# Presentation: 416481

## Modern Isolation and Quarantine 

**Modern Isolation and Quarantine **
**Infection Control Issues**

**Ruth Lynfield, M.D. **
**Kathy LeDell, M.P.H., R.N.**
**Minnesota Department of Health**

## Isolation and Quarantine, continued

- Isolation: separation/restriction of movement of persons who are ill to prevent transmission of disease
- Quarantine: separation/restriction of movement of persons who are not ill but who have been exposed to infection to prevent transmission of disease

## Isolation and Quarantine History

- Leprosy
- Bible: Isolation for persons with leprosy
- Emperor Justinian, Rome
- 532 AD: Persons arriving into Constantinople from “contaminated localities” be placed in special housing facilities
- Plague
- 14th-15th centuries: Venice imposed 40-day harbor detention or quarantine (quarantina or quaranta)
- Land quarantine (lazaret) incorporating isolation station for individuals arriving in Venice from plague-infected areas
- 1647: Massachusetts Bay Colony restricted ships from West Indies due to plague

## Isolation and Quarantine History (cont.)

- NYC: 1880s
- Inspection of ships, passengers                         and cargo for contagion
- Persons with quarantinable disease (cholera, yellow fever, plague, leprosy, smallpox) admitted to isolation hospital Staten Island, quarantine station

- Persons with other infectious diseases sent to      Marine Hospital, Ellis Island

## Historical Example of Mandatory Isolation

- 1907- Mary Mallon (Typhoid Mary) involuntarily admitted to NYC Detention Hospital and held for three years
- Released on condition that she not work with food
- Accepted a job as a hospital cook and infected dozens with typhoid
- Re-admitted involuntarily for isolation (life-long)

## Smallpox Hospital, Roseville Minnesota

## When are Isolation and Quarantine Indicated?

- A person or group of people has been exposed to a highly dangerous and contagious disease
- Exposed “well” can be separated from “ill cases”
- Resources are available to implement and support interventions
- Ensure essential needs
- Monitor health status
- Provide medical care
- Implement isolation of those who become ill
- Quarantine should continue only as long as necessary to ensure that quarantined persons do not become ill (use incubation period of disease to guide)

## Community Containment 

- 	CDC term for community-level measures to control transmission of disease:
- Isolation and quarantine
- “Snow days”
- Restrictions on group assembly
- Cancellation of public events, closure of public places
- Closure of mass public transit
- Restriction or scaling back of non-essential travel
- Cordon sanitaire (sanitary or quarantine line)

## Community Containment (cont.)

- Other interventions used in combination with measures:
- Primary and secondary preventive interventions, including vaccination or prophylactic antibiotics, personal protective equipment (masks, gloves, etc.)
- Enhanced disease surveillance and symptom monitoring
- Rapid diagnosis and treatment for those who become ill

## Community Containment (cont.)

- More likely to be applied to small numbers of exposed persons in focused settings
- Exposed persons on conveyance containing ill passenger(s)
- Close contact with a case
- Exposed persons in an auditorium where an intentional release has been announced

## Potential Agents of Bioterrorism with   Person-to-Person Transmission

- Smallpox
- Isolate cases
- Contacts vaccinated and on fever watch for 18 days after last exposure or 14 days following successful vaccination (if >101°F x 2 readings then isolate)
- Pneumonic Plague
- Isolate cases x 72 hours after initiation of antibiotics and clinically improved
- Contacts < 3 feet of plague patient should receive chemoprophylaxis
- Viral Hemorrhagic Fever
- Isolate cases for duration of illness
- Fever and symptom watch x 21 days for persons exposed to blood, secretions, or excretions from an infected person

## “Quarantinable Diseases”

**	**Executive Order 13295: Revised list of quarantinable communicable diseases (April 4, 2003):
- Cholera
- Diphtheria
- Infectious tuberculosis
- Plague
- SARS
- Smallpox
- Yellow fever
- Viral hemorrhagic fever (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named)

- Section 361(b) of the Public Health Service Act , Title 42 U.S.Code Section 264(b)

## Implementation of Community Containment

- Understanding of public health roles at local, state, and federal levels
- Cooperation between public and private healthcare sectors
- Well-understood legal authority at each level
- Coordination among emergency responders, public safety, transportation authorities, legal community, public health, and healthcare providers

## Implementation of Community Containment (cont.)

- Inform public of the dangers of “quarantinable”  infectious diseases before an epidemic/outbreak occurs
- Inform public of the justifications for quarantine when an outbreak is in progress
- Inform public of anticipated duration and endpoints of control measures
- Assistance from the media

##   SARS 

**  ****SARS **
**(Severe Acute Respiratory Syndrome)**

## SARS Cases Reported to WHO in 2003

- -**	**China:  5,327
- -	Hong Kong:  1,755
- -	Singapore:  238
- -	US:  19
- -	Vietnam:  63

- 8,098 cases including 774 deaths
- (21% of overall cases were in HCWs)

- -**	**Canada:  251
- -	Taiwan:  346
- -	Germany: 9
- -  Philippines: 14
- -	Thailand:  9

## Dr. Carlo Urbani

** ****	**President of Italian Chapter of 	Doctors without Borders and an 	ID specialist sent by WHO to 	Hanoi to investigate cases of 	atypical pneumonia
-  	Dr. Urbani first to identify SARS
-  	Dr. Urbani died of SARS on 	March 29, 2003

## SARS Coronavirus (CoV) 

- Found in respiratory secretions, saliva, blood, urine and stool of infected patients
- Virus may be stable at room temperature for 48 hours and longer at lower temperatures
- Virus loses infectivity after exposure to commonly used disinfectants or heat (56°C for 15 minutes)
- Some patients may be highly infectious (“super-shedder”), particularly when critically ill
- No evidence of transmission prior to fever but may be transmission during prodromal period (period of early symptoms prior to the development of a full blown respiratory illness)
- Period of communicability is up to 10 days following resolution of fever

## CDC SARS Case Definition (Spring 2003)

- Clinical Criteria:
- Temperature of >100.4o F (>38o C) *and *
- One or more clinical findings of lower respiratory illness (e.g., cough, shortness of breath, difficulty breathing)
- Epidemiologic Criteria:
- One or more of the following exposures in the 10 days before onset of symptoms:
- Travel to a foreign or domestic location with documented or suspected recent transmission of SARS-CoV *or*
- Close contact with a person with mild-to-moderate or severe respiratory illness and with history of** **travel in the 10 days before onset of symptoms to a foreign or domestic location with documented or suspected recent transmission of SARS-CoV
*** ***

## CDC Definition of a Close Contact

- Having cared for or lived with a person with SARS
- Having a high likelihood of direct contact with respiratory secretions and/or body fluids of a person with SARS
- Examples of close contact include kissing, sharing eating utensils, close (i.e.,< 3 feet) conversation, physical examination
- Close contact does not include walking by a person or sitting across a room for a brief time

## Efforts to Contain Spread

- In areas with SARS community spread:
- Home quarantine
- Hospital closures
- School closures
- Internationally:
- Health alert notices
- Travel advisories
- Screening airline passengers

**Notes:**
[Slide 14] Several measures have been taken locally and internationally to contain the spread of SARS.  

In several countries, exposed individuals have been asked to stay at home and monitor symptoms.  Hospitals have been closed or limited to SARS patients.  In Singapore and Hong Kong, schools have been closed due to public fears about possible spread among school children.

The WHO and the CDC have issued travel advisories and distributed health alert notices to travelers to and from affected areas.  In the U.S. alone, 200,000 alerts have been distributed as of March 31st.  The CDC has coordinated the translation of travel advisories into Vietnamese, Chinese, Korean and Japanese, and we are close to distributing 20,000 alerts daily at 23 points of entry.

In some destinations, airline personnel are screening passengers for symptoms of respiratory illness to prevent possible on-board transmission.  

Effective quarantine is difficult when dealing with a new agent that appears highly infectious but for which the routes of transmission are still under investigation.

## Isolation and Quarantine for SARS

** **
- Isolation of cases until 10 days after resolution of fever and improvement of respiratory symptoms
- Promptly identify, evaluate and monitor close contacts of SARS cases
- If no community transmission is occurring, passive or active monitoring of close contacts for evidence of infection (and the need for isolation) may be conducted
- If community transmission is occurring, quarantine may be recommended to prevent spread of disease from close contacts

## SARS in Ontario, Canada

- 250 probable cases and 40 deaths (including three HCW deaths)
- Provincial state of emergency declared on March 26 and lifted May 17, 2003
- Two SARS clusters related to healthcare facilities
- Five hospitals were closed to new admissions; elective surgery cancelled at all other hospitals
- Hospital visitor restrictions
- Voluntary quarantine of contacts (23,000) of cases

## SARS Cases Among Quarantined Personsin Taiwan

- 671 suspect or probable SARS cases
- 131,132 persons quarantined
- 50,319 close contacts, 80,813 travelers
- Overall suspect or probable cases:	0.09%
- Family members	  		0.33%
- HCWs			 		0.34%
- Travel			 		0.03%

**MMWR 2003, 52: 680-83**

## Home Isolation for SARS

- Before implementing home isolation, ensure that the necessary features for provision of care and infection control precautions are met
- Availability of caregiver to assist patient with basic needs
- Access to telephone, electricity, heat, and potable water
- Access to groceries, medications, and other needs
- If multi-family dwelling, separate air handling system (if possible)
- Ideally, separate bedroom and bathroom for the patient** **

## Home Isolation for SARS (cont.)

- Patients should not leave home for the duration of the isolation period, except for necessary medical care
- When movement outside of the home is required, the patient should wear a surgical mask and not use public transportation
- Other persons in the household should be limited to those who are essential for patient support
- Household members who cannot comply with infection control precautions (e.g., young children) should be housed elsewhere
- Household members at risk of serious SARS complications (e.g., persons with heart or lung disease, elderly, etc.) should be housed elsewhere
- The patient should be separated from other persons in household to the extent possible and contact with patient should be minimized

## Follow-up of Exposed Household Members for SARS

- Household members and other close contacts should be vigilant for fever and should measure temperature twice a day
- If fever, respiratory or other symptoms develop such contacts should be medically evaluated
- In absence of symptoms, household members and other close contacts typically need not limit their activities outside the home
- However, under some circumstances the health department may recommend limiting the activities of exposed, asymptomatic household members and other close contacts