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Meeting the COVID-19 challenges
Millions of Americans continue to live under state-issued stay-at-home orders in an effort to contain the spread of the novel coronavirus (COVID-19, or SARS-CoV-2). As this pandemic evolves, home caregivers face new challenges and responsibilities.
To better prevent, prepare for and cope with COVID-19 in our homes, we spoke with Milana Trounce, MD, Clinical Professor of Emergency Medicine at Stanford Medicine and the Chair of BioSecurity for the American College of Emergency Physicians. We have also drawn from the most pertinent information and recommendations from The Centers for Disease Control (CDC), World Health Organization (WHO), Stanford Health Alerts, Stanford Medicine and Stanford Healthcare to formulate this guide to home management.
Before COVID-19 strikes your home: Get your household ready
Create a household plan of action, and write it down.
- Stay informed and in touch by getting up-to-date information about local COVID-19 activity from public health officials.
- Make a list of local organizations you and your household can contact in case you need access to information, healthcare services, support, and resources.
- Create an emergency contact list including family, friends, neighbors, carpool drivers, healthcare providers, teachers, employers, the local public health department, and other community resources.
Take everyday preventive steps to reduce chance of transmission.
- Wash your hands frequently. But what does that really entail?
Dr. Trounce recommends washing your hands often with soap and water for at least 20 seconds. This is especially important when you re-enter your home after being in your car or outside your home; after blowing your nose, coughing, or sneezing; after going to the bathroom; and before eating or preparing food. If soap and water are not available, use an alcohol-based hand sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry.
- Avoid touching your eyes, nose, and mouth. But why is this step so important?
When someone coughs or sneezes, they spray small liquid droplets from their nose or mouth, which may contain virus. While you can breathe in the droplets if you are too close to an individual who has COVID-19 (even prior to that infected individual having symptoms of the disease), the most common way the virus is transmitted is probably when the droplets get on your hands, and then you touch your face. Or, the droplets remain on surfaces or even clothing, which you then touch, and then you touch your face.
- Avoid sharing personal items. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people in your home. After using these items, wash them thoroughly with soap and water or put in the dishwasher.
- Clean and disinfect frequently touched objects and surfaces. As Dr. Trounce notes, “The good news is that COVID-19 is very susceptible to [being killed by] anti-bacterial cleaning agents.”
- Wear disposable gloves when cleaning and disinfecting surfaces. Gloves should be discarded after each cleaning. If reusable gloves are used, those gloves should be dedicated for cleaning and disinfection of surfaces for COVID-19 and should not be used for other purposes. Consult the manufacturer’s instructions for cleaning and disinfection products used. Clean hands immediately after gloves are removed.
- Make a checklist to include, at a minimum: tables, hard-backed chairs, doorknobs and stove/oven knobs, light switches, remotes, handles (refrigerator, microwave, drawers), desks, toilets, sinks.
- Most common EPA-registered household disinfectants will work. Use disinfectants appropriate for the surface. Options include:
- Diluting your household bleach. To make a bleach solution, mix: 5 tablespoons (1/3rd cup) bleach per gallon of water OR 4 teaspoons bleach per quart of water.
- Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted
- Alcohol solutions: Ensure solution has at least 70% alcohol.
- See this complete guide to disinfecting for further details.
- Launder items (including washable plush toys) using the warmest appropriate water setting for the items and dry items completely. Dr. Trounce notes that, “COVID-19 gets killed after being exposed to 70 degree temperatures for at least 30 minutes, so if your dryer setting can reach 70 degrees, you can consider doing sanitary steam for at least 30 minutes at 70 degrees or more for outer layers of clothing.”
- Wear disposable gloves when handling dirty laundry and then discard after each use. If using reusable gloves, those gloves should be dedicated for cleaning and disinfection of surfaces for COVID-19 and should not be used for other household purposes. Clean hands immediately after gloves are removed.
- If no gloves are used when handling dirty laundry, be sure to wash hands afterwards.
- If possible, do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air.
- Clean and disinfect clothes hampers according to guidance above for surfaces. If possible, consider placing a bag liner that is either disposable (can be thrown away) or can be laundered.
Put distance between yourself and other people.
Yes, even in your home (and certainly if the home caregiver must leave the home for necessary food or medical supplies), it would be wise if each family member keeps a distance of at least 3 if not 6 feet apart. Some people that have the virus are asymptomatic (without symptoms) for several days, during which time they may be able to spread the virus to others.
Keep your family unit as small as possible. As Dr. Trounce notes:
“You should assume that all visitors are carriers because you don’t know if someone is COVID-19 positive if they’ve not been tested, and testing is currently being performed only on symptomatic individuals. However, asymptomatic individuals can still carry the disease and infect others.”
Focus on staying healthy.
People both at average risk as well as at higher risk of getting seriously ill with COVID-19 should do all that they can to stay physically and mentally healthy. COVID-19 is a virus that attacks the immune system, and immune system health can be boosted by:
- Getting enough sleep
- Staying hydrated
- Exercising regularly
- Eating nourishing food
- Getting a little sunshine. Dr. Trounce notes that “immunity gets a bit of a boost from Vitamin D, so when possible, get outside in the sunshine, especially in an open-air backyard, alone; or take a walk in your neighborhood, abiding by 6-ft. social distancing guidelines.”
- Maintaining personal connections, even if virtually (see: Sheltering in place: A BeWell Coach’s perspective) and addressing your emotional health (see: Guide to self-care: Coping with coronavirus)
Masks and face coverings
As far back as early February, and most certainly by the end of that month (as reported in the Journal of the American Medical Association, 2.21.20, “Presumed Asymptomatic Carrier Transmission of COVID-19”), leading scientists and physicians were reporting evidence that individuals positive for COVID-19 can transmit the disease to others, even in the absence of symptoms. Accordingly, early on Stanford Healthcare printed that, “Wearing a mask can help prevent those who are infected from spreading the virus and offers some protection to the person wearing it.”
CDC finally reversed, in early April, its previous, limited guidance on wearing masks. Initially, CDC recommended masks only for those confirmed ill with COVID-19. Now, because of more widespread understanding that you can spread COVID-19 to others even if you do not feel sick, CDC now recommends that everyone wear a cloth face cover when they have to go out in public, for example to the grocery store or to pick up other necessities. The CDC goes on to advise:
- Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing, and a cloth face cover will not completely protect the wearer from contracting COVID-19. The wearer is simply helping to limit the spread of the disease by wearing the mask.
- Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
- People should avoid touching the front of any face covering and remove it by using the ear loops. Immediately set it aside for laundry, and wash it in soapy hot water.
- The CDC provides guidelines for how to make and wear your own cloth face covering, but says medical and surgical masks, including N95 respirators, should be saved for health professionals.
- Dr. Trounce adds that, “If someone already has surgical masks, those can be used as well. It is very important to clean the masks after wearing them, every time: you need to assume they may have virus on them. It is also important to wash hands for 20 seconds after touching them, since viral particles on dirty masks can contaminate hands.”
- Megan Mahoney, MD, Stanford Health Care’s chief of staff and a Stanford Medicine professor of primary care and population health, concurs, and further states (June 16, 2020 Stanford Medicine Scope interview):
“Cloth masks should have at least two layers of fabric, and tightly woven fabric is best. Surgical masks protect better than cloth masks — they have an electrostatic charge that helps capture more particles — and they provide some protection to the person wearing the mask. Unlike early in the pandemic, they’re now readily available and inexpensive. Face shields are becoming more commonplace and offer some advantages: They can be reused and are easily cleaned with soap and water or common household disinfectants.”
Face coverings are now mandatory in most CA counties:
On April 17, 2020, San Mateo County (and most other Bay Area counties) announced a new order (the “Face Coverings Order”), which generally requires that you wear a face covering when around other people outside of your residence, including at work unless you are in an enclosed, private office. The order does not require a mask, but any kind of cloth face covering, such as a bandana, is sufficient. Importantly, the Face Coverings Order does not change the shelter in place orders (including social distancing requirements) that are already in place; while face coverings are a tool for reducing the spread of the COVID-19 virus, they are not a substitute for sheltering in place, physical distancing of at least six feet, and frequent hand washing. See complete details in Stanford Health Alerts.
Returning from home:
Optional guidelines (that healthcare workers follow)
Family members that are heads of households, or “essential workers” that have to leave their homes for work, or who are the home’s main caregivers, can (optionally) follow the routine that many healthcare workers are advised to follow, in an abundance of caution:
- Disinfect your automobile before leaving it: door handles, steering wheel, gear shift and start buttons.
- Take off your shoes at the front door. Wash your hands after you remove them.
- Leave a box by the door to hold your car keys, backpack or briefcase, other items.
- Take off your outer clothes at the door, placing them in a plastic bag at the door for washing. As stated previously by Dr. Trounce, “COVID-19 gets killed after being exposed to 70 degree temperatures for at least 30 minutes, so if your dryer setting can reach 70 degrees, you can consider doing sanitary steam for at least 30 minutes at 70 degrees or more for outer layers of clothing.”
- Sanitize your cell phone and eyeglasses, if any.
Dr. Trounce then recommends heading straight to the shower.
Prepare for possible illness.
- Choose a room in your house that can be used to separate a sick household member from others.
- Consider members of the household who may be at greater risk. (Bear in mind that this is a rapidly evolving situation and the risk assessment – CDC guideline may change daily.):
- Those people with diabetes, chronic lung disease (including people with moderate to severe asthma), and heart disease have endured the most severe complications with COVID-19, according to data published on March 26, 2020 by the CDC.
- People who are immunocompromised, including those who have had cancer treatment; who smoke; or who have had bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications.
- People with severe obesity (body mass index [BMI] of 40 or higher), chronic kidney disease undergoing dialysis, or liver disease are also at higher risk.
- Lastly, certain (but not all) people over 60 could face a more difficult course of COVID-19; a person’s immune system starts to gradually decline in function and speed of response around middle age, with a sharper decline at 65.
If you may have come in contact with someone with COVID-19
CDC guidelines continue to evolve on this topic. As of this report date, if you suspect that you have come into contact with someone who may have COVID-19, you should:
- Stay at home at least 14 days after the most recent exposure; so, if you are in a home where someone else could go out to perform essential tasks, such as getting groceries, reassign that task to them. Even if you don’t have symptoms, you could be contagious for up to 48 hours after becoming COVID-19 positive, should you do so.
- Isolate yourself at home, in a separate bedroom and if possible use a separate bathroom.
- If you must come to a common area, such as a kitchen, wear a mask. Disinfect any surfaces you may have touched before returning to your bedroom. Wash any dishes you may have used.
- Completely avoid contact with any members of your family that are deemed at higher risk for severe illness. Dr. Trounce states that “the best way to protect vulnerable individuals in your home is to avoid exposure to all members of the household. If such exposure occurred, self-quarantine for 14 days of self or the vulnerable individual may be warranted. For example, many healthcare workers choose to self-isolate from their families while they work, and for 14 days after (i.e., for duration of the incubation period for COVID-19).”
- Self-monitor for symptoms by checking your temperature twice a day and watching for fever, cough, or shortness of breath. (See below for symptom monitoring details.)
If a family member becomes ill
We divide this guidance into three different scenarios:
1. If you, the head of household or main caregiver, become ill …
Start by contacting your health care provider, ideally via telemedicine, to formulate a plan for remaining at home if you have mild symptoms, what medicines to take, etc.: As WHO has suggested, “If and where feasible, a communication link with a health care provider or public health personnel, or both, should be established for the duration of the home care period — that is, until the patient’s symptoms have completely resolved.”
As Dr. Trounce notes, “if you get initial symptoms mimicking a cold or flu — such as fatigue, shortness of breath, fever — assume it’s COVID-19 until you get tested,” and take all the precautions in your household that you would if you knew, definitively, that you indeed have COVID-19, including:
- Self-isolate from others at home — in your own bedroom, using your own bathroom (if possible).
- If you need to be around other people, wear a facemask.
- Cover cough and sneezes. Throw used tissues in a lined trash can.
- Maintain a distance of at least 6 feet from other family members.
- Wash hands regularly.
- If it is at all viable for another family member to do so, ask them to leave food at your bedroom door, so that you (the sick individual) do not leave virus all over the kitchen. As Dr. Trounce states, “a sick person eating at the kitchen poses a higher risk to other family members, as there is also fomite spread (spread by touching surfaces).”
- When/if in kitchen to eat, disinfect surfaces after departing to go back to your room.
- Avoid sharing utensils.
- Consider using paper or disposable products for eating.
- Stay hydrated.
- Monitor temperature and keep a journal of your other symptoms. Call your provider back if you experience*:
a) Difficulty breathing
b) Extremely high temperature, 103 F or above
c) Chest pain or pressure
e) Severe cough with choking
f) Blue lips or face
*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning. Dr. Trounce adds that: “It’s key to monitor for respiratory decompensation, and if there is presence of shortness of breath, or the patient is looking significantly more ill, consider taking the patient to the hospital.”
- If you have a temperature above normal, take any medications your doctor prescribes, such as fever-reducing medications. Dr. Trounce comments that “some MDs do use acetaminophen (Tylenol) preferentially to ibuprofin (Motrin, Advil, Nuprin), but there is no data to suggest one is safer than the other in COVID-19.” However, Trounce does note that:
“There is some debate about how much to control fever in COVID-19, since elevated temperatures slow the replication of the virus. This has to be balanced with the cardiovascular risk to the patient from the fever. If someone has mild symptoms and is otherwise healthy, taking an antipyretic should not be a knee- jerk treatment. I would recommend it for someone with cardiovascular/pulmonary underlying conditions whose body is not as well equipped to ‘run a marathon’ due to fevers.”
2. Caring for family member with mild symptoms (and not high-risk for severe illness)
- Limit the number of caregivers. Ideally, assign one person who is in good health and has no underlying chronic or immunocompromising conditions. Visitors should not be allowed until the patient has completely recovered and has no signs or symptoms of COVID-19.
- Contact the patient’s health care provider, preferably via telemedicine.
- Follow the advice in the previous section, but consider these modifications:
a) Dr. Trounce strongly suggests that, if viable, the caregiver leave food at the sick person’s door so that the sick individual does not leave virus all over the kitchen. “A sick person eating at the kitchen poses a higher risk to other family members, as there is also fomite spread (spread by touching surfaces) — it is a choice.”
b) If the caregiver must enter the patient’s room, open a window (if possible) to allow for increased airflow.
c) Although not everyone will have access, it is recommended that those who may be in close contact with the virus use personal protective equipment (PPE), such as a mask and gloves. The WHO recommends the use of medical masks for people who are sick and those caring for sick people at home. If you are using disposable PPE, remove gloves first, immediately cleaning hands before removing; then dispose of the facemask and cleaning the hands again after removing the mask. Place all used PPE and other items that may have been contaminated in a lined container before disposing of them in the trash. It could be helpful if the sick person ties up the garbage bag before the caregiver comes in and takes it out.
If masks are in short supply, Dr. Trounce says that you can consider reusing them. “If reuse is necessary, CDC recommends rotating masks. One can place a used mask in a clean paper bag and keep it there for 5 days to allow the virus to disintegrate. Therefore, you can rotate 5 masks. If 5 masks are not available, one can consider disinfecting them. COVID-19 gets killed by dry heat at 70 degrees for 30 minutes or longer. I would not put them in an oven where the food is cooked, to avoid contamination.” See this mask decontamination guidance from the CDC.
d) If you must help a family member (such as young child or infirm adult) with monitoring their temperature, Dr. Trounce states that “caregivers have to be excellent at hand hygiene, and also wash the thermometer with soap and water afterwards, or wipe it down with sanitizer.”
e) Worth repeating: “It’s key to monitor the patient for respiratory decompensation, and if there is presence of shortness of breath, or the patient is looking significantly more ill, consider taking the patient to the hospital.”
3. Caring for a higher-risk family member
While your high-risk family member is still healthy, CDC recommends:
- Creating a care plan that summarizes a person’s health conditions and current treatments. Many care plans include a summary of your health conditions, medications, healthcare providers, emergency contacts, and end-of-life care options (for example, advance directives). People complete their care plans in consultation with their doctor, and if needed, with help from a family member or home nurse aide. Download a fillable care plan form.
- Know what medications your loved one is taking and see if you can help them have extra on hand. A minimum two-month supply is suggested.
- Monitor food and other medical supplies (oxygen, incontinence, dialysis, wound care) needed and create a back-up plan.
- Stock up on non-perishable food to have on hand in your home to minimize trips to stores.
If your high-risk family member starts to experience symptoms
First and foremost, we stress that older adults and people of any age with certain serious underlying medical conditions such as lung disease, heart disease, or diabetes — because they are at higher risk for developing more serious complications from COVID-19 illness — should seek care (by first phoning or emailing their health care provider) as soon as symptoms start. In many cases, home convalescence will not be advisable.
If, however, the patient’s provider does allow for a period of home convalescence during early, mild symptoms of COVID-19, all of the care recommendations in the previous sections apply. As stated previously by Dr. Trounce: “It’s key to monitor the patient for respiratory decompensation, and if there is presence of shortness of breath, or the patient is looking significantly more ill, consider taking the patient to the hospital.”
While some children and infants have been sick with COVID-19, adults make up most of the known cases to date, and the pediatric age group appears to be the least affected. Dr. Trounce notes that “children actually tend to do far better than adults with COVID-19 and develop serious illness from it only rarely.” That said, with the general exposure to COVID-19 through mucus membranes, any human being could be susceptible to the disease. While there is limited data concerning the issue of whether specific underlying medical conditions in children are associated with worsened disease, it is recommended that parents take extra precautions right now if their child has asthma or a congenital heart problem.
You can encourage your child to help stop the spread of COVID-19 by teaching them to do the same things everyone should do to stay healthy, including social distancing and thorough handwashing. See above sections. (See also: How to talk with kids about COVID-19.) If your child is healthy, there is no need for them to wear a facemask.
If your child does become ill, parents should contact their pediatrician and follow their doctor’s directions on obtaining testing if appropriate. Parents of patients with subspecialty needs should call their subspecialty providers if their child is diagnosed with or being tested for COVID-19, so that their care team can advise them in real time. See the Caring for family member with mild symptoms section, above.
CDC states: “We do not currently know if pregnant women have a greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have serious illness as a result. Pregnant women experience changes in their bodies that may increase their risk of some infections.”
Because clinicians do categorize pregnant women as, by definition, immunocompromised — as they are known to be at greater risk of severe morbidity and mortality from other respiratory infections such as influenza and SARS-CoV, the American College of Obstetricians and Gynecologists does state that they “should be considered an at-risk population for COVID-19.” However, in limited recent case series of infants born to mothers infected with COVID-19 published in the peer-reviewed literature, none of the infants have tested positive for COVID-19 — suggesting that COVID-19 is not crossing through the transplacental route to the fetus. Lucy Tompkins, MD, PhD, Stanford Medicine Professor of Medicine (Infectious Diseases) and Professor of Microbiology & Immunology, stated in recent Stanford Medicine Grand Rounds (3.25.30) that, to date, there is “no data suggesting that pregnant women are at any more risk [than the general pubilc] either of contracting COVID-19 or of becoming more severely ill than average if they do contract COVID-19.”
But what about the prenatal medical appointments that pregnant women are supposed to have regularly, throughout the pregnancy? “Many ob-gyns are changing the structure of prenatal care to limit patient, relative and staff exposure and to practice social distancing as much as possible,” says Dr. Vincenzo Berghella, the editor in chief of the American Journal of Obstetrics & Gynecology MFM, in a recent interview with The New York Times. “Many visits can be done by telehealth, usually through an app.” And when the woman does need to be seen in the medical office, “Ultrasounds will still be necessary but can safely be spaced out for most patients.” Having a blood pressure monitor at home is helpful for these visits so that you can take a blood pressure measurement and report it to your provider, he added.
Breast milk is the best source of nutrition for most infants. However, much is unknown about COVID-19. In limited studies on women with COVID-19 and another coronavirus infection, Severe Acute Respiratory Syndrome (SARS-CoV), the virus has not been detected in breast milk; however, information on this issue is still evolving. Thus, whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and healthcare providers. However, in CDC’s interim guidelines, there are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended.
If you are breastfeeding, the CDC advises you to take all possible precautions to avoid spreading the virus to your infant. This includes washing your hands before touching the infant and wearing a cloth face covering over your nose and mouth. If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow these recommendations for proper pump cleaning after each use. If the mother is symptomatic, consider having someone who is well feed the expressed breast milk to the infant.
At this time, there is no evidence that companion animals, including pets, can spread COVID-19 to people or that they might be a source of infection in the United States. To date, CDC has not received any reports of pets becoming sick with COVID-19 in the United States.
However, since animals can spread other diseases to people, it’s always a good idea to practice healthy habits around pets and other animals, such as washing your hands and maintaining good hygiene. See also: Animals and COVID-19.
When to end home isolation
If you have been fortunate enough to recover at home from COVID-19, follow the guidance of your healthcare provider and local health department. Local decisions depend on local circumstances. In Santa Clara county, the current requirement is that after you tested positive for COVID-19, “you must self-isolate for 14 days OR 7 days after fever is gone and other symptoms are better, whichever is longer.” Stanford cautions that these guidelines will likely evolve; at the present time, data is limited regarding how long, after symptoms subside, an individual could remain positive for COVID-19 and possibly still be contagious.
CDC has provided similar guidelines for determining when you can safely end your home isolation. This set of guidelines is extremely important to read and follow if you have had COVID-19: While initial data indicates that you will probably be immune to COVID-19 (i.e., you will not get COVID-19 a second time), in some countries former patients have re-entered regular family life and their communities too soon after symptoms have only begun to abate, leading them to unknowingly infect others with the virus that they could still be shedding.
April 9, 2020; updated June 17, 2020
Guide to self-care: Coping with coronavirus
Sheltering in place: A BeWell Coach’s perspective
Helping Kids and Families Cope with COVID-19
How to Cope with Being Home Again
BeWell’s response to COVID-19