The Question of Quarantine

Despite all the national attention being paid to a potential avian flu pandemic and all the uncertainty that attends it, one thing does seem certain—if, in fact, a pandemic occurs, the task of containing it will fall primarily on state and local responders.
"We would like to think that big problems like avian flu or, really, any other kind of major infectious disease, natural or man-made, will be taken care of by the federal government. But if that was ever realistic, it certainly no longer is," Christine Quinn, head of the New York City Council health committee, said recently. "Rightly or wrongly, the burden is going to fall on the cities and towns."
As apocalyptic scenarios become part of our day-to-day lives, the practical question of how to be ready for the "worst case" looms ever larger, especially in the quite likely event that vaccine is unavailable or insufficient.
"If you look at where most of the emphasis is in pandemic planning right now, it’s on distributing a vaccine—which would be wonderful if we were certain we’d have one in time to stop an outbreak in its tracks," David Heyman, director of the homeland security program at the Center for Strategic and International Studies (CSIS) in Washington, DC, told HSToday. "But everybody knows we may well not. So the real question that has to be faced in planning is: ‘ What to do until the vaccine comes? ‘”
For many, the prospect conjures up images of panic, chaos and the need for martial law, scenes reminiscent of the movie "Outbreak," which portrayed the military forced to quarantine terrified citizens at gunpoint, herding large chunks of the urban population into latter-day concentration camps.
This specter of a military-run quarantine was stoked further at a Nov. 1 press conference when President George Bush said, "I have thought through the scenarios of what an avian flu outbreak could mean. I tried to get a better handle on what the decision-making process would be by reading Mr. Barry’s book on the influenza outbreak in 1918. I would recommend it. The policy decisions for a president in dealing with an avian flu outbreak are difficult. One example: If we had an outbreak somewhere in the United States, do we not then quarantine that part of the country? And how do you, then, enforce a quarantine? It’s one thing to shut down airplanes. It’s another thing to prevent people from coming in to get exposed to the avian flu. And who best to be able to affect a quarantine? One option is the use of a military that’s able to plan and move. So that’s why I put it on the table. I think it’s an important debate for Congress to have."
State and local public health officials on the front lines ramping up their own plans to deal with a potential pandemic must think not only quarantine but the wider topic of disease-exposure containment. How does one fashion a practical response based neither on the hope for a vaccine nor on the fear that all forms of civic order and cooperation will break down?
The means to achieve that goal will vary from locale to locale, but, said Heyman, "There does exist a set of tools and protocols for controlling and containing disease exposure in the absence of a comprehensive vaccine option. And now is the time for us as a nation to be getting familiarized with and educated about them on a grass-roots level."
Types of protection
Based on an analysis of a wide range of sources, including State Department health manuals, World Health Organization (WHO) Infectious Disease reports and historical articles on quarantine, Heyman and CSIS recently put together a study called Model Operational Guidelines for Disease Exposure Control (a pre-publication draft is available at http://www.csis. org/media/csis/pubs/051102_dec_guidelines.pdf) to help clarify thinking about how states and locales can go about doing this, sooner rather than later.
"Quarantine is a common term," he said, "but it’s often completely misused by the public and government alike in ways that fail to show the nuances of disease-control measures within a wider framework for controlling the spread of infectious disease. Most people, including government officials, fail to appreciate the variety of different degrees and scales of quarantine and levels of enforcement it can entail."
Quarantine, the report notes, can often be a voluntary measure by citizens, as it primarily was during the SARS outbreak of 2003. It can also involve as few as one or two citizens, as well as hundreds. It is also, popular preconceptions to the contrary, as likely or more likely to take place at home than in a masspublic space under armed guard.
"Enforcement may be necessary in some instances," said Heyman. "But quarantine is not intrinsically a military or law-enforcement matter, though law enforcement has a role to play. Nor is it necessarily a mass event."
In addition, and perhaps most crucially, the report notes, quarantine itself is neither an isolated standalone strategy nor a panacea, but one in a continuum of tools at a community’s disposal. Indeed, the first community-wide tool and, Heyman believes, the cornerstone of disease exposure containment, is infection control. "Proactive hygiene practices, decontamination procedures and proper use of personal protective equipment" (PPE), he said, can play a significant role in limiting the spread of an infectious disease.
There are four basic sets of infection-control precautions, each depending on the mode of disease transmission:

  • Standard precautions are used to prevent contact with blood, body fluids or open wounds, and may include gloves, gowns, surgical masks and/or eye protection.
  • Contact precautions are taken for diseases that spread through direct or indirect contact—through touch, for instance—and include gowns and gloves.
  • Droplet precautions, which include face and eye protection, are needed for diseases that spread through large droplets traveling only small distances.
  • Airborne precautions are taken for diseases that can spread through small droplets over long distances.

{mospagebreak}While responders, hospital workers, physicians and clinicians will likely be quite familiar with the concept, during an infectious outbreak, extensive coordinated use of infection control by the wider public can help reduce direct contact transmission, as well as raise awareness of how the disease may be transmitted.
In certain circumstances, the report says, it may be advisable to ask citizens to wear some protective gear, such as masks. If the wearing of personal protective equipment is advised, distribution may require the assistance of law enforcement working with other agencies to ensure safe and timely delivery of resources.
The report also recommends that locales maintain a real-time inventory of supplies and maximize publicity of distribution plans through prominent posting of signs in public spaces like billboards and churches, written handouts and public-service announcements on local TV and radio, as well as the maintenance of a town or city health emergency website.
"In a pandemic, the old adage, ‘ People are either part of the solution or part of the problem,’has never been truer," said Heyman. "The public can’t be looked at as just an ignorant mass that needs to be ordered around and administered by experts. Every citizen needs to think of himself as a first responder."
Quarantine
As an extension of, but by no means a replacement for, community infection-control measures, quarantine, properly defined, is the physical separation and restriction of movement of persons who are not ill but are suspected to have been exposed to infection. Its purpose is to closely monitor their health and prevent further disease transmission. The four principle types are: home quarantine; public-facility quarantine; work quarantine; and community-wide quarantine, involving a street, neighborhood or, if necessary, wider geographic area.
During home quarantines, exposed or potentially exposed people remain at home for the duration of the estimated incubation period of the disease. Home quarantines may be implemented on a person-by-person or household-by-household basis or for entire buildings if it appears likely that everyone in the building has been exposed. Where feasible, home quarantines are thought to be an effective approach since they involve less outside contact than a work or facility situation.
Where home quarantine is not feasible, officials may establish designated buildings or facilities for quarantine, which may include adapting community locales such as hotels, schools, recreation centers, nursing homes or other structures. In addition, work quarantines may be called for when outbreak control requires health care, emergency response or other employees whose jobs are considered critical to the maintenance and continuity of local services during the crisis. In work quarantines, individuals are permitted to continue working but are required to use personal protective equipment as prescribed by health officials. When not working, those under work quarantine may be transported to home or facility quarantine.
Community quarantine, the last potential phase of the continuum of quarantine options, could theoretically be invoked when there is a perceived high likelihood that all or most residents in a community have been exposed, and officials believe they can confidently determine wide-scale geographic boundaries to cordon off. This type of quarantine is seen as the most difficult to implement because of its scope and because precise determination of the geographic perimeters and parameters where exposure was likely to have occurred is inherently difficult, if not impossible, in a pandemic. The report recommends this option only in cases where health officials have a very clear understanding of the exact source of the outbreak, a scenario more likely to be relevant in an outbreak like "Legionnaire’s Disease" than a flu pandemic.
To the maximum extent possible, the report recommends that quarantines be voluntary. In soliciting a maximum degree of public compliance and understanding of the quarantine strategy, government should be prepared to provide care and support—physical, nutritional, medical and even financial—to help those in quarantine not feel abandoned or unduly burdened. Those under quarantine will also require the best possible access to public-health personnel, if not in person then through e-mail, phone or two-way radio or video. They also need access to public information and educational materials about the disease and communication with friends.
"What needs to be done ahead of time is to frame and convey a consistent message," said Dorothy Teeter, head of the Washington state Seattle and King County Department of Public Health pandemics preparation. "You don’t want to have the public believing everything is going to be smooth and easy, or not to worry about it: ‘ We’ve got it covered.’At the same time, you don’t want to inflame anxiety or panic. What you need to try to do to keep people’s confidence is to be clear, calm, level-headed and honest. To avoid panic, there needs to be two-way trust between people and emergency managers. Without that, the best plans are meaningless."
Isolation
Related to, but distinct from, quarantine is isolation, which is the separation and restriction of movement or activities of people infected with the disease. Isolation may also take place at home or work or in facilities.
Another major tool in local responders’disease exposure-control arsenal is community restriction, also known as "social distancing." This refers to reducing community-wide interaction by limiting or postponing large public gatherings or activities and restricting public travel or entrance to certain facilities.
Unlike quarantine, this option focuses not only on people who are suspected of already having been exposed but to an entire community. The extent and severity of these restrictions, again, may and will vary with each community’s profile and the extent of the disease. The rule of thumb remains to attempt to use the least restrictive and most focused measures possible, such as issuing travel warnings or curtailing mass transport schedules, rather than across-the-board shutdowns, where possible.
{mospagebreak}In addition to steps by local government and authorities, the support and participation of local business arecrucial in making community restrictions work.
Companies need to be involved with community leaders and other stakeholders in the community ahead of time to develop contingency plans for an outbreak crisis. Among the key measures that should be on the table are encouraging sick workers to stay home (and supporting that option by expanding current sick- and medical-leave policies for the eventuality of a public health emergency), staggering work schedules to limit the concentration of people traveling, providing a telecommuting option, where possible, and instituting infection-control hygiene awareness in the workplace.
A final component of disease-exposure control is sheltering, which involves encouraging and/or persuading citizens to stay home, radically limiting their social interactions for the duration of the crisis. This option is not considered to be a matter for enforcement, but is a choice of rational self-interest that can be promoted, particularly in situations where quarantine and community restriction may not be adequate to stem the spread of disease.
Analysis
Heyman emphasized that the toolkit of disease-control protocols is only useful insofar as there is a wider emergency response infrastructure in which they play a part, including such things as disease surveillance, disease screening, community support and hospital treatment resources.
Teeter agreed: "It’s clear from all the tabletop and field work we’re doing and all the analysis we’ve done so far that containment strategies are best deployed as early in the game as possible on a micro-scale before the disease mushrooms." For that reason, she said, a major emphasis in field exercises will be on earliest-stage screening and surveillance to catch the disease as soon as possible, and that mounting effective information flow and communications between hospitals throughout the county will be key to that.
While the skill sets and planning to mount effective disease-exposure management can and must be cultivated at the local level, Heyman argued that it is crucial that the resources to support local operations in executing them be forthcoming from the federal level.
"There’s been very little in the way of concrete federal leadership so far," Heyman complained. "Out of the current 450-page federal plan, there are about 37 pages that really deal with the practical elements of disease-exposure control. It’s good that something’s finally happening to ramp up drug research and production, but there’s a whole dimension that’s still missing from the federal perspective."
The conflict, philosophically and practically, between personal liberty and the needs of public safety, order and community has always been an issue in American society, perhaps more strongly than in any other culture. Even in such a seemingly clear-cut area as public health or in the case of pandemic and survival, the tension persists. Many people, not without reason, distrust and fear encroachments of and overreach by federal authorities even — maybe even especially — during a crisis.
In approaching the prospect of a pandemic, one hopes that even if these two important values can’t be reconciled in theory they can—with common sense—each be accommodated in practice.

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The Government Technology & Services Coalition's Homeland Security Today (HSToday) is the premier news and information resource for the homeland security community, dedicated to elevating the discussions and insights that can support a safe and secure nation. A non-profit magazine and media platform, HSToday provides readers with the whole story, placing facts and comments in context to inform debate and drive realistic solutions to some of the nation’s most vexing security challenges.

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