Do I have to stay home if I have COVID in 2024? The rules might surprise you.

Amidst reports this week that federal officials are considering changing COVID-19 isolation guidelines, experts offered reminders that the coronavirus remains dangerous, killing more than 1,000 people a week nationwide and more than 2,000 a week as of last month.

But the approach to prevention has shifted now that most Americans have been infected and vaccinated at least once.

There are also treatments available for the most vulnerable, though they are dangerously underused and most of the people who end up hospitalized are among the vulnerable groups who missed the opportunity to get an updated vaccine or a timely treatment, experts say.

"We're not going to prevent COVID anymore ‒ people are going to get COVID," said Dr. Anand Parekh, chief medical adviser for the Bipartisan Policy Center, a think tank.

But what's important is preventing hospitalizations, severe illness and deaths in the face of a virus that "is much more transmissible than the flu or than a regular rhinovirus that gives you the common cold," he said.

So how hard should you be trying to avoid COVID-19 and what should you do if you get it?

That depends on your level of risk and risk tolerance, experts say.

"The science hasn't changed, but the public's perception (has) and the willingness of the public to inconvenience themselves has definitely dropped since the early days of the pandemic," said Dr. Daniel Griffin, an infectious disease specialist with Optum and a co-host of the podcast "This Week in Virology."

Even early in the pandemic when 2,000 people were dying daily in New York, the vast majority of Americans decided that isolating themselves when they fell ill was inconvenient, he said.

About 75% of people typically hide their illnesses when they are sick even though they know it might be harmful to others, because they don't want to miss out, especially on social activities, according to a recent study.

"People are already going to the office, they're going to school, they're taking their antihistamine, so no one notices," he said.

Most people have been quick to forget the lessons learned during four years of the pandemic, Griffin said. "For the elderly, for the immunocompromised, we're turning back to our previous rugged individual approach to public health."

What should you do if you get sick?

Anyone who has a respiratory illness ‒ a cough, stuffy nose, often a fever ‒ should assume they have either COVID-19, the flu, or RSV, each of which kills tens of thousands of vulnerable Americans a year, said Dr. Paul Offit, a pediatrician and infectious disease specialist at the Children's Hospital of Philadelphia.

"We've added COVID-19 to the pantheon of winter respiratory viruses," he said.

Offit recommends that people at risk for severe disease from COVID-19, including those who are pregnant, immunocompromised, or over 65, get tested quickly if they develop these symptoms so they can benefit from the very effective available treatments: Paxlovid and the antiviral Molnupiravir.

People who are not at high risk should assume they have one of these highly contagious infections and wear a mask to protect the vulnerable, he said.

Dr. William Schaffner, an infectious disease specialist at Vanderbilt University School of Medicine, said he's one of the few people in his Nashville, Tennessee, region still masking in public. He and his wife are caring for a family member undergoing chemotherapy for cancer and he doesn't want to bring anything home.

Schaffner said the government should offer more attention and support for treating high-risk people who catch COVID-19. Many doctors are hesitant to prescribe Paxlovid even to extremely vulnerable patients because they don't understand the medication, Schaffner said. He said he wished there was a "911 equivalent" that doctors could call for advice.

Parekh, speaking on Day 9 of his own mild COVID-19 infection, said the current system assumes people at high risk will be willing and able to go through "nine hoops to get Paxlovid."

When is it OK to return to work?

Still testing positive but with a faint red line, Parekh, from the Bipartisan Policy Center, said he'd stayed home for the first three days and then benefitted from a weekend before coming to work wearing an N95 mask to conform to CDC guidelines.

"I've been asking myself, just in terms of the convenience, how other people could do this," said Parekh, acknowledging that not everyone can work from home or time their infection for a weekend.

He's worried that much of the public is now a few years away from their last vaccination and people are not staying home if they're sick, so it's likely that "a lot more people potentially could be walking around with COVID-19 and be infectious."

Still, many people don't have the luxury of taking a day off work.

On a recent trip, Offit saw ‒ and heard ‒ an airport cleaner sniffling, sneezing and coughing. He watched people's faces change as they saw the man and they quickly moved away.

"If we value human life," he said, "we should make it easier for people" who are sick to take a day off. It would also save businesses money in the long run if one sick worker didn't get all their co-workers sick, he said.

"But at the very least, he should have worn a mask," Offit said of the airport worker.

What about testing?

Dr. Michael Mina has been a fan of rapid testing since the earliest days of the pandemic and says they can still play a vital role in fighting COVID-19.

Mina, an epidemiologist and immunologist, said he thinks people should test themselves if they think they might have COVID-19 and stay at home if at all possible, if they test positive, particularly if the line is strongly red.

"If it's positive, especially if it's dark, you know you're infectious," said Mina, also chief science officer at eMed, a home testing company.

Typically, he said, people are most contagious in the first few days of an illness.

Mina's upset with new state regulations in California and Oregon – which may become a federal model. These rules say people should isolate only if they have a fever and other symptoms are mild or improving.

Fever is a terrible metric for deciding whether someone is contagious with COVID-19, Mina said. Many people are contagious without ever having symptoms or have symptoms other than fever.

Other people may feel quite sick with COVID-19, but the virus is contained in their gastrointestinal system, rather than shedding from their respiratory tract, so they wouldn't be contagious, he said. A test from a person in this scenario would show up negative.

"Symptoms alone have always been a poor indicator ‒ both positive symptoms and the absence of symptoms," Mina said.

Do people with COVID-19 need to isolate themselves?

Guidance from the Centers for Disease Control and Prevention still calls for people to isolate themselves for five days if they test positive and then wear a mask in public for five more days.

There were reports this week that the guidance was about to change, but CDC officials said they're not ready to make a change yet.

Several experts said it makes sense to change the rules because few people are following the current guidelines.

Any change needs to be supported by lots of public communication Offit said.

"The CDC should be out in front of the media every other day and explain what's going on," he said. If they want to change a recommendation, they should be explaining the science behind that change and "keep pounding it out there."

The goal of any policy change should be to get people to isolate for the first two to three days of illness when people are the most contagious, said Griffin, an infectious disease specialist.

"If you can actually come up with guidance that more people will follow, you can effectively reduce the amount of people out there who are highly transmissible," he said.

Is it still worthwhile to get vaccinated?

Yes, all the experts say vaccination is still worth the effort and sore arm, particularly for people in high-risk groups or for anyone who doesn't want to miss an important life event, like a wedding or a trip.

Most Americans got their last shot more than a year ago, which means that when they catch COVID-19, the immunity they got from it will have faded. They won't get as sick as a person who'd never been vaccinated or exposed to the virus at all, but they will get sicker than if they'd had a recent shot, experts say.

That's just how the immune system works.

Immune protection typically fades over time, which is why people can catch a cold year after year. Plus most viruses, like the one that causes COVID-19, mutate over time, so the body isn't prepared for precisely the one that arrives the year after an infection or shot.

A vaccine, like an infection or probably even an exposure that's not enough to cause illness, Mina said, gives the body a reminder, a memory "boost" that helps it fight off illness.

The current COVID-19 vaccine doesn't prevent all infections. But a vaccine almost certainly reduces the severity of illness, experts say, along with the risk for long COVID, in which symptoms linger for months or years after the initial infection is gone.

In terms of side effects, most people will still get a sore arm. Some might feel lousy for a day or two. People who had a severe reaction to an earlier dose of the COVID-19 vaccine should talk to their doctors before getting another one.

For everyone else, the vaccines available in the United States and worldwide have been shown to be remarkably safe overall.

Anything given to tens of millions of healthy people will have negative consequences for some.

Teenage boys and young men have a higher risk for myocarditis and pericarditis, a swelling of the heart muscle and area around the heart. But Mina noted that the risk for these is higher during a COVID-19 infection than following a vaccination.

Vaccination during pregnancy has also been shown to be safe and to protect the newborn.

The bottom line, Offit said: if you're sick and can't stay home, wear a mask.

"The goal is to keep people out of the hospital, out of the ICU and out of the morgue," he said.