What constitutes COVID-19 exposure and when to quarantine vs. isolate
Sorting through the maze of public health information overload and overlap
When facing any emergency, more often than not, we’re complaining that we need more information. I think it’s safe to say that right now, while navigating the COVID-19 crisis, we’re in an information overload.
Add to the overload, the overlap – that is, potentially conflicting directives resulting among, for example, the first declared federal public health emergency, followed by the federal state of emergency, followed by individual state declarations, orders and resolutions.
The overload can cause us to become desensitized to the news and miss important information, while the overlap can produce conflicting orders across health and emergency management disciplines.
Here we’ll sort through the overload and overlap to provide fire and EMS personnel some commonsense guidance about key terminology: exposure, diagnosis, isolation, quarantine, lockdown and shelter-in-place.
Exposure vs. diagnosis
When considering diagnosis vs. exposure, the diagnosis element is the simpler of the two.
A diagnosis is determined using a qualified test as verified by a medical professional and/or the agency responsible in your area. For my department, that is the State Department of Health. If someone has been diagnosed with COVID-19, they should receive directions from a medical professional guiding their next move – whether that’s quarantine or medical surveillance.
What constitutes exposure, on the other hand, differs by jurisdiction. For my department, our Risk Management Office makes the determination, announcing that for workers’ compensation purposes, an exposure is defined as being involved with someone who has a positive diagnosis. Simple, right? Not so simple is who’s doing the testing to produce the diagnosis, who’s providing the information back to EMS or fire, and how it is being communicated – IF it’s being communicated at all.
It is easy to understand exposure from the declaration of a workers’ comp claim, yet much more difficult to execute for isolation and quarantine decisions in the field. We have seen the two extremes – departments that are immediately taking entire shifts out of service when there’s been an exposure, even without confirmation, and departments that have crews continuing to provide service after exposure if they’re not exhibiting signs/symptoms, which they wouldn’t for 5 or so days.
If you put crews out of service for every sniffle or 100.4-degree F temperature patient, you will quickly run out of responders. That being said, it is critical that crewmembers protect themselves. If you’ve handled a patient who meets all the testing criteria and the hospital tests that patient, our people must wear eye, mouth/nose, gown and hand protection all the way through decontamination or they are likely to be quarantined until the patient’s test results come back. A full-face shield should help protect the ears as well.
Should a suspected exposure occur, the ranking firefighter or paramedic on scene has directions to immediately contact the on-duty battalion chief, who will make contact with Emergency Management, who will immediately contact the Health Department. The Health Department will work with that unit and the local hospitals to determine the next steps.
Such steps for internal notification will vary by jurisdiction. One county north of me, for example, personnel at a suspected exposure are directed to immediately contact the on-duty infectious control or safety officer, who will then follow a different set of steps for notifications.
Much like we weigh the decision to enter a burning building, we must work with our medical professionals to weigh the degree of exposure. In Highlands County, our decision on provider disposition weighs two factors: 1) the level of provider PPE in use from patient contact through decontamination and 2) the determination of COVID-19 testing by a physician at a receiving facility (that test/no-test decision is being made quickly.).
A fully protected provider will not be quarantined. An unprotected provider who was within 6 feet with a productive-coughing patient (who is being tested by the hospital) may be quarantined if they were directly exposed to the cough. That is a call for which you will need internal guidance to make. Either way, providers exposed to a patient who is being tested should take their temperature daily and monitor their health for the CDC-recommended 14 days.
Chiefs and medical directors MUST establish connections with their hospital and health officials to ensure that they can receive the results of patient tests. Protective measures for both the providers and the organization can then be appropriately measured. Some departments have experienced the unwillingness to share the medical information, leading to a waiting game to watch for signs/symptoms.
Our experience with confirmatory testing is currently at a three-day window. While we are making immediate decisions on provider disposition at the hospital setting, the disposition of our providers does not change with a positive patient diagnosis. The key to our decision on provider disposition is most importantly driven by the level of protection the providers are using.
What does change at a positive diagnosis is 1) the understandable angst of the providers and the organization and 2) provider monitoring by the Health Department. Providers will be contacted by the Health Department and will need solid guidance, reassurance and support from their chiefs and departments, while maintaining their confidentiality. This has been a tremendous learning curve, which we continue to learn and critique hourly.
Finally, once a disposition of the crew is determined, the transport unit needs decontamination. Get with your local medical chief or director to determine what’s right for your membership and your equipment. No matter what your protocol, please ensure staff is using the proper eye, mouth/nose, gown and hand PPE throughout the process.
Quarantine vs. isolation
We’ve heard a lot of terms related to what actions people must take if they have been exposed to COVID-19.
The CDC defines isolation and quarantine as follows:
- Isolation separates sick people with a contagious disease from people who are not sick.
- Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
We have heard numerous reports of firefighters and EMS personnel being quarantined. The continuing challenge will be the exponential growth of those orders and the effects on households and departments.
What we’re really describing in these situations is a self-quarantine model that is not enforceable at the scale it is happening. This differs from an official quarantine order from the government, under “lock and key.” I describe “true” quarantine as a function of government (health department or law enforcement), not an opinion or option of the masses.
Isolation, on the other hand, separates sick people from not sick people. The term isolation should be reserved for those who have a diagnosis and are under medical surveillance, not for people who simply a potential exposure or sitting at home.
The easiest way to compare quarantine and isolation is to consider quarantine as Step 1 and isolation as Step 2. At Step 1, everyone who has been exposed would be held together in a pod until test results come back. Step 2 would move anyone with a positive test result into monitored isolation and treatment.
I have yet to find a department that is actually able to hold people in that quarantine-pod model. Firefighters are being sent home, further complicating and expanding the quarantine to the entire home and all residents.
I don’t have a perfect answer of how to stop that spread, but our ability to properly define the two words and appropriately identify ourselves and the public will go a long way toward public understanding of the true scope of the emergency.
Lockdown vs. shelter-in-place
State and locales are issuing various lockdown and shelter-in-place orders.
At all levels, including federally, shelter-in-place has typically been used in OSHA, hazardous materials, wildland and law enforcement search-related community messaging. Shelter-in-place orders differ from jurisdiction to jurisdiction; however, they generally limit movements to essential trips to food stores, pharmacies, doctor’s offices and gas stations. Community members must pay attention to their local restrictions. We are currently seeing a wave of shelter-in-place orders across the country, from localities to statewide orders (California, New York and Illinois at the time of this writing).
The term lockdown is typically used in active assailant situations, not community environmental situations. In a lockdown situation, there is no option to leave the area to which you are confined. I am not aware of this currently happening as a result of COVID-19, although there are some localities inaccurately using the term lockdown to describe their shelter-in-place or quarantine situations.
Communication is key
It has been my experience that public health officials and fire/EMS officials communicate very differently. Fire/EMS officials are accustomed to providing information and answering questions daily in their communities, with a decentralized flow through their local organization or jurisdiction. Public health officials, on the other hand, have a culture that promotes centralized information flow to control one message.
We have found time after time that centralized systems communication flow during aggressively fluid situations, especially in this social media information age, slows the output of information to the point that rumors become truth. It is likely the statutory responsibility of public health in your jurisdiction to provide information under the public health emergency. As we should always be doing, we must only provide accurate information to our communities, and refer them to the responsible agencies where we are unable to provide accurate information. If you don’t have the correct message, don’t make up a message.
Fire and EMS services are being affected by health institution access rules related to the situational orders being provided to them by state and/or certifying organizations – a significant amount of which has NOT been communicated to responding crews. This is slowing access to patients during 911 responses.
Reach out now, if not directly to the facilities, then through your emergency management partners to determine what rules are in place that will affect your access.
Shelter-in-place orders do not mean you won’t receive 911 calls to facilities; it just means your access and normal facility preplans may be out the window, as they say.
It will be important for fire and EMS leaders to stay abreast of the rules for access and movements in your specific areas. Work with your law enforcement, health and emergency management partners the best that you can to keep lines of communication open. The communities that see you every day, trust you, so let’s do the best we can to help them understand what’s going on – once we understand it ourselves.
We all need to understand that this is a long-term global public health emergency, not a house fire that’s going to be out in 20 minutes.
Editor's Note: What is your department's decision-making process for when to quarantine firefighters? Share in the comments below or with the editor at firstname.lastname@example.org.