The number of people recovered from COVID-19 is rising. But what is ‘recovered’?

Each day the North Carolina Department of Health and Human Services updates its coronavirus dashboard with the number of new cases found in the state and the number of deaths.

One number goes unreported — the number of people who have recovered and been released from quarantine.

The number seems to be available. At least two Triangle-area counties — Alamance and Harnett — report their number of recoveries. Wake County does not.

With a disease that can be spread by people who are not showing symptoms, how do medical personnel know when someone has recovered? Is it that the person’s symptoms have subsided? Or is it that signs of the virus have cleared a person’s system?

Turns out, it’s a bit of both.

“When do you count someone as recovered versus when do you count someone as non-infectious may be two different things,” said Dr. Cameron Wolfe, a Duke University associate professor of medicine in the Division of Infectious Diseases.

According to Wolfe, physical recovery is most often based on symptoms, and it can be difficult to judge since some people with the virus may have minimal to no symptoms.

“Conversely, on the other end of the spectrum, some of the folks that we look after in the hospital unfortunately are so desperately sick that they may have residual symptoms or complications ... that last for months, if not longer,” Wolfe said.

Recovery from a contagion point of view is a different matter.

There is a test for determining an active coronavirus infection. Wolfe said it relies in part on the collection of a sample of secretions from the back of the nose and throat. Samples are collected on two consecutive days to see if a person tests positive or negative for an infection.

However, these tests may fail in a few ways.

For example, a clinician may fail to collect an adequate sample. Or a test may stay positive for a long time from detecting dead fragments of a virus, even if the person isn’t in danger of passing coronavirus on to another person.

There is also the lack of available test kits in the United States, which has made it difficult to use this method in some areas.

Another way of determining the end of a person’s ability to share the virus with others is based on what Wolfe called “a non-testing strategy.”

People are considered to be non-contagious if at least seven days have passed since they first developed symptoms, and if it has been three days since the resolution of a fever without the use of fever-reducing medicines.

Respiratory symptoms such as coughing and breathlessness also must have improved.

“Then you can come out of quarantine, so to speak,” said Wolfe.

Again, it’s difficult to use this method on someone who has contracted COVID-19 but not developed symptoms, and he acknowledged that a lack of access to tests for the virus has made it difficult to track.

Still, the non-testing strategy is recommended by the United States Centers for Disease Control and Prevention and the North Carolina DHHS.

The strategy is used by the Alamance County Health Department in Burlington, according to public information officer Arlinda Ellison, who said the health department received its guidelines from NCDHHS.

On April 13, the Alamance Health Department reported that the county had 39 confirmed cases. Twenty-one of those people had been released from isolation using the non-testing guidelines outlined by Wolfe.

Wolfe said he believed these guidelines had been adopted by most health departments in North Carolina.

Debra Hawkins, a public health administrator from the Hartnett County Health Department in Lillington, released a statement to The News & Observer that it was also following NCDHHS guidelines. Their Facebook page reported 33 confirmed cases of COVID-19, with 23 people having recovered.

Hawkins wrote that people who have been hospitalized for coronavirus infection or who have weakened immune systems may have to wait longer than seven days to be released from isolation.

Similarly, Wolfe reported that hospital staff tend to see people with coronavirus who are sicker, and who may still have a fever seven or eight days into their illness, and could therefore still be infectious.

“We have a number of people here at the moment who would say, ‘Look I was feeling OK, I was at home, I was feverish and having a cough but now suddenly here I am day seven or day nine, and I’m suddenly becoming that much more breathless,’” Wolfe said.

“That’s a more ominous turn for the worse that seems to happen after that one week mark. It’s pretty dramatic when it happens.”

Despite reports that some people are recovering from coronavirus and then relapsing, Wolfe said people who made it past three days without a fever and with reduced symptoms were not falling ill again.

“We would take it to the bank as being pretty reassuring if you’ve had that sort of consistent trend,” said Wolfe.

Jennifer DeMoss is a freelance writer. In 2019, she was an American Association for the Advancement of Science fellow with The News & Observer.