Measles Quarantine—The Individual and the Public

Travelers infected with measles in Canada were grounded due to measles.1 Air carriers are no longer willing to transport potential risk persons, as it may result in litigation or similar situation as described in this issue.2,3 The recently introduced World Health Organization (WHO) International Health Regulations 4 may result in some limitations to personal freedom in favor of public security. Quarantine still is an effective weapon in controlling a threat to public health—whereas freedom is a recent achievement of democracy and not historic. Persons who are noncompliant with official health requirements constitute a danger to health safety and may cause costly interventions. Tracing the origin of avoidable disease has become easier and therefore the person responsible for transmitting an infectious disease may be detected. Protecting against infection is a balancing act between public good and personal freedom. Should responsible individuals have to pay for an outbreak? When an epidemic of physical disease starts to spread, the community approves and joins in a quarantine of the patients in order to protect health of the community against the spread of the disease (Franklin D. Roosevelt, Speech at Chicago, October 5, 1937). In May 2007, 42 Japanese tourists among a group of 130 were denied the right to fly back from Canada because 1 member had developed measles upon arrival and another fell ill just before the scheduled return flight. All individuals in the group who were not immune to measles had to stay quarantined for 3 to 5 days before being allowed to return home.5 Are such dramatic travel restrictions justified? There are historical, epidemiological, and legal arguments to this question.6 In 2005, a 36‐year‐old unvaccinated Brazilian man acquired measles in the Maldives. On his return flight, he transmitted the infection to two passengers. Subsequent investigations revealed another four cases indirectly related to the index case. As this man had traveled not only on international but also on five domestic flights within Brazil, 73,282 contact persons had to be vaccinated against measles.7 In 2004, students from an Iowa college with a high number of nonmedical exemptions to vaccination traveled to India; 25% of them contracted measles while there. One exposed nonimmune student returned home while being infectious, necessitating 2 months of containment efforts in Iowa. More than 2,500 hours were expended to review flight lists, contact exposed passengers, trace more than 1,000 potentially exposed contacts, and enforce quarantine orders for vaccination refusers. More than 2,000 phone calls were received from the public. The total estimated cost was US$142,452.8 Actually, how many low‐income nations would have the resources or capacities to rapidly identify nonmeasles‐immune travelers as done in Canada for the Japanese tourists? If these differences exist, then how good is the global system? Measles has always been a potentially dangerous infection and an important cause of childhood mortality. Before the introduction of measles vaccine, about 500,000 cases of measles, 500 of them fatal, occurred in the United States annually.9 In 2003, an estimated half a million children worldwide still died of measles, half of them in Africa.10 Thanks to measles immunizations, there has been a decline in deaths associated with measles of 60% from 1999 to 2005.11 The Americas showed an estimated vaccination coverage for one measles vaccine dose in the target population of 92% in 2005. Successful vaccination campaigns in the Americas have reduced the number of measles cases to 85 in 2005, over half of these cases had been imported.12,13 Importations become a major source of measles in the Americas and other countries with a high herd immunity, and in 2004, the respective rate was even 73%. Actually, the measles genotypes of the regions of the Americas and Australia have been eliminated.14 Some European countries, Japan, and other Asian countries show an unsatisfactory compliance with WHO recommendations 15 and national vaccination guidelines, especially with respect to measles, mumps, and rubella immunization.16,17 Even though Europe had an overall measles vaccine coverage of 93% in 2005, there were countries such as Italy (87%), the UK (82%), and Switzerland (82%) where herd immunity was clearly not achieved.18 Japan in 2005 had an estimated vaccination coverage of 99% for one measles vaccine dose in the target population of the up to 90‐month‐olds.18 However, 9.8% of medical students were not protected against measles in 2006 19 because in 1990, the vaccination coverage for one dose had been only 66%. The generation of unprotected teenagers and young adults who escaped catch‐up vaccination campaigns represent a large susceptible population. Consequently, it is not surprising that in the past years, Europe and certain Asian countries (India, China, Japan, Philippines, and others) not only have been afflicted by measles outbreaks 20–22 but also have been the source of measles imported to the Americas and also to Australia.12,23,24 According to the Article 31 in the revised International Health Regulations, 4 persons might face “vaccination, isolation, quarantine or placing under public health observation” no longer only due to plague, yellow fever, or cholera but also due to any “event constituting a public health emergency of international concern.” Most educational facilities in the United States do not allow unprotected individuals to study at their colleges and universities unless measles vaccination is contraindicated or has been refused by claiming individual rights. Recently, however, unvaccinated students showing wavers against measles immunization were excluded from staying on the campus for 3 weeks after an unvaccinated student infected three other students with measles.25 Is it acceptable that individual preferences threaten the health of others? Must we tolerate that passengers in an airplane or individuals in public places or compulsory institutions like public schools might inadvertedly be exposed to measles? Personal freedom is limited by the rights of the public. Being noncompliant, eg, with vaccination recommendations can be sanctioned by authorities on the basis of national legislation. Individuals refusing to protect themselves and others are a public health hazard and now face consequences while traveling. As tracing has become easier, an index case nowadays might face claims for penalties and covering costs of subsequent investigations, basing on the revised International Health Regulations. If nations allow their citizens to avoid routine measles immunization, should it be the state or the individual who is responsible for downstream exposure to travelers? The authors state that they have no conflicts of interest.

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