congregate settings, or experience factors and conditions stemming from social determinants of health that increase their risk for poor outcomes from respiratory infections. Recommendations include antiviral treatments for some people with disabilities and unique considerations for working with support providers.
• Pregnant and recently pregnant people because pregnancy can cause changes in the immune system, heart, and lungs that make people more likely to get very sick from respiratory viruses. Recommendations include vaccines during pregnancy to help protect the mother as well as the baby after birth, and special considerations about treatment during pregnancy.

6. Does the updated Respiratory Virus Guidance apply to schools? Healthcare settings? Correctional facilities and shelters?

Schools

Schools should align their respiratory illness policies with the updated Respiratory Virus Guidance. CDC will release general infection and control guidance for K-12 school prior to the start of the next school year. This guidance will align with the Respiratory Virus Guidance and include strategies schools can use to help prevent other types of infections among students and staff, such as norovirus, strep pharyngitis, and others. This guidance is being developed with education partners and will include considerations for children with special health care needs, disability, equity, and communities served.

Healthcare Settings

No. CDC's Respiratory Virus Guidance is intended for a general audience and community settings, and does not apply to healthcare settings. CDC offers separate, specific guidance for healthcare settings (COVID-19, flu, and general infection prevention and control) and Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that is not currently changing.

Correctional facilities and shelters

This guidance applies to community settings, including non-healthcare portions of correctional and detention facilities and non-healthcare portions of shelters for people experiencing homelessness. These settings continue to have high risk for transmission of respiratory viruses due to congregate living conditions. People living in these settings often have underlying health conditions that increase their risk of severe outcomes from respiratory illnesses. Healthcare workers who provide care in these settings should refer to the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that is not currently changing.

Because an individual's personal prevention decisions are often limited during confinement, many will rely on correctional and detention facilities to provide what they need to protect themselves. It is important for facilities to make sure that the populations in their care and custody can protect themselves from respiratory viruses through the core prevention strategies listed in this guidance.

• Providing recommended vaccinations and everyday hygiene supplies including soap and running water;
• Cleaning frequently touched surfaces;
• Taking steps for cleaner air in the facility;
• Providing access to healthcare (including treatment for respiratory illness and monitoring for people at higher risk for severe outcomes); and
• Providing spaces for people with respiratory illness to stay away from others to prevent spread (sometimes called "medical isolation").

It is important that shelter and essential services are available for people experiencing homelessness, and that people are not turned away when they have symptoms of respiratory illness. It is also important for homeless service sites to provide access to supplies for everyday hygiene, clean frequently touched surfaces, and take steps for cleaner air in their facilities.

7. Do you expect an increase in COVID-19 hospitalizations and deaths as a result of these changes?

We do not expect an increase in COVID-19 hospitalizations and deaths as a result of this updated guidance. Instead, by focusing on core prevention strategies with the best evidence and highest impact, this updated guidance is intended to help reduce illness and death from COVID-19 and other respiratory disease threats.

COVID-19 remains a health threat, but it makes far fewer people seriously ill because our immunity is stronger, with over 98% of the U.S. population now having some protective immunity against COVID-19. We also have the tools needed to fight serious illness and death caused by COVID-19. For example, effective vaccines and treatments for COVID-19 cut the risk of severe disease in half.

The updated guidance continues to focus on those who are at higher risk for severe illness. It includes specific recommendations for groups at higher risk including older adults, young children, people with compromised immune systems, people with disabilities, and pregnant people.

States and countries that changed their COVID-19 isolation guidance to recommendations similar to CDC's updated guidance did not experience clear increases in community transmission or hospitalization and death rates. Examples include the most populous Canadian provinces (Ontario, Quebec, and British Columbia), Australia, Denmark, France, and Norway, as well as California (on January 9, 2024) and Oregon (May 2023). In California and Oregon, for the week ending February 10, COVID-19 test positivity, emergency department visits, and hospitalizations were lower than the national average.

8. What does "improving symptoms" or "symptoms are getting better" in the updated guidance mean?

This means that a person is starting to feel better, and the body is returning to normal after an infection. Symptoms can be used as simple indicators to help people make decisions about prevention strategies, such as how long to stay home or when to return to work or school. A respiratory virus infection can have many types of symptoms, some of which can last beyond when someone is infectious, such as a lingering cough. So having a single symptom or a combination of symptoms is not as important as the overall sense of feeling better and the ability to resume activities. Fever is mentioned as a specific symptom in the guidance because people tend to be more infectious when they have a fever.