What a Negative COVID-19 Test Really Means

It’s still unclear how good COVID-19 tests are at finding these presymptomatic cases, but the timing of the test matters. As soon as the coronavirus finds its way into a new host, it hijacks cells to copy itself. The amount of virus builds over this time, peaking at or right before symptom onset, which can take two to 14 days but usually takes an average of five or six. Accordingly, public-health authorities have advised getting tested about four days after exposure.

This is a reasonable recommendation, given the knowns, but surprisingly little data exists on how early COVID-19 tests can detect infection before symptom onset. One model using COVID-19 cases from seven previously published studies suggests that the false-negative rate is 100 percent on day one of exposure, which falls to 38 percent on day five (when symptoms on average appear) and then a minimum of 20 percent on day eight. But in combing the literature, the researchers behind this model found only one case where a patient was tested before feeling sick—as part of a cluster at a chalet in the French Alps. Moreover, the model doesn’t address a whole other set of people who never develop symptoms at all. “It gave no information about people who are permanently asymptomatic,” Justin Lessler, an epidemiologist at Johns Hopkins University who co-authored that study, told me.

More data are likely to come soon. On Tuesday, the Food and Drug Administration released recommendations for labs and manufacturers that want to validate COVID-19 tests in people who don’t have symptoms. (Currently, no tests are FDA-authorized for screening asymptomatic people.) Testing large numbers of asymptomatic people—such as by pooling samples—to identify potential silent carriers will also be an essential part of the reopening strategy for schools and businesses.

For individuals, however, the FDA cautions that negative results do not rule out infection. It asks that asymptomatic tests include this statement: “Negative results must be considered in the context of an individual’s recent exposures, history, presence of clinical signs and symptoms consistent with COVID-19.” And this, in the face of imperfect COVID-19 tests, is key to interpreting a negative result. It depends on your probability of having COVID-19 in the first place.

Consider again the decision to visit elderly relatives after a negative test. “If you have symptoms or you work in a place where you’re at high risk for exposure, then even with a negative test, you might want to think really hard about it,” Steven Woloshin, a co-director of the Center for Medicine and Media at the Dartmouth Institute, explained to me. “If you’re at low risk because you live in some remote area, you’re practicing social distancing, you always wear a mask, and you feel fine,” a negative test is probably a true negative. So even with widespread testing, social distancing and masks will continue to be important for controlling the spread of COVID-19.

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Sarah Zhang is a staff writer at The Atlantic.