Would an Ebola Quarantine Work?

quarantineThere has been a lot of buzz about the possibility of quarantines of health care staff. It is time that someone explained how a quarantine works and discussed whether it makes sense in this setting.

What is a Quarantine?

An important distinction needs to be made between quarantine and isolation. Isolation is to take people who are infectious and isolate them to prevent them from spreading the disease. Isolation can be mandatory or voluntary. Historically, Ebola has had mandatory isolation but for the most part, patients and families were willingly isolated to prevent the spread of the disease to others. Isolation is very good practice for a disease like Ebola.

A quarantine is more aggressive. Quarantines are where a population of healthy people are isolated because they might become infectious. They are usually involuntary because no one wants to be locked in with infectious people. It is usually accompanied by aggressive state actions to enfoce the quarantine.

When would a Quarantine make sense?

The justification for a quarantine requires two elements. First, the illness must be infectious. It would make no sense to quarantine cancer patients because they can’t transmit their disease. In the epidemiology community, the measure of infectivity is the Basic Reproduction Number or R-Naught (written as R0). It is the number of people you would expect, on average, to get an illness from an infectious person. Influenza has an R0 of 2-3, smallpox 5-7, measles is 12-18. The 2014 Ebola outbreak has an R0 of about 1.7 in West Africa. In the US, it is much lower with only two transmissions from the seven patients who have been treated.

The second factor is the severity of the illness.  Ebola, of course, is one of the deadlier illnesses out there, so its severity is certainly enough that isolation and quarantine are worth considering.

Both factors are important. Rabies and Mad Cow disease, which are nearly %100 fatal, do not require a quarantine because they are relatively difficult to transmit. Chicken Pox may be very infectious, but it is not so severe that we should consider isolation and quarantine. We would live in quite an oppressive society is the common cold was justification for isolation just because it was infectious despite the fact it is fairly benign as an illness.

What are the Advantages of a Quarantine?

At least in theory, quarantining an illness should isolate it to a small group of people where it can be safely treated or allowed to fizzle out on its own. To separate the potentially sick from the healthy does protect the healthy and may minimize the spread of the illness.

Another major advantage of quarantines is that they are a simple solution that makes the healthy feel safer. Quarantines are usually done by the healthy to the potentially sick. It allows the local leaders to say they did something which pacifies a frightened public.

One of the most justifiable and terrible quarantines in history is Typhoid Mary, who was an symptom free carrier of Typhoid. She was quarantined for 26 years of her life to protect the public from the outbreaks of typhoid that followed her. She was essentially imprisoned for life because of a disease she had.

What are the Disadvantages of a Quarantine?

Quarantines are not particularly effective. The only moderately effective quarantine I can find is management of Mad Cow Disease. It involved slaughtering 4.5 million head of cattle, which was the only effective solution because Mad Cow is universally fatal and untreatable.

Of course, this is not an option for humans. Quarantines have been rare in modern times. In 2007, a man named James Speaker was quarantined with extensively drug resistant tuberculosis. The last American quarantine before him was in 1963.

Quarantines can pacify a large segment of the population, but they often enrage the quarantined. During a smallpox outbreak in 1983, Local authorities attempted to quarantine the municipality of Muncie, Indiana. The population did not believe they had smallpox and several local officials were shot. Not only was the quarantine unenforceable, it created more problems than it solved.

Another difficulty of quarantines has been how often they are thinly veiled racial oppression. When a majority views a minority as dirty or disease ridden, it lowers the threshold necessary to quarantine them as a group. In 1900, California quarantined a section of San Francisco which was almost exclusively made of Chinese immigrants and their businesses. The effects were devastating to the local businesses and the quarantine was later thrown out by a federal court.

Does a Quarantine make sense for Ebola in America?

Ebola is certainly a dangerous illness with a 70% fatality rate in West Africa. A quarantine was tried in Liberia and Sierra Leone and both seem to have had no benefit and generally only aggravated an already tense public.

Ebola also is quite contagious to those performing funerals and direct caregivers of the sick. So the basic criteria for a quarantine are met in West Africa. Despite this, the quarantines that have been tried were failures. The energy and resources placed in the quarantine would have been much better spent on caring for the sick.

So would and Ebola quarantine in America make sense? The severity of Ebola in a modern health care setting has been much better than in Africa. There has been one death of Ebola in the US with this outbreak of the seven who have been treated. The death of Thomas Duncan was not surprising because even when he came for treatment in Dallas, he was sent home for several days. Despite this, Duncan only gave Ebola to the people you would expect him to transmit to, direct caregivers.

In fact, despite a botched handling of that outbreak, no one in the community developed Ebola. This is consistent with European treatment of Ebola patients where only direct caregivers of the sick have gotten Ebola.

So Ebola is not as severe nor as transmittable in a Western setting. This is not surprising as the toilet may be a greater safeguard than anything else. To take those infected body fluids away and have then adequately treated is probably more important than all of the personal protective equipment on the planet.

Taking all of this into consideration, I think a quarantine of health care workers or civilians who are not sick (which is to say, not contagious) would be neither effective nor beneficial. It is a political band-aid for a non-existent problem. In the history of this outbreak, no one has caught Ebola from a Western health care worker and no one has caught Ebola on a plane. There is simply no evidence to justify a quarantine.

But if even one person would get Ebola, wouldn’t a quarantine be justified?

This is an objection I have found is pretty common. As long as the life of a West African carries as much weight as an American, then this makes no sense. The small risk of an American getting Ebola much be weighted against the hundreds and thousands of lives that traveling health care staff going to West Africa can save. It only makes sense to say this if their lives don’t count. And their lives count!

Isn’t it selfish of those health care workers to risk the public by not quarantining themselves?

No more risk than when you get behind the wheel of your car. 34,000 Americans die in car accidents every year, so far one has died of Ebola ever. When you stop driving for public health reasons, get back to me.

As I have argued before, the burden on the health care workers who go overseas is heavy and to make it heavier only discourages us from going, which is a loss for everyone.

In conclusion

Let me end by asking that we, who want to go to West Africa, not be hindered. Care enough for the dying in West Africa to allow us to go and do what we are good at. It is no risk to you and a very great risk for them. Love them enough to overcome your fear.

And even if you are afraid, know that quarantines don’t really work that well. Find a better solution before you shackle us with a quarantine.

-Chip

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Seven Difficulties Health Care Workers Face to Fight Ebola

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As a nurse, I am one of the many who wishes to run toward Ebola. Don’t credit us with too much courage. We of all people know how manageable Ebola is and how few health care workers get it when good precautions are used and how many fewer die when given good treatment. Ebola is not as dangerous as advertised.

We see how many will die in West Africa if no one runs toward the explosion. In our protective gear, we are quite safe from contracting Ebola unlike the people of West Africa are in danger with about 70% of the infected dying. With the total cases now crossing 10,000 and a bleak future ahead if nothing changes, we feel the urgency to go.

With the new quarantines in New York, New Jersey, Illinois, and Florida, it is becoming increasingly difficult. There is a presumption on health care workers that our time and resources are acceptable sacrifices so that Americans can feel safe from their irrational fears. While West Africa is in serious danger, America is not. Even if 1000 sick patients got in a plane today and flew to every major American city, the outbreak would be under control within a few weeks.

The very first case of a nurse returning to the U. S. from an Ebola ward shows how needlessly aggressive the quarantining of health care workers can be. She was not treated as a kind person who took a risk for others and more like a  criminal waiting for the DA to charge her.

I don’t believe the public at large understands the sorts of barriers we face in getting to West Africa.

I hope to show you the difficulties I have faced in my own attempt to go to Liberia so that you can see that our help should not be presumed upon. We are not asking for your support as much as we ask that you not stand in our way.

1. The Fear for my Family

My greatest fear in all this is to come home and give Ebola to one of my kids. This is a remote possibility and a devastating one. It weighs so much on me that I plan on not returning home for the 21 days I could be infectious.

Lest I be accused of being hypocritical, I am not returning home because I can’t avoid close physical contact with my kids or my wife. It’s hard to avoid close contact with the lady sleeping in my bed or the kids climbing in my lap. I plan on returning to work (I have a phone job, so no close physical contact there either) and resuming my normal life. The public is at a minimal/non-existent risk and my life is not terribly inconvenienced.

Additionally, I will be checking my temperature multiple times a day and would promptly report a fever to the authorities. It is entirely possible I will be hospitalized with full protective gear for a minor stomach bug, but so be it.

2. The Fears of my Family

The next greatest weight we carry is the fear of those who love us. They mean well and wish for us to be safe. Of course, if I were sick with Ebola, my family would hope someone who had the resources and knowledge to help would come from far away to help me. I am hoping to be that person for someone else’s son or sister or mother or friend.

Their concern is not crazy. This is a dangerous disease. I don’t fear for myself because I am not in particular danger, but I understand their concern.

3. The Financial Pressure

When I go, I will be using my vacation time to do it. In fact, to even take three weeks of vacation time is difficult for my employer. I can’t support a house payment and our other expenses while taking significant time off. In addition, I am adding some expenses even though most NGOs pay for the travel and expenses there. Who will shovel my driveway when it snows? There are countless little things that need to be attended to while I am gone.

4. Work Pressures

My employer has been very understanding of my trip. Even so, many of my coworkers aren’t thrilled with the idea that someone who has been near Ebola will be working in the cube next to them. I suspect that I will given a wide berth when I arrive back.

Additionally, I feel that because people would be concerned that I should alert them that I have been to an Ebola hit country. I don’t want them to wonder if they should have shaken hands with me. They should be afforded the courtesy of making that decision for themselves even if I am comfortable with it.

 5. Public Pressures

Many health care workers have been afforded a return from West Africa like the Vietnam Veterans received. Many are thankful for their sacrifice and a vocal and frightened few are quite vicious to the nurse who was needlessly quarantined in New Jersey.  Here are several choice examples just posted in the comments from the link above:

Nurse Medusa with the outdated snake hair,showing her true liberal democrat selfish roots.

Then Jesus said, ‘How selfish of you to care for the afflicted at risk of your own life. And how dare you complain about unwarranted ill treatment on your return. You must be a liberal. I hate you’.

If she was a responsible health provider, who respects her profession and her fellow Americans, she would have quarantined herself for 1 month before stepping on a plane home. Isolation is a key factor when trying to contain an epidemic, one does not have to work in the health sciences field to figure that out. Selfish and ignorant!

I now see the Kaci is going by private carrier to her home in Maine where she will “self quarantine”. A small part of me hopes she develops Ebola, and like the Dallas nurse recovers fully.

Additionally, we are treated like public property. There is no great discussion of the rights of these workers. As a libertarian myself, I have been stunned at the lack of discussion of the civil liberties of the health care community. We are not a resource or commodity, we are human beings.

6. The Difficulty of Even Getting To West Africa

It is not small feat to get the time to do the CDC training and get over to West Africa. While many of the NGOs pay for the travel, it is a lot of time and phone calls to even get to that point. We, like all of you, have busy lives with many responsibilities. Getting to West Africa is no small feat.

7. The Uncertainty of How the Government will Treat Us

When I take off in that plane to go to West Africa, at any moment the policy of Minnesota or the Federal Government could change requiring me to be quarantined for three additional weeks on my return. It would be a serious financial burden on my family if this happened.

A week ago, I might have agreed to go through JFK or Newark airport once I returned, now I will specifically request to avoid these airports to avoid the quarantines that have been placed there. There is even talk of health care community of flying into Toronto and driving home to avoid these onerous requirements.

Should I go?

As you can see, there are many barriers to going to serve these patients. I don’t want applause for this, I simply don’t want to be hindered. A few more roadblocks and, in the name of public safety, I will be prevented from going at all.

If we don’t go to help those in West Africa, this outbreak will spread and grow. Do you think that if Ebola exploded in Guatemala it would be contained well there. Wouldn’t it then march into Mexico and start walking across our own border there? The only way the U. S. will be safe from Ebola is if it is stopped where it is.

Without the aid of U. S. health care volunteers, it will never be stopped in West Africa. For their safety and for your safety, please let us go unhindered and return without barriers placed before us. If we don’t go, who will?

-Chip

Five Reasons We Are Afraid of Ebola

quarantineWhen Thomas Duncan, a Liberian man who lived in Texas, was diagnosed with the Ebola virus, the reaction in the community and the press was strong, surprisingly strong. I had anticipated fear when a case came to the US (something that was nearly inevitable), but not this level of fear.

Even as I write this, the headline story on the Drudgereport is Ebola is ‘disaster of our generation’ says aid agency. There are countless stories discussing every step Mr. Duncan took and the thousands of people he might have come in contact with. Unfortunately, Mr. Duncan died of Ebola. The news would have ended there except that two of his nurses have since contracted the virus. With fresh fervor, the hysteria reasserts itself.

This fear is out of proportion to the danger. It is no surprise that a patient gets Ebola and some of his caregivers get it. certainly there were serious failures of the health care system in this case, but if the total price we pay for those mistakes is only two infections, then we should feel fortunate. After puzzling over this for some time, I think there are a few explanations for this deep fear we feel as Ebola walked onto our shores.

1. We Overestimate Dramatic Deaths and Underestimate Boring Ones

Humans are terrible at estimating danger. We fear snakes when mosquitos kill a million people every year. We are afraid of bears when white-tail deer kill about 130 people a year. We fear flying when about 1.24 million people are killed in car accidents every year worldwide. We fear Ebola, which has killed about 5,000 people so far and yet ignore influenza which kills about 250,000 to 500,000 every year.

Ebola is definitely the diva of the deadly viruses. Symptoms such as vomiting blood, uncontrollable fever and shaking, terrible diarrhea, and bleeding from the eyes and ears make it a virus out of a zombie movie. If drama makes for great news coverage, then Ebola makes great coverage.

2. We Fear that Ebola will Spread in the US like it does in West Africa

One good watching of the movie Outbreak would make me fear Ebola too. While Ebola is not the virus in the movie, it is clearly based on Ebola. Dustin Hoffman is telling us to close the US border, right?

The fact is that Ebola is not as contagious as advertised. The lengths we are going through to establish Ebola as an airborne threat indicate how difficult it has been to show Ebola spreading through the air. But it does not spread like influenza or a cold virus.

Close physical contact accounts for most if not all of Ebola spread. Think of who got Ebola from Thomas Duncan, it was two nurses who had, you guessed it, close contact with Mr. Duncan. To worry that it is spread by casual contact is to borrow trouble. Certainly it is possible, but it doesn’t seem to be happening. If you are a nurse caring for an Ebola patient, an abundance of caution is justified. If you are a member of the general public in the US, any fear you have of getting Ebola is unwarranted. You should be more concerned about white-tail deer.

3. We Fear the Unknown

Ebola is very other. It is foreign to us: far-away. Ebola epitomizes the dangerous jungle illness that has never been seen on our shores. This frightens us.

Now that Ebola is here, among us. We’re not sure what to do. There is this feeling that we shouldn’t have to face this. It ought to be someone else’s problem. The fear of this unknown drives us to feel silly things like that we should be immune or protected from it simply because we are here and it should stay over there.

While understandable, the only cure for fear of the unknown is to get to know it. Knowing Ebola doesn’t cause panic, but like anything dangerous, we learn to treat it with respect. Far from being unknowable, Ebola can be known. We just need to take the time to learn.

4. It is an Election Year

Ebola has a great marketing plan going. It chose to arrive in America in the months leading up to a Federal election. There are countless candidates looking for a stage to be heard from. There are very few stages more popular than one that pretends to protect the public from a dangerous disease.

Playing on our fears to get our attention, many have blamed the Obama administration not primarily because they care about public health, but because blaming the administration is what one does to the opposition party in October.

This is understandable, but very frustrating when it aggravates some of our most uninformed fears. What galls me the most is that it is working? Certainly the CDC and the hospitals involved should have done a better job, a much better job. But by reading the headlines you would have thought hundreds or thousands had Ebola in the US, not just three.

5. There is a Deep Distrust of the Health Care Establishment and Politicians

There is a deep and growing distrust of the health care establishment and of politicians. After years of wondering if cancer treatments really help, if vaccines are safe, should we really have antibiotics in our meat, and asking just when they figured out that this drug has a tragic side effect, the casual observer has a general distrust of the health care establishment.

It is worsened when Dr. Friedman, the head of the CDC, represents both politicians and medicine. It is further aggravated when he does the tried and true political process of providing the same talking points answers no matter what the question is. We feel manipulated because we are being manipulated.

But just because he is playing politics does not mean he is wrong. I wish he would give the straight answers to the questions. No, he should not be fired. Yes, the CDC was too slow. No, closing the US border to West Africans would not help. Yes, America is safe from a large outbreak of Ebola. Maybe the political environment makes such straight answers impossible, but I wish he would give them.

To Love People, We Need to Calm Down

Most of the fear we are experiencing over Ebola is not justified. We are reacting to our own anxieties and prejudices and not to the situation we are in. Ebola is not a serious threat to public health in the U.S. Heart disease is, but it lacks the drama that Ebola brings to the table.

The fear we experience is preventing us from considering carefully how we should proceed. There is a chorus of voices demanding that people from West Africa be prevented from entering the US. This might prevent some US cases of Ebola and it would certainly sentence tens of thousands to millions of West Africans to die. Ebola has been successfully contained throughout Africa for decades and even recently the outbreaks in Senegal and Nigeria have not had a new case in weeks.

The fear of Ebola is causing people to demand that health care workers who have cared for Ebola patients be quarantined for 21 days. This sounds like a grand plan unless you are the health care worker who has bills to pay and a life to live. By placing this artificial requirement, you make it very difficult for nurses to provide care for these patient. It does not protect the public and it is a bandaid political solution to a non-problem.

We need to accept that some people in the US will get Ebola. Some of them will even be cute ladies with dogs. Some might even be nice people we would like. Ebola will be spread to a few in America and it will stop there.

The same cannot be said for West Africa. If you are there you should be afraid. You should be cautious in public places. They face the prospect of living through Ebola and starving in the famine that is coming. They are dealing with homes where mom and dad have died and children are left to survive on their own. We should see through the blindness of our fear and have compassion on these people. They are in danger and we are not.

-Chip

The Image Above is courtesy of Jason Scragz and used with permission.