It’s virtually impossible to know how many people have recovered from Covid-19 because of inadequate testing, but one estimate is 18% of those who’ve contracted the disease, according to data collected by Johns Hopkins University. That number doesn’t take into account the countless people who weren’t tested and recovered at home, so it may be much higher. It’s also complicated by how the CDC classifies “recovery.”
According to the CDC, a person is considered recovered from Covid-19 when they test negative on two FDA-authorized tests spaced at least 24 hours apart, or if three days have passed since their fever broke without the use of fever-reducing medications, their respiratory symptoms improved, and it’s been at least 10 days since their symptoms first appeared.
The problem is, “improved” does not equal resolved, and fever and respiratory symptoms are only the tip of the iceberg of what many Covid-19 patients experience. “This infection causes remarkable inflammation that directly affects the lungs and could rapidly affect multiple other vital organs, affecting the whole body,” says Andres Romero, MD, an infectious disease specialist who’s been on the front lines of fighting Covid-19 at Providence Saint John’s Health Center in Santa Monica, California. “So even after the virus is gone, this inflammatory state will take some time to completely disappear.” This is why many people continue to experience symptoms long after their fever breaks.
The other issue complicating recovery is all the unknowns. Because doctors are still learning about how Covid-19 affects the body, there is no standardized guidance on how to approach post-infection care. “I usually tell my patients that they will need two days to recover for every day they spend at the hospital,” says Romero.
But what if you’ve been recovering at home for weeks and still don’t feel 100%? Or you are pretty much back to normal but want to help make sure your body is back in fighting shape? Here’s how experts recommend you navigate your recovery based on what’s currently known about Covid-19.
Contact your primary care physician
This is especially important if your doctor isn’t the person who diagnosed you. Opening up a line of communication gives you access to real-time support in case new symptoms arise or your existing symptoms worsen. Your doctor can also refer you to specialists, like a respiratory therapist, should you need additional care. “Every patient is unique so you really have to have a personalized approach to decide what to do when and how,” says Romero.
Monitor your symptoms
You may be feeling lots better, but there’s evidence that symptoms can rapidly worsen about a week into the disease for some patients, and many patients report multiple waves of symptoms, though doctors aren’t certain why. “Viruses are really, really smart and they have a way of tricking the human body,” says Romero. So stay vigilant. If possible, Romero recommends taking your temperature and blood oxygen levels with a pulse oximeter (your doctor may be able to provide one) twice a day. If your oxygen levels drop below 94% or you develop a fever above 100.4 for more than an hour or above 101 degrees Fahrenheit for any amount of time, contact your doctor.
You should also seek immediate help if you experience difficulty breathing, shortness of breath, persistent chest pain/pressure, confusion, bluish lips or face, the inability to stay awake or anything else that seems out of the ordinary — especially if you were previously admitted to the intensive-care unit — as this can be a sign that you may now require critical care.
Once your fever is gone for 72 hours, it’s probably safe to stop taking your temperature unless you start to feel feverish again. The same goes for measuring your blood oxygen levels, especially if it remains above 94% after exertion, like a walk around your home. However, “recovered patients should be followed closely by primary care doctors,” stresses Romero. “I would encourage using their guidance since every patient is unique and medicine should be personalized.”
It’s also a good idea to monitor yourself for any new ailments, even if they seem unrelated. Most adults who survive a stay in the ICU will experience aspects of post-intensive care syndrome (PICS), a constellation of symptoms such as impaired muscle strength, Alzheimer’s disease-like cognitive deficits, depression, and anxiety, that can last months, if not years. PICS isn’t a diagnosis — it’s a term that was coined about a decade ago to call attention to new or worsening symptoms after ICU care — and its connection to Covid-19 remains to be seen, but it is thoroughly documented in survivors of acute respiratory distress syndrome, the condition that leads the sickest Covid-19 patients to be intubated. Because PICS is relatively new, there may be limited awareness and understanding of it among health care providers. In other words, the onus is on you to advocate for yourself.
Many people lose their appetite when they’re diagnosed with Covid-19, but not getting enough calories can impede your recovery.
Get adequate sleep
Although the research is evolving, experts believe that a lot of the work your body does to heal — mentally and physically — happens while you’re asleep. “It’s hard for the body to recover if you’re sleeping two or three hours a night,” says Romero. “But you don’t need to sleep 12 or 14 hours either.” Instead, stick to the conventional guidance of getting seven to nine hours a night. Practicing good sleep hygiene can help you get there.
Increase your food intake
Many people lose their appetite when they’re diagnosed with Covid-19, but not getting enough calories can impede your recovery.
Inflammatory disorders like Covid-19 tend to be very catabolic, meaning that as your immune system revs up to fight the infection, your metabolism increases as well. If there isn’t enough energy available from food, your body will break down the most convenient source of fuel — your muscles, says Nadine Pazder, RDN-AP, an outpatient dietitian at Morton Plant Hospital in Clearwater, Florida, who has transitioned to working with hospitalized patients during the pandemic. This can lead to malnutrition, weight loss, and suppressed immune function.
As a result, dietitians like Pazder are focused on trying to get more calories and protein — one of the building blocks of muscle tissue — into their patients. “When we calculate energy requirements in the hospital, we base it on calories per kilogram of body weight,” says Pazder, “but that’s not really practical for someone at home.” Instead, if you’re losing weight, Pazder recommends increasing the number of calories you’re taking in by 25% to 30% and the grams of protein by 47% to 85%. For example, if you were eating 1,500 calories and 55 grams of protein a day to maintain your weight when you were healthy, then while recovering from Covid-19, you may need to bump that up to between 1,875 and 1,950 calories a day and 81–102 grams of protein. However, personal needs vary, especially if you have an underlying health condition, so it’s best to tweak your diet under the care of a doctor or dietitian and only return to normal eating patterns once they feel like you’ve adequately recovered.
In terms of what you should be eating, some scientists have theorized that certain vitamins and minerals may be helpful to help quell the inflammation associated with Covid-19, but there’s nothing on their list that you would need to take as a supplement. “Eating a well-balanced diet that provides all of the needed vitamins and minerals is really the best approach,” says Pazder.
If your prior eating habits weren’t great, consider adopting a Mediterranean-style diet. It’s built around nutrient-rich, inflammation-fighting foods such as brightly colored fruits and vegetables, healthy fats, whole grains, nuts, seeds, and lean sources of protein. If your energy is low, Pazder suggests keeping food in the house that doesn’t require a lot of preparation, like hard-boiled eggs, or making a big batch of something that you can eat over the course of a few days.
If you can’t stomach that much real food, add a protein shake or liquid nutritional supplement, like Ensure, to what you’re already eating. It’ll provide added calories and some much-needed hydration. (“If you’ve been running a fever, even if it’s a low-grade fever, that increases the amount of fluids you need,” says Pazder.)
If you start to lose weight, your energy doesn’t improve, you’re not urinating as much as usual, or you’re just concerned that you’re not eating or drinking well enough, contact your doctor or a registered dietician at your local hospital. “They may end up seeing you through a telehealth appointment, but the help is out there,” says Pazder.
Ease back into exercise
The key word here is “ease.” You’re not going to be able to jump right back into your normal daily activities, let alone your regular exercise routine. After critical illness, about 70% of people experience physical complications, such as impaired muscle strength, lung function, and walking ability, according to research. And “even if you just had a fever and you’re lying in bed for two days, your muscles literally start to become deconditioned after just 24 hours,” says Theresa Marko, DPT, a board-certified orthopedic clinical specialist in physical therapy and owner of Marko Physical Therapy in New York City.
“I definitely think it’s good for people to get moving. Your body will let you know how much you’re able to tolerate.”
Doctors often recommend the “neck check” when deciding whether it’s safe for someone to resume exercise after an illness. In other words, if your symptoms are confined to above the neck (that is, runny nose, minor sore throat), then you’re okay to exercise as long as you feel able. However, this advice is based on weak scientific evidence and ignores the potential risk of a respiratory tract infection leading to other complications, like inflammation of the heart muscle, a condition that’s popping up among Covid-19 patients.
Given this development, researchers have started issuing new suggested guidelines on when to return to sport. One set, published in The Lancet Respiratory Medicine, suggests waiting at least 10 days from the onset of symptoms and/or seven days from when your symptoms subside. A second set, published in JAMA Cardiology, recommends that Covid-19 patients with mild symptoms wait until two weeks after their symptoms have subsided and they’ve been able to be evaluated by a doctor.
“I definitely think it’s good for people to get moving,” says Romero. “Your body will let you know how much you’re able to tolerate.” For some, that may be a short walk a few times a day. Other people may be able to start with some gentle intervals: jogging 30 seconds, then walking for two minutes. The key to safely progressing, says Marko, is to only increase one variable (for example, time, frequency, intensity) at a time. (This Covid-19 recovery guide, from the Departments of Rehabilitation Medicine at Columbia University Irving Medical Center and Weill Cornell Medical Center, which is part of the New York-Presbyterian Hospital System, includes a helpful and thorough exercise plan.)
If you develop chest pains, heart palpitations, exhaustion, dizziness, or light-headedness during exercise or are in pain or having trouble returning to normal functioning during your downtime, stop exercising and contact your doctor or a physical therapist — thanks to direct access laws, you no longer need a physician’s prescription or referral to see one. “Look at us like your personal mechanic,” says Marko. “Come to get assessed, see how you’re doing, and get a fitness plan so that you don’t injure yourself.”
Protect your mental health
Prioritizing your mental and emotional well-being is essential, even if you don’t have a preexisting mental health condition. Not only does chronic stress lower immunity, but over time, it can lead to both physical and emotional issues.
“Once somebody goes through trauma, whether it be physical or emotional, they may no longer see the world as safe,” says licensed psychologist Renee A. Exelbert, PhD, founding director of The Metamorphosis Center for Psychological and Physical Change in Nyack, New York. “They experience it in a different way. So there are a lot of identity changes going on.”
And often those changes are delayed. “Sometimes when somebody is going through the actual medical emergency, they’re so focused on just getting well that it’s not until months later that they process what actually happened to them,” says Exelbert, who often treats patients who have survived a medical trauma. This happened after the 2003 SARS outbreak: Survivors had higher stress levels during the initial spread, and one year later, nearly two-thirds were also experiencing significant levels of depression, anxiety, and post-traumatic stress symptoms, according to a study in the Canadian Journal of Psychiatry.
That’s why it’s important to be proactive about self-care. Exelbert recommends doing anything that gives you a sense of power and control. For instance, exercise if you’re able, keep a gratitude journal, bake a cake, or practice grounding techniques.
Most importantly, if you’re anxious, depressed, having difficulty sleeping, experiencing flashbacks, using drugs or alcohol more than usual, or experiencing any other common signs of distress, ask for help. The National Alliance on Mental Illness has compiled a great list of resources.
Listen to your body and be patient
Once your recovery is underway, you’ll eventually have to decide (with the help of your doctor) when it’s appropriate for you to leave quarantine and/or return to work — either at home or, depending on where you live and what you do, at an outside workplace. With all the uncertainty over how long people remain infectious and whether immunity exists, this can be stressful. You may worry about getting sick again or infecting others, or feel guilty that you’re not able to parent your children or perform at work like you normally would. These feelings are normal. Take your time and lean on your support system. There is no ideal or expected timeline.
“This time period of Covid-19 presents many unique challenges, however, in normal everyday life, people experience emotional hardships that can prevent them from effectively carrying out their duties,” says Exelbert. “It’s about utilizing the Family Medical Leave Act and seeing what you’re legally entitled to and communicating with your boss about what might be helpful.” Be open and honest with yourself about what you can handle right now so you don’t push through, causing yourself more stress and anxiety. But do try to return to work. “It’s almost like when you have a car accident,” says Exelbert. “The longer you stay away from driving, the more frightening the car is going to become.”
If you are able to, or need to, leave your home and/or return to work, take common-sense precautions — like wearing a mask and washing your hands properly — and follow the recommended guidelines of your local authorities. Experts don’t yet know what causes a Covid-19 relapse or if reinfection is even possible, so take heart in knowing that following this advice is the best that anyone can do. Full recovery may take a while. And that’s okay. “There’s a term in trauma literature,” says Exelbert. “It’s post-traumatic growth, which means that after we go through a trauma, we not only bounce back from it, but we grow even more.” Make that your goal.