When are you safe to de-isolate?
By Dr Daniel Israel, General Practioner, Johannesburg
Discovering that your winter flu is really COVID-19 may bring a wave of physical discomfort and mental loneliness.
Our resilience at this time is empowered by our knowledge that the COVID-19 experience doesn’t go on forever. Let us examine how long you’re likely to be ill with a COVID-19 infection.
A COVID-19 infection can be divided into three phases: the viraemic phase, the pneumonic phase and the cytokine phase. All patients experience the viraemic phase but only 15% of patients progress to the pneumonic or cytokine phases. These latter stages unfortunately may require hospitalisation or even ICU, depending on the severity of their complications.
If you are a healthy individual (but even if you have a comorbidity, particularly if it is a controlled comorbidity) you are likely only to experience the viraemic stage. This is characterised by body aches, fatigue, chills, fever, dry coughing, loss of taste/smell, headaches and abdominal pain. You may even only have one or two of these symptoms. Various studies have shown that these symptoms present 2-14 days after exposure to a COVID-19 positive patient.
The good news is that the primary symptoms are likely to last only 7 days and then you are likely to start feeling better and better.
When am I safe to go out? At 14 days or at 10 days?
This question has probably been the topic of hottest debate in the South African Corona-space this week. The Director-General of the Department of Health, Dr S Buthelezi, released information this week that uncomplicated cases would be allowed to de-isolate after 10 days compared to the previous recommendation of 14 days. This is based on the international scientific finding that the virus is not cultured in sputum after 8 days of illness. This approach also follows the practice of the UK, but not necessarily the rest of the world.
A study closely monitoring 181 incubation periods in the Hubei province in China in February 2020 showed a wide contagious range of 2-28 days. 97% of cases were no longer contagious at 10 days though. It is important to note that there is no zero-risk approach though, and that public health systems continually chip away at making regulations to balance societal needs and health safety against what is considered negligible risk in order to come up with these recommendations.
The Department of Health has announced a reduction from 14 days to 10 days for active COVID-19 patients recovering from the disease. This applies to asymptomatic cases as well. It is not clear yet whether this applies to people in quarantine ie. people who are not infected but who have been exposed. Healthcare workers who have been exposed may return to work in PPE after 5 days – the average incubation time – if they have no symptoms and a negative test to prevent depletion of the healthcare infrastructure.
What is the basis of these recommendations as to when patients no longer have COVID-19? Do I need a second negative PCR swab to show I am clear?
The PCR tests we use to detect the SARS-COV-2 virus are advanced molecular medicine tests that pick up viral RNA on a swab. They are so sensitive that they even indicate a positive result when a scrap of viral RNA is picked up. This method gives no indication of active disease or infectiousness though. We have learnt that PCR swabs may remain positive for 6-8 weeks after an infection, which may give a false impression of an active infection that is not there.
The real test of infectiousness is a viral culture. Viral cultures are unavailable, more difficult to perform, have lower sensitivity and are largely unnecessary. Studies have showed that viral cultures produce negative results after 8 days of infection. This is the basis of the recommendations by the Department of Health that patients are safe to return to the community after 10 days.
I’m at day 15 after my diagnosis and I still have an aching body and I’m exhausted! How long will this take? Are you sure I’m not still contagious?
Writing in the JAMA Journal, a team of researchers from Italy reported that 9 out of 10 patients discharged from a Rome hospital after COVID-19 still had at least one symptom at 60 days after onset. Of the 143 patients examined, 32% had one or two symptoms, and 55% had three or more. Many still reported fatigue (53%), shortness of breath (43%), joint pain (27%), and chest pain (22%).
This phenomenon describes a post-viral-syndrome to which we, as GP’s, are accustomed with other viruses. I am fairly used to seeing patients struggling with fatigue, myalgia and headaches after recovering from coxsackie virus, ebstein-barr virus and the like. This virus should be no different. Despite this post-viral-syndrome, and the persistence of symptoms, the evidence shows that patients no longer shed virus at this stage and are therefore no longer contagious.
As we progress on the path of learning about and caring for patients with COVID-19, the parameters become clearer and clearer. The clearer parameters become, the more we reduce the need for panic and the more we keep COVID-19 in perspective. For the vast majority of South Africans, COVID-19 is now a defined illness with a relatively predictable course. For those who are unfortunately thrown into the sea of ‘diagnosed with COVID’, may you now use this knowledge as a float.