Quarantine Law Exploring Issues Related To Travel With An Infectious Disease

Quarantine Law for the 21st Century

Exploring Issues Related to Travel with an Infectious Disease

U. S. health and government officials are pledging to tighten procedures in wake of an incident in which a man infected with a drug resistant form of tuberculosis was able to travel out of the United States and return evading health protection measures at the border. Atlanta lawyer, Andrew Speaker, 31, made headlines when he traveled on seven commercial flights (both domestic and international) with a rare and dangerous form of drug resistant tuberculosis, called XDR-TB.

Details of the Case

To begin, a brief chronology of Speaker's case is necessary:

In January 2007, Speaker was diagnosed with tuberculosis. He was treated in Atlanta. By May 10, Speaker's doctor, as well as Fulton County, Georgia health officials, had come to the conclusion that although his strain of TB was latent (meaning it was not contagious), it was highly resistant to treatment. There is some dispute as to whether Speaker was told that he was permitted to travel at this meeting. However, it seems clear from a tape recording that was made at that meeting by Speaker's father that he was told he was not contagious. According to Mr. Speaker: "doctors recommended he not travel but never mentioned that he was contagious or a threat to others" (USA TODAY, June 6, 2007).

On May 12, Speaker and his fiancйe flew to Europe for their wedding and honeymoon, having changed tickets that would previously have had them depart on May 14. After Speaker had left the country, the Centers for Disease Control, in consultation with the physicians who had met with Speaker on May 10, concluded that he had a highly virulent, contagious form of tuberculosis known as XDR TB.

On May 21, a family member contacted Speaker, who was in Italy, and said that he should contact the CDC. When he did, the CDC informed Speaker that Italian officials were going to come in the morning and take him to a hospital, because his XDR TB could potentially kill him. He was also told that he would be placed on a "no fly" list" and should not fly.

Disregarding these instructions, Speaker purchased airline tickets to Prague, flew from Prague to Montreal, drove across the Canadian/U.S. border, and eventually arrived in New York City, where he was admitted to a U.S. hospital. Mr. Speaker, presently in medical quarantine, maintains he has not broken the law, but the controversy sparked by his travels has re-focused the attention of Congress and government on gaps in the nation's border security system. However, the more important issue revolves around enforcement of medical compliance procedures related to issues regarding travelers with contagious diseases and, subsequently, the protection of the public at large.

Jeffrey Runge, chief medical officer for the Department of Homeland Security said that despite best efforts, U.S. borders remain vulnerable to infectious diseases. "Short of draconian and economically draining health screening techniques being routinely implemented at each port of entry for the millions of people crossing the border, there will always be opportunities for people who are ill to cross our borders undetected", he said (USA TODAY, June 6,2007).

Quarantine

There are two principal sources of current legal thinking on quarantine for contagious diseases. The first originates in the law of quarantine itself. The second concerns civil commitment adjudication. Quarantine laws are limited to controlling infectious diseases. Civil commitment laws govern incarceration when people are a danger to themselves or others are mentally ill and unable to care for themselves, or present a danger to others because they spread infectious disease. Before antibiotics, quarantine was important in preventing the spread of infection. Since it was not possible to attack bacterial causes of disease directly, sources of disease had to be kept away from other people. Many state statutes which address the control of contagious diseases have been in existence since the turn of the century. The leading case on quarantine, Jacobson v. Massachusetts was decided in 1905. Even more recent statutes were enacted forty years ago. Only ten states have substantially changed their TB-related law within the last few years.

The public health powers in state statutes include: compulsory examination and treatment, emergency detention and quarantine. Quarantine may be defined as either in-home isolation or commitment to state facilities. These measures are accomplished through public health orders or court orders. Some states have civil and/or criminal penalties for failing to comply with such an order. Other statutes do not spell out penalties.

Some statutes define which diseases are contagious and therefore subject to quarantine regulations. Others authorize state health departments to decide which illnesses are contagious. Some empower public health authorities to make quarantine or isolation decisions without any direction as to illnesses or conditions.

Thirty-three states permit authorities to isolate people in their homes. In most cases there are no due process protections specified out in the law.

Forty-two states permit commitment to treatment facilities. Thirty-six states require a court order to commit someone to a facility. Several do not require a court order or a hearing. Generally court orders will be initiated by a petition from public health authorities requesting a hearing. Written notice to the person concerned is usually required, but the hearing may be held with or without the patient. Only thirteen states explicitly grant the right to be represented by counsel in any part of the proceedings. Of these, eleven will provide counsel to indigent individuals.

Release is accomplished when a determination is made that the person is no longer a threat to the public health, or no longer infectious. Some statutes specify criteria for release which may be vague ("no longer a danger to the public health") or specific (evidence in sputum tests that the person is no longer actively contagious). Ten states have no statutory time limits on the length of time a patient may be held without discharge or recommitment. In many states the only explicit due process protection afforded persons who are quarantined is the opportunity to petition the court for release.

Legal precedence

Quarantine is a very old public health measure. Historical references date back at least to the Old Testament. When people were thought (rightly or