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CDC Director: Why I don’t support a travel ban to combat Ebola outbreak

Posted on by Dr. Tom Frieden, Director of CDC

 

This blog was originally posted on Fox News on October 9, 2014.

 

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CDC Director Dr. Tom Frieden
CDC Director Dr. Tom Frieden

The first case of Ebola diagnosed in the United States has caused some to call on the United States to ban travel for anyone from the countries in West Africa facing the worst of the Ebola epidemic.

That response is understandable. It’s only human to want to protect ourselves and our families. We want to defend ourselves, so isn’t the fastest, easiest solution to put up a wall around the problem?

But, as has been said, for every complex problem, there’s a solution that’s quick, simple, and wrong.

A travel ban is not the right answer. It’s simply not feasible to build a wall – virtual or real – around a community, city, or country. A travel ban would essentially quarantine the more than 22 million people that make up the combined populations of Liberia, Sierra Leone, and Guinea.

We don't want to isolate parts of the world, or people who aren't sick, because that's going to drive patients with Ebola underground, making it infinitely more difficult to address the outbreak.When a wildfire breaks out we don’t fence it off. We go in to extinguish it before one of the random sparks sets off another outbreak somewhere else.

We don’t want to isolate parts of the world, or people who aren’t sick, because that’s going to drive patients with Ebola underground, making it infinitely more difficult to address the outbreak.

It could even cause these countries to stop working with the international community as they refuse to report cases because they fear the consequences of a border closing.

Stopping planes from flying from West Africa would severely limit the ability of Americans to return to the United States or of people with dual citizenship to get home, wherever that may be.

In addition to not stopping the spread of Ebola, isolating countries will make it harder to respond to Ebola, creating an even greater humanitarian and health care emergency.

Importantly, isolating countries won’t keep Ebola contained and away from American shores. Paradoxically, it will increase the risk that Ebola will spread in those countries and to other countries, and that we will have more patients who develop Ebola in the U.S.

People will move between countries, even when governments restrict travel and trade. And that kind of travel becomes almost impossible to track.

Isolating communities also increases people’s distrust of government, making them less likely to cooperate to help stop the spread of Ebola.

Isolating communities and regions within countries will also backfire. Restricting travel or trade to and from a community makes the disease spread more rapidly in the isolated area, eventually putting the rest of the country at even greater risk.

To provide relief to West Africa, borders must remain open and commercial flights must continue.

There is no more effective way to protect the United States against additional Ebola cases than to address this outbreak at the source in West Africa. That’s what our international response—including the stepped-up measures the president announced last month—will do.

What works most effectively for quelling disease outbreaks like Ebola is not quarantining huge populations.

What works is focusing on and isolating the sick and those in direct contact with them as they are at highest risk of infection. This strategy worked with SARS and it worked during the H1N1 flu pandemic. Casting too wide a net, such as invoking travel bans, would only provide an illusion of security and would lead to prejudice and stigma around those in West Africa.

Americans can be reassured we are taking measures to protect citizens here.

Today, all outbound passengers from Guinea, Liberia, and Sierra Leone are screened for Ebola symptoms before they board an airplane.

Staff from CDC and the Department of Homeland Security’s Customers & Border Protection will begin new layers of entry screening, first at John F. Kennedy International Airport in New York this Saturday, and in the following week at four additional airports — Dulles International Airport outside of Washington, D.C.; Newark Liberty International Airport; Chicago’s O’Hare International Airport; and Hartsfield-Jackson Atlanta International Airport.

Combined, these U.S. airports receive almost 95 percent of the American-bound travelers from the Ebola-affected countries.

Travelers from those countries will be escorted to an area of the airport set aside for screening. There they will be observed for signs of illness, asked a series of health and exposure questions, and given information on Ebola and information on monitoring themselves for symptoms for 21 days. Their temperature will be checked, and if there’s any concern about their health, they’ll be referred to the local public health authority for further evaluation or monitoring.

Controlling Ebola at its source – in West Africa – is how we will win this battle. When countries are isolated, we cannot get medical supplies and personnel efficiently to where they’re needed – making it impossible to fight the virus in West Africa.

As the WHO’s Gregory Hartl said recently, “Travel restrictions don’t stop a virus. If airlines stop flying to West Africa, we can’t get the people that we need to combat this outbreak, and we can’t get the food and the fuel and other supplies that people there need to survive.”

We know how to stop Ebola: by isolating and treating patients, tracing and monitoring their contacts, and breaking the chains of transmission.

Until Ebola is controlled in West Africa, we cannot get the risk to zero here in the United States.

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Posted on by Dr. Tom Frieden, Director of CDCTags , , ,

19 comments on “CDC Director: Why I don’t support a travel ban to combat Ebola outbreak”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    “When a wildfire breaks out…” Mr Frieden, we dig firebreaks, or did at one point in firefighting history. We do this while fighting the fire.

    I don’t suggest we cease humanitarian efforts. A ban on non-essential travel between Ebola-ravaged nations and the United States is not unreasonable. “Essential” would include those seeking to provide aid and those seeking political refuge or, as you have said, a return home. I will point out that for those returning, surely twenty-one days’ quarantine for public health purposes isn’t unreasonable. Anyone who’s gone visiting lately (that is, within the past few months) in the aforementioned nations knew perfectly well she was entering a hot zone. Anyone fleeing a deteriorating situation would be grateful just to find herself safe, never mind waiting three weeks to see if she’s ill. Or would you blithely walk off such a flight into the arms of your family, wondering if you were exposed?

    As for screening passengers, we now know exactly how well that works, between the gentleman who was asymptomatic upon boarding and the nurse who, when she reported a fever post-exposure, was told by your organisation to fly anyway.

    Again, I am not suggesting we halt all efforts to stop this disease at its source. I am suggesting a sensible middle ground between a complete ban and completely open borders. I do not believe my city will become the next Dallas — we have too good a teaching hospital for that; they’d never let themselves get lax for fear of losing their reputation! I ask that the United States consider exercising caution for the sake of public health. That’s all.

    To me this statement by Frieden strikes of total ignorance, and irresponsibility. Oceans are natural barriers to disease. Why is it agricultural products are banned at customs to prevent the transmission of pests, fungi and other pathogens that could infect our crops and yet people possibly carrying a deadly disease don’t pose a threat?
    This outbreak isn’t under control-that is obvious. The safety clothing for health workers isn’t 100% effective; the virus now takes 42 not 21 days to incubate in 3 % or so of cases; the virus can now apparently live on surfaces; can be spread by coughs and sneezes, etc etc.Sweat and mucus are bodily fluids-who has never sweated etc on a plane-apparently fit or otherwise ?If 0% people enter the country, then 100% of that source is prevented. Sure there are others, but isolation is the most effective way to contain the spread of a disease-that’s not news. Hospitals do it all the time( when they actually think and recognize potential diseases that is)Air travel need not be 100% banned, as obviously these poor folk in Africa need food, medicine etc, but how exactly can isolating the virus cause it to spread more than flying thousands of people into this country every day from an infected area, when there is NO means of ensuring they are disease free? How can anyone possibly follow every contact an infected person may have had? They CAN’T!. Other scientists at the CDC don’t apparently agree with the directors comments-isn’t it time Frieden was replaced? As Frieden thinks Ebola is so hard to catch maybe he should personally fly to W.Africa and assess the situation and rethink his organisation’s policy( after he’s spent 42 days in isolation before re-entering the US. I have dual citizenship, but would not dream of flying home if this country were in the midst of a deadly epidemic!

    As an RN. I believe this outbreak is already out of control as we can see to date even personnel in the USA is not ready to deal with this in all hospitals. Air travel does not have to be ban but there should be pre and post containment units where travels can be detained for 7-10 before boarding an airline and 7-10 days after arriving to there destination airport before going into the major population and exposing others. We can see that the infected can convert during travel even if they board with out fever. Interventions of this magnitude should be implement immediately to avoid further havoc that seems inevitable and out of control already.

    My question is, since they don’t want to suspend travel from these infected countries why don’t the just quarantine these travelers for 21 days after they arrive here in the US? The ignorance on the part of the leadership of the CDC is appalling. Why isn’t there and infectious disease Dr. from the CDC explaining the dangers of Ebola? We are not being told the complete truth. This virus has the potential to wipe out hundreds of thousands of Americans if not millions. And they just want to treat it as a casual disease that can’t really be spread around by casual contact. This could turn into an epidemic if it isn’t brought under control. Please stop this insanity and take this virus seriously. The irresponsibility of the CDC is beyond the pale!!

    As a professional virologist, I believe that strict quarantine is essential, unless it is already too late. The anti-quarantine mind set is very dangerous. The US and other countries should send help, and plenty of it. However, ALL people responding to this humanitarian crisis should be quarantined themselves for at least 3 wks. before being let back into their home countries. Sorry, but this calls for tough measures and quarantine is better than a lethal, biohazard level 4 pandemic. This means Ebola is right up there with smallpox and anthrax. It makes you wonder where we would be if the US had been subjected to Ebola as a bioweapon. On the other hand, I don’t wonder….I KNOW.

    I agree with the previous writers. We should ban travel to the US from West Africa until this epidemic is under control.
    As a clinical laboratory scientist the thought that Ebola-tainted blood could be tested in any clinical lab without knowledge ( universal precautions not withstanding) would put lab staff at serious risk. UP’s are not enough protection when an entire instrument(s)
    is contaminated. The hands on maintenance and trouble-shooting alone could easily contaminate the operator. It is not unheard-of for plastic tubing and probes to fail, squirting lethal body fluids onto the operator; who would then soon infect coworkers and their families…on and on. This is chilling. Sometimes the government and the public forget that other professional healthcare workers exist beyond just the doctor and the nurse. ANYONE handling body fluids from an Ebola patient needs full protection-not easily achieved today by those on the front lines. What about everyone else?

    Dr. Frieden,

    Based off my two STEM degrees, chemical engineering and biological sciences, I know that activity like this could cause MANY Americans to die[1]. Think I am being an alarmist? Consider the following and then read the final quote.

    How long did it take the Ebola virus to travel “equivalent distances” in Africa? It took very little time for Ebola to be recognized in Texas, Kansas, and Ohio. That is rapid advancement in little time because our society, unlike Africa, has significant travel between States.

    The above is also a reason why travel should be minimized.

    When I worked for the US FDA as a Consumer Safety Officer, we would, for example, monitor the “risk” of imports. If the “risks” were great because, for example, a manufacture was known to make contaminated or adulterated product, we would force the “hold” of the product until the importer had the product properly sampled, tested, and proved safe. If they did not, the product was seized and destroyed. Why did we do this?

    There are people in this world that have no concern for others and only concern for themselves. Why? Because of financial gain in most cases. Governments are composed of “people.”

    Ebola is a very dangerous virus. I have read the “Hot Zone,” and I know the possibilities.

    Quote: “Six of the 178 people who had contact with the infected monkeys at the Reston Quarantine Unit seroconverted. All six of the individuals worked with the primates. None of the six who seroconverted developed a filovirus-related illness. Of them, four (all of whom were animal handlers at one quarantine facility) had serologic evidence of recent infection with Ebola-Reston. It is likely that one of the four infected himself when he cut his finger while performing a necropsy on an infected monkey. The mode of transmission for the other three handlers is not known. The remaining two people were seropositive at low titer and had evidence of past infection. One of these two people is a worker at a facility that temporarily houses nonhuman primates before delivery to U.S. quarantine facilities and had had regular contact with quarantined nonhuman primates for three years. The second person was an employee at Hazleton’s Texas Primate Center.”[2]

    I have done preliminary research about research into Ebola, and I have discovered that only a few cases of animal research have used the full Ebola virus because of the “dangers.”

    Dr. Frieden, there are times when positive thinking is stupid. As a chemical engineer, I witnessed severe illegal activity at one major pharmaceutical corporation that adulterated at least 25-30 batches of a major antibiotic. Note that each batch relates to approximately 6,000,000 preparations. Now, that drug has been associated with Torsades de Pointes[5;6]. I believe it is possibly because of the manufacturing process. I have read research related to Torsades de Pointes (sudden cardiac death) as well, and the FDA believes other factors related to ion channels, along with QT prolongation, is responsible for why some QT prolonging drugs cause Torsades de Pointes, and some don’t[4]. Why did I waste your time with the above?

    The engineers and scientist that did the above, in my opinion, were sociopathic and psychopathic. Still, they also engaged in much “positive thinking.” They literally said that “no body has died have they.” It looks like they were likely wrong, and I was likely correct.

    Quote: “After adjusting for factors such as age, sex, baseline cardiac risk and use of other medication, ongoing use of clarithromycin was associated with a 76% higher risk of cardiac death compared with use of penicillin V. There was no increased risk of cardiac death with clarithromycin after treatment had ended.”[6]

    By the way, my life was destroyed for blowing the whistle, my career was destroyed, and the stress exacerbated my 1991 Gulf War Illnesses and precipitated schizoaffective disorder (bipolar type). Yes, I am ill, but I realize dangerous situations when I see them.

    Dangerous Quote: ”The CDC confirmed to FOX 4 News that they gave Vinson the green light to fly. “Vinson was not told that she could not fly,” a government spokesperson told NBC News.

    Vinson’s comments contradict remarks made earlier today by CDC Director Tom Freiden, who said that she never should have gotten on the plane.” [1]

    References:

    [1] Horowitz, Alana. (2014, Oct. 15). Amber Vinson, Dallas Ebola Patient, Says CDC Gave Her Green Light To Fly. Retrieved (2014, Oct. 15). huffingtonpost[online]. Available from: http://www.huffingtonpost.com/2014/10/15/amber-vinson-cdc-ebola_n_5993486.html

    [2] Stanford University. Ebola Reston Outbreaks. stanford.edu[online]. 2014. Available from: http://www.stanford.edu/group/virus/filo/ebor.html

    [3] Kenyon College. Infection Mechanism of Genus Ebolavirus. Retrieved (2014, Oct. 03). microbewiki.kenyon.edu[online]. Available from: https://microbewiki.kenyon.edu/index.php/Infection_Mechanism_of_Genus_Ebolavirus

    [4] Johannesen, L; Vicente, J; Gray, RA; Galeotti, L; Loring, Z; Garnett, CE; Florian, J; Ugander, M; Stockbridge, N; Strauss, DG. Improving the Assessment of Heart Toxicity for All New Drugs through Translational Regulatory Science, Dec. 2013. Clin Pharmacol Ther[online]. 2013. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24336137 doi: 10.1038/clpt.2013.238

    [5] Harding, Chris. (2014, Aug. 20). I blew the whistle on this drug: “Common antibiotic linked with heart deaths (clarithromycin).” Retrieved (2014, Aug. 20). facebook.com[online]. Available from: https://www.facebook.com/notes/chris-harding/i-blew-the-whistle-on-this-drug-common-antibiotic-linked-with-heart-deaths-clari/10152403178948477

    [6] Medicalxpress. (2014, Aug. 19). Common antibiotic linked with heart deaths (clarithromycin). Retrieved (2014, Aug. 20). medical express.com[online]. Available from: http://medicalxpress.com/news/2014-08-common-antibiotic-linked-heart-deaths.html

    I understand, applaud, agree with and try to defend your argument, Dr. Frieden. But perhaps there is something more that could be done IF we could fund it and find willing partners to manage it, and If we could secure the cooperation of the travelers involved. That would be (I know this sounds awful) placing the 150 or so passengers who fly here daily (via one route or another) under some form of isolation until 21 days has expired since they were last in West Africa. I think that’s essentially the plan for our returning troops. The great advantage to some of those travelers would be that we would have them inside a sort of safety net already IF they began to display symptoms of ebola. Again, like with our troops. I also know that this wouldn’t necessarily completely stop the import of ebola into the USA because it’s already gotten to Spain (for example). But, at the same time, perhaps this strategy could be managed in a way that would slow the impact of ebola here and give us all a better chance to fight it there. Obviously, I don’t know for certain. Murphy’s Law and human nature (e.g. Dr. Snyderman) being what they are. Yet, perhaps some of your strategic thinkers should toss this around if they haven’t already. All the best, and thank you for everything CDC is doing.

    Revised:
    Dr. Tom Frieden,

    I absolutely disagree with you on your reasoning against the proposed travel ban. You propose to have NO TRAVEL RESTRICTIONS/BANS on people from endemic countries to the USA. You have not explained how that will help to stop the spread of Ebola. You have presented the proposed ban on travel as if it is a bad thing. Stating it simply, the take home message from your statement is: Allow free travel between countries, no quarantine needed because it neither can be done, nor is it helpful. Not only that, you go on to categorically state that a travel ban/quarantine is actually WRONG!

    This is shocking, to say the least.

    Quarantine and travel restrictions from and to endemic areas are known to be scientifically robust means to prevent the spread of communicable diseases.

    In case of Ebola infected communities in Africa, what needs to be done is to
    A) Isolate those geographical communities as best as possible, and it involves voluntary quarantine and travel restrictions by the people of those communities.
    B) Bring treatment facilities to those geographical communities
    C) Travel restrictions from those countries to the USA (and it is scientific, not a desperate effort to protect ourselves as you portray it, and I quote you “only human to want to protect ourselves and our families. We want to defend ourselves, so isn’t the fastest, easiest solution to put up a wall around the problem?”

    If we won’t use quarantine principles now, then when will we use them? Quarantine is a great way (of course not the only way … it should be a part of a comprehensive program) to check/stop the spread of infectious and contagious diseases.

    Dr. Frieden, your comments about quarantine fly in the face of all scientific principles known to be helpful to check/stop the spread of communicable diseases.

    Anant V Joshi DVM

    Illusion of security indeed…
    Friedan is a true scientist, I appreciate this statement; better to use the money to be spent for the travel Ban to support affected countries to stop rapidly this deadly virus and combat poverty while improving governance and Health systems to avoid other similar crisis.

    It is beyond me how anyone can agree with you in this.
    It is a pandemic and should by All means necessary be stopped.
    Obviously the CDC is just another talking head that sells its soul to the devil.
    God help this country.

    While I believe the U.S. will avoid an ebola epidemic (because at some point voters will demand and finally get more responsibility from the government), on our current course we will see some number (tens? hundreds? more?) of Americans suffer and die needlessly from sporadic infections by travelers from west Africa. The attitude taken here seems to be that losing that number of Americans is the price we pay for keeping airline traffic open to west Africa, in order (I suppose) to make it easier for health care workers to go back and forth and (we hope) eventually stamp out the epidemic there.

    But if the government believes that sending some of our HCWs there is the right approach and treats the task as seriously as it deserves, then it should not be relying on commercial airlines in the first place. This becomes a military-run operation with tight controls everywhere and quarantines here for returning HCWs.

    Voluntary screening in west Africa is absurd. The incentive to lie is enormous — one’s life is quite literally at stake.

    Events of the last few days discredit previous CDC assurances. You are playing with a forest fire, to use your own analogy, and you really have no idea how out of control it may get in this country from the sparks that cross the ocean via airliners.

    I wish we had some grownups in charge who regard protecting Americans, not world citizenry, as their solemn obligation. Please stop the obfuscations and do your job properly — or step aside.

    Don’t become “Heckuva-job-Tommy”.

    Some additional thoughts regarding my comment (#5). 1. While 21 days of true physical isolation would be ideal for purposes of ensuring that no one with ebola was missed, perhaps we could begin a test phase to work out any issues with a shorter duration (say 5 or 10 days) physical isolation on the grounds that a. such would at least enable the discovery of more of those infected than we currently discover, and b. at the present time, the percentage of such travelers who are infected is very likely to be low. Then, over time we might ramp up the number of days of isolation as said percentage might increase. 2. I don’t know whether we have suitable facilities for such physical isolation. Perhaps we do. Ask all agencies. Then there is the private sector. Crazy idea, huh? Yes, it is; but so was FDR’s idea that US manufacturers should retool to build tanks, airplanes and weapons for next to no profit. 3. If these physical isolation ideas are too extreme or unworkable, I presume we could request all travelers to self-isolate (or at least self-contain) and monitor themselves for 21 days. Perhaps you are already doing this. It’s hard to keep up. Again, many thanks.

    I think the spread of Ebola is already out of control…Vaccination is cannot help to prevent the of Ebola….How protect yourself and his family from of Ebola?

    I’m sure the first thought that would go through this man’s head if his family or himself contracted ebola would be “Why didn’t I prevent this?”

    Just because you put travel restrictions in place doesn’t mean that military planes couldn’t take medical personnel to and from.

    I could not disagree with you more Dr. Frieden. There is a logical and simplistic way to get the people in that are needed to give aid and a logical way to curtail who is allowed to fly back to the US.
    Your first and foremost concern must be the American people not saving the African people. Of course I support sending help but again that is not and should not be your main concern.
    You have already brought the disease to this country. That was irresponsible. As a nurse I disagree with you 100%.
    There are ways to strictly control the persons coming in and out of the area of concern. Do your job and protect Americans first!!!

    I am sorry Dr but the fact that you are using the term “drive them underground” to describe a response to people dying of a horrible disease “to me” is problematic. All it will take is one infected human to start a pandemic in the USA and incubation rates can vary more than 21 days and the claim that you are only an infective vector when symptomatic is questionable. WHO clearly documented survivors with active Ebola virus in seman when no longer symptomatic “AND” The US military guidelines under “Medical Management of Biological Casualties 7th Edition” clearly document airborne transmission of Ebola. What that will means in terms of modern circulated enclosed ventilation systems is probably not established. I am a pharmacist at a high volume pharmacy with a huge population of Foreign customers. Just imagine one showing up thinking they have the flu and coughing all over a hand then touching the credit card scanner followed by 200 other people touching the credit card scanner.
    http://ireport.cnn.com/docs/DOC-1180967

    The developed nations could have dealt with this outbreak when it was manageable, instead they sat on their hands. A person who suits and thinks about this could conclude that Africa is the new promised Land like the America’s were and the natives of the land were exterminated by disease. While the cause of the affliction is conceivably different the desired outcomes, the eradication of the indigenous peoples, is the same. To now say people are produce is despicable! Really, this is humanity at its best? I can see atheist reasoning in this, godless with no accountability in the long run. The almighty dollar has become your god, and your own pleasures matter more than helping those in need. Corporations have stripped all the excess money out of the economy and we let them. Now, individuals feel too insignificant to lend a hand. Those who should be lending a hand are the ones who have taken your pensions and are working on stealing your children’s inheritance. That’s all I have to say about that!

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