Friday, May 05, 2006

The Role of Quarantine

So I'm Quarantined...

Institute of Medicine member Marty Cetron opens a published discussion about quarantine as follows: "By utilizing quarantine and isolation as public health tools we are in many ways battling twenty-first century pathogens with a fourteenth century toolbox." The public control of disease is not new. A sizeable number of empirical prescriptions exist in the book of Leviticus that control and reduce the spread of disease. Individual and community health still play a very important role in contemporary Jewish culture. Quarantine as first applied in bubonic plague infested Europe referred to a forty day isolation period.

Having been under quarantine for about 24 hours of an expected 9 day period, I am glad that the Washington and King County health boards no longer stick to that duration. I am already feeling the tension between individual liberty and the public good. This manifests in its own disease: cabin fever. I have repeated to many that, "I believe in public health," and still stand by that statement. In my opinion, public health departments should have even greater reign over the health risks that we confront daily. I would like to see some public authority take more control of school food, for example. (Hooray for the curb on sweet drinks at school!) My condition however falls within the imminent threat category of public health. Perhaps it will help me better think about the real and potential quarantines issued in response to SARS or H5N1 bird flu.

Let me clarify my situation with mumps, in case any of you are worried about me or about yourselves! The public health officials I have spoken with report that a significant number of the mumps cases in Iowa occurred in individuals who had received two MMR vaccines. The MMR vaccine is not without controversy. A report by Dr. Andrew Wakefield published in Lancet in 1998 documented increased numbers of kids with Crohn's disease and autism. Even though this article was retracted, numerous parents - particularly in Great Britain - refused to immunize their children with MMR. This episode is a particularly good one illustrating a dysfunctional relationship between biomedical science and the public, but that is for another entry... Regarding the vaccine's efficiency, the common report is that the MMR is 90-95% effective at producing protective antibodies. Let's say I received 2 MMRs as a child (the standard regimen, confirmed by my mom), a booster shot before high school at age 13, and a booster at age 22 before medical school. By my calculations, that would put my chances of seroconversion between 99.99% and 99.9994%. This is not even close to the risk of infection we would see with a SARS or bird flu outbreak. That puts my experience in quarantine in a different category than its infectious colleagues, but does not refute the legitimacy of my experience.

I believe I am serving what is called a voluntary quarantine. I do not believe I am under any legal obligation to stay home. My doctor says it is okay to go jogging and biking, as long as I do not engage in close contact with others. My wife has already been exposed, so it is okay for me to live in the same place as her – thank goodness! From the statistical data above, I am very inclined to believe that I neither infected or infectious. I wonder what percentage of quarantined individuals in a SARS or H5N1 will actually be sick, and how many will endure the quarantine unaffected (& bored). Another aspect of an epidemic outbreak would be fear of infection. Perhaps if I was really afraid of getting sick, I would not mind as much a forced absence from work and play. If I could telecommute to do experiments, I guess this situation would be very different. Until I figure that out, I will have to put off my studies for a week.

For members of the academic community, see the full transcript of the discussion these quotes are extracted from in the Journal of Law, Medicine & Ethics, Winter 2004 v32 i4 pS83(4). This proceedings includes a number of important topics ranging from the need for quarantine, how it should be enforced, and the mechanism by which state legislators put quarantine laws in place.


MJ said...

The role of quarentine as a public health tool is very interesting, and more than anything seems to embody the tension between public and private rights that public health has to deal with. I just wanted to add $0.02 about the role of quarentine in the event of pandemic flu. At the annual Society for Epidemiologic Research (SER) conference last year there were a number of talks about SARS and the control thereof. One of Toronto's public health pros, Elizabeth Rea, talked specifically about quarentine. One of her main points was that quarentine worked well for SARS because SARS has a long-ish latent period, and because indivuals don't become contagious until they are symptomatic.

Pandemic flu, on the other hand, would be a different beastie altogether. Flu has a short incubation period, and (more importantly) people are infectious before they are symptomatic. By the time you could quarentine someone, they would already have been exposing others for several days. Dr. Rea (and others at this conference) strongly discouraged the idea of relying on quarentine in the case of pandemic flu.

In the case of flu, other ways of "social distancing" will probably be more effective (e.g. close schools, telecommute wherever possible).

thomas said...

This is good to know. My experience clearly lines up more with SARS than H5N1, as the mumps incubation period is 12-25 days.

Thanks for the entry MJ. That is just the sort of information I was interested in!