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With a steady increase in daily Covid-19 cases, its patients occupy almost all beds and Intensive Care Units of hospitals across the country. Against this backdrop, management of asymptomatic, mild, and moderate cases of Covid-19 at home or non-healthcare settings is important for both patients and authorities in order to relieve pressure on the healthcare system.  

Moreover, the WHO says 80 percent Covid-19 are asymptomatic, mild or moderate cases, 15 percent have severe infections, and the remaining 5 percent are critically infected patients. The apex global health organization says asymptomatic cases including patients with mild and moderate symptoms can be treated at home by following preventive measures.

Mild cases of Covid-19 are the ones diagnosed positive in PCR test but without any evidence of viral pneumonia or hypoxia while the Moderate cases have mild pneumonia. Fever (<102.38°F), dry cough, smell blindness, and sore throat are the most common symptoms in mild to moderate cases. Severe and critical cases have trouble breathing, persistent pain in the chest, bluish lips, serious to severe pneumonia, or acute respiratory distress syndrome (ARDS). Both severe and critical cases require emergency treatment or hospitalization.

Irrespective of the level of severity of the coronavirus infection, pregnant women or those above 60 or individuals with underlying medical conditions like diabetes, asthma, hypertension, kidney problems, cancer, and obesity must seek hospital treatment. Home-based care is recommended for adults or children when the hospital setting is unsafe, health facilities limited in numbers or unable to meet demand. 

Covid-19 Cases Isolation Management Guidelines issued by the Government of Nepal also say asymptomatic and mild cases can be managed through home isolation by following set preventive measures to avoid cross-transmission. The below-mentioned measures are as helpful for home-quarantined patients as well:

Physical exercise: Activities like walking within the room, for 15-20 minutes at least three times a day, help maintain proper blood circulation and prevents blood clots in lower limbs from prolonged bed rest. Deep breathing through the nose, spirometer or balloon blowing exercise 8-10 times a day helps restore lung function and improve oxygenation in mild cases. (But lung exercises are not recommended soon after food consumption.)

Gargling: Coughing, the second most common symptom after fever, causes sore throat. Gargling, an ancient therapeutic measure, four times a day, at an interval of four hours, helps reduce viral load in the oropharynx and remove throat irritation. Betadine diluted with lukewarm water in the ratio of 1:3 can be used to gargle on throat made sore by corona infection. You should not eat at least 15-20 minutes after the gargle with betadine.

Balanced diet: The person in isolation needs to eat low-carb but protein-rich foods with spices like ginger, turmeric, and garlic that generally boost physical immunity. Combination of food rich in Vitamin C, Vitamin D, and zinc that produce a synergistic role in boosting immunity is recommended. Alcohol drinking during isolation can result in anxiety disorders or depression, with greater risk of suicide. In addition, alcohol harms the immune system. Smoking by individuals with mild or moderate symptoms further weakens their respiratory system and elevates the risk of severe pneumonia. Avoiding both alcohol and smoking is important during the infection.

Medical Evaluation through Measurement of Vitals and Observation: The health condition of mild or moderate coronavirus patients must be monitored at least thrice a day and their health status updated. The patients too must immediately contact concerned authorities if their health condition worsens or they experience any difficulty. Patients can take their vitals like body temperature with thermometer and blood oxygen saturation with pulse oximeter.  If body temperature steadily increases above 102.38°F and oxygen saturation (SPO2) gradually drops below 90-92 percent, help must be immediately sought. Besides these, if there are threatening medical conditions like troubled breathing, persistent chest pain/pressure, dehydration, mental confusion, and bluish lips, immediate medical attention must be sought at government-assigned Covid-19 dedicated hospitals.   

Regular communication: The government’s isolation guidelines say at least one health worker should be assigned to monitor 50 patients under self-isolation. As per the guidelines, the designated health worker must monitor health condition of the patients, especially vital measurements at least two times a day through a phone call or message. The health worker can prescribe antipyretics drugs like paracetamol and ibuprofen for management of fever and pain during isolation. Patients also must immediately contact their health worker if they experience further symptoms or if their caretaker observes deteriorating health conditions.

Patients should disassociate themselves from rumors and misinformation about coronavirus and maintain regular communication with their friends, family, and relatives via phone or video chatting to keep themselves in good spirits—all vital to beat the infection.  

Precaution by caretakers: Children and pregnant women without underlying medical conditions but with mild and moderate symptoms can be treated at home. However, they require a caretaker at home during their isolation period. Caretakers must maintain personal hygiene and sanitation and put on a medical mask, plastic apron, and gloves while providing care or disinfecting the frequently touched surfaces, clothes, and bed items.

The WHO estimates that people with mild to moderate symptoms generally recover within two weeks. But there are some instances of the symptoms extending by a week. Hence it is advisable not to overlook the cases as mild or moderate and seek immediate medical attention if symptoms prevail for over three weeks.

Asymptomatic patients in home isolation can discontinue their self-isolation 10 days after the date of their first positive RT-PCR test on mild or moderate cases; for those with symptoms, self- isolation can end after at least 10 days from the onset of symptoms and three more days without any symptoms. More importantly, if the patients with mild or moderate symptoms have a fever, it must recede without the use of any antipyretic drugs 24 hours before discontinuing self-isolation.

The author is a graduate in Epidemiology and Biostatistics from SRM University, India

The Covid-19 pandemic has undoubtedly taken a huge toll on lives the world over and overwhelmed even the strongest health systems. The only positive thing is the high recovery rate: over 90 percent. The People’s Daily reported that overall recovery rate in Wuhan was 99.2 percent while it was 88.2 percent in severe cases. Skepticism however has been expressed over chances of reoccurrence of infection among the discharged patients. It is assumed that any person who has recovered from pathogenic infections develops antibodies to prevent relapse.

Li QinGyuan, Director of Pneumonia Prevention and Treatment at China Japan Friendship Hospital in China, says the infected do develop antibodies against that virus. But he says it is unclear how long the antibodies remains. The recovery rate in Nepal has been seen encouraging yet the public is in dilemma over reappearance of infection. As of now, three recovered cases in Nepal have again tested positive on Real time Reverse Transcription–Polymerase Chain Reaction (RT-PCR) test during follow-up.

Recovered patients with underlying conditions or weak immune systems may not develop sufficient antibodies to ward off fresh attack from the virus. Relapse is high in patients suffering from diabetes, cancer, cardiovascular diseases, HIV/AIDS, even malnutrition. Even for a person with a strong immune system, it is unclear how long antibodies are at work following the recovery.

The WHO on April 24 said “no study has evaluated whether the presence of antibodies of Covid-19 confers immunity to subsequent infection.” However it has also been reported that like other coronaviruses—‘Severe acute respiratory syndrome’ or ‘Middle Easter respiratory syndrome’ that caused pandemics in 2002 and 2012 respectively)—Covid-19 antibodies persists for longer, probably two to three years. Public health and medical professionals also believe immunity against Covid-19 remains for long period.

No test including RT-PCR is 100 percent valid for confirming Covid-19 infection. Hence patients who have recovered may test positive in follow-up owing to false negative in earlier test. Likewise, there is a chance that patient discharged from the hospital might be falsely diagnosed positive in follow-up test. BMC journal states that sensitivity (true test positive rate) and specificity (true test negative rate) of RT-PCR is 70 percent and 95 percent respectively. It implies that despite having Covid-19 virus, there is 30 percent probability that test results might be negative. In follow up test of the same case, there is chance that patient can be correctly diagnosed positive by RT-PCR machine. Similarly, there is five percent probability of being diagnosed falsely positive in follow-up test after being discharged despite not having Covid-19 pathogens. This is why many countries, including India, mandate at least two tests in 24 hours, with both of them testing negative, to declare that the patients has recovered.

The big flaw of RT-PCR is that although it is good at identifying Covid-19, it cannot differentiate whether the virus is dead or alive. WHO says the person discharged from hospital may test positive in RT-PCR for several weeks but he/she is unlikely to be infectious enough to spread the disease. According to Dr. Oh Myoung-don of Seoul National University Hospital, dead virus can be present in human body long after recovery. So the RT-PCR test can still turn out positive result in this time. To confirm the virus is dead, the collected throat sample can be cultured in laboratory. As the process of culture takes time and calls for viral isolation measures, it may not be feasible during epidemics.

A study in China mentioned that 5-10 percent of the Covid-19 cases there are reinfections. Reactivation of the virus is one reason the cured patient tests positive on RT-PCR during follow-up test. The pathogens tend to be dormant or latent within a cell and hide from immune cells during the stage of viral latency. They don’t cause any illness in this stage and no symptoms are seen. This might ultimately lead medical professionals to believe patients are infection-free and thus discharge them from hospitals, mainly in resource-poor settings. After a certain time, replication and multiplication of the virus leads to RT-PCR test positive result.

Public health experts and virologists have shown increasing concerns over possible mutation, the change in genetic sequence of new coronavirus. Unlike DNA virus, the new coronavirus, which is RNA virus, is more susceptible to change. It can lead to evolution of virus into less or more harmful forms. Severe forms of Covid-19 may worsen the global health crisis as it augments the risk of re-infection of recovered patients despite their antibodies.

There are no in-depth studies to prove recovered patients are immune to Covid-19, while some reports suggest they might be re-infected. Thus the recovered patients should continue to maintain self-isolation, physical distancing, personal hygiene, and taking balanced diet. In addition, they should be under medical surveillance for at least two weeks following ‘full recovery’ and undergo a follow-up RT-PCR test in line with the Good Microbiological Practice and Procedure (GMPP) to avoid any test error.

The author is a graduate in Epidemiology and Bio-Statistics from SRM University, India