Social Consequences of Mass Quarantine during Epidemics: A Systematic Review with Implications for the COVID-19 Response

"Mass quarantines can lead to multidimensional social consequences and may potentially heighten existing disparities across various contexts."

Four billion people worldwide have experienced confinement during the COVID-19 pandemic. This systematic review sought to identify (i) the social consequences of mass quarantine - that is, community-wide movement restrictions - during previous and current infectious disease outbreaks, and (ii) recommended strategies to mitigate the negative social implications of COVID-19 lockdowns.

Considering social determinants of health, the researchers conducted a systematic review by searching 5 databases (Ovid-MEDLINE, EMBASE, PsycINFO, China National Knowledge Infrastructure, and the World Health Organization (WHO) COVID-19 database) for publications from the inception of each database to April 9 2020. Of 3,067 publications found, 15 original peer-reviewed articles were selected for full-text extraction: 8 focused on the 2003 severe acute respiratory syndrome (SARS) outbreak, 4 focused on the 2014-16 Ebola virus disease (EVD) outbreaks in Sierra Leone and Liberia, 2 focused on the 2020 COVID-19 pandemic, and 1 focused on the 2009/2010 influenza A (H1N1) pandemic in Canada. The reported periods of quarantine varied from 7 days to 1 month.

The researchers identified 7 types of social consequences of mass quarantine in 6 infectious disease epidemics; examples of each are included below:

• Psychological distress (n=11) - One study pointed out that the state-enforced quarantine in Liberia during the 2014-16 EVD outbreak heightened the extent of stigma experienced by residents under compulsory isolation with travel ban regardless of Ebola virus infection. Those who self-isolated were treated as disease spreaders, and their behaviour was morally judged by other community members. A religious leader worried that misinformation during mass quarantine heightened the mistrust between racial and religious groups, as some interviewees accused ethnic minorities of spreading diseases.
• Heightened communication inequalities (n=9) - A Canadian study found that racial and linguistic minorities might suffer a higher risk of having inaccurate information on measures of SARS confinement, which might result from inadequate literacy of the audience or a lack of clarity of the messages. Suggestions from the research to bolster communication equity include:
  • Design equity-based communication messages (e.g., information tailored to individual needs by age, education level, and language use) based on correct data and risk-adapted measures;
  • Learn from countries successfully tackling COVID-19 misinformation (in mass media or by politicians), being aware that transparency, community engagement, and context-tailored strategies for combating misinformation are key;
  • Develop community-based peer education programmes and improve communication infrastructure to reduce the negative social impacts of quarantine;
  • Improve the transparency of decision-making on community-wide movement restrictions and inform the public about how outbreak surveillance works to avert unnecessary panic; and
  • Avoid top-down-enforced lockdowns without community engagement, which may fuel distrust of authorities and resistance to restrictive measures. In particular, consult social minority representatives in developing supplementary measures to lockdowns.
• Food insecurity (n=8) - In one study, Liberians stressed that the compulsory quarantine order damaged the tradition of mutual support between village dwellers and left those self-isolated unaided and starving.
• Economic challenges (n=7) - The authors of a study of Canadians' responses to the 2003 SARS outbreak argued that closure of restaurants, intersecting with SARS-related stigma against Asian businesses, could harm the local economy.
• Diminished access to health care (n=6) - One study of EVD outbreak management found that the reported reduction in malnutrition screenings resulted from movement restrictions under quarantine and behaviour changes in service users due to lack of trust and resource competition between the EVD outbreak management and humanitarian nutrition programmes.
• Disruptive education (n=4) - During the EVD outbreak, informants in Sierra Leone reported no schooling in general, whereas several community members in Liberia took on the responsibility to educate children who had lost their parents.
• Gender inequity and violence (n=3) - One study maintained that the trend of domestic violence cases escalated since the COVID-19 lockdown in both Hubei province, China, and the United Kingdom (UK). The authors emphasised the invisibility of gendered home care in countries undergoing mass quarantine and called for rights-based support to prevent violence against women.

In contrast, altruistic attitudes during mass quarantine were reported in 3 studies. For example, interviewees mentioned how community members offered emotional support and took care of orphans during the mass quarantine in the Toronto, Canada, SARS epidemic and in the Liberia EVD outbreak, respectively. Reflecting on such findings, the researchers suggest that "COVID-19 offers an opportunity for comprehensive investigations on other positive consequences of mass quarantine. While promoting altruism, policymakers should develop culturally competent and context-specific interventions,...facilitate the use of technology to retain social connections and increase the capacity of health care services with digital innovations..."

Among the suggestions offered here for further research: Explore how, and to what extent, political determinants of health affect the social consequences of COVID-19 confinement across various socio-economic and cultural contexts. "Further research on the needs of vulnerable populations during confinement with appropriate considerations based on verified data is crucial to informing equitable and sustainable interventions."

In conclusion, the researchers suggest that - with particular attention to those who are socially marginalised - policymakers should balance the pros and cons of movement restrictions, facilitate multisectoral action to tackle social inequalities, provide clear and coherent guidance to the public, and undertake time-bound policy evaluations to mitigate the negative impact of COVID-19 lockdowns and to establish preparedness strategies for future epidemics.