Quarantine CDC COCA Conference Call February 2006

Quarantine CDC COCA Conference Call February 2006
Danitza Tomianovic, MPH Quarantine Public Health Officer Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Global Migration and Quarantine Miami Quarantine Station SAFER • HEALTHIER • PEOPLE

SAFER • HEALTHIER • PEOPLE
Objectives Basics of quarantine Definitions History Legal basis and authority Functions of U.S quarantine stations Principles of modern quarantine as containment measure SAFER • HEALTHIER • PEOPLE

Definitions: Quarantine
Separation and restriction of movement of well persons presumed to have been exposed to contagion often at home or residential facility may be voluntary or mandatory First let me start by defining Q. So these persons are the “contacts” of cases of an illness and are asymtpomatic. -Q can be done at home or in residential facility -And may be voluntary or mandatory SAFER • HEALTHIER • PEOPLE

Definitions: 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 The term isolation on the other hand refers (read bullet). Or the “case.” Applies to persons with the illness or disease -Isol is commonly done in a hospital setting -Primarily at ind. Level or may be applied to population -Often voluntary but can be mandatory -Isolation commonly used a a public health practice in hospitals Both applied with common goal of disease containment SAFER • HEALTHIER • PEOPLE

Historic Roots of Quarantine
Biblical accounts of quarantine practices for persons with leprosy Epidemic plague in 14th C. Europe had profound impact on commerce 1485: Venice established 40-day (Lat. Quadragina) harbor detention, i.e., quarantine 1626: First Quarantine Station, Marseille The Quarantine Flag: Became the “Q” flag in the international maritime code of flag signals 1- Historically, the concept and mission of quarantine has always been to prevent the importation and spread of diseases and protect populations from contagious diseases. 2- The root of Quarantine go way back to the old testament, in which a description can be found of the practice of isolating persons afflicted with leprosy 3- In 14th century Europe, the plague epidemic, or “Balck death” moved across Europe, prompting Venice to impose a mandatory 40-day harbor detention for ships landing on its port. 4- Therefore the word “quarantine” is derived from the Italian quaranta and the Latin quadragina, and refers to the period of time 40 days during which a disease was believed to be contagious. 5-Venice’s example was followed by other European city-states, and the first quarantine station was established in 1626 in Marseille, France, which introduced the first “bill of health”, which certified incoming ships to be a healthy vessel and disease free. 6-In the 1700s, vessels en route to England were required to show a solid yellow flag to indicate that they were under quarantine- became known as Q flag. This flag is still on the Quarantine inspectors’ uniform. Shifting over to the new world…. SAFER • HEALTHIER • PEOPLE

Quarantine in the United States
Quarantine in Colonial America (17th C.) handled locally by each colony 1647--Massachusetts Bay Colony 1798--Yellow Fever Outbreak in Philadelphia Governor declared cordon sanitaire 1878: National Quarantine Act Shift of quarantine powers from state to federal government 1944: Public Health Service Act: Basis for current federal quarantine powers 1-Initially, Quarantine in the US was handled as a local matter by individual colonies. 2-The earliest evidence of quarantine in the US was in Massachusetts Bay Colony due to plague in west Indies – ships from this region banned to land. 3- Later, in 1798, for example, the Governor of Pennsylvania declared a cordon sanitaire around Philadelphia in response to an outbreak of yellow fever. The extreme actions, which included isolating the Federal Government, which was sitting in Philadelphia at the time, were generally considered to be appropriate to the threat of yellow fever. Unhealthy or sickly vessels were not to come closer than one mile from land without a certified bill of health 4- The shift of Q powers from the state to the federal gov’t began in 1878 with the passing of the Nat’l Q Act, but it was the passing of the PHSA in 1944 that defined the current role of the fed. gov’t in Q and I will describe this in more detail in a moment. SAFER • HEALTHIER • PEOPLE

Quarantine: Statutory Authority
Intrastate quarantine power Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border Considered a police power-- an inherent authority to protect health and welfare of citizens Reserved to states (10th Amendment) As the federal government became more active in regulating the practice of quarantine, in the 19th century a conflict resulted between federal and state quarantine powers. Today, the states are primarily responsible for the exercise of public health powers to control outbreaks within the state. Quarantine is a police power that is reserved to the states by the 10 Amendment to the U.S. Constitution. States therefore have the primary responsibility for quarantine within their own borders. The Federal Government derives its authority from the Commerce Clause of the Constitution and has the primary responsibility for quarantine of persons arriving from foreign countries and for interstate quarantine. So, when the risk of transmission of an infectious disease occurs across state lines, the federal government has authority to enact quarantine, with the decision of the President. The CDC is the federal agency authorized to ,amage federal quarantine and its implementation could involve assets frp Courts, however, have historically defined the Federal Government’s Commerce Clause jurisdiction very broadly and allowed the Federal Government to regulate wholly intra-state activities that may affect interstate commerce. Therefore, in practice, there may be significant overlap between federal and state authority to impose a quarantine. SAFER • HEALTHIER • PEOPLE

Quarantine: Statutory Authority
Foreign and interstate quarantine Considered essential in regulation of foreign and interstate commerce Federal authority (Commerce clause) Executive decision by the President of U.S. CDC manages federal quarantine, with possible utilization of assets from other agencies CDC may intervene in intrastate incidents if requested by state or if local control efforts considered inadequate Now, let me describe federal authority regarding foreign and interstate Q: 1-The Federal Government has the primary responsibility for quarantine of persons arriving from foreign countries and for interstate quarantine. 2-It derives its authority from the Commerce Clause of the Constitution. So, when the risk of transmission of an infectious disease occurs across state lines, the federal government has authority to enact quarantine, with the decision of the President. The CDC is the federal agency authorized to implement federal quarantine and implementation can involve assets from other agencies. 3-The CDC Director may intervene in intra-state incidents, and apply a variety of disease containment measures, if help is requested from state or in the event of inadequate local control. 4-As you can see, in practice, there may be significant overlap between federal and state authority to impose a quarantine. SAFER • HEALTHIER • PEOPLE

Foreign Quarantine Regulations: Title 42 CFR Part 71
Reporting of “ill persons” defined by Fever (≥100º F or 38º C) persisting ≥48 hours and Rash or glandular swelling, or jaundice or Diarrhea (≥3 stools in 24 hours or greater than normal amount) Medical surveillance of arriving persons Sanitary measures over inbound carriers, cargo Quarantine of arriving persons (with diseases listed in the Executive Order signed by the President) 1-42 CFR part 71 is the foreign Q regulation that prevents the introduction, transmission, and spread of communicable diseases from foreign countries. (The interstate part is found at Part 70.) 2- It mandates the “master if a ship destined for a U.S port shall report immediately to the quarantine station at or nearest the port at which the ship will arrive, the occurrence, on board, of any death or any ill person among passengers or crew” during the 15 days prior arrival date or during the period since departure from a U.S, port) 3-An ill person is defined as anyone who has (read bullet) 4-Also, persons arriving into the United States may be quarantined or placed under medical surveillance. Individuals placed under medical surveillance must provide information about their health and intended destination and report for medical examinations as may be required. 5-The regulations also authorize a variety of sanitary measures over carriers, articles, and cargo destined for entry into the United States. 6-The power to Q however is limited to the nine qable diseases listed on the Executive order signed by the President of the US. SAFER • HEALTHIER • PEOPLE

President George W. Bush SAFER • HEALTHIER • PEOPLE
Executive Order 13295: Revised List Of Quarantinable Communicable Diseases Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named) (b) Severe Acute Respiratory Syndrome (SARS) (c) Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic This is the Executive order which lists the nine Diseases for which quarantine can be enforced. Currently it includes nine diseases (read a) and SARS and novel/reemergent influenza viruses are the most recent additions. President George W. Bush April 1, 2005 SAFER • HEALTHIER • PEOPLE

Interstate Quarantine Regulations: 42 CFR (Code of Federal Regulations) Part 70 Report of communicable disease to local health authority Provision for Federal travel permit requirement Written permit for travel from one state to another Intrastate federal intervention only if local control inadequate A complimentary set of regulations are contained in the interstate part which are codified at Part 70 of Title 42, Code of Federal Regulations. This section, like the foreign section, contains a disease reporting requirement, though reports, in this case, are made to the local health authority rather than the federal quarantine station. These regulations also authorize the implementation of quarantine through a federal travel permit system. Under the regulations, persons in the communicable stage of certain communicable diseases may not board a conveyance or travel inter-state without first obtaining a written permit from the Surgeon General. It is also prohibited to transport a person in the communicable stage of these diseases, except in accordance with the terms of their permit. Such persons must also comply with any state travel permit requirements that may exist under state law. The regulations also authorize the CDC Director to intervene intra-state, and apply a variety of disease containment measures, in the event of inadequate local control. SAFER • HEALTHIER • PEOPLE

Public Health Service Act, 1944
Basis for current federal quarantine authority Expanded maritime health service Public Health Service hospitals Health screening of immigrants Illness assessment on vessels and aircraft 1-Let me now refer back to the PHSA signed in 1944 that I mentioned briefly earlier. With it, Congress clearly stated the quarantine authority of the federal government for the first time. 2-This act created the extension of the maritime health service ( the forerunner of the modern U.S public health service), and outlined major responsibilities of U.S quarantine service, now under the jurisdiction of the Division of Global Migration and Quarantine 3-Three major responsibilities of U.S. quarantine were established. First was the treatment of ill seamen or those without land based homes at free public health service hospitals, which is the precursor to the travelers’ health activity in the division today. Second was the health screening of arriving immigrants(TB, syphillis, chancroid, gonorrhea,granuloma inguniale, LGV, leprosy)— which today is accomplished by the division’s immigrant, refugee, and migrant health program. And Third was the assessment of illnesses aboard arriving vessels, such as was done daily at Q stations by quarantine officers on aircraft and vessels during CDC’s SARS response. SAFER • HEALTHIER • PEOPLE

Quarantine Program, 1960s Board aircraft Review documents Monitor illness Through the late 1960’s there were approximately 50 quarantine stations located at international ports of entry in the United States. The first and only person to board all arriving international aircraft was the quarantine inspector who visually observed each passenger and crew member for signs of illness, looking most carefully for rash that might indicate the presence of smallpox. Airports were required to have “sterile” corridors (frequently referred to as the “sheep runs”) that separated passengers arriving on different international flights, thus avoiding the intermingling that might result in exposure to an infectious disease. SAFER • HEALTHIER • PEOPLE

Quarantine Program 1970s Smallpox eradicated; less fear of infectious disease Smaller stations closed Oversee refugee screening 1980s Mass migration emergencies Health information for international travel Distribute emergency immunobiologics 1990s Cholera, Plague, Ebola Refugee arrivals 1-In the 1970’s with the eradication of smallpox there was less fear of infectious diseases. 2- In the 1980’s, mass migration emergencies occurred, health info for int travelers was needed and given, and distribution of emergency immunobiologics began. 3-In the 90’s, old infectious diseases resurged. In response to the reappearance of cholera in South America in 1991, a pneumonic plague outbreak in Surat, India in 1994, and Ebola hemorrhagic fever in Kikwit, Zaire in 1995, the quarantine staff responded as they would do for SARS in 2003 at the ports of entry. 4-Throughout this decade, reports of illnesses among travelers continued to occur, and refugees continued to pour into the United States from Europe, Africa, and elsewhere, providing constant activity at many of our Q stations. SAFER • HEALTHIER • PEOPLE

U.S. Quarantine Program DHEW 1953 52 seaports 41 airports 17 border stations 33 territory stations 41 U.S. consulates 50 maritime vessels 600 employees DHHS 2004 8 airports 70 employees 1-When the Foreign Quarantine Program became a part of the Department of Health, Education, and Welfare in 1953, there were stations at every major port in the United States, and then some. 2-In 2004 and today, the program is a skeleton of its former self, but the responsibility of our mission has not diminished, and in fact has grown greater in light of recent world health events. SAFER • HEALTHIER • PEOPLE

This shows major migration flow patterns during SAFER • HEALTHIER • PEOPLE

And this in 1990s: during which Global Migration has increased by 4 fold since the 60s and 70s SAFER • HEALTHIER • PEOPLE

Not to mention the global challenges of emerging infx diseases such as SARS During this outbreak it became obvious that the Quarantine program can no longer rely on our history, as proud and distinguished as it is, if we wish to continue to play a role in and contribute to the safekeeping of public health in the United States today. Quarantine stations faced challenges in manpower while responding at ports (visual screening) and contact tracing Partnerships were important QS were “rediscovered” as public health partners SAFER • HEALTHIER • PEOPLE

CDC Quarantine Stations
Anchorage Seattle Minneapolis Boston Detroit New York Newark Chicago San Francisco Washington DC Los Angeles San Diego Atlanta However, the value of having an extensive Q program to perform its very important duties has reemerged. Currently there is an expansion program taking place where to date we have 18 Q station and expanding to 25. El Paso Houston Miami Honolulu San Juan Operational Stations (18) SAFER • HEALTHIER • PEOPLE

Functions of CDC Quarantine Station
Responding to reports of illnesses on maritime vessels (cruise and cargo) and airplanes Emergency planning and preparedness Inspecting animal and human products posing threat to human health Monitoring health, and collecting, distributing and managing medical information of new immigrants, refugees, and parolees SAFER • HEALTHIER • PEOPLE

Functions of CDC Quarantine Station (continued)
Performing inspections of cargo and hand-carried items for potential vectors of human infectious diseases Distributing immunobiologics and investigational drugs Providing travelers with essential health information Responding to mass migration emergencies SAFER • HEALTHIER • PEOPLE

1-Q is still viewed as a “dirty” word by most due to portion of its history depicted in this photo. 2-During a wave of poor immigrants from E. Europe were driven our from their countries by Czarist practices and socioeconomic factors into the US on crowded ships, and bringing with them many infectious disease. Once in the US they were stigmatized by the rich Western Europeans who had migrated during the early 1800’s. Q became a political tool to exclude people (based on wealth and ethnicity) and to prevent infusion of lower class into a prospering America. 3-This history has shaped principles of modern Q and highlighted that Q should be based on scientific and public health principles, paying respect to civil liberties and rights. SAFER • HEALTHIER • PEOPLE

Principles of Modern Quarantine
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 good Civil liberties Just remember: This slide displays modern principles of Q, defined as (read slide). There has to be a fine balance between PG and CL. SAFER • HEALTHIER • PEOPLE

Purpose of Quarantine Range of community containment strategies for infectious diseases Applied to persons exposed but not ill, i.e., contacts (not cases) Designed to meet two objectives Facilitate early recognition of symptoms of a contagious disease, should they develop Reduce risk of transmission before progression to disease has been recognized SAFER • HEALTHIER • PEOPLE

Legal Authority Legal right to take a particular action based on statute, regulation, or other legal precedent Authority does not necessarily equal policy Important tool, but not a substitute for Resources Planning Communication Before proceeding too far into my discussion, I believe it is important to clarify that I will be discussing legal authority and not necessarily government policy. Legal authority is simply a legal right to take a particular action based statute, regulation, caselaw, or some other legal precedent. While legal authority is an important and, in fact, indispensable tool for government policy-makers, it is not a substitute for resources, planning, and communication. Rather, legal authority is only one aspect of preparedness for a bioterrorist or other public health emergency. Furthermore, simply because legal authority exist to take a particular action, does not necessarily that that action is the best or most appropriate thing to do in any given situation. SAFER • HEALTHIER • PEOPLE

Key Questions before Decision to Quarantine
Is there public health and medical justification? Infectious agent, communicability, risk of fatality Are implementation and maintenance of quarantine feasible? Define who is to be quarantined and for how long, and availability of resources Do potential benefits of quarantine outweigh adverse consequences? Determine health risks for those quarantined, consequences of quarantine disobedience, and effect on commerce 1- The key questions before decision to Q: 2- (read first bullet with answer) Incubation period: never longer than incubation period- if it is a disease with a long incubation period, such as smallpox (2 weeks), can people be quarantined for this period and acan resources such as food, water, healthcare, mental health communication be provided to those in quarantine -Available treatment and chemoprophylaxis -Case fatality rate 3-(read second bullet with answer) Mental health, wage losses (use example SARS) 4-(read 3rd bullet with answer) 5-Diseases like varicella for which costs of Q may be high (many work school days are lost when noninf contacts kept home) and the return minimal (a relatively mild disease is avoided) require a different approach. Mode of transmission Period of communicability Level of person-to-person transmission in community JAMA, Dec 5,2001-vol 286, No 21: 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 SAFER • HEALTHIER • PEOPLE

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 nonessential travel Cordon sanitaire SAFER • HEALTHIER • PEOPLE

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 secondary preventive interventions, including vaccination or prophylactic antibiotics, PPE SAFER • HEALTHIER • PEOPLE

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

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 for those subjected to quarantine restrictions SAFER • HEALTHIER • PEOPLE

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 SAFER • HEALTHIER • PEOPLE

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 with a case SAFER • HEALTHIER • PEOPLE

Implementation of containment measures requires: A clear understanding of public health roles at local, state, and federal levels Well-understood legal authorities at each level Cooperation between public and private health-care sectors SAFER • HEALTHIER • PEOPLE

Implementation of containment measures requires coordinated planning by many partners: Public health practitioners Health-care providers/facilities Transportation authorities Emergency response teams Law enforcement Security/Credentialing personnel SAFER • HEALTHIER • PEOPLE

To achieve trust and cooperation, the public must be informed of: The dangers of “quarantinable” infectious diseases before an outbreak occurs The justifications for quarantine when outbreak is in progress Anticipated duration and endpoints of control measures 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? The 3 most important questions to ask at END of Q (read slide). SAFER • HEALTHIER • PEOPLE

Question 1: Elements of Response
What were the elements of response to SARS containment? Was quarantine used alone? Elements of SARS containment: Case management Contact management Hospital/facility infection control Community containment such as quarantine Border responses SAFER • HEALTHIER • PEOPLE

Question 2: Level of Response
What were deciding factors for the levels of containment response? Two levels of response: Basic and enhanced response, depending on: Magnitude and scope of outbreak Pattern of transmission Resources available for response Community cooperation and trust SAFER • HEALTHIER • PEOPLE

Question 3: Case Management
What is correct term for separation of cases? What were some basic methods of isolation (during minimal community transmission or fatality)? Isolation Home isolation Suitable for providing adequate care Adequate infection control measures possible Hospital isolation if medically necessary SAFER • HEALTHIER • PEOPLE

Question 4: Case Management
What were some possible enhanced methods of isolation for cases (if greater community transmission occurred)? Community-based facility isolation Facility must meet patient care and infection control requirements SAFER • HEALTHIER • PEOPLE

Question 5: Contact Management
What is the correct term for separation of those who are contacts? What were some basic activities in contact management in the U.S? Quarantine Monitoring without activity restrictions Assessment for signs and symptoms in well person(s) exposed to a contagious disease Passive or active Mention this was done in the united states and since there were no restrictions, no quarantine was implemented, unlike Canada where there were “enhanced activities” SAFER • HEALTHIER • PEOPLE

Question 6: Contact Management
Describe some of the enhanced activities for restriction of movement of contacts in Canada and Asia Home quarantine Working quarantine Facility-based quarantine What was monitored daily in those under quarantine? Clinical monitoring (Fever and respiratory symptoms) Duration of quarantine? Quarantine should not be longer than incubation period (for SARS, 10 days from exposure) What resources need to be provided to those in quarantine? Food Healthcare/Mental health Communication SAFER • HEALTHIER • PEOPLE

Question 7: Community Containment measures
Discuss some basic activities of community containment measures utilized around the world? Public information and education Promote “respiratory hygiene” and hand washing Describe some enhanced activities of community containment in Canada and Asia? Cordon sanitaire Widespread community quarantine Measures to increase social distance Basic done in U.S and enhanced other parts of world with more cases, and level of transmission SAFER • HEALTHIER • PEOPLE

Question 8: Community Containment Measure
What are ways to increase social distance? Implement “Snow Day” restrictions Close schools, day-care centers, etc. Cancel large public gatherings (concerts, theaters) Minimize other exposures (markets, churches, public transit) Other measures Distribution of surgical masks Temperature screening in public venues Scaling back transportation services SAFER • HEALTHIER • PEOPLE

Question 9: Containment Strategy: Border and Travel Responses
Describe some basic activities towards border and travel response in the U.S? Travel advisories and alerts Distribution of health alert notices Visual inspection of passengers from SARS-affected areas Responding to ill passengers Enhanced activities would have included…? Pre-departure and arrival screening Quarantine of travelers from areas with SARS Restriction of nonessential travel Comment on U.S versus outside U.S Visual inspection of passengers from SARS-affected areas and dissemination of Health Alert Notices (HAN) - Visual inspection: 2.7 million passenger on 11,000 flights - HAN distribution : 5,000 travelers/day traveling to U.S from 15 land border crossings Crafted and posted website guidance documents Expanded usual airline passenger contact tracing efforts SAFER • HEALTHIER • PEOPLE

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

Acknowledgments Division of Global and Migration and Quarantine Marty Cetron, MD, Chief, Division of Global Migration and Quarantine Ram Koppaka, MD, PhD, Acting Branch Chief, Quarantine and Border Health Services Marty Remis: Deputy Branch Chief, Quarantine and Border Health Services CDC Miami Quarantine Staff SAFER • HEALTHIER • PEOPLE

To conclude, the potential for an explosion of a communicable disease is always lurking given our highly mobile global population. Our division and Q stations are in the forefront in preventing the importation, transmission and spread of communicable illnesses from foreign countries into the United States. We rely on cooperation from CBP in meeting our mission. SAFER • HEALTHIER • PEOPLE

Questions? SAFER • HEALTHIER • PEOPLE

Quarantine CDC COCA Conference Call February 2006

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