"We commend the health care workers from the U.S. and other countries who are providing critical medical provider capacity by volunteering in Sierra Leone, Liberia, and Guinea," the HIV Medicine Association and the Center for Global Health Policy said on Monday. "A robust health care provider workforce is vital to end Ebola Virus Disease in West Africa and ending this infectious disease at its source is the best protection for preventing serious outbreaks in the U.S. and in other countries. Mandatory quarantine of health care workers will threaten efforts to control Ebola Virus Disease and is not justified based on what is known about Ebola Virus Disease and its transmission."

"IDSA does not support mandatory involuntary quarantine of asymptomatic healthcare workers returning from Ebola-affected areas," the Infectious Diseases Society of America concurred. "This approach carries unintended negative consequences without significant additional benefits."

The U.S. Centers for Disease Control and Prevention (CDC) has scrambled to keep up with rapidly evolving events, starting with a Liberian man being diagnosed with Ebola in Texas (now deceased), followed by two nurses who treated him becoming infected (both since recovered and released from treatment), and an American doctor who came down with Ebola in New York City after volunteering with Médecins Sans Frontières/Doctors Without Borders in West Africa (still in serious condition).

As word spread about the state quarantines last week, veteran AIDS activists began discussing the need to take action, both to demand that the world devote more resources to help the most heavily affected countries and to denounce discrimination and stigma directed at healthcare workers, people from West Africa, and others seen as potential threats.

Among the first to raise the call was Anne-christine d'Adesky, writing for The Body:

"As many pundits have observed, Ebola has freshly exposed the weakness of the global public health response, and of national health systems in poor countries," she wrote. "Liberia, Sierra Leone, and Guinea are hardest-hit by Ebola now, and it's fueled by fragile health systems and governments recovering from civil wars. The key components of an effective emergency public health response -- public education, rapid screening, and treatment for disease, ethical access to drugs and vaccines, financing and leadership -- are all in limited supply. As in the early days of AIDS, activists see too much politicking and a lack of overall coordination as the key problems, making them critical targets for protest."

Advocates urged politicians and others to learn from the AIDS epidemic that fear-based, punitive measures can actually drive people underground and thereby promote disease transmission. But in contrast to the 1980s and '90s, this time the activists and federal government officials were on the same page in calling for evidence-based policies.

"As medical providers and researchers specializing in HIV, we have seen firsthand that public policies not informed by science can fuel rather than control spread of an epidemic," the HIVMA/Center for Global Health Policy statement declared.

"If we do things that make it very difficult for [healthcare workers] to come back, if we turn them into pariahs, instead of recognizing the heroic work they are doing," they may be less likely to volunteer to help the countries that need it most, CDC director Thomas Frieden told reporters.

This week -- after states had begun instituting quarantines on their own -- the CDC issued new Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure. However, the guidance is not mandatory and states are not required to follow it. The guidelines, covering people in 5 risk categories, include the following (see full guidelines for definitions and more detail):

1. Symptomatic individuals in the high, some, or low (but not zero) risk categories who meet the symptom criteria for the category should undergo required medical evaluation with appropriate infection control precautions in place. Isolation orders may be considered if necessary to ensure compliance. Federal public health travel restrictions will be issued for individuals in the high risk category, and may be issued for those in the some or low (but not zero) risk categories if there is reasonable belief that the person poses a public health threat during travel.
2. Asymptomatic individuals in the high risk category should have direct active monitoring for 21 days after the last potential exposure. The individual should be ensured, through public health orders as necessary, to undergo direct active monitoring, have restricted movement within the community, and not travel on any public conveyances. Non-congregate public activities while maintaining a 3-foot distance from others may be permitted. These individuals are subject to controlled movement which will be enforced by federal public health travel restrictions.
3. Asymptomatic individuals in the some risk category should have direct active monitoring until 21 days after the last potential exposure. Public health authorities may consider additional restrictions based on a specific assessment of the individual’s situation.
4. Asymptomatic individuals in the low (but not zero) risk category should be actively monitored until 21 days after the last potential exposure. Direct active monitoring is recommended for some individuals in this category. Individuals in this category do not require separation from others or restriction of movement within the community. For these individuals, CDC recommends that travel, including by commercial conveyances, be permitted provided that they remain asymptomatic and active (or direct active) monitoring continues uninterrupted.
5. Individuals in the no identifiable risk category do not need monitoring or restrictions unless these are indicated due to a diagnosis other than Ebola.

According to the new CDC guidance, healthcare workers providing direct care to Ebola patients in countries with widespread transmission are classified in the "some risk" category, while those providing care to Ebola patients in U.S. facilities while wearing appropriate personal protective equipment and with no known breaches in infection control are considered to have "low (but not zero) risk" of exposure. However, workers caring for Ebola patients in a U.S. facility where another worker has been diagnosed with Ebola without an identified breach in infection control -- as happened in Texas -- are considered to be at "high risk" and would be subject to restrictions, including controlled movement, for 21 days.

As previously reported, the CDC last week issued new guidelines detailing stricter procedures for use of personal protective equipment by healthcare providers. The agency then announced that travelers arriving from Guinea, Liberia, and Sierra Leone should be actively monitored for 21 days, the longest known Ebola incubation period. Those who develop a fever or experience other symptoms should be promptly isolated, tested, and if necessary, treated in a properly equipped hospital.

The New Jersey quarantine policy ensnared American nurseKaci Hickox,who had treated Ebola patients as a Médecins Sans Frontières volunteer. Though she had no symptoms and tested negative for Ebola virus infection, she was held against her will in a tent outside University Hospital in Newark. Facing criticism from the CDC and state health officials, New Jersey and New York governors Chris Christie and Andrew Cuomo agreed that potentially exposed people could be quarantined at home; on Monday Hickox was transported to her home state of Maine.

"Healthcare workers who take care of patients with Ebola are not only helping the nations facing the Ebola outbreak but also protecting people in the United States by helping to fight the outbreak at its source," the CDC stated in its latest guidelines. "The risk in this country will only be fully addressed when the current outbreak in Africa is over, and the participation of U.S. and other healthcare workers from outside of the countries with widespread transmission is essential to control the disease."

On Sunday a group of more than 100 health professionals, researchers, and activists -- including International AIDS Society president Chris Beyrer, Partners in Health co-founder Paul Farmer, and members of the Treatment Action Group and ACT UP -- issued an open letter to Cuomo urging him to rescind New York's mandatory quarantine policy.

"If we are to effectively prevent additional isolated cases of EVD disease -- and with them, public fear and panic -- in the New York metropolitan area, and halt the spread of the disease in other parts of the world, the only evidence-based solution is to dedicate the resources required to break chains of transmission in countries where the disease is prevalent," the letter reads in part.

In a similar vein, 7 prominent authors, including veteran AIDS researcher Scott Hammer from Columbia University, penned an editorial on "Ebola and Quarantine" in the October 27 online edition of the New England Journal of Medicine.

"This approach...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," they wrote. "The governors' action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial."

The scientists reviewed the state of knowledge about Ebola and its transmission, concluding that evidence indicates that transmission occurs when viral load in bodily fluids is high, that an asymptomatic person is not contagious, and that fever precedes the contagious stage. They noted that the sensitive PCR blood test for Ebola is often negative on the day when fever or other symptoms begin, and only becomes reliably positive 2 to 3 days after symptom onset.

"A cynic would say that all these 'facts' are derived from observation and that it pays to be 100% safe and to isolate anyone with a remote chance of carrying the virus. What harm can that approach do besides inconveniencing a few health care workers?"

"We strongly disagree," they concluded. "Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source...These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves."

10/28/14

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