Quarantine Angst: What It Might Mean for EMS, Public Health

Quarantine is a concept no one likes to think about. But especially in the age of terrorism, the public-health community has to plan for everything, including how to monitor and control exposed patients to thwart the spread of contagious disease.

Quarantines-always a last resort in a public-health emergency-can involve EMS responders in two ways: 1) directly, if they are exposed to a disease, and 2) through treatment and transport of quarantined patients. It's important to know exactly what each might entail for you.

"There could be a lot of different roles for EMS in a quarantine situation," says Pattie Simone, MD, Associate Director for Medical Science in the Centers for Disease Control and Prevention's Division of Global Migration and Quarantines. "There are the obvious things, the assessment and transportation of ill people. If there were a smallpox exposure, for example, there could be ways to engage them in the vaccination campaign. There are probably roles in monitoring and treatment delivery that could take place. It depends on the local situation and what the interventions are."

Frontline Responder Issues

First some basics: Quarantines are the states' to call. The feds control the borders and can step in if a state's response is inadequate or if an outbreak becomes interstate in nature. States today have a variety of quarantine plans, enacted at different times and for different reasons. This means quarantines would potentially be handled differently depending on where an outbreak occurs.

A quarantine will entail restricting an individual's activities and monitoring them, as well as their close contacts, for symptoms. Those merely exposed are segregated from those actually infected, and if symptoms are detected, isolation occurs. Full quarantine-physically confining people to a location, rather than just asking them to stay home-is resource-intensive and requires enforcement. Quarantinees will also have to be provided necessities like food, water and medical care.

The latter could be where EMS comes in.

"In a large event, we'll need all the public health people to participate," says Simone. "In the spectrum of things we might use for containment measures, geographic quarantine is pretty extreme, and wasn't used that much even during SARS. But the systems that seemed to work the best were the ones that had agreements in place with the ambulance services."

Interfacing with possibly contagious quarantinees presents an element of risk. During SARS, patients being transported or treated for other conditions were given masks, and EMS personnel took comparable extra precautions. Use of PPE became more important than ever in protecting the protectors.

At least in the case of SARS, that seemed to work. But what if it doesn't? What if large segments of the EMS and public-health work forces are exposed and themselves need quarantine?

"That actually happened in Canada," recalls Simone. "They realized that they couldn't quarantine people at home and not let them work, because there would not be anybody to transport ill patients. So they instituted what they called a work quarantine, which was a sort of compromise that entailed close monitoring of possible symptoms and fever. At least twice a day, somebody took your temperature, and you had to wear personal protective equipment the whole time you were at work. You could go home at night, but they encouraged you to stay in a separate room in your house and not have close contact with your family.

"These people were working, but they were, in every other sense of the word, quarantined. And everybody felt that yes, there was some risk they could expose other people, but with the close monitoring, it was low."

The CDC offers a good bit of guidance on quarantine issues. Much of this is specific to the recent threats of SARS and smallpox, but many of the notions have a general applicability as well.

"The principles are similar," notes Simone. "You would apply them a little bit differently depending on what you're dealing with and how it's transmitted, but the same ideas apply."

Public-Health Issues

Beyond EMS, the concept poses a challenge for the broader public-health community. The powers it will need, as determined by a recent multidisciplinary CDC conference, will include the collection of data and medical records (likely including EMS run reports); control of property (closing or commandeering facilities); management of persons (mandatory medical exams, etc.); and communications to the health community and the public at large. The latter was a major lesson of the SARS experience.

"You need frequent and specific communications," says Simone. "People are willing to help, but they want information on how they're going to protect themselves and their families. Fortunately, we have some great tools, such as satellite broadcasts and the Internet, to get information out to people in a short period of time."

States will have to determine such things as who will enforce a quarantine, who detains the infected/exposed, how due process and civil liberties will be respected and what, if any, penalties will result from failure to comply. To help them decide such things, the CDC has developed the Model State Emergency Health Powers Act, a template for the authorities needed in such an event. It is available at www.publichealthlaw.net/ MSEHPA/MSEHPA2.pdf.

For both EMS and the public-health community as a whole, the best advice is to sit down and talk about all these issues now. Waiting for a large outbreak to occur is a recipe for catastrophe.

"The local and state levels have to develop their own plans tailored to the resources they have," says Simone. "People have smallpox plans and other bioterrorism plans, and it really should be with all the same players. Emergency responders definitely need to be at the table."