Tag Archives: Public Health Ethics

Quarantine on a Cruise Ship

USA Laws on Quarantine

According to the Center for Disease Control and Prevention (CDC, 2014), the Commerce Clause of the U.S. Constitution section 361 of the Public Health Service Act (42 U.S. Code § 264), empowers the U.S. Secretary of Health and Human Services (HHS) with the authority to prevent the entry and spread of communicable diseases not only from state to state, but also from foreign countries into the United States. The Federal HHS gives power to the CDC (2014) under 42 Code of Federal Regulations parts 70 and 71 “to detain, medically examine, and release persons arriving into the United States and traveling between states who are suspected of carrying these communicable diseases;” this includes cruise ship passengers and crew to find the cause of the illness.

Logistics on a Medical Tourist Cruise Ship?

Quarantine and public health interventions as it relates to cruise ship passengers’ issues may have some effectiveness because there are cabins for the customers. If each person had his or her own cabin when it comes to isolation, the sick could be isolated. If the disease is air-borne, there would need to be proper ventilation in place for the isolated and perhaps the area would need to be sectioned off from the rest of the ship to provide the best ventilation. The CDC (2017) has a Vessel Sanitation Program empowered by the Public Health Service Act (42 U.S.C. Section 264 Quarantine and Inspection Regulations to Control Communicable Diseases) with specific CDC (2010) site to check different cruise lines scores. Breaking a quarantine is a criminal misdemeanor and the laws are enforced by local, state, federal, and tribal authorities according to the CDC (2014). Sometimes, passengers travel for medical tourism. In this situation, the passenger would need to be cleared to travel to the foreign country to receive treatment. If a traveler went to India to receive a cheaper treatment, Petersen & Mohsin (2016) ask should that patient/passenger be screened for multi-resistant strains of bacteria?

International Cruise Ships and Refugees

According to the World Health Organization (WHO, 2017), a 2005 document called the IHR provides the foundation for the legal basis for the health documentation necessary for international travelers and for the safe “transport and sanitary protections for the users of international airports, ports, and ground crossings.” The third edition of the International Health Regulation (IHR, 2005), added on July 11, 2016, includes the World Health Assembly resolution WHA58.3, which is about a “period of protection of vaccination against yellow fever.” If there were travel restrictions and travel bans from areas where disease transmission is high, these would not be boarding a cruise ship, unless a Greek cruise ship were to pick-up Syrian refugees whose boats may have capsized, for example. Those saved may be likely quarantined even if yellow fever is not endemic to Syria due to the size and nature of a cruise ship experience expectations of hygiene, health, and customer service considerations. Regardless, the international and interstate rules on travel restrictions and the Ethics of all Passenger’s Rights to Know would have to be followed.

Safety, Ethics, and Keeping Passengers Informed 

On a cruise ship, there is usually one large cafeteria and maybe some smaller bars and snack shops. All the food service would have to be carefully controlled along the quarantine and isolation regulations. Control of communicable disease could be efficient as it would not take very long to de-board all other passengers not under quarantine or isolation.  Resources at stops along the cruise could be easily requested besides any in-house medical team that may distribute personal protective equipment as well. Issues some cruise passengers would have if there were a travel restriction would be the discomfort on their vacation at the very least. Customer service would need to be included in the quarantine and isolation requests.  Ethically, the whole ship would need to know their risks and the reason for the isolation and quarantine situations. For example, in Turkey, 2016, at a land tourist site there were suicide bombers according to Gonzalez & Lipman (2016). Making sure cruise passengers know their safety is secure is important besides making sure a disease in under control.

Sheila Bitts is a graduate student in Public Health at American Public University System, a poet, novelist, and an APUS 3MT Finalist for 2017.

Supporting Citation/References

CDC. (2014, October 8). Quarantine and Isolation. Legal Authorities for Isolation and Quarantine. https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html

CDC. (2010, January 6). Vessel Sanitation Program (Cruise Line). Advance Cruise Lone Inspection Search. Scores. https://wwwn.cdc.gov/InspectionQueryTool/InspectionSearch.aspx

CDC. (2017, June 28). Vessel Sanitation Program. https://www.cdc.gov/nceh/vsp/default.htm

Gonzalez, V. V., & Lipman, J. K. (2016). Tours of Duty and Tours of Leisure. American Quarterly68(3). (pp. 507-521).

Petersen, E., & Mohsin, J. (2016). Should Travelers Be Screened for Multi-Drug Resistant (MDR) Bacteria after Visiting High Risk Areas Such as India? Travel Medicine and Infectious Disease14(6). (pp. 591-594).

World Health Organization. (2016).  International Health Regulations (2005), 3rd edition.  https://edge.apus.edu/access/content/group/1997db15-1275-f9c5-b052-e3f6f6c9ef26/Lessons/Week%205/WHO%20IHR.pdf

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Retrospective on Ebola: Mitigation Blog

To the UN Executive Board and Advisory Committee: My student Blog Retrospective on Ebola

Sheila Bitts

American Public University System

July 16, 2017

Mitigation Blog

The West African Ebola Outbreak of 2013-2015: What Should Have Been Done?

The Protection of the United States and Other WHO Member States

At an August 8th, 2014 press conference in Geneva, Keiji Fukuda, the World Health Organization (WHO)’s assistant director general for health security and environment, located the Ebola “hotspot” as centered in Guinea, Liberia, and Sierra Leone where the borders meet as reported by Hawkes (2014).  Chan, the WHO director general, convened a two-day meeting held by the WHO emergency committee teleconference where the group proclaimed the outbreak as “a public health risk to other states” although no travel ban was implemented as per Hawkes (2014) who added that Chan did however call for those exiting the countries involved to be monitored for 21 days, as the incubation period ranges greatly from 2 to 21 days.

United States Quarantine Policy

Lee (2016) explains, that in the US, the Public Health Accreditation Board (PHAB) only approves of health departments that have a public health ethics board to discuss and deliberate the intervention among stakeholders.  The Center for Disease Control and Prevention (CDC, 2003) in the United States, orders that the communicable diseases which require isolation and quarantine are authorized through a Presidential executive order to control: “cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers,” and lastly, “severe acute respiratory syndrome (SARS),” which was added in April 2003.

The Zaire Ebola Virus as the Cause of the Epidemic

The Ebola Virus Zaire strain, which first appeared in the 1970s, was the “causative agent” of the outbreak which had about a 60% mortality rate, historically, but had a wider area of infection according to Hawkes (2014), who explained that Fukuda discouraged “large gatherings of people” at the hotspot area.  Chan conceded that techniques for containing Ebola’s spread were known, but that it was difficult to implement them in practice, because the areas involved had recently been fighting civil wars, and Hawkes (2014) further explained that Chan welcomed the help of  The World Bank and Médecins Sans Frontières, but knew the African weak medical infrastructure would be overwhelmed, therefore compelling Chan to convince the hotspot areas to shift into “urgent mode” and provide security for health workers as well, but this was to no avail.

The Epidemic Spreads

Initially, the WHO made their declaration in August 2014, when only Guinea, Liberia, Sierra Leone, and Nigeria had roughly 1779 cases with 961 deaths, as per Hawkes (2014), but by Mid-September 2014, the outbreak had spread to five countries in West Africa (Senegal), with approximately 4507 confirmed cases of Ebola, with 2296 deaths according to Team (2014).

Non-Compliance with Quarantine

Non-compliance with many of the African public health restrictions was pervasive.  In a recent publication in Social Science & Medicine, Blair, Morse & Tsai (2017) surveyed Liberian respondents who replied to the questionnaires expressing more distrust in the Liberian government if they had hardships.  Valeri, Patterson-Lomba, Gurmu, Ablorh, Bobb, Townes & Harling (2016) reported that the White regions reported no Ebola cases during the whole study period.

More Educated, The More Money to Bribe?

At the end of the study, Valeri et al (2016) were eventually led to the conclusion that education level did not mean more compliance during the outbreak according to their study on the sociological data from the whole region involved in the Ebola Virus Disease African epidemic of 2013-2015.  In fact, Valeri et al (2016) found that the “more educated areas of Guinea, Liberia and Sierra Leone had more severe Ebola outbreaks as measured by speed of epidemic growth and final epidemic size.”  The fastest growth rates of Ebola affected three capital cities: Conakry, Guinea; Monrovia, Liberia; and Freetown, Sierra Leone according to Valeri et al (2016), which are the same ones with the highest average education levels.  According to Pellecchia, Crestani, Decroo, Van den Bergh & Al-Kourdi (2015), it was common for people to bribe the burial teams for a burial in a private cemetery and to have funeral services at the funeral homes, defying the Liberian government’s cremation order interpretation of Fukuda’s WHO orders to show precaution regarding funerary practices.  In Social Science & Medicine, Blair’s (2017) Liberian questionnaire respondents who expressed non-compliance most likely did not trust the Liberian government even if the WHO was the initial messenger.

WHO Had Asked for Ethical Guidance

Knowing that this situation would have complicated dynamics from the beginning, according to Hawkes (2014), Marie-Paule Kieny, the WHO assistant director general, is quoted as saying in 2014, “We are in an unusual situation in this outbreak.  We have a disease with a high fatality rate without any proven treatment or vaccine.  We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”  Public health Ethicist Lee (2016) asks us to consider what we should do.  For example, Pellecchia et al (2015) explains that there was not only inconsistency in food distribution for those in the Liberian quarantine, but also stigma and hostility between the citizens and the government since the local leaders were not invited to the decision-making forums and no spiritual leaders were consulted, although they were essential for the affected communities.  Knowing that burial and cremation values conflict, citizens affected needed representation to safely and legally resolve the conflict without resorting to military violence. Otherwise, with such distrust due to health inequities, the public beneficence is not present nor authentic for the community involved; the WHO should have intervened to negotiate for inclusiveness for there to have been justice. The result could have saved more lives.


Tags: Public Health Ethics, Ebola, West Africa, Mitigation, Preparedness, Response, World Health organization (WHO), Center for Disease Control and Prevention (CDC), Community Engagement, Quarantine

Sheila Bitts is a graduate student in Public Health at American Public University System, a poet, novelist, and an APUS 3MT Finalist for 2017.

Ebola Vaccine Progress WHO Update: http://www.who.int/mediacentre/news/releases/2016/ebola-vaccine-results/en/


Supporting Citation Links/References

Blair, R. A., Morse, B. S., & Tsai, L. L. (2017, January). Public Health and Public Trust: Survey Evidence from The Ebola Virus Disease Epidemic in Liberia. Social Science & Medicine172. (pp. 89-97). http://www.sciencedirect.com/science/article/pii/S0277953616306256

CDC. (2003. April 4). Executive Order 13295: Revised List of Quarantinable Communicable Diseases: Former President George Bush. https://www.cdc.gov/sars/quarantine/exec-2004-04-03.html

Hawkes, N. (2014, August 9). Ebola Outbreak Is a Public Health Emergency of International Concern, WHO Warns. BMJ. 349: g5089. http://www.bmj.com/content/349/bmj.g5089

Lee, L.M. (2016, October 19). Ethics and Decision Making in Public Health October 2016. bioethicsgovhttps://www.youtube.com/watch?v=pMLCgekjTDw&feature=youtu.be

Pellecchia, U., Crestani, R., Decroo, T., Van den Bergh, R., & Al-Kourdi, Y. (2015). Social Consequences of Ebola Containment Measures in Liberia. PloS one10(12). e0143036. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0143036

Team, W. E. R. (2014, October 16). Ebola Virus Disease in West Africa—The First 9 Months of The Epidemic and Forward Projections. N Engl J Med2014(371). (pp. 1481-1495). http://www.nejm.org/doi/full/10.1056/NEJMoa1411100#t=article

Valeri, L., Patterson-Lomba, O., Gurmu, Y., Ablorh, A., Bobb, J., Townes, F. W., & Harling, G. (2016, October 12). Predicting Subnational Ebola Virus Disease Epidemic Dynamics from Sociodemographic Indicators. PLoS One. 11(10). doi: http://dx.doi.org.ezproxy2.apus.edu/10.1371/journal.pone.0163544 supporting citation link: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0163544



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