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Follow-up of close contacts, quarantine and home isolation- advice for healthcare personnel

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Description of what is meant by quarantine and home isolation, and advice on these measures.

Description of what is meant by quarantine and home isolation, and advice on these measures.


Follow-up of close contacts, isolation and quarantine are measures to prevent transmission of the virus that causes COVID-19. Isolation and quarantine should be carried out in the most appropriate place, preferably at home. When the measures are introduced elsewhere than at home, the same principles apply.

Home isolation

Home isolation applies to people with confirmed or probable COVID-19 but who do not need to be isolated in hospital.

More information about what home isolation entails, with advice for the patient:

Home isolation is only appropriate if the living conditions are acceptable with regards to infection control and clinical follow-up. For each patient, the healthcare service should make a plan to ensure that: 

  • the patient gets any necessary practical assistance
  • any deterioration in health is detected
  • the patient can comply with the measures

In the majority of cases, and always for patients in risk groups, strive to maintain daily contact. Telephone/digital contact or home visits are appropriate. The patient should be told who to contact if their condition deteriorates.

Healthcare personnel who shall enter the home of, or treat, patients isolated at home or their household members, must follow recommended infection control measures, including the use of personal protective equipment. See the advice given for the different healthcare sectors.

Follow-up of close contacts

All close contacts shall be followed up for 10 days after the last exposure. There is a distinction between "household members of equivalent close contacts" who will be in quarantine and other "close contacts" who can be followed up with testing and self-monitoring. 

Examples of equivalent close contacts as someone in a household are partners, nearest colleague in an open-plan office, same cohort in childcare centre or school up to and including 4th grade, or someone who has cared for a sick person without using the recommended protective equipment. The person responsible for contact tracing will decide which category each close contact belongs to after an assessment of the risk of infection.

Home quarantine does not apply for people who have had confirmed COVID-19, documented by an approved laboratory method (RT-PCR for SARS-CoV-2) during the last six months. Currently, antibody testing does not give exemption from quarantine.

Quarantine

Regulations relating to infection control measures etc. in connection with the coronavirus outbreak (COVID-19 Regulations) imposes quarantine for:

  • household members or equivalent close contacts of confirmed cases of COVID-19, or
  • anyone who has cared for the confirmed patient or has had similar close contact without the correct protective equipment
  • anyone arriving in Norway from abroad, with some exceptions

In addition, quarantine is recommended for:

  • household members or equivalent close contacts of people with "probable COVID-19" (where testing can not be carried out).

Quarantine measures

More information about what quarantine entails:

In each case it should be considered whether closer follow-up by the healthcare service is necessary during the quarantine period.

Healthcare professionals who need to enter the home or treat people in home quarantine should follow basic infection control measures including the use of personal protective equipment. See the advice given for the different healthcare services.

Duration of quarantine

  • For close contacts, quarantine lasts for 10 days after the last exposure, in the period of 48 hours before symptom onset until isolation ends.
  • If the patient who is sick has no symptoms, calculate the quarantine duration from the test date.
  • For household members with continued contact with a person with confirmed or probable COVID-19, quarantine lasts for 10 days after they are free of symptoms.

The figure below shows examples of the duration of home isolation and quarantine in households. Click on the figure to enlarge it.

26.06.2020 figur varighet karantene isolering Engelsk.JPG

Exemption from duty of quarantine

Have had the disease 

The COVID-19 regulation §6.7 and §9.4 gives exemption from quarantine duty for people who have had confirmed COVID-19 that is documented by approved laboratory methods during the last six months. Currently, only RT-PCR for SARS-CoV-2 is a recommended method. Having "probable COVID-19" does not give an exemption.

Arrival from the Nordic countries

The COVID-19 regulation §5a gives exemption from quarantine duty for people who arrive in Norway from regions in Denmark, Finland, Iceland, Faroe Islands, Greenland or Åland. 

Work travel from regions in Sweden with quarantine duty

The COVID-19 regulation §6.1 gives exemption from quarantine duty for workers from regions in Sweden with quarantine duty while they are at work, or commuting to/from work. In their free time, they are in quarantine. For healthcare personnel from areas in Sweden with quarantine duty, the decisions for work travel from the Schengen area and EEA countries apply. This does not apply to daily commuters who do not work in the healthcare service in Sweden. After individual assessment, it may be appropriate to consider regular testing of these workers.

Work travel from the Schengen area and EEA countries

From 22nd June 2020, the COVID-19 regulation §6.8 allows for an employer or contractor to choose to organise for testing and infection control measures as an alternative to quarantine for people who would otherwise have had quarantine duty upon arrival in Norway from Schengen or EEA countries to work.

If the employer or contractor chooses this solution, they are responsible for arranging and paying for the tests. 

If this is not feasible, the requirement for quarantine of 10 days upon arrival in Norway applies. 

Key workers in critical functions to society

The COVID-19 regulation §6.3 gives the possibility for managers in organisations with critical functions in society to make exemptions from quarantine duty for employees with essential roles in maintaining safe operations (§6 and §9). 

Before deciding on the exemption, the employer should consider the following: 

  • Possibility to reallocate personnel from elsewhere in the organisation
  • Possibility to downgrade activity

Examples of employees who can be considered for work during the quarantine period: 

  • Employees who are in quarantine after travel
  • Employees at the end of their quarantine period
  • Employees who have been least exposed to infection, after an assessment of the exposure.

The following should not be exempt from quarantine duty:

  • Employees who are household members or in an equivalent close contact circle with the person with confirmed COVID-19. 

Infection control measures for follow-up of "other close contacts" and when people are exempt from quarantine duty

The following infection control measures are recommended with 1) follow-up of #other close contacts" 2) when employers give exemption from quarantine to critical workers, and 3) when people are exempt from quarantine at work after travelling to Norway: 

  • Be tested for COVID-19 a short time (day 0) after arrival in Norway or on approximately day 3 after known exposure to infection.
  • Wait with starting work until the first negative test result is available.
  • Carry out a new test on approximately day 5 after arrival, or on approximately day 7 after last known exposure to infection. There should be at least 48 hours between the first and second test, and the second test cannot be taken earlier than day 5.
  • Quarantine applies during leisure time until the second test result is negative.
  • Monitor your condition. With symptoms of respiratory tract infection, those who are responsible for follow-up should be alerted and testing should be carried out as quickly as possible.
  • Do not go to work/leave work immediately if symptoms of respiratory tract infection arise or there is a positive test for SARS-CoV-2.
  • Keep a safe distance (>1 metre) from colleagues and others.
  • Organise work so that close contact with colleagues and others is limited.
  • Be extra careful with cough etiquette and hand hygiene.
  • For work in the vicinity of patients, use a face mask when you are less than 2 metres from the patient, particularly for work with patients in risk groups.

The duration for the measures is 10 days after the last possible exposure, or 10 days after arrival in Norway.

People in the "other close contacts" group should inform their employer to ensure that the above measures are followed.

It is assumed that the employer only gives exemptions from quarantine duty if testing and recommended infection control measures can be implemented. In addition, it is recommended that the employer ensures:

  • Tailored information in a language that the employee understands about advice for infection control and self-monitoring.
  • Possibility to follow infection control advice in the workplace, with a view to keeping a distance from each other and access to facilities for hand washing / hand disinfection.
  • Access to rapid testing, analysis and test results.
  • No risk of loss of income if there is a positive result.
  • Easy, safe and free access to medical help if symptoms arise.

 

 

Background for the measures

Quarantine is used to prevent the spread of infection before symptoms of COVID-19 infection have been reported.  Over time, better knowledge of COVID-19 has made it clear that most of the transmission occur at the very beginning of the disease course. Extensive use of quarantine is unfortunate where there is very low risk of disease. Ideally, as many sick people as possible will be detected with the fewest possible quarantine days.

The NIPH has therefore recommended that the days in quarantine be targeted by these three changes.

  • One is considered to be a close contact 48 hours before symptom onset (increased from 24 hours)
  • Quarantine time is shortened from 14 to 10 days
  • People who have had COVID-19 disease are exempt from quarantine duty for the subsequent six months.

Reasons for test time points with exemption from quarantine

The time points for testing are based on when the virus is usually detectable after infection, the contagious period before symptom onset and probability for asymptomatic/atypical disease. The aim is to find as many people who are infected as possible and at the same time catch most of them before symptoms develop. 

Reasons for the changes

Quarantine is effective in preventing transmission of COVID-19 to uninfected people. At the same time, it is a costly measure and can impair preparedness if an entire work team is taken out of a business. Several countries, including Sweden and Denmark, have therefore stopped using quarantine. Countries that still use quarantine have used a quarantine period of 14 days since the start of the epidemic. This is in line with the advice of the World Health Organization (WHO) and the European Centre for Disease Control (ECDC).

Preliminary experience in Norway shows that a few hundred days are spent in quarantine per person who develops the disease. The NIPH has therefore assessed whether the use of quarantine could be better targeted. Is there a better alternative between 0 and 14 days? When should quarantine start? Is a new quarantine period necessary for a person who has had the disease?

Close contact from 48 hours before symptom onset

ECDC recommends that contact tracing be done from 48 hours before symptom onset (1), as does the WHO (2). Additional knowledge indicates that the infectivity is relatively high 1-2 days before symptoms appear (3,4). Therefore, NIPH recommends that close contacts should now be quarantined from 48 hours before symptoms began instead of 24 hours before.

Quarantine from 14 to 10 days

We are getting an increasingly accurate estimate of the average incubation period (the time from infection to becoming sick). Recently published studies have found an incubation period of 4-6 days, and similar times have been found from the time of onset of symptoms in a person with confirmed infection to onset of symptoms in infected close contacts (4-7). Overall, this indicates that much of the infection occurs early in the course and probably before the onset of symptoms.

Based on figures from these studies, there is a clear tendency for the quarantine effect to flatten out after 8-9 days. After 8-9 days, the main effect of the quarantine measure is already considered to have been gained, as very few become sick after this. If the overall risk of a close contact being infected is 15 per cent, just under 1 per cent of infected close contacts will be missed by shortening the quarantine time to 10 days (5,6,8,9). However, it is important to note that some people will have longer incubation periods. Therefore, the risk will be small, but not completely removed, by shortening the quarantine period from 14 to 10 days. Nor will the risk be removed by maintaining a 14-day quarantine period.

Exemption from quarantine following disease

Based on the Norwegian Institute of Public Health's systematic review of immunity after COVID-19 infection, which also looked at knowledge about immunity after SARS, it is likely that undergoing infection with COVID-19 provides protection, but it is uncertain how long the protection lasts. Seroconversion has been identified to start early after symptom onset, and is detected in most patients after 14-24 days (10). Most likely, you are protected at least one to two years from reinfection, but this cannot be determined yet. Based on this, we recommend that a person who has undergone COVID-19 confirmed by approved laboratory method during the past 6 months should be exempt from quarantine.

Total focus of quarantine time

By extending the definition of close contact to apply to all those who have been exposed to COVID-19 infection for 48 hours before symptom onset, work in the municipalities to find close contacts is increased. More people will be taken out of work and quarantined. In some places, this will increase the burden considerably, while some municipalities have already chosen to do so. Evaluated together with the recommendation to reduce the duration of the quarantine, the change will mean that the use of quarantine days is centred on the time around illness and early in the course of the disease. This is also the most contagious period. Quarantine use is also reduced by exempting people who have undergone the disease. Overall, this provides a better focusing of quarantine time.

 

References

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