Key Considerations: Quarantine in the Context of COVID-19

"Constructive engagement with local communities and trusted public authorities, both formal and informal, is essential for the implementation of quarantine measures that will be acceptable, well understood and therefore more likely to succeed."

Quarantine and other movement-restricting measures have been used for centuries as a strategy to control epidemic diseases. Developed for the Science in Humanitarian Action Platform (SSHAP) by Anthrologica, this brief sets out practical considerations relating to the design and impact of various measures that restrict human movement patterns in the context of the COVID-19 pandemic.

Measures considered in the brief include: quarantine, in which individuals who have been exposed to a communicable disease are separated from others for the duration of the disease's incubation period; isolation, in which individuals with a communicable disease are separated from others for as long as they are infectious; and social distancing, in which individuals or large groups of people are restricted from gathering. Measures can be mandatory, voluntary, or coerced; they may be top-down measures led by the state or bottom-up measures driven by the community or individuals.

Lessons from previous restrictions on movement during outbreaks are outlined. In brief:

• Factors influencing compliance - which will differ between and within countries, regions, and cultures - include understanding of the health threat, trust in leaders, personal risk assessment, social and cultural norms, social and familial obligations, life circumstances, and work and financial concerns. Suggestion: When developing public health messaging, attend to the fact that societies differ in terms of their ideals regarding collectivism versus individualism and that the influences and behaviours of an individual's social networks and the reactions of family, friends, peers, trusted community leaders, and well-known figures may all impact decisions regarding compliance.
• The fundamental ethical tension of quarantine is between individual and population rights; most democracies' public health laws permit quarantine under warranted conditions. Suggestion: Provide sufficient accurate and actionable information, as well as effective resources (e.g., methods of communicating with people outside a quarantine zone) so that individuals under quarantine can protect themselves and their family members from infection.
• A study following the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 concluded that individuals are more likely to trust authorities and to comply with home quarantine if they are provided with clear, consistent, relevant, practical, and actionable information. Suggestion: Take into account preferred and accessible communication methods, language and dialect preferences, and levels of education and literacy when considering how to communicate information about quarantine measures. "[T]here is more likely to be public acceptance for quarantine measures when the public at large is engaged in open dialogue on the ethical use of restrictive measures, and when collaboration occurs with communities and local leaders...."

Different approaches to quarantine are outlined; some examples and lessons to emerge from past outbreaks include:

• Top-down approaches (e.g., mandatory home quarantine, mandatory quarantine in designated establishments, area quarantine, social distancing, and voluntary measures guided by state or international advisories) - In the context of the Ebola outbreak in Bong County, Liberia, for example, taking the time to involve community members, as well as informing them and working through trusted local leaders who could act as a liaison between the community and district health authorities, was found to help implement an effective community quarantine. For instance, this engagement facilitated quick action when residents of Mawah village (population of approximately 800 people) raised concerns about food and medicine shortages and the need for psychosocial support during the time they restricted from moving in and out of the village.
• Bottom-up approaches (e.g., community-led mandatory home and area quarantine, voluntary home quarantine and movement restriction) - During the H1N1 outbreak, for example, 400 million Chinese people used blogs, discussion forums, instant messaging tools, and social networking sites to gather and share information and to call for returning travellers to take a number of measures before and after travelling to China. This shifted the burden of surveillance to the individual and yet appealed to China's collectivist ideals.

SSHAP stresses the need for understanding and effective communication between external actors (e.g., from government) and communities so that top-down advice or measures can work in synergy with locally led practices.

Ramifications of quarantine and other movement restrictions include:

• Social impacts - For example, interventions that restrict movement of certain groups or individuals can exacerbate existing social tensions, fuel fear and mistrust, and lead to stigmatisation and discrimination. Messaging and media blaming those thought to be responsible for a disease (e.g., references to COVID-19 as the "Chinese virus") can exacerbate this.
• Psychosocial impacts - People placed under quarantine often report anxiety and distress due to fear of contagion, as well as isolation, loneliness, anger, and negative feelings associated with perceived or real stigmatisation. "It is important for people in quarantine to have access to adequate psychosocial support from someone they trust and who are well informed about the situation. Support may be provided via telephone or other communications technology if in-person support is deemed to be too high risk. Access to newspapers and television may help people to maintain a sense of connectedness with the outside world, although the circulation of misinformation in the media (as discussed above) may be problematic..."
• Economic impacts - "It is important to ensure access to affordable prevention and healthcare services as well as supplies to individuals and families being asked to suspend their personal liberties for the public good."

Concluding thoughts: "To reduce panic and emotional distress and improve compliance with preventative measures, official sources must provide clear, up-to-date, transparent and consistent guidelines, information and verbal messages about quarantine measures and how to mitigate infection during the quarantine period....The needs of vulnerable populations should be prioritised in the structure of and communication about quarantine measures. In the context of COVID-19 this includes the elderly and those with co-morbidities who are more vulnerable to severe disease."

Click here for the brief in English (PDF, 6 pages).
Click here for the brief in French (PDF, 8 pages).
Click here for the brief in Chinese (PDF, 8 pages).