Learning From Ebola: Was Quarantine Too Extreme a Response?

yes they were because the health workers who returned to the us after their exposure had gone there as volunteers and have no right to expose their fellow americans. the question is whether or not quarantines halted the spread within the us. those I personally love in this nation should never be put at risk by disease carriers, released sex offenders, or crooked bankers who have paid their small fines and have returned to their practices.

The recent Ebola crisis underlined our lack of option and therefore a necessary reliance on quarantine. There is in fact another strategy that has been woefully ignored. Certainly Ebola and many other infectious diseases, especially those that can be weaponized, can be treated with vaccines and preformed "passive" antibodies ( remember those gamma globulin shots to prevent hepatitis when you went to Mexico !) In fact the technology is there to scale up these 2 strategies with multiple potential contagious diseases if basic preparation has been done.

There should be a "Manhattan" like project to create this very infra structure. This is the perfect task for government and should be part of the basic defense of the nation.

Unfortunately, the Ebola craziness in the US and the Syrian refugee hysteria both were fanned/are being fanned by shameless politicians and their propaganda machine trying to gain politically at the expense of sanity and good policy.

The only people who contracted Ebola in the United States were the two nurses who had treated a severely ill patient in Texas who had contracted the disease outside the US, and one doctor who treated Ebola patients in Africa and was diagnosed shortly after returning to the US. All of the health workers recovered. Some politicians, mostly Republican, sought to exploit the fear and hysteria.

Between 2001 and 2013, the last year for which data 12 available, 3,030 people were killed in domestic acts of terrorism. Of the 3,030, 2,977 died in the 9/11 attacks. During the same period, there were more than 306,000 gun deaths in the US, but Republican "leaders" don't think that is a crisis.

The leading candidate for the Republican nomination wants to stop Muslims from entering the US, apparently including American citizens who leave the country, and implies that he wants to register all Muslims in the US. What's next? Having them wear patches with Muslim symbols on their clothing and rounding them up into camps?

Hysteria can be expected from many people when there is a crisis. Political candidates who exploit the hysteria for political purposes certainly don't help the situation.

It is better to be safe than sorry. Ebola is not well understood and it was better to protect the rest of the community. The rights of those possibly exposed did not trump our rights to be protected from a contagious disease. The quarantine might have to be longer. Some people who have recovered from Ebola have infected others many months later.
Those health care workers who violated the conditions of quarantine should have been charged with the crime of leaving while under "house arrest". Going out for dinner or bowling was not a reason to possibly infect others. How did they know that during the time they were away from home they wouldn't become symptomatic? Not only was it selfish but dangerous. They were lucky they didn't cause any harm but of course all they were interested were their own rights. These were health care workers so they should have known it was for the common good. The nurse just knew she wasn't contagious, how was she so sure. Too bad if they felt imprisoned. Quarantine is part of good health care practice.

The level of ignorance-born hysteria was ridiculous, embarrassing, and shameful. Good lord, I can't believe how uneducated and completely lacking in capacity to reason that some many Americans are. I don't know how many of us get our shoes tied in the morning, much less grasp a public health policy decision. The 'bleeds/leads' mentality of current journalism certainly doesn't help, but it's truly the lack of capacity to understand the basics of science and probability that portend our doom. These are dark and dangerous times.

Is everyone remembering the exact circumstances of Kaci Hickox's "quarantine"? That she was treated like a criminal, confined in a tent without bathing facilities, by the grandstanding governor of New Jersey (who at that time contemplated running for President)? There was a lot more going on than medical caution in that case. What excuse can anyone come up with for not just quarantining a health worker, but imprisoning her in primitive conditions to make political capital?

A quarantine was justified because the CDC and WHO response to the epidemic inspired no confidence in their ability to control a domestic outbreak of the disease. As we found out later, the disease spread due to the population's custom of handling dead bodies and not burying dead people right away. This was an extremely low-tech disease. We had to read a lot of nonsense about how impossible a quarantine would be to administer despite the fact that it involved simply checking passports to see if people had visited the afflicted countries. Finally, we were considering quarantining a few small African countries, not Mexico or Canada, something which could be done with very little or no economic and social disruption to the country especially compared to the cost of even a minor outbreak of Ebola.

HIV-AIDS is not a good comparison. When infections started, it was a mystery. Ebola was not an unknown virus, it had been studied for years, and the means by which it is transmitted (or not) are known. But let's forget about being scientific or logical, using our minds and knowledge. Let's allow unscrupulous politicians use hysteria and ignorance as tools to garner support.

The only thing we have to fear is still fear itself. The object of unreasoning fear changes over time--Ebola, Syrian refugees, you name it, but the impulse is the same.

This questionable hindsight article assumes that healthcare personnel will of course always do the right thing by the public. But Hickox herself is a case of the opposite: the incubation period (as far as is known--and we don't really know for sure, do we?) is 21 days, and she felt she was just fine and didn't need to stay home. So is the bottom line: any healthcare person gets a free pass to self-declare their wellness by virtue of the fact that they have a job ofv some kind in healthcare? She didn't know any more than anyone else. And what about the NYC "E-bowler" who went out to his local bowling alley, also feeling confident about his wellness--until suddenly he was taken ill? And what about the nurse who, after being exposed to the Texas patient (via admittedly inadequate medical precautions) blithely hopped on a plane so she wouldn't miss a shopping trip for her wedding dress, while a colleague in the same situation took off on a cruise trip? NYT has a very short memory, despite all its archives. The health of the public and the risk of a pandemic is too important to let one healthcare individual unilaterally decide that they are the exception who is not a risk. These people should not be in healthcare.

Ironically, quarantine would not have prevented the Dallas nurses from infection by Mr. Duncan. Only proper hospital procedures, which had been promulgated by the CDC but not followed in the Dallas hospital, could have prevented those infections. Quarantine is a crucial public health tool, one that should not be subject to political hysteria. It should be implemented in a rational fashion when it is needed and not when it is unneeded. Implementing quarantine when it is not appropriate will reduce compliance, reduce respect for law, and endanger us all when we truly need it.

Fomaites can be a common form of exposure for many infectious diseases - that is, indirect contact with infected surfaces without required close contact with people known to be symptomatic. Ebola spread may be considered such a disease. Is it really a burden on civil liberties to invoke precautionary temporary quarantine procedures during the potential incubation period in the good of population level public health? I personally think not as the risk of even one secondary transmission is unthinkable.

I am in awe of Kaci Hickox after her reading her piece. Can she please run for president? Or at least governor?

As a previous ICU nurse during the beginning of the HIV infection, I understand her anguish. BUT, because people were lax in the beginning of the HIV infection, millions became infected!
Ebola could have been like HIV, if someone didn't do something! While HIV doesn't kill as quickly, Ebola DOES! However, both diseases show a lax in previous and present medical care! When you see a potential disease that can spread, take ALL precautions and NEVER take an easy way out (i.e. wear the appropriate gear, and monitor yours and others actions).
I saw chicken pox spread in the ICU, because a doctor whose kids had it (he never had it) came to work and infected some patients. He ended up in one of our beds!

Two characteristics of Ebola allowed us to contain the epidemic despite many errors and a late and weak response. It was not very contagious until well after symptoms appeared and it was not readily airborne. When, not if, a lethal new disease variant emerges that is more contagious we will be hard pressed to prevent a global pandemic. Forewarned does not appear to mean forearmed when it comes to global preparedness for disease.

As a medical microbiologist who taught that subject at university, I would like to point out a couple of things. When the few people started becoming ill with Ebola virus in the U.S. or returned here with the virus, we had few facilities and even less training in some cases for dealing with the disease. Quarantining of those returning to the U.S. who had been either involved in the care of those with Ebola or known to have been in close proximity of those with Ebola (the reporters) was a prudent response by health officials to contain and prevent the spread of the virus, should that be the case, even if those individuals had been initially asymptomatic upon their return. Why? There are few drugs available to deal with the virus, and most used at the time were experimental, and none were/are available for treating masses of people, other than replacement of bodily fluids.
As we are finding out, we still know little about the Ebola virus. We are seeing relapses in some of the people who were thought to be free of it.
As with vaccines, the good of the general population has to be considered when dealing with disease.

Quarantine is an effective method of containment. Had it been applied in West Africa at the onset, many lives may have been saved. Ebola did not spread in the US. It can't be known what the outcomes would have been if the responses had been different. Nurses put themselves in harms way to save our lives. We all owe them our thanks for that.

So your core argument is that a quarantine is an inconvenience? So was contracting ebola by the two nurses who didn't volunteer to go fight disease in a foreign country. For all of your claims that the disease doesn't transmit easily with only a handful of people who entered the country with it, two people were infected. That doesn't really support your idea that you should be allowed to walk around in public. Perhaps the issue isn't your idea of the public's "irrational fear" but you own "irrational optimism".

Is this not an article that can only be written because as it turned out we dodged a bullet this time? Maybe it was just luck. But yes, let's scrutinize ourselves. Lower our guard next time. And what will be the article if we get it wrong?

Are you serious? This is ridiculous. It's a matter of how long to quarantine now, since one patient relapsed after months of supposed cure. Your right to travel comes with a cost.

How can one paper be adamantly opposed to guns that kill relatively few people and open to unleashing a plague that could kill millions?

The logic that monitoring is as safe as quarantine rest on the assumption a person who realizes that they might be coming down with a horrific disease is going to act rationally. We had few data points during this crisis, but what we saw indicated that even the most well informed person might decide instead to take a jog, go bowling, or get on an air plane. While it is an inconvenience and not a vacation, it is a weak assertion that a temporary medical quarantine to ensure public health is a trampling of an individual's rights.

It is a fact those who oppose quarantine in such outbreaks are not as frightened of a disease as others. It does not follow that such fear is unjustified. People who lack a detailed understanding of bacteria and viruses are unaware of how dangerous they sometimes are, -how fragile life is. Also many people look up to the medical profession with a reverence, seeing scientist who are well equipped to deal with the death and chaos of something like last years Ebola outbreak. While I consider anyone who went to Africa to help fight Ebola a true hero, I hold no such delusions about the business of American medicine. Americans should be quick to question medical opinions whenever the may be self-serving and illogical.

Asked to spend two weeks at home in order to allay the fears of frightened neighbors and fellow citizens, who are dealing with a confused and disorganized government, and to allow them to feel protected from exposure to a horrible disease? That's just too much of a sacrifice. Hire a lawyer and go to court.

Rights, after all, and before all else.

Let's weigh the possible outcomes: 3 weeks of trouncing civil liberties vs pandemic. How many people contracting Ebola is acceptable so potential carriers avoid quarantine? How many of these is it ok to die to avoid stepping on civil liberties?

I meant to write "fomite," not "comity" in the previous comment.

Apologies...

The CDC Ebola website states that symptoms appear between 2 and 21 days after infection.

Yes, maybe Kaci Hickox lucked out, and did not become symptomatic in later days of her isolation. But the high road was, and is, to consider the very densely populated area in which she lived - and set a good example.

Hickox whined "Civil liberties violation! Civil liberties violation!" due to the inconvenience of 21 days of isolation.

The ACLU never gives life saving care.

It merely gives legal aid to access an American legal construct.

Had Hickox graciously accommodated the CDC protocol, it would have set an example to other healthcare workers (some of the highest mortality victims of Ebola). It would have said, "I'm not too special to be a comity (a carrier of pathogens). I care enough about my community not to put them in any unnecessary risk whatsoever."

Instead, BEFORE the 21 days of possible symptoms had passed, she raged.

Healthcare workers like her don't belong in the third world - they are not concerned at human beings: only themselves.

Thank you for publishing this article. My experience with the Oakland County Michigan Health Department was ridiculous when I returned from Sierra Leone this past February. George Miller, the director of the Oakland County Health and Human Services Division, acted like bully. The funny thing is I called before I left and was told Oakland County was following the CDC recommendations, which were no movement restrictions for my level of exposure. The big surprise when I came home was that they did impose movement restrictions and they acted like wackos. I totally agree, people who worked in the Ebola Treatment Units were highly motivated to watch for symptoms, and certainly were not interested in putting their community or families at risk. If I had known what I was going to be facing, I would have spent my quarantine in Europe. The American Public Health community has me really worried, if they continue to use politics instead of science to make decisions, we are in big trouble. If I ever hear "abundance of caution" again, as an excuse for abundance of magical thinking, I'm sure I'll cry.

Thank you.

Lessons can be learned from hindsight. We might learn how better to deal with communicable disease in general or Ebola specifically. One lesson of 2014 was how effectively strong leadership can be. The CDC approach was successful.

But we might also learn what distinguishes overreactions from prudence. The Ebola experience in the US included a demonstration of politicians getting in front of a mob attempting to appear leading. This panicked behavior made no one safer. Had the threat been more serious excessive displays of actions might have increased risks. While it was important to identify anyone entering the country who was at risk, treatment such as to that which nurse Hickox was subjected risked an adverse consequence; people arriving who would disguise their risk.

In that respect, we were lucky.

In the real world of medicine decisions have to be made with incomplete data because timeliness is unforgiving. For a patient, a late intervention misses the window of opportunity to halt replication of a pathogen ( Ebola ) AND to halt a cascade of mal-adaptive bodily functions that become irreversible ( hypotension/hypoperfusin, consumption of clotting factors, hyper inflammation etc)
Ebola is still imperfectly understood. It appears just touching some one in the throes of the clinical illness can transfer the virus. That transition from asymptomatic to symptomatic relative to transmissibility of the virus is an area of conjecture, especially in every case considering a patient's state of immunity fluctuates from totally susceptible to apparent total immunity. Recent outlying cases with the persistence of the virus in semen and intraocular fluid after apparent recovery testify to our imperfect understanding. There are issues of the time viability of Ebola on various fomites ( other surfaces beyond the patient itself)

Public health consideration of quarantine seek to prevent the typical geometric progression of a viral disease in a population that indicates a catastrophe has happened. In fact WHO is being taken to task for it's slow reaction to the Ebola epidemic in Africa that clearly got out of control.

Since there is no widely available vaccine or antiviral therapy, timely quarantine is the only game in town for a population. Timely is more important than perfect.

First we had several months of near-constant media drum-beating about the unstoppable Ebola epidemic in West Africa.

Then we had a handful of highly publicized cases turning up in the US. Republican politicians stoked the fear for electoral gain. Obama, the most reviled President of my lifetime, was depicted as soft on African killer viruses. The democrats lost the Senate. The issue went away.

Lesson learned? Well-informed caution is not nearly enough, when the electorate is fearful and control of Congress is on the line.

In the USA people have a right to be free unless they are convicted of a crime.

If the government decides to imprison them (and that is what quarantine is)
for other good reason, they should be adequately compensated. The amount should depend on whether they really are sick, but should always be there.

A person never getting sick that is quarantined should get say $10,000 a day
in compensation plus compensation for lost income and permanently lost opportunity (e.g. if they got prevented from a unique vacation, like to see a certain solar eclipse,)

A perfect illustration of today's faults in the workforce: opinions without facts.
The only effective method of disease control since the Black Death has been quarantine. It ignores all class and wealth distinctions and is certainly not political or race based.
And whenever a person's freedom is restricted they feel it; it is their duty to be restricted to protect all the others.
Personal discomfort is not overruled by Public Health as Dr. Snyderman should certainly have known.
None of the relevant authorities seemed to have any firm insight into Ebola and how to assure the Public that they knew what they were doing.

In a perfect world quarantine is excessive for certain folks. No doubt.

But paradoxically the experts who reassured us that any hospital in America could effectively manage and quarantine Ebola victims caused the over reaction.

Recall one of the first victims arrived at a large respected Dallas hospital ER, underwent thousands of dollars worth of testing, was told he had sinusitis and was sent home only to return and die from Ebola.
Shortly two of his nurses are infected with Ebola exploding the claim that any US hospital can effectively contain the virus.

Now the reassuring CDC bedtime stories about Ebola turn out to be entirely false.

It is no wonder that folks were scared and demanded quarantine measures.

The sad fact is that US hospital infection control is pitiful. Now we know that.
Hopefully, the CDC and hospitals have improved their training and equipment so that the next time around our health care system is educated and prepared to meet the next infections disease threat.

This article isn't sufficiently comprehensive in that it doesn't discuss the fear-mongering aspect of the political context, in which (mostly) Republican politicians cynically exploited concern about Ebola for the sake of political expediency. The deliberate attempts to undermine confidence in the CDC and public health officials more generally has significant relevance beyond the specifics of the situation with Ebola. The strategy of leveraging distrust of government, and "liberal elite" academics and scientists, counterproductively, is a broader phenomenon, and "Ebolanoia" is a very instructive example of that phenomenon.

Not everyone shares your sense of personal responsibility and Ebola is so deadly that reason must not be the only criteria. Every effort should continue to be taken to protect the public from this horrific disease. Thousands of dead people is all I need to want everything possible done to prevent the entry of this dangerous disease to the United States.

Snyderman can't have it both ways. She can't say "i'll self-quarantine" and then go out for a joy ride. She was wrong. And yes, she contributed to public confusion and misunderstanding -- the exact opposite of her responsibility, both as a physician and a journalist. Really -- it was a new lesson learned that she had to be 'impeccable with words', wasn't that her job? And she wasn't new to it.

Right -- quarantine is not a vacation. Not only is a quarantined person (and contacts) confined, but someone (the government) must be responsible for all their basic needs that require outside input (food, garbage pickup, laundry, maintenance & repairs, pet care, etc) for the whole period. Not to mention the individuals' loss of income, schooling, etc. It is a serious thing to quarantine (yes, imprison) a person. Just think -- people recoil from mandatory vaccination to protect the community from real deadly threats, but think it's ok to confine people to satisfy nonexistent threat.

Shhh-- don't tell anyone that the people taking care of Craig Spencer were going home and back and forth to New Jersey and elsewhere everyday, going to supermarkets, movies, church, everywhere. And yes, the New Jersey State Health Department knew even while the governor's shameful treatment of Hickox continued.

I don't even have to read this, although I will. We in the US do not have much experience dealing with epidemic disease, and somehow we think that a quarantine is too much to bear? Can we consider the complete total chaos and havoc that would be wreaked on our nation should Ebola virus get loose here? I think staying at home in quarantine is perfectly acceptable to lower the risk for everyone. Good God, save this country and ourselves FROM ourselves. My mom worked as a nurse in foreign country in the late 40's and 50's and quarantine was where people with tuberculosis and infectious disease was standard operating procedure. If you put everyone at risk, because of a contracted disease, that's where you went. And TB as bad as it is, is a pin prick compared to Ebola. Stop the madness, please...

If there are lessons to be learned from the public panic over Ebola, it's that in today's virulent political environment, millions of Americans simply do not trust the government, to be competent in managing crises or to tell the truth. Moreover, and possible even scarier, is that facts don't matter. Science isn't believed. Fearful and angry citizens, egged on by the people like the Cruz staffer who tweeted that there had never been a case of Ebola in the U.S. "before Obamacare," simply ignore facts, not unlike many do with global warming and vaccinations. We are entering a frightening time when un- or ill-informed citizens prodded by ignorant and/or craven politicians could be incited to behaviors that are difficult to comprehend. We saw it last week with a crazed shooter muttering Carly Fiorina's rhetoric about baby parts. We see it tonight with people posting on the Times comments section that the Koran says all Muslims are required to conquer others or face death. And when pols like Christie and, we now learn sadly, my own Governor Malloy in CT, fuel the heat of panic . . . . . who are the clear-headed and informed influencers who can quell the fire of fear?

Are you kidding? How is 2 or 3 weeks extreme? Ebola is a deadly disease. We're talking about about the safety of hundreds, possibly thousands of people. Surely the healthcare workers who take weeks or months out of their lives to care for the ill halfway around the work can spare 2 or 3 weeks to insure the safety of their own neighbors and coworkers. And don't forget - hospitals barred their own volunteers from returning to work FOR WEEKS at time. You're not calling THAT policy extreme. Why? Are you comfortable with double standards? Do you have more respect for the lives of health care workers than you do for the rest of us?