Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement D: Community Containment Measures, Including Non-Hospital
Isolation and Quarantine

# Contents

I.  Rationale and Goals

II. Lessons Learned

III. Management of SARS Patients in Isolation

IV. Management of Contacts of SARS Cases

V.  Community-Based Control Measures

VI. Enforcement of Community Containment Measures

VII. Roles and Responsibilities

VIII. Preparedness Planning

Appendix D1: Interventions for Community Containment

Appendix D2: Frequently Asked Questions about Use of Community
Containment Measures

Appendix D3: Guidelines for Evaluating Homes and Facilities for
Isolation and Quarantine

Appendix D4: Threshold Determinants for the Use of Community Containment
Measures

Appendix D5: Preparedness Checklist for Community Containment Measures

Community Containment Measures,

Including Non-Hospital Isolation and Quarantine

#   {#section .unnumbered}

# I. Rationale and Goals

Community containment strategies, including isolation and quarantine,
are fundamental public health measures used to control the spread of
communicable diseases. All such strategies have in common the primary
goal of preventing person-to-person spread of disease by separating
those with disease or at increased risk for developing disease from
those at lower risk. Although the terms "isolation" and "quarantine"
have often been used interchangeably, they actually represent distinct
concepts (see Box).

*Isolation* is a commonly used practice in modern public health.
Isolation refers to the separation of ill persons with a communicable
disease (e.g., *SARS patients*) from those who are healthy. A
prototypical example is the isolation of persons with potentially
infectious tuberculosis. Isolation not only prevents transmission of
infection to others but also allows for the focused delivery of
specialized health care to ill persons. SARS patients can be isolated in
a hospital, at home, or in a designated community-based facility.

*Quarantine* is the separation or restriction of activities of persons
who are not ill but who are believed to have been exposed to a
communicable disease and are therefore at highest risk of becoming
infected (e.g., *close contacts of SARS patients*[^1]). Although rarely
used in the modern era \-- due in part to the advent of antibiotics and
antiviral agents and to the negative connotations associated with past
use \-- quarantine and other community containment strategies were
valuable for the control of the 2003 global SARS outbreaks.

Contacts of SARS patients can be managed through a range of strategies,
all of which are designed to facilitate early recognition of illness in
persons at high risk and thereby to prevent transmission to others. Key
to each of these strategies is the ability to closely monitor contacts
of SARS patients for the onset of symptoms. Monitoring may be *passive*,
in which contact themselves report the appearance of symptoms, or
*active*, in which healthcare officials periodically assess contacts for
symptoms.

In this document, "quarantine" refers to interventions \-- either
voluntary or compulsory \-- in which active monitoring is accompanied by
a restriction on the activities of persons exposed to SARS-CoV to
prevent transmission if they develop SARS-CoV disease. Quarantine may
also have a specific legal definition that may differ among
jurisdictions based on applicable laws. Although quarantine, by
definition, restricts some personal liberties, it is a collective action
implemented for the common good. Modern quarantine is predicated on the
need to aid persons who are infected with or exposed to infectious
agents while protecting others from the dangers of inadvertent exposure.
As such, it differs substantially from the quarantine of the past.

In addition to separating exposed persons from unexposed persons,
quarantine can have other potential benefits. For diseases, such as
measles, that can be transmitted from asymptomatic persons (i.e.,
persons who appear healthy and have not yet developed symptoms),
quarantine can reduce the risk of further spread. Although transmission
from asymptomatic persons is considered unlikely for SARS-CoV disease,
symptom onset may be insidious and quarantine can reduce the risk of
transmission from those in whom symptoms are yet to be recognized and
acknowledged. In addition, restricting the activities of exposed but
asymptomatic persons should facilitate careful monitoring of these
persons for development of symptoms and thereby reduce delays in their
recognition. In this way, closer follow-up can expedite the
implementation of appropriate precautions, thereby preventing additional
transmission. The utility of quarantine in this context is to:

-   Identify through contact tracing those at greatest risk for the
    onset of SARS symptoms,

-   Separate them from others by restricting their movements,

-   Actively monitor them, and

-   Rapidly institute appropriate isolation procedures as soon as
    symptoms are detected.

In this way, quarantine reduces both the period during which
transmission might occur and the number of persons who might be exposed
during this period.

Whereas isolation and contact management strategies such as active
monitoring are directed to individuals, broader *community containment
measures* may be applied to groups of persons or to communities during
outbreaks characterized by extensive transmission. These interventions
range from *measures to increase social distance* among community
members (e.g., cancellation of public gatherings, use of masks,
implementation of community-wide "snow days") to *community-wide
quarantine*.

Although all of these interventions are designed to prevent transmission
by limiting social interactions and preventing inadvertent exposures,
the less stringent actions may be easier to implement on a large scale.
For example, in the "snow day" approach, community members are asked to
stay home as they would during a major snowstorm. Schools are closed,
work sites are closed or restricted, large public gatherings are
cancelled, and public transportation is halted or scaled back.
Implementation requires fewer resources than are needed to activate and
maintain community-level quarantine. In addition, as snow days are a
familiar concept in most communities, implementation can occur quickly.
Implementation of quarantine, on the other hand, can be resource
intensive, requiring mechanisms for enforcement and provision of
necessities. Snow days and other measures to increase social distance
are therefore the preferred community-level responses, with quarantine
reserved for situations in which less drastic measures have not been
successful in containing an outbreak.

Appendix D1 provides detailed descriptions of the interventions for
community containment, including definitions, applications, benefits,
challenges, and required resources. Answers to frequently asked
questions about community containment measures, including quarantine,
are provided in Appendix D2.

## 

## Although isolation, quarantine, and other containment measures are optimally performed voluntarily, many levels of government (local, state, federal) have the legal authority to compel mandatory isolation and quarantine of persons and communities to protect the public's health. (See Supplement A and Section VI: Enforcement of Community Containment Measures.)

#  

# II. Lessons Learned

During the 2003 epidemic, the community containment strategy for the
United States consisted mainly of coordinating SARS response activities
through CDC's Emergency Operations Center and providing information and
education to the public, healthcare workers, and others. Activities
included issuing guidelines and fact sheets, holding press conferences,
and meeting with groups and communities to address their concerns about
stigmatization. CDC also recommended isolation of SARS patients until
they were believed to be no longer infectious. This practice allowed
patients to receive appropriate care and helped contain the spread of
infection. Severely ill persons were cared for in hospitals; those with
mild illnesses were cared for at home. Sick persons in home isolation
were asked to avoid contact with others and to remain at home until 10
days after the resolution of fever, provided respiratory symptoms were
absent or improving. In the United States, where there was little or no
transmission of SARS-CoV, neither individual nor population-based
quarantine of contacts was recommended. CDC advised persons who were
exposed but not symptomatic to monitor themselves for symptoms and
advised home isolation and medical evaluation if symptoms appeared.

Large-scale quarantine was used for the first time in decades in several
countries that were severely affected by the 2003 SARS outbreak.
Strategies included quarantine of close contacts in healthcare and
household settings, work and school contacts, travelers arriving from
other SARS-affected areas, and, in some cases, of entire apartment
complexes or areas of a city. Other strategies used to control and
prevent SARS-CoV transmission in these countries included 1) requiring
fever screening before entry to schools, work sites, and other public
buildings, 2) requiring use of face masks in certain settings, such as
public transportation systems, 3) implementing population-wide
temperature monitoring and SARS fever hotlines and referral services,
and 4) implementing community-level disinfection strategies.

The impact and effectiveness of individual isolation and quarantine
measures and community- and population-level interventions undertaken to
contain the SARS epidemic globally are not yet fully understood, but
some important generalizations can be made. Overall, strategies
associated with timely and successful control of local outbreaks were
characterized by rapid and aggressive use of case and contact
identification and community containment strategies. Other lessons
learned from this modern experience with community containment include
the following:

-   Most, but not all, SARS patients have a clear history of exposure to
    another SARS patient or to a specific setting with recognized
    SARS-CoV transmission.

-   Strict infection control measures are needed for isolation of SARS
    patients; these may be difficult to implement in home and community
    settings.

-   Tracing and monitoring of contacts of SARS patients are resource
    intensive but critical to the containment and early recognition of
    illness in persons at greatest risk for development of disease.

-   Community control measures such as cancellation of public events and
    other "snow day" measures may reduce the risk of exposure to
    SARS-CoV at the population level by limiting social interactions.

-   Although quarantine of individual contacts was an integral part of
    SARS control in most settings, quarantine of large groups was used
    only in selected settings where transmission was extensive.

-   To be effective, quarantine does not have to be mandatory and
    compliance does not have to be 100%; voluntary compliance with
    quarantine requests was \>90% in most settings.

-   A variety of quarantine strategies (e.g., home quarantine, working
    quarantine) may be used, depending on specific needs.

-   Isolation and quarantine raise legal, social, financial, and
    logistical challenges (e.g., financial support, provision of
    services, prevention of stigma) that should be anticipated and
    addressed. Meeting the social, financial, and psychological needs of
    persons with SARS and their contacts is key to the successful
    application of containment measures.

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-   Effective implementation of quarantine requires a clear
    understanding of the roles and legal authorities of local, state,
    and federal public health officials.

-   Effective implementation of quarantine requires identification of
    appropriate traditional and non-traditional partners (e.g., law
    enforcement) and their engagement in coordinated planning and
    response.

-   The financial, social, and psychological impact of quarantine
    measures is substantial; preparedness planning should include
    measures to reduce this impact.

-   Obtaining and maintaining public trust are key to successful
    implementation of these measures; clear messages about the criteria
    and justification for and the role and duration of quarantine and
    ways in which persons will be supported during the quarantine period
    will help generate public trust.

#   {#section-3 .unnumbered}

# III. Management of SARS Patients in Isolation

Preventing transmission from SARS patients is critical to controlling
SARS. This requires limiting the public interactions of possible or
known SARS patients (e.g., at work, school, out-of-home child care) and
preventing transmission wherever the patients are housed during the
period of infectivity (10 days after the resolution of fever, provided
respiratory symptoms are absent or improving).

SARS patients should be isolated in a hospital only if medically
necessary. Local and state authorities should also be prepared to
isolate patients at home or in alternative facilities designated for
this purpose. SARS preparedness planning must address home isolation of
SARS patients, the availability and use of existing or temporary
structures as alternative facilities for isolation, the management of
patients housed at home or in alternative facilities, and resources for
supplies and services.

> **Objective**: Separate and confine patients who meet the case
> definition for probable or confirmed SARS-CoV disease or SARS report
> under investigation (RUI) during the period of communicability (See
> MMWR 52(49):1202-1206
> \[[www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm)\]).
>
> Activities aimed at separating persons with known or possible SARS-CoV
> disease should be modulated as needed based on the status of the
> outbreak. Basic activities should be initiated with the identification
> of the first confirmed or probable case or SARS RUI. Enhanced
> activities may become necessary as an outbreak evolves and the number
> of persons requiring isolation increases.

### Basic Activities 

-   SARS patients should be admitted to a healthcare facility for
    isolation only if clinically indicated or if isolation at home or in
    a community facility cannot be achieved safely and effectively.
    **Isolation of SARS patients in hospitals is described in detail in
    Supplement C**.

-   Before a SARS patient is placed in a residence or community facility
    for isolation, arrangements should be made to ensure that the
    residence has the features necessary for provision of appropriate
    care to the patient and to determine if sufficient infection control
    measures can be established to prevent/limit exposures to household
    members, other primary caregivers, and the community. Guidelines on
    evaluation of residences for isolation are provided in Appendix D3
    and in Supplement I.

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-   During the period of home isolation, household members not providing
    care should be relocated if possible so that only the primary
    caregiver and the patient remain in the residence. If household
    members cannot be relocated, they should minimize their contact with
    the SARS patient. Persons at risk for serious SARS complications
    (e.g., persons with underlying heart or lung disease, persons with
    diabetes mellitus, elderly persons) should not have contact with the
    patient.

-   The SARS patient in home isolation and all persons in contact with
    the patient should follow the infection control recommendations
    described in Supplement I.

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-   Close contacts of SARS patients[^2] should be vigilant for fever
    (i.e., measure temperature twice daily), respiratory symptoms, and
    other symptoms of early SARS-CoV disease, such as chills, rigors,
    myalgia, headache, or diarrhea. If symptoms develop, the designated
    health department should be contacted to arrange for immediate
    medical evaluation and follow-up.

### Enhanced Activities

> If a surge in patients overwhelms healthcare capacity or if home
> isolation is not feasible, health departments may need to use
> alternative facilities for isolation of SARS patients. Additional
> information on community isolation of SARS patients is provided in
> Appendix D3 and in Supplement I.

# 

# IV. Management of Contacts of SARS Cases

# 

> **Objective 1**: Monitor and evaluate contacts of SARS patients
> (probable and confirmed cases of SARS-CoV disease; SARS RUIs) to
> ensure early identification of illness and rapid institution of
> infection control precautions to prevent further spread (See MMWR
> 52(49):1202-1206
> \[[www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm)\]).

###  Basic Activities: Passive or Active Monitoring

-   In a limited SARS outbreak, contacts of SARS patients may be managed
    by using passive or active monitoring. Monitoring consists of direct
    contact -- by phone or in person -- with the health department or a
    designee at least once a day to assess the affected person for
    symptoms and address any needs. Frequent monitoring (e.g., twice a
    day) can reduce the interval between the onset of symptoms and the
    institution of precautions. *Passive monitoring* relies on the
    affected person to contact health authorities if symptoms develop.
    *Active monitoring* involves direct assessment of each contact at
    least once a day by a designee of the health department.

> Persons with high-risk exposures (e.g., healthcare workers involved in
> aerosol-generating procedures on a SARS patient) may require activity
> restrictions in addition to monitoring (see *Enhanced Activities*
> below).

-   Regardless of the type of monitoring recommended, all contacts of
    SARS cases should be advised to:

    -   Be vigilant for fever (i.e., measure temperature twice a day),
        respiratory symptoms, and other symptoms of early SARS-CoV
        illness for 10 days after exposure (See MMWR 52(49):1202-1206
        \[[www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm)\]).

    -   If symptoms develop, contact a designated health department
        staff member so that clinical evaluation can be performed
        without delay.

    -   Before visiting a healthcare facility for evaluation, inform the
        healthcare provider in advance about the possible exposure to
        SARS-CoV.

### Enhanced Activities: Quarantine of Contacts

> During a large outbreak or in situations of high-risk exposures
> (e.g*.*, if transmission from a particular case has been demonstrated
> by emergence of secondary cases among one or more contacts),
> consideration should be given to managing contacts with activity
> restrictions in addition to active monitoring. This combined approach
> is referred to as *quarantine*. The purpose of quarantine is to reduce
> transmission by 1) separating contacts of SARS patients from others,
> 2) monitoring contacts for symptoms, and 3) instituting appropriate
> infection control precautions as soon as symptoms are detected.
>
> Implementation of quarantine for contacts can be complicated and
> resource intensive, and the activity restrictions can be difficult for
> affected persons to endure. In deciding when to use quarantine and
> which persons should be included in a quarantine order, public health
> officials must strike a balance based on the epidemiologic situation
> and available resources. Limiting quarantine to only high-risk
> contacts may be more labor intensive at the outset but will be easier
> to maintain since fewer resources will be needed for provision of
> services and enforcement of restrictions. Applying quarantine too
> narrowly in the midst of an extensive outbreak can, however, blunt the
> efficacy of the policy if missed cases result in additional
> generations of transmission. If the resources required for
> investigation and risk stratification of contacts are not available,
> broader application of quarantine may be more practical. Whenever
> quarantine is implemented, close clinical monitoring and provision of
> essential services and needs must be ensured.

-   Based on the situation, select among the three main options for
    quarantine of contacts: home quarantine, quarantine in designated
    facilities, and working quarantine.

> **Home quarantine \--** Home quarantine is most suitable for contacts
> with a home environment that can meet their basic needs and in which
> unexposed household members can be protected from exposure.

-   Persons in home quarantine must be able to monitor their own
    symptoms (or have them monitored by a caregiver).

-   As is the case for isolation, a home should be evaluated for
    suitability before being used for quarantine. Because the infection
    control requirements for healthy contacts in quarantine are less
    stringent than those for ill persons in isolation, this evaluation
    may be performed by use of a questionnaire administered to the
    quarantined person or the caregiver. Additional guidance on use of a
    residence for quarantine is provided in Appendix D3 and Supplement
    I.

-   Household members require no specific precautions as long as the
    quarantined person remains asymptomatic. However, because the onset
    of symptoms can be insidious, it may be prudent for the quarantined
    contact to minimize interactions with other household members to
    prevent exposure during the interval between the development and the
    recognition of symptoms. Precautions might include 1) sleeping and
    eating in a separate room, 2) using a separate bathroom, and 3)
    wearing a surgical mask when in a room with others.

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-   Persons in quarantine may be assessed for symptoms by either active
    or passive monitoring. Delayed recognition of symptoms and a
    resulting delay in the institution of isolation contributed to
    extensive chains of transmission in several areas during the 2003
    SARS outbreaks, even when the areas were under heightened
    surveillance. Active monitoring of contacts in quarantine might
    overcome any delays resulting from the insidious onset of symptoms
    or denial among those in quarantine.

-   Persons who develop symptoms should immediately notify the
    designated health department to arrange for medical evaluation. The
    health department should provide explicit instructions for isolation
    and other infection control precautions to be observed in the home
    while the ill person is awaiting evaluation. At minimum, persons
    with symptoms should be separated from others in the household.

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-   Household members may go to school, work, etc., without restrictions
    unless the quarantined person develops symptoms. If the quarantined
    person develops symptoms, household members should remain at home in
    a room separate from the symptomatic person and await additional
    instructions from health authorities.

-   Household members can provide valuable support to quarantined
    persons by helping them feel less isolated and ensuring that
    essential needs are met.

> **Quarantine in designated facilities** \-- Contacts who do not have
> an appropriate home environment for quarantine or who choose not to be
> quarantined at home may be quarantined in facilities designated for
> this purpose. Facilities designated for quarantine of persons who
> cannot or choose not to be quarantined at home should meet the same
> criteria listed for home quarantine. Evaluation of potential sites for
> facility-based quarantine is an important part of preparedness
> planning. Additional guidance on use of a residence for quarantine is
> provided in Appendix D3 and Supplement I.
>
> **Working quarantine** \-- This restriction applies to healthcare
> workers or other essential personnel who have been exposed to SARS
> patients and may need to continue working (with appropriate infection
> control precautions) but who are quarantined either at home or in a
> designated facility during off-duty hours (See Supplement C). When off
> duty, contacts on working quarantine should be managed in the same way
> as persons in quarantine at home or in a designated facility. Local
> officials will also need to develop:

-   Systems for monitoring persons in working quarantine for symptoms
    during work shifts

-   Mechanisms for immediate medical evaluation of anyone who develops
    symptoms

-   Provisions for transportation to and from work, if needed

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-   The recommended duration of quarantine for SARS is generally 10 days
    from the time of exposure. During that period, contacts should be
    monitored at least daily for fever and respiratory symptoms. In
    addition, health officials should provide the necessary support to
    enable contacts to comply with quarantine appropriately.
    Recommendations for monitoring of contacts include the following:

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-   Monitor daily, or more frequently if feasible, for fever,
    respiratory symptoms, and other symptoms of early SARS-CoV disease.

-   Monitor compliance with quarantine through daily visits or telephone
    calls.

-   Provide a hotline number for quarantined persons to call if they
    develop symptoms or have other immediate needs.

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-   If a quarantined person develops symptoms suggestive of SARS,
    arrangements should be in place for immediate medical evaluation of
    the patient. The health department should provide explicit
    instructions on the isolation and infection control precautions to
    be observed while the ill person is awaiting evaluation. At a
    minimum, symptomatic persons should be isolated from others in a
    separate room.

-   Provide persons in quarantine with all needed support services,
    including 1) psychological support, 2) food, 3) household and
    medical supplies, and 4) care for family members. Financial issues,
    such as medical leave, may also need to be considered.

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-   At the end of the designated quarantine period, contacts should have
    a final assessment for fever and respiratory symptoms. Persons
    without fever or respiratory symptoms may return to normal
    activities.

> **Objective 2**: Compile and analyze the information on contacts
> needed to evaluate and monitor the effectiveness of contact management
> strategies and containment interventions.
>
> Contact tracing and monitoring require substantial data management
> resources. The information technology needs for timely surveillance,
> monitoring, and management of contacts of SARS cases are currently
> under discussion among CDC and partners in state and local health
> departments, and development of a contact tracing and monitoring
> database is under way.

### Basic Activities

-   Public health officials responsible for contact tracing and
    management should compile and analyze information collected from
    contacts during the investigation and in the course of monitoring to
    evaluate the effectiveness of control measures. These data will
    inform decision making about the need for more stringent measures
    such as quarantine. Information should be collected for contacts of
    all SARS cases to determine the following:

    -   Number of contacts identified per case

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-   Number of days between onset of symptoms and reporting to health
    officials and between reporting and isolation

-   Number of cases occurring with unknown exposure

### Enhanced Activities

If quarantine is implemented, information gathered during the
investigation and monitoring of contacts should be analyzed on an
ongoing basis to evaluate the effectiveness of the intervention. This
information will be critical in determining the need for broader
application of quarantine and the timing of withdrawal of containment
measures. In addition to the parameters listed above, which should be
determined for contacts of all SARS cases, the proportion of contacts in
quarantine (by risk group) who develop SARS-CoV disease should be
determined.

# V. Community-Based Control Measures

Whereas decisions on use of containment measures in individual
situations depend primarily on the characteristics of the exposure and
the affected contact, the decision to institute broader use of community
measures is more complex. The different options -- e.g., active
monitoring with voluntary activity restrictions, legally mandated
quarantine, institution of snow days -- will vary in their effectiveness
in controlling the outbreak and their impact on personal liberties.
Other measures that might prevent inadvertent SARS-CoV exposures (e.g.,
temperature monitoring in public places; use of masks) should also be
considered. Decisions should be based primarily on the epidemiologic
characteristics of the outbreak. Other considerations will include the
healthcare and public health resources available and the level of
community cooperation (see Appendix D4).

Local officials will face enormous logistic, economic, ethical, and
psychological challenges in implementing community-level containment
measures. Preparedness planning should include development of essential
partnerships to address: 1) provision of essential services and support
(e.g., food, household and medical supplies, medical attention,
caretaking, continuation of work/school via telecommuting or home-based
curricula, financial support), 2) mental health (e.g., stigma management
and prevention, psychological support), and 3) enforcement (e.g.,
controlling entry into and exit from narrowly defined geographic areas;
border surveillance/monitoring; travel permits and credentials).

Even with the most comprehensive planning, however, officials must be
prepared to make decisions on the basis of incomplete or inadequate
information and to modify strategies as the situation unfolds. Although
control measures should never be used indiscriminately or in a manner
out of proportion to the situation, undue caution should not inhibit the
bold and swift implementation of the interventions upon which effective
control depends.

> **Objective 1**: Reduce the risk of transmission of SARS-CoV at the
> community level by implementing large-scale measures that limit social
> interactions and prevent inadvertent exposures.

### Activities

-   Implement community containment measures based on the epidemiologic
    characteristics of the outbreak, according to the graded response
    outlined in the Box below.

-   In the absence of SARS-CoV transmission in the world, activities
    should focus on *preparedness, planning and surveillance* for the
    first case(s). Public health and healthcare officials should provide
    community members with information about SARS and promote hand
    hygiene and respiratory hygiene/cough etiquette (See Supplement C).

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-   If SARS-CoV transmission is occurring in the world but the United
    States is reporting only a few imported cases and no or limited
    local transmission from those cases, then officials in areas with
    SARS cases should consider passive (at minimum) or active
    *monitoring of close contacts*. Although active monitoring promotes
    early identification of non-specific or insidious symptoms and
    reliable assessment of fever and symptoms, it also requires
    substantial resources. Local conditions therefore may dictate at
    least initial use of passive monitoring, particularly in the
    management of contacts with lower-risk exposures. For persons with
    high-risk exposures (e.g., healthcare workers with unprotected
    exposure to a SARS case, especially during a high-risk procedure),
    home quarantine with either passive or active monitoring may be
    considered.

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-   Jurisdictions should consider *more restrictive measures* for any of
    the following situations:

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-   Identification of cases without known epidemiologic links (i.e.,
    cases occurring in persons who, at the time of diagnosis, are not
    known to have had contact with a known SARS case or exposure to a
    known transmission setting)

-   Increasing number of cases among contacts of SARS patients

-   Significant interval between the onset of symptoms and the isolation
    of cases

-   Inadequate resources for continued isolation of cases and tracing
    and monitoring of contacts

> Measures to be considered include *quarantine of close contacts*, such
> as family members or healthcare workers who provided care to SARS
> patients. This approach has the advantage of limiting the use of
> quarantine to those at greatest risk, but implementation requires
> time, effort, and availability of skilled interviewers.
>
> Whenever possible, contacts should be *quarantined at home*. Home
> quarantine requires the fewest additional resources, although
> arrangements must still be made for monitoring patients, reporting
> symptoms, transporting patients for medical evaluation, and providing
> essential supplies and services.
>
> In some cases, affected persons may not have access to an appropriate
> home environment for quarantine. Examples include travelers; persons
> living in dormitories, homeless shelters, or other group facilities;
> and persons whose homes do not meet the minimum requirements for
> quarantine. In other instances, contacts may have an appropriate home
> environment but may not wish to put family members at risk. In these
> situations, health officials should identify a *facility with the
> appropriate characteristics for quarantine of contacts*. Monitoring
> may be either passive or active, although active monitoring may be
> more appropriate in a facility setting.

-   Jurisdictions with large numbers of cases without known
    epidemiologic linkages should consider instituting *measures to
    increase social distance*. Identification of an unlinked case can
    mean either that transmission is occurring from undetected cases or
    that contact tracing efforts are not identifying all potential
    contacts. Increasing social distance can reduce the likelihood that
    unexposed community members will be exposed to SARS-CoV and that
    persons who have already been exposed will unknowingly transmit to
    others if they become symptomatic. Interventions to increase social
    distance are usually applied to groups of persons in settings where
    there might have been exposure to SARS-CoV (e.g., a school in which
    several cases of SARS have been diagnosed). In a community with
    ongoing transmission, these measures may be applied to settings
    without known exposure (e.g., cancellation of concerts or sporting
    events; restricted use of public transportation).

The "snow day" approach may be an effective way to increase social
distance and reduce transmission because it is a concept with which most
Americans are familiar. This intervention would likely be instituted for
an initial 10-day period, with final decisions on duration based on
assessment of current epidemiologic information. Other community-level
measures, such as community-wide temperature monitoring, temperature
screening before entering public buildings, or recommended or mandatory
mask use, may also be considered. Although the effectiveness of these
interventions has not been quantified, they might enhance public
awareness and facilitate early detection of cases.

-   In extreme circumstances, when control measures do not appear to be
    effective or resources are overwhelmed, more restrictive measures
    such as *widespread or community-wide quarantine* may be considered.

> **Objective 2:** Scale back community containment measures as soon as
> appropriate.
>
> Communities may scale back community containment measures as the
> outbreak comes under control. For example, with significant declines
> in the number of new cases, unlinked cases, and generations of
> transmission, the community measures can be halted and efforts can be
> refocused on quarantine of known contacts.
>
> The process by which community containment measures are lifted
> requires as much thought and planning as their implementation. When
> applied to individuals, movement restrictions such as quarantine can
> be removed as soon as the exposed contact has remained without signs
> or symptoms of disease for a complete incubation period for SARS-CoV
> disease (i.e., 10 days).
>
> A decision to discontinue the broader use of community-level measures
> is more complex. A decision on the optimal time to remove these
> measures must balance the need to restore personal liberties against
> community safety. Premature removal of containment strategies can
> increase the risk of additional transmission and recurrent outbreaks.
> Decisions should be based on evidence of improving local/regional
> control, such as 1) consistent decrease in the number of confirmed
> cases, 2) reduction in the number of probable and known cases, and 3)
> confirmation that all cases either were imported or have a known
> source or well-defined epidemiologic link.

### Activities

-   When there is reasonable evidence of improved control of the
    outbreak, discontinue quarantine of contacts of persons meeting the
    criteria for SARS RUI (see MMWR 52(49):1202-1206
    \[[www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm)\]).
    Continue quarantine of contacts of persons with probable or
    confirmed SARS-CoV disease, particularly those with known exposures
    or well-defined epidemiologic links.

-   When three incubation periods have elapsed since the last reported
    confirmed case of SARS-CoV disease, discontinue quarantine of
    contacts. Also discontinue maintenance of designated facilities for
    quarantine.

-   As soon as appropriate, discontinue use of community-level
    containment measures. Withdraw the most stringent measures (e.g.,
    geographic or population-based movement restrictions, mass transit
    interruptions, travel restrictions) first. Begin scaling back
    community-level measures when three incubation periods have elapsed
    after identification of the last unlinked or probable case of
    SARS-CoV disease (i.e., all cases are imported or have known
    exposures or well-defined epidemiologic links).

# VI. Enforcement of Community Containment Measures

Data from modeling studies suggest that community containment measures
such as quarantine are effective for controlling an outbreak even if
compliance is less than perfect. Optimally, quarantine applied on a
voluntary basis will afford sufficient compliance to attain the
necessary effect. Nevertheless, protocols must be established for
enforcement of both individual and community measures when higher levels
of compliance are required.

**Objective 1:** Enforce individual quarantine restrictions as
necessary.

## 

### Activities

-   Develop protocols for follow-up of persons who cannot be reached by
    telephone. Protocols might include a threshold period for
    non-responsiveness that should trigger a home visit or other means
    to locate the person. Partnerships with law enforcement and other
    community-based resources will be helpful in tracing the whereabouts
    of persons who have violated restrictions.

-   Consider and plan for the use of alternative arrangements for
    persons who cannot or will not comply with voluntary home
    quarantine. These might include:

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-   Issuing official, legally binding quarantine orders

-   Posting a guard outside the home

-   Using electronic forms of monitoring

-   Using guarded facilities

> **Objective 2:** Enforce community-level containment measures as
> necessary.

### Activities

> Enforcement of community-wide containment measures is necessarily more
> complex given the larger number of persons involved. Although some
> measures, such as cancellation of public events or scaling back of
> mass transit services, are self-enforcing, others (e.g., restrictions
> on travel between areas) may require use of physical measures such as
> checkpoints. Implementation will require close partnerships and
> cooperation with law enforcement at the local and state levels.
> Federal law enforcement resources may also be available in some
> situations.

# VII. Roles and Responsibilities

Historical precedents, both legal and practical, suggest that states
have primary authority to invoke and enforce quarantine in their own
jurisdictions. This authority derives from the states' "police power,"
i.e., the inherent authority of a government to enact laws and promote
regulations to safeguard the health and welfare of its citizens. As a
result of this authority, the individual states are responsible for
intrastate isolation and quarantine practices and conduct their
activities in accordance with their respective statutes. Of note,
quarantine is not the only public health action that can be compelled by
state health authorities. Other frequently enforced actions include
school immunization and tuberculosis treatment laws.

Current quarantine laws, regulations, and enforcement procedures vary
widely from state to state, as do states' lists of notifiable and
quarantinable diseases. Many of these laws date back to the nineteenth
century. In response to a request from CDC, the Center for Law and the
Public's Health at Georgetown and Johns Hopkins Universities has
developed a "Model State Emergency Health Powers Act"
([www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf](http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf))
to assist state governments in reviewing emergency public health powers
to ensure they are adequate to respond to modern disease and
bioterrorism concerns.

At the federal level, the HHS Secretary has statutory responsibility for
preventing the introduction, transmission, and spread of communicable
diseases from foreign countries into the United States (e.g., at
international ports of arrival and from one state or possession to
another). The communicable diseases for which federal isolation and
quarantine are authorized are set forth by executive order of the
President. An executive order adding SARS to the list of detainable
communicable diseases was issued in April 2003. By statute, the HHS
Secretary may accept state and local assistance in the enforcement of
federal quarantine regulations and may also assist state and local
officials in the control of communicable diseases. For more information
on legal authorities and a checklist on legal considerations for SARS
preparedness, see Supplement A.

# 

# VIII. Preparedness Planning

A checklist for preparedness planning for community containment measures
is provided in Appendix D5.

### 

### 

# Appendix D1

# Interventions for Community Containment

Contacts of SARS patients can be managed by use of a range of
interventions, all of which are designed to facilitate early recognition
of illness in persons at greatest risk of becoming infected and thereby
to prevent transmission to others. Whereas many of these interventions
are applied individually to persons identified as contacts of a person
with possible or known SARS-CoV disease, others are applied to larger
groups of persons, or communities, who share a similar risk of exposure.
The interventions include the following:

## Passive Monitoring

***Definition*** The contact is asked to perform self-assessment at
least twice daily and to contact authorities immediately if respiratory
symptoms or fever occur

***Application*** Situations in which 1) the risk of exposure and
subsequent development of disease is low, and 2) the risk to others if
recognition of disease is delayed is also low.

***Benefits*** Requires minimal resources

Places few constraints on individual freedoms

***Challenge*** Relies on self-reporting

Affected persons may not perform an adequate self-assessment

***Resources Required*** Supplies (thermometer; symptom log; written
instructions)

Hotline to notify authorities about symptoms or needs

Staff to receive telephone reports and provide in-person

evaluation and care

***Partners*** Household members

***Forms/Templates*** Symptom logs

Instructions for patients and healthcare workers

######## 

## Active Monitoring without Explicit Activity Restrictions

***Definition*** A healthcare or public health worker evaluates the
contact on a regular (at least daily) basis by phone and/or in person
for signs and symptoms suggestive of SARS-CoV disease

***Application*** Situations in which 1) the risk of exposure to and
subsequent development of disease is moderate to high, 2) resources
permit close observation of individuals, and 3) the risk of delayed
recognition of symptoms is low to moderate

***Benefits*** Places few constraints on individual liberties

***Challenges*** Requires adequate staffing

Requires a system to track information and to verify monitoring

and appropriate actions based on findings

***Resources Required*** Trained staff to provide in-person and/or
telephone evaluations

Contingency plans for managing noncompliant persons

Contingency plans for rapid isolation of persons who develop

symptoms

Hotline to notify authorities about symptoms or needs

***Partners*** Professional and lay healthcare workers to perform
evaluations on behalf of the health department

Possible need for law enforcement to assist with

> management of noncompliant persons

***Forms/Template*** Checklist for assessment of active monitoring

> Template for recording results of clinical evaluation

## Active Monitoring with Activity Restrictions (Quarantine)

***Definition*** The contact remains separated from others for a
specified period (generally 10 days after potential exposure), during
which s/he is assessed on a regular basis (in person at least once
daily) for signs and symptoms of SARS-CoV disease. Persons with fever,
respiratory, or other early SARS-CoV symptoms (See MMWR 52(49):1202-1206
\[[www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a2.htm)\])
require immediate evaluation by a trained healthcare provider.
Restrictions may be voluntary or legally mandated; confinement may be at
home or in an appropriate facility.

No specific precautions are required for those sharing the household
with a person in quarantine as long as the person remains asymptomatic.
However, because onset of symptoms may be insidious, it may be prudent
to minimize interactions with household members during the period of
quarantine.

***Application*** Situations in which the risk of exposure and
subsequent development of disease is high and the risk of delayed
recognition of symptoms is moderate

***Benefits*** Reduces risk of spread from persons with subacute or
subclinical presentations or from delayed recognition of symptoms

***Challenges*** Infringes on personal freedom of movement

> May lead to a feeling of isolation from family and friends
>
> May lead to loss of income or employment
>
> Requires plans/protocols for provision of essential services
>
> Requires plan for provision of mental health support
>
> Risk of noncompliance, particularly as duration increases
>
> May require enforcement for noncompliance

***Resources Required*** Staff for monitoring and evaluation

> Appropriate facility if home setting is unavailable or inadequate
>
> Staff, funding, goods for provision of essential services
>
> Hotline for notification of symptoms or personal needs
>
> Mechanisms to communicate with family members outside the household or
> facility
>
> Mental health and social support services
>
> Delivery systems for food and other essential supplies

***Partners*** Professional and lay healthcare workers to perform
assessments on behalf of the health department

> Community volunteers/workers to assist with provision of essential
> services
>
> Potential need for law enforcement to assist with noncompliant persons

***Forms/Templates*** Checklist for active monitoring

> Template for recording results of clinical evaluation
>
> Checklist and guidelines for evaluation of homes for quarantine
>
> Checklist and guidelines for evaluation of community-based sites for
> quarantine
>
> Guidelines for monitoring compliance with home quarantine
>
> Guidelines for monitoring compliance with quarantine in
> community-based facilities

Forms for recording compliance with quarantine

***Examples*** Home quarantine (voluntary or mandatory)

Facility quarantine (voluntary or mandatory)

## Working Quarantine

***Definition*** Persons are permitted to work but must observe activity
restrictions while off duty. Monitoring for fever and other symptoms
before reporting for work is usually required. Use of appropriate PPE
while at work is required.

***Application*** Persons for whom activity restrictions (home or
facility quarantine) are indicated but who provide essential services
(e.g., healthcare workers)

***Benefits*** Reduces risk of community spread from high-risk contacts
while minimizing adverse impact of activity restrictions on provision of
essential services

> Clinical monitoring at work reduces the staff required for active
> monitoring at the quarantine site

***Challenges*** Need for close and consistent pre-shift monitoring at
the work site to prevent inadvertent exposures

> May require means of transporting persons to and from work site to
> minimize interactions; persons in working quarantine should wear
> appropriate PPE during transport.
>
> Must maintain close cooperation and communication between work-site
> and local health authorities

***Resources Required*** Appropriate facility for off-duty quarantine if
home is unavailable or inadequate

> Staff, funding, goods for provision of essential services
>
> Hotline for notification of symptoms and personal needs
>
> System to track results of work-site monitoring and location(s) of
> off-duty quarantine
>
> Mental health and psychosocial support services, especially if work
> includes care of SARS patients

***Partners*** Work-site administrators and infection control personnel

Community volunteers/workers

> Staff/volunteers to assist with transportation to and from work
>
> Potential need for law enforcement to assist with noncompliant persons

***Forms/Templates*** Guidelines and instructions for persons in working
quarantine

> Instructions for supervisors of persons in working quarantine

Checklist to evaluate homes for quarantine

> Guidelines for monitoring compliance
>
> Checklist for active monitoring at work site
>
> Template for recording results of clinical evaluation
>
> Forms for recording compliance

## Focused Measures to Increase Social Distance

***Definition*** Intervention applied to specific groups, designed to
reduce interactions and thereby transmission risk within the group. When
focused, the intervention is applied to groups or persons identified in
specific sites or buildings, most but not necessarily all of whom are at
risk of exposure to SARS-CoV

***Application*** Groups or settings where transmission is believed to
have occurred, where the linkages between cases is unclear at the time
of evaluation, and where restrictions placed only on persons known to
have been exposed is considered insufficient to prevent further
transmission

***Benefits*** Applied broadly, reduces the requirement for urgent
evaluation of large numbers of potential contacts to determine
indications for activity restrictions.

> May enable reductions in transmission among groups of persons without
> explicit activity restrictions (quarantine)

***Challenges*** May be difficult to solicit cooperation, particularly
if popular buildings are closed or popular events are cancelled

> Requires excellent communication mechanisms to notify affected persons
> of details and rationale
>
> May need to provide replacement for affected activities (e.g*.*,
> school, essential services)
>
> Generally relies on passive monitoring

***Resources Required*** Systems to communicate relevant messages

> May require enforcement, particularly if closure of popular buildings
> or gathering places is necessary
>
> Requires resources for passive monitoring
>
> Hotlines to report symptoms and obtain follow-up instructions
>
> Transportation for medical evaluation, with appropriate infection
> control precautions

***Partners*** News media and communication outlets

Law enforcement

> Community groups

***Forms/Templates*** Messages for affected persons

> Messages for employers of affected persons
>
> Messages for persons supplying essential services

***Examples*** Closure of schools or office buildings

Suspension of public markets

## Community-Wide Measures to Increase Social Distance

***Definition*** Intervention applied to an entire community or region,
designed to reduce personal interactions and thereby transmission risk.
The prototypical example is implementation of a "snow day," in which
offices, schools, transportation systems are cancelled as for a major
snowstorm.

***Application*** All members of a community in which 1) extensive
transmission of SARS-CoV is occurring, 2) a significant number of cases
lack clearly identifiable epidemiologic links at the time of evaluation,
and 3) restrictions on persons known to have been exposed are considered
insufficient to prevent further spread

***Benefits*** Reduces need for urgent evaluation of large numbers of
potential contacts to determine indications for activity restrictions

> May enable reductions in transmission among groups without explicit
> activity restrictions (quarantine)
>
> "Snow days" are familiar concepts and thus easy to implement on short
> notice

***Challenges*** May be difficult to solicit cooperation

> Requires excellent communication mechanisms to notify persons of
> details and rationale
>
> May need to provide replacement for affected activities *(*e.g.,
> school, essential services)
>
> May need to address mental health and financial support issues
>
> When an entire community is involved, requires cooperation with
> neighboring jurisdictions that may not be using a similar
> intervention, particularly in situations where persons live in one
> city and work in another and only one locale is affected by the
> intervention.
>
> Generally relies on passive monitoring

***Resources Required*** Communication outlets

> Enforcement

Resources for passive monitoring

> Hotlines and other communication systems to report symptoms and obtain
> follow-up instructions
>
> Transportation for persons requiring medical evaluation, with
> appropriate infection control precautions

***Partners*** News media and other communication outlets

> Law enforcement
>
> Transportation officials to enforce restrictions (e.g., closure of
> bridges, roads, or mass transit systems), plan detours, and maintain
> critical infrastructure supplies

***Forms/Templates*** Messages for affected persons

Messages for employers of affected persons

> Messages for persons supplying essential services

***Examples*** Community-wide "snow day"

Scaling back of mass transportation

Closure of bridges and tunnels

Closure of schools and work sites

## Widespread Community Quarantine, Including Cordon Sanitaire

***Definition*** Legally enforceable order that restricts movement into
or out of the area of quarantine of a large group of people or
community; designed to reduce the likelihood of transmission of SARS-CoV
among persons in and to persons outside the affected the area. When
applied to all inhabitants of an area (typically a community or
neighborhood), the intervention is referred to as *cordon sanitaire*
(sanitary barrier).

***Application*** All members of a group in which 1) extensive
transmission is occurring, 2) a significant number of cases lack
identifiable epidemiologic links at the time of evaluation, and 3)
restrictions placed on person known to have been exposed are considered
insufficient to prevent further spread. Widespread quarantine is
unlikely to be necessary because other less restrictive measures (e.g.,
snow days) may be equally effective.

***Benefits*** Reduces need for urgent evaluation of large numbers of
potential contacts to determine indications for activity restrictions

***Challenges*** Most extreme of the potential containment measures

> May be controversial because of infringement on personal liberties
>
> May be difficult to solicit cooperation for extended periods,
> particularly if the rationale is not readily apparent or was not
> clearly explained
>
> Requires excellent communication mechanisms to inform affected persons
> and to maintain public confidence in the appropriateness of the chosen
> course of action
>
> May need to provide replacements for affected activities (e.g.,
> school, essential service providers)
>
> Must address mental health and financial support for affected
> population
>
> When an entire community is involved, requires cooperation with
> neighboring jurisdictions that may not be using a similar
> intervention, particular in situations where persons live in one city
> and work in another and only one locality is affected by the
> intervention

Generally relies on passive monitoring

> Need to provide mechanisms for isolating symptomatic persons with
> minimal delay

***Resources Required*** Systems to communicate relevant messages

> Will likely require enforcement to maintain security at borders
>
> Resources for passive monitoring
>
> Transportation for persons requiring medical evaluation, with
> appropriate infection control precautions
>
> Staff and supplies to maintain access to and availability of essential
> services and goods, including food, water, medicine, medical care,
> utilities
>
> Plan to divert flow of critical infrastructure supplies and materials
> that normally transit through quarantined area

***Partners*** News media and other mass communication outlets

> Public and private groups, industries, and officials to coordinate
> supply and provision of essential services to affected area
>
> Law enforcement to maintain security at borders and to enforce
> movement restrictions
>
> Transportation industry

***Forms/Templates*** Messages for affected persons

Messages for employers of affected persons

> Messages for persons supplying essential services

***Examples*** Quarantine (*cordon sanitaire)* of a city or town

> Quarantine of occupants of a housing complex or office building

Number range CHAPTER

# Appendix D2

# Frequently Asked Questions about

# Use of Community Containment Measures

**If SARS-CoV reappears in the United States, will quarantine definitely
be required and used?**

No. Quarantine is only one of a spectrum of actions that may be
considered during a future SARS outbreak in the United States. Although
rapid control is likely to require bold and swift action, measures that
are less drastic than legally enforced quarantine may suffice, depending
on the epidemiologic characteristics of the outbreak. For example,
active monitoring without activity restrictions may be adequate when
most cases are either imported or have clear epidemiologic linkages at
the time of initial evaluation. When the epidemiology of the outbreak
indicates a need for stronger measures, jurisdictions can adopt a
voluntary quarantine approach and reserve legal measures only for those
who fail to comply. When an outbreak progresses to include large numbers
of cases for which no epidemiologic linkages can be identified,
community-level interventions may become necessary. Even at this stage,
however, measures designed to increase social distance, such as
snow-days, may be preferred alternatives. Wider use of quarantine is
generally reserved for situations in which all other control measures
are believed to be ineffective.

The choice of containment measures requires frequent and ongoing
assessment of an outbreak and evaluation of the effectiveness of
existing control measures. Officials must be prepared to make decisions
based on limited information and then modify those decisions as
additional information becomes available.

### 

### Does the effectiveness of containment measures require 100% compliance?

No. Containment measures, including quarantine, are effective even if
compliance is less than 100%. Even partial or "leaky" quarantine can
reduce transmission. Therefore, strict legal enforcement is not
necessarily always needed; in most cases, jurisdictions can rely on
voluntary cooperation. Modeling studies of the relative contributions of
quarantine and vaccination in control of smallpox outbreaks suggest a
benefit from quarantine even when compliance is as low as 50%. The
incremental benefit of quarantine approaches a maximum at a compliance
rate of approximately 90%, with little additional benefit from higher
rates of compliance. Therefore, containment measures can be important
components of the response to a communicable disease outbreak even when
compliance is not high.

**Does "quarantine" always mean using a legal order to restrict
someone's activity?**

No. The term "quarantine" is often defined narrowly to refer to the
legally mandated separation of well persons who have been exposed to a
communicable disease from those who have not been exposed. Although the
precise legal definition of quarantine may differ from jurisdiction to
jurisdiction, when used clinically or programmatically, quarantine may
be defined more broadly to include all interventions, both mandatory and
voluntary, that restrict the activities of persons exposed to a
communicable disease. Therefore, whenever an exposed person is placed
under a regimen of monitoring that includes an activity restriction,
even when those restrictions are adhered to voluntarily, the person is
said to be under quarantine.

### 

### Must quarantine be mandatory to be effective?

No. Although the federal government and nearly all states have the legal
authority to place persons exposed to certain communicable diseases
under quarantine and enforce the required restrictions on activity, use
of this authority may not always be necessary or practical. Previous
experiences with the use of quarantine, including those during the 2003
SARS outbreaks, suggest that the majority of persons comply voluntarily
with requests from health authorities to remain in quarantine and
observe the recommended activity restrictions.

During the 2003 outbreaks, at least one jurisdiction outside the U.S.
used an incremental approach to institution of quarantine. A request for
voluntary quarantine resulted in compliance by more than 90% of affected
persons. Those who did not adhere to the request were served with a
legally enforceable order. This approach has the advantage of being
perceived by the public as being less severe, since compliance with the
initial request is voluntary. In addition, in jurisdictions where
prevailing statutory quarantine authorities require separate orders for
each person placed under activity restrictions, this approach reduces
the legal workload to a more practical level.

**Does being placed in quarantine increase a person's risk for acquiring
disease?**

Historically, placement in quarantine has been associated with increased
disease transmission. One reason may be that separation between ill and
well persons was not maintained. One of the fundamental principles of
modern quarantine is that persons in quarantine are to be closely
monitored so that those who become ill are efficiently separated from
those who are well. A second principle is that persons in quarantine
should be among the very first to receive any available
disease-prevention interventions. Adherence to these two principles of
modern quarantine should prevent an increase in risk for acquiring
disease while in quarantine.

**Is quarantine really necessary if everyone who develops symptoms is
rapidly placed in isolation?**

Although theoretically true, it would be unrealistic to believe that
even the most efficient system for initiation of isolation will minimize
delays to the extent required to prevent transmission. Among the factors
contributing to delays in recognition of symptoms are the insidious
nature of disease onset and denial that symptoms have developed. Early
in the 2003 outbreak in Singapore, the average delay from onset of
symptoms to initiation of isolation was 7 days. Officials were able to
reduce this delay only to 3 days, even with an aggressive public
awareness campaign on the importance of symptom recognition and
isolation.

Quarantine helps to reduce transmission associated with delays in
isolation in two ways. First, quarantine enables health officials to
quickly locate symptomatic persons who should be placed in isolation.
Second, although quarantine locations may not be as efficient as
isolation facilities in preventing transmission, quarantine reduces the
number of persons who might be exposed while awaiting transfer to an
isolation facility. If quarantine was not used, symptomatic and
infectious persons could move about freely in public places, potentially
exposing large numbers of additional persons and thereby fueling the
outbreak.

**Is quarantine useful only for diseases in which transmission is
possible before the onset of symptoms?**

No. Although quarantine clearly has benefits for prevention of diseases
in which the period of communicability precedes onset of symptoms, a
second, often overlooked, benefit is relevant to diseases such as SARS,
in which infectiousness is likely to coincide with the onset of
symptoms. Quarantine facilitates both close monitoring and prompt
follow-up of persons who are at high risk for developing disease. Both
these factors are likely to reduce the delay in initiation of isolation
following onset of symptoms. Quarantine also limits the number of
additional persons exposed if the quarantined person develops disease.
Thus, quarantine can be a useful strategy even with diseases that are
infectious only after symptoms develop.

**Is quarantine useful only for diseases that are spread by the airborne
route?**

No. Quarantine simply refers to the separation and restriction of
activity of persons exposed to a communicable disease who are not ill.
It is designed to minimize interactions between those exposed to a
disease and those not yet exposed. As such, quarantine can be used for
any disease that is spread from person to person. In practice, however,
because the activity restrictions associated with quarantine infringe on
personal liberties, the intervention is generally reserved for diseases
that are easily and rapidly spread from person to person. The indication
for quarantine for diseases purely transmitted by the airborne route is
clear. However, this tool can also be useful where transmission can
occur through close personal contact with secretions or objects
contaminated by an ill person. Smallpox is an excellent example of a
disease where quarantine can be effective in controlling spread although
transmission may occur by means other than the airborne route.

### 

### Will the public accept the use of quarantine?

Yes. The negative connotations associated with quarantine likely stem
from its misuse or abuse in the past. Although inappropriate use of
quarantine, either voluntary or mandatory, would not and should not be
accepted by the public, efforts should be made to gain public acceptance
when use of this measure is indicated. Experiences with the use of
quarantine during the SARS outbreaks of 2003 suggest that public
acceptance of quarantine may be greater than previously thought. In
Canada, almost all persons asked to observe quarantine restrictions did
so willingly, with only a small number requiring a legal order to gain
cooperation. In all cases, cooperation and acceptance was achieved
through clear and comprehensive communication with the public about the
rationale for use of quarantine.

# Appendix D3

# Guidelines for Evaluating Homes and Facilities

# for Isolation and Quarantine

###### 

### I. Isolation Facilities

####### 

#######  **A. Home isolation**

> Ideally, persons who meet the criteria for a confirmed or probable
> case of SARS-CoV disease or a SARS RUI and who do not require
> hospitalization for medical reasons should be isolated in their homes.
> The home environment is less disruptive to the patient's routine than
> isolation in a hospital or other community setting.
>
> Any home being considered as an isolation setting should be evaluated
> by the patient's physician, health department official, or other
> appropriate person to verify its suitability. The assessment should
> center on the following minimum standards for home isolation of a SARS
> patient:

[Infrastructure]{.underline}

-   Functioning telephone

-   Electricity

-   Heat source

-   Potable water

-   Bathroom with commode and sink

-   Waste and sewage disposal (septic tank, community sewage line)

[Accommodations]{.underline}

-   Ability to provide a separate bedroom for the SARS patient

-   Accessible bathroom in the residence; if multiple bathrooms are
    available, one bathroom designated for use by the SARS patient

> [Resources for patient care and support]{.underline}

-   Primary caregiver who will remain in the residence and who is not at
    high risk for complications from SARS-CoV disease

-   Meal preparation

-   Laundry

-   Banking

-   Essential shopping

-   Social diversion (e.g., television, radio, internet access, reading
    materials)

-   Masks, tissues, hand hygiene products

#######  **B. Isolation in a community-based facility**

> When persons requiring isolation cannot be accommodated either at home
> or in a healthcare facility, a community-based facility for isolation
> will be required. The availability of a community-based facility will
> be particularly important during a large outbreak.
>
> Much of the work in identifying and evaluating potential sites for
> isolation should be conducted in advance of an outbreak as part of
> preparedness planning. Each jurisdiction should assemble a team to
> identify appropriate locations and resources for community SARS
> isolation facilities, establish procedures for activating them, and
> coordinate activities related to patient management. The team should
> consider the use of both existing and temporary structures. Options
> for existing structures include community health centers, nursing
> homes, apartments, schools, dormitories, and hotels. Options for
> temporary structures include trailers, barracks, tents, and "bubble
> systems." Considerations include the following:
>
> [Basic infrastructure requirements]{.underline}

-   Meets all local code requirements for a public facility

-   Functioning telephone system

-   Electricity

-   Heating, ventilating, and air conditioning (HVAC)

-   Potable water

-   Bathroom with commode and sink

-   Waste and sewage disposal (septic tank, community sewage line)

-   Multiple rooms for housing ill patients

[Ventilation capacity]{.underline}

-   Preferably, rooms with individual ventilation systems (e.g., room or
    window fan coil units that do not recirculate to other parts of the
    building)

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-   Alternatively, facility with a non-recirculating ventilation system
    that permits redirection of the air flow from corridors and staff
    areas into patient rooms.

> [Access considerations]{.underline}

-   Proximity to hospital

-   Parking space

-   Ease of access for delivery of food and medical and other supplies

-   Handicap accessibility

[Space requirements]{.underline}

-   Administrative offices

-   Offices/areas for clinical staff

-   Holding area for contaminated waste and laundry

-   Laundry facilities (on- or off-site)

-   Meal preparation (on- or off-site)

[Social support resources]{.underline}

-   Television and radio

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-   Reading materials

> To determine priorities among available facilities, consider these
> features:

-   Separate rooms for patients or areas amenable to isolation of
    patients with minimal construction

-   Single pass (non-recirculatiing) ventilation for each room or
    isolation area

-   Feasibility of modifying existing infrastructure as needed to meet
    AIIR standards (see Supplement I)

-   Feasibility of controlling access to the facility and to each room

-   Availability of potable water, bathroom, and shower facilities

-   Facilities for patient evaluation, treatment, and monitoring

-   Capacity for providing basic needs to patients

-   Rooms and corridors that are amenable to disinfection

-   Facilities for accommodating staff

-   Facilities for collecting, disinfecting, and disposing of infectious
    waste

-   Facilities for collecting and laundering infectious linens and
    clothing

-   Ease of access for delivery of patients and supplies

-   Legal/property considerations

> Additional considerations include:

-   Staffing and administrative support

-   Training

-   Ventilation and other engineering controls

-   Ability to support appropriate infection control measures

-   Availability of food services and supplies

-   Ability to provide an environment that supports the social and
    psychological well-being of patients

-   Security and access control

-   Ability to support appropriate medical care, including emergency
    procedures

-   Access to communication systems that allow for dependable
    communication within and outside the facility

-   Ability to adequately monitor the health status of facility staff

### II. Quarantine Facilities

A.  **Home quarantine**

> A person's residence is generally the preferred setting for
> quarantine. As with isolation, home quarantine is often least
> disruptive to a person's routine. Because persons who have been
> exposed to SARS-CoV may need to stay in quarantine for as long as 10
> days, it is important to ensure that the home environment meets the
> ongoing physical, mental, and medical needs of the individual. An
> evaluation of the home for its suitability for quarantine should be
> performed, ideally before the person is placed in quarantine. This
> evaluation may be performed on site by a health official or designee.
> However, from a practical standpoint, it may be more convenient to
> evaluate the residence through the administration of a questionnaire
> to the individual and/or the caregiver. Points to be considered in the
> evaluation include:

-   Availability of/access to educational materials about SARS and
    quarantine

-   Basic utilities (water, electricity, garbage collection, and heating
    or air-conditioning as appropriate)

-   Basic supplies (clothing, food, hand-hygiene supplies, laundry
    services)

-   Mechanism for addressing special needs (e.g., filling prescriptions)

-   Mechanism for communication, including telephone (for monitoring by
    health staff, reporting of symptoms, gaining access to support
    services, and communicating with family)

-   Accessibility to healthcare workers or ambulance personnel

-   Access to food and food preparation

-   Access to supplies such as thermometers, fever logs, phone numbers
    for reporting symptoms or accessing services, and emergency numbers
    (these can be supplied by health authorities if necessary)

-   Access to mental health and other psychological support services

B.  **Quarantine in a community-based facility**

> Although the home is generally the preferred setting for quarantine,
> alternative sites for quarantine may be necessary in certain
> situations. For example, persons who do not have a home situation
> suitable for this purpose or those who require quarantine away from
> home (e.g., during travel) will need to be housed in an alternative
> location. Because persons who have been exposed to SARS-CoV may
> require quarantine for as long as 10 days, it is important to ensure
> that the environment is conducive to meeting the ongoing physical,
> mental, and medical needs of the individual. Ideally, one or more
> community-based facilities that could be used for quarantine should be
> identified and evaluated as part of SARS preparedness planning. The
> evaluation should be performed on site by a public health official or
> designee. Additional considerations, beyond those listed above for
> home quarantine, include:

-   Separate rooms and bathrooms for each contact

-   Delivery systems for food and other needs

-   Staff to monitor contacts at least daily for fever and respiratory
    symptoms

-   Transportation for medical evaluation for person who develop
    symptoms

-   Mechanisms for communication, including telephone (for monitoring by
    health staff, reporting of symptoms, gaining access to support
    services, and communicating with family)

-   Services for removal of waste. (Note: No special precautions for
    removal of waste are required as long as persons remain
    asymptomatic)

# Appendix D4

# Threshold Determinants for the Use of Community Containment Measures

+----------------------------+-----------------------------------------+
| **Parameter**              | **Variable**                            |
+----------------------------+-----------------------------------------+
| **Epidemiologic parameters | Absolute number of cases                |
| of the outbreak**          |                                         |
+----------------------------+-----------------------------------------+
|                            | Rate of incident cases                  |
+----------------------------+-----------------------------------------+
|                            | Number of hospitalized cases            |
+----------------------------+-----------------------------------------+
|                            | Number and percent of cases with no     |
|                            | identified epidemiologic link           |
+----------------------------+-----------------------------------------+
|                            | Morbidity (including disease severity)  |
|                            | and mortality                           |
+----------------------------+-----------------------------------------+
|                            | Number of contacts under surveillance   |
|                            | and/or quarantine                       |
+----------------------------+-----------------------------------------+
|                            |                                         |
+----------------------------+-----------------------------------------+
| **Healthcare resources**   | Hospital/facility bed capacity          |
+----------------------------+-----------------------------------------+
|                            | Isolation/negative pressure room        |
|                            | capacity                                |
+----------------------------+-----------------------------------------+
|                            | Staff resources                         |
+----------------------------+-----------------------------------------+
|                            | Patient/staff ratio                     |
+----------------------------+-----------------------------------------+
|                            | Number of isolated or quarantined staff |
+----------------------------+-----------------------------------------+
|                            | Availability of specifically trained    |
|                            | specialists and ancillary staff         |
+----------------------------+-----------------------------------------+
|                            |                                         |
+----------------------------+-----------------------------------------+
| **Equipment and supplies** | Availability of ventilators             |
+----------------------------+-----------------------------------------+
|                            | Availability of other respiratory       |
|                            | equipment                               |
+----------------------------+-----------------------------------------+
|                            | Availability of personal protective     |
|                            | equipment and other measures            |
+----------------------------+-----------------------------------------+
|                            | Availability of therapeutic medications |
|                            | (SARS and non-SARS specific)            |
+----------------------------+-----------------------------------------+
|                            |                                         |
+----------------------------+-----------------------------------------+
| **Public health            | Investigator to case and contact ratios |
| resources**                |                                         |
+----------------------------+-----------------------------------------+
|                            | Number of contacts under active         |
|                            | surveillance                            |
+----------------------------+-----------------------------------------+
|                            | Number of contacts under quarantine     |
+----------------------------+-----------------------------------------+
|                            | Ability to rapidly trace contacts       |
|                            | (number of untraced/interviewed         |
|                            | contacts)                               |
+----------------------------+-----------------------------------------+
|                            | Ability to implement and monitor        |
|                            | quarantine                              |
|                            |                                         |
|                            | (staff to contact ratio)                |
+----------------------------+-----------------------------------------+
|                            | Ability to provide essential services   |
|                            | (food, water, etc.)                     |
+----------------------------+-----------------------------------------+
|                            |                                         |
+----------------------------+-----------------------------------------+
| **Community cooperation,   | Degree of compliance with voluntary     |
| mobility and compliance**  | individual isolation                    |
+----------------------------+-----------------------------------------+
|                            | Degree of compliance with active        |
|                            | surveillance and voluntary individual   |
|                            | quarantine                              |
+----------------------------+-----------------------------------------+
|                            | Degree of movement out of the community |
+----------------------------+-----------------------------------------+
|                            | Degree of compliance with               |
|                            | community-containment measures          |
+----------------------------+-----------------------------------------+

#  Appendix D5

# Preparedness Checklist for Community Containment Measures

### [Number range CHAPTER]{.smallcaps}

## General

-   Establish an incident command structure that can be used for SARS
    response.

    -   Establish a legal preparedness plan

    -   Establish relationships with partners, such as law enforcement,
        first responders, healthcare facilities, and the legal
        community.

    -   Plan to monitor and assess factors that will determine the types
        and levels of response, including the epidemiologic profile of
        the outbreak, available local resources, and level of public
        acceptance and participation.

    -   Develop communication strategies for the public, government
        decision makers, healthcare and emergency response providers,
        and the law enforcement community.

## Management of cases and contacts (including quarantine)

-   Develop protocols, tools, and databases for:

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```
-   Case surveillance

-   Clinical evaluation and management

-   Contact tracing, monitoring, and management

-   Reporting criteria

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-   Develop standards and tools for home and non-hospital isolation and
    quarantine

-   Establish supplies for non-hospital management of cases and contacts

-   Establish a telecommunications plan for "hotlines" or other services
    for:

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-   Case and contact monitoring and response

-   Fever triage

-   Public information

-   Provider information

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```
-   Plan to ensure provision of essential services and supplies to
    persons in isolation and quarantine, including:

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```
-   Food and water

-   Shelter

-   Medicines and medical consultations

-   Mental health and psychological support services

-   Other supportive services (e.g., day care).

-   Transportation to medical treatment, if required

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-   Plan to address issues of financial support, job security, and
    prevention of stigmatization

## Non-hospital-based isolation of cases

-   Identify appropriate community-based facilities for isolation of
    patients who have no substantial healthcare requirements.

-   Develop policies related to use of these facilities.

-   Identify facilities for persons for whom home isolation is indicated
    but who do not have access to an appropriate home setting, such as
    travelers and homeless populations.

-   Ensure that required procedures for assessment of potential
    isolation or quarantine sites are available and up to date.

## Community containment measures

-   Ensure that legal authorities and procedures are in place to
    implement the various levels of movement restrictions as necessary.

-   Identify key partners and personnel for the implementation of
    movement restrictions, including quarantine, and the provision of
    essential services and supplies:

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```
-   Law enforcement

-   First responders

-   Other government service workers

-   Utilities

-   Transportation industry

-   Local businesses

-   Schools and school boards

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-   Develop training programs and drills

-   Ensure fit-testing and training in PPE for responders and providers
    as necessary

-   Develop plans for the mobilization and deployment of public health
    and other community service personnel

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)

[^1]: Close contact: A person who has cared for or lived with a person
    with SARS-CoV disease or had a high likelihood of direct contact
    with respiratory secretions and/or body fluids of a person with
    SARS-CoV disease. Examples of close contact include kissing or
    hugging, sharing eating or drinking utensils, talking within 3 feet,
    and direct touching. Close contact does not include activities such
    as walking by a person or briefly sitting across a waiting room or
    office.

[^2]: Close contact: A person who has cared for or lived with a person
    with SARS-CoV disease or had a high likelihood of direct contact
    with respiratory secretions and/or body fluids of a person with
    SARS-CoV disease. Examples of close contact include kissing or
    hugging, sharing eating or drinking utensils, talking within 3 feet,
    and direct touching. Close contact does not include activities such
    as walking by a person or briefly sitting across a waiting room or
    office.