Head of COVID response at UCSF: 'I have not intubated a single COVID patient during this omicron surge'

On Saturday, in response to hospitals begging for relief from a massive staffing crisis, the California Department of Public Health announced that most hospitals and skilled nursing facilities can bring COVID-positive and exposed staff back to work without testing or quarantines. The staffers must be asymptomatic, are required to wear N95 masks and are encouraged to work with patients who are already COVID-positive as much as possible.

This news might come as a surprise to people who have been reading dire warnings about omicron and some public health officials' pleas to cancel plans and stay home. Many public health officials have argued these measures are necessary to prevent hospitals from being overwhelmed with COVID patients. Indeed, for the past few weeks, San Francisco hospitals have been in dire straits. But it's not because people are sick — it's because of staffing shortages driven by overly strict state quarantine rules, the director of COVID response at UCSF said.

After reviewing the charts of every COVID-positive patient at UCSF hospitals on Jan. 4, Dr. Jeanne Noble, an associate professor of emergency medicine at UCSF, determined that 70% of them were in the hospital for other reasons.

"The real COVID crisis that our hospitals are facing is a severe staffing shortage that is compromising the quality of our care," Noble said Friday, shortly before the policy change was announced.

Staffing shortages are so severe that California is considering canceling elective surgeries, as happened during the worst of last year's peak.

"The crisis from the Omicron peak is not generated by serious COVID illness in regions with highly vaxxed populations," Noble wrote in an email to SFGATE. "The crisis we are suffering in the Bay Area is largely driven by disruptive COVID policies that encourage asymptomatic testing and subsequent quarantines. ... The vast majority of COVID-plus patients I take care of need no medical care and are quickly discharged home with reassurance."

It's true that case counts are shattering records set last year, and Noble predicts the peak is still a week away. But fewer people are hospitalized with COVID today in California compared with this time last year. And, especially in highly vaccinated areas, few of those patients are actually in the hospital because of COVID illness. In LA, where 71% of eligible people are fully vaccinated, two-thirds of hospital cases were caught on screening for the virus, the LA Times reported.

Policies encouraging people to take a test whether or not they're sick, and to stay home just because they were near someone who tested positive, may be doing little to slow the virus; in San Francisco, four times as many people are testing positive every day than at the peak of last year's winter surge. But isolation policies have strained hospitals, shuttered restaurants, disrupted public transportation, reduced capacity at testing sites and sent some kids back to virtual education, some experts say. Punishing quarantine measures have compounded already-existing staff shortages driven by large numbers of health care providers quitting in the past year.

It's not just health care workers who have recently received updated guidance. Both the California Department of Public Health and the Centers for Disease Control and Prevention recently made quarantine requirements less punishing for everyone else, as well.

Now, if you test positive for COVID-19, both agencies ask that you isolate for five days, even if you have no symptoms. At the end of day five, the CDC says people with COVID can leave quarantine without taking a test, but ask that they wear a mask for another five days. In California, public health officials say people with COVID can end their isolation after five days, but only with a negative test. (Read SFGATE's guide to the confusing quarantine guidelines.)

Over the weekend, the state Department of Public Health loosened guidance on COVID-19 isolation and testing for health care workers. Local health departments have the option to implement stricter procedures and follow prior guidance.

Dr. Monica Gandhi, an infectious disease expert and a professor of medicine at UCSF, thinks more changes to the quarantine requirements are coming.

"At some point — once the population and public health officials feel comfortable enough with their vaccination rates and the effectiveness of the vaccines- isolation protocols are likely to be shortened even further," Gandhi wrote in an email.

Noble said that when she reviewed the charts on Jan. 4 at four UCSF campuses (UCSF Parnassus, Mission Bay, Mount Zion and Children's Hospital of Oakland), she identified 44 hospitalized patients (both adults and children) with COVID. Of those, just 13 were admitted because of COVID. "I do not expect that number to increase substantially, or become unmanageable in the coming week," she wrote. "The death rate in California is actually falling. And the predicted peak of cases is only about a week away."

The remaining 31, or 70%, of patients tested positive after being admitted for unrelated reasons, including a hip fracture and a bowel obstruction. They're all "completely asymptomatic or minimally symptomatic," Noble said.

"[Emergency departments] are flooded with the worried well that are simply seeking testing and reassurance," she added. "I have not intubated a single COVID patient during this Omicron surge. We have a total of 5 patients with COVID on ventilators across our 4 hospitals. An average of 1.25 intubated COVID patients per hospital is a good news story."

For most of the pandemic, public health officials have used the number of COVID patients in hospitals as a key metric for determining how an area is faring with the virus. They use that number when determining whether to tighten or loosen restrictions, including school closures and mask mandates.

The hospitalization number now has new meaning, according to several experts who spoke with SFGATE. The majority of people in the Bay Area are vaccinated, and huge numbers of unvaccinated people have already been infected over the past two years, which confers significant protection against severe disease. In addition, 79% of cases in California are now caused by the omicron variant, which causes more mild illness than previous strains of the virus. A study from the U.K. Health Security Agency found people who contracted the omicron variant were about half as likely to need hospital care as those who contracted the delta variant.

Last week, the U.S.'s top health official Dr. Anthony Fauci said that "it is much more relevant to focus on the hospitalizations as opposed to the total number of cases."

But some experts think we need even more nuance than that, taking into account the number of people who happen to have (or catch) COVID while in the hospital for something else, as well as local immunization rates. While omicron appears to be kinder to unvaccinated people than delta, anyone without prior immunity is still at significant risk of severe illness and death. People who are immunocompromised and elderly people are especially vulnerable to COVID-19, and that's why the CDC highly recommends that they get vaccinated and boosted.

In California, the hospitalization numbers can be misleading. For one thing, almost the same number of people were in the hospital for any reason at this time last year as this year, about 50,000. But in January 2021, more than 20,000 people in the hospital had COVID at the peak, and the vast majority were there to treat symptoms of the virus, according to the California Department of Public Health. Now, about 11,000 people in California hospitals have tested positive for COVID. Some of the discrepancy is likely because last year many people who were sick with other things stayed away from hospitals and doctors canceled patients' appointments to make room for COVID patients.

At a press conference last Wednesday, the state's top health official, Dr. Mark Ghaly, addressed hospitalization numbers and couldn't say how many patients were admitted to hospitals because of illness associated with COVID versus how many went to the hospital for different reasons and incidentally tested positive.

"Right now, we don't have a specific number," Ghaly, secretary of Health and Human Services, said at the press conference, as reported by Cal Matters. "That distinction is really important and helps us not only help manage the staffing challenges within some of the hospitals, but also project out the need for additional ICU capacity. And as we see an increasing number of fully vaccinated individuals, boosted individuals, admitted to the hospital with incidental COVID. I think we're starting to see a sort of different approach to that."

But county-level data tells the story. Last week, Marin County, where close to 90% of the total population is fully vaccinated, recorded a spike in COVID-19 hospitalizations. But of the 19 people hospitalized in the county, at least 42% were incidental cases, including five patients in a psychiatric ward who have no symptoms of the virus. (Marin is the most highly protected county in the state, with 93% of the eligible population fully vaccinated).

The same is true at hospitals run by the LA County Department of Health Services, where about two-thirds of positive tests came from patients there for other reasons, as Health Services Director Dr. Christina Ghaly told the LA Times. It's not just California, either. In New York City, an estimated 51% of cases in hospitals are incidental.

"If we view everyone in the hospital with COVID-19 as being in there because of infection, we'll estimate severity in a potentially damaging way," Marin County Health Officer Dr. Matt Willis told SFGATE. "I'm not saying we're there yet, but ... if, in fact, we're at a point where the consequences of being infected are predictably benign enough, then we need to rethink the entire notion of quarantine and isolation."