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Follow-up of close contacts, quarantine and home isolation- advice for healthcare personnel
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.
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 suitable. If not, a suitable place should be offered to 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
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 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 English 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 English 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 English variant has been proven.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Guidelines for COVID-19 testing and quarantine of air travellers – Addendum to the Aviation Health Safety Protocol. In: ECDC, editor. Stockholm.2. Dec 2020.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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 more in the chapter Test criteria.
There are separate recommendations for handling large, complex outbreaks where a new variant has been detected from the United Kingdom (501Y.V1 (B.1.1.7) or from South Africa (501Y.V2 (B.1.351)).
Read more about this in
Close contacts who have had COVID-19 in the last 6 months, documented by an approved laboratory method from the Norwegian healthcare service (RT-PCR for SARS-CoV-2 or antigen test) are exempt from quarantine. Currently, antibody testing does not give exemption from 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 is considered to be a "probable COVID-19 case") and it is recommended that the entire household is quarantined pending a 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 quarantined, including all household members.
In outbreaks where a more contagious virus variant has been detected, and in large, complex outbreaks, it is recommended that household members of close contacts stay at home until the close contact has received a negative answer on the first test.
In other situations, there are no special restrictions for household members of the person/people in quarantine.
See Smittesporing i ulike situasjoner for more details.
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.
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 December, 10 days of quarantine ends at 6 p.m. on 11th December (or until a negative test result taken at least 7 days after, maybe December 9).
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).
Exemption from duty of quarantine
People who have had COVID-19, documented by an approved laboratory method, during the last 6 months, are exempt from quarantine after close contact. From Sunday 31 January 00.00 a.m. there are no longer exceptions from the entry quarantine for people who have had COVID-19.
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", confirmed presence of antibodies or vaccination do not give exemption from quarantine.
For exemption from entry quarantine, only Norwegian certificates for documented COVID-19 are approved.
There is no quarantine duty for people who arrive in Norway from regions/countries with sufficiently low transmission. For an overview of which areas/ countries this applies to see:
- Infection control advice for travel
- Regulations for infection control measures for the coronavirus outbreak
There are some exemptions from quarantine duty and the most important are described below. See the regulations and the Norwegian Directorate of Health's pages for more information:
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 invited by Norway because of foreign policy, as well as 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.
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 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.
Fully-vaccinated foreign 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.
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 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.
- Employees who are vaccinated against COVID-19.
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.
Follow-up at workplace when people are exempt from quarantine duty according to §6e
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 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 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.