With the emergence of coronavirus there has been much discussion on the use, extent and importance of quarantine for containing infection. If done correctly disease transmission can be reduced. If done incorrectly or too aggressively the the effort may exacerbate the spread of disease. Efforts to round up large numbers of people or incarcerate them could actually encourage those who are sick to avoid getting medical care or worse flee, further worsening contagion. Depending on the facilities provided, corralling potentially infected individuals could promote spread. The strategies for decreasing transmission range from isolation, quarantine, cordon sanitaire to social isolation.
Definitions from the CDC
Isolation and quarantine are public health practices used to stop or limit the spread of disease.
Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. For example, hospitals use isolation for patients with infectious tuberculosis.
Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. Quarantine can also help limit the spread of communicable disease.
The term cordon sanitaire is a word used by some which means movement restrictions which apply to everybody, not just the exposed people. The distinction is somewhat semantic since everyone in Wuhan is potentially exposed and could be deemed to be quarantined
For purposes of this discussion I will use the terms quarantine and isolation interchangeably understanding the distinction is usually not critical except when medical care is being administered. Even when medical treatment is warranted it can often be provided through robotics or remote monitoring more safely than in health care facilities.
While on initial perusal the concept of isolating someone to prevent spread of disease seems straight forward, unfortunately the exact nature of the isolation, timing, placement and locale must be highly tailored. Balancing public welfare against the infringement on personal freedom can be very nuanced.
Based on the extent and risk of each individual Infectious disease including the mortality, morbidity and infectivity requires responses tailored to the specific circumstances. China has used large quarantine centers which may not provide adequate isolation. This strategy could be counterproductive leaving people who are not infected with people who are infected and furthering the spread. Also any gathering of quarantined groups puts those caring for them , medical workers, food distributors at risk.
Making a cruise ship a quarantine vehicle while again seeming to be prudent can also actually exacerbate the problem especially while 1/3 of the ship, the crew, is forced to interact with each other and also distribute food and other necessities to the isolated passengers in their cabins
Does screening work?
With coronavirus screening for fever or symptoms as a means to determine who should be quarantined seems misguided. There there seems to be a significant subset of asymptomatic or minimally symptomatic people who can spread the disease in addition there is always a group who are infected but are in the incubation period of 7 to 14 days but have yet to get ill.
Individuals who can spread the disease must be housed in a setting which limits spread but doesn’t put those tasked with over seeing them at risk. Ideally allowing people to stay in their own residence where they have access to the essentials for living seems prudent Distribution of essential medicines food or other needs to a home setting can be done with small risk if operationalized appropriately . Even within the home setting the individuals in the shared space with friends or family must be very careful to stay isolated.
With regard to the infringement on personal freedom again a balance must be created. Certainly sending someone to in incarceration setting is draconian. This technique has been used historically especially with tuberculosis but certainly does not represent the least restrictive alternative for containing disease. Courts in the US have variably invoked the legal standard of requiring the least restrictive alternative when depriving an individual of their personal freedom.
Especially for highly contagious and highly lethal infectious disease, quarantine becomes that much more important. The Ebola virus would fit the category of highly infectious and lethal viruses which would warrant more aggressive quarantine measures. Many are concerned that quarantine will be used in a racist or discriminatory fashion and this has happened historically. This can be avoided using evidence-based and objective measures for reducing spread. Quarantine efforts should not be racist, discriminatory or promote irrational fear or create panic.
Making public health decisions when limited information is known about a particular disease is always problematic. In those situations a balance of public welfare and protecting individual freedoms should be achieved with caution being needed. Different countries tolerate quarantine to a different extent based on cultural and legal historical differences. What may be deemed acceptable quarantine and governmental action in China may be deemed reprehensible in the United States.
It is likely that if the disease spread continues, public health officials may call for social distancing or isolation by limiting public gatherings, events , meetings and discouraging gatherings of large groups of people. Maintaining a discrete distance from other people has been discussed as well. To date China has started this policy and some international meetings including in Europe have been canceled.
The issue of quarantine is highly complex, it must be addressed and implemented In a fair balanced fashion based on the scientific evidence. Both extremes of opinion on quarantine leave plenty of middle ground for compromise. Having ongoing reasoned debate as evidence accumulates is the most prudent means for achieving both protection of public health and minimizing infringing on personal freedom. Choosing the best setting for quarantine which limits spread and minimizes restriction of individual freedom is the proper balance.
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