Quarantined!

manFenceOver the centuries, the official response to infectious disease has been quarantine. For example, the bible (Leviticus XII and XIV) goes into considerable discussion of the diagnosis and treatment of leprosy. People who were found to have leprosy (described as a blanched skin area of some depth, with whitened hair) were excluded from the community. Those who recovered were permitted to return after completing rites of purification. Modern leprosy, Hansen’s disease, which is both curable and not highly infectious, is still subject to quarantine in some nations. Canada’s last leprosarium, on Bentinck Island, British Columbia, closed in 1957. The United States closed its only leprosarium, in Carville, Louisiana, in 1999.

Although programs of separation and isolation of lepers or people from plague-infected areas were developed in various places in Europe and Asia, the first true system of quarantine dates from Venice in 1348, during the time of the Black Death. There, a council was given the power to detain ships, their crew and cargo, for up to 40 days prior to unloading and disembarkation. (The word “quarantine” may derive from the Italian quarantena, which in turn was derived from quarenta, meaning 40, although not all etymologists agree on this derivation.)

In later years, many governments developed quarantine systems to halt the spread of epidemics – with varying degrees of success. The problem, in too many cases, was lack of knowledge of the means by which infection was spread. In 1656, Rome was faced with a plague epidemic in its Trastevere slum and in the Jewish ghetto. The problem was that while the quarantine effectively limited the movement of people, it didn’t stop the movement of the rats, which carried fleas, which actually spread the disease.

Cholera & Typhus

Grosse-Île, a small island located in the St. Lawrence River, 28 miles (46 kilometers) east of Quebec City was a notorious quarantine site. In an effort to prevent cholera from spreading from immigrants (mostly from Ireland) to the local population, a quarantine station was established on the island in 1832. Tragically, not enough was known about the transmission of cholera, a waterborne disease, and the quarantine station lacked the sanitation needed to prevent its spread. The epidemic spread among detainees and eventually off the island, where between 1833–1834, it would claim 3,800 lives in Quebec City and 1,900 lives in Montreal.

And in 1847, Grosse-Île was used to quarantine the mass influx of immigrants escaping the Irish potato famine. Sailing on vessels that became known as “coffin ships,” many of the immigrants were malnourished, hungry, and suffering from typhus and dysentery. It is estimated that among the 441 immigrant-bearing ships to reach Canada in 1847, 5,000 passengers had already been buried at sea. Additionally, the quarantine station’s staff buried at least 5,424 people in 1847 alone. (Unfortunately, the true numbers of the dead cannot be known, because many of the official records were lost in a fire in 1878.) Again, the quarantine failed, and typhus spread to both Quebec City and Montreal.

HIV

In contrast to these tragic examples, Cuba’s quarantine of HIV-infected patients in the late 1980s and early 1990s was a model of good medical practice, although it was subject to criticism on ethical grounds. During that period, Cuba practiced mandatory HIV testing, and those found to be infected were sent to a sanitarium (the word “quarantine” was avoided) where they were told they must spend the rest of their lives. The people in the quarantine area were provided with nondescript furnished apartments, and despite being removed from their jobs, continued to draw a salary. Although treatment appears to have been humane, Ronald Bayer, associate professor at Columbia University’s School of Public Health, said in an interview with the Los Angeles Times, that the total impression was frightening, because it amounted to life without parole.

SARS

In the United States, the Secretary of the Department of Health and Human Services has the responsibility for preventing the introduction, transmission, and spread of communicable diseases. Quarantines are enforced by groups that include the CDC’s Division of Global Migration and Quarantine, US Customs and Coast Guard, and state and local officials and health authorities. The list of diseases subject to quarantine has to be specified by an Executive Order signed by the president, and since 1983, the list has included cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers (e.g. Marburg, Ebola, and Congo-Crimean). SARS was added to the list in April 2003.

SARS, a still mysterious illness, appeared primarily in China and Canada. The first case was seen in China in November 2002. The disease spread rapidly, causing almost 800 deaths worldwide, including 350 in China, and 44 in Canada. Because of the initial belief that the disease was spread by civet cats, the Chinese health authorities ordered 10,000 of these weasel-like animals to be killed. In July 2003, it was thought that the global epidemic of SARS was over, but between December 2003 and January 2004, China confirmed four new cases in southern Guangdong province. While the disease has not been eradicated, it is no longer epidemic.

SARS in China

In Beijing, quarantine was required if an individual had 30 minutes’ exposure to a SARS patient under any of the following conditions: healthcare workers who did not use personal protective equipment while evaluating or treating a SARS patient; other persons (e.g., family members) who provided care for a SARS patient; persons who shared the same living quarters as a SARS patient; persons who visited a SARS patient; persons who worked in the same office room or workshop as a SARS patient; classmates or teachers of a SARS patient; and persons using the same public conveyance as a SARS patient. It was quite a comprehensive list.

SARS in Canada

The first Canadian cases were identified in March 2003 in people who had just returned from trips to Hong Kong. The majority of cases were in Ontario, but cases were also reported in British Columbia, Alberta, New Brunswick, Prince Edward Island, and Saskatchewan. As of September 5, 2003, 438 cases of SARS had been reported in Canada.

Canadian quarantine rules were not as Draconian as China’s, but still seem to have been stricter than were truly essential. The initial reaction was to quarantine everyone – patients, staff, and visitors – who had been at Toronto’s Scarborough Grace Hospital (where the first SARS patient was admitted) over a 10-day period. At least 13,000 people were placed in quarantine, although there were some reports that the quarantine was not always rigidly adhered to, and subsequent analysis concluded that adherence to quarantine restrictions declines as the quarantine period grows longer.

Excessive Quarantining?

While the quarantines in China and Canada have been credited with stopping the spread of SARS and saving thousands of lives, retrospective reviews indicate that the quarantines may have been too aggressive. The CDC has noted that there were no infections observed among people who were in contact with SARS victims before the disease entered into the acute phase. Only those who had contact with a SARS patient who had fever were placed at significant risk. The restrictions in both Beijing and the Haidian District, which was also studied, were progressively relaxed as more became known about how the disease was transmitted.

Sanitariums

Many of the traditional quarantine centers have been in decline. During the 19th and early 20th centuries, tuberculosis was the most common cause of death in developed nations. Little was known about the cause or treatment of the disease, except that patients survived longer in areas with good ventilation and low humidity. This led to the building of sanitariums, essentially hospitals for tuberculosis care, throughout North America and Western Europe. Canada was the leader in sanitarium building, and in Saskatchewan, Manitoba, and Alberta there were enough sanitarium beds to accommodate every patient diagnosed with the disease.

Today, almost all cases of tuberculosis are treated on an outpatient basis. In the United States, only one sanitarium remains: the A.G. Holley Tuberculosis Sanitarium in Lantana, Florida. This last remnant of the sanitarium program of the 20th century has only 50 inpatient beds, and most admissions are by court order, usually because of non-adherence to treatment protocols.

Efficacy of Quarantines

Quarantines were – and are – generally instituted to deal with a deadly, dreaded disease. Even today, as SARS reminded us, the cause and transmission of new infectious diseases usually are not immediately known. As a result, quarantine seems like a reasonable, practical solution. At the same time, the World Health Organization has identified the infectious diseases whose worldwide re-emergence should be monitored: diphtheria, cholera, dengue fever, yellow fever, and bubonic plague. So even today, quarantines may fill a vital role in public health.

One thing that SARS taught us was that, in this age of economics, many people break quarantine because they have to work. And we only have to look at the experience of early plagues (such as that in Rome in 1656) and of SARS in 2002–2003, and at the new Avian flu threat, to see two other problems. First, in the age of air travel, disease can spread from nation to nation much faster than it could via the old trade routes of Europe and the Near East, making quarantine a vast catch-up procedure raising cries of costs, and of impractical, if not impossible solutions. And second, in the case of disease transmission through wild animals and migratory birds, quarantining in the 21st century may even be more impossible than it was in the 17th.

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