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| If You Have Coronavirus Symptoms, Assume You Have the Illness, Even if You Test Negative | If You Have Coronavirus Symptoms, Assume You Have the Illness, Even if You Test Negative |
| (1 day later) | |
| You had some exposures that may put you at risk for coronavirus. A few days later you come down with a bad cough yourself and feel a little short of breath and really tired. You take your temperature: 101 degrees. A fever. | You had some exposures that may put you at risk for coronavirus. A few days later you come down with a bad cough yourself and feel a little short of breath and really tired. You take your temperature: 101 degrees. A fever. |
| You suspect you might have Covid-19, the disease caused by the novel coronavirus. The days roll into each other, and your doctor urges you to stay home unless your condition worsens. You feel pretty bad, though, and finally get an appointment. | You suspect you might have Covid-19, the disease caused by the novel coronavirus. The days roll into each other, and your doctor urges you to stay home unless your condition worsens. You feel pretty bad, though, and finally get an appointment. |
| They test you for influenza by sticking a swab far up your nose, and you are told the test came back negative, you don’t have flu. They tell you they are saving the Covid-19 tests for those who are even worse off than you are. You go home with a prescription for antibiotics, possibly because they don’t know what else to do, and read about celebrities who are testing positive but don’t seem so sick. | They test you for influenza by sticking a swab far up your nose, and you are told the test came back negative, you don’t have flu. They tell you they are saving the Covid-19 tests for those who are even worse off than you are. You go home with a prescription for antibiotics, possibly because they don’t know what else to do, and read about celebrities who are testing positive but don’t seem so sick. |
| A couple of days later, still with fevers, you go back, and the doctors relent and test you for SARS-CoV-2, the virus that causes Covid-19. They again stick something up your nose to what feels like the bottom of your eyeball. | A couple of days later, still with fevers, you go back, and the doctors relent and test you for SARS-CoV-2, the virus that causes Covid-19. They again stick something up your nose to what feels like the bottom of your eyeball. |
| They tell you that the results will be available in a couple of days and you go home and wait. Finally, the results come back and you are told you do not have Covid-19. Now what? | They tell you that the results will be available in a couple of days and you go home and wait. Finally, the results come back and you are told you do not have Covid-19. Now what? |
| This is a real patient’s story. In fact, it is a lot of people’s story — at least some version of it. Across the world, people with signs and symptoms of Covid-19 are testing negative and wondering what it means. They are not showing up in the statistics, and they are left in limbo about what to do next. | This is a real patient’s story. In fact, it is a lot of people’s story — at least some version of it. Across the world, people with signs and symptoms of Covid-19 are testing negative and wondering what it means. They are not showing up in the statistics, and they are left in limbo about what to do next. |
| The problem may be with the test. Current coronavirus tests may have a particularly high rate of missing infections. The good news is that the tests appear to be highly specific: If your test comes back positive, it is almost certain you have the infection. | The problem may be with the test. Current coronavirus tests may have a particularly high rate of missing infections. The good news is that the tests appear to be highly specific: If your test comes back positive, it is almost certain you have the infection. |
| The most common test to detect the coronavirus involves a process known as reverse transcription polymerase chain reaction, or RT-PCR, a jumble of words that describes a method capable of detecting virus particles that are generally present in respiratory secretions during the beginning of an infection. From a technical standpoint, under ideal conditions, these tests can detect small amounts of viral RNA. | The most common test to detect the coronavirus involves a process known as reverse transcription polymerase chain reaction, or RT-PCR, a jumble of words that describes a method capable of detecting virus particles that are generally present in respiratory secretions during the beginning of an infection. From a technical standpoint, under ideal conditions, these tests can detect small amounts of viral RNA. |
| In the real world, though, the experience can be quite different, and the virus can be missed. The best the Centers for Disease Control and Prevention can say is that if you test negative, “you probably were not infected at the time your specimen was collected.” The key word there is “probably.” | In the real world, though, the experience can be quite different, and the virus can be missed. The best the Centers for Disease Control and Prevention can say is that if you test negative, “you probably were not infected at the time your specimen was collected.” The key word there is “probably.” |
| False-negative test results — tests that indicate you are not infected, when you are — seem to be uncomfortably common. Increasingly, and disturbingly, I hear a growing number of anecdotal stories from my fellow doctors of patients testing negative for coronavirus and then testing positive — or people who are almost certainly infected who are testing negative. | False-negative test results — tests that indicate you are not infected, when you are — seem to be uncomfortably common. Increasingly, and disturbingly, I hear a growing number of anecdotal stories from my fellow doctors of patients testing negative for coronavirus and then testing positive — or people who are almost certainly infected who are testing negative. |
| Unfortunately, we have very little public data on the false-negative rate for these tests in clinical practice. Research coming out of China indicates that the false-negative rate may be around 30 percent. Some of my colleagues, experts in laboratory medicine, express concerns the false-negative rate in this country could be even higher. | Unfortunately, we have very little public data on the false-negative rate for these tests in clinical practice. Research coming out of China indicates that the false-negative rate may be around 30 percent. Some of my colleagues, experts in laboratory medicine, express concerns the false-negative rate in this country could be even higher. |
| Updated June 2, 2020 | |
| Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. | |
| Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. | Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. |
| States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. | States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. |
| Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. | Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. |
| Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. | Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. |
| If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) | If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) |
| More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said. | More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said. |
| Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. | Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. |
| The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. | The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. |
| If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. | If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. |
| If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. | If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. |
| There are many reasons a test would be falsely negative under real-life conditions. Perhaps the sampling is inadequate. A common technique requires the collection of nasal secretions far back in the nose — and then rotating the swab several times. That is not an easy procedure to perform or for patients to tolerate. Other possible causes of false negative results are related to laboratory techniques and the substances used in the tests. | There are many reasons a test would be falsely negative under real-life conditions. Perhaps the sampling is inadequate. A common technique requires the collection of nasal secretions far back in the nose — and then rotating the swab several times. That is not an easy procedure to perform or for patients to tolerate. Other possible causes of false negative results are related to laboratory techniques and the substances used in the tests. |
| So, where does that leave us? Even with more testing, we are likely to be underestimating the spread of the virus. For now, we should assume that anyone could be carrying the virus. If you have had likely exposures and symptoms suggest Covid-19 infection, you probably have it — even if your test is negative. We should all continue to practice the behaviors — rigorous hand washing, not touching the face, social distancing — that impede its spread. And we need better information about the performance of these tests — including any new tests that are introduced — in the real world. | So, where does that leave us? Even with more testing, we are likely to be underestimating the spread of the virus. For now, we should assume that anyone could be carrying the virus. If you have had likely exposures and symptoms suggest Covid-19 infection, you probably have it — even if your test is negative. We should all continue to practice the behaviors — rigorous hand washing, not touching the face, social distancing — that impede its spread. And we need better information about the performance of these tests — including any new tests that are introduced — in the real world. |
| Even as better tests emerge, we should always put the test result in the context of the other information we have. It’s a lesson that endures throughout medicine: Look at the big picture, not a single piece of data. Triangulate on the truth, using all the sources of information you have, no matter how good a single test. And don’t be shy about questioning a conclusion that doesn’t fully fit the facts. | Even as better tests emerge, we should always put the test result in the context of the other information we have. It’s a lesson that endures throughout medicine: Look at the big picture, not a single piece of data. Triangulate on the truth, using all the sources of information you have, no matter how good a single test. And don’t be shy about questioning a conclusion that doesn’t fully fit the facts. |
| Harlan Krumholz, M.D., is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. | Harlan Krumholz, M.D., is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. |