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Table of Contents
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 29-33

“Quarantine”: An unparalleled and pragmatic weapon in the prevention of infectious diseases

Department of General Medicine, SBKS MI and RC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission20-May-2020
Date of Decision01-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Pradeep Sareddy
Department of General Medicine, SBKS MI and RC, E-26, Staff Quarters, Sumandeep Vidyapeeth Campus, Vadodara - 391 760, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIHS.JIHS_11_20

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In the 21st century, the risk for deadly infectious diseases with pandemic potential (e.g., severe acute respiratory syndrome [SARS]) is increasing worldwide with the current pandemic, COVID-19 infecting populations across almost all the countries in the world. In response to the emerging and reemerging infectious diseases as well as acts of biological terrorism, the centuries-old strategy of quarantine is becoming a powerful component of the public health. We made an extensive review of relevant articles from various search engines. During the 2003 pandemic of SARS, the use of quarantine, border controls, contact tracing, and surveillance proved effective in containing the global threat in just over 3 months. In a globalized world which is becoming ever more vulnerable to communicable diseases, a historical perspective can help to clarify the use and implications of a still-valid public health strategy. The historiographer and the experts of public health did not give much attention to isolating the movement and barter of goods or people on land or sea to contain a contagious disease. Yet, a historical perspective of quarantine can contribute to a better understanding of its effectiveness in enclosing current pandemic like COVID-19.

Keywords: COVID 19, pandemics, preventive medicine, quarantine

How to cite this article:
Pandya H, Sareddy P. “Quarantine”: An unparalleled and pragmatic weapon in the prevention of infectious diseases. J Integr Health Sci 2020;8:29-33

How to cite this URL:
Pandya H, Sareddy P. “Quarantine”: An unparalleled and pragmatic weapon in the prevention of infectious diseases. J Integr Health Sci [serial online] 2020 [cited 2020 Oct 26];8:29-33. Available from: https://www.jihs.in/text.asp?2020/8/1/29/288680

  Introduction Top

The history of quarantine—how it began, how it was used in the past, and how it is used in the modern era—is a fascinating topic in history of sanitation. Over the centuries, from the time of the Black Death to the first pandemics of the twenty- first century, public health control measures have been an essential way to reduce contact between persons sick with a disease and persons susceptible to the disease. Quarantine and other public health practices are effective and valuable ways to control communicable disease outbreaks.

  Methodology Top

In the times of the current COVID 19 pandemic, reviewing the historical aspects of the quarantine and the effectiveness in containing the spread of the communicable diseases seemed to be beneficial. Hence, a conceptual design was drafted, and an extensive search for various articles published in this area of interest was conducted in search engines such as Pubmed, Medline, and Google scholar with keywords as quarantine, pandemics, Covid-19, and preventive medicine, and few sources were also reviewed from Wikipedia. A total of 21 published articles and 11 news articles were reviewed and relevant information was gathered for the preparation of the present review article.

  What Actually is Quarantine and from Where it Took Its Origin? Top

Quarantine is reducing the risk of spreading and infecting the people who are not exposed to a contagious disease or person in a community by separating, isolating, and restraining the movement of people who have been exposed to a contagious disease.[1] This definition differs from isolation, which is the separation of people who have been diagnosed with a contagious disease from people who are not sick; however, the two terms are often used interchangeably, especially in communication with the public.[2] The word quarantine comes from quarantena, meaning “forty days,” used during the days of Black Death in the 14th–15th centuries where all ships coming onshore were mandatorily required to isolate the passengers and crew before they could go ashore; it was followed by the trentino or 30-day isolation period, first imposed in 1347 in the Republic of Ragusa, Dalmatia (modern-day Dubrovnik in Croatia).[3],[4],[5],[6] Quarantine may be used interchangeably with cordon sanitaire, which refers to the restriction of movement of people into or out of a defined geographic area, such as a community, to prevent an infection from spreading.[7] The concept of quarantine was strongly embedded in the preventive practices of medicine globally for centuries. In the present situation, where the world is suffering from one of the most devastating pandemic without having a definitive treatment, “Quarantine” is one of the most searched works on various search engines as the people of the current century were not familiar with the term, which evoked fear, anxiety, curiosity, and anger toward its implementation. This review was an attempt to address the various aspects of quarantine in terms of the usefulness, psychological impact, prevailing laws, and most importantly, the practicality of its implementation in the prevention of emerging and reemerging infections.

  Historical Aspects and Evolution of Quarantine Top

For the people of the 21st century, quarantine might be new and power pack tool of the public health services, but for centuries, this practice remained cornerstone preventive strategy against emerging and reemerging infectious diseases. Perhaps, the earliest documented mention of isolation dates back to the 7th century of before, in the Biblical book of Leviticus, which describes the procedure for separating out infected people to avoid spreading of disease under the Mosaic Law.[8] The birth of quarantine was related to the history of the Black Death in Europe. In the middle of the 14th century, after the repeated waves of plague swept across the continent, this strategy of keeping the plaque infected or exposed persons out of the city was used in many regions. In the Mediterranean sea port of Ragusa (modern-day Dubrovnik, Croatia) to strengthen these effects, a law establishing a trentino or 30-day isolation period was passed in 1377. Further extending to 40 days, the term “trentino” had been changed to “quarantine”-derived from Italian word quaranta which means forty.[9],[10] The precise reason for changing the duration to 40 days was not known, but some of the theories put forward are (i) shorter duration might be found insufficient for preventing disease spread,[11] (ii) duration reflects the same biblical events such as great flood, Moses stay in Mt Sinai, or Jesus stay in wilderness,[12] (iii) derived from the ancient Greek doctrine of “critical days.”[12] Although the underlying rationale for 40 days duration may not be discovered, the basic concept assimilated in quarantino formed basis for quarantine which prevailed and took driving seat in modern medicine as an important preventive measure. Quarantine period may vary according to disease in question. Other diseases like plague required people to be in quarantine before and after the devastation of the plague, whereas in the case of a suspected anthrax attack, people are allowed to leave or abort quarantine as soon as they shed their potentially contaminated garments and undergo decontamination shower.[13]

  Notable Quarantine Incidences Top

We reviewed here some of the notable quarantine incidences in history which lead to effective containment of the infection, thereby laying a foundation for the modern-day quarantine concept. During the 1492 syphilis outbreak in Northern Europe, strict quarantine measures were implemented, thereby leading to the containment of the disease. In July 1814, the convict ship Surry on arrival at Sydney Harbor from England was placed in quarantine on the North Shore, as 46 people had died of typhoid during the voyage. This was the first site in Australia to be used for quarantine purposes.[14] The second pandemic of cholera started in Asian countries and spread over the Asian continent and all over the Europe in between 1829 and 1831, [Figure 1]. Britain passed several laws to help detain or limit the spread of the disease, which included schemes such as implementing quarantines and establishing district boards of health and family welfare. Mary Mallon was a cook who was found to be a carrier of Salmonella enterica, the cause of typhoid fever, and was forcibly isolated from 1907 to 1910 [Figure 2]. Before spending her life in isolation for 23 years, she at least infected 53 cases which were traced to her and included three deaths. The presence of the bacteria in her gallbladder was confirmed on autopsy.[15] During the 1918 flu pandemic, Governor of American Samoa imposed a full quarantine of the islands from all incoming ships, successfully achieving zero deaths within the territory.[16] In contrast, the neighboring New Zealand-controlled Western Samoa was among the hardest hit, with a 90% infection rate and over 20% dying from the disease.[17] In 1942, during World War II, British forces tested out their biological weapons program on Gruinard Island and infected it with anthrax. Subsequently, a quarantine arrangement was enacted on the island. The quarantine was lifted in 1990[18] when the island was declared safe. A self-imposed protective sequestration of Eyam village in Britain was done in 1965 to stop the spread of Bubonic plague. The plague ran its course over 14 months and one account states that it killed at least 260 villagers.[19] The 1972 Yugoslav smallpox outbreak was the final outbreak of smallpox in Europe. The World Health Organization fought back the outbreak with strict and comprehensive quarantine, and the government enforced military deployment. In 2014, Kaci Hickox, a nurse from Doctors without Borders from Maine, legally challenged 21-day quarantines imposed by the states of New Jersey and Maine after returning home from caring for Ebola virus-infected patients in Sierra Leone.[20]
Figure 1: In the 1890s, travelers from Switzerland were quarantined in Italy to make sure they did not have cholera HIP/Art Resource, NY

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Figure 2: Mary Mallon, known as “Typhoid Mary,” was immune to the typhoid she carried. Working as a cook, she spread the disease in New York and ended up quarantined on Brother Island (above) for more than two decades Bettmann/Corbis

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  Present-Day Quarantine Laws Top

As the years passed, the concept of quarantine remained the same but modified according to the disease and prevailing situations. Some countries notably the United States of America, the United Kingdom, Canada, and Australia make federal laws and standard protocols for enacting the strict implementation. As it varies according to the countries' federal law, in the United States, state and the federal governments both amend the laws for quarantine of people with infectious disease. States have primary authority to quarantine people within their boundaries. Federal jurisdiction only applies to people moving across state or national borders or people on federal property.[21] Biosecurity in Australia is governed by the Biosecurity Act 2015. Northern Australia is free of many pests and diseases which is a major border where The Australian Quarantine and Inspection Service is in control of border inspection of products imported into Australia and assesses the risks the products might harm Australian environment. This being the reason, the region along the Northern border is the locus for quarantine facilities and activities that protect all general population.[22] There are three quarantine Acts of Parliament in Canada: Quarantine Act (humans), Health of Animals Act (animals), and Plant Protection Act (vegetations). In India, The Epidemic Diseases Act of 1897 was first enacted to tackle the outbreak of the bubonic plague in Mumbai in former British India and is frequently applied to the containment of epidemics such as cholera, malaria, dengue fever, and swine flu. The enforcement of quarantine law and clamping of a nationwide lockdown has been implemented in dealing with COVID 19 pandemic. The concept of quarantine provides for social distancing to contain the spread of the virus and undertake measures to ensure the maintenance of essential services and supplies.

  Quarantine in the Fight Against Covid 19 Pandemic Top

In Hubei, the origin of the epidemic, a cordon sanitaire was imposed on Wuhan and other major cities, affecting around 500 million people, which is unprecedented in scale in human history, to limit the rate of spread of the disease.[23] The “lockdown” of Wuhan, and subsequently a wider-scale “lockdown” throughout Hubei province, beginning on January 23, 2020, brought down the rate of growth in cases per day in mainland China from approximately 50% to below 10% within a span of 2 weeks, which was a significant change. As the outbreak spread in Italy, beginning February 22, 2020, a cordon sanitaire was imposed on a group of at least ten different municipalities in Northern Italy, effectively quarantining more than 50,000 people.[24],[25] After a week's time, the detection rate significantly reduced all the way from 567% to 23%. On the next day, the quarantine was extended to the whole of Italy, effective on March 10, 2020, placing roughly 60 million people under quarantine.[26] As cases of the virus spread to and took hold in more European countries, many followed the earlier examples of China and Italy and began instituting policies of lockdown. Notable among these were Ireland,[27] Spain,[28] the Czech Republic, Norway, Denmark, Iceland, Poland, Turkey, and France, while the United Kingdom noticeably lagged behind in adopting such measures.[29] In the immediate context of the start of the pandemic in Wuhan, countries neighboring or close to China adopted a cautious approach. For example, Sri Lanka, Macau, Hong Kong, Vietnam, Japan, and South Korea had all imposed some degree of lockdown by February 19.[30] In India, a complete lockdown was implemented in two phases beginning from March 25, 2020, to April 14 being the first phase and second phase from April 15, 2020, to May 3, 2020. It was followed by the third phase of lockdown with the same restrictions in high-risk areas and gentle relief in other areas. As the disease spread and infectivity rate and death rate continued to rise in various countries, bringing almost every country under its wing, countries increasingly began to denounce their travel schemes, be it by land/air or sea route and enforcing lockdowns and restrictions of public transport.[30] Africa and Latin America were relatively delayed in the spread of the virus, but even on these continents, countries began to impose travel bans and lockdowns. By the start of April, much of Africa was on lockdown.[30] Hence, in the current pandemic, the quarantine had given fruitful results in most of the countries, by containing the infectious agent and thereby preventing the spread of Covid-19, which may had caused a major catastrophe in the history of humankind.

  Psychosocial Impact of Quarantine Top

Quarantine is often an unpleasant experience for those who undergo it. Longer periods of quarantine were associated with posttraumatic stress symptoms, avoidance, and anger feared for their own health and/or fears of infecting others. Sometimes, frustration and boredom during quarantine can cause irritable behavior among the family members. Having inadequate basic supplies (e.g., food, water, clothes, or accommodation) during quarantine led to frustration can on occasion lead to anger. Having inadequate socioeconomic stability can lead to starvation and even. Suicide has been reported, substantial anger generated, and lawsuits brought following the imposition of quarantine in previous outbreaks.[31],[32] The potential benefits of mandatory mass quarantine need to be weighed carefully against the possible psychological costs. Successful use of quarantine as a public health measure requires us to reduce, as far as possible, the negative effects associated with it. A notable number of studies [33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] had been conducted in recent times and studied the impact of quarantine on humans in terms of psychological and social life. Most studies concluded negative psychological effects including posttraumatic stress symptoms, confusion, and anger. Stressors include prolonged quarantine time, getting infected or risk of infecting other, frustration, boredom, inadequate supplies, economic loss, and loss of social behavior. Some experts were of the conclusion that these effects can be long lasting. In such situations, officials should provide the information regarding the importance of quarantine via social media and the individuals should be quarantined for no longer than required period, ensuring sufficient supplies in terms of food and financial help. Efforts and appeals of selflessness by the people about the benefits of quarantine can ensure well-being of the society as a whole.

  Financial Burden of Quarantine Top

Financial loss can be a problem during quarantine, with people unable to work and having to interrupt their professional activities with no advanced planning; the effects appear to be long lasting. In the reviewed studies, the financial loss as a result of quarantine created serious socioeconomic distress [42] and was found to be a risk factor for symptoms of psychological disorders [44] and both anger and anxiety several months after quarantine.[45] A study [37] of people quarantined because of potential ebola contact found that although participants received financial assistance, some felt that the amount was insufficient and that it came too late; many felt wronged as the assistance they received did not cover their ongoing professional expenses. Many became dependent on their families to provide for them financially during quarantine which was often hard to accept and could cause conflicts. In one study,[36] none of those quarantined in Toronto during severe acute respiratory syndrome reported much financial hardship because employers or the government compensated them, but where that reimbursement was slow to arrive, it caused those less financially well off to struggle. Financial reimbursements should be provided where possible and programs developed to provide financial support throughout the quarantine period.

  Conclusion Top

Quarantine is an age-old practice, which had given significant results in the prevention of spread of the diseases many times in the history of humankind. Similar to other measures, quarantine is not a complete remedy for all diseases and has its own limitations. Since the turn of the 20 century, nonprophylactic interventions have had a diminishing impact in preventing the geographical spread of communicable diseases. The decline in their general utility as control interventions has been witnessed by changes in the speed and volume of international travel. Now, no parts of the populated globe are more than 24–48 h apart, well within the incubation period of most communicable diseases. This can allow the inter-area disease spread to occur asymptomatically and thus undetected perpetuating chains of infection. The main value of quarantine and isolation today is that careful use (with regard to situation and duration of implementation) will delay rather than prevent intercommunity propagation of infection. These interventions may thus buy precious time to deploy other control methods such as vaccines. Quality evidence overall suggests that the basic concept of quarantine is still fully valid and that the implementation of correct quarantine procedures must be tailored according to individual disease and geographical conditions with special consideration to psychosocial and financial aspects.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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