1. SAFER HEALTHIER PEOPLE Role of Containment Measures in the Response to SARS Division of Global Migration and Quarantine Centers for Disease Control and Prevention

2. SAFER HEALTHIER PEOPLE Outline Principles of community containment Strategies that may be used in a future response to SARS Planning and preparedness activities

3. SAFER HEALTHIER PEOPLE Emergence of a Worldwide Outbreak February 11: China reports 305 cases of atypical pneumonia Guangdong province, with 5 deaths since Nov 16, 2002 in February 26: WHO notified of unusual respiratory disease in a businessman in Hanoi who had recently traveled to Hong Kong March 5-11: HCWs caring for the patient in Hanoi developed a similar illness. Similar illness observed in HCWs in HK.

4. SAFER HEALTHIER PEOPLE SARS Outbreak, Worldwide Cases by Country (June 3, 2003) Australia: 5 New Zealand: 1 Malaysia: 5 Indonesia: 2 Philippines: 12 Taiwan: 684 Hong Kong: 1,746 Rep. Of Korea: 3 China: 5,328 Russian Federation: 1 Mongolia: 9 Kuwait: 1 India: 3 Romania: 1 South Africa: 1 Brazil: 2 Colombia: 1 United States: 66 Canada: 198 Finland: 1 Germany: 10 Sweden: 3 United Kingdom: 4 Ireland: 1 France: 7 Spain: 1 Switzerland: 1 Italy: 9 Macao: 1 Vietnam: 63 Thailand: 8 Singapore: 206

5. SAFER HEALTHIER PEOPLE Quarantine for SARS 2003 Taiwan –671 cases of SARS –131,132 persons quarantined –Included 50,319 close contacts and 80,813 travelers China –5237 cases of SARS (2521 in Beijing) –30,000 (approx) persons quarantined Canada –250 cases of SARS –Over 13,000 persons quarantined (Toronto)

6. SAFER HEALTHIER PEOPLE Historic Roots of Quarantine Biblical accounts of quarantine practices for persons with leprosy Epidemic plague in 14th century Europe had profound impact on commerce –1348: System for treatment of infected ships, travelers, and merchandise –1485: Venice established 40-day (Lat: quadragina) harbor detention or quarantine

7. SAFER HEALTHIER PEOPLE Quarantine in Colonial America Handled locally by each colony Massachusetts Bay Colony (1647): arrival of vessels from West Indies restricted due to plague Philadelphia (1699) Quarantine Act: “unhealthy or sickly” vessels barred from approaching shore without a bill of health and permit

8. SAFER HEALTHIER PEOPLE Constitutional Basis of Quarantine Intrastate quarantine power –Considered a police power-- an inherent authority to protect health, welfare, and morals of citizens –Reserved to states (10 th Amendment) Foreign and interstate quarantine –Considered essential in regulation of foreign and interstate commerce –Federal authority (Commerce clause)

9. SAFER HEALTHIER PEOPLE Public Health Service Act (1944) Articulates the quarantine authority of the Federal government Authorizes “…apprehension, detention, and conditional release of individuals to prevent spread of communicable disease” Applies to persons: –infected with a communicable disease in a qualifying stage” Communicable stage Pre-Communicable if likely to cause a public health emergency –arriving from foreign countries or moving state to state 42 U.S.C. § 264 (PHSA § 361)

10. SAFER HEALTHIER PEOPLE Diseases Subject to Quarantine (2003) Cholera Diphtheria Infectious TB Plague Smallpox Yellow fever Viral hemorrhagic fevers SARS Others as determined by the Secretary of Health and Human Services

11. SAFER HEALTHIER PEOPLE Epidemic Exponentiation Ro = 2.0, Progression = 1:2:4:8:16

12. SAFER HEALTHIER PEOPLE Management Strategies: Persons with Disease Isolation separation and restricted movement of ill persons with contagious disease often in a hospital setting primarily individual level, may be applied to populations often voluntary, but may be mandatory fundamental, commonly used public health practice

13. Contact tracing Public health notified 2º case ascertainment Period of communicability Contagion Epidemic Modeling Goal: R< 1, Extinction or Quenching d(sx)d(exp)d(hc)d(ddx)d(ic end)d(ic onset) Infection Exposure Symptom onset Pt seeks health care SARS diagnosis Appropriate infection control isolation EncounterRecognition Isolation initiated Isolation ended ? Asymptomatic shedding? Incubation 2-10 Period of risk for epidemic propagation Time (days) 2º contacts exposed and infected Duration of isolation Time (days)

14. SAFER HEALTHIER PEOPLE Management Strategies: Contacts to Persons with Disease Range of strategies designed to meet two objectives –Facilitate early recognition of symptoms should they develop –Reduce risk of transmission before progression to disease has been recognized Applied at the individual or community level Close clinical monitoring key to all contact management strategies

15. SAFER HEALTHIER PEOPLE Management Strategies: Contacts to Persons with Disease Clinical monitoring –Assessment for signs and symptoms in well person(s) exposed to a contagious disease –May be passive or active –May be done with or without activity restrictions (quarantine)

16. SAFER HEALTHIER PEOPLE Management Strategies: Contacts to Persons with Disease Quarantine –separation and restricted movement of well persons presumed to have been exposed to contagion –often at home, may be designated residential facility – may be voluntary or mandatory

17. SAFER HEALTHIER PEOPLE Evaluating the Effectiveness of Quarantine Key Questions: Was quarantine applied to the appropriate population? (efficiency) Did use of quarantine limit progression of the outbreak? (efficacy) Was the implementation of quarantine humane?

18. SAFER HEALTHIER PEOPLE Efficiency of Quarantine: SARS 2003 SARS attack rate among those quarantined Beijing, China (n= 30,000 approx.) –Overall: 2.3% –Contact with patient 3.8% –Cared for sick patient31.1% Taiwan (n= 131,132) –Overall: 0.09% –Close contact 0.22% –Travel 0.09%

19. SAFER HEALTHIER PEOPLE 0 500 1000 1500 2000 2500 V100%, Q0% V100%, Q50% V100%, Q90% V100%, Q95% V100%, Q99% V100%, Q100% Ro=3Ro=5Ro=10 Impact of Varying R 0 and % Quarantined on Total Smallpox Cases* Scenario: Smallpox aerosolized inside plane 500 persons exposed

20. SAFER HEALTHIER PEOPLE Modeling Responses to Smallpox Attack In theory, post-exposure vaccination or quarantine alone can stop outbreak Relying solely on either increases cases and length of outbreak Relying on combined strategy –decreased total cases –stopped transmission, controlled outbreak sooner –fewer vaccinations needed Meltzer M, et al. EID 2001 (Nov-Dec);7(6)

21. SAFER HEALTHIER PEOPLE Quarantine Dichotomy “Quarantine” may have negative connotations –Black Death, Yellow fever, Pandemic Flu –Detention camps equate disease with crime –Stigmatizes victims (e.g., foreign born) –Historical abuses of power Quarantine works –As good or better than other tools to prevent spread of contagion –When combined with other techniques may result in more rapid control

22. SAFER HEALTHIER PEOPLE A collective action for the common good predicated on aiding individuals infected or exposed to infectious agents while protecting others from the dangers of inadvertent exposure Public goodCivil liberties Modern Quarantine Meeting needs of individuals infected and exposed is paramount

23. SAFER HEALTHIER PEOPLE Principles of Community Containment (1) Containment measures are appropriate when: A person or group of people has been exposed to a highly dangerous and contagious disease Exposed well persons are separated from ill cases Resources are available to implement and support interventions –Provide essential goods and services –Monitor health status (active vs. passive) –Provide immediate triage & medical care / isolation

24. SAFER HEALTHIER PEOPLE Principles of Community Containment (2) Containment measures encompass a range of strategies: “Snow days” or “shelter-in-place” Suspension or restrictions on group assembly Cancellation of public events Closure of mass public transit Closing of public places Restriction or scaling back of non-essential travel Cordon sanitaire

25. SAFER HEALTHIER PEOPLE Principles of Community Containment (3) Containment measures are used in combination with other interventions Enhanced disease surveillance and symptom monitoring Rapid diagnosis and treatment for those who become ill Primary and 2 0 preventive interventions, including vaccination or prophylactic antibiotics, PPE

26. SAFER HEALTHIER PEOPLE Principles of Community Containment (4) Quarantined persons must be among the first to receive all available disease- preventing interventions Vaccination (e.g., smallpox) Antibiotics (e.g., plague) Early and rapid diagnostic testing and symptom monitoring Early treatment if symptoms appear

27. SAFER HEALTHIER PEOPLE Principles of Community Containment (5) Modern quarantine lasts only as long as necessary to ensure that quarantined persons do not become ill Maximum quarantine duration related to the incubation period of disease “Due process” rights among those subjected to quarantine restrictions

28. SAFER HEALTHIER PEOPLE Principles of Community Containment (6) Modern quarantine does not have to be absolute to be effective Even partial or “leaky” quarantine can reduce disease spread Partial quarantine can be an effective supplement to vaccination

29. SAFER HEALTHIER PEOPLE Principles of Community Containment (7) Containment measures are more likely to be applied to small numbers of exposed persons in focused settings: –Exposed persons on conveyance containing ill passenger(s) –Exposed persons in a theater where an intentional release has been announced –Close contact to a person with SARS

30. SAFER HEALTHIER PEOPLE Principles of Community Containment (8) Implementation of containment measures require: a clear understanding of public health roles at local, state, and federal levels cooperation between public and private healthcare sectors well-understood legal authorities at each level

31. SAFER HEALTHIER PEOPLE Principles of Community Containment (9) Implementation of containment measures requires coordinated planning by many partners: Public health practitioners Healthcare providers Healthcare facilities Transportation authorities Emergency response teams Law enforcement

32. SAFER HEALTHIER PEOPLE Principles of Community Containment (10) To achieve trust and cooperation, the public must be: Informed of the dangers of “quarantinable” infectious diseases before an epidemic/outbreak occurs Informed of the justifications for quarantine when an outbreak is in progress Informed of anticipated duration and endpoints of control measures

33. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Elements of Response Case management Contact management Hospital/facility infection control Community response and quarantine Border responses

34. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Levels of Response Basic and Enhanced Activities Magnitude and scope of outbreak Patterns of transmission Resources available for response Community cooperation and trust

35. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Case Management Basic Activities –Home isolation Suitable for providing adequate care Adequate infection control measures possible –Hospital isolation if medically necessary Enhanced Activities –Community-based facility isolation –Facility must meets patient care and infection control requirements

36. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Contact management Basic Activities –Monitoring without activity restrictions Assessment for signs and symptoms in well person(s) exposed to a contagious disease May be passive or active –Furlough of exposed HCWs

37. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Contact management Enhanced Activities –Monitoring with activity restrictions Home quarantine Working quarantine Facility-based quarantine –Active monitoring for all in quarantine –May be voluntary or mandatory –Range of options for optimizing compliance

38. SAFER HEALTHIER PEOPLE Quarantine 2003: Lessons Learned Clear messages about need for quarantine increased public acceptance Quarantine can be voluntary in most cases Mental health support is a critical need for those in quarantine Implementation of large-scale quarantine is complex and resource-intensive

39. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Community Response Basic Activities –Public information and education –Promote “respiratory hygiene” and hand washing Enhanced Activities –Focused measures to increase social distance –Community-wide measures to increase social distance

40. SAFER HEALTHIER PEOPLE Ways to Increase Effective Social Distance Implement “Snow Day” restrictions –Close schools, daycare centers, etc. –Cancel large public gatherings (concerts, theaters) –Minimize other exposures (markets, churches, public transit) Consider additional measures –Distribution of surgical masks –Temperature screening in public venues –Scaling back transportation services

41. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Community Response Basic Activities –Public information and education –Promote “respiratory hygiene” and hand washing Enhanced Activities –Focused measures to increase social distance –Community-wide measures to increase social distance –Widespread community quarantine –Cordon sanitaire

42. SAFER HEALTHIER PEOPLE SARS Containment Strategy: Border and travel responses Basic Activities –Travel advisories and alerts –Distribution of health alert notices –Responding to ill passengers Enhanced Activities –Pre-departure and arrival screening –Quarantine of travelers from areas with SARS –Restriction of non-essential travel

43. SAFER HEALTHIER PEOPLE Preparedness Planning: General Establish incident command structure Establish relationships with essential partners Plan for monitoring and assessing appropriate response Develop message strategies for various responses and groups

44. SAFER HEALTHIER PEOPLE Preparedness Planning: Case and Contact Management Ensure management protocols up to date Establish supplies for non-hospital management Establish telecommunications plan Plan for ensuring essential services

45. SAFER HEALTHIER PEOPLE Preparedness Planning: Community Containment Ensure that necessary legal authorities and procedures are in place Identify key partners and personnel for quarantine Develop training programs and drills Develop plans for mobilization and deployment

46. SAFER HEALTHIER PEOPLE Preparedness Planning: Non- hospital facility management Identify community-based facilities for quarantine of contacts Ensure procedures for assessment of sites are in place Develop protocols for evaluation and management of arriving ill passengers

47. SAFER HEALTHIER PEOPLE Conclusions In the modern age, community containment –Represents a range of interventions –Can be resource- and labor-intensive –Is an important tool used in conjunction with other containment measures Effective implementation of modern quarantine and other containment measures is impossible without planning and preparedness.

48. SAFER HEALTHIER PEOPLE Acknowledgements State and Local Health Department and CDC staff who responded to SARS 2003State and Local Health Department and CDC staff who responded to SARS 2003 Staff of the 8 US Quarantine Stations that protect our ports of entryStaff of the 8 US Quarantine Stations that protect our ports of entry