[Dr Lobsang Tsetim]
Stay, stay at home, my heart, and rest; Home-keeping hearts are happiest,
For those that wander they know not where,
Are full of trouble and full of care;
To stay at home is the best.
– HW Longfellow
So, will home, sweet home be the new normal in the Covid-19 management guidelines in our state? Is home isolation the way forward?
There has been an alarming surge of positive cases in Arunachal in the recent few days. With the state government ramping up testing, the number of Covid-19 positive cases in the state, especially in the Itanagar capital region (ICR), is creating new records.
As per the new ICMR guidelines, patients under home isolation will stand discharged after 10 days of the onset of symptoms and no fever for three days. It includes asymptomatic positive cases also, besides very mild and pre-symptomatic cases, in order to widen the net of monitoring and medical care in view of a large number of asymptomatic cases being detected. However, after that, the patient will be advised to isolate at home and self-monitor their health for a further seven days. There is no need for testing after the home isolation period is over.
Our state, on the contrary, has a very strict and robust standard operating procedure (SOP) of mandatory Covid care centre (CCC) isolation of all asymptomatic and mild positive cases and a negative test report before discharge.
The ICR has seen the maximum surge in the number of positive cases in the last few days. The capital region has a population of 122930 (2019). With the current trend, about 90 percent of Covid-19 cases are asymptomatic. The capital region has a one CCC, in Lekhi, with a capacity of 640 beds. The positive cases have hit a crescendo and will soon inundate the lone CCC.
So, what are the options open to us?
The government should seriously plan for another CCC with good bed capacity. Paid CCCs in hotels can be another option to be explored. A third viable option is to go for home quarantine or isolation.
Home isolation: a tested model
Home isolation models for Covid-19 positive asymptomatic cases and with very mild and pre-symptomatic cases have been successfully implemented in many states like Delhi, Karnataka, Jharkhand and Uttar Pradesh, to name a few. If proper guidelines for the same are followed, it will reduce the burden on CCCs.
However, patients with immune-compromised status (like HIV, transplant recipients, cancer therapy) are not eligible for home isolation. Patients over 60 years and those with co-morbid conditions such as hypertension, diabetes, heart disease, chronic lung/liver/kidney disease and cerebro-vascular disease are also not ideal candidates for home isolation.
There needs to be strict guidelines and a detailed protocol for monitoring the cases under home isolation. The clinical status of each case should be recorded by the field staff/call centre (body temperature, pulse rate and oxygen saturation). The field staff should guide the patient on measuring these parameters and provide the instructions (for patients and their caregivers). The state must develop a mechanism to shift patients in case of violations or need for treatment if they become symptomatic
Geotagging of the house can be done in case of home quarantine. The information can be passed to ANMs, ASHAs and ward volunteers. The staff will monitor the health condition on a daily basis. The Aarogya Setu mobile application should be downloaded and it should remain active at all times (through Bluetooth and Wi-Fi). Immediate medical attention must be sought if serious signs or symptoms, including difficulty in breathing, dip in oxygen saturation, persistent pain/pressure in the chest, mental confusion or inability to arise, slurred speech/seizures, weakness or numbness in any limb or face, and developing bluish discoloration of lips/face develops.
Details about patients under home isolation should also be updated on the Covid-19 portal and facility apps of the state.
The state should have a separate control room set up in each district and the state capital for the home quarantine facility. Medical teams should monitor the cases on a daily basis actively or passively through messages, tele-consultation or telemedicine.
Guidelines for home quarantine/isolation
Instructions to the patient: A home-quarantined person should stay in a well-ventilated single room, preferably with an attached/separate toilet. Wash hands often and thoroughly with soap and water or with alcohol-based hand sanitizer. Avoid sharing household items with other people at home.
Wear a surgical mask at all times. The mask should be changed every 6-8 hours and disposed of. Disposable masks are never to be reused. A used mask should be considered as potentially infected.
Instructions for the family members: According to the guidelines, only one member should be assigned as caregiver and he/she should be available to provide care on a 24/7 basis. A communication link between the caregiver and a hospital is a prerequisite for the entire duration of home isolation.
The caregiver should avoid shaking the soiled linen or making direct contact with skin. The caregiver should use disposable gloves when cleaning the surfaces or handling soiled linen, and wash hands after removing gloves.
Visitors should not be allowed.
In case a person being quarantined becomes symptomatic, all his/her close contacts will be home quarantined for 14 days till the report of such case turns out negative on lab testing.
Environmental sanitation: Clean and disinfect frequently touched surfaces in the quarantined person’s room daily with 1 percent sodium hypochlorite solution. Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic disinfectants. Clean the clothes and other linen used by the person separately, using common household detergent and dry.
In case the district administration comes to the conclusion that the conditions at the home of the person are not appropriate for home quarantine, or that the person concerned is not following the guidelines of home quarantine, the district administration is authorized to penalize and put the person in CCC.
Why go for home isolation?
Less population: Our main advantage in this Covid-19 battle is the state’s sparse population. Arunachal has a projected population of 1.74 million (2019) and a population density of 17 per square kilometre, which is the least in the whole country. Barring the ICR, Pasighat and a few district headquarters, houses are properly spaced and not very crowded. Itanagar, too, has many single houses owned by affluent families, and localities away from the main town fit for home isolation
Occupying bed facilities and infrastructure: Even if you get a bed in the CCC for mild symptomatic patients, you end up lodging in a place and blocking it to a person who might need it more urgently.
Improving quality care in CCC: For dedicated Covid healthcare centres and Covid hospitals, less patients would mean better attention and quality healthcare. Already the doctors and medical frontline workers are overburdened and overstretched in this Covid-19 battle. Home isolation would ease their work and they can focus more on patients who really need medical attention.
Mental peace when at home: Covid-19 is a tricky mind game. Your mind plays with your emotions when you are alone, especially in a hospital/CCC where you witness/breathe the same air with other infected inmates. For a mildly symptomatic coronavirus patient, recuperation is better at home, where individuals can hear them out, feed better meals and feel safe while fighting the disease. People do not even get tested only out of the fear of being shifted into an isolated room in a CCC. Home isolation can indirectly help in making people come forward voluntarily for testing.
Exceptional cases: There are critical situations where a minor or infant breast-fed baby is negative and the mother is positive, or vice versa. A bedridden sick is positive and the caretaker negative, and many more such instances wherein shifting to CCC is not ideal. Such exceptional cases, too, go in favour of home isolation.
Challenges of home isolation
Physical infrastructure and environment: In India, large-scale home quarantining could be difficult to implement. In our state, most homes just aren’t big enough for people to safely quarantine themselves or isolate members who are exhibiting symptoms or have tested positive. Many stay in rented places along with family members, where they share common rooms and toilets, which is not ideal for home isolation.
Social stigmatization: If patients are residing in apartments, then home quarantine may not be feasible, due to the fear of spread of disease and social stigmatization. Other residents in the apartments may oppose due to fear/stigma if we allow any resident who turns positive for home quarantine. Such ostracization from neighbours and the society can take a toll on the mental and psychological status of the positive individual undergoing home isolation.
Irresponsible social behaviour: Our tribal societies have shown less maturity towards following the laid down guidelines and SOPs. If home isolation is incorporated in the SOP, then a few positive asymptomatic individuals undergoing home isolation may roam freely, breaking the rules, and in turn infect the whole locality or community. This will then be very disastrous.
Medical care: Monitoring of individuals undergoing home isolation would be an issue. Already many medical staffs are multitasking and there is an acute shortage of human resource, especially in the field works. Internet connectivity is an issue. Hence, how effective telemedicine to monitor the home quarantine work would be is also an issue. Availability of ambulances for lifting patients still remains a challenge.
Home isolation is not so difficult, and it is practical and feasible in our state. Most important is proper quality medical care, complete physical isolation, and proper monitoring of oxygen saturation, temperature and blood pressure, and intake of immunity boosters.
The choice of home isolation should be given to those who agree to the norms and whose house fulfils the criteria for the same. Home isolation will lessen the burden on CCC. However, it would need active participation from the society too for acceptance, and to address the issues of stigmatization.
Whatever we may say, in the end it’s our sweet home that we thrive for. As John Howard Payne commented: “Mid pleasures and palaces though we may roam, be it so humble, there’s no place like home.” (Dr Lobsang Tsetim is Senior Consultant Ophthalmologist, RKMH, Itanagar.)