Intended for healthcare professionals


CDC rejects mandatory quarantine for travelers arriving from Ebola stricken nations

BMJ 2014; 349 doi: (Published 28 October 2014) Cite this as: BMJ 2014;349:g6499
  1. Michael McCarthy
  1. 1Seattle

Travelers arriving in the United States from the Ebola affected countries of Guinea, Sierra Leone, and Liberia who do not have a fever or symptoms of the disease—including healthcare workers who have cared for patients with Ebola virus disease—should be actively monitored but do not need to be quarantined, new US guidelines have said.

The guidelines were issued on 27 October by the US Centers for Disease Control and Prevention (CDC) after several states indicated that they would quarantine all travelers from the affected countries.1 Many US health officials feared that quarantine of all travelers would lead some to hide their exposure history on arrival in the US, making it harder to track individuals at risk, and would discourage volunteers from going to west Africa, where there is a desperate need for doctors, nurses, and other skilled healthcare workers.

“We do have to recognize that if we do things that make it very difficult for people to come back, if we turn them into pariahs instead of recognizing the heroic work, a couple of things may happen that none of us want to happen,” said CDC director Tom Frieden at a press conference announcing the new guidelines.

Under previous guidelines travelers arriving from the affected countries were screened on arrival. Those without fever or symptoms were asked to voluntarily monitor themselves for 21 days (the incubation period for Ebola), watching for symptoms and taking their temperatures twice a day. Should fever or symptoms appear they were to contact local health authorities.

However, after a New York physician, Craig Spencer, was diagnosed with the infection shortly after returning from Guinea, where he had cared for patients with Ebola, the states of New York, New Jersey, Florida, and Illinois announced that they would implement mandatory quarantine policies.2 Spencer had gone out to eat, gone bowling, and traveled around by subway and cab in the days before he developed a fever and was hospitalized. The fact that someone infected with Ebola had been freely traveling around the city for several days caused widespread public concern and prompted calls for tougher restrictions on people coming to the US from west Africa.

The first person to be detained under New Jersey’s new quarantine rules was a nurse who had been caring for patients with Ebola in Sierra Leone. The nurse, Kaci Hickox, 33, said she had a normal temperature and was without symptoms when she arrived at Newark Liberty International Airport on 24 October, but after being detained for four hours at the airport she was tested again.

In an article that was published in the Dallas Morning News the next day, Hickox wrote, “Four hours after I landed at the airport, an official approached me with a forehead scanner. My cheeks were flushed, I was upset at being held with no explanation. The scanner recorded my temperature as 101. The female officer looked smug. ‘You have a fever now,’ she said. I explained that an oral thermometer would be more accurate and that the forehead scanner was recording an elevated temperature because I was flushed and upset.”

Hickox was then transported to University Hospital in Newark under a police escort. “At the hospital I was escorted to a tent that sat outside of the building. The infectious disease and emergency department doctors took my temperature and other vitals and looked puzzled. ‘Your temperature is 98.6,’ they said. ‘You don’t have a fever but we were told you had a fever,’” Hickox said. She was kept in the tent for three days and subsequently tested negative for the virus. After she was released on 27 October she traveled to her home in Maine, where health officials say they will allow her to stay at home but will continue to monitor her.

Hickox was sharply critical of New Jersey Governor Chris Christie’s decision to implement the quarantine policy. “I think we have to be very careful about letting politicians make medical and public health decisions, and all of the evidence about Ebola shows that if you are not symptomatic, you are not infectious,” Hickox told CNN. She has retained a noted civil rights attorney, Normal Siegel, and announced plans to file suit over her confinement.

Christie defended his decision. “I’m not going to step away for a minute from protecting the people of our state and our region. I understand she didn’t want to be there. She made that clear from the beginning. But my obligation is to all the people of New Jersey,” he said.

Under the new guidelines travelers who have no symptoms are placed in one of four levels of risk: high risk, some risk, low (but not zero) risk, or no-identifiable risk. For example, people who took care of a patient with Ebola without protective gear would be considered at high risk. These people, the guidelines said, should undergo direct active monitoring for 21 days from the last potential exposure to the virus, with daily visits by public health officers to check the traveler’s temperature and to review symptoms. In addition, they should not take public transport or go to public areas, except areas where they can stay at least three feet away from others.

People at “some risk,” such as those who took care of patients with Ebola while wearing protective gear, should also undergo direct active monitoring, the recommendations said, and health authorities may consider imposing additional restrictions if the individual’s exposure was more intense, such as working with infected patients daily as opposed to visiting an Ebola treatment center intermittently.

People in the “low (but not zero) risk” category, in general, do not need to be directly monitored, the guidelines said, but should be actively monitored by health officials with daily phone calls during the 21 day monitoring period. Their movements within the community do not need to be restricted. Travelers with no identified risk do not need monitoring or to have restrictions placed on their movements, the guidelines said.

State health departments generally follow CDC guidelines, Frieden said, but “if they wish to be more stringent than what CDC recommends that’s within their authority.”


Cite this as: BMJ 2014;349:g6499


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