1 Family-focused Home Care Plan During a COVID-19 Epidemic: A Consensus Statement by the PAFP Task Force on COVID-19 PAFP Task Force on COVID-19 Maria Victoria Concepcion P. Cruz, MD (Chair) Karin Estepa-Garcia, MD Lynne Marcia H. Bautista, MD Jane Eflyn Lardizabal-Bunyi, MD Policarpio B. Joves, Jr. MD Limuel Anthony B. Abrogena. MD Ferdinand S. De Guzman, MD Noel L. Espallardo, MD Aileen T. Riel-Espina, MD Anna Guia O. Limpoco Leilanie Apostol-Nicodemus, MD March 2020
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Family-focused Home Care Plan During a COVID-19 Epidemic:
A Consensus Statement by the PAFP Task Force on COVID-19
PAFP Task Force on COVID-19
Maria Victoria Concepcion P. Cruz, MD (Chair)
Karin Estepa-Garcia, MD
Lynne Marcia H. Bautista, MD
Jane Eflyn Lardizabal-Bunyi, MD
Policarpio B. Joves, Jr. MD
Limuel Anthony B. Abrogena. MD
Ferdinand S. De Guzman, MD
Noel L. Espallardo, MD
Aileen T. Riel-Espina, MD
Anna Guia O. Limpoco
Leilanie Apostol-Nicodemus, MD
March 2020
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Family-focused Home Care Plan During a COVID-19 Epidemic:
A Consensus Statement by the PAFP Task Force on COVID-19
The Philippine Academy of Family Physicians, Inc.
Statement of Recommendations
Initial Planning
Statement 1: Develop a Family-focused Care Plan that contains tasks and activities related to the
family structure, home environment and processes in order to mitigate the effect of the COVID-19
epidemic.
Adjustment in the Family Structure and Home Environment
Statement 2: Identify a Family Caregiver who will remind the family to follow and implement the
plan. Make sure this person is supported by all family members.
Statement 3: Identify a room or area that can be used for isolation in the event that a family member
is exposed to a diagnosed COVID-19 patient.
Statement 4: Identify those who are at risk i.e. more than 60 years old, with existing chronic illness
or other life-threatening conditions, and advise to take extra precaution.
Statement 5: During the declared community quarantine period, all family members should stay
at home, limit family celebrations, avoid home parties with outside guests, cancel travels as much
as possible, and be ready to have more members staying at home.
Performance of Routine Tasks and Activities
Statement 6: Practice personal hygiene that includes regular and appropriate hand washing, daily
bath, cough and sneezing etiquette, minimal hand contact with eyes, nose and mouth, and strict
personal use of eating utensils, bath towels, etc.
Statement 7: Daily cleaning of frequently touched surfaces like doorknobs, light and appliance
control switches, gadgets, armchairs and tabletops. Cleaning agents can be ordinary detergents and
water or 70% alcohol.
What to Do When a Member is Exposed
Statement 8: Advise an exposed family member to stay home, in a room or area, which may be
allocated for isolation, wear mask and maintain at least 2 meters physical distance from other family
members.
Make sure their clothing, personal belongings and other things that they usually hold is cleaned regularly
and not touched by other members.
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Statement 9: Watch out and monitor for the appearance of symptoms like fever, colds and cough. If
the person exposed is low risk and there is difficulty of breathing or worsening of symptoms, consult
your family doctor. If the person is high risk i.e. elderly or with existing chronic disease, and symptoms
appear, consult your family doctor right away. Call first before going to the clinic or hospital.
Statement 10: If the symptoms are mild, continue home quarantine, take over-the-counter medications
like paracetamol for fever, increase water intake and ensure adequate nutrition, sleep and rest. Other
family members are encouraged to provide psychological and social support for an exposed and isolated
member.
Statement 11: Symptoms usually resolve within 14 days, after which home quarantine can be
discontinued between 14-21 days. If symptoms persist beyond 14 days consult your family doctor for
advice.
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Philippine Academy of Family Physicians
Officers and Board of Directors 2020-2021
President Maria Victoria Concepcion P. Cruz, MD
Vice-President Karin Estepa-Garcia, MD
Secretary Lynne Marcia H. Bautista, MD
Treasurer Jane Eflyn Lardizabal-Bunyi, MD
Immediate Past President Policarpio B. Joves, Jr. MD
National Directors Limuel Anthony B. Abrogena. MD
Disi Yap-Alba, MD
Ryan Jeanne V. Ceralvo, MD
Ferdinand S. De Guzman, MD
Noel L. Espallardo, MD
Aileen T. Riel-Espina, MD
Ricardo S. Guanzon, MD
Cheridine Oro-Josef, MD
Josefina S. Isidro-Lapeña, MD
Anna Guia O. Limpoco
Leilanie Apostol-Nicodemus, MD
Regional Directors Rhodora M. Falcon-Pesebre, MD (North Luzon)
Ceasar V. Palma, MD (South Luzon)
Jimmy Jay F. Bullo, MD (Visayas)
Ricardo B. Audan, MD (Mindanao East)
Belinda Cu-Lim, MD (Mindanao West)
Josephine A. Chikiamco-Dizon, MD (NCR)
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Family-focused Home Care Plan During a COVID-19 Epidemic:
A Consensus Statement by the PAFP Task Force on COVID-19 The Philippine Academy of Family Physicians, Inc.
Background
Corona Virus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Corona
Virus 2 (SARS-CoV-2), is the third severe respiratory illness after the Severe Acute Respiratory Syndrome
coronavirus (SARS-CoV) in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012,
that affected the human population in this century. These epidemics occurred in cold dry winter
seasons, during major holidays where dietary consumption of wildlife is practiced. The viruses have
broken through human defenses when winter and cold weather makes the human body more
vulnerable. (Sun Z et al, 2020)
As of 1 March 2020, a total of 87,137 confirmed cases of COVID-19 globally, 79,968 confirmed in
China and 7,169 outside of China, with 2977 deaths (3.4%) had been reported by WHO. The WHO
consider it now to be a pandemic. (Guo et al, 2020) The SARS-CoV and MERS-CoV had inefficient
human-to-human transmission, unlike the current SARS-CoV-2 which has an efficient transmission. The
spread was then facilitated by increased social gathering and holiday travel. (Sun Z et al, 2020) This
explains the sudden rise in incidence.
Compared to the 9.6% morality of SARS and the 34.4% mortality of MERS, it seems COVID-19 is
not as fatal as many people thought. But we still have to be cautious and make sure we have a good
surveillance system, adequate laboratory to be able to recognize cases and provide efficient public
health control. Since it is a new virus, there is no vaccine and no recommended effective pharmacologic
treatment. Current efforts are directed towards blocking transmission, isolation, and protection. (She J
et al, 2020)
These consensus statements by the Philippine Academy of Family Physicians, Inc. were
developed to guide family physicians and community practitioners on how to provide family-focused
care plan to patients and their families in facing the current COVID-19 epidemic. It is recommended that
these statements be disseminated to family physicians and community health practitioners, converted
as service package in a family physician’s clinic and evaluated in terms of its effectiveness, acceptability
and implementation.
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Method of Development
The PAFP Task Force on COVID-19 assigned an expert to review the published medical literature
to identify, summarize, and operationalize the evidences in clinical publication on how to manage
COVID- 19 in the family and home environment. PubMed search used the terms “COVID-19” and limited
the search to “guidelines”. The articles were reviewed and recommendations relevant to family health
care at home were summarized into statements. Then each statement was updated by further search
and review of articles with priority focused on the following type of clinical publications: meta-analysis,
randomized controlled trials and clinical trials. The statements were then reviewed by the task force
that acted as a panel of experts, and approved the statements. The statements were disseminated to
PAFP chapters and members, and other stakeholders. Dissemination was also done by publication in the
PAFP website and to other stakeholders.
The following consensus statements were designed to guide families on strategies they can do
at home to mitigate the effect of COVID-19 epidemic. The initial statements 1 to 7 are based on the
assumption that no member is exposed to a diagnosed COVID-19 patient. Statements 8 to 11 are based
on the assumption that a family member is exposed to or developed mild symptoms of COVID-19. If the
exposed or affected family member develops a condition that requires consultation with a family doctor
or admission to a hospital, it is advisable to continue the precautionary measures in the plan and follow
the treatment protocol of the admitting hospital.
Statement of Recommendations
Initial Planning
Statement 1: Develop a family-focused care plan that contains tasks and activities related to family
structure, home environment and processes in order to mitigate the effect of the COVID-19 epidemic.
Family-focused behavioral interventions have been shown to be effective in preventing complex
health problems with social and behavioral components. Such interventions can be face-to-face
delivered by a family doctor or a trained allied health worker, or over the internet and other forms of
digital communication. (Prado G et al, 2019) A standard face-to-face family-focused intervention consist
of a single or several family meeting sessions that discuss with the family the care plan, treatment goals
and preferences and advance directives for terminal illness on palliative care. (Dallas RH et al, 2016) The
capacity of the family to comply with the care plan can be assisted by indigenously developed and
pretested, culturally sensitive instructions, flyers and simple audio-video tool. (Verma A et al, 2017) The
care plan can also be facilitated and sustained if the plan includes home visits by trained allied health
workers. (Walker N et al, 2015) Family-focused interventions have been tested in randomized controlled
trials that resulted in positive effect on medication adherence (Lyon ME et al, 2011), more positive
rating and acceptability by patients and their family. (Lyon ME et al, 2009)
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Adjustment in the Family and Home Environment
Statement 2: Identify a Family Caregiver who will remind the family to follow and implement the plan.
Make sure this person is supported by all family members.
Family caregivers (FCG) play a vital role in the direct and supportive care to patients in the
family. This strategy is used on patients with chronic infections like tuberculosis (treatment partner) and
patients with cancer. The hospice strategy in cancer care is supportive of family caregiver’s involvement
in care planning. They are encouraged to take leadership role in facilitating the implementation of care
plan and conduct of family affairs. (Parker et al, 2017) The importance of FCG will further be
emphasized in the Universal Health Care reform as there is a shift from hospital care to outpatient and
home-based care. (Ferrell B and Wittenberg E, 2017)
In the context of COVID-19 epidemic, there is a need to encourage the cooperation of all the
family members to sustain their adherence to the family plan. The effectiveness of FCG in this aspect has
been reviewed in several publications. In families with terminal illness, FCG was able to engage the other
family members into decisions and cooperation. In one randomized controlled trial, FCGs were able to
engage family members into discussion and agreement on the care plan. After the care plan was agreed,
FCGs were also able to have continuing discussion, modification and implementation of the plan.
(Schubart JR et al, 2018)
However, FCGs may struggle with complicated medical management plan. There may be a need
for a structured training. Such training can be a series of face-to-face meetings, web-based or use of
other digital technology. Face-to-face training have been used to improve the FCG’s ability to decrease
inappropriate use of medications in patients with dementia. (Thorpe JM et al, 2012) Because of the
grave task given to them, some FCG develop stress and anxiety during the course of care giving. A web-
based training program has been successfully used to address the FCG’s anxiety and distress. (Kales HC
et al, 2018)
Statement 3: Identify a room or area that can be used for isolation in the event that a family member
will be exposed to a diagnosed COVID-19 patient.
The experience of this COVID-19 outbreak emphasize the importance of environmental and
infection control at home. Transmission of airborne infection depends on the concentration of
breathable infectious pathogens in room air. Room infection control is achieved by removing
contaminated air from a room, controlling the direction of airflow and air cleaners. (Medical Advisory
Secretariat, 2005) Negative pressure isolation rooms have been a standard strategy to control the
spread of not only of tuberculosis but as a part of general infection control. (Nanovic Z et al, 2018) A
negative pressure room at home is simply a room with an exhaust fan installed either in the windows or
ceiling. This is a common appliance for bathroom and toilets.
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Statement 4: Identify those who are at risk i.e. more than 60 years old, with existing chronic illness or
other life-threatening conditions and advice to take extra precaution.
As of 1 March 2020, a total of 87,137 have been confirmed cases globally, 79,968 from China
and 7,169 outside of China, with 2977 deaths (3.4%). The elderly and people with underlying diseases
are susceptible to infection and prone to serious outcomes. (Guo YR et al, 2019) In the United States,
the CDC recommended aggressive measures to contain transmission of COVID-19. These measures
require the identification of cases and contacts of persons. (Jernigan DB, 2020) It recommends that
higher risk individuals because of age or have a serious long-term health problem should take extra
effort to reduce your risk of getting sick with the disease. They should keep space between themselves
and others, at least 2 meters. Avoid going out in public, but if absolutely necessary, keep away from
others and limit close contact and wash hands often. (CDC. 2020)
Statement 5: During the declared community quarantine period, all family members should stay at
home, limit family celebrations, avoid home parties with outside guests, cancel travels as much as
possible and be ready to have more members staying at home.
During an evolving epidemic, community mitigation strategies, such as social distancing, can
slow down virus transmission. Other strategies are cancelling or postponing school or after-school
activities or activities with a high rate of mixing contact. (Uscher-Pines L et al, 2018) At present
therapeutic strategies for COVID-19 are only supportive and prevention aimed at reducing transmission
in the family and community using strict quarantine strategy. Aggressive isolation measures in China
have led to a progressive reduction of cases. In Italy, because of the aging population, political and
health authorities are implementing home containing efforts especially for the high risk and elderly.
(Cascella M et al, 2020) Singapore adopted a multipronged surveillance strategy that included applying
the case definition tracing contacts of patients with confirmed COVID-19. Containment measures,
including patient isolation, quarantine and community education and precautions were performed to
minimize disease spread. These have been effective in suppressing expansion of the outbreak. (Ng Y et
al, 2020) On the other hand this strategy of quarantine and isolation did not seem to work in South
Korea which already has more than a thousand identified cases. Its below 1% mortality compared to
Italy however can be explained by difference in population demographics. (Yoo JH and Hong ST, 2020)
Public health experts studied the Wuhan, China experience and propose conceptual models for
the COVID-19 outbreak. In this model, factors that affect limit the spread are individual behavior,
holidays extension, hospitalization and quarantine of sick persons. (Lin Q et al, 2019) Other models
suggest that intensive contact tracing followed by quarantine and isolation, can effectively reduce the
number and transmission risk. On top of these strategies, Beijing also implemented strict travel
restriction increased the effectiveness of quarantine more than a thousand times. With these strategies,
the spread can reach its peak in two weeks from which it is expected to decline. However, it is essential
to estimate the economic cost implication of such intervention. (Tang B et al, 2020)
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Performance of Routine Tasks and Activities
Statement 6: Practice personal hygiene that includes regular and appropriate hand washing, daily
bath, cough and sneezing etiquette, minimal hand contact with eyes, nose and mouth, and strict
personal use of eating utensils, bath towels, etc.
Hand washing with soap and water for 20 seconds or more, covering your mouth and nose while
coughing or sneezing, daily bath, minimal hand contact with facial area are standard recommendations
to minimize respiratory infections. The effectiveness of these recommendations has been shown in
several randomized controlled trials. One trial in a village in China compared intensive education and
training on hand hygiene while the other group received general hygiene education. The hand hygiene
group resulted to better knowledge, improved practice and reduced incidence of hand-foot-and-mouth
disease. (Guo N et al, 2018) It does not matter if the soap or detergent has antibacterial property or
none. In one trial, households were randomized to use either commercially available nonantibacterial
and antibacterial general cleaning products, laundry detergents and handwashing soap. The incidence of
respiratory symptoms during an average of 24 months observation was similar whether the products
had antibacterial or nonantibacterial property. (Larson EL et al, 2004) Personal hygiene education and
training can also be delivered using video and digital media. This strategy has been shown to be
acceptable to parents and caregivers. (Verma A et al, 2017)
Encouraging hand hygiene has also been tested in the workplace. In a cluster trial of 21 working
units, persons in the soap-and-water arm reported a significant 24% lower weekly prevalence of
gastrointestinal tract illness with some marginal effects on respiratory tract illness. There was no
difference if hand hygiene was either by soap and water or alcohol-based rub. (Hovi T et al, 2017)
Providing a comprehensive hand hygiene program in the workplace also significantly reduced the
incidence of health care claims and increased employee satisfaction. (Arbogast JW et al, 2016)
Statement 7: Daily cleaning of frequently touched surface like doorknobs, light and appliance control
switches, gadgets, armchairs and tabletops. Cleaning agents can be ordinary detergents and water or
70% alcohol.
SARS-CoV-2 is stable on plastic and stainless steel and viable virus was detected up to 72 hours
on these surfaces. Corona viruses are sensitive to heat and can be killed at 56°C for 30 min. In addition,
ether, 75% alcohol, chlorine disinfectant, peracetic acid and chloroform can effectively inactivate the
virus. These are common household cleaning products that can be used for home sanitation and safety.
Home environment safety is a common issue that affects the health of children in the household. In one
survey of community households, there was a high rate of safety failures. (Gielen AC et al, 2012)
Improving sanitation in the home has been shown to improve health of household members. A
community-randomized-controlled trial in 51 rural communities was done to evaluate whether an