Isolation and Quarantining
Isolation and Quarantining
Isolating mild or asymptomatic cases at home with professional guidance and supervision can be safer, cheaper, and more acceptable to the public than institutional isolation
Some countries (e.g. China, Vietnam) required COVID-19 positive patients–including mild cases–to be isolated in institutional facilities rather than at home. This was seen as vital for preventing spread of the disease and improving patient care, a view shared by the Indian central government. However, the city government of Delhi (population 20 million) argued for, and got permission to, isolate patients with mild or asymptomatic cases in their own homes with medical monitoring and supervision. As a result, Delhi's limited hospital capacity was saved for more serious cases, patients were happier staying at home with family and eating home-cooked meals, and the public became more willing to be tested and treated, because fears of being whisked away by the authorities abated. Home isolation also reduces the risk of hospital infections. Apparently, home isolation did not lead to a spike in within-family or community infections in Delhi. BBC reports that the Delhi strategy seems to be working.
Delhi's home isolation strategy works as follows. Anyone testing positive is assessed by medical workers to determine if patients are eligible for home isolation, based on the severity of symptoms, comorbidities, and whether the patient's home is fit for isolation. Patients are allowed to isolate in designated hotels if they are willing to pay a discounted rate out of pocket. Every test is linked to the patient's ID and tracked thereafter using a nationally available app called Aarogya Setu. Those in home-isolation communicate with medical personnel two or three times a day through the app and phone calls. Medicines are delivered at home by volunteer teams. Patients are instructed to monitor their own symptoms, temperature, and oxygen level using an oximeter provided by the government; this information is then shared with their doctor. If a patient reports low oxygen levels and hospital beds are not available nearby, portable oxygen concentrator machines are transferred to the patient's doorstep and trained medical personnel instruct patients on their use. More than 250 oxygen machines are stored at local government dispensaries for this purpose. Instructional videos and SOPs have been developed by the Delhi government to provide detailed guidance on home isolation, for patients, caregivers, and even neighbors. After 14 days of home isolation, the patient is duly examined and may be discharged. Given the scientific knowledge that the virus becomes non-replicable and therefore non-infective after the 9th day from onset of the illness, discharged patients do not undergo additional testing, which conserves RT-PCR test kits for new suspected cases. If a patient's condition worsens, he or she is then taken by ambulance to a designated COVID-19 facility. To do this speedily, ambulance capacity was quickly augmented. To educate and reassure the public, the government created a website, https://delhifightscorona.in/ with data on key metrics, including how many beds and ventilators were open in each hospital in the city.
According to Dr. Nimmi Rastogi, coordinator of the Delhi government's health task force, the Delhi model of home isolation has made people less fearful of getting tested, built confidence and trust in the government, and mobilized civil society in the fight against the disease. When a person gets infected, home isolation helps educate the whole family about how to handle COVID-19. And the serious shortage of hospital beds anticipated in May or June 2020 turned into a large surplus by August 2020. Delhi's COVID-19 strategy leveraged the government's earlier investments in primary health centers (mohallas) where citizens got free consultation and medicines, and earlier initiatives against infectious diseases such as dengue. Another reason for the government's success appears to be its flexibility and willingness to make mid-course corrections. Delhi's home-isolation is being emulated by other parts of India.
Hospitals in Bogota, Columbia have developed a comprehensive geriatric assessment program to systematically screen older patients to determine whether they are eligible for home-based isolation. According to John Fredy Barrero Romero, a university researcher studying the impact of these geriatric strategies, the program was created to alleviate hospital capacity given Colombia's low hospital beds per capita (1.5 per 1,000 people). To decide if hospital or home care is appropriate, patients 65 years or older with a COVID-19 diagnosis are interviewed by a doctor to assess their degree of functionality on three geriatric scales: the Barthel index of patient functionality in daily living; the Lawton index of patient functionality in instrumental activities; and Mini-Mental examination to detect cognitive impairment. The national government has also issued a policy on managing elderly COVID-19 patients.
Home isolation has also been employed in the United States, with differing levels of monitoring by health personnel, even for patients requiring oxygen or other special equipment at home. If a patient's condition worsens, he or she can be rushed by ambulance to a hospital. The CDC has published interim guidance for at-home care of patients.
Potential Contacts: Dr. Nimmi Rastogi, Coordinator, Health Task Force, Dialogue & Development Commission, Chief Minister's Office, Govt. of NCT of Delhi; John Fredy Barrero Romero, Director of Health Administration Program at Unipanamericana
Nearly One in Four in Delhi Had Covid-19 – Study, BBC, July 21, 2020
Delhi Has Modified COVID Strategies. For the Future, a Public Health Cadre Must Be Created as a Priority, The Indian Express, July 17, 2020
Home Isolation Guidelines for Corona Patients, Delhi Government (Youtube), May 30, 2020 [Official government guidance video, 14 min]
Delhi's New SOPs For Coronavirus Testing, Home Quarantine, NDTV, June 23, 2020 [With short video]
Hospital Beds (Per 1,000 People) – Colombia, The World Bank 
A COVID-19 Lesson: Some Seriously Ill Patients Can be Treated at Home, The New York Times, July 22, 2020
Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19), Centers for Disease Control and Prevention, Updated June 28, 2020
An Expert Explains: The Best Practices for Home Quarantine of COVID-19 Patients, The Indian Express, June 19, 2020
Strict Isolation and Quarantining
Isolation refers to the removal of COVID-19 positive patients from the general population, and quarantine refers to the separation of potentially infected people from the public
There are at least three dimensions to the strictness of isolation and quarantining. First, a country can be quick or slow, and thorough or spotty, in identifying people who need to be isolated or quarantined, depending on the quality of public health information and the thoroughness of contact tracing. Second, quarantining and isolation can be voluntary/recommended activities or they can be mandatory as in Hong Kong, and they can be done at home, in governmental facilities, or government-supervised hotels, etc. Quarantining at home may involve digital enforcement. In either case, with strict quarantining, as in Vietnam, a case worker is likely to contact the person one or more times a day for up to two weeks. (A related issue is whether institutional quarantining is free, as in Vietnam, or has to be paid for, as in Rwanda.) Third, contact tracing can look at an infected person's direct contacts, or extend this further to second-level contacts, i.e. contacts of contacts, and those people can also be required to self-quarantine at home (again, with government monitoring).
Vietnam likely had one of the strictest isolation and quarantining programs. Vietnam had a national system to track the public's health, and contacts were traced exhaustively and quickly, apparently aided by the public's trust in the authorities. (The Communist party's deeply penetrating network may have facilitated supervision and compliance.) Isolation and quarantining were mandatory (and free) and had to be done in government facilities, not at home. And Vietnam is the only country known to require the contacts of contacts to self-quarantine at home (with government monitoring).
China imposed a lockdown on the widest scale in recorded history in Wuhan in Hubei province, keeping a population of 11 million people locked at home. A QR code system emerged later to classify people into one of three categories based on whether they were required to isolate (red), quarantine (yellow), or free to move about (green). Recently, a resurgence of cases in Beijing and Jilin province has provoked similar strict quarantines.
Singapore's “circuit breaker” lockdown strategy shows that even as restrictions are gradually lifted, the government can enforce strict isolation for a segment of the population or a region, such as the thousands of migrant workers that make up the country's working class. While the country has been hailed for its response to the pandemic, a flare-up among migrant workers living in very close quarters accounted for the vast majority of new COVID-19 cases.
In India, the Bilwhara model was implemented to contain the spread of the disease in India's most significantly impacted region. The strategy imposed strict lockdowns on the region and drastically reduced movement while resulting in a drop in cases. The model was lauded by Narendra Modi, India's prime minister, for its efficacy.
In Hong Kong, South Korea and Taiwan, home quarantine through E-Fencing is enforced by various technologically-mediated methods. Hong Kong's StayHomeSafe app and wristband enforce quarantine by monitoring users' movements and location. South Korea requires new arrivals to quarantine for 14-days either at home or at government-provided hotel sites.
Post employee describes spending a week inside a Hong Kong government quarantine centre, South China Morning Post, April 4, 2020 (Video, describing in detail a person's experience in quarantine)
Coronavirus Quarantine In Vietnam Documented By Photography Student : The Picture Show, National Public Radio, April 6, 2020.
7-day mandatory quarantine for new arrivals, The New Times, May 23, 2020
Containing the coronavirus (COVID-19): Lessons from Vietnam, World Bank Blogs, April 30, 2020.
Scale of China's Wuhan Shutdown Is Believed to Be Without Precedent, The New York Times, January 22, 2020
Beijing's Partial Lockdown a Sign of the World's New Normal, The New York Times, June 17, 2020
After New Coronavirus Outbreaks, China Imposes Wuhan-Style Lockdown, The New York Times, May 21, 2020
What You Can and Cannot Do During the Circuit Breaker Period, Singapore Government, April 11, 2020
Post-Circuit Breaker – When Can We Move On to Phases 2 and 3?, Singapore Government, May 28, 2020
Singapore Is Trying to Forget Migrant Workers Are People, Foreign Policy, May 6, 2020
Why Singapore, Once a Model for Coronavirus Response, Lost Control of Its Outbreak, Time, April 20, 2020
From Worst To A Role Model, How Bhilwara Turned The Corner In War Against Coronavirus, Outlook India, April 20, 2020
Hong Kong Uses Tracking Wristbands for Coronavirus Quarantine, Quartz, March 20, 2020
How's Your Quarantine? If No One's Banging Gongs, Count Your Blessings, The New York Times, July 4, 2020
Repurposing Public Venues for Mild Cases
Medical capacity can be augmented by converting public venues into quarantine centers for mild cases
As the epicenter of the virus, China swiftly developed the first temporary facilities to treat COVID-19 patients. Given the high transmission of the virus within households, it became critical to isolate patients outside of their homes in designated facilities. Milder cases were quarantined in novel “Fangcang” hospitals: temporary, rapidly-built, and low-cost facilities that were repurposed from public venues. A total of 14 Fangcang hospitals were created by February 2020, receiving nearly a quarter of all patients from Wuhan. The makeshift hospitals provided essential living, with meals and treatment free of charge, and community support through social engagement. Coordination with other hospitals allowed for rapid referral of severe cases.
India has also been recognized for significant development of temporary facilities, moving to repurpose stadiums, places of worship, hotels, and trains into isolation and treatment centers. The world's largest quarantine facility was opened in the capital of New Delhi in early July, contributing 10,000 additional beds. Set up in a repurposed spiritual center, the massive facility provides basic medical care for milder cases and refers severe cases to local hospitals.
Temporary field hospitals, testing sites, or isolation centers have been established in an exhibition center in Singapore, or in sports stadiums in the U.S. This website has pictures of public venues repurposed for COVID-19 care in several countries, including Argentina, Brazil, China, and the Gaza Strip.
Fangcang Shelter Hospitals: A Novel Concept For Responding to Public Health Emergencies, The Lancet, April 2, 2020
Makeshift Hospitals Useful Abroad, China Daily, April 8, 2020
Some Indian States Are Turning Stadiums Into Quarantine Centres, Vice, March 27, 2020
Sikh Body Offers to Run COVID Care Facilities in Delhi Gudwwaras, The Times of India, June 16, 2020
Delhi to Transform 25 Luxury Hotels Into COVID-19 Care Centres, The Guardian, June 21, 2020
India's Idle Trains May Soon Become Isolation Wards For COVID-19 Patients, Quartz, March 29, 2020
India Is Planning to Build the ‘World's Largest' Quarantine Facility, Vice, June 17, 2020
India: New Delhi Spiritual Centre Converted Into World's Largest COVID-19 Hospital, Ruptly, June 25, 2020 [Short video]
First Batch of COVID-19 Patients Transferred to Singapore Expo, The Straits Times, April 10, 2020
The World's Sports Stadiums Are Being Converted Into Hospitals to Fight the Coronavirus Outbreak, Time, April 1, 2020Photos of Field Hospitals Set Up Around the World to Treat Coronavirus Patients, CNBC, April 3, 2020
E-fences are digital quarantine tools that allow governments to confirm that quarantined citizens are staying within the boundaries of their homes using GPS tracking and cell phone apps
Electronic fences, or E-fences, are used in Taiwan, Hong Kong, and other countries, to quarantine arriving travelers by monitoring their cell phone signal. Police are alerted if the signal is disrupted or the person leaves their home. To deter people from leaving their phones at home and going out, police use an advanced integrated database to search popular locations for quarantine jumpers.
In Hong Kong, instead of tracking via cell signal, recent travelers are given a wristband and instructed to download an app, StayHomeSafe. Upon pairing the wristband to the app, the person can then map out their apartment to create the “geofence” that confines them to their 14-day quarantine space. The quarantine is compulsory; authorities will check on residents and fines are levied against rule breakers. The wristband technology was developed by a Hong Kong-based research group, Logistics and Supply Chain Multitech R&D Cente.
Potential Contacts: Logistics and Supply Chain Multitech R&D Center
Taiwan Phone Tracking System Monitors 55,000 Under Coronavirus Quarantine, Quartz, April 1, 2020
Tech Approach to Home Quarantine, Government of Hong Kong News, March 16, 2020
Taiwan's New ‘Electronic Fence' for Quarantines Leads Wave of Virus Monitoring, Reuters, March 20, 2020,
The Digital Fence: Taiwan's Response to COVID-19, Simmons Institute, April 6, 2020 [Video]
Hong Kong Uses Tracking Wristbands for Coronavirus Quarantine, Quartz, March 20, 2020