By Dr. Osama Ummer
Image courtesy: 99designs.com
In the absence of any specific treatment, the only available public health tools to control the transmission of a disease are isolation and quarantine, physical distancing, testing, tracing and surveillance.
What is isolation and quarantine?
Isolation and quarantine helps to protect the public by preventing exposure to people who have or may have a contagious disease.
Isolation separates sick people with a contagious disease from people who are not sick.
Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
So, what exactly is reverse quarantine or reverse isolation?
The ‘reverse quarantine’ approach is opposite to what is mentioned above. It is an approach that separates those people who are vulnerable, and are not exposed to infection or are asymptomatic, from the rest of the people within homes and preventing anyone from introducing an infection to them. The concept is not just about isolating the vulnerable, it is about providing them with adequate health care and other basic services. This could either be implemented in a special facility or at home itself with appropriate measures.
Who are those vulnerable/high risk groups?
The virus that causes COVID-19 infects people of all ages. However, evidence available till date suggests that certain groups of people are at a higher risk of getting severe COVID-19 disease than the rest. These are older people (i.e. people over 60 years old); those with underlying medical conditions (such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer); those with a weaker immune system from a medical condition or because of ongoing treatments, such as chemotherapy or any other immunosuppressive conditions.
Do we need reverse quarantine?
The risk of severity of the disease gradually increases with age starting from around 40 years. It is important that adults in this age group protect themselves and in turn protect others that may be more vulnerable. It is significant to follow this strategy since it keeps high risk individuals farther apart, making every opportunity for transmission marginally lower. The reports show that over 95% of the deaths occurred in those older than 60 years. Whereas, more than 50% of all deaths were people aged 80 years or older. It was also reported that 8 out of 10 deaths are occurring in individuals with at least one underlying comorbidity, mostly those with cardiovascular diseases/hypertension and diabetes, but also with a range of other chronic underlying conditions.
In India, those above 60 years of age account for 60% of COVID-19 deaths as reported by Union Health Ministry on 6th April 2020. However, the age-group analysis of COVID-19 patients in India shows that most patients (42%) are of 21-40 years, 33% of 41-60 years, 17% are above 60 years and 9% are of 0-20 years. Similarly, in Maharashtra, a primary analysis of the 45 COVID-19 deaths till 5th April showed that the minimum age of 60% of the deceased was 61 years, and 78% had ailments like diabetes, hypertension and other serious illness. This is not the case just with COVID-19; many infectious diseases, like Severe Acute Respiratory Syndrome (SARS), influenza, Middle Eastern Respiratory Syndrome (MERS) and dengue, had this kind of situation.
Italy, which is among the worst-hit countries today, registered such a large number of death from COVID-19 because one-fourth of its population, around 13 million people, is elderly and likely had comorbidities like cancer and diabetes. While the demographics differ in India, of concern is that in sheer numbers, the elderly population of India far outnumbers that of Italy. According to the 2011 census, 5.3% of the Indian population is older than 65 years, i.e. roughly 64 million people. Additionally, India is considered as the world's capital of diabetes with 49% of the world’s diabetes burden, a total of 72 million people. Even if 1% of this population was infected, they would likely develop a severe form of illness requiring ICU care and mechanical ventilation, said Giridhar R. Babu, an epidemiologist at the Public Health Foundation of India, New Delhi.
“Low-level community transmission might actually render herd immunity to the community but special measures will have to be taken to protect the elderly during this time,” a public health expert in The Hindu
Despite the best efforts, if we are no longer able to detect all infected people and their contacts in the attempt to slow the spread of disease, a possible next step is to apply community-wide containment measures, which is far more complex than isolation or quarantine because of the larger number of people involved. These include more stringent measures ranging from self-reporting, strict physical distancing among community members including cancellation of public gatherings, and finally implementing community quarantine.
We could implement this strategy with increased community support to ensure that high risk groups are protected from COVID-19 without being isolated, stigmatized, left in a position of increased vulnerability or unable to access basic provisions and social care. It will also allow individuals to adhere to WHO advices on receiving visitors, planning for supplies of medication and food, going out safely in public and staying connected with others through phone calls or other means. It is essential that these groups are supported by their communities during the COVID-19 outbreak. Many countries like Germany, Sweden, Iceland, South Korea, etc. have either directly or indirectly implemented the principles of reverse quarantine/isolation. At the same time we can’t negate the inherent differences in the sociocultural aspects of our society.
“We need to work together to protect older people from the virus. Older people carry the collective wisdom of our societies. They are valued, and valuable members of our families and communities but they are at higher risk of the more serious complications of COVID-19”, said WHO director general, Dr. Tedros Adhanom
The lock-down for a prolonged period of time is not a desirable method anywhere in the world as it could hinder everyday life and livelihood of the people. The reverse quarantine is an effective answer to the question of how to save lives without affecting the economy in the long run. It is understood that this strategy should definitely be accompanied by strengthening public health systems with adequate testing kits, sufficient Personal Protective Equipments (PPEs) for health workers, Intensive Care Units (ICUs), ventilators, and other social initiatives.