history of quarantine, from plague to influenza

8/13/2019 History of Quarantine, from Plague to Influenza

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In the new millennium, the centuries-old strategy of

quarantine is becoming a powerful component of the pub-lic health response to emerging and reemerging infectious

diseases. During the 2003 pandemic of severe acute re-

spiratory syndrome, the use of quarantine, border controls,

contact tracing, and surveillance proved effective in contain-

ing the global threat in just over 3 months. For centuries,

these practices have been the cornerstone of organized

responses to infectious disease outbreaks. However, the

use of quarantine and other measures for controlling epi-

demic diseases has always been controversial because

such strategies raise political, ethical, and socioeconomic

issues and require a careful balance between public interest

and individual rights. In a globalized world that is becoming

ever more vulnerable to communicable diseases, a histori-

cal perspective can help clarify the use and implications of

a still-valid public health strategy.

The risk for deadly infectious diseases with pandemicpotential (e.g., severe acute respiratory syndrome[SARS]) is increasing worldwide, as is the risk for resur-gence of long-standing infectious diseases (e.g., tuberculo-sis) and for acts of biological terrorism. To lessen the riskfrom these new and resurging threats to public health, au-thorities are again using quarantine as a strategy for limit-ing the spread of communicable diseases (1). The historyof quarantinenot in its narrower sense, but in the largersense of restraining the movement of persons or goods onland or sea because of a contagious diseasehas not beengiven much attention by historians of public health. Yet,a historical perspective of quarantine can contribute to a

better understanding of its applications and can help tracethe long roots of stigma and prejudice from the time of theBlack Death and early outbreaks of cholera to the 1918 in-uenza pandemic (2) and to the rst inuenza pandemic

of the twenty-rst century, the 2009 inuenza A(H1N1)

pdm09 outbreak (3).Quarantine (from the Italian quaranta, meaning 40)was adopted as an obligatory means of separating persons,animals, and goods that may have been exposed to a conta-gious disease. Since the fourteenth century, quarantine has

been the cornerstone of a coordinated disease-control strat-egy, including isolation, sanitary cordons, bills of healthissued to ships, fumigation, disinfection, and regulation ofgroups of persons who were believed to be responsible forspreading the infection (4,5).

Plague

Organized institutional responses to disease control

began during the plague epidemic of 13471352 (6). Theplague was initially spread by sailors, rats, and cargo arriv-ing in Sicily from the eastern Mediterranean (6,7); it quick-ly spread throughout Italy, decimating the populations of

powerful city-states like Florence, Venice, and Genoa (8).The pestilence then moved from ports in Italy to ports inFrance and Spain (9). From northeastern Italy, the plaguecrossed the Alps and affected populations in Austria andcentral Europe. Toward the end of the fourteenth century,the epidemic had abated but not disappeared; outbreaks of

pneumonic and septicemic plague occurred in different cit-ies during the next 350 years (8).

Medicine was impotent against plague (8); the onlyway to escape infection was to avoid contact with infected

persons and contaminated objects. Thus, some city-statesprevented strangers from entering their cities, particu-larly, merchants (10) and minority groups, such as Jewsand persons with leprosy. A sanitary cordonnot to be

broken on pain of deathwas imposed by armed guardsalong transit routes and at access points to cities. Imple-mentation of these measures required rapid, rm action

by authorities, including prompt mobilization of repres-sive police forces. A rigid separation between healthy and

Lessons from theHistory of Quarantine,

from Plague to Inuenza AEugenia Tognotti

254 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 2, February 2013

Author afliation: University of Sassari, Sassari, Sardinia, Italy

DOI: http://dx.doi.org/10.3201/eid1902.120312

HISTORICAL REVIEW


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Lessons from the History of Quarantine

infected persons was initially accomplished through theuse of makeshift camps (10).

Quarantine was rst introduced in 1377 in Dubrovnikon Croatias Dalmatian Coast (11), and the rst perma-

nent plague hospital (lazaretto) was opened by the Repub-lic of Venice in 1423 on the small island of Santa Mariadi Nazareth. The lazaretto was commonly referred to as

Nazarethum or Lazarethum because of the resemblanceof the word lazaretto to the biblical name Lazarus (12).In 1467, Genoa adopted the Venetian system, and in 1476in Marseille, France, a hospital for persons with leprosywas converted into a lazaretto. Lazarettos were locatedfar enough away from centers of habitation to restrict thespread of disease but close enough to transport the sick.Where possible, lazarettos were located so that a natural

barrier, such as the sea or a river, separated them from thecity; when natural barriers were not available, separation

was achieved by encircling the lazaretto with a moat orditch. In ports, lazarettos consisted of buildings used toisolate ship passengers and crew who had or were sus-

pected of having plague. Merchandise from ships was un-loaded to designated buildings. Procedures for so-calledpurgation of the various products were prescribed mi-nutely; wool, yarn, cloth, leather, wigs, and blankets wereconsidered the products most likely to transmit disease.Treatment of the goods consisted of continuous ventila-tion; wax and sponge were immersed in running water for48 hours.

It is not known why 40 days was chosen as the lengthof isolation time needed to avoid contamination, but itmay have derived from Hippocrates theories regardingacute illnesses. Another theory is that the number of dayswas connected to the Pythagorean theory of numbers. Thenumber 4 had particular signicance. Forty days was the

period of the biblical travail of Jesus in the desert. Fortydays were believed to represent the time necessary fordissipating the pestilential miasma from bodies and goodsthrough the system of isolation, fumigation, and disinfec-tion. In the centuries that followed, the system of isolationwas improved (1315).

In connection with the Levantine trade, the next steptaken to reduce the spread of disease was to establish billsof health that detailed the sanitary status of a ships portof origin (14). After notication of a fresh outbreak of

plague along the eastern Mediterranean Sea, port cities tothe west were closed to ships arriving from plague-infectedareas (15). The rst city to perfect a system of maritimecordons was Venice, which because of its particular geo-graphic conguration and its prominence as a commercialcenter, was dangerously exposed (12,15,16). The arrival of

boats suspected of carrying plague was signaled with a agthat would be seen by lookouts on the church tower of SanMarco. The captain was taken in a lifeboat to the health

magistrates ofce and was kept in an enclosure where hespoke through a window; thus, conversation took place ata safe distance. This precaution was based on a mistakenhypothesis (i.e., that pestilential air transmitted all com-

municable diseases), but the precaution did prevent directperson-to-person transmission through inhalation of con-taminated aerosolized droplets. The captain had to show

proof of the health of the sailors and passengers and pro-vide information on the origin of merchandise on board. Ifthere was suspicion of disease on the ship, the captain wasordered to proceed to the quarantine station, where passen-gers and crew were isolated and the vessel was thoroughlyfumigated and retained for 40 days (13,17). This system,which was used by Italian cities, was later adopted by otherEuropean countries.

The rst English quarantine regulations, drawn up in1663, provided for the connement (in the Thames estu-

ary) of ships with suspected plague-infected passengersor crew. In 1683 in Marseille, new laws required that allpersons suspected of having plague be quarantined anddisinfected. In ports in North America, quarantine was in-troduced during the same decade that attempts were beingmade to control yellow fever, which rst appeared in NewYork and Boston in 1688 and 1691, respectively (18). Insome colonies, the fear of smallpox outbreaks, which coin-cided with the arrival of ships, induced health authorities toorder mandatory home isolation of persons with smallpox(19), even though another controversial strategy, inocula-tion, was being used to protect against the disease. In theUnited States, quarantine legislation, which until 1796 wasthe responsibility of states, was implemented in port cit-ies threatened by yellow fever from the West Indies (18).In 1720, quarantine measures were prescribed during anepidemic of plague that broke out in Marseille and ravagedthe Mediterranean seaboard of France and caused great ap-

prehension in England. In England, the Quarantine Act of1710 was renewed in 1721 and 1733 and again in 1743during the disastrous epidemic at Messina, Sicily (19). Asystem of active surveillance was established in the majorLevantine cities. The network, formed by consuls of vari-ous countries, connected the great Mediterranean ports ofwestern Europe (15).

Cholera

By the eighteenth century, the appearance of yellowfever in Mediterranean ports of France, Spain, and Italyforced governments to introduce rules involving the useof quarantine (18). But in the nineteenth century, another,even more frightening scourge, cholera, was approach-ing (20). Cholera emerged during a period of increasingglobalization caused by technological changes in trans-

portation, a drastic decrease in travel time by steamshipsand railways, and a rise in trade. Cholera, the Asiatic

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HISTORICAL REVIEW

disease, reached Europe in 1830 and the United Statesin 1832, terrifying the populations (2124). Despite prog-ress regarding the cause and transmission of cholera, therewas no effective medical response (25).

During the rst wave of cholera outbreaks, the strate-gies adopted by health ofcials were essentially those thathad been used against plague. New lazarettos were plannedat western ports, and an extensive structure was establishednear Bordeaux, France (26). At European ports, ships were

barred entry if they had unclean licenses (i.e., ships arriv-ing from regions where cholera was present) (27). In cities,authorities adopted social interventions and the traditionalhealth tools. For example, travelers who had contact withinfected persons or who came from a place where chol-era was present were quarantined, and sick persons wereforced into lazarettos. In general, local authorities tried tokeep marginalized members of the population away from

the cities (27). In 1836 in Naples, health ofcials hinderedthe free movement of prostitutes and beggars, who wereconsidered carriers of contagion and, thus, a danger to thehealthy urban population (27,28). This response involved

powers of intervention unknown during normal times, andthe actions generated widespread fear and resentment.

In some countries, the suspension of personal libertyprovided the opportunityusing special lawsto stop po-litical opposition. However, the cultural and social contextdiffered from that in previous centuries. For example, theincreasing use of quarantine and isolation conicted withthe afrmation of citizens rights and growing sentiments of

personal freedom fostered by the French Revolution of 1789.In England, liberal reformers contested both quarantine andcompulsory vaccination against smallpox. Social and po-litical tensions created an explosive mixture, culminating in

popular rebellions and uprisings, a phenomenon that affectednumerous European countries (29). In the Italian states, inwhich revolutionary groups had taken the cause of unica-tion and republicanism (27), cholera epidemics provided a

justication (i.e., the enforcement of sanitary measures) forincreasing police power.

By the middle of the nineteenth century, an increas-ing number of scientists and health administrators beganto allege the impotence of sanitary cordons and maritimequarantine against cholera. These old measures dependedon the idea that contagion was spread through the inter-

personal transmission of germs or by contaminated cloth-ing and objects (30). This theory justied the severity ofmeasures used against cholera; after all, it had worked wellagainst the plague. The length of quarantine (40 days) ex-ceeded the incubation period for the plague bacillus, pro-viding sufcient time for the death of the infected easneeded to transmit the disease and of the biological agent,Yersinia pestis. However, quarantine was almost irrelevantas a primary method for preventing yellow fever or cholera.

A rigid maritime cordon could only be effective in protect-ing small islands. During the terrifying cholera epidemicof 18351836, the island of Sardinia was the only Italianregion to escape cholera, thanks to surveillance by armed

men who had orders to prevent, by force, any ship that at -tempted to disembark persons or cargo on the coast (27).

Anticontagionists, who disbelieved the communica-bility of cholera, contested quarantine and alleged that thepractice was a relic of the past, useless, and damaging tocommerce. They complained that the free movement oftravelers was hindered by sanitary cordons and by controlsat border crossings, which included fumigation and disin-fection of clothes (Figures 1 3). In addition, quarantineinspired a false sense of security, which was dangerous to

public health because it diverted persons from taking thecorrect precautions. International cooperation and coordi-nation was stymied by the lack of agreement regarding the

use of quarantine. The discussion among scientists, healthadministrators, diplomatic bureaucracies, and governmentsdragged on for decades, as demonstrated in the debates inthe International Sanitary Conferences (31), particularly af-ter the opening, in 1869, of the Suez Canal, which was per-ceived as a gate for the diseases of the Orient (32). Despite

pervasive doubts regarding the effectiveness of quarantine,local authorities were reluctant to abandon the protectionof the traditional strategies that provided an antidote to

population panic, which, during a serious epidemic, couldproduce chaos and disrupt public order (33).

A turning point in the history of quarantine came afterthe pathogenic agents of the most feared epidemic diseaseswere identied between the nineteenth and twentieth centu-ries. International prophylaxis against cholera, plague, andyellow fever began to be considered separately. In light ofthe newer knowledge, a restructuring of the internationalregulations was approved in 1903 by the 11th SanitaryConference, at which the famed convention of 184 articleswas signed (31).


Figure 1. Disinfecting clothing. FranceItaly border during the

cholera epidemic of 18651866. (Photograph in the authors

possession).


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Lessons from the History of Quarantine

Infuenza

In 1911, the eleventh edition of Encyclopedia Britan-nica emphasized that the old sanitary preventive system ofdetention of ships and men was a thing of the past (34).

At the time, the battle against infectious diseases seemedabout to be won, and the old health practices would only

be remembered as an archaic scientic fallacy. No oneexpected that within a few years, nations would again beforced to implement emergency measures in response toa tremendous health challenge, the 1918 inuenza pan-demic, which struck the world in 3 waves during 19181919 (online Technical Appendix, wwwnc.cdc.gov/EID/article12-0312-Techapp1.pdf ). At the time, the etiology ofthe disease was unknown. Most scientists thought that the

pathogenic agent was a bacterium,Haemophilus infuen-zae, identied in 1892 by German bacteriologist RichardPfeiffer (35).

During 19181919, in a world divided by war, themultilateral health surveillance systems, which had beenlaboriously built during the previous decades in Europeand the United States, were not helpful in controlling theinuenza pandemic. The ancestor of the World Health Or-ganization, the Ofce International dHygine Publique,located in Paris (31), could not play any role during theoutbreak. At the beginning of the pandemic, the medical of-cers of the army isolated soldiers with signs or symptoms,

but the disease, which was extremely contagious, quicklyspread, infecting persons in nearly every country. Variousresponses to the pandemic were tried. Health authoritiesin major cities of the Western world implemented a rangeof disease-containment strategies, including the closure ofschools, churches, and theaters and the suspension of pub-lic gatherings. In Paris, a sporting event, in which 10,000youths were to participate, was postponed (36). Yale Uni-versity canceled all on-campus public meetings, and somechurches in Italy suspended confessions and funeral cere-monies. Physicians encouraged the use of measures like re-spiratory hygiene and social distancing. However, the mea-sures were implemented too late and in an uncoordinatedmanner, especially in war-torn areas where interventions(e.g., travel restrictions, border controls) were impractical,during a time when the movement of troops was facilitatingthe spread of the virus.

In Italy, which along with Portugal had the highest

mortality rate in Europe, schools were closed after therst case of the unusually severe hemorrhagic pneumonia;however, the decision to close schools was not simultane-ously accepted by health and scholastic authorities (37).Decisions made by health authorities often seemed focusedmore on reassuring the public about efforts being made tostop transmission of the virus rather than on actually stop-

ping transmission of the virus (35). Measures adopted inmany countries disproportionately affected ethnic and

marginalized groups. In colonial possessions (e.g., New

Caledonia), restrictions on travel affected the local popula-tions (3). The role that the media would play in inuencingpublic opinion in the future began to take shape. Newspa-pers took conicting positions on health measures and con-tributed to the spread of panic. The largest and most inu-ential newspaper in Italy, Corriere della Sera, was forced

by civil authorities to stop reporting the number of deaths(150180 deaths/day) in Milan because the reports causedgreat anxiety among the citizenry. In war-torn nations, cen-sorship caused a lack of communication and transparencyregarding the decision-making process, leading to confu-sion and misunderstanding of disease-control measuresand devices, such as face masks (ironically named muz-

zles in Italian) (35).During the second inuenza pandemic of the twen-tieth century, the Asian u pandemic of 19571958,some countries implemented measures to control spreadof the disease. The illness was generally milder than thatcaused by the 1918 inuenza, and the global situation dif-fered. Understanding of inuenza had advanced greatly:the pathogenic agent had been identied in 1933, vaccinesfor seasonal epidemics were available, and antimicrobialdrugs were available to treat complications. In addition,the World Health Organization had implemented a globalinuenza surveillance network that provided early warn-ing when novel inuenza (H2N2) virus, began spreading inChina in February 1957 and worldwide later that year. Vac-

cines had been developed in Western countries but werenot yet available when the pandemic began to spread simul-taneously with the opening of schools in several countries.Control measures (e.g., closure of asylums and nurseries,

bans on public gatherings) varied from country to coun-try but, at best, merely postponed the onset of disease fora few weeks (38). This scenario was repeated during theinuenza A(H3N2) pandemic of 19681969, the third andmildest inuenza pandemic of the twentieth century. The

Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 2, February 2013 257

Figure 2. Quarantine. The female dormitory. FranceItaly border

during the cholera epidemic of 18651866. (Photograph in the

authors possession).


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HISTORICAL REVIEW

virus was rst detected in Hong Kong in early 1968 and

was introduced into the United States in September 1968by US Marines returning from Vietnam. In the winter of196869, the virus spread around the world; the effect waslimited and there were no specic containment measures.

A new chapter in the history of quarantine opened inthe early twenty-rst century as traditional interventionmeasures were resurrected in response to the global cri-sis precipitated by the emergence of SARS, an especial-ly challenging threat to public health worldwide. SARS,which originated in Guangdong Province, China, in 2003,spread along air-travel routes and quickly became a globalthreat because of its rapid transmission and high mortal-ity rate and because protective immunity in the general

population, effective antiviral drugs, and vaccines werelacking. However, compared with inuenza, SARS hadlower infectivity and a longer incubation period, providingtime for instituting a series of containment measures thatworked well (39). The strategies varied among the coun-tries hardest hit by SARS (Peoples Republic of China andHong Kong Special Administrative Region; Singapore;and Canada). In Canada, public health authorities asked

persons who might have been exposed to SARS to volun-tarily quarantine themselves. In China, police cordoned off

buildings, organized checkpoints on roads, and even in-stalled Web cameras in private homes. There was strongercontrol of persons in the lower social strata (village-levelgovernments were empowered to isolate workers from

SARS-affected areas). Public health ofcials in some areasresorted to repressive police measures, using laws with ex-tremely severe punishments (including the death penalty),against those who violated quarantine. As had occurred inthe past, the strategies adopted in some countries duringthis public health emergency contributed to the discrimi-nation and stigmatization of persons and communitiesand raised protests and complaints against limitations andtravel restrictions.

Conclusions

More than half a millennium since quarantine becamethe core of a multicomponent strategy for controlling com-municable disease outbreaks, traditional public health tools

are being adapted to the nature of individual diseases and tothe degree of risk for transmission and are being effectivelyused to contain outbreaks, such as the 2003 SARS outbreakand the 2009 inuenza A(H1N1)pdm09 pandemic. Thehistory of quarantinehow it began, how it was used in the

past, and how it is used in the modern erais a fascinatingtopic in history of sanitation. Over the centuries, from thetime of the Black Death to the rst pandemics of the twen -ty-rst century, public health control measures have beenan essential way to reduce contact between persons sickwith a disease and persons susceptible to the disease. In theabsence of pharmaceutical interventions, such measureshelped contain infection, delay the spread of disease, avert

terror and death, and maintain the infrastructure of society.Quarantine and other public health practices are effec-tive and valuable ways to control communicable diseaseoutbreaks and public anxiety, but these strategies have al-ways been much debated, perceived as intrusive, and ac-companied in every age and under all political regimes byan undercurrent of suspicion, distrust, and riots. These stra-tegic measures have raised (and continue to raise) a varietyof political, economic, social, and ethical issues (39,40). Inthe face of a dramatic health crisis, individual rights haveoften been trampled in the name of public good. The use ofsegregation or isolation to separate persons suspected of be-ing infected has frequently violated the liberty of outwardlyhealthy persons, most often from lower classes, and ethnicand marginalized minority groups have been stigmatizedand have faced discrimination. This feature, almost inher-ent in quarantine, traces a line of continuity from the timeof plague to the 2009 inuenza A(H1N1)pdm09 pandemic.

The historical perspective helps with understanding theextent to which panic, connected with social stigma and prej-udice, frustrated public health efforts to control the spread ofdisease. During outbreaks of plague and cholera, the fear ofdiscrimination and mandatory quarantine and isolation ledthe weakest social groups and minorities to escape affectedareas and, thus, contribute to spreading the disease fartherand faster, as occurred regularly in towns affected by deadlydisease outbreaks. But in the globalized world, fear, alarm,

and panic, augmented by global media, can spread fartherand faster and, thus, play a larger role than in the past. Fur-thermore, in this setting, entire populations or segments of

populations, not just persons or minority groups, are at riskof being stigmatized. In the face of new challenges posed inthe twenty-rst century by the increasing risk for the emer-gence and rapid spread of infectious diseases, quarantineand other public health tools remain central to public health

preparedness. But these measures, by their nature, require


Figure 3. The control of travelers from cholera-affected countries,

who were arriving by land at the FranceItaly border during the

cholera epidemic of 18651866. (Photograph in the authors

possession).


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history of quarantine, from plague to influenza

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