30 March 2020
Practical guidelines for successful home quarantine
We are in the early stages of a coronavirus pandemic. Projections suggest up to 50% of people will become infected, so this may affect you or your family.
It is important to delay/prevent the spread as much as possible within the home and the community, as this reduces the burden on the healthcare system, allows time for appropriate treatments and for vaccines to be developed, tested and mass produced.
In this evolving situation, you should check the website of your State Health Department, for up-to-date on advice on diagnostic testing and disease management in the home. NSW Health guidelines are found at https://www.health.nsw.gov.au/Infectious/factsheets/Pages/hubei-contacts-and-travellers.aspx. Presuming the symptoms are mild, it is prudent to care for someone with COVID-19 at home. The infection risk to the carer and other family members can be reduced following simple guidelines.
Three things are important:
- Start quarantine at the first sign of symptoms, as this is when the person is most likely to spread infection.
- Quarantine must be done rigorously, as coronavirus spreads very easily.
- Be prepared. Know what to do and have basic items already available at home.
The first symptoms vary between people and are similar to cold or the flu. These include: fever (above 37.3?C), cough, a feeling of being unwell or exhausted. Runny nose and diarrhoea or vomiting are uncommon but possible.
Coronavirus is thought to spread between people in multiple different ways:
- Contact with contaminated surfaces or hands. Virus picked up by touching surfaces or by shaking hands is transferred to mucus membranes of the face (eyes, nose or lips), passing on the infection. An infected person will have virus on their hands after blowing or wiping their nose, or they can transfer virus to surfaces by coughing or sneezing which creates droplets of mucus or saliva which settle onto the surfaces. High touch surfaces in the home or workplace include table tops, door handles, phones, keyboards, light switches, toys, bedding etc.
- Large droplets sprayed out while coughing, talking and sneezing can be directly inhaled by a person or sprayed onto the person. This requires close contact between people. Once generated these droplets are generally considered to only stay airborne for a few minutes at most, during which they can be inhaled from the air, after that, large particles settle onto surfaces, contaminating them. They probably only travel a few metres in that time.
- Very small droplets (termed aerosols). These are generated by both breathing and also by coughing, talking and sneezing. These behave more like smoke than a spray and stay airborne for long periods and can travel many metres, around corners, with airstreams et cetera. At present it is thought that such aerosol transmission is not an important route for this virus.
- Faecal-oral route. This method of transmission is also possible as some patients have large amounts of this virus in their stools, especially if they have diarrhoea. Droplets or aerosols containing virus can be generated by toilet flushing, which creates a spray from the water and faeces. There were cases of SARS coronavirus-1 spread by this route in Hong Kong during the 2003 outbreak, and in a recent case, a hospital bathroom used by an infected patient had virus detected all over the fittings and walls. Virus can persist in faeces after symptoms get better.
All these routes can be important at different times and circumstances. Addressing all routes is necessary to minimise infection and spread.
If someone in your home begins to show symptoms of COVID-19, the infected person should be quarantined immediately. This means they should remain in a room alone and if possible have their own bathroom. They will have to eat, sleep and generally carry on life in this room. Food should be left at their door (knock and leave, don’t greet).
Afterwards, the plates and utensils, if not disposable, should be treated as infectious and put through the dishwasher. They should not be allowed in any other rooms of the house, or outside the house other than to a backyard or a well-ventilated balcony and they should maintain a distance of at least two metres at all times from other people. In this case, both parties should be wearing masks and the infected person should turn away to cough.
If some physical contact is required in the home, for example when caring for children, keep contact to the minimum, wash hands afterwards, clean surfaces with diluted bleach and keep windows open if possible. Pets should not be allowed in the person’s room as they may transport virus on their fur.
The guidelines are written on the presumption of adults in a nuclear family. Many millions of Australians live singly or in other domestic arrangements and will have to adapt this advice to their situations. In some situations, it would be preferable for one family member to be the designated carer, in order to limit the risk of wider transmission. If two parents are infected and children are sent to others for temporary care, because the children may be infected but not showing symptoms, it is better to send to a young adult and not grandparents if at all possible.
The whole family should consider themselves to be under quarantine, that is in lockdown, because there is a risk that other family members have already become infected. A person can become infectious one to two days before they start to show symptoms. Symptoms usually appear five to six days after infection, but this can be up to 12 to 14 days later. Thus the whole family should not go out of the house. This will require a range of wide range of support; food supplies, medical, and other support for at least a week.
No doubt this is very challenging in a world where we are all used to a high level of social mobility. The quarantining of entire families was one of the successful strategies practised during the Spanish Flu pandemic in 1919, when Australia had one of the lowest infection rates in the world. It is also a key to successful approaches in Asian countries who have a collective social memory of SARS. If the infected person requires movement to medical facilities, the house is still contaminated for four to seven days.
Minimising the risk of infection
Minimising the transmission of the virus within the home means addressing all the known routes. Studies of effective approaches in hospitals during the SARS (a different coronavirus) pandemic are instructive and are used as the basis for approaches at home. These approaches were: the use of mask or respirator, wearing gowns, thorough cleaning of surfaces, wearing gloves and handwashing at least 10 times per day. While each had some effect, a combination of them was most effective. Among healthcare workers, N95 respirators were more effective than surgical masks but this probably reflects the very high exposure situations involved.
Each will be dealt with separately here.
Masks and respirators (P2): Surgical masks were originally designed to prevent doctors infecting their patients. They come in a wide variety of shapes and are held on with loops around ears or tie at the back. There is no filtration standard which varies between brands. They do not seal tightly to the face and are generally comfortable to wear for long periods. They are good for filtration of large droplets and less useful for filtering small aerosols.
Some studies of infection rates for healthcare workers for other viruses do not show differences in protection between wearing surgical masks and P2/N95 respirators, other studies favour P2 respirators.
Respirators (called P2 in Australia, N95 in US, FFP2 in Europe) are made with a thicker filter and are standardised to provide very good protection against inhaling small aerosols. However, to work properly the mask needs to seal tightly to the face, if not, they will leak, particularly around the nose and chin. It is very important to closely follow instructions for use on the packaging. No design of respirator fits 100% of face shapes.
More than two days’ beard growth can be enough to cause leakage. P2 can become quite uncomfortable on extended wear (headaches, itchy faces, rash or other problems). The wearing of P2 by an infected person is not useful if the respirator has an exhalation valve. If P2 are not available, P1, which are slightly less effective, are an option. P2 should be reserved for high exposure situations as there is limited evidence that small particle aerosols play an important role in most domestic transmission, which involves close contact.
The normal advice has been that respirators are single use with a limited life of six to eight hours. However, in emergencies and shortages they can be reused until they fail in some way, get hard to breathe through, or visibly deteriorate. Remember don’t swap respirators with people, write your initials on them, and once used, the outside is contaminated with virus so only hold by the straps and wash hands as if infected after putting on and taking off. At home it is not easy to clean or sterilise masks and respirators without damaging the electrostatic cloth filter, very hot water with no soap or detergent is possibly best, but this is not validated.
If surgical masks or respirators are not available, it is not clear what the best advice is. One study using cloth masks showed they were inferior to surgical masks. People have used scarves, shawls, masks made from several layers of gauze or dry electrostatic wipes. None of these have been validated. Any of these will stop you touching your face and will capture at least some droplets and presumably is better than nothing. Under such a situation, make sure the windows are open before, or as soon as entering a room and spend as little time as possible being exposed.
Wearing gowns: In a hospital context, medical staff would put on a gown before entering the room and remove it on leaving and then washing their hands. You will have to use your imagination here, perhaps a cotton coat, slippers or thongs and a headscarf that can be easily laundered as it will become contaminated. Use only for this purpose and preferably store in an enclosed space close to the entry door.
Thorough cleaning: In the only study so far, the titre of this coronavirus was reduced 1000-fold after three days on plastic, two days on stainless steel and one day on cardboard. However, viruses can be more stable in human mucus than buffers as used here, and stability also changes with temperature and humidity, so longer times may apply. If possible, flat surfaces in the room should be cleaned regularly. The WHO recommends cleaning with soap (or detergent) and water and then decontaminating with an agent such as bleach; advice varies from 1:35 to 1:100 dilution of 5% sodium hypochlorite, 0.5% hydrogen peroxide solution or 70% alcohol solution.
If the infected person moves from their room to the bathroom, afterwards decontaminate surfaces that have been touched on the way and in the bathroom.
Wearing gloves: It is normal in infection control to use disposable gloves when handling any potentially infectious material and reduce virus transfer and exposure. If not available, use washing-up gloves. Treat the outside of the gloves as potentially contaminated after using, requiring disposal or cleaning with soap and water or disinfectant. There is a low risk of allergy from prolonged use of latex examination gloves, and there are many PVC, nitrile, vinyl or powder-free latex alternatives.
Frequent hand washing: In the case of influenza and colds, hand washing at least 10 times per day typically provides around 20% reduction of disease, and this effect is likely to be greater for coronavirus. However, while hand washing might prevent individual infections, it will not stop all spread through a community as there are multiple routes of infection. Hand washing should be frequent and for at least 20 seconds each time using warm water and vigorous hand-to-hand action. It takes this amount of time for the soap molecules to penetrate into the crevices of the skin, loosen the grip of the virus on the skin, and to wreak destruction on the coat of the virus.
Dry your hands on a clean paper towel and dispose of. There is no advantage in using specialised “antibacterial” or medicated soap. Probably wise to use a hand cream or moisturiser after washing to replace lost oils as such frequent washing can lead to skin problems. Some sanitisers also contain oils for this reason. While several experts advocate soap, not published studies of its effectiveness could be found. Handwashing should be performed after any possible exposure to contamination, visiting the person or shared bathroom, handling objects they have handled, before preparing foods, after mask removal, and in many other situations; you will have to use common sense based on activities.
If soap and water is not available, alcohol sanitiser is a good alternative. This should contain around 70% alcohol to be effective. There are some incorrect articles on the web about making your own alcohol sanitiser. If you absolutely must, then at least take the advice of the WHO site.
There are several other things which can be done.
Handling contaminated material: Because the infected person will be generating virus aerosols through coughing, talking and blowing their nose at least, it is important that these are safely collected at the source. The simplest way is for them to wear a surgical mask if available. Advice is also given to cough into the crook of the arm to limit droplet and aerosol spread. It is recognised that surgical masks may be in short supply and coughing into a disposable tissue is a substitute.
Tissues used to collect all mucus blown from the nose should be immediately put in a lined container and disposed of in the garbage. If no tissues are available, use soft toilet paper (if you have spare) and flush down the toilet, or bag and put in garbage. The infected person should wash their hands in warm soapy water or use an alcohol sanitiser after each handling of tissues.
Infection control practices in hospitals would use regular changes and laundry of bedding and clothing to remove virus. This should definitely be done if there is any soiling of clothing and bedding. Wear a mask and gloves while handling contaminated clothing and bedding in a plastic bag. Laundry with normal detergent is said to be effective at removing virus; dry in the sun or on the hottest setting that can be used with the items. Preferably washing at home, not a laundromat.
Increase ventilation: Open windows in all rooms as frequently as possible. There are numerous studies showing lower rates of virus and bacterial transmission in well-ventilated hospital wards, dormitories and houses. It’s likely that good circulation of outside air flushes out the important droplets and aerosols as well as providing cleaner air for anyone else present in the room.
Eye protection: There is some data that some viruses at least, can enter the body via droplets sprayed into the eyes, as well as by wiping fingers on the eyes. In hospitals, some form of goggles or eye shields are frequently used. It would seem prudent to find an equivalent, like wrap-around sunnies or goggles when direct exposure to an infectious person was likely.
Visiting the room: It may sound harsh, but, where practical, members of a family should avoid all direct contact with an infectious person, that is, being in the same room. This also applies to home visitors as much as possible. If people do want to talk and socialise at home, this should be done outside the house in the backyard or on an open balcony and maintain a two-metre distance between people and both wear masks.
Sit upwind of the case, as droplets can travel in plumes. These restrictions could be distressing and a challenge to family dynamics and it will raise anxiety for everyone. It means the infectious person will have to eat alone and only be visited in situations where the visitor is directly providing necessary care. Try using a phone at other times and try to find other ways to keep spirits up, entertain, make the time useful and provide reassurance. Remember any items that have been in the room, books, furniture, eating utensils et cetera, will potentially carry virus and could be a source of infection for a few days afterwards.
Any person entering the room should have a mask and should wash their hands or use an alcohol-based sanitiser immediately on leaving.
Sleep and rest: Getting a lot of sleep is important, as is extended rest and not returning to any strenuous activity or stress for an extended period. The body is vulnerable to additional infections and needs time to heal properly.
Diet: There are many articles in the popular media about boosting your immune system or particular foods with health-giving properties. There is not much in the medical literature about this, other than the obvious advice about the extra importance of a healthy well-balanced diet at times like this. At least for colds, there was an interesting study of the benefits of chicken soup.
If you live by yourself, make a plan for a friend, Meals on Wheels or use an on-line shopping service to deliver food and other necessities to your door while you are quarantined.
How long for: People with confirmed coronavirus infection should remain under home isolation precautions until the risk of secondary transmission to others is thought to be low. This could be two to three weeks. The decision to discontinue home isolation precautions should be made on a case-by-case basis, in consultation with your doctor or whoever is providing professional advice.
- The infected person is a mini virus factory, shedding virus into the air and onto surfaces
- They need to be isolated as much as possible within the house
- If at all possible they should have their own bathroom. If not, the bathroom should be well ventilated after use, and the surfaces should be considered as contaminated
- Surfaces, and where possible floors, need to be routinely cleaned with water and detergent or other cleaning solution (1:30 dilution of household bleach). No advice possible about carpets.
- Wash your hands regularly, and thoroughly (20 seconds with soap and water or 70%-based alcohol based sanitiser) particularly after being in the room of an infectious person or handling anything they may have touched.
- Wear disposable or washable gloves whenever handling items that may carry virus to limit spread and also when using cleaning agents to protect your hands from harsh chemicals.
- The infected person should wear a surgical mask in the presence of anyone else.
- Any person attending the infectious person should also wear a surgical mask (at least).
- Good ventilation of the room is important as it flushes out large and small airborne droplets and provides clean air. Leave windows open as much as practical.
- Get plenty of rest and sleep, eat well and plan for a better future.
- Finally, support medical research and evidenced-based experts, not what anyone says on the web. We have had five near-miss respiratory viral epidemics in the last 20 years, it will happen again, there is a lot to learn, so start planning now.
Shopping and action list
- Disposable gloves, or failing that dishwashing gloves
- If available, disposable surgical masks, P2 respirators, (if not available, then P1)
- Bleach, cleaning detergent and disinfectant, bucket and mop, cleaning cloths.
- Laundry liquid
- Thermometer to check temperatures
- Hand moisturiser
- Soap for handwashing
- A plan to provide food, medical communication and other necessities over a period of three weeks.
- Discuss with family and friends and agree to check on each other regularly.
- Maintaining isolation requires dealing with the boredom, stress and anxiety, so think about positive ways to encourage compliance.
Euan Tovey is an associate professor, honorary affiliate senior research fellow at the Woolcock Institute, University of Sydney, with special interests in virus transmission and sampling biological aerosols.
Sacha Stelzer-Braid is a senior postdoctoral scientist in the Virology Research Lab at University of New South Wales/Prince of Wales Hospital with special interests in surveillance of enteroviruses, and the transmission and role of respiratory viruses in chronic airways disease.