QuarantineTM
Quarantine and the Emerging
Influenza Pandemic
Quarantine and the Emerging
Influenza Pandemic
Steven L Harris, MD, MScQuarantine Medical Officer
CDC / Houston Quarantine Station
30 March 2007
Steven L Harris, MD, MScQuarantine Medical Officer
CDC / Houston Quarantine Station
30 March 2007
QuarantineTM
DefinitionsDefinitions
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
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
QuarantineTM
DefinitionsDefinitions
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
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
QuarantineTM
Historic roots of QuarantineHistoric 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
• 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
QuarantineTM
Quarantine in the United StatesQuarantine in the United States
• Quarantine in Colonial America handled locally by each colony – Massachusetts Bay Colony (1647)– Yellow Fever outbreak in Philadelphia (1793)
• Governor declared cordon sanitaire
• National Quarantine Act (1878)– Shift of quarantine powers from state to federal
government
• Public Health Service Act (1944)– Basis for current federal quarantine powers
• Quarantine in Colonial America handled locally by each colony – Massachusetts Bay Colony (1647)– Yellow Fever outbreak in Philadelphia (1793)
• Governor declared cordon sanitaire
• National Quarantine Act (1878)– Shift of quarantine powers from state to federal
government
• Public Health Service Act (1944)– Basis for current federal quarantine powers
QuarantineTM
Purpose of QuarantinePurpose of Quarantine
• Range of community containment strategies for infectious diseases
• Applied to persons exposed but not ill, ie, 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
• Range of community containment strategies for infectious diseases
• Applied to persons exposed but not ill, ie, 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
QuarantineTM
Quarantine DichotomyQuarantine Dichotomy
• Quarantine is a “dirty” word– Black Death, yellow fever, Pandemic
influenza– Detention camps equate disease with crime– Stigmatizes victims (e.g., foreign born)– Historical abuses of power
• Quarantine works– Effective tool to prevent spread of contagion– As good or better than other tools in the box
• Quarantine is a “dirty” word– Black Death, yellow fever, Pandemic
influenza– Detention camps equate disease with crime– Stigmatizes victims (e.g., foreign born)– Historical abuses of power
• Quarantine works– Effective tool to prevent spread of contagion– As good or better than other tools in the box
QuarantineTM
Legal AuthorityLegal Authority
• Legal right to take a particular action based on statute, regulation, or other legal precedent
• Important tool, but not a substitute for– Resources– Planning– Communication
• Authority does not necessarily equal policy
• Legal right to take a particular action based on statute, regulation, or other legal precedent
• Important tool, but not a substitute for– Resources– Planning– Communication
• Authority does not necessarily equal policy
QuarantineTM
Quarantine: Statutory AuthorityQuarantine: Statutory Authority
• Intrastate quarantine power – Considered a police power -- an inherent
authority to protect health and welfare of citizens
– Reserved to states (10th Amendment)
– Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border
• Intrastate quarantine power – Considered a police power -- an inherent
authority to protect health and welfare of citizens
– Reserved to states (10th Amendment)
– Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border
QuarantineTM
Interstate Quarantine Regulations: 42 CFR Part 70
Interstate Quarantine Regulations: 42 CFR 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 – Written permit for operators of conveyances– Must comply with applicable state travel permits
• Intrastate federal intervention only if local control inadequate
• Report of communicable disease to local health authority
• Provision for Federal travel permit requirement– Written permit for travel from one state to another – Written permit for operators of conveyances– Must comply with applicable state travel permits
• Intrastate federal intervention only if local control inadequate
QuarantineTM
Quarantine: Statutory AuthorityQuarantine: Statutory Authority
• Foreign and interstate quarantine– Considered essential in regulation of foreign and
interstate commerce– Federal authority (Commerce clause)– Executive decision by the President– 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
• Foreign and interstate quarantine– Considered essential in regulation of foreign and
interstate commerce– Federal authority (Commerce clause)– Executive decision by the President– 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
QuarantineTM
Foreign Quarantine Regulations:42 CFR Part 71
Foreign Quarantine Regulations:42 CFR Part 71
• Reporting of “ill persons” defined by
– Fever (≥100º F or 38º C) persisting ≥48 hours– Fever and rash, glandular swelling, or jaundice– 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 Presidential Executive Order
• Reporting of “ill persons” defined by
– Fever (≥100º F or 38º C) persisting ≥48 hours– Fever and rash, glandular swelling, or jaundice– 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 Presidential Executive Order
QuarantineTM
Executive Order 13295: Revised List of Quarantinable Communicable Diseases Executive Order 13295: Revised List of Quarantinable Communicable Diseases
(a) 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
(a) 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
President George W. Bush
April 1, 2005
QuarantineTM
Functions of Quarantine StationsFunctions of Quarantine Stations
• Respond to reports of illnesses on cruise ships, cargo ships, and airplanes
• Inspect animal and human products posing threat to human health
• Monitor health and collect, distribute, and manage medical information for new immigrants, refugees, and parolees
• Respond to reports of illnesses on cruise ships, cargo ships, and airplanes
• Inspect animal and human products posing threat to human health
• Monitor health and collect, distribute, and manage medical information for new immigrants, refugees, and parolees
QuarantineTM
Functions of Quarantine StationsFunctions of Quarantine Stations
• Inspect cargo and hand-carried items for potential vectors of human infectious diseases
• Distribute immunobiologics and investigational drugs
• Provide travelers with essential health information
• Respond to migration emergencies• Planning for emergency response
• Inspect cargo and hand-carried items for potential vectors of human infectious diseases
• Distribute immunobiologics and investigational drugs
• Provide travelers with essential health information
• Respond to migration emergencies• Planning for emergency response
QuarantineTM
VT
ME
MANY
PA
NH
WV
VA
MD
NJ
RICT
AZ
IN
WI
KY
MI
OHIA
MN
MO
ILNE
KS
SD
ND
AL
TN
GA
SC
NC
AR
LA
MS
OK
AtlantaAtlanta
ChicagoChicagoSeattleSeattle
WY
ID
WA
AK
OR
MT
NVUT
NM
CO
East TX
MiamiMiami
FL
No.CA
So.CA
Los AngelesLos Angeles
San FranciscoSan Francisco
Jurisdictions of CDC Quarantine StationsJurisdictions of CDC Quarantine Stations
DE
HI
HonoluluHonolulu
Washington D.C.Washington D.C.
El PasoEl Paso
HoustonHouston
NewarkNewark
New YorkNew York
BostonBoston
GU
San JuanSan Juan
MinneapolisMinneapolis
DetroitDetroit
AnchorageAnchorage
San DiegoSan Diego
West TX
PR
CDC Quarantine Station
QuarantineTM
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
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
Principles of Modern QuarantinePrinciples of Modern Quarantine
QuarantineTM
• Without intervention, expect international spread in one month and U.S. cases in 1 - 2 months
• Failed containment may still delay international spread by one month
• Severe travel restrictions may delay U.S. cases by 1 - 4 weeks
• Without intervention, expect international spread in one month and U.S. cases in 1 - 2 months
• Failed containment may still delay international spread by one month
• Severe travel restrictions may delay U.S. cases by 1 - 4 weeks
U. S. planning assumptionsU. S. planning assumptions
QuarantineTM
Non-pharmaceutical interventionsNon-pharmaceutical interventions
• Depend on virus transmission characteristics and illness severity
• Measures at borders (international or within countries) - limited early focus, phase 5-6a Health alert notices Entry screening of international travelers Exit screening from affected countries is
recommended, especially if most countries not yet affected
• Depend on virus transmission characteristics and illness severity
• Measures at borders (international or within countries) - limited early focus, phase 5-6a Health alert notices Entry screening of international travelers Exit screening from affected countries is
recommended, especially if most countries not yet affected
QuarantineTM
Layered interventionsLayered interventions↓ cases↑ household & community transmission
↓ cases↑ household & community transmission
Close schoolsClose schools
Household (HH)quarantineHousehold (HH)quarantine
↓ cases↑ relative importance of workplace & community
↓ cases↑ relative importance of workplace & community
Socialdistancing
Socialdistancing ↓ cases↓ cases
Keep kids homeKeep kids home↓ HH & community transmission↑ relative importance of HH & workplace transmission
↓ HH & community transmission↑ relative importance of HH & workplace transmission
QuarantineTM
Potential tools in our toolboxPotential tools in our toolbox
• Our best countermeasure – vaccine – will probably be unavailable during the first wave of a pandemic
• Anti-viral treatment may improve outcomes but will have only modest effects on transmission
• Anti-viral prophylaxis may have more substantial effects on reducing transmission
• Infection control and social distancing should reduce transmission, but strategy requires clarification
• Our best countermeasure – vaccine – will probably be unavailable during the first wave of a pandemic
• Anti-viral treatment may improve outcomes but will have only modest effects on transmission
• Anti-viral prophylaxis may have more substantial effects on reducing transmission
• Infection control and social distancing should reduce transmission, but strategy requires clarification
QuarantineTM
Considerations for a decision to quarantineConsiderations for a 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
• 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: 286, 21: 2711-2717
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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
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
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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
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
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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 prevention interventions, including vaccination or prophylactic antibiotics, PPE
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 prevention interventions, including vaccination or prophylactic antibiotics, PPE
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
Quarantined persons must be among the
first to receive all available disease
prevention interventions• Vaccination (eg, smallpox)• Antibiotics (eg, plague)• Early, rapid diagnostic testing and symptom
monitoring• Early treatment if symptoms appear
Quarantined persons must be among the
first to receive all available disease
prevention interventions• Vaccination (eg, smallpox)• Antibiotics (eg, plague)• Early, rapid diagnostic testing and symptom
monitoring• Early treatment if symptoms appear
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
• 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
• 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
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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
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
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
Implementation of containment measures requires:– A clear understanding of public health
roles at local, state, and federal levels
– Cooperation between public and private health-care sectors
– Well-understood legal authorities at each level
Implementation of containment measures requires:– A clear understanding of public health
roles at local, state, and federal levels
– Cooperation between public and private health-care sectors
– Well-understood legal authorities at each level
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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
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
QuarantineTM
Principles of Community ContainmentPrinciples of Community Containment
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
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
QuarantineTM
Quarantine: Lessons learnedQuarantine: 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
• 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
QuarantineTM
http://www.pandemicflu.gov/plan/community/commitigation.html
