As the COVID-19 epidemic continues to unfold in the U.S. and around the world, the media and scholars are increasingly talking about isolation, quarantine, and social distancing. Sometimes the words are used as if they are interchangeable, but they’re not: they have differences in meaning that are quite significant. What are those differences, and what do they mean for public health officials and the public?
Isolation and Quarantine
Isolation and quarantine are communicable disease control strategies that are used to contain the spread of disease in a population. The terms are often used together and they have similar meanings, but there is a key distinction: isolation is used for people who have known or suspected infections (in other words, they’re sick), while quarantine is used for people who are at risk of becoming infected, usually because they have a known or suspected exposure to an infected person.
Isolation limits the freedom of movement or action of a person who is infected with a communicable disease or condition, or who is reasonably suspected of being infected. G.S. 130A-2(3).
In North Carolina, either a local health director or the State Health Director may issue an isolation order to an infected person. In practice, an order is usually issued by a local health director. G.S. 130A-145(a). The local health director is the lead public health official for a county—either the director of the local health department, or in counties with consolidated human services agencies, the person who has been designated to serve in the local health director role.
At present, individuals with known or reasonably suspected COVID-19 are being isolated. Isolation can occur in an individual’s home, unless the individual needs to be in a health care facility to have his or her medical needs met.
Quarantine limits the freedom of movement or action of a person who has been exposed to a communicable disease or condition, or who is reasonably suspected of having been exposed. In North Carolina, the quarantine authority can also be used in two additional circumstances: (1) to limit access to an area or facility that may be contaminated with an infectious agent, or (2) to limit the freedom of movement of unimmunized persons during an outbreak of a vaccine-preventable disease. G.S. 130A-2(7a). Either a local health director or the State Health Director may issue a quarantine order, but as with isolation orders, in practice an order is usually issued by a local health director.
The term “quarantine” is sometimes used colloquially to refer to actions that affect geographic areas rather than individuals. For example, a news program I watched last night used “quarantine” to describe the actions that other countries have taken to prohibit people from entering or exiting large geographic areas. This is an outdated concept of quarantine that has not been used in the state in decades, is not considered good public health practice, and is likely not supported by North Carolina’s quarantine laws. Our state’s definition of quarantine refers primarily to individuals who are at risk, either because of exposure to a communicable disease, or lack of immunization against a vaccine-preventable disease. Although the definition of quarantine also refers to property that is contaminated by an infectious agent, that would seem to require that the property be the risk, not the individuals within it. For example, a building could be contaminated by anthrax spores, an infectious agent. Further, the state’s emergency management laws provide other state and local officials the authority to address larger geographic areas. I will leave it to my colleague Norma Houston to address those laws in a blog post that will be published later this week. For my purposes, I think it’s sufficient to say that local health directors should not expect to use their quarantine authority to address geographic areas, and they should certainly be collaborating closely with local emergency management as they prepare to respond to COVID-19.
Individuals who are reasonably suspected of having an exposure to a person with COVID-19 are undergoing risk assessments to determine what medical follow-up they need and whether they need to be quarantined. Communicable disease professionals in local health departments are conducting the risk assessments according to guidelines provided by state and federal public health officials. If the risk assessment indicates that the person’s movement should be restricted, public health officials will direct the individual to stay home (or in another location that will be arranged if necessary—for example, if the person does not have a home). The person will also be instructed to monitor symptoms and communicate with the local health department. The department will explain and provide documents with the details of the symptom monitoring and communication requirements. In addition, the local health director may issue a quarantine order.
The North Carolina Division of Pubic Health (DPH) has template isolation and quarantine orders that are specific to COVID-19, as well as guidelines for their use. Local health directors and their attorneys can obtain the templates and guidelines from DPH’s Communicable Disease Branch.
I discuss isolation and quarantine in more detail in Chapter 6 of my 2017 book, North Carolina Communicable Disease Law. The chapter is presently available for free through the School’s COVID-19 resource site.
Social distancing refers to strategies that focus on keeping people from coming into close contact with others who might be ill. Social distancing guidelines are different for different diseases. For COVID-19, the Centers for Disease Control & Prevention (CDC) defines social distancing as “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.”
Social distancing strategies may be undertaken voluntarily, but they could also be made mandatory in some circumstances. If they became mandatory, who would have the authority to enforce them? It depends. It’s possible that social distancing strategies could be adopted as communicable disease control measures, in which case public health officials would have some relevant authority (see G.S. 130A-144). But other state and local officials are likely to be involved in social distancing strategies, especially if they involve closures of public spaces, cancellations of events, and similar actions taken under state or local emergency declarations. For more information, watch for my colleague Norma Houston’s blog post on emergency authorities later this week.
Earlier today, N.C. Governor Roy Cooper announced a state of emergency in North Carolina because of COVID-19. Simultaneously, the N.C. Department of Health and Human Services issued recommendations for the public intended to slow the spread of the outbreak and reduce the number of people infected. Among other things, the recommendations include some social distancing strategies, especially for high-risk individuals. DHHS’s COVID-19 Mitigation Guidance is available here.
For More Information
The situation with COVID-19 is evolving very rapidly so recommendations could change. Blog readers are encouraged to visit the N.C. DHHS Coronavirus website for updated information.
The School of Government will host a webinar on Tuesday, March 24: Coronavirus in the Workplace and the Community: A Primer for N.C. Local Governments. The live webinar is full but you can register for the on-demand (recorded) version, which will be available for viewing on March 25.