Effectively monitoring people exposed to Ebola requires more than just checking symptoms. A quarantine plan also needs to help people keep up with work and school and pay for essentials like housing and food, a U.S. report concludes.
To understand the challenges encountered by ordinary citizens exposed to Ebola, a team led by researchers at the U.S. Centers for Disease Control and Prevention reviewed concerns raised by people monitored as part of an Ebola cluster in Dallas last year.
"If yet-to-be-identified contacts notice that those who come forward as Ebola contacts are shunned from society and quarantined in their homes, with no way to provide for themselves and their families, they will be less likely to come forward," said lead study author Dr. Charnetta Smith, a CDC epidemic intelligence service officer.
There have been over 23,000 cases of Ebola and more than 9,300 deaths worldwide since the current epidemic began in West Africa, according to the World Health Organization. Most of the cases have been in Guinea, Liberia and Sierra Leone.
Last fall, 179 people needed monitoring for Ebola symptoms after Thomas Eric Duncan, a Liberian national visiting Dallas, became the first person diagnosed with the Ebola virus in the U.S., according to the CDC report. He died in an isolation unit inside a Dallas hospital in October.
Most of the people exposed to the virus in Texas were healthcare workers, including two who became infected with Ebola after treating Duncan. But the group also included 20 people in the community and 10 individuals who rode in the same ambulance that transported Duncan before it was completely cleaned and disinfected, the authors write in CDC's Morbidity and Mortality Weekly Report.
Duncan's case in Dallas prompted questions about the timeliness of his care. He initially sought treatment two days before being admitted to the hospital, but he was sent home with antibiotics.
It also raised questions about the best way to monitor people who came in contact with Ebola. In Texas, five "community contacts" and two "ambulance contacts" were formally quarantined, according to Smith. Another 20 health care workers voluntarily self-quarantined.
The CDC recommends that people exposed to Ebola who don’t have any symptoms of the virus be monitored for 21 days. During that period, these individuals may be advised to limit their movements within the community and avoid public transportation. They may be asked to remain at home, missing work and school.
As these individuals are asked to disrupt their lives, it’s critical that public health officials understand how any restrictions on daily activities may impact their ability to get food, fill prescriptions and get necessary supplies, Smith told Reuters Health.
In Dallas, the group of people monitored for Ebola symptoms included eight school-aged children, three non-English speakers, two people with complex chronic medical conditions and one homeless individual. Each of these vulnerable populations needed special assistance.
For example, the children exposed to Ebola missed school. They needed help getting assignments, books and access to computers. They also needed support returning to school at the end of the 21-day monitoring period.
“Physicians from the Dallas County Medical Society volunteered their time to educate administrators, teachers and parents about Ebola,” Smith said. “This helped to minimize stigma and ensure that all students would be welcomed back to their schools.”
Beyond making this type of accommodation, public health officials also need to recognize that Ebola and other infectious diseases can disproportionately impact low-income communities where people have few resources to deal with a quarantine, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston.
“Whenever you are dealing with an infectious disease issue you are often dealing with people in the marginalized portions of society,” said Hotez, who wasn’t involved in the CDC report. “Here in Texas, where we often find widespread tropical disease outbreaks, it is almost always the poor and the homeless who are affected.”
Efforts to contain Ebola in Dallas clearly worked because there wasn’t a single transmission in the community, Hotez said. But a 21-day quarantine might not always make sense, particularly for the people who would face extreme financial hardship as a result.
“Twenty one days means that there is a 5 percent or less likelihood that you could still develop Ebola if you don’t have symptoms, but there is also a case to be made that the risk isn’t as great after 14 to 15 days,” Hotez said. “Twenty one days should be questioned.”