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Home-based management of Covid-19 patients

By Dr. Charuni Kohombange 

A number of countries in Asia, including the countries that experienced the relatively successful containment of Covid-19 last year, have detected a sharp rise in cases with the outbreak of the Delta variant.

According to the World Health Organisation (WHO), the Delta variant has been described as the “most transmissible of the variants identified so far” and has been identified in at least 132 countries worldwide. With the increasing number of cases, many countries across the globe had to manage the patients with mild symptoms at homes to prevent the healthcare facilities from getting exhausted.

In many countries, home-based health services are delivered at community level and in the home by community health workers, social care workers, or a variety of formal and informal community-based providers, including caregivers. Hence, it is critical to ensure that caregivers have appropriate training and guidance on how to care for patients as well as how to minimise the risk of transmission of the disease.

The Ministry of Health has implemented the home-based management of eligible patients, expecting to reserve hospital care for the symptomatically ill. This article elaborates on the necessary information for patients who are undergoing home management.

Eligibility for home management

The decision on home management of Covid-19 patients is made on a case-by-case basis, considering a number of aspects including the clinical presentation, risk factors, and availability of a supportive environment. All patients who test positive with a Covid-19 PCR or rapid antigen test (RAT), need to stay isolated in order to prevent transmission of the disease, irrespective of their vaccination status or the presence of symptoms. The decision of home management of a patient will be taken by the Medical Officer of Health (MOH) of the relevant area based on the following set criteria:

  • Patients should be above two years and under 65 years of age
  • The patient can be isolated in a well-ventilated separate room with adequate washroom facilities at home
  • The patient should not have any uncontrolled comorbidities such as morbid obesity (BMI >30), diabetes, hypertension, chronic heart/lung/renal disease, or other medical conditions
  • The patient should not suffer from any immunocompromised diseases or should not be on any long-term treatment with medicines suppressing the immunity
  • Patients should have adequate caregiver support at home
  • The patient or the caregiver should have proper communication facilities
  • Pregnant women should be at less than 24 weeks of gestation without risk factors

Home management process

Upon the decision of the MOH, information of the eligible patients for home management will be registered in the Patient Home Isolation and Management System (PHIMS). These registered patients will be taken care of by a team of medical officers who will manage them via a call centre. A doctor will be assigned to each and every patient, their daily status will be assessed by the assigned doctor, and necessary advice will be provided over the phone. The patients who are residing in the Western Province and registered in the PHIMS can consult their doctors by dialling 1390.

Natural course of the disease

A large number of patients with Covid-19 develop only mild symptoms and recover without complications. 

Highly infective phase

The maximum SARS-CoV-2 viral load can be observed in the patient’s airway at the time of the onset of symptoms or during the first week of illness. The viral load will subsequently decline thereafter. Hence, the patients are highly infective just before this and during the first five days since the onset of symptoms. 

Reverse transcription polymerase chain reaction (RT-PCR) tests can detect the viral SARS-CoV-2 RNA in the upper respiratory tract for an average of 17 days. It has been evident that the spreading of the virus is mostly happening during the symptomatic and pre-symptomatic (one to two days before symptom onset) phases. 

Asymptomatic patients 

Symptoms of Covid-19 may vary from one person to another. And the symptoms also vary in severity due to underlying health conditions. It has been identified that the majority of the patients are asymptomatic or will have only mild symptoms. 

Day one 

  • The onset of symptoms will appear between four to five days from the day of exposure
  • Symptoms usually include fever (temperature 100.4 F or greater), dry cough, shortness of breath, and loss of smell or taste
  • Many people with Covid-19 will spend 2-14 days with minimal symptoms

Days 2-10 

  • Mild to moderate illness lasts for about 7-10 days

The three most commonly reported symptoms of Covid-19 are; 

  • Fever 
  • Cough  
  • Fatigue 

Other symptoms of Covid-19 include; 

  • Shortness of breath 
  • Loss of smell or taste 
  • Body aches and pains 
  • Headache 
  • Sore throat 
  • Runny or stuffy nose 
  • Nausea, vomiting, or diarrhoea

 Most patients will recover from this phase without any difficulty. However, some may experience worsening of symptoms during the second week. Therefore, it is important to detect this worsening of symptoms to prevent severe Covid. Breathlessness upon exertion could be an early symptom of worsening, and this should be detected early.

Days 10-12  

If a patient develops severe Covid-19, this is the typical time period when they are admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) and extreme difficulty breathing, requiring ventilator support. The Centres for Disease Control and Prevention (CDC) has noted that the diagnosis of severe Covid with ARDS typically happens between days 8-12. However, sometimes it occurs as late as 15 days after the beginning of the symptoms. Onset of difficulty breathing sometimes may occur suddenly.

Days 10-14 

This is the time period where the patients with mild Covid-19 symptoms begin to feel better. 

Advice on symptomatic management 

  • Patients should take adequate rest, plenty of fluids, and lie preferably in a prone position or turning to the left or right
  • Patients should take their regular medicines without fail 
  • Take paracetamol for management of fever, body aches, and headache. Never use painkillers (NSAIDS) or steroids (unless on long-term steroid therapy for a chronic illness)
  • Symptomatic treatment for cough and cold with a mild cough syrup and koththamalli, warm water, and steam inhalation will alleviate symptoms
  • Vomiting/diarrhoea can be treated with antiemetics and oral rehydration solutions
  • Patients who are on inhalers for asthma should continue these medications as prescribed

Red flag signs which indicates need for immediate hospital admission

  • Cold extremities
  • Difficulty in breathing when resting
  • Persistent chest pain/chest tightness
  • Bluish discolouration of lips, nails, and face
  • Oxygen saturation < 96% when resting, or < 94% after mild exertion (if a pulse oximeter is available with the patient)
  • Recent onset of confusion/difficult to awake

 Post-Covid syndrome

Some people infected with Covid-19, regardless of severity, can experience persistent symptoms for weeks or months after the acute illness, which is known as “post-Covid syndrome”. Symptoms of post-Covid syndrome include fatigue, shortness of breath, joint pain, chest pain or palpitations, and cough. These patients are managed based on the symptoms.

Measures for infection prevention and control

  • The patient must isolate him/herself from other household members. He/she should be kept in a well-ventilated room, especially away from the elderly and those with comorbidities such as hypertension, cardiovascular disease, renal disease, etc. 
  • Limit the patient’s movement around the house and minimise shared space
  • Limit the number of caregivers. Ideally, assign one person who is in good health and has no underlying chronic conditions 
  • Visitors should not be allowed in the home until the person has completely recovered, shows no signs or symptoms of Covid-19, and has been released from isolation
  • The patient should use a medical mask if coming into contact with healthy family members is inevitable
  • If the caregiver enters the patient’s room, both the caregiver and patient should use medical masks
  • The patient must rest, take plenty of fluids to maintain adequate hydration, and have nutritious meals
  • Follow respiratory etiquettes at all times
  • Patients and the caregivers should frequently wash hands with soap and water for at least 40 seconds or clean hands with alcohol-based sanitiser
  • The patient should not share personal items (towels, bedding, cups/plates, toothbrush, etc.) with other members of the household
  • The patient should clean these items by him/herself with soap and water 
  • Ensure cleaning of surfaces in the room that are touched often (tabletops, doorknobs, handles, etc.) with any household disinfectant preferably with bleach (0.1% sodium hypochlorite)
  • When attending to patients and handling their body fluids (blood, stool, or saliva, mucus, vomitus, and urine) caregivers must wear gloves and both must wear medical masks 
  • Dispose of gloves/masks and other patient items with care adhering to safety measures. Wash hands right away. The used masks shall be buried or disposed of safely to avoid spreading of the virus
  • Self-monitoring of blood oxygen levels (SpO2) with a pulse oximeter is recommended if available
  • Self-monitor symptoms (fever, breathlessness, cough, etc.) and daily temperature and report promptly to the doctor if there’s any deterioration of symptoms
  • If any worsening of symptoms is noted, the patient or the caregiver should contact the call center, the public health inspector (PHI), or 1990 immediately to arrange hospital admission
  • Patient should never overexert him/herself
  • Keep contacts with friends and family via phone, email, video calls, or texting
  • Engage in what makes you happy, such as writing, reading, music, etc.

Management of contacts 

A contact is a person who has experienced any one of the following exposures during two days before and 14 days after the onset of symptoms of a probable or confirmed case: 

  • Face-to-face contact with a probable or confirmed case within one metre and for at least 15 minutes
  • Direct physical contact with a probable or confirmed case
  • Direct care for a patient with probable or confirmed Covid-19 without using recommended personal protective equipment
  • Any other situations as indicated by local risk assessment on a case-by-case basis

Contacts should remain in quarantine at home and monitor their health for 14 days from the last day of possible contact with the infected person.

Helplines for medical advice

The Sri Lanka Medical Association (SLMA) has activated the SLMA-Doc Call 247 facility to provide necessary information for Covid-19-infected patients who are undergoing home management. The SLMA-Doc Call 247 facility has been introduced in 2012 by Prof. Vajira Dissanayaka, then the President of the SLMA. During 2020, with the guidance of SLMA Immediate Past President Prof. Indika Karunathilake, SLMA-Doc Call 247 had been directed to provide accurate information about Covid-19 to the public. 

This Covid-specific telemedicine system is a collaboration with Sri Lanka Telecom-Mobitel and Suwa Seriya. Any individual can obtain the service of SLMA-Doc Call entirely free of charge by simply dialling 247 from an SLT-Mobitel connection or 1247 from an SLT-Mobitel home connection and dialling 0719 247 247 from other connections. Almost 200 doctors and 100 specialist doctors are currently active in the system and provide 24/7 service. Suwa Seriya plays a vital role in this system by transporting the patients who are identified as critically ill. Currently, the system receives about 450 calls per day and about 15 patients identified as severely ill are being hospitalised each day. While helping to save the lives of critically ill patients, it also provides immense relief by providing medical advice and reassurance for mildly symptomatic patients who are cooped up in their homes with gloomy feelings and uncertainties.  

Early identification of patients whose condition is deteriorating is very important in order to prevent mortality and morbidity during home management of Covid-19 patients. In order to prevent the impending wave of deaths, immediate priority should be given to triaging and evacuation of patients that are at high risk to the treatment facilities. 

(The writer is a Medical Officer at the Directorate of Healthcare Quality and Safety, Ministry of Health)