Experience and Challenges for Establishing Quarantine Facility for Suspected COVID-19 Cases: Field Brieng

Due to unprecedented SARS-CoV2 pandemic, in late January 2020, many countries in the world imposed travel ban. The governments across the world initiated repatriation operations for stranded nationals. It was important to instantly develop quarantine facilities for evacuees. As the disease was fairly new, data on it was sparse to full the requirement. With this article, we are sharing our experience of establishing and managing India’s rst quarantine facility for repatriate nationals focusing on key parameters including infection prevention & control, environmental cleaning and bio-medical waste management along with basic living requirements. The facility housed a total of 617 evacuees from China and Italy out of who 17 turned out positive on initial testing constituting 27.55% and one tested positive on the 14 th day testing. Mindful of the level of exposure 25 contacts were traced and were prescribed additional quarantine period of fourteen days in the facility and discharged accordingly. All evacuees were put on community surveillance under State Surveillance Units by the Integrated Disease Surveillance Programme. Supply of logistics, manpower management and ensuring compliance to protocols were some of the major challenges faced. Appropriate actions were designed and taken to address them. In conclusion, impeccable collaboration and coordination between different stakeholders is most essential ingredient for successful operation of any quarantine facility in the context of current pandemic. Passive presence of written guidelines/ SOPs is not sucient to establish a quarantine facility. Committed leadership, improvement in collaborations and coordination between different stakeholders, transparency between key partners, regular supplies of logistic, dedicated and skilled manpower, general and task oriented training and development at multi-disciplinary approach, motivation and awareness are the most essential ingredients for successful operation of quarantine facility for suspected cases of COVID-19 in current pandemic.


Background
In early January 2020, a novel coronavirus (2019-nCoV) was identi ed as the infectious agent causing an outbreak of viral pneumonia in Wuhan, China. The rst few cases with symptoms though were traced in December 2019 [1] Like wild re the infection spread globally and turning into an unprecedented pandemic. During the early stage of the pandemic; considering the SARS-CoV2 crisis and its ability to transmit from human to human, [2] many countries imposed travel restrictions and lockdown. Like other nations the Indian government too planned repatriation of stranded Indian nationals from the infected countries.
On arrival to India, all repatriated nationals were prescribed mandatory institutional quarantine at a designated facility for a period of 14 days followed by self-quarantine for an equal period.
As pioneers in establishing quarantine facility; by this communication we intend to share our experience of managing such facility for the repatriated nationals evacuated from China, Italy, etc. from February to April, 2020.

Selection of Facility and Infrastructure
It was early stage of outbreak and there was paucity of scienti c evidence and literature speci c to natural history of disease and transmission dynamics of the infection. No approved guidelines were available for SARS-CoV2. Therefore, we relied on guidelines for evaluating homes and facilities for isolation and quarantine. We made a checklist for evaluating the quarantine facility. A newly constructed ve storey building of the Indo Tibetan Border Police (ITBP) was identi ed as the potential site for the facility based quarantine. An expert team was constituted for the evaluation, based on criteria like location, accessibility, basic infrastructure and available space. Since ITBP building was on the outskirts of Delhi, in close vicinity of international airport and had su cient infrastructure and space, it tted the locational requirement of a quarantine facility.
The original purpose of the building at ITBP Chawla Camp was to use it as a transit stay for 6 soldiers per barrack. The building capacity was for 500 people with 100 on each oor. In order to maintain adequate distance between beds, three beds were arranged in each barrack and almost 32-42 evacuees per oor were housed with common toilets and bathrooms on each oor. Ancillary services like reception, nursing station, room for donning / do ng of personal protective equipment (PPE), closed-circuit television (CCTV) surveillance room, recreational activity hall and holding area for bio-medical waste were identi ed at ground oor. This building was cordoned off from other areas by fencing and deploying 24*7 security guards. A separate building in the campus housed the administrative o ce, control room, clerical room, logistics/store room, and lounge for doctors/nurses and supporting staff.
Logistic support and manpower Logistic support for equipment; materials required for sample collection, packaging and transportation; laboratory support for COVID-19 testing including ambulance services was also provided. Human resource was arranged primarily from ITBP and other agencies like state medical colleges and govt hospitals for patient care and management, security, housekeeping services, meal preparation etc. Services had been provided round the clock by preparing duty rosters and engaging man power accordingly.
Capacity building and key activities

Screenings & repatriation
Exit screening was conducted for all evacuees before boarding the repatriation ight. Entry screening for SARS-CoV2 symptoms was conducted at Indira Gandhi International (IGI) airport by Airport Health O cials (APHO) in collaboration with other stakeholders (Fig. 1). Every evacuee was being subjected to thermal screening. Suspected evacuees were isolated from others at the airport itself and examined by Airport medical o cer and shifted to isolation facility in dedicated ambulances if required. Rest of the evacuees were sent to the ITBP quarantine facility by buses. All vehicles used for transportation were disinfected with 1% Sodium hypochlorite after each use. (4) A total of 617 Indian and other nationals were repatriated between February to April, 2020. Out of these, 112 (18.15%) evacuees were from Wuhan and non-Wuhan provinces of China, 24 (3.89%) were from India, 21 were Italian tourists and 3 Indians (Guide, driver and conductor)], 218 (35.33%) were from Milan, Italy and 263 (42.63%) were Rome, Italy. (Table-2)  Table 2 Demographic characteristics and period of quarantine of the suspected cases of COVID-19 kept in quarantine facility positive Indian Guide and 2 Indian nationals (driver and conductor) were immediately transferred to a designated tertiary care hospital for the isolation. Fourteen Italian tourists who tested positive for SARS-CoV2 and also 7 Italians were transferred to reputed private tertiary care hospital at Gurugram in separate vehicles.
After completion of speci ed quarantine period, the evacuees were again tested through RT-PCR on 14th day and discharged on negative results.
Since evacuees from Rome had already been tested just before the evacuation activity, hence were retested only at the end of quarantine period.
Among them, only one (0.16%) evacuee from Rome was turned out positive.
Contact tracing and reset of quarantine Whenever con rmed SARS-CoV-2 positive cases were recognised, contact tracing was initiated. Close seating in aircraft, sharing the same barrack, hand shaking, sharing of personal articles, dining at same table or any activity where the person was within 1 m distance with con rmed case was taken as high risk exposure. [5] To facilitate contact tracing, photograph of positive cases was used and interviews of passengers and telephonic interview of positive cases were taken to determine the level of exposure of an individual. Among the evacuees from Milan, 5 were identi ed as close contacts where 4 shared same barrack and 1 shared dining table with con rmed case. Likewise, 18 evacuees from Rome were identi ed as close contact where 5 were in same barrack, 1 shared personal article (laptop) and 12 had exposure during recreational activities. A 14 day quarantine period was reset for them from the day of last contact with con rmed SARS-CoV2 case. (Table-1

Challenges and action taken
In present study, we have tried to share our experience of establishing and running the very rst quarantine facility of India for repatriated nationals. Reasons for successful or unsuccessful operation of any facility are often multiple and interconnected. And so, challenges are a universal part of human experience.
Arrangement and supply of logistics viz PPE, materials required for sample collection, packaging and transportation, medicines, medical equipment, grocery for meal preparation, vehicles for transportation etc was leading limitation factor for the successful running of the facility.
Since the facility was situated in outskirt of city, transportation and commute cost was signi cantly high due to distance thereby more consumption of fuel.
Manpower management was another challenge. Intent was to retain same members in a team for complete quarantine period which could not be achieved due to fear among workers or their family members about their health and well-being. Training and quality communication with them was essential requirement which was handled in solution oriented effective way. Psychosocial counselling was also conducted whenever required. Ensuring compliance to protocols and recommendations among HCW and evacuees the key parameter for successful quarantine facility were put in place. Disagreement with guideline or speci c recommendation, lack of commitment, motivation and awareness led to suboptimal compliance to recommendations by individuals. When used alone, printed information and educational material generally lead to limited improvement in practices. However, implementation of and compliance with recommendation improved with communication. Round the clock surveillance with CCTV camera and public address system at each oor was established to improve communication with evacuees and provide necessary instructions. Signage like restricted access, arrows to display functional ow was pasted to minimize the interaction between HCW and quarantined inhabitants. Since CCTV camera could not be installed in bathroom and toilet areas hence demarcated use of them could not be ensured. (Table 1) Routine evaluation of cleaning, hygiene and sanitation methods were ensured by supervisory team. Determination of e cacy of cleaning method was tough and subjective by mere visual inspection of cleaned area. [7] Other chemical method like RLU measurement in ATP swab system or microbial methods like aerobic colony count, MRSA count could not be exercised due to limitation of resources in eld settings.

Conclusion
Passive presence of written guidelines/ SOPs is not su cient to establish a quarantine facility. Committed leadership, improvement in collaborations and coordination between different stakeholders, transparency between key partners, regular supplies of logistic, dedicated and skilled manpower, general and task oriented training and development at multi-disciplinary approach, motivation and awareness are the most essential ingredients for successful operation of quarantine facility for suspected cases of COVID-19 in current pandemic. approval is not applicable as part of public health response. All Government of India ethical principles and guidelines were adopted during the outbreak response: the investigation was aimed at achieving public good (bene cence) and collective welfare (solidarity); no harm was done to any individual (non-male cence); fair, honest and transparent (accountability and transparency); and participants' data was de-identi ed prior to analysis (con dentiality). This study involve secondary data analysis and hence no consent was taken.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declares that they have no competing interests Funding There was no funding required for this study Authors' contributions SG conceptualized the manuscript, did data curation and analysis, wrote the original draft, edited the draft, AK conceptualized the manuscript, did data curation and analysis, edited the draft, TN did data curation and analysis, edited the draft, NV did data curation and analysis, edited the draft, MD conceptualized the manuscript, supervised the process, reviewed & edited draft, SKJ conceptualized and supervised the process SKS conceptualized and supervised the process. All authors have approved the submitted version and have agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Figure 1
Evacuation ow of repatriate nationals from different countries to India and further discharge *Source: Adapted from Integrated Disease Surveillance Programme India. Note: The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of Research Square concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. This map has been provided by the authors.