By Dr Edward Nazareth
Aug 19: Sudheer (name changed) was shell shocked when his nephew Samuel got a positive report after a COVID19 test. Samuel who had come on holidays from Dubai was stranded here due to lockdown. He had booked a ticket to fly back and as per requirements he went for COVID test two days prior to his departure. Samuel is a healthy young man; he had no symptoms of any illness. Within three days the reports of Sudheer, his wife and two children were also positive. None of them had symptoms. No one knows how they got infected, they could only wonder if Sudheer got it from his office or Samuel got it from his local friends. The big relief was when health authorities informed them that they need not get admitted to the hospital and can remain in their house. They had to follow certain norms.The health authorities stuck a poster on their compound wall to alert the neighbors.The entire neighborhood was anxious about an infected family staying there. They wanted the family of Sudheer to be shifted to some hospital. As the number of COVID19 positive cases are rising steadily, the authorities have now allowed positive individuals (infected by the virus) who are asymptomatic or with mild symptoms to confine themselves to their houses. For home isolation the authorities have given certain guidelines with an aim to safeguard the infected person and the family members staying with that infected person. These guidelines are not easy for everyone to follow as there is lot of apprehension, fear of contracting the virus and wrong perception about the disease itself.
The earlier attempts to educate people about the infection has created undue stigma. The people who protested against performing last rites of the deceased positive individuals in their neighborhood would naturally oppose the positive individuals from staying close to them. In an attempt to reduce social stigma, the government of Karnataka while revising the guidelines of ‘home isolation’ recently have changed the use of the term ‘home isolation’ to‘home care’. This may not have greater impact on de-stigmatizing positive cases, unless the negative attitude towards the infection is changed.
Mainly because of the stigma, many of the family members have no other option but to keep the infected person in private hospitals paying hefty charges. Mean time, private facilities are not feasible to all because the expenses involved in keeping a positive individual in a common ward of a private hospital is many folds higher compared to a patient of some other illness.
With this background, it may be better if we have clear information about ‘home care’ of an infected person. The COVID19 virus is highly infectious, but not dangerous in healthy people irrespective of the age. The vulnerable are to be protected and others have to take care while living in the same house with an infected person.
Who can opt for ‘home care’
Most people, except a few, irrespective of their age, if asymptomatic and or with mild symptoms can opt for home care. Earlier, for allowing an infected person to stay in the house, personal verification by a medical officer was required, now any health official can decide this through telephonic conversation. The exceptions for home care are the immune-compromised patients such as HIV patients, transplant recipients and those on cancer therapy. The people who have received cancer therapy years ago and are healthy now can be kept in home care.
Earlier, people above the age of 60 were admitted to the hospital or shifted to covid care centers. As per the current guidelines, all the elderly need not be admitted to the hospital as long as they do not have symptoms. The elderly individuals aged more than 60 years and those with co-morbid conditions such as hypertension, diabetes, heart disease, chronic lung or liver or kidney disease, previous stroke disease are to be evaluated by a physician and can be allowed home care if they are fit. Many senior citizens, irrespective of age related co-morbid conditions who are able to maintain good health can remain at their houses even if they are infected by COVID19 virus. They only require to be monitored closely by a responsible family member.
Earlier the pregnant ladies with positive COVID19 report were advised to be hospitalized. Now they can be at home care till two weeks before expected date of delivery. Even the breast feeding mothers are allowed home care after evaluation by a physician or a family doctor.
With these modifications, the burden of managing COVID19 patients in the government hospitals has reduced. Only those who really require care will be admitted to government facilities where the care is totally free. However, many of the private hospitals admit the infected persons with or without symptoms and keep them in isolation wards. They are monitored for deterioration of health by the medical team.
Requirements at home
The infected person opting for home care has to have a separate well ventilated room, ideally with a separate wash room at their house. The main objective is that they should not infect others at home especially the elderly and vulnerable. If there are senior citizens with co-morbid conditions, the possibility of complications of the infection is high. It is advisable to isolate them completely from the infected person. They may be sent to a relatives’ house if possible. If they are staying in the same house, extra care is needed to avoid infection.
Most important is that elderly and vulnerable people should not share the same room with the infected person. Whenever such facility is not available, the infected person may have to be moved to covid care centers established by the government where the total care is free of cost.
In many of the situations the infected person would have stayed with other family members before being tested positive. All other members of the family or in the neighborhood who had contact with the infected person two days before testing should isolate for ten days or go for testing, even if they don’t have symptoms themselves.The 10-day period starts from the last time they were in contact with the person who is tested positive. The tests for COVID19 infection are done free of cost in government hospitals and even in primary health centers.
The individual who is tested positive should strictly remain in the room identified for them. When inside the room alone, wearing a mask is not needed, however if there is possibility of other people entering the room, surgical mask or N-95 mask has to be used. The other family members also are required to use the masks. The surgical masks have to be discarded after using for 6 hours. N-95 masks are expensive can be used again after 5 days. The surgical masks are less expensive and suitable for home care of COVID19 positive individuals.
The infected person should have their personal items like eating utensils, dishes,drinks, bath/hand towels, wash cloths or bed linen etc and these should not be mixed with similar items used by other family members and should be cleaned separately. These items are to be soaked in 1% sodium hypochlorite(bleaching powder) solution or 70% Lysol for about 30 minutes and then to be cleaned. The wash room including fixtures and toilet surfaces are also to be cleaned using a similar solution at least once a day. The furniture, door knobs, remote control of television, mobile phones and all similar items are also to be cleaned using disinfectant solution.
The infected person should have good balanced food which may be prepared at home. No extra diet is needed, normal family meals and food can be taken.The person is required to take plenty of fluids (in the form of cooled boiled water and fresh fruit juices). Adequate sleep is desirable.
In most of the places, the government health officials provide vitamin and zinc tablets which can be taken, though they are optional. Normally no other medication is needed. The guidelines suggest hydroxy chloroquine for the family members as prophylaxis; however its role is not officially approved.
The most important is to have a digital thermometer and a finger tip pulse oximeter. These are better to be bought from authorized surgical shops. The body temperature has to be checked in the armpit using the thermometer and oxygen saturation at the finger tip using pulse oximeter. The temperaturehas to be less than100.4 degree Fahrenheit (or 38 degree Celsius) and oxygen saturation has to be more than 95%. This has to be checked thrice daily and if any variation then medical assistance has to be sought.Though rare in healthy individuals, drop in the oxygen saturation may be the earliest sign of deterioration of health in a COVID19 infected person.
Positive attitude with the positive
It is not easy to take care of the positive person at home, unless the family members have positive attitude about the infection. Though COVID19 is highly infectious it is not as dangerous as we perceive. More than 80% of the infected persons do not show symptoms, do not become sick and only a few need hospital admissions. The complications are more in those with other co-morbidities irrespective of age. As stated above, if there is an infected person at home, the elderly and vulnerable need to be isolated. It would be better to remain in a different house if possible. Though the immunity is relatively less, the complications from the disease are not common in children. However, if there is provision, even children below the age of 10 years may be isolated from the infected person.
The family members should wear surgical facemask especially when in the same room with the Covid positive person. It is important not to touch the front portion ofthe mask during use. Maintaining a physical distance of at least 2 meters (6 feet) from the infected person is also important.
Frequent washing of hands with soap and water at least for 30 seconds can reduce the possibilities of infection. Disposable gloves are to be used while handling an infected person or the materials used by the person. If the positive person is to be helped to clean his room or to wash the utensils, clothes etc by others, they need to wear gloves which are to be removed as soon as the cleaning is done and hands are to be washed. Wearing a set of gloves through the entire day and washing the gloved hands is not advisable.
Warning signals
Though most of the healthy individuals with COVID19 infection do not develop complications, the signs of deterioration should be known to the family members. They should watch for them. When any of the following is noticed the health officials should be informed immediately.
• If the person finds it difficult to breathe, hospitalization may be required. Other signs such as pain or tightness in the chest also need evaluation.
• Mental confusion, slurred speech, semi-comatose (not responding properly) or convulsions requires immediate hospitalization.
• Reduction in the oxygen saturation to less than 94% continuously in the pulse oximeter is again a warning signal of impending problem.
• Persistent fever of more than 38 degree Celsius (100.40 Fahrenheit) for more than 24 hours is again not a good sign and medical assistance has to be sought.
When to end ‘home care’?
All these restrictions can be terminated after 10 days of testing or if there is no fever for 3 days whichever is later. Thereafter, the person is advised to continue isolating at home and self-monitor their health for another one week. There is no need for testing again after the home isolation period is over.
Covid Care Center
If a COVID19 infected individual with no symptoms (asymptomatic) or with mild symptoms cannot be looked after at their residences for whatever reason (as decided by the health officials), they have the option of moving to ‘Covid Care Centre’ established by district authorities.Covid Care Centers are hotels, hostels, halls, etc., which have been turned into facilities for COVID patients. All these are equipped with pulse oximeter, handheld thermal scanners, and other essential items. They are also supposed to have one nurse per 500 patients at all times. People are normally kept there for 10 days.
Some questions
1. I went for testing as two of my colleagues were tested positive. Unfortunately my report was positive. I stay with my parents who are more than 65 years and have diabetes as well as hypertension; but are under control and on medication. Two days after my test, they too were tested positive. My wife is positive, but my son who is 5 years is negative. The people from health department have advised all of us to stay at home. We are worried about my parents and my son. I cannot admit my parents to the hospital as there is no one to stay with them. My relatives are scared to take my son with them and he is also not ready to leave us.
** You need not worry about your parents or son as long as they do not develop symptoms. Your son might have contracted the virus, but the virus has not infected him. It is possible in children.
You need not admit your parents to the hospital now as they do not have symptoms. Keep a watch on your parents, record their body temperature and oxygen saturation thrice daily. If any change, you may contact the health officials for guidance. In most of the situations, even in healthy individuals with co-morbid conditions the infection may not cause complications.For about 10 days you have to be cautious about your family.
2. My husband has tested positive for corona virus. He is advised home isolation.We have two children and a domestic help with us. None of us are positive. We are staying in the apartment and the association of the apartment has informed that we should not move out of the house for two weeks. They have offered to help us to get required items. As we are negative, can’t we go out?
** Though you are negative so far, there is a possibility of you getting infected and infection might pass off without symptoms. You or your children may not know that you are infected.In such a situation, if you move out of the apartment, it is possible that you may infect others who come in contact with you or your children. As your neighbors in the apartment have offered help, you can get the required items through them. It is better for your family members to cooperate with your neighbors for 10 days till your husband completes the home isolation period.
3. We are five members in the family and all are tested positive for COVID19 infection. We are advised home isolation. When inside the house, do we require to wear mask? Do we require to have individual thermometers and pulse oximeter?
** Theoretically, once a person is infected by COVID19 virus, the re-infection should not be a problem as the body develops antibodies to fight re-infection. How the system reacts to re-infection that too while still in the disease by the original infection, what happens in the body is not known yet. We do not know whether re-infection passes off after the original infection or whether it causes complications.
It is possible to get re-infected by a heavy viral load when many infected people are staying together without taking precautions. This can complicate an asymptomatic or mild disease status.(This is not yet proved, but an assumption).Therefore it is better to take precautions like wearing masks, maintaining social distance, washing hands frequently, and using gloves while dealing with the materials used by other infected persons.
However digital thermometer and pulse oximeter can be shared by others. After use by a person it can be disinfected by using 70% Lysol solution or with a sanitizer containing 70% alcohol. Cotton dipped in the solution may be used to wipe the surfaces.
4. Though it is easy to advise, it is very difficult to follow the guidelines of home care. Many people do not have facilities in their houses. There are no beds in the government hospitals and people are scared to go there. It is very expensive in the private hospitals; they simply have raised the charges and have made it impossible for poor people to go there. What is the solution?
** We have wrong notion about the government facilities. Many of us have perceived these without visiting the government hospitals. It is true that they are not up to the standard of corporate hospitals, but are not too bad. I have done my entire training in the government hospitals decades ago and even at that time the facilities were enough for managing common health problems. Over the years the facilities have improved. Many people are being treated for COVID 19 infection in government facilities and have recovered.
At present if anyone has suspicion of COVID19 infection, he/she can go to the nearest government hospital. The swab will be taken and result will be available within two days. If the person is positive and has no symptoms or has mild symptoms, the health officials/workers will contact to know whether the person can stay at his own residence. If there are no facilities for home care, the person can opt to go for ‘Covid Care Centre’. Here again the care is free of cost as explained above.
Admission to government hospitals is reserved for those who have moderate to severe illness. If there are no beds in the government hospitals, the government hospital itself will send the patient to private hospital and the entire expenses of the treatment will be taken care of by the government. So, even those who cannot afford any treatment can get appropriate care if he/she is infected by COVID19.
If a person directly goes to the private hospital, the entire expenses will have to be borne by the person and government will not reimburse it. The government has permitted to collect up to Rs 10,000/= per day in the general ward of a private hospital from a COVID19 patient without oxygen. When on the ventilator it can be up to Rs 25,000/= per day. The treatment is expensive because of the PPEs required for the attending doctors and paramedics, the medicines and other logistics.
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