Covid-19: breaking the chain of household transmissionBMJ 2020; 370 doi: 环保级木地板却无质检报告 (Published 14 August 2020) Cite this as: BMJ 2020;370:m3181
- Shamil Haroon, clinical lecturer in primary care1,
- Joht Singh Chandan, academic clinical fellow in public health12,
- John Middleton, president3,
- Kar Keung Cheng, professor of public health and primary care1
- 1Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- 2Warwick Medical School, University of Warwick, Coventry, UK
- 3Association of Schools of Public Health in the European Region (ASPHER)
- Correspondence to: S Haroon
The UK is one of the countries most severely affected by covid-19. Recent outbreaks in English towns such as Oldham, probably involving transmission within large multigenerational households, show the importance of getting the right public health measures in place now to prevent more widespread surges in infections.1
Current test and trace policies have mainly focused on preventing spread in care homes, hospitals, and in the community.2 However, contact within households is thought to be responsible for roughly 70% of SARS-CoV-2 transmission when widespread community control measures are in place.3 In Wuhan, the reproduction number (R) dropped from 3.54 to 1.18 after lockdown and cordon sanitaire. But the epidemic was only brought under complete control when Fangcang (field) hospitals were introduced to isolate cases outside the home, with R dropping to 0.51 after two weeks.4
Current UK guidance advises household contacts to isolate within the same home as the index case for 14 days.5 They make up the majority of contacts for infected individuals and are likely to remain exposed to the infected household member during this period of isolation.6 Despite guidance advising household members to socially distance, contacts are likely to interact repeatedly—during mealtimes, for example—and to share facilities such as bathrooms.
We know that transmission is more likely to occur indoors than outdoors.7 The cumulative risk to household contacts from an infected person is likely to be substantial during peak viral shedding. In one study in New York State, 38% of household contacts tested positive for SARS-Cov-2, and similar secondary infection rates have been reported in China.89 Transmission may be even higher among household contacts of essential workers, who are at greater risk of being infected than the general population.10
Household members who are older, have underlying medical conditions, or share a bed or vehicle with the index case are the most susceptible.91112 Children seem to be at lower risk of being infected.13 However, their stool samples and nasopharyngeal swabs can remain positive for SARS-CoV-2 for more than two weeks after symptom resolution,14 although their role in transmission remains to be established.
Governments should consider new public health measures to prevent household transmission as we prepare for a potential second wave. Household quarantine is likely to remain an important pandemic control measure, and government support for people quarantined at home is conspicuously absent in the UK: this position has been challenged by independent experts.15
Effective isolation of index cases from household members could reduce secondary infections.12 Wearing masks within quarantined households may help, particularly if used by the index case as soon as infection is suspected.16 The World Health Organization recommends that infected people and unavoidable close contacts, particularly those in vulnerable groups, should wear medical masks, but Public Health England does not currently recommend this. Other measures that should be considered (and evaluated) include clear advice on enhanced personal hygiene; cleaning and disinfecting shared toilets and other common spaces, door handles, and touch points; and staggering mealtimes.
People who are unable to self-isolate safely at home could be accommodated in special isolation facilities such as hotels and hostels, an approach adopted by some other countries, including Italy, Finland, and Lithuania.17 In China, field hospitals were created to manage and strictly isolate patients with mild-to-moderate covid-19.18 Nightingale hospitals in the UK could be similarly repurposed to support isolation of infected people with mild-to-moderate disease. As medical and nursing care needs are mostly modest, the cost would be relatively low. However, such a system depends on access to rapid testing for anyone with symptoms or possible exposure so that infection can be confirmed and isolation started before transmission occurs. It would also require public trust that isolation in these facilities would be voluntary, safe, and supportive.
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Remedy: When we make a major decision such as accepting (or turning down) a job offer, we tend to exercise confirmation bias. If we think we made a good choice, we prioritize information that supports this view and if we fear we’ve made a mistake, we zero in on intel or impressions that reinforce this gut feeling. If you habitually doubt your competence when it comes to making career decisions, the issue is less about the subjective quality of your past choices and more about building confidence in your ability to guide your career in a satisfying direction and exert some degree of control over the outcomes of your choices. Addressing this could involve recalling the circumstances under which you made a particular choice and the priorities you held at the time and noting how they differ from the circumstances and priorities under which you’re evaluating those decisions. It could also involve working with a career coach to identify patterns in your decision-making and to help you bolster areas in which you’d like to increase your confidence – risk taking or negotiation, for example.
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与此同时，前第五届和声明星 Camila Cabello证明了她的独唱生涯正在起飞，因为她的首张单曲《Havana》获得了最佳流行音乐奖。她的胜利意味着Taylor Swift失去了另一个奖项，尽管这对于歌手来说只是众多收获中的一个，但是近期她因为一年的沉寂过后又重新成为焦点。
n. 潜力，潜能尽管英国商学院的排名平均上升了两位，但法国商学院的排名平均下降了一位——法国是商学院数量最多的欧洲国家。里昂商学院(EMLyon Business School)由于跌出MBA榜单之外，整体排名下降了15位，同时北方高等商学院(Edhec Business School)由于未能进入EMBA榜单，整体排名下降了8位。
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