family-focused home care plan during a covid-19 epidemic...
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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.
References
1. Sun Z, Thilakavathy K, Kumar SS, et al. Potential Factors Influencing Repeated SARS Outbreaks in
China. Int J Environ Res Public Health. 2020 Mar 3;17(5). pii: E1633.
2. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus
disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res. 2020 Mar 13;7(1):11.
3. She J, Jiang J, Ye L, et al. 2019 novel coronavirus of pneumonia in Wuhan, China: emerging
attack and management strategies. Clin Transl Med. 2020 Feb 20;9(1):19.
4. Prado G, Estrada Y, Rojas LM, et al. Rationale and design for eHealth Familias Unidas Primary
Care: A drug use, sexual risk behavior, and STI preventive intervention for hispanic youth in
pediatric primary care clinics. Contemp Clin Trials. 2019 Jan;76:64-71.
5. Dallas RH, Kimmel A, Wilkins ML, et al. Adolescent Palliative Care Consortium. Acceptability of
Family-Centered Advanced Care Planning for Adolescents With HIV. Pediatrics. 2016 Dec;138(6).
pii: e20161854. Epub 2016 Nov 1.
13
6. Verma A(1), Maria A, Pandey RM, Hans C, Verma A, Sherwani F. Family-Centered Care to
Complement Care of Sick Newborns: A Randomized Controlled Trial. Indian Pediatr. 2017 Jun
15;54(6):455-459.
7. Walker N, Johnston V, Glover M, et al. Effect of a family-centered, secondhand smoke
intervention to reduce respiratory illness in indigenous infants in Australia and New Zealand: a
randomized controlled trial. Nicotine Tob Res. 2015 Jan;17(1):48-57.
8. Lyon ME, Garvie PA, Kao E, et al. Spirituality in HIV-infected adolescents and their families:
FAmily Centered (FACE) Advance Care Planning and medication adherence. J Adolesc Health.
2011 Jun;48(6):633-6.,
9. Lyon ME, Garvie PA, Briggs L, et al. Development, feasibility, and acceptability of the
Family/Adolescent-Centered (FACE) Advance Care Planning intervention for adolescents with
HIV. J Palliat Med. 2009 Apr;12(4):363-72.
10. Parker Oliver D, Demiris G, Washington K, et al. Hospice Family Caregiver Involvement in Care
Plan Meetings: A Mixed-Methods Randomized Controlled Trial. Am J Hosp Palliat Care. 2017
Nov;34(9):849-859.
11. Ferrell B and Wittenberg E. A review of family caregiving intervention trials in oncology. CA
Cancer J Clin. 2017 Jul 8;67(4):318-325.
12. Schubart JR, Reading JM, Penrod J, et al. Family Caregivers' Characterization of Conversations
Following an ACP Event. Am J Hosp Palliat Care. 2018 Sep;35(9):1161-1167.
13. Thorpe JM, Thorpe CT, Kennelty KA, et al. The impact of family caregivers on potentially
inappropriate medication use in noninstitutionalized older adults with dementia. Am J Geriatr
Pharmacother. 2012 Aug;10(4):230-41.
14. Kales HC, Gitlin LN, Stanislawski B, et al. Effect of the WeCareAdvisor™ on family caregiver
outcomes in dementia: a pilot randomized controlled trial. BMC Geriatr. 2018 May 10;18(1):113.
15. Medical Advisory Secretariat. Air cleaning technologies: an evidence-based analysis. Ont Health
Technol Assess Ser. 2005;5(17):1-52. Epub 2005 Nov 1.
16. Nanovic Z(1), Kaeva-Jovkovska B(2), Breskovska G(2), Petrovska M(3). Key Issues in the
Management of Multi-Drug Resistant Tuberculosis: A Case Report. Open Access Maced J Med
Sci. 2018 Jul 14;6(7):1282-1288.
17. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus
disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res. 2020 Mar 13;7(1):11.
18. Jernigan DB; CDC COVID-19 Response Team. Update: Public Health Response to the Coronavirus
Disease 2019 Outbreak - United States, February 24, 2020. MMWR Morb Mortal Wkly Rep. 2020
Feb 28;69(8):216-219.
19. CDC. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/get-ready.html. Visited
March 22, 2020.
20. Uscher-Pines L, Schwartz HL, Ahmed F, et al. School practices to promote social distancing in K-
12 schools: review of influenza pandemic policies and practices. BMC Public Health. 2018 Mar
27;18(1):406.
21. Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-
19). Treasure Island (FL): StatPearls Publishing; 2020-.2020 Mar 8.
22. Ng Y, Li Z, Chua YX, et al. Evaluation of the Effectiveness of Surveillance and Containment
Measures for the First 100 Patients with COVID-19 in Singapore - January 2-February 29, 2020.
MMWR Morb Mortal Wkly Rep. 2020 Mar 20;69(11):307-311.
14
23. Yoo JH and Hong ST. The Outbreak Cases with the Novel Coronavirus Suggest Upgraded
Quarantine and Isolation in Korea. J Korean Med Sci. 2020 Feb 10;35(5):e62. doi:
10.3346/jkms.2020.35.e62.
24. Lin Q, Zhao S, Gao D, et al. A conceptual model for the coronavirus disease 2019 (COVID-19)
outbreak in Wuhan, China with individual reaction and governmental action.
25. Tang B, Wang X, Li Q, et al. Estimation of the Transmission Risk of the 2019-nCoV and Its
Implication for Public Health Interventions. J Clin Med. 2020 Feb 7;9(2). pii: E462.
26. Guo N, Ma H, Deng J, et al. Effect of hand washing and personal hygiene on hand food mouth
disease: A community intervention study. Medicine (Baltimore). 2018 Dec;97(51):e13144.
27. Larson EL, Lin SX, Gomez-Pichardo C, et al. Effect of antibacterial home cleaning and
handwashing products on infectious disease symptoms: a randomized, double-blind trial. Ann
Intern Med. 2004 Mar 2;140(5):321-9.
28. Verma A, Maria A, Pandey RM, et al. Family-Centered Care to Complement Care of Sick
Newborns: A Randomized Controlled Trial. Indian Pediatr. 2017 Jun 15;54(6):455-459.
29. Hovi T, Ollgren J and Savolainen-Kopra C. Intensified hand-hygiene campaign including soap-
and-water wash may prevent acute infections in office workers, as shown by a recognized-
exposure -adjusted analysis of a randomized trial. BMC Infect Dis. 2017 Jan 9;17(1):47.
30. Arbogast JW, Moore-Schiltz L, Jarvis WR, et al. Impact of a Comprehensive Workplace Hand
Hygiene Program on Employer Health Care Insurance Claims and Costs, Absenteeism, and
Employee Perceptions and Practices. J Occup Environ Med. 2016 Jun;58(6):e231-40.
31. Gielen AC, Shields W, McDonald E, et al. Home safety and low-income urban housing quality.
Pediatrics. 2012 Dec;130(6):1053-9.
32. Hartinger SM, Lanata CF, Hattendorf J, et al. Improving household air, drinking water and
hygiene in rural Peru: a community-randomized-controlled trial of an integrated environmental
home-based intervention package to improve child health. Int J Epidemiol. 2016 Dec
1;45(6):2089-2099.
33. Gastañaduy PA, Banerjee E, DeBolt C, et al. Public health responses during measles outbreaks in
elimination settings: Strategies and challenges. Hum Vaccin Immunother. 2018;14(9):2222-2238.
34. Teasdale E, Santer M, Geraghty AW, et al. Public perceptions of non-pharmaceutical
interventions for reducing transmission of respiratory infection: systematic review and synthesis
of qualitative studies. BMC Public Health. 2014 Jun 11;14:589.
35. Ren SY, Gao RD and Chen YL. Fear can be more harmful than the severe acute respiratory
syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic. World J Clin
Cases. 2020 Feb 26;8(4):652-657.
36. Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread
of respiratory viruses. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD006207.
37. Pasquini-Descomps H(1), Brender N(2), Maradan D(3). Value for Money in H1N1 Influenza: A
Systematic Review of the Cost-Effectiveness of Pandemic Interventions. Value Health. 2017
Jun;20(6):819-827.
38. Adhikari SP, Meng S, Wu YJ, et al. Epidemiology, causes, clinical manifestation and diagnosis,
prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a
scoping review. Infect Dis Poverty. 2020 Mar 17;9(1):29.
15
39. Lai CC, Liu YH, Wang CY, et al. Asymptomatic carrier state, acute respiratory disease, and
pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and
myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2.
40. Wu Z and McGoogan JM. Characteristics of and important lessons from the coronavirus disease
2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese
Center for Disease Control and Prevention. JAMA. 2020; (published online Feb 24.)
41. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, Evaluation and Treatment
Coronavirus (COVID-19). 2020 Mar 8. StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2020 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK554776.
42. Arashiro T, Furukawa K and Nakamura A. COVID-19 in 2 Persons with Mild Upper Respiratory
Symptoms on a Cruise Ship, Japan. Emerg Infect Dis. 2020 Jun 17;26(6).