Legal Authorities for Isolation and Quarantine

Staff Writer, R. Patrick Chapman
Infectious Disease / Law of the Land
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With the controversy surrounding a nurse who defies legal authority for her quarantine from possible Ebola virus exposure in her medical treatment of patients with the disease in Africa, here are a few federally enforceable laws derived from the U.S. Constitution:

Isolation and Quarantine

Isolation and quarantine help protect the public by preventing exposure to people who have or may have a contagious disease.

• Isolation separates sick people with a contagious disease from people who are not sick.
• Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.

In addition to serving as medical functions, isolation and quarantine also are “police power” functions, derived from the right of the state to take action affecting individuals for the benefit of society.

Federal Law

The federal government derives its authority for isolation and quarantine from the Commerce Clause of the U.S. Constitution.

Federal isolation and quarantine are authorized for these communicable diseases:

• Cholera
• Diphtheria
• Infectious tuberculosis
• Plague
• Smallpox
• Yellow fever
• Viral hemorrhagic fevers
• Severe acute respiratory syndromes
• Flu that can cause a pandemic

Federal isolation and quarantine are authorized by Executive Order of the President. The President can revise this list by Executive Order.

Under section 361 of the Public Health Service Act (42 U.S. Code § 264), the U.S. Secretary of Health and Human Services is authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states.

The authority for carrying out these functions on a daily basis has been delegated to the Centers for Disease Control and Prevention (CDC).

CDC’s Role

Under 42 Code of Federal Regulations parts 70 and 71, CDC is authorized to detain, medically examine, and release persons arriving into the United States and traveling between states who are suspected of carrying these communicable diseases.

As part of its federal authority, CDC routinely monitors persons arriving at U.S. land border crossings and passengers and crew arriving at U.S. ports of entry for signs or symptoms of  communicable diseases.

When alerted about an ill passenger or crew  member by the pilot of a plane or captain of a ship, CDC may detain passengers and crew as  necessary to investigate whether the cause of the illness on board is a communicable disease.

State, Local, and Tribal Law

States have police power functions to protect the health, safety, and welfare of persons within their borders. To control the spread of disease within their borders, states have laws to enforce the use of isolation and quarantine.

These laws can vary from state to state and can be  specific or broad. In some states, local health authorities implement state law. In most states, breaking a quarantine order is a criminal misdemeanor.

Tribes also have police power authority to take actions that promote the health, safety, and welfare of their own tribal members. Tribal health authorities may enforce their own isolation and quarantine laws within tribal lands, if such laws exist.

Who Is in Charge

The federal government

• Acts to prevent the entry of communicable diseases into the United States. Quarantine and isolation may be used at U.S. ports of entry.
• Is authorized to take measures to prevent the spread of communicable diseases between states.
• May accept state and local assistance in enforcing federal quarantine.
• May assist state and local authorities in preventing the spread of communicable diseases.

State, local, and tribal authorities

• Enforce isolation and quarantine within their borders.

It is possible for federal, state, local, and tribal health authorities to have and use all at the same time separate but coexisting legal quarantine power in certain events. In the event of a conflict, federal law is supreme.

Enforcement

If a quarantinable disease is suspected or identified, CDC may issue a federal isolation or quarantine order.

Public health authorities at the federal, state, local, and tribal levels may sometimes seek help from police or other law enforcement officers to enforce a public health order.  

U.S. Customs and Border Protection and U.S. Coast Guard officers are authorized to help enforce federal quarantine orders.

Breaking a federal quarantine order is punishable by fines and imprisonment.

Federal law allows the conditional release of persons from quarantine if they comply with medical monitoring and surveillance.

For more information, please visit our source material. 

The Federal Law: 

Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA) Medical Countermeasure (MCM) Authorities

Is it time for the CDC to issue quarantine orders for exposed individuals?

Also read VDP Gazette's A Crisis of Conscience. 

Source: CDC, FDA

A Crisis of Conscience: Healthcare Workers, Ebola, and You

Staff Writer, R. Patrick Chapman and DL Mullan

Medicine / Ebola
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Today in the sea of bacteria and viruses, in the United States we have the best medical system in the world, including consummate professional healthcare workers.

Waa-What? We don't? 

Let's start from the beginning, shall we? 

Hickox, a nurse who had been treating Ebola victims in Sierra Leone, landed at Newark Liberty Airport Friday night just hours after Christie's abrupt announcement about the mandatory quarantine, made in conjunction with New York Gov. Andrew Cuomo (D). In an op-ed published in the Dallas Morning News Saturday, Hickox described the "emotionally exhausting" ordeal she endured following her arrival, during which she was held in a quarantine office for six hours and only given a granola bar and water while officials refused to answer her questions.

She complained she had a portable toilet, no television, no shower, and sparse cellular reception. Oh, boo hoo. Instead of thinking like a healthcare worker who has been attending to patients with a lethal virus such as Ebola and that she might need to be quarantined for the 42-day gestation period like any normal, sane professional would extrapolate, Ms. Hickox called for a lawyer instead.

Because that in no way sounds morally or ethically corrupt.

Kaci Hickox, the nurse currently being held in quarantine at Newark University Hospital despite testing negative for Ebola, has hired a prominent civil rights attorney to help get her out of isolation.

The lawyer, Norman Siegel, told the New York Times on Sunday that Hickox's quarantine order has "raised substantial civil liberties issues."

Siegel told Reuters that Hickox will file a federal lawsuit over her quarantine.

How about the civil rights of rest of us? Don't we have the right not to be infected by Ebola or similar contagion by people who travel in areas known for a deadly epidemic? Especially those individuals who volunteer to assist the medical needs of infected patients and know the risks, know the quarantine perimeters, and know they can at any time be isolated by any government or agency? 

If you cannot handle the rules of the situation, why did you go knowing that you could be put in quarantined isolation? 

Healthcare workers who have in practice given up their civil rights to be placed in a quarantine status at any time as part of their social contract to the rest of the world are now complaining about it?

Doctors Without Borders states that:

Click to Enlarge

Every district in Sierra Leone is now affected by the epidemic. Current hotspots for the disease include the capital, Freetown, and the areas of Port Loko, Bombali, and Moyamba. There are continued issues with poor surveillance systems, full transit centers, delays with lab testing, and too few ambulances, which all increase risks of cross-contamination. The government has now moved the national Emergency Response Committee from the jurisdiction of the Ministry of Health to the Ministry of Defense.

With so many deaths from Ebola, MSF is still seeing an increasing number of orphaned children in our centers, and a lack of caregivers.

As the health system has collapsed due to the Ebola crisis, MSF is planning an intervention to reduce mortality. This includes a distribution of 250,000 protective and disinfection kits and 500,000 anti-malarial kits, mosquito nets, oral rehydration salts, and medications for respiratory tract infections.

The international response is beginning to get underway, but it is slow and uncoordinated. Governments and various NGOs have sent teams to construct new centers at different locations around the country, including Jiu, Port Loko, and Freetown. Getting these new centers up and running is a matter of urgency.

So Sierra Leone is an active Ebola virus area but the response of a supposed seasoned nurse created an even bigger situation. 

"I was tired, hungry and confused, but I tried to remain calm," she wrote. "My temperature was taken using a forehead scanner and it read a temperature of 98. 

"Hickox later registered a temperature of 101 (which she said was a result of being flushed and upset), and she was subsequently put into quarantine at Newark University Hospital, where she tested negative for Ebola but is still being held.

Instead of being professional and waiting out the quarantine, Ms. Hickox gave authorities a reason to hold her longer. Just because a medical test comes out negative or positive does not mean that test is correct. The display of a fever was enough evidence that the test may be wrong and the authorities held Ms. Hickox for observation. 

In the article, Medical False Positives and False Negatives (Conditional Probability), we learn how medical tests are not absolute. In probability, a negative result is usually correct, nearly 100% of the time, unless you use numbers in accordance with a known disease and its statistics. Take breast cancer for instance: 

Now you can compute probabilities. First, the false-positive rate, the likelihood of a positive result where there’s actually no cancer, was given as

P(positive | no cancer) = 1% to 3% (I used 2%) 

Click to Enlarge

But you’re interested in the probability that a positive result has actually detected cancer, and this is not 100% minus 2%.

P(cancer | positive) = 25,800/27,200 = 95%

The given false-negative rate, the probability that a woman who has breast cancer gets a negative biopsy result, was given as

P(negative | cancer) = 10% to 18% (I used 14%)

But what’s the probability that a woman with a negative result actually has breast cancer?

P(cancer | negative) = 4,200/72,800 = 6%

These discrepancies come from the difference between P(A|B) and P(B|A), such as the difference between “getting a positive result if cancer is present” and “having cancer if the test result was positive”. The differences are less than they were in the original example, because the incidence is greater (30% versus 0.1%).

So when Ms. Hickox showed signs of a fever, she could be one of the few whose test did not match the possibility of not having the viral contagion. As a healthcare worker, shouldn't she also know this fact? 

A lot of facts do not add up here. You either are a professional or you are not when dealing with deadly illnesses. If you cannot be professional and hold up your social contract to be quarantined by officials at any given moment, then why are you in that profession?  

The CDC and the State of New Jersey should have been more forthcoming in their approach and information to Ms. Hickox, but given the outbreak and her volunteerism, the quarantine should have not been broken.  

Being a whiny brat should not preclude anyone from their duties to be contagion free when they are a volunteer healthcare worker in virus infested countries. 

The only crisis here is the crisis of conscience. 

What would you do? Go out in public with a fever? Or stay in quarantine until you were given the all clear? 

In a terrible situation like this one where Ebola is rampant and killing, we need professionals. We need people to act like adults.

But until then, we should have the rules set: you volunteered; you get quarantined. It is not about your civil rights being violated (you already acquiesced to that). It is about having a conscience that the rest of us matter too. 

10/29/14 Updated Information: Some May Carry Ebola Virus Without Having the Symptoms, Human asymptomatic Ebola infection and strong inflammatory response, as well as, Symptomless infection with Ebola virus, which tries to calm any fears of the former studied results, but cannot make a full explanation as to how individuals were exposed to Ebola in contact only with asymptomatic persons.

So the determination again is of your conscience.

In addition, read the VDP Gazette's article: Legal Authorities for Isolation and Quarantine. 

Source: Tompkins Cortland Community College, Huffington Post, Doctors Without Borders