Andes hantavirus: The case for quarantine at home.
The CDC initially said MV Hondius cruise passengers did not have to quarantine. Now it won’t even let them decide where they must do so.
Yesterday, I spoke with four former MV Hondius cruise passengers currently staying at the National Quarantine Unit in Omaha, Nebraska. Each of them reached out to me, wanting to tell their story, give their opinion, or contribute insights. From them—and some from a travel photographer prolifically posting about life in quarantine on Instagram—I have gained a good sense of how people on the inside are thinking about things.
They are mostly in good spirits, if unnerved by the realization that their stay is not quite as voluntary as they had been initially led to believe. (Yesterday, Inside Medicine broke the news that a mandatory quarantine order signed by the CDC’s top official Dr. Jay Bhattacharya will be fought by at least one passenger. We can now add that a second passenger is also resisting, and I spoke to that individual on Tuesday as well.)
The most important news is excellent: None of the 18 Americans at the NQU have tested positive for the Andes hantavirus, either on PCR or serology (antibody) tests. That’s according to Angela Perryman, with whom I spoke for around thirty minutes on a video call yesterday.
The honeymoon is over.
Beyond that, though, things have become dicier. The other dissenting passenger at the NQU, a 30-year-old man from New York State who asked not to be named, said that on a Sunday evening Zoom call, officials “threatened…that if we didn’t agree to stay through May 31, we would be required to do so by formal quarantine orders.” He said Ms. Perryman and he declared that they “did not intend to cooperate and wanted to be transferred to home quarantine as everyone had been planning.”
He feels that the CDC is trying to strong-arm people into complying. “They really don’t want to formally quarantine anyone, so if they can get away with threatening and slow-walking then they will.” Now unable to leave, as of Tuesday evening, both he and Ms. Perryman (who are not otherwise connected) were exploring how to challenge the mandatory quarantine orders.
He and Ms. Perryman received a declaration from a CDC medical officer in support of the quarantine order (albeit the rationale does not quite add up, as we’ll discuss), signed by the same CDC physician, Dr. Nicole Cohen, the Associate Director for Science in the CDC’s Division of Global Migration Health.
The penalty for non-compliance? “Violations of this order may subject you to a criminal fine and/or up to one year in jail.”
Meanwhile, the other 16 passengers are remaining at the NQU voluntarily—though given the fact that the CDC issued mandatory quarantine orders for the two passengers who indicated that they wanted to leave, Dr. Bhattacharya does not seem to grasp what the word voluntary means. Regardless, everyone else has indicated that, for now, they will choose to stay at the NQU through May 31—or at least not resist the pressure to stay—which will mark the halfway point of the CDC’s advised 42-day monitoring period.
Is home quarantine safe?
In the documents that I reviewed, there seemed to be a debate over whether home-based quarantine for individuals with high-risk exposures to Andes hantavirus is safe or not.
On one side of the argument: the CDC. On the other: the CDC. So, who is right, the CDC or the CDC?
Indeed, in all versions the interim guidance published by the CDC (including the most recent one) since the hantavirus cluster was discovered, the agency has maintained that even for high-risk individuals, home-based management is an option. Some of this was based on prior CDC research, which demonstrated successful home-based quarantine for those with Andes hantavirus exposures. (Again, in those documents, the agency would not even admit that any of this was a quarantine.) Of course, we now know that the CDC is forcing everyone to stay in quarantine at the NQU in Omaha.
Online (including Inside Medicine commenters) many people said that the cruise passengers should be required to stay at the NQU for the full 42-day period that the CDC advises for monitoring. However, the CDC guidance itself did not previously take anything near that stance. But now that Jay Bhattacharya has taken that view—and he’s in charge—that’s what’s happening. At least for now.
The strange part, to me, is the medical justification document. The facts it provides would tend to favor the viewpoint of Ms. Perryman and the New York man fighting the order forcing them to remain at the NQU campus. The document lays out some facts including the median incubation period (20 days), the risk of symptoms being highest in (the first 21 days), and that infected individuals “are generally only infectious while symptomatic.” It further states that the spread of the virus from a newly infected person most often happens during the early phase of the illness. All of this could coherently explain why the CDC is not requiring other cruise passengers who left the ship in late April to report to the NQU. (Those individuals, whose existence was first reported by Kristina Fiore and me in MedPage Today are doing home-based management now. The CDC refuses to call that quarantine.) But none of that particularly justifies a fiat requiring that quarantine be completed at the NQU, rather than at home. It’s a bit of a non-sequitur—a series of facts that, in my view, facts that actually indicate that Ms. Perryman and her fellow travelers pose no special risk requiring a facility-based lockdown. Again, home-based management had been dangled as an option, if not promised to the passengers on arrival, when Ms. Perryman and the others were told they had to stay for 72 hours, but could leave after that, if they had a safe plan for home.
Nor is staying at the NQU necessarily any better. In the case of some emergency evacuation, what would happen to the 18 passengers? There are no backup rooms for everybody. So, in many cases, home-based quarantine would actually expose far fewer people than staying at the NQU would, in some situations. Moreover, Ms. Perryman was not thrilled about the masks they’ve been given for such eventualities. While they had been given N95’s on the voyage to Omaha, she says they now have “paper surgical masks,” in the event that they need to be around others, say, for blood testing, or other interactions with people.
Other online commenters reminded me that early in the Covid-19 pandemic, many people who were supposed to be in quarantine often violated it. But Covid-19, while deadly, did not have a fatality rate anywhere near that of Andes hantavirus. And in the early days of Covid-19, quarantines suddenly applied to thousands of people, meaning that even if a small percentage of people behaved badly, they seemed to be everywhere. Here, the group is small and taking this all very seriously.
Even commenters who defended the CDC’s new mandatory quarantine had not stopped to ponder why the CDC’s official guidance continues to explicitly contradict it. I asked HHS for a comment after hours, but haven’t heard back yet.
Additionally, the CDC seems to think that because over half of Andes hantavirus cases are expected in the first half of the 42-day monitoring period, it will be safe for everyone to leave 21 days in. That’s why they ideally want everyone staying at the NQU until May 31, and then to go home for the remainder. Are the more zealous members of the public who want this quarantine to be done at the NQU cool with this? It might reduce the risk, but it seems to me that those critical of Ms. Perryman’s approach might also want the CDC to go all-in, and require all of the passengers to remain at the NQU for the full 42 days.
These are admittedly complicated decisions. But misleading the passengers does not seem right to me—a point we’ll return to.
Some passengers have safe plans in mind.
The question on my mind, and on the minds of many, is whether these individuals really can safely quarantine in their homes. Getting home should not be a problem, as the government already informed them all that it would charter noncommercial flights, so as to not expose the public.
But once they’re home, how will it work? That’s something that CDC officials certainly had already thought of when they issued the guidance allowing home-based management as an option. So, this didn’t come out of nowhere. Still, the logistics matter, and I think the public has a right to ask how realistic it is.
So, I asked.
“The original at-home plan would still involve a formal, legal, mandatory quarantine. Just at home,” the New York male passenger fighting the mandatory NQU quarantine order told me.
He was both confident and serious about the task at hand. “I can do it at home safely,” he said. He lives in New York State (but asked that the county be withheld). “I can stay in my parents’ guesthouse on the same property as them and they can leave groceries and stuff outside the door, if that’s what’s required. No contact with any human at all for the whole period if required,” he said.
This wasn’t seen as some wild, unrealistic idea. Prior to receiving the mandatory order to stay at the NQU, he had discussed this all in detail with state and federal authorities. From that, he had not anticipated any problems. “We were all blindsided by this decision: us, the rank-and-file doctors at CDC, and our state and county public health authorities.”
From his perspective, the wheels had been in motion, and he was eager and willing abide by the restrictions necessary for home-based quarantine.
“My contact at the NY Department of Health told me that [the county] had already prepared a legal quarantine order keeping me at home. I’m not even asking not to be placed under legal quarantine. I just want to do it at home,” he said.
Now the CDC won’t let him, despite initial assurances. “Under the federal regulation (42 CFR Part 70), CDC is required to determine whether there are less restrictive alternatives that would adequately serve to protect the public health,” he said. “I don’t see how they can possibly determine that there aren’t, when there is one we had already been planning for and that NY was ready to implement.”
The reality is that he was planning on a regimen that was in fact more strict than the CDC’s initial guidance would have required.
A breach of trust.
“I want to mention another thing,” the male passenger told me, “which is that the regulations require these orders to be issued within 72 hours of a person’s being ‘apprehended.’ But the CDC/HHS folks evaded that requirement by continuously obfuscating whether we were here voluntarily since our arrival last Monday, even in response to repeated, pointed questions. So I think we have plenty of reasons to believe they are acting in bad faith.”
That bad faith led Ms. Perryman to refuse further hantavirus testing. While she initially accepted blood testing which proved that she was negative, she’s now worried that she can’t trust the officials. So as long as she is asymptomatic, she has no plans to allow further testing, that is, until she gets back to Florida (where she would like to complete her quarantine). She was offered testing two days ago, which would have been her second set of tests. She refused.
“At this point, I don’t actually trust them to use information responsibly. I’m no longer willing to offer them additional information because of a violation of trust. I’ve in fact asked that the information that I previously provided them in good faith be removed if I can legally do that. Now it’s a violation of trust,” Ms. Perryman said.
Dr. Alyssa Burger, a physician and ethicist wrote (in an Inside Medicine comment),“My concern is that this group was lied to [and] told they were staying voluntarily, but when they attempted to leave, the lie was revealed. The government had clearly thought through isolation options and presented isolation elsewhere as a choice. If the government had been willing to openly state they felt quarantine in the facility was so important that they would require it, that’s a choice within a range of choices. The reliance on coercion, manipulation, and threats is unacceptable. But, as you’ve pointed out, the government isn’t even willing to honestly use the word ‘quarantine.’”
A mental toll.
My friend Dr. Craig Spencer, an Ebola survivor, told me that Ms. Perryman’s words resonated with his own past. “The public and the press often talks about these issues in the abstract—what are the legal considerations, what does state law allow, what does the CDC recommend, etc?” he asked. “But at the end of the day, what people who have been exposed to a dangerous pathogen think about is not just how they can stay safe, but also how they can keep others safe.”
Ms. Perryman would seem to agree with that. “The idea that, ‘Well, this does no harm, so why don’t you just suck it up?’ But, in fact, this probably does do harm. It’s put us at a higher level of risk and it’s causing psychological trauma,” she said. “There is harm done…by issuing an order like this.”
Dr. Spencer also emphasized that it’s easy to tell other people to remain isolated for extended periods. “Until you’re forced to do it yourself and you don’t know just how horrible it can be.”
So just what does Angela Perryman—who has a master’s degree in emergency management— fear? Not Andes hantavirus. At least not at this point, given her negative tests and lack of symptoms. “We fear retaliation from federal officials.”
Resources:
Hemorrhagic fever with renal syndrome hantavirus.
Thank you for reading! If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.
Excellent piece, Jeremy.
I think that Ms. Perryman's final quote sums up where many of us are right now: “We fear retaliation from federal officials.” To generalize a bit, I suspect even more of us are fearful of and untrusting of our own government. It seems to me that the French underclass had the right approach in the late 1700s.
The newer details make the transparency and proportionality questions more difficult to dismiss.
Public health authorities have legitimate authority to impose quarantine in the setting of a dangerous communicable disease, particularly one with documented human-to-human transmission and a substantial fatality rate. But if home-based quarantine was previously considered medically acceptable, discussed with state authorities, and apparently presented to some passengers as a viable option, then the burden of explaining the sudden shift toward mandatory institutional confinement becomes substantially stronger.
Cases like this are difficult precisely because both public safety and civil liberties matter. Maintaining public trust requires not only sound medical judgment, but also clarity, consistency, and candor about why less restrictive alternatives are no longer considered adequate.