This post will answer these questions:
- How long do I have to isolate myself if I get sick with COVID-19?
- I heard 7 days and I heard 14 days, what’s the deal with that?
- What if I am still coughing?
It’s been a bit up and down for me down here in the basement. Yesterday afternoon, I had a couple hours where I didn’t feel great. It was nothing terrible, just a bit more of ick than the day before. An hour in bed and it passed. I hope it’s the last gasp of the dying coronavirus particles. This morning my usual coughing fits are not intense. This all has brought into the fore the question of when I can be released from my maximum security prison. Granted I will only be paroled to house arrest like the rest of the country, but I’ve got to get out of this basement.
The question of how we decide to end isolation is an important one. Obviously, you don’t want to torture people unnecessarily trapping them in a hole never to see the light of day until they want to pull their hair out and lose their mind!!! (The isolation is getting to me a bit.) On the other hand, you don’t want to unleash people out to the world if they still are contagious to bring back the virus.
This is not an entirely easy question to answer. You would think they could just test people and, if they’re still positive, keep them in isolation. This is what some Chinese researchers did in February. They kept four recovered patients in isolation and checked repeated PCR tests to see if they still were positive.
A quick aside to explain what a PCR test is. PCR stands for the polymerase chain reaction. It is a technique using special enzymes and a repeated temperature cycling procedure. The technique can take a known string of DNA or RNA and amplify it very quickly to see if it is present in a sample. In the case of SARS-COv2, they take a nasopharyngeal sample. This means they have to get a sample from that part of your head where your nasal cavity meets the back of your throat. This is the place where a piece of corn can get stuck throwing you into a fit of coughing and grunting (I hope I am not the only one this has happened to). Regardless, as if you weren’t miserable enough with your COVID-19 fevers, aches, and cough, you get to have a straw inserted into what feels like the middle of your brain. They take this piece of snot from the cavernous regions of your inner face and put it into a machine with a special chemical assay that can amplify the RNA from the coronavirus.
The researchers found that these four subjects still had positive PCR testing for coronavirus even after they had recovered. On the surface this sounds concerning. It sounds like people are still shedding virus after they recover and that I may never leave my basement for the rest of my life. There are three problems with this conclusion:
First, this is a very, very small sample of a population that had a huge viral exposure. They were infected in the highest concentration center in the world in the Wuhan province. They all had abnormal CT scans indicating significant involvement. These things may lead to longer viral shedding than milder infections or lower density populations.
Second, just because someone is still shedding virus it doesn’t mean that they are shedding enough virus to be contagious. There may be a bit of residual dying virus fighting to the bitter end and refusing to surrender but those little guys are not enough to infect someone else.
Third, and most important, PCR only tells you that there is genetic material from the coronavirus present. It doesn’t tell you if the virus is active. It is entirely possible for the PCR to detect the scattered genetic bits of dead virus left over from the infection. It may take time for the debris to be cleared so the positive test has no relationship to whether the person is still contagious. There was a study in Germany of 9 patients where they checked PCR but they also did viral culture. In a viral culture the sample is put in a dish with actual cells and they can then see if the virus starts to propagate. If it doesn’t propagate, it’s not a live virus.
They found live virus easily during the first week of symptoms from most sputum samples. After day 8, they had high levels of virus by PCR but none of the samples gerew in viral culture. These patients were very contagious during the first week of symptoms but not after day 8 even though they had high viral loads by PCR. A caveat, however, is that they were not elderly, did not have comorbidities, had mild disease, and had resolution of their symptoms by the end of a week. Sicker patients may be contagious for longer.
This all leads to the recommendations by the CDC about discontinuing home isolation. The CDC recommends using either one of two different strategies which is presented in a confusing way. Government websites are nothing if not consistently obfuscated. The first is a testing based strategy. This means someone would get repeated tests until they were clear. This is a problem for two reasons. First, good luck getting one test, let alone two. Second, they are doing PCR testing which is problematic as above. So ignore that method unless you are a healthcare worker and your hospital requires that approach.
The second approach is to determine when you get paroled using what they call the “non-test-based strategy”. This means you go by your symptoms. Its based on the study above and extrapolation from an understanding of other viruses. You can leave isolation when:
- You have no fevers for 3 days. You can’t cheat and use fever-reducing medications. You have to have no fever without taking these.
- Your respiratory symptoms have to be improving (not necessarily gone – more on this below).
- It has to have been at least 7 days from symptom onset.
Here’s how that played out for me personally. I developed symptoms the evening of the 19th. I had fevers last on the morning of the 22nd (day 3). My cough has been improving since then. That means that last night was day 7 and this is the morning of day 8. Wait, I’M DONE!! WOOOOHHOOO!!!.
(I’m not scheduled to go back to the hospital for a while but they are recommending healthcare workers wear a mask at work until day 14 after symptom onset to be safe).
A bit of an aside about the respiratory symptoms not needing to be resolved. You may still have a cough even after the virus is gone. The official name for that is post-inflammatory or post-viral cough syndrome. Viruses and bacterial infections that cause a bad cough lead to inflammation and irritation in the upper airway. That leads to that tickle and the urge to cough. The problem is that cough itself leads to irritation. This leads to a situation where the cough is perpetuating itself even though the virus is gone. The cough becomes the source of the cough (insert Inception reference here). Therefore, as long as the cough is improving you can come off isolation. For those of you where are not infected, don’t worry if your COVID-19 recovered friend is still coughing, they won’t get you sick. In fact, the person who has recovered from infection and still is coughing is less likely to get you sick than the other people in the office who may be infected and not know it. So speaking on behalf of my people (you can call us the COVIDs), don’t shun us.
So what about the 14 day quarantine?
It is important to understand the difference between someone who is infected and someone who is exposed. In studies in China, some people who were exposed did not develop symptoms until 14 days after exposure. So people who are quarantined are waiting 14 days to see if they are infected. Remember, people are contagious before they develop symptoms. If you wait for symptoms, you’d be walking around spreading the infection for a few days without realizing (been there, done that). Once you develop symptoms and know you are infected, you only need to wait for the above criteria to be met. Then you know you are no longer contagious.
As an example, let’s say a coworker tested positive. You interacted with him yesterday which becomes day 0. Your quarantine starts today (day 1) and goes for 14 days. If you do not get sick during that 14 days, it means you were not infected.
Now, let’s say you get sick on day 5. You have fever and cough on days 6, 7, and 8. Your symptoms improve over days 9, 10, 11, and 12. You can take yourself off isolation on day 12 (you got a 2 day discount!)
Let’s say If you get sick on day 9 and have fever on day 9, 10, 11, 12, and 13 (you got it bad) but feel better on day 14. You would need to stay in isolation days 14, 15, and 16.
Enough for now, I hope that explains it, feel free to comment below, I’ll try to answer questions as best as I can. For now, seeing as how I’m being released, I’ve got so much to see and explore out in the great wide world – I hear there is a kitchen and family room on the outside. Very exciting.
13 thoughts on “When can I get out of isolation?”
May you have a speedy and complete recovery. Thank you for your blog. Very Helpful.
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Glad you are feeling better. How are your kids? (Your dad led our teen tour to Israel in 79). Curious, someone that has had cancer, I think Leukemia years ago and took all kinds of cancer drugs…is he less likely than the average person to get it because he took the cancer drugs? I found this hard to believe, so curious. Hope you are paroled soon!
Having cancer and being treated, even with recovery, may have a lasting impact on all aspects of immunity even if not well understood.
Dr. Grove, I just read your answer to Audrey’s comment on previous cancer or cancer treatment affecting one’s immune system. My thyroid was removed in January 2014 due to papillary thyroid cancer. In May 2014, I had follow-up radioactive iodine treatment. I am now 74 years old, and there has been no recurrence of the cancer.Would you consider my immune system compromised? Thank you.
Not from the thyroid cancer.
a blessing on your head. thank you for this mitzvah of candid facts not unknown projections.
Thank you. Very informative.
Perhaps you can give me some insight. I am in touch with my doctor but feel kind of lost.
I decided to self-isolate Tuesday night because of chills and a slightly elevated temperature. my usual temp is 97.6 so my temp was 98.6, and never higher than 99 since then.
There was No cough, but upper back ache and burning which could easily have been from my having slept in the cold attic for 7 days while my husband had self quarantined (after 14 days he is BH fine). I also felt some burning by my sternum.
Have you heard that burning in the chest is a symptom?
Perhaps my chills were from being in the cold attic too.
Thursday morning (18 hrs into self iso) i started feeling a bit congested, like a small ball of mucus in my air pipe. I also heard some wheezing, but I sometimes wheeze all year long.
I tried coughing but nothing comes up.
Shabbos the congestion might have become a bit worse but my temp is 98.2
Not sure what to make of all this.
I’m in touch with my doctor, but he isn’t saying much, just maybe I have the virus.
I don’t know how to proceed.
I’m also scared to sleep, I’m afraid that I will God forbid not be able to breathe. I read that symptoms of hospitalized ppl worsened by day 8 so I am really scared.
Do my symptoms require testing? What does it matter if I get tested?
Am I able to leave isolation after 7 days?
I understand if you can’t or don’t feel comfortable answering, but it might help me know what to focus on.
May Hashem send a Refuah Shleima to all.
I am really appreciative of your blog! I feel that you have been so informative without any of the media sensationalism. So I was wondering if you could answer this question that I have: in the beginning of the Coronavirus pandemic, the general message was that this is a disease mostly affecting 60+. However, I’m hearing more and more—on the news, from my community, and from family and friends—about younger people, with no comorbidities, becoming very sick, sometimes fatal, with Covid-19. Can you address this, please?
Mortality is higher as people get older but there are cases of younger people dying. Remember, when they say the mortality is mostly among the elderly it is not the same as saying mortality is “entirely” among the elderly. Younger people have a much lower mortality but its not zero.
Refuah shelayma b’karov!
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Hi, thank you so much for this blog! It is very informative and clear. I had A question about the length of time one should be isolated. If one was exposed and then experiences very very mild symptoms like loss of smell or a headache? No fever, cough, shortness of breath, just those very mild symptoms. How long does he have to wait to come out of isolation and to be sure he is not contagious? Thank you!
If there were no fevers you should stay in isolation for 7 days.