CASE STUDY

Isolation of an individual already treated for Ebola: has India gone too far?

Mahesh Devnani, Yan Guo

DOI: https://doi.org/10.20529/IJME.2015.065

Published online: April 28, 2015


Abstract

A 26-year-old Indian male travelling from Liberia to India after being treated for Ebola Virus Disease (EVD) was isolated at Delhi airport, even though he was symptom-free, because his semen was positive for Ebola virus. His blood, saliva and urine samples had tested negative for Ebola. There is no conclusive evidence of sexual transmission of EVD and the World Health Organisation does not recommend the isolation of convalescent patients whose blood is negative for Ebola virus. The decision of the Indian health authorities to isolate this individual is not only unscientific and excessively precautionary, but also raises various ethical and legal issues related to the potential violation of individual rights. The decision to impose individual restrictions during public health emergencies should be a transparent one that is guided by science, and should follow consultations among the various stakeholders. Further, such restrictions should be imposed only when alternative approaches are not sufficient or effective.

Ebola Virus Disease (EVD) has never been reported in India. In view of the experts’ warning that the disease will have devastating effects if it arrives in India, the Government of India (GoI) is taking several measures to prevent its entry. These include screening people coming and/or travelling from West African countries, designating certain hospitals in major cities as Ebola management centres, training healthcare workers and deploying rapid response teams in every state (1). So when a 26-year-old Indian male travelling from Liberia to India landed at Delhi’s Indira Gandhi International airport on November 10, 2014 and informed the Indian health authorities that he had been admitted in a health facility in Liberia from September 11-30, 2014, they decided to isolate him for further evaluation. This was in spite of the fact that he was asymptomatic and carried a certificate of medical clearance from the Ministry of Health and Social Welfare, Government of Liberia, stating that “he has successfully undergone care and treatment related to EVD and after post-treatment assessment, he has been declared free of any clinical signs and symptoms and confirmed negative by laboratory analysis” (2).

His three blood samples tested in India between November 10-13, 2014 were found to be negative for the Ebola virus. By now, the health authorities should have terminated his isolation. However, they decided to test his semen, probably because a few studies in the past have reported the presence of the Ebola virus in the semen of convalescent patients, with one such study reporting live Ebola virus in the semen of a convalescent man even 82 days after the onset of the disease (2, 3, 4). Two samples of this Indian traveller’s semen were sent to two different laboratories and these tested positive for the virus on November 17, 2014. After this, the Indian health authorities decided to keep him in isolation until all his body fluids tested negative, something which could take as long as three months (2). His urine and saliva samples, tested on November 21, 2014, were negative for the virus. However, it was decided that he would continue to remain in isolation till his semen tested negative (5). Meanwhile, the GoI imposed travel restrictions on individuals who had been treated for Ebola: they are not to enter India until 90 days after the date of discharge from hospital unless they produce a certificate stating that the Ebola virus is not present in their body fluids, including the blood, urine, vaginal fluid and semen, as well as stool (6).

A GoI press statement released on November 18, 2014 states that the testing of the Indian traveller’s semen and his subsequent isolation were done as a “matter of abundant caution” which would rule out even the remote possibility of the spread of EVD by the sexual route (2). Till date, there is no evidence of sexual transmission of EVD. One study that followed four men recovering from EVD and their sexual partners found that no sexual partner developed symptoms (7). The World Health Organisation (WHO) does not recommend the isolation of male convalescent patients whose blood has tested negative for EVD, as in case of this traveller. WHO advises that men who have recovered from EVD should maintain good personal hygiene after masturbation, and either abstain from sex (including oral sex) for three months after the onset of the symptoms, or use condoms if abstinence is not possible (8).

In the absence of any evidence of sexual transmission of EVD, isolation of a person for a period which could last as long as three months is not only an unscientific overreaction, but also raises serious ethical and legal issues related to the potential violation of individual rights (9). It is evident that the Indian health authorities have not made enough efforts to let the public know about the decision-making process, and the rationale behind imposing restrictions on the individual is arbitrary. There is no mention of the stakeholders involved in decision-making and if at all the ethical ramifications of such an extreme measure were deliberated upon while making a decision. The decision-making process is obscure and it seems that the decision was taken in haste, without consulting experts in law and bioethics. Due to the obscure decision-making process and the paucity of communication (eg few press releases), there is very little information on the alternative measures (if any) that were considered and found insufficient or ineffective before restrictive measures were imposed on the individual. There is no discussion of ethics and this person’s individual rights, and whether isolation is the best strategy for balancing the interests of the community and the rights of the individual in this particular instance. Experience with previous public health emergencies has shown that in the absence of a clear ethical framework and an understanding of the decision-making process, decisions may not be readily accepted and there may be long-term repercussions (10, 11).

During a public health emergency, a government has the legal right to take appropriate measures, in a transparent and ethical manner, to protect its citizens. However, while doing so, it must ensure that the decisions are evidence-based and that the interests of the community and the rights of the individual are well balanced. The rights of groups are important, but those of the individual are equally, if not more, important. According to Human Rights Watch, “International human rights law requires that restrictions on human rights in the name of public health or public emergency meet requirements of legality, evidence-based necessity, and proportionality. Restrictions such as quarantine or isolation of symptomatic individuals must, at a minimum, be provided for and carried out in accordance with the law. They must be strictly necessary to achieve a legitimate objective, the least intrusive and restrictive available to reach the objective, based on scientific evidence, neither arbitrary nor discriminatory in application, of limited duration, respectful of human dignity, and subject to review” (12). The Siracusa Principles also recommend that the restrictions imposed should be based on sound scientific evidence. In a democratic society, the restrictions should be strictly necessary to achieve the objective, and should be imposed only when no less intrusive and restrictive means are available to achieve the objective. The Siracusa Principles also say that such measures should be taken with due regard to the international health regulations of WHO (13).

Isolation and quarantine are extreme measures that require rigorous safeguards, including scientific assessment of the risk posed by the patient and the effectiveness of the measure. The process of taking a decision on such restrictions should be well thought out and communicated to all concerned in advance (14, 15). The stakeholders involved in the decision-making process should be representative of the society, and should include experts in public health, bioethics, law and human rights. They should disclose any conflict of interests. Researchers have proposed ethical frameworks for restricting personal freedom when managing such situations. Kass has suggested a six-step framework to guide health authorities in deciding upon an ethically sound course of action. The emphasis of this framework is on evaluating the various options available to them (16). According to Kinlaw and colleagues, restrictive interventions and procedures should be in the form of recommendations for voluntary action. Mandatory liberty-limiting interventions should be imposed only in cases in which voluntary actions seem unlikely to be effective (17).

What is more surprising in the present case is that there is not much national discourse in the scientific community and media on the ethical issues arising out of this decision. In contrast, the decision of the state of New Jersey in the United States to quarantine a symptom-free nurse returning from Sierra Leone gave rise to a huge debate and the matter was taken to court (18). In the present case, if the matter were taken to court, it would be very difficult for the GoI to justify its measures to curb individual rights for the larger good of society as (i) it lacks scientific evidence, (ii) such measures are not recommended by various international organisations, such as WHO and the Centers for Disease Control and Prevention, and (iii) no other democratic country in the world has taken such a drastic step to isolate convalescent patients who are coming from West African countries, having been cured of Ebola, on the basis of positive semen samples.

In conclusion, keeping a symptom-free person who is convalescing from Ebola in isolation, even though his/her blood, saliva and urine samples are negative, is not only unscientific and excessively precautionary, but also constitutes a clear violation of individual rights as there is no evidence that the person is a threat to the community. Unscientific and arbitrary “abundance of caution” cannot be a justification for the suspension of individual rights. Individual restrictions should be imposed with the utmost care and only when alternative approaches are not sufficient or effective. Such decisions should be guided by science and taken transparently, after prior consultations among the various stakeholders (community, providers and recipients), so as to balance the community’s interests and the individual’s rights.

Conflicts of interest: The authors declare no conflict of interest.

References

  1. The Indian Express. If Ebola comes to India. indianexpress.com. 2014 Nov 17 [cited 2015 Apr 4]. Available from: http://indianexpress.com/article/opinion/columns/if-ebola-comes-to-india/3/
  2. Press Information Bureau, Government of India, Ministry of Health and Family Welfare. Ebola treated and cured person from Liberia quarantined at Airport Health Organisation Quarantine Centre, Delhi [Internet]. New Delhi: MoHFW; 2014 Nov 18 [cited 2015 Apr 4]. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=111541
  3. Mackay IM, Arden KE. Ebola virus in the semen of convalescent men. Lancet Infect Dis. 2015 Feb; 15(2): 149-50. (article in press; DOI: 10.1016/S1473-3099(14)71033-3).
  4. Rodriguez LL, De Roo A, Guimard Y, Trappier SG, Sanchez A, Bressler D, Williams AJ, Rowe AK, Bertolli J, Khan AS, Ksiazek TG, Peters CJ, Nichol ST. Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, Democratic Republic of the Congo, 1995. J Infect Dis. 1999;179 (Suppl 1):S170-6.
  5. Press Information Bureau, Government of India, Ministry of Health and Family Welfare. Press note on Ebola [Internet]. New Delhi: MoHFW; 2014 Nov 22 [cited 2015 Apr 4]. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=111685 (accessed on December 1, 2014).
  6. Embassy of India, Niamey, Niger. Advisory for travelers to India who underwent treatment for Ebola Virus Disease [Internet]. 2014 Nov 25 [cited 2015 Apr 4]. Available from: http://www.indembniamey.org/pages.php?id=156 (accessed on December 1, 2014).
  7. Rowe AK, Bertolli J, Khan AS, Mukunu R, Muyembe-Tamfum JJ, Bressler D, Williams AJ, Peters CJ, Rodriguez L, Feldmann H, Nichol ST, Rollin PE, Ksiazek TG. Clinical, virologic, and immunologic follow-up of convalescent Ebola hemorrhagic fever patients and their household contacts, Kikwit, Democratic Republic of the Congo. Commission de Lutte contre les Epidémies à Kikwit. J Infect Dis. 1999;179 (Suppl 1):S28-S35.
  8. World Health Organization. Ebola virus in semen of men who have recovered from Ebola virus disease [Internet]. Geneva: WHO; 2015 Feb 9 [cited 2015 Apr 4]. Available from: http://www.who.int/reproductivehealth/topics/rtis/ebola-virus-semen/en/
  9. Devnani M, Guo Y. Ethical issues in isolating people treated for Ebola. BMJ. 2015;350:h140.
  10. Bernstein M, Hawryluck L. Challenging beliefs and ethical concepts: collateral damage of SARS. Crit Care. 2003;7:269-71.
  11. Devnani M. Factors associated with the willingness of health care personnel to work during an influenza public health emergency: an integrative review. Prehosp Disaster Med. 2012;27:551-66.
  12. Human Rights Watch. West Africa: Respect rights in Ebola response [Internet]. 2014 Sep 15 [cited 2015 Apr 4]. Available from: http://www.hrw.org/news/2014/09/15/west-africa-respect-rights-ebola-response
  13. United Nations, Economic and Social Council. Siracusa Principles on the limitation and derogation provisions in the international covenant on civil and political rights, U.N. Doc. E/CN.4/1985/4, Annex (1985). Geneva: UNESCO; c1985 [cited 2015 Apr 4]. Available from: http://www1.umn.edu/humanrts/instree/siracusaprinciples.html
  14. Gostin L. Public health strategies for pandemic influenza: ethics and the law. JAMA. 2006;295:1700-4.
  15. Devnani M, Gupta AK, Devnani B. Planning and response to influenza (H1N1) pandemic: ethics, equity and justice. Indian J Med Ethics. 2011;8:237-40.
  16. Kass NE. An ethics framework for public health. Am J Public Health. 2001;91:1776-82.
  17. Kinlaw K, Barrett DH, Levine RJ. Ethical guidelines in pandemic influenza: recommendations of the Ethics Subcommittee of the Advisory Committee of the Director, Centers for Disease Control and Prevention. Disaster Med Public Health Prep. 2009;3 (Suppl 2): S185-92.
  18. Drazen JM, Kanapathipillai R, Campion EW, Rubin EJ, Hammer SM, Morrissey S, Baden LR. Ebola and Quarantine. N Engl J Med. 2014;371:2029-30.