Coronavirus

Are Quarantines a Proportionate Response to the Coronavirus?

While the use of force can be justified to curtail the spread of communicable diseases, the threat has to be weighed against the burdens on potential carriers.

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Now that COVID-19, the coronavirus disease that has infected an estimated 89,000 people worldwide, seems to spreading within the United States, we will hear more discussion of coercive measures aimed at curtailing it, including increased use of quarantines and mandatory cancellation of large-scale public events. In principle, an actual epidemic—as opposed to metaphorical "epidemics" of self-endangering behavior—can justify the use of force to protect the public against a potentially deadly threat that moves from person to person. But deciding whether a particular intervention is appropriate requires weighing several factors.

How easily is the disease transmitted?

While some pathogenic microorganisms, such as the Ebola virus, spread primarily through direct contact with the blood, bodily fluids, and skin of infected individuals, COVID-19, like the common cold, can be transmitted via airborne particles. According to the U.S. Centers for Disease Control and Prevention (CDC), COVID-19 "is thought to spread mainly from person to person" through "close contact," defined as prolonged proximity within six feet. The virus also can spread through respiratory droplets generated by coughs and sneezes. The CDC adds that "it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads."

Although COVID-19 is easier to catch than Ebola, it is far less contagious than, for example, measles. "Measles is so contagious," the CDC says, "that if one person has it, up to 90% of the people close to that person who are not immune will also become infected." According to commonly cited estimates, the average measles carrier can be expected to infect 12 to 18 people in a susceptible population. The World Health Organization estimates that the corresponding number for COVID-19 is between 1.4 and 2.5, compared to roughly 1.3 for influenza.

How deadly is the disease?

The current estimate of fatalities caused COVID-19 is about 3,000 out of 89,000 identified cases, which suggests a death rate of 3.4 percent. But there is a lot of uncertainty about the denominator, since not all cases are confirmed and many cases in asymptomatic individuals probably have not been detected yet. A study of more than 72,000 COVID-19 patients in China, reported in The Journal of the American Medical Association, puts the fatality rate at 2.3 percent, essentially the same as the rate among 355 cruise ship passengers infected with the virus, according to a study published in the International Journal of Infectious Diseases.

The vast majority of cases (more than 80 percent in the China study) involve mild symptoms, and the death rate varies widely by age. In the China study, the death rate was 8 percent for patients in their seventies and nearly 15 percent for patients 80 or older. The death rate also was especially high among people with pre-existing medical conditions: 10.5 percent for cardiovascular disease, 7.3 percent for diabetes, 6.3 percent for chronic respiratory disease, 6 percent for hypertension, and 5.6 percent for cancer. No deaths among children 9 or younger were reported.

The 2.3 percent overall case fatality rate (CFR) for COVID-19 is much lower than the rates for the SARS (severe acute respiratory syndrome) outbreak of 2003 (9.6 percent) and the ongoing MERS (Middle East respiratory syndrome) outbreak (34.4 percent). Estimated CFRs for the 2009 influenza pandemic vary widely, with some studies reporting rates as high as 10 percent. The CFR for the 1918 Spanish flu pandemic, which affected about one-third of the world population and caused some 50 million deaths, was somewhere between 2 percent and 5 percent.

How long is the incubation period?

The World Health Organization says someone can be infected by COVID-19 for up to 14 days without showing symptoms.

How severe is the proposed intervention?

The Chinese government imposed a quarantine on the area around Wuhan, a city of 11 million that was at the center of the COVID-19 outbreak. It also imposed travel restrictions that have affected around 780 million people. In the United States—where 90 cases have been reported so far, including six fatalities—such interventions have been much more narrowly tailored, limited to restrictions on foreign visitors, isolation of hospitalized COVID-19 patients, mandatory quarantines of travelers returning from areas affected by the epidemic, and voluntary home quarantines of people who have been infected but do not require treatment.

The legal authority for such measures is broad. The Public Health Service Act empowers the secretary of health and human services to "to make and enforce such regulations as in his judgment are necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession."

In Washington, the first state to see signs of COVID-19 transmission within the local community, the state board of health is charged with writing "rules for the imposition and use of isolation and quarantine." Under the board's rules, a local health officer, "at his or her sole discretion," can issue "an emergency detention order causing a person or group of persons to be immediately detained for purposes of isolation or quarantine" when he "has reason to believe" that they are infected by a "communicable disease" and that they "would pose a serious and imminent risk to the health and safety of others if not detained for purposes of isolation or quarantine."

A health officer also can seek an ex parte court order to enforce isolation or quarantine, which the court "shall issue" if there is a "reasonable basis to find that isolation or quarantine is necessary to prevent a serious and imminent risk to the health and safety of others." Those orders last up to 10 days but can be extended up to a month by a court, based on "clear, cogent, and convincing evidence that isolation or quarantine is necessary to prevent a serious and imminent risk to the health and safety of others."

There are several restrictions on that authority. The health officer must first make "reasonable efforts, which shall be documented, to obtain voluntary compliance" or else determine, "in his or her professional judgment," that "seeking voluntary compliance would create a risk of serious harm." The rules also specify that "isolation or quarantine must be by the least restrictive means necessary to prevent the spread of a communicable or possibly communicable disease to others." The health status of individuals subject to orders "must be monitored regularly to determine if they require continued isolation or quarantine," and they "must be released as soon as practicable" when the health officer determines that they no longer pose a threat. Quarantined or isolated individuals have a right to petition for release, with the assistance of court-appointed counsel, in which case the government has to "show cause" for their continued detention.

Is the intervention likely to be effective?

It remains controversial whether China's quarantine of the Wuhan area and the associated travel restrictions did much to slow the spread of COVID-19. Critics of the Chinese quarantine argued that it entailed a massive violation of civil liberties and was in some respects counterproductive.

"There have, in fact, been numerous, and in some cases fatal, unintended knock-on effects of the quarantine," Sharon Begley noted last month in a STAT News story. "People were unable to reach sick, elderly parents in Wuhan, let alone take them out of the city for treatment of heart disease, cancer, diabetes, and other illnesses. This week, UNAIDS announced that one-third of people in China who are living with HIV reported that because of lockdowns and travel restrictions they were at risk of running out of their HIV medications within days. And China's economy has slowed to a crawl."

Nor is it clear that the more targeted approach in the United States will have much of an impact. "A substantial proportion of secondary transmission may occur prior to illness onset," three researchers at Japan's Hokkaido University wrote in an analysis published last month. "Pre-symptomatic transmission…may even occur more frequently than symptomatic transmission." Quarantine and isolation cannot reach carriers who do not seem to be sick and have no known risk factors, such as visiting the Wuhan area or interacting with COVID-9 patients.

Are quarantines a proportionate response to the threat that COVID-9 poses in the United States? "I don't think that we have seen enough proof, in any cases, that quarantine is necessary for this particular virus," bioethicist Kelly Hills told Business Insider last month. "It doesn't meet what we would consider the minimum standards necessary for violating somebody's civil rights."

In a Journal of the American Association commentary published last month, bioethicists Lawrence Gostin and James Hodge argued that "quarantines of passengers arriving from mainland China appear excessive and are inconsistent with available epidemiologic data." They noted that "thousands of US residents who have returned from China are already sheltering at home," adding that "home quarantine orders are lawful, effective, and more respectful of individual rights to liberty and privacy than restrictive, off-site measures."

The Cato Institute's Alex Nowrasteh argues that "extreme options like travel and immigration bans" would be more expensive than can be justified based on what we currently know about COVID-9. "The cheapest and most effective way to combat the transmission of flu-type viruses is proper hand hygiene," he notes, recommending increased use of hand sanitizers, especially at airports and nursing homes.

Nowaresteh also notes that mass quarantines can backfire. "It's difficult to know who is sick and who is not, so quarantines end up locking many sick people in with many healthy people," he writes. "Healthy people and those who think they are healthy understand accurately that they would reduce their chance of becoming ill if they emigrate. By doing that, some people transmit the disease. Under some scenarios, the stricter the quarantine, the more people invest in emigrating. Sometimes, this behavioral response results in wider transmission of the disease."

In a society that values civil liberties, forcibly detaining people who may be carrying a disease that is readily transmissible but has a relatively low case fatality rate is not a step that should be taken lightly. And assuming it can be justified, the burdens it imposes should be mitigated as much as possible.

The New York Times recently highlighted the case of Frank Wucinski, a Pennsylvania native who was evacuated from Wuhan with his 3-year-old daughter in early February. They spent 14 days in quarantine, including two mandatory stays at a children's hospital near San Diego. Afterward Wucinksi was billed about $4,000 for medical services he was forced to receive. People deprived of their freedom for the benefit of the general public through no fault of their own should be indemnified against such costs.

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  1. Quarantines are rarely effective. Unless the outbreak is in Washington DC, in which case we need to wall off that entire city. Including machine gun turrets and moats with alligators.

    1. The only way to be sure the outbreak is eradicated is to flood the city with chlorine gas.

      1. No, that’s not the “Only way to be sure”.

      2. “I say we take off and nuke the entire site from orbit. It’s the only way to be sure.”

  2. https://qz.com/1810869/covid-19-quarantine-leads-to-surprise-medical-bills-for-us-family/
    PAY UP
    Covid-19 quarantine leads to surprise medical bills for US family

    End title import

    So what we are looking at here is yet another flavor of “never let a good crisis go to waste”! Government Almighty (statists of ALL flavors and parties) will MANDATE that you go to the hospital for quarantine! There, you will rack up charges for $77-per-pill aspirin, and $135 sanitary face masks, and so on. AND THEN YOU WILL BE SENT A HUGE BILL (even if you have insurance) for your Government-Almighty-mandated hospital stay!

    And then all the statists will say, “SEE these outrageous bills that so many of you are having to pay? THIS is why we need single-payer Government-Almighty-run health care!” See the link above; it is already starting to happen!

    (Sorry to rain on y’all’s parades).

    1. If it’s state mandated and you refuse to pay, what happens?

      1. What happens when you refuse to pay your taxes?

        1. In my experience, you get lots and lots of letters from the IRS. The first few are polite, then they start estimating the taxes you owe.
          Then they force your withholding exemption down to 0.

          Eventually you give in just to make the letters go away.

      2. You hire a lawyer to argue against the contract, quasicontract, and equitable theories the hospital would rely on.

  3. bioethicist Kelly Hills told Business Insider last month. “It doesn’t meet what we would consider the minimum standards necessary for violating somebody’s civil rights.”

    The fact that bioethicists have a threshold for violating someone’s civil rights is far more disturbing than coronavirus not meeting that standard.

    1. Unless you go in with an absolutist mind-set, that nothing can justify violating someone’s civil rights, it’s not troublesome to think on the issue ahead of time (when not in a crisis situation, for example), to determine what things would be such a justification.

      If you do go in with such an absolutist mind-set, I suspect bioethicists are the least of things you find disturbing.

      1. I’m not an absolutist. I’m perfectly fine with them violating your rights.

      2. If they are attractive enough, I’m pretty sure a good portion of the commentariate would violate someone’s civil rights merely for the asking.

        The disturbing/concerning part isn’t the violation of civil rights, it’s the ‘we’.

        1. The disturbing/concerning part isn’t the violation of civil rights, it’s the ‘we’.

          How dare professionals talk to each other about ethics! The scandal!

          1. How dare they impose their ethics on me.

            1. Discussing ethics with peers (and occasionally reporters) imposes them on you?

              1. “It doesn’t meet what we would consider the minimum standards necessary for violating somebody’s civil rights.”

                1. yeah this ^^ part is the lolz.

                2. … you’re pointing to an assistant professor discussing ethics with a reporter as her imposing something on you?

                  1. If she had the power to, she would do it in an instant. Read what I write, not what you want me to have written.

                    1. I have read what you wrote. All that this woman has actually done is talk. And for the audacity of saying something you don’t like, you said “How dare they impose their ethics on me.”

                      And let’s go back to what was actually said:

                      “It doesn’t meet what we would consider the minimum standards necessary for violating somebody’s civil rights.”

                      Even in your hypothetical where she’s making any substantive decisions, her decision is to not institute a quarantine.

                      So to be clear… in the real world, she has done nothing more then say things you don’t like.

                      In your hypothetical world, she still hasn’t done anything to you.

                      But for this, you’ve declared that she has “impose[d] [her] ethics on you”.

                      For that matter, since when do hypotheticals impose anything? We could talk about the Trolley Problem till we’re blue in the face, and that doesn’t “impose” anything on the other.

                      Stop being such a snowflake. Her words haven’t hurt you.

                    2. “…Even in your hypothetical where she’s making any substantive decisions, her decision is to not institute a quarantine…”

                      So she’s being kind to us.
                      Hint; the implication is clear to most anyone. She is reserving the ability to impose her ethics if the situation meets her criteria.
                      I’m not sure if you’re this stupid or just being a pedant to deny being called on your bullshit.

                    3. And let’s go back to what was actually said:

                      “It doesn’t meet what we would consider the minimum standards necessary for violating somebody’s civil rights.”

                      Yes, let’s go back to what she said. She said she has a minimum standard where she would violate civil rights. The clear implication is that if this “minimum standard” is exceeded, a quarantine should be implemented. And yes, she would. In an instant.

                      Ask the nurse that Gov. McFattyfat (R-NJ) wrongly quarantined (in a tent, in a parking lot) if her civil rights should be violated.

                    4. @Sevo
                      To be clear, Sevo, are you an absolutist on this? That no forced quarantine can ever be justified?

                      If you are, then, as I pointed out in my first post, of course you have a problem, and it’s way bigger then what any bioethicist says.

                      If you aren’t, then what’s the problem with talking about what conditions a forced quarantine can be justified?

                      @Unicorn Abattoir
                      And I suppose I should check in here… are you an absolutist on this? ’cause as I already said, if you are, then I understand your point of view. This entire conversation (from my side at least) is premised on people not being an absolutist.

                    5. Escher – as I said upthread, I am not an absolutist. I’m perfectly fine with your civil liberties being taken from you.

  4. I don’t trust our government for one minute and no one should based on its history. I think this whole thing is being blown way out of proportion by both government entities and political parties for their own purposes that have nothing to do with our safety. quit frankly Trump has been the only sober person yet.

    1. It is best to stick with the scientific literature and ignore the politicians and media articles.

      There is a lot of it around. Johns Hopkins, NEJM and others have web pages up. I do think NIH and the CDC are good resources. Article from NIH today about a clinical trial underway testing an antiviral drug on infected patients.

      https://www.nih.gov/news-events/news-releases/nih-clinical-trial-remdesivir-treat-covid-19-begins

  5. bioethicists lol.

  6. I’m waiting for Reason to argue that open borders are the solution to arresting the spread.

    1. I think you just lit the Shikha bat signal.

  7. The only way to contain an outbreak is to air drop Dustin Hoffman in

    1. Without a parachute.

      1. From a helicopter?

  8. Is writing 10 articles per day about the coronavirus an effective diversion from Trump ending the longest war in American history?

    1. Apparently not, Terry.

    2. It ain’t over till the fat lady sings. In this particular case here, I don’t believe that the fat lady has sung yet.

      In Iraq, we had near-back-to-back, a 2-phase war. There are even those who say WW I and WW II were 2 phases of the same war against the Germans. If we’re outta Afghanistanistanistanistanistan for 5 months, and then right back in, has the fat lady sung yet, or not? It gets to be kinda hair-splitting…

      1. I’m surprised you’re not standing on some ledge for how much Trump has made you look like complete idiots… over and OVER!

        Really? What’s it going to take for you to admit he’s doing a damn good job?

        1. On Afghanistanistanistanistanistan, the now-signed agreement is only the tiniest step towards reducing NATO troops there, in dribbles and drabs. ***IF*** all goes well, we’ll be REALLY out in 14 months!

          https://www.politico.com/news/2020/02/29/taliban-peace-deal-afghanistan-118300
          All U.S. troops to withdraw from Afghanistan under peace deal
          ‘Conditions-based’ withdrawal will be complete in 14 months if Taliban keep commitments.

          I will believe it when I see it! If I had my way, we’d pull out unilaterally right now! We have no business there; this is national pride like usual.

          Trump has done a few good things here and there, I will admit that. Reduced regs, and reduced corporate taxes (which were WAAAY too high).

          Now drastically reduce the size of Government Almighty across the board, and THEN I will more whole-heartedly sing Trump’s praises!

    3. I think the daily Lady GaGa news is a more effective diversion.

      I mean I like her but do I really need daily updates?

  9. The primary purpose of a quarantine is to stop or slow down the spread of a disease. Even when it can’t be stopped, slowing it down acts to prevent the Health care system from being overwhelmed.

    “The Chinese government imposed a quarantine on the area around Wuhan, a city of 11 million that was at the center of the COVID-19 outbreak. ”

    And for the most part, most of China had a much lower infection and casualty rate than Hubei province did. 67,000 out of the 80,000 infections in China are in Hubei. 2,800 out of the 2,900 death in China are in Hubei.

    The circumstantial evidence is that the Hubei quarantine was both necessary and effective.

    1. Even within Hubei province – 75+% of the deaths and 50+% of the cases are in Wuhan with 20% of the peeps.

      That quarantine is the only thing that kept Wuhan from feeding out an exponentially increasing number of infected after Jan 23.

  10. if this virus really only offs the old and infirm, we’d do better to encourage its spread.

    ravaging the over 70 population would do a lot to get this country out of some financial holes

    1. Can’t tell if serious or Hitler

      1. LITERALLY hitler!

    2. I’m in!! I say let burn through a few times. A lot of cases out in the west coast, it think letting the virus burn through a few dozen times would be great. No cases in DC,yet, but I would mind it burning through DC a few times either

    3. The survivors will be nigh on invulnerable! Is that what you want, a race of super-elderly?

    4. You do realize that if the country shifted younger, our electorate would also shift bluer? That Boomers are weighted red isn’t a secret.

  11. ‘The Cato Institute’s Alex Nowrasteh argues that “extreme options like travel and immigration bans” would be more expensive than can be justified based on what we currently know about COVID-9. ‘

    The Open Borders Uber Alles crowd argues that we must keep the borders open!

      1. Not really.
        An FAQ site, answering all the questions you didn’t have.
        Please link, E, to the US mortality rate stats.

  12. Given that the tests for it are hit and miss at best, we have no real clue how contagious or deadly it really is. It is entirely possible it is as contagious as measles and much less deadly than the flu.

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  14. A couple of thoughts.

    One, because so much is unknown about COVID-19 in this outbreak (and other novel pathogens in new outbreaks in the future), I have less of a concern with a quarantine of limited duration and periodic reviews. We need good data and that is just not available yet (but we are close).

    Two, the downside risk to American society by getting the call wrong would be catastrophic: socially, economically, and from a public health perspective. The financial markets were in a near panic, and the MSM did us no favors amping up the rhetoric.

    Three, Does anyone really trust the data from China cited here? I say, “Look closely, but must verify before accepting it”. China has a track record of…opacity….in matters like these in the past. I am not willing to bet American lives on the veracity of Chinese data.

    In the absence of good clinical data that is reproducible and verifiable, my view is it is better to err on the side of limited (e.g. local or state, never Federal) and timebound local quarantines, then flatly prohibiting them.

  15. So, we seem to be speaking of a disease where asymptomatic people can spread the disease, and the results of catching it are that 20% require hospitalization, up to intensive care, and 2% or so will die.
    My wife is a doc, and her group has just published rules for dealing with suspected cases of the disease. One of those rules is a negative-pressure isolation environment, that does not share ventilation with other parts of the facility. Also, such patients should never be allowed in waiting rooms or hallways with unaffected patients.
    So do the math. How many negative pressure isolation rooms are in your city or county? How many ICU patients can your local hospital handle? What percentage of first responders or hospital workers can get sick before the capacity to respond is critically reduced?
    Quarantine is pretty much the most basic method to avoid these situations.

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    –Voltaire

    “Disease generally begins that equality which death completes.”

    –Samuel Johnson

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