Evidence-Based Practice for Public Health Emergency Preparedness and Response (2020) / Chapter Skim
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Appendix B4: Mixed-Method Review of Implementing Quarantine to Reduce or Stop the Spread of a Contagious Disease
Appendix B4: Mixed-Method Review of Implementing Quarantine to Reduce or Stop the Spread of a Contagious Disease
Pages 387-432
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From page 387... ...
. 1 This appendix draws heavily on four reports commissioned by the committee: "Data Extraction and Quality Assessment: Methodology and Evidence Tables" by the Brown University Center for Evidence Synthesis in Health; "Quarantine as a Non-Pharmaceutical Intervention: Qualitative Research Evidence Synthesis" by Pradeep Sopory and Julie Novak; "Use of Quarantine as a Non-Pharmaceutical Intervention for Public Health Emergencies: Findings from Case Reports" by Sneha Patel; and "In What Situations Do Modeling Studies Suggest Quarantine is More Versus Less Effective to Control Infectious Disease Outbreaks?
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EVIDENCE SUPPORTING THE PRACTICE RECOMMENDATION This section summarizes the evidence from the mixed-method review examining implementing quarantine to reduce or stop the spread of a contagious disease. It begins with a description of the results of the literature search and then summarizes the evidence of effectiveness.
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Reduced morbidity and/or social harms and mortality » Inability of quarantined individuals to meet social and economic demands » Increased risk of infection » Increased disparities » Missed work, personal financial loss, lost economic productivity, and lost opportunities (e.g., lost education) FIGURE B4-1 Analytic framework for implementing quarantine during a public health emergency.
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390 EVIDENCE-BASED PRACTICE FOR PHEPR FIGURE B4-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for the mixed-method review of implementing quarantine to reduce or stop the spread of a contagious disease.
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These three studies examined whether quarantine reduced disease transmission in response to three different contagious diseases: H1N1 pandemic influenza, severe acute respiratory syndrome (SARS) , and measles.
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Other forms of evidence considered for effectiveness included mechanistic evidence, evidence from modeling studies, and quantitative data reported in case reports of real disasters or public health emergencies. Benefit: Reduced Overall Disease Transmission in the Community Evidence from quantitative research studies Three quantitative comparative studies examined whether the use of quarantine can reduce disease transmission in the community.
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was deemed to be of poor methodological quality. Other evidence that may inform effectiveness The committee considered mechanistic evidence, modeling evidence, and quantitative data from case reports for the primary outcome of interest -- reducing or stopping disease transmission.
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Three quantitative comparative studies (Bondy et al., 2009; Delaporte et al., 2013; Miyaki et al., 2011) provide low COE regarding the effect of quarantine on reduced overall disease transmission (see Table B4-2)
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Benefit: Reduced Time from Symptom Onset to Diagnosis Evidence from quantitative research studies A single retrospective nonrandomized comparative study conducted by Hsieh and colleagues (2005) during the SARS outbreak in Taiwan in 2003 compared quarantined (N = 24)
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There are no discordant studies. TABLE B4-3 Effect of Quarantine on Reduced Time from Symptom Onset to Diagnosis in Quarantined Individuals Number of Studies 1 Hsieh et al., 2005 Study Infomation Retrospective nonrandomized comparative study (NRCS)
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was deemed to be of poor methodological quality. Other evidence that may inform effectiveness The committee considered mechanistic evidence for the outcome of increased risk of infection in congregate quarantine settings.
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= mixed effect/conflicting findings. Harm: Psychological Evidence from quantitative research studies Three quantitative comparative studies and three noncomparative quantitative studies examined the potential for psychological harms in quarantined individuals.
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The study authors do not provide a clear definition of quarantine, and it is possible that some of those considered quarantined were actually in isolation and experienced illness with SARS. For PTSD and depression symptoms, the study was deemed to be of moderate methodological quality, and for alcohol-related symptoms, the study was deemed to be of poor methodological quality because of the use of an unvalidated tool.
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. Six qualitative studies found that the sources for these psychological harms 5 This italicized statement with an associated confidence level is a qualitative evidence finding statement from the commissioned report "Quarantine as a Non-Pharmaceutical Intervention: Qualitative Research Evidence Synthesis" by Pradeep Sopory and Julie Novak (see Appendix C)
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provide low COE regarding the effect of quarantine on psychological harms among quarantined individuals (see Table B4-5)
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= mixed effect/conflicting findings. Harm: Individual Financial Hardship Evidence from quantitative research studies Two quantitative noncomparative studies -- by Reynolds and colleagues (2008)
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Two nonquantitative comparative studies (Kavanagh et al., 2012; Reynolds et al., 2008) provide low COE regarding the effect of quarantine on financial hardship among quarantined individuals (see Table B4-6)
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One nonquantitative comparative study (Adler et al., 2018) provides very low COE regarding the effect of health-promoting leadership on depression in quarantined individuals (see Table B4-7)
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= mixed effect/conflicting findings. Strategies for Improving Adherence to Quarantine Measures Evidence from quantitative research studies A single quantitative noncomparative study examined the implementation of risk communication and messaging and social and resource support strategies as ways of improving adherence to quarantine.
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Summary of the evidence The committee concluded that there is moderate COE that while adherence to quarantine measures can vary by culture, disease, and socioeconomic status, use of various strategies, including risk communication and messaging and access to employment leave, can improve adherence. One quantitative noncomparative study (Kavanagh et al., 2011, 2012; McVernon et al., 2011)
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, whose authors provide analyses for a range of diseases and attempt to provide answers to this question within a common modeling framework.7 Consistent with the findings of Peak and colleagues (2017) , as well as the other modeling studies and the drivers of effectiveness their authors identify or imply, quarantine was more likely to be effective at reducing or stopping the spread of a contagious disease in the following circumstances: 6 An expert in modeling methodology assessed the selected group of quarantine modeling studies in detail, including the specific model structures and equations and how the interventions were instantiated within these structures and equations.
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As a practical matter, for pathogens with a very low R0 (i.e., <1) disease transmission will not be sustained, making quarantine theoretically effective but perhaps practically unnecessary (see also footnote 2 earlier in this appendix)
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and reducing time from symptom onset to diagnosis in quarantined individuals (low COE)
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Most of the case reports reviewed note the unintended consequences or harms related to quarantine, including the potential for increased transmission and mortality due to its inappropriate application, its impact on emergency and routine services, restrictions on civil liberties, psychological impacts and stigmatization, and lost wages and school absence. 4. Acceptability and Preferences Qualitative Evidence Synthesis Nine qualitative studies examined the acceptability of quarantine (Baum et al., 2009; Bell and WHO, 2004; Cava et al., 2005b; Desclaux et al., 2017; DiGiovanni et al., 2004; Leung et al., 2008; Lin et al., 2010; Pellecchia et al., 2015; Robertson et al., 2004)
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The vast majority of respondents expressed strong support for the use of quarantine in a contagious disease outbreak, for legal penalties against absconders, for social supports for those affected, and for public safeguards against potential inappropriate use. A survey conducted by Teh and colleagues (2012)
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A further finding of modeling studies is that if quarantine is implemented in an uncoordinated manner in multiple areas, the result can be redundancy and the expenditure of excess effort and resources. Qualitative Evidence Synthesis The corpus of qualitative studies makes clear that all of the staffing and operational capacities necessary to implement quarantine, such as the ability to initiate a legal order and ensure its enforcement, conduct contact tracing, and monitor adherence to quarantine, currently exist in many agencies and need not be newly created.
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Resources related to the medical care of quarantined individuals include those needed for environmental decontamination, waste management, safe transportation, and availability of sufficient stocks of such supplies as masks and thermometers (Schemm Dwyer et al., 2017; Sell et al., 2018)
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. Three qualitative studies found that health care workers on whom quarantine is imposed may experience additional harms beyond those experienced by the general public (high confidence in the evidence)
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conducted a survey to determine the community's attitude toward pandemic influenza in Australia, and found that respondents who were self-employed or in casual employment were statistically significantly more likely to view being unable to work during home quarantine as problematic. Blake and colleagues (2010)
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Given this ethical justification, one could say that any quarantine action that does not in fact reduce or stop the spread of a contagious disease is, by definition, unethical. Of course, the problem with saying this is that one might not know whether quarantine will be effective until it has been tried.
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Although staffing and operational capacities to implement quarantine currently exist in many agencies, operational limitations may arise when quarantine is implemented on a large scale. Home quarantine may be more feasible than providing designated facilities for quarantined individuals, but is not without concerns over such harms as increased risk of infection among those housed together and challenges with adherence.
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In the United States, these laws are primarily at the state rather than the federal level, which means it is important for public health professionals to be familiar with the specific legal requirements in their locality. CONSIDERATIONS FOR IMPLEMENTATION The following considerations for implementation were drawn from the syntheses of quantitative comparative studies, modeling studies, qualitative research studies, and case reports, as well as descriptive surveys.
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Adapt Policy: Voluntary Versus Legally Enforced Quarantine Synthesis of modeling studies Some modeling studies found that adherence may be greater with less strict quarantine procedures, making those procedures more effective despite them being less strict. Qualitative evidence synthesis Seven qualitative studies found a flexible quarantine implementation policy to be important (Bell and WHO, 2004; Cava et al., 2005b; Charania and
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Provide Financial Compensation, Food, and Social and Psychological Support Synthesis of evidence of effect The committee's synthesis of the evidence of effect showed that an emphasis on health by those leading the outbreak response (i.e., health-promoting leadership, discussed earlier) can reduce depression and anxiety symptoms among quarantined individuals (very low COE)
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suggest that public health emergency preparedness for an Ebola outbreak could be enhanced by engaging a wide range of community partners, such as businesses, schools, charitable foundations, community and faith-based organizations, and mental health providers and organizations in readying support resources to meet potential needs of quarantined individuals (Smith et al., 2015)
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Case report evidence synthesis Given the cultural diversity of the United States, culturally informed strategies may enable more effective quarantine. For instance, during measles outbreaks in a Somali community in Minnesota and an Amish community in Ohio, efforts were made to engage community, religious, and spiritual leaders as advisors because of their strong influence on social networks (Gahr et al., 2014; Gastañaduy et al., 2016)
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investigated factors and specific sociodemographic characteristics that may influence an individual's decision to adhere to quarantine measures. The findings of this survey align with the qualitative and case report evidence regarding the importance of understanding the life circumstances of and working in cooperation with the community to increase adherence.
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Develop Options for Different Levels of Quarantine and Plan for Integration with Other Non-Pharmaceutical Interventions Synthesis of modeling studies The modeling studies reviewed provide a number of other important points regarding the invasiveness of quarantine. Findings from modeling studies that compared quarantine with other, less invasive or intensive interventions, such as symptom monitoring or voluntary reporting, suggest that these alternatives may make it possible to achieve similar levels of effectiveness and control for less transmissible infections that lack asymptomatic infectious periods without incurring the potential harms of social stigma, social and economic disruption, and large-scale use of resources.
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This interagency coordination needs to include plans for the scalability of operations in terms of the number of people placed in quarantine during the course of a contagious disease outbreak. Case report evidence synthesis Findings from case reports indicate that effective control measures do not work in isolation and require coordination among key stakeholders (Tsang and Lam, 2003)
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2009. Emerging Infectious Diseases 16(8)
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2006. When is quarantine a useful control strategy for emerging infectious diseases?
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2003. Transmission dynamics and control of severe acute respiratory syndrome.
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Emerging Infectious Diseases 10(11)
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2006. SARS outbreak in Germany 2003: Workload of local health depart ments and their compliance in quarantine measures -- Implications for outbreak modeling and surge capacity?
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Emerging Infectious Diseases 16(11)
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2008. Ethical guidance for public health emergency preparedness and response: High lighting ethics and values in a vital public health service.
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