safer healthier people quarantine cdc coca conference call february 2006 danitza tomianovic, mph...

SAFER • HEALTHIER • PEOPLE

QuarantineQuarantine

CDC COCA Conference CallFebruary 2006

Danitza Tomianovic, MPHQuarantine Public Health Officer

Centers for Disease Control and PreventionNational Center for Infectious Diseases

Division of Global Migration and QuarantineMiami Quarantine Station


ObjectivesObjectives• Basics of quarantine

– Definitions– History– Legal basis and authority

• Functions of U.S quarantine stations

• Principles of modern quarantine as containment measure


Definitions: QuarantineDefinitions: 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


Definitions: IsolationDefinitions: 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


Historic Roots of Historic Roots of QuarantineQuarantine

• 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


Quarantine Quarantine in the United Statesin 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


Quarantine: Quarantine: Statutory AuthorityStatutory 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)


Quarantine: Quarantine: Statutory AuthorityStatutory 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


Foreign Quarantine Foreign Quarantine Regulations:Regulations:

Title 42 CFR Part 71Title 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)


Executive Order 13295: Revised List Of Executive Order 13295: Revised List Of Quarantinable Communicable DiseasesQuarantinable 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 pandemicPresident George W. Bush

April 1, 2005


Interstate Quarantine Interstate Quarantine Regulations: 42 CFR (Code of Regulations: 42 CFR (Code of Federal Regulations) Part 70Federal 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


Public Health Service Act, Public Health Service Act, 19441944

• Basis for current federal quarantine authority• Expanded maritime health service

– Public Health Service hospitals – Health screening of immigrants– Illness assessment on vessels and aircraft


Quarantine Program, Quarantine Program, 1960s1960s

• Board aircraft• Review documents• Monitor illness


Quarantine Quarantine ProgramProgram

• 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


U.S. Quarantine U.S. Quarantine ProgramProgram

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


11Source: Population Action International 1994

Major Migration Flows: 1960-75


22

4 x increase in volume as compared to 1960-754 x increase in volume as compared to 1960-75Source: Population Action International 1994

Major Migration Flows: 1990s


CDC Quarantine StationsCDC Quarantine Stations

Honolulu

San Francisco

Los Angeles

San Diego

SeattleAnchorage

El Paso Houston

Atlanta

Miami

San Juan

Minneapolis

Chicago

Detroit

Boston

New York

Newark

Washington DC

Operational Stations (18)


Functions of CDC Quarantine Functions of CDC Quarantine StationStation

• 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


Functions of CDC Functions of CDC Quarantine Station Quarantine Station

(continued)(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


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 Principles of Modern QuarantineModern Quarantine


Purpose of QuarantinePurpose 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


Legal AuthorityLegal 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


Key Questions before Key Questions before Decision to QuarantineDecision 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


Principles of Principles of Community Community

Containment (1)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



Containment (2)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



Containment (3)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



Containment (4)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



Containment (5)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


Principles of Community Principles of Community Containment (6)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



Containment (7)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


Principles of Community Principles of Community Containment (8)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



Containment (9)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



Containment (10)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


Evaluating the Evaluating the Effectiveness of Effectiveness of

QuarantineQuarantineKey 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?


Question 1: Elements of Question 1: Elements of ResponseResponse

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


Question 2: Level of Question 2: Level of ResponseResponse

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


Question 3: Case Question 3: Case ManagementManagement

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


Question 4: Case Question 4: Case ManagementManagement

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


Question 5: Question 5: Contact Management 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


Question 6: Question 6: Contact Management 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?


Question 7: Community Question 7: Community Containment measuresContainment 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


Question 8: Community Question 8: Community Containment MeasureContainment 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


Question 9: Containment Question 9: Containment Strategy: Border and Travel Strategy: Border and Travel

ResponsesResponses • 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


Quarantine 2003: Quarantine 2003: Lessons LearnedLessons 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


AcknowledgmentsAcknowledgments

• 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


Questions?Questions?

safer healthier people quarantine cdc coca conference call february 2006 danitza tomianovic, mph...

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