Quarantine

Ashley Hahn March 22, 2006

Outline:
What is Quarantine?

History of Quarantine in the World

Use of Quarantine in the world today Ethical Concerns of Quarantine Legal Authorities for Control of

Communicable Diseases (Quarantine) Conclusion Questions?

What is Quarantine?
Quarantine is the:
Separation or restriction of activities of well persons who are not ill but who are believed to have been exposed to a communicable disease and are therefore at high risk of becoming infected. In the context of SARS, quarantine refers to a combined approach to managing contacts, which consists of active monitoring plus activity restrictions

 Quarantine, a medical term (from Italian:

quaranta giorni, forty days) is the act of keeping people or animals separated for a period of time before, for instance, allowing them to enter another country. By doing this, it is possible to limit the risk of spreading disease.

Quarantine vs. Isolation

Quarantine is the for those who have been

exposed to the disease but are not ill. Isolation is the separation of persons who have a specific infectious illness. These terms do differ in definition, but they are often used synonymously in the media.

History of Quarantine:
Quarantine has been around for a very long

time, there are records in the Old Testament where rules existed for the quarantine of Lepers. It wasnt until the Black Death of the 14th Century that Venice established the first formal system of Quarantine, requiring ships to lay anchor for 40 days before landing, thus giving Quarantine the meaning of 40 days.

Quarantined Diseases:

Bubonic Plague Yellow Fever Syphilis/Gonorrhea Leprosy Cholera Tuberculosis Poliomyelitis Typhoid Smallpox

Bubonic Plague:
The Bubonic Plague had several devastating outbreaks,

the most devastating occurring in the 6th, 14th, and 17th centuries. 25 Million People died in just over five years between 1347 and 1352. The total death toll of the Bubonic Plague has been estimated to be about 137 million people. The bubonic plague mainly effects rodents, but fleas are able to transmit the disease to people. Once a person is infected, they are highly contagious. Plague causes fever and painful swelling of the lymph glands, or buboes, the disease also causes spots on the skin that at first appear red, then turn black.

 549 AD- Byzantine emperor Justinian enacts a

new law meant to hinder and isolate people arriving from plague infested regions. 600s- China has well-established policy to detain plague stricken sailors and travelers who arrive in Chinese Ports. 1300s- Number of European/Asian countries begin enforcing quarantine of infected regions by encircling them with guards, (those caught trying to escape are returned, sometimes executed as a warning to others).

 1348- Venice establishes the first

institutionalized system of quarantine. This included giving a council of three the power to detain ships, cargo, and individuals in the Venetian Lagoon for up to 40 days to try and prevent the spread of the Bubonic Plague. 1374- Duke of Milan draws an edict mandating that all those inflicted with the plague should be take outside the city to a field or forest until they recover or die.

 1664-1665- Plague epidemic reaches Russia,

and officials organize quarantine stations to prohibit the entry into Moscow of people from other countries, under threat of death. 1850-1851-Following horrific epidemics of plague and cholera that spread through Europe from Egypt and Turkey towards the middle of the 19th century, the first international sanitary conference is held in Paris, with an eye to making quarantine an international cooperative effort. These sanitary conferences continue well into the 20th century

Smallpox
Smallpox is a disfiguring and potentially deadly

infectious disease caused by the Variola major virus. Smallpox existed in two forms, Variola major, the deadly disease, and Variola minor, a much milder form. The last naturally occurring case of smallpox was reported in 1977. In 1980, W.H.O. declared that smallpox had been eradicated.

 1663- During smallpox epidemic in New York City, the

General Assembly passes a law forbidding people coming from infected areas from entering the city until sanitary officials deem them no threat to residents. 1701- A Massachusetts statute stipulates that all individuals suffering from plague, smallpox and other contagious diseases must be isolated in separate houses. 1738- New York City Council sets up a quarantine anchorage off Bedloes Island. This island becomes a quarantine station for contagious passengers and crew from arriving ships.

Leprosy:
Leprosy is among the worlds oldest and most

dreaded diseases, it often resulted in terrible deformity and was thought to be communicable. In 1980 an effective cure for leprosy became available and has successfully treated 14 million people. chronic infectious disease caused by the bacillus lepr, characterized by the formation of growths in the skin, mucous membranes, peripheral nerves, bones, and internal viscera, producing various deformities and mutilations of the human body, and usually terminating in death.

 The quarantine of leprosy has been recorded

since Old Testament times when the leprous were excluded from cities and formed their own communities. 583 A.D.- The Council of Lyons restricts lepers from freely associating with healthy persons. 1179- The Third Lateran Council decrees living arrangements for lepers and how their necessary separation from society is to take place.

 1200- Europe now has some 19,000 leprosaria,

(houses for leper patients); France alone has some 2,000. In third world countries today those with leprosy are still banned from society and forced to live in leprous compounds. Although medicine does exist in the form of Multi Drug Therapy, very few inflicted with leprosy have access to the treatments.

Global use of Quarantine?

Brainstorm: What diseases have the potential for becoming epidemics, or pandemics, that Quarantine could be used for in todays world?

Modern Diseases:
HIV/AIDS

Avian flu
SARS Hemorrhagic Viruses

HIV/AIDS
HIV/AIDS has become a global epidemic,

(also known as a pandemic). There are many different ideologies as to how to help slow and eventually stop the spread of global AIDS. HIV/AIDS is a global emergency claiming over 8,000 lives every day. In fact 5 people die of AIDS every minute.

HIV and AIDS around the World

People living with HIV and AIDS 40.3 million

Adults Women Children under 15

38.0 million 17.5 million 2.3 million

4.9 million

New HIV cases in 2005

Adults Children under 15

4.2 million 700,000

3.1 million

AIDS deaths in 2005 Adults Children under 15 2.6 million 570,000

Total HIV cases to date Total AIDS deaths to date

64.3 million 23.1 million

The Quarantine of HIV:

Cuba has initiated quarantine for anyone testing

HIV+. This mandatory Quarantine has resulted in a very low rate of HIV infection there. However, Quarantine has not totally eradicated the presence of HIV in Cuba because some infected are able to spread the virus before knowing they are carriers, or before being Quarantined for the disease.

 1986

Treating the first cases of HIV/AIDS in the country as a public health emergency, Cuba begins compulsory, indefinite quarantine for citizens testing positive for HIV. Three years later, rules are relaxed to allow such patients to leave sanatoriums for long stretches, and beginning in 1993, HIV patients can choose to live at home after an eight-week course at a sanatorium.

 The quarantine of HIV+ could not be legally done

in the United States, doing so would violate the rights to liberty and freedom from incarceration without committing a crime, also those who have the HIV Virus in the United States are protected under the Americans with Disabilities Act from segregation and persecution, which some people think includes forced quarantine. As a result of the American with Disabilities Act, HIV/AIDS is currently not on the list of diseases that can be quarantined in the United States. The quarantine of HIV+ could be done in other parts of the world, such as in South Africa, where 1 in 10 Adults is HIV+

Avian Flu:
Avian influenza is an infectious disease of birds

caused by type A strains of the influenza virus. The disease, which was first identified in Italy more than 100 years ago, occurs worldwide. There currently is no commercially available vaccine to protect humans against H5N1 virus that is being seen in Asia and Europe. According to the WHO global influenza preparedness plan, the current phase of the pandemic flu is Phase 3; human infections with a new subtype, but no human-to-human spread. There is currently no pandemic flu on the earth, but the Avian Flu could potentially become the next flu pandemic.

Executive Order: Amendment to E.O. 13295 Relating to Certain Influenza Viruses and Quarantinable Communicable Diseases By the authority vested in me as President by the Constitution and the laws of the United States of America, including section 361(b) of the Public Health Service Act (42 U.S.C. 264(b)), it is hereby ordered as follows: Section 1. Based upon the recommendation of the Secretary of Health and Human Services, in consultation with the Surgeon General, and for the purpose set forth in section 1 of Executive Order 13295 of April 4, 2003, section 1 of such order is amended by adding at the end thereof the following new subsection: "(c) Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic." Sec. 2. This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, entities, officers, employees or agents, or any other person. GEORGE W. BUSH THE WHITE HOUSE, April 1, 2005.

SARS:
According to W.H.O. a total of 8,098 people

became sick with SARS during the 2003 outbreak. Of these, 744 died. In the United States only eight people had laboratory evidence of SARS-CoV Infection The primary way SARS is thought to be spread is through close person-to-person contact, and most readily by respiratory droplets produced when an infected person sneezes or coughs.

 2003

An outbreak of severe acute respiratory syndrome, or SARS, in Asia and Canada occurs in the spring. Officials credit the use of both isolation (for those sick with SARS) and quarantine (for those exposed to the sick) with forestalling an even more severe epidemic. In April, President George W. Bush adds SARS to the list of quarantinable diseases, which also include cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers such as the Ebola and Marburg viruses.

Hemorrhagic Fevers:
Viral Hemorrhagic Fever (VHF) is used to describe a

severe multisystem syndrome, (multiple organ systems in the body are affected). VHFs are caused by viruses of four distinct families which share a number of distinct features including: all are RNA viruses (covered/enveloped in fatty coating), their survival is dependent upon host, they are restricted to areas where their host lives, humans are infected when they come into contact with hosts (most commonly mosquito, field mice, and arthropod ticks), the occurrence of outbreaks in humans is not easily predicted, and there is no known cure or established treatment for VHFs.

Ebola virus:
The incubations period of the Ebola virus is 2 to 21

days, and the onset of illness is characterized by fever, headache joint and muscle aches, sore throat, weakness, diarrhea, vomiting, stomach pain, rash, red eyes, hiccups, and internal/external bleeding. The Ebola virus was first identified in 1976 and has since killed about 1,000 people. The Ebola virus is transmitted through direct contact with body fluids of an infected person. There is no cure for the Ebola virus and between 50 and 90 percent of people infected die within a few days.

Ebola warning in Congo

KINSHASA Two people had died in the Democratic Republic of Congo after showing symptoms similar to those caused by the deadly Ebola virus, the World Health Organization (WHO) said yesterday. A rickshaw driver and one of his passengers died in Bumba, 500km north of Mbandaka, after suffering hemorrhagic fever, the WHO announced. The WHOs head of epidemiology in the Congo, Florent Ekwanza, said that a third person, the wife of the driver, had presented with the same symptoms as her husband and is in the care of Bumba general hospital. Swabs taken from the bodies of the two dead victims would be sent to SA to be tested for Ebola, he said. Ebola, one of the worlds most feared and contagious diseases, causes raging fever and massive hemorrhaging. In 60%-90% of cases, death follows within a few days. Two previous outbreaks in the former Zaire, one in 1976 and one in 1995, killed about 525 people, according to health ministry figures. The virus, transported in infected blood and respiratory droplets, takes three weeks to incubate. 15 March 2006

Effectiveness of Quarantine:
When the proper steps are taken to initiate a

Quarantine, Quarantine can actually be very effective. As both the SARS case and the quarantine of HIV+ in Cuba have shown, quarantine can quickly and successfully decrease the rate at which a communicable disease travels, as well as decrease the number of individuals that become infected.

Ethical Concerns of Quarantine:

Brainstorm: What are some of the ethical concerns that may be behind the ideas of Quarantine?

Ethical Concerns of Quarantine:

Many people believe that quarantine

constitutes an unwarranted diminution of personal liberty. Others see quarantine as an integral aspect to communicable disease control. "Nowhere does a physician have an obligation to restrain people," Dr. George Annas, (chair of Health and Law at Boston University).

Four Ethical Principles of Quarantine Ross Upshur, MD, MSc, MA

Harm Principle- there should be a clear and

measurable harm to others, for quarantine this means infection that is transmitted person to person. Least-Restrictive-Means Principle- public health authorities should use the least restrictive measures proportional to the goal of achieving disease control. Reciprocity must be upheld- if society asks individuals to curtail their liberties for the good of others, society has a reciprocal obligation to assist them in the discharge of their obligations. Transparency Principle- public health authorities have an obligation to communicate clearly the justification for their actions and allow for a process of appeal.

Legal Authorities for Control of Communicable Diseases:

Title 42 United States Code Section 264 gives the

Secretary of the Department of Health and Human Services responsibility for preventing the introduction, transmission, and spread of communicable disease from foreign countries into the United States and within the United States and its territories/possessions. The CDC, through the Division of Global Migration and Quarantine, is empowered to detain, medically examine, or conditionally release persons suspected of carrying a communicable disease.

Legal Authorities for Control of Communicable Diseases:

The list of diseases for which quarantine is authorized

must first be specified in an Executive Order of the President. The list has included cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, SARS, and (most recently) potentially pandemic causing influenzas. The CDC anticipates that the need to use the federal authority of quarantine will only occur in rare situations, such as in events at port of entry or other time sensitive settings. This authority would be used if a person posed a threat to public health and refused to cooperate with a voluntary request

Current Quarantine Stations:

Anchorage Atlanta Boston Chicago Detroit El Paso Honolulu Houston Los Angeles Miami Minneapolis Newark New York San Diego San Francisco San Juan, PR Seattle Washington DC

Conclusion:
Quarantine is an effective way to help stop

the spread of communicable disease. Quarantine is strictly regulated in the United States to ensure that liberties are not being taken away. Class opinions on United States Quarantine, HIV+? Guidelines too loose? Benefit worth it?

Questions?