Written by:

Jonathan Pugh

Dominic Wilkinson

Julian Savulescu

 

This is an output of the UKRI Pandemic Ethics Accelerator project – it develops an earlier assessment of the English hotel quarantine policy, published by The Conversation)

 

The UK has announced that from 15^th Feb, British and Irish nationals and others with residency rights travelling to England from ‘red list’ countries will have to quarantine in a government-sanctioned hotel for 10 days, at a personal cost of £1,750. Accommodation must be booked in advance, and individuals will be required to undergo two tests over the course of the quarantine period.

Failure to comply will carry strict penalties. Failing to quarantine in a designated hotel carries a fine of up to £10,000, and those who lie about visiting a red list country are liable to a 10-year prison sentence.

International travel enables the international spread of the SARS-CoV-2 coronavirus. For this reason, many countries enforced significant travel restrictions early in the pandemic in order to prevent the importation (and exportation) of cases. However, there is some evidence to suggest that imported cases are likely to contribute little to local COVID-19 epidemics. Nonetheless, the public health risks of international travel have been exacerbated by more transmissible variants of the coronavirus that have developed in countries such as South Africa and Brazil. Cases of these variants have already been recorded in the UK.

There are a range of measures that could be deployed in order to reduce the risk of incoming international travellers from spreading the virus in the community. These range from outright travel bans from ‘high risk’ countries, testing on arrival, self-isolation in private accommodation, and quarantine in a government-sanctioned institution. Some countries implemented hotel quarantine policies much earlier in the pandemic (in March 2020 in Australia’s case).  Other countries that have implemented  institutional quarantines for incoming travellers, include New Zealand, Qatar and India amongst others.

This review will outline the ethical justification of these measures, potential exemptions, and different payment systems.

 

Public Health and Freedom

 

Public health measures aimed at preventing the spread of infectious disease may involve the infringement of robust moral and legal rights. However, it is well established that it can, under certain conditions, be justifiable to infringe upon certain rights in order to protect public health. Indeed, a number of frameworks for the justifiable infringement of rights to protect public health have been proposed. For instance, according to the WHO Guidance on human rights and involuntary detention for xdr-tb control, any permissible restriction of rights to protect public health must meet the following criteria adopted from the Siracusa Principles:

 

• The restriction is provided for and carried out in accordance with the law;

 

• The restriction is in the interest of a legitimate objective of general interest;

 

• The restriction is strictly necessary in a democratic society to achieve the objective; There are no less intrusive and restrictive means available to reach the same objective;

 

• The restriction is based on scientific evidence and not drafted or imposed arbitrarily i.e. in an unreasonable or otherwise discriminatory manner.

 

In a similar vein, Childress et al have claimed that there are five justificatory conditions that should be invoked to determine whether the promotion of public health warrants overriding values such as individual liberty: effectiveness, proportionality, necessity, least infringement, and public justification.

It should be noted that these conditions can conflict, necessitating trade-offs. In particular, more effective interventions for achieving a public health goals will often involve more significant restrictions of individual liberty. For this reason, some frameworks eschew reference to the least restrictive alternative criterion. However, in frameworks that do incorporate this criterion, such cases require us to ask whether the least restrictive alternative available will be sufficiently effective in achieving a public health aim to warrant the use of that intervention instead of a more restrictive alternative that could achieve the aim more effectively.

 

Travel Bans and The Right to Return

 

An outright ban on all international travel would be the most effective way of preventing international transmission. However, this is a highly restrictive intervention. International travel is necessary for a range of social and economic benefits. Indeed, the UK policy exempts a range of incoming professionals from institutional quarantine arrangements, including crown servants and government contractors, and defence personnel (amongst others).

Expatriate nationals and those with residence rights have a particularly strong right to return to their country of origin or citizenship. Indeed, this ‘right to return’ is recognised in Article 13 of the Universal Declaration of Human Rights. Given the strength of this right, preventing citizens from re-entering their own country would plausibly be disproportionate, even when international travel poses a significant transmission risk. Even considerable public health benefits may not outweigh the costs of infringing such a significant right. However, it could yet be proportionate to ban other travellers who do not enjoy such strong rights to entry when the public health costs of travel are sufficiently high.

Accordingly, there is an ethical public health basis for imposing a travel ban on high risk countries, whilst allowing exemptions for expatriate nationals, and those with residence rights. How should the infection risk that such individuals pose be managed?

 

Managing Potentially Infectious Arrivals – Private Self-Isolation or Institutionalised Quarantine?

 

In order to prevent onward transmission, infected individuals must be prevented from passing on the virus to others for the duration of the period in which they are infectious. However, there are a number of challenges in achieving this in the context of SARS-CoV-2. The first relates to the identification of infected individuals. There is some evidence to suggest that asymptomatic individuals may be infectious , and available testing may either lack sufficient accuracy or not allow for a rapid return of results to incoming travellers. Accordingly, management strategies that apply only to travellers who are identified as infectious on arrival (by virtue of a positive test result or because they display symptoms) are highly unlikely to identify all infectious cases. Management strategies that apply to all travellers on arrival will be more effective at preventing onward transmission, but they will involve infringing the rights of persons who in fact pose no actual risk of transmission. This latter cost could be reduced by testing individuals over the course of quarantine/self-isolation periods and allowing those who test negative to be released from restrictions. However, ‘test to release’ strategies raise the prospect of unintentionally releasing false negative cases into the community.

A second challenge relates to the lack of certainty about the duration of the infection period for SARS-CoV-2. A recent systematic review and meta-analysis has suggested that infectiousness could reflect viral load dynamics and may therefore be expected to last for up to 10 days from symptom onset in non-severe cases. The UK government guidance on self-isolation and quarantine reflects this evidence; in December the guidance regarding the duration of mandatory self-isolation and quarantine periods was changed from 14 days to 10 days.Other countries have imposed institutional quarantine periods for incoming travellers that are shorter than the UK in some cases (5 days in Indonesia), and longer in others (14 days in Australia and New Zealand, 21 in Hong Kong). Longer quarantines are more likely to cover the entire infection period; however, they will also involve greater infringements on individual liberty. Moreover, restrictions that last longer than (what we may reasonably expect to be) the duration of the infection period will not qualify as being necessary for preventing transmission.

The third challenge relates to the extent of enforcement, and the need to balance public health against the rights and interests of potentially infectious travellers. Outside of international travel, UK citizens who are either symptomatic or in receipt of a positive test result must self-isolate at home. In a similar vein, incoming international travellers could be permitted to self-isolate in private accommodation. This would allow travellers a greater degree of freedom than institutional quarantine, and it would not involve the financial cost of quarantine. However, adherence to unsupervised self-isolation in private accommodation may be low; indeed, data suggests that less than 20% of symptomatic individuals adhere to self-isolation mandates in the UK. In response to breaches of mandated self-isolation, some countries permitting incoming travellers to isolate in private accommodation have required them to wear tracking devices linked to mobile phone apps to prevent further breaches. However, such devices raise considerable concerns about privacy in addition to restricting individual liberty.

Enforced institutional quarantine is likely to ensure higher compliance than self-isolation in private accommodation, although breaches may still occur. However, the increased compliance that institutional quarantine may ensure will come at greater cost. In addition to the financial cost of quarantine (which we return to the below), institutional quarantine involves a greater restriction of freedom, with its attendant costs to mental and physical health. Furthermore, some institutionally quarantined individuals may be put at higher risk of exposure to the virus than they would have been had they been permitted to self-isolate in private accommodation.

In addition to effective security measures preventing travellers from escaping, the overall effectiveness of  institutional quarantine will depend a great deal on the safety protocols employed in the institution. Indeed, countries employing  institutional quarantine for incoming travellers have traced widespread outbreaks in the community to hotel employees. In order to prevent such outbreaks, it is crucial that staff are able to maintain high safety standards, and that staff who move between the institution and the wider community have minimal contact with potentially infectious individuals.

It is also important to minimise exposure between quarantined individuals. Some ways of minimising exposure between quarantined individuals may have low costs; for instance, delivering meals to rooms at staggered intervals reduces the chance of unintended exposure across corridors. Others have higher costs; for instance, in some countries quarantined individuals are not permitted to leave their rooms for outdoor exercise. Whilst this will reduce the potential for exposure, evidence suggests that regular outdoor exercise can help to reduce the significant mental health costs of quarantine. Regulations governing the precise restrictions incorporated into institutional quarantine arrangements will have to make trade-offs between the use of effective public health restrictions and the rights and interests of the individuals subject to those restrictions.

 

Who Should Pay?

 

Some countries requiring incoming travellers to quarantine in government sanctioned hotels initially covered the cost of the stay. This was fair in some sense; individuals subject to quarantine are already required to bear a considerable non-financial cost in the interests of public health. The wider public are the primary beneficiaries of the quarantine – travellers are therefore being asked to pay to benefit other people. Providing ‘free’ quarantine also helps to ensure that all are equally able to exercise their right to enter their country. At present, the Philippine government still covers the cost of quarantine for returning Overseas Fillipino Workers.

However, quarantine is expensive, and money spent on providing it to travellers free of charge cannot be spent on other pressing public health initiatives. As such, countries have increasingly chosen to pass on the cost to travellers themselves, either in full, or in systems of co-payment. In the latter case, the government subsidises the cost of the quarantine in recognition of the public health benefits of institutional quarantine. Under the UK policy, the government bears the costs of food and drinks consumed by arrivals aged between 3 and 5 years old.

There may sometime be ethical reasons for waiving the fee. Travellers are arguably more liable for payment when they could have known that they would need to pay to re-enter. In New Zealand returning nationals are only liable to be charged for entry if they left the country after the charges came into place (on 11^th August) or if they are returning for a period of less than 90 days. States may also choose to waive the fee for those who have particularly strong reasons to travel. New Zealand considers waiver applications, indicating that they may be granted for medical or compassionate reasons.

New Zealand also considers waivers for those facing financial hardship. This exemption is necessary to ensure that the quarantine does not lead to unfair inequality in individuals’ ability to exercise their right to enter the country. This concern was voiced in response to the quarantine policy in Uganda. In the UK, the fee is not waived for those facing financial hardship, but individuals can apply for a deferred payment plan if they already receive income related benefits.

Questions about inequality may arise when travellers can choose to pay more than a baseline amount to access more comfortable accommodation for their institutional quarantine. Some countries (including the UK) employ a flat rate for all travellers, and individuals are allocated to a government sanctioned hotel. In contrast, some countries (such as Qatar) offer a range of quarantine ‘packages’ with various prices.

Employing a flat rate allows for a far simpler system to roll-out, and it ensures that all travellers receive equal treatment. The main ethical question about setting the flat-rate is the maximum amount that we can reasonably demand of travellers to exercise their right to return, and the minimum standard of accommodation that it is permissible to offer to travellers at a flat rate. The lower the cost of quarantine, the more individuals will be able to exercise their right to return. Higher costs prevent people from exercising this right. It is therefore important that the baseline cost of quarantine (i.e. that  which all travellers are required to pay) reflects only the amount that is strictly necessary for providing an acceptable level of accommodation and public health protection in institutional quarantine. It would be inappropriate for states to increase the cost of quarantine in order to generate profit.

However, beyond payment of the flat-rate baseline, we typically allow travellers to choose how much they pay for the quality of accommodation they desire, and it is not clear that restricting freedom of choice in this manner is strictly necessary from a public health perspective. Yet, if better quality accommodation reduces the mental health costs of quarantine, then allowing differential access on ability to pay may lead to an unequal distribution of the mental health costs of quarantine. Whilst employing a flat rate for all for the same standard of accommodation represents a form of levelling down, it does prevent this form of inequality. As is the case with many allocation questions raised by the pandemic, determining an ethical approach to payment and accommodation access here requires a careful balance between ensuring fairness and equality on the one hand, whilst minimising harms and maximizing benefits on the other.