Should persons who may be infected with Ebola be ordered into quarantine? If they are, what does that mean exactly? At the foundation of this controversy is a delicate balance between the rights of an individual versus the rights of the public. Does the public’s right to feel safe – even when it is not based on medical evidence – supersede the rights of an individual?
The Case of Kaci Hickox
When Kaci Hickox, a Doctors Without Borders nurse, landed at Newark Airport after caring for Ebola patients in West Africa, she faced a new and unexpected challenge. She was placed into quarantine in a makeshift tent facility set up in a hospital parking lot. Kaci was the first health care worker to be quarantined under a directive issued by Governor Chris Christie of New Jersey and Governor Andrew Cuomo of New York that mandates a 21-day quarantine for any travelers arriving from West Africa—whether or not they were symptomatic.
The governors were reacting to growing public concern after Dr. Craig Spencer had become infected as a result of caring for Ebola patients in West Africa. Dr. Spencer had been in a number of public venues in the days just before his diagnosis. Illinois and Florida have also declared similar quarantine measures.
Almost immediately, the mandatory quarantine announcement was met with objections from President Obama and medical experts citing a lack of scientific evidence for the decision. Governor Cuomo quickly revised his order and allowed medical workers who had had contact with Ebola patients to be quarantined in their homes and to receive compensation for lost income. Later, Governor Christie also said that New Jersey residents who did not exhibit symptoms could be quarantined in their homes.
Kaci was eventually permitted to return to Maine where she was ordered to be quarantined in her home. She had tested negative for Ebola twice and exhibits no symptoms. After she launched a legal battle, a Maine district court chief judge overturned the quarantine, ruling that local health officials had failed to provide a scientific basis for their argument.
Support from the American Nurses Association
The American Nurses Association (ANA) issued a statement clearly opposing mandatory quarantines and coming down squarely on the side of Kaci Hickox in the quarantine debate. The ANA affirmed Centers for Disease Control (CDC) monitoring guidelines that do not require quarantine for anyone who is asymptomatic. The ANA joins the American Medical Association and the American Hospital Association in supporting CDC guidelines. The statement went on to say that “Policies to protect the public from the transmission of Ebola must be based on evidence and science, not fear.”
What the CDC Says
The CDC updated its monitoring guidelines a week ago. These guidelines focus on ensuring that anyone who has been exposed to Ebola is properly monitored and that a system is in place to identify anyone who requires care. Some of the changes reflected in the revised guidelines:
- direct active monitoring or active monitoring by state and local public health officials rather than self-monitoring
- stricter actions based on an escalating level of risk that is determined by the type of exposure
- specific guidance for monitoring health care workers who cared for Ebola patients in a country with widespread transmission versus monitoring health care workers who provided care to Ebola patients in the U.S.
The revised CDC guidelines spell out four risk levels for people who may have been exposed to Ebola – each based on the degree of exposure. High risk refers to those who:
- had direct contact with infected body fluids through a needle stick or splashes to the eyes, nose, or mouth
- had infected body fluids come in direct contact with their skin
- had handled infected body fluids without wearing personal protective equipment
- touched the dead body of an Ebola patient
- were living with or caring for a person who had Ebola symptoms.
Anyone at high risk requires direct active monitoring as well as restricted contact with the public and restricted travel. Direct active monitoring means that a public health official must directly observe the individual for fever or other symptoms at least once a day; a second follow-up each day can be done by telephone. Restricted travel means that these persons may not travel by plane, ship, bus, or train even if asymptomatic. They may be permitted to travel by private plane or car. Permission to use local public transportation is at the discretion of local health authorities.
The CDC defines some risk as close contact (within 3 feet) with a person who has symptoms of Ebola. People at some risk also require direct active monitoring. Restriction on public contact and travel are assessed on a case-by-case basis.
Persons are considered at low risk if they have been in the same room with someone who is infected only briefly but without direct contact or have had brief skin contact with a person who is symptomatic. Traveling on an airplane with a person who is not showing symptoms of Ebola is also considered low risk. The CDC recommends direct active monitoring in some low-risk cases and active monitoring in others. In active monitoring, the person must be checked for fever or other Ebola symptoms at least once daily by a public health official. Individuals who are being actively monitored must take their temperature twice each day and immediately report any symptoms to public health officials. Active monitoring must continue for 21 days after the last possible exposure. Low-risk cases are not restricted from public contact or travel.
The CDC defines no risk as someone that has had contact with a person before the person becomes symptomatic or that has traveled to a country with an Ebola outbreak more than 21 days ago. There are no monitoring or activity restrictions on no-risk individuals.
Theoretically, the CDC could issue a federal quarantine order if it believes one is warranted. But that doesn’t seem likely. A large-scale national quarantine has not been enforced since the Spanish flu pandemic in 1918–1919.
Complete updated CDC guidelines on Ebola are available at http://www.cdc.gov/vhf/ebola/index.html.