How to home quarantine?

As the cases in India increase, more and more people are under home quarantine both patients and suspected cases. But this may increase the risk of exposure and hence spread of the disease especially to the family members. After talking to multiple patients and suspected cases who were home quarantined we realised that there wasn’t enough awareness about how to home quarantine. So we decided to do a little research to understand what it takes to successfully quarantine at home.

Who is home quarantined?

Either someone who is suspected to may have contracted Covid-19 or someone who has tested positive but has very mild symptoms can be home quarantined.

Based on Government’s guidelines, an individual may or may not be eligible for home quarantine. But if an individual is recommended home quarantine then they fall under two major categories:

Suspected cases and contact

A suspected case generally correspond to someone who has recently been in an affected region.

(i) travel related cases and (ii) focal clusters arising from a travel related/unrelated case where cluster containment strategy is adopted (iii) Persons coming from COVID-19 affected areas where local and community transmission is evident. -MoHFW[1]

A contact on the other hand corresponds to someone who has been directly in contact with an infected person or a contaminated environment. Such a person hence is at slightly higher risk than a suspected case of having exposed to and developing the disease.

In general, any close proximity (within 1 m or >15 minutes in a closed space) with a COVID-19 patient from 2 days before and up to 14 days after the onset of symptoms in the patient makes you a contact.

As per MoHFW[1]:

A contact in the context of COVID-19 is:

A person living in the same household as a COVID-19 case,

A person having had direct physical contact with a COVID-19 case or his/her infectious secretions without recommended personal protective equipment (PPE) or with a possible breach of PPE,

A person who was in a closed environment or had face to face contact with a COVID-19 case at a distance of within 1 metre including air travel

Both a suspected case and a contact is expected to be otherwise a healthy person.

Mild cases

A person who has been diagnosed to be infected with the disease but having mild symptoms and without underlying chronic conditions − such as lung or heart disease, renal failure, or immunocompromising conditions that place the patient at increased risk of developing complications − may be cared for at home.

The person should be clinically assigned as a very mild case/ pre-symptomatic case by the treating medical officer. -MoHFW[2]

As per WHO[1]

Mild illness may include: uncomplicated upper respiratory tract viral infection symptoms such as fever, fatigue, cough (with or without sputum production), anorexia (loss of appetite), malaise (general discomfort), muscle pain, sore throat, dyspnea (shortness of breath), nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea, and vomiting.

What if you feel symptomatic?

If you are feeling unwell then isolating yourself and following a quarantine routine is recommended while you await testing and reports. It is further recommended that you consider yourself as a Mild case and not a Suspected case because with suspected case the assumption is that you are otherwise healthy.

Is your home eligible for quarantine?

Only a person having the requisite facility at his/her residence for
self-isolation will have the option for home isolation. A qualified professional shall do the assessment for whether your home is eligible for quarantine or not.

Following are the major criteria to consider as they are necessary to ensure successful isolation.

• Isolation Room: Well-ventilated single-room preferably with an attached/separate toilet (MoFHW[1]). It is preferred that the ventilation isn’t shared with other family members or neighbours (CDC[1]).
  - Separate toilet is important especially if patient has diarrhea (CDC[1]).
  - If another family member needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two (MoFHW[1]). Though we wouldn’t recommend that in case of Mild case.
• Distance from other people: Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities like hypertension, cardiovascular disease, renal disease etc.within the household (MoHFW[1][2]).
  -It is preferred that other household members either be relocated or minimize contact with the patient in the home (CDC[1]).
• Caregiver: A must have requirement for mild cases is that there must be someone with the patient to take care of them and monitor their health.
  - Care giver should be available to provide care on 24 x7 basis. A communication link between the caregiver and hospital is a prerequisite for the entire duration of home isolation (MoHFW[2]).

Apart from above major criteria, availability of certain additional resources would be required for a successful quarantine.

• Basic infrastructure: Telephone, Electricity, Potable water, sewage etc.
• Aarogya Setu App: Download Arogya Setu App on mobile (available at: https://www.mygov.in/aarogya-setu-app/) and it should remain active at all times (through Bluetooth and Wi-Fi) (MohFW[2]).
• Resources: Food, Medication, Masks, Gloves, PPE, Hand hygiene (soap, sanitizer etc.), Cleaning products etc.
• Primary Care: Caregiver, Medical advise and healthcare, Ambulance etc.

What to monitor and when to seek medical assistance?

One has to be vigilant of symptoms for either onset of disease for suspected cases or for change in severity of suspected cases. Regular monitoring, identifying cause of concern and taking appropriate action is very important.

If the person quarantined qualifies as a Mild Case then all other members of the family especially the caregiver have to consider themselves as a contact and monitor accordingly.

Patient: Mild Case

• The patient or caregiver shall monitor patient’s temperature at least twice a day on a daily basis.
• If there is any deterioration of symptoms then medical assistance must be immediately sought.
• Deterioration in symptoms may include:
  - Difficulty in breathing,
  - Persistent pain/pressure in the chest,
  -Mental confusion or inability to arouse,
  - Developing bluish discolorations of lips/face and
  - As advised by treating medical officer

Suspected case or contact and caregiver

• The quarantined person and all family members who come in contact shall monitor their temperatures on a daily basis and be vigilant for respiratory symptoms.
• If symptoms appear (cough/fever/difficulty in breathing), they should immediately inform the nearest health centre or call 011–23978046 (MoHFW[1]).
• Symptomatic household or other close contacts should follow the same precautions recommended for the quarantined person (CDC[1]).
• In the absence of fever or respiratory symptoms, household contacts need not limit their activities outside the home, unless otherwise required by quarantine regulations (CDC[1]). Though this is not recommended for caregivers in Mild cases.
• In case the person being quarantined becomes symptomatic, all his close contacts will be home quarantined (for 14 days) and followed up for an additional 14 days or till the report of such case turns out negative on lab testing (MoHFW[1]).

When to discontinue?

Suspected cases and contact

The home quarantine period is for 14 days from contact with a confirmed case or earlier if a suspect case (of whom the index person is a contact) turns out negative on laboratory testing (MoHFW[1]).

Mild cases

Patient under home isolation will end home isolation after 17 days of onset of symptoms (or date of sampling, for pre-symptomatic cases) and no fever for 10 days. There is no need for testing after the home isolation period is over (MoHFW[2]).

What will it take to successfully home quarantine?

A lot of preparations will be required to ensure successful quarantine so that you don’t breach the quarantine and expose other people.

Based on recommendations from WHO[2],

Infrastructure

• Functioning telephone or any other means to rapidly communicate with the health system
• Potable water: The patient shall have access to drinking water at all times.
• Sewerage system
• Cooking source (and fuel)
• Operable electricity
• Operable heat source when required
• Adequate environmental ventilation: Preferably not shared with other family members and neighbours.

Accommodation

• Separate room or bedroom for the patient
• Accessible bathroom

Resources

• Food: Enough ration to last 14–17 days
• Water: If dependent on bottled water, then enough to last 14–17 days for entire family.
• Necessary medications
• Medical masks (patient): Disposable masks to be replaced every 6–8 hours. Around 50 masks will be required.
• Medical masks (care providers, household contacts): At least one triple layered mask shall be available for each individual.
• Gloves: Disposable gloves for cleaning and handling any items associated with the isolated person.
• Hand-hygiene items (soap, alcohol-based hand rub): Separate soaps and sanitisers for the isolated person and other family members.
• Household cleaning products: Phenol, bleach, Sodium hypochlorite.

If possible get training for patient and household contacts on use of PPE

Primary care and support

These become important especially in case of a Mild Case.

• Person to provide care and support: A primary caregiver shall be available at all times.
• Access to medical advice and care: Qualified doctors, Access to ambulance in case of emergency.
• Any at-risk people at home (e.g. children < 2 years of age, elderly > 65 years of age, immunocompromised people): If any at-risk people at home then ensure maximum distance from both the quarantined person and primary caregiver.

Precautions and Measures to take

The virus is most likely transmitted through contact and droplet spread and hence appropriate precautions can reduce the risk of spread and make isolation of a suspected person or a patient at home possible.

Use Masks

Use of masks by both the isolated person and other people of the home is very important.

Isolated Individual
MoHFW recommends that isolated individuals wear masks at all times and the same shall be changed and disposed off after 6–8 hours or earlier if the mask is visibly soiled or wet. For Suspected cases and contacts surgical masks are recommended (MoHFW[1]) while for Mild cases triple layer masks are recommended (MoHFW[2]).

WHO[1] recommends that Individuals who cannot tolerate a medical mask should use rigorous respiratory hygiene; that is, the mouth and nose should be covered with a disposable paper tissue when coughing or sneezing. Materials used to cover the mouth and nose should be discarded or cleaned appropriately after use (e.g. wash handkerchiefs using regular soap or detergent and water).

Caregiver
As per (MoHFW[2]),
The caregiver should wear a triple layer medical mask appropriately when in the same room with the ill person.
Front portion of the mask should not be touched or handled during use. He/she should avoid touching own face, nose or mouth.
If the mask gets wet or dirty with secretions, it must be changed immediately. Discard the mask after use and perform hand hygiene after disposal of the mask.

Disposal of Mask
Masks should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial (MoHFW[1]).

Maintain distance from others

The isolated individual shall stay in a separate, well-ventilated room with a separate bathroom and shall interact only with the caregiver. If that is not practically possible then following considerations shall be taken.

• Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household (MoHFW[1]).
• Limit the movement of the patient in the house and minimise shared space. Ensure that shared spaces (e.g. kitchen, bathroom) are well ventilated (keep windows open) (WHO[1]).
• Household members should stay in a different room or, if that is not possible, maintain a distance of at least 1 metre from the ill person (e.g. sleep in a separate bed) (WHO[1]).
• Other household members should use a different bathroom, if not possible and sharing the same bathroom, cleaning of taps, door knobs and utensils with water and soap are a must (WHO[3]).
• Infected person should not have any visitors.
• Patients should not leave the home for the duration of the isolation period, except as necessary for follow-up medical care. When movement outside the home is necessary, the patient should wear a mask, if tolerated, and should not use public transportation (CDC[1]).
• An exception may be made for breastfeeding mothers. Considering the benefits of breastfeeding and the insignificant role of breast milk in the transmission of other respiratory viruses, a mother could can continue breastfeeding. The mother should wear a medical mask when she is near her baby and perform hand hygiene before and after having close contact with the baby (WHO[1]).

Wash hands

The isolated person ,caregiver and other family members shall, in general, wash hands with soap and water for at least 40 seconds or alcohol based sanitiser as often as possible. The caregiver shall ensure that they wash hands after every contact with the isolated person.

Special care shall be taken in following cases:

• Hand hygiene should also be practised before and after preparing food, before eating, after using the toilet, and whenever hands look dirty (MoHFW[2]).
• After using soap and water, use of disposable paper towels to dry hands is desirable. If not available, use dedicated clean cloth towels and replace them when they become wet (MoHFW[2]).
• After touching body fluids (e.g., respiratory secretions, stool, urine, vomitus) and potentially contaminated surfaces and materials (e.g., linen) (CDC[1]).

Personal care and safety

Isolated person
As per MoHFW[2],

• Patient must take rest and drink lot of fluids to maintain adequate hydration
• Follow respiratory etiquettes all the time.
• The patient must strictly follow the physician’s instructions and medication advice.
• The caregiver will make sure that the patient follows the prescribed treatment.

Caregiver
The caregiver shall use gloves while handling the isolated individual or any potentially contaminated items.
Following considerations shall be taken in account especially for Mild Cases:

• Avoid direct contact with body fluids of the patient, particularly oral or respiratory secretions. Use disposable gloves while handling the patient. Perform hand hygiene before and after removing gloves (MoHFW[2]).
• Avoid exposure to potentially contaminated items in his immediate environment (e.g. avoid sharing cigarettes, eating utensils, dishes, drinks, used towels or bed linen) (MoHFW[2]).
• Gloves are not intended to replace proper hand hygiene. Immediately after gloves are removed, they should be discarded and hand hygiene should be performed. Gloves must never be washed or reused (CDC[1]).

Cleaning and environmental sanitation

Regular sanitation of items which may have been in contact with the isolated person shall be done while wearing gloves and mask. Any unnecessary contact and shaking of soiled linen/clothes shall be avoided.
Take following considerations in account:

• Avoid shaking the soiled linen or direct contact with skin. Use disposable gloves when cleaning the surfaces or handling soiled linen (MoHFW[1]).
• Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people at home (MoHFW[1]).
• Clean and disinfect frequently touched surfaces in the quarantined person’s room (e.g. bed frames, tables etc.) daily with 1%Sodium Hypochlorite Solution (MoHFW[1]).
• Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic disinfectants (MoHFW[1]).
• Clean the patient’s clothes, bed linen, and bath and hand towels using regular laundry soap and water or machine wash at 60–90 °C (140–194 °F) with common household detergent, and dry thoroughly (WHO[1]).
• Depending on the context, either utility or single-use gloves can be used. After use, utility gloves should be cleaned with soap and water and decontaminated with 0.1% sodium hypochlorite solution. Single-use gloves (e.g. nitrile or latex) should be discarded after each use. Perform hand hygiene before putting on and after removing gloves (WHO[1]).
• Gloves, masks, and other waste generated during home care should be placed into a waste bin with a lid in the patient’s room before disposing of it as infectious waste (WHO[1]).

Food

The isolated person shall be served food separately and it is preferred that objects used for eating are not shared though separation of utensils isn’t necessary as long as they are thoroughly cleaned with soap and water while wearing gloves.
If possible use gloves while preparing the food and practice hand hygiene before and after preparing food.

Travelling for suspected cases

In case a suspected case, contact, caregiver or family member develops symptoms then following precautions shall be ensured while travelling to seek care as per WHO[1].

• Wear a medical mask.
• Avoid taking public transportation to the facility if possible; an ambulance can be called, or the ill contact can be transported in a private vehicle with all windows open, if possible.
• The symptomatic contact should be advised to perform respiratory hygiene and hand hygiene and to stand or sit as far away from others as possible (at least 1 metre) when in transit and when in the health care facility.
• Any surfaces that become soiled with respiratory secretions or other body fluids during transport should be cleaned with soap or detergent and then disinfected with a regular household product containing a 0.5% diluted bleach solution.

Leave your queries and feedback in comments.

References

• MoHFW[1]: https://www.mohfw.gov.in/pdf/Guidelinesforhomequarantine.pdf
• MoHFW[2]: https://www.mohfw.gov.in/pdf/RevisedguidelinesforHomeIsolationofverymildpresymptomaticCOVID19cases10May2020.pdf
• CDC[1]: https://www.cdc.gov/sars/guidance/i-infection/patients-home.html
• CDC[2]: https://www.cdc.gov/sars/guidance/d-quarantine/app3.html
• WHO[1]: https://www.who.int/publications/i/item/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts
• WHO[2]: https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf?sequence=1
• WHO[3]: https://www.who.int/docs/default-source/searo/whe/coronavirus19/the-guideline-for-home-quarantine---quarantine-in-non-health-care-settings-is-intended-for-anyone-who-believes-they-have-been-exposed-to-covid-19-and-are-required-to-be-home-quarantined-to-prevent-community-trans.pdf?sfvrsn=1bc12565_4