Home isolation for asymptomatic and mild cases - how many can fulfill the conditions?
COVID-19 crisis in Manipur points to lack of planning and preparedness on the part of the government
There was delay in the start of Covid Care Centres (CCC) and a scramble when it was required. At the start, the planner perhaps thought that the beds in the isolation wards of the two main hospitals will suffice. But when cluster transmission started, the number rose sharply and there was a rush to start more such centres. Better late than never; but it points to lack of planning and preparedness.
Infectious disease spread has four phases. Phase I is when a few isolated cases were found and the response is to isolate them and their contacts. Phase II is when cluster spread starts and the response besides the two will also include containment of the cluster. Phase III is when the source of infection is not known and the spread is more widespread known as community transmission and besides the above responses, lockdown is added. In Phase IV which is epidemic phase the response is solely concentrated towards treatment and not waste time, energy and money on containment as that time is over. It will be in order to differentiate between quarantine and isolation. Quarantine is to keep certain individuals whose status is not known while isolation is for those who are positive.
Although many believe that Phase III had started in the last week of July, and the Technical Committee met and recommended that the initial stage of Phase III had commenced in the first half of August, the Government is yet to declare as such. The Government however issued an order on August 15, 2020 for home isolation of asymptomatic and mild cases under certain conditions. In developed countries, it is believed that for such cases home isolation is the best, and even before community transmission starts this is the norm. But in places like Manipur where the economic conditions of the people is poor and where the most of the citizens are not enlightened, many felt that it would be a disaster and transmission would be rapid. But with limited resources, it would not be possible for the state to cater to the need to accommodate all in the CCC, when cases rise. Thus this orders attempts to involve those who have the requisite facilities to take care for themselves.
The facility for home isolation is not mandatory but elective. Only those who can afford or fulfil the conditions can opt for home isolation. The conditions are many, some of which are – (1) Separate bedroom and bathroom for patient, though shared bathroom is allowed with strict infection control; (2) Following of strict instructions for the patient and care provider as detailed in Annexure II of the order; (3) An adult care provider to provide 24/7 support with communication link between the care provider and the hospital and (4) patient should self monitor his health as per the prescribed formats and inform his health status to the health team for further surveillance; (5) Availability of adequate disinfectants and masks and gloves; etc. Installation and activation of Aarogya Setu is mandatory, though there are serious concerns about the likely misuse of the personal data collected. The instruction to both the patient and the care provider in Annexure II is very detailed and there is always a concern that these detailed guidelines may be short circuited. One of the conditions is that the State and District Covid-19 Community Awareness teams should conduct proper awareness to the community before the start of implementation but till now nobody knows whether there is such a team, as no awareness has been conducted.
Limitation in creation of awareness
In fact the role of the health department in providing awareness is limited and it is because of this failure that useless exercise like spraying of sodium hypochlorite solution was carried out on roads and gutters and even on human body or the use of sanitisation chamber or tunnel or cabinet which are discouraged by WHO. Formation of inspection teams associated with local clubs/civil organisations/village council are mentioned as well as supply of sufficient quantities of masks and gloves. It is unfortunate that most of the masks supplied in the government institutions do not fit snugly on the nose bridge. The genuine product has either a metal or plastic strip which is amenable to pressure and when the mask is worn, the strip can be manipulated with the fingers to snugly fit the nose bridge so that there is no leak. But unfortunately, those supplied has a rigid plastic strip which can’t be shaped to fit the contour of the nose leaving free space where air can enter; thus making it risky.
After looking into the conditions laid down in the order, despite the desire of the state to ensure that those who has the capacity and are asymptomatic or mild may look after themselves, it will be difficult to implement due to various reasons. One factor till Phase IV of the transmission is reached will be objections from the locality and convincing them will be an uphill task and if this was forced, discrimination and stigmatisation will increase. There are however a few cases where the community was supportive and home isolation permitted and hats off to the community leaders. The assurance that the patients or the care provider will be diligent enough is lacking. The examples of wealthy people hiding and trying to treat at home will be a major dampener on this initiative. Many believe that the orders was issued as some people in high position had tested positive though asymptomatic and don’t want to stay in the CCC where the conditions to say are poor!
When Phase IV epidemic phase is reached, there is no option but to have home isolation. With the health care system overstretched, one major objection which came out during discussion with various clubs etc is whether the health authorities will be able to respond when the condition of the patient deteriorates?
Blaming the health authorities not an answer
The main reason is when there is delay in transporting positive cases to the CCC as of now due to various constraints and when the monitoring in the CCC are not up to the mark, whether the health teams will be able to respond to different locations when needed? Blaming the health authorities is not an answer as they are overwhelmed by the spread of the disease and those medical professionals working in the outlying health centres deserve all the sympathies, the long hours, the risk, etc is unfathomable.
Questions were raised whether the 15th August orders was issued taking into account the ground reality in the state or just copied from the MHFW guidelines for the benefit of a few? If it is the latter, better to revisit and take into consideration the feedback from the ground health professionals and avoid the top down style of management which hardly succeeds.
With the increase in community transmission where the percentage of those who has no travel history constitute more than 80% daily with some days reaching 100%, there is a risk that the existing CCC may not be able to cater. There are still who are suspected to be primary contact but who refused to be tested claiming. Either it is fear of stigmatisation or the fear of staying in the CCC or avoiding the reality, quite a few unreasonable individuals are creating problems. Sero-surveillance survey must be put in selected places to determine the intensity of the spread. According to a latest report as per sero-survey in Delhi 34.7% of the participants aged 5-17 and 31.2% of above 50 carries the antibody for SARS-Cov2 indicating very high prevalence.
Some doctors in the forefront for treatment of serious and critical cases told that the time taken for a serious patient to turn critical is very short. The conditions of the patients deteriorate very fast and hence, all severe cases may be required to be kept in the hospitals which can provide critical care. In video clips, people who look absolutely normal are in the isolation wards of the hospitals. There should be proper screening so that only those who deserve to be in the hospital isolation wards are kept there; not those who have the connections.
There are reports that private hospitals are being sounded to treat covid-19 patients, without realising the facilities available. Very few have more than one OT, or even if there are more are quite close to each other. Once covid-19 patients are taken it will be next to impossible to treat non-Covid patients, thereby denying them the right to treatment; thus the option is either to die of Covid or from other diseases. The worst sufferers are those giving childbirth, which can’t be postponed. The thought of roping in private hospitals for treatment of Covid-19 patients needs a revisit taking into consideration the overall health care system in the state.
The orders for home isolation of asymptomatic and mild cases is unavoidable but it seems very few can fulfil the conditions. Those with co-morbid conditions especially those whose home is away from the hospitals may be kept in CCC rather than home isolation as their condition may deteriorate fast. The order will however put greater strain on the health care system which is already overstretched. The community awareness needs to be carried out fast and systematically.
(The views expressed are the writer’s own)