Quarantine

1. 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

2. 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

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4. Definitions: Quarantine • Separation and restriction of movement of wellpersons presumed to have been exposed to contagion • often at home or residential facility • may be voluntary or mandatory SAFER • HEALTHIER • PEOPLE

5. Definitions: Isolation • Separation and restricted movement of illpersons 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 SAFER • HEALTHIER • PEOPLE

6. 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 SAFER • HEALTHIER • PEOPLE

7. 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 SAFER • HEALTHIER • PEOPLE

8. 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) SAFER • HEALTHIER • PEOPLE

9. 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 SAFER • HEALTHIER • PEOPLE

10. 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) SAFER • HEALTHIER • PEOPLE

11. 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 President George W. Bush April 1, 2005 SAFER • HEALTHIER • PEOPLE

12. 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 SAFER • HEALTHIER • PEOPLE

13. 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 SAFER • HEALTHIER • PEOPLE

14. Quarantine Program, 1960s • Board aircraft • Review documents • Monitor illness SAFER • HEALTHIER • PEOPLE

15. 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 SAFER • HEALTHIER • PEOPLE

16. 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 SAFER • HEALTHIER • PEOPLE

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20. CDC Quarantine Stations Anchorage Seattle Minneapolis Boston Detroit New York Newark Chicago San Francisco Washington DC Los Angeles San Diego Atlanta El Paso Houston Miami Honolulu San Juan Operational Stations (18) SAFER • HEALTHIER • PEOPLE

21. 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

22. 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

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24. 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 SAFER • HEALTHIER • PEOPLE

25. 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

26. 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 SAFER • HEALTHIER • PEOPLE

27. 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 JAMA, Dec 5,2001-vol 286, No 21:2711-2717 SAFER • HEALTHIER • PEOPLE

28. Principles of Community Containment (1) Containment measures are appropriate when: • A person or group of people has been exposed to a highly dangerousand contagiousdisease • Exposed well persons are separated from illcases • 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

29. 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 nonessential travel • Cordon sanitaire SAFER • HEALTHIER • PEOPLE

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

31. 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, rapid diagnostic testing and symptom monitoring • Early treatment if symptoms appear SAFER • HEALTHIER • PEOPLE

32. 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 for those subjected to quarantine restrictions SAFER • HEALTHIER • PEOPLE

33. 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 SAFER • HEALTHIER • PEOPLE

34. 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 with a case SAFER • HEALTHIER • PEOPLE

35. Principles of Community Containment (8) 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

36. Principles of Community Containment (9) 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

37. Principles of Community Containment (10) 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

38. 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? SAFER • HEALTHIER • PEOPLE

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40. 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

41. 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

42. 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

43. 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

44. 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 SAFER • HEALTHIER • PEOPLE

45. 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? SAFER • HEALTHIER • PEOPLE

46. 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 SAFER • HEALTHIER • PEOPLE

47. 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

48. 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 SAFER • HEALTHIER • PEOPLE

49. 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

50. 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