Cochrane
Library
Cochrane Database of Systematic Reviews

   
Quarantine alone or in combination with other public health
measures to control COVID-19: a rapid review (Review)

  Nussbaumer-Streit B, Mayr V, Dobrescu AI, Chapman A, Persad E, Klerings I, Wagner G, Siebert U,  

Christof C, Zachariah C, Gartlehner G

  Nussbaumer-Streit B, Mayr V, Dobrescu AIulia, Chapman A, Persad E, Klerings I, Wagner G, Siebert U, Christof C, Zachariah C,  
Gartlehner G.
Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review.
Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD013574.
DOI: 10.1002/14651858.CD013574.

  www.cochranelibrary.com  

 
Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review
(Review)
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

[Prototype Review]

Quarantine alone or in combination with other public health measures

to control COVID-19: a rapid review

Barbara Nussbaumer-Streit1, Verena Mayr1, Andreea Iulia Dobrescu1, Andrea Chapman1, Emma Persad1, Irma Klerings1, Gernot
Wagner1, Uwe Siebert2,3,4,5, Claudia Christof1, Casey Zachariah1, Gerald Gartlehner1,6

1Cochrane Austria, Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria. 2Department
of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical
Informatics and Technology, Hall in Tirol, Austria. 3Division of Health Technology Assessment and Bioinformatics, Oncotyrol -
Center for Personalized Cancer Medicine, Innsbruck, Austria. 4Center for Health Decision Science, Department of Health Policy and
Management, Harvard T.H. Chan School of Public Health, Boston, USA. 5Institute for Technology Assessment and Department of
Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. 6RTI International, Research Triangle
Park, North Carolina, USA

Contact address: Barbara Nussbaumer-Streit, Barbara.nussbaumer-streit@donau-uni.ac.at.

Editorial group: Cochrane Infectious Diseases Group.

Publication status and date: Edited (no change to conclusions), published in Issue 5, 2020.

Citation: Nussbaumer-Streit B, Mayr V, Dobrescu AIulia, Chapman A, Persad E, Klerings I, Wagner G, Siebert U, Christof C, Zachariah C,
Gartlehner G. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane
Database of Systematic Reviews 2020, Issue 4. Art. No.: CD013574. DOI: 10.1002/14651858.CD013574.

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background
Coronavirus disease 2019 (COVID-19) is a rapidly emerging disease that has been classified a pandemic by the World Health Organization
(WHO). To support WHO with their recommendations on quarantine, we conducted a rapid review on the effectiveness of quarantine during
severe coronavirus outbreaks.

Objectives
We conducted a rapid review to assess the effects of quarantine (alone or in combination with other measures) of individuals who had
contact with confirmed cases of COVID-19, who travelled from countries with a declared outbreak, or who live in regions with high
transmission of the disease.

Search methods
An information specialist searched PubMed, Ovid MEDLINE, WHO Global Index Medicus, Embase, and CINAHL on 12 February 2020 and
updated the search on 12 March 2020. WHO provided records from daily searches in Chinese databases up to 16 March 2020.

Selection criteria
Cohort studies, case-control-studies, case series, time series, interrupted time series, and mathematical modelling studies that assessed
the effect of any type of quarantine to control COVID-19. We also included studies on SARS (severe acute respiratory syndrome) and MERS
(Middle East respiratory syndrome) as indirect evidence for the current coronavirus outbreak.

Data collection and analysis

Two review authors independently screened 30% of records; a single review author screened the remaining 70%. Two review authors
screened all potentially relevant full-text publications independently. One review author extracted data and assessed evidence quality with
GRADE and a second review author checked the assessment. We rated the certainty of evidence for the four primary outcomes: incidence,
onward transmission, mortality, and resource use.
Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review (Review) 1
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

Main results
We included 29 studies; 10 modelling studies on COVID-19, four observational studies and 15 modelling studies on SARS and MERS. Because
of the diverse methods of measurement and analysis across the outcomes of interest, we could not conduct a meta-analysis and conducted
a narrative synthesis. Due to the type of evidence found for this review, GRADE rates the certainty of the evidence as low to very low.

Modeling studies consistently reported a benefit of the simulated quarantine measures, for example, quarantine of people exposed
to confirmed or suspected cases averted 44% to 81% incident cases and 31% to 63% of deaths compared to no measures based on
different scenarios (incident cases: 4 modelling studies on COVID-19, SARS; mortality: 2 modelling studies on COVID-19, SARS, low-certainty
evidence). Very low-certainty evidence suggests that the earlier quarantine measures are implemented, the greater the cost savings (2
modelling studies on SARS). Very low-certainty evidence indicated that the effect of quarantine of travellers from a country with a declared
outbreak on reducing incidence and deaths was small (2 modelling studies on SARS). When the models combined quarantine with other
prevention and control measures, including school closures, travel restrictions and social distancing, the models demonstrated a larger
effect on the reduction of new cases, transmissions and deaths than individual measures alone (incident cases: 4 modelling studies on
COVID-19; onward transmission: 2 modelling studies on COVID-19; mortality: 2 modelling studies on COVID-19; low-certainty evidence).
Studies on SARS and MERS were consistent with findings from the studies on COVID-19.

Authors' conclusions
Current evidence for COVID-19 is limited to modelling studies that make parameter assumptions based on the current, fragmented
knowledge. Findings consistently indicate that quarantine is important in reducing incidence and mortality during the COVID-19 pandemic.
Early implementation of quarantine and combining quarantine with other public health measures is important to ensure effectiveness. In
order to maintain the best possible balance of measures, decision makers must constantly monitor the outbreak situation and the impact
of the measures implemented. Testing in representative samples in different settings could help assess the true prevalence of infection,
and would reduce uncertainty of modelling assumptions.

This review was commissioned by WHO and supported by Danube-University-Krems.

PLAIN LANGUAGE SUMMARY

Does quarantine control coronavirus (COVID-2019) either alone or in combination with other public health measures?

Background

Coronavirus disease 2019 (COVID-19) is caused by a new virus that has spread quickly throughout the world. COVID-19 spreads easily
between people who are in close contact, or through coughs and sneezes. Most infected people suffer mild, flu-like symptoms but some
become seriously ill and even die.

There is no effective treatment or vaccine (a medicine that stops people catching a specific disease) for COVID-19, so other ways of
slowing (controlling) its spread are needed. One of the World Health Organization’s (WHO) recommendations for controlling the disease
is quarantine. This means separating healthy people from other healthy people, in case they have the virus and could spread it. Other
similar recommendations include isolation (like quarantine, but for people with COVID-19 symptoms) and social distancing (where people
without symptoms keep a distance from each other physically).

What did we want to find out?

We wanted to find out whether and how effectively quarantine stops COVID-19 spreading and if it prevents death. We wanted to know if it
was more effective when combined with other measures, such as closing schools. We also wanted to know what it costs.

Study characteristics

COVID-19 is spreading rapidly, so we needed to answer this question as quickly as possible. This meant we shortened some steps of the
normal Cochrane Review process. Nevertheless, we are confident that these changes do not affect our overall conclusions.

We looked for studies that assessed the effect of any type of quarantine, anywhere, on the spread and severity of COVID-19. We also looked
for studies that assessed quarantine alongside other measures, such as isolation, social distancing, school closures and hand hygiene.
COVID-19 is a new disease, so, to find as much evidence as possible, we also looked for studies on similar viruses, such as SARS (severe
acute respiratory syndrome) and MERS (Middle East respiratory syndrome).

Studies measured the number of COVID-19, SARS or MERS cases, how many people were infected, how quickly the virus spread, how many
people died, and the costs of quarantine.

Key results

Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review (Review) 2
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

We included 29 studies. Ten studies focused on COVID-19, 15 on SARS, two on SARS plus other viruses, and two on MERS. Most of the studies
combined existing data to create a model (a simulation) for predicting how events might occur over time, for people in different situations
(called modelling studies). The COVID-19 studies simulated outbreaks in China, UK, South Korea, and on the cruise ship Diamond Princess.
Four studies looked back on the effect of quarantine on 178,122 people involved in SARS and MERS outbreaks (called ‘cohort’ studies). The
remaining studies modelled SARS and MERS outbreaks.
The modelling studies all found that simulated quarantine measures reduce the number of people with the disease and the number of
deaths. With quarantine, estimates showed a minimum reduction in the number of people with the disease of 44%, and a maximum
reduction of 81%. Similarly, with quarantine, estimates of the number of deaths showed a minimum reduction of 31%, and a maximum
reduction of 63%. Combining quarantine with other measures, such as closing schools or social distancing, is more effective at reducing
the spread of COVID-19 than quarantine alone. The SARS and MERS studies agreed with the studies on COVID-19.

Two SARS modelling studies assessed costs. They found that the costs were lower when quarantine measures started earlier.

We cannot be completely certain about the evidence we found for several reasons. The COVID-19 studies based their models on limited
data and made different assumptions about the virus (e.g. how quickly it would spread). The other studies investigated SARS and MERS
so we could not assume the results would be the same for COVID-19.

Conclusion

Despite limited evidence, all the studies found quarantine to be important in reducing the number of people infected and the number of
deaths. Results showed that quarantine was most effective, and cost less, when it was started earlier. Combining quarantine with other
prevention and control measures had a greater effect than quarantine alone.
This review includes evidence published up to 12 March 2020.

Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review (Review) 3
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.