Mandatory Quarantines Criticized; Monitoring Recommended for Ebola Exposure

The fight against the Ebola virus has expanded beyond the Centers for Disease Control and Prevention (CDC) into the states, a move the New England Journal of Medicine (NEJM) called “destructive.” The recent state-level steps, most of which are aimed at health care workers who return to the United States after treating Ebola patients in Africa, have expanded far beyond the CDC’s recommendations and guidances. After one quarantined health care worker accused the governors of New York and New Jersey of violating her basic human rights, the state policies have been widely criticized, and the CDC has provided additional recommendations on how to track individuals who may have been exposed to the virus.


The current outbreak of Ebola virus disease, commonly known as Ebola, began in West Africa, where the first cases were identified by the World Health Organization (WHO) in March 2014. The virus is primarily spread through direct contact (through broken skin or mucous membranes) with the blood or body fluids of a person who is sick with Ebola. Symptoms include sudden fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage. Individuals are only infectious after symptoms appear, and thereafter as long as their blood and body fluids, including semen and breast milk, contain the virus. The incubation period for the virus is between two and 21 days; after 21 days have passed, individuals who may have had contact with Ebola are not at risk of infection.

The first case of Ebola on American soil was diagnosed on September 30, 2014. A man from Liberia sought care at Dallas’ Texas Presbyterian Hospital once he began experiencing symptoms. All individuals who had close contact with the man were monitored for 21 days after exposure; he died on October 8, 2014. Two health care workers who treated the man at Texas Presbyterian tested positive for Ebola; both have since been discharged as Ebola-free. According to the CDC, the highest risk of exposure to Ebola is for health care providers caring for Ebola patients, as well as others in close contact with Ebola patients such as family and friends.

In response to the initial three cases of Ebola, the CDC, working with the Department of Homeland Security, began screening travelers from Guinea, Liberia, and Sierra Leone upon arrival at five U.S. airports (New York’s JFK International, Washington-Dulles, Newark, Chicago-O’Hare, and Atlanta). The agency announced active post-arrival monitoring of travelers from those three countries, which requires travelers to report their symptoms (or lack thereof) on a daily basis for 21 days. The CDC also provided updated guidance to health care workers to help prevent further transmission from treating patients with the virus. The new guidance requires “rigorous and repeated training” in how to properly use personal protective equipment, and stresses the need for oversight and observers to ensure that all procedures are being completed fully and correctly.

New York Aid Worker

A New York man who had volunteered in Guinea as a health care worker returned to the United States without any Ebola symptoms. He cleared the airport’s enhanced screening, then returned to his home with instructions on post-arrival screening. Six days later on October 23, 2014, the man experienced a low-grade fever and reported it to local health officials. He was then transferred–by a specially trained HAZ TAC unit wearing Personal Protective Equipment—from his home to Bellevue Hospital in New York City, a designated Ebola treatment facility, where he tested positive for the virus. The CDC identified four individuals to monitor for possible infection due to close contact with the man. To date, none have presented symptoms.

States React

On October 24, 2014, the day after the New York aid worker was diagnosed with Ebola, New York Governor Andrew M. Cuomo (D) and New Jersey Governor Chris Christie (R) jointly announced additional Ebola screening protocols for the international airports in their states, JFK and Newark. One major change was the mandatory quarantine imposed upon any individual who had direct contact with an individual infected with the Ebola virus while in Liberia, Sierra Leone, or Guinea. The states specifically included medical personnel who have performed medical services for individuals infected with the Ebola virus for mandatory quarantine.

The quarantine policy was implemented immediately. That same day, the New Jersey Department of Health released a statement announcing the quarantine of a health care worker who arrived at Newark Liberty International Airport without Ebola symptoms; the health care worker was placed in isolation at Newark’s University Hospital. Kaci Hickox, a nurse who recently treated Ebola patients in Sierra Leone, contacted CNN while under quarantine to publicize the “inhumane” treatment she was experiencing. Hickox repeatedly tested negative for Ebola, despite the state announcing that she had developed a fever. Hickox states that her temperature was taken only with a forehead scanner, which is less accurate than an oral thermometer.

Christie defended the decision to place Hickox under mandatory quarantine, saying “I understand that this has made this woman uncomfortable and I’m sorry that she’s uncomfortable but the fact is I have the people in New Jersey as my first and foremost responsibility to protect their public health.” Hickox was released from University Hospital on October 27, 2014; the state announced its plan to transport her to her home in Maine, where she will spend the remainder of her 21-day quarantine. New York released a fact sheet regarding its quarantine policy, which allows in-home quarantine with unannounced visits from the state to check the individual’s health and to ensure he or she is honoring the quarantine.

Other States

In Illinois, Governor Pat Quinn (D) announced a mandatory 21-day home quarantine for high-risk individuals who have had contact with an individual infected with Ebola, including medical personnel. Chicago-O’Hare International Airport is one of the designated points of entry for individuals entering the U.S. from the countries experiencing the Ebola outbreak. The state issued a guidance clarifying its position for determining whether an individual is “high-risk.” Similarly, Florida Governor Rick Scott (R) signed an executive order requiring mandatory twice-daily monitoring for all individuals returning from Liberia, Sierra Leone, and Guinea. Despite the absence of a designated screening airport in the state, Scott maintained the necessity of his action because “four individuals have already returned to Florida after traveling to Ebola-affected areas.”

Criticism of States

Physicians and other health experts have heavily criticized the mandatory quarantines that states are implementing. The NEJM criticized these policies as “not scientifically based,” “unfair and unwise,” and “more destructive than beneficial.” It argued that “hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source”—therefore, skilled health care workers must not have additional barriers making it harder for volunteers to return home. The NEJM lauded the New York aid worker, saying that returning workers can follow his example of alerting public health officials if they develop symptoms. Dr. Anthony Fauci, Director of the National Institute of Allergies and Infectious Diseases at the National Institutes of Health (NIH), warned against mandatory quarantines, saying that “draconian” requirements may have unintended consequences, such as preventing aid workers from going to Africa. He recommended treating returning people with respect, and told the states to “go with the science.”

Continued CDC Action

On October 27, 2014, the CDC released an interim guidance for monitoring and movement of persons with potential Ebola virus exposure and a corresponding fact sheet. It recommends monitoring depending on an individual’s risk level: active monitoring, where an individual monitors himself or herself and reports any symptoms to the public health authority, for individuals at low-risk, and direct active monitoring, in which a public health official directly observes the individual daily to review symptoms and monitor status, for those with some or high risk. Individuals who may have been exposed to Ebola virus should limit their travel to “controlled movements”—no long-distance commercial conveyances, such as planes, trains, or buses, and should ensure that any movement allows the continuation of active or direct active monitoring.

Ongoing updates to the governmental response are available at and