Guidance on cocooning to protect people over 70 years and those extremely medically vulnerable from COVID-19 - updated guidance from 29 June

This guidance is for people over 70 years of age, those who are at very high risk of severe illness from coronavirus (COVID-19) because of an underlying health condition, and for their family, friends and carers.

It is intended for use in situations where the extremely medically vulnerable person is living in their own home, with or without additional support or in long term residential facilities.

Cocooning is a measure to protect people who are over 70 years of age and those who are extremely medically vulnerable by helping them to understand how to minimise their risk of getting COVID-19.

People over 70 years of age and those with serious underlying medical conditions (as listed below) which put them at very high risk of severe illness from coronavirus (COVID-19) are advised to follow cocooning measures in order to keep themselves safe.

Those most at risk from COVID-19 are people who:

• Are over 70 years of age - even if you're fit and well
• Have Down Syndrome
• Have cancer and are

(a) being treated with chemotherapy or similar drugs other than hormone therapy

(b)have lung or head and neck cancer and are having radical surgery or radiotherapy

(c) having radical radiotherapy for lung cancer or head and neck cancer

(d) having certain complex cancer surgery, for example surgery for lung cancer, head and neck cancer or oesophageal cancer

(e)have advanced cancer or cancer that has spread to another part of the body

• Are on dialysis or have end stage kidney disease and an eGFR less than 15
• Have a condition affecting the brains or nerves that has significantly affected your ability to breathe, meaning you require non-invasive ventilation (such as motor neurone disease or spinal muscular atrophy)
• Have unstable or severe cystic fibrosis, including people waiting for a transplant
• Have severe respiratory conditions including Alpha-1 antitrypsin deficiency, severe asthma, pulmonary fibrosis, lung fibrosis, interstitial lung disease and severe COPD
• Have uncontrolled diabetes
• Have had an organ transplant or are waiting for a transplant
• Have had a bone marrow or stem cell transplant in the last 12 months, or are waiting for a transplant
• Have a rare condition that means you have a very high risk of getting infections (such as APECED or errors in the interferon pathway)
• Have sickle cell disease
• Have been treated with drugs such as Rituximab, Cyclophosphamide, Alemtuzumab, Cladribine or Ocrelizumab in the last 6 months
• Have certain inherited metabolic disorders (such as Maple Syrup Urine Disease)
• Have obesity with a body mass index (BMI) greater than 40
• For any essential/key worker, advice should be sought from Occupational Health who can give specific advice on individual conditions.

Cocooning is advised for your personal protection and you will make your own judgement about the extent to which cocooning guidance applies to you. If you are unsure whether or not you fall into one of the categories of extremely medically vulnerable people listed above, you should discuss your concerns with your GP or hospital clinician.

It is recognised that you have the right to exercise your own judgement as to the extent to which you consider the cocooning guidance appropriate for you. However, older people (aged 70 years and over) and those with pre-existing chronic conditions have been found to be more susceptible to COVID-19 infection and are most likely to experience severe consequences from infection so it is still recommended that you remain cocooned for your safety. Should you wish to visit someone, receive visitors in your home, visit shops, and engage in other outdoor activities, you should continue to strictly adhere to the public health and social distancing guidance.

When COVID-19 is not circulating in the community, it reduces the risk of getting the disease. You can keep yourself informed of the level of COVID-19 in your local area from data on the Department of Health website.

It is also really important that you continue to attend essential medical services and receive medical care at home (if you normally have care at home) to ensure your overall health and wellbeing is maintained.

For members of the public supporting those who are cocooning when they are outside their home, there are a number of things that you can do to help minimise their risk:

• keep at a distance of 2 metres
• allow them space for walking
• avoid physical contact such as shaking hands

As society opens up, you need to be aware that certain activities carry more risk of exposure, for example attending events, crowded areas, activities where physical distancing cannot be maintained.

It is important to note, that the measures outlined below are to minimize risk of COVID-19 infection but as with any social interaction, risk cannot be completely eliminated and you will have to decide what is right for you and your health.

In general, if you choose to go outside you should:

• strictly adhere to 2 metres physical (social) distancing measures
• avoid close face-to-face contact
• avoid touching people or surfaces
• wash your hands on returning home

If you choose to go for a drive, you should adhere to the following measures:

• make the journey alone, with someone who is cocooning with you or at least someone who is in your core group of family or friends. However, if you do need to share a car journey with someone from outside your core circle, for example getting a taxi, apply strict hand hygiene, the use of face coverings for both passenger and driver and keep as much distance as is practical
• strictly adhere to the 2 metres physical (social) distancing measures when out
• wash your hands on returning home

Public transport should be used in non-peak times if at all possible and where a physical distance of 2 metres can be maintained. Face coverings should be used, and wash your hands-on returning home.

You can also have visitors to your home, ideally from the same core group of family or friends who are aware of your circumstances and willing to adhere to protective measures while you cocoon. In addition, visitors must not visit you if they are unwell, should keep at least 2 metres away from you, wash their hands with soap and water for at least 20 seconds on arrival to your house and should wear face coverings.

If you choose to visit other people’s homes, tell them in advance that you are coming, make sure that no one in the household is unwell with COVID-19, ideally wear a face covering, strictly adhere to the 2 metres physical (social) distancing measures and wash your hands on returning home.

Businesses are now opening up to customers and many of these shops plan to have dedicated hours for those who are cocooning.

If you choose to visit these retail units, it is best to adhere to the following measures:

• attend shops that provide dedicated hours for those who are cocooning which will enable you to do your shopping in a safer way
• ideally wear a face covering
• strictly adhere to the 2 metres physical (social) distancing measures when out
• wash your hands on returning home

Other activities such as religious services, attending libraries and museums are also becoming available and you may wish to attend. However, it is important that you take the necessary precautions regarding physical distancing, hand washing and face covering to reduce your risk of infection.

For services such as attending restaurants, it is important that you risk assess the situation before partaking in the activity.

The following considerations will help to minimise your risk:

• if you wish, you can indicate that you are cocooning to the service provider
• make sure you attend venues that are large enough to accommodate 2m physical distancing between tables and that are adhering to the measures required for safe re-opening of food businesses which include strict hygiene measures and safe entry and exit from the venue
• keep attendance time as short as possible
• wear a face covering when moving around the restaurant
• wash your hands on returning home

For services where adherence to physical distancing is not always practical for certain activities, for example hair salons, it is important that you risk assess the situation before partaking in the activity.

The following considerations will help to minimise your risk:

• if you wish, you can indicate that you are cocooning to the service provider
• make sure you limit the number of visits to essential only
• keep appointments as short as possible
• ask for a time when the business may have fewer customers, for example at the start or end of the day
• use a business that adheres to the strictest hygiene precautions and understands your needs
• wear a face covering
• wash your hands on returning home

Travel around Ireland has opened up and you may wish to move around the country. The risk of travel is dependent on the activities you partake in.

To minimise risk:

• follow the general measures described above re hand hygiene, physical distancing, face coverings
• choose accommodation where you are not sharing facilities with those who are not cocooning with you
• choose accommodation that adheres to strict measures for the safe opening of the accommodation sector
• use transport as described above

Regarding social gatherings, it is important to note that the more people in a venue the greater the risk. However, as society re-opens, there may be certain events that are important for you to attend, for example funerals, weddings and family events. As the risk increases the larger the event, you will have to assess if attending is the right option for you and your health.

The following considerations will help to minimise the risk should you choose to attend:

• as with any gathering of people, it is important that you maintain strict physical distancing, strictly adhere to 2 metres physical (social) distancing measures
• choose events that are mostly your close family or friend circle who understand your need to adhere to certain protective measures
• wear a face covering
• avoid close face-to-face contact
• avoid touching people
• limit the time at the event to the smallest amount possible
• outdoor events are preferable
• wash your hands regularly during the event and on returning home

Those who are working remotely should continue to do so and only return to the workplace if appropriate safety measures are in place.

If you are living in a long-term residential care facility, talk to your carer to determine what is the safest option.

It is really important that you continue to have the care you need to maintain your health and wellbeing. Visits from people who provide essential support to you such as healthcare, personal support with your daily needs or social care should continue, but carers and care workers must stay away if they have any of the symptoms of COVID-19. They may find this guidance for Health and Social care workers who visit homes useful. All people coming to your home should wash their hands with soap and water for at least 20 seconds on arrival to your house and often whilst they are there.

You should have an alternative list of people who can help you with your care if your main carer becomes unwell. For assistance with this, Family Carers Ireland has a range of practical supports and guides available to family carers during the COVID-19 pandemic, including an Emergency Care Plan Booklet, which can be accessed at familycarers.ie/wp-content/uploads/2020/03/EMERGENCY-CARE-PLAN_Family-Carers-Ireland-REVISED.pdf.

If you have someone else living with you, who does not fit the criteria for cocooning, they are not required to adopt these protective cocooning measures for themselves. They should do what they can to support you in cocooning and they should stringently follow guidance on physical distancing, reducing their contact outside the home. They should wash their hands thoroughly and regularly, especially upon arrival home and observe good respiratory etiquette at all times.

If you care for but don’t actually live with someone who is extremely medically vulnerable you should still stringently follow the public health guidance on physical distancing.

Whilst the rest of your household are not required to adopt these protective cocooning measures for themselves, we would expect them to do what they can to support you in cocooning and to follow guidance on physical distancing.

• you should clean your hands regularly and practice good respiratory etiquette
• if you can, you should use a toilet and bathroom that no one else in the house uses
• if you cannot have your own toilet and bathroom, the toilet and bathroom you use needs to be kept clean (see advice below). Another tip is to consider drawing up a rota for bathing, with you using the facilities first
• make sure you use separate towels from the other people in your house, both for drying themselves after bathing or showering and for hand-hygiene purposes
• if you have one, use a dishwasher to clean and dry the family’s used crockery and cutlery. If this is not possible, wash them using your usual washing-up liquid and warm water and dry them thoroughly. Do not share cutlery and utensils. When using your own utensils, remember to use a separate tea towel for drying these
• clean all surfaces, such as counters, table-tops, doorknobs, bathroom fixtures, toilets and toilet handles, phones, keyboards, tablets, and bedside tables, every day with your usual household cleaning products. Follow the instructions on the manufacturer’s label and check they can be used on the surface you are cleaning
• we understand that it will be difficult but you should do your very best to follow this guidance and everyone in your household should regularly wash their hands, avoid touching their face, and clean frequently touched surfaces such as door handles and table tops

If the rest of your household follows advice on physical distancing and minimises the risk of spreading the virus within the home by following the advice above, there is no need for them to also cocoon alongside you.

There are general principles you should follow to help prevent the spread of airway and chest infections caused by respiratory viruses, including clean your hands regularly - This is one of the most important things you can do. Do this after you blow your nose, sneeze or cough, and before and after you eat or handle food.

• try not to touch your face or anyone else’s face
• cover your mouth and nose with a paper tissue when you cough or sneeze
• place used tissues into a plastic waste bag and immediately clean your hands with alcohol hand rub or wash your hands with soap and water for at least 20 seconds
• avoid close contact with people who have symptoms

The most common symptoms of coronavirus (COVID-19) are recent onset of:

• fever (high temperature) and
• cough
• shortness of breath or difficulty breathing
• loss of taste and smell

If you develop the symptoms of COVID-19, seek clinical advice by phoning your GP. In an emergency, call 112 or 999 if you are seriously ill. Do this as soon as you get symptoms. Do not visit the GP, pharmacy, urgent care centre or a hospital unless you are told to do so.

To help us provide you with the best care if you need to go to hospital as a result of catching coronavirus, we ask that you prepare a single hospital bag. This should include your next of kin or emergency contact, a list of the medications you take (including dose and frequency), any information on your planned care appointments and things you would need for an overnight stay (snacks, pyjamas, toothbrush, medication and so on). If you have an advanced care plan, please include that.

In the first instance, family, friends and neighbours can support you once you adhere to cocooning guidelines and they adhere to physical distancing guidelines. Where possible use online services and shops that have dedicated times for those who are cocooning.

If these options are not available to you, the government has put in place assistance through the local authorities, working with the voluntary sector services, to ensure you can have access to food, essential household supplies and medicines. Each local authority has published contact details.

ALONE is providing a telephone support line, seven days a week from 8am – 8pm, for all older people and their families to contact if they would like any advice, reassurance or additional support: 0818222024. This support line is also open to extremely medically vulnerable people.

The support line complements the clinical advice being provided by the HSE through its website and helpline.

If you receive support from health and social care organisations, for example, if you have care provided for you through the HSE or privately, this should continue as normal. Your provider will be asked to take additional precautions to make sure that you are protected. The advice for formal carers is included in the advice for health and social care workers who visit homes.

We advise everyone to access medical assistance remotely, wherever possible. However, if you have a scheduled hospital or other medical appointment during this period, talk to your GP, Specialist or other relevant health care professionals to ensure you continue to receive the care you need and determine which of these are absolutely essential.

It is possible that your hospital may need to cancel or postpone some clinics and appointments. You should contact your hospital or clinic to confirm appointments.

Contact regular visitors to your home, such as friends and family to let them know that you are cocooning and that they should not visit you if they are unwell.

If you receive regular health or social care from an organisation, either through the HSE or paid for by yourself, inform your care providers that you are cocooning and agree a plan for continuing your care.

If you receive essential care from friends or family members, speak to them about extra precautions they can take to keep you safe and about backup plans for your care in case they are unwell and need to self-isolate.

If you are caring for someone who is over 70 or extremely medically vulnerable to severe illness from COVID-19, there are some simple steps that you can take to protect them and to reduce their risk at the current time. Ensure you follow advice on good hand hygiene and respiratory etiquette.

• wash your hands on arrival and often, especially before and after being in contact with the person you are caring for. Use soap and water for at least 20 seconds or use hand sanitiser
• avoid touching your face
• cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze
• put used tissues in the bin immediately and wash your hands afterwards
• do not visit or provide care if you are unwell and make alternative arrangements for their care
• provide information on who they should call if they feel unwell, write out the phone number of their GP and GP out-of-hours service and leave these prominently displayed
• if it is an emergency, call the emergency services at 112 or 999 and remember to tell them that the person may have or has been diagnosed with COVID-19

The following contact details may be helpful:

• Family Carers Ireland have a dedicated Careline 1800 240724. www.familycarers.ie
• Alzheimer Society of Ireland provide a National Helpline on 1800 341 341, email helpline@alzheimer.ie or via Live Chat at www.alzheimer.ie

Social isolation, reduction in physical activity, unpredictability and changes in routine can all contribute to increasing stress. Many people including those without existing mental health needs may feel anxious about this impact, including support with daily living, ongoing care arrangements with health providers, support with medication and changes in their daily routines.

If you are receiving services for your mental health, learning disability or autism and are worried about the impact of isolation please contact your key worker/care coordinator or provider to review your care plan.

It is very easy to become anxious and lonely when you have to spend time on your own but remember, you can always pick up the phone and call a friend. For more information on minding your mental health during the COVID-19 outbreak go to www.hse.ie. You can also call the Samaritans on Ph: 116 123.

At times like these, it can be easy to fall into unhealthy patterns of behaviour which in turn can make you feel worse.

There are simple things you can do that may help to stay mentally and physically active during this time such as:

• spend time doing things you enjoy – this might include reading, cooking, other hobbies or listening to favourite radio programmes or watching TV
• try to eat healthy, well-balanced meals, drink enough water, exercise regularly, and try to avoid smoking, alcohol and drugs

Draw on support you might have through your friends, family and other networks during this time. Try to stay in touch with those around you over the phone or online or with a visit. Let people know how you would like to stay in touch and build that into your routine. This is also important in looking after your mental wellbeing and you may find it helpful to talk to them about how you are feeling, if you want to.

The advice also applies to those over 70 years of age or extremely medically vulnerable persons living in long-term care facilities. Care providers should carefully discuss this advice with the families, carers and specialist doctors caring for such persons to ensure this guidance is strictly adhered to.

In terms of residents expanding their activities in line with the government roadmap, it is important that care providers perform a risk assessment with the resident to determine if the person is able to adhere to the recommended public health measures to ensure the safety of the resident and others in the care facility. However, equally important is that a sense of normality is phased into the daily life of a person whose home is in a residential care facility. Cocooning in these settings need to evolve so residents can return to a sense of normality, for example making provision for enjoyable communal activities in small groups within the parameters of social distancing measures and public health guidance.