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  • Follow-up of close contacts, quarantine and home isolation

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.


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Follow-up of close contacts, isolation and quarantine are measures to prevent transmission of the virus that causes COVID-19. Isolation and quarantine shall be carried out in an appropriate place, usually at home. When the measures are introduced elsewhere than at home, the same principles apply. They are key measures in the TISK strategy (Testing, isolation, contact tracing and quarantine). 

Isolation

Isolation applies to those who have confirmed SARS-CoV-2 or probable COVID-19 and also applies if you are fully vaccinated or protected. If the living conditions are suitable and the patient does not need to be admitted to hospital, isolation can be carried out at home. If it is not possible to keep a good distance from others in the home, the patient should be offered another suitable place.

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

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

Follow-up of the patient is done after individual assessment, and both telephone / digital contact and home visits may be relevant. Daily contact should be considered, especially for patients in risk groups. The patient must be told who they should call or otherwise contact if their symptoms get worse.

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.

Isolation of people diagnosed with SARS-CoV-2 upon arrival in Norway

Upon arrival in Norway, everyone is routinely tested with rapid antigen tests. In the event of a positive response, a PCR test is taken and the patient is isolated until a PCR result is available. If the PCR result is negative, the person can be come out of isolation.

In some situations, if a person is only PCR-positive (not positive according to a rapid antigen test) and can present documentation of having had COVID-19 in the last 3 months, isolation can end if an antibody test taken in Norway is positive in an analysis that detects IgG or total antibodies. 

People who test positive at border crossings for both rapid antigen testing and positive for confirmatory PCR testing cannot come out of isolation using antibody testing. They shall be in isolation as recommended.

Follow-up of close contacts

All close contacts shall be in quarantine. Quarantine lasts for 10 days after the last exposure to infection. The quarantine can be shortened if the close contact tests negative on a PCR test taken no earlier than 7 days after the last infection exposure. It is recommended that close contacts should be tested both at the start and end of quarantine to speed up contact tracing around infected cases and to detect asymptomatic cases.

Justification for shortening quarantine by a negative PCR test taken after 7 days

Several studies have shown that we can expect a detectable virus several days before the onset of symptoms using a PCR test (1, 2). New knowledge shows that the serial interval for SARS-CoV-2 (time from index case showing symptoms to infected close contact showing symptoms) is shorter than previously calculated, especially when the index case is quickly isolated, as in the Norwegian context, that it can be 2-3 days instead of 5-6 days as previously thought (3-5).

Based on this, NIPH's calculations and several modelling studies have shown an equal or better effect of shorter quarantines combined with testing on day 7 instead of just quarantine for 10 days (6-8).

Tests at the end of the quarantine period will also detect those with asymptomatic infections as well as those with such mild / atypical symptoms that they consider themselves healthy and do not self-isolate and test themselves according to current recommendations. By identifying people with asymptomatic infection in quarantine and then initiating the quarantine of exposed household members, it will also be possible to reduce the risk of further spread into society.

Compliance with quarantine is probably correlated with duration, so a shorter quarantine period with a test opportunity will probably increase compliance. This has been the experience reported from Iceland, which has switched to a test-based quarantine strategy.

Similar recommendations to shorten quarantine by testing are also now seen in several countries and from the ECDC, the European Commission and the CDC (9, 10).

The UK virus variant

Public Health England announced on 14 December 2020 that a new variant of SARS-CoV-2 (called VOC 202012/01 and B.1.1.7.) outperformed the other variants there in a relatively short time. Based on epidemiological data, it is assumed that this is the reason for the rapid surge in cases that started in the regions of the South East and East of England as well as in London.

There are several hypotheses to explain a possible increased transmission rate for this variant (for example that there are higher virus levels in those infected or that a lower dose of infection is sufficient) but without any conclusions drawn on these (11-14). There is no data basis that gives reason to suspect that the new variant has a longer incubation time. So far, there is no indication that the new variant has a different mode of transmission than the others (15). However, increased transmission risk requires vigilance and stricter compliance with the already implemented and recommended infection control routines and measures.

The NIPH has advised that close contacts in outbreaks with a known epidemiological connection to the UK virus variant are tested both at the beginning and end of the quarantine period.

It has also been discussed whether one should postpone the last test (and extend the quarantine period) from day 7 to day 10. However, this will lead to about 50 % of infected close contacts spending an extra 3 days before testing positive. This could increase the risk of transmission and delay further transmission and contact tracing. Increased quarantine time may also reduce compliance. It is therefore possible that postponing the last testing day will entail an even higher, rather than lower, risk of infection, notwithstanding that a long incubation period may allow detection of a few extra people (1-2%).

NIPH has therefore concluded that it does not recommend postponing the last test or extending the quarantine period for close contacts in outbreaks where the new UK variant has been proven.

References

  1. Kissler SM, Fauver JR, Mack C, Olesen SW, Tai C, Shiue KY, et al. SARS-CoV-2 viral dynamics in acute infections. 2020:2020.10.21.20217042.
  2. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. 2020;382(22):2081-90.
  3. Ali ST, Wang L, Lau EHY, Xu XK, Du Z, Wu Y, et al. Serial interval of SARS-CoV-2 was shortened over time by nonpharmaceutical interventions. Science (New York, NY). 2020;369(6507):1106-9.
  4. Mettler SK, Kim J, Maathuis MH. Diagnostic serial interval as a novel indicator for contact tracing effectiveness exemplified with the SARS-CoV-2/COVID-19 outbreak in South Korea. International Journal of Infectious Diseases. 2020;99:346-51.
  5. Sun K, Wang W, Gao L, Wang Y, Luo K, Ren L, et al. Transmission heterogeneities, kinetics, and controllability of SARS-CoV-2. 2021;371(6526):eabe2424.
  6. Ashcroft P, Lehtinen S, Angst DC, Low N, Bonhoeffer S. Quantifying the impact of quarantine duration on COVID-19 transmission. 2020:2020.09.24.20201061.
  7. Quilty BJ, Clifford S, Hellewell J, Russell TW, Kucharski AJ, Flasche S, et al. Quarantine and testing strategies in contact tracing for SARS-CoV-2: a modelling study. The Lancet Public health. 2021.
  8. Wells CR, Townsend JP, Pandey A, Moghadas SM, Krieger G, Singer B, et al. Optimal COVID-19 quarantine and testing strategies. Nature Communications. 2021;12(1):356.
  9. Guidelines for COVID-19 testing and quarantine of air travellers – Addendum to the Aviation Health Safety Protocol. In: ECDC, editor. Stockholm.2. Dec 2020.
  10. Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html.
  11. Kidd M, Richter A, Best A, Mirza J, Percival B, Mayhew M, et al. S-variant SARS-CoV-2 is associated with significantly higher viral loads in samples tested by ThermoFisher TaqPath RT-QPCR. 2020:2020.12.24.20248834.
  12. Santos JC, Passos GA. The high infectivity of SARS-CoV-2 B.1.1.7 is associated with increased interaction force between Spike-ACE2 caused by the viral N501Y mutation. 2021:2020.12.29.424708.
  13. Volz E, Mishra S, Chand M, Barrett JC, Johnson R, Geidelberg L, et al. Transmission of SARS-CoV-2 Lineage B.1.1.7 in England: Insights from linking epidemiological and genetic data. 2021:2020.12.30.20249034.
  14. Walker AS, Vihta K-D, Gethings O, Pritchard E, Jones J, House T, et al. Increased infections, but not viral burden, with a new SARS-CoV-2 variant. 2021:2021.01.13.21249721.
  15. Public Health England. COVID-19: Guidance for maintaining services within health and care settings. Infection prevention and control recommendations

 

Antigen rapid testing cannot be used to shorten quarantine, see also Test criteria.

Close contacts who have had COVID-19 in the last 6 months, or are vaccinated, are exempt from infection quarantine. See more details and requirements associated with exemptions in the section "Exemption from duty of quarantine for those who are vaccinated or have had COVID-19 (§ 4)" below.

Quarantine

Regulations relating to infection control measures etc. in connection with the coronavirus outbreak (COVID-19 Regulations) impose quarantine for everyone defined as a close contact with a person who has tested positive for SARS-CoV-2. 

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

If the person in quarantine experiences symptoms of COVID-19, they are considered to be a "probable COVID-19 case") and it is recommended that the entire household is in quarantine pending a negative test result. If the probable case receives a negative test result, the quarantine for household members ends. If there is a positive test result, the person tested shall be isolated and contact tracing begins. All close contacts are in quarantine, including all household members.

In outbreaks, regardless of the virus variant, it is recommended that household members of close contacts stay at home (waiting quarantine) until the close contact has received a negative answer on the first test.

Quarantine measures

During the quarantine period, keep a good distance from other adults and older children. 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

The quarantine for close contacts lasts 10 days after the last exposure. The time is calculated from the time you were last exposed, to the same time 7 or 10 days later. For example, if you were exposed at 6 p.m. on 1st April, 10 days of quarantine ends at 6 p.m. on 11th April (or until a negative test result taken at least 7 days after, maybe 9th April).

When living with one or more people who are isolated, it can be difficult to keep a physical distance. Most transmission occurs in the days around symptom onset, so it is not necessary to wait until the last person in the household comes out of isolation before starting to count 10 quarantine days. Contact can be estimated as day 5 (with the last patient in the household), as the last exposure, and count 10 days from there (see flow chart; Example 1, person C). A PCR test to end quarantine can be taken at the earliest 12 days (5 + 7) after the onset of the disease in the last patient in the household.

If you can live sufficiently separated in the household, count 10 days from the date you were separated (see flow chart; Example household 1, person D).

If the person who tested positive did not have symptoms (asymptomatic), count 10 days from the testing date (see flow chart; Example household 3, persons A and B).

Flow chart

2020.11.04 oppfølging av smittede engelsk.JPG
The figure shows examples of the duration of home isolation and quarantine in households. (Click on the figure to enlarge it) .

Exemption from duty of quarantine for those who are vaccinated or have had COVID-19 (§ 4)

Some exemptions from the quarantine duty apply to protected and fully vaccinated people.

Documentation

Having had COVID-19 disease is documented by a certificate presenting the test result and method used, with personal identifiable information and test date. Currently, only RT-PCR and rapid antigen tests for SARS-CoV-2 are recommended laboratory methods. Recovery from "probable COVID-19", or confirmed presence of antibodies do not give exemption from quarantine.

For exemption from infection quarantine, only certificates (Norwegian, Swedish, Danish or EU COVID-19 certificate) for documented COVID-19 or vaccination are approved (the Swedish COVID-19 certificate is not yet ready for this use). For exemption from entry quarantine, quarantine hotel and the possibility of shortening entry quarantine, currently the only secure and verifiable way to document status as protected is to show a COVID-19 certificate with a QR code that can be verified by Norwegian authorities.

Only vaccines against COVID-19 that are approved by the European Medicines Agency are considered.

Exemptions from infection quarantine

  • People who are fully vaccinated against COVID-19 or have had COVID-19 in the last 6 months are exempt from infection quarantine after close contact.
  • People who at the time of exposure/close contact had received the first vaccine dose between 3 and 15 weeks ago are also exempt from infection quarantine, if they take a PCR test between 3 and 7 days after exposure. They do not have to be in quarantine either until they take the test or until the test result is available. If they cannot/ will not be tested, they must be in infection quarantine as normal.
    In households where the vaccinated person has continuous contact with the infected person, the test should be taken 3-7 days after the infected person developed symptoms (or after the test date if the infected person has no symptoms). If they receive a positive test result, they must be isolated from the time the test result is available and contact tracing will begin.
    People who at the time of exposure/close contact had received the first vaccine dose less than 3 weeks ago are followed up in the same way as unprotected people.

Exemptions from entry quarantine

For an overview of which regions/ countries give rise to quarantine duty: 

People who are fully vaccinated and those who have had COVID-19 in the last six months are exempt from entry quarantine. Protected persons who have received the first vaccine dose for between 3 and 15 weeks can end entry quarantine if they test negative no earlier than three days after arrival. The same applies to children under 18 years of age.

Table 1. Quarantine and isolation for people who have been vaccinated and have previously been infected
Measures
(reference to COVID-19 regulation)

Main rule

3-15 weeks after first vaccine dose

Fully vaccinated (1 week after last vaccine dose or 3 weeks after vaccination with single dose vaccine)

Previously infected (had infection during last 6 months)

Isolation
(for infected, § 7)

Ten days after symptom onset; must have been fever-free for at least 24 hours

No exemption

No exemption

No exemption
(Advice from NIPH: Can come out of isolation with a positive antibody test with known infection during the last 3 months)    

Infection quarantine
(for close contacts of an infected person, § 4 letter b)

Ten days after the day with close contact. Can be ended with a negative PCR test taken after 7 days.

Exemption if PCR test taken between days 3 and 7 (§ 4 second paragraph).

Exemption
(§ 4 second paragraph)

Exemption
(§ 4 second paragraph)

Entry quarantine
(for travellers to Norway, § 4 letter a)

Ten days after day of arrival in Norway.

Can be ended by negative PCR taken seven days after arrival, children under 18 can end after negative PCR taken after 3 days.


(Exemptions for certain groups entering, cf. §6 a- i, k)

Can end entry quarantine after negative PCR taken after three days, provided reliable documentation (§ 4c third paragraph)

Exemptions for health personnel during working hours if strictly necessary for critical societal function (§ 6e third paragraph), provided there is a negative test result on arrival in Norway.

Exemption
(§ 4 fourth paragraph).

Exemption
(§ 4 fourth paragraph).

There are some exemptions from quarantine duty and the most important are described below. See the following pages for more information:

Testing and follow-up in the health service

For employees and patients / residents in the health service, there should always be testing with symptoms, and after exposure there should always be a low threshold for testing.

Below are recommendations for testing after exposure to employees and patients / residents in the health service. Individual local assessments can be considered, especially in institutions with, for example, severely immunosuppressed patients.

Table 2: testing/quarantine for employees in health service after exposure

Exposure

 

Household/
equivalent

Other close contacts 

Outbreak

Fully vaccinated

No testing  

No testing  

No testing  

Partially vaccinated 

Test day 3 and day 7, can consider
avoiding work until negative test taken on day 3 **

Can work if a test is taken between day 3-7 

Test according to outbreak regimen as soon as possible, then every 3rd day. Can consider avoiding work until negative test taken on day 3 **

Unvaccinated

Quarantine  

Quarantine  

Quarantine or testing in outbreak regimen 

After exposure, facemask use is recommended for partially vaccinated or unvaccinated people with close contact <2 metres. Facemask use can be considered by fully vaccinated people.

* With outbreaks, facemasks and eye protection are recommended

**Waiting for a negative test on day 3 can be replaced by an alternative test regimen with daily rapid antigen test for the first 4 days.

Table 3: testing / quarantine for residents or patients in the health service after exposure

Exposure 

 

Outbreak

Close contact

Fully vaccinated  

can be considered for testing as soon as possible for monitoring

No testing  

Partially vaccinated  

Test according to outbreak regimen immediately and then every 3 days. Recommended separate room until negative test taken on day 3

Test day 3 and day 7, separate room is recommended until negative test taken day 3

Unvaccinated  

Quarantine and testing in outbreak regimen  

Quarantine and testing in outbreak regimen  

 

 

Exemptions for certain employees and contractors with frequent border crossings (§6b)

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 for SARS-CoV-2 in Norway at least every 7 days, unless they have stayed in another area than Sweden and Finland with quarantine duty in the 10 days prior to arrival in Norway. 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.  

Other exemptions from quarantine duty

Special exemption from entry quarantine (§6d)

People who cross Norway's borders in connection with planned or stipulated visits between parent and child, or shared residence for children, are exempt from entry quarantine during work and school hours after a negative PCR test taken at the earliest 3 days after arriving in Norway. During leisure time, they should be in quarantine for 10 days or until a negative PCR test taken at the earliest 7 days after arriving in Norway. Children under the age of 12 are exempt from quarantine, even if they are not tested after 3 days. The NIPH still recommends that they take a test on arrival in Norway. They should also wait to start school until there is a negative test result. They should monitor their own health and have a low threshold for testing if symptoms arise.

Those who have been invited by the Norwegian state authorities because of important foreign policy reasons are exempt from entry quarantine during both working hours and leisure time.

People who have been in areas with a quarantine duty, on behalf of the Norwegian state authorities and for important foreign policy reasons, are exempt from entry quarantine during both working hours and leisure time if they have been fully vaccinated against SARS-CoV-2 or have had COVID-19 in the last 6 months. People who are have had their first vaccine dose against SARS-CoV-2 between 3-15 weeks ago are exempt from entry quarantine during both working hours and leisure time after a negative PCR test taken no earlier than 3 days after arrival in Norway. The Ministry of Foreign Affairs must approve the use of this exemption in advance.

Key workers in critical functions to society (§6e)

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, and who have a negative test result for SARS-CoV-2 using the PCR testing method, taken 3 days after arrival in Norway/ after last close contact at the earliest.

In emergency situations, in which there is no time to wait for a PCR result, the person can go to work after a negative rapid antigen test taken on the same day the work is to be completed.

Protected health personnel in critical functions to society are not required to wait for a negative PCR test three days after arrival at the earliest, and can, after a negative test on arrival (rapid antigen test or PCR), be completely exempt from entry quarantine during working hours. The employer is obliged to approve the use of the exemption and obtain and assess documentation of the vaccination. NIPH recommends that only vaccines recommended by the European Medicines Agency (EMA) and approved by the European Commission should be given exemptions.

Exemption from quarantine duty can only be used in cases where it is necessary to avoid a threat to life and health. When exemption is granted, testing and other infection control measures should be carried out, see the paragraph below.

Before granting the exemption from quarantine to maintain safe operations, employers 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 vaccinated and in entry 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.

Exemptions from quarantine for protected health personnel (section 6k)

Exemptions from infection quarantine according to § 4 apply to everyone, including healthcare personnel, but require documentation of vaccination or having had COVID-19 from the Norwegian health and care service.

However, the COVID-19 regulations section 6k allow the possibility to provide protected healthcare personnel without documentation from the Norwegian health and care service exemptions from infection quarantine during working hours.

The following requirements exist for the use of the exemption:

  • Healthcare professionals using the exemption during working hours should be tested for SARS-CoV-2 by PCR test on the 3rd and 7th day after the last exposure. The test requirement does not apply to those who, with an approved laboratory method, can document having had COVID-19 in the last 6 months.
  • In leisure time, infection quarantine applies.

The exemption can only be used in situations where it is necessary to maintain adequate treatment capacity in the institution.

In addition, the paragraph allows for fully vaccinated health personnel who arrive in Norway after having collected or delivered patients by ambulance abroad to be granted exemptions from entry quarantine during working hours and during leisure time.

Fully vaccinated healthcare personnel from Sweden and Finland who are employed in the Norwegian healthcare service are exempt from entry quarantine.

The employer is obliged to obtain and assess documentation that the healthcare personnel are protected.

The NIPH recommends that only vaccines recommended by the European Medicines Agency (EMA) and approved by the European Commission should be given exemptions.

Follow-up at workplace when people are exempt from quarantine duty according to §6e and 6k

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: 

  • Follow the test regime for travellers coming to Norway and the exemption decision. 
  • Quarantine applies during leisure time even though exemption is given for work.
  • If strictly necessary, use public transport to and from work after the first negative test result is available. Follow the advice for people who are in quarantine but who must use public transport.
  • 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.

The duration for the measures is 10 days after last possible exposure, or 10 days after arrival in Norway taken at the earliest 7 days (3 days with shortened quarantine) after last exposure/arrival.

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 shall stay in a quarantine hotel cannot use public transport from the place of arrival to the quarantine hotel. 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.

PCR-test

PCR test refers to PCR and other nucleic acid amplification tests.

Other nucleic acid amplification (NAT) tests are considered equivalent to PCR tests (as specified in COVID-19 regulations).

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

29.07.2021: Updated sentence: Isolation applies to those who have confirmed SARS-CoV-2 or probable COVID-19 and also applies if you are fully vaccinated or protected

27.07.2021: Minor change i section about "isolation of people with confirmed SARS-CoV-2 upon arrival in Norway"

01.07.2021: Added clarification regarding time of exposure / first close contact for exemptions from the infection quarantine for partially vaccinated people.

01.07.2021: Updated text in accordance with a change in the COVID-19 regulations that the waiting quarantine scheme will be removed from 1 July. Changed from 1 to 2 m and added alternative test regime in table 1.

29.06.2021: New tables 1 and 2 and advice for health personnel

28.06.2021: clarification of sentence about partially vaccinated healthcare professionals

24.06.2021: Changed to refer to EU COVID-19 certificates

23.06.2021: Added that the Swedish COVID-19 certificate is not yet ready for this use.

23.06.2021: Clarification that other nucleic acid amplification tests (NAT) are considered equivalent to PCR tests (also specified in the COVID-19 regulations)

23.06.2021: Added that Fully vaccinated health personnel from Sweden and Finland who are employed in the Norwegian health service are granted an exemption from entry quarantine. The employer and client are obliged to obtain and assess documentation that the health personnel are protected.

21.06.2021: Added that Swedish and Danish COVID-19 certificates are approved documentation of vaccination and having had COVID-19, plus some minor language changes.

17.06.2021: Added that vaccination with single dose vaccine is considered fully vaccinated from 3 weeks after vaccination

14.06.2021: Updated documentation requirements

11.06.2021: From 11.6, fully vaccinated and people who have had COVID-19 in the last 6 months will not go into quarantine. Updated information on exemptions from quarantine according to this.

08.06.2021: New sentence: For exemption from quarantine in a quarantine hotel and the possibility of shortening entry quarantine, currently the only secure and verifiable way to document status as protected is through login to helsenorge.no.

07.06.2021: From 4.6, children under the age of 12 and those who are protected against COVID-19, provided reliable documentation, can shorten the quarantine after a negative test after 3 days.

03.06.2021: Clarifications and changes added, cf. changes in the regulations §6e and §6k.

01.06.2021: Follow-up frequency should be determined based on an individual assessment.

19.05.2021: In the section "Isolation of persons who have been diagnosed with SARS-CoV-2 in connection with arrival in Norway": clarification of antibody test IgG or total antibody.

18.05.2021: change from protected to partially vaccinated in advice about healthcare workers and exposure. Change in table from 3-12 weeks to 3-15 weeks

18.05.2021: Addition of advice for protected health personnel with an infected household member. Changes in exemption from the quarantine duty for those who have been vaccinated or undergone infection.

13.05.2021: Added to the EEA and Schengen area or the United Kingdom, cf. Amendments to the COVID-19 regulation from 13.5.

12.05.2021: Added that people who have been outside the EEA and Schengen area for the last 10 days cannot use public transport to the quarantine hotel, cf. the changes in section 5 of the COVID-19 regulations which came into force on 9.5.21.

10.05.2021: Removed sentence: "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."

10.05.2021: Clarification of exemptions from infection quarantine for vaccinated healthcare personnel

10.05.2021: Clarification that people who have received the first vaccine dose between 3 and 15 weeks ago should not be in infection quarantine if they take a PCR test between 3 and 7 days after exposure.

04.05.2021: Clarification about vaccinated people and infection quarantine

04.05.2021: Added information about changes in infection quarantine for vaccinated after regulatory changes

30.04.2021: Persons who have stayed in Bangladesh, India, Iraq, Nepal or Pakistan during the last 10 days before arrival in Norway shall not use public transport from the place of arrival to the quarantine hotel.

12.04.2021: Added table about exemptions after vaccination and recovery from infection.

30.03.2021: Updated because waiting quarantine for household members is added to the regulations

22.03.2021: specification of exemptions for vaccinated health workers, regardless of vaccine type.

19.03.2021: New exemption, section 6k, for vaccinated healthcare workers.

10.03.2021 Added "3 weeks after first dose" in section about "People in functions critical to society"

03.03.2021 Updated paragraph about quarantine, link to TISK

25.02.2021 It is specified that vaccinated foreign health personnel can be exempted from entry quarantine during working hours after a negative test upon entry.

19.02.2021: Updated according to Norwegian version. Added that fully vaccinated healthcare personnel with critical functions may be exempt from entry quarantine. 

04.02.2021: Added text about South African virus variant

02.02.2021: Added text about how household members who continue to live with someone who is infected can shorten quarantine with a negative test taken 7 days after the last exposure at the earliest.  

01.02.2021: Removed section about Exemptions for cross-border workers from EEA countries and Switzerland (§ 6c in covid-19 regulations) that ceased 31.1.21. Added No longer exemption from quarantine for people who have had COVID-19.

29.01.2021:  Added justification for shortening quarantine by negative PCR test taken after 7 days.

26.01.2021: Updated to reflect changes to the Covid-19 regulation sections 4 and 6, in effect January 25th, 2021.

10.01.2021: 
23.59: Updated list of countries requiring quarantine

08.01.2021: Adjusted text about exemption according to §6d after regulation changes, added vaccinated to the list of people who can be considered to be exempt according to  §6e.

23.12.2020 Added that vaccination does not provide exemption from quarantine, added that separate provisions have been introduced for travellers from the United Kingdom, specified that the requirement for a 2-week-old test for exemption after undergoing COVID-19, applies at entry.

20.12.2020: 23.59: Updated list of countries requiring quarantine

11.12.2020: 23.59: Updated list of countries requiring quarantine

27.11.2020: 23.59: Updated list of countries requiring quarantine

10.12.2020: Added "The test must have been done be at least 2 weeks ago" to section about exemptions.

05.12.2020: 23.59: Updated list of countries requiring quarantine

27.11.2020: 23.59: Updated list of countries requiring quarantine

20.11.2020: 23.59: Updated list of countries requiring quarantine

17.11.2020: Added "The certificate shall be in Norwegian, Swedish, Danish, English, French or German."

13.11.2020 23:59: updated list of countries requiring quarantine. Added sentence "The recommended test timepoint is between day 3 and day 7 after exposure, preferably on day 5."

11.11.2020: Added "Anyone who has been exposed to COVID-19 infection, who are of lower secondary school age or above, should be tested."

07.11.2020 00:00 a.m.: Updated with tables for regions and countries affected by different exemptions from quarantine decisions for cross-border workers. 

04.11.2020: Updated flow chart

02.11.2020: Quarantine section - added that household members to probable cases are in quarantine while waiting for test results. Simplified text about quarantine duration.

30.10.2020: Updated paragraph about cross-border workers according to new decisions that apply from 31 October 2020.

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.