The misguided attempts to quarantine asymptomatic health care workers returning from fighting Ebola in West Africa last year were unethical and counterproductive, a federal bioethics group concluded in a recent report.1
“Needlessly restricting the freedom of expert and caring health care workers is both morally wrong and counterproductive -- it will do more to lose than to save lives,” says Amy Gutmann, PhD, chair of the Presidential Commission for the Study of Bioethical Issues (Bioethics Commission). “The Ebola epidemic in western Africa overwhelmed fragile health systems, killed thousands of people, and highlighted major inadequacies in our ability to respond to global public health emergencies. It demonstrated the dire need to prepare before the next epidemic. A failure to prepare and a failure to follow good science — for example, by not developing vaccines and not supporting health care providers — will lead to needless deaths.”
Future epidemics and public health emergencies should be guided by the ethical principle of “least infringement,” which means “any restrictive measures should be grounded in the best available scientific evidence and restrict individual and community liberties only so much as is necessary to protect public health,” the panel recommended. “These measures should not present unnecessary barriers to movement of health care workers to and from affected areas so that they can contribute their skills to the management of the public health emergency and other health problems.”
After the first U.S. case of Ebola onset in a patient last year, two Dallas nurses were occupationally infected. Ebola fears began to triumph over science, particularly when the Dallas incident was followed by an asymptomatic physician out and about in New York City before developing symptoms related to his care of Ebola patients in West Africa. Though he was monitoring for symptoms and presented for care appropriately, some states enacted or proposed 21-day quarantines for health care workers returning from the epidemic frontlines in West Africa. The three-week duration was to cover the outer limits of the incubation period of the virus, but these restrictions ignored the fact that Ebola is not transmissible in the absence of symptoms. Indeed, they reinforced the incorrect fear-based perception that asymptomatic health care workers who treated Ebola patients could transmit the virus.
The CDC recommended self-monitoring policies and “individualized assessment” of health care workers who treated Ebola patients based on their risk of exposures: high risk (i.e., needlestick); some risk (close contact with someone with symptoms); and low, but not zero risk (air travel with a symptomatic patient). Based on the risk assessment, monitoring, travel restrictions and other control measures are recommended as health care workers report to their state health departments. The CDC ultimately prevailed, but it appeared for a while that health care workers would refuse to volunteer to fight the epidemic if they were going to be quarantined for three weeks upon return. In fact, this actually happened while the quarantines were still in place, according to a nurse who participated in one of the Bioethics Commission hearings. Having previously completed a deployment to Africa, Kate Hurley, RN, MBA, MSN, was asked by the World Health Organization if she would return for a brief 10-day stint.
“I’ve come back from West Africa, I’ve integrated back into my job,” said Hurley, an ICU nurse manager at Providence St. Patrick Hospital in Missoula, MT. “So you look at it economically, okay, can you leave your job for another ten days? Sure. You look at it socially. Can you leave your teenage children at home? Well, maybe. But you decide that probably socially and economically, that you could probably leave for ten days. So you’re ready to make the decision, and then you know what flashes in the back of your head? Twenty-one days [in quarantine upon return]. Twenty-one days. I declined — not based on economic or social issues — but based on the lack of clarity in what happens to someone when they come back [from West Africa].
Another factor in the Draconian quarantine laws was the buildup to Nov. 4, 2014 midterm elections, with Ebola inevitably seized upon in all the hype and rhetoric. Future outbreaks are going to be difficult to contain if CDC recommendations are ignored, which is essentially what the proposed and enacted quarantine laws did.
“We are in a period where we don’t have a lot of trust in government because the government hasn’t been functioning well,” says Eddie Hedrick, MT(ASCP), CIC, project coordinator in the state Bureau of Communicable Disease Control & Prevention in Columbia, MO. “The political aspects of the quarantine they put on that young nurse from Maine polarized people. A lot of people looked at her as being some kind of pariah and others on the other side recognized what was happening — that these guys were using this for political gain. It just further divided people.”
Political tactic: Fear
That nurse was Kaci Hickox, RN, who was detained at Newark (NJ) Liberty Airport for three days in a tent with a portable toilet. “I was quarantined against my will by overzealous politicians after I volunteered to go and treat people affected by Ebola in West Africa,” she wrote in an op-ed piece for the Guardian newspaper in London.2 “My liberty, my interests and consequently my civil rights were ignored because some ambitious governors saw an opportunity to use an age-old political tactic: fear. [NJ Gov. Chris] Christie and my governor in Maine, Paul LePage, decided to disregard medical science and the constitution in hopes of advancing their careers. They bet that, by multiplying the existing fear and misinformation about Ebola – a disease most Americans know little about – they could ultimately manipulate everyone and proclaim themselves the protectors of the people by “protecting” the public from a disease that hasn’t killed a single American.”
Employee health, nursing and infection control groups came out against the harsh measures initially adopted in New York and New Jersey. The American Nurses Association opposed the mandatory quarantine of health care professionals urging “authorities to refrain from imposing more restrictive conditions than indicated in the CDC guidelines, which will only raise the level of fear and misinformation that currently exists.”
The Association for Professionals in Infection Control and Epidemiology (APIC) noted in comments submitted to the Bioethics Commission that “there is no scientific basis to justify placing a person who had contact with an infectious patient, but is currently asymptomatic into quarantine. … The experience of isolation during quarantine can be a traumatic experience for individuals, with serious financial and psychological hardships reported. In the absence of scientific evidence of a public health benefit to quarantine, we believe the ethical consideration of curtailment of personal liberty must be the primary deciding factor. Fear and anxiety increase when the general public lacks understanding of the science behind movement restrictions or quarantine recommendations.”
APIC recommended that quarantine and travel restrictions be consistent with CDC recommendations, discouraging autonomous actions by individual municipalities or states which can create confusion and anxiety.