#15,106
While it is unrealistic to expect that all countries would be on exactly the same page, we continue to see conflicting, and widely varying advice being offered by public health authorities around the globe on managing mild COVID-19 patients outside of the hospital environment.
Yesterday, in his opening remarks to their March 16th briefing, WHO Director-General Dr. Tedros warned that patients may shed the virus after they recover, and that those being cared for at home with suspected COVID-19 should remain isolated for 14 days AFTER symptoms resolve.
WHO Director-General's opening remarks at the media briefing on COVID-19 - 16 March 2020
16 March 2020
(EXCERPT)
Another option is for patients with mild disease to be isolated and cared for at home.
Caring for infected people at home may put others in the same household at risk, so it’s critical that care-givers follow WHO’s guidance on how to provide care as safely as possible.
- For example, both the patient and their care-giver should wear a medical mask when they are together in the same room.
- The patient should sleep in a separate bedroom to others and use a different bathroom.
- Assign one person to care for the patient, ideally someone who is in good health and has no underlying conditions.
- The care-giver should wash their hands after any contact with the patient or their immediate environment.
- People infected with COVID-19 can still infect others after they stop feeling sick, so these measures should continue for at least two weeks after symptoms disappear.
- Visitors should not be allowed until the end of this period.
This advice appears to be based on reports from China of prolonged shedding of the virus, and their criteria for release from the hospital.
Today, the UK upgraded their advice on the home care and isolation of mild COVID-19 cases, and while they now require household members of a positive case to self-isolate for 14 days, they advise that the presumed infected patient can be released from isolation 7 days after symptoms appear.After discharge, patients are recommended to continue 14 days of isolation management and health monitoring, wear a mask, live in a single room with good ventilation, reduce close contact with family members, eat separately, keep hands clean and avoid outdoor activities.
- Afebrile for > 3 days,
- Improved respiratory symptoms,
- pulmonary imaging shows obvious absorption of inflammation, and
- nucleic acid tests negative for respiratory tract pathogen twice consecutively (sampling interval ≥ 24 hours).
Even if still symptomatic.While no rationale is cited, a study published on the MedRxiv pre-print server last week (see Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster) strongly suggested that most mild COVID-19 cases shed the virus most vigorously over the 1st 5 days after symptoms appear, and while they may still test positive for weeks, are likely non-infectious after 10 days.
The authors of the study suggested this could lead to early discharge of mild cases from hospitals - but into home isolation - even if they were still testing positive (see Helen Branswell's STAT article).Exactly why they settled on recommending patients be released from isolation just 7 days after symptoms first appeared appeared isn't clear. A link and some excerpts from today's guidance (bolding & underlines mine), after which I'll have a bit more.
News story
New guidance for households with possible COVID-19 infection
Next stage of COVID-19 public information campaign highlights guidance for households with possible infection.
Published 17 March 2020
From : Department of Health and Social Care and Public Health England
New guidance to stay at home for 14 days if someone in your household has symptoms of COVID-19 is the focus of the next stage of a public awareness campaign launched by Health and Social Care Secretary Matt Hancock today.
The new guidance will set out that individuals will still be asked to self-isolate for 7 days from the onset of COVID-19 symptoms but any individuals in the household will now be asked to self-isolate for 14 days from that moment as well.
If other members of your household develop symptoms, however mild, at any time during the 14 days, they must not leave the home for 7 days from when symptoms started.
The new phase of the campaign will build on the existing TV, radio, online, digital and billboard adverts currently visible all over the country. These reinforce the importance of washing your hands more often and for 20 seconds, and ask people to self-isolate for 7 days if they develop a high temperature or a new continuous cough, however mild.
Government has taken the further measure of asking whole households to isolate because it is likely that people living with others will infect each other or be infected already. Staying at home for 14 days will greatly reduce the overall amount of infection the household could pass on to others in the community.
The Prime Minister also today set out a number of social distancing measures to reduce the risk of infection from the spread of coronavirus. For those who remain well, are under 70 or do not have an underlying health condition, they are advised to limit their social contact where possible, including using less public transport, working at home and considering not going to pubs, restaurants, theatres and bars.
(Continue . . .)
Although this new guidance doesn't mention what to do if you still have a fever after 7 days, slightly older advice from the NHS website offers this:
If you still have symptoms after 7 days
After 7 days, if you no longer have a high temperature you can return to your normal routine.
If you still have a high temperature, stay at home until your temperature returns to normal.
If you still have a cough after 7 days, but your temperature is normal, you do not need to continue staying at home. A cough can last for several weeks after the infection has gone.
Here in the United States, the CDC's guidance for release from home isolation is stricter, as it requires a minimum of 7 days from onset, and a resolution of fever (without meds) for 72 hours.
How to discontinue home isolation
People with COVID-19 who have stayed home (home isolated) can stop home isolation under the following conditions:
If you will not have a test to determine if you are still contagious, you can leave home after these three things have happened:
You have had no fever for at least 72 hours (that is three full days of no fever without the use medicine that reduces fevers)AND
Other symptoms have improved (for example, when your cough or shortness of breath have improved)
AND
at least 7 days have passed since your symptoms first appeared
If you will be tested to determine if you are still contagious, you can leave home after these three things have happened:
You no longer have a fever (without the use medicine that reduces fevers)
AND
other symptoms have improved (for example, when your cough or shortness of breath have improved)
AND
The ECDC's guidance, like the WHO, recommends 14 days of isolation after release from a hospital, with daily health monitoring.you received two negative tests in a row, 24 hours apart. Your doctor will follow CDC guidelines.
The discharge from hospital of mild cases – if clinically appropriate – may be considered, provided that they are placed into home care or another type of community care.
After discharge, 14 days of further isolation with regular health monitoring (e.g. follow-up visits, phone calls) can be considered, provided the patient’s home is equipped for patient isolation and the patients takes all necessary precautions (e.g. single room with good ventilation, face-mask wear, reduced close contact with family members, separate meals, good hand sanitation, no outdoor activities) in order to protect family members and the community from infection and further spread of SARS-CoV-2.
It's not my intent to be a tie-breaker here. Each agency has made their own risk assessment, and has balanced that against the need to get people out of isolation, and hopefully back to work. It may be that 2 additional weeks of isolation - after symptoms resolve - is too strict.
But this is one of those things, that if you get it wrong, can seriously derail the critical goal of flattening the curve. The `rather safe than sorry' side of me worries that an arbitrary 7 days of isolation after symptoms appear is too shortBut I guess we're going to find out.
