In a bioterror preparedness plan released to states last month, the Centers for Disease Control and Prevention says quarantines might be recommended to confine a smallpox attack. But in the new report, appearing in the Dec. 5 issue of the Journal of the American Medical Association, researchers argue that there are better options.
"Less extreme measures" -- isolating people with clear evidence of infection, voluntary curfews, handouts of masks, and speedy vaccination, for instance -- are preferable to the blunter instrument of mass confinement, they say.
"We had trouble coming up with a scenario where we felt comfortable that it would be effective and acceptable," says Dr. Joseph Barbera, lead author of the report and co-director of the Institute for Crisis, Disaster, and Risk Management at George Washington University in Washington, D.C. "From our research and discussions and everything else, there are probably more effective and certainly less onerous containment methods," he adds.
The report was undertaken after a bioterrorism simulation in Denver last year, well before the terrorist attacks of Sept. 11 and the subsequent anthrax-by-mail infections and deaths. But the researchers saw that the failures of quarantine in the Denver exercise risked repeating in the aftermath of the recent events.
"We were all concerned that policy makers and decision makers were making this abrupt and tight link between contagious disease and quarantine," says Dr. Tara O'Toole, a Johns Hopkins University bioterrorism expert and a co-author of the report. But, she says, "there are a lot of ways of thinking about containing contagious diseases, as there are a lot of things that you could do before cordoning off a city."
These include home detention of cases and isolation of contacts, for starters. And outbreak responses must take pains not to consider each disease the same. Plague, for example, spreads more slowly than smallpox, and "most bioterrorism agents are not severely contagious person-to-person," says Barbera.
O'Toole, who directs the Hopkins Center for Civilian Biodefense Studies, believes that although quarantine might be easy to apply on a desert island with a few inhabitants, it would be almost impossible to impose on an island like Manhattan, with all its commuters and movement of goods and services.
In the Denver simulation, called TOPOFF, officials quickly found out that quarantining cut off the city's food supply, threatened the viability of its hospitals, and otherwise crippled its infrastructure.
"Frankly, I don't think it could work in a modern mobile society. But I wouldn't rule it out, and in some cases, I might have to try it," O'Toole says.
Quarantine, as the researchers explain, comes from the Italian word quarante, a reference to the 40-day period that incoming ships were sequestered during plague outbreaks in the 13th century. Although the modern word has gathered a variety of meanings, the researchers say it's best understood as "compulsory physical separation" or segregation from the population of healthy people potentially exposed to a contagious agent.
Barbera's group describes historic instances when quarantines were imposed in the United States with poor results.
In a 1893 outbreak of smallpox in Muncie, Ind., the quarantine led to healthy people being sequestered with sick family members, roving patrols of armed enforcers, and arrests of quarantine scofflaws. The public became irate, and several public officials were shot, leading them to declare the move "an utter failure."
And in a 1900 episode, San Francisco officials trying to prevent the spread of plague in a Chinese neighborhood "arbitrarily" locked down only Chinese households and business, doing grave damage to the economy of the community.
That response, although later found to be unconstitutional, illustrates that quarantine efforts can unfairly penalize minorities and the politically disconnected, Barbera's group argues.
Elizabeth Fenn, author of the book "Pox Americana," which details the role of smallpox in the early history of the United States, calls the 19th century's record on quarantines "horrific" in terms of their application against minorities and immigrants
"If you were white and wealthy, you weren't quarantined. But if you were a Jewish immigrant from Eastern Europe, you were," says Fenn, who teaches early American history at George Washington University.
However, she adds, "I think it's clear that quarantines are effective" in preventing the spread of infections, as long as they're applied properly.
Whether they violate civil rights and whether they're legal are debatable, she adds. "At what point does the good of the whole override the rights of the individual? It's [an issue] that needs to be decided," she says.
O'Toole hopes politicians and public health officials will consider the new report as they try to refine their emergency plans. She and her colleagues also recommend more investment in emergency management technologies and better communication among scientists, politicians and the public.
The report's conclusions aren't limited to bioterrorism, but apply to naturally occurring emerging infections as well, she says.
"We're all trying to rethink epidemics in the 21st century, and we need to rethink them," she notes.
What To Do
What can you do in an emerging bioterror attack? The most important thing, experts say, is not to panic. And the good news, according to a new study from Johns Hopkins, is that Americans seem to keep their cool in the face of such incidents.
The study, coming out next month in the journal Clinical Infectious Diseases, finds that the spike in sales of Cipro and gas masks in response to the recent anthrax attacks was a rational act of prevention, not a frantic stampede of fear.
For more on bioterrorism, try the Center for Civilian Biodefense Studies at Johns Hopkins University or the Institute for Crisis, Disaster, and Risk Management at George Washington University.
And for the latest on the anthrax investigation, try the Centers for Disease Control and Prevention.