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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

environmental home-based intervention package, consisting of improved solid-fuel stoves, kitchen sinks,

solar disinfection of drinking water and hygiene promotion, reduced lower respiratory infections and

diarrheal disease. After the trial the mean diarrhea incidence was 2.8 episodes per child-year in the

intervention compared with 3.1 episodes in the control arm. There was no observed difference in the

incidence of respiratory tract infection. (Hartinger SM et al, 2016)

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What to Do When a Member is Exposed

Statement 8: Advise an exposed family member to stay home and in a room or area 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 are cleaned

regularly and not touch by other members.

Strategies that include isolation of cases while infectious, exclusion and quarantining of

individuals without evidence of immunity, and vaccination have been shown to be effective in

controlling measles outbreak. However, the idea to maximize containment should be based on the

expected benefit of reactive interventions, balanced against the logistical challenges in implementing

them. (Gastañaduy PA et al, 2018) Isolation and containment efforts must be done carefully as there is

ambivalence about adopting isolation and personal distancing due to their perceived adverse impact

and potential to attract social stigma. (Teasdale E et al, 2014) This is already being seen in the current

response to the COVID-19 pandemic. Discrimination and prejudice towards a certain country or people

because of fear or misinformation have been seen on social media. This might jeopardize the efforts to

control the pandemic. (Ren SY et al, 2020) Other interventions include screening at ports of entry and

personal protection like wearing masks, gloves and gown.

The effectiveness of these strategies is the subject of a Cochrane meta-analysis during the

period of H1N1 outbreak. The results showed that hygienic measures, such as handwashing, especially

around younger children can prevent the spread of infection in the household. Surgical masks or N95

masks were equally consistent effective measures. N95 mask was equal to simple surgical masks but

more expensive, uncomfortable and irritating to the skin. There was limited evidence that social

distancing was effective, especially if related to the risk of exposure. (Jefferson T et al, 2011) These

interventions were also subjected to health economic analysis in the background of H1N1 epidemic. The

results showed that hospital quarantine is highly cost-effective. However, school closures, antiviral

treatments, and social distancing were not cost-efficient measures. The authors however concluded that

such interventions may become cost-effective for severe pandemics and when there is human-to-

human transmission. (Pasquini-Descomps H et al, 2017)

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.

A recent scoping review of the epidemiology, causes, clinical diagnosis, prevention and control

of COVID-19 reported that the initial symptoms include fever, cough, fatigue, pneumonia, headache,

diarrhea, hemoptysis, and dyspnea. (Adhikari SP et al, 2020) It can also present as an asymptomatic

carrier state, acute respiratory disease, and pneumonia. Adults represent the population with the

highest infection rate based on recent statistics. But neonates and children can also be infected. Severe

cases are more likely to be older patients with underlying comorbidities compared to mild cases. In

addition, nosocomial infection of hospitalized patients and healthcare workers, and viral transmission

from asymptomatic carriers are possible. (Lai CC et al, 2020) The figure below can guide the family on

when the symptoms might appear if a member is exposed or affected.

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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.

It is important to emphasize that about 81% of people with COVID-19 have mild disease and

does not require hospitalization. (Wu Z and McGoogan JM, 2020) These cases have not been clearly

described in the medical literature. There is no specific antiviral treatment recommended for COVID-19.

There is no vaccine available either. The treatment for mild cases at home is symptomatic and

supportive that includes anti-pyretic for fever, adequate fluid intake and nutrition. For moderate to

severe cases, or those who are at high risk, hospital admission and oxygen therapy represents the major

treatment intervention. Hemodynamic support is essential for those in septic shock. (Cascella M et al,

2020)

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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.

There are few publications describing the course of illness in mild cases. A case report revealed

that patients’ symptoms started to appear on the 3rd day. The symptoms were usually slight sore throat,

cough and mild fever. After testing positive for COVID-19 the symptoms disappear by the 10th day. But

polymerase chain reaction can remain positive until 21st day. (Arashiro T et al, 2020)

Recommendation for Dissemination and Implementation

The recommendations for dissemination of these statements will be similar to the dissemination

of clinical pathways developed by the PAFP QA Committee. The PAFP Task Force on COVID-19 will

disseminate to PAFP chapters and members in form of letters and circulars via emails. The other task

force members will develop communication materials containing the consensus statements and

disseminate it via their respective committees and adapted to be relevant to their tasks. At the clinic

level, family physicians are encouraged to use this as family-focused health education and advice to the

patient and family in every consultation opportunity i.e. whether the consultation is for an infection or

not.

At the organizational level, aside from dissemination, the PAFP should establish a new model of

service delivery, training and quality improvement initiatives related to the implementation of the

family-focused consensus statements. The training programs (hospital or practice-based) are

encouraged to develop 5 to 10-minute health education/promotion packages during the consultation

process and promote the use of this family-focused consensus statements, evaluate its delivery through

research or quality improvement activity.

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