Isolation and Quarantine

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Isolation and Quarantine

Introduction

Isolation and quarantine are two strategies that can be used to control the spread of a disease that is contagious (easily passed from person-to-person). Both approaches are minimize the exposure of other people to infected persons.

Isolation and quarantine are not the same. Isolation is more common than quarantine and used for someone who is known to have a disease. Quarantine is used for someone who has been exposed to a disease or diseasecausing agent, but who is not currently displaying symptoms and who may not necessarily become ill.

Isolation and quarantine may be voluntary. For example, during the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Canada, over 15,000 people were asked to voluntarily quarantine themselves for 10 days during the height of the outbreak. During a voluntary quarantine, people may elect to remain at home, forgo public gatherings, and curtail travel on airplanes, busses, trains, and other forms of public transit. However, if an outbreak involves a disease that is judged by public health authorities to be a severe contagious threat, isolation or quarantine may be imposed by law. In the United States, only disease threats that are listed in an Executive Order by the President qualify for government-imposed quarantine.

WORDS TO KNOW

CONTAGIOUS: A disease that is easily spread among a population, usually by casual person to person contact.

EXECUTIVE ORDER: Presidential orders that implement or interpret a federal statute, administrative policy, or treaty.

NON-GOVERNMENTAL ORGANIZATIONS (NGOS): A voluntary organization that is not part of any government; often organized to address a specific issue or perform a humanitarian function.

History and Scientific Foundations

The concept of quarantine dates back to the 14th century, when ships arriving in Venice from regions where plague was occurring were required to anchor in the harbor for forty days before the crew were permitted to go ashore. The word quarantine is derived from the Italian quaranta giorni, meaning forty days.

In the United States, federal legislation governing the imposition of quarantine was first enacted in 1878 in response to outbreaks of yellow fever. Then the quarantine powers of the federal government were minimal and did not override state and local government public health practices. The federal government assumed more responsibility for quarantine in 1892, in response to outbreaks of cholera.

While states continue to have powers to issue quarantines for illnesses within their borders, the federal government has had responsibility for quarantine on a national scale since the implementation of the 1944 Public Service Act. In 1967, the federal responsibility for the imposition and enforcement of quarantine was transferred to the Centers for Disease Control and Prevention (CDC), where it has remained. The Division of Global Migration and Quarantine is responsible for the nationwide system of quarantine stations (as of 2006 there were 18, with two more slated to open during 2007).

Both quarantine and isolation are designed to protect the larger community from people known to be infected with a contagious disease deemed to be a public health threat (isolation) or people who have had contact with someone who has become ill with the disease and so who may themselves be infected while not yet displaying symptoms (quarantine). Those in isolation can be treated while at the same time minimizing the chance that the disease will spread. People under quarantine can be monitored for symptoms of the disease; if symptoms do not appear within a certain time (10 days is typical, since voluntary compliance with a quarantine becomes difficult after that) then the quarantine can be lifted.

Applications and Research

Isolation and quarantine are public health responses to an illness outbreak. Of these, isolation is common, being practiced daily in most hospitals, particularly since the appearance and increasing prevalence of tuberculosis and disease causing bacteria that are resistant to multiple antibiotics (an example is methicillin resistant Staphylococcus aureus, or MRSA). A common site in hospitals nowadays are posted warnings restricting visitation to a ward room housing a patient with a contagious infection.

Isolation is a standard procedure. In contrast, quarantine is less common and is more of a drastic measure to control an infectious disease. While it can be useful in controlling an illness outbreak, quarantine can leave lasting effects on those involved. A study conducted on some of those who were quarantined during the 2003 SARS (severe acute respiratory syndrome) outbreak in Toronto, Canada, documented symptoms of posttraumatic stress disorder and depression in about 30% of study respondents.

Impacts and Issues

Quarantine can affect civil liberties. Imposed quarantines may restrict freedoms of movement and assembly. Schools, restaurants, businesses, means of transit, and public spaces may be closed. The degree to which civil liberties are curtailed in response to an epidemic may be controversial, and whenever possible, quarantine is a voluntary measure. In the event of an imposed quarantine, government entities, law enforcement, media, and public health organizations should provide as much information as possible to those affected by a quarantine.

Isolation and quarantine can also affect someone's privacy, since of necessity the community will need to know who is being contained. This lack of privacy can even include revealing a person's medical history. Thus, isolation and quarantine are considered carefully and not undertaken without a demonstrated and immediate need to do so.

In the United States, an Executive Order of the president identifies quarantinable diseases and authorizes government action to implement quarantines, restrict travel, and detain persons to stop the spread of certain infectious diseases. Executive Order 13295 lists cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers (such as Ebola, Marburg, and others) as quarantinable. In 2003, following an outbreak in Asia, SARS was added to the list. The growing threat of H5N1 virus and possible pandemic influenza prompted the Department of Health and Human Services (HHS) to request its addition to the list. On April 3, 2005, U.S. President George W. Bush amended Executive Order 13295, identifying pandemic influenza as quarantinable in the United States.

IN CONTEXT: EFFECTIVE RULES AND REGULATIONS

In the United States, [42 U.S.C. 247d] Sec. 319(a) of the Public Health Service Act allows the Health and Human Services (HHS) Secretary to declare a public health emergency and “take such action as may be appropriate to respond” including quarantine, prevention of disease, treatment recommendations, research, etc. if “the Secretary determines, after consultation with such public health officials as may be necessary, that (1) a disease or disorder presents a public health emergency; or (2) a public health emergency, including significant outbreaks of infectious diseases or bioterrorist attacks, otherwise exists, the Secretary may take such action as may be appropriate to respond to the public health emergency, including making grants, providing awards for expenses, and entering into contracts and conducting and supporting investigations into the cause, treatment, or prevention of a disease or disorder as described Any such determination of a public health emergency terminates upon the Secretary declaring that the emergency no longer exists, or upon the expiration of the 90-day period beginning on the date on which the determination is made by the Secretary, whichever occurs first. Determinations that terminate under the preceding sentence may be renewed by the Secretary (on the basis of the same or additional facts), and the preceding sentence applies to each such renewal. Not later than 48 hours after making a determination under this subsection of a public health emergency (including a renewal), the Secretary shall submit to the Congress written notification of the determination.”

Increased movement of peoples worldwide—through migration, travel, or war—has prompted the need for better international protocols for preventing the spread of infectious diseases. Quarantine across national borders is problematic, sometimes complicated by war, political tensions, different languages, health, and legal systems. Over the past several decades, national governments and international agencies have worked to develop a global network of disease reporting. Increased communication about outbreaks of infectious diseases help nations prepare for disease threats and enact preventative measures within their own borders. The United Nations World Health Organization (WHO) and other non-governmental organizations (NGOs), such as Doctors Without Borders, also report and respond to infectious disease outbreaks. International agencies and NGOs typically work with national and local governments to implement disease treatment and prevention strategies, including recommendations of isolation or voluntary or imposed quarantine.

Many of the newest international epidemic identification and national quarantine protocols were tested during the intercontinental SARS outbreak in 2003. Italian physician Carlo Urbani (1956–2003) identified the new illness when asked to travel to a Vietnamese hospital to look at a patient thought to have a new strain of influenza. Urbani diagnosed the patient, an American businessman, as suffering from a new, and possibly highly contagious disease. Urbani notified the WHO, CDC, and Vietnamese national health officials, recommending isolation of patients, quarantine of SARS-exposed healthcare workers, and screening of travelers. Urbani himself contracted SARS, and after developing symptoms while aboard an airline flight to Bangkok, Thailand, relayed the need for his own isolation upon landing. Urbani died shortly thereafter of SARS-related complications. However, his rapid identification of the disease and notification of international health authorities, and the concerted efforts of health officials in implementing screening, isolation, and quarantine, stemmed the spread of the disease and saved many lives.

BIBLIOGRAPHY

Books

Barry, John M. The Great Influenza: The Epic Story of the Deadliest Plague In History. New York: Viking, 2004.

Rothstein, Mark A. Quarantine And Isolation: Lessons Learned from Sars: A Report to the CDC. Darby PA: Diane Publishing, 2003.

Tierno, Philip M. The Secret Life of Germs: What They Are, Why We Need Them, and How We Can Protect Ourselves Against Them. New York: Atria, 2004.

Periodicals

Day, Troy, Andrew Park, Neal Madras, Abba Gumel, and Jianhong Wu. “When is quarantine a useful control strategy for emerging infectious diseases?” American Journal of Epidemiology. 163 (2006): 479-485.

Hawryluck, Laura, Wayne L. Gold, Susan Robinson, Stephen Pogorski, Sandra Galea, and Rima Styra. “SARS control and psychological effects of quarantine, Toronto, Canada.” Emerging Infectious Diseases. 10 (2004): 1206–1212.

Brian Hoyle

Infectious Diseases: In Context