ABSTRACT
In the interest of protecting the public from infectious diseases, as well as the workers that come into contact with infected persons, isolation and quarantine procedures and policies are established and managed. Infectious and communicable diseases have ethical, legal, and political implications both historically and currently, including domestic and international ramifications if not controlled and eliminated. The paper provides an overview of isolation and quarantine definitions, conditions, and situations. Ethical, legal, and political impacts from historical and current perspectives are discussed. A review of recent literature is examined of these impacts. Recommendations related to policies and legal modifications are suggested, along with opportunities for future implications and research avenues. Ethical issues of public health encourages the use of police power, raises issues of public welfare, autonomy, freedom, privacy, confidentially, as well as distribution of resources, and transparency of action and responsibility. The balance of these ethical, legal, and political concerns is also reviewed.
Key words: isolation, quarantine, ethical issues, public welfare

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Overview: Current Scope of Isolation and Quarantine
Isolation and quarantine are methods used to protect the public, along with preventing exposure to infected persons. Isolation separates the sick person that has a communicable or infectious disease from healthy people, due to knowledge that the person has a contagious disease. Quarantine not only separates, but the approach restricts healthy people that may have been exposed to someone that is infected, to observe and monitor the person to make sure they do not become ill from contact, thus reducing the risks of spreading any communicable or infectious disease. “Infectious diseases are caused by microorganisms and therefore potentially infinitely transferable to new individuals; communicable diseases are infectious diseases that are contagious, along with being transmitted from source to source by infectious bacteria or viral organisms; contagious diseases are a very communicable disease that can spread rapidly from entity to entity by contact or close proximity” (CDC.gov, 2014).The population can become infected in a multitude of ways. Contaminated food contains germs, water can contain infectious bacteria, and diseases and infections can be transferred directly from individual to individual, because the germs are contagious and easily transmitted. Contagious and infectious diseases are a health threat to the public and include such diseases as cholera, diphtheria, infectious tuberculosis, plague, smallpox, viral hemorrhagic fevers, and SARS, as well as yellow fever in the list (CDC.gov, 2014). Vaccinations have historically controlled most contagious diseases, but new outbreaks and epidemics threaten individuals nationally and globally. The U.S. Center for Disease Control and Prevention (CDC) defines quarantine as situations that can be applied to “people, animals, buildings, conveyance, and cargo entities, requiring the entity that has been exposed to a contagious disease to be closed off or kept apart from others” (2014). Procedures are defined to identify, track, and control disease spread, along with administration and execution by the CDC, state, local, and municipal health departments using emergency preparedness and response plans to address early detection, rapid diagnosis, and antiviral or antibiotics dissemination in isolation and quarantine settings.

Isolation periods are unique to the type of communicable disease involved and any specific treatments that are required. An isolation setting is generally a hospital, an individual home, or other types of health care facilities. The individual is kept in their own private room and any person that interacts with the isolated person must wear protective garments, as well as other defensive measures. Isolation is normally voluntary, but any type of government can mandate that a sick person is isolated due to public risks. Quarantine has the same uniqueness as isolation, depending upon the disease involved, but entails an incubation requirement based upon the symptom developments after exposure to the disease or the disease causing agent. The quarantine period can last as long as it is necessary to administer health care, drug treatments, and immunizations, as well as making sure the quarantined individual does not infect others. Quarantines are mandated by government and designated authority, typically associated with small groups and small areas, but can occur in larger environments. Individuals are fed, cared for, and sheltered in a home, hospital, emergency facility, or designated building. All medical interventions are administered to control the spread of the communicable disease and consist of vaccinations, antibiotics, and immediate diagnostic tests, symptom review, along with rapid treatment. Authority is over individuals arriving to the United States from foreign countries, as well as Mexico and Canada by all modes of transportation, including foot travel, as well as individuals from other states in the U.S.

Historical Perspective: Legal and Political Impacts
According to the Centers for Disease Control, the performance and application of quarantine has existed since the fourteenth century in many coastal cities as an effort to protect people living there from plague epidemics associated with ships arriving from other infected global ports; ships were required to be anchored for forty days before landing, establishing the practice of quarantine (CDC.gov, 2014). Infectious diseases have been immersed in American culture by many historical accounts with few early steps taken to tackle the issues by the governments, local, state, or federal, which forced local municipalities to try to resolve the quarantine activities. After repeated outbreaks of yellow fever, the U.S. Congress passed federal quarantine legislation in 1878, which prompted further view and federal interest in answering to the outbreaks (CDC.gov, 2014). Cholera outbreaks surfaced soon after due to more vessels entering the U.S. from Europe. In 1892, the U.S. government again reviewed the requirements of quarantine only to discover that the state and local entities were not equipped to fully handle the infectious outbreaks, thus amending legislation to assume complete control (CDC.gov, 2014).

Aggressively acting to manage the outbreaks, the government constructed facilities to support increased staff needs, completely nationalizing the administration of quarantine matters in 1921, along with passing the Public Health Service Act of 1944, which created a PHS organization and gave the U.S. quarantine responsibilities of “preventing the introduction, transmission, and spread of communicable diseases from foreign countries into the United States” (CDC.gov, 2014). Infected vessels were identified with yellow flags indicating that inspectors had boarded the ships, signifying that quarantine and customs officials needed to clear the ship before it could dock at any port. The PHS organization became part of the Department of Health, Education, and Welfare (HEW) initially and ultimately transferred to the Center for Disease Control and Prevention (CDC) in 1967, creating over five hundred employees, along with roughly sixty quarantine stations located in every port and international airports, along with all major border crossings (CDC.gov, 2014). Under CDC control, changes were made. The CDC modified the organizations focus to include program management and intervention, instead of just inspections and crisis supervision, leading the way to address epidemic onsets, along with monitoring international traffic, as well as enhancing the existing inspection process (CDC.gov, 2014). Organizational changes took place again in 1995 with a downsize in quarantine stations to 7, and to 18 after the severe acute respiratory syndrome (SARS) 2003 epidemic; an additional ninety field staff members were added to solidify the anticipated needs, as well as address current issues (CDC.gov, 2014).

Today the CDC has an additional division. The Division of Global Migration and Quarantine operations as part of the centers Emerging and Zoonotic Infectious Diseases unit located in Atlanta, Georgia; quarantine stations are located nationwide from Anchorage, Alaska to New York to Los Angeles, California, as well as Washington, D.C. (CDC.gov, 2014). This division has authority to “detain, medically examine, or conditionally release individuals and wildlife suspected of carrying a communication disease…identified in a presidential Executive Order, that includes cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, such as Ebola, and SARS, along with influenza”, which was included in 2005 (CDC.gov, 2014). Division staff members respond to all sick travelers no matter what the transportation mode or border location, as well as operate on a 24 hour basis daily.

Review of Literature
According to research by Rutkow et al., due to the number of health emergencies related to infectious diseases, the Institute of Medicine has recommended that all state and local governments “review and modernize laws related to these issues to ensure that appropriate powers are in place to enable public health agencies to address contemporary challenges to population health” (2014). The concern is there due to lessons learned from Hurricane Katrina, Hurricane Sandy, and recent H1N1 influenza pandemics, which highlight the unpreparedness of existing state laws and entities to respond successfully and effectively to public health issues, as well as recognition of the influence of these agencies on public health workforce participation (Rutkow et al., 2014, p. 64). Public health workers have concerns about how the laws protect them during an emergency response due to safety concerns and potential liability for a rescue effort. The authors determined that “state public laws can effect increased or decreased public health care worker participation, after a systematic identification and analysis of state emergency preparedness laws” (2014). The research looked at various components. A complete search of states laws related to the following emergency preparedness was conducted: “(1) power of the state to declare a public health emergency or public disaster; (2) state requirements to have an emergency plan; (3) state-level liability protections for first responders; (4) priority access to health resources such as vaccines, and (5) promotion of intra-state collaboration during a response” (Rutkow et al., 2014, p. 65). Research results disclosed that every state had enacted two of the five components; less than 50% had the ability to declare a public health emergency; 25% required an emergency preparedness plan; all provided some form of first responder liability protection; 15 granted responders access to priority health resources; and every state required intra-state collaboration during an emergency response (Rutkow et al., 2014, p. 65).

Justification for public health polices is the focus of research conducted by Ng and Ruger, along with issues of individual freedom, distributive justice, and ethical guidelines in public policymaking (2014). Public policies are evaluated based upon outcomes and successful interventions, as well as the amount of harm or negligence that is incurred from a poor public health emergency response performance. Public health emergencies consist of not only communicable and infectious diseases risk mitigation, but also encompasses protection from health endangering substances and environments such as sanitation and high risks behaviors, such as unprotected sex (Ng & Ruger, 2014, p. 287). Policies are required to promote public welfare, protection of vulnerable groups and individuals, and other policies that can reduce health care inequities. The authors conclude that resource allocation is critical to fairly addressing public health concerns, as well as the necessity that all states be required to provide a “basic minimum standard or something higher regarding responses to public health emergencies, as well as the establishment of ethical guidelines by showing good faith efforts, along with providing public disclosure and justification of selected approaches, exposing the risks, costs, and benefits of such actions” (Ng and Ruger, 2014, p. 291).

Literature review of Tognotti’s Lessons from the History of Quarantine, from Plague to Influenza A reminds the world of how important it is to never ignore or assume that diseases are eradicated, as demonstrated by the resurface of influenza (Tognotti, 2013). Resurfacing communicable and infectious diseases is rekindling the need for isolation and quarantine. This evidenced in the authors research of the effectiveness of “quarantine, border controls, contact tracing, and surveillance in containing the global threat of the 2003 pandemic of sever acute respiratory syndrome, SARS, along with biological terrorism acts (Tognotti, 2013, p. 254). The author discusses the controversy surrounding isolation and quarantine that has occurred during centuries, associated with political, ethical, and socioeconomic issues that require balance between public welfare and interest versus individual rights (2013). Quarantine has been at the foundation of any strategy used for protection of public health and the spread of disease, along with isolation, sanitary barriers, “bills of health issued to ships, fumigation, disinfection, and regulation of groups of persons who are believed to be responsible for spreading the infection” (Tognotti, 2013). Tognotti concludes by stressing that quarantine is still a viable option because of its ability to immediately and effectively control communicable and infectious disease outbreaks or pandemics, as well as restrain infection, impede the spread of disease, prevent terror and death, and preserve the public infrastructure, along with controlling public anxiety.

Selgelid highlights ethical issues of the “right to privacy, infringement of basic rights and liberties, informed consent to medical interventions, and freedom of movement” due to isolation, quarantine, surveillance, and mandatory treatments, as well as vaccinations (2009). The author raises the issues of justice and infectious diseases. Selgelid cites concerns of poor people being more likely to be exposed to “malnutrition, dirty water, overcrowded living and working conditions, lack of sanitation and hygiene, poor education, and lack of access to healthcare” (2009). These conditions are major factors of people becoming sick, as well as they continue to perputuate poverty and disease, along with long-term bad health. The author further highlights the fear, panic, discrimination, and emotional, along with irrational decisions and policymaking, and finally the potential threats to security due to outbreaks rapid occurrence, that impacts response and capacity, as well as creates chaos and panic.

A 2012 study reported by Jacobson et al. evaluated how laws shape the preparedness of public health care systems and activities, which was based upon 144 qualitative interviews across nine states (Jacobson et al., 2012). Jacobson et al. examined knowledge of the legal environment, knowledge sharing, the ability of the state legislation to handle and resolve large-scale public health emergencies, types of legal authority and enforcement, liability concerns, and issues of privacy and confidentiality, along with intra and multistate jurisdiction challenges (2012). Study results concluded that public health, first responders, and other emergency professionals do not have a clear understanding of the legal environment due to needed training, limited knowledge of procedures and laws, and inconsistent legal reports of emergency preparedness outcomes. The authors believed that better response can be obtained from associated personnel by educating these professionals, resolving legal issues that surface, establishing leadership to manage and administer emergency plans, and making every effort to completely eliminate delays in response.

Current Perspective: Legal, Political, and Research Impacts
After reviewing the historical and current research associated with public health issues, as well as isolation and quarantine, there are opportunities for the nation. This is clearly evidenced by the comprehensive research of Rutkow et al., reflecting the status of the 50 states regarding emergency preparedness, along with the almost total unpreparedness, as well as the need for a legal federal standard due to the states not responding as responsibly as needed. Tognotti’s research exposes the practical necessity of retaining quarantine and isolation as steps to rapidly respond to a public health emergency despite the risks of intrusiveness, suspicion, distrust, and public outcry. Ng and Ruger research asserts the need for accountability, as well as full disclosure. Selgelid presents the most compelling issues associated with infectious diseases and the ethics, which persuades one to view the necessity of isolation and quarantine as minimum issues versus the risks of biological terror and more pandemics.

Recommendations and Future Implications
Violating liberty and freedom of individuals has to be weighed and balanced against public welfare, but not at the expense of ethnic and minority groups or individuals due to socioeconomic conditions. Prejudice cannot be a factor in creating public policy regarding emergency preparedness, isolation, or quarantine because the cost of recovery impacts everyone. The federal government along with organizations such as the Institute of Medicine have a responsibility and obligation to ensure public safety and to work together to develop state requirements because the states have displayed the lack of skills and desire to accomplish basic plans and components necessary to ensure that ethical issues can be addressed, along with effective policies and procedures. Legal issues are abundant at every level of government, despite meetings, training and response exercises, as well as task forces that analyze public health response aftermath; a clear understanding of responsibility and accountability must be completely defined and established for all persons involved and at every level, as well as continuous education and information sharing. Communications are critical at all levels of government with community and other health care focused organizations, as well as continuous education of the risks associated with communicable and infectious diseases. Lessons learned must be fully examined with a focus on resolution, implementation, and execution, not just documentation. Ethical issues continue to require empirical data to support decisions, as well as research and analysis of philosophical questions regarding public welfare and individual rights. Scientific investigation must be merged with ethical concerns to improved policymaking, along with federal mandates when states continue to disregard the risks of infectious and communicable diseases.

    References
  • Jacobson, P. D., Wasserman, J., Botoseneanu, A., Silverstein, A., & Wu, H. (2012, April). The Role of Law in Public Health Preparedness: Opportunities and Challenges. Journal of Health Politics, Policy, and Law, 37(2), 297. doi:10.1215/03616878-1538629
  • Ng, N. Y., & Ruger, J. P. (2014). Ethics and Social Value Judgments in Public Health. Encyclopedia of Health Economics, 1, doi:10.1016/B978-0-12-375678.-7.00415-6
  • Rutkow, L., Vernick, J. S., Gakh, M., Siegel, J., Thompson, C. B., & Barnett, D. J. (2014, Spring). The Public Health Workforce and Willingness to Respond to Emergencies: A 50-State Analysis of Potentially Influential Laws. Journal of Law, Medicine & Ethics, 42(1), 64. doi:10.1111/jlme.12119
  • Tognotti, E. (2013, February). Lessons from the History of Quarantine, from Plague to Influenza A. Emerging Infectious Diseases, 19(2), doi:10.3201/eid1902.120312
  • Understand Quarantine and Isolation. (2014, March 10). Retrieved July 2014, from U.S. Centers for Disease Control and Prevention website: http://www.cdc.gov/quarantine/quarantineisolation.html