I’ve given a few talks recently on pandemic influenza. This topic of isolation and/or quarantine hasn’t come up frequently during the question-and-answer period, but almost every time I’ve had someone approach me after the talk to ask about it (since I mention it briefly during the presentation). It seems to be something that really concerns people, and it’s a difficult topic. No one wants someone out spreading a deadly disease that could kill you or your loved ones, but at the same time, no one wants to be locked away from their loved ones if they’re potentially dying from a deadly disease, either. It’s a difficult scenario and there are no easy solutions. However, it’s my impression that the general public probably hasn’t been exposed to this potential controversy very frequently, so I wanted to highlight a recent example of just what could happen:

Robert Daniels has been locked up indefinitely, perhaps for the rest of his life, since last July. But he has not been charged with a crime. Instead, he suffers from an extensively drug-resistant strain of tuberculosis, or XDR-TB. It is considered virtually untreatable.

County health authorities obtained a court order to lock him up as a danger to the public because he failed to take precautions to avoid infecting others. Specifically, he said he did not heed doctors’ instructions to wear a mask in public.

I’ve mentioned XDR-TB here and here. Though it hasn’t been a huge problem yet in the United States, cases like this one show just how quickly it could potentially become one–and that’s the reason for isolation and/or quarantine in the first place.

Let me back up just for a second to explain the difference between these two. “Quarantine” sometimes is used in the media as a catch-all for just separating diseased from non-diseased, but that’s not quite right. Rather, quarantine refers to the act of removing people who are *potentially exposed* to an infectious agent from the general population for a specific window of time (historically 40 days, hence the name). It doesn’t matter if one shows symptoms of the disease or not; what matters is that they’ve been exposed to someone who does, and therefore they may be incubating it as well. That symptomatic person, then, may be put into isolation (as is the case with Robert Daniels, above) to prevent them from spreading the disease to others. As noted, this could be indefinite, and certainly is controverisal:

How to deal with people infected with the new strain is a matter of debate.

Dr. Ross Upshur, director of the Joint Centre for Bioethics at the University of Toronto, said authorities should detain people with drug-resistant tuberculosis if they are uncooperative.

“We’re on the verge of taking what was a curable disease, one of the best known diseases in human endeavors, and making it incurable,” Upshur said.

And of course, it’s not only XDR-TB; the same principles can be applied to someone who may be knowingly spreading other illnesses, or someone who has influenza during a pandemic. It’s a murky area, but one that has huge potential impact on the public health:

University of Pennsylvania medical ethicist Art Caplan said Maricopa County health officials were confronted with the same ethical dilemma that communities wrestled with generations ago when dealing with leprosy and smallpox.

“Drug-resistant TB, or drug-resistant staph infections, or pandemic flu will raise these questions again,” Caplan said. “We may find ourselves dipping into our history to answer them.”

Comments

  1. #1 wright
    April 3, 2007

    I believe civil and health authorities should have this power, but they should also be accountable for how they use it. The process should be as transparent to the public as possible, to curtail the suspicion / temptation of abuse.

  2. #2 Sandra in Dallas
    April 4, 2007

    Tara – can you give us any idea of his prognosis? i.e. how many years might he live?

  3. #3 Ursula
    April 4, 2007

    Hi,

    In many ways this is a legal problem, rather than principally an ethical one.

    Some jurisdictions still have legislation on their statute books, which was passed so that those who were refusing treatment for tuberculosis (when it was virtually endemic within the community)could be helped.

    This could be seen as an ingringement of individual rights, but the ‘negative rights’ of others, (viz. the right not to be infected with a potentially lethal disease) were seen as more important.

    Legislation still exists, in some jurisdictions, enabling the authorities to enter an infested individual’s home, and to clean both it and the person.

    This might happen if, e.g. an elderly person is so confused that they have allowed things to deteriorate to the point where they may have a personal infestation, and the house may be so filthy that vermin have taken residence.

    Sometimes the elderly person does not want intervention, so this is when the law is potentially invoked. The rights of the neighbours, (e.g. not to have rats running up the common stairs, and possibly biting them, causing Weil’s disease etc.), are taken into account.

    It seems that the government will see to it that legislation of this sort is passed, when the rights of the many outweigh the right of the individual.

  4. #4 lincoln
    April 4, 2007

    In the Robert Daniels case of antibiotic resistant TB, Daniels was locked up in the county hospital’s prisoner detainment room. He was denied the use of cell phone, reading materials, and TV, radio, and personal computer by the Maricopa county Sherrifs deputies that are in charge of his quarantine.

    As for myself, I find this to be a bit much as this comes across as punishing Daniels for having TB. I am appalled by this. I fail to see how depriving an ill person from communication with the world or with his loved ones is necessary or is in any way beneficial to his possible recovery.

    Is our society so ill that we would treat sick people in such a way as to treat them in such a way.

    Depriving a sick person of communication with his loved ones seems to me to be morally bankrupt and seems to be abuse of a patient.

  5. #5 Tara C. Smith
    April 5, 2007

    Sandra, not sure about his prognosis. The cases in the South African outbreak succumbed quickly, but from the story at least, it seems he’s doing better than he was previously.

    Ursula, it certainly is both a legal and an ethical problem. Many places have some kind of law on the book allowing for public health interventions in these types of cases, but even if the law is there, enforcing it also can become a quagmire. In this case it was one person, but what if there were 100 who needed quarantine or isolation? Or a thousand? The majority of a town? How would it be enforced? These issues also pop up regarding pandemic flu or bioterrorism and travel restrictions–what if, essentially, you “quarantined” an entire town or state by making border crossings illegal? How would *that* be enforced? There are tons of issues regarding not only the law, but enforcement of it, that have yet to be addressed, and are kind of pushed out of the way for now because they are so thorny.

  6. #6 Ursula
    April 5, 2007

    Hi Tara,

    I think that you are right, in that the difficulties can become more fraught when dealing with large numbers.

    TB reared its ugly head throughout my family history, and (before the curative drugs were discovered), sometimes whole streets were affected. The rich went to Switzerland, others were nursed in sanatoria, or were cared for at home. Not everyone caught it, because much depends on genetic factors, or whether it was open or closed TB, and on the immune system possibly ‘clamping it down’ only for it to re-emerge many years later.

    Drug resistant TB is frightening, but maybe this poor person will have a better prognosis if he is treated ‘the old way’, e.g. fresh air, plenty of rest, and a good diet. Some did survive in the pre-treatment era with this regimen, although a great many died.

    Pandemic flu and bioterrorism are possibilities. If the threat is bad enough, I think that emergency legislation would be passed to supplement that which may be on the statute books.

    People will do what they need to survive. I am thinking of the underground accommodation that was built during the cold war. It may not necessarily be the infected who go into isolation if a pathogen is airborne. Maybe, in some circumstances, (if the threat is seen as dangerous as radiation), the uninfected might seek seclusion, while the government or scientists devise a cure.

    The ethics might involve looking at the sanctity of life. Would most people agree that a hijacked aeroplane should be shot out of the sky, if, by doing so, many more innocent lives could be saved?

    What if the airborne threat eventually dissipated, but those infected with a deadly pathogen still posed a grave risk? If there was no reasonable possibility of a cure, and if they were suffering, and wanted to die, should they be offered assistance in dying? We only have to look at Oregon, the Netherlands and Switzerland for the answer to voluntary euthanasia or assisted suicide.

  7. #7 Joshua White
    April 6, 2007

    I just had to be reading “The Stand” right now too.

  8. #8 Ktesibios
    April 6, 2007

    Lincoln wrote:

    In the Robert Daniels case of antibiotic resistant TB, Daniels was locked up in the county hospital’s prisoner detainment room. He was denied the use of cell phone, reading materials, and TV, radio, and personal computer by the Maricopa county Sherrifs deputies that are in charge of his quarantine.

    As for myself, I find this to be a bit much as this comes across as punishing Daniels for having TB. I am appalled by this. I fail to see how depriving an ill person from communication with the world or with his loved ones is necessary or is in any way beneficial to his possible recovery.

    Maricopa County is the fiefdom of Joe Arpaio, self proclaimed “toughest sheriff in the USA” and elevator of piss-ant petty sadism to an art form.

    The deputies are probably just conforming to the norm he has established- inflicting suffering on someone who can’t defend himself for their own gratification and because they know they will get away with it.

    Protecting public health does not require cheap bullies and thugs in uniforms. Arpaio is a pig. It really is that simple.

    http://www.arpaio.com/

  9. #9 Dark Matter
    April 8, 2007

    Mary Mallon at least got a cottage to live in…
    (even after her escape attempts…)

    Does anybody think this is going to be a test case
    on how diseaes like mutiple drug resistant TB /avian
    flu are going to be handled from now on? Another
    “opportunity” for the prison industry?

  10. #10 Ursula
    April 10, 2007

    Hi,
    I am not sure how your system is organised. Is Robert Daniels in the care of the prison service, or is it more like a secure hospital (where people can be detained, but are looked after by doctors and nurses)?
    If the worst case scenario happens, and the avian flu virus mutates so that human to human transmission occurs, I think that those infected will be so ill that they will only be able to lie in bed, and will require very specialist input from the healthcare profession.

  11. #11 M. Randolph Kruger
    April 10, 2007

    Last year in Romania, 60,000 people were isolated into their houses as BF apparently got loose in the population. Media coverage was nil. Did they have cases of H2H? No one is saying, but they werent at home for the local football game.

    The orders I was told was that they were to stay indoors and failing that they were to be arrested and placed into “custody” with said custody to be in an abandoned military hospital. This lasted for three weeks for the isolation and those that ventured out were held for a month.

    60,000 people would suck up all the resources in a city very quickly. Food, heat, perhaps water. But it was the most underreported story in Europe. News blackout? Very likely.

    For this kind of thing to happen here there HAS to be a declaration of a state of emergency at the least, and martial law at the most. Understand that under the SOE the Constitution is not suspended, it is under DOML. I dont think that it would get to martial law in the US unless there were full blown riots or the like. Besides we would be really too busy past the first three weeks which is about the point of no return for the food supply..

    Instead of Typhoid Mary, we would have TB Harry. XDR-TB would run through the population like a fire and thats the reason he is locked up. He isnt allowed a cellphone because he is in the same area as the other inmates. HIs room is disinfected every several hours and if he is a carrier which is the indication, he is there because he refused to wear his mask in public. There are lots of videos of the effects of TB on humans, just put “tuberculosis effects on humans videos” into a web search and you’ll find pretty quickly what you are looking for. Its a lousy way to die and if it means this guy has to be compensated just to sit for the rest of his life then so be it. The Constitution says no person may be denied life, liberty or the pursuit of happiness without due process. The laws are already on the books to hold him. If they hold him then he and/or his family will be compensated for it and in that the law is and will be followed.

    As for the shooting out of the sky Ursula, thats contained in a process in the US called SCANTANA. Look that one up.

    Its always the old diseases in new forms that get us. Lets talk about something really cheery like smallpox.

  12. #12 Ursula
    April 11, 2007

    Hi M.Randolph Kruger,

    I will look up SCANTANA, thank you.

    I am shocked about the Romania story, as this was most certainly under reported.

    Tuberculosis is not a pleasant condition to have. Pulmonary tuberculosis is usually very debilitating, in that the person affected feels generally exhausted, and experiences pleuritic pain (not from the lung parenchyma itself), night sweats, weight loss, a racking cough producing haemoptysis and perhaps ‘cheesy’ lumps in the expectorate. The tubercle can migrate to other organs or sites, e.g. bones, which must be via the blood, although I do not think any have been isolated via a blood sample.

    It would seem that the putatively new clinical syndrome of Morgellons Fiber disease (please see appropriate thread on this site)is even more debilitating than tuberculosis. If this condition is the same as neurocutaneous syndrome it is inaccurate to say (as many do) that no-one has died from it.

    Since there is little in the way of professional recognition, there is also nothing being done to curtail the apparent incidental increase.

    At least with the old diseases we know what we are dealing with.

    Humans suffering from avian flu become very ill (if curative drugs are unavailable)in a much more acute fashion compared with tuberculosis, and the chest X Rays of the former group show much more in the way of pulmonary destruction.

    Once in this state, they would tend to become moribund, and would not be able to eat or drink. They would probably require artificial ventilation if the pulmonary destruction is severe.

    If the avian flu virus subsequently mutated so that human to human transmission became possible, the problem with resource allocation would of course include the basic requirements of life, but it would also extend to those of a more therapeutic ilk.

    Would there be sufficient of these to treat every person affected?

  13. #13 gsgs
    April 14, 2007

    yes, I also noticed this, that people are very reluctant
    in USA to have their children or relatives separated from them in a pandemic.
    There was a thread here:
    https://www.singtomeohmuse.com/viewtopic.php?t=21
    with a poll and engaged discussion.
    And these are “flubies” , usually open for all kinds of
    measures and mitigation strategies.
    I also noticed that CDC is careful to address the issue.
    They avoid it or speak about “voluntary” isolation.
    However there can be pressure to make it voluntary…
    I also see the problem that those people who now
    refuse the separation of their sick or suspected
    fellow-lodgers will change their mind in a severe pandemic
    (as seen in historic pandemics) and even _require_
    the isolation and removal of their suspected fellow-lodgers.

  14. #14 Blythe
    May 31, 2007

    I don’t have much sympathy for our isolated TB patient
    here in Phoenix. He preferred putting an entire storeful
    of people at risk to wearing a cheap facial mask. And it
    probably wasn’t the first time.
    Perhaps being treated as a criminal for a few months will
    teach him not to endanger people’s lives.
    He has his tv back, and will be getting the computer as well. (Thank’s to ACLU)
    The ACLU is working on the phone issue. They are not trying
    to get him released, although he has a hearing in a month.
    If he can convince authorities that he will protect others
    from himself, he will be back to voluntary containment.
    By the way, Joe Arpaio is an excellant sheriff.

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