When It Comes to Ebola, What Does Quarantine Really Mean?
As governors scramble, the CDC outlines different kinds of isolation.
A
protester in front of the White House calls for mandatory quarantine of
travelers from West African countries affected by Ebola.
Photograph by Mark Wilson, Getty
Published October 28, 2014
The word "quarantine" would seem to have a straightforward
definition: It's when a sick person is shut in for a period of
time—perhaps with yellow tape or a sticker on the door—until he or she
is cured or can no longer spread the disease.
But with the Ebola epidemic, the meaning of quarantine is not nearly so clear.
That's partly because Ebola patients aren't contagious
until they've started exhibiting symptoms such as fever, vomiting, and
diarrhea. Someone may be incubating the disease for a week or more
without knowing it, potentially putting others at risk. And yet locking
up everyone returning to the U.S. from the three Ebola-stricken
countries in West Africa seems pointless if they can't pass on the
disease anyway.
On the other hand, Ebola is contagious enough that it's
infected six Americans working in West Africa and two Dallas nurses who
treated a Liberian who came to the United States with the disease, Thomas Eric Duncan.
In recent days, public health officials and the public have
struggled with the complexity of how to isolate those who may have been
exposed to Ebola and who could be at risk for spreading it while
preserving individual rights and tamping down irrational fears.
Many have criticized American doctor Craig Spencer
for taking the New York subway and visiting a bowling alley the day
before he was diagnosed with Ebola—and before he had symptoms.
At the same time, public health officials said it was absurd to lock up nurse Kaci Hickox in a hospital tent after she returned from treating Ebola patients in West Africa.
In an editorial published Tuesday, the prestigious New England Journal of Medicine said such quarantines are "not scientifically based" and are "unfair and unwise."
Hickox had no symptoms, though an early check at the
airport recorded a moderate fever. She has since been released to her
home state of Maine, where health officials say they presume she'll
agree to a voluntary quarantine.
Along with Spencer's and others, her case and is raising
questions about what quarantine really means and about what isolation
requires to be effective.
Different Isolations
U.S. Centers for Disease Control and Prevention director Thomas Frieden
announced new federal criteria on Monday for monitoring people who are
returning from West Africa or who have been exposed to Ebola in the U.S.
Frieden broke these people into four groups, depending on
their risk, and said their standard for isolation should vary by their
experiences.
Those at the highest risk, including people who have been
stuck with patient needles or who cared for an Ebola victim without
protection in West Africa, should voluntarily isolate themselves,
Frieden said.
That means avoiding large gatherings and mass transportation. Solitary jogs and car rides, like the one NBC News chief medical correspondent Nancy Snyderman
took to a nearby restaurant during her own self-quarantine, would be
okay as long as the person doesn't have Ebola symptoms, such as fever.
The next category includes people who share a household
with an Ebola patient but didn't provide direct care, like those living
with Duncan—none of whom caught the disease—as well as aid workers in
West Africa, such as Spencer.
Frieden said about 46 such health care workers have
returned to the U.S. from West Africa since October 11, out of about 800
travelers from the affected countries. In the West African countries
Liberia, Sierra Leone, and Guinea, Ebola has infected more than 10,000 people, killing 5,000.
Police hold back media and onlookers from a bowling
alley in Brooklyn, New York, visited by Craig Spencer, a doctor who
treated patients with Ebola and has since come down with the disease.
Photograph by Spencer Platt, Getty
Frieden said that health care workers returning from the
Ebola zone will be monitored daily for 21 days, the Ebola virus's
longest potential incubation period, and will check in with a health
care worker who will either take their temperature or watch while they
do it and will ask about symptoms like fatigue.
Their activities will be reviewed and permission given,
depending on "what makes sense for that individual at that time,"
Frieden said. Someone who feels fine during their third week at home,
after the highest risk period has passed, might be given more
flexibility than someone feeling fatigued and who has been back only a
week.
People in the low-risk category, such as health care
workers who treated Ebola patients here in the United States with full
protective gear, will be asked to monitor their temperatures twice a day
looking for any spikes that might indicate the onset of Ebola's
contagious phase.
Those at no clear risk because they had not been in close
contact with someone sick with Ebola or their body fluids, such as the
taxi driver who drove Spencer home from the bowling alley, do not need
any restrictions at all, according to the new CDC standards.
Heroes, Not Pariahs
In making the announcement Monday, Frieden spoke about balancing the need to protect the public without feeding public panic.
"We believe these [guidelines] are based on science," he
said, adding that he wanted to avoid treating health care workers
returning from West Africa's Ebola zone as "pariahs, instead of
recognizing the heroic work they're doing."
If quarantine requirements are too stringent, he said,
people will lie to cover up their exposure, raising the risk of
transmission. And he warned that health care workers might be unwilling
to help out in West Africa, making it more likely the disease will keep
landing on American shores.
Frieden said he expects that people will voluntarily comply
with the new guidelines, though states have legal authority to make
them comply if needed.
Health authorities have long favored voluntary isolation,
mostly for practical reasons. "If you make people feel as if they will
be stigmatized and outcast and scapegoated, they're not going to come
forward the next time someone gets sick, and that would be a disaster,"
said Wendy E. Parmet, director of the health policy and law program at Northeastern University in Boston.
The new federal guidelines seem designed to take the
pressure off governors, who have been struggling to find the right
balance between voluntary and enforced isolation. After strongly supporting mandatory quarantines along with New Jersey Governor Chris Christie, New York Governor Andrew Cuomo tried to strike a moderate tone on Sunday.
Christie also softened a bit Monday, allowing nurse Kaci Hickox to leave a New Jersey hospital and return to Maine, though he defended his mandatory quarantine policy on Tuesday. Cuomo said that the government will pay workers for time missed while under quarantine.
In Georgia on Monday, the governor announced a more stringent plan,
calling for mandatory quarantine of people who have had direct contact
with Ebola patients from the three affected West African countries,
though health care workers are exempt.
Others, including the governor of Virginia, appeared to be considering different standards.
Most public health experts appear to side with George Risi,
an infectious disease doctor in Montana who slept in the spare room and
didn't hug his wife and son for a week after treating Ebola patients in
Sierra Leone.
He also skipped seeing patients, though he did go into his
office. Risi was mindful of staying at least 3 feet from his coworkers,
particularly for the first week, when he was most likely to come down
with the disease if he'd caught it in West Africa.
Doing more than that is giving into public fear, Risi said,
without providing any benefit to the public and likely harming West
Africa.
"No one's going to want to go over there," he said, "if
they have to spend 21 days in some remote hotel in New Jersey just
because they've been helping."
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