Pribilstan Quarantine Sign

"I'm a believer in an abundance of caution but I'm not a believer of an abundance of idiocy." Ashish Jha, MD

Quarantine craziness has continued since my last post, with more states joining in the fray. The sudden silence since Election Day has been quite striking, but since the irrational hodgepodge of regulations persists, here is a brief update. Given what we have learned in the past several weeks, I would love to see a more rational approach adopted, modified by these experiences. Keep this in mind as you read: people with Ebola are not contagious until they become symptomatic, unlike flu or measles, for example. And there has been ZERO transmission of Ebola in the US since the first case in Dallas. So quarantines are causing more harm than good, by dissuading volunteers from going to W. Africa, where we must focus our attention.

States

We now have more states issuing their own regulations, usually more stringent than the recommendations of the CDC. Why did they do so? An abundance of politics, posturing, and flexing “state’s rights” muscles vs those nasty federal experts.

The worst regulations remain from the states with the most vociferous political posturing:

New Jersey—where Governor Chris Christie favored a blustering show of his “concern” for the welfare of his citizens (as though CDC, NIH, scientists, etc. don’t care about protecting the public) over civil rights. After creating a legal and publicity nightmare for himself by needlessly quarantining a returning MSF nurse in a bare tent, he foisted the problem onto Maine, where Gov. Paul LePage continued the confrontation and intimidation of Kaci Hickox until he lost in court.

New York—while initially insisting on quarantining health care workers who had been in Guinea, Sierra Leone, and Liberia for 21 days, backed off a little, agreeing to let these people be at home during this period. This is still excessive, but better than welcoming heroic volunteers back to an unheated tent, a la Christie. New York has also agreed to provide some compensation for lost wages.

Connecticut—capricious quarantine

Georgia—home of the CDC—has opted for a 21-day quarantine for all HCW, regardless of their level of exposure, and will provide no compensation.

California—also 21-day quarantine, but is allowing exceptions to the house arrest on a case-by-case basis.

Louisiana, again exceeding CDC recommendations, gets this month’s award for the most counter-productive rules, as I’ll illustrate.

Quarantines by state

The good news? North Carolina, although denying climate change and legislating against reports of rising seas, has opted not to impose more restrictive quarantines on travelers, but to defer to the CDC’s already conservative recommendations. South Carolina is following suit.

Louisiana showed the height of anti-science narrow mindedness and rigidity recently. The major meeting of Tropical Medicine physicians and scientists, ASTMH, was held in New Orleans in late October. This conference draws experts from all over the world. Yet Gov. Bobby Jindal’s minions sent the following letter to attendees who had been to W. Africa in the prior 21 days, even if they had no exposure to patients (e.g., epidemiologists, diplomats, executives).

“From a medical perspective, asymptomatic individuals are not at risk of exposing others; however…we must balance (LA) hospitality with the protection of Louisiana…we see no utility in you traveling to New Orleans to simply be confined to your room…We do hope that you will consider a future visit to New Orleans, when we can welcome you appropriately.” So 30 of the world’s leading experts were banned from ASTMH, although State leaders knew they posed no risk. ASTMH stressed, “To Stop Ebola Outbreak, Virus Must Be Contained in West Africa,” but their plea for a rational response fell on deaf ears. Gov. Jindal, how does banning experts make the US safer? Ironically, the annual APHA (American Public Health Association) meeting will also be in NOLA next week, against the better judgment of many.

After watching a talking head argue for quarantines, and engaging with him on Twitter, I was so outraged I made my first Storify, “#Ebola #Quarantines #ASTMH, and an @msnbc celebrity doc portraying a public health expert.” This was reposted by PLOS blogs in their meeting coverage. Sense never prevailed.

More craziness

Here are a few recent examples of behavior driven by fear and lack of understanding of geography:

Ebola - Geography, by Anthony England

Connecticut third-grader banned from school because of Ebola fears—though she had visited a country where there is no outbreak now.

Ted Wilbur, Kaci Hickox’ boyfriend and a nursing student at U. Maine was banned from school by Robert Dixon, vice president of academic affairs: “We have to respond to how people are going to feel about it, and we don’t want hysteria on the campus,” Kaci Hickox has announced that she and Ted will be moving from Maine, having received a less than welcoming homecoming there.

A teacher at a Catholic school in Louisville resigned rather than being forced into a 21-day leave from school after having visited Kenya—where there has been no Ebola.

There are so many similar responses. Many of these #Ebolanoia tidbits are collected by myself and by Maryn McKenna. Note that the term was first coined on Twitter by Steve Silberman (@stevesilberman), however.

Nina Pham's tweet

For cute, and showing that she still maintains a sense of humor, we have Nina Pham’s tweet, after being reunited with her dog, Bentley.

Perhaps the best response to the geographically impaired are the series of maps that Anthony England (@Ebolaphone) made to lend perspective.

How transmissible is Ebola?

I was reminded hearing Dr. Kent Sepkowitz (also on msnbc), that in Kikwit, in the Congo, in a 1995 epidemic, there was only 16% transmission of Ebola to household members. Risk was higher later in the course and with contact with body fluids or the dead body itself. None of the family members who did not have direct contact became ill.

So what happened with the dire predictions of an epidemic in the US from the first tragic case in Dallas? None of Thomas Duncan’s 11 contacts with definite exposure—including his fiance, who helped care for him when he was having vomiting and diarrhea—became ill, nor did the ~165 other monitored contacts. Two nurses who cared for him shortly before he died, when his viral load, and risk, were the highest, did become infected. Both also recovered remarkably rapidly, perhaps in part because of their youth and good health, as well as the excellent care they received.

Similarly, 165 people were monitored after exposure to nurse Amber Vinson. Zero secondary cases. A large number were monitored after exposure to Dr. Craig Spencer and each of the other cases in the US. Zero secondary cases.

Even in Mali, where concerns have been very high after a 2 year old child died of Ebola, exposing many during a 1200 km bus ride, there have thankfully been no cases to date. Saturday will mark the end of the 21 day quarantine period for the 108 contacts significantly exposed to her.

Health care workers have been fighting Ebola for decades. MSF alone has had more than 700 staff in W. Africa since March, to say nothing of thousands of other workers earlier, with zero transmission at home.

But Ebola is a death sentence, right?

While terror over Ebola’s deadliness in Africa—about 70%, up to 90%—fueled Ebolanoia, what have we learned about the death rate recently?

In the US, Thomas Duncan, the first patient, diagnosed very late in his illness, is the only person who has died. He also did not receive a plasma transfusion, as no donor with a matching blood type was available, and he did not receive experimental treatment with anti-virals until at least 10 days after his symptoms began.

No other patient in the US has died. Even in W. Africa, mortality has dropped as low as <30% with aggressive hydration and supportive care. In the US, only 1 of 9 patients has died—11%. The mortality rate with prompt treatment should be far lower, and lower still than the rate from septic shock in the US of 25-35%.

What’s the harm in continuing the quarantines, “just in case?”

As noted in my previous blog, there is widespread agreement among infectious disease, epidemiology, public health experts and their societies, and even the UN and WHO, that quarantines and isolationist strategies that some here propose, and some countries (Australia and Canada) have misguidedly done, will worsen the epidemic. We should not be wasting time, energy, and vast sums on security theater, like the airport screening, which previously was shown to be ineffective during the SARS and flu epidemics. Such screening would not have detected Mr. Duncan, who was asymptomatic when he arrived. Our sole focus should be to direct more effort at controlling the infections in W. Africa.

Quarantines have a chilling effect on volunteer recruitment, as noted by MSF. Many simply cannot take more time off from their regular positions or employers will not allow another three weeks “vacation.” The New England Journal of Medicine explained this nicely: “What harm can that approach do besides inconveniencing a few health care workers? We strongly disagree. Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source…we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal… These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves.”

Dr. Abraham Verghese wrote perhaps most eloquently: "And the possibility now exists of quarantine when we return — no 'Welcome back, our hero' signs at the airport, but straight to house arrest. Employers are gently pointing out that if we choose to volunteer, that is admirable, but we’re effectively on our own, not covered by our health insurance. If we fall sick in Africa, there is no guarantee of being evacuated, no promise that even our bodies would be flown back…The impulse to serve must now compete with the public perception of recklessness and irresponsibility. But dozens of doctors have come back safely, and if the outbreak is indeed being contained, it is their service, along with that of so many others, that has made the difference. Still, a strategy that punishes those putting themselves at risk, rather than rewarding them, is flawed. It’s hard to imagine Americans regarding our other defenders, the military, in this way.

As with HIV, quarantines are likely to drive people to hide exposures or take a circuitous route to the isolationist countries, fueling an epidemic.

Quarantines also promote the perception that there is something to be very fearful of, as well as being enormously socially stigmatizing, as you can see from the Ebolanoia collection.

Finally, as Tulane University physicians, themselves experienced in Ebola research, admonished in response to NOLA’s banning experts from meeting, “Policies which reject science in the name of calming public fears send mixed messages and only enhance mistrust. Most importantly, in reality such policies will do nothing to protect the health of the public, but may well harm it by hampering the response in West Africa, prolonging the epidemic, and ultimately increasing the number of cases of Ebola appearing in the United States.

What now?

As Dr. Tom Frieden said, "At CDC, we base our decisions on science and experience. We base our decisions on what we know and what we learn. And as the science and experience changes, we adopt and adapt our guidelines and recommendations.”

Were this true as public policy, we would have one set of unified rules based on science and written by experts. In this case, the CDC recommendations are already quite conservative, having been very attuned to public fears, and trying to balance that with civil rights and science. As Louisiana, New Jersey and other states have amply demonstrated, posturing over state’s rights or politics comes at a significant cost to public health efforts, endangering us all. Are these governors capable of demonstrating real leadership, learning from these experiences, and adapting their guidelines to conform to a unified, scientifically sound plan? If so, I call on them to recant their extremist positions and eliminate the costly, needless, and wasteful screening and quarantines. To protect the US from Ebola, we must focus all efforts on controlling the epidemic in W. Africa. That is the only effective means of doing so, as well as being the moral and ethical approach.

Previously in this series:

Quarantines: Chaos and Confusion

Why Ebola Is a Wake Up for Infection Control

Ebola in the U.S.—Politics and Public Health Don’t Mix

Superbugs should scare you more than Ebola in US

Credits:

"Molecules to Medicine" © Michele Banks

Know Ebola map - courtesy @ebolaphone, Anthony England

Pribilistan - wikimedia "run_swim"