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Medical News & Perspectives
October 1, 2003

SARS Thrusts Quarantine Into the Limelight

JAMA. 2003;290(13):1696-1698. doi:10.1001/jama.290.13.1696

Quarantine has been around since the 14th century when officials in Venice, Italy, forced arriving ships to sit anchor for 40 days before landing to protect locals from plague. Last spring, seven centuries later, the global outbreak of severe acute respiratory syndrome (SARS) forced public health officials around the world to implement or consider quarantine (the term was derived from the Latin word quaresma, meaning 40), a time-honored but controversial prevention tool.

(Credit: CDC)

Thousands were placed under quarantine in China, Hong Kong, and Canada. President George W. Bush issued an executive order on April 10 adding SARS to the list of communicable diseases for which public health officials could use quarantine, although the measure was not invoked for the 33 people in the United States who were diagnosed as having SARS.

Old issues revisited

Old issues revisited

With quarantine once again in the public eye, age-old questions regarding its usefulness and effect on civil liberties are being reexamined.

Old issues revisited

"When you look at the effectiveness of quarantine, there is a hierarchy of cases," explained Lawrence O. Gostin, JD, a professor of law at Georgetown University in Washington, DC, and director of the Center for Law and the Public Health.

Old issues revisited

"If you have a single individual or small group, known to be infected, and you isolate them, then most people believe that this is proper," he said. More controversial is mass quarantine of large numbers of individuals who may or may not be infected.

Old issues revisited

Individuals who are healthy or think they are unaffected by a particular disease resist being forced to stay at home or in some isolated environment. This was seen during the SARS outbreak: When Hong Kong officials went to an apartment to place its residents under quarantine for SARS, they found many residents had fled, leaving more than half the units unoccupied.

Old issues revisited

Some governments respond to that reluctance to being quarantined with severe penalties against those resisting. In China, where more than 10 000 individuals were quarantined, the measure came with threat of execution for violators.

Old issues revisited

"Intentional spreading of pathogens in sudden epidemics, endangering public security, causing serious injuries or death, or serious loss to private or public properties will attract a sentence of imprisonment for a minimum of 10 years, or life imprisonment or death sentence," said the Chinese state-controlled news agency Xinhua.

Old issues revisited

US government officials, noting 85 suspected SARS cases in the United States, downplayed any legal threats against those ignoring the theoretical quarantine. But the law does allow for the "apprehension and detention of persons with specific diseases" (68 Federal Register 17558 [2003]).

A long history

A long history

In the United States, protection from infectious diseases was left to local public health authorities until 1878, when a wave of yellow fever epidemics led to the passage of the first Federal Quarantine Act. Still, infectious disease control remained primarily with state public health officials. It was not until 1892, with the arrival of cholera from abroad, that the law was reinterpreted to allow the federal government more authority in imposing quarantine.

A long history

In 1944, with codification of the Public Health Service Act, the federal government's authority over quarantine was fully established, although states also are allowed to implement quarantine. However, the last federal use of quarantine in the United States was during the Spanish Flu outbreak of 1918-1919.

A long history

Today, quarantine is run by the Division of Global Migration and Quarantine—a part of the Centers for Disease Control and Prevention's (CDC's) National Center for Infectious Diseases. Quarantine stations are located in Atlanta, New York, Miami, Chicago, Los Angeles, San Francisco, Seattle, and Honolulu, with each responsible for all ports in their assigned regions.

A checkered history

A checkered history

Prior to US federal control over quarantine, the isolation tool had a checkered history. One episode, involving an Irish immigrant cook named Mary Mallon, highlights the importance of quarantine. In 1907 New York, "Typhoid Mary" was found to have infected 22 individuals, one of whom died. While she denied having typhoid, Mallon was taken to North Brother Island to live in isolation. By 1910, a health official decided Mallon could go free provided she did not cook for people.

A checkered history

But Mallon resumed cooking, and in 1915 another outbreak of typhoid occurred in New York among 25 individuals, with two fatalities. The source of the outbreak was a cook named "Mrs Brown"—in actuality, Mallon, using an alias. Mallon was again sent to the island, where she lived for another 23 years in relative confinement.

A checkered history

While Mallon was identified as a typhoid carrier who posed a health threat to others, quarantine has been used too often against specific minorities under the guise of protecting public health. The quarantine of Jewish immigrants during a cholera epidemic in New York in 1892 had more to do with prejudice, class, and politics than containing the outbreak. Similarly, the discovery of plague in San Francisco in 1910 led local officials to arbitrarily set quarantine boundaries around Chinese residences and businesses.

A checkered history

Such discrimination makes public health officials hesitant to use quarantine again. It also makes certain populations leery about motives for the use of quarantine, as evidenced by the uproar in the 1980s that met suggestions that individuals with AIDS be subjected to quarantine.

A checkered history

"Nothing brings out the worst and best in a society as an infectious disease—there are stereotypes and cultural bias, and it's a way society can separate ‘them' from ‘us,'" Gostin said. "We saw this with AIDS and the call for isolation, and with SARS and cultural stereotypes about Asian communities being unclean and uncaring about transmitting infection."

Protecting civil rights

Protecting civil rights

But today, with new diseases such as Ebola hemorrhagic fever, the fear of another Spanish flu-scale influenza pandemic, and the threat of bioterrorists using infectious agents such as smallpox or plague, federal and state government officials are preparing to include quarantine in their public health arsenal (JAMA. 2001;286:2711-2717). What appears to be different about current discussions of the use of quarantine is an awareness of the need to protect civil rights.

Protecting civil rights

When President Bush signed the executive order adding SARS to the quarantine list of the Public Health Service Act, it joined only a handful of specific communicable diseases—cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers. And even if a quarantine is issued with regard to these diseases, the federal law provides for civil rights and due process.

Protecting civil rights

States have their own quarantine laws, but that may be changing. Thirty-six state governments have adopted "The Model State Emergency Health Powers Act" (JAMA. 2002;288:622-628). The act puts into law five basic public health functions: preparedness, surveillance, management of property (such as pharmaceuticals and hospitals), communications, and protection of persons (including quarantine).

Protecting civil rights

Gostin, along with colleagues from the Center for Law and the Public's Health, coauthored the act at the request of the CDC. He said the document provides protection from onerous government intrusion into a person's life.

Protecting civil rights

It's important to ensure that the public authorities have all the power they need to stem the tide of an epidemic, including quarantine, but safeguards are needed to protect individuals against abuse of power, Gostin noted. "There has to be due process, review by the courts, and strong standards."

Protecting civil rights

For the first time, the model act gives legal rights to those under quarantine issued by a state—they have to be assured safe environments, food, and clothing while under isolation.

Protecting civil rights

"Government always wants to appear it is strong and decisive, and nothing is as strong as depriving citizens of their liberty—we saw this in China, Hong Kong, Vietnam, and a little in Canada," Gostin said.

Protecting civil rights

"But now the (US) government has to show that the risk from disease is real and not a subterfuge for discrimination," he said.

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