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

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).

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)