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 reducing 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 2 metres (6 feet) combined with frequent hand hygiene and respiratory etiquette.
This document provides updated guidance for the implementation of 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. The document also addresses the requirements for release from quarantine based on updated technical guidance.
Epidemiology and virology studies suggest that transmission occurs from both symptomatic and asymptomatic persons, to others by close contact through respiratory droplets, direct physical contact, or through contact with contaminated objects and surfaces. Shedding of SARS-CoV-2 is highest in the upper respiratory tract (URT) (nose and throat) early in the course of the disease up to 2-3 days prior the onset of symptoms, and during the first 5-7 days of symptoms.
Incubation Period for COVID-19
The incubation period for COVID-19, (the time between exposure to the virus 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. The Turks and Caicos Islands Public and Environmental Health Regulations speaks to the local legal authority to impose quarantine.
Considerations for the quarantine of contacts of COVID-19 cases
The purpose of quarantine is to have persons who are suspected to have, or who have been exposed to COVID-19 to reduce further spread. Quarantine is different from isolation, which is the separation of infected persons (confirmed to have COVID-19) from others to prevent the spread of the virus.
The following should be taken in consideration:
- 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. COVID-19 cases should be quarantined with their entire household as these individuals by virtue of their living situation are considered exposed.
- WHO recommends that all contacts of individuals with confirmed or probable COVID-19 be quarantined in a designated facility or at home with their household. Duration of quarantine/isolation is discussed below.
- 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 OR 2 days before and up to 14 days after an asymptomatic tests positive in the confirmed or probable case of COVID-19:
- Face-to-face contact with a probable or confirmed case of COVID-19 within 2 meters and for more than 15 minutes without wearing face mask/covering;
- 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.
Home quarantine should include the following provision:
- Quarantined person should occupy a well ventilated single room, or if a single room is not available, maintain a distance of at least 2 metres 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.
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
- 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.
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.
Infection prevention and control measures
- 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.
- 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 a >70% alcohol-based hand rub.
- Ensure that all persons in quarantine are practicing 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.
Requirements for monitoring the health of quarantined persons
- Follow up of persons who are quarantined should be conducted within the facility or home for the duration of the quarantine period 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.
- Any individual with severe symptoms: shortness of breath, difficulty breathing or severe chest pain should contact 911 for medical treatment at the nearest hospital.
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. Testing should be offered to any symptomatic individual in quarantine.
- For household contacts who do not develop symptoms, testing may be offered at any time during quarantine. For contacts outside the household, testing may be offered at least 7 days after the last exposure.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.
A limited number of persons with severe illness, or underlying medical conditions may produce replication competent virus beyond 10 days that may warrant extending the duration of isolation; 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.
Special Considerations for COVID-19 Vaccinated Individuals:
Individuals are considered fully vaccinated for COVID-19 ≥2 weeks after they have received the second dose in a 2-dose series (e.g. Pfizer-BioNTech, Astra Zeneca, Moderna) or ≥2 weeks after receiving single dose series (Johnson & Johnson). Evidence of vaccination must be available for review by the Public Health Team in order to qualify for the quarantine periods outlined below:
- Fully vaccinated individuals with a history of exposure to a suspect or confirmed case of COVID-19 who are asymptomatic
These individuals may have a reduced quarantine period after known exposure to COVID-19 (i.e. close contact) from 14 days to 7 days. Individuals in this situation should monitor for signs and symptoms of COVID-19 and notify the Public Health Team if these develop; in such a case these individuals may require testing and an extension of the quarantine period.
- A fully vaccinated individual that tests positive for COVID-19:
- If all vaccine-eligible* members of the household are fully vaccinated, a quarantine period of 10 days is recommended.
- If all vaccine-eligible* members of the household are notfully vaccinated, a quarantine period of no less than 14 days is recommended.
• Fully vaccinated people with COVID-19 symptoms
Although the risk that fully vaccinated people could become infected with COVID-19 is low, any fully vaccinated person who experiences symptoms consistent with COVID-19 should isolate themselves from others, contact the MOH hotlines and be tested for SARS-CoV-2 if indicated. The symptomatic fully vaccinated person should inform their healthcare provider of their vaccination status at the time of presentation to care.
- Household members who have received one or more doses of COVID-19 vaccine
While COVID-19 vaccines have been shown to reduce the likelihood of severe illness for those who have received them, the risk of transmission (a vaccinated person spreading COVID-19 to others) is not yet fully known. Therefore, even if a person has been vaccinated, there is still a risk they could catch COVID-19 and spread it to other people.
If someone in the household has symptoms of COVID-19 or has received a positive test result, the household members must be quarantined even if they have received one or more doses of COVID-19 vaccine. The information in this guideline will reduce the risk of spreading infection and help to protect the wider community.
If an individual has symptoms of COVID-19 or has received a positive test result, they are still required to quarantine even if they have received one or more doses of a COVID-19 vaccine. This will reduce the risk of spreading infection and help protect other people.
*Vaccine-eligible: individuals who are able to receive the vaccine based on local and international recommendations/guidelines.
Role of PCR testing to discontinue isolation or precautions
- A test-based strategy is no longer recommended except to discontinue isolation or precautions earlier than would occur normally; under special circumstances.
- Considerations for quarantine of contacts of COVID-19 cases 19thAugust 2020
- Home Care or patients with suspected for confirmed COVID-19 and management of their contacts 12thAugust 2020 https://apps.who.int/iris/bitstream/handle/10665/333782/WHO-2019-nCoVIPCHomeCare-2020.4-eng.pdf?sequence=5&isAllowed=y
- https://www.cdc.gov/coronavirus/2019ncov/hcp/duratiohtml#:~:text=For%20most%20persons%20with%20COVID,wi th%20improvement%20of%20other%20symptoms.
- Stay at home: guidance for households with possible or confirmed coronavirus (COVID-19) infection - GOV.UK (www.gov.uk)
As the COVID-19 situation continues to develop, the Ministry of Health will update these guidelines based on the best available evidence.