Covid-19: breaking the chain of household transmissionBMJ 2020; 370 doi: 广州租金回报率为2.61% 居全国一线城市之首 (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.
Also important to EMBA entrepreneurs was the support of their school and alumni network. About three-quarters of entrepreneurs thought that both the school and their alumni network were helpful or very helpful when setting up their company. “Alumni support was key to getting the idea vetted and getting the right contacts needed for the business”, said one.
"Well, I believe I am a feminist because I believe that women deserve the same rights as men in every aspect of our economy and our society, here at home and around the world," Clinton said to applause. "You know, I've devoted a lot of my public life to advocating for women's rights being human rights, and making the case that we have to do everything we can, through laws, regulations, culture, to change the still-existing stereotypes that hold women back."
8. Employment futures weak as pensions drain states, municipalities
Experts waited until dark had fallen before detonating demolition charges which brought down 150000 square metres of concrete glass and steel in 10 seconds.
The former pupil at Audenshaw's Poplar Street Primary is studying at Withington Girls' School and starts at Altrincham Grammar School for Girls in September. She lives with her parents, Neelanga and Shiromi, who moved to Manchester from Sri Lanka in 2001. Dad Neelanga, 44, praised Nishi's first teachers at Poplar Street Primary. He said: 'We knew very early on that she was gifted. She started reading and writing very early and was became very good at mathematics. We gave her challenging, interesting things to do. As a parent, you do not want their talents to be wasted, but there has to be a balance with their childhood. She is just a normal 10-year-old, just like any other 10-year-old really. She loves reading, cycling and walking, and we're all very proud of her.'
8. Employment futures weak as pensions drain states, municipalities
You don't know how to fix the holes in our ozone layer. You don't know how to bring salmon back up a dead stream. You don't know how to bring back an animal now extinct.And you can't bring back forests that once grew where there is now desert. If you don't know how to fix it, please stop breaking it! 您不知道怎么去修补大气的臭氧空洞，您也不知道怎么去从死亡的河流中拯救鱼类，您更不知道如何把灭绝的动物复苏，您也不能把沙漠中从前完整的森林带回来。如果您不知道如何拯救，那么请您停止破坏吧！
The president lashed out at the UN on Sunday for voicing human rights concerns over his war on drugs, saying the Philippines might leave the organisation and form a new body with China and African nations.
There were also shows that didn’t live up to early expectations but still had traction, most notably “The Affair,” on Showtime, which began as a Hamptons film noir and instead turned into a French art film. The crime may not be commensurate with the series’s punishingly slow pace and “Rashomon"-like storytelling, but the series picked up momentum — and suspense — in the final episodes.