Ebola was identified in the 1970s. Since then, the World Health Organization has documented 24 outbreaks, all in West Africa. They ranged from one to 425 reported cases, with mortality rates of between 25 percent and 100 percent, resulting in between one and 280 deaths.
The current outbreak in Guinea, Sierra Leone and Liberia is the worst in history. As of Oct. 25, there were 12,008 suspected cases resulting in 5,078 deaths, for a mortality rate of about 42 percent.
The disease is caused by a virus. The current wisdom is that once it gets into a person’s system in sufficient quantity, it replicates. After an incubation period of between two and 21 days it reaches levels that produce symptoms, starting with fever, sore throat, muscle pain and headache. They progress to vomiting, diarrhea and rash. The virus impairs the blood’s ability to clot and causes internal and external bleeding. It damages liver and kidney function. By outpacing the body’s defense mechanisms, Ebola causes death through fluid loss and low blood pressure.
In its early stages, Ebola resembles several other diseases, including malaria, dengue, typhoid, cholera and influenza. It can be diagnosed differentially, by the process of elimination, but that takes too long. It can be identified by testing the blood for the presence of the virus itself, its proteins or a person’s antibodies. The fastest method of detection appears to be real-time testing for the presence of proteins, which can be done in hours. Even so, those proteins don’t seem to reach detectable levels until after a person has become symptomatic.
There is no approved vaccine. Treatment consists of supportive care, primarily rehydration and pain management, that allows the body to defend itself. Experimental administration of antibodies from survivors seems to be helpful, as does the use of dialysis and ventilation.
Scientists think that Ebola was initially passed from animals, such as fruit bats or bush meat, to humans who were either bitten by an infected animal or who ate one. Between humans, the prevailing wisdom is that it is transmitted by contact with the bodily fluids of a symptomatic person. The theory is that only at those levels of concentration can a person become infected.
No one has documented transmission through the air during an outbreak. One laboratory study demonstrated transmission between monkeys via aerosolized droplets, and current CDC policy recommends that care-givers avoid performing aerosol-generating procedures on infected persons.
Outbreaks are controlled by identifying and isolating infected people, and treating them. Care-givers must rigorously observe personal protective practices, including wearing clothing that leaves no skin exposed, and follow strict infection control and sterilization practices. Contaminated surfaces must be disinfected with heat, bleach, alcohol or detergents. People with whom the sick have had contact must be traced and monitored for the incubation period. Waste must be properly disposed of, and the dead must be handled carefully.
With regard to people at risk for infection, the New England Journal of Medicine opined that because fever precedes the contagious stage, infected people have time to identify themselves to authorities before they become a threat to their community, and that more stringent measures than self-monitoring are not necessary. The journal’s opinion was influenced in part by the premise that the epidemic must be stopped at its source in Africa by the efforts of thousands of volunteers who would be deterred from volunteering by the prospect of being quarantined.
However, our understanding, protocols and people are imperfect. Experts, doctors and nurses make mistakes. Dr. Craig Spencer contracted Ebola from treating patients in Guinea, returned to New York City and rode the subway. Texas Health Presbyterian Hospital mishandled patient Thomas Duncan, and nurses Amber Vinson and Nina Pham were infected.
The federal government has authority to protect the public by isolating and quarantining people sick with contagious disease. Executive order specifically authorizes isolation and quarantine for viral hemorrhagic fevers like Ebola. That power has been delegated to the Centers for Disease Control and Prevention. It can apprehend, examine and detain persons arriving in the country and traveling between the states if they are suspected of carrying a contagious disease. The last time that the federal government enforced a large-scale isolation and quarantine was during the Spanish Flu pandemic of 1918. It is estimated to have killed 675,000 Americans and tens of millions of people worldwide.
States have the power and the responsibility to protect the public’s health within their borders. In Maine, the Department of Health and Human Services can temporarily detain a person on an emergency basis by showing a judge that they pose a clear and immediate public health threat, such as by being infected, engaging in risky behavior, or by refusing to cooperate with measures designed to prevent transmission.
If, after a hearing, the department establishes the existence of a public health threat, then a court must impose the least restrictive measure that will protect the public. Those measures range from education, to counseling, to treatment, to monitoring, to commitment for 30 days. In the event of an extreme public health emergency, the department may detain and treat a person without a court order if the delay involved in securing a court order would risk transmission of the disease.
To date, federal and state responses have been inconsistent. The CDC suggests voluntary, active self-monitoring and reporting. An army general imposed a mandatory quarantine on soldiers returning from the hot zone. New York, New Jersey, Illinois and California imposed quarantines. Then New York and New Jersey backed away from them.
Volunteers who risk their lives to try to stop this disease deserve our admiration. However, given the stakes, it is not unreasonable to err on the side of caution and temporarily isolate and quarantine people at risk for contracting and spreading Ebola – especially given the current level of our understanding, our ability to control, and our ability to treat it. And if we quarantine returning volunteers, we should compensate them.