Quarantining travelers from Ebola areas


(A google search for the subject line.)

The purpose of this post is to suggest and request that
travelers to the United States,
arriving from parts of the world
where Ebola is running through the population in an unchecked manner,
i.e., where an Ebola epidemic is occurring,
be quarantined upon their arrival in the United States
until the first of two events happens:
  1. They are tested for whether they are carrying the Ebola virus,
    and the test returns a negative (no Ebola virus) result.
  2. Such time passes that,
    if they did have the Ebola virus when they entered the U.S.,
    that fact would become known because
    they were exhibiting external signs of the virus.
    I.e., the "incubation period" for the virus had passed.
    (Reports are that that "incubation period" is 21 days,
    but of course further research may change that duration.)

Some practical questions and issues about such a quarantine:
  • Question: Where would the quarantined travelers be held?
    Answer: Supposedly the U.S. military has more base structure
    than the size of its forces require.
    Indeed, reports are that DoD would like to have
    another round of base closings.
    In any case, given the priority this issue has,
    forces could be moved around so that
    some military base would be freed up
    to hold the quarantined travelers.
    Advantages of this approach include:
    most, if not all, military bases have a nearby airfield;
    the bases are separated from the surrounding civilian community;
    they were, in many cases,
    designed with some security features between them and their surroundings;
    they are currently available to the government without the need for
    time-consuming construction or purchase of new facilities.
  • Less restrictive than an outright travel ban
  • Requires effective tracking of airline passenger flight itineraries.
    To be most effective, it would be necessary to determine the original boarding location
    of a passenger arriving from, say, Brussels.
    Did the passenger change planes there (or at another layover point)?
    The airline industry would, hopefully, be willing to provide such information,
    if necessary, taking steps to produce the information.
  • The Ellis Island precedent
    While this proposal might sound radical in 2014,
    in fact it is merely returning to our 1880s America precedents.
    Here is an excerpt from a 2014-10-09 NYT story:
    Historically, American health authorities have had
    elaborate systems to check immigrants’ health.
    On Ellis Island, for example,
    medical workers gave immigrants full medical examinations
    and even took cultures of bodily fluids,
    Professor Markel said.
    There were facilities nearby where the immigrants could be held
    while waiting for results.

    But those days were different:
    Many traveled for days or weeks to reach the United States,
    giving diseases ample time to surface.
    For more, see google at Ellis Island health screening

Miscellaneous Articles

CDC must control Ebola quarantines, honor system not working
By Dr. Manny Alvarez
Fox News, 2014-10-24


I think that
the approach that is being taken by the federal government—
the concept of
“It’s a matter of time before we see another case”
reveals a poor strategy.

Yesterday, New York City had its first case of an Ebola-infected patient.
Identified as Dr. Craig Spencer,
he is an emergency room physician who everybody knew
had recently returned from West Africa,
where he was treating Ebola victims with the non-profit,
Doctors Without Borders.

Luckily enough, this health care professional, when he became flagrantly ill,
immediately called emergency services and thankfully was descriptive enough
to allow medics to come prepared for full isolation.

Now, here’s where it all breaks down for me:
I give him an A for effort,
but I give him a failing grade
for his full execution once he got back to the United States from West Africa.

He, of all people, should have known that a proper quarantine means
daily monitoring of temperatures, monitoring of any flu-like symptoms
and no contact with anybody else.
That’s what quarantine means.

And we have seen, over and over again,
not only from non-medical professionals,
but sadly by health care workers,
that this breach of protocol continues to happen.
This doctor went about the city of New York for several days
riding the subways, going to dinner and even bowling,
just to fall significantly ill only 12 hours after his latest outing.

So, what’s the bottom line here? Let me repeat:
If you’re not going to close the borders and put a travel ban or a visa ban in place,
t least create a very comprehensive quarantine protocol and monitor it—
because this honor system that has been in place,
just by telling people “monitor yourselves,”
is certainly not working.

I am not worried that hundreds of people are going to get infected
by this one doctor in New York.
That’s not what I’m saying.
But every time a case of Ebola pops up in any major city,
it creates chaos, anxiety and certainly an exuberant amount of costs that—
let’s face it—
we cannot continue to afford on a daily basis.

I wish this doctor a speedy recovery,
and I would love to hear his side of the story once he gets out of the hospital.

Dr. Manny Alvarez serves as
Fox News Channel's Senior Managing Editor for Health News.

Tested Negative for Ebola, Nurse Criticizes Her Quarantine
New York Times, 2014-10-26

A nurse who was being quarantined at a New Jersey hospital after working with Ebola patients in Sierra Leone criticized her treatment on Saturday as an overreaction after an initial test found that she did not have the virus.

“I am scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa,” the nurse, Kaci Hickox, wrote in an essay on the website of The Dallas Morning News, in collaboration with a friend who works for the paper. “I am scared that, like me, they will arrive and see a frenzy of disorganization, fear, and most frightening, quarantine.”

She described being held in isolation for about seven hours at Newark Liberty International Airport on Friday, left alone for long stretches and given only a granola bar when she said she was hungry.

Ms. Hickox, 33, was placed in quarantine under a new policy announced on Friday by the governors of New York and New Jersey. All people entering the United States through Newark Liberty and Kennedy Airports will now be quarantined for 21 days if they had direct contact with Ebola patients in Guinea, Liberia or Sierra Leone, even if they show no symptoms of infection.

On Friday night, New Jersey health officials said the nurse had developed a fever after arriving, but on Saturday, they said her blood had tested negative for Ebola. Additional tests will be conducted.

Ms. Hickox disputed that she had had a fever. She wrote that at the airport, a forehead scanner showed her temperature to be 101, but that came after four hours during which she had not been allowed to leave.

“My cheeks were flushed, I was upset at being held with no explanation,” she wrote. “The female officer looked smug. ‘You have a fever now,’ she said.”

She was eventually escorted by eight police cars to University Hospital in Newark and taken to a tent outside the building. An oral thermometer showed her temperature to be 98, she wrote.

She added that the doctor felt her neck and rechecked the temperature. “ ‘There’s no way you have a fever,’ he said. ‘Your face is just flushed.’ ”

Her complaints served as a broadside against the new quarantine policy, which goes further than recommendations from the Centers for Disease Control and Prevention. The new policy has raised concerns among some health experts and doctors that it will discourage people from going to West Africa to try to contain Ebola at its source. The World Health Organization reported on Saturday that there were more than 10,000 suspected or confirmed cases in the three hardest-hit countries.

The C.D.C. calls for self-monitoring for travelers who have had contact with Ebola patients, but not for isolation, because a patient is not believed to be contagious until symptoms appear. But C.D.C. officials said that states had the right to go beyond their recommendations.

On Saturday, in a sign of growing concern about the virus, Gov. Pat Quinn of Illinois, the home of O’Hare International Airport in Chicago, began a quarantine program similar to the one in place in New York and New Jersey. Connecticut, which enacted a similar policy on Oct. 7, has quarantined nine people who have so far showed no symptoms.
Continue reading the main story

White House officials held a meeting on Saturday to discuss whether to revise nationwide policies regarding the return of health care workers from affected West African countries. An official said the administration may take further action, although it wanted to avoid anything that would hinder the ability to fight Ebola in West Africa.

On Friday, the day after a New York City doctor who had worked in Guinea through Doctors Without Borders tested positive for Ebola, the governors of New York and New Jersey described the quarantines as a necessary caution. Some of the details of where travelers would be quarantined, whether at their homes or elsewhere, were still being worked out Saturday.

Asked about the nurse’s essay while visiting Iowa, Gov. Chris Christie of New Jersey said, “My heart goes out to her because she’s someone who has been trying to help others and is obviously ill,” referring to earlier reports of a fever.

“I’m sorry if in any way she was inconvenienced but inconvenience that could occur from having folks that are symptomatic and ill out amongst the public is a much, much greater concern of mine,” he continued. “I hope she recovers quickly, and we’re going to do everything we can in New Jersey and in our public health system to make sure that she does.” In a telephone interview on Saturday night, Ms. Hickox’s father, Leon Hickox, said that his daughter “is not ill in any way.”

Doctors Without Borders said on Saturday that “there is a notable lack of clarity about the new guidelines,” and that it was concerned about the treatment of Ms. Hickox, who worked with the organization. It said she was in an unheated tent set up as an isolation ward next to a building at University Hospital. But a hospital spokeswoman, Stacie Newton, said the nurse was “in a building that’s part of the hospital.”

The New York City doctor, Craig Spencer, 33, remained in isolation at Bellevue Hospital Center in Manhattan on Saturday, with officials saying he had “entered the next and more serious phase of his illness, as anticipated with the appearance of gastrointestinal symptoms.” Mayor Bill de Blasio continued his reassurance tour on Saturday, sampling most of the menu at a meatball shop in Manhattan that Dr. Spencer had visited last week, as “a reminder about some core truths about Ebola.”

“It cannot be contracted through casual contact. It is not an airborne disease,” he said.

In New Jersey, health officials did not say how long Ms. Hickox was to be kept at University Hospital. The nurse’s mother, Karen Hickox, said her daughter called her on Saturday morning crying. “She felt like you would treat a dog better than she’s been treated,” she said in an interview.

Kaci Hickox grew up in Texas and worked for the C.D.C. in Las Vegas until recently, when she moved to Fort Kent, Maine, her mother said. She has worked in several African countries with Doctors Without Borders.

In the essay, Ms. Hickox described her last night at an Ebola management center in Sierra Leone, when she gave crushed Tylenol and anti-seizure medicine to a dying 10-year-old girl as her body jolted in bed. “It was the hardest night of my life,” she wrote.

“We need more health care workers to help fight the epidemic in West Africa,” she wrote. “The U.S. must treat returning health care workers with dignity and humanity.”

The essay drew more than 1,000 comments on the Morning News’s website, including some criticism of Ms. Hickox. Many readers argued that the quarantine was necessary and that it should not be a major inconvenience for the nurse to spend 21 days in quarantine to ensure that the virus does not spread. Still, others argued that the quarantine was fair but that the authorities should have treated her better.

In a statement, the C.D.C., which was involved in Ms. Hickox’s case, described workers like her as “heroes” and said: “We must protect their health, safety, and well-being and treat them with respect when they return home while continuing to take action to protect Americans so Ebola does not spread here.”

If Ms. Hickox was asymptomatic, said Udi Ofer, executive director of the American Civil Liberties Union of New Jersey, he would have questions about the legality of her quarantine.

“Mandatory quarantine of people exhibiting no symptoms and when not medically necessary raises serious constitutional concerns about the state abusing its police powers,” Mr. Ofer said.

Nicolas P. Terry, director of the Hall Center for Law and Health at the McKinney School of Law at Indiana University, said Ms. Hickox could challenge her quarantine on the grounds that she was being held without cause. But he said if the order was directed only at travelers in countries affected by Ebola and did not say they had to be symptomatic, then her only choice would be to challenge the validity of the order itself.

“If she fits the definitions and the symptoms of the New Jersey emergency regulation, they can keep her,” Mr. Terry said.

Ms. Hickox’s mother said she had sent her daughter a text message asking if she thought she would be detained when she returned home: “She texted back: LOL that’s not going to happen.”

[Note: An ABC News story on 2014-10-27 contains the following:

In a text message this morning [2014-10-27],
[Kaci Hickox] told ABC News Chief Health and Medical Editor Dr. Richard Besser,
"I'm so thankful for the immense attention and support I've received.
I just hope this nightmare of mine and the fight that I've undertaken
is not in vain!"

Hickox has tested negative for the virus twice
but was held in a quarantine tent at University Hospital in Newark anyway.
Her lawyer argued that her basic human rights were being violated.

End of excerpt from the ABC News story.

I wonder if I am the only one who thinks that
Ms. Hickox is way overreacting and overdramatizing what happened to her?
"A nightmare"? Really?]

The Dangers of Quarantines
Ebola Policies Made in Panic Cause More Damage
New York Times Editorial, 2014-10-28

With good reason, Americans are deeply confused about the risks of Ebola. It is a frightening disease, made more so by dueling theories about how best to deal with people arriving from West Africa and by wildly different messages — based partly on erroneous information given out by New York City officials — about whether the doctor who returned to New York from treating patients in Guinea and came down with the disease was or was not a danger to others when he moved around the city.

To make matters worse, two ambitious governors — Chris Christie of New Jersey and Andrew Cuomo of New York — fed panic by imposing a new policy of mandatory quarantines for all health care workers returning from the Ebola-stricken countries of West Africa through John F. Kennedy and Newark Liberty international airports. There is absolutely no public health justification for mandatory quarantines.

It’s not surprising that they have started to adjust their earlier positions, which seemed politically motivated, as they have come under a barrage of criticism from public health experts for their dangerous overreaction. They now say they will allow health care workers to be confined to their own homes, where they will be checked twice a day by public health officials.

Lost in this grandstanding was one essential point. The danger to the public in New York in the case of Dr. Craig Spencer, who had worked in Guinea for Doctors Without Borders, was close to nonexistent. Health experts are virtually unanimous in declaring that people infected with the virus do not become contagious until after they develop a fever or other symptoms, such as diarrhea, vomiting, or severe headaches, at which time they need to be hospitalized and taken out of circulation.

Health care workers like Dr. Spencer know that it is in their interest to ensure that — if symptoms do arise — they get care quickly to improve their chances of survival and to reduce the risk of infecting their friends and families. Dr. Spencer reported his temperature promptly when it was a low-grade fever of a 100.3 degrees and was rushed to Bellevue Hospital Center for isolation and treatment while his fiancée and two friends were put into voluntary isolation.

Fortunately, for the public, there are clearer heads at the federal level than there are in the statehouses of New York and New Jersey. On Monday, strict new federal monitoring rules, announced by the Centers for Disease Control and Prevention last week, went into effect for travelers entering the United States from Guinea, Liberia and Sierra Leone. The rules are designed to avoid the confusion of state-by-state policies, give health workers and other travelers a clearer idea of what to expect and reassure the public that somebody is in charge. State and local health departments will contact travelers daily for 21 days after their departure from West Africa to check on their temperatures and other symptoms (21 days is the maximum period for symptoms to develop). If the returning health care workers fail to report as required, health officials will track them down using contact information they have provided upon entry.

The C.D.C. further refined this approach on Monday with additional guidelines recommending how people with direct exposure to Ebola patients or burials should be handled. A doctor at high risk of Ebola because he was exposed to a patient’s bodily fluids would be strongly advised — and, if necessary, even ordered by health authorities — to avoid traveling or congregating in public.

The problem with a mandatory quarantine, even if done at home, is that it can discourage heath care workers from volunteering to fight the virus at its source in West Africa. Doctors Without Borders, the nongovernmental organization that has led the battle there, typically sends its workers on arduous four- to six-week assignments. The risk of being quarantined for another 21 days upon return has already prompted some people to reduce their length of time in the field and may discourage others from volunteering in the first place.

An editorial published Monday in The New England Journal of Medicine cited estimates that tens of thousands of additional volunteers will be needed to control the epidemic and warned that a mandatory 21-day quarantine, for people who are not sick and may never become sick, would be “more destructive than beneficial.” Policies that will reduce the chances of recruiting additional volunteers — without actually protecting the public — will only make the Ebola crisis worse.

A Rational Quarantine
By STEVEN J. CORWIN, Chief Executive, NewYork-Presbyterian Hospital
New York Times Letter to the Editor, 2014-10-29

Re “The Dangers of Quarantines” (editorial, Oct. 28):

The arrival of Ebola in the United States has made two things abundantly clear: More needs to be done to fight the virus at the epidemic’s center in West Africa, and containing and treating the virus here on American soil are difficult and complex undertakings, particularly in a place like New York City.

I commend Gov. Andrew M. Cuomo and Mayor Bill de Blasio for their rapid and decisive actions over the past week to protect the health of New Yorkers while ensuring that returning heroes like Dr. Craig Spencer receive the best possible treatment. Governor Cuomo has instituted a rational quarantine policy that will help prevent the spread of the disease.

Because each Ebola patient requires enormous amounts of resources, scores of personnel, including nurses and physicians, and specialized equipment and protective gear, even small numbers of Ebola cases could hinder the delivery of other essential health services in New York City and State. The governor’s policy recognizes this. It will allow our region’s hospitals and medical professionals to focus their efforts on caring for people who become sick, while alleviating New Yorkers’ concerns about this frightening disease.

It is also entirely fitting that employers of medical professionals who have been on the front lines of the Ebola fight be required to provide them with full compensation during the 21-day waiting period. We at NewYork-Presbyterian Hospital are honored to recognize their enormous personal contributions in this small way.

Chief Executive
NewYork-Presbyterian Hospital
New York, Oct. 28, 2014

Labels: ,