When is someone contagious?

 

When is someone contagious? Some of the most common questions that I get as an advice nurse revolve around when kids are contagious and at what point are they ready to go back to school, daycare or nanny-share. Wouldn’t it be nice if there was a little human equivalent of the butterball turkey pop up timer that could easily signal if someone is contagious or not? Alas that doesn’t exist, so we have to do the best we can. Covid adds a whole extra layer of stress into this discussion. I need to remind everyone that MOST of the illnesses that we are seeing are the same ones that we have been dealing with for generations. Kids who are around other kids get sick. That’s simply the way it is. Of course, we want to be responsible parents and not expose others to our sick child. We also want to protect our own recovering child from going back into the 'germ pool' too quickly. If they are just getting over something, their immune system may be a bit diminished and they are vulnerable to coming down with something new. What makes it even more challenging is that kids aren’t always accurate reporters about how they are feeling. For older kids, some are reluctant to miss school and will put on a brave face. Maybe they have a test that they don’t want to miss, or really want to be with their friends. These kids will push themselves to return as quickly as possible. Others will earn an academy award convincing you that they really need to stay home in bed. Another consideration is that some parents can take time off to stay home with their little sick child and others simply can't afford to. It is naive to think that these aren't real factors.  Early warning signs Many kids may be a little fussier than usual. Perhaps they don't eat quite as much. Most savvy parents know enough to be suspicious when their 5 year old who fights naps with a vengeance announces that they are going up to have a daytime snooze. Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? It isn’t always an easy answer. Figuring out if someone is contagious or not is almost never clear cut. What makes it all so tricky is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Also, as discussed below, tests for illnesses like covid are not always accurate at the beginning of an illness. The fact is, if your child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return. Lets address Covid first According to the CDC, the incubation period for Covid-19 is thought to extend up to 14 days, although the average is 5-6 days. This means that if 2 weeks go by after an exposure, you are most likely in the clear. Some young children may catch covid and become infectious without ever exhibiting any symptoms. For those that do develop symptoms, they usually show signs of illness long before that 14 day mark. Testing for Covid There are 2 kinds of tests for Covid. The PCR/NAAT is a very sensitive test that looks for any genetic material on a surface (such as a nostril). You would likely get this test from a doctor's office or lab. These are great to find out if you have COVID or not, but because the DNA fragments can remain in the nostrils for days to weeks, they will still show up as positive even after someone is no longer contagious. This makes them somewhat useless if you are trying to figure out if you can stop your isolation.  The rapid antigen tests are the ones many folks have at home. These tests look for large chunks of virus pieces that are signatures of Covid (the “spike” protein). A negative antigen test in the first day or two is not necessarily accurate because the virus can replicate in other parts of the body (i.e. the throat or bloodstream) without leaving accessible spike proteins in the nose. So if you have been exposed and have symptoms, retest in a couple of days or check with the PCR options before you take that negative test to heart. On the other hand, after the infection if you test negative with the home tests it means you are likely no longer contagious Quarantine versus isolation. Quarantine means staying home after an exposure but before symptoms start. It was common practice at the beginning of the pandemic but is no longer recommended as a strategy for controlling COVID-19. Isolation means staying home and away from others in your household if you have symptoms or you test positive. If you test positive, contact your doctor to see if you should receive treatment. There is no need to isolate from family members who are also testing positive. Here are the 2023 CDC exposure and isolation guidelines If you were exposed but have no symptoms Regardless of your vaccination status: Get tested immediately and 3-5 days after last exposure* Wear a good mask when around others for 10 days after exposure, even at home if other people are present If you test positive, isolate *If you had COVID-19 within the last 30 days: You don’t need to test after exposure unless symptoms start If symptoms start, isolate and get tested If you test positive, whether you have symptoms or not Regardless of your vaccination status or infection history: Isolate for at least 5 days Sleep and stay in a separate room from those not infected Use a separate bathroom if you can Wear a mask around others, even at home You can end isolation early, after Day 5, if: You have no fever for 24 hours without taking fever-reducing medication, AND Your other symptoms are gone or improving If you still have a fever, continue to isolate until the fever is gone for at least 24 hours If other symptoms are not improving, continue to isolate through Day 10 If after Day 10 you still have mild symptoms (runny nose, cough, fatigue) that are improving and no fever, you can end isolation no matter what. After you end isolation: Wear a mask around others for 10 full days after the start of symptoms. If you have no symptoms, wear a mask for 10 full days after your positive test. You may remove your mask sooner than Day 10 if you have two negative tests in a row, at least one day apart.(remember the PCR test will probably still be positive, so use the at home antigen tests) For children who test positive: Children under 2 years can end isolation after Day 5 Children 2 years and older should follow the steps above for ending isolation Okay…Thank you to the CDC for their guidance, but how realistic is it to actually successfully avoid contact with family members? It is very difficult to isolate siblings. Of course be scrupulous with your hand washing, avoid sharing utensils and sloppy wet kisses, but in many cases it is hard to avoid catching each other’s cooties. They were also likely to have been exposed to each other before you knew anyone was sick. If you have a newborn, keeping the sick toddler away from the baby is a worthy goal, but don’t beat yourself up if it is simply not possible. Breastfeeding moms, sorry to say that by the time you realize you are ill, it is too late to prevent an exposure. Hopefully the magic of breast milk will protect your baby, but we would generally suggest that you continue nursing while masked. As an aside, breastfeeding moms, if you are sick, it is especially important to make sure that you are getting plenty of fluids. Also, if you are given medication, check with your nurse or doctor’s office to see if it is compatible with breastfeeding. (spoiler alert: Paxlovid has not been cleared for nursing moms. Tamiflu is probably fine) So how important is it to get an actual diagnosis in the first place/ In other words, is it worth sticking a swab up your toddler’s nose? These days, some doctors rely on symptoms and don’t always bother to test. If you are a candidate for taking Paxlovid then it is worthwhile finding out if you have Covid or not, but some folks don’t bother. If you have an infant or vulnerable family member it is nice to know what you are dealing with. However if you aren’t inclined to test and treat make sure you monitor and if symptoms warrant, make sure you go and get checked.  Coughs, colds and other viruses Most of the illnesses are NOT covid. As far as common colds go, the average child under 2 years of age has EIGHT symptomatic colds a year. Frankly, if you plan on keeping your child at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house. Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause. (There is debate about whether or not teething is associated with congestion. Nurse Judy votes yes.) While I would strive to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing the immune system. At some point they are going to have to deal with the myriad of illnesses that make the rounds. During the first couple of years of the pandemic, kids were kept in a bit of a bubble and did not get the normal amount of coughs and colds. Guess what, the minute we got back to being with others and loosened the mask wearing, most families got overwhelmed with all of the respiratory infections. Hand Foot Mouth questions come up a lot.  I respect that schools want to keep this yucky virus from getting spread around. Unless you have been on a break, there is a reasonable chance that the infected kids likely got it from school in the first place and/or were contagious before they were identified and segregated. Patients can actually shed that virus in their stool for several weeks. Since I don’t think schools are able to genuinely keep children out until they are completely clear, I suggest common sense guidelines.  If they have a fever, keep them home. If they are fussy and miserable, they will be much happier at home with mom or dad. If they seem to be feeling okay and are fever free, for the above reasons, I don’t think it is reasonable to exclude them from daycare/school until all the blisters are completely cleared.   I know that the name alone makes parents shudder, but this is one of those illnesses that most kids end up getting. Think of it as a rite of passage. It is actually better to get some of the childhood illnesses out of the way. Unfortunate adults that lack immunity and catch these illnesses are pretty miserable. The American Academy of Pediatrics says that kids can go back when they’re fever free, feel up to participating, and don’t have many open weepy blisters (dry ones are okay). With most viral syndromes time is the ultimate healer. However, If you suspect the flu, it might be worth getting seen and tested. As opposed to most viruses, influenza hits quickly and hard with a ‘hit by a truck’ feeling. Once you get a positive flu test there are treatment options that can be useful if started within the first few days of symptoms. Bacterial infections  If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours. Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops (of course you need to finish the course.)   So can you go on that play date? Regardless of the illness you are dealing with, if you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event or vacation coming up and want to be more cautious. Maybe someone is pregnant and hasn’t told people. We never know exactly what other families are dealing with. Let them decide. Full disclosure ahead of time is the best practice. If you are in a small share-care situation It is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page. I would suggest that you agree that the kids will have a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each other’s mild illnesses. Typically if I have a child with a fever over 101, a new case of diarrhea, or a brand new cold that has them spewing green mucus it is worth keeping them home for at least a day or so to see what is coming next. Just this week one of Dr. Ted’s patients asked him, “I was dropping my kid off at daycare and saw all these kids with crazy snotty noses. How can you tell me they aren’t contagious?” He reminds parents of two things: First, what are you going to do about it? Kids under five essentially live their entire winters with runny noses, and kids who are kept in a bubble without exposure to the community germ pool will do the whole process when they start kindergarten. After a virus, the body’s mucous membranes have been damaged, and the virus has left behind plenty of inflammation. As the immune system clears the debris, there is a lot of swelling and leaky fluid membranes. This is where that persistent runny nose and lingering cough come from. It is not necessarily an active infectious virus that causes these symptoms.  We wish there was a magic light that signaled the "all clear." Alas, there isn't. Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.  Thanks to Dr. Ted for his valuable wisdom and input! Thanks to Sylvie’s mom Leah (just getting over covid) for helping me identify some of the questions that needed to be addressed