Covid-19: breaking the chain of household transmissionBMJ 2020; 370 doi: 杭州已备案长租公寓有16万套 租客入住能否安心？ (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.
Most observers would think the single-aisle Comac C919’s first flight last May (pictured) is illustrative of this, but while it is a key milestone, it does not represent the whole story about what is happening in the industry. Two other events are much more telling.
President Barack Obama won re-election to a second term in the White House on Tuesday, television networks projected, beating Republican challenger Mitt Romney after a long and bitter campaign。
Interviewers made their share of blunders, too.
“That’s the first time we’ve seen that,” said Thomas Karl, director of the US National Oceanic and Atmospheric Administration’s national centres for environmental information.
Men and women rated the strengths of their programme equally.
This year's best midseason trade action happened early:
Newly launched Eleven James is bringing collaborative consumption to men’s watches. With a membership program offering access to a curated collection of high-end watches, Eleven James is extending the membership model that has previously been associated with private jets, luxury cars and vacation homes. Beyond the watches, members are enrolled in a dedicated loyalty program which includes a concierge service, access to partner benefits and unique experiences like watch-themed events. Sounds a little bit like men’s watches meet a Net Jets experience? Founder Randy Brandoff has deep experience in luxury marketing, having previously served as the Senior Vice President and Chief Marketing Officer of Net Jets and the Executive Vice President and Chief Marketing Officer of Marquis Jets. Combining his expertise with a watch industry that’s grown year over year and a business model that’s proven successful in other markets, it looks like Eleven James could be hitting the market at just the right time.
Trium is ranked first for the work experience of its alumni before the programme, second for aims achieved and third for international course experience. The programme is second for average salary ($307,003) of alumni three years after graduation, just behind the Kellogg/HKUST programme.
“If hearing that the CEO of Apple is gay can help someone struggling to come to terms with who he or she is, or bring comfort to anyone who feels alone, or inspire people to insist on their equality, then it’s worth the trade-off with my own privacy,” he wrote in Bloomberg Businessweek in October.
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.
18. 最有趣的道歉（并列）。11月18日，《好莱坞报道者》发表了一份1200多字的道歉，因为它的“奥斯卡女星圆桌会议”没有邀请非白人演员出席。很快，导演亚历克斯·普罗亚斯(Alex Proyas)和狮门公司就为新片《埃及众神战》(Gods of Egypt)中的演员缺乏多样性而道歉。
“这是我们租户运动生死攸关的时刻，”大都会住宅委员会(Metropolitan Council on Housing)的项目总监伊拉娜·迈尔(Ilana Maier)说，“如果我们现在不能大举强化规定，那么这些政策在十年内都发挥不了作用。”