The Quarantine Conundrum: Perspectives for the humanitarian community

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Author: Prof. Dr. Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS

Humanitarian aid workers may be activated to respond to Emerging Infectious Disease (EID) crises, such as the Ebola outbreak in West Africa declared by the World Health Organization to be a Public Health Emergency of International Concern in August 2014. Sometimes these heroes are functioning in their full time positions, but more commonly they are volunteers who temporarily separate themselves from their regular duties and their families. The question of whether it is really necessary to mandate a quarantine after completion of the mission and before returning home is therefore of critical importance, and needs scientific evidence.

Using Ebola as an example, mixed messages and inconsistent policies prevailed during the height of the outbreak. This stemmed in part from misapplications of the terms quarantine and isolation. While both represent public health tools that involve physical separation and confinement of individuals to prevent disease transmission and protect the public health, there are important differences. Quarantine is used for healthy (asymptomatic) individuals after exposure to a contagious disease, if and only if there is potential to transmit the disease. Conversely, isolation is applied to infected (symptomatic) people, also with the goal to prevent disease transmission.

In the case of Ebola, many asymptomatic humanitarian aid workers were ‘quarantined’ after caring for patients in West Africa, thus keeping them away from their routine work and their families for an additional 21 days after completing their service abroad. Since science tells us that Ebola is not contagious from person to person prior to symptom onset, there was no potential for these healthcare workers to transmit disease.[13] This mandated quarantine of asymptomatic health care workers was not founded in evidence.

Despite this, some politicians and public health decision makers argued that it was safer to quarantine “just in case” and “out of an abundance of caution.”[12] Yet this approach is fraught with unintended consequences. In addition to the obvious infringement of civil liberties, the policy inhibits healthcare workers from traveling to West Africa to eradicate the disease at its source; discourages them from caring for Ebola patients within their own countries; and exacerbates existing shortages by removing caregivers from work for an additional 21 days.

Within the United States alone, inconsistences in application of policy included some states mandating quarantine for returning healthcare workers, and the military requiring quarantine, while there was free movement for the United Nations Ambassador returning from West Africa and for physicians and nurses caring for Ebola patients within the United States. To address these discrepancies, the American College of Emergency Physicians, Ebola Expert Panel developed policy in support of statements by the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the World Health Organization to “oppose mandatory quarantine of asymptomatic health care workers who have treated Ebola patients in the U.S. or have returned from caring for patients overseas in Ebola-affected areas.”[9]

Furthermore, to inform policy makers and mitigate this conundrum, Barbisch and Koenig developed a novel ‘Quarantine and Isolation Decision Tool’. This tool considers disease characteristics, including whether the infection is contagious prior to symptom onset to form an evidence base for policy decisions. In summary, the application of quarantine for ill-informed reasons must be avoided and we need to advocate for scientifically-based principles to guide quarantine policy so that we are prepared to contain the next EID, whatever nature or a nefarious entity throws our way!

Kristi photo smallProf. Dr. Kristi L. Koenig is a Professor Emerita of Emergency Medicine & Public Health, University of California, Irvine, USA. Professor Koenig, an internationally recognized expert in Disaster Medicine, Emerging Infectious Diseases, Surge Capacity, and Crisis Care, is founding director of the UC Irvine Center for Disaster Medical Sciences.  A Fulbright Scholar and Fellow of the International Federation for Emergency Medicine, she published a definitive Disaster Medicine text, authored more than 115 peer-reviewed articles, and delivered nearly 500 lectures in more than a dozen countries.  Dr. Koenig previously held a 5-year appointment with the federal government as National Emergency Management Director for the Department of Veterans Affairs. During the 2014 Ebola outbreak, Dr. Koenig served on the national ACEP Ebola Expert Task Force and as Co-Editor of the Disaster Medicine and Public Health Preparedness Journal Special Ebola Issue. In this capacity, she developed the Identify-Isolate-Inform algorithm that was adopted by the U.S. Centers for Disease Control and Prevention for emergency department, EMS, and ambulatory care center preparedness for Ebola.

References and additional reading: 

  1. Koenig KL, Schultz CH. The 2014 Ebola Virus Outbreak and Other Emerging Infectious Diseases – draft chapter from Koenig & Schultz’s Disaster Medicine:  Comprehensive Principles and Practices, 2nd Edition.  October 21, 2014. http://www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/publichealth/The%202014%20Ebola%20Virus%20Outbreak.pdf.
  2. Koenig KL. Ebola Triage Screening and Public Health: The New “Vital Sign Zero.” Disaster Medicine and Public Health Preparedness. https://www.ncbi.nlm.nih.gov/pubmed/25351634
  3. Koenig KL. Identify, Isolate, Inform: A 3-pronged Approach to Management of Public Health Emergencies. Disaster Medicine and Public Health Preparedness. https://www.ncbi.nlm.nih.gov/pubmed/25351772
  4. Koenig KL. Health Care Worker Quarantine for Ebola: To Eradicate the Virus or Alleviate Fear? Ann Emerg Med. https://www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/publichealth/Health%20Care%20Worker%20Quarantine%20for%20Ebola%20To%20Eradicate%20the%20Virus%20or%20Alleviate%20Fear.pdf
  5. Beadling CW, Burkle FM, Koenig KL, Sharp TW. Introduction:  Ebola Virus and Public Health.  Disaster Medicine and Public Health Preparedness, doi: 10.1017/dmp.2015.6.
  6. Barbisch D, Koenig KL, Shih FY. Is There a Case for Quarantine? Perspectives from SARS to Ebola. Disaster Medicine and Public Health Preparedness, doi:10.1017/dmp.2015.38.
  7. Schultz CH, Koenig KL, Alassaf W. Preparing an Academic Medical Center to Manage Patients Infected With Ebola: Experiences of a University Hospital. Disaster Medicine and Public Health Preparedness, Sept 2015, pp 558-567. doi:10.1017/dmp.2015.111.
  8. Koenig KL. Quarantine for Zika Virus?  Where is the Science?  Disaster Medicine and Public Health Preparedness, 2016.
  9. ACEP Ebola Expert Panel consensus statement on restrictive movement including quarantine of health care workers. Available at: http://www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/publichealth/ACEP%20Ebola%20Expert%20Panel%20Consensus%20Statement.pdf.
  10. Barbisch D, Gostin LO. Quarantine in: Koenig KL, Schultz CH (Eds.) Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. Cambridge University Press, New York; 2010:203–212.
  11. Koenig KL. Ten key “facts” about Ebola: true or false? NEJM Journal Watch, November 7, 2014. http://www.jwatch.org/na36218/2014/11/07/ten-key-facts-about-ebola-true-or-false.
  12. No unity over Ebola monitoring of travelers. Washington Post. October 27th, 2014. http://www.washingtonpost.com/national/health-science/ebola-quarantine-issue-proves-divisive/2014/10/27/16ccf12c-5df2-11e4-91f7-5d89b5e8c251_story.html.
  13. https://www.cdc.gov/vhf/ebola/pdf/ebola-factsheet.pdf
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