# Presentation: 029594

## Quarantine

**February 2006 CDC COCA Conference Call**
**Presented by:**
**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**
**For additional information about quarantine, visit: **_[www.cdc.gov/ncidod/dq/](http://www.cdc.gov/ncidod/dq/)_
**To request a speaker from the Division of Global Migration and Quarantine, send an email to **_[gkb6@cdc.gov](mailto:gkb6@cdc.gov)_

## Overview

**Introduction to quarantine**
**Definitions**
**History**
**Legal basis and authority**
**Who we are**
**Functions of U.S quarantine stations**
**Principles of modern quarantine as containment measure**

## Slide 3

## 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**

## 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**

## 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 **

## Quarantine in the United States

**Quarantine in Colonial America (17****th**** 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: 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 (10****th**** Amendment)**

## 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**

## Foreign Quarantine Regulations:Title 42 CFR Part 71 

**Reporting of “ill persons” defined by **
**Fever (****≥****100****o ****F or 38****o ****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 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)**
**Severe Acute Respiratory Syndrome (SARS)**
**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**

## 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**

## 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**

## Quarantine Program, 1960s

**Board aircraft**
**Review documents**
**Monitor illness**

## 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**

## 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**

## Slide 17

**Notes:**
This shows major migration flow patterns during 1960-75

## Slide 18

## Slide 19

## CDC Quarantine Stations

**CDC Quarantine Stations**

- Honolulu

- San Francisco

- Los Angeles

- San Diego

- Seattle

- Anchorage

- El Paso

- Houston

- Atlanta

- Miami

- San Juan

- Minneapolis

- Chicago

- Detroit

- Boston

- New York

- Newark

- Washington DC

**Operational Stations (18)**

## Who We Are

- Department of Health and Human Services
- Centers for Disease Control and  Prevention (CDC)
- National Center for Infectious Diseases (NCID)
- Division of Global Migration & Quarantine
- Quarantine and Border Health Branch
- Miami Quarantine Station (MQS)

## Division of Global Migration and Quarantine: Quarantine and Border Health Branch

- Mission:
- To protect the health of the public
- from communicable diseases
- through science, partnerships and
- response at U.S. ports

## 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

## 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

## Slide 25

## Principles of Modern Quarantine

**Public good**

**Civil liberties**

**Principles of ****Modern Quarantine**

## 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**

## 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**

## 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**

## 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**

## 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***

## 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**

## 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**

## 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**

## 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**

## 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**

## 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 **

## 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**

## 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**

## 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?**

## Slide 41

## 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**

## 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**

## 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**

## 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**

## 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**

## 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?**

**Notes:**
Food
Healthcare/Mental health
Communication

## 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**

**Notes:**
Basic done in U.S and enhanced other parts of world with more cases, and level of transmission

## 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**

## 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**

## 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**

## 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

## Slide 53

## Questions?