Reviewing quarantine, isolation, and why these are still important
CLINICAL MATTERS
After a very quiet few months following the Omicron wave in January, cases are once again on the rise. Many of us were expecting thousands of cases shortly after elections but this never materialized. Indeed, WHO projected up to 300,000 active Covid-19 cases by the end of May but the actual number was 2,415. Unfortunately, good things don’t last forever. Due to a combination of factors, cases are rising anew. Among the reasons for the increase in cases are the entry of the new Omicron sublineages BA.4, BA.5, and BA.2.12.1, increased mobility, and decreased adherence to public health standards.
Thankfully, almost all new cases are mild and do not need hospitalization. This is a direct result of widespread vaccination and boosting. Even mild Covid-19 cases remain contagious, however, so isolation and quarantine protocols are still important. Some of these protocols have changed over time. One major change this year is that fully vaccinated individuals with close contact with confirmed cases no longer need to physically quarantine.
These updated, less stringent protocols assume that the compliance to public health standards remain high, especially the use of masks, which are needed more than ever with the entry of immunity-evading Omicron sublineages. While our vaccines continue to protect against severe disease, they have become less effective in preventing infection and transmission. Boosting is important and essential in maximizing protection against severe disease. With BA.5 spreading globally, many countries are thinking of re-enforcing mask mandates both outdoors and indoors. Continuing to use masks at least until updated vaccines with better transmission blocking efficacy arrive is still the best way to decrease overall transmission.
It has been a while since cases were this high and so a review of the latest protocols may be helpful.
Quarantine is the protocol to follow if someone is asymptomatic but was a close contact of a Covid-19 case while wearing no or inadequate PPE. It doesn’t automatically mean the exposed person will develop Covid-19.
Isolation is the protocol to follow if someone develops Covid-19 symptoms (whether confirmed or still for confirmation). It also applies to RT-PCR or antigen positive Covid-19 patients, who remain asymptomatic throughout their infection.
Quarantine protocols differ depending on vaccination status. Isolation protocols differ depending on vaccination status and disease severity. The IATF resolution from June 2022 on length of quarantine and isolation is shown in the figure. Healthcare worker protocols can be modified at the discretion of infection control committees.
An appropriate quarantine room is a single room with good ventilation and an attached toilet and bath. The person being quarantined should not leave the room, except for emergencies. If it is unavoidable for the person to step outside during the quarantine period, he should wear a well-fitting mask and spend as little time as possible outside the room. If the person is unable to take care of himself, a companion (preferably fully vaccinated and boosted and not in the high risk category) wearing appropriate PPE should accompany him for the duration of the quarantine. Cohorting for quarantine (more than one exposed person in one room) is discouraged since not all exposed persons will develop Covid-19.
An appropriate isolation room is a room with good ventilation and an attached toilet and bath. The person being isolated should not leave the room except for emergencies. If it is unavoidable for the person to step outside during the isolation period, he should wear a well-fitting mask and spend as little time as possible outside the room. If the person is unable to take care of himself, a companion (preferably fully vaccinated and boosted and not in the high risk category) wearing appropriate PPE should accompany him for the duration of the isolation. Cohorting is allowed especially if within the same household since all subjects have already tested positive and cannot infect each other in the short term.
Fully vaccinated means at least 14 days from second dose (or first dose of Janssen). There are no specific quarantine or isolation guidelines for those who have been boosted at this time, but these may change in the future. No testing is needed to discontinue isolation, except for the severely immunocompromised. A negative test cannot be used to shorten the minimum required isolation days since tests are imperfect and cannot completely rule out the risk of transmission.
QUARANTINE
- Fully vaccinated—there is no need to quarantine but do intensive self-monitoring for the next 14 days and wear a mask (even at home especially if living with high-risk individuals) as much as possible during this time. If you develop symptoms, start isolation backto day one, regardless of testing results.
- Unvaccinated/Partially vaccinated - quarantine for at least 14 days (long incubation period of Covid-19). If you develop symptoms, start isolation backto day one regardless of testing results.
ISOLATION
Asymptomatic Confirmed Case
- Fully Vaccinated—isolate at least seven days from positive result. If symptoms develop during the isolation period, start day one again from the first day of symptoms and isolate depending on severity as written below.
- Unvaccinated—at least 10 days from positive result. If symptoms develop during the isolation period, start day one again on the first day of symptoms and isolate depending on severity as written below.
Symptomatic Confirmed Case
- Fully vaccinated Mild (no pneumonia, no risk factors)—at least seven days from start of symptoms. Can stop isolation on the seventh day as long as no longer febrile for at least 24 hours and symptoms are improving.
- Unvaccinated or Partially vaccinated Mild (no pneumonia, no risk factors)—at least 10 days from start of symptoms. Can stop isolation on the 10th day as long as no longer febrile for at least 24 hours and symptoms are improving.
- Moderate regardless of vaccination status (with pneumonia but not oxygen requiring; also refers to elderly/comorbids even if with just mild symptoms)—at least 10 days from start of symptoms. Can stop isolation on the 10th day as long as no longer febrile for at least 24 hours and symptoms are improving.
- Severe or Critical regardless of vaccination status—at least 21 days from start of symptoms. Can stop isolation on the 21st day as long as no longer febrile for at least 24 hours and symptoms are improving.
- Severely immunocompromised—at least 21 days from start of symptoms. Will need negative RT-PCR testing to stop isolation on the 21st day as long as no longer febrile for at least 24 hours and symptoms are improving.
These guidelines continue to evolve over time and may be updated to take into consideration the effect of boosters. Most antigen positives will not need confirmation with an RT-PCR unless required for treatment, genotyping surveillance, or for insurance purposes. When in doubt, always talk to your doctor for guidance.