John O Warner and Jill A Warner describe their recent experience of the quarantine system and say they witnessed shortcomings at every point

When the UK’s system for quarantining travellers from high risk countries was introduced by the government in February 2021, many commentators lamented that it had taken so long. Now, months later, we’ve found that not only were the quarantine hotels long overdue, they are also seriously flawed in how they’ve been implemented. We returned from South Africa, a red listed country, on 11 May, after three months spent fulfilling our commitment as honorary academics in the University of Cape Town. For the past 18 months we have also been involved with a multinational research team investigating various aspects of covid-19 infection. We are therefore very aware of optimal practice to control the pandemic, and found it frustrating to see how this was frequently disregarded in the process of travelling to and quarantining in the UK.

Our return home from Cape Town to the UK began with having to get a negative RT-PCR test result within 72 hours of departure. Our journey saw us stop over at Doha, Qatar (also a red listed country) and Madrid, Spain (amber listed). The Qatar airline made efforts to ensure appropriate social distancing. However, this was not the case on the Iberia flight from Madrid. Despite the plane having only around 30-40% occupancy, we were directed to a row of three seats sitting next to someone not from a red listed country. He was clearly concerned and we all moved to appropriately distanced seats after take-off. Surely the airline should have had better systems for spacing passengers? 

Once we were in the UK at Heathrow Airport, we joined the queue of people from red listed countries. Thankfully, the queue was not long, but still there was not adequate social distancing—something that continued throughout our time in Heathrow and on the coach to the hotel. Officials at the various stages of scrutiny as we progressed through the airport were confused about the quarantine requirements, which led to delays and arguments. Some security staff clearly lacked training, and while this does not directly impact on infection transmission, it has the potential to adversely affect people’s willingness to cooperate.

We eventually reached the hotel, where the registration procedure was well organised in itself. One of us has food intolerances, which were carefully recorded on a form we were given to log our meal preferences. However, this had no impact on the meals delivered, which repeatedly contained the offending ingredients. Thankfully, the intolerance only results in symptoms with relatively large doses, which can be spotted by smell and taste before inappropriate exposure. However, those with a food allergy would have been at serious risk. We urge authorities to be aware that this could be a recipe for disaster. 

The system for dropping off meals also felt risky, with deliveries progressing linearly down the hotel corridors so that the doors to rooms opposite one another were opened within seconds of each other. Reports from Australia suggest that cross infection can and has occurred in this way. 

There was a large contingent of security staff to ensure that no one left their room without permission and an accompanying guard. However, it became clear during the stay that the security team had neither been well trained about cross infection avoidance, nor did they have sufficient authority and support to enforce adherence to good practice. 

Exercise was possible in a sectioned-off area of the car park behind the hotel. We were taken there by a security guard and several supervised the exercise area. Yet walking to and from the car park involved passing other quarantined occupants in the corridors—again, we were not always appropriately distanced. While we were required to wear masks at all times outside our rooms, many were not doing so in the exercise area. People smoking were a particular source of concern, as they often walked around blowing smoke in relatively close proximity to those attempting to exercise. Our attempts to ask the security team to address this failed: on some occasions they took no action, and on others their attempts to ask smokers to remain in a designated area were ignored. 

As rooms were sealed with locked windows, it was necessary to run the air conditioning system even though we were worried about the potential risks. Some ventilation systems have been found to risk spreading covid-19 and have been linked to outbreaks at quarantine hotels in Australia.

Our greatest misgivings, however, were over the process for the RT-PCR swabs that took place on day two and eight. The swab kit was delivered to rooms for the occupants to collect the throat and nose samples without supervision. While this may be done reasonably well by the general public when they are concerned that they might have the infection, it is important to consider the psychology influencing human behaviour in this rather different situation. A positive result mandates not only an extension to the quarantine period, but also a significant increase in costs (if positive on day two it means an extra two days, or on day eight an extra 10 days, in quarantine, which costs £152 per day per person). In other words, following the guidance risks incurring a financial penalty. Many people whose finances had already been compromised by travelling would be inclined to be less than committed to sampling appropriately. They are also hardly likely to report the onset of symptoms when they are within two days of release from quarantine.

Experts in infection control and policy makers should follow people through the whole quarantine procedure to identify critical points where cross infection is possible. Lived experience provides the best way to improve procedures. This process is well established in the food processing industry under the Hazard Analysis Critical Control Point procedure. This identifies points in the process where action is required to reduce risk and increase safety, particularly in relation to contamination with toxins or infectious organisms. We recommend this approach to improving the safety of quarantine.

Heathrow Airport also recently opened a separate terminal to be used for passengers arriving directly from red listed countries, yet this attempt to minimise transmission at airports requires more careful evaluation. There are no direct flights to the UK from many red listed countries, notably South Africa, and so most people arriving from those countries will have transited via an amber or green listed country. Mixing will have occurred in the transit airports, on the flights, and during disembarkation. This amplifies the need for more detailed scrutiny of potential cross infection critical points on flights and at airports.

Given the concerns about the quality of self-sampling for RT-PCR, we’d also argue that if the government is truly committed to ensuring quarantine works, it should establish a trained nurse in each hotel to collect the samples as is done in other countries. The government should be collecting and publishing data on the number of people becoming covid-19 swab positive during quarantine. We should also be carrying out full genomic sequencing of viruses found during quarantine to establish accurately how and where infection was contracted. 

The current quarantine process is seriously flawed, to the extent that we question whether it is just a political stunt to assuage public concern. We encountered shortcomings at every step: inadequate training of airline, airport, and hotel staff; procedures and hotel facilities that are not fit for purpose; and a failure to account for the psychology influencing human behaviour in this specific situation. We need a quarantine system that protects the population, not one that generates a false sense of security, while risking the spread of infection and new variants. 

John O Warner is an emeritus professor of paediatrics at Imperial College London and an honorary professor at the University of Cape Town. He is a member of the ISARIC paediatric long-COVID working group.

Competing interests: I have received bursaries for Scientific Advisory Board membership and grants from Danone/Nutricia, Friesland Campina, and Airsonett, all related to paediatric allergy research.

Jill A Warner is an immunologist and honorary professor at the University of Cape Town.

Competing interests: none declared.