The problem with Home Recovery for COVID

One month since daily COVID-19 cases in Singapore have breached a hundred, and two weeks on from when Home Recovery for COVID-19 positive cases have started, Singapore enters yet another lockdown to put the brakes on rising COVID cases and protect the public healthcare system. I write about three things that have proved difficult with Home Recovery for COVID positive cases.

Firstly, isolation orders issued to COVID positive cases to curb the spread of COVID have not been effective because the household environment is not sufficient to prevent the spread of COVID-19 within the household. Upon detection of a COVID positive case, the entire household is placed under quarantine order. Unfortunately for most households, effectively isolating a COVID positive person in the household is challenging in the home environment. COVID-19 have been found to be transmitted by aerosolized droplets, and can linger on surfaces for up to 6 hours. Given that the delta variant of SARS-CoV2 is highly infectious with a reproductive number estimated to be between 3 to 8 (or about twice more infectious compared to previous variants of SARS-CoV2), spread of infection within the household seems near inevitable. Furthermore, environmental factors such as the use of shared common spaces within the home, lack of regular sanitization, and lack of negative pressure isolation facilities mean that household members are unlikely to be able to safely isolate themselves from COVID positive patients in the same house. Non-COVID positive household members also have to take on the additional burden of caring for COVID positive patients isolated in their rooms, receiving food deliveries, preparing meals, and managing other household chores. What happens as a result is the inevitable spread of COVID-19 throughout the entire household, with quarantine orders rescinded for the whole household only when every member have gotten infected, and recovered from COVID-19.

What does this mean from a public health perspective? One possible conclusion is that Home Recovery is not an effective method to curb the spread of the virus. However, if containment of the virus is no longer a strategy, and preservation of healthcare facilities are the priority, then identification of COVID positive cases should be considered at the household level. The recovery period for COVID positive households should be based on the time taken for an entire household to become infected, and recover from COVID. Currently the recovery period of 10 days is based on the disease trajectory of a single individual. However, assuming that there is an inevitable time lag between the time an individual is infected, becomes infectious, and is tested positive, we need to assume that asymptomatic transmission within the household would have occurred prior to testing positive by ART or PCR tests. Streamlining the isolation orders and quarantine orders for the entire household would also help reduce the logistical burden for Home Recovery.

Secondly, our telemedicine infrastructure is not able to cope with the number of C+ cases placed on Home Recovery. Currently, the bulk of telemedicine providers are private healthcare groups, some general practitioners and a few dedicated telemedicine providers. Given the sudden increase in COVID cases, these providers are unable to cope with an additional 1000+ patients each day. Almost all COVID positive cases experience some symptoms, mild or otherwise. The most crucial function of telemedicine providers however, is screening for red flag symptoms or trending worsening symptoms that indicate an escalation of care. Unfortunately, scaling up telemedicine provision is not an easy task. Doctors need to be trained specifically to conduct consultations through virtual means, substituting physical examination for its “digital” equivalent and knowing how to best make use of virtual platforms. These best practices are extensive, but well detailed in MOH’s training materials for doctors who wish to provide telemedicine services. Proper telemedicine also requires the provision of medication to individual households. While our delivery services have expanded extensively, delivery of medication requires stricter control in accounting for drugs dispensed, and ensuring that the drugs reach the intended recipient. Furthermore, ensuring proper compliance with medication regimen usually involves a pharmacist checking on drug allergies, issuing instructions on the regimen, checking back on what was understood and following up with a suitable caregiver if necessary. These functions may require couriers specifically trained for the delivery of medication, and may take more time to scale up fully.

Thirdly, logistical support for COVID positive households needs to be improved should more households be placed on quarantine. While we may marvel at how convenient food and grocery delivery services are today, we cannot expect all households to be able to deal with prolonged periods of quarantine without a hitch. Basic provision of food and groceries should be extended to quarantined households to ensure that they are able to maintain their quality of life. Furthermore, as household members fall ill, they may not be able to provide for each other as they have been doing before the quarantine. Neighbours and grassroots committees are well positioned to extend their help to quarantined households and have worked tirelessly to reach out to those placed under quarantined. However, these community members need to be trained on infection control measures to protect themselves from the virus. 远亲不如近邻 — a distant relative is not as good as a near neighbour. During these difficult times, our communal spirit have been tested, and will continue to be tested. But Singaporeans have shown time and again their willingness to reach out and help one another when in need.

This piece is based solely on the author’s own opinions and do not constitute formal advice.

Note: MOH, SAF and grassroots organizations have recently made great efforts to ensure that COVID positive patients recover in the safest and best possible manner and the situation is dynamic but improving by the day.