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

Published Updated

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 treated in hospital.

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

Home isolation is only appropriate when the living conditions are appropriate 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

From 13.08.2020, all close contacts shall be in quarantine, and there is no longer a distinction between the types of close contact.

All close contacts shall be in quarantine for 10 days after the last exposure to infection.

In some circumstances, it can be useful to differentiate between "household members of equivalent close contacts" and other "close contacts". See 

Close contacts who have had COVID-19 in the last 6 months, documented by an approved laboratory method (RT-PCR for SARS-CoV-2) are exempt from quarantine. 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 everyone who has been in close contact with a person who has tested positive for SARS-CoV-2. The contact must have taken place during the contagious period, i.e. within 48 hours before they first displayed symptoms. 

The regulations also require quarantine upon arrival in Norway as a general rule.

Quarantine measures

More information about what quarantine entails, including advice about what is an appropriate place for quarantine:

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 the recommended infection control measures including the use of personal protective equipment. 

Duration of quarantine

Duration of quarantine for close contacts

If you are defined as close contact to someone who has tested positive for COVID-19, you must be in quarantine for 10 days from the last contact with the patient (see Definition of close contacts).

Duration of quarantine for close contact who is a household member

It is common for household members to infect each other if they continue to live together. To reduce the risk of transmission, it is recommended that infected and healthy people live apart, if possible. This may also shorten the quarantine period for healthy household members. The quarantine period in a household is calculated as follows:

  • Healthy household members to a COVID-19 patient with symptoms can end their quarantine 10 days after the last near contact with the person who is sick. This assumes that the healthy and the sick can live separately in the same household; i.e. separate bathroom, bedroom and common rooms during the quarantine period. See example household 1, person D. If living separately in a joint household is not possible, the quarantine for the healthy household members will end 15 days* after the onset of symptoms for the household member who last became ill. See example household 1, person C

* The virus appears to be most contagious around the onset of symptoms and the infectivity decreases rapidly after symptoms have begun. The last day of exposure for a household member can be considered to be 5 days after symptom onset. Healthy household members living together with COVID-19 patients with symptoms can end their quarantine 5 + 10 days after the last patient in the household developed symptoms and was isolated.

  • Healthy household members of a COVID-19 patient without symptoms (asymptomatic) can end their quarantine 10 days after the test date for the infected person. This is regardless of whether there is contact between the infected person and other household members. See example household 4, persons A and B. If the isolated, asymptomatic person develops symptoms during their isolation period, the quarantine for household members will be affected.

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

2020.10.23 figure duration quarantine isolation.JPG

Exemption from duty of quarantine

There is no 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.

There is no quarantine duty for people who arrive in Norway from regions/countries with sufficiently low transmission ("yellow countries"). For an overview of which areas/countries this applies to see: 

There are some exemptions from quarantine duty and the most important are described below. A full overview of the exemptions can be found on the website of the Directorate of Health. 

Exemptions for work travel

There are some exemptions from entry quarantine for commuters who travel to work, but 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. 

Employees and contractors with frequent border crossings who arrive in Norway from areas in Sweden or Finland with quarantine duty are exempt from entry quarantine during working hours if they are tested in Norway every 7 days. This also applies for healthcare workers who commute from Sweden and Finland, as long as they are not also working in the Swedish or Finnish health service.  

The COVID-19 regulation §6 allows employers or contractors to choose to organise testing and infection control measures as an alternative to quarantine for people who would otherwise have had quarantine duty.
This applies to people residing in and arriving in Norway from a red country in EEA/Switzerland or people who are exempt from entry restrictions (see the Interim Act relating to entry restrictions for foreign nationals out of concern for public health) with the purpose of working or performing assignments in Norway. The exemption also applies for people residing in Norway. This also applies for healthcare personnel from areas in Sweden and Finland who do not commute.

Key workers in critical functions to society

The COVID-19 regulation §6 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. This applies regardless of the reason for the employee being in quarantine. The exemption from quarantine duty can only be used in cases where it is necessary to avoid danger to life and health.

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 and follow-up when people are exempt from quarantine duty

The following infection control measures are recommended both when employers give exemption from quarantine to critical workers, and when people are exempt from quarantine at work after travelling to Norway: 

  • Be tested for COVID-19 a short time (day 1) 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 day 5 after arrival at the earliest, or on approximately day 7 after last known exposure to infection. There should be at least 48 hours between the first and second test.
  • 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 result 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.
  • For advice on necessary transport to the home/suitable place to stay for "other close contacts", see Infection tracking in different situations - at the bottom of the section on infection tracking after a flight (in Norwegian).

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.

Use of public transport in quarantine

As a rule, people in quarantine shall not use public transport, and never if they have COVID-19 symptoms.

Anyone who arrives in Norway and is in entry quarantine can use public transport to their quarantine accommodation from the airport, port or similar entry point. People who leave Norway during their quarantine period can use public transport during their journey. Anyone over 12 years of age shall use a face mask. 

In some cases, people in infection quarantine may be allowed to use public transport after evaluation by the Municipal Medical Officer. Anyone over 12 years of age shall use a face mask. The NIPH recommends that close contacts such as household members or their equivalent should have a negative test result for SARS-CoV-2 at the earliest 48 hours before the journey. 

 

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

  1. European Centre for Disease Prevention and Control. Guidance for discharge and ending isolation in the context of widespread community transmission of COVID-19, 8 April 2020. Stockholm: ECDC2020.
  2. Considerations in the investigation of cases and clusters of COVID-19. Interim guidance. 13 March 2020. WHO. 2020.
  3. Wei WE LZ, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morbidity and mortality weekly report. 2020;2020;69::411-5.
  4. Du Z, Xu X, Wu Y, Wang L, Cowling BJ, Meyers LA. Serial Interval of COVID-19 among Publicly Reported Confirmed Cases. Emerging infectious diseases. 2020;26(6).
  5. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Annals of internal medicine. 2020.
  6. Zhang J, Litvinova M, Wang W, Wang Y, Deng X, Chen X, et al. Evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside Hubei province, China: a descriptive and modelling study. The Lancet Infectious Diseases. 2020.05.09.
  7. Zhao S, Gao D, Zhuang Z, Chong M, Cai Y, Ran J, et al. Estimating the serial interval of the novel coronavirus disease (COVID-19): A statistical analysis using the public data in Hong Kong from January 16 to February 15, 2020. medRxiv. 2020:2020.02.21.20026559.
  8. Luo L, Liu D, Liao X-l, Wu X-b, Jing Q-l, Zheng J-z, et al. Modes of contact and risk of transmission in COVID-19 among close contacts. medRxiv. 2020:2020.03.24.20042606.
  9. Bi Q, Wu Y, Mei S, Ye C, Zou X, Zhang Z, et al. Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts. medRxiv. 2020:2020.03.03.20028423.
  10. Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature. 2020

History

23.10.2020: Updated figure

08.10.2020: Updated section about duration of quarantine according to Norwegian version. Changed from Day 0 to Day 1 in bullet point about testing.

24.09.2020: Small adjustment: Carry out a new test on day 5 after arrival at the earliest...

21.09.2020: In the paragraph on exemptions for work travel the following is corrected: The exemptions in § 6c can also include people arriving from countries outside Schengen and EEA.

15.09.2020: Updated figure, changes to text about duration, as per Norwegian version. Changes to text about exemption from quarantine.

13.08.2020: Changed text so the distinction between household members and other close contacts is removed with regards to quarantine.

31.07.2020: Added the following bullet point in the section on follow-up of "other close contacts": For advice on necessary transport to the home/suitable place to stay for "other close contacts", see Infection tracing in different situations - at the bottom of the section on infection tracing after flight (in Norwegian).

10.07.2020: Updated section about Nordic, Schengen and EU/EEA countries.

03.07.2020 Added sentence that "quarantine applies during leisure time until the second test result is negative" in the list about follow-up of other close contacts and when people are exempt from quarantine duty. Clarified that "people in the "other close contacts" group should inform their employer to ensure that the above measures are followed". Specified time point for testing with exemption from quarantine so it is in accordance with the regulations. Referred to advice for different healthcare services for infection control measures when they will enter the home or treat people who are isolated or in quarantine.

01.07.2020 Updated figure about duration of quarantine and isolation. Collated measures for "other close contacts" and for exemption from quarantine in one paragraph. Explained time points for testing. Added that for healthcare workers  from Sweden, the decisions for workers from the Schengen area and EEA countries apply. Added advice to employers who give exemption from quarantine.

24.06.2020
Section about exemption from quarantine - specified which groups and which quarantine rules apply - for those who have had the disease, workers from Sweden, workers from Schengen and EEA countries and key workers in critical functions.

16.06.2020
Adjustment to text about exemption from quarantine duty, including infection control measures when people are exempt.

12.06.2020
Added "if this is feasible within the follow-up time of 10 days" to the section about testing.

05.06.2020 Added figure with examples of duration. Some restructuring as per Norwegian version. Removed text about when to have exemption and what should be considered with quarantine and work.

04.06.2020 Added examples of equivalent close contacts. Added sentence about testing

03.06.2020
"Close contacts" split into "household members and equivalent" and "other", and how they should be followed up is described. Changes in order (isolation first), text adjustments and links to other pages.   

29.05.2020
Added references. Added links about impending quarantine rules. Added information about background for updates to quarantine (7th May) that had not been translated.

26.05.2020
Added first paragraph under section "exemption from quarantine."

08.05.2020
Changed duration of quarantine to 10 days from 14 days. Added sentence about quarantine not applying to people who have had confirmed COVID-19

30.04.2020

Added definition of probable case under "Duration of home quarantine."

29.04.2020
Added "Employees who have recovered from COVID-19 disease, confirmed by a recommended laboratory method".

17.04.2020
Updated two sentences as per Norwegian version. First sentence under Home isolation and sentence in Background about quarantine lasting until the person comes out of isolation.

14.04.2020
Updated text. Added "probable COVID-19" as a category.

03.04.2020

Updated text according to Norwegian version

31.03.2020
Removed "or no" from first bullet point under background, as per Norwegian version 

17.03.2020 - updated text about quarantine according to changes in the Norwegian text

14.03.2020 - added link to travel advice with information about quarantine rules

13.03.2020

Updates to reflect changes in the Norwegian text "everyone who has travelled outside of the Nordic Region

12.03.2020

Changed text according to Norwegian text. Moved section about background. Added "Healthcare personnel who live in the same household as suspected cases until laboratory test results are ready".

09.03.2020

Changed text according to Norwegian text. Removed text about work restrictions for employees in health service after changes in quarantine advice. Quarantine applies to everyone who has been in areas with ongoing transmission.

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