XDR-TB incident raises specter of quarantine

Do you have a plan for HCW quarantine?

Andrew Speaker causes an international incident by getting on an airplane although he has been diagnosed with active XDR-TB (extensively drug-resistant tuberculosis) — and asked not to travel. Meanwhile, in Arizona, Robert Daniels sits in a jail ward of Maricopa Medical Center where he was confined after breaking his quarantine.

Although public health officials have broad quarantine authority, a federal quarantine hadn't been used in the past 40 years. Yet these recent incidents, along with the quarantine experience during the SARS epidemic in Toronto, raise an important question: Are hospitals — and health care workers — prepared to respond to an infectious disease outbreak that could include a form of quarantine?

The Hospital Pandemic Planning Checklist, developed by the Centers for Disease Control and Prevention (CDC), states simply, "A contingency plan has been developed in the event of hospital quarantine in conjunction with local jurisdictions to ensure quarantine is enforced and necessary supplies, equipment, and basic necessities can be delivered and maintained."

The agency's Community Strategy for Pandemic Influenza Mitigation provides for the use of a voluntary quarantine. During a pandemic influenza, the CDC will request that household contacts of ill patients stay home for seven to 10 days after the first onset of the person's symptoms.

"We're counting on voluntary compliance with these types of measures in the situation of a pandemic," says Francisco Averhoff, MD, MPH, a captain in the U.S. Public Health Service and chief of the Quarantine and Border Health Services Branch of the Division of Global Migration and Quarantine.

The quarantine guidance is intended as a tool for community preparedness, but hospitals also should consider the possible impact, says Averhoff. For example, some health care workers might face quarantine if pandemic influenza spread in other countries but only isolated cases had occurred in the United States, he says.

But clearly, health care workers will need support if they are expected to work while under quarantine — separated from family members or unable to travel freely. The U.S. Occupational Safety and Health Administration advises employers to plan for support services such as housing, meals, a place to rest, and child care services.

Lessons from SARS

Beyond the logistical nightmare of being restricted to home and/or work, health care workers who are quarantined face stigma, fear, and anxiety for their health and that of their family members.

The spread of SARS in Toronto occurred predominantly in hospitals, and 45% of those diagnosed with SARS were health care workers. In an effort to prevent community transmission, public health authorities used quarantine for the first time in Ontario in 50 years.

During SARS, one hospital considered renting space in a hotel to house staff who were on quarantine, but that idea was abandoned, according to the SARS Commission report. Instead, hospitals developed a "work quarantine."

"[W]e realized that if we sent all of the staff home, the patients were going to suffer and that we aren't going to be able to bring people in from elsewhere," Bonny Henry, MD, associate medical officer of health with Toronto Public Health, told the SARS Commission.

Nurses were prohibited from riding public transportation and going to public places such as a grocery store or school. While at home, they slept and ate in a separate room and wore a respirator while they were near family members. Some nurses literally slept at the hospital. "You can just imagine what kinds of pressures that puts on people," says Nancy Johnson, occupational health and safety specialist at the Ontario Nurses Association. "You're wondering about your family and if everything is being taken care of."

The SARS experience demonstrates the need to think through the potential for quarantine restrictions on staff during an influenza pandemic or outbreak of a newly emerging infectious disease, says Johnson. Hospitals must plan now to help employees with their personal responsibilities if they have been confined at work during an influenza pandemic or other severe infectious disease outbreak, she says.

"If you have a working quarantine for nurses, what happens to all the things they're responsible for at home if they can't get home? What happens to their child care or their parent care or their pet care if they're quarantined at work?" she says. "So we're urging that they look at those things. What are the measures that are going to be taken to take care of all those aspects of people's lives?"

The recent quarantine of patients with XDR-TB points out that quarantine remains a public health method for preventing community spread of potentially fatal infectious diseases. Health care workers have a higher likelihood of being affected by a quarantine because of their potential exposure. "It happened once and we have to be prepared for the possibility of it happening again," says Johnson.