Tina Abi Abdallah. Lost in isolation, Don't Forget the Bubbles, 2020. Available at:
The WHO declared COVID-19 a pandemic on 11 March 2020, and encouraged countries to “take urgent and aggressive action….”
One of the best ways we can reduce the numbers is to stay away from each other. A lot of terms have been bandied around so let’s make things a little clearer.
Social distancing: Everyone is encouraged to reduce the number of close physical and social contacts they have with one another. The current recommendation of 1.5 metres is just about too far to cough. What has been apparent over the last few weeks is the difference between physical distancing and social distancing. Whilst we are staying in our houses we are connecting more than ever.
Isolation: Those who have been diagnosed with COVID-19 (until medically cleared) or have returned from overseas or been in close contact with a person diagnosed with COVID-19 (within 14 days), must stay at home/in a hotel room and are not permitted to go to any public places. This can be self-imposed or imposed by an authority. Isolation is assigned to people who have been diagnosed with the disease while quarantine is assigned to those who have potentially been exposed to the disease.
The process of quarantine has been around since the 14th century at a time when Venice was the hub of the known universe. As a key port at the heart of the Mediterranean, it was the point of entry of the plague to mainland Europe. Ships would raise the yellow and black checked flag to let everyone know that they were at anchor for quaranta giorni, or forty days.
Lockdown: A government-enforced quarantine of a population with strict travel restrictions, closure of schools/universities/businesses with people required to stay at home (with the exception of essential services – as deemed by that government).
Although the WHO did not explicitly direct countries to go into lockdown, several nations such as China, Italy, France, Spain, South Africa, Poland, India, New Zealand and more recently, the UK has commenced nationwide lockdowns. Australia has slowly been introducing a lockdown, with gradual closures of non-essential services over the last two weeks. With almost a third of the world’s population in lockdown in an attempt to contain COVID-19, the question is are how effective will these public health measures be in reducing viral transmission, how will we all cope, and are there measures to help protect our health and well-being during this time?
Effectiveness of social distancing
There is very little research looking at the impact of social distancing measures in the workplace during pandemics. Ahmed et al. (2018) conducted a systematic review looking at the effectiveness of social distancing in delaying the influenza peak. The hope is that this would allow time for vaccine development and distribution, would reduce stress on the health care system, and would reduce the overall number of influenza cases, thus decreasing morbidity and mortality. A total of 15 studies were included in the review. Some other studies looked at other options such as staggered work hours, spacing workers and the use of telecommunications/remote meetings. Overall, these measures did reduce the overall number of influenza cases as well as reduce and delay the peak.
The biggest question on many parents’ minds is, “should I be sending my child to school?” Given that almost all workplaces have now transitioned to working from home (WFH – another new acronym being embedded into our daily lives), why are schools remaining open in Australia? Overseas, countries across Asia have taken different approaches to this issue, and all with varying results. Singapore has kept nationwide COVID-19 infections down whilst keeping all their schools open, whilst the US has opted for rapid shutdown of schools. The closure of schools has a significant impact on children, with disruption of the normal routine, interrupting learning and potentially delaying academic progression. It also has a big impact on the health workforce, many of whom have school-age children.
A 2018 review by Pines et al. looked at various strategies implemented by schools across the United States of America during the 2009-2010 H1N1 Influenza Pandemic. Of the schools that underwent either partial or complete closure, they reported significant reductions in peak influenza infections and reduction in transmissions within the school. For thee schools that remained open, the two most common practices were rearranging classrooms to increase the physical distance between students and canceling/postponing various school activities where student intermingling was common e.g. after school care, sports or music practice, recess/lunch breaks, limiting the number of students in schoolyards at any one time. Hand hygiene and good respiratory etiquette were consistently encouraged across all schools. The schools that remained open utilizing social distancing measures had small but effective reductions in influenza transmission.
There is inconclusive evidence about the effectiveness of school closures on preventing transmission, however, if schools do remain open, it is clear that social distancing should be employed. Precisely what forms this social distancing should take is unclear. On the flip side, quarantining children at home comes with its own stressors and can add to the psychological distress already being felt by parents and children.
The psychological impact of quarantine
It is normal to feel stressed during a pandemic . A recent review published in The Lancet by Brooks et al. (2020) [11 – ] explored the negative effects of previous quarantine periods in relation to the SARS, MERS, H1NI Influenza, Equine Influenza and Ebola outbreaks. Searching three electronic databases, they identified 3,163 records using a combination of the words ‘quarantine’ or ‘patient isolation’ and ‘psychological outcomes’. For the studies to be included in the review, they had to be published in peer review journals, report on primary research, and be written in English or Italian. Patients had to be quarantined outside of a hospital for at least 24 hours, and data collected needed to include the prevalence of psychological well-being. Ultimately, only 24 studies were included in the final review.
The studies varied in methodology however each showed that there was an increase in psychological issues such as anxiety, depression, irritability, insomnia, anger and even acute stress disorder. Some studies reviewed by Brooks et al., dug a little deeper and identified factors which contributed to poor psychological outcomes. These included the duration of quarantine, sense of frustration and boredom, inadequate basic supplies, fears of infecting others, and importantly, inadequate information from public health authorities. Looking at the state of many nations across the world, including here in Australia, these stressors are clearly present and the lack of clear, concise and reassuring information from our leaders is compounding the general public’s fears.
One study looked at hospital staff during the SARS Epidemic in 2003 and found that staff who were quarantined for nine days were more likely to report “exhaustion, detachment from others, anxiety when dealing with febrile patients, irritability, insomnia, poor concentration and indecisiveness, deteriorating work performance and reluctance to work or consideration of resignation”. Given the amount of work and stress being placed on health care workers at the moment, what measures you can take to help maintain a positive work environment and look after yourself and your colleagues?
Ways to help
Whilst there are very few studies looking at the psychological health of health care workers, the review by Brooks et al. (2020) noted a high prevalence of psychological distress in quarantined health care workers. They felt stigmatized and rejected by their community. They felt tension at home and were fearful of being infected themselves or infecting others. This was linked with persistent avoidance behaviours after quarantine. They also reported increased anger, annoyance, fear, frustration, guilt, helplessness, isolation, loneliness, nervousness, sadness and worry.
The WHO released a statement for the general public and healthcare workers, flagging mental health and psychosocial concerns during this COVID-19 pandemic. It is crucial that hospital management follow these recommendations, as well as provide psychological support to their employees. Hospital executive and senior medical staff should provide up to date guidelines and protocols regarding their strategies for delivering mental health care for those affected by COVID-19.
It is heart-warming to see the positive community response to help those in need and large corporations providing discounted or free products, online services or entertainment during these difficult times. Many of these measures have been applied to health care workers to support them as they work through this pandemic, but one of the biggest ways you can help as an individual is through small gestures of kindness, each and every shift. Bring in some food to share (individually wrapped of course), organize a coffee run, thank your colleagues for all their hard work, smile. It all starts with you, and kindness can be very contagious.
Ahmed, F., Zviedrite, N., Uzicanin, A. (2018) Effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review, BMC Public Health, 18: 518
Brooks, Samantha K et al. 2020 The psychological impact of quarantine and how to reduce it: rapid review of the evidence, The Lancet, Volume 395, Issue 10227, 912 – 920
Lori Uscher-Pines, Heather L. Schwartz, Faruque Ahmed, Yenlik Zheteyeva, Erika Meza, Garrett Baker, Amra Uzicanin (2018) School practices to promote social distancing in K-12 schools: review of influenza pandemic policies and practices, BMC Public Health. 2018; 18: 406.
Wang, Y., Wang, Y., Chen, Y., Qin, Q., (2020) Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures, Journal of Medical Virology, Published 5/3/2020, doi: 10.1002/jmv.25748