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  If SARS Hits U.S., Quarantine Could Too

New York Times
12/09/2003

As the health officer of Alameda County, Dr. Anthony Iton is prepared to make tough choices if SARS re-emerges this winter or spring, as many infectious disease experts fear.

The county, just across the bay from here, has identified two large buildings where, if voluntary steps to quell an epidemic were to fail, the authorities could sequester not just people who were sick but also people who might have been exposed to the SARS virus, Dr. Iton said.

The buildings, he said, could house up to 100 people and could be guarded to keep anyone from leaving.

"It's a virtual certainty that sometime in the near future we will see a SARS-like event in the United States, a highly communicable infectious disease that will require mass quarantine or isolation," Dr. Iton said.

Since last spring's outbreak of SARS, or severe acute respiratory syndrome, public health officials across the country have been spending extraordinary amounts of time and energy preparing for the prospect that the disease - or pandemic flu, smallpox or something as yet unknown - could require them to order a quarantine, a once common public health measure virtually abandoned for most of the past century.

In a draft SARS preparedness plan released this fall, the Centers for Disease Control and Prevention advises states and communities to impose restrictions on people's movements based on the severity of an outbreak. In the event of a quarantine, the plan envisions extensive tracing of contacts of SARS patients, combined with a largely home-based, voluntary regime.

The plan, however, also calls for health authorities to cooperate closely with law enforcement, and to consider in extreme cases "electronic forms of monitoring," "detention facilities" and the establishment of heavily guarded quarantine "zones." It also calls for respecting civil liberties and keeping the public informed.

Patrick Libbey, executive director of the National Association of County and City Health Officials, said the health authorities in many jurisdictions had been identifying possible buildings and preparing for possible outbreaks.

"People are taking this question absolutely seriously," Mr. Libbey said. "With the SARS outbreak, it really sharpened the focus on nuts-and-bolts planning."

Some issues facing health officials, Mr. Libbey added, concern legal processes for imposing quarantines, ways to house people and manage their needs, and the financing of such undertakings.

In New York City, the authorities have revised the health code to make sure they can legally quarantine people not just for known diseases but for suddenly emerging ones that present a major health threat, said Dr. Marci Layton, who is the city's assistant commissioner of communicable disease at the Department of Health and Mental Hygiene.

Dr. Layton and officials in other cities and states are discussing how they would provide food, medical care and psychological support to people placed under quarantine, whether at home or in a government-monitored building.

"Our preference would be for people to stay at home," Dr. Layton said, echoing Dr. Iton of Alameda. "But we need alternatives in case people aren't compliant, and we've had teams identifying the kinds of facilities we might use."

Until the advent of advances like antibiotics and routine vaccinations, quarantine was a widely used - and sometimes abused - method of controlling the spread of infectious diseases. While often effective, it was also applied disproportionately against immigrants, racial minorities and people in lower socioeconomic groups. And the word itself can still summon images of medieval plagues and of people abandoned to their fate on boats and islands and in fenced-off parts of a town.

Today's public health authorities remain intensely aware of the historical baggage. "You've got to own up to all of the demons, the fears that have evolved from quarantine's misuse," said Dr. Martin Cetron, a quarantine specialist at the disease control agency. "We're talking about a balance between a public health tool and a limitation on individual rights.

"The key is to get that balance as delicately aligned as possible, so that you have a minimum infringement on civil liberties but the maximum effect in quenching or preventing an epidemic."

These days, public health officials clearly distinguish between what they call isolation, reserved for those already found to have the disease in question and who are under care, and quarantine, which involves restricting the movement of people who have been exposed to an infected individual and may - or may not - become sick themselves. The authorities say they will never lump together those who are ill and others only thought to be exposed, as happened frequently in past quarantines.

If those under quarantine were to remain free of symptoms until the end of the incubation period, they would be free to go. If they were to develop symptoms, they would be treated and isolated from those remaining in quarantine to minimize the possibility of infecting others.

Many health authorities credit the use of both isolation and quarantine - mostly at home or at health care complexes - with preventing an even worse epidemic of SARS this year in places like Singapore, Hong Kong, Taiwan and Canada.

In Toronto, the epicenter of the Canadian epidemic, thousands of asymptomatic people were asked to remain at home for about 10 days, the generally accepted incubation period for SARS. Almost all agreed, and health officials, who telephoned regularly to monitor their compliance and medical condition, were forced to issue formal quarantine orders in only a few cases.

Because SARS is considered transmissible only once someone has developed symptoms, the families of those quarantined at home were not considered to be at risk.

"The human cost of doing this was obviously large," said Dr. Paul Gully, a senior director general at Health Canada, the main agency overseeing health care. "People basically couldn't go to work, they couldn't go to school, they couldn't socialize. It stopped their lives for 10 days. But people were very concerned about the spread of this disease, so they were willing to accept it."

But in Singapore, with its more authoritarian traditions, the state installed video cameras in quarantined people's homes and threatened to clamp on electronic bracelets if they did not show their faces at regular intervals.

Some people express alarm at talk of government-imposed quarantines, especially given current political tensions over civil liberties. While critics say they generally trust public health officials, they fear that political leaders and law enforcement authorities may actually call the shots if a quarantine is imposed.

"The existence of emergency powers in the hands of the government just makes it more likely that the government is going to overreact," said Dr. George Annas, chairman of the health law department at Boston University.

Few dispute the state's authority to isolate people with an infectious disease like tuberculosis. In the United States, the small clusters of diagnosed and suspected cases of SARS were mostly kept isolated, sometimes against their will.

But the quarantine of suspected contacts, who may or may not become ill themselves, is much more contentious. Federal health officials say the largely voluntary compliance in Canada and other countries suggests that American will comply, but others are not so sure.

For one thing, critics say that an illness that is more virulent or has a longer incubation period than SARS will require a more severe form of quarantine.

"I think Americans will be more skeptical about quarantine proposals than Canadians are, and probably more anxious to exercise their legal rights," said Barry Steinhardt, director of the American Civil Liberties Union's Program on Technology and Liberty. "I think they will by and large cooperate, but we're going to want some proof that there's a genuine threat."

States and some cities have the authority to impose emergency public health measures like quarantine. The federal government retains the power to police the nation's borders against disease and to act to prevent transmission between states. In April, President Bush signed an order adding SARS to the list of "quarantinable" diseases.

With guidance from a model statute proposed by the disease-control centers two years ago, many states have revised antiquated public health laws. They have both clarified their authority to take emergency measures and improved provisions that allow people to protest quarantine orders.

Mr. Steinhardt and other civil libertarians say that these due process protections are far from ironclad. But the problem, public health authorities argue, is that a framework must be flexible enough to be deployed against a spectrum of known and unknown diseases, each with its own treatment regimen, incubation period, mode of transmission and degree of infectiousness.

"One of the challenging policy aspects is what steps do you take, particularly steps that infringe on a person's rights, with a syndrome that is totally new or not clearly defined," Mr. Libbey said. "The earlier the intervention, the fewer the subsequent infections.

"But how much information is enough to act on, short of an absolute and complete causal connection, before you get to the point at which it may be too late to intervene effectively and stop transmission?"
 
   
 

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