The COVID Conundrum…Did YOU Have It, or Not?

The COVID Conundrum: If you had classic symptoms of COVID- high fever, chills, fatigue, muscle aches, cough, shortness of breath, new loss of smell or taste, GI symptoms- but a negative test, no test, or negative antibodies, did you REALLY have COVID?

And, well,…does it matter?

After dealing with this question both professionally (I focus on college health) and personally (read about our family’s experience with COVID), here are my thoughts:

First: Yes, you can have COVID without testing positive (but also, maybe not).

1. As with many diagnoses in medicine (like flu and strep), your doctor’s clinical judgement is more important than a single test. Tests help guide us, but they are not perfect. We have to look at the whole picture of your illness in context, in addition to your tests. For example:
   1. If you have known exposure to COVID (family member or a close contact tests positive) and then you develop symptoms within a week, you are very likely infected, regardless of your test results.
   2. If you develop classic symptoms and your community has a high prevalence of COVID, you are likely infected.
   3. On the flip side, if there is almost no COVID in your community and you have a positive screening test and no symptoms, you most likely do NOT have COVID.
2. What about people who had “awful flu symptoms” in very early 2020 but had negative flu tests? We had NO tests back then, so could that have been COVID?
   1. If you had traveled internationally, just finished a cruise or attended a conference with many international travelers…maybe, but otherwise probably not.
   2. We know COVID was in the US before we started looking for it, but evidence (like lack of severely ill people in hospitals with unknown diagnoses at that time) suggests it was not widespread here before March.
   3. Can you get a COVID antibody test now to see if that’s what it was? No- even if you developed COVID antibodies back then, it appears these antibodies are often only detectable for a couple months.
3. False negative antigen tests abound from a combination of poor swabbing technique, processing delays and technical errors.  Hopefully newer tests, better techniques and more experience should greatly reduce this issue moving forward.
4. COVID antibodies take time to develop, so testing too early (especially less than 14-21 days after the start of symptoms) can give you a false negative result.
5. Finally, NOT EVERYONE who has COVID develops detectable antibodies (with our current tests.) This recent large study in Spain showed that despite living in an area of high COVID prevalence, only 5% of people tested positive for antibodies. Additionally, even 10% of people with confirmed positive COVID antigen tests still tested negative for antibodies. Other studies have shown closer to 20% of patients with confirmed COVID do not make detectable antibodies. (For example, this smaller study where 81% of confirmed positive COVID people without symptoms and 83% of confirmed + COVID with symptoms developed COVID antibodies.) Complicating these statistics, there are different types of antibodies (IgM, IgG, IgA) and different specific antibodies (some which effectively neutralize the virus, while others do not.) We obviously still have MUCH to learn and understand about COVID.

SECOND: Does it MATTER whether or not you had COVID? YES…and no.

1. YES, because:
   1. We are learning more about long term consequences of this disease, primarily in those with persistent symptoms (like fever, fatigue, and cardiovascular symptoms) but we simply don’t yet know all the ways this disease might affect our bodies down the road. With examples of viruses causing adverse effects far downstream- like HPV causing cancers and chickenpox causing shingles- we know that viral effects don’t end when the first symptoms disappear.
   2. Although it may be possible to get COVID a second time (as reported from a few scattered cases), at this point it looks like most people will be relatively protected from a second round of COVID for at least six months or possibly a year, which may be a bit reassuring for people with high exposure-risk jobs or at-risk family members.
2. NO, because:
   1. Having COVID does NOT give you an indefinite “immunity passport”. Although you are less likely to contract a new case of COVID in the near future, you need to assume you CAN catch one, and therefore continue to follow the same masking, social distancing and sanitizing precautions. Psychologically, it’s REALLY hard not to relax your precautions after you’ve survived one round…but it’s important.

BOTTOM LINE: Many people are frustrated trying to figure out whether or not they have had COVID. Please talk with your doctor, work together, and KEEP wearing your mask, social distancing, and washing your hands/sanitizing for the FULL 20 seconds (Don’t splash and dash!)