COVID-19 spreads through inhalation of small droplets from the coughing or sneezing of people who are infected, as well as through touching contaminated surfaces. Hence, public health measures in the form of isolation and quarantine of confirmed and suspected cases are key to preventing the further spread of the virus.
In this contribution, we provide a comparative analysis of 31 countries of the World Health Organization (WHO) European Region, which have implemented isolation and quarantine measures in line with WHO recommendations. Evidence included here has been gathered from the information available on the COVID-19 Health Systems Response Monitor (HSRM) (up to 13 May 2020).
While we acknowledge that quarantine differs from isolation, both terms were often used interchangeably in HSRM country responses. This policy snapshot will focus on individuals who are confirmed cases and close contacts of confirmed cases, and will also provide information on contact tracing and enforcement of isolation and quarantine measures. This policy snapshot is part of a series of linked posts looking at public health capacity and the test, trace, isolate strategy. A forthcoming post will look how countries create the needed public health surge capacity to scale-up this strategy as lockdowns are eased.
Individuals with mild cases generally self-isolate at home, while some countries have established additional facilities
Individuals who tested positive to COVID-19 but do not necessitate hospitalization are required to initially isolate at home in most countries (Albania, Belarus, Bosnia and Herzegovina, Bulgaria, Cyprus, Denmark, Estonia, Finland, France, Iceland, Ireland, Israel, Italy, Latvia, Moldova, the Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, San Marino, Serbia, Slovenia, Spain, Ukraine, the United Kingdom). For those who cannot isolate at home, some hotels, hostels, dormitories or specialized facilities have been converted into special isolation facilities to accommodate people, as in Bosnia and Herzegovina (until April 21), Finland, Italy, Lithuania, Poland and Serbia.
In most countries, home isolation lasts 14 days, with a few exceptions such as Bulgaria and Serbia, who have set it at 28 days. Several countries, including Denmark and Estonia, also explicitly require infected cases to meet more explicit criteria, such as no exhibited symptoms for 48 hours, before they can leave home isolation. In other instances, such as in the United Kingdom, a 7-day isolation is advised for individuals with symptoms, while anyone living with them are require to isolate for 14 days (to cover the incubation plus infectious period). A number of countries enforce fines and/or criminal proceedings for breaking isolation, with some examples illustrated in figure 1.
In all countries surveyed, isolation takes place at home, unless hospitalization is required. Several countries reported that infected cases were initially hospitalized until the number of cases began increasing, at which point the policy changed to isolation at home. For example, in Portugal, hospitalization in isolation beds was the initial procedure for confirmed cases. As the pandemic evolves, only confirmed COVID-19 cases with clinical criteria for hospitalization are currently being treated in hospitals, while cases with mild symptoms are sent home and regularly contacted by health care workers for monitoring.
In general, close contacts of suspected and confirmed cases are also urged to quarantine for 14 days
Close contacts of suspected and confirmed COVID-19 cases are asked to quarantine in Albania, Belarus, Bosnia and Herzegovina, Cyprus, Estonia, France, Hungary, Iceland, Israel, Italy, Latvia, Luxemburg, Malta, Moldova, the Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, San Marino, Spain and the United Kingdom. In almost all cases, the quarantine at home lasts for 14 days.
Denmark, Finland and Ireland require quarantine for close contacts on a case-by-case basis, as decided by the individual medical professional or if symptoms occur. In Estonia and the Netherlands, family members of suspected cases who do not have health complaints are allowed to leave the house in certain instances (e.g. grocery shopping). In Luxemburg, close contacts of confirmed cases must quarantine for 7 days, followed by a 7-day period of self-surveillance in which they are allowed to resume normal activities.
In some countries, symptomatic or asymptomatic close contacts of COVID-19 patients undergo testing. For example in Italy, close contacts with mild symptoms must be tested, and if positive, they must remain in quarantine until tested negative and symptoms disappear; those with a negative test result must stay in quarantine for 14 days from their last contact with the case. In the Russian Federation, contacts of confirmed cases are to be traced, tested and initially hospitalized for observation; they are discharged if they have no symptoms and two negative tests 24 hours apart.
Figure 1. Selected examples of potential enforcement measures for breach of isolation or quarantine
Epidemiological surveillance for contact tracing occurs often via phone calls, though the use of apps is scaling up across countries
Contact tracing is implemented in most of the countries surveyed (Albania, Belarus, Bosnia and Herzegovina, Bulgaria, Denmark, Estonia, Finland (in some regions), Hungary, Iceland, Ireland, Israel, Italy, Kyrgyzstan, Latvia, Lithuania, Malta, Moldova, the Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Russian Federation, Serbia, Slovenia, Spain, Ukraine and the United Kingdom). In general, this epidemiological surveillance occurs through phone calls by trained personnel, and a number of countries (e.g. the United Kingdom) are training and hiring staff to help with contact tracing.
However, certain countries (Hungary, Iceland, Italy, Lithuania, Norway and Ukraine) are planning to use or are already using a contact-tracing app for people in mandatory isolation if they agree to download the application to their mobile device and share their geo-location. In Israel, mandatory tracing of geo-location data to identify (and quarantine) people who were in contact with COVID-19 patients will continue until May 26.
In Hungary since May 7, individuals who are in mandatory home quarantine can voluntarily download a tracking application that shares their location, photo and health data with the authorities in order for the police to regularly check whether they comply with the quarantine. If the application data suggest that someone is not observing the rules, the authorities can check on him/her personally. Once home quarantine ends, the individual can delete the software, but the authorities will retain the data for another 60 days. If someone does not voluntarily agree to install the software, the police will perform home visits more often to personally check on compliance with home quarantine.
In Ukraine, an app monitors citizens in quarantine and isolation using their GPS (Global Positioning System) data. The app will send its users 10 push notifications at random times for 14 consecutive days, asking them to take selfies from their place of self-isolation. The app’s artificial intelligence will then analyze the selfies through their GPS locations to confirm location and self-isolation.
In the United Kingdom, plans to scale up contact tracing will depend in part on the use of a Bluetooth-based mobile phone app, designed by Google and Apple and implemented by the National Health Service (NHS). Individuals in the community with symptoms will receive testing and the app will perform automated contact tracing for individuals who test positive, identifying others who have been in prolonged close contact (of less than 2 meters) using Bluetooth. Further, there are plans to recruit 18,000 call handlers who will be trained to provide advice to contacts of confirmed cases determined through the app.
Conclusions and policy recommendations
As countries continue to be hit by COVID-19, isolation and quarantine measures for suspected cases remain prevalent public health measures to stem the spread of the infection. Our comparative analysis shows that the response from countries has been fairly homogenous in the WHO European Region, and in line with international recommendations. By assessing the effectiveness of isolation and quarantine measures adopted so far in reducing infected cases, policymakers will be able to redefine future responses to new outbreaks of COVID-19.
Early action through implementation and strict enforcement of isolation and quarantine measures for those infected and their close contacts could contain the virus spreading both in areas where the virus is already circulating, or in new areas. However, if self-isolation is not possible at home, it needs to take place in other appropriate settings.
Contact tracing is of crucial importance as a key disease control measure, and requires personnel with certain skills and knowledge. A number of countries recognize the need to hire and train more individuals to strengthen their contact tracing efforts. The COVID-19 pandemic also raises questions on whether countries should reorganize or even increase the capacity of their public health services to better manage contact tracing for future demands.
Further, several countries are using apps to identify cases and monitor the spread of the virus among the population, and provide data to help contain the chain of transmission. However, a debate on the delicate balance between contact tracing and data privacy has emerged, and policymakers must make important decisions, especially on the use of technology to strengthen contact tracing and support the transition to a post-lockdown future.
Giada Scarpetti, Erin Webb, Cristina Hernandez-Quevedo