Isolations and Quarantines
New Orleans Missed A Bullet; Dallas Didn’t
New Orleans dodged two bullets this past fall: No hurricanes and no Ebola. On the other hand, Dallas, a city with a much larger medical infrastructure, was hit by a cannon ball.
Ebola paralyzed our news coverage as effectively as polio paralyzed our youth in the 1950s.
“We were behind a locked door with a guard. I was only 5 or 6 years old, but I remember being in that huge ward with 40 to 50 other polio victims. Except for your mother and father, the guards would allow visitors,” says Kenneth Hanning, a 71-year-old jewelry designer and artist.
“They put us in quarantine and treated us like lepers. There wasn’t a vaccine to prevent polio when I had it in 1949. It affected both my legs, which was considered very serious, but not as bad as the ones in iron lungs. I saw them, too. They were on another floor.”
Technically speaking, Hanning was isolated, not quarantined. Isolation refers to the separation of sick persons who may be contagious to others. But isolation never slowed the spread of polio. By the time nerve paralysis developed, the enterovirus that triggered the damage was long gone from the intestinal tract. Isolation simply gave an impression that something was being done.
Hospitals have different isolation barriers based on the infection diagnosed or suspected. Needlestick precautions were once reserved for patients with HIV, hepatitis B and hepatitis C. Now these precautions are wisely applied to everyone. A person can be a carrier of transmissible bloodborne infections without having a diagnosis or even symptoms.
Contact isolation is typically for persons with infections that can be spread by hands. Staphylococcal skin infections are an example, and masks add little if any protection. Enteric isolation is geared towards infections spread via feces such as salmonella and hepatitis A. Respiratory isolation is a bit more involved, with various masks depending on the pathogen of concern. And reverse isolation supposedly protects persons with damaged immune systems from the viruses and bacteria living on their caregivers.
These various isolation categories are common in all community hospitals. And the more masks and protective garb a caretaker has to adorn, the less care the patient usually gets. Actually, these routine isolation practices are probably less effective than plain old good hygiene and hospital cleanness.
Most health care-related infections are from the patient’s own bacteria and viruses. Treatment with antibiotics and other antimicrobials eliminate good bacteria and fuel the emergence of more resistant bugs. And all sorts of medical treatments – from steroids to chemotherapy – assault already impaired immune systems, making patients more prone to shingles, herpes and fungal infections.
Ebola showed how ineffective routine isolation techniques are for infections spread by close contact with vomit, feces and blood. The Dallas situation revolved around the first case of Ebola diagnosed in the United States and the secondary infections of two nurses taking care of him at the height of his illness. It caught the Centers for Disease Control with their pants down.
Occupational infections are nothing new for health care workers. Needle sticks and blood exposures commonly infected health care workers with hepatitis B, once known as serum hepatitis, before there was a protective vaccine. In addition, health care workers are still at risk of contracting HIV from needlestick injuries. A scabies outbreak infested several University Hospital employees a few years ago. But until Ebola visited Dallas, modern health care workers had never faced an occupationally acquired infection that could turn lethal in just a few days.
Contagious diseases lacking specific cures and protective immunizations fuel quarantines. A quarantine is a legally imposed barrier to separate and restrict movement of well persons who may be incubating an infectious disease. Quarantines can arise from being in contact with a known infection or just from coming from an area with reported infections.
In the Old Testament, lepers wore bells to announce their presence. Such verbal cues were not quarantines but what we call social distancing today.
Fourteenth century Italians first imposed official quarantines. They feared the spread of plague, a bacterial disease spread by infected fleas living on rats. Port officials required foreign ships to moor in sight but offshore for 40 days before loading or unloading. But disease-free sailors didn’t translate into disease-free rats. Improved sanitation and rat control stopped the Black Death, not quarantines.
The same old tool was called out in our yellow fever days. Port cities, including those up and down the Mississippi River, turned to quarantine during yellow fever outbreaks in the 1800s. Again, quarantine never controlled yellow fever. That came later with mosquito control.
Quarantines can apply to animals as well as people. For example, Great Britain required a six-month quarantine for all of dogs entering its borders for almost a century. Even as effective rabies immunizations for dogs developed, British authorities refused to accept proof of vaccination certifications from other countries. Elizabeth Taylor and Richard Burton had to hire a yacht to drop anchor near the Tower of London to be near their four pet pooches in the 1960s.
The British quarantine law stayed on the books until 2012. Now the six-month quarantine is history, but the certification process that took its place involves more paperwork than required to get a Louisiana homestead exemption.
Quarantines vs. immunizations
Quarantines rarely snuffle out infectious diseases, but immunizations do. The road to an effective vaccine is usually cluttered with false starts and bumps. The eradication of poliomyelitis in the United States was no exception. Jonas Salk was out of the gate first with his vaccine, but Albert Sabin and his oral vaccine won the race. And part of that race happened right here in New Orleans.
Salk paired up with Cutter Laboratories to immunize America. Unfortunately, and perhaps related to a race to market, two batches of the vaccine contained a wild polio virus that had evaded the inactivation process and contaminated the vials, syringes and arms of several thousand children in 1955.
Cutter Laboratories sent vaccine samples to decision-making leaders in the medical community, including Dr. Alton Ochsner. His first grandson, Eugene Allen Davis Jr., received the vaccine on April 26, 1955. The next day the vaccine was recalled based on a surge in vaccine-related polio cases first identified in California. Ochsner’s 30-month-old grandson “died of infantile paralysis eight days after he received the Salk anti-polio vaccine” according to a newspaper report at the time.
“It was a scary moment for us. We received a polio vaccine that was actually causing polio,” says Dr. David Snyder, a retired pediatrician living in North Carolina. He and his three siblings received that same vaccine.
“I remember it well,” says Dr. Stanton Shuler, a semiretired Ochsner pediatrician. “Dr. Ochsner’s grandson died. It was from the live virus. A young doctor taking care of the child also came down with polio but he survived. All blame went to the vaccine.”