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HICprevent

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This award-winning blog supplements the articles in Hospital Infection Control & Prevention.

Strangers in a strange land: Health care workers returning from Ebola frontlines find that fear has trumped reason

March 18th, 2015

Ironically, misguided Ebola quarantine laws for asymptomatic health care workers – ostensibly enacted by states to ensure public safety -- could have the opposite effect both in the U.S. at the outbreak epicenter in West Africa.

“If we turn them into pariahs instead of recognizing their heroic work they may be less likely to disclose their health care worker status and we lose the opportunity to directly monitor them,” said Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention. “They may be less likely to go help stop it at the source in Africa, and with that, if it spreads further or longer in the three countries ... the risk to us would increase.“

Urging “individualized assessment” of health care workers returning to the U.S., the CDC unveiled a risk stratification approach at an Oct. 27 press conference. The three risk categories are high (i.e., needlestick); some (close contact with someone with symptoms); and low, but not zero (air travel with a symptomatic patient). Based on the risk assessment, monitoring, travel restrictions and other control measures are recommended.

Infection control groups immediately came out against the kind of Draconian measures initially adopted in New York and New Jersey, which were triggered by a symptomless physician who was out and about in New York City after returning from the frontlines of the Ebola outbreak in Africa. Craig Spencer, MD, who remains under care at Bellevue Hospital in NYC, was appropriately self-monitoring and called in when he began to spike a fever. Ebola is not communicable until the viral titer builds and begins triggering symptoms in the host -- fever, headache, nausea, diarrhea et al. Though the CDC has been emphasizing that point for months, it seems to have gotten largely lost amid the public fear of Ebola.

Appealing to reason, the Association for Professionals in Infection Control and Epidemiology (APIC) reminded that no one in the community was infected by the U.S. index case, the late Thomas Duncan who died in Dallas on Oct. 8.

“The evidence is clear that individuals are not infectious until they show symptoms of the illness,” APIC said in a statement. “[Ebola] is not transmitted through the air. It is important to be guided by the scientific evidence, and apply the lessons learned so far from other experiences, including the fact that even family members who were in close contact with [index case] Mr. Duncan in Dallas have not gotten sick.”

That is a point well taken, as the late Duncan was clearly symptomatic for two days in the community after a Dallas hospital failed to admit him, in part because his travel history was not communicated between staff. Duncan acquired the disease in Africa and came in during the incubation period. Two Dallas nurses who treated Duncan remain the only people to acquire the virus in the U.S. and they have both been successfully treated. No one has acquired Ebola in a U.S. community and Duncan remains the only person to die of the virus in this country. Seven other people have been successfully treated and the aforementioned New York physician remains under care.

“Forced quarantines of healthcare workers with no symptoms of Ebola -- who have risked their lives to protect others -- are unnecessarily harsh and are not aligned with scientific evidence,” APIC stated. “Quarantines may affect the healthcare worker’s ability to make a living and may also have negative emotional and social consequences as a result of being stigmatized for their service.”