U.S.  Department of Health and  Human Services  
Office of Inspector General  
During the Initial COVID-19  
Response, HHS Personnel  
Who Interacted With 
Potentially Infected  
Passengers Had Limited 
Protections   
Christi A. Grimm  
Inspector  General  
October  2022, OEI-04-20-00360   U.S. Department of Health and Human Services  
 
Office of Inspector General  
Report  in Brief  
October 2022, OEI-04-20-00360  
Why OIG  Did This Review   During  the Initial COVID-19  Response,  HHS 
In  early  2020,  various  sources 
Personnel Who  Interacted  With  Potentially 
including  personnel from  HHS,  
Members  of Congress,  and the   Infected  Passengers  Had  Limited  Protections  
mediaexpressed  concerns  with 
how  HHS personnel  were  What OIG Found  
protected from  risk  of  COVID-19  Key Takeaway   During  the  initial 
exposure at  quarantine  stations   Initially,  CDC  recommended  limited   3 months of  the  COVID-19 
and sites  during  the  initial 
protections  for  HHS  staff who  were  responseJanuary  
COVID-19 response.   The Centers  
interacting  with  passengers  entering the   through  March  2020 
for  Disease  Control  and   United  States.   During  the  period we  CDC  initially  
Prevention (CDC),  within  HHS,  
reviewed,  CDCs  understanding of  recommended limited  
issues recommendations for  
COVID -19 was  evolving  and  the   personal  protective  
protection against  infectious  
protections  improved  but  still contained   equipment  (PPE)  for  some 
disease exposure, which  includes  
some  vulnerabilities.   As a  result,  HHS   HHS  personnel at  
travel-related  containment  
personnel may  have been  at  increased  quarantine  stations  and  
measures.   At  quarantine   risk  of  COVID -19 exposure  and  may  have   sites.   As a  result,  some  
stations,  CDC  personnel   inadvertently  spread  COVID -19.    personnel wore  only  
screened passengers  who  were 
limited  PPE  while  
entering  the United States  as  
interacting  with  potentially  infected  passengers.   In  addition,  CDCs  PPE 
private  citizens  via  commercial 
trainings  appear  to  have  failed  to meet  two standards  set  by  the  
flights.   At  quarantine  sites  (six  Occupational  Safety  and  Health Administration  (OSHA).  CDC  was also 
Federal worksites),  HHS  
initially  limited  in  the  extent  to  which  it  recommended  other  protections,  
personnel  screened  and 
such  as  physical  (also  referred to  as  social)  distancing,  symptom 
quarantined passengers  entering  
monitoring,  and self-quarantining.  As  data  and knowledge about  
the United States  as  evacuees.   In  
COVID-19 increased over  time, CDC improved its  recommendations  for  
total, HHS  screened hundreds  of 
PPE and  other  protections,  although some  vulnerabilities  remained.   
thousands of  passengers  and  
quarantined  thousands  of them   CDC said that  its approach  to recommending  protections  for  personnel  
in  an  effort  to  prevent  the spread   was  guided  primarily  by  evolving  COVID-19 data and  previous  
of COVID-19  in the  United   pandemic-planning  documents.   However,  we  note  that  CDCs  approach  
States.     did  not  align  with assumptions  outlined  in  these  documents.   Finally,  CDC  
did  not  have  a  comprehensive  plan  for  recommending travel-related 
How OIG Did This Review   containment  measures  that  weighed  the  riskssuch  as  the  risks  to  HHS  
Our  review  covers  the  initial   personnel  conducting  screeningrelative  to  the  public  health benefits.  
COVID-19 response  (i.e., January  
through March  2020).   We   What OIG  Recommends and How the Agency Responded  
interviewed officials  and  OIG recommends  that  CDC:  (1)  update its  guidance recommending 
program  staff  within  HHS,   protections  for  personnel  who  interact  with  potentially  infected  
including CDC.  We surveyed  passengers,  (2)  ensure  that  its  PPE  trainings  meet  OSHA  standards,  and 
nearly  700  HHS  personnel  who   (3) develop  a  comprehensive plan  for  recommending  travel-related 
worked  at  quarantine  stations   containment  measures  that  weighs  the  risks  relative  to  the  public  health 
and sites,  and  we reviewed  benefits.   CDC concurred with  all three recommendations. 
written responses  and 
documentation.   We  also  
analyzed  several thousand  HHS  
 
documents.   TABLE OF  CONTENTS  
BACKGROUND ................................................................................................................................................  1 
FINDINGS .......................................................................................................................................................  13 
CDC initially recommended limited  PPE for some HHS personnel who interacted with potentially 
infected passengers at quarantine stations and sites, and its PPE trainings appear to have not met  
OSHA standards  ...................................................................................................................................................................... 13 
Between January and March 2020, CDC  was also  initially limited in the extent to which it  
recommended other protections for personnel who interacted with potentially infected passengers, 
but these other protections also  improved over time .............................................................................................. 18 
CDC did not have a comprehensive plan for recommending travel-related containment measures that  
weighed the riskssuch as the risks to HHS personnel conducting screeningrelative to the public 
health benefits  ......................................................................................................................................................................... 23 
CONCLUSION AND RECOMMENDATIONS ........................................................................................... 27 
Update its guidance recommending protections for personnel interacting with potentially infected  
passengers, particularly when data are limited  ........................................................................................................... 28 
Ensure that its PPE trainings meet OSHA standards  ................................................................................................. 29 
Develop a comprehensive plan for recommending travel-related containment measures that weighs 
the risks relative to the public health benefits ............................................................................................................. 29 
AGENCY COMMENTS AND OIG RESPONSE  .........................................................................................  31 
APPENDICES .................................................................................................................................................  32 
Appendix A: COVID-19 Key Events: Quarantine Stations and  Sites, December 2019November 2020  32 
Appendix B: Prior Documents on Preparedness and Response Planning for Travel-Related  
Containment Measures ......................................................................................................................................................... 34 
Appendix C: More Information on OSHA and  CDC Hierarchy of  Controls for Infectious Disease 
Exposure (existing prior to and relevant during OIGs review period)................................................................ 38 
Appendix D: Agency Comments ....................................................................................................................................... 41 
ACKNOWLEDGMENTS AND CONTACT  ................................................................................................  46 
Acknowledgments  .................................................................................................................................................................. 46 
Contact ........................................................................................................................................................................................ 46 
ENDNOTES....................................................................................................................................................  47 
ABOUT THE OFFICE OF INSPECTOR GENERAL....................................................................................  58   
BACKGROUND  
OBJECTIVE  
To assess the Centers for Disease Control and Preventions (CDCs)  recommended  
infection prevention and  control protections for  Department of Health and Human 
Services (HHS) personnel who  were interacting with potentially infected passengers at  
quarantine  stations and  quarantine sites during the initial COVID-19 response (i.e., 
January through March 2020).  
 
In mid-January 2020, HHS personnel began to  take steps to prevent the spread of  
COVID-19 in the United States through, among other things, travel-related 
containment measures.  CDC, other HHS and  Federal agencies, and  the White House 
faced the challenge of protecting the United States from a novel infectious disease.  
At the time, data on  COVID-19  symptoms, transmission, and expected mortality were  
extremely limited and knowledge was evolving.  
One step that was taken, starting in January 2020, was implementation of  travel-
related containment measures.  These measures included conducting public health 
assessments (hereinafter referred to as screening) of  commercial airline passengers 
entering  the United States from certain areas with high rates of  COVID-19 infections, 
as well as the screening  and quarantining of emergency repatriation evacuees.  These  
measures were conducted by HHS personnel from CDC, the  Administration for 
Strategic  Preparedness and Response (ASPR),  the Administration for  Children and  
Families (ACF), and the  U.S. Public Health Service Commissioned Corps.1   See  
Appendix  A for a detailed timeline of COVID-19 key events related to quarantine 
stations and sites, from December 2019when the Wuhan Municipal Health 
Commission released its initial reportsthrough November 2020.   
Federal regulations require all employers, including HHS, to  provide employees with  
sufficient protection from hazards  while performing their job duties.   In the context of  
HHSs response to an infectious disease outbreak, these  regulations are important for 
the protection of  both the HHS personnel who respond  to the outbreak  and the 
members of the public with whom those personnel subsequently interact.   
Various stakeholders raised concerns about efforts to protect HHS personnel while 
trying to also prevent the spread of  COVID-19 within the United States.  Specifically, 
beginning in late February 2020, several HHS personnel filed complaints regarding  
how they were protected while interacting with potentially infected passengers at  
quarantine stations and  quarantine sites.2   OIG also received and responded to  
two  congressional  requests into related matters.  Finally, media reports also  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  1    highlighted  concerns about the screening of passengers entering  the United States 
after potential exposure to COVID-19 while abroad, and the impact  that these 
activities may have had on the health  and safety of  Federal personnel.3, 4, 5, 6   This 
assessment  of  CDCs recommended protections for HHS personnel while interacting  
with potentially infected passengers is intended to improve future response efforts by 
identifying vulnerabilities in the initial response to COVID-19.  
Federal authorities  for passenger screening  
CDC has the authority to quarantine and/or isolate7  passengers if they are infected  
with or have been exposed to quarantinable diseases as defined by Executive Order of  
the President (e.g., yellow fever, severe acute respiratory  syndromes, smallpox).8, 9   
Under this authority, CDC operates 20 quarantine stations at  ports of entry and land  
border crossings where passengers arrive for entry into the  United States.  Among  
other daily activities, personnel  who are  permanently assigned to CDC quarantine  
stations (hereinafter referred to as base personnel) respond to reports of ill  
passengers;  screen them;  and determine whether  they should be isolated,  
quarantined, or  released.10, 11    
When an infectious disease outbreak occurs, CDC may implement additional travel-
related containment measures, such as enhanced passenger screening.  This could  
entail proactively identifying groups of passengers to screen, rather than relying on 
reports from other entities regarding individual ill passengers.  Prior to the COVID-19 
outbreak, CDC most recently enhanced its quarantine-station screening activities  in 
2014 in response to the Ebola virus epidemic in West Africa.    
Planning  for travel-related  containment  measures  during  an 
infectious  disease outbreak  
Since at least 2005, HHS (including  CDC), the Department of  Homeland Security 
(DHS), the Homeland Security Council,12  the National Security Staff, and  the National 
Security Council have issued planning documents that contain guidance about travel-
related containment measures (e.g.,  enhanced entry screening, isolation, quarantine, 
and/or conditional release) during an infectious disease outbreak.13   These documents 
contain, among other things, guidance on the benefits, risks, and other factors to  
consider when deciding whether and/or when to  implement these measures at  
quarantine stations.  None of these documents contain guidance for establishing  
federally operated  long-term quarantine sites as a travel-related containment  
measure.  
An assessment of benefits, risks, and other factors can help inform whether travel-
related containment measures are worthwhile and, once implemented, whether these  
measures continue to be effective as the pandemic progresses.  See Appendix B for 
more information on prior planning  related to travel-related  containment measures.   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  2   Benefits. The public  health benefit  of travel-related containment measures is to delay 
the spread of the infectious disease within the United States,  which provides valuable 
time to  activate  a U.S. response.14   The measures can accomplish this by isolating, 
quarantining, and/or conditionally releasing passengers who are identified as 
potentially infected based on a screening criterion.15, 16   Travel-related containment  
measures can also result in directing  sick passengers to medical care, if needed.  
Health and safety risks.  Some travel-related containment measures pose health and  
safety risks to personnel who are carrying out the response activities.  Specifically,  
personnel may be exposed to the infectious disease while interacting with potentially  
infected passengers.   These personnel could  inadvertently  spread  infectious disease to  
members of  the public with  whom they  interact.  However, these risks can be 
mitigated by implementing protections to safeguard personnel  and, in turn,  the 
public.17    
Other factors. Other factorssuch  as knowledge about the disease, the degree of  
community spread,  the risk of misdirecting resources during  a critical  time period, and  
the number of  passengers travelingcan  also inform  a risk-benefit assessment of  
travel-related containment measures.  For example, the 2005 HHS Pandemic Influenza  
Plan  acknowledges that  asymptomatic and/or presymptomatic transmission may 
minimize the effectiveness of screening but states that nonetheless, screening early in 
a pandemic may help slow the spread  of a disease and allow  additional time for the  
implementation of other response measures (e.g., testing, vaccines).18,  19    
In addition, when developing policy regarding  travel-related  containment measures, 
the 2005 HHS Pandemic Influenza Plan  states that  one factor to consider is the degree 
of community spread versus the risk associated  with further introduced cases.   Once 
a  disease  has spread outside and within the United States, screening for ill passengers 
becomes less useful and feasible.20   This plan advises that other community-based  
measures, such as increased  physical  (also referred to as social) distancing,  to 
reduce disease transmission should be considered.21    
Finally, the 2016 National Security  Council Playbook for Early  Response to  High 
Consequence, Emerging  Infectious  Disease Threats and Biological Incidents  highlights 
that another factor to consider is the number of passengers.   It states that if the 
outbreak is in a region that has a large volume of travel, then screening all passengers  
from that region becomes operationally difficult, if not impossible.22    
Travel-related  containment  measures  in response to  COVID-19  
In January 2020, CDC began implementing travel-related containment measures, 
which included enhancing passenger screening at quarantine stations in response to  
COVID-19.23   Such efforts were taken  for passengers entering  the United States as 
private citizens via commercial flights at 15 CDC quarantine stations between January 
and September 2020.24   CDC reported that the primary public  health benefit of  
passenger screening for COVID-19 was to prevent the spread by collecting passenger 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  3   contact information in case they became symptomatic after traveling.  After screening  
passengers for symptoms, CDC conditionally released passengers for State and/or 
local followup  in the event that they developed symptoms in the 2  weeks  following  
their travel.  CDC also issued Federal  isolation and quarantine orders for some 
passengers as a result of passenger screening at quarantine stations.  
Because of the large volume of  
passengers needing  to  be 
screened for COVID-19 in 
early 2020, the number of  CDC  
base personnel at quarantine 
stations was not sufficient to  
implement these enhanced  
screening efforts.  CDC  
solicited  additional (i.e., surge)  
personnel from CDC  and the 
U.S. Public Health Service 
Commissioned Corps to  
temporarily deploy and  aid quarantine stations.25   During our review period, CDC  
deployed nearly 375 surge personnel to  assist approximately 75 base personnel with 
COVID-19 screening at quarantine stations.  Customs and Border Protection (CBP)  
also assisted with passenger screening.   
Travel-related containment measures were also  implemented for passengers entering  
the United States as emergency repatriation evacuees.  This included quarantining  
these passengers at  six  quarantine sites from January through March 2020.26   
Quarantine sites are Federal worksites, such as  Department of Defense military 
installations,  that were stood up for the first time during the COVID-19 response.  At  
these sites, HHS personnel, including personnel from ACF, ASPR, the U.S. Public 
Health Service Commissioned Corps, and CDC screened and  oversaw the quarantine 
of passengers entering  the United States as emergency repatriation evacuees.  While 
commercial  passengers at  airport  quarantine stations went through screening to  
determine whether they should be isolated, quarantined, or conditionally released, 
evacuees at quarantine sites were screened and then required to adhere  to a 14-day  
quarantine during which they were monitored and could not leave the quarantine 
site.  Therefore, in addition to passenger screening, HHS personnel at quarantine sites 
also carried  out a variety of  other services to help oversee evacuees quarantine 
period, which sometimes required interactions with potentially infected passengers.  
These other services included case management, social support, and wraparound  
services (e.g., medical care, logistics, and operations).  More than 1,000  HHS  personnel 
were deployed to carry out duties at quarantine sites between January and March 
2020.  
See Exhibit  1 for more details regarding passenger screening and quarantining that  
occurred between January and March 2020 in response to COVID-19.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  4    
Exhibit 1: COVID-19 passenger screening at quarantine stations, as well as 
screening and quarantining at quarantine sites, between January and March  
2020  
Source: OIG interviews with ACF, ASPR,  and  CDC and  review of documentation (e.g., written materials and briefs  
provided  to personnel prior to  deploying)  regarding  COVID-19  screening and  quarantining, 2021.  
* CBP generally  conducted  primary screening during  the  initial COVID-19 response at quarantine  stations.  The  
Department of State primarily identified the emergency repatriation evacuees who were processed at  quarantine sites.   
HHS personnel  did  not conduct primary  screening.   
   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  5     
Protecting  HHS  personnel from  occupational hazards  
The risks associated with interacting with potentially infected passengers can be 
mitigated by  implementing protections to safeguard involved personnel.  Controlling  
exposure is the fundamental method of protecting personnel from infectious diseases 
like COVID-19.27   Infection controls are intended to limit the spread of infectious 
diseases to  personnel and, in turn, indirectly help protect the public from such 
exposures.28   
Federal requirements and recommendations  for protecting  
personnel  
The Department of Labors Occupational  Safety and Health Administration (OSHA)  
has promulgated regulations implementing the  Occupational  Safety and  Health Act  
(i.e., OSHA standards).  These regulations apply to all Federal agencies.29   As a part of  
the OSHA standards, OSHA requires employers:  (1) to assess occupational hazards, 
such as infectious diseases, to which personnel may be exposed and (2) to protect  
personnel, as necessary, based on those hazards.30    
CDCs National Institute for Occupational Safety and Health (NIOSH)  is responsible for 
conducting research and making recommendations for the prevention of work-
related injury and illness.31   OSHA uses NIOSHs guidance and recommendations to  
develop and enforce workplace safety and health regulations.32  
NIOSH and  OSHA have developed a Hierarchy of Controls to determine how to  
implement feasible and  effective control solutions for identified hazards.  See Exhibit  
2 for NIOSHs representation of the Hierarchy of Controls.  
   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  6     
Exhibit 2: CDC/NIOSH Hierarchy  of Controls for protecting  personnel  
 
Source: CDC/NIOSH, Hierarchy of Controls, January  13, 2015.  Accessed at  
https://www.cdc.gov/niosh/topics/hierarchy/default.html  on April  22, 2021.  
The Hierarchy of Controls reflects the order in which employers should approach 
protecting personnel.  Employers should first determine whether they can eliminate  a  
hazard by not putting personnel in situations in which they are exposed to the hazard  
or substituting it for something less hazardous.  For example, an employer could  
eliminate a  hazard by not requiring  an employee to perform the job duty where a  
hazard is present (e.g., not requiring  personnel to interact with potentially infected  
passengers).   If eliminating or substituting the hazard is not possible and  personnel  
must be exposed, employers should next use engineering controls (isolating people 
from the hazard) and administrative controls (changing the way people work)  to 
protect personnel from  the hazard.33   These controls include, for example, installing  
clear plastic sneeze guards (a type of engineering control)  or establishing alternating  
work days to reduce the total number of personnel working  onsite (a type of  
administrative control).   
When engineering and administrative controls are not feasible or do not  provide 
sufficient protection, OSHA requires that employers provide personal protective 
equipment (PPE)  to personnel and ensure its use.34   Although used to protect against  
exposures, PPE is considered potentially less effective at preventing exposure than 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  7    other controls.35   As such, OSHA advises that PPE should be a supplemental control  
and should not take the place of engineering and administrative controls.36   See 
Appendix C  for more information regarding OSHA and CDC Hierarchy of Controls, 
including engineering and administrative controls for infectious disease exposure.   
OSHA standards outline the requirements for employers regarding PPE, including PPE 
training, for personnel in the  event they need to wear PPE.  OSHA standards set forth 
that any employee who  is required to wear PPE shall receive training, and OSHA  
standards outline the required components of this training.37   OSHA standards 
regarding PPE training apply both to respirators (e.g., filtering facepiece respirators, 
such as N95 respirators, and half-mask air-purifying respirators) and  nonrespirator 
PPE  (e.g., gloves, gowns, and face shields).38   (See  Appendix C  for more information 
regarding PPE types.)    
OSHA standards require  that both respirator and nonrespirator PPE training include:  
  what PPE is required and when the PPE must be worn; 
  the limitations and capabilities of  the PPE; 
  how to inspect, put on (don), remove (doff), and use the PPE; and 
  the procedures for maintaining and  storing the PPE. 
In addition, OSHA standards specify the need for personnel to demonstrate an 
understanding of the training and the ability to use the PPE properly before being  
allowed to perform work requiring its use.39   
CDCs recommended protectionswhich pre-date COVID-19for 
quarantine station personnel who interact with  potentially  
infected passengers  
As required by OSHA standards, CDC conducted a hazard assessment in 2019 that  
required base personnel  who interact with  potentially infected  passengers at  
quarantine stations to wear certain PPE.40   This 2019 assessment  required  the 
following PPE:   
  respirators, 
  safety glasses with side shields, 
  face shields, 
  earmuffs, 
  ear plugs, 
  Tyvek disposable suits, 
  jackets  or  coats,  and 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  8    
   a double set  of disposable nitrile or latex gloves.41   
This hazard assessment  was the most recent assessment prior to COVID-19, and it did 
not distinguish among the required PPE for the various types of interactions with 
passengers that could occur (e.g., secondary and  tertiary screening).42   Because 
quarantine sites had never existed prior to COVID-19, there are no prior hazard  
assessment  or other health and safety documentation specific to quarantine sites 
prior to the COVID-19 response.  
CDCs recommended COVID-19 protections  for quarantine station  
and quarantine site  personnel who interacted with  potentially  
infected passengers  
During our review period, CDC issued  various guidance documents recommending  
COVID-19-related health and safety protections at quarantine stations and sites.  
These recommendations guided the protections afforded to HHS personnel  who  were 
interacting with potentially infected passengers during COVID-19 screening and  
quarantine-related activities.  However, CDC did  not have legal authority to direct  
personnel of any HHS component agency other than CDC personnel to comply with 
CDC recommendations regarding PPE use or other suggested COVID-19 protections.  
Related  work  
In April 2021, the Government Accountability Office (GAO) issued a report on HHSs  
response to COVID-19 at quarantine sites.43   GAO found a lack  of clarity regarding  
which agency was identified as the lead at quarantine sites, as well as coordination 
issues among HHS agencies, which led to frustrations and complications.  Further, 
GAO  found  that HHSs delay in issuing quarantine orders led to a passengers attempt  
to leave a quarantine site.  Finally, GAO found that HHS personnel inconsistently used  
PPE, and that HHS  officials disagreed over which agency oversaw infection prevention 
and control  protections.  GAO recommended that HHS:  (1) revise or develop new  
emergency repatriation response plans and clarify agency roles and responsibilities, 
including those for an evacuation and quarantine during a pandemic,  and (2) plan and  
conduct regular exercises with relevant stakeholders to test repatriation plans in 
response to a pandemic and update relevant plans based on lessons learned.  HHS  
concurred with both recommendations but,  as of  this reports release, had not yet  
implemented them.  
In addition, the HHS Office of  the General Counsel (OGC) acknowledged  similar issues 
in a report published by the Office of Special  Counsel in January 2021.44   Specifically,  
like GAO, HHS-OGC found interagency coordination issues and inconsistent PPE 
use. 45  
   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  9     
Methodology  
Scope  
To assess the COVID-19 protections for HHS personnel at quarantine stations and  
sites, we determined how passenger screening and quarantining occurred and what  
protections were in place to mitigate the risks associated with infectious disease  
exposure.  As such, we primarily focused our assessment on the protections that CDC  
recommended  during the initial  COVID-19 response.  In some circumstances, we also  
assessed the implementation of those protections by each respective HHS agency.46    
We define HHS personnel as personnel from ACF, ASPR  (including the National  
Disaster Medical System), CDC, and  members of the U.S. Public Health Service 
Commissioned Corps.47   U.S. Public Health Service  Commissioned Corps officers 
supported ACF, ASPR, and CDC personnel.  Therefore, when we refer to HHS  
personnel by agency (e.g., CDC personnel), this includes any Commissioned Corps 
officers who  were either temporarily or permanently stationed at and/or deployed by 
that agency.    
Our  assessment of protections focused on those controls relevant to responding to  
COVID-19.  Thus, we reviewed elimination controls  (physically removing the hazard), 
engineering controls  (isolating people from the hazard), administrative controls  
(changing the way people work), and PPE.  We  did not review substitution controls 
(replacing the hazard)  because they are impossible in an infectious disease response.   
With regard to PPE training, we focused our review on CDCs PPE training because it  
was the only PPE training that was reported to us as having been provided  to 
personnel immediately before their COVID-19 deployments at quarantine stations 
and sites.  Our review of  CDCs PPE training included  analyzing  pre-deployment  
briefing documents; CDCs electronic respirator training; CDCs  Health, Safety, and 
Environmental Policy  (including CDCs  Respiratory Protection Program); and other 
written responses from CDC.  We also  analyzed  survey and interview data  and CDC 
NIOSH safety officer reports  that provided  firsthand accounts  of PPE training.   
Data sources and analysis  
From March 2020 through February 2022, we collected and analyzed data for this 
review.  We collected and analyzed  data from interviews with officials, staff, and U.S. 
Public Health Service Commissioned Corps officers within ACF, ASPR,  and CDC.  We 
obtained documentation from interviewees to support their interview statements and  
supplement  our analysis.   
We also collected and analyzed data from an electronic survey of  nearly  700 base and  
surge HHS personnel.  These HHS personnel conducted screening at John F. Kennedy 
International Airports Quarantine Station (hereinafter referred to as JFK) and/or 
quarantine-related activities at quarantine sites located at March Air Reserve Base and  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Background |  10    Travis Air Force Base.48   We also submitted questions to and collected and  analyzed  
written responses and HHS documents, such as guidance, emails, and memoranda, 
from ACF, ASPR, and CDC.   
We also conducted an extensive review of other relevant documentation.  In total, we  
reviewed more than 3,400 documents encompassing memoranda, letters, emails, 
spreadsheets, meeting agendas, meeting summaries, and other records created or 
received by HHS personnel associated with this review.   
We also reviewed existing planning, guidance, and other knowledge associated with  
travel-related containment measures and infection prevention and controls that  
existed prior to our review period.  These documents include  OSHA standards and  
guidance, as well as pandemic planning and guidance for infection prevention and  
control and  travel-related containment measures.    
To understand  the protections for personnel that CDC recommended during our time  
period for personnel at quarantine stations and  sites, we analyzed interviews, survey 
responses, written responses, and documentation.  We also  used these data to  
identify potential vulnerabilities with these protections.   
Limitations  
Wherever possible, we compared interview and survey statements to facts we could  
determine from our review of publicly available information, HHS correspondence, 
memos, and numerous other documents.  However,  we did not independently verify 
all  information provided by officials, staff, and U.S. Public Health Service 
Commissioned Corps Officers within ACF, ASPR, and CDC.   
Because of  limited COVID-19 testing and contact tracing during our review period, it  
is not possible to determine the extent to which these risks translated to  actual  
COVID-19 infection among HHS personnel or the public.49   Diagnostic testing for 
SARS-CoV-2 was not  available in the United States until January 20, 2020, and testing  
was initially available only for those  determined to be a patient under investigation 
for COVID-19 by a local  health department.50   Additionally, the first emergency use 
authorization for a commercial SARS-CoV-2 test was not issued until  April 1, 2020.51   
Finally, a COVID-19 vaccine was not available to anyone throughout the entirety of  
our review period.  
Our review of  CDCs PPE training does not capture all prior or subsequent training or 
other education or knowledge that  HHS personnel may have had regarding PPE 
(e.g., such as that provided through ASPRs annual PPE training or that provided  
through just-in-time  training onsite at quarantine stations or sites).52   Largely, this 
other PPE training was either not formally documented and/or not  included in the 
scope of this study (e.g., it was provided to personnel for purposes other than COVID-
19 quarantine station and site deployments).  As a result, our identification of  any  
gaps in CDCs training does not necessarily speak to all  of  the means by which HHS  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  11   personnel could have been trained on this topic prior to this response effort or after it  
started.  
Standards  
We conducted this study in accordance with the Quality Standards for Inspection  and  
Evaluation  issued by the Council  of the Inspectors General on Integrity and Efficiency. 
This review is not an OSHA investigation.  We have notified  OSHA of  our related  
findings for further review and appropriate action.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Background |  12   FINDINGS  
CDC initially recommended  limited  PPE  for  some  HHS  personnel  
who  interacted with  potentially infected  passengers  at  
quarantine stations  and  sites,  and  its  PPE  trainings appear to  
have  not  met  OSHA standards  
During our review period, CDC recommended PPE to protect HHS personnel from 
COVID-19 exposure while interacting with potentially infected passengers at  
quarantine stations and  sites.53, 54   Although only CDC personnel are required to  
comply with CDC recommendations, some HHS  personnel, including staff from CDC,  
ASPR, and ACF, wore limited  PPE, consistent with  CDCs recommendations.    
Further, although CDCs PPE training met many OSHA standards, the training appears 
to have violated two OSHA standards because it did not contain all information  
necessary to ensure that  personnel were properly using the PPE.  It is possible that  
personnel may have received annual  training prior to their deployment and/or just-in-
time training that could have compensated for these training gaps;  however, we did  
not include this other training in our review.   
Limited  PPE and insufficient training  posed vulnerabilities that could have increased  
HHS personnels risk of  exposure to COVID-19 at quarantine stations and sites.   As a 
result, the publics risk of exposure could have been  increased  when these personnel  
interacted with their communities during and after their deployments.   
CDCs PPE recommendations resulted in some personnel initially  
wearing  limited  PPE, but  improvements occurred  over time  
As a result of CDCs PPE recommendations, personnel conducting secondary 
screening at quarantine stations initially wore only  limited  PPE.  The PPE was limited  
relative to  that worn by personnel conducting other job duties (e.g., tertiary 
screening) at quarantine stations, as well  as to  that of base personnel at quarantine 
stations who interacted with potentially infected passengers prior to the COVID-19 
pandemic.55, 56   CDC updated  its PPE recommendations  for secondary screening at  
quarantine stations at  various points through the end of  March 2020, but  the updated  
recommendations were still  less protective relative to the PPE worn for other  job  
duties.   
Although CDCs PPE recommendations varied  according to  quarantine station job 
duties, all  of these job duties required personnel  to come within  6 feet of passengers 
who were potentially infected with COVID-19.  In some respects, personnel  
conducting secondary screening may have had greater risk of exposure  to COVID-19 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  13    
compared to other positions because secondary screening occurred for all  passengers  
entering from areas identified during primary screening regardless of symptoms 
tens of thousands of passengers during our review period.  In contrast, personnel  
conducted tertiary screening only for  passengers exhibiting symptoms or exposures 
of concern (i.e., fewer  than 300 passengers in total during our review period).  If  
passengers were flagged for tertiary screening, they were then advised to wear a  
mask, if they could tolerate it.  
PPE  recommendations  for personnel conducting tertiary screening  at  quarantine  
stations did  not change from January through March 2020 and  included  respirators 
and gowns, in addition to gloves and eye protection.  CDCs initially limited  PPE  
recommendations  for personnel conducting secondary screening and subsequent PPE 
enhancements through March 2020 were:  
   In mid-January 2020,  when screening first began,  CDC required only gloves 
I probably  would  
during secondary screening and did not allow  personnel to voluntarily wear 
have allowed   additional PPE.    
personnel  to wear  
   By late January 2020,  CDC continued to require gloves during secondary  
a respirator if they  
screening.  CDC allowed, but did not require, surgical masks  and eye 
were fit to it. . .    
protection (i.e., goggles or face shields).  CDC did not allow respirators.  
But I  dont 
understand the     By mid-February 2020,  CDC continued to require gloves during secondary  
rationale behind  screening and allow, but not require, eye protection.  In addition, CDC  
not being allowed  required surgical masks.  CDC continued  not to  allow respirators.  
to wear it.   
   By mid-March 2020,  CDC required  gloves, surgical masks,  and eye protection 
   CDC  
during secondary screening.  In addition, CDC allowed, but did not require, 
Quarantine   personnel to voluntarily wear a respirator instead of a surgical mask  if  
Station Leader,   personnel had prior respirator training.57  
May 2020 
A similar evolution in PPE recommendations occurred at quarantine sites.  Between 
January 28 and February 2, 2020, no formal PPE recommendations existed for 
personnel interacting with potentially infected passengers at  quarantine sites.  On 
February 2, 2020, CDC issued PPE recommendations for personnel providing public 
health and other services, but these recommendations still varied by job duties.  As a  
result, some HHS personnel who had close contact with (i.e.,  came within 6  feet of)  
potentially infected passengers wore less protective  PPE relative to  personnel  
performing  other job duties during our review period.58    
CDCs guidance at quarantine sites recommended that workers collecting  clinical  
specimens or providing medical care wear a gown, gloves, eye protection, and  
respirators while performing those job duties.  However, other HHS personnel who  
were also performing job duties requiring close interactions with potentially infectious 
passengers (e.g., case managers providing social support services) wore less 
protective PPE.  Specifically, these personnel were recommended to wear a surgical  
mask and face shield or goggles when interacting with individuals at a distance of less 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  14     
than 6 feet and  to add gloves if  these personnel were taking  temperature  readings or 
touching potentially contaminated surfaces.  CDC did not recommend additional PPE 
enhancements (like those made for secondary screening at quarantine stations)  for 
these personnel during our review period.  The reason  may be because  PPE  
enhancements for secondary screening at quarantine stations occurred  in mid-March 
2020, when response efforts at quarantine sites began to slow down.  
Further, personnel at quarantine sites were required to wear PPE only when within 
6  feet  of a potentially infected passenger.  Several personnel reported to us that  
passengers sometimes unexpectedly approached and came within 6  feet of them  
when they were not wearing PPE.   
These initial,  limited  PPE  recommendations for some job duties caused health and  
safety concerns among HHS personnel at several quarantine stations and sites,  
including those in leadership positions and safety officers.  For example,  HHS  
personnel (including leadership) specifically reported feeling  uncomfortable and  
unsafe with the initial, limited  PPE required for some job duties.59   A CDC safety officer 
also reported concerns with personnel not being required to wear more protective  
PPE, such as respirators.   
I was disappointed the N95 respirator was not utilized by all  personnel,  as the  
science behind the surgical mask is not supportive of protecting the employee.   
NIOSH-certified  respiratory protection and OSHA regulations  under 29 CFR   
1910.134 require the use of  NIOSH-certified respiratory protection when employees  
are  exposed  to respiratory hazards.   Personnel conducting secondary screening should 
have been  in respirators  and not directed to utilize surgical  masks.  
  CDC NIOSH Safety Officer, April  2020  Survey Response  
(referring to  scientific evidence  and OSHA  regulations  that existed prior  to COVID-19) 
Also troubling to personnel, CDC did not allow its own personnel to voluntarily wear 
PPE beyond  what was outlined in its recommendations, even when personnel  
requested to do so.60   For example, at one quarantine station, some personnel serving  
as secondary screeners requested to wear respirators but were initially not permitted  
to do so, even if they had been fitted for one.  Leadership at this quarantine station 
raised concerns about this to  CDCs headquarters leaders, who confirmed that  
personnel conducting secondary screening could not wear more PPE than CDC  
recommendations allowed.   
Some personnel reported not implementing CDCs PPE recommendations based on 
their clinical  expertise, which may have mitigated some risks despite deviating from 
CDCs guidance.  For example, some ASPR personnel, including a quarantine site 
safety officer, reported overruling CDC recommendations and allowing personnel to  
wear more protective PPE based on their prior infectious disease and PPE 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  15    experiences.61   These activities were not without consequence, though.  Another ASPR  
employee reported being berated by a CDC  official for exceeding the minimum PPE. 
CDC reported recommending PPE based on the amount of contact time that  
personnel were expected to have with symptomatic passengers (e.g., 2 to 3 minutes 
for some job duties versus 15 minutes for others).  Reducing the amount of time with 
a hazardan example of an administrative controlis generally protective to the 
employee.  However, OSHA and NIOSH guidance recommends that PPE selection be 
based on the potential  presence of  an infectious disease and the infectious diseases 
mode(s) of transmission.62  
Further, prior pandemic planning and infection prevention and control guidance 
advise a course of action  if an employer has limited information about the hazard.  
OSHA standards state that if an employer cannot identify or reasonably estimate 
whether  an employee will be exposed to a respiratory hazard, the employer should  
consider the atmosphere Immediately Dangerous to Life or Health  and have 
employees use respirators.63   Further, the 2005 HHS Pandemic Influenza Plan  states  
that respiratory protection may be considered for disease strains that transmit  
between individuals easily, or during initial stages of  an outbreak of an emerging or 
novel strain.  It also states that early in a pandemic, it may not be clear that an 
individual  is infected, so protections consistent with all possible modes of  
transmission, including a newly emerging infectious disease, should be implemented, 
including the use of respiratory protection.64    
There is evidence that indicates that  CDCs PPE recommendations may have been 
influenced by a desire to minimize public alarm.  One  quarantine stations leader 
reported understanding that the initially limited  PPE recommendations, and the 
directive to  not wear more PPE than required, were established by CDC headquarters 
leaders to avoid alarming  the public.  A quarantine site safety officer also reported  
being told that the limited  PPE was  due to a visual aesthetic that needed to be paid  
attention to.  Additional survey respondents reported being told that they were not  
allowed to  wear additional PPE to avoid alarming the public.  For example, one survey 
respondent  reported that personnel  were asked to remove their PPE while escorting  
symptomatic passengers through baggage claim to tertiary screening because other 
passengers in the airport would see them.  Personnel were allowed to put their  PPE  
back on upon arriving at  the tertiary screening room, which was not viewable by the 
public.   
When we asked CDC headquarters leaders whether other factors  (e.g.,  the desire to  
minimize  public alarm; the risks associated with personnel wearing too  much PPE; 
and/or shortages of PPE supplies) contributed to CDCs PPE recommendations, CDC  
responded that the safety of their personnel and the public were the most important  
considerations shaping the PPE recommendations.  CDC did not contend that  
allowing personnel to wear respirators would create a hazard,  provided employees 
had been fitted and trained to wear them properly.65   Additionally, CDC headquarters 
leaders also  reported that the decision to initially recommend  limited  PPE for  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  16    
secondary screeners was not driven by a lack of  PPE availability, despite the 
widespread reporting that PPE was in short supply during the early  months of the 
pandemic.  For example, a tertiary screener reported deploying with 30 respirators 
that went unused while interacting with potentially infected passengers for the first  2 
to 3  weeks of the respondents deployment.  
CDCs PPE trainings appear  to  have  not  met  two OSHA standards  
OSHA standards require  personnel:  (1) to be trained on, among other things, the 
proper use, maintenance, and disposal of PPE and (2) to demonstrate their ability to  
use the PPE prior to performing job duties.66   CDC has two separate PPE trainings 
one for respirators (e.g., N95  respirators) and one for nonrespirator PPE (e.g., gloves, 
gowns, and  face shields).   
We  analyzed  documentation associated with the PPE trainings that personnel  
reported receiving from CDC prior to conducting job duties during the COVID-19 
response.   We also analyzed  firsthand accounts  of PPE training.   Although  CDCs PPE  
trainings appeared to meet most OSHA standards, its trainings appear to have not  
met  at least  two OSHA standards, as described below.    
   Apparent violation of 29 CFR  1910.132(f)(1): None of  the documentation that  
we reviewed indicated that  CDCs  training for nonrespirator PPE  included  
information regarding the limitations of such PPE or procedures for safely 
maintaining  and disposing of the PPE.  Information regarding the limitations 
of nonrespirator PPE could have included, but would not be limited to, noting  
that PPE is considered less effective compared to  other controls and  
acknowledging that the PPEs effectiveness depends on proper use by 
personnel.67   An additional limitation of nonrespirator PPE is that surgical  
masks, for example, do  not provide strong protection against airborne 
contaminants compared to a respirator, a limitation that was applicable during  
the COVID-19 pandemic.68   In contrast, CDCs respirator training contains 
detailed information regarding the limitations of  a respirator, when to dispose 
of a respirator, and how  to take proper care of a respirator.    
   Apparent violation of 29 CFR  1910.132(f)(2) and/or 29 CFR  1910.134(k)(1): 
None of  the documentation that we reviewed indicated that  CDCs PPE  
trainings ensured that  employees demonstrate their ability to use the PPE 
properly before performing job duties.  The respirator training did not ensure 
that employees could demonstrate how to properly inspect, don, and doff the 
respirator.69,  70   Similarly, the nonrespirator PPE training did not require 
personnel, for example, to demonstrate that they could properly don and doff  
gloves.   
Further, some  firsthand accounts also indicate  that personnel  were not  
required to demonstrate how  to  use the PPE prior to using it during our 
review period.  For example, a CDC  NIOSH Safety Officer who was  onsite at a 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  17     
quarantine station wrote in a  February 2020 safety report that no one had to 
undergo a competency test to demonstrate that they could properly don and  
doff the respirator or other required PPE.   Another CDC employee  serving as 
a secondary and tertiary screener at a quarantine station reported:  Once I was 
deployed for COVID-19,  the only respiratory protection training I received was 
fit  testing.  I did not complete any hands-on training or formally learn how to  
put on or take off the equipment.    
Between  January  and  March  2020, CDC  was  also  initially limited  
in the extent  to  which  it  recommended  other protections  for  
personnel who  interacted  with  potentially infected  passengers, 
but these other protections  also  improved  over time  
The extent to which CDC  recommended  other protections (e.g., physical distancing, 
symptom screening, and self-quarantining) for HHS personnel interacting with 
potentially infected passengers at quarantine stations and sites was also initially  
limited  with respect to potential risks of  COVID-19 exposure.  Specifically, CDC  initially  
recommended limited  administrative controls, such as self-quarantining, for all HHS 
personnel who had interacted with potentially infected passengers.  CDC  also did not  
recommend engineering controls, such as the installation of clear plastic sneeze 
guards,  while personnel were having close contact with potentially infected  
passengers.71    
These gaps in infection prevention and control  protections  were particularly 
problematic given the fact that COVID-19 symptoms and transmission were not well  
understood, testing was generally unavailable, we  identified  vulnerabilities with the 
PPE that some personnel wore,  and most HHS personnel were at greater risk of  
potential exposure by the nature of their job duties,  compared to the general public 
during our review period.  During this response, though, CDC waited until more 
information became available about  the virus before recommending more protective  
actions regarding HHS personnel health and safety.  
CDC headquarters leaders reported that they did  not recommend these controls 
immediately because they did not consider them to be necessary until there was 
sustained, human-to-human transmission of  COVID-19 in the United States.  CDC  
further reported that it did not believe that transmission by individuals with minimal  
to no symptoms would  be a significant driver of COVID-19 spread because until the 
COVID-19 pandemic, [this type of transmission had] never been a significant driver of  
a pandemic disease, and CDC did not shape its recommendations based on a worst-
case scenario speculation.   In subsequent interviews, CDC  later specified that it does  
not have the authority to implement  engineering  controls  in non-CDC spaces (i.e.,  
screening areas in quarantine stations and military installations used as quarantine 
sites).72  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  18    However, CDCs approach to recommending protections did not fully leverage the  
Federal guidance and planning  and/or knowledge about other infectious diseases 
that existed  at the time.  Since at least 2005, CDC  and other Federal agencies have 
acknowledged the importance of implementing engineering and administrative 
controls, such as  self-quarantining  and physical  distancing, when a virus with 
pandemic potential emerges.73   For example, the 2006 Homeland Security  Councils  
National Strategy for Pandemic Influenza Implementation  Plan  states that 
implementing protective measures, such as physical  distancing procedures, is an 
immediate action upon identification of the first  human case in North America.74   CDC 
has reported that this timing is important, as these controls help slow transmission in 
communities, particularly when a vaccine is not  yet available.75   Further, other 
scientific and medical literature describes respiratory viral infections that  are 
asymptomatic and/or presymptomatic.  For example, a 2018 study found that the rate 
of asymptomatic individuals for the  coronavirus  that causes Middle East  Respiratory 
Syndrome  (MERS)  is about 9.8 percent across different studies.76   Another 2005 study 
reviewed asymptomatic cases of severe acute respiratory syndrome (SARS) and found  
an overall rate of 13 percent, which this study reported was lower than many other 
viral respiratory  diseases.77    
In response to these limited protections, some HHS personnel reported taking steps 
to reduce the risk to their and the publics health and safety.  For example, a  
quarantine station leader reported wearing extra  layers of clothing to work and  
setting up a decontamination zone at home to help protect family members.  HHS  
personnel took these measures on their own, as they reported not being  required or 
advised to do so as part  of a coordinated approach to protect frontline HHS  
personnel involved in screening and quarantining.  
CDCs recommendations  for  physical  distancing were initially  
limited but improved over  time  
Physical distancinga type of administrative controlis  an important infection 
prevention and control  protection  for  both HHS personnel and their communities.  
HHS personnel were at risk of potential  COVID-19 exposure because most, if not  all, 
job duties at quarantine stations and sites required personnel to come  within 6 feet of  
potentially infected passengers.  These job duties  include CDC personnel  conducting  
screening at both quarantine stations and sites, ACF personnel conducting case 
management at quarantine sites, and ASPR personnel providing wraparound services  
(e.g., medical care, logistics, and operations)  at quarantine sites.   
Although CDC  advised  personnel verbally and in writing to  physically distance from 
potentially infected passengers when not performing job duties (an example of an 
administrative control), personnel could not  always control their work environment  
and maintain physical  distancing.  Physical distancing was particularly difficult  to 
maintain at  quarantine sites, where HHS personnel reported that potentially infected  
passengers would approach personnel unexpectedly to ask  questions.78   Specifically,  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  19   during  approximately 40  percent  (222 of 547)  of  deployments where HHS personnel  
reported interacting with potentially infected passengers, HHS personnel also  
reported that they did not consistently practice physical  distancing while deployed.   
Further, CDC also did not initially issue guidance recommending that all  HHS  
personnel practice physical  distancing while they were off duty in the community  
during or following their deployment, which posed a risk to the public.  For example,  
some personnel reported using public transit to  commute to and from their job site.  
Although quarantine site personnel typically resided onsite, which would minimize the 
publics risk of exposure, some deployed personnel reported leaving the quarantine 
sites to run errands, go to dinner, and visit tourist destinations, which  put the public at  
increased risk.  Some personnel were also temporarily housed offsite, within the 
surrounding community.  Although CDC cannot enforce or ensure HHS personnels  
adherence to  physical  distancing guidance while out in the community, issuing  the 
guidance is an important first step.   
CDC later improved its recommendations for HHS personnel to practice physical  
distancing.  On March 1, CDC advised all personnel who  were returning from Travis 
Air Force Base and Seattle-Tacoma International Airports quarantine station to  
practice physical  distancing for the 14 days following their deployments.79   Several  
days later, on March 9, CDC recommended that all personnel (regardless of  location)  
practice physical  distancing for 14 days after they returned  home and to carry a mask  
while  traveling  in the event that they feel unwell during their trip home.  Although 
these improvements provided greater protection to the public, neither of them 
recommended improvements to allow for physical  distancing while personnel were 
conducting job duties.  The guidance also did not recommend practicing  physical  
distancing while out  in the community during deployments.    
Later, in mid-March 2020, CDC further strengthened  physical  distancing  guidance for 
its personnel, which  corresponds to the launch of the U.S. Governments Slow the 
Spread campaign.80   Around this time, CDC allowed secondary screeners at  
quarantine stations torather than having to come into close contact with 
passengers to take their temperaturesremain at a distance greater than 6  feet from 
passengers, and to inspect them visually from that distance.  This is an  example of an 
administrative control (protecting personnel by changing the way people work).  
CDCs recommendations  for symptom screening and  
self-quarantining  were initially limited but improved  over time  
Although CDC encouraged personnel to  limit their interactions with potentially 
infected passengers to mitigate their risk of exposure (an example of  an 
administrative control), CDC did not initially issue formal guidance recommending  
other administrative controls, such as symptom screening and  self-quarantining.  This 
increased the risk of  HHS personnel contributing to infection spread among the 
public with whom they interacted  during and after their deployments.  CDC eventually 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  20    
issued symptom screening and self-quarantining guidance for HHS personnel at  
various points during our review period.   
CDC issued formal guidance recommending that HHS personnel screen  
themselves  and report their symptoms beginning February 10, 2020,  more than  
3 weeks  after screening and quarantine efforts began.   Initially (i.e., beginning  
January 17, 2020), CDC reported verbally conveying its recommendation that  
personnel conduct daily symptom screening and report if they had a fever.  However, 
HHS personnel at quarantine stations and sites reported that this did not  occur 
consistently.  Specifically, of the 50 deployments that HHS personnel we surveyed  
participated  in with deployment dates that ended prior to  February 10, 2020, HHS  
personnel reported not screening for symptoms (and not being required  to do so) for  
42  percent  (21) of these deployments.  In an interview, one individual at a quarantine 
site reported not being  told about this requirement between January 27 and February 
7. However, this individual proactively conducted daily symptom self-monitoring  
because the individual  inferred that this was the proper screening protocol based on 
how CDC was screening potentially infected passengers.   
On  February 10, 2020, nearly a month after screening began at quarantine stations 
and nearly 2 weeks after quarantine sites received their first passengers, CDC  
established a text-based illness monitoring (TIM)  system and recommended  
enrollment of all HHS personnel in the system both during and for 14 days after their 
deployments.81   The TIM system automatically prompted personnel at both stations 
and sites to  report daily whether they exhibited COVID-19 symptoms.  Individuals 
who reported symptoms or who did  not respond to the prompts were contacted by 
CDC for  followup.  Most HHS personnel at quarantine stations and sites reported that, 
after February 10, they were required to screen and report symptoms for COVID-19 
during and after their deployments.  However, a quarantine station safety assessment  
dated February 24, 2020, recommended further CDC guidance regarding this 
requirement because personnel appeared confused about whether daily symptom 
screening should be conducted.   
CDC recommended  that all HHS personnel self-quarantine  in early March,  nearly  
7 weeks  after screening and quarantine efforts began.   CDC did not  initially issue  
guidance recommending self-quarantining for all HHS personnel  who interacted with  
potentially infected passengers at quarantine stations and sites.  Personnel who  were 
symptomatic were told to avoid contact with others, which included not getting on an 
airplane.  However, personnel who did not show  symptoms  did not have information 
on the  circumstances under which they should self-quarantine, what self-quarantining  
should involve, or where it should  occur.  For example, a CDC leader who  was onsite  
at March Air Reserve Base reported not quarantining following a 3-week deployment  
during which this individual reported not always wearing PPE during interactions with 
potentially infected passengers.82   Although they had not been advised  to do so,  
several other personnel reported voluntarily self-quarantining at home.  However, 
these personnel were not initially reimbursed for self-quarantining at locations other 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  21     
than their homes if they voluntarily chose to do  so.  The delay in issuing guidance that  
recommended self-quarantining  meant that any  HHS personnel  who had COVID-19 
but did not  display symptoms could potentially have contributed  to the spread of the 
virus within the community, including  taking it  back to their usual duty stations.    
In early March, nearly 2 months after screening  and quarantine efforts began, CDC  
issued guidance recommending that certain CDC  personnel who were not  exhibiting  
symptoms self-quarantine, but  this guidance was not comprehensive.  The guidance  
recommended that CDC personnel not showing  symptoms remain at home or in a  
comparable setting for 14 days following the end of their deployments.83, 84   This 
guidance also advised that personnel could receive approval  on a case-by-case basis 
to  self-quarantine in a hotel for the 14 days after their deployment.   However, this 
guidance still did not address (or recommend)  self-quarantining  for CDC  personnel  
who lived in the local vicinity of their deployment locations.     
The lack of application of this guidance to local CDC personnel posed risks for 
community spread, both during the deployment for local personnel and for the  
14-day period after their deployments.  In one instance, one individual who lived  
locally reported to CDC that an at-risk family member lived in the employees home.  
Halfway through that employees deployment, in March 2020, after already potentially 
exposing the employees at-risk family member, the employee requested  
reimbursement for a hotel to protect this family member.  CDC  agreed to reimburse  
the employee for the lodging.  In another instance, one locally  based individual  
inquired as to what  local surge personnel should do following their deployment, as 
the guidance issued in early March did not apply to those personnel.  This individual  
did not receive an answer and self-quarantined for 1 week before returning to work in 
person with populations at high  risk for severe COVID-19 infection in March 2020.  
By the end of our review  period, CDCs self-quarantining guidance still did not include  
sufficient information to  maximize its effectiveness.  Specifically, this guidance did not  
advise personnel  about how  to safely self-quarantine away from family members or  
others within their homes and  advised reimbursement for alternative lodging only if  
personnel had close contacts or family members who were at higher risk for severe 
disease.  However, at least one member of surge personnel (who returned home on 
March 25, 2020) reported not having clear self-quarantining guidance if  a spouse or 
family member was at higher risk for severe disease.  This  individual reported  
spending personal funds to stay in a  hotel for 14 days after returning from 
deployment.  The guidance did not address, for example, wearing masks  or increasing  
ventilation within homes,  using separate bathrooms,  making and serving food,  or  
washing dishes and laundry.  Including guidance for how to maximize the  
effectiveness of  self-quarantining  is critical to ensuring  that personnel protect their 
families and  household members, as well as their communities.  
Other HHS  personnel reported  that  their agencies instituted CDCs self-quarantining  
guidance for its personnel.  Prior to  adopting CDCs self-quarantining guidance, these 
agencies reported that personnel were able to  immediately return to work.  For 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  22    example, one survey respondentan  ASPR employee who had worked  at a  
quarantine sitereported returning  home and going to  work on March 6, as this 
respondent  reported not being required to quarantine.  However, this respondent  
reported being notified  on March 9 that the risk  category had been elevated for 
quarantine site deployments and a 14-day  self-quarantine  was now required.  
CDC did  not  have a  comprehensive plan for recommending  
travel-related  containment measures  that  weighed  the risks 
such  as  the  risks  to  HHS personnel  conducting  screening 
relative to  the public  health  benefits  
Existing planning documents issued by HHS (including  CDC), DHS, the Homeland  
Security Council, and the National  Security Council address planning assumptions and  
activities associated with travel-related containment measures (e.g., screening, 
isolation, quarantine and/or conditional release).  However, these documents failed to  
inform decisionmakers on how to comprehensively assess the risks and benefits of  
these activities, including the risks to  HHS personnel health and safety.  Specifically,  
CDC has not documented a comprehensive plan for decisionmakers regarding when 
and how to implement travel-related  containment measures, based on the risks and  
public  health benefits, as the outbreak unfolds.    
Without a comprehensive plan to inform the decision making for adjusting or 
stopping travel-related containment  measures, CDC  and other Federal agencies 
involved in decision making  may not take all relevant risks and benefits into account  
once those measures are implemented.  Such risks could include, for example: health 
and safety risks to HHS  personnel; the risk that  HHS personnel could become infected  
and spread the disease to their families and communities; and the risk of  misdirected  
resources during a critical time in the response.  
CDC continued to  expand  passenger  screening after  community  
spread had been identified  in the United States  
Beginning January 2020, CDC took actions to  fulfill  its statutory responsibilities to  
prevent the spread of COVID-19 within the United States through travel-related  
containment measures.85   Enhanced passenger screening began at quarantine 
stations on January 17, 2020.  Three days later, the first documented case of  COVID-
19 in the United States was identified.  By the end of  February, U.S. community spread  
was identified, and infection rates continued to increase through the end of  our 
review period.86   During this same period, passenger screening expanded, which 
required additional personnel.87   (See Exhibit 3 for a  detailed timeline of both the 
identification and spread of  COVID-19 within the United States and the 
implementation and expansion of passenger screening for international passengers at  
quarantine stations.)  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  23   Exhibit 3: Screening expanded as COVID-19 spread within the United States. 
January 2020 
January 17:  Screening implemented at  three quarantine stations for 
passengers with recent  travel to  the Hubei Province. 
January 21:  Screening expanded to include two  additional  quarantine 
stations. 
January 30:  WHO  declared COVID-19 a Public Health Emergency of 
International Concern. 
January 31:  Federal  quarantine orders issued to all  passengers with recent 
travel  to the Hubei  Province. 
February 2020 
February 3:  Screening  expanded to  six additional  quarantine stations and to 
include all passengers with recent  travel to  mainland  China, which resulted in 
an increase of  approximately 4,000 passengers per week. 
February 26:  First identified U.S.  COVID-19 case resulting  from community 
spread. 
February 28:  First identified U.S.  COVID-19 death. 
March 2020 
March 2:   Screening  expanded to  include passengers with recent  travel  to Iran 
at  the same 11 quarantine stations. 
March 11:  WHO  declared COVID-19 a pandemic. 
March 14-17:  Screening expanded to 4 additional  quarantine stations and to 
include all passengers with recent  travel to Europe, the United  Kingdom, and 
Ireland, which resulted in an increase of  approximately 30,000 passengers per 
week. 
March 25:  The United States reported at  least 65,000 cases and nearly 1,000 
deaths. 
May 2020 
May 27:  Screening  expanded  to include all passengers with recent  travel to 
Brazil. 
September 2020 
September 14:  All  screening  for passengers arriving at  quarantine stations 
terminated. 
Source:  OIG analysis  of documentation, 2021 and  CDC,  Risk Assessment and Management of COVID-19 Among 
Travelers Arriving at Designated U.S. Airports, January 17September  13, 2020, November 13, 2020.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Findings |  24    
CDC reported  relying on evolving knowledge of  COVID-19 
transmission to inform its  decision to halt screening at  
quarantine stations, citing  a lack of  effectiveness  
On September 9, 2020, via a public media release, CDC reported that it  would be 
suspending  its screening efforts at quarantine stations beginning September 14, 2020,  
due to their limited effectiveness.88   CDC pointed to the evolving knowledge about  
the asymptomatic and/or presymptomatic transmission of COVID-19 in guiding that  
decision.  CDC stated:  
We now have a better understanding of  COVID-19 transmission that  indicates 
symptom-based screening has limited effectiveness because people with 
COVID-19 may have no symptoms or fever at the time of screening, or only mild  
symptoms.  Transmission of the virus may occur from passengers who have no  
symptoms or who have not yet developed symptoms of  infection.  Therefore,  
CDC is shifting its strategy and prioritizing  other public health measures to  
reduce the risk of travel-related disease transmission.89  
Evidence of potential  asymptomatic spread had been mounting since the end of  
January 2020.  In a press briefing on January 31, 2020, CDC leadership reported that  
there was emerging evidence  this week of the growth and spread of this outbreak,  
the increase in deaths, and the incoming data about person-to-person transmission, 
as well as concerning reports about  asymptomatic spread.90   Further, by February 19,  
2020, it was reported that at least 48 percent of the confirmed COVID-19 cases on the 
Diamond Princess cruise ship were  among individuals not exhibiting symptoms.  At  
several other points between January and mid-March 2020, multiple other 
stakeholders reported possible  transmission occurring among individuals not  
exhibiting symptoms or exhibiting mild symptoms.91, 92, 93  
In its decision to halt passenger screening at quarantine stations, CDC  offers a  
rationale that focuses on the effectiveness of screening to identify COVID-19 cases 
but does not offer insight into any additional risk-benefit calculation it may have 
conducted.   Similarly, in November 2020, CDC published a retroactive review of  
COVID-19 screening at quarantine stations from January through September 2020.94   
Although this review did  incorporate one consideration of risk (i.e., resources), it does 
not mention factoring  in other potential risks related to this response activity.  
Notably, CDCs November 2020  review concluded that COVID-19 passenger screening  
was  ineffective and resource intensive with a  low yield  of laboratory-diagnosed 
COVID-19 cases.95   The study found that screening detected few COVID-19 cases 
(one identified case per 85,000 travelers screened) and required considerable 
resources.  It also noted that these findings were consistent with a mathematical  
model examining the effectiveness of airport screening for COVID-19, published in 
February 2020.  The authors of that  analysis concluded that entry screening is an 
intuitive barrier for the prevention of infected people entering a country or region.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Findings |  25    However, evidence on its effectiveness remains limited.  This includes limited  
evidence for its effectiveness during  the 2003 SARS epidemic and 2009 influenza A  
(H1N1) pandemic.96   
Further, CDC  reported to OIG that by March 31, 2020, screening at quarantine stations 
had  resulted in identifying 282 (of tens of thousands) passengers showing symptoms 
of possible COVID-19 infection but  none were required to quarantine.  All passengers 
were  cleared to either continue traveling  or go  home if that airports quarantine 
station was their destination.97   Further, by March 23, 2020, all quarantine orders were 
rescinded at quarantine sites.  However, CDC did not shift  its strategy at quarantine 
stations until 6 months later, in September 2020.  
With a more comprehensive plan for determining the risks and benefits of travel-
related containment measures, CDC, and other Federal  agencies involved in the 
decision making, might  have reached a determination earlier than September 2020 to  
alter its approach to travel-related transmission to more effective mitigation efforts 
that focus on the individual passenger, including: pre-departure, in-flight, and post-
arrival health education for passengers, among  other things.98   We cannot determine 
the impact that halting screening earlier could have had on COVID-19 transmission 
within the United States, but this change would certainly have had one impactit  
would have reduced the risk of exposure for HHS  personnel and the risk they posed  
to community spread within the United States.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360    Findings |  26    
CONCLUSION AND  RECOMMENDATIONS  
CDC, along  with other HHS and Federal agencies, as well as the White House,  
confronted the task  of protecting the United States from a novel infectious disease  
outbreak during our review period (January through March 2020).  CDC, in particular, 
faced the challenge of  recommending  protections for HHS personnel  who interacted  
with  potentially infected  passengers while conducting passenger screening and other 
duties associated with quarantining certain evacuees.  This challenge was complicated  
by the fact that during this time COVID-19 symptoms and transmission were not well  
understood, COVID-19 testing  was generally unavailable, and a COVID-19 vaccine did  
not exist.  
We found that, as a result of  CDCs initial recommendations, some personnel wore 
only limited  PPE when interacting with potentially infected passengers.  Additionally,  
although CDCs PPE trainings appeared to meet  most OSHA  standards, these trainings 
did not appear to meet  two OSHA standards.   CDC was also  initially limited in the  
extent to which it recommended other protections, such as physical  distancing, 
symptom monitoring, and self-quarantining.   These limited  protections may have 
increased  the  risk of  COVID-19 exposure among HHS personnel.  As data and  
knowledge  about COVID-19  increased  over time, CDC strengthened its 
recommendations for PPE and other protections, although some vulnerabilities  
remained.  
CDC stated  that  it made scientifically informed  decisions about recommended  
protections in keeping with the evolving understanding of  COVID-19 transmission 
risks, such as whether COVID-19 could spread asymptomatically.  CDC  asserted  to 
OIG  that its  actions in January through March 2020 were shaped by the best  
available scientific information known at the timenot worst-case-scenario  
speculation.  In its technical comments to OIG, CDC also noted that until the COVID-
19 pandemic, asymptomatic and presymptomatic transmission have never been a  
significant driver in the spread of a pandemic disease.  However, prior planning and  
existing literature in this area acknowledge the need to make decisions without  
complete data and suggest that planning assumptions take asymptomatic and  
presymptomatic infection into  account.  
We do not  knowand cannot knowwhether  any HHS personnel or, in turn, the 
public, became infected or inadvertently spread  COVID-19 as a result of  these limited  
protections.  However, we  do know that HHS personnel were at heightened risk  
because of  the limited protections in place.  
More broadly, we found  that CDC did not have a comprehensive plan for  
recommending  travel-related containment measures  that weighed the riskssuch as 
the risks to  HHS personnel  conducting screeningrelative to  the public  health 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Conclusion and Recommendations | 27    benefits.  A  comprehensive plan to  inform the decision making for these measures 
could have helped CDC  ensure that it was taking  all the relevant risks and benefits 
into account.    
Our findings offer insights that can help HHS better prepare for future emergency 
responses.  These complement the insights that GAO provided about vulnerabilities 
regarding HHS response activities at  quarantine sites.  Our recommendations are 
intended to  help CDC learn from the COVID-19 response in its efforts to  prepare for 
the future.  
Therefore, to prepare for future emergencies, we recommend that CDC:  
Update its  guidance recommending  protections  for personnel 
interacting  with  potentially infected  passengers,  particularly 
when  data are  limited  
CDC should  update its guidance outlining its recommended protections for personnel  
interacting with potentially infected passengers during an infectious disease response.  
When limited data about disease transmission are available, OIG recommends, in 
keeping with existing planning documents, that CDCs guidance accounts for 
asymptomatic and/or presymptomatic infection.  
CDCs updated guidance should outline the protections it  will  recommend to protect  
all personnel  against a novel infectious disease where data  are  limited.   For example, 
CDC should  outline recommendations for personnel that protect against all possible  
modes of transmission until the disease can be better understood and controlled.  As 
a part of this, CDC could consider developing messaging materials to communicate to  
personnel  and the public why it is recommending that these personnel use more 
protective measures in the absence of information and how those recommendations 
will be updated as more information becomes available.  
In this guidance, CDC should include, at a minimum, recommended engineering  
controls, administrative controls, and PPE usage  (consulting  the Hierarchy of Controls 
and other relevant NIOSH and OSHA guidance) for personnel interacting with 
potentially infected passengers.  As part of this, CDC should  seek the necessary 
authority to  establish engineering controls in non-CDC spaces to protect its 
personnel.  If CDC cannot obtain that authority, it should document how it will  
otherwise mitigate risks.  Finally, CDC should also  outline the circumstances under 
which personnel may voluntarily wear more protective PPE than what is 
recommended, including how personnel can request to voluntarily wear more PPE 
and obtain additional training, if needed.  
Finally, CDC  should work with other agencies that may have personnel interacting  
with potentially infected passengers  to clarify how the other agencies plan to  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Conclusion and Recommendations | 28   implement and enforce CDC recommendations to ensure consistent protection for all  
HHS staff  interacting with potentially infected passengers.    
Ensure that  its  PPE  trainings  meet  OSHA  standards  
CDC should  ensure that its respirator and nonrespirator PPE trainings meet OSHA  
standards.  This includes ensuring that the content of the training addresses the 
limitations of nonrespirator PPE, as well  as procedures for the proper care, 
maintenance, useful life, and disposal  of nonrespirator PPE.  
CDC should  also document its procedures for ensuring  that personnel demonstrate 
an ability to  use PPE properly before performing job duties.  CDC should  do this for 
both its respirator and nonrespirator PPE training.   Demonstrating an ability to use all  
PPE properly could include a physical demonstration test that is documented and  
certified by the agency providing the PPE training.  It should not entail only an online 
quiz and/or written demonstration.  
Develop  a  comprehensive plan for recommending  travel-related  
containment measures  that  weighs  the risks  relative to  the  
public  health  benefits    
CDC should  develop a comprehensive plan for assessing the risks and the public  
health benefits of travel-related containment measures.  Comprehensive planning  
should include prompts for decisionmakers to take all relevant risks and benefits into  
account, including but not limited to, the risk to  HHS personnel health and safety 
while conducting activities that require interactions with potentially infected  
passengers (i.e., when an elimination control is not possible).   
This plan should build upon existing guidance, such as the 2009 HHS and DHS  Entry  
Procedures for Travelers  at Airports of Entry  in  the Event of a Severe Influenza  Pandemic  
Concept of Operations and Standard  Operating Procedures, as well  as the 2016 
National Security Council Playbook for Early Response to High Consequence, Emerging  
Infectious  Disease Threats and Biological Incidents, lessons learned, and after-action 
reports.  
Within this plan, CDC should:  
  Document the benefits and risks of  travel-related containment measures at 
any location, including quarantine stations and sites.  CDC should also 
document other factors that may affect these benefits and risks.  Examples 
include available information on the disease (e.g., symptoms and modes of 
transmission),  rapid diagnostic testing capabilities,  and medical 
countermeasure availability. 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Conclusion and Recommendations | 29     Document how benefits, risks, and other factors evolve as an infectious 
disease outbreak worsens and improves (e.g., degree of community spread). 
  Document how  it will implement travel-related containment  measures when it 
lacks complete information on the infectious disease, as well as how  it  will 
assess and adjust its implementation as more information is gathered. 
  Document a process for using the plan during an infectious disease outbreak, 
including how CDC  will document what decisions are being made, why those 
decisions are being made, and how those decisions will be shared with 
coordinating partners (e.g., DHS, ASPR, and/or an emergency response task 
force).  To the extent that any decisions deviate from the planning, this 
process should include steps to document and update the plan afterwards. 
Comprehensive planning will  help CDC and other decisionmakers respond to future 
public health crises.  With planning in place, decisionmakers can focus on responding  
to the unique challenges of the crisis.  Additionally, this planning would serve as a  
helpful tool  to guide other public health  and non-public health officials who may also  
be involved in decision making.  As such, CDC should consider sharing this plan with 
other partners, such as ACF, ASPR, and DHS.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Conclusion and Recommendations | 30   AGENCY COMMENTS  AND  OIG  RESPONSE  
CDC concurred with all three of OIGs recommendations.  
In response to our first recommendation, CDC stated that it  will continue to regularly  
review its guidance pertaining to  infection control, personal protection, engineering, 
and administrative controls to minimize occupational risks to its employees.  CDC  also 
stated that it will  also regularly review and update guidance as new information is 
available relating to potential exposures that employees may face in quarantine 
stations and on deployments.  Aside from offering guidance, CDC stated that it  
cannot direct the efforts of other agencies even when CDC  is the subject  matter 
authority.   
In response to our second recommendation, CDC stated that its respirator PPE 
training is OSHA compliant,  but it will continue to conduct regular reviews to ensure 
that the trainings meet all  OSHA standards and  ensure that appropriate 
documentation of employee proficiency is maintained.   OIG requests that in closing  
this recommendation, CDC provide documentation  that it has updated the 
nonrespirator training to include information on the limitations of nonrespirator PPE,  
as well as procedures for the proper care, maintenance, useful life, and disposal of  
nonrespirator PPE.  Further, CDC should also  document its  procedures for ensuring  
that  personnel demonstrate an  ability to use the PPE properly before performing job 
duties.   
In response to our third  recommendation, CDC  stated that it will develop a plan that  
clearly defines public health considerations, triggers, and risks to assist  U.S. 
Government decisionmakers when determining the use of  travel-related containment  
measures in response to an infectious disease outbreak.   CDC further stated that it  will  
incorporate lessons learned from previous outbreaks, including the COVID-19 
response, to increase the likelihood that any enacted travel-related containment  
measures efficiently accomplish the stated public health objective while minimizing  
the risks posed to U.S. Government  employees and the American public.  CDC will  
also rely on the best available scientific evidence and the most relevant technology 
and tools to develop appropriate standard operating procedures.  CDC  also reiterated  
that it  is not the only decision-making or implementing entity required when travel-
related  containment  measures, such as passenger screening  or repatriation efforts, 
are enacted.    
For the full text of  CDCs comments, see Appendix D.  We also ensured that all of  
CDCs technical comments were addressed, where  we had  evidence  to support  
making technical changes.     
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   OIG Response to Agency Comments | 31   APPENDICES  
Appendix A:  COVID-19  Key Events:  Quarantine Stations  and  
Sites, December  2019November 2020  
December 2019 
December 31: The Wuhan Municipal  Health Commission reports 27 cases7 of  them 
severeof an unknown pneumonia-related disease. 
January 2020 
January 11: The first COVID-19 death is reported in China. 
January 13: The first case outside of China is reported  in Thailand. 
January 17: Screening implemented at three quarantine stations (JFK, LAX, and  SFO)  for 
passengers with recent  travel  to the Hubei  Province.  PPE for secondary screeners at 
quarantine stations is gloves only. 
January 20: First U.S. COVID-19 case identified  by CDCs test. 
January 21: Screening expanded  to  two  additional  quarantine stations (ORD  and ATL), 
bringing  the total  to five (JFK, LAX, SFO, ORD, ATL). 
Late January: PPE for secondary screeners at  quarantine stations is increased  to allow, 
but not  require,  eye protection (i.e., goggles or face shield) and  a surgical mask, in 
addition to  the required gloves. 
January 29: March Air Reserve Base receives the first  group of  passengers requiring 
quarantine at  a quarantine  site. 
January 30: WHO declared  COVID-19 a  Public Health Emergency of International 
Concern, with 9,600 infections and 213 deaths worldwide. 
January 31: Federal  quarantine orders are issued  to  all  passengers with recent travel to 
the Hubei Province. 
February 2020 
February 3: Screening expanded to  six additional  quarantine stations (EWR, IAD, DFW, 
DTW, SEA, HNL)  and  all passengers with recent  travel to mainland China. 
February 5-17: Quarantine sites receive  more passengers to quarantine. 
February 10: CDC  issues formal  guidance recommending that HHS  personnel screen 
themselves for symptoms. 
Mid-February: PPE for secondary screeners at  quarantine stations is increased to 
require surgical masks. 
February 11: WHO  reports 42,708 cases and 1,017 deaths in China. 
February 26: First identified U.S. COVID-19 case resulting from community spread. 
February 28: First identified U.S. COVID-19 death. 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix A | 32   March 2020 
March 2: Screening is expanded  at  the same 11 quarantine stations to  include 
passengers with recent travel  to  Iran. 
March 5: Europe reported 4,250 cases and 113 deaths. 
Mid-March: Secondary screeners continue to  be required to  wear gloves, surgical 
masks, and eye protection.  However, PPE for secondary screeners at  quarantine 
stations is updated to  allow, but not  require, a  respirator instead of  a  surgical mask if 
personnel had prior respirator training. 
March 9: CDC  issues guidance recommending  that  HHS  personnel  self-quarantine. 
March 10-12:  Passengers continue to  arrive at  quarantine sites. 
March 11: WHO declared  COVID-19 a pandemic. 
March 14: Screening is expanded to  15 quarantine stations (MIA, BOS, IAH, FLL)  and to 
include  all passengers with recent  travel to the Schengen Region (i.e., Europe). 
March 16: The Federal  Government  launched the Slow  the Spread campaign. 
March 17: Screening is expanded to  include all  passengers with recent  travel  to the 
United  Kingdom and Ireland. 
March 17: New  U.S. cases nearly quadrupled in 1 day, from 755 to  2,797. 
March 23: All  quarantine orders for passengers at quarantine sites are rescinded.  No 
additional  quarantine sites are opened. 
March 25: The United States reported at least  65,000 cases, and  nearly 1,000 deaths. 
May 2020 
May 27: Screening  expanded  to include all passengers with recent  travel  to Brazil. 
September 2020 
September 14: All  screening  for passengers arriving at  quarantine stations terminated. 
November 2020 
November 13: CDC issued  its Morbidity and Mortality Weekly Report on screening, 
where it  identifies these efforts as ineffective and resource intensive. 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix A | 33   Appendix B:  Prior Documents  on  Preparedness  and  Response 
Planning  for Travel-Related  Containment  Measures  
CDC response plans for communicable diseases  
CDC requires each quarantine station to establish and exercise a communicable 
disease response plan.  These plans outline quarantine station activities for routine 
illness responses and describe the potential need for surge personnel in the event of  
a pandemic.  However,  neither these plans nor previous responses or exercises that  
the quarantine stations conducted include planning for the screening and  
quarantining of passengers to the scale used during COVID-19 (i.e., hundreds of  
thousands of passengers  entering  the United States from international destinations 
with potential exposure to a novel infectious disease).  Further, although 
communicable disease response plans note the potential need for facility-based  
quarantine (e.g., hotels and motels near the airport), CDC has not issued specific plans 
for standing up long-term Federal quarantine sites.  
Homeland Security Council and HHS pandemic influenza  
planning documents from 2005 and  2006   
In 2005 and  2006, the Homeland Security Council and HHS  issued several planning  
and  guidance documents for a pandemic influenza outbreak, including a  national  
strategy and implementation plan and an HHS-specific plan.99   These documents 
outline high-level travel-related containment measure procedures for Federal, State,  
and local governments, including when to broadly use these procedures, as well as 
other planning considerations for these measures.  
The 2006 Homeland Security Council  Pandemic Influenza Implementation  Plan  outlines 
travel-related containment measures as an immediate action to be considered when 
there is confirmed, sustained, human-to-human transmission of a novel influenza  
virus overseas (i.e., U.S. Government Stage 2).100, 101   During Stage 3 (i.e., widespread  
human outbreaks in multiple locations overseas), this plan states that HHS, in 
coordination with  the Department of State and  DHS, should re-examine limitation on 
international travel from affected regions and maintain layered  screening measures 
for host country pre-departure, en route, and arrival of U.S.-bound travelers.102   
During Stage 5 (i.e., spread throughout the United States), this plan states that a  
policy decision should determine when travel restrictions previously enacted can be 
lifted.103   
Like the  2006 Homeland  Security Council  Pandemic Influenza Implementation Plan, the 
2005 HHS Pandemic Influenza Plan outlines HHS actions for travel-related  
containment measures during the World Health Organization (WHO) pandemic  
phases.104   This plan states that travel-related containment measures should be used  
beginning in WHO Phases 4 and 5, when there is limited human-to-human 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix B | 34  transmission, and through Phase 6 (i.e., the pandemic phase), when there are no cases 
in the United  States.105   Upon identification of cases in the United States during WHO  
Phase 6, this plan states that HHS such reassess containment strategies, such as travel  
advisories and restrictions.106    
These plans offer additional considerations for pandemic travel-related containment  
measures applicable to Federal, State,  and local efforts.  For example, the 2005 HHS  
Pandemic Influenza Plan  states in recommendations to State and local partners that  
when disease transmission is occurring in communities throughout the United States,  
individual quarantine is much less likely to have an impact and likely would not be 
feasible to implement.107   Because the usefulness and feasibility of procedures 
focused on containment measures for individuals will be limited once the pandemic 
has started to spread, this plan advises that other measures that reduce disease 
transmission by increasing  physical  distancing should be considered instead.108    
Further, though influenza is different than COVID-19, these documents note that  
asymptomatic and presymptomatic transmission is a consideration.  Specifically, the  
2005 HHS Pandemic Influenza  Plan  states that some infected passengers will be  
shedding the virus asymptomatically, or have mild symptoms, and it will, therefore,  
not be possible to identify and isolate all  arriving infected or ill passengers and  
quarantine their fellow passengers.109   However, this plan states thatdepending on 
the situationtravel-related containment measures might slow the spread early in a  
pandemic, allowing additional  time for implementation of  other response measures, 
such as vaccines.110   Further, the 2006  Homeland Security  Council  Pandemic Influenza  
Implementation Plan  states that screening is challenged by a lack of sensitivity (e.g., 
asymptomatic infected individuals may not be detected) and specificity (e.g., many 
individuals with symptoms will not  actually be infected).111  
CDC and  DHS  planning documents from 2009 on  pandemic  
influenza passenger screening   
In 2009, CDC and DHS, in coordination with the Department of Transportation, 
developed  a Concept of  Operations (CONOPS)  and Standard Operating Procedures  
(SOPs)  for the  Entry  Procedures for Travelers at Air Ports of Entry in the  Event of a  
Severe Influenza Pandemic.112   (Hereinafter, these documents are referred to as the 
2009 CONOPS  and  2009 SOPs).  These documents detail how and when CDC and  
DHSs CBP should implement passenger screening to slow the introduction of a  
pandemic-causing influenza virus into the United States.   
Quarantine stations are  to plan for the onsite, mandatory quarantine of exposed  
passengers for up to 72 hours.  However, in the event that passengers require a  
longer period of quarantine or that the number of exposed  passengers overwhelms 
the quarantine stations, those passengers required to quarantine will need to be 
transported to a suitable, pre-designated quarantine facility within a reasonable 
distance from the airport (i.e., a facility equivalent to a quarantine site).113   Further,  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix B | 35  should a significant number of cases have developed in the United States, the 
isolation and/or quarantine may occur at an individuals home.114   The 2009 CONOPS  
and  2009 SOPs  outline only that  long-term quarantine will be executed under 
Emergency Support Function 6: Housing and Mass Care and  that public health 
personnel will coordinate with State health departments in the event of mandatory 
home quarantine.115     
The 2009 CONOPS  also acknowledge several considerations related to passenger 
screening, including the timing  of the efforts, as well as the possibility of  
asymptomatic or presymptomatic transmission.116   Specifically, the 2009 CONOPS  
aligns with the 2006 Homeland Security Council  Pandemic Influenza Implementation  
Plan  and states that screening procedures would be  implemented prior to a pandemic 
virus reaching the United States (USG Stages 2 or 3) and continue until such time that  
the virus is established within the United States (USG Stage 5).117    
National Security  Council planning  documents from 2016  for  
early  response decision making  in a pandemic  
The 2016 National  Security Council  Playbook for Early Response to High-Consequence, 
Emerging Infectious  Disease Threats  and Biological Incidents  (hereinafter referred to as 
the NSC Playbook) provides a  decision-making tool that  identifies key decisions to  
be made, including the implementation of travel-related containment measures 
during a pandemic.118   This decision making applies to novel  infectious diseases and  
those with high rates of  morbidity, mortality, and/or transmissibility, including novel  
coronaviruses.119  
The NSC Playbook  outlines several considerations that apply to the early stages of a  
pandemic response, including travel-related containment measures.  It directs 
decisionmakers to consider that the primary mode of transmission for a newly 
emerging pathogen may not be readily available.  Therefore, initial estimates are likely 
to be based  on limited and incomplete information and will  be continually reassessed  
based on new information.  As a result, decisionmakers will  be required  to choose 
courses of action with incomplete information.120    
The NSC Playbook  further outlines key considerations related  to travel-related  
containment measures in its international playbook when there is not yet  a confirmed  
case within U.S. territorial borders.  These considerations include, if the outbreak  
covers a large area, there are often not enough control points to continue effective 
border measures.  Further, if the outbreak is in a region that has a large volume of  
travel, then screening all passengers from that region becomes operationally difficult, 
if not impossible.121    
The NSC Playbook  also  includes these containment measures as a consideration 
during various phases of a domestic pandemic response (i.e., when there is an 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix B | 36  emerging disease threat within U.S. territorial borders).  (See Exhibit 4  on the next  
page.)  
Exhibit 4: NSCs decision-making guidance for travel-related containment 
measures during a domestic pandemic response.  
Phase   Phase Definition,  Triggers and Key  Screening and Quarantining Key  
Epidemiologic Indicators   Decisions and Questions  
1A: Normal Operations   No specific threat.   N/A  
1B: Elevated Threat   Identification of a human case of a  N/A  
pathogen of pandemic potential.  
1C:   Confirmation  of multiple human cases of a  (1) Is the pathogen susceptible to 
Credible Threat   pathogen of pandemic potential anywhere   detection by screening travelers? 
and/or a determination of a significant   (2) Consider implementation of travel 
potential for a public health emergency.     restrictions and border controls. 
2A: Initial Response:     Demonstrative of efficient and  N/A  
Activation, Situational  sustained human-to-human 
Assessment, and   transmission of a  novel virus 
Movement   anywhere; and/or 
  Declaration of Public Health 
Emergency 
2B: Employment of     Increasing number of cases in the  Determine whether to implement  
Resources and   United States or  health  care system  screening and monitoring measures, or 
Stabilization  burden that exceeds State resources;  other travel measures within the United  
and/or  States or globally.  
  State  or local request for assistance 
2C: Intermediate    Cases continue to climb with    Can the disease be effectively 
Operations   long-term service disruption and  screened in travelers as a means to 
critical infrastructure impacts; and/or  stop transmission? 
  Presidential Stafford Act declaration;    Are travel or screening and monitoring 
and/or  requirements,  either globally or at U.S. 
  State  or local request for assistance  borders, appropriate and would those 
measures stop the spread  of disease? 
  Determine whether to implement 
screening and monitoring measures, 
or other travel measures within the 
United States or press for measures 
globally.* 
3A: Sustained   Long-term recovery operations with or    N/A  
Operations   without continued incidence of new cases.   
Source:  National Security Council,  National Security Council Playbook for Early Response to High Consequence,  
Emerging Infectious Disease Threats and Biological Incidents, 2016, pp. 7; 3140.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360    Appendix B | 37  * NSC also  states that the issue of  border  screening is very complex  and  requires extensive  legal consultations and a 
public health determination on its value as a tool to slow the  spread of  diseases  vis  a  vis harm to  travel, trade, and 
ability to mount  a response within affected region. 
Appendix C:  More Information on OSHA  and  CDC Hierarchy of  
Controls  for Infectious  Disease Exposure  (existing  prior to  and  
relevant  during  OIGs  review  period)  
In several documents, OSHA and  CDC outline Hierarchy of Controls broadly, as well as 
for an infectious disease exposure specifically.122   Taken together, these documents 
outline ways to protect personnel by controlling exposure to infectious diseases, an 
example of  which would include COVID-19.  
OSHA and  CDC  advise that the controls used to  protect personnel depend on the 
type of hazard and route of exposure.  Further, the primary sources of infectious 
disease transmission in occupational settings are contact, droplet, and airborne 
exposures:  
  Contact transmission involves exposure through both direct (e.g., skin-to-skin) 
and indirect (e.g., doorknobs) contact. 
  Droplet transmission involves exposure through direct contact through your 
eyes, nose, or mouth with infectious secretions emitted when an infected 
individual coughs, sneezes, or talks. 
  Airborne transmission involves exposure through very small infectious 
particles that remain suspended in air for extended periods of time and  are 
then inhaled by non-infected individuals. 
Engineering and administrative controls  
Engineering  controls isolate personnel from the hazard by removing hazardous 
conditions or by placing a barrier between personnel and the hazard.  These types of  
controls reduce exposure to an infectious disease without relying on personnel  
changing their behavior and have lower operating costs than other types of controls 
in the longer  term.123   OSHA and CDC  advise that engineering controls to protect  
personnel from being exposed to infectious diseases (e.g., influenzas and novel  
coronaviruses, such as COVID-19) could consist of:  
  improving ventilation where personnel are working (e.g., installing high-
efficiency air filters or using specialized negative pressure ventilation);124, 125 
  installing physical barriers, such as clear plastic sneeze guards; and126, 127 
  installing a  drive-through window.128 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix C | 38   Administrative controls are typically changes in work policies or procedures to reduce 
or minimize exposure to a hazard.  They are typically used with other elimination, 
substitution, and/or engineering controls that more directly prevent or control  
exposure to the hazard.129   OSHA and  CDC provide  examples of  administrative 
controls to  protect personnel from being exposed to infectious diseases (e.g., 
influenzas and novel coronaviruses, such as COVID-19),  including:  
  symptom monitoring,130 
  encouraging sick personnel to stay home (i.e., self-quarantining),131 
  promoting  physical  distancing by implementing telework  or virtual 
communications,132 
  establishing alternating  days or extra shifts to reduce the total number of 
personnel working onsite,133 
  discontinuing nonessential travel to  locations with high transmission rates, 
and134 
  providing personnel with education and training on risk factors and protective 
behaviors.135, 136 
PPE  
PPE refers to a variety of  barriers and respirators used alone or in combination to  
prevent mucous membranes, airways, skin, and clothing from contact with infectious 
agents.137   PPE is generally used with other elimination, substitution, engineering, 
and/or administrative controls.138   PPE protects the mucous membranes (i.e., the 
mouth, nose, and eyes) and other skin surfaces with compromised integrity (e.g., by 
acne, dermatitis) that are susceptible portals of entry for infectious agents.  The  
selection of  PPE is based on the nature of the patient interaction and/or the routes of  
transmission (e.g., droplet vs. airborne).   
Types of PPE that may be utilized  when the hazard is an infectious disease, include:  
  Protective body  clothing  (e.g., gowns, aprons) protects exposed body parts. 
Gowns  protect arms and exposed body areas and prevent contamination of 
clothing with potentially infectious material.  They are usually the first  PPE to 
be donned.  Gowns are  worn  only if  contact with blood  or body fluid is 
anticipated.139   Disposable aprons  cover the torso to the mid-calf and  may be 
worn  over a  gown.  An apron provides additional protection from body 
fluids.140   Coveralls  (e.g., Tyvek suits) are designed to cover the entire body, 
including back and lower legs and sometimes feet and head as well.141 
  Masks  protect personnel from contact with infectious material  and protect 
patients from exposure to infectious agents carried in a workers mouth or 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix C | 39   nose.142   Masks are put on after gowns are properly donned.  Masks may be 
used with goggles to protect the mouth, nose, and eyes.  Alternatively, a face 
shield may be used instead of  a mask and goggles, although it does not  
prevent airborne transmission of infectious agents.   
  Respiratory protection  requires the use of a respirator with N95-level  or 
higher filtration to prevent inhalation of  infectious particles.  Respiratory 
protection is regulated by OSHA, which requires medical clearance to wear a 
respirator, user-seal checking (i.e., fit testing), and education on respirator 
use. 143
  Eye protection  (i.e., goggles, face shields, safety glasses) are chosen for 
specific work situations based on the circumstances of exposure, other PPE 
used, and personal vision needs.  Goggles and/or face shields are put on after 
masks and respiratory protection are  properly donned.  Although effective as 
eye protection, goggles do not provide splash or spray protection to  other 
parts of the face.  Face shields may  be used as an alternative to goggles.   Face 
shields can provide protection to  other facial areas in addition to the eyes.144 
  Gloves  prevent contamination of hands when anticipating  or having direct 
contact with infectious material  or infected patients, or when touching 
contaminated or potentially contaminated equipment or surfaces.  When worn 
in combination with other PPE, gloves are the last PPE to be donned.  Either 
latex or nitrile gloves are preferable for clinical procedures that require manual 
dexterity or will involve more than brief contact.145 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix C | 40   Appendix D:  Agency Comments  
Following this page are the official comments from CDC.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected  Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix D |  41   TO:   Gregory E. Demske   
Acting Principal Deputy Inspector General  
FROM:   Centers for Disease Control and Prevention (CDC)  
DATE:    September  2, 2022  
SUBJECT:   Office of the Inspector General  (OIG) Draft Report  
Attached is the CDC  response to the OIG. This response details CDCs planned actions  
regarding recommendations contained in the OIG report, During the  Initial COVID-19 
Response, HHS Personnel Who Interacted With Potentially Infected Passengers Had Limited 
Protections, OEI-04-20-00360. 
The CDC appreciates the opportunity to review and comment on this report prior to final release.  
Sincerely,  
Rochelle P. Walensky, MD, MPH  
Director, CDC, and  
Administrator, ATSDR  
Enclosure  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected  Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix D |  42   Enclosure  
CDC appreciates the OIGs ongoing work on the draft report, During the Initial COVID-19 
Response, HHS Personnel Who Interacted With Potentially Infected Passengers Had Limited 
Protections.  The safety and security of CDC staff is a top CDC priority.  In  accordance with 29  
CFR 1960, federal agencies must develop occupational health and safety programs to protect  
their employees from occupational hazards, including the development and enforcement of  
organizational occupational health and safety programs.  CDC established a safety  and health  
program consistent with guidance from the Occupational Safety and Health Administration 
(OSHA), which supports safe workplace  conditions through training, services, and other  
resources.  This important review of the initial three months of the coronavirus disease 2019 
(COVID-19) pandemic  also directly supports CDCs efforts to meet those  standards.  
According to OIGs report, concerns about CDC and other Department of  Health and Human 
Services  (HHS)  staff  and their risk of COVID-19 exposure at quarantine stations and sites were  
expressed during this initial response period from  January 1-March 31, 2020.  The circumstances  
and available information were  constantly evolving.  CDCs actions in January through March  
2020 were shaped by the  best available scientific information known at the  time.   
To protect its employees, CDC conducted risk assessments prior to the COVID-19 response.  
These assessments were  based on routine tasks performed under normal operating conditions. 
Guidance to CDC employees at quarantine stations was updated as new information became 
available.   
Separately, there were personnel from several HHS  operating divisions deployed to quarantine  
sites as the response progressed.   There was not a clear delineation as to which agency  was the 
lead for issuing orders relating to infection control and the use of personal protective equipment  
(PPE) at those quarantine sites for HHS personnel.  CDC does not have legal authority to direct  
personnel of any HHS component agency other than CDC to comply with CDC  
recommendations regarding PPE use or other suggested COVID-19 mitigation measures.  
Therefore, recommendations and direction for mitigation measures, such as  PPE  
recommendations, were directed to  CDC employees at quarantine stations.  
Since then, CDC has taken steps to expand recommendations to support the safety of its staff at  
quarantine stations.  This includes  specific all hazard risk assessments for  CDC deployers,  
symptom monitoring, and establishing and continuing to update policies and guidance on 
additional safety precautions.   
CDC will continue to review the available science  and update guidance and recommendations  
consistent with that information.  CDC also supports some of the findings and recommendations, 
although some discrepancies can still be found in the OIG report, as documented within the  
technical comments.   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected  Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix D |  43   Enclosure  
OIG  Recommendation (1)  
OIG recommends CDC update its guidance recommending protections for  personnel who 
interact with potentially infected passengers.  
CDC Response: CDC concurs with OIGs  recommendation to update its guidance  
recommending protections for personnel who interact with potentially infected passengers.  As  
acknowledged by OIG, CDC improved its recommendations for PPE and other protections as  
data and knowledge about COVID-19 grew over time.  However, CDC cannot direct the efforts  
of other agencies even when CDC is the subject matter authority.   CDC will continue to review  
its guidance pertaining to infection control, personal protection, engineering, and administrative  
controls to minimize occupational risks to its employees.  Guidance will be regularly reviewed, 
and updates will occur as new information is available relating to the potential exposures that  
employees may face in quarantine stations and on deployments. 
OIG  Recommendation (2)   
OIG recommends CDC  ensure that its PPE trainings meet OSHA standards. 
CDC Response: CDC concurs with OIGs  recommendation to ensure that  its PPE trainings meet  
OSHA standards.  CDCs Respirator Protection Program (RPP) is OSHA compliant, just as it 
was during the period examined by OIG.  CDCs  RPP meets OSHA Standard 29 CFR 1910.132 
and 29 CFR 1910.134, and the program is audited every two years.  OIGs  review of CDCs  
respiratory protection training consisted of electronic documents only.  CDC provided the  
electronic  respirator training, which is followed by a pass or fail fit test.  It  is during the fit test 
that employees demonstrate their ability to utilize the equipment correctly and receive additional 
training and guidance, if  needed.  This required step in the training is in person only and OIG did 
not visit the CDC RPP fit test room to observe this process.  For this training and other PPE  
trainings, CDC will continue to conduct regular reviews  to ensure they meet all OSHA standards  
and that appropriate documentation of employee proficiency is maintained.  
OIG  Recommendation (3)  
OIG recommends  CDC develop a comprehensive  plan for recommending travel-related  
containment measures that weighs the risks relative to the public health benefits.  
CDC Response: CDC concurs with OIGs  recommendation to develop a plan that clearly 
defines public health considerations, triggers, and risks to assist U.S. government decision 
makers  when determining whether travel-related containment measures should be implemented, 
adjusted, or discontinued in response to an infectious disease outbreak.  In its plan, CDC will  
incorporate the lessons learned from previous outbreak responses, including the COVID-19 
response, to increase the  likelihood that, in the event travel-related containment measures are 
necessary in the future, the enacted measures efficiently accomplish the stated public health  
objective while minimizing the risks posed to U.S. government employees  and the American 
public. CDC also will rely on the best available scientific evidence and will utilize the most 
relevant technology and tools, to the extent possible, to develop appropriate  standard operating 
procedures.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected  Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix D |  44   Enclosure  
CDC is not the only decision-making or implementing entity required when travel-related  
containment measures, such as entry screening, are enacted.  CDC already coordinates with U.S. 
government  partners such as  the Department of Homeland Security, the Department of  
Transportation, and the  Department of State through the National Security Council (NSC)  and  
through other interagency collaboration processes when planning, implementing, or expanding 
travel-related containment measures.  CDC requests a revision of this recommendation to 
acknowledge that the determination regarding if, when, and how to implement  travel-related  
containment measures (i.e., entry screening)  at U.S. ports of entry may be  an NSC decision 
informed by interagency partner input using current knowledge and public  health best practices. 
Furthermore, CDC is not the initiating U.S. government entity for repatriation efforts, nor is  
CDC the entity that determines if the U.S.  Repatriation  Plan is activated to support a repatriation 
operation. CDC is one of several identified components of the U.S. Repatriation Plan and 
participates in coordination groups that support the implementation when activated to include  the 
Administration for Children and  Families  and the  Administration for Strategic Preparedness and 
Response.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected  Passengers Had Limited 
Protections  
OEI-04-20-00360   Appendix D |  45    
ACKNOWLEDGMENTS  AND  CONTACT  
Acknowledgments  
Lauren Buss  served as the team leader for this study.  Others in the Office of  
Evaluation and Inspections  (OEI)  who conducted the study include Margaret  Dore  and  
Rebekah Schwartz.  OEI  headquarters staff  who  provided support include Joe 
Chiarenzelli, Kevin Farber, and Christine Moritz.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Emily Borgelt, Victoria  Coxon, Matthew DeFraga, Emily 
Dieckman, Sarah Hijaz, Seta Hovagimian, Jason Kwong, Rebecca Laster, Christina  
Lester, Anna Lin,  Alexis Mills, Aaron Plotke, Amy Sernyak, Malaena Taylor, Jenny Tu,  
Brianna Weldon, and Lucio Verani.  
This report was prepared under the direction of  Dwayne Grant, Regional  Inspector 
General for Evaluation and Inspections in the Atlanta  Regional Office, Jaime Stewart,  
Assistant Regional Inspector General and Evan Godfrey, Deputy Regional Inspector 
General.  
Contact  
To obtain additional information concerning this report, contact the Office of Public 
Affairs at  Public.Affairs@oig.hhs.gov. OIG reports and other information can be found  
on the OIG website at  oig.hhs.gov.  
Office of Inspector General  
U.S. Department of Health and Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections    
OEI-04-20-00360    Acknowledgments and Contact | 46    ENDNOTES  
1  ASPR was formerly known as the Office of the Assistant Secretary for Preparedness and  Response.  
2  The Office of Special Counsel has publicly released two  full reports  at  https://osc.gov/Documents/Public%20Files/FY22/DI-
20-000557/DI-20-000557%20-%20Agency%20Report%20w%20CDC%20Response.pdf  (including an OIG analysis)  (including 
an OIG analysis) and  https://osc.gov/Documents/Public%20Files/FY21/DI-20-0537/OSC%20File%20No.%20DI-20-
000537%20-%20Supplemental%20Report%20with%20Addendum%20(1)_Redacted.pdf. 
3  ABC  7 Chicago, Coronavirus  screening forces hundreds of travelers to wait hours at Chicagos OHare International Airport,  
March  15, 2020.  Accessed at https://abc7chicago.com/ohare-airport-chicago-coronavirus-screening/6014169/  on April  27,  
2021.    
4  CNN,  They didnt protect us: Some coronavirus responders stunned by lack of protective  measures,  March  11, 2020.   
Accessed at  https://www.cnn.com/2020/03/11/health/coronavirus-first-responders-invs/index.html  on April  27, 2021.  
5  CNBC,  White House task force kept airport COVID screeners in place despite known risk of infection,  December  22,  2020.   
Accessed https://www.cnbc.com/2020/12/21/white-house-covid-task-force-kept-airport-health-screeners-in-place-despite-
risk.html  on April  27, 2021.   
6  The New York Times, Hundreds Exposed to Coronavirus on Cruise Ship Fly Home,  March  20, 2020.   Accessed at  
https://www.nytimes.com/2020/03/20/us/coronavirus-cruise-ship-costa-luminosa.html  on April  27, 2021.  
7  42 CFR  71.1.  Quarantine separates and restricts the movement of people who were exposed to a contagious disease  to 
see if they become sick.  Isolation separates  sick people  with a contagious  disease from  people  who are  not sick.  CDC,  About  
Quarantine and Isolation, last  reviewed on January  27, 2020.  Accessed at 
https://www.cdc.gov/quarantine/quarantineisolation.html  on November  17, 2021.  
8  Under Section 361 of the Public Health Service Act (42 USC  264), the Secretary of Health and Human Services is authorized  
to take measures to prevent the entry and spread of  communicable diseases from foreign countries into the United States  
and between States.  The authority for carrying out these  functions daily has been delegated to CDC.  Communicable  
diseases are defined by Executive Order of the President.  CDC,  Legal Authorities for Isolation and Quarantine, September 17,  
2021.  Accessed at  https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html  on July 1, 2022.  
9  42 USC  264(b).  Regulations addressing the prevention, introduction, and spread of communicable diseases from foreign 
countries into the United States are found at 42 CFR Part 71.  
10  CDCs Division of Global Migration and Quarantine personnel staff quarantine stations on a daily, routine basis.  Base  
personnel at quarantine stations include an Officer  in Charge, among other  full-time medical and public health officers,  and 
sometimes  a full-time Quarantine Medical Officer.  Quarantine Medical Officers are on call  24/7 to support quarantine station  
illness response activities.  In addition, a Regional Officer in  Charge oversees quarantine station operations within each 
region.  In addition to passenger screening,  base personnel also screen  cargo; inspect animals and animal products; and 
monitor the health of and collect any medical information of new immigrants, refugees, asylees, and parolees.  CDC,  
Quarantine Stations, last updated on September  29, 2017.   Accessed at https://www.cdc.gov/quarantine/quarantine-stations-
us.html  on September  22, 2021.  
11  CDC is generally alerted to potentially infectious passengers in one of three ways: (1) a Customs and Border Protection 
(CBP) agent, within the Department of Homeland Security (DHS), reports visually identifying ill  passengers going through  
customs; (2) an airline pilot reports onboard illnesses prior to arrival  in the  United States; or (3) other airport partners who 
interact  with arriving international passengers (e.g., Fire and Rescue, Emergency Medical Services, and airport operation  staff)  
report visually identifying ill passengers.  CBP agents, airline pilots, and other airport partners report these ill passengers  
according to CDC  illness-reporting  criteria.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes |  47   12  The Homeland Security Council was formerly within the Executive Office  of the President and was created by Executive  
Order 13228.  In 2009, the Homeland Security Council was  merged with the National Security Council and named the  
National Security Council in 2014.  Fed.  Reg., Vol.  66, No. 196,  October  10, 2001.  Accessed at 
https://www.govinfo.gov/content/pkg/FR-2001-10-10/pdf/01-25677.pdf  on August 31, 2021.  Executive Order,  Changing the  
Name of the  National Security Staff to the National Security  Council Staff,  February  10, 2014.  Accessed at 
https://obamawhitehouse.archives.gov/the-press-office/2014/02/10/executive-order-changing-name-national-security-staff-
national-security  on August  31, 2021.  Administration of Barack H. Obama,  Statement on the White House Organization for  
Homeland Security and Counterterrorism,  May 26, 2009.   Accessed at https://www.govinfo.gov/content/pkg/DCPD-
200900403/pdf/DCPD-200900403.pdf  on September  29, 2021.  
13  Planning,  including documented guidance, policies, and procedures, collectively helps  inform decisionmakers on the factors  
to consider when taking action, such as implementing travel-related  containment measures during a novel infectious disease  
outbreak.  The relevant planning and guidance includes: CDC quarantine station communicable disease response planning  
(including exercises); HHS and DHSs 2009  Entry Procedures for Travelers at  Air Ports of Entry in the Event of a Severe Influenza 
Pandemic: Concept of Operations and  Standard Operating Procedures;  HHSs 2005 Pandemic Influenza Plan; the Homeland 
Security Councils 2005 and 2006 National Strategy for Pandemic Influenza and  National Strategy for Pandemic Influenza:  
Implementation Plan;  and the National Security Councils 2016 Playbook for Early Response to High Consequence, Emerging 
Infectious Disease Threats,  and Biological Incidents.  We identified these  documents as relevant because they pertain either  
broadly to a pandemic infectious disease or specifically to passenger screening (and other travel-related containment  
measures) during  an infectious disease outbreak, or both.   
14  Homeland Security Council,  National Strategy for Pandemic  Influenza: Implementation Plan, May 2006, p. 13.  Accessed at 
https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation.pdf  on September  27, 2021.    
15  Conditionally releasing passengers is the temporary supervision by a public health official (or designee) of an individual or  
group, who may have been exposed to a quarantinable communicable disease, to determine the risk of disease spread and  
includes public health supervision through in-person visits, telephone, or through electronic or internet-based monitoring.   
16  Generally, CDC issues one to two isolation orders per year (primarily for infectious tuberculosis).  Prior to COVID-19, CDC 
issued the most recent Federal quarantine order in 1963 for  a  suspected case of smallpox.    
17  For ill passengers, it should be assumed that all are potentially infected with an organism that could be transmitted in the  
health  care setting and there are precautions  to take based on the infectious diseases mode(s) of  transmission.  CDC,  
Quarantine Station Communicable Disease  Response Plans, 2019.  
18  The plan specifically states that some infected passengers  will shed the virus asymptomatically, or have  mild symptoms,  
and it will, therefore, not be possible to identify  and isolate  all arriving infected or ill passengers and quarantine their fellow  
passengers.  However, depending on the situation, screening and quarantining might slow the spread early in a pandemic,  
allowing additional time for  implementation of other response measures, such as vaccines.  HHS,  Pandemic Influenza Plan, 
November 2005, p. S9-3.  
19  Asymptomatic transmission occurs when an infected  individual without symptoms transmits the virus to another individual.   
Presymptomatic transmission occurs when an infected individual who  is not yet displaying symptoms transmits the virus to 
another individual.  
20  HHS, Pandemic Influenza Plan, November 2005,  pp. S9-8  and S9-9.  
21  Ibid.,  pp. S8-9  through S8-11, S8-15.  
22  National Security Council,  National Security Council Playbook for Early Response to High Consequence, Emerging Infectious 
Disease Threats and Biological  Incidents, 2016, p. 18.   
23  The law  authorizes the Surgeon General, with the approval of the Secretary of HHS, to issue and  enforce regulations  
necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign  countries  into the  
United States  and between States.   (42 U.S.C.  264).   Regulations addressing the prevention, introduction, and spread of  
communicable  diseases from foreign countries into the United States are found at 42 CFR    71.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes |  48  24  The 15 quarantine stations were John F. Kennedy International Airport (JFK) in New York City, Los Angeles International  
Airport (LAX), San Francisco International Airport (SFO), OHare International Airport (ORD) in Chicago, Hartsfield-Jackson  
Atlanta International Airport (ATL), Newark Liberty International Airport (EWR), Washington Dulles International Airport (IAD),  
Dallas-Fort Worth International Airport (DFW), Detroit Metropolitan Airport (DTW), Seattle-Tacoma International Airport 
(SEA), Daniel K. Inouye International Airport (HNL) in Honolulu, Miami International Airport (MIA), Boston Logan International  
Airport (BOS), George Bush Intercontinental  Airport (IAH) in Houston, and Fort Lauderdale-Hollywood International Airport 
(FLL).    
25  The Office of the Assistant Secretary for Health oversees the U.S. Public Health Service Commissioned Corps, which is a  U.S.  
uniformed services branch committed to the service of health.  Officers advance U.S. public health by serving in agencies,  
such as CDC, across the  Government, as physicians, nurses,  dentists, and other professionals.  In this review, when we refer to 
HHS agency personnel by agency (e.g., CDC  personnel), this includes any Commissioned Corps officers  who are either  
temporarily or  permanently stationed at  and/or deployed by that agency.    
26  The six  quarantine sites were  March Air Reserve Base, Travis Air Force Base, Lackland Air Force Base, Marine Corps Air  
Station Miramar, Dobbins Air Force Base, and the University of Nebraska Medical Centers  quarantine  center.  The University  
of Nebraska Medical Centers  quarantine  center is the Nations only Federal quarantine unit and is funded by ASPR.   
University of Nebraska Medical Center, National Training, Simulation,  and  Quarantine Center (TSQC).   Accessed at  
https://www.unmc.edu/newsroom/2020/01/29/training-simulation-quarantine-center-now-open-at-med-center/  on July 7,  
2022.  
27  CDC,  Hierarchy of  Controls, last updated on January  13, 2015.  Accessed at 
https://www.cdc.gov/niosh/topics/hierarchy/default.html  on August  31, 2021,  and OSHA,  COVID-19 Hazard Recognition. 
Accessed at https://www.osha.gov/coronavirus/hazards  on August  31, 2021.  
28  CDC categorizes these controls as Standard  Precautions that are used for  all patient care and Transmission-Based 
Precautions, which are used in addition to Standard Precautions, for patients with known or suspected infectious diseases.   
CDC,  Infection Control Basics, last updated on January 5, 2016.  Accessed at  
https://www.cdc.gov/infectioncontrol/basics/index.html  on July 8, 2022.   
29  Relevant to this review, these  include OSHA standards under 1910 Subpart I regarding  Occupational Safety and Health  
Standards for Personal  Protective Equipment. Further,  OSHA has  promulgated implementing regulations at 29 CFR Parts 1960  
regarding Basic Program Elements for Federal Occupational Safety and Health Programs and Related Matters  (with additional 
relevant provisions in Part 1910).  29 CFR  1960.16 requires each Federal Agency head to comply with all occupational  safety 
and health standards issued under section 6  of the [Occupational Safety and Health] Act,  or with alternate standards issued 
pursuant to this subpart.  
30  29 CFR  1910.132(d)(1) states that the employer shall assess the workplace to determine  if hazards are present, or are  
likely to be present, which necessitate the use of personal protective equipment.  OSHA  also  makes recommendations for  
how employers can identify and assess workplace hazards.   OSHA,  Recommended Practices for Safety and Health Programs, 
October 2016, p. 15.        
31  CDC,  National Institute for Occupational Safety and Health,  2013.  Accessed at https://www.cdc.gov/niosh/docs/2013-
140/pdfs/2013-140.pdf?id=10.26616/NIOSHPUB2013140  on July 8, 2022.  
32  OSHA,  OSHA Standards Development.  Accessed at  https://www.osha.gov/laws-regs/standards-development  on August  31,  
2021.  
33  CDC/NIOSH,  Hierarchy of Controls, January  13, 2015.   
34  29 CFR  1910.132(d)(1)(i) states that the employer shall select, and have  each affected  employee use, the types of PPE that 
will  protect the affected employee from the  hazards identified in the hazard assessment.    
35  CDC/NIOSH,  Hierarchy of Controls, January  13, 2015,  and OSHA,  Hierarchy of Controls, 2018.  Accessed at  fy10_sh-20839-
10_hierarchy_of_controls.pdf (osha.gov)  on August  31, 2021.   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  49  36  OSHA,  Hazard Prevention and Control, 2018.   Accessed at https://www.osha.gov/sites/default/files/2018-12/fy11_sh-22318-
11_Mod_3_HazardPrevention.pdf  on May 10, 2021.  
37  29 CFR  1910.132(f)(1) outlines the training  requirements for all PPE,  including when and what PPE is necessary; how to 
properly don, doff, adjust, and wear PPE; the limitations of the PPE; and the  proper care, maintenance, useful life, and disposal 
of the PPE.      
38  N95 respirators  are protective  devices designed to achieve  a very close facial fit and very efficient filtration of airborne  
particles.  The N95 designation means that when subjected to careful testing, the respirator blocks at least 95 percent of  
very small (0.3  micron) test particles.   
39  29 CFR  1910.132(f)(2) requires employees to demonstrate  an understanding of the training and the ability to use PPE 
properly before being allowed to perform  work requiring the use of PPE.  For respirators specifically, 29 CFR  1910.134(k)(1) 
requires employers to ensure that employees can demonstrate knowledge  of, for example, how to inspect, don, and doff the  
respirator.  
40  29 CFR  1910.132(d) mandates that an employer assess the workplace to determine  whether  hazards are present or likely  
to be present,  which necessitates the use of  PPE.  If the assessment determines that hazards are present or likely to be  
present, the employer is to select and have  personnel use the PPE that will protect against the hazards identified,  
communicate these selection  decisions to personnel, and select PPE that properly fits each affected individual.  The employer  
is to perform a  written certification that identifies: (1) the workplace  assessed,  (2) the person certifying that the hazard  
assessment was performed,  and (3) the dates of the hazard  assessment.    
41  The hazard assessment states that respirators are required  as part of full PPE because CDC identified  infectious aerosols or  
mists, such as infectious diseases,  and animal dander as a potential hazard.  
42  See Endnote  53  for more information regarding the CDC documentation and other information that we relied on to 
determine the  PPE recommendations  at quarantine stations and sites during our review period.   
43  GAO,  HHS Should Clarify Agency Roles for Emergency Return of U.S. Citizens  During a Pandemic, April 2021.  Accessed at  
https://www.gao.gov/assets/gao-21-334.pdf  on April  27, 2021.  
44  HHS-OGC,  Findings of the Immediate Office  of the General  Counsels Investigation Into March Air Reserve  Base and Travis Air 
Force Base Deployments, November  12, 2020.  Accessed at https://osc.gov/Documents/Public%20Files/FY21/DI-20-
0537/OSC%20File%20No.%20DI-20-000537%20-%20Supplemental%20Report%20with%20Addendum%20(1)_Redacted.pdf  
on September  3, 2021.  
45  HHS-OGC recommended that:  (1) roles and responsibilities  be clearly defined in advance  of future cross-agency missions;  
(2) CDC ensure preparedness for future deployments that include the type of screening  and quarantine that ultimately 
occurred  at quarantine sites; (3) CDC personnel be trained for operationalizing missions that include an infectious disease 
control element; (4) the National Emergency  Repatriation Plan require written CDC guidance be available  to all personnel; and 
(5) two specific HHS personnel be referred for remedial, adverse employment action due to their involvement in these 
matters.  HHS-OGC did not indicate whether  HHS concurred with or had  implemented these recommendations. 
46  Beginning mid-March 2020, CDC contracted  with DHS to assist with screening at quarantine stations.   We did not explicitly  
review the controls that were recommended  and implemented for DHS contractors at quarantine stations,  although our  
findings may have implications for those personnel. 
47  ASPRs National Disaster Medical System provides personnel, equipment, supplies, and a system of partner hospitals to  
support an emergency response.  ASPR,  National Disaster Medical System,  May 26, 2021.   Accessed at 
https://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx  on June 4, 2021.  
48  We selected JFK, March Air Reserve Base, and Travis Air Force Base because there were  initial reports of health and safety  
concerns associated  with these locations.  Numerous personnel  who deployed to these locations also deployed to other  
quarantine stations and sites during our review period.  
49  Of the  729  deployments that surveyed  personnel  reported participating in, personnel  being  tested for COVID-19 within 2 
weeks of completing 18 of those deployments.  We did not ask respondents for the results of those tests.    
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  50   50  CDC,  Update and Interim Guidance  on Outbreak of Coronavirus Disease 2019, February  28, 2020.  Accessed at 
https://emergency.cdc.gov/han/2020/HAN00428.asp  on March  1, 2022.  
51  FDA,  In Vitro Diagnostics EUAsMolecular Diagnostic Tests for SARS-CoV-2.  Accessed at  https://www.fda.gov/medical-
devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-
molecular-diagnostic-tests-sars-cov-2  on March  1, 2022.  
52  Just-in-time training  is  training that is administered and scoped once an  immediate need is identified.  
53  To determine the PPE  recommendations  at quarantine stations and sites during our review period, we relied on CDC 
documentation, including a CDC role-based  assessment, interviews, and survey responses.  The CDC role-based assessment is  
a 1-page chart  that indicates the skin protection, respiratory protection, and eye protection recommended for CDC personnel  
at quarantine stations.    
54  Although CDC was responsible for ensuring that its own personnel at quarantine stations and sites wore the PPE it 
recommended, CDC stated that it was not responsible for ensuring that personnel from other HHS agencies wore the PPE 
that CDC recommended.  These other agencies reported to us that they  generally ensured that their personnel  wore the PPE  
recommended  by CDC. 
55  All tertiary screeners could  conduct secondary screening,  but not all secondary screeners could conduct tertiary screening.   
Although many personnel were trained to conduct tertiary screening, due to the nature of the screening, personnel most 
often conducted secondary screening because few  passengers actually met the criteria to go to tertiary screening.  
56  The  PPE required  for base personnel  is  outlined in CDCs  2019 hazard assessments.   Although the  PPE  that CDC  required  
for tertiary screeners was  different than that required for base personnel, the respiratory protection required was the same.   
Additionally, some personnel reported  instances where enforcement of CDCs PPE recommendations  at quarantine stations  
was a concern; however, we did not determine that this was  a widespread issue at quarantine stations.  Specifically, one  
respondent reported being a translator that was not fit tested, so this respondent was not cleared to wear an N95 respirator.   
However, this respondent reported being involved in tertiary screening (i.e., a medical assessment in a closed-door room) as a 
translator for a  potentially infected passenger without a mask.    
57  In response to this policy change, one quarantine stations leadership reported that most secondary screeners chose to 
wear  a respirator rather than  a surgical mask.  If personnel were not fitted and trained to  wear  a respirator prior to deploying,  
they were unable to obtain the fitting and training to voluntarily wear the respirator.  However, by this point in time, CDC had 
deployed most personnel with the required fitting and training to wear  a respirator.  
58  Prior OGC and GAO reports discuss potential  PPE  breaches at quarantine sites in detail.  OIG heard similar instances  
described in interviews and surveys of HHS personnel at quarantine sites. 
59  For example, at  1 quarantine  station, 11 of the 18 survey respondents  who deployed in January raised concerns about the  
PPE  required  while performing their job  duties.    
60  29 CFR  1910.134(c)(2) and 29 CFR  1910.134(c)(2)(i).  When respirators are not required, employers may (but are not 
required to) provide respirators at the request of employees or permit employees to use their own respirators, if the  
employer  determines that a respirator will not in itself create a hazard (e.g., if the respirator is used improperly or not kept 
clean).  OSHA also encourages respirator use,  even when exposures are below the exposure limit, to provide an additional  
level of  comfort and protection for workers.  (29 CFR  1910.134, App. D.)  
61  This quarantine site safety  officer reported that CDCs PPE recommendations for COVID-19 deviated from prior guidance  
that was more  protective.  This safety officer  reported  being concerned that if a potentially infected passenger had a heart 
attack,  safety officers  would need to respond and already be wearing the proper PPE to avoid delaying patient care.  
62  CDCs communicable disease response plans and OSHA define PPE selection for infectious diseases by Contact Precautions,  
Droplet Precautions, and Airborne Precautions.  Contact Precautions require gloves and may recommend gowns; Droplet  
Precautions require  a procedure or surgical  mask for close  contact with a  passenger, and they require gloves, gowns, and  
goggles if substantial spray of  respiratory fluids is anticipated; and Airborne Precautions require a respirator, and they require  
gloves, gowns, and goggles if  substantial spray of respiratory fluids is anticipated.  OSHA,  Healthcare Infectious Diseases. 
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  51   Accessed at  https://www.osha.gov/healthcare/infectious-diseases  on September  7, 2021.  CDC,  Quarantine Station 
Communicable Disease Response Plans, last updated 2017.   
63  29 CFR  1910.134(d)(1)(iii) and  29 CFR  1910.134(d)(2).  
64  HHS, Pandemic Influenza Plan, 2005, p.  S4-9.  Accessed at  
https://www.cdc.gov/flu/pdf/professionals/hhspandemicinfluenzaplan.pdf  on July 12,  2021.  
65  Some PPE can increase core  body temperature, which contributes significantly to worker fatigue.  Worker fatigue  may  
increase the risk  of injuries and/or accidents, such as errors in donning and  doffing PPE.  In these cases, using more  protective  
PPE could result in hazardous  conditions for the worker.  NIOSH and OSHA,  Preventing Worker Fatigue Among Ebola  
Healthcare Workers and Responders.  Accessed at  
https://www.cdc.gov/niosh/topics/ebola/pdfs/preventingworkerfatigueamongebolahcw122914.pdf  on April  5, 2022.  
66  29 CFR  1910.132(f)(1) outlines the training  requirements for all PPE,  including when and what PPE is necessary; how to 
properly don,  doff, adjust, and wear PPE; the limitations of the PPE; and the  proper care, maintenance, useful life, and disposal  
of the PPE.  Further, 29 CFR  1910.132(f)(2) specifies the need for employees to demonstrate an understanding of the  
training and the ability to use PPE properly before being  allowed to perform work requiring the use of PPE.  Finally, for  
respirators specifically,  29 CFR  1910.134(c)(1) requires employers to establish a program that includes, for example,  
employee training for potential respiratory hazard exposure and how to properly use respirators.  Further, 29 CFR   
1910.134(k)(1)  requires employers to  ensure that  employees can demonstrate knowledge  of, for example, how to inspect,  
don, and doff the respirator.  
67  CDC,  Hierarchy of Controls, January  13, 2015.  Accessed at https://www.cdc.gov/niosh/topics/hierarchy/default.html  on April  
30, 2021.  
68  OSHA,  Respiratory Infection Control: Respirators Versus Surgical Masks, 2009.  Accessed at  
https://www.osha.gov/sites/default/files/publications/OSHA3219.pdf  on May 6, 2021.  CDC also recommends a fit-tested,  
NIOSH-approved N95 or higher-level respirator for airborne precautions.  CDC,  Transmission-Based Precautions, January  7,  
2016.  Accessed at https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html  on April  30, 2021.  
69  Although  CDCs respirator training included knowledge checks (i.e., electronic assessment of knowledge using multiple  
choice  questions) within the training to help  ensure that  staff understood the training, these checks did not require  
employees to physically demonstrate that they knew the correct procedures for donning or doffing the respirator.  
70  CDC reported  that personnel  who take the respirator training are  also required to pass an in-person respirator fit test 
where  personnel are also observed donning and doffing a respirator and are provided additional training and guidance, if  
needed.  Personnel are not cleared to  wear a  respirator if they cannot pass the fit test, which CDC reported included  
demonstration of proper use of the respirator.  CDC did not report that this demonstration of proper use occurred for PPE  
types other than respirators.  CDC also indicated that the respirator training may not be  an apparent violation of 29 CFR   
1910.134(k)(1) because fit testing includes employee demonstration of the ability to properly use a respirator.  However, we  
could not independently verify CDCs statements, such as in its documented procedures for fit testing in its  Respiratory  
Protection Program, within Chapter 10 of CDCs  Health, Safety, and Environmental Policy.  CDCs  Respiratory Protection 
Program  defines a fit test as the use of a protocol to qualitatively or quantitatively evaluate the fit of a respirator on an 
individual.  It further states that:  
Individuals who wear a tight-fitting respirator must ensure that they  have a good fit.  While this is done in the fit test, it  
is up to the worker to take the  steps to ensure  their respirator is fitting properly.  This can be  achieved by performing the  
following steps: (1) individuals with facial hair must be clean shaven prior to donning a respirator; (2) workers place the  
respirator over their face, and adjust the straps  to ensure the  respirator is snug, but not uncomfortably tight; (3) a 
negative pressure check is performed.  The worker inhales deeply. A respirator with a good fit will collapse slightly  
against the face; (4) a positive pressure  check is performed.  The worker exhales and covers the outlet valves if the  
respirator has them, or the entire respirator itself in the case of an N95.  Air should not escape.  Supervisors will develop  
their own workplace specific protocols for doffing their respirator.  They will  also develop protocols for decontaminating 
non-disposable respirators.  Supervisors who need assistance  with this are encouraged to contact the OLSS  Biosafety  
Team or the OHSO IH Team.  CDC,  Chapter 10Respiratory  Protection, 2020 (draft version),  pp. 3;  78.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  52   We could not find any other reference within CDCs  Respiratory Protection Program  or other evidence describing how  
employees  demonstrate an understanding of how to inspect, don, and doff the respirator prior to using it.  
71  Based on COVID-19 CDC safety assessments  at quarantine stations, well-ventilated isolation rooms (an example of an  
engineering control) were necessary but were not always available  during,  at a minimum, tertiary screening.  For example, a 
safety officer found that the ventilation in the Detroit quarantine stations tertiary screening rooms was not adequate. In 
another example, a safety officer reported concerns that part of the air from the tertiary screening room  was being  
recirculated to the rest of the  building within the DallasFort  Worth quarantine station.  
72  Each airport receiving international passengers in the United States must provide suitable  office, isolation, and other  
exclusive space for CDC to carry out its duties to prevent the introduction  and spread of  communicable  diseases.   (42 CFR    
71.47).  CDC reported that this authority does not extend to common space used by all airport tenants (including Federal  
agencies), airport employees,  and travelers.  
73  There is not a  specific designation for a virus that has pandemic  potential.  However, by the end of February 2020, WHO  
began alerting the  world  that COVID-19 had pandemic potential.   STATnews, WHO tells countries to prepare for  coronavirus  
pandemic, but  insists its too soon to make that call,  February  24, 2020.  Accessed at 
https://www.statnews.com/2020/02/24/who-tells-countries-prepare-coronavirus-pandemic-too-soon-to-make-call/  on July  
22, 2020.  
74  Homeland Security Council,  Pandemic Influenza Implementation Strategy,  2006, p. 40.  Accessed at 
https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation.pdf  on July 9, 2021.   
75  CDC,  Community Mitigation Guidelines to Prevent Pandemic  InfluenzaUnited States, April  21, 2017.  Accessed at 
https://www.cdc.gov/mmwr/volumes/66/rr/rr6601a1.htm  on August  31, 2021.  
76  This study found that the rate of asymptomatic cases increased from 0 to 28.6 percent as the outbreak spread  and there  
was increased surveillance  and contact tracing.  This study reports that early in the course  of any outbreak, severe cases  are  
recognized first and then less severe  (i.e., mild or asymptomatic) cases  are  detected as the  outbreak spreads.  The study  was  
originally published in  2018, with an additional article  posted in February 2020 due to the COVID-19 outbreak.  The 2020 
publication was accessed at  
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102602/#:~:text=The%20occurrence%20of%20asymptomatic%20individuals, 
to%2028.6%25%20%5B1%5D  on March  24, 2022.  The original publication  was accessed at  
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110966/  on March  24, 2022.    
77  The authors attributed this difference to:  (1) the novelty of the pathogen and (2) SARS having minimal genetic relatedness  
to other coronaviruses, which reduces immunity and may have caused more symptomatic cases.  Wilder-Smith, A., Teleman, 
M. et al.,  Asymptomatic SARS  coronavirus infection among healthcare workers, Singapore, 2005.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3371799/pdf/04-1165.pdf  on March  24, 2022. 
78  A CDC team leader reported to OIG that personnel at quarantine sites were told to carry PPE with them  in case they  
needed to interact with a  potentially infected  passenger.  However, we did  not find any documentation indicating that this  
was required and/or conveyed to quarantine site personnel.  
79  Personnel deployed to other  quarantine stations and sites were not included in this guidance.  
80  This campaign advised individuals in the United States to stay home, avoid gathering in  groups, forgo discretionary  travel,  
and discontinue eating in restaurants and bars for 15 days.   Accessed at  
https://www.justice.gov/doj/page/file/1258511/download  on July 14, 2021.  
81  This system was implemented for all individuals involved  with the COVID-19 response.  CDC,  Text Illness Monitoring One  
Pager, March  18, 2020.     
82  It was not recommended that this individual  self-quarantine  based on the guidance available at that time.  This individual  
reported not quarantining despite PPE breaches because this individual believed that the chances of the passengers being 
infectious were small.   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  53  83  If any personnel developed symptoms while quarantining, they were  instructed to contact CDCs  Occupational Health Clinic 
for  next steps.  
84  A version of this policy dated a few  days earlier advised that  personnel deployed to Travis Air Force Base  should remain  at  
home or in a  comparable setting to the extent possible and practice  physical distancing.   Additionally, it advised that  
personnel should not report to work for 14 days from the day of arriving home.  This policy did not apply to personnel at 
other quarantine stations or sites.  
85  Regulations to control communicable diseases are found at 42 USC  264.  Regulations addressing the  prevention,  
introduction, and spread of  communicable  diseases from foreign countries into the United States are found at 42 CFR Part 71.  
86  The first U.S. case associated  with probable  community spread was identified on February  26, 2020, in Solano County,  
California, which is the county where the Travis Air Force Base quarantine site was located.  CDC,  Epidemiologic Findings from  
Case Investigations and Contact Tracing for First 200 Cases of Coronavirus Disease, Santa Clara County, California, USA, May  
2021.  Accessed  https://wwwnc.cdc.gov/eid/article/27/5/20-4876_article  on September  24, 2021.  
87  Passenger screening and quarantining at quarantine sites also expanded during this time  period.  Passengers continued to 
arrive  at quarantine sites between March  10 and March  12, 2020.  By March  23, 2020, however, all quarantine orders for  
passengers at  quarantine sites were rescinded and no new  quarantine sites were opened.  
88  CDC,  Federal  Government Adjusts COVID-19 Entry Strategy  for International Air Passengers, September  9,  2020.  Accessed at 
https://www.cdc.gov/media/releases/2020/s-0909-covid-19-entry-strategy-air-passengers.html  on October  8, 2021.   
89  CDC,  Federal  Government Adjusts COVID-19 Entry Strategy  for International Air Passengers, September  9,  2020.   
90  CDC leadership continued: [A]ll of  that data taken together has led CDC to make evidence-based recommendations, and 
this has been driven from the  perspective of  CDC by scientifically evidence-based recommendations.  CDC,  Transcript for 
CDC Media Telebriefing: Update on 2019 Novel Coronavirus (2019-nCoV), January  31, 2020.   Accessed at  
https://www.cdc.gov/media/releases/2020/t0131-2019-novel-coronavirus.html  on March  16, 2022.  
91  The Hill, The coronavirus can spread  without signs of  symptoms,  January  31, 2020.  Accessed at 
https://thehill.com/changing-america/well-being/prevention-cures/480891-the-coronavirus-can-spread-without-signs-of  on 
March  23, 2022.   
92  BBC, China coronavirus spreads before symptoms show,  January  26, 2020.  Accessed at 
https://www.bbc.com/news/world-asia-china-51254523  on March  23, 2022.  
93  Li, Ruiyan et al.,  Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (COVID-19), 
February  17, 2020.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239048/pdf/nihpp-2020.02.14.20023127.pdf  
on March  23, 2020.  
94  CDC,  Risk Assessment and Management of COVID-19 Among Travelers Arriving at Designated U.S. Airports, January 17 
September  13, 2020;  November  13, 2020.  
95  CDCs  Morbidity and Mortality Weekly Report  does not include discussion on quarantine sites or the implications of its  
findings on HHS personnel health and safety.  CDC,  MMWR:  Risk Assessment and Management of COVID-19 Among Travelers 
Arriving at Designated U.S. Airports, January  17September 13, 2020; November  13, 2020.  Accessed at 
https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a4.htm#T1_down  on February  9, 2021.  
96  Eurosurveillance,  Effectiveness of airport screening at  detecting travelers infected with novel coronavirus (2019-nCoV), 
February 2020.  Accessed at  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7014668/pdf/eurosurv-25-5-2.pdf  on December  
2, 2021.  
97  Beyond identifying symptomatic passengers, another intended public  health benefit of passenger screening was for the  
passengers contact information to be collected and shared with State public health authorities for  followup  in the event that 
passengers became ill after  traveling.  However, State public health authorities received only  approximately two-thirds of  
passengers information.   CDC reported sending State public  health authorities  contact information for approximately 68 
percent of screened passengers.  CDC,  MMWR: Risk Assessment and Management of COVID-19 Among Travelers Arriving at  
Designated U.S. Airports, January 17September 13, 2020;  November  13, 2020.   Accessed at  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  54   https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a4.htm.  Further, GAO released  a report in July 2022 that highlighted  
similar  challenges.  GAO found that although CDC has taken some action, it is not positioned to  efficiently analyze and 
disseminate  data to inform public health policies and respond to disease threats.   Also, CDC is  not positioned to evaluate its  
performance in collecting and sharing quality passenger information.   GAO,  CDCs Data System Needs Substantial  
Improvement, July 2022.  Accessed at https://www.gao.gov/assets/gao-22-105018.pdf  on July 21, 2022.    
98  CDC,  Federal  Government Adjusts COVID-19 Entry Strategy  for International Air Passengers, September  9,  2020.   Accessed at  
https://www.cdc.gov/media/releases/2020/s-0909-covid-19-entry-strategy-air-passengers.html.  
99  Homeland Security Council,  National Strategy for Pandemic  Influenza, November 2005.  Accessed at 
https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-strategy-2005.pdf  on September  27, 2021.  Homeland  
Security Council,  National Strategy for Pandemic Influenza: Implementation Plan, May 2006.  Accessed at  
https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation.pdf  on September  27, 2021.  HHS,  
Pandemic Influenza Plan, November 2005.  Accessed at https://www.cdc.gov/flu/pandemic-
resources/pdf/hhspandemicinfluenzaplan.pdf  on September  27, 2021.  
100  The 2006 planning outlines  six  stages for a pandemic response by the Federal Government: Stage 0: New Domestic Animal 
Outbreak in At-Risk Country, Stage 1: Suspected Human Outbreak Overseas, Stage 2: Confirmed Human Outbreak Overseas, 
Stage 3: Widespread Human  Outbreaks in Multiple Locations Overseas, Stage 4: First Human Case in North America, Stage 5: 
Spread Throughout the United States, and Stage 6: Recovery and Preparation for Subsequent Waves.  The stages are built on 
a framework provided by the  World Health  Organization (WHO), which has defined six phases  before and during a pandemic,  
that are linked to the characteristics of a new  influenza virus  and its spread through the population.   See Endnote 104 for  
further discussion of WHO phases.   Homeland Security Council,  National Strategy for Pandemic Influenza: Implementation 
Plan, May 2006, pp. 31 and 32.   
101  In a 2014 MMWR, CDC updated its framework for describing influenza pandemic progression using six intervals and eight  
domains.  CDC reported  doing this on the basis of experience from influenza responses between 2006 and 2014 and that 
this updated framework provides greater detail and clarity regarding the  potential timing of key decisions and actions aimed 
at slowing the  spread and mitigating the impact of an emerging pandemic.  From OIGs perspective, these updates did not  
add any additional specificity  to screening and quarantining planning.  CDC,  MMWR: Updated Preparedness and Response  
Framework for Influenza Pandemic, September 26, 2014.  Accessed at 
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6306a1.htm  on November  10, 2021.  
102  Homeland Security Council,  National Strategy for Pandemic  Influenza: Implementation Plan, May 2006, p. 38.  
103  Ibid., p. 41.  
104  WHO  defines the six phases as follows:  Phase 1:  no new influenza virus subtypes detected  and existing virus subtypes  risk  
is considered low; Phase 2:  no new influenza virus subtypes, but a circulating virus subtype poses a substantial risk of human 
disease;  Phase 3:  human infection, but no human-to-human spread, or at  most, rare instances of spread to a close contact; 
Phase 4:  small cluster(s) with limited human-to-human transmission,  but spread is highly  localized;  Phase 5:  larger cluster(s),  
but human-to-human spread is still localized but has substantial pandemic risk; and Phase 6:  pandemic phase, where there is  
increased and sustained transmission in the  general population.  Homeland Security Council,  National Strategy for Pandemic  
Influenza: Implementation Plan, May 2006, p. 31.   
105  HHS, Pandemic Influenza Plan, November 2005, pp. 3340.  
106  Ibid., p. 38.  
107  Ibid., p. S8-3.  
108  Ibid., p. S8-9.  
109  Ibid., p. S9-3.  
110  Ibid.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  55   111  Homeland Security Council,  National Strategy for Pandemic  Influenza: Implementation Plan, May 2006, p. 76.  Accessed at 
https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-implementation.pdf  on September  27, 2021.  
112  HHS, Entry Procedures for Travelers at Air Ports of Entry in the Event of a Severe Influenza Pandemic: Concept of Operations, 
March 2009, and HHS,  U.S. Public Health Entry Screening of Arriving International Travelers at Airports During an Influenza 
Pandemic: Standard Operating Procedures, March 2009.   
113  HHS, Entry Procedures for Travelers at Air Ports of Entry in the Event of a Severe Influenza Pandemic: Concept of Operations, 
March 2009, Section 8.2, p. 13.  
114  Ibid., Section 8.1, p. 11.   
115  Ibid., Section 8.1, p. 12,  and Section 8.2, p. 13.  
116  Ibid.,  pp.  45.  
117  The 2009 CONOPS  also states  that  screening and quarantining measures, specific to slowing the spread of a pandemic 
influenza virus  to the United States, will cease once there  is no longer a  public  health benefit from conducting such measures,  
based  on the recommendation of the Secretary of Health and Human Services, in conjunction with the Secretary of Homeland  
Security.  Ibid.,  pp. 45.  
118  National Security Council,  National Security Council Playbook for Early Response to High Consequence, Emerging Infectious 
Disease Threats and Biological  Incidents, 2016.  
119  Ibid., p. 8.  
120  Ibid.,  pp. 8 and 31.  
121  Ibid., p. 18.  
122  OSHA and CDC issued rules and guidance specific to COVID-19 and non-health  care and health  care settings during and 
after the period of our  review.  OSHAs rules  are based on the requirements of the OSH Act.  For example, OSHA,  Interim Final  
Rule: Occupational Exposure to COVID-19, Emergency Temporary Standard,  86 FR 32376, June 21, 2021.  Accessed at 
https://www.federalregister.gov/documents/2021/06/21/2021-12428/occupational-exposure-to-covid-19-emergency-
temporary-standard  on November 9, 2021.  CDC,  COVID-19 Information for the Workplace.  Accessed at  
https://www.cdc.gov/niosh/emres/2019_ncov_default.html  on November  3, 2021.  
123  CDC,  Engineering Controls, last updated January 14, 2015.  Accessed at  
https://www.cdc.gov/niosh/engcontrols/default.html  on July 15, 2021.  
124  Ibid.   
125  CDC,  Prevention Strategies for Seasonal Influenza in Healthcare Settings.  Accessed at  
https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm  
126  Ibid.  
127  OSHA,  Guidance on Preparing Workplaces for an Influenza Pandemic, 2009,  pp. 17 and 33.  Accessed at  
https://www.osha.gov/sites/default/files/publications/OSHA3327pandemic.pdf  on November  18, 2021.  
128  Ibid.,  pp. 15 and 29.   
129  OSHA,  Hazard Prevention and Control, 2018.   Accessed at https://www.osha.gov/sites/default/files/2018-12/fy11_sh-
22318-11_Mod_3_HazardPrevention.pdf.  
130  OSHA,  Guidance on Preparing Workplaces for an Influenza Pandemic, 2009,  p. 19.   
131  Ibid., p. 19.  
132  Ibid., p. 14.   
133  Ibid.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  56   134  Ibid., p. 19.  
135  Ibid., p. 15.    
136  CDC,  Prevention Strategies for Seasonal Influenza in Healthcare Settings. 
137  CDC,  2007  Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare  Settings, updated 
July 2019, p. 51.  
138  OSHA,  Hazard Prevention and Control, 2018.   
139  Ibid.,  pp. 5253.  
140  CDC,  Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients 
with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting,  or 
Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE, August  30, 2018.  Accessed at 
https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html  on September  25, 2020.   
141  CDC,  Considerations for Selecting Protective Clothing used in Healthcare for Protection Against Microorganisms in Blood and 
Body Fluids.  Accessed at  https://www.cdc.gov/niosh/npptl/topics/protectiveclothing/default.html  on September  25, 2020.   
142  CDC,  2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare  Settings, updated 
July 2019, p. 53.  
143  Ibid., p. 55.  
144  Ibid.,  pp. 5455.  
145  Ibid., p. 51.   
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   Endnotes  |  57   ABOUT THE OFFICE OF INSPECTOR GENERAL  
The mission of the Office of Inspector General (OIG), as mandated by Public Law  
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well  as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of  Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work  
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to  provide independent assessments of HHS programs and operations.   
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS.  
The Office of Evaluation and Inspections  (OEI)  conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable  
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also  present practical recommendations 
for improving program operations.  
The Office of Investigations  (OI)  conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and  
beneficiaries.  With investigators working in all 50 States and the District  of  Columbia, 
OI utilizes its resources by actively coordinating  with the Department of  Justice and  
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil  
monetary penalties.  
The Office of Counsel to the Inspector General (OCIG)  provides 
general legal services to  OIG, rendering advice and opinions on  HHS programs and  
operations and providing all  legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and civil monetary  penalty 
cases.  In connection with these cases, OCIG also  negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.  
During the Initial COVID-19 Response, HHS  Personnel  Who Interacted With Potentially Infected Passengers Had Limited 
Protections  
OEI-04-20-00360   About OIG | 58