Podcast: Quarantine versus isolation: What's the difference?
Transcript
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Kirsten Patrick: I'm Dr. Kirsten Patrick executive editor for the Canadian Medical Association Journal and today I'm speaking with two of the authors of a practice article on quarantine. Dr. Wayne Gold and Dr. Eric Coomes are joining me from Toronto to discuss their article. Hello.
Wayne Gold: Hello thanks for having us.
Kirsten Patrick: Please, can you tell our listeners a little bit about who you are? Wayne, you go first.
Wayne Gold: So by way of introduction, I'm an infectious diseases specialist at the University Health Network and Sinai Health Systems in Toronto. I also serve as the deputy physician and chief for education at those two hospitals. I'm also the residency program director for the adult infectious diseases program at the University of Toronto and supervise residency training in infectious diseases.
Kirsten Patrick: And Eric?
Eric Coomes: Yeah so I'm I'm Eric Coomes. I'm one of the residents who are training in the infectious diseases program here at the University of Toronto and I'm currently on a dedicated infection prevention and control elective related to the COVID-19 outbreaks.
Kirsten Patrick: So I'm curious about how your days have been of late Eric. Can you tell us what the life of a resident is like at the moment?
Eric Coomes: Absolutely. So as a resident training in infectious diseases this is a really important time for all of us in the hospital. Really what I'm seeing as I'm on my dedicated infection prevention and control block is that from a day-to-day perspective we are really trying to scale up the use of telemedicine to safely provide care to patients and at the same time I can see significant preparations and scaling up that's occurring for infection control efforts to not only keep our patients but also importantly our healthcare workers safe during this ongoing pandemic.
Kirsten Patrick: Wayne, what do your days look like?
Wayne Gold: For myself part of my days are very much like they always have been and part of my days are very much different with an increased number of teleconferences and emergency planning meetings in order to build response efforts. Currently, I'm attending on the infectious disease consultation service at University Health Network Sinai Health System providing clinical care and teaching I have scaled back my ambulatory practices to reduce traffic through the hospital and whenever possible and I'm engaging in virtual care in my educational roles I'm currently spending significant time on educational planning including how we will provide care in the face of surging patient volumes and how we will restructure our resident run services in order to fill in care needs on services that will likely need an escalation of volumes while maintaining safe patient care and to ensure the wellness of our trainees both psychologically and physically.
Kirsten Patrick: So you've written this article on quarantine for CMAJ. Can you help our listeners to understand the difference between quarantine, isolation and social distancing?
Wayne Gold: All of the measures that you have stated are means of infectious diseases containment specifically quarantine refers to sequestering healthy asymptomatic persons who have been exposed to an infectious disease for the duration of their incubation period to prevent further spread. In the case of COVID-19 if a healthy person that gets exposed to a person with a documented infection they would be instructed to self quarantine for 14 days. Quarantine has been used in both ancient and modern times dating back to the 14th century Italy when ships stayed for 40 days at port to prevent the spread of black death or the bubonic plague. It has also been used in Canada for both the SARS outbreak in 2003 and our current COVID-19 pandemic. Quarantine can be applied to individuals, groups of exposed individuals and entire geographic locations such as has happened with the national quarantine in Italy. In contrast, isolation refers to separation of patients with active infection from healthy unexposed persons to prevent its transmission. Pragmatically, they both mean staying at home monitoring your self for symptoms, avoiding contact with others, and if there are other people living in your home, staying in separate rooms using a separate bathroom, maintaining a distance between yourselves, wearing a mask for brief interactions, not sharing personal items and disinfection of surfaces that are touched. To contrast the two our prime minister's wife Sophie Gregoire Trudeau has COVID-19 infection and is under isolation. While our Canadian Prime Minister Justin Trudeau, who is exposed to her and is asymptomatic is under voluntary quarantine.
Eric Coomes: Exactly. And in addition to quarantine and isolation, there is one more containment strategy, social distancing, which is where people at a broader scale make a deliberate effort to keep a physical distance between themselves and others to prevent the transmission of disease. These sorts of distancing measures would be applied to everyone, regardless of exposure or disease status. And already in the current outbreaks of COVID-19, we've seen this applied across multiple social events, travel restriction, and then more recently, the extended closure of schools after March Break, and of particular relevance to our medical trainees, the cancellation of licensor examinations.
Kirsten Patrick: Could you explain then, what the purpose is of social distancing? So if healthy people are distancing themselves from other presumably healthy people, what's the purpose of that?
Eric Coomes: For sure. So there's the possibility that people have been exposed to the infection, or someone who has COVID-19 without even realizing it. They are either in the asymptomatic or early symptomatic phase of infection, and not realize that they have the potential to transfer the infection on to someone else who's healthy and unexposed. And so by applying social distancing, and make these almost a normalized practice, we can help minimize these less recognized or unrecognized avenues for disease transmission.
Kirsten Patrick: So I was just looking on Air Canada. And I saw that the directive that the Canadian government put out is that people coming in from other countries will be quarantined for 14 days after they arrive in the country. Now is quarantine or isolation for that matter enforceable under the law.
Wayne Gold: So under the Canadian quarantine act, this applies to border settings. And in that at border settings, quarantines are enforceable by the federal government. It dates back to the 1870s and was updated in 2005 after the SARS epidemic. The Canadian quarantine act, including incoming flights and people traveling into Canada from abroad, protects the Canadian borders and falls under the jurisdiction of the federal health minister. It allows the federal health minister to enact measures from screenings to mandatory quarantine at Canadian borders. At the provincial level, quarantine falls under the Health Protection and Promotion Act, specifically in Ontario, where medical officers of health may invoke quarantine and isolation. While quarantines are enforceable by law, I would like to note that more than 15,000 people in Toronto were quarantined during SARS. While only 27 formal orders were issued in the city of Toronto. This was an extraordinary testament for people wanting to do the public good. This means that the majority of people quarantined during SARS did so voluntarily because of their understanding of the risk of exposure or through direction with public health. The 27 formal orders issued are done in circumstances where people fail to comply with quarantine. And this can result in either financial penalty and or being kept under detention.
Kirsten Patrick: That's really interesting. I had no idea how it worked. How do you identify obviously, if somebody is not complying with quarantine, and they're going out then who has to bring that complaint? Is it the Ministry of Health, the city?
Wayne Gold: All of this is delegated to the medical officers of health and they are charged with enforcement of quarantine at the local levels. And also surveillance of people under quarantine. So this may be done through check-ins, through virtually by connecting with people and people may also report people who they they know are failing to comply with self quarantine orders.
Kirsten Patrick: So you were talking about people who were quarantined during the SARS outbreak in 2003. Some of them voluntarily and then a number of orders for quarantine. What did we learn from that experience?
Wayne Gold: I cannot overstate the benefit of quarantine on the ultimate control of SARS in Toronto and Ontario in 2003. At that time, I was a first line healthcare worker managing persons with SARS, and also running our inpatient unit. During that time, more than 15,000 people were quarantined during the outbreak. While we recognize the tremendous beneficial impact of quarantine during SARS, it is also important to acknowledge that hardships due to quarantine exists. And that those lie both at the individual level and at the societal level. It was clear to me in the early phases of SARS, that there was significant psychological impact of quarantine. We're basically telling people to restrict movement and stay away from those persons they love most. I was involved at that time and work assessing the psychological impact of SARS. Through a voluntary survey conducted through public health, we were able to determine that upwards of 30% of people who were quarantined experienced symptoms of both post traumatic stress disorder and depression. We also learned that longer durations of quarantine and more stringent adherence to quarantine measures were associated with a higher prevalence of the symptoms. As well as being an acquaintance of someone who had SARS. Recent reviews of the literature published in The Lancet have shown that having inadequate information, experiencing financial loss and experiencing stigma add to the stress. What we learned during SARS is that to promote compliance, quarantine persons need ongoing access to resource materials, open lines of communication and psychological support. I might add that quarantine during SARS and that during COVID-19 may differ due to the use of social media and the internet connectedness of our populations. While FaceTime, Skype and Zoom may provide ways for people to socially connect virtually and may mitigate against feelings of isolation and stress, there is the potential for access to information through social networks from unreliable sources that may exacerbate stress and anxiety. I also learned through leading the efforts during SARS with people at our hospital that the ability for people to cope with the stress will be enhanced by clear communication styles and medical leaders as well as experts in the field. Based on the work that I was involved in, acknowledging uncertainty and not overly reassuring people is important to ensure that they don't develop mistrust when situations change. Finally, I will speak on my role as a residency program director. Providing clear and concise information from a central source to avoid conflicting information and misinformation is essential for our learners. They are frontline health care workers who are under considerable stress, and we need to understand their needs and provide needed support to them.
Kirsten Patrick: So what's your message at this time to the public, policymakers and healthcare workers?
Eric Coomes: There's so many things to be said about the ongoing coronavirus outbreak. But to start for the public, we all would like to acknowledge that the past few months during this global outbreak of COVID-19 has been overwhelming. And as health care workers, we appreciate the impact that this pandemic has had on our work, and all of our day to day lives and activities. It's important for us to understand that we're all in this together and what can we do, we need to wash our hands, make sure we stay away from others while we're sick and try to practice social distancing to minimize spread of infection. Now, for policymakers, I think it's really important to listen to the guidance of our public health and physician advocates as we build our national response to COVID-19. And not only that, but please continue to support medical research, so that we may develop further understanding of this novel emerging infection and at the same time, develop effective therapeutics, vaccines and control strategies. And lastly, for all of my peers working in healthcare, I want you to know that we all appreciate everything that you do. We know the tireless efforts that you're all making to care for patients. But despite all that is going on, don't forget to take care of yourself. We're all working together to provide care for patients during the ongoing pandemic.
Wayne Gold: And I will add that having a healthy physician workforce, both physically and psychologically, is the best way to care for our patients.
Kirsten Patrick: Well, absolutely, thank you. And that's a great message to end on there. Take care of yourselves. Thank you for taking the time to join us.
Eric Coomes: It was a pleasure. Thanks for having us.
Kirsten Patrick: I've been speaking with doctors Eric Coomes and Wayne Gold. Dr. Coomes is an infectious diseases resident at the University of Toronto, and Dr. Gold is an infectious disease specialist at UHN Sinai Health Systems and the residency program director. To read the practice article they coauthored with Dr. Jerome Leis, visit cmaj.ca. We also have a special page dedicated to all our COVID-19 related content, we encourage you to book mark it. I'm Dr. Kirsten Patrick, executive editor for CMAJ. Thank you for listening.