A. Bandera

A. Gori

A. Lombardi

A. Muscatello

A.M. Peri

D. Mangioni

G. Bozzi

L. Taramasso

R. Ungaro

English

AIR Universita degli studi di Milano

Journal Pre-proof
Duration of quarantine in hospitalized patients with severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) infection: a question needing an answer
Andrea Lombardi, Giorgio Bozzi, Davide Mangioni, Antonio Muscatello, Anna Maria
Peri, Lucia Taramasso, Riccardo Ungaro, Alessandra Bandera, Andrea Gori
PII: S0195-6701(20)30102-X
DOI: https://doi.org/10.1016/j.jhin.2020.03.003
Reference: YJHIN 5931
To appear in: Journal of Hospital Infection
Received Date: 28 February 2020
Accepted Date: 2 March 2020
Please cite this article as: Lombardi A, Bozzi G, Mangioni D, Muscatello A, Peri AM, Taramasso
L, Ungaro R, Bandera A, Gori A, Duration of quarantine in hospitalized patients with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a question needing an answer, Journal of
Hospital Infection, https://doi.org/10.1016/j.jhin.2020.03.003.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.
© 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
1 
 
RUNNING TITLE: Hospital quarantine for COVID-19 1 
Duration of quarantine in hospitalized patients with severe acute respiratory 2 
syndrome coronavirus 2 (SARS-CoV-2) infection: a question needing an answer 3 
Andrea Lombardi1, Giorgio Bozzi1, Davide Mangioni1,2, Antonio Muscatello1, Anna 4 
Maria Peri1, Lucia Taramasso1,2, Riccardo Ungaro1, Alessandra Bandera1,2, Andrea 5 
Gori1,2 6 
1Infectious Diseases Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, 7 
Milano, Italy; 2Department of Pathophysiology and Transplantation, University of Milano, 8 
Milano, Italy.  9 
 Corresponding author: Andrea Lombardi Infectious Diseases Unit IRCCS Ca'  10 
Granda Ospedale Maggiore Policlinico Foundation Via Francesco Sforza 35, 20122, 11 
Milan, Italy E-mail: andrea.lombardi@policlinico.mi.it Tel: +393409010358  12 
Electronic words count: 691  13 
Keywords: COVID-19; SARS-CoV-2; quarantine; nosocomial transmission. 14 
2 
 
In December 2019 a new form of pneumonia was observed in the Chinese province 15 
of Hubei.[1] The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 16 
was subsequently identified as responsible of this condition, defined coronavirus 17 
disease (COVID-19).[2] The virus has now spread outside Chinese borders with 18 
82,297 cases and 2,804 deaths worldwide at the 26th of February.[3] After infection, 19 
symptoms appear after an incubation time of 3-5 days, with 80% of those infected 20 
developing a mild disease, 15% a severe disease and 5% will require support in 21 
intensive care unit (ICU).[4] Overall, the estimated case-fatality rate is comprised 22 
between 0.4% and 2.9% and the basic reproduction number is approximately 23 
3.28.[4,5] SARS-CoV-2 is a new pathogen for humankind and any type of immune 24 
protection exist, thus everybody can be potentially infected. Moreover, no primary 25 
prophylaxis measures (vaccination) nor effective treatments are available. If the 26 
above represented percentages are applied to the worldwide populations, it appears 27 
clear why any measure should be considered to avoid a further diffusion of the virus 28 
and prevent the saturation and collapse of health systems and the most catastrophic 29 
pandemic since 1919 Spanish flu. 30 
Isolation of those affected and the use of personal protective equipment (PPE) are 31 
the mainstay to block transmission of this pathogen, which is presumed through 32 
respiratory droplets. A 14 days quarantine is applied to subjects coming from 33 
endemic areas or who had contact with confirmed cases. It is assumed that, if in this 34 
period the subject does not develop any sign or symptoms compatible with COVID-35 
3 
 
19, he is not infected and thus the quarantine can be removed, and the subject 36 
returned to the community. Domiciliary quarantine of 14 days since a positive test is 37 
applied also for patients with a diagnosed mild disease who did not need medical 38 
support.  39 
These rules are effective in controlling infections in the community, but several 40 
doubts arise when it is necessary to transpose them in the hospital setting. Hospitals 41 
are indeed a delicate place in epidemics: they collect fragile persons who can be 42 
exposed to the virus and are subsequently readmitted to the community thus 43 
spreading the infection. Indeed, the ongoing outbreak in Northern Italy has been 44 
linked to a single infected patient who accessed to a community hospital where he 45 
transmitted the virus to several other patients and health-care operators.[6] 46 
Moreover, the isolation of patients in the hospital setting impose a significant burden 47 
in terms of PPE used by the health-care operators, space dedicated and time 48 
employed in their management. Even more complex is the situation of patients in 49 
ICU, where viral spreading is facilitated by endotracheal tubes and manoeuvres 50 
performed on the respiratory tract. Therefore, a clear definition of the infectiousness 51 
timing and intensity of viral spreading is mandatory to alleviate the burden on the 52 
health-care system.  53 
Unfortunately, the data available on the topic are scarce and composed only of 54 
measurements of viral shedding, without an assessment of the infectivity. Kim et 55 
al.[7] assessed the viral load kinetics of SARS-CoV-2 in upper and lower respiratory 56 
4 
 
tract materials in the first two confirmed patients in Korea. They employed real-time 57 
reverse transcriptase polymerase chain reaction (rRT-PCR) to detect SARS-CoV-2 58 
and converted cycle threshold (CT) values of rRT-PCR into RNA copy number. The 59 
detection limit of rRT-PCR was 2,690 copies/mL. Overall, viral load above detection 60 
limit was detected until 14 and 25 days after symptoms onset and for 13 and 11 days 61 
after the first detection, respectively.[7] Of note, both patients received treatment 62 
with lopinavir/ritonavir. Instead, Zou and colleagues analysed viral load in repeated 63 
nasal and throat swabs obtained from the 17 symptomatic patients.[8] They also 64 
employed rRT-PCR and considered a CT of 40 as detection limit. Higher viral loads 65 
were observed in nasal swabs and in samples collected soon after symptoms onset. 66 
Overall, only two patients presented positive samples, and only in nasal swab, 14 67 
days after symptoms onset, and with low viral load.   68 
In conclusion, a larger amount of data about duration of viral spreading and 69 
infectivity in hospitalized patients, especially in ICU, is badly needed to better define 70 
quarantine period and avoid nosocomial transmission. Before their availability, the 71 
canonical 14 days period of quarantine should be respected.  72 
Acknowledgments: Authors are grateful to all the healthcare operators involved in 73 
the care of patient with COVID-19. 74 
Financial support: none related to the content of this manuscript. 75 
Conflict of interests: none related to the content of this manuscript. 76 
77 
5 
 
References 78 
[1] Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus 79 
from Patients with Pneumonia in China, 2019. N Engl J Med 2020:727–33. 80 
doi:10.1056/nejmoa2001017. 81 
[2] Naming the coronavirus disease (COVID-2019) and the virus that causes it n.d. 82 
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-83 
guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-84 
causes-it (accessed February 27, 2020). 85 
[3] Novel coronavirus (COVID-19) situation n.d. 86 
https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd 87 
(accessed February 27, 2020). 88 
[4] Wu Z, McGoogan JM. Characteristics of and Important Lessons From the 89 
Coronavirus Disease 2019 ( COVID-19 ) Outbreak in China Summary of a 90 
Report of 72 314 Cases From the Chinese Center for Disease Control and 91 
Prevention. JAMA - J Am Med Assoc 2020:E1–4. 92 
[5] Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of 93 
COVID-19 is higher compared to SARS coronavirus. J Travel Med 2020:1–4. 94 
doi:10.1093/jtm/taaa021. 95 
[6] Covid-19 - Situazione in Italia n.d. 96 
http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioContenutiNuovo97 
6 
 
Coronavirus.jsp?lingua=italiano&id=5351&area=nuovoCoronavirus&menu=vu98 
oto (accessed February 27, 2020). 99 
[7] Kim JY, Ko J, Kim Y, Kim Y, Kim J, Chung Y, et al. Viral Load Kinetics of 100 
SARS-CoV-2 Infection in First Two Patients in Korea. J Korean Med Sci 101 
2020;35:1–7. 102 
[8] Zou L, Ruan F, Huang M, Liang L, Huang H. SARS-CoV-2 Viral Load in 103 
Upper Respiratory Specimens of Infected Patients. N Engl J Med 2020:1–3. 104 
 105 


Duration of quarantine in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a question needing an answer

https://air.unimi.it/bitstream/2434/721902/2/PIIS019567012030102X.pdf

Duration of quarantine in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a question needing an answer

Abstract

Similar works

Full text

Available Versions

AIR Universita degli studi di Milano