best practices in isolation and quarantine

Expert Panel on Quarantine and IsolationUniversity of Michigan School of Public Health ● Office of Public Health Practice

Best Practices in Isolation and Quarantine

Part I: Legal Basis for Isolation and Quarantine

Results of a National Survey of State Epidemiologists

1


Have you consulted with a legal adviser to answer the questions in Part I?

Response

Frequency

Response Count

Yes 73.2% 30

No 26.8% 11

2


Do your state isolation and quarantine laws exist as statutes (written laws passed by legislature) or as regulations (administrative rules with the force of law promulgated and enforced by government agencies)?

Response Frequency

Response Count

Statutes 36.6% 15Regulations 0.0% 0Both 63.4% 26Neither- no isolation and quarantine laws exist

0.0% 0

3


When were the state's isolation and quarantine laws last revised?

Response Frequency

Response Count

< 2 years 24.4% 102 to 5 years 41.5% 176 to 10 years 7.3% 3> 10 years 26.8% 11

4


Where do the laws and statutes related to isolation and quarantine reside?

Response Frequency

Response Count

State Public Health Code 80.0% 32

Other (please specify) 20.0% 8

Other: CT General Statutes, Ohio Revised Code Chapters 3701, 3707 and 339 (TB), KSA 65-128, 65-129ato 65-129e, KAR 28-1-5 and KAR 28-1-6 ; state statutes and 173NAC6; Health and Safety Code; Massachusetts General Laws; SDCL 34-22 & ARSD 44:20

5


Does the code specify a length of time that state and local public health officials can detain an individual or groups of persons for quarantine or isolation? If so, please specify length of time.

Response Frequenc

y

Response Count

Yes 60.0% 24No 40.0% 16

Yes: depends on agent/situation; not to exceed the period of incubation and communicability; as long as needed; until disease has been rendered noncommunicable; minimum necessary to accomplish public health objective; 36 hrs- if court order is granted can detain until no longer contagious; 72 hrs; not more than 20 days; 30 days (4); 180 days; 6 months (2)

6


Does the state law provide for due process for individuals and groups (i.e. procedural protections requiring a judicial hearing either before or after quarantine is imposed)?

Individual Groups

Response Count

Yes 36 22 36

No 5 13 13

7


Have the state and local health departments promulgated regulations to implement due process when isolation and quarantine are ordered?

Response Frequenc

y

Response Count

Yes 46.3% 19

No 53.7% 22

8


Does the state code differentiate isolation and quarantine procedures and response based on the number of persons affected (e.g. individual vs. groups of persons)?

Response Frequency

Response Count

Yes 30.8% 12

No 69.2% 27

9


Do the legal criteria for differentiating procedures and response based on number of persons affected reside in statutes or regulations?

Response Frequenc

y

Response Count

Statutes 24.4% 10

Regulations 9.8% 4

Not Applicable 65.9% 27

10


Which of the following persons have independent legal decision-making authority to declare an emergency for epidemics or other communicable disease threats and/or implement isolation and quarantine of INDIVIDUALS or GROUPS OF PERSONS? (Check all that apply)

Emergency Declaratio

ns

Quarantine of

Individuals

Isolation of

Individuals

Quarantine of

Groups

Isolation of

Groups

Response Count

Governor 39 9 9 9 9 39State Health Officer 6 35 35 32 33 35Chief Medical Executive

0 3 3 3 3 3

State Epidemiologist 0 4 4 5 4 5State Director of Emergency Preparedness

0 0 0 0 0 0

Local Health Officer 2 27 27 23 23 27Other 3 6 5 7 5 10

Other: Municipal and county governments; physician designated by State Health Officer; county or city chief executive official; State Medical Officer; local health officer for groups only with permission of State Health Officer; Dept of Health and Environment; on-call physicians and other disease control staff with delegated authority; Local Board of Supervisors or designee; Deputy Secretary of Health Planning and Assessment

11


Has the person(s) with legal authority to order quarantine and/or isolation provided written formal guidance to state and local public health officials on how to proceed with implementation of quarantine/isolation?

Response Frequency

Response Count

Yes 65.0% 26

No 35.0% 14

12


Who has the state public health agency identified to serve as "legal adviser" to provide interpretation of quarantine and isolation authority? (Check all that apply)

Response Frequency

Response Count

Attorney General 43.9% 18

Health Department Chief Counsel 70.7% 29

Other legal counsel (please specify) 29.3% 12

Other: State public health agency staff attorneys; Assistant Legal Counsel- Health Department; Assistant Attorney General; County attorneys; Cabinet for Health Family Services Legal Counsel; Staff Attorney, Public Health Preparedness and Emergency Response; Local Health Officer’s Counsel; Bureau for Public Health Legal Counsel; Health Department Deputy Counsel

13


Has the legal adviser issued formal guidance on how to meet individual and group due process requirements?

Response Frequency

Response Count

Yes 47.4% 18

No 52.6% 20

14


Does the State Health Officer have express authority to order isolation and quarantine in the absence of a declared emergency?

Response Frequency Response Count

Yes 90.2% 37No 9.8% 4

15


In the event of a legal challenge to an isolation or quarantine order authorized by the local public health agency, who has authority to override the order? (Check all that apply)

Response Frequency

Response Count

Governor 20.0% 8State Health Officer 37.5% 15Chief Medical Executive 5.0% 2State Epidemiologist 7.5% 3CDC Official 0.0% 0N/A- no legal authority to override a local order

20.0% 8


Other: Judges/Courts (12) ; local board of health; state board of health

Comments: Only the State Health Department has authority to establish quarantine or isolation; orders by local agencies are coordinated with state health officer; locals can’t order isolation or quarantine (2); not specified in statute or rule

16


From your state's perspective, does the CDC or other federal entity have the legal authority to mandate individual or group isolation or quarantine?

Response Frequency

Response Count

Yes 55.0% 22

No 45.0% 18

17


If CDC or another federal entity mandates individual or group isolation or quarantine in your state, which governmental entity bears the attendant costs? (Check all that apply)

Response Frequency

Response Count

State Health Department 15.0% 6Local Health Department 7.5% 3CDC/Other federal agency 52.5% 21

Not applicable- CDC/federal entity has no legal authority to mandate individual or group quarantine in my state

32.5% 13


Comments: CDC has authority at international border, our attorney is not aware of in-state authority (3); federal government should fund federal order but since a formal statement has not been made, we are assuming state funds may be necessary; determined jointly on a case-by-case basis; CDC can only order isolation and quarantine when federal declaration of emergency has been issued; not specified by law, rule or policy; don’t know

18


Does the state public health agency have memoranda of understanding (MOU) on isolation and quarantine with any of the following? (Check all that apply)

Response Frequenc

y

Response Count

Local Health Department 6.3% 1Local Government 6.3% 1Tribal Health Board 0.0% 0Indian Health Center 0.0% 0CDC Quarantine Station 12.5% 2Law Enforcement 12.5% 2Emergency Medical Services 0.0% 0Other (please specify) 75.0% 12

Comments: All local health departments are in the state system; we have MOUs with some facilities for use for emergency response purposes but not specifically iso/quar; not required- our statutes grant that authority only to the state; public health agency has taken education and informational, rather than legalistic approach, to outreach to government and private sector partners

19


Do isolation and quarantine laws in your state mandate MOUs with law enforcement or Emergency Medical Services?

Response Frequency

Response Count

Yes 0.0% 0

No 100.0% 39

20


Does state law mandate/provide for the following quarantine/isolation (Q&I) procedures? If YES, identify whether the law exists as a STATUTE, REGULATION, or BOTH. If NO, choose NO LEGAL MANDATE.

StatuteRegulatio

n BothNo Legal Mandate

Response Count

Due process for individuals 21 4 8 5 38Due process for groups 17 4 5 11 37Drills/exercises for state and local public health to test Q&I procedures & capabilities

0 0 0 39 39

Provision of incentives to private citizens to enhance Q&I compliance

2 0 0 35 37

Job protection for those placed in Q/I 5 0 0 34 39Income replacement for those placed in Q/I

0 0 0 38 38

Use of "least restrictive alternative" when ordering Q&I

12 7 7 10 36

21


Please describe any deficiencies in the legal authority in ordering or enforcing isolation/quarantine as identified by the state public health agency or state Attorney General. • We need to better define due process for group quarantine or isolation.

Where there is concurrent authority we need MOUs specifying how each entity will carry out its authority

• The lack of express due process rights within the quarantine and isolation statutes is currently being addresses by state legislation

• No appeal from a local Q&I order; no administrative procedure• Need "exercises”• Training local judges on isolation/quarantine laws to avoid delays or gaps

in an emergency• Chemical, radiologic, and nuclear events• Although Massachusetts has adequate legal authority, the statutes are

archaic. Pending legislation would update and modernize law regarding I&Q

22


Please describe any deficiencies in the legal authority in ordering or enforcing isolation/quarantine as identified by the state public health agency or state Attorney General. (Continued)• Not a deficiency but a comment. Our statues do not identify "groups" as a

unit for I&Q. Legal department interpretation is that we still need to serve orders that identify each person as an individual

• Need better statutory clarification on groups-no provision for income replacement

• The statute provides for the appointment of counsel to represent individuals who are about to be quarantined. The provision should be further clarified

• Habeas corpus statute (KSA 60-1505) currently requires the district court judge to appoint at least two competent physicians to examine persons under isolation or quarantine and report their findings to the judge. We have introduced a bill in the current legislative session to strike this language from the statute.

23


Best Practices in Isolation and Quarantine

Part II: Isolation and Quarantine Policies and Practice

Results of a National Survey of State Epidemiologists

24


Please indicate the number of times in the last 5 years that your state has invoked isolation or quarantine policies for INDIVIDUALS or GROUPS.

25


Has state-ordered isolation or quarantine been an effective disease control tool in your state in the last 5 years?

Response Frequency

Response Count

Yes 70.0% 28No 0.0% 0Not applicable: no state-ordered isolation or quarantine in the last 5 years

30.0% 12

26


In practice, who is responsible for declaring an emergency for epidemics or other communicable disease threats and/or implementing isolation and quarantine of INDIVIDUALS and GROUPS OF PERSONS? (Check all that apply)

Emergency Declarations

Quarantine of

Individuals

Isolation of

Individuals

Quarantine of Groups

Isolation of Groups

Response Count

Governor 33 3 3 3 3 33

State Health Officer 12 32 32 31 31 33

Chief Medical Executive 0 1 1 1 1 1

State Epidemiologist 2 9 9 8 8 9

Director of Public Health Preparedness

1 1 1 1 1 1

Local Health Officer 4 26 26 23 23 26

Other 5 8 8 8 8 11

Other designees: A State Medical Officer, Local executive officer (emergency declarations), State disease control program, State public health director, secretary of the department of health, Deputy/Assistant State Health Officer, Chief presiding officer of the local government, Local Boards of Supervisors, Deputy Secretary for Health Planning and Assessment, Mayor

27


Who is primarily responsible for advising the state health officer on whether to implement isolation and quarantine? (Check all that apply)

Quarantine IsolationResponse

CountChief Medical Executive

7 7 7

State Epidemiologist

39 39 39

Director of Public Health Preparedness

6 6 6

Other 7 7 7Other: General Counsel, Regional Directors, Assistant State Epidemiologist, Disease Control Program Staff, Local Health Officers, Director of the Office of Public Health, Deputy Commissioner, Division of Acute Epidemiology, Deputy Secretary for Health Planning and Assessment

28


In your state public health agency, which department/office has primary responsibility for handling logistics for GROUP isolation and quarantine?

Response Frequency Response CountPublic Health Preparedness

47.4% 18

Administration 2.6% 1Communicable Diseases

31.6% 12

Legal Affairs 2.6% 1Other (please specify) 15.8% 6

Other: Bureau of Health Emergency Preparedness, Local responsibility, multiple agencies at state level, shared between Public Health Preparedness and Communicable Disease

Comments: No plans for group isolation/quarantine; emergency support functions as defined in the state plan

29


Which organizational entities have responsibility for ensuring each of the following components of isolation and quarantine? (Check all that apply)

State Public Health

Local Public Health

Law Enforcemen

tHospitals/clinics

NGOs (Red

Cross, Salvation Army) Other

Response Count

Monitoring compliance 27 34 8 11 1 1 38Providing basic necessities to people

14 25 1 8 20 13 37

Medical and mental health evaluation and treatment

21 25 0 27 5 11 37

Social support services 10 22 0 4 17 18 37Systems support (e.g. communications, personnel)

23 23 7 6 6 14 36

Funding support 24 20 0 1 6 14 34Transport of persons 13 20 14 7 5 16 36

30


Are there provisions made in the state public health agency's plan (including delegation of responsibility to local public health) for each of the following when ordering AT-HOME isolation or quarantine?

Yes No

Response Count

Basic necessities (food, water, etc.) 29 9 38Physical infrastructure (location, heat, electricity, etc.)

25 12 37

Medical evaluation and treatment 31 7 38

Mental health evaluation and counseling 21 16 37

Social support services 27 10 37

Funding support (funding for personnel, etc.) 11 25 36

Transport (relocation to higher level of care) 25 11 36

31


Are there provisions made in the state public health agency's plan (including delegation of responsibility to local public health) for each of the following when ordering INSTITUTIONAL (hospital) isolation or quarantine?

Yes No

Response Count

Medical evaluation and treatment 29 8 37

Mental health evaluation and counseling 21 15 36

Social support services 23 13 36

Funding support (i.e. all associated costs for hospitalization)

18 18 36

Transport to higher level of care 24 12 36

32


Which of the following has primary responsibility for covering associated costs for INSURED and UNINSURED patients in the event of state-ordered isolation and quarantine in a healthcare facility? (Check all that apply)

Answer Options

Local health

department

State health department

Other state

agencyHealthcare facility

Private insurance Other

Response Count

Insured7 12 6 10 29 8 38

Uninsured8 18 14 21 1 13 37

33


Does the state ever order isolation and quarantine without engaging the affected local public health agencies in the decision-making process?

Response Frequency

Response Count

Yes 7.7% 3

No 79.5% 31


34


Which of the following organizations has the state public health agency engaged to coordinate roles and responsibilities dealing with isolation and quarantine? (Check all that apply)

Response Frequency

Response Count

Local Health Departments 87.2% 34Local Governments 53.8% 21Tribal Health Board 30.8% 12Indian Health Service 15.4% 6CDC Quarantine Station 64.1% 25Law Enforcement 79.5% 31State Department of Agriculture 53.8% 21National Guard 35.9% 14State Department of Human (Social) Services

43.6% 17

State Office on Aging 25.6% 10Emergency Responders 61.5% 24Private Entities 43.6% 17None 0.0% 0Other (please specify) 41.0% 16

Other: State Department of Homeland Security, Red Cross, hospitals, Attorney General, Circuit Courts, Regional Public Health Emergency Planning Teams, Department of Education, legal associations, private healthcare, military, behavioral health, Department of Corrections, Emergency ManagementComments: All local health departments are part of the state system; Isolation/quarantine have been a local responsibility

35


When were the state's isolation and quarantine laws/statutes last reviewed by state public health officials?

Response Frequency Response Count

< 2 years 61.5% 24

2 to 5 years 35.9% 14

6 to 10 years 2.6% 1

> 10 years 0.0% 0

36


Please rate the level of importance of each of the following concerns in impacting decisions to ORDER and TERMINATE isolation or quarantine using the following scale: 1=not important 2=of little importance 3=moderately important 4=important 5=very important

1 2 3 4 5Response Count

Scientific (specific disease, transmission patterns, magnitude, severity, etc.)

0 0 1 26 12 39

Resource (available personnel, funding, logistical restrictions, etc.)

2 9 22 3 2 38

Legal (authority, etc.) 1 1 5 25 7 39Political (public pressure, legislative action, media attention, etc.)

8 14 14 1 1 38

TERMINATE

1 2 3 4 5Response Count

Scientific (specific disease, transmission patterns, magnitude, severity, etc.)

0 0 2 25 11 38

Resource (available personnel, funding, logistical restrictions, etc.)

4 8 21 4 2 39

Legal (authority, etc.) 2 1 6 24 5 38Political (public pressure, legislative action, media attention, etc.)

8 13 14 3 1 39

37


Which criteria determine whether isolation/quarantine for an emergency event can be ordered by a state agency or by a local agency? (Check all that apply)

Response Frequency

Response Count

Number of people to be isolated/quarantined (individual v. groups)

39.5% 15

Geographic spread of event 65.8% 25

Media, public, and/or political attention to event 15.8% 6

Specific disease involved 71.1% 27


Other: Mode of transmission, legal authority, insufficient/inappropriate action of local HDs, threat to public health, syndrome, jurisdictional considerations, recommendations from CDC consultants,

Comments: State HD is sole authority to order iso/quar (5); not specified by rule, law, or policy

38


Are there different procedures for implementing GROUP isolation/quarantine versus INDIVIDUAL isolation/quarantine?

Response Frequency

Response Count

Yes 52.9% 18

No 47.1% 16

39


Does your state have an isolation and quarantine electronic tracking system that may be used independently by local public health agencies?

Response Frequency

Response Count

Yes 28.2% 11

No 71.8% 28

40


Does your state have a case management system for persons in isolation or quarantine that is integrated with other electronic systems, such as a NEDSS-compliant surveillance system?

Response Frequency

Response Count

Yes 23.1% 9

No 76.9% 30

41


Has the state public health agency identified incentives to enhance compliance of private citizens in a state-ordered isolation or quarantine?

Response Frequency

Response Count

Yes 22.5% 9

No 77.5% 31

If an incentive program was developed, has it ever been employed?

Response Frequency

Response Count

Yes 5.0% 2

No 15.0% 6


42


How much time would be needed to obtain an isolation or quarantine order from the state health department following report of a physician-diagnosed quarantinable disease?

Response Frequency

Response Count

Less than 24 hours 90.0% 36

24-48 hours 7.5% 3

49-72 hours 0.0% 0

4-7 days 0.0% 0

More than 7 days 0.0% 0

Don't know 2.5% 1

43


If the CDC issues a federal order for INDIVIDUAL or GROUP quarantine in your state, for which of the following areas would the state be willing to provide resources to implement and maintain that order? (Check all that apply)

Individual GroupResponse

CountMonitoring compliance 28 24 28Basic necessities 19 16 19Medical and mental health evaluation and treatment

20 18 20

Social support services 18 17 18Systems support (e.g. personnel, communications, surge capacity)

21 19 21

General Funding support 9 8 9Transportation services 18 15 18None of the above 5 6 6Other 6 6 7

Comments: Unable to respond; depends on situation; not specified by statute, rule, or policy; CDC has no legal authority to mandate individual or group quarantine in my state; without a federal quarantine station, unsure how federal authority applies; in right circumstances would do all

44


Which of the following areas are too under-resourced in the state to effectively implement and maintain an INDIVIDUAL-level or GROUP-level isolation or quarantine? (Check all that apply)

Individual Group

Response Count

Financial resources 14 25 26Human resources 13 23 25Physical infrastructure 14 25 26None 9 5 9Other 6 8 8

Comments: Situation dependent; legal restrictions- no MOUs in place to accommodate isolation or quarantine; little large scale capability

45


Which of the following locales is your state considering for use in group isolation/quarantine? (Check all that apply)

Response Frequency

Response Count

Hospital 62.2% 23

Armory 27.0% 10

Schools 45.9% 17

Other 73.0% 27

Other: Designated mass care shelters, motels, hotels, casinos, correctional facilities, churches, community centers, airport hangars, colleges, military bases, gyms, homes, vacant State properties, nursing homes

Comments: Have not discussed; have not been able to identify; we do not plan to do group isolation/quarantine

46


Has a preparedness checklist specific to isolation and quarantine been created by your state public health agency for use by the general public?

Response Frequency

Response Count

Yes 30.0% 12

No 70.0% 28

47


What percentage of the GENERAL PUBLIC in your state do you believe is prepared for an event requiring isolation or quarantine (i.e. plans in place; supplies readied)?

Response Frequency

Response Count

0-10% 64.1% 25

11-25% 23.1% 9

26-50% 12.8% 5

51-75% 0.0% 0

76-100% 0.0% 0

48


On a scale of 1-10, please rate your state public health agency's level of preparedness for the following activities related to isolation and quarantine. 1= not at all prepared 10= fully prepared

1 2 3 4 5 6 7 8 9 10Rating

AvgResponse

CountInitiation of order

0 0 0 0 1 0 2 11 12 14 8.88 40

Maintenance 0 1 3 3 7 6 5 9 2 1 6.19 37Termination of order

0 0 0 0 2 2 1 9 14 12 8.68 40

Recovery 0 1 3 1 7 8 7 3 4 2 6.31 36

49


What type of exercises, if any, has the state public health agency conducted in the last 5 years to test group isolation and quarantine procedures and/or capabilities? (Check all that apply)

Response Frequency

Response Count

Full-scale 12.5% 5

Functional 25.0% 10

Tabletop 70.0% 28

None 20.0% 8


Other: School closure exercises, participated in exercises led or co-led by with other agencies

Comments: No plans for group isolation/quarantine

50


Which of the following populations has been targeted by the state public health agency for a public education campaign on isolation and quarantine? (Check all that apply)

Response Frequency

Response Count

General public 51.4% 19Children and families 21.6% 8Geriatric population 21.6% 8Physically impaired 13.5% 5Minority groups 21.6% 8Low income population 16.2% 6Non-English speaking 32.4% 12None 43.2% 16Other (please specify) 10.8% 4

Other: Generic references, health care, law enforcement, public health

51


If your state public health agency has developed a public education campaign, which message(s) has served as the main content? (Check all that apply)

Response Frequency

Response Count

Ready.gov: Prepare. Plan. Stay Informed. 23.7% 9Pandemicflu.gov: Get Informed. Be Prepared. 44.7% 17

American Red Cross: Get a Kit. Make a Plan. Be Informed.

18.4% 7

Not Applicable 39.5% 15Other (please specify) 18.4% 7

Other: “Get 10”, Preparedness Today, internally developed materials

52

best practices in isolation and quarantine

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