Institutional versus home isolation to curb the COVID-19 outbreak

Borame Dickens and colleagues' Correspondence¹ is an interesting read. They have modelled and contrasted the epidemic curves of China with those of the USA and Europe to arrive at the conclusion that institutional isolation is better than home isolation.¹ They, however, do not explicitly discuss the caveats—both theoretical and real-life.

Theoretically, Dickens and colleagues¹ have made favourable over-simplistic assumptions, such as lower rates of infectivity (basic reproduction number of 2·0, unlike 1·4–6·5 reported elsewhere²) and a lower prevalence of asymptomatic individuals (up to 50%, unlike reports of up to 80% elsewhere³). There are further underlying assumptions—eg, early stage of importation, homogeneity of risk-exposure, and virulence of severe acute respiratory syndrome coronavirus 2within and between populations. Differences in systems' capacity have been overlooked, such as strength of implementation of universal physical distancing, workplace or school closures, surveillance, testing and contact tracing interventions, surge capacity, and sustainability.

From a real-life perspective, Dickens and colleagues¹ could have discussed why Israel (an example cited for failed home-based isolation) has been able to implement other containment measures stringently and could still mitigate the spread of the virus. In fact, Germany could achieve success despite home-based isolation and management of cases with mild symptoms, which could have also been discussed. Dickens and colleagues¹ mention, but do not elaborate on, the so-called legal enforcement dimension for facility-based isolation in Wuhan, China. Could legal enforcement of mandatory facility-based isolation confound and accentuate the effect of such isolation on containment, vis-à-vis that of voluntary home-based isolation? Would stringent enforcement violate individuals' right to freedom of choice? Quarantine and isolation have mental health consequences. Why remove individuals from familiar home environments?⁴

The pandemic is now also ravaging the low-income and middle-income countries (LMICs). WHO data show that these countries are under-resourced (eg, 25·9 doctors per 10 000 population in the USA [2016] vs 17·9 in China [2015] vs 7·8 in India [2017]) and overpopulated. Institutional isolation in LMICs has challenges related to capacity and quality of care. There is risk of undue exposure and further depletion of scarce health-care resources.⁵ The WHO-China Joint Mission on COVID-19⁶ suggested that infection among health-care workers could be high if supplies such as personal protective equipment are lower—a situation more likely in LMIC settings. Health systems in LMICs are not as resilient as in high-income countries. High rates of infection in their health-care workers could lead to a health services crisis.

We acknowledge that, at times, home-based isolation might have its disadvantages—eg, risk of transmission to others. Yet can we be as sure that institutional, and not home-based isolation, could contain the outbreak? Should these be stand-alone strategies? In figure A of the Correspondence,¹ it seems that the curves touch the x-axis almost simultaneously. Thus, the interventions will not reduce the duration of the outbreak but the peak. Since most countries have opted for both home-based and institutional isolation and lockdown, how do the 95% CIs of the curves overlap? A discussion of these issues would be insightful.

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