6. Isolation/Quarantine

Patient isolation and population quarantine comprise two methods that have been used intermittently through history to deal with outbreaks of infectious disease. Unfortunately, historical data would lead us to believe that frequently they were inappropriately or unsuccessfully utilized (Barbera et al., 2001). Both of these techniques, in varying degrees of application, may play a significant role in controlling communicable transmission following a large-scale bioterrorist attack or a naturally occurring infectious pandemic. Unfortunately, knowledge and experience in the large-scale utilization of these techniques has fallen into disuse, with no large-scale quarantine being implemented in recent U.S. history and large-scale patient isolation not being practiced since the advent of antibiotic treatment for tuberculosis. These concepts are rarely studied by the health care community today, although the recent outbreaks of severe acute respiratory syndrome (SARS) have rekindled some interest. Because of the potential importance of these techniques in helping combat a large-scale bioterrorist attack, these concepts were discussed by the RMBT Working Group in an effort to develop characteristics and identify unresolved issues associated with having facilities successfully serve as isolation or quarantine units.

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Definitions

Historically there has been much confusion about and misuse of the terms "isolation" and "quarantine". Useful and coherent definitions of these terms are offered by Barbera et al. (Barbera et al., 2001).

• Isolation: Separation and confinement of individuals known or suspected (based upon signs, symptoms or laboratory findings) to be infected with a contagious disease to prevent them from transmitting the disease to others.
• Quarantine: Compulsory physical separation, including restriction of movement, of populations or groups of healthy individuals who have potentially been exposed to a contagious disease.

These definitions were used in the discussion of these topics by the RMBT Working Group.

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Identified Issues

As would be expected, there was much discussion (and little agreement) about the overall feasibility and utility of large-scale facility-based quarantine. There is a need for states to research current statutes providing legal authority for the public health sector to establish and enforce quarantine, and to establish enabling legislation or draft gubernatorial orders when current statute authority is found wanting (For an example, go to Executive Order 6.0). There were also issues identified concerning the physical enforcement of anything other than a voluntary quarantine, the medical decisionmaking process to decide on a large-scale quarantine and the lack of appreciation of the severity of some of the potential adverse consequences versus the benefits of a large-scale quarantine. There was also discussion that home-based quarantine may be desirable over facility-based quarantine (as been demonstrated in dealing with SARS), although this creates problems for some vulnerable populations such as the homeless, the disabled, and the chronically ill.

Discussion of facility-based isolation (and treatment) also revealed several issues. Surveys of hospitals in 4 of the Region VIII States (Colorado, Utah, Montana, North Dakota) revealed that there is a maximum of 828 isolation beds, total, to serve these 4 States. It was also found that in 3 States, an average of only 28 percent of the emergency departments had isolation rooms. It is the general conclusion that this number of isolation beds would be inadequate in the face of a large-scale bioterrorist attack or a wide spread pandemic and would require conversion of entire hospitals, units of hospitals or outside facilities to support isolation.

The willingness of any hospital to become a designated isolation facility has become an issue. Utah, in its survey, found that 23 percent of its hospitals would be willing to be so designated, but this number, in reality, might be smaller, based upon the fear associated with the agent in question. Some institutions may be willing to be an isolation facility when dealing with plague (which is treatable and can be prophylaxed against with antibiotics) although the number might decline if dealing with smallpox (which has very limited treatment options). Some institutions would be willing to be designated as an isolation facility if they were offered ongoing monetary support to enhance infrastructure and operations. It is clear that many hospitals fear the lasting stigma associated with being an isolation facility for a communicable agent, even after that agent has been controlled. There was some discussion of home-isolation for certain agents (such as smallpox), since little definitive treatment can occur in a hospital, although this brings forward several issues regarding family protection and support.

There was much concern expressed about the impact of the Federal Emergency Medical Treatment and Active Labor Act (EMTALA) during a bioterrorist event. EMTALA requires a hospital to provide a medical screening examination for any patient presenting to the hospital's emergency department for care. This would be very problematic in the situations of a contagious patient showing up at a non-isolation institution, a non-contagious patient appearing at an isolation hospital or patients appearing at an over-crowded hospital rather than an active alternative care site. In these situations, EMTALA would actually be an impediment to best possible medical care. This issue can be addressed through State-level enabling legislation or draft gubernatorial orders (for example, Executive Order 1.1, ). Recent rule interpretations by the Centers for Medicare and Medicaid Services (CMS) have made this less of an issue by allowing some flexibility during a bioterrorist event.

It was repeatedly emphasized that any large-scale quarantine or isolation effort mandates very close cooperation between local, State, and Federal officials during both the planning and implementation stages. There have been some efforts in these areas, but much remains to be done.

Facility Characteristics

The following facility characteristics/capabilities were identified to establish a facility as a quarantine unit:

• Willingness of facility owner to allow structure to be used as a quarantine facility.
• Ability to provide basic human needs on an ongoing basis: food, water, shelter, heat, light, waste disposal, laundry.
• Ability to provide other types of support, as indicated (low level medical care for those with chronic disease, counseling, etc.).
• Ability to provide protection for support workers as decided by public health experts, based upon the agent in question (PPE, vaccination, prophylactic antibiotics).
• Ability (in terms of physical layout and personnel) to limit access and enforce (if necessary) a lockdown procedure.
• Communication capability.
• Ability to deal with extensive media exposure.

Potential sites for a quarantine unit could include:

• Nursing Homes.
• Schools.
• Churches.
• Hotels.
• Convention/event centers.
• Portable tents/trailers.
• Unused hospital areas (unlikely in a large-scale outbreak).
• Meeting halls.
• Military facilities.
• Government buildings.

The following facility characteristics/capabilities were identified to establish a facility as an isolation unit:

• Willingness of facility owner to allow structure to be used as an isolation facility—this may include reimbursement for costs associated with returning the facility to its previous use and a predefined plan to accomplish this.
• Ability to provide basic human needs on an ongoing basis: food, water, shelter, heat, light.
• Waste disposal—this may be complicated by much of the waste being of biohazard status
• Laundry—this may include capability to autoclave dirty linen prior to washing as is the current recommendation for smallpox-contaminated linen (Henderson, 1999).
• Ability to isolate facility air flow to keep it from any nearby or attached non-isolation structure
• Ability to support designated level of care for ill patients (suction, oxygen, etc. if deemed necessary components).
• Ability to provide other types of support, as indicated (low level medical care for those with chronic disease, counseling, etc.).
• Ability to provide protection for care providers and their families as decided by public health experts, based upon the agent in question (PPE, vaccination, prophylactic antibiotics).
• Ability (in terms of physical layout and personnel) to limit access and provide appropriate entry/exit of infectious patients (based upon agent in question) and enforce (if necessary) a lockdown procedure.
• Communication capability.
• Ability to deal with extensive media exposure.

Potential non-hospital sites for an isolation unit become quite limited if the assumption is made that they will be able to support the same level of care as a hospital. If a lower level of care is accepted, sites could include:

• Clinics.
• Day surgery centers.
• Medical office complexes.
• Nursing homes.
• Schools.
• Churches.
• Hotels.
• Convention/event centers.
• Portable tents/trailers.
• Meeting halls.
• Military facilities.
• Government buildings.

Note: These characteristics are further delineated in the site-selection scoring tool.

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Conclusion

The ability to adequately provide for quarantine and isolation facilities presents many difficult challenges and mandates close cooperation between public health and acute medical care sectors at local, State, regional, and Federal levels. Financial compensation may be an issue in establishing these facilities and would best be dealt with in advance. Advance institutional and alternative site evaluation should be performed to determine abilities/weaknesses for the facility to support quarantine and patient isolation issues.

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