Dr M S Seshadri is retired Professor & Head of Endocrinology & Medicine, Christian Medical College, Vellore, and currently Medical Director at Thirumalai Mission Hospital, Ranipet, Tamil Nadu. Dr T Jacob John is retired Professor & Head of Clinical Virology, Christian Medical College, Vellore. They write:
“Hide your grandpas and grandmas,” Israel’s Prime Minister Benjamin Netanyahu said in his initial response to the COVID-19 threat in his country — an elegant phrase, born out of common sense and canny wisdom. Truer words cannot be said in the current pandemic, nor can they be put across more effectively and succinctly to all countrymen at risk.
Why are these words of wisdom? Conventionally in an epidemic of contagious disease, the approach is to quarantine those who are infected in order to protect those who are well, so that the latter could carry on with normal life.
But the COVID pandemic is different in some critical ways. Mortality graphs worldwide show that case fatality rates are heavily influenced by age and by pre-existing chronic non-communicable diseases.
Mortality tends to increase from about age 55, and rapidly so as age advances. Therefore, most COVID-19 deaths occur in the elderly or those with ‘co-morbid’ conditions such as hypertension, chronic heart disease, diabetes, and chronic lung disease. Mortality is quite high when the elderly have chronic diseases.
We must anticipate that 50%-70% of the population will acquire immunity by actually having asymptomatic or symptomatic infection before this epidemic is over. That is the natural history of any epidemic of contagious disease.
The majority of such immune individuals will be youngsters. Among children and young adults, the majority would have no disease symptoms or only a mild, self-limiting respiratory illness from which they would recover in a week or two.
However, the problem is that they are likely to pass on the infection to the old and vulnerable individuals in their households, places of work, or at social and religious gatherings, even if the group is as small as four or five.
Remember, the elderly and the vulnerable (due to chronic diseases) have a risk of about 10%-15% fatal outcome if infected with SARS-CoV-2. If the elderly and the vulnerable are isolated from others during the time of the epidemic, they have a good chance of escaping infection altogether. Such isolation, for their safety, is ‘reverse quarantine’ or ‘cocooning’.
How then do we practise cocooning of the elderly/vulnerable? What are the do’s and don’ts? It is really simple.
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All those steps you want a COVID-19 patient or coronavirus infected person to take in order to prevent spreading the infection, you ask the elderly and vulnerable household members to practise in order to avoid getting infected!
They should strictly stay at home for the next several months until after the epidemic is over. Government pension, rations, free medication etc., should be delivered at home.
All their physical and emotional needs must be met by the family members. Healthcare needs must be met by telephone consultations. They should neither visit sick people nor entertain anyone with a febrile illness. They should wear a mask and spectacles if they have them, all the time when talking even to other family members and household help.
They should certainly avoid getting together in groups to socialise, but remain socially connected through telephone and social media. Home entertainment, playing indoor games, practising hobbies such as reading, painting, gardening, playing musical instruments etc., will be very worthwhile pastimes.
They can and should interact with children in the family, but they should maintain the critical physical distance (minimum 2 metres), as school-going children are likely to bring infection home. Everyone should wear a mask when so interacting.
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All should practise frequent and thorough hand washing, particularly after touching potentially contaminated surfaces such as wash basins, taps, doorknobs, buttons in lifts, etc. When hands are washed with soap, the tap must also be washed and rinsed.
Preferably, elders and vulnerable people should use a napkin/clean handkerchief when they need to open a door or press a button. They should not share a mobile phone with any family member. They should keep their toilet articles separate, and their rooms and bathrooms should be sanitised periodically with sodium hypochlorite solution or soapy water. They should use a separate bathroom/toilet, if one is available. If they do need to share, the floor and surfaces that anyone may touch should be cleaned with soap and water, before and after use.
Many elderly people live by themselves; they will need a caretaker from within the family or from outside, preferably one who is less than 40 years old. The caretaker should wear a mask, and wash hands thoroughly before and after physically helping them.
The caretaker should not come to work for four weeks in the event of a febrile illness — even in any of his/her family members. Time is counted from the day of recovery. During this time, a young relative or family friend could take charge.
“Protect the elderly and vulnerable” is a culturally appropriate slogan and a practical strategy to curtail COVID-19 mortality, during the current public health emergency.