Bangalore: Imagine this. You wake up one morning with a headache and fever. You’re coughing as well, but you’re not sure if you have difficulty breathing. You wonder if you have the new coronavirus. What can you do next?
The latest reports indicate that up to 80% of those testing positive for the novel coronavirus in India are asymptomatic: they aren’t displaying any symptoms. The typical symptoms of COVID-19 are fever, dry cough and difficulty breathing, in some cases chest pain as well. Anyone displaying all these symptoms should visit the nearest hospital to report themselves.
If you’re displaying only some of these symptoms, however, consult a physician – such as a family doctor if you have one, or visit the nearest one, perhaps in a clinic or at a hospital. The government has also set up a national helpline for consultations: +91 11 2397 8046. Proceed according to their advice.
At the moment, the only way to treat COVID-19 is to treat its symptoms, such as to take paracetamol for the fever (note: this is not medical advice; please consult a doctor before consuming any medicines).
If you think you should get tested, consult the Indian Council of Medical Research guidelines, and visit a doctor; only doctors can ask for tests. Quoting verbatim from version 4 (published on April 9, 2020) of the guidelines, anyone fitting at least one of the following descriptions has to be tested:
- All symptomatic individuals who have undertaken international travel in the last 14 days
- All symptomatic contacts of laboratory confirmed cases
- All symptomatic healthcare workers
- All patients with severe acute respiratory illness (fever and cough and/or shortness of breath)
- Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming contact
At least, these people are supposed to be tested.
If you were recently in a hotspot or area where clusters of coronavirus cases have been discovered, were part of a large gathering or in an evacuees’ centre, you are to undergo an RT-PCR test if you have symptoms of an influenza-like illness: “fever, cough, sore throat, runny nose”.
Finally, if you are a symptomatic individual who travelled abroad in the last 14 days (unlikely these days), a symptomatic contact of a lab-confirmed patient or a symptomatic healthcare worker, you will have to undergo quarantine – either at home or, if your symptoms require round-the-clock attention, in a designated hospital.
Now, how do you quarantine yourself at home?
The extramural research division of the Union health ministry has a set of protocols for this situation.
You will have to stay home in circumstances defined by the protocols for 14 days. During the quarantine, you are prohibited from stepping outside and have to keep away from all social gatherings. You are now said to be at high risk for developing COVID-19.
For the confinee
The following points are drawn from the ministry’s protocols:
- Stay in a room of your own, which is well-ventilated, has an attached bathroom/toilet for your use
- To the extent possible, always maintain a distance of at least 1 meter from any of the house’s other inhabitants
- Stay away from people at higher risk of developing severe infections (if they get the virus) relative to the general population: senior citizens, pregnant women and those with comorbidities (especially heart disease, diabetes, hypertension and ailments that suppress or otherwise compromise the immune system, such as HIV/AIDS)
- Wash your hands as often as possible with soap and water, if not then with an alcohol-based sanitiser
- Wear a surgical mask at all times. Dispose of a mask every 6-8 hours and wear a new one.
For the confinee’s caregiver
The following points are drawn from the ministry’s protocols:
- Assign one person as the caregiver and don’t change caregivers during the course of the quarantine
- Don’t come into direct contact with the person in quarantine, and don’t handle their clothes or any objects they have used without disposable gloves and mask on
- Properly dispose of the gloves once used, and wash your hands with soap and water or an alcohol-based sanitiser
- Don’t allow the person in quarantine to receive any visitors
- Disinfect and clean all frequently touched surfaces in the quarantined person’s room with a 1% solution of sodium hypochlorite
- Disinfect all surfaces in the bathroom/toilet with bleach- or phenol-based disinfectants
- When washing the person’s clothes, don’t mix others’ garments with them; use a regular detergent and dry after washing in the sun
The minimum required quarantine period is 14 days. If during this period you develop the symptoms of COVID-19 and test positive, you will have to continue quarantine until you test negative on two RT-PCR tests within 24 hours. And all the people you recently came in contact with will have to be quarantined at home for 14 days.
The Tamil Nadu government, if not others, has been broadcasting the quarantine guidelines on Tamil channels in the form of a skit played by multiple actors, replete with masks, gloves and cleaning routines.
Home quarantine is a feature of all public healthcare systems around the world trying to arrest the spread of the new coronavirus. But it isn’t without criticism. A group of Chinese doctors who travelled to Italy in March 2020 have said, according to Bloomberg, that Italy shouldn’t repeat China’s mistake: which is that people with even mild symptoms are allowed to quarantine themselves at home. However, the team argued that they should all be mass-quarantined to avoid the pitfalls of thinking that mild infection equals mild infectiveness, which is not true.
However, nearly all countries following the quarantine-and-test strategy to slow the pandemic require one class of patients and persons of interest to self-quarantine, primarily to spare hospitals the burden of treating more people than they have the resources for.
The Indian health ministry’s protocols are also in line with the WHO’s guidelines for home quarantine. The sole difference is that the WHO recommends the person in quarantine check their temperature twice a day.
Hong Kong’s guidelines about “home confinees” provide a more detailed description of the composition of disinfectants to be used to clean different surfaces (quoted verbatim):
“Home should be cleaned thoroughly at least once per week with 1 in 99 diluted household bleach (mixing 10 ml of bleach containing 5.25% sodium hypochlorite with 990 ml of water), leave for 15-30 minutes and then rinse with water. For metallic surface, disinfect with 70% alcohol. If places are contaminated by respiratory secretions, vomitus or excreta, clean up the visible matter. Then disinfect the surface and the neighbouring area with appropriate disinfectant. For non-metallic surface, disinfect with 1 in 49 diluted household bleach (mixture of 10 ml of household bleach containing 5.25% hypochlorite solution with 490 ml of water), leave for 15-30 minutes, and then rinse with water. For metallic surface, disinfect with 70% alcohol. Maintain drainage pipes properly, and regularly (about once a week) pour about half a litre of water into each drain outlet (U-traps) to ensure environmental hygiene.”
The American guidelines, provided by the Centres for Disease Prevention and Control, stipulate, “Any home being considered as an isolation setting should be evaluated by the patient’s physician, health department official or other appropriate person to verify its suitability.” A suitable home or facility is expected to have the following (quoted verbatim):
- Functioning telephone
- Heat source
- Potable water
- Bathroom with commode and sink
- Waste and sewage disposal
- Ability to provide a separate bedroom for the patient
- Accessible bathroom in the residence
- Resources for patient care and support
- Primary caregiver who will remain in the residence and who is not at high risk for complications from SARS-CoV disease
- Meal preparation
- Essential shopping
- Social diversion (e.g., television, radio, internet access, reading materials)
- Masks, tissues, hand hygiene products
Taiwan’s home quarantine protocol comes with an ‘electronic fence’ – an evocative name for a system that tracks your phone signals to see if you’ve stepped out of your home. If you have, police and health officials are alerted, and show up at your doorstep within 15 minutes.
Quarantine and stigma
According to the Indian government’s prevailing policies, public health officials are to test “high-risk” contacts of all people who have tested positive for COVID-19, both inside and outside hotspots. According to the National Centre for Disease Control, a person is deemed ‘high-risk’ if they have “touched body fluids of the patient, had direct physical contact with the body of the patient including physical examination without PPE, touched or cleaned the linens, clothes, or dishes of the patient, lives in the same household as the patient [and/or has come] within three feet of the confirmed [patient] without precautions [and/or has been a passenger for more than six hours] within three feet of a conveyance with a symptomatic person who later tested positive for COVID-19.”
However, data presented in a recent paper by ICMR researchers indicates community transmission has begun in parts of India. This in turn means contact-tracing can’t fruitfully identify potential new cases of COVID-19 in these parts. As a result, it is currently unclear how the government has been identifying asymptomatic cases outside hotspots, if any.
In his press conference with journalists on April 21, health ministry secretary Lav Agarwal said all of India’s cases are currently split as 31% symptomatic and 69% asymptomatic. However, the fraction of asymptomatic cases varies according to the active cases currently under consideration. So the ‘69%’ figure could have been different earlier and could change in future.
For example, ICMR’s chief epidemiologist Raman Gangakhedkar had said on April 20 that 80% of India’s infections were asymptomatic. On April 19, Delhi chief minister Arvind Kejriwal said all 186 people who had tested in the city in the previous 24 hours had been asymptomatic.
Agarwal didn’t share any information about how asymptomatic people are being followed up, aside from subjecting them to the usual quarantine protocols.
Even if there is clarity on protocols, and even faith that they will suffice to keep the virus from spreading to more people, anecdotal reports from around the country suggest a considerable stigma has enveloped the status of being quarantined itself.
After public health officials in Delhi placed a sticker on the door of a house with someone in quarantine inside, the house “became like a zoo,” a resident told BBC. “People stop to take pictures when they pass by. Our neighbours tell us to go inside even when we step out into our balcony for a minute.”
Even people who have died of or with COVID-19 have often not been permitted a decent or uncontested burial, with people fearing that an improperly buried body could contribute to spreading the virus locally.
This is not true: unless you come into direct contact with the body, such as by touching the skin with your skin or by, say, hugging the body as an expression of sorrow, you have nothing to fear. Apart from skin contact, the virus needs to be sneezed, coughed or breathed out to spread – none of which a dead person can do.