Home Alone . . . With The Flu

My `under-the-bed’ flu kit

 

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Although you can never really know what kind of flu season lies ahead, early indications are that the H3N2 virus is leading the pack and that a new strain – not covered in this year’s vaccine – may have an impact (see A `Drift’ In A Sea Of Influenza Viruses). 

 

Years in which H3 viruses dominate often produce more severe flu seasons – particularly among those over the age of 65.

Like many Americans, I live alone.  It is a demographic trend that has been increasing for decades. A couple of years ago the Census bureau reported that 1 in 4 households had just a single occupant - greater than at any time in the past century.

Currently, more than 32 million Americans live alone (see chart below), and while many of those are younger people who are waiting later to get married, a side effect of our longer lifespan and high divorce rate is that many of these single households are held by those over the age of 65.

Whether we live alone by choice or by happenstance, we all share a common vulnerability.  If we get sick, or injured, there may be no one around to notice, or to help. 

 

As a paramedic I saw a significant number of people who lived alone who either died, or spend miserable hours or even days incapacitated and unable to call for help, due to an illness or accident.

 

Another vulnerable group are households with only 1 adult, and minor children.  This too is a growing demographic, with more than 5 million households falling into that category.  If the adult falls seriously ill, then even more are potentially at risk.

In 2007, I suffered my last serious bout with the flu that laid me up, delirious and unable to move, for about 24 hours. I described the experience HERE, and since I live alone, it inspired me to take steps in case it ever happens again.

 

First, and perhaps most important, I’ve moved my cell phone charger to my beside table.  My phone now goes with me when I retire at night, that way I can call for help if ever the need arises.

A sensible precaution for anyone of my years.

 

Second, I made a simple under-the-bed flu kit (see photo at top of blog). In a small plastic box, I keep:

 

• A couple of pouch Sports drinks (rehydration)
• A bottle of acetaminophen
• A bottle of expectorant pills
• Imodium pills
• A thermometer
• Throat lozenges
• Surgical masks for me to wear in case I have to call for help or have visitors.

 

As a result of this little `flu-life adventure’, I also began to promote the idea of having – and being – a `flu buddy’ in this blog. Particularly for those who either live alone, or are the sole adult caregiver in a household.

 

A `Flu buddy’ is simply someone you can call if you get sick, who will then check on you every day, make sure you have the medicines you need (including fetching Tamiflu if appropriate), help care for you if needed, and who can call for medical help if your condition deteriorates.

 

While various governments floated the idea of having a `flu friend’ or buddy during the 2009 H1N1 pandemic, the truth is, influenza kills tends of thousands each year – and so this should be a yearly reciprocal arrangement – not just something you arrange for during a  pandemic.

 

About 5 years ago, I reworked this `flu buddy’ idea into a more generic `Disaster buddy’ concept (see In An Emergency, Who Has Your Back? ). The idea of setting up a `mutual aid’ agreement with a friend, relative, or trusted neighbor is the same – just expanded to cover more than just an illness. 

We live in uncertain times, and frankly, I can’t imagine not having a disaster buddy or two.  No one likes to impose on a friend, of course. But if you’ve already established a `disaster buddy’ relationship  – one that is fair and reciprocal – it shouldn’t be considered an imposition.

Now - before a disaster occurs - is the time to sit down and talk to your friends, family, and neighbors about how you will help one another during a personal or community wide crisis.

 

For more on increasing your level of preparedness, a partial list of some of my preparedness blogs include:

 

The Gift Of Preparedness – 2014 Edition

When 72 Hours Isn’t Enough

An Appropriate Level Of Preparedness

WHO Issues Ebola Home Care Advice For Sierra Leone

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Given the need to isolate patients in order to reduce the spread of the Ebola virus, the news on Saturday that due to badly overburdened Ebola treatment centers - Sierra Leone’s Ebola Battle Shifts To Facilitating Home Care - is considered to be a major (although hopefully, temporary) setback.

 

While more assets are being sent to the region, the number of patients continues to rise faster than beds can be set up and staffed, which has led today to the  World Health Organization issuing a statement  regarding the home care of Ebola cases.

 

The ramifications of this are far from certain, but the CDC’s MMWR report Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015 offered up a couple of hypothetical's.

 

In a hypothetical scenario, the epidemic begins to decrease and eventually end if approximately 70% of persons with Ebola are in medical care facilities or Ebola treatment units (ETUs) or, when these settings are at capacity, in a non-ETU setting such that there is a reduced risk for disease transmission (including safe burial when needed).

In another hypothetical scenario, every 30-day delay in increasing the percentage of patients in ETUs to 70% was associated with an approximate tripling in the number of daily cases that occur at the peak of the epidemic (however, the epidemic still eventually ends).

 

The goal of treating 70% of persons with Ebola in Sierra Leone in medical care facilities or (ETUs), at least for now, seems a distant one.

 

This update was emailed out by the WHO earlier today.

 

Staying safe : advice for households with Ebola virus disease in Sierra Leone

Freetown – 11 October 2014 - The Ebola virus disease outbreak in Sierra Leone is continuing to accelerate with a total of 2950 cases reported by October 8, and hundreds of new infections identified each week. With so many critically ill people to care for, treatment centres are currently overwhelmed and struggling to meet demand.

The goal shared by the Government of Sierra Leone and partners working to overcome Ebola is to increase the number of beds in Ebola treatment units as rapidly but also as safely as possible. This takes time as facilities must be constructed or redesigned to reduce the risk of health care worker infection and increase patient safety. Already 123 health care workers have developed Ebola virus disease and, tragically, 97 of them have died.

To shorten waiting times and provide care closer to home, community Ebola care units are now being put in place in the communities most heavily affected. These have an average of eight beds per centre and are staffed by health care workers and members of the community trained in infection control. They give Ebola care such as oral rehydration salts and medicines to relieve symptoms and treat other common causes of fever such as malaria. Current plans for building Ebola care units will add an extra 1000 beds for people ill with Ebola virus disease.

Anyone with Ebola virus disease needs access to good care as quickly as possible. However, while waiting for the ambulance or for a bed to be free in the nearest treatment unit, it is essential that family members and others caring for the sick person understand how to protect themselves from infection.

To enable household members to stay safe while waiting, “interim recommendations for protection of households” have been developed and approved by the Sierra Leone Emergency Operations Committee (EOC)

In summary these state that:

• Taking care of the patient suspected to have EVD at home is NOT recommended; all efforts should be made to safely transport patients to an appropriate Ebola care facility.
• To reduce risk of infection of other family members, the following general recommendations should be followed:

1. The patient should be asked to restrict movement to one room or area in the house and should avoid leaving it, if possible.
2. Where possible, the patient should be asked to use one toilet that other household members do not use. If a separate toilet is not available, the patient can use a separate waste bucket, followed by proper decontamination with strong chlorine solution. Avoid direct contact with other family members.
3. If care must be given to the patient, only one family member should be designated to provide the care.
4. Caregivers should wear gloves or use towels soaked in weak chlorine solution whenever they touch the patient, personal items belonging to the patient (e.g., clothing, bedding, eating and drinking utensils,  mobile phones, etc.) or their body fluids (e.g., vomit, stool, urine, etc.).
5. Caregivers should avoid contact with the patient’s body fluids by staying behind or beside the patient while giving care, and never facing the patient.
6. Hands should be washed very well with soap and water or weak chlorine solution before and after entering the patient’s room/area and after removing gloves.
7. A mask or a dry towel wrapped around the face can be used to protect the nose and mouth when entering the patient’s room/area.

Sierra Leone’s Ebola Battle Shifts To Facilitating Home Care

 

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In some of the bleaker flu pandemic scenarios that floated around during the middle of the last decade – with 30% (or more) of the population expected to fall ill with a comparable-to-1918  flu – at some point hospitals would be overrun, healthcare worker infections (and defections) would degrade their ability to provide services, and 90% of those infected would end up being treated in their homes by family and friends (see Alabama Pandemic Drill & Home Alone).

 

This graphic is from the State of Florida Pandemic plan

With roughly 50,000 hospital beds in the State of Florida – 80%-90% of which are occupied at any given time - finding a way to treat an additional 640,000 cases during a pandemic would be an extreme challenge.  But at least in the United States, with more than 1 million hospital beds, there is a fair amount of surge capacity.

 

In Sierra Leone, where healthcare facilities and community resilience were already badly degraded before the epidemic began, that tipping point appears to have already been reached as the official (albeit, likely badly underestimated ) case count nears 3,000 (see WHO Situation report - 10 October 2014).  

 

Yesterday, in what has been described as an admission of `defeat’ (see NYTs Officials Admit a ‘Defeat’ by Ebola in Sierra Leone), health officials there have approved plans to assist families in treating patients at home. 

 

While work is still being done to increase the number of hospital beds and treatment centers in Sierra Leone – until that can be done – there is little else that health providers can do at this point.  Hundreds of people have already been turned away from over crowded treatment facilities, and their option of last resort – treatment at home by family and friends – is already a reality for many.

 

After months of extolling the advantages of seeking early, professional treatment – in part to save lives, and in part to isolate infectious patients and lower the community transmission rate – the number of people seeking treatment has completely overwhelmed their limited ability to deliver care.  

 

The plan now is to distribute gloves, rehydrating solution, and pain killers to hundreds of Ebola stricken households, and hope that additional aid will arrive in time to prevent a massive spike in deaths, and new cases in the community. 

 

For more details, we turn to Adam Nossiter’s report from the NYTs.

 

Officials Admit a ‘Defeat’ by Ebola in Sierra Leone

FREETOWN, Sierra Leone — Acknowledging a major “defeat” in the fight against Ebola, international health officials battling the epidemic in Sierra Leone approved plans on Friday to help families tend to patients at home, recognizing that they are overwhelmed and have little chance of getting enough treatment beds in place quickly to meet the surging need.

(Continue . . . )

 

As the collapse of the healthcare systems in Liberia, Sierra Leone, and Guinea proceed, getting routine or emergency medical care for non-Ebola conditions is becoming all but impossible.  Collateral damage – from hunger, violence, and numerous untreated non-Ebola health concerns – threaten to claim nearly as many lives in the region as the disease itself.

A genuine concern is, as this epidemic spirals out of control, that Sierra Leone’s capitulation will be repeated in Liberia and Guinea.  And if the virus were to spread substantially beyond these three countries, that other healthcare dominos could fall.

 

While we seem to be overly focused on few errant, scattered, cases showing up in Texas, or Madrid . . .  the real battleground against this virus lies in West Africa, and that is where the most focus must remain. 

 

For now – while it may not be perfect, or pretty – I’m confident that the public health response in most developed nations can prevent large outbreaks of the disease.  That said, I fully expect to see ongoing introductions of the virus from infected travelers, and the possibility of seeing small clusters of locally acquired disease cannot be ruled out. 

But should the world fail to stop this virus in West Africa – and relatively soon – that dynamic could easily change, with difficult to predict, but potentially dire consequences for other regions of the world.

CDC: Infection Control Guidance For Home Care Of MERS-CoV Cases

 

Credit CDC

 

 

 

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While we’ve not seen any MERS-CoV cases diagnosed here in the United States, if cases continue to show up on the Arabian peninsula, the odds favor having the virus turn up here eventually.

 

While that wouldn’t necessarily lead to a serious epidemic, it would require a coordinated public health response.  To avoid further spread, steps would have to be taken regarding hospitalization of those severely ill, the isolation of those mildly affected, and the monitoring of their close contacts.

Steps similar to those taken a decade ago to bring SARS under control in Asia and Canada (see EID Journal: A Brief History Of Quarantine).

I would also note that this current guidance doesn’t recommend quarantine of asymptomatic contacts (`Asymptomatic exposed persons do not need to limit their activities outside the home.’)

 

Since some people only experience mild symptoms with MERS, it makes sense to treat them at home, rather than expose them (and others in the hospital) to additional infection risk.  In today’s MMWR, the CDC unveiled new guidance for the home isolation and care of MERS cases, should they begin to appear in this country;

 

CDC has issued new guidance for care and management of MERS-CoV patients in the home and guidance for close contacts of these patients (http://www.cdc.gov/coronavirus/mers/hcp/home-care.html).

Persons who are confirmed, or being evaluated for MERS-CoV infection, and do not require hospitalization for medical reasons should be isolated in their homes as long as the home is deemed suitable for isolation.

CDC currently recommends MERS-CoV patients should be isolated at home until public health authorities or a health-care provider determine that they are no longer contagious.

Persons who might have been exposed†† to MERS-CoV should be monitored for fever and respiratory symptoms for 14 days after the most recent exposure. Asymptomatic exposed persons do not need to limit their activities outside the home. If persons exposed to MERS-CoV have onset of symptoms, they should contact a health-care provider as soon as possible and follow the precautions for limiting possible exposure of other persons to MERS-CoV.

 

 

This new guidance is divided into two parts.  This first part is for public health officials who must decide if home care is a viable option for mildly affected MERS cases. 

 

Interim Home Care and Isolation Guidance for MERS-CoV

This guidance is for local and state health departments, infection prevention and control professionals, healthcare providers, and healthcare workers who are coordinating the home care and isolation of ill¹ people who are being evaluated for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection. The guidance is based on what is currently known about viral respiratory diseases and MERS-CoV. CDC will update this guidance as needed.

Ill people who are being evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home. Isolation is defined as the separation or restriction of activities of an ill person with a contagious disease from those who are well.

Before the Ill Person is Isolated at Home

A healthcare professional should:

• Assess whether the home is suitable and appropriate for isolating the ill person. You can conduct this assessment by phone or direct observation.
  • The home should have a functioning bathroom that only the ill person and household members use. If there are multiple bathrooms, one should be designated solely for the ill person.
  • The ill person should have his or her own bed and preferably a private room for sleeping.
  • Basic amenities, such as heat, electricity, potable and hot water, sewer, and telephone access, should be available.
  • If the home is in a multiple-family dwelling, such as an apartment building, the area in which the ill person will stay should use a separate air-ventilation system, if one is present.
  • There should be a primary caregiver who can follow the healthcare provider’s instructions for medications and care. The caregiver should help the ill person with basic needs in the home and help with obtaining groceries, prescriptions, and other personal needs.
• Contact your local or state health department if you have not already done so.

 

If the Home is Suitable and Appropriate for Home Care and Isolation

You should:

• Provide CDC’s Interim Guidance for Preventing MERS-CoV from Spreading in Homes and Communities to the ill person, the caregiver, and household members.

 

The second part of this guidance is directed to patients, caregivers, household members, and close contacts. .

 

Interim Guidance for Preventing MERS-CoV from Spreading in Homes and Communities

CDC wants to make sure that you are protected if there is ever a case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the United States. The following guidance may be able to help prevent MERS-CoV from spreading in homes and communities. The guidance is based on what we currently know about other viral respiratory diseases and MERS-CoV. CDC will update this guidance as needed.

This guidance is for:

• ill¹ people being evaluated by a healthcare provider for a possible MERS-CoV infection who can receive care at home and do not need to be hospitalized, and
• caregivers, household members, and other people who have had close contact with someone who is being evaluated for MERS-CoV infection.

People Being Evaluated for MERS-CoV Infection

You should be cared for and isolated in your home if you:

• are ill and are being evaluated for MERS-CoV infection, and  
• do not need to be hospitalized for medical reasons.

You should follow the prevention steps below while you are:

• ill and being evaluated for MERS-CoV infection, and
• until a healthcare provider or local or state health department says you can return to your normal activities.

 

Prevention Steps

Stay home
You should restrict activities outside your home, except for getting medical care. Do not go to work, school, or public areas, and do not use public transportation.

Separate yourself from other people in your home
As much as possible, you should stay in a different room from other people in your home. Also, you should use a separate bathroom, if available.

Call ahead before visiting your doctor
Before your medical appointment, call the healthcare provider and tell him or her that you may have MERS-CoV infection. This will help the healthcare provider’s office take steps to keep other people from getting infected.

Wear a facemask
You should wear a facemask when you are in the same room with other people and when you visit a healthcare provider. If you cannot wear a facemask, the people who live with you should wear one while they are in the same room with you.

Cover your coughs and sneezes
Cover your mouth and nose with a tissue when you cough or sneeze, or you can cough or sneeze into your sleeve. Throw used tissues in a lined trash can, and immediately wash your hands with soap and water.

Wash your hands
Wash your hands often and thoroughly with soap and water. You can use an alcohol-based hand sanitizer if soap and water are not available and if your hands are not visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid sharing household items
You should not share dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people in your home. After using these items, you should wash them thoroughly with soap and warm water.

(Continue . . . )

 

You’ll find detailed infection control guidance on this page also, with advice regarding the wearing of facemasks, gowns & gloves, along with surface and laundry disinfection instructions. Last month, the World Health Organization released similar guidance (see WHO: Homecare Advice For Mild MERS-CoV Cases).

 

Most of this infection control advice is valid whether you are dealing with MERS-CoV, pandemic flu, or seasonal flu.  All are infectious, and all should be treated with respect.  

The CDC has recommended keeping a box of surgical masks, and some exam gloves on hand for just these sorts of home care scenarios, something you may want to stock up on now, while they are easily available (for more, see The Great Mask Debate Revisited).

 

For general care instructions for someone with influenza, MERS-CoV, or any other respiratory virus a good place to start is with the Home Care Guide: Providing Care at Home During Pandemic Flu  by the Santa Clara County Health Department, California and is available on CIDRAP’s Public Health Practices website.

 

Home Care Guide (Vietnamese) Download pdf, 551 KB

Home Care Guide (Spanish)Download pdf, 203 KB

Home Care GuideDownload pdf, 6 MB

The Home Care Guide provides the public with a comprehensive description of how to care for sick family members at home during a pandemic. It includes lists of emergency supplies, guidelines on how to limit the spread of disease at home, instructions on how to take care of sick household members safely and effectively and basic information about pandemic flu. This guide was created prior to the emergence of novel H1N1 flu virus in 2009. Therefore, the fact sheets located under the attachments tab in the guide contain some generalized information about pandemics, as well as information about avian influenza that may need to be updated. The guide is available in English, Spanish, and Vietnamese.

 

Should MERS, avian flu, or any other novel virus threaten, I’m certain we’ll see the release of additional guidance documents such as these.

.

WHO: Homecare Advice For Mild MERS-CoV Cases

 

Photo Credit CDC

 

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Today The World Health Organization released a brief (7 page) document advising on how best to care for `mild’  MERS-CoV cases at home in the event that hospital care is either not feasible, or not desired by the patient.

 

We’ve already seen a small number of mild cases managed successfully at home, and should this virus ever begin to spread widely, the home care option will likely become even more common.

 

While acknowledging that hospitalization – at least at this stage of the spread of the virus – is probably preferable for all symptomatic cases, this document recognizes there may be some instances where home care is a reasonable option. They write:

 

Home care for patients with MERS-CoV infection presenting with mild symptoms

In view of the currently limited knowledge of the disease and its transmission, it may be prudent to hospitalize confirmed and probable (2) symptomatic cases of the MERS-CoV infection. This would ensure both safety and quality of healthcare and public health security.

However, for several possible reasons, including situations when inpatient care is unavailable or
unsafe, or in a case of informed refusal of hospitalization, alternative settings 3 for health care provision may need to be considered.

 
Depending on the local circumstances and resource availability, symptomatic contacts with milder symptoms 4 and without underlying conditions that put the patient at increased risk of developing complications, may be cared for in the home environment.

 

The same principle of care in the home environment applies to symptomatic patients not requiring or no longer requiring hospitalization. This decision requires careful clinical judgment and should be informed by assessing the safety of the patient’s home environment 5. 

 

I’ve included some excerpts, but you’ll want to download and read the entire document.

 

Rapid advice note on home care for patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection presenting with mild symptoms and management of contacts

08 August 2013

(EXCERPT)

Because of the possibility of rapid progression to the acute respiratory distress syndrome (ARDS) and other severe, life-threatening complications, even otherwise healthy, symptomatic contacts or probable cases should be placed under close medical observation when receiving care at home.

 

The patients and the household members should be educated on personal hygiene and basic infection prevention and control measures, and they should adhere to the following recommendations:

• Limit contact with the ill person as much as possible. The household members should stay in a different room or, if that is not possible, maintain a distance of at least one metre from the ill person (e.g. sleep in a separate bed).
• Ensure that anyone who is at increased risk of severe disease does not care for the ill person or come into close contact with the ill person. The current groups considered at increased risk for the MERS-CoV infection nclude those with chronic heart, lung or kidney conditions; diabetes; immunosuppression; blood disease; and older adults. If contact with the ill person
  cannot be avoided by those with an increased risk of severe disease, alternative housing should be considered.
• Perform hand hygiene (12) following all contact with the ill person or his/her immediate environment. Hand hygiene should also be performed before and after preparing food, before eating, after using the toilet, and whenever hands look dirty. Perform hand hygiene using soap and water. If hands are not visibly soiled, alcohol-based hand rub can be used. Assistance for the ill person to perform regular hand hygiene may be provided as needed. Paper towels to dry hands are desirable; if they are not available, use dedicated cloth towels and replace them when they become wet.
• Respiratory hygiene should be practiced by all, especially the ill person. Respiratory hygiene
  refers to covering the mouth and nose during coughing or sneezing using medical masks, cloth masks, tissues or flexed elbow, followed by hand hygiene.
• Discard materials used to cover the mouth or nose, or clean them appropriately after use (e.g. wash handkerchiefs using regular soap or detergent and water).
• The caregiver should wear a medical mask fitted tightly to the face when in the same room with the ill person. Masks should not be touched or handled during use. If the mask gets wet or dirty with secretions, it must be changed immediately. Discard the mask after use and perform hand hygiene after removal of the mask.

(Continue . . . )

 

 

Whether we are talking about a greater outbreak of MERS-CoV, or the spread of pandemic flu, the reality is during a genuine epidemic hospitals will quickly reach their capacity, and will be able to admit only the `sickest of the sick’.

 

Home care will become the norm, not the exception.

 

Flu.gov warns of Overloaded Health Care Systems during any severe influenza pandemic, writing:

 

• Most people have little or no immunity to a pandemic virus. Infection and illness rates soar. A substantial percentage of the world’s population will require some form of medical care.
• Nations are unlikely to have the staff, facilities, equipment, and hospital beds needed to cope with the number of people who get the pandemic flu.

 

Anticipating this, a number of state and federal agencies have prepared Home Care Guides for use during a pandemic. 

 

One of the most comprehensive, comes from the Santa Clara County Health Department, California and is available on CIDRAP’s Public Health Practices website. 

 

 

Home Care Guide: Providing Care at Home During Pandemic Flu

 

Home Care Guide (Vietnamese) Download pdf, 551 KB

Home Care Guide (Spanish)Download pdf, 203 KB

Home Care GuideDownload pdf, 6 MB

The Home Care Guide provides the public with a comprehensive description of how to care for sick family members at home during a pandemic. It includes lists of emergency supplies, guidelines on how to limit the spread of disease at home, instructions on how to take care of sick household members safely and effectively and basic information about pandemic flu. This guide was created prior to the emergence of novel H1N1 flu virus in 2009. Therefore, the fact sheets located under the attachments tab in the guide contain some generalized information about pandemics, as well as information about avian influenza that may need to be updated. The guide is available in English, Spanish, and Vietnamese.

 

Part of the advice in the WHO MERS guidelines, and the Pandemic Flu Homecare guides, is to use facemasks to reduce the spread of infection.  This from the Santa Clara County guide:

 

 

 

We obviously don’t  know if another pandemic is in the offing anytime soon, but it is always prudent to be prepared. Besides, most of the information provided in these flu brochures is applicable for dealing with seasonal flu at home, as well. 

 

So you may want to download one of these guides today, and think about what supplies you may want to have on hand that are available now, but that may be in short supply during an outbreak.

 

For more on the relative merits of different types of facemasks, you may also want to revisit The Great Mask Debate Revisited.