Guidance for quarantine of COVID-19 cases and their contacts
As the COVID-19 pandemic continues to evolve, World Health Organization Member States need to implement a comprehensive set of public health measures that are adapted to the local context and epidemiology of the disease. The overarching goal is to control COVID-19 by slowing down transmission of the virus and preventing associated illness and death.
Several core public health measures that break the chains of transmission are central to this comprehensive strategy, including:
- Identification, isolation, testing, and clinical care for all cases,
- Tracing and quarantine of contacts, and
- Encouraging physical distancing of at least 1 metre combined with frequent hand hygiene and respiratory etiquette.
These guidelines provide updated guidance for the implementation of quarantine, as well as additional guidance on ventilation and on the care of children in quarantine. The guidance is based on evidence on controlling the spread of SARS-CoV-2, the virus that causes COVID-19, and scientific knowledge of the virus. These guidelines also addresses the requirements for release from quarantine based on updated technical guidance.
Symptomatic transmission refers to transmission of SARS-CoV-2 from persons with symptoms. Epidemiology and virologic studies suggest that transmission mainly occurs from symptomatic people to others by close contact through respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces. Clinical and virologic studies that have collected repeated biological samples from confirmed patients demonstrate that shedding of SARS-CoV-2 is highest in the upper respiratory tract (URT) (nose and throat) early in the course of the disease within the first 3 days from onset of symptoms.
Incubation Period for COVID-19
The incubation period for COVID-19, which is the time between exposure to the virus (becoming infected) and symptom onset, is, on average, 5–6 days, but can be up to 14 days. During this period, also known as the “pre-symptomatic” period, some infected persons can be contagious, from 1–3 days before symptom onset. It is important to recognize that pre-symptomatic transmission still requires the virus to be spread via infectious droplets or by direct or indirect contact with bodily fluids from an infected person. An asymptomatic case is a person infected with SARS-CoV-2 who does not develop symptoms.
Definition of Quarantine
Quarantine means “the restriction of activities and/or separation from others of suspect persons, who are not ill in such a manner as to prevent the possible spread of infection or contamination.” Today, many countries have the legal authority to impose quarantine, which, in accordance with Article 3 of the International Health Regulations (2005), must be fully respectful of the dignity, human rights and fundamental freedoms of persons.
Considerations for the quarantine of contacts of COVID-19 cases
The objective is to monitor their symptoms and ensure the early detection of cases. Quarantine is different from isolation, which is the separation of infected persons from others to prevent the spread of the virus.
These guidelines provides guidance on quarantine measures and the appropriate support that is required to enable individuals to quarantine safely.
The following should be taken in consideration:
- Provide people with clear, up-to-date, transparent and consistent guidance, and with reliable information about quarantine measures.
- Persons who are quarantined need access to health care as well as to financial, social and psychosocial support; protection; as well as to support to meet their basic needs, including food, water, hygiene, communication and other essentials for themselves and for household members and children who they are supporting or caring for. The needs of vulnerable populations should be prioritized.
- Cultural, geographic and economic factors affect the effectiveness of quarantine. Rapid assessment of the local context should evaluate both the drivers of success and the potential barriers to quarantine, and they should be used to inform plans for the most appropriate and culturally accepted measures.
Who should be quarantined
- In the context of the current COVID-19 outbreak, WHO recommends the rapid identification of COVID-19 cases and their isolation and management either in a medical facility or an alternative setting, such as the home.
- WHO recommends that all contacts of individuals with confirmed or probable COVID-19 be quarantined in a designated facility or at home for 14 days from their last exposure.
- A contact is a person in any of the following situations from 2 days before and up to 14 days after the onset of symptoms in the confirmed or probable case of COVID-19:
- Face-to-face contact with a probable or confirmed case of COVID-19 within 1 meter and for more than 15 minutes;
- Direct physical contact with a probable or confirmed case of COVID-19.
- Direct care for an individual with probable or confirmed COVID-19 without using proper personal protective equipment or other situations, as indicated by local risk assessments.
Recommendations for implementing quarantine
If a decision to implement quarantine is taken, the Public Health Team should ensure that:
- Adequate food, water, protection, hygiene and communication provisions can be made for the quarantine period;
- The infection prevention and control (IPC) measures can be implemented;
- The requirements for monitoring the health of quarantined persons can be met during quarantine.
**These measures apply to both quarantine in a designated facility and quarantine at home.
Ensuring an appropriate setting and adequate provisions
- The implementation of quarantine implies the use or creation of appropriate facilities in which a person or persons are physically separated from the community while being cared for.
- Possible settings for quarantine include hotels, dormitories, other facilities catering to groups, or the contact’s home. Regardless of the setting, an assessment must ensure that the appropriate conditions for safe and effective quarantine are being met.
- Facilities for those in quarantine should be disability inclusive, and address the specific needs of women and children.
- If quarantine is undertaken at home, the quarantined person should occupy a well ventilated single room, or if a single room is not available, maintain a distance of at least 1 metre from other household members. The use of shared spaces, crockery and cutlery should be minimized, and shared spaces (such as the kitchen and bathroom) should be well ventilated.
Quarantine arrangements in designated facilities should include the following measures:
Those who are in quarantine should be placed in adequately ventilated rooms with large quantities of fresh and clean outdoor air to control contaminants and odours.
There are three basic criteria for ventilation:
- Ventilation rate: the amount and quality of outdoor air provided into the space;
- Airflow direction: the direction of airflow should be from clean to less-clean zones; and 3. Air distribution or airflow pattern: the supply of air to each part of the space to improve dilution and removal of pollutants from the space.
- For quarantine at home, consider using natural ventilation, opening windows if feasible and safe to do so.
Protection and provision of care for children
When implementing quarantine, the Public Health Team should avoid family separation, weighing the welfare of the child against the potential risk of COVID-19 transmission within the family. Any decision to separate a child from his or her caregiver when implementing quarantine should include careful and thorough consideration of the possible consequences of family separation.
If a child is a contact:
- Children should ideally be quarantined at home, in the care of a parent or other caregiver.
- When this is not possible, children should be quarantined in a household in the care of an adult family member or other caregiver who is at low risk of severe COVID-19. Known risk factors for severe disease include individuals aged >60 years and individuals with underlying medical conditions.
- If quarantine at home is not possible, children should be quarantined and cared for in a child-friendly space, taking into consideration the specific needs of children, their safety as well as physical and mental well-being. All efforts should be made to allow a caregiver or other adult family member to visit daily and/or stay with the child throughout the quarantine period.
- Policies and individual decisions should allow home-based quarantine of children and caregivers based on a holistic assessment in which the child’s best interests are the primary consideration.
Infection prevention and control measures
The following IPC measures should be used to ensure a safe environment for quarantined persons. These measures apply to quarantine in a designated facility and to quarantine at home.
Early recognition and control
- Any person in quarantine who develops febrile illness or respiratory symptoms at any point during the quarantine period should be treated and managed as a suspected COVID-19 case and immediately isolated. Ensure the quarantine facility has a designated referral centre and clear process for any symptomatic person. A designated room (or, if not feasible, designated area) is recommended for isolating any persons who develop symptoms, if the facility uses shared rooms, while waiting to transfer the individual to the referral centre.
- Standard precautions apply to all persons who are quarantined and to quarantine personnel.
- Perform hand hygiene frequently, particularly after contact with respiratory secretions, before eating, and after using the toilet. Hand hygiene includes either cleaning hands with soap and water or with an alcohol-based hand rub. Alcohol based hand rubs are preferred if hands are not visibly dirty; hands should be washed with soap and water when they are visibly dirty.
- Ensure that all persons in quarantine are practising respiratory hygiene and are aware of the importance of covering their nose and mouth with a bent elbow or paper tissue when coughing or sneezing, and then immediately disposing of the tissue in a wastebasket with a lid and then performing hand hygiene.
- Refrain from touching the eyes, nose and mouth.
- Physical distance of at least 2 metres should be maintained between all persons who are quarantined.
- To prevent COVID-19 transmission effectively in areas of community transmission, the general public should be encouraged to wear masks in specific situations and settings, such as on public transport, in shops or in other confined or crowded environments, as part of a comprehensive approach to suppress SARS-CoV-2 transmission.
- Implementation of appropriate measures to ensure the safe disposal of this type of waste in a sanitary landfill and not in an unmonitored open area.
Requirements for monitoring the health of quarantined persons
- Daily follow up of persons who are quarantined should be conducted within the facility or home for the duration of the quarantine period and should include screening for body temperature and symptoms in accordance with WHO and/or national surveillance protocols and case definitions.
- Groups of persons at higher risk of severe disease (individuals aged >60 years and individuals with underlying medical conditions) may require additional surveillance or specific medical treatments.
- Consideration should be given to the resources needed, including personnel and, for example, rest periods for staff at quarantine facilities. Appropriate resource allocation is particularly important in the context of an ongoing outbreak, when limited public health resources may need to be prioritized for health-care facilities and case-detection activities.
Laboratory testing during quarantine
- Any person in quarantine who develops symptoms consistent with COVID-19 at any point during the quarantine period should be treated and managed as a suspected case of COVID-19 and tested.
- For contacts who do not develop symptoms, WHO no longer considers laboratory testing a requirement for leaving quarantine after 14 days.
Duration of isolation/quarantine and precautions
- For most persons with COVID-19 illness, isolation and precautions can generally be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms, however isolation precautions are being recommended for 14 days.
o A limited number of persons with severe illness may produce replication competent virus beyond 10 days that may warrant extending duration of isolation and precautions for up to 20 days after symptom onset; this will be evaluated on a case by case basis.
- For persons who never develop symptoms, isolation and other precautions can be discontinued 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 RNA however 14 days is being recommended.
Role of PCR testing to discontinue isolation or precautions
- For persons who are severely immunocompromised, a test-based strategy could be considered in consultation with infectious diseases experts/consultants.
Additional groups such as those in high risk categories should be considered for test-based release from quarantine in combination with symptom-based release as follows; health care workers, Police, Prison Staff, Nursing Home Staff.
- For all others, a test-based strategy is no longer recommended except to discontinue isolation or precautions earlier than would occur normally under special circumstances. However, in most cases, the test-based strategy results in prolonged isolation of patients or work exclusion of HCP who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.
- Considerations for quarantine of contacts of COVID-19 cases 19th August 2020
- Home Care or patients with suspected for confirmed COVID-19 and management of their contacts 12th August 2020
- https://www.cdc.gov/coronavirus/2019-ncov/hcp/durationhtml#:~:text=For%20most%20persons%20with%20COVID,with%20improveme nt%20of%20other%20symptoms.
As the COVID-19 situation continues to develop, the Ministry of Health will update these guidelines based on the best available evidence.