#biosecurity planning

[biodefensebugchaser-blog]

An Evaluation of the Ethical Considerations of Forced Quarantine

Michelle L Magario-May 5, 2011

Abstract

            It is ethical, moral and legal, to use physical force to attain quarantine of potentially infectious persons. Using the ethical theory of utilitarianism, and adhering to the principles of beneficence, non-maleficence and justice, quarantine can be an important tool for public health administrators during both emergency and non-emergency situations. When approached with careful scrutiny and prudence, quarantine can assist public health officials and personnel to fulfill their obligation of protecting the public’s safety and welfare. 

History

In modern day terms, quarantine refers to the act of segregating asymptomatic individuals who have been exposed to infectious disease (and are potentially contagious) and differs from isolation which refers to the segregation of individuals known to be infectious and therefore capable of transmitting the disease (Gostin & Berkman, 2007).  The term quarantine comes from the Italian “quaranta giorni”, and refers to the 40 day waiting period for vessels entering the port of Venice during the 14th century Black Death plague outbreak in Italy (Swendiman & Elsea, 2006).  Mandatory or forced quarantine has been practiced by virtually all civilizations since the beginning of recorded history. The practice is mentioned in both Leviticus and Numbers in the Old Testament as well as in the ancient Greek writings of Thucydides and Hippocrates, and is well known to have occurred in medieval Europe in response to The Plague. The first report of quarantine being practiced in America was in the Massachusetts Bay Colony in 1647 and the first American federal quarantine law was passed in 1796 during a yellow fever outbreak (Swendiman & Elsea, 2006). More recently, quarantine was employed internationally in response to the SARS outbreak between 2002 and 2003 that claimed the lives of 774 people in 29 countries (Rothstein, 2004).

While generally considered to be an acceptable recourse to impede the transmission of infectious diseases, the use of quarantines has been applied with poor judgment, ignorance, and under the most deplorable conditions. In 1900, President McKinley ordered the quarantine of all Chinese and Japanese residents of San Francisco’s Chinatown after a bubonic plague victim was discovered, under the assumption that their diet of rice was a contributing factor in contracting the disease (Ries, 2004). While this event occurred long before a thorough understanding of the infectious disease process was known, this scenario has been repeated up until very recently and includes the Cuban government ordering the mandatory quarantine of HIV infected persons as recently as 1994 (Ries, 2004). In order to protect the rights, freedoms and liberties that we, as Americans enjoy, and to balance those entitlements against the need to protect society as a whole, the U.S. Supreme Court has made several rulings regarding the constitutionality of quarantines’ practice. In addition, the U.S. Supreme Court has ruled on who has the authority to impose such restrictions.

Legal Authorization

While the legalities of quarantine are beyond the scope of this paper, it is important to make note of the landmark decisions that allow public health officials to restrict the rights of certain individuals. The question of federal authority was most recently affirmed in the case of the United States v. Shinnick  in 1963 which gave the U. S. Federal government the right to quarantine persons arriving into the United States from foreign countries, or those traveling across state lines, who pose a potential health risk to the public (Richards, Burris, McNelis, & Hargan, 2005). The question of state authority was originally addressed in the 10th Amendment to the U.S. Constitution which states that powers not delegated to the federal government are thereby reserved to the states respectively, or to the people. This premise was defined and upheld in Jacobson v. Massachusetts in 1905, the use of force to attain quarantine-affirmed in Gibbons v. Ogden in 1824, and the application of quarantine to an entire geographical area-affirmed in Compagnie Francaise de Navigation a Vapeur v. Louisiana State Board of Health in 1902 (Swendiman & Elsea, 2006). While these landmark decisions give the authority to use quarantine, by force if necessary, to protect the safety and welfare of the community, the question remains—Should we avail ourselves of this authority?

Ethical considerations

            The utilitarian model for ethics in public health is based on the principle that “decisions should be judged by the sum consequences, in particular by their effect on the sum total of individual well being” (Roberts & Reich, 2002, p. 1055). Basically, it refers to the processes and procedures that give the greatest good to the greatest numbers. Using this theory, in response to the previous question, the answer would be a resounding yes; it is not only acceptable, but highly recommended that we avail ourselves of the authority to use force to protect society as a whole, even if the consequences to a minority of the population are undesirable. The utilitarian theory is additionally supported by the ethical principles of beneficence, non-maleficence  and justice. Each of these principles can be addressed in turn to affirm this belief.

            Beneficence is the ethical principle that dictates that actions benefit others and in the case of quarantine, applies to society as a whole. This is a cornerstone belief in the application of quarantine. The interests and welfare of the community must outweigh those of the individual. This belief comes at a cost and likewise, its acceptance must be earned in order to be acceptable to the people. In a democratic society, such the United States, it is the people who dictate, through the political process, what will and will not be acceptable to the majority. With regards to quarantine, defended by the principle of beneficence, governmental decisions that restrict or encumber individual freedoms must be made through transparency and trust (Beyrer, 2003). Likewise, decisions must not cause unnecessary harm to those they are imposed upon. This is the foundation of the principle of non-maleficence.

            The principle of non-maleficence dictates that decisions must do no harm, or at a minimum cause the least harm possible and in the case of quarantine, applies to those being quarantined. It prescribes that the benefits of an action outweigh the burdens associated with that action. In the case of quarantine, the benefits to society (protection from infectious disease) must be greater than the burdens placed upon those in quarantine. Harms to those placed in quarantine can be numerous and multifaceted. The medical and psychological needs of the quarantined must be thoroughly addressed. In addition, many researchers have supported the notion of financial reciprocity for those burdened by quarantine (Rothstein, 2004). The practice of financial reciprocity in exchange for quarantine was implemented by the Canadian government during the recent SARS outbreak in an effort to ease the burdens of those in quarantine (Ries, 2004). It was, however, acknowledged that the same may not be feasible in the U.S. as it would be seen as a burden to taxpayers and employers (Rothstein, 2004). Some would see this additional burden as unjust.

            The balance between beneficence and non-maleficence can be an ethical dilemma for policy makers. The challenge for public health officials is to achieve a balance between preserving individual liberties while at the same time defending the health and safety of the community. This challenge can be minimized, to a certain extent, by employing practices that are fair and just. The third ethical principle that supports the use of quarantine is justice. The principle of justice dictates that decisions are fair and equitable to those involved. Decisions must not be applied in a manner that is discriminatory or biased. In the context of quarantine, it means that decisions for the application of quarantine be made using a fair process, include a publicly available rationale for those decisions, a mechanism for dispute resolution, and a regulatory body to enforce decisions (Baum, Golllust, & Jacobson, 2007). In addition, officials need to exhibit transparency regarding the goals to be accomplished, and whether the benefits and burdens of the decisions are expected to be distributed equally throughout the community. Where inequality exists, there must be a rationale and justification for that disparity (Baum, et al., 2007). Mistrust will occur if deception or secrecy is suspected and will have a profoundly negative impact on the quarantine process. Likewise, conflicts of interest, serving for profit or catering to special interests will not be tolerated by the public and the notion of public health will lose all credibility (Etkind, Arias, Bagley, & Nelson, 2008).

            In accordance with the principle of justice, the U. S. justice system’s foundation of substantive due process can be applied to the quarantine scenario and is likely to be accepted by citizens as it is a prized and recognized institution. Mark Hitchcock (2007) has offered four criteria to ensure that substantive due process applies to quarantine situations. They include:

A demonstrated public health necessity

An effective intervention with a demonstrable means-end connection

Proportionality-the intervention is neither too narrowly or broadly tailored

It is the least restrictive in terms of infringing on individual rights while accomplishing its purpose and does not inflict unnecessary harm (Hitchcock, 2007, p. 15)

Through applying these protocols to quarantine situations, it is suggested that society will respond favorably, or at least not hostilely, to those measures.

Conclusion

            The institution of forced or mandatory quarantine to halt the spread and transmission of infectious diseases is ethical and justifiable. The ethical principles supporting this notion include beneficence, non-maleficence and justice and agree with the utilitarian model of ethical theories. Through utilization of systematic and prudent protocols the challenges of the quarantine process can be mitigated. The obligation of public health officials is to protect and preserve the safety, welfare and health of the communities they serve. While the use of quarantine should be reserved for serious and drastic situations where the consequences of the disease outweigh all other considerations, it is important to have a clear set of protocols and standards in place before the need for application arises. It is not an option to be used indiscriminately or without caution, but it must remain an option.

  References

Baum, N. M., Golllust, S. E., & Jacobson, P. D. (2007). Looking Ahead: Addressing Ethical Challenges in Public Health Practice. The Journal of Law, Medicine & Ethics, 35(4), 657-667. doi: 10.1111/j.1748-720X.2007.00188.x

Beyrer, C. (2003). Public Health, Human Rights, and the Beneficence of States. Human Rights Review, 5(1), 28-33. doi: 10.1007/s12142-003-1002-0

Etkind, P., Arias, D., Bagley, B., & Nelson, M. S. (2008). Preparing for the Usual, Preparing for the Unusual: Ethics in Routine and Emergency Public Health Practice. Journal of Public Health Management and Practice, 14(4), 367-371. doi: 10.1097/01.PHH.0000324565.64910.bc

Gostin, L. O., & Berkman, B. E. (2007). Pandemic Influenza: Ethics, Law and the Public's Health. Administrative Law Review, 59(4), 121-175.

Hitchcock, M. (2007). Government Rights to Quarantine: An Examination Under the Modern Notion of Due Process. Retrieved from http://www.law.berkeley.edu/library/disasters/Hitchcock.pdf

Richards, E. P., Burris, S., McNelis, R. P., & Hargan, E. (2005). Quarantine Laws and Public Health Realities. The Journal of Law, Medicine & Ethics, 33(4), 69-72.

Ries, N. M. (2004). Public Health Law and Ethics: Lessons from SARS and Quarantine. Health Law Review, 13(1), 3-6.

Roberts, M. D., Evan G., & Reich, M. R. (2002). Ethical Analysis in Public Health. The Lancet, 359(9311), 1055-1059.

Rothstein, M. A. (2004). Are Traditional Public Health Strategies Consistent with Contemporary American Values. The Temple Law Review, 77(2), 175-192.

Swendiman, K., & Elsea, J. K. (2006). Federal and State Quarantine Authority CRS Report for Congress (Vol. RL 333201). Washington, DC: Congressional Research Service.

[biodefensebugchaser-blog]

Emerging Infectious Diseases: Drug Resistant Threats

Michelle L Magario-March 6, 2010

Abstract

            In an age of ever evolving infectious diseases, decisions must be made not only as to how limited public health funding should be allocated, but also as to what agents should receive priority with regards to that same limited funding. In the past few decades, the medical community has not only been faced with the routine day to day battles with infections and infectious diseases, but is now faced with an even more troubling battle against those diseases that were successfully treatable just a few short years ago. Drug resistant microbes and viruses present a specific challenge in that they may no longer respond to the standards or treatments that currently exist. It would be prudent for the public health community to include this specific category of diseases when addressing infectious disease threats.

The Threats

            Among the three categories of emerging or reemerging diseases, as described by Kapur, known agents in a new geographical locale, known agents in a unsusceptible species, and previously unknown agents discovered for the first time, drug resistant agents are placed within the “newly discovered” category (Kapur & Smith, 2011). I would argue that these diseases do not fall into this category at all, but instead warrant their own distinct category. The importance of these diseases lies not only in their resistance to traditional treatments, but in the tenacity of their virulence as well.

          Drug resistant agents, a relatively recent phenomenon, are those agents, either microbes or viruses, which no longer respond favorably to once routine standards of care. In the recent past, a person infected with a particular organism could be successfully treated with either antibiotics or antivirals and could expect to recover fully. This is no longer the case. This report will discuss four of the more prominent drug resistant agents present in today’s society along with mitigation efforts aimed at containing and preventing the spread of these agents.

            Staphylococcus aureus, a gram positive microbe that can be found virtually everywhere, has historically been successfully treated with anti-microbial agents known as beta-lactams; a category of antibiotics including methicillin, amoxicillin, oxacillan, and penicillin. During the late 1980’s the face of staphylococcal infection treatments began to change. A more resilient staph infection, one resistant to traditional methods of treatment, began to emerge. This organism, termed MRSA for methicillin resistant Staphylococcus aureus, began to emerge in IV drug users, prisons and day care settings. More alarming, MRSA began to appear in hospitals and clinical settings where they were especially virulent among the immunosuppressed population (Klevens, 2007).

            Around the same time that MRSA appeared on the health care radar, another equally troubling and virulent resistant microbe was discovered. Vancomycin resistant Enterococci (VRE) infections were noted in hospital settings and became an important and alarming addition to the drug resistant microbe family. While most VRE infections are nosocomial, in that they are contracted in the hospital, transmission is not always limited to health care settings, especially in the absence of strict personal hygiene protocols (Rice, 2001).

            Another disturbing addition to the growing family of drug resistant agents is the addition of multi-drug resistant Tuberculosis (MDRTB) and extensively drug resistant Tuberculosis (XDRTB). Tuberculosis, while not necessarily prevalent in the United States, remains an especially important disease in many parts of the world. Despite the steady decline in reported TB cases in the U.S., 107 cases of MDRTB were reported in 2009, while no new cases of XDRTB were reported that year (CDC, 2010).

            Lastly, and perhaps the most disturbing of the drug resistant agents, is the newest addition of Oseltamivir-Resistant Influenza A, or the H1N1 virus. H1N1, the very same agent that caused the deaths of 20-50 million during the 1918-1919 influenza pandemic, has been reported recently to have developed a resistance to our best defense against the virus (Stebbins, n.d.). Oseltamivir, or Tamiflu, a neuraminidase inhibitor, once the gold standard and chief weapon in our arsenal against the flu, is no longer effective in all cases and may not be effective at all in the near future. Three recent reports of drug resistant Influenza A are used as examples of this theory. In the summer of 2009, an outbreak of Influenza A occurred at a summer camp in North Carolina. In order to prevent the spread of the disease, prophylaxis doses of Oseltamivir were administered to campers and camp employees. Despite this preventive measure two adolescent female campers became ill and were subsequently diagnosed with a drug resistant strain of H1N1, Influenza A (CDC, 2009).  In another case, this one occurring in South Korea between May of 2009 and January of 2010, 11 patients were diagnosed with drug resistant H1N1 virus (Shin, 2011). In both of these cases, there was evidence of the H275Y mutation. And in yet another disturbing case, eight patients in a hematology unit in the United Kingdom presented with drug resistant H1N1. The most disturbing fact of these occurrences was not only the fact that Influenza A was now becoming drug resistant, but the United Kingdom case represented the first confirmed case of person-to-person transmission of the drug resistant strain recorded (Moore et al., 2011).

            All of these cases represent a potential catastrophe for public health professionals. The fact that one of the cases of drug resistant influenza occurred so close to there I live, posed a special concern for our area. The normal protocols for dealing with influenza may no longer be sufficient in the wake of a drug resistant agent. If prophylaxis treatment only results in a drug resistant agent, other avenues must be investigated. In the face of a pandemic, preparedness protocols dictate that we be aware of the changing face of the disease, and are prepared to adjust strategies accordingly.

Mitigation Practices

            In 1998, the Centers for Disease Control and Prevention (CDC) issued a report concerning strategies for preventing emerging infectious diseases. While this report is a number of years old, its common sense and practical approach retains validity and value to this day. The report addresses three key objectives in the area of Prevention and Control of infectious diseases. These are to “implement, support and evaluate programs for the prevention and control of emerging infectious diseases; to develop , evaluate and promote strategies to help health-care providers and other persons change behaviors that facilitate disease transmission; and to support and promote disease control and prevention internationally” (Binder, 1998).

            In addition, there are steps that can be taken at the local level to help citizens to prepare for and mitigate the effects of an infectious disease outbreak. According to the Trust for America’s Health, overuse and misuse of antibiotics, poor infection control in healthcare and community setting and poor hand hygiene, have all exacerbated the proliferation of antimicrobial resistance (Hamburg, 2008). One of the most common sense and financially feasible solutions to the issues addressed by the Trust is through mass, public health, public safety announcements (PSA’s). The importance of hand washing, maintaining personal distance in community settings, and proper hygiene in schools, churches and shopping centers cannot be stressed enough. Parents should be cautioned to not expect an antibiotic for every sniffle that affects their children. The same can be said for adults; it is best to wait and see if the body’s natural defense system is capable of defeating the bug. And lastly, antibiotics should only be administered in a clinically confirmed case of bacterial infection and should never be administered “just in case”.

            Another step that would limit the spread of infectious diseases would be to include employers as a target group in PSA’s. Employers should be encouraged to allow employees who are ill to remain at home, or to even possibly work from home. Workers likewise, should not be made to feel as though their livelihood wood be in jeopardy if they remained at home while potentially infectious. Along these same recommendations, parents should be encouraged to not send potentially infectious children to school. Schools should enforce a policy that prohibits sick children from being at school, potentially infecting other children, teachers and staff.

            The entire culture of infectious disease awareness must be changed. The population must be educated as to what to do, not do and what to expect during an infectious disease event. The mass use of antibiotics and prophylactic antiviral/antibiotic use is breeding an ever more virulent and dangerous host of infectious diseases. Simple common sense practices, such as those mentioned will play a large role in limiting the effects and spread of an infectious disease and will also minimize the risk of more agents developing drug resistance. 

  References    

Centers for Disease Control and Prevention. (2009). Oseltamivir-Resistant 2009 Pandemic Influenza A (H1N1) Virus Infection in Two Summer Campers Receiving Prophylaxis-North Carolina, 2009 Morbidity and Mortality Weekly Report (Vol. 58). Atlanta GA: Centers for Disease Control and Prevention.       

Centers for Disease Control and Prevention. (2010). Decrease in Reported Tuberculosis Cases-United States, 2009 Morbidity and Mortality Weekly Report (Vol. 59). Atlanta, GA: Centers for Disease Control and Prevention.

Binder, S. L., Alexandra M. (1998). Preventing Emerging Infectious Diseases: A Strategy for the 21st Century Morbidity and Mortality Weekly Report (Vol. 47). Atlanta, GA: Centers for Disease Control and Prevention.

Hamburg, M., A.; Levi, Jeffery; Elliott, Kimberly; Williams, Lynora. (2008). Germs Go Global: Why Emerging Infectious Diseases are a Threat to America Issue Report. Washington, DC: The Trust for America's Health.

Kapur, G. B., & Smith, J. P. (2011). Emergency Public Health. p253. Sudbury, MA: Jones & Bartlett Learning.

Klevens, R. M. M., Melissa A.; Nadle, Joelle; Petit, Susan; Gershman, Ken; Ray, Susan; Harrison, Lee H.; Lynfield, Ruth; Dumyati, Ghinwa; Townes, John M.; Craig, Allen S.; Zell, Elizabeth R.; Fosheim, Gregory E.; McDougal, Linda K.; Carey, Roberta B.; Fridkin, Scott K. (2007). Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. Journal of the American Medical Association, 298(15), 1763-1771.

Moore, C., Galiano, M., Lackenby, A., Abdelrahman, T., Barnes, R., Evans, M. R., . . . Davies, E. (2011). Evidence of person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus in a hematology unit. [Research Support, Non-U.S. Gov't]. The Journal of infectious diseases, 203(1), 18-24. doi: 10.1093/infdis/jiq007

Rice, L., B. (2001). Emergence of Vancomycin-Resistant Enterococci. Emerging Infectious Diseases, 7(2), 183-187.

Shin, S. Y. K., Chun; Gwak, Jin; Kim, Hyun Su; Kang, Young, A.; Lee, Ha Gyung; Kim, Jin Seok; Lee, Jong-Koo; Kim, Sung-Han. (2011). Drug-Resistant Pandemic (H1N1) 2009, South Korea. Emerging Infectious Diseases, April 2011. doi: 10.3201/eid1704.101467

Stebbins, M. (n.d.). Biological Agent Fact Sheet-1918 (H1N1) Influenza A. Washington, DC: Federation of American Scientists.