Our anonymized questionnaire survey demonstrated that most HCWs in our hospital advocated for the development of criteria for in-hospital release from isolation. However, three-fourths of the HCWs practically faced no troubles due to the absence of criteria, and over half of them registered discomfort on seeing recently quarantined COVID-19 patients under general management even after meeting the criteria. These could be the main reasons underlying the failure to gain an understanding of the initial criteria launched in mid-January 2021 in our hospital. The tendency not to express individual opinions in public may be a peculiarity among Japanese people, which makes it difficult for us to be aware of their real impressions and considerations. In particular, this could be the case regarding COVID-19, an emerging infectious disease, whose actual entity and infectivity are not yet fully uncovered.
Our first proposal regarding the criteria for in-hospital release from isolation, which was gleaned from the United States and European CDCs [3, 4], was based on evidence of the disappearance of replication-competent viruses within a certain period [5, 6]. However, this criterion was not adhered to by HCWs managing COVID-19 patients due to concerns regarding potential infectivity and safety. Despite the scientific evidence-based recommendations, there was a latent, difficult-to-verbalize fear of the unprecedented virus among the HCWs regarding the risk of infection. This was undoubtedly a solid barrier to their ready acceptance of the criteria. Another month ensued before the discussion matured, and we were eventually able to enforce the criteria on March 1, 2021. Before that, patients, especially those under critical care, were isolated for prolonged periods of time; in such cases, we continued with full precautions and complete isolation even up to over 60 days after disease onset.
There are many negative implications emanating from the absence of criteria for in-hospital release from isolation for the management of emerging infectious diseases. First, it imposes a practical burden on HCWs. The physical and emotional stress of providing medical care in a contaminated area (the so-called “red zone”), even while wearing personal protective equipment (PPE), is considerable. Second, a shortage of PPE is also a major concern. The longer the isolation period, the more the PPE needed. The wastage or overuse of PPE should be avoided to the greatest extent possible, especially in the midst of a prolonged epidemic. Third, the required consultation or rehabilitation are greatly limited in the absence of the criteria, resulting in adverse effects, such as a delay or failure in properly diagnosing other conditions at the right moment as well as prolonged recovery time before discharge and reintegration into society. In light of these observations, the enforcement of reasonable criteria with a high compliance rate is imperative, for which sufficient time for consideration, repeated discussion, and small group meetings would be required.
Emerging infectious diseases will surely appear in the future. In particular, in this age of globalization as a consequence of developed transportation systems, it is plausible to anticipate an even higher infection risk than before, as evidenced by history. The nature of the next pandemic to strike the world is unknown; however, as medical professionals, we need to make courageous, generally acceptable, field-oriented, and sustainable decisions based on data available at each moment, while having a balanced view of gradually emerging evidence and various opinions from multidisciplinary medical personnel. Our current knowledge base, established through our experience with the COVID-19 pandemic, is potentially beneficial in the event of another menace due to a newly emerging infectious disease.