Will history repeat? The Plague Doctor

There has been a quantum change in the past few days as to how healthcare workers (HCW) returning from the West African countries of Liberia, Guinea and Sierra Leone are being treated. This was prompted by two cases. First, Dr. Craig Spencer, a physician with M?decins Sans Fronti?res (MSF, aka Doctors Without Borders) developed a fever after his return to New York City from Guinea. He promptly called the appropriate health officials, was isolated at Bellevue Hospital on October 23, and found to have Ebola. He is currently undergoing treatment there. Subsequently, MSF nurse Kaci Hickox returned from Liberia to Newark New Jersey on Friday, October 24. Although she was asymptomatic and had no fever, she is was involuntarily quarantined by the governor. What has changed? Why are there different standards? What, based on science, should our response be?

Facts vs. Fear
It is understandable that there is fear about Ebola, especially given media portrayals, as well as early missteps with the first case in the U.S. But it is critical to separate fear from fact.

A key point about Ebola is that people who have no symptoms are not contagious, and that it requires very close contact with infectious secretions (blood, vomit, diarrhea) to transmit disease.

This has been shown repeatedly in outbreaks in Africa. Even here in the U.S., remember that none of the family members or close contacts of the first patient, Thomas Duncan, became ill, even though they had considerable contact with him. Nor did the Emergency Room workers who initially cared for him, though he had a temperature of 103 F. As you become more seriously ill, the amount of virus in your blood increases and you become more infectious. This, and some (inadvertent) gap in isolation when he was having copious diarrhea, is likely how the two Dallas nurses became infected. Transmission is not through casual contact nor is it airborne. It is also important to remember that NO HCW has transmitted Ebola to others–it is they who are risk of infection from patients.

It’s also important to understand that the rate of infectivity for Ebola, or R0, is 1.5 to 2. This means that, on average, one person with Ebola infects only two others. Contrast this with measles, with an R0 = 18, or 1 person will infect 18 others, or pertussis (whooping cough), with an R0 of 12-17. Note, too, that both measles and pertussis have airborne transmission–which makes them more contagious–and both of these viruses, which kill many children, are vaccine preventable. Why no similar outcry and panic?

Standards
All countries and international health groups have standards for their workers. Until this weekend, those followed common sense, and were rational responses to perceived risk levels. The Centers for Disease Control (CDC) recommended travelers self-monitor temperatures twice daily and that there was no need for quarantining asymptomatic individuals.

In the case of MSF, guidelines have been consistent with the CDC and returning HCW were counseled: “Self-quarantine is neither warranted nor recommended when a person is not displaying Ebola-like symptoms.” They were told to:

1. Check temperature two times per day
2. Finish regular course of malaria prophylaxis (malaria symptoms can mimic Ebola symptoms)
3. Be aware of relevant symptoms, such as fever
4. Stay within four hours of a hospital with isolation facilities
5. Immediately contact the MSF-USA office if any relevant symptoms develop

Dr. Spencer followed all of these guidelines carefully, and reported a low-grade fever immediately.

The story unfolds…
Initially, NYC Mayor Bill DiBlasio and Health Commissioner Dr. Mary Bassett, participated in an effective press conference, explaining the epidemiology of Ebola transmission and clearly sharing their response plans for contact tracing. They then demonstrated their knowledge that Dr. Spencer had not been contagious prior to his fever, by dining in the same restaurant Spencer? had eaten at, riding the subway, and visiting the bowling alley Spencer had gone to. This is leadership.

Yet there has since been a furor and chaos since Spencer’s illness was announced, throwing the focus away from the essential activity–getting more HCW and help to West Africa. The result has been shameful, divisive, and disruptive, as well as having the potential to exacerbate the crisis in Africa, making it more likely that Ebola will further spread around the world.

First, the Governors of New York and New Jersey unilaterally declared, ignoring federal guidelines and epidemiologists, that all returning HCW would be quarantined for 21 days, even if they were entirely asymptomatic.

Over the weekend, there have been outcries from many groups, centered around these major issues:

a) Who has authority to issue quarantines? Is it the states’ or the federal government’s right?

b) What is the role of experts in recommending such quarantine policies? Should this be decided by infectious disease and epidemiology experts, working with government, or by elected officials alone?

c) What impact do different states’ decisions have on neighboring states, and on having a unified response to fighting any infectious disease threat?

d) What are the rights of individuals, who are entirely asymptomatic and have been cleared by medical professionals as being non-contagious, to their freedom vs. involuntary quarantine? How is this applied to broad categories of people, e.g., all HCW returning from W. Africa?

e) What is the impact of broad quarantines on our ability to have adequate manpower to fight infections either here or abroad, and how does that impact our own national security?

States vs Federal jurisdiction
The CDC has tried to defuse the turf issue a bit: “Federal communicable disease regulations, including those applicable to isolation and other public health orders, apply principally to arriving international travelers and in the setting of interstate movement. State and local authorities have primary jurisdiction for isolation and other public health orders within their borders. Thus, CDC recognizes that state and local jurisdictions may make decisions about isolation, other public health orders, and active (or direct active) monitoring that impose a greater level of restriction than what is recommended by federal guidance, and that decisions and criteria to use such public health measures may differ by jurisdiction.”

In turn, the NY and NJ governors have backed off a little, saying that HCWs could be quarantined at home, rather than in a tent.

In the meantime, a number of states have followed their lead, issuing individual and conflicting guidelines. Maryland has had the most reasoned, at least offering a tiered approach based on the extent of exposure. They are quite difficult to follow, so I have made the following chart, correct as of 10/27, but likely to change:

State by State Quarantine Regs Create Confusion

Connecticut was a leader in restrictions; anyone who is suspected of having had an exposure can be quarantined, as happened in mid-October to Yale student Ryan Boyko, who is under house arrest, with a New Haven police cruiser parked outside to prevent visitors, despite the opinion of physicians and the school’s Dean of Public Health.

These are in contrast to the initial CDC recommendation, which favored no isolation and that self-monitoring by HCW was adequate–after all, HCWs who have seen far too many Ebola patients die, know that early treatment greatly improves their chances. Why would they not seek care urgently?

But the CDC, also trying to respond to the concerns expressed by governors and a segment of the public, has just issued more restrictive guidelines, with directly observed monitoring of returning HCW and home isolation for some groups.

Federal Quarantine Guidelines

Finally, here are the recommendations of every public health group and several major medical societies, based on the known method of transmission of Ebola:

NO Quarantine NEEDED

Recommendations of Experts, Societies

Rationale against quarantine-inconsistencies
I understand the frustration of people with changes in recommendations, and that this leads to mistrust and confusion. Unfortunately, any type of guideline will change as more is learned about a problem. That is uncomfortable, but is evidence-based progress. We know that nothing is zero risk. But this patchwork of quarantine guidelines like these are especially difficult to interpret.

One of the many problems with quarantines is that it makes no sense to impose them on HCW returning from abroad, but not on those taking care of patients here. By the “logic” displayed, many of the HCW at Emory, U of Nebraska, Dallas Presby, and Bellevue should be confined for three weeks. If you do that, who will be left to care for patients?

Dr. Sacra, a volunteer physician who contracted Ebola in Liberia, notes that neither he nor Ashoka Mukpo, the NBC cameraman, would have met the “direct contact” criteria.

HCW will self-monitor and report symptoms. After all, they, more than anyone, know that their survival depends on early treatment. There has only been one death in the US of 9 Ebola patients, and that (Mr. Duncan) had a very delayed diagnosis. At late stages, patients have higher viral loads and are more infectious, which no doubt contributed to the two nurses in Dallas becoming infected. Before this, as Helen Branswell notes, HCW have helped fight Ebola for decades. How many people have they infected back home? Zero.”

The problem with the quarantine is not just that it is unscientific and burdensome. Every expert in infectious diseases, epidemiology and related fields, has stressed that quarantines and isolationist strategies with backfire and will harm national security. It is akin to the beginning of the HIV/AIDS epidemic.

Quarantines will hurt by:

a) decreasing the number of volunteers. Many are already taking time off from their regular jobs and employers are unlikely to grant them another three weeks “vacation.” Volunteers can often ill-afford their lost income, either.

b) fueling the perception that there is something to be very fearful of and being enormously socially stigmatizing. West Africans are already facing ostracism, exclusion from work or school, and threats and violence–captured in my #Ebolanoia collection and in Maryn McKenna’s tumblr. Now returning MSF volunteers are facing worse threats, despite the heroic work they have done saving lives.

c) ignoring that HCWs are people. As Sarah Kliff noted, “If the cost of treating infectious diseases was to give up everything else you love in life, no doctors would treat infectious diseases, and we would all be at much greater risk.”

d) Quarantines will likely lead people to “go underground,” and either lie about possible exposures or travel, or take a circuitous route, perhaps flying to Canada first, and then crossing the border. As with HIV, where people learned to hide their exposures, people would then present later in their illness and be more infectious to others. This will only fuel an epidemic.

e) While there may be some differences in details, there is broad agreement with Dr. Frieden that “We can’t get to zero risk in the U.S. until we stop the Ebola epidemic at its source in West Africa.”

As an editorial in the New England Journal of Medicine explains: “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.”

So what should our policy be?
First, it is essential to have a standard policy. While the Governors kept saying that their job was to protect their citizens, it is absurd and offensive for them to suggest that the President, CDC, NIH, and all these experts do not have the same goal.

I understand “states’ rights” but the charts, above, show that such a hodgepodge of different rules is unmanageable. The federal government, guided by science and health expertise, should be making these rules.

Lawrence O. Gostin, a global health professor at Georgetown University Law School and an adviser to the World Health Organization, “said quarantining medical workers might sound reassuring, but it is an overreaction that if widely adopted ‘will come back to haunt us…The more we make it difficult for health workers to stem the epidemic in Sierra Leone, Guinea and Liberia, the more at risk we are.’” If we do not control Ebola there, and it becomes entrenched in crowded city slums of Nigeria or India, or wherever, that will truly be something to fear.

It is imperative that we do everything we can to encourage HCW to volunteer in West Africa. We should support them financially and treat them as the heroes they are, honoring their sacrifices, rather than vilifying them.

As the late Dr. Jonathan Mann said, “Our responsibility is historic. For when the history of AIDS and the global response is written, our most precious contribution may well be that, at a time of plague, we did not flee, we did not hide, we did not separate ourselves.” His words are as true now as in 1998, and apply equally to this epidemic.

~ ~ ~

Earlier in this series on Ebola:

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” banner (C) Michele Banks
kind review of info by Larry Lynam and Lonnie Marcum