Isolating the ill: when to quarantine

"I would rather be too cautious than not cautious enough."

Those were the words of Health Minister Leona Aglukkaq on May 1, 2009, as the number of Canadians coming down with swine flu accelerated.

She had called a news conference to announce the next step in Canada's plan to battle what many believe is an imminent pandemic. The next step, outlined by Canada's chief medical officer of health, was the initial phase of a citizen readiness campaign.

"Knowledge," Dr. David Butler-Jones said, "is our best defence."

Key to the campaign is making sure Canadians understand there are simple steps they can take to protect themselves. Those steps include:

• Wash your hands regularly and use hand sanitizer in public places.
• Stay home if you're sick.
• Wash things that other people might use, like door handles.

There are many more steps the government can take to ensure the overall health of the population — up to invoking the Emergencies Act, which came into effect in 1988, replacing the War Measures Act.

Under the Emergencies Act, the government can:

• Regulate or prohibit travel to, from or within any specified area, where necessary for the protection of the health or safety of individuals.
• Order you to leave any specified area and make arrangements for the adequate care and protection of the persons and property.

China became the first country to order people quarantined — during the current swine flu situation — when it ordered 70 people from Mexico and 25 Canadian students held for a week, even though none showed symptoms of swine flu.

Hans Troeddson, a World Health Organization (WHO) official in China, told CBC News that although the quarantine caused inconveniences for travellers, China is not doing anything wrong.

It is up to each country to determine how it attempts to control the outbreak of the disease, Troeddson said. What China has done so far is in accordance with its policies, he said.

"It's really up to each country and should be in accordance with their own regulations and legislation on public health and protection of the population."

It's also in accordance with Canada's policies. Under Canada's pandemic preparation plan — and the Quarantine Act of 2005 — health officials would be able to do the same thing Chinese health officials did.

Quarantine, if necessary

Under the Quarantine Act, border services officers can call in a quarantine officer if they suspect a person may have come in contact with someone who has a communicable disease or be suffering from such a disease when they are trying to enter or leave the country. The quarantine officer can order the person held until the threat to other people passes. Those who resist can be arrested and held without a warrant.

The pandemic preparation plan calls for quarantine at various stages of the evolution of a pandemic.

In phases four and five — there are clusters of cases resulting from human-to-human transmission outside Canada and some cases in Canada, but we're not yet in full pandemic mode — health officials can recommend people who have been in contact with confirmed cases be quarantined. If they decide against that, they can ask those people to:

• Restrict contact with others for three days after last exposure to the case or for the duration of the incubation period, whichever is longer. 
• Refrain from travelling for the duration of the monitoring period.

Quarantine is for people who have been in contact with confirmed cases of a disease but may not actually be sick or showing symptoms. They're kept in quarantine until tests show that they are disease-free.

'If you are sick, you might be put in isolation'

Quarantine can be voluntary or mandatory. During the SARS outbreak in 2003, people in Singapore who were under a quarantine order had a choice of staying at home or at a designated centre (a resort taken over by the government). In Toronto, anyone who entered Scarborough Grace Hospital after March 13, 2003, was asked to stay home for 10 days because they may have been exposed to a SARS case before the hospital had taken adequate infection control measures. An order could not be enforced, because it would have been extremely difficult to track down everyone who had entered the hospital.

However, if you're already sick, you may be put in isolation — to keep you away from healthy people — until you recover or are no longer contagious. You could be in isolation with a lot of other sick people.

Quarantine and isolation are two methods that health officials use to try to contain an outbreak. But, once an outbreak has progressed to pandemic level — phase six in the WHO's pandemic alert scale — containment is no longer viable. The virus is running rampant.

Canada's pandemic preparedness plan calls for quarantine to be discontinued.

Health officials and the government shift gears in this phase. They may:

• Cancel public gatherings.
• Close schools.
• Modify or refine priority target groups for vaccination.
• Acquire extra supplies to provide medical care at non-traditional sites and open non-traditional sites as needed.
• Monitor capacity of mortuary and burial services as well as need for social and psychological services for families of victims.

But that's only if things get really bad. They haven't been that bad since the 1918-1919 Spanish flu epidemic.