When can I get out of isolation?

This post will answer these questions:

1. How long do I have to isolate myself if I get sick with COVID-19?
2. I heard 7 days and I heard 14 days, what’s the deal with that?
3. 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:

1.  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.
2. Your respiratory symptoms have to be improving (not necessarily gone – more on this below).
3. 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.

• https://jamanetwork.com/journals/jama/fullarticle/2762452
• https://www.medrxiv.org/content/10.1101/2020.03.05.20030502v1
• https://www.livescience.com/coronavirus-spread-after-recovery.html