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To Quarantine or not to Quarantine Ebola Health Workers

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  • To Quarantine or not to Quarantine Ebola Health Workers

    Ebola Crisis: White House/States Disagree

    So, there's recently been an uproar about New Jersey Governor Chris Christie ordering a nurse returning from Liberia to go through a 21 day quarantine. She vocally opposed the quarantine, which now he's said can be carried out in her home in Maine. Now, she has been asymptomatic and pointed out that politicians don't know their medicine. She also didn't live in the best of conditions in NJ. In order to accommodate her, they are using a private plane to send her to her home state.

    But for me, this is about the needs of the many versus the needs of a few. We in America are too individualistic - and see everything through the lense of rights. Ok, so she loses the right to move around for 21 days? If she really cares about the ebola victims in Africa, that shouldn't make a difference. In Liberia, every Dick and Jane has to undergo the same 21 day quarantine if it's found they've had contact with someone with the virus. Why should health workers be any different? Furthermore, a 21 day quarantine should be sponsored by the government body enforcing it - meaning she would not lose out on pay. Yes, I think that accommodations needs to be improved and thought of carefully. What will that person do for 21 days? But IMHO our government should stray on the side of caution.

    What, from a medical standpoint, do you think our government should do in response to ebola?
    sigpic

  • #2
    If she really cares about the ebola victims in Africa her countrymen, that shouldn't make a difference.
    Ftfy.

    What will that person do for 21 days?
    If your country had had SARS outbreak of a significant degree, this wouldn't even be a question.

    What, from a medical standpoint, do you think our government should do in response to ebola?
    Strip all medical personnel who are as irresponsible as Craig Spencer of their right to practice; Kaci Hickox should also qualify.

    Comment


    • #3
      The best answer to questions such as this need to be informed by dispassionate and realistic evidence based medical knowledge.

      I'm open to actual evidence based arguments pro or con on this. That is what it will take. I'm not paying much attention at all to the politicians, of any side. Not because of any low view of politicians; but because they are not the experts. They are in the position of having to make the decisions, and the best way for them is also to look at evidence based medical knowledge.

      Here's a relevant editorial in the The New England Journal of Medicine; it comes down firmly against quarantine.

      Ebola and Quarantine, Oct 27, 2014
      Source: Ebola and Quarantine, NE J of Med, 27 Oct 2014


      The governors of a number of states, including New York and New Jersey, recently imposed 21-day quarantines on health care workers returning to the United States from regions of the world where they may have cared for patients with Ebola virus disease. We understand their motivation for this policy — to protect the citizens of their states from contracting this often-fatal illness. This approach, however, is not scientifically based, is unfair and unwise, and will impede essential efforts to stop these awful outbreaks of Ebola disease at their source, which is the only satisfactory goal. The governors' action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial.

      ...

      © Copyright Original Source



      The editorial is echoing, indirectly, something I have heard again and again and again on Ebola; which is that it isn't a prospect for a big epidemic spreading through countries like the USA (or Australia). The infection risk can be identified and controlled relatively easily, given conventional medical facilities and infection control. The hard issue, and where the control needs to occur, is in Africa, which lacks the facilities needed. It is there that the epidemic can spread, and it is there that we need health workers and practical support for them in the way of basic medical resources. Quoting the editorial again, with my highlight.

      Source: Ebola and Quarantine, NE J of Med, 27 Oct 2014


      In the end, the calculus is simple, and we think the governors have it wrong. The health care workers returning from West Africa have been helping others and helping to end the epidemic that has killed thousands of people and scared millions. At this point the public does need assurances that returning workers will have their temperatures and health status monitored according to a set, documented protocol. In the unlikely event that they become febrile, they can follow the example of Craig Spencer, the physician from New York who alerted public health officials of his fever. As we continue to learn more about this virus, its transmission, and associated illness, we must continue to revisit our approach to its control and treatment. We should be guided by the science and not the tremendous fear that this virus evokes.

      © Copyright Original Source



      Cheers -- sylas
      Last edited by sylas; 10-28-2014, 08:08 AM. Reason: New England journal... not England journal

      Comment


      • #4
        I'm open to actual evidence based arguments pro or con on this.
        I'm puzzled that you don't quote the argument, only the conclusions. What do you think of the argument?

        Comment


        • #5
          The reason I quote the conclusions is because I am not a health expert myself; I am not actually well positioned to evaluate the argument itself, but I am interested in expert opinion for appropriate conclusions. IMO the right thing is the focus primarily on conclusions... and this seems to be the wide spread conclusion of people who are best placed to look at the argument.

          The argument is important as well and its perfectly sensible to look into that as an aid to deeper understanding. (I still want politicians to be focused on the conclusions of experts, and not my own evaluations of the argument.)

          Anyhow... the argument looks perfectly sensible to me, and fits well with what I currently understand to be the basic facts with respect to Ebola. It's pretty straightforward. There is not actually a big health risk from people returning from the crucial and important work of managing the outbreak at its source. The disease is not infectious until you are showing symptoms. It is transmitted by fluids, not by air. Hence Dr Spencer (for example) did exactly the right thing. More importantly, the response was also the right response. As a result, there was very low risk of infections. And indeed, it seems there have been no further infections from that potential carrier.

          Sweeping quarantine measures are pretty much universally represented as overkill in what I have seen on this from actual medical sources. Quarantine comes with its own risks and downside, and it needs to be justified with a commensurate benefit. The additional benefit of a sweeping quarantine just isn't there, with this disease and this outbreak. Given the transmission characteristics of the disease, the right approach is careful monitoring of potential carriers returning from affected regions, with immediate response to the initial onset of symptoms. Dr Spencer's example is a good case study of what should be done, and it is widely and explicitly identified as such ... in this editorial and in other professional medical commentary that I have seen.

          As noted; I'm open to actual evidence based arguments either way on this, but as it stands and given the nature of the disease.... quarantine and isolation of people who have been exposed and who are showing symptoms is the way to go. Quarantine and isolation of all health workers is not... in fact, it runs the risk of making things worse by inhibiting the work where it is needed. There is no credible prospect of an epidemic in the USA. Even the most negative professionally credible analysis I have seen agrees on this.

          Cheers -- sylas
          Last edited by sylas; 10-28-2014, 04:12 AM.

          Comment


          • #6
            Originally posted by sylas View Post
            Sweeping quarantine measures are pretty much universally represented as overkill in what I have seen on this from actual medical sources. Quarantine comes with its own risks
            What risks?

            Given the transmission characteristics of the disease, the right approach is careful monitoring of potential carriers returning from affected regions, with immediate response to the initial onset of symptoms. Dr Spencer's example is a good case study of what should be done, and it is widely and explicitly identified as such ... in this editorial and in other professional medical commentary that I have seen.
            So basically self-monitoring?

            As noted; I'm open to actual evidence based arguments either way on this, but as it stands and given the nature of the disease.... quarantine and isolation of people who have been exposed and who are showing symptoms is the way to go. Quarantine and isolation of all health workers is not... in fact, it runs the risk of making things worse by inhibiting the work where it is needed.
            I fail to see how it 'inhibits' the actual work; when they return from West Africa they are hardly working. To claim that those who really want to risk their own health by going over to save lives in West Africa in suboptimal conditions will be further deterred by having to self-quarantine 21 days seems implausible to me; the inconvenience and danger of the work is much higher than quarantine.

            Comment


            • #7
              Originally posted by Paprika View Post
              What risks?
              Actively inhibiting people from doing what is needed to deal with the outbreak, economic costs, and conflicts with basic liberties.

              The point is that none of these are absolutes. There's a trade off -- always. The first point is the big one IMO; and it makes a blanket quarantine (in the view of what expert opinion I have seen) actually a negative in terms of dealing with the disease itself. I note you don't actually agree with that, however, so let's move on....

              If quarantine was actually likely to have a significant effect on transmission, then weighing costs and benefits would change substantially. What makes the risks in matters of cost or civil liberties weigh significantly here is the fact (according to expert opinion) that quarantine does not make a lot of real difference, except in the case of people who have started to show symptoms. Sweeping quarantine has a negligible practical benefit, and so the other costs do matter -- even if you ignore that first cost of inhibiting health workers doing the work on the ground in Africa.

              So basically self-monitoring?
              A formal monitoring process is much better of course, and it seems that sanity is prevailing mostly and that this is the direction policy is going.

              If that is not available, yes; self-monitoring, and immediately reporting any onset of symptoms, is quite adequate -- as long as people really are having potential symptoms monitored. That's based on what is actually known about the disease and transmission. It's isn't just being slack; it really is what is needed given how the disease spreads.

              The point of a formal process is to help this along and make it consistent, as I see it. Not everyone is going to self-monitor adequately and a formal assistance is a good idea,, IMO. It's recommended by the CDC.

              I fail to see how it 'inhibits' the actual work; when they return from West Africa they are hardly working. To claim that those who really want to risk their own health by going over to save lives in West Africa in suboptimal conditions will be further deterred by having to self-quarantine 21 days seems implausible to me; the inconvenience and danger of the work is much higher than quarantine.
              That's .... odd. Quarantine for 3 weeks is really really intrusive, but if you honestly can't see how that might inhibit the numbers of health workers, shrug. I'll just disagree with you on that. Quarantine still carries negligible practical benefits when applied to people without any symptoms.

              Cheers -- sylas

              Comment


              • #8
                Originally posted by sylas View Post
                Actively inhibiting people from doing what is needed to deal with the outbreak, economic costs, and conflicts with basic liberties.
                People aren't actively inhibited from going overseas; there are no real obstacles being thrown in their path. Rather, (according to you) because of their own non-important preferences (my FREEDOM!), some might be deterred.

                If quarantine was actually likely to have a significant effect on transmission, then weighing costs and benefits would change substantially. What makes the risks in matters of cost or civil liberties weigh significantly here is the fact (according to expert opinion) that quarantine does not make a lot of real difference, except in the case of people who have started to show symptoms... The point of a formal process is to help this along and make it consistent, as I see it. Not everyone is going to self-monitor adequately and a formal assistance is a good idea,, IMO. It's recommended by the CDC.
                Now, self-monitoring has been the norm, the protocol recommended by MSF and followed by Spencer, for example. Under this protocol the question would be whether self-monitoring would adequately cover the time between the patient being symptomatic and the patient noticing it and reporting it. As you say, "not everyone is going to self-monitor adequately", so that has been one of my main concerns.

                'Formal assistance' should, of course, be better than self-monitoring, though how much better cannot be evaluated until concrete measures are listed.

                That's .... odd. Quarantine for 3 weeks is really really intrusive, but if you honestly can't see how that might inhibit the numbers of health workers, shrug. I'll just disagree with you on that.
                I'll grant that I don't understand you USAians' obsessions with freedom, and that for such people the fact that "my freedoms are being violated!" may induce them not to go save lives when otherwise they would have gone, or go for a shorter period.
                Last edited by Paprika; 10-28-2014, 05:14 AM.

                Comment


                • #9
                  Originally posted by Paprika View Post
                  People aren't actively inhibited from going overseas; there are no real obstacles being thrown in their path. Rather, (according to you) because of their own non-important preferences (my FREEDOM!), some might be deterred.
                  Yes, of course. The pragmatic cost is less workers choosing to go to Africa to help deal with the disease at its source. (There some pretty obvious quibbles about what might qualify as a "real obstacle" and whether preferences and freedoms are "non-important", but hey.)

                  Practically speaking, a policy of sweeping quarantine will predictably result in less people choosing to do the work at the source. That's a real cost simply in terms of how well it helps deal with Ebola. That cost is to be weighed alongside the pragmatic benefits of quarantine that might result for reducing transmission. That remains true even if you are only concerned with what happens outside Africa... because stopping the epidemic at its source is the only way to stop the ongoing introduction of isolated cases to other locations.

                  Now, self-monitoring has been the norm, the protocol recommended by MSF and followed by Spencer, for example. Under this protocol the question would be whether self-monitoring would adequately cover the time between the patient being symptomatic and the patient noticing it and reporting it. As you say, "not everyone is going to self-monitor adequately", so that has been one of my main concerns.

                  'Formal assistance' should, of course, be better than self-monitoring, though how much better cannot be evaluated until concrete measures are listed.
                  Self monitoring is what we do when there's no official management strategy in place at all. The question ought to be... what is the proper formal strategy? Monitoring, or quarantine? Expert opinion is solidly with monitoring, as far as I can see. Even if we only use self monitoring, a formal set of guidelines to help people monitor effectively is practically speaking very useful indeed, with minimal cost. Other formal measures would be either to help people with the practicalities of monitoring, or enforcing it for those who might not do the responsible thing.

                  I'll grant that I don't understand you USAians' obsessions with freedom, and that for such people the fact that "my freedoms are being violated!" may induce them not to go save lives when otherwise they would have gone, or go for a shorter period.
                  Australian here, not USA. G'day.

                  I've distinguished two costs. One is the pragmatic one about people choosing whether to go and do the work in Africa.

                  I can speak here with some experience. I do a bit of volunteering myself, on a regular basis. A while ago I cut back on some Red Cross volunteering, basically because of time commitment issues, and balancing with work. I still keep up another volunteering gig with helping refugee students at a local high school through "Northern Settlement Services", and have informed my work place that I am not available for shifts that conflict with that. The Red Cross one just got to be a bit much, with an early start making shift work that much more tiring. When one volunteers, one does indeed balance pros and cons. Am I selfish for not continuing to give up Saturday mornings to Red Cross? It's not about "freedoms", but about deciding how much I'm willing to give.

                  The "freedoms" cost is a distinct cost from the matter of simply measuring how policy impacts the numbers of health workers dealing with the epidemic. It is the more abstract point that ANY action which forcibly limits individuals needs to have a commensurate benefit. That is, if people's liberty is being curtailed, it needs to be for a good reason. I'm no absolutist on this. I'm fine with constraining liberty for important social benefits. But surely you agree there's a genuine trade off there?

                  For quarantine: the benefit is a reduction in transmission risk. The cost is a major limit on the liberties of some individuals. NEITHER of these is an absolute that makes the other irrelevant. Both need to be weighed in the balance.

                  A vital part of this equation really that there is very little practical benefit from sweeping quarantine measures. Given how the disease works, general quarantine just isn't going to make much difference at all. If it would make a significant difference, then sure, the enforced loss of freedom imposed would be less compelling. But if quarantine has negligible impact on transmission -- then you don't have to be a USA style freedom fundamentalist to see that there's a cost here. And so yeah... that really is one of the costs you asked about.

                  Cheers -- sylas

                  Comment


                  • #10
                    Originally posted by sylas View Post
                    Practically speaking, a policy of sweeping quarantine will predictably result in less people choosing to do the work at the source. That's a real cost simply in terms of how well it helps deal with Ebola. That cost is to be weighed alongside the pragmatic benefits of quarantine that might result for reducing transmission. That remains true even if you are only concerned with what happens outside Africa... because stopping the epidemic at its source is the only way to stop the ongoing introduction of isolated cases to other locations.
                    Self monitoring is what we do when there's no official management strategy in place at all. The question ought to be... what is the proper formal strategy? Monitoring, or quarantine? Expert opinion is solidly with monitoring, as far as I can see. Even if we only use self monitoring, a formal set of guidelines to help people monitor effectively is practically speaking very useful indeed, with minimal cost. Other formal measures would be either to help people with the practicalities of monitoring, or enforcing it for those who might not do the responsible thing.
                    We agree that self-monitoring is insufficient with regards to transmission risk, unlike Medecins sans Frontieres. I am willing to consider that "official" monitoring (which I take as monitoring by government agencies) can be sufficient; but it would depend on what it consists of.

                    Australian here, not USA. G'day.
                    My bad. Take it as "those USAians".

                    I've distinguished two costs. One is the pragmatic one about people choosing whether to go and do the work in Africa.
                    ...The "freedoms" cost is a distinct cost from the matter of simply measuring how policy impacts the numbers of health workers dealing with the epidemic. It is the more abstract point that ANY action which forcibly limits individuals needs to have a commensurate benefit. That is, if people's liberty is being curtailed, it needs to be for a good reason. I'm no absolutist on this. I'm fine with constraining liberty for important social benefits. But surely you agree there's a genuine trade off there?
                    Sure, I agree that there's a tradeoff.

                    A vital part of this equation really that there is very little practical benefit from sweeping quarantine measures. Given how the disease works, general quarantine just isn't going to make much difference at all. If it would make a significant difference, then sure, the enforced loss of freedom imposed would be less compelling. But if quarantine has negligible impact on transmission -- then you don't have to be a USA style freedom fundamentalist to see that there's a cost here. And so yeah... that really is one of the costs you asked about.
                    I believe that there exists significant practical benefit from sweeping quarantines measures as opposed to the self-monitoring protocols advocated by MSF and followed by Spencer with respect to risk of transmission. It may be that measures by the the government will be able to create a better tradeoff as regards freedoms of the individual vs transmission risks.

                    However, it is not sufficient to consider the only benefit of quarantine as reduced risk of transmission; you haven't discussed three obvious main costs that under the third option: Firstly, public peace of mind. In addition, when someone like Spencer was diagnosed with Ebola, there are significant costs due to contact tracing and monitoring, as well as decontamination (the bowling alley and a restaurant he visited were closed for decontamination).

                    Comment


                    • #11
                      Originally posted by Paprika View Post
                      We agree that self-monitoring is insufficient with regards to transmission risk, unlike Medecins sans Frontieres. I am willing to consider that "official" monitoring (which I take as monitoring by government agencies) can be sufficient; but it would depend on what it consists of.
                      I don't really know for myself what is "sufficient" or not; the most I can say as a total non-expert is that some formal process makes sense to me at this point. I confess to giving more weight to the views of "Medecins sans Frontieres" than those of general people in the street. The editorial in NE journal of medicine appears to go with something more formal. But I'm honestly no expert that my own feelings should count for much.

                      My bad. Take it as "those USAians".
                      No problem. USA was the context of the initial question, and most members here are from the USA, so it's fine. I don't really think the idea of sweeping quarantine for all returning health workers is going to get much traction elsewhere in the world. It looks to me that the reason a sweeping quarantine was raised is that a couple of governors of states in the USA went full Monty without any good medical advice or grounding. (Politics and science have a tempestuous relationship in the USA, in this and many other issues.) Quarantine and isolation of people who are showing some symptoms is another matter of course!

                      Sure, I agree that there's a tradeoff.
                      Good... that's plenty of agreement for me, for now. People are bound to disagree on relative costs and benefits; agreeing that there is actually a trade off is enough shared ground for me to be happy.

                      However, it is not sufficient to consider the only benefit of quarantine as reduced risk of transmission; you haven't discussed three obvious main costs that under the third option: Firstly, public peace of mind. In addition, when someone like Spencer was diagnosed with Ebola, there are significant costs due to contact tracing and monitoring, as well as decontamination (the bowling alley and a restaurant he visited were closed for decontamination).
                      Yes.. valid point!

                      Be that as it may, I'm continuing to be guided in my own opinions by expert opinion... which as far as I can see comes down solidly on universal quarantine being over-kill that pragmatically speaking hinders rather than helps in limiting the spread of the virus, by making it harder to find the workers needed on the ground in Africa, with negligible immediate transmission risk reduction from returning workers.

                      Over and out -- sylas

                      Comment


                      • #12
                        Originally posted by sylas View Post

                        Be that as it may, I'm continuing to be guided in my own opinions by expert opinion...
                        That's fair, though my caution would be that the expert opinions involves only the medical and will focus on transmission, generally not taking into account social and economic costs.

                        Comment


                        • #13
                          We should continue to run in circles and scream and shout.
                          Micah 6:8 He has told you, O man, what is good; and what does the LORD require of you but to do justice, and to love kindness, and to walk humbly with your God?

                          Comment


                          • #14
                            That does seem to be working very well. There are only three cases known of people catching Ebola outside of West Africa, and all of them were nurses directly working with affected patients; and there are no indications that any of those nurses were running in circles, screaming or shouting. All three are recovered and virus free; probably helped by all the circles, screaming and shouting provided on their behalf.

                            Comment


                            • #15
                              Originally posted by Paprika View Post
                              However, it is not sufficient to consider the only benefit of quarantine as reduced risk of transmission; you haven't discussed three obvious main costs that under the third option: Firstly, public peace of mind. In addition, when someone like Spencer was diagnosed with Ebola, there are significant costs due to contact tracing and monitoring, as well as decontamination (the bowling alley and a restaurant he visited were closed for decontamination).
                              Well, I'd be happy to discuss them, commie.

                              My peace of mind regarding medically approved "USAian" protocols comes from a combination of relevant medical opinion and observed transmission data, or more rightly, observed lack of transmission data, in combination with observed mortality data, or more rightly, observed lack of mortality data.

                              What damage there may be to public peace of mind is notably not linked to any of these, but rather to misinformation and hysteria from folks who, simply put, have not a freaking clue what they're talking about. Or do, and don't care to correct their misinformation and hysteria.

                              The damage to my peace of mind comes from knowing beyond doubt there's an actual crisis that these ill-considered quarantine measures will exacerbate, leading not only to increased mortality in the affected regions, but to a prolonged risk of transmission outside of those affected regions. The damage to my peace of mind comes from simple arithmetic. To the extent that medical response to the actual crisis is restrained, these measures will kill people who could otherwise have been saved.

                              In addition, I can't imagine a more cooperative subject for contact tracing than a medical professional directly involved in epidemiological efforts against the specific disease. To the extent there are costs to that tracing, a better adjective is "minimal" rather than significant. Decontamination of the bowling alley and restaurant can only be ascribed to an excess of caution, and any excess in expense involved is more properly ascribed to the same misinformation and hysteria working at counter-purposes to effectively addressing the crisis.

                              I note that earlier you went so far as to suggest stripping Dr. Spencer of his medical credentials, and suggesting the same for Kaci Hickox. That's hysteria. And more, that's a clear indication that your thinking is not clear enough to generate a cogent response.

                              Surprise me.

                              As ever, Jesse

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