What to do if you get Covid

Guidelines on isolating, and possible treatments to reduce your risk of hospitalization

This is part of a collection of articles on Covid-19

Several people I know got Covid over the recent weeks. They were mild cases, as the vast majority of cases are. But though the vast majority of cases are mild, the risk of severe illness is small but real. In terms of Covid risk, what I primarily focus on is understanding the risk of severe illness and of long covid, and what are the best ways to reduce it.

In my previous posts I already discussed the best measures to reduce your risk of infection, and not getting infected in the first place is also the best way to reduce your risk of severe disease.

But what if you do get infected? What should you do then?

Generally, you should monitor your symptoms and recover while isolating at home, unless your symptoms become severe.

Summary (more details below):

• Isolate for 5 days ending with a negative test or 10 days if you can’t test; and wear a high-quality mask (N95 or similar) when you have to be in shared spaces. See below for more details.

• I suggest taking Paxlovid if it’s available and you have mild to moderate symptoms. It’s highly effective at reducing the risk of severe illness and likely reduces your risk of long covid. I recommend asking a doctor about it over the phone or online - try to avoid in-person visits unless your symptoms get more severe. (Updated now that Paxlovid is more widely available and the medical system is less strained.)

  • Here is an article about where/how to get Paxlovid if you don’t have a doctor or your doctor doesn’t prescribe it for you:

    How to Get Paxlovid Quickly, If You Get Covid

  • And here is another article listing several ways to get Paxlovid: https://www.npr.org/sections/health-shots/2022/05/11/1097698090/3-ways-to-get-covid-pills-if-youve-just-tested-positive

  • For Paxlovid to work you have to start taking it as early as possible, which also requires that you detect that you’re Covid-positive early.

  • Paxlovid is valuable as a preventative measure to reduce the risk of severe illness or long covid, so it’s still valuable when you don’t have severe symptoms (yet).

  • Paxlovid is extremely valuable to high-risk people, but even if you are healthy and at low risk, I think it’s still worth it if easily available to you.

  • You may also want to ask a doctor about other treatment options, such as monoclonal antibodies.

• I recommend taking a Vitamin D supplement of 2,500-5,000 IU per day. This is actually a general recommendation for general health, not just for Covid. You can avoid the risk of Vitamin D deficiency, which is surprisingly common (40% of US adults are deficient, and 5% severely deficient), at basically no cost. And as a bonus, it may be slightly protective against Covid.

• Check with your healthcare provider or state/local health department for care instructions and instructions on reporting information e.g. for contact tracing.

• Depending on location, you may be able to easily self-report a positive test result, e.g. the CA Notify app.

• This advice is mostly geared towards non-high-risk people. If you're in a high-risk group e.g. immunocompromised, you should contact a doctor about treatment options such as Paxlovid as quickly as possible. These can significantly lower your risk of hospitalization.

Some good info here as well: Twitter thread - Tatiana Prowell, MD. And you can see the official CDC guidance on What to Do If You Are Sick.

If I have Covid, how do I avoid spreading it to others?

tl;dr: Isolate for 5 days ending with a negative test or 10 days if you can’t test; and wear a high-quality mask (N95 or similar) when you have to be in shared spaces.

Protecting others is pretty much the same set of things as protecting yourself from Covid infection, just multiply the importance by 50x if you're known covid-positive:

• Isolate as much as possible. As much as possible, avoid shared air - use separate spaces for the person who is infected and the people who are not.

• Wear a mask when you need to be around others (well-sealed N95 or similar)

• Improve ventilation and use HEPA air purifiers and/or MERV-13 filters in your HVAC

It is very much possible to avoid spreading Covid to people you live with, especially if they're vaccinated and boosted, so don't give up on it just because Omicron is more transmissible. And reducing the amount of virus they're exposed to lowers severity of infection as well.

How long should you isolate after you get Covid? Here's my guidance (which is aligned with California's and different than CDC for very good reason):

• If you have access to rapid antigen tests: Assume you are still infectious until you have been symptom-free for 24 hours AND it has been 5 days since your symptoms started or your first positive test AND you get a negative antigen test result. You should isolate until then.

  • Antigen tests are a great indicator of when you are infectious, so waiting for a negative test eliminates the bulk of the transmission risk. (PCR tests continue to give positives for much longer so they aren't useful for determining when you've recovered.)

  • I would suggest to start testing after you're symptom-free and it's been about 5 days since your symptoms started or your first positive test. If you're around the 5 day mark and get a negative test result, I would wait for an extra 1-2 days before ending isolation to be more safe.

• If you don't have access to rapid antigen tests: There's a substantial risk that you're still infectious until you have been symptom-free for 24 hours AND it has been 10 days since your symptoms started or your first positive test. You should isolate until then.

It's a good idea to continue to wear a mask when around others for an extra couple days after this.

See this thread for a picture of why the onset of symptoms is earlier now due to vaccines, and therefore the time from symptom onset to end of infectiousness is longer.

The CDC guidance was shortened out of necessity, to keep essential services running because we'd run out of staff with the previous longer isolation guidelines. You shouldn't pay it too much heed, instead evaluate your own tradeoffs, in terms of what would it cost you to continue isolating vs what are the chances you're still infectious. (The CDC itself said that "after the 5th day after a positive test, an estimated 31% of persons remain infectious".)

How do I take care of myself when sick with Covid?

Here are some preliminary suggestions - this is much less well researched and much lower-confidence than most things I write, but I'm collecting the best information I've seen so far, mostly from Zvi's Omicron guidance.

First, quoting Zvi:

By default, recover while isolating at home. The medical system is there if you need it, but most of the time you will not need it. Trouble breathing is the biggest ‘seek treatment now’ sign, but I am not a doctor, this is not medical advice, and when in doubt call a real doctor.

I'll add one thing here, which is that a pulse oximeter, which measures your blood oxygen levels, is a good way to distinguish mild vs severe illness, which can give you some peace of mind or alert you if your illness is more severe than your symptoms suggest. They're available in pharmacies (over the counter) and online, and inexpensive, often available for ~$20. (I got one back in 2020 just in case, but you could just get one after you get infected if you're anxious and worried about whether you need to see a doctor.)

From Zeynep:

How you feel, subjectively, and what a medical doctor may think of as severe are not necessarily identical. Some of the symptoms are caused by your immune system fighting off the virus. That’s why besides the obvious signs like high fever, the saturation levels of oxygen in your red blood cells is a great indicator. If it falls below 95%, it may be time to seek medical help. If it is getting below 92-90%, it is an emergency, regardless of how you feel subjectively.

Do check how to use a pulse oximeter - two common issues that can prevent it from getting a good reading are cold hands and nail polish.

From Zvi again:

Vitamin D and Zinc, and if possible Fluvoxamine, are worth it if you get infected, also Vitamin D is worth taking now anyway (I take 5k IUs/day). Paxlovid is great (~88%) if available right after you test positive, but in very limited supply for now.

1. If you do have symptoms or test positive, take at least Zinc and Vitamin D. You should be taking Vitamin D regardless. This isn’t a statement that you shouldn’t take anything else, but there’s nothing else that I know rises to this level.

2. If you test positive, consider Fluvoxamine. It is an SSRI, so it’s not something one should take lightly or proactively, only when you know you’ve been infected. Again, I’m not saying not to take anything else that I’m not listing, I’m merely saying I don’t have this level of confidence in anything else that’s available. Merck’s pill increases risk of mutations and I now believe it should not have been approved, but it likely is good for your personal health outcomes if you can get it in time and adhere to the protocol. If you do take it, you really really really need to follow the full protocol exactly.

3. If you test positive and can get it in time, take Paxlovid. Paxlovid reduces hospitalization and severe disease by about 88%. If you’re young and in good health and don’t want to take from the currently limited supply, I applaud that decision until there’s sufficient supply.

Some links and very quick research on these (confidence in my own research: low, but Zvi’s research and guidance on Covid is very high-quality)

Paxlovid

Update: Paxlovid is now pretty widely available.

It’s highly effective and you should get it if possible. For it to work you have to start taking it early, which also requires that you detect that you’re Covid-positive early.

As of the original time of writing (January), supply was limited so it was mostly prioritized to high-risk people. It should have been available earlier (which also means potentially with more supply now) if not for our healthcare system’s usual bureaucracy.

Vitamin D

Confidence level: I’m confident it’s worth it overall, I’m not confident that the effect on Covid is substantial

Vitamin D - NIH COVID-19 Treatment Guidelines 

Vitamin D - Mayo Clinic 

Most of us are indoors a lot these days and at risk of Vitamin D deficiency in general - studies found 40% of the US population are Vitamin D deficient, and 5% severely deficient (sources: 1 2 3). And you can avoid this simply by taking a Vitamin D supplement. Pre-Covid, I specifically started taking a multivitamin for this reason, because the expected benefits easily outweigh the costs. It’s not necessary to know whether you’re Vitamin D deficient, you can just take a supplement regardless (my doctor recommended this to me).

However, the typical Vitamin D dosage in multivitamins is 1,000 IU which I believe is lower than optimal (but better than nothing!). I’d suggest 2,500 IU as a starting point - you can take one of the two gummies in a 5,000 IU supplement like these gummies. Up to 4,000 IU a day is considered generally safe. Taking a ton more than that may cause side effects, so I would probably stick with no more than about 5,000 IU (Zvi’s dosage, and a fairly common dosage you can find in supplements) to 6,000 IU (Fauci’s dosage). (See Austin’s post for more info on dosage and evidence.)

Overall, I take Vitamin D supplements to avoid the risk of Vitamin D deficiency, which is surprisingly common, and because it may be slightly protective against Covid - and there’s almost no cost. (If you don’t like pills, try gummy vitamins instead!)

Zinc

Confidence level: low

Zinc and the common cold - Wikipedia 

Zinc | NIH COVID-19 Treatment Guidelines 

Consider Taking Zinc Every Time You Travel

Note: only a few forms of Zinc work for this. You want acetate if possible, gluconate if not, and it needs to be a lozenge, not something you swallow. Zinc works by physically coating your throat to prevent infection, it’s not a nutrient in this case. You need much more than you think to achieve the effect, the brand I use barely fits in my tiny mouth.

Caveats: anything that does anything real can cause damage. The side effects we know about for zinc lozenges are typically low, but pay attention to your own reaction in case you are unlucky.

Zinc Lozenges Definitely Cure Colds, But Only If You Have the Right Kind   

And discussion thread on it with a text summary if you prefer reading over podcasts: Is this info on zinc lozenges accurate? - LessWrong 

Note: Zinc can have risk of causing permanent damage. "There have been several cases of people using zinc nasal sprays and suffering a loss of sense of smell" (Wikipedia) With lozenges, I suspect that the risks of short-term use are small, but there do appear to be concerns about long-term use of zinc.

The evidence for it helping with common cold appears moderate, and the effect size large, but the amount of effort involved is also quite nontrivial. The evidence for it helping with Covid appears quite weak, but it’s reasonable to have a fairly strong prior that its effect on the cold and Covid are most likely similar.

Overall, I'm not sure I see the point of using zinc once you’re sick, since it sounds like it mostly works to prevent infection, not as something you'd take after infection? Maybe if you use it early enough in the course of infection it still helps?

Fluvoxamine 

Confidence level: low

Common antidepressant slashes risk of COVID death, study says - Nature 

Omicron is here. What treatments can help if you get a Covid-19 infection? - Vox 

Fluvoxamine | NIH COVID-19 Treatment Guidelines 

I guess the idea is that if you have a worrying enough condition to consult a doctor, but aren't yet hospitalized, you can ask your doctor about it and they can potentially prescribe it to you to reduce your risk of hospitalization.