CDC, some states differ over quarantine for Ebola responders

Healthcare workers in Guinea
Healthcare workers in Guinea

Health workers early in the outbreak in Guinea don protective gear., European Commission ECHO / Flickr

The US Centers for Disease Control and Prevention (CDC) today unveiled more specific, risk-based guidance for monitoring people entering the country from West Africa, including healthcare workers who recently served in the outbreak zone, as some states imposed new, more stringent restrictions that will create a patchwork of policies across the United States.

The actions come in the wake of the Ebola hospitalization of a New York doctor who recently returned from battling the disease in West Africa. His case prompted New York and New Jersey to announce mandatory quarantine, which prompted strong criticism from the White House and several public health groups.

In their pushback over the mandatory quarantine orders for health workers potentially exposed to Ebola, groups said the policies aren't based on science, could raise fears about the spread of the disease, and could reduce the flow of medical volunteers going to West Africa, where isolation and treatment of patients is considered the lynchpin for slowing the disease.

Nurse subjected to forced quarantine

A New York doctor's Ebola hospitalization on Oct 23 triggered a joint announcement from the governors of New York and New Jersey about mandatory quarantine measures, which were invoked after the arrival that day at the Newark airport of a healthcare worker who had a recent history of treating Ebola patients.

The states announced that any medical worker returning from working in West Africa would be subject to mandatory quarantine, and the health worker—Kaci Hickox,a nurse who had been working in Sierra Leone for Doctors without Borders (MSF)—was taken to University Hospital in Newark where she was ordered to stay for 21 days, CNN reported

In an interview with CNN, she lashed out at New Jersey Gov. Chris Christie—who reportedly described her as "obviously ill"—and said the mandatory quarantine order was a violation of her civil rights. Christie has said both New Jersey's and New York's quarantine orders for health workers provide for mandatory home quarantine, but that if it wasn't feasible for nonresidents to be taken home, they would be quarantined in New Jersey. Kickox 's home is in Maine.

In a first-person account for the Dallas Morning News yesterday about being detained at the airport for several hours and taken to the hospital, Hickox said, "I sat alone in the isolation tent and thought of many colleagues who will return home to America and face the same ordeal. Will they be made to feel like criminals and prisoners?"

The New Jersey Department of Health said Hickox tested negative for Ebola on Oct 25 and has been symptom free and has asked to go to Maine, where she will travel by private carrier, rather than mass transit or commercial aircraft. It said she didn't have symptoms upon her arrival at the airport on Oct 24, but later developed a fever, which triggered her transfer to the hospital, where she was isolated under a quarantine order for review and testing.

In the Dallas Morning News report, she said her initial temperature taken at the airport with a forehead scanner was 98°F, but after she waited around for 4 hours and felt upset, her cheeks were flushed and the scanner recorded a temperature of 101°F. However, the oral temperature reading at the hospital was 98.6°F, she said, noting that a doctor said she didn't have a fever, but her cheeks were flushed.

The Maine Department of Health and Human Services today announced updated protocols for travelers from West Africa. It said those who had direct contact with or treated Ebola patients will have active monitoring plus home quarantine for 21 days. It said the policy will be implemented for the first time with Hickox when she returns from New Jersey. "Under this policy Maine will make every possible effort to implement an agreed-upon in-home quarantine. We fully expect individuals to voluntarily comply with an in-home quarantine."

States scramble, spark high-profile pushback

Other states instituting tougher quarantine orders for health workers include Illinois and Florida. Still other states, however, are clarifying their protocols, which line up with the CDC's new guidance.

For example, the Minnesota Department of Health (MDH) today announced a plan that addresses four types of travelers, from those who provided no healthcare to those who did and have a known exposure. All travelers will be actively monitored twice a day for 21 days by MDH staff. Travel restrictions are based on level of possible exposure, but home quarantine is indicated only for those who treated an Ebola patient and were exposed to the virus.

A senior Obama administration official said yesterday that the White House has let the governors of New York, New Jersey, and other states know that it has concerns about the unintended consequences of the mandatory quarantine policies and the lack of scientific backing, the Washington Post reported today.

Several professional medical organizations have also weighed in. For example, the Association for Professionals in Infection Control and Epidemiology (APIC) said in a statement yesterday that it understands public concerns, but it does not support mandatory quarantine of asymptomatic healthcare providers who treated patients with Ebola.

"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 Mr. Duncan in Dallas have not gotten sick," APIC said. It added that the policies could deter health professionals from volunteering, hamper their ability to work when they return, and stigmatize them for their service in West Africa.

The Society for Healthcare Epidemiology of America (SHEA) said yesterday that, based on strong evidence that Ebola isn't transmitted by those who aren't having symptoms, it doesn't support the mandatory quarantine of individuals, including those who have cared for Ebola patients. However, SHEA said it supports active monitoring (twice a day for fever and other symptoms) of all healthcare workers who have cared for Ebola patients, both at home and abroad.

The Infectious Diseases Society of America (IDSA) also said it doesn't support mandatory quarantine of asymptomatic health workers, emphasizing that the approach has negative consequences without significant benefits.

CDC revises guidance

At a media briefing today to introduce the revised interim monitoring guidance, CDC Director Tom Frieden, MD, MPH, said the CDC 's protocols are based on science and experiences and are evolving in the face of unfolding developments.  He said they will add another level of protection while protecting those doing heroic work in West Africa, which helps protect the US and other countries against the disease.

The new guidance defines four different levels of exposure in travelers from West Africa: high-risk with a known exposure (such as a needle-stick injury), some risk (such as a healthcare worker returning from West Africa), low but nonzero risk (such as healthcare workers caring for US-based Ebola patients), and no identified risk.

The guidance is designed to help state and local health officials set criteria for instituting public health actions, such as active monitoring and movement restrictions. Six states today begin previously announced active monitoring for travelers coming from the three hardest-hit West African nations. The states are New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia. Others will start the process in the days ahead.

The CDC guidance puts health departments in charge of daily monitoring for the 21-day disease incubation period. Frieden said most health workers returning from West Africa would fall into the second category, and daily monitoring will be more detailed and include a careful review of symptoms designed to reveal even a vague one, such as fatigue, and a review of the individual's activity plan for the day.

The CDC urges health departments to decide on a case-by-case basis whether other restrictions are appropriate, such as controlled movements or workplace exclusions. Those who plan to travel face specific recommendations based on their risk, but health officials would need to ensure that the person's health will be monitored without any interruptions.

Frieden acknowledged that states have authority to put more stringent restrictions in place, "but we believe ours are based on science." He said the CDC is concerned about some of the stricter policies states are implementing, which he said could stigmatize health workers and give false impressions about how the disease is spread.

Of 807 travelers from West Africa who have been screened since tighter screening went into effect on Oct 11, 46 were healthcare workers, Frieden said.

Other developments

  • The number of Ebola infections West Africa and other nations has reached 10,414, including 4,922 deaths, the World Health Organization (WHO) said in an Oct 25 update. The number is thought to dramatically underestimate the true burden of the disease in Guinea, Liberia, and Sierra Leone. The update included cases reported through Oct 23. It said all districts of Sierra Leone have now reported Ebola cases, and only one district in Liberia has yet to report a case. Of eight Guinea and Liberia districts that border Ivory Coast, which hasn't yet reported a case, six have reported a confirmed or probable case.

  • A 5-year-old boy who was transported to New York City's Bellevue Hospital last night by a special emergency medical service (EMS) team for the workup of possible Ebola symptoms has tested negative for the disease, the New York City Health and Hospitals Corp. said in a statement. The boy had been in one of the three outbreak countries within the past 21 days, according to a hospital statement. Though fever was initially reported, he didn't have a fever when he was examined at Bellevue, but he developed a fever early this morning and was tested for Ebola. Out of extra caution the patient will be tested again to make sure he is free of the virus, and he will remain in isolation until all test results are in.

  • Craig Spencer, MD, the doctor hospitalized at Bellevue Hospital for Ebola, is in serious but stable condition, the hospital said in a statement yesterday. It said he received convalescent plasma treatment, which he tolerated well. In an earlier statement the hospital said Spencer received antiviral therapy within hours of his admission and that the date of his plasma therapy was Oct 24. According to media reports, the plasma was donated by Nancy Writebol, who recovered from her Ebola infection after she got sick while working for the missionary group SIM in Liberia.

See also:

Oct 27 MDH statement

Oct 27 CNN Hickox interview

Oct 25 Dallas Morning News report

Oct 27 NJDH press release

Oct 27 MDHHS statement

Oct 27 Illinois Department of Health statement

Oct 25 Florida Department of Health statement

Oct 27 Washington Post story

Oct 26 APIC statement

Oct 26 SHEA statement

Oct 27 IDSA statement

Oct 27 Bellevue Hospital statement

Oct 28 New York City Health and Hospitals Corp statement

Oct 25 WHO update

Oct 26 Bellevue Hospital statement

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