US President Nixon greeting the Apollo 11 astronauts in NASA's mobile quarantine facility
Signal flag "Lima", called the "Yellow Jack", which when flown in harbour means the ship is under quarantine
A quarantine is a restriction on the movement of people and goods which is intended to prevent the spread of disease or pests. It is often used in connection to disease and illness, preventing the movement of those who may have been exposed to a communicable disease, but do not have a confirmed medical diagnosis. It is distinct from medical isolation,
in which those confirmed to be infected with a communicable disease are
isolated from the healthy population. Quarantine considerations are
often one aspect of border control.
The concept of quarantine has been known since biblical times,
and is known to have been practised through history in various places.
Notable quarantines in modern history include that of the village of Eyam in 1665 during the bubonic plague outbreak in England; East Samoa during the 1918 flu pandemic; the 1972 Yugoslav smallpox outbreak, and extensive quarantines applied throughout the world during the COVID-19 pandemic.
Ethical and practical considerations need to be considered when
applying quarantine to people. Practice differs from country to country.
In some countries, quarantine is just one of many measures governed by
legislation relating to the broader concept of biosecurity; for example Australian biosecurity is governed by the single overarching Biosecurity Act 2015.
Etymology and terminology
The word quarantine comes from quarantena, meaning "forty days", used in the 14th–15th-centuries Venetian language and designating the period that all ships were required to be isolated before passengers and crew could go ashore during the Black Death plague epidemic; it followed the trentino, or thirty-day isolation period, first imposed in 1347 in the Republic of Ragusa, Dalmatia (modern Dubrovnik in Croatia).
Merriam-Webster
gives various meanings to the noun form, including "a period of 40
days", several relating to ships, "a state of enforced isolation", and
as "a restriction on the movement of people and goods which is intended to prevent the spread of disease or pests". The word is also used as a verb.
Quarantine is distinct from medical isolation, in which those confirmed to be infected with a communicable disease are isolated from the healthy population.
Quarantine may be used interchangeably with cordon sanitaire, and although the terms are related, cordon sanitaire
refers to the restriction of movement of people into or out of a
defined geographic area, such as a community, in order to prevent an
infection from spreading.
History
Ancient
An early mention of isolation occurs in the Biblical book of Leviticus,
written in the seventh century BC or perhaps earlier, which describes
the procedure for separating out infected people to prevent spread of
disease under the Mosaic Law:
"If the shiny spot on the skin is white but does not appear to be more than skin deep and the hair in it has not turned white, the priest is to isolate the affected person for seven days. On the seventh day the priest is to examine him, and if he sees that the sore is unchanged and has not spread in the skin, he is to isolate him for another seven days."
Medieval Islamic world
The
Islamic prophet Muhammad advised quarantine: "Those with contagious
diseases should be kept away from those who are healthy." Ibn Sina also recommended quarantine for patients with infectious diseases, especially tuberculosis.
The mandatory hospital quarantine of special groups of patients, including those with leprosy, started early in Islamic history. Between 706 and 707 the sixth Umayyad caliph Al-Walid I built the first hospital in Damascus and issued an order to isolate those infected with leprosy from other patients in the hospital.
The practice of mandatory quarantine of leprosy in general hospitals
continued until the year 1431, when the Ottomans built a leprosy
hospital in Edirne.
Incidents of quarantine occurred throughout the Muslim world, with
evidence of voluntary community quarantine in some of these reported
incidents. The first documented involuntary community quarantine was
established by the Ottoman quarantine reform in 1838.
Medieval Europe
The word "quarantine" originates from quarantena, the Venetian language form, meaning "forty days". This is due to the 40-day isolation of ships and people practised as a measure of disease prevention related to the plague. Between 1348 and 1359, the Black Death wiped out an estimated 30% of Europe's population, and a significant percentage of Asia's population. Such a disaster led governments to establish measures of containment to handle recurrent epidemics. A document from 1377 states that before entering the city-state of Ragusa in Dalmatia (modern Dubrovnik in Croatia), newcomers had to spend 30 days (a trentine) in a restricted place (originally nearby islands) waiting to see whether the symptoms of Black Death would develop. In 1448 the Venetian Senate prolonged the waiting period to 40 days, thus giving birth to the term "quarantine".
The forty-day quarantine proved to be an effective formula for handling
outbreaks of the plague. Dubrovnik was the first city in Europe to set
up quarantine sites such as the Lazzarettos of Dubrovnik where arriving ship personnel were held for up to 40 days.
According to current estimates, the bubonic plague had a 37-day period
from infection to death; therefore, the European quarantines would have
been highly successful in determining the health of crews from potential
trading and supply ships.
Other diseases lent themselves to the practice of quarantine
before and after the devastation of the plague. Those afflicted with leprosy were historically isolated long-term from society, and attempts were made to check the spread of syphilis in northern Europe after 1492, the advent of yellow fever in Spain at the beginning of the 19th century, and the arrival of Asiatic cholera in 1831.
Venice
took the lead in measures to check the spread of plague, having
appointed three guardians of public health in the first years of the
Black Death (1348). The next record of preventive measures comes from Reggio/Modena in 1374. Venice founded the first lazaret (on a small island adjoining the city) in 1403. In 1467 Genoa followed the example of Venice, and in 1476 the old leper hospital of Marseille
was converted into a plague hospital. The great lazaret of Marseille,
perhaps the most complete of its kind, was founded in 1526 on the island
of Pomègues.
The practice at all the Mediterranean lazarets did not differ from the
English procedure in the Levantine and North African trade. On the
arrival of cholera in 1831 some new lazarets were set up at western
ports, notably a very extensive establishment near Bordeaux, afterwards turned to another use.
Modern history
The quarantine ship Rhin, at large in Sheerness. Source: National Maritime Museum of Greenwich, London
Epidemics of yellow fever ravaged urban communities in North America
throughout the late-eighteenth and early-nineteenth centuries, the
best-known examples being the 1793 Philadelphia yellow fever epidemic and outbreaks in Georgia (1856) and Florida (1888). Cholera and smallpox epidemics continued throughout the nineteenth century, and plague epidemics affected Honolulu and San Francisco from 1899 until 1901. State governments generally relied on the cordon sanitaire as a geographic quarantine measure to control the movement of people into and out of affected communities. During the 1918 influenza pandemic, some communities instituted protective sequestration (sometimes referred to as "reverse quarantine") to keep the infected from introducing influenza into healthy populations.
Isolating a village in Romania whose inhabitants believe that doctors poison those suspected of cholera (1911)
By the middle of the 19th century, the Ottoman Empire had established quarantine stations, including in Anatolia and the Balkans. For example, at the port of Izmir,
all ships and their cargo would be inspected and those suspected of
carrying the plague would be towed to separate docks and their personnel
housed in separate buildings for a determined period of time. In Thessaly,
along the Greek-Turkish border, all travellers entering and exiting the
Ottoman Empire would be quarantined for 9–15 days. Upon appearance of
the plague, the quarantine stations would be militarised and the Ottoman army would be involved in border control and disease monitoring.
International conventions 1852–1927
Since
1852 several conferences were held involving European powers, with a
view to uniform action in keeping out infection from the East and
preventing its spread within Europe. All but that of 1897 were concerned
with cholera.
No result came of those at Paris (1852), Constantinople (1866), Vienna
(1874), and Rome (1885), but each of the subsequent ones doctrine of
constructive infection of a ship as coming from a scheduled port, and an
approximation to the principles advocated by Great Britain for many
years. The principal countries which retained the old system at the time
were Spain, Portugal, Turkey, Greece and Russia (the British
possessions at the time, Gibraltar, Malta and Cyprus, being under the
same influence). The aim of each international sanitary convention had
been to bind the governments to a uniform minimum of preventive action,
with further restrictions permissible to individual countries. The
minimum specified by international conventions was very nearly the same
as the British practice, which had been in turn adapted to continental
opinion in the matter of the importation of rags.
The Venice convention of 30 January 1892 dealt with cholera by the Suez Canal
route; that of Dresden of 15 April 1893, with cholera within European
countries; that of Paris of 3 April 1894, with cholera by the pilgrim
traffic; and that of Venice, on 19 March 1897, was in connection with
the outbreak of plague in the East, and the conference met to settle on
an international basis the steps to be taken to prevent, if possible,
its spread into Europe. An additional convention was signed in Paris on 3
December 1903.
A multilateral international sanitary convention was concluded at Paris on 17 January 1912.
This convention was most comprehensive and was designated to replace
all previous conventions on that matter. It was signed by 40 countries,
and consisted of 160 articles. Ratifications by 16 of the signatories
were exchanged in Paris on 7 October 1920. Another multilateral
convention was signed in Paris on 21 June 1926, to replace that of 1912.
It was signed by 58 countries worldwide, and consisted of 172 articles.
In Latin America, a series of regional sanitary conventions were
concluded. Such a convention was concluded in Rio de Janeiro on 12 June
1904. A sanitary convention between the governments of Argentina,
Brazil, Paraguay and Uruguay was concluded in Montevideo on 21 April
1914. The convention covers cases of Asiatic cholera, oriental plague and yellow fever.
It was ratified by the Uruguayan government on 13 October 1914, by the
Paraguayan government on 27 September 1917 and by the Brazilian
government on 18 January 1921.
Sanitary conventions were also concluded between European states.
A Soviet-Latvian sanitary convention was signed on 24 June 1922, for
which ratifications were exchanged on 18 October 1923.
A bilateral sanitary convention was concluded between the governments
of Latvia and Poland on 7 July 1922, for which ratifications were
exchanged on 7 April 1925.
Another was concluded between the governments of Germany and Poland in
Dresden on 18 December 1922, and entered into effect on 15 February
1923.
Another one was signed between the governments of Poland and Romania on
20 December 1922. Ratifications were exchanged on 11 July 1923.
The Polish government also concluded such a convention with the Soviet
government on 7 February 1923, for which ratifications were exchanged on
8 January 1924.
A sanitary convention was also concluded between the governments of
Poland and Czechoslovakia on 5 September 1925, for which ratifications
were exchanged on 22 October 1926.
A convention was signed between the governments of Germany and Latvia
on 9 July 1926, for which ratifications were exchanged on 6 July 1927.
One of the first points to be dealt with in 1897 was to settle the incubation period
for this disease, and the period to be adopted for administrative
purposes. It was admitted that the incubation period was, as a rule, a
comparatively short one, namely, of some three or four days. After much
discussion ten days was accepted by a very large majority. The principle
of disease notification
was unanimously adopted. Each government had to notify to other
governments on the existence of plague within their several
jurisdictions, and at the same time state the measures of prevention
which are being carried out to prevent its diffusion. The area deemed to
be infected was limited to the actual district or village where the
disease prevailed, and no locality was deemed to be infected merely
because of the importation into it of a few cases of plague while there
has been no diffusion of the malady. As regards the precautions to be
taken on land frontiers, it was decided that during the prevalence of
plague every country had the inherent right to close its land frontiers
against traffic. As regards the Red Sea,
it was decided after discussion that a healthy vessel could pass
through the Suez Canal, and continue its voyage in the Mediterranean
during the period of incubation of the disease the prevention of which
is in question. It was also agreed that vessels passing through the
Canal in quarantine might, subject to the use of the electric light,
coal in quarantine at Port Said by night as well as by day, and that
passengers might embark in quarantine at that port. Infected vessels, if
these carry a doctor and are provided with a disinfecting stove, have a
right to navigate the Canal, in quarantine, subject only to the landing
of those who were suffering from plague.
21st century
In the 21st century, people suspected of carrying infectious diseases have been quarantined, as in the cases of Andrew Speaker (multi-drug-resistant tuberculosis, 2007) and Kaci Hickox (Ebola, 2014). Moving infected patients to isolation wards and home-based self-quarantine of people potentially exposed was the main way the Western African Ebola virus epidemic was ended in 2016; members of the 8th WHO
Emergency Committee criticised international travel restrictions
imposed during the epidemic as ineffective due to difficulty of
enforcement, and counterproductive as they slowed down aid efforts. The People's Republic of China has employed mass quarantines – firstly of the city of Wuhan and subsequently of all of Hubei province (population 55.5 million) – in the COVID-19 pandemic. After few weeks, the Italian government imposed lockdowns in all the country (more than 60 million people) to stop the coronavirus pandemic. During the COVID-19 pandemic, India quarantined itself from the world for a period of one month.
Signals and flags
Signal flag
"Quebec, " also called the "Yellow Jack" is a simple yellow flag that
was historically used to signal quarantine (it stands for Q), but in modern use indicates the opposite, as a signal of a ship free of disease that requests boarding and inspection.
Plain yellow, green, and even black flags have been used to symbolise
disease in both ships and ports, with the colour yellow having a longer
historical precedent, as a colour of marking for houses of infection,
previous to its use as a maritime marking colour for disease. The
present flag used for the purpose is the "Lima" (L) flag, which
is a mixture of yellow and black flags previously used. It is sometimes
called the "yellow jack" but this was also a name for yellow fever, which probably derives its common name from the flag, not the colour of the victims (cholera ships also used a yellow flag). The plain yellow flag ("Quebec" or Q in international maritime signal flags) probably derives its letter symbol for its initial use in quarantine, but this flag in modern times indicates the opposite—a ship that 'requests free pratique', i.e. that declares itself free of quarantinable disease, and requests boarding and routine port inspection.
Ethical and practical considerations
The quarantining of people often raises questions of civil rights, especially in cases of long confinement or segregation from society, such as that of Mary Mallon (also known as Typhoid Mary), a typhoid fever carrier
who was arrested and quarantined in 1907 and later spent the last 23
years and 7 months of her life in medical isolation at Riverside
Hospital on North Brother Island.
The United Nations and the Siracusa Principles
Guidance
on when and how human rights can be restricted to prevent the spread of
infectious disease is found in The Siracusa Principles, a non-binding
document developed by the Siracusa International Institute for Criminal Justice and Human Rights and adopted by the United Nations Economic and Social Council in 1984. The Siracusa Principles state that restrictions on human rights under the International Covenant on Civil and Political Rights must meet standards of legality, evidence-based necessity,
proportionality, and gradualism, noting that public health can be used
as grounds for limiting certain rights if the state needs to take
measures 'aimed at preventing disease or injury or providing care for
the sick and injured.' Limitations on rights (such as quarantine) must
be 'strictly necessary,' meaning that they must:
- respond to a pressing public or social need (health)
- proportionately pursue a legitimate aim (prevent the spread of infectious disease)
- be the least restrictive means required for achieving the purpose of the limitation
- be provided for and carried out in accordance with the law
- be neither arbitrary nor discriminatory
- only limit rights that are within the jurisdiction of the state seeking to impose the limitation.
In addition, when quarantine is imposed, public health ethics specify that:
- all restrictive actions must be well-supported by data and scientific evidence
- all information must be made available to the public
- all actions must be explained clearly to those whose rights are restricted and to the public
- all actions must be subject to regular review and reconsideration.
Finally, the state is ethically obligated to offer certain guarantees:
- Infected people will not be threatened or abused.
- Basic needs such as food, water, medical care, and preventive care will be provided.
- Communication with loved ones and with caretakers will be permitted.
- Constraints on freedom will be applied equally, regardless of social considerations.
- Patients will be compensated fairly for economic and material losses, including salary.[46]
Psychological impact
Quarantine can have negative psychological effects on those that are quarantined. These include post-traumatic stress, confusion and anger. According to a "Rapid Review" published in The Lancet in response to the COVID-19 pandemic,
"Stressors included longer quarantine duration, infection fears,
frustration, boredom, inadequate supplies, inadequate information,
financial loss, and stigma. Some researchers have suggested long-lasting
effects. In situations where quarantine is deemed necessary, officials
should quarantine individuals for no longer than required, provide clear
rationale for quarantine and information about protocols, and ensure
sufficient supplies are provided. Appeals to altruism by reminding the
public about the benefits of quarantine to wider society can be
favourable."
Short-term quarantines, e.g. for decontamination
Quarantine periods can be very short, such as in the case of a suspected anthrax attack, in which people are allowed to leave as soon as they shed their potentially contaminated garments and undergo a decontamination
shower. For example, an article entitled "Daily News workers
quarantined" describes a brief quarantine that lasted until people could
be showered in a decontamination tent.
The February/March 2003 issue of HazMat Magazine suggests that people be "locked in a room until proper decon could be performed", in the event of "suspect anthrax".
Standard-Times senior correspondent Steve Urbon (14 February 2003) describes such temporary quarantine powers:
Civil rights activists in some cases have objected to people being rounded up, stripped and showered against their will. But Capt. Chmiel said local health authorities have "certain powers to quarantine people".
The purpose of such quarantine-for-decontamination is to prevent the
spread of contamination and to contain the contamination such that
others are not put at risk from a person fleeing a scene where
contamination is suspect. It can also be used to limit exposure, as well
as eliminate a vector.
New developments for quarantine include new concepts in quarantine vehicles such as the ambulance bus,
mobile hospitals, and lockdown/invacuation (inverse evacuation)
procedures, as well as docking stations for an ambulance bus to dock to a
facility under lockdown.
Standard quarantine practices in different countries
Australia
Biosecurity in Australia is governed by the Biosecurity Act 2015. The Australian Quarantine and Inspection Service
(AQIS) is responsible for border inspection of products brought into
Australia, and assesses the risks the products might harm Australian
environment. No person, goods and vessels are permitted into Australia
without clearance from AQIS. Visitors are required to fill in the
information card on arriving in Australia. Besides other risk factors,
visitors are required to declare what food and products made of wood and
other natural materials they have. Visitors who fail to do so may be
subject to a fine of A$220, or may face criminal prosecution and be
fined up to A$100,000 or imprisonment of up to 10 years.
Australia has very strict quarantine standards. Quarantine in
northern Australia is especially important because of its proximity to
South-East Asia and the Pacific, which have many pests and diseases not
present in Australia. For this reason, the region from Cairns to
Broome—including the Torres Strait—is the focus for quarantine activities that protect all Australians.
As Australia has been geographically isolated from other major
continents for millions of years, there is an endemically unique
ecosystem free of several severe pests and diseases that are present in
many parts of the world.
If other products are brought inside along with pests and diseases, it
would damage the ecosystem seriously and add millions of costs in the
local agricultural businesses.
Canada
There are three quarantine Acts of Parliament in Canada: Quarantine Act (humans) and Health of Animals Act (animals) and Plant Protection Act (vegetations). The first legislation is enforced by the Canada Border Services Agency after a complete rewrite in 2005. The second and third legislations are enforced by the Canadian Food Inspection Agency. If a health emergency exists, the Governor in Council can prohibit importation of anything that it deems necessary under the Quarantine Act.
Under the Quarantine Act, all travellers must submit to screening and if they believe they might have come into contact with communicable diseases or vectors, they must disclose their whereabouts to a Border Services Officer.
If the officer has reasonable grounds to believe that the traveller is
or might have been infected with a communicable disease or refused to
provide answers, a quarantine officer (QO) must be called and the person
is to be isolated. If a person refuses to be isolated, any peace officer may arrest without warrant.
A QO who has reasonable grounds to believe that the traveller has
or might have a communicable disease or is infested with vectors, after
the medical examination of a traveller, can order him/her into
treatment or measures to prevent the person from spreading the disease.
QO can detain any traveller who refuses to comply with his/her orders or
undergo health assessments as required by law.
Under the Health of Animals Act and Plant Protection Act,
inspectors can prohibit access to an infected area, dispose or treat
any infected or suspected to be infected animals or plants. The Minister
can order for compensation to be given if animals/plants were destroyed
pursuant to these acts.
Each province also enacts its own quarantine/environmental health legislation.
Hong Kong
Under the Prevention and Control of Disease Ordinance
(HK Laws. Chap 599), a health officer may seize articles they believe
to be infectious or containing infectious agents. All travellers, if
requested, must submit themselves to a health officer. Failure to do so
is against the law and is subject to arrest and prosecution.
The law allows for a health officer who have reasonable grounds
to detain, isolate, quarantine anyone or anything believed to be
infected and to restrict any articles from leaving a designated
quarantine area. He/she may also order the Civil Aviation Department to
prohibit the landing or leaving, embarking or disembarking of an
aircraft. This power also extends to land, sea or air crossings.
Under the same ordinance, any police officer, health officer, member of the Civil Aid Service, or member of the Auxiliary Medical Service can arrest a person who obstructs or escapes from detention.
United Kingdom
To reduce the risk of introducing rabies
from continental Europe, the United Kingdom used to require that dogs,
and most other animals introduced to the country, spend six months in
quarantine at an HM Customs and Excise pound; this policy was abolished in 2000 in favour of a scheme generally known as Pet Passports, where animals can avoid quarantine if they have documentation showing they are up to date on their appropriate vaccinations.
British maritime quarantine rules 1711–1896
The
plague had disappeared from England for more than thirty years before
the practice of quarantine against it was definitely established by the
Quarantine Act 1710 (9 Ann.) The first act was called for due to fears that the plague might be imported from Poland and the Baltic states. The second act of 1721 was due to the prevalence of plague at Marseille and other places in Provence, France. It was renewed in 1733 after a new outbreak in continental Europe, and again in 1743, due to an epidemic in Messina. In 1752 a rigorous quarantine clause was introduced into an act regulating trade with the Levant,
and various arbitrary orders were issued during the next twenty years
to meet the supposed danger of infection from the Baltic states.
Although no plague cases ever came to England during that period, the
restrictions on traffic became more stringent, and in 1788 a very strict
Quarantine Act was passed, with provisions affecting cargoes in
particular. The act was revised in 1801 and 1805, and in 1823–24 an
elaborate inquiry was followed by an act making quarantine only at
discretion of the privy council,
which recognised yellow fever or other highly infectious diseases as
calling for quarantine, along with plague. The threat of cholera in 1831
was the last occasion in England of the use of quarantine restrictions.
Cholera affected every country in Europe despite all efforts to keep it
out. When cholera returned to England in 1849, 1853 and 1865–66, no
attempt was made to seal the ports. In 1847 the privy council ordered
all arrivals with a clean bill of health from the Black Sea
and the Levant to be admitted, provided there had been no case of
plague during the voyage, and afterwards the practice of quarantine was
discontinued.
After the passing of the first Quarantine Act (1710) the
protective practices in England were haphazard and arbitrary. In 1721
two vessels carrying cotton goods from Cyprus, then affected by the
plague, were ordered to be burned with their cargoes, the owners
receiving an indemnity.
By the clause in the Levant Trade Act of 1752, ships arriving in the
United Kingdom with a "foul bill" (i.e. coming from a country where
plague existed) had to return to the lazarets
of Malta, Venice, Messina, Livorno, Genoa or Marseille, to complete a
quarantine or to have their cargoes opened and aired. Since 1741 Stangate Creek (on the Medway)
had been the quarantine station but it was available only for vessels
with clean bills of health. In 1755 lazarets in the form of floating hulks were established in England for the first time, the cleansing of cargo (particularly by exposure to dews)
having been done previously on the ship's deck. No medical inspections
were conducted, but control was the responsibility of the Officers of Royal Customs
and quarantine. In 1780, when plague was in Poland, even vessels with
grain from the Baltic had to spend forty days in quarantine, and unpack
and air their cargoes, but due to complaints mainly from Edinburgh and
Leith, an exception was made for grain after that date. About 1788 an
order of the council required every ship liable to quarantine to hoist a
yellow flag
in the daytime and show a light at the main topmast head at night, in
case of meeting any vessel at sea, or upon arriving within four leagues of the coast of Great Britain or Ireland.
After 1800, ships from plague-affected countries (or with foul
bills) were permitted to complete their quarantine in the Medway instead
of at a Mediterranean port on the way, and an extensive lazaret was
built on Chetney Hill near Chatham (although it was later demolished). The use of floating hulks as lazarets continued as before. In 1800 two ships with hides from Mogador in Morocco were ordered to be sunk with their cargoes at the Nore,
the owners receiving an indemnity. Animal hides were suspected of
harbouring infections, along with a long list of other items, and these
had to be exposed on the ship's deck for twenty-one days or less (six
days for each instalment of the cargo), and then transported to the
lazaret, where they were opened and aired for another forty days. The
whole detention of the vessel was from sixty to sixty-five days,
including the time for reshipment of her cargo. Pilots had to pass
fifteen days on board a convalescent ship. From 1846 onwards the
quarantine establishments in the United Kingdom were gradually reduced,
while the last vestige of the British quarantine law was removed by the Public Health Act
of 1896, which repealed the Quarantine Act of 1825 (with dependent
clauses of other acts), and transferred from the privy council to the Local Government Board
the powers to deal with ships arriving infected with yellow fever or
plague. The powers to deal with cholera ships had been already
transferred by the Public Health Act 1875.
British regulations of 9 November 1896 applied to yellow fever, plague and cholera. Officers of the Customs, as well as of Royal Coast Guard and the Board of Trade
(for signalling), were empowered to take the initial steps. They
certified in writing the master of a supposedly infected ship, and
detained the vessel provisionally for not more than twelve hours, giving
notice meanwhile to the port sanitary authority.
The medical officer of the port boarded the ship and examined every
person in it. Every person found infected was taken to a hospital and
quarantined under the orders of the medical officer, and the vessel
remained under his orders. Every person suspected could be detained on
board for 48 hours or removed to the hospital for a similar period. All
others were free to land upon giving the addresses of their destinations
to be sent to the respective local authorities, so that the dispersed
passengers and crew could be kept individually under observation for a
few days. The ship was then disinfected, dead bodies buried at sea,
infected clothing, bedding, etc., destroyed or disinfected, and bilge-water and water-ballast
pumped out at a suitable distance before the ship entered a dock or
basin. Mail was subject to no detention. A stricken ship within 3 miles
of the shore had to fly a yellow and black flag at the main mast from
sunrise to sunset.
United States
In
the United States, authority to quarantine people with infectious
diseases is split between the state and federal governments. States (and
tribal governments recognised by the federal government)
have primary authority to quarantine people within their boundaries.
Federal jurisdiction only applies to people moving across state or
national borders, or people on federal property.
Federal rules
Communicable diseases for which apprehension, detention, or conditional release of people are authorised must be specified in Executive Orders of the President. As of 2014, these include Executive Orders 13295 13375, and 13674; the latest executive order specifies the following infectious diseases: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral haemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named), severe acute respiratory syndromes (SARS), and influenza from a novel or re-emergent source.
The Department of Health and Human Services is responsible for quarantine decisions, specifically the Centers for Disease Control and Prevention's Division of Global Migration and Quarantine. As of 21 March 2017, Centers for Disease Control and Prevention (CDC) regulations specify:
- All commercial passenger flights must report deaths or illnesses to the CDC.
- Individuals must apply for a travel permit if they are under a Federal quarantine, isolation, or conditional release order.
- When an individual who is moving between U.S. states is "reasonably believed to be infected" with a quarantinable communicable disease in a "qualifying stage", the CDC may apprehend or examine that individual for potential infection.
- This includes new regulatory authority permitting the CDC Director to prohibit the importation of animals or products that pose a threat to public health.
The rules:
- Do not authorise compulsory medical testing, vaccination, or medical treatment without prior informed consent.
- Require CDC to advise individuals subject to medical examinations that they will be conducted by an authorised health worker and with prior informed consent.
- Include strong due process protections for individuals subject to public health orders, including a right to counsel for indigent individuals.
- Limit to 72 hours the amount of time that an individual may be apprehended pending the issuance of a federal order for isolation, quarantine, or conditional release.
US quarantine facilities
The Division of Global Migration and Quarantine (DGMQ) of the US Center for Disease Control (CDC) operates small quarantine facilities at a number of US ports of entry. As of 2014, these included one land crossing (in El Paso, Texas) and 19 international airports.
Besides the port of entry
where it is located, each station is also responsible for quarantining
potentially infected travellers entering through any ports of entry in
its assigned region. These facilities are fairly small; each one is
operated by a few staff members and capable of accommodating 1–2
travellers for a short observation period.
Cost estimates for setting up a temporary larger facility, capable of
accommodating 100 to 200 travellers for several weeks, have been
published by the Airport Cooperative Research Program (ACRP) in 2008 of
the Transportation Research Board.
US quarantine of imported goods
The
United States puts immediate quarantines on imported products if a
contagious disease is identified and can be traced back to a certain
shipment or product. All imports will also be quarantined if the disease
appears in other countries. According to Title 42 U.S.C. §§264 and 266, these statutes provide the Secretary of Health and Human Services
peacetime and wartime authority to control the movement of people into
and within the United States to prevent the spread of communicable
disease.
History of quarantine laws in the US
Public Health Service Quarantine Station, New Orleans, Louisiana, 1957
Quarantine law began in Colonial America in 1663, when in an attempt to curb an outbreak of smallpox, the city of New York established a quarantine. In the 1730s, the city built a quarantine station on the Bedloe's Island. The Philadelphia Lazaretto was the first quarantine hospital in the United States, built in 1799, in Tinicum Township, Delaware County, Pennsylvania. There are similar national landmarks such as Swinburne Island and Angel Island. The Pest House in Concord, Massachusetts was used as early as 1752 to quarantine those suffering from cholera, tuberculosis and smallpox.
In early June 1832, during the cholera epidemic in New York, Governor Enos Throop
called a special session of the Legislature for 21 June, to pass a
Public Health Act by both Houses of the State Legislature. It included
to a strict quarantine along the Upper and Lower New York-Canadian
frontier. In addition, New York City Mayor Walter Browne established a
quarantine against all peoples and products of Europe and Asia, which
prohibited ships from approaching closer than 300 yards to the city, and
all vehicles were ordered to stop 1.5 miles away.
The Immigrant Inspection Station on Ellis Island, built in 1892, is often mistakenly assumed to have been a quarantine station, however its marine hospital (Ellis Island Immigrant Hospital) only qualified as a contagious disease facility to handle less virulent diseases like measles, trachoma
and less advanced stages of tuberculosis and diphtheria; those
afflicted with smallpox, yellow fever, cholera, leprosy or typhoid
fever, could neither be received nor treated there.
Mary Mallon was quarantined in 1907 under the Greater New York Charter, Sections 1169–1170, which permitted the New York City Board of Health to "remove to a proper place…any person sick with any contagious, pestilential or infectious disease."
During the 1918 flu pandemic,
people were also quarantined. Most commonly suspect cases of infectious
diseases are requested to voluntarily quarantine themselves, and
Federal and local quarantine statutes only have been uncommonly invoked
since then, including for a suspected smallpox case in 1963.
The 1944 Public Health Service Act
"to apprehend, detain, and examine certain infected persons who are
peculiarly likely to cause the interstate spread of disease" clearly
established the federal government's quarantine authority for the first time. It gave the United States Public Health Service
responsibility for preventing the introduction, transmission and spread
of communicable diseases from foreign countries into the United States,
and expanded quarantine authority to include incoming aircraft.
The act states that "...any individual reasonably believed to be
infected with a communicable disease in a qualifying stage and...if
found to be infected, may be detained for such time and in such manner
as may be reasonably necessary."
No federal quarantine orders were issued from 1963 until 2020, as American citizens were evacuated from China during the COVID-19 pandemic.
List of quarantine services in the world
- Australian Quarantine and Inspection Service
- MAF Quarantine Service, in the New Zealand
- Quarantine, Western Australia
- Samoa Quarantine Service, in the West Samoa
- Racehorse & Equine Quarantine Services, A company built & developed by Frankie Thevarasa Kuala Lumpur Malaysia
- Federal Service for Supervision of Consumer Rights Protection and Human Welfare, a Federal Quarantine Service of the Government of Russia.
Notable quarantines
Eyam village, 1665 (plague)
Eyam was a village in Britain that imposed protective sequestration
on itself to stop the spread of the bubonic plague in 1665. The plague
ran its course over 14 months and one account states that it killed at
least 260 villagers. The church in Eyam has a record of 273 individuals who were victims of the plague.
Convict ship Surry, Sydney Harbour, 1814 (typhoid)
Quarantine of the convict ship Surry on the North Shore of Sydney Harbour in 1814, the first quarantine in Australia
On 28 July 1814, the convict ship Surry arrived in Sydney Harbour from England. Forty-six people had died of typhoid
during the voyage, including 36 convicts, and the ship was placed in
quarantine on the North Shore. Convicts were landed, and a camp was
established in the immediate vicinity of what is now Jeffrey Street in Kirribilli. This was the first site in Australia to be used for quarantine purposes.
'Typhoid Mary' (US), 1907–1910 and 1915–1938
Mary Mallon was a cook who was found to be a carrier of Salmonella enterica subsp. enterica, the cause of typhoid fever,
and was forcibly isolated from 1907 to 1910. At least 53 cases of the
infection were traced to her, and three deaths. Subsequently she spent a
further 23 years in isolation prior to her death in 1938. The presence
of the bacteria in her gallbladder was confirmed on autopsy.
East Samoa, 1918 (flu pandemic)
During the 1918 flu pandemic, the then Governor of American Samoa, John Martin Poyer, imposed a full quarantine of the islands from all incoming ships, successfully achieving zero deaths within the territory. In contrast, the neighbouring New Zealand-controlled Western Samoa was among the hardest hit, with a 90% infection rate and over 20% of its adults dying from the disease. This failure by the New Zealand government to prevent and contain the Spanish Flu subsequently rekindled Samoan anti-colonial sentiments that led to its eventual independence.
Gruinard Island, 1942–1990 (anthrax)
In 1942, during World War II, British forces tested out their biological weapons program on Gruinard Island and infected it with anthrax. Subsequently a quarantine order was placed on the island. The quarantine was lifted in 1990, when the island was declared safe, and a flock of sheep was released onto the island.
Apollo series space explorers, 1969–1971
Between 24 July 1969 and 9 February 1971, the astronauts of Apollo 11, Apollo 12, and Apollo 14,
were quarantined (in each case for a total of 21 days) after returning
to Earth, initially where they were recovered and then being transferred
to the Lunar Receiving Laboratory, to prevent possible interplanetary contamination by microorganisms from the Moon. All lunar samples were also held in the biosecure environment of the Lunar Receiving Laboratory for initial assay.
Yugoslavia, 1972 (smallpox)
The 1972 Yugoslav smallpox outbreak was the final outbreak of smallpox in Europe. The World Health Organization fought the outbreak with extensive quarantine, and the government instituted martial law.
Case of Kaci Hickox' return to US, 2014 (Ebola)
In 2014, Kaci Hickox, a Doctors Without Borders
nurse from Maine, legally battled 21-day quarantines imposed by the
states of New Jersey and Maine after returning home from treating Ebola patients in Sierra Leone.
"Hickox was sequestered in a medical tent for days because New Jersey
announced new Ebola regulations the day she arrived. She eventually was
allowed to travel to Maine, where the state sought to impose a
'voluntary quarantine' before trying and failing to create a buffer
between her and others. A state judge rejected attempts to restrict her
movements, saying she posed no threat as long as she wasn't
demonstrating any symptoms of Ebola. Hickox said health care
professionals like those at the U.S. Centers for Disease Control and
Prevention – not politicians like New Jersey Gov. Chris Christie and
Maine Gov. Paul LePage – should be in charge of making decisions that
are grounded in science, not fear."
COVID-19 pandemic
During the COVID-19 pandemic, multiple governmental actors enacted quarantines in an effort to curb the rapid spread of the virus.
On 26 March, 1.7 billion people worldwide were under some form of lockdown, which increased to 2.6 billion people two days later—around a third of the world's population.
Hubei
In Hubei, the origin of the epidemic, a cordon sanitaire was imposed on Wuhan and other major cities in China, affecting around 500 million people, which is unprecedented in scale in human history,
to limit the rate of spread of the disease. The 'lockdown' of Wuhan,
and subsequently a wider-scale 'lockdown' throughout Hubei province,
began on 23 January 2020. At this stage, the spread of the virus in
mainland China was running at approximately 50% growth in cases per day.
On 8 February, the daily rate of spread fell below 10%.
Italy
As the outbreak spread there, beginning 22 February 2020, a cordon sanitaire was imposed on a group of at least 10 different municipalities in Northern Italy, effectively quarantining more than 50,000 people.
This followed a second day when the declared detected cases leapt
enormously (the period from 21 to 23 February saw daily increases of
567%, 295% and 90% respectively). A week later the rate of increase of
cases in Italy was significantly reduced (the period from 29 February to
4 March saw daily increases of 27%, 50%, 20%, 23% and 23%).
On 8 March 2020, a much wider region of Northern Italy was placed
under quarantine restrictions, involving around 16 million people.
On the next day, the quarantine was extended to the whole of Italy,
effective on 10 March 2020, placing roughly 60 million people under
quarantine.
A team of Chinese experts, together with some 31 tonnes of
supplies, arrived in Rome on 13 March 2020 to help Italy fight the
virus.
On 22 March 2020, Russia sent nine Ilyushin 76 planes with expert
virologists, epidemiologists, medical equipment and pharmaceuticals in a
humanitarian aid operation that Italian media dubbed "From Russia With
Love".
Rest of Europe
Slovakia closed borders to non-residents because of the coronavirus pandemic.
As cases of the virus spread to and took hold in more European
countries, many followed the earlier examples of China and Italy and
began instituting policies of lockdown. Notable among these were Ireland (where schools have been closed for the rest of March and limits set on sizes of meetings), Spain (where a lockdown was announced on 14 March), Czech Republic, Norway, Denmark, Iceland, Poland, Turkey and France, while the United Kingdom noticeably lagged behind in adopting such measures.
As of 18 March, more than 250 million people are in lockdown across Europe.
Rest of the world
In the immediate context of the start of the pandemic in Wuhan,
countries neighbouring or close to China adopted a cautious approach.
For example, Sri Lanka, Macau, Hong Kong, Vietnam, Japan and South Korea
had all imposed some degree of lockdown by 19 February.
As countries across the world reported escalating case numbers and
deaths, more and more countries began to announce travel restrictions
and lockdowns.
Africa and Latin America were relatively delayed in the spread of the
virus, but even on these continents, countries began to impose travel
bans and lockdowns. Brazil and Mexico began lockdowns in late February
and much of the rest of Latin America followed suit in early March. Much of Africa was on lockdown by the start of April. Kenya, for example, blocked certain international flights and subsequently placed a ban on 'global' meetings.
As of 1 April, more than 280 million people, or about 86% of the population, are under some form of lockdown in the United States, 59 million people are in lockdown in South Africa, and 1.3 billion people are in lockdown in India.
Self quarantine
Self quarantine (or self-isolation) is a popular term that emerged during the COVID-19 pandemic, which spread to most countries in 2020. Citizens able to do so were encouraged to stay home to curb the spread of the disease.
Other uses
U.S. President John F. Kennedy euphemistically referred to the U.S. Navy's interdiction of shipping en route to Cuba during the Cuban Missile Crisis as a "quarantine" rather than a blockade, because a quarantine is a legal act in peacetime, whereas a blockade is defined as an act of aggression under the U.N. Charter.
In computer science, "quarantining" describes putting files infected by computer viruses into a special directory, so as to eliminate the threat they pose, without irreversibly deleting them.
The Spanish term for quarantine, (la) cuarentena, refers also to the period of postpartum confinement in which a new mother and her baby are sheltered from the outside world.
