Introduction to Quarantine and the EMS Public Health Role Danitza Tomianovic, MPH Assistant Officer...

Introduction to Quarantine and the EMS Public Health Role

Danitza Tomianovic, MPH Assistant Officer in Charge, CDC Miami Quarantine Station

Division of Global Migration & Quarantine (DGMQ)National Center for the Preparedness, Detection, and Control of Infectious

Diseases (NCPDCID)Centers for Disease Control and Prevention (CDC)

Overview• Intro to DGMQ

– Our mission

• Basics of quarantine– Definitions– History

• Quarantine Station functions– Illness surveillance and response– EMS collaboration

• Ongoing activities– Partner Needs Assessment Project– Public Health Preparedness

• Summary

Federal Structure

Department of Health and Human Services (DHHS)↓

Centers for Disease Control and Prevention (CDC)↓

Coordinating Center for Infectious Diseases (CCID)

↓

Division of Global Migration and Quarantine (DGMQ)

↓

Quarantine and Border Health Services Branch (QBHSB)

Quarantine and Border Health Services Branch (QBHSB)

Mission

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

Quarantine Basics

Definitions

History

Definition: Isolation

Separation and restricted movement of ill persons with contagious disease– Often in a hospital setting– Primarily individual level, may be applied

to populations

– Often voluntary, but may be mandatory

– Fundamental, commonly used public health practice

Definition: QuarantineSeparation and restriction of movement of well persons presumed to have been exposed to contagion

– often at home or residential facility– may be voluntary or mandatory

History of U.S. Quarantine

Before 1967• Quarantine Inspectors

monitored passengers disembarking from aircraft, ships, and across land borders

• Large workforce enabled direct inspection, observation, and response

1967-2003• Reorganization of quarantine station system

reduced staff and facilities• Reorientation of quarantine staff roles

2003-present• Newly emerging threats initiated an expansion of

quarantine system

History of U.S. Quarantine, cont.

11Source: Population Action International 1994

Major Migration Flows: 1960-75

22

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

Major Migration Flows: 1990s

U.S. Quarantine Program

HEW 1953• 52 seaports• 41 airports• 17 border stations• 33 territory stations• 41 U.S. consulates• 50 maritime vessels• 600 employees

HHS 2004• 8 airports• 70 employees

HHS 2008• 18 airports• 2 border stations• ~100 employees

US Average Daily Entry: 1.16 Million (FY06)

176,000 Bus, Train, Walk

240,000 Airline

71,000 Ship

681,000 Private vehicle 154 Land

ports154 Land

ports

113 Airports44 User air

15 Seaports

1.16M People 326 POEs

~80 Staff20 QS

Quarantine Stations

Source: CBP June 2007

San DiegoSan Diego

VTVT

MEME

MAMANYNY

PAPA

NHNH

WVWV

VAVA

MDMD

NJNJ

RIRICTCT

AZAZ

ININ

WIWI

KYKY

MIMI

OHOHIAIA

MNMN

MOMO

ILILNENE

KSKS

SDSD

NDND

ALAL

TNTN

GAGA

SCSC

NCNC

ARAR

LALA

MSMS

OKOK

AtlantaAtlanta

ChicagoChicagoSeattleSeattle

WYWY

IDID

WAWA

AKAK

OROR

MTMT

NVNVUTUT

NMNM

COCO

East TXEast TX

MiamiMiami

FLFL

No.CANo.CA

So.CASo.CA

Los AngelesLos Angeles

San FranciscoSan Francisco

HIHI

HonoluluHonolulu

Washington, D.C.Washington, D.C.

El PasoEl Paso

HoustonHouston

NewarkNewark

New YorkNew York

BostonBoston

GUGU

San JuanSan Juan

MinneapolisMinneapolis

DetroitDetroit

AnchorageAnchorage

West TXWest TX

PRPR

CDC Quarantine StationCDC Quarantine Station

PhiladelphiaPhiladelphia

DallasDallas

North TXNorth TX

CTCT

DEDE

CDC Quarantine Stations 2008 Jurisdictions

Quarantine Station Staff Roles

• Officer in Charge (OIC)/ Assistant OIC– Oversees the administration and management of

the station

• Quarantine Medical Officer (QMO)– Oversees the clinical and medical activities and

scientific research

• Quarantine Public Health Officer (QPHO)– Handles daily operative functions

CDC Miami Quarantine Station

• Jurisdiction:– State of Florida, Mississippi, Alabama, and Bahamas Pre-

clearance port

• Located:– Miami International Airport (MIA)– Concourse E, 3rd Floor FIS Area

• Staff: – 1 ROIC/OIC + 1 AOIC + 1 QMO (in Atlanta) + 3 QPHO’s + 2

Admin Assistants

• 24-hour Phone Number:– 305-526-2910

The Quarantine System

Relationships among the Quarantine Core System and Network for U.S. Ports of Entry

Air Transport Assoc. of America

Network

System

CoreQ StationsDGMQ HQ

CDCCBPEMS

Int. Org. for Migration

State PHAs

Hospitals

Health-care providers

Port officials

USFWS

USDA APHIS

PH labs

Air Transport Assoc. of AmericaForeign Gov'ts

Courts

Int. Council of Cruise Lines

Canadian/ Mexican BorderAuthorities

PHAC

DHSFAA

FBI

State Dept.

WHO

News Media CSTE

NACCHO

ASTHO

BIDS

APHL

DOT

Media (general)

Int. Civil Aviation Org.

USCG

FBI (local)

LPHAs

OverseasPanel Physicians

USCG (local)

FDA

Source: IOM Report

Quarantine Station Functions

Illness Surveillance and Response

EMS Collaboration

• Responding to reports of illnesses on maritime vessels (cruise, cargo), airplanes, and at land border crossings

• Performing inspections of animals, cargo, and hand-carried items

• Emergency planning and preparedness

Quarantine Station Functions

• Distributing life-saving immunobiologics and investigational drugs

• Providing travelers with essential health information

Quarantine Station Functions, cont.

Quarantine Station Functions, cont.

• Monitoring health and collecting medical information of new– immigrants,

– refugees,

– asylees, and

– parolees • Responding to mass

migration emergencies

Quarantine Station Functions, cont.

• Building partnerships for disease surveillance and control

Quarantine Station Functions, cont.

Responding to an Ill Traveler on a Conveyance

The captain of a plane, ship, or other conveyance is required by federal law to report any “illness” or death on board to a public health authority (i.e. quarantine station or local health department) prior to arrival at the port of entry.

• Applies to all international travelers: crew and passengers; U.S. citizens and non-U.S. citizens

• Definition of “ill person”:– Fever ≥100°F persisting for >48 hours

– Fever and certain other symptoms:• Fever ≥100°F AND rash, or• Fever ≥100°F AND swollen glands, or• Fever ≥100°F AND jaundice

– Severe diarrhea (with or without fever)

International Travelers (42 Code of Federal Regulations Part 71)

OR

OR

Additional Reportable Syndromes

• Current regulations being revised• Proposed regulations will have

additional reportable syndromes (“requested” reporting for now)

• Fever and any one of the following:– Difficulty breathing or suspected/

confirmed pneumonia– Cough of more than 2 weeks’ duration or

cough plus bloody sputum– Headache with neck stiffness– Reduced level of consciousness – Unexplained bleeding

Executive Order 13295 Revised List of Quarantinable Communicable

Diseases • Cholera; diphtheria; infectious

tuberculosis; plague; smallpox; yellow fever; and viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named)

• Severe acute respiratory syndrome (SARS)

• Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic

President George W. BushApril 1, 2005

Domestic Travelers (42 Code of Federal Regulations Part 70)

• Applies to all domestic travelers: crew and passengers; U.S. citizens and non-U.S. citizens

• “Domestic travel”: From any State to a point of destination in any other State; or Between points in the same State

• “Ill person”: a case or suspected case of a communicable disease

1. Identification• Signs or symptoms indicative of

communicable disease• Traveler on international or domestic

conveyance2. Notification

• International traveler: EMS notify CDC Quarantine Station (QS)

• Domestic traveler: EMS notify County Health Department

• Public Health authorities share notification with EMS

3. Response• International traveler:

• CDC QS staff not on-site communicate by phone and obtain the EMS assessment or CDC QS staff in-person with EMS

Notification and Response Protocol at POE

Public Health Information Needed

• Medical Information– Signs, symptoms, complaints, history

• Itinerary– Method of travel, from where, U.S. entry

• Exposure history and demographics– Contact with ill person or livestock or poultry – Travel history in last 10 days – Occupation– Date of Birth, country of residency

• Traveler contact information

Health Insurance Portability and Accountability Act (HIPAA)

• 45 CFR 164.512(b) – Allows for disclosure, without individual

authorization, protected health information to public health authorities

• CDC authorized by law to collect or receive protected health information for: – Preventing or controlling disease, injury, or

disability– Reporting of disease, injury, vital events– Conducting public health surveillance,

investigations, and interventions

• Goal of CDC Staff : Determine public health risk and appropriate public health action

• Three possibilities:

CDC Quarantine Station Illness Surveillance and Response Protocol

Recommend seeking medical care and/or delay travel until noninfectious1

Allow travel to continue, if desired3

Require transfer to Memorandum of Agreement Hospital if quarantinable disease suspectedRequire transfer to hospital if quarantinable disease suspected2

EMS Role in Illness Surveillance and Response

• Identification• Notification • Assist CDC on site and by phone

to assess public health risk• Assist with transport

Primary EMS* and Total QARS† Reports, by Quarantine Station, Jan 2006- Sep 2007

Quarantine

Station ‡Primary EMS Calls Total Illness Percent primary

EMS

ANC 16 155 10%

ATL 4 78 5%

HNL 3 490 1%

MIA 20 181 11%

SFO 4 137 3%

IAD 3 57 5%

JFK 3 89 3%

BOS 2 38 5%

HOU 2 103 2%

MSP 1 85 1%

SEA 7 83 8%

Total 65 1496 4%*Primary EMS is when QS first informed by EMS† Exclude other information reports‡ Quarantine Stations not listed had no primary EMS reports

Ongoing Activities:

Partner Needs Assessment Project

Public Health Preparedness

Goals of Needs Assessment Project

• Build and strengthen relationships with key partners at ports of entry

• Develop appropriate training and education content and communication messages

• Deliver through preferred and effective formats

Partners (and Audience)

• U.S. Customs and Border Protection (CBP)

• Airlines • Cruise lines• EMS• Customs Brokers• Border Patrol

• U.S. Department of Agriculture (USDA)

• U.S. Fish & Wildlife• U.S. Transportation

Security Administration (TSA)

Needs Assessment Topics

• Knowledge, attitudes, and beliefs related to– Health issues

– Public health roles

• Barriers to fulfilling public health role

• Current training related to public health issues

• Topics for which staff want training

Needs Assessment Topics, cont.

• Preferred formats for timely and effective communications

• Preferred formats for training– Methods used

– Frequency

• Opportunities to work together

Roundtable DiscussionsEMS & CDC Collaborative Meeting

• 70 participants from EMS and CDC• Presentations and roundtable discussions• Purpose

– Strengthen the partnership between CDC and EMS

– Identify ways to improve reporting of illnesses to CDC

– Identify opportunities to collaborate in training and education

– Identify opportunities for sharing data

Aircraft Rescue Firefighting Working Group Annual Meeting

• ~200 attendees from airports around the world

• CDC presentation

• Roundtable discussions with 10 attendees from international airports

Roundtable Discussions

Training & MaterialsDraft EMS Public Health Card

• In development

• Size of ID card

• Consultation with Miami-Dade Fire Rescue– Need for quick assessment of

communicable diseases– Need to know triggers for contacting CDC

Quarantine Station– Need 24-hour contact telephone number

Front Back

Training & MaterialsDraft EMS Public Health Card

Roundtable Discussion Results

• Identified needs for– Clear protocols for responses to public

health situations– Job aids to support protocols

• Include algorithms and diagrams• Use sticker format instead of card

– Training and education (signs and symptoms)

– Active outreach by Quarantine Stations• Training opportunities = conferences and

certification programs• State Medical Director plays pivotal role

Public Health Preparedness• MIA Communicable Disease and

Bioterrorism Response Plan– Developed in collaboration with Miami-Dade

County Health Department, CBP, Airport Authorities, MD Police Department, MD EMS & Fire rescue, TSA, Red Cross

• Surge capacity training for Florida Department of Health employees

• Trainings and regular communication with EMS partners

Public Health Preparedness, cont.• Full-scale exercise at MIA (2005)

– SARS and Smallpox on aircraft– Lead to refining MIA CDR Plan

• Tabletop exercise at POM (2005)

– Cruise arriving with avian flu and plague

– Identified major gaps in resources and surge capacity

• Tabletop exercise at MIA (2007)

– Avian Influenza on aircraft– Quarantine entire flight– Introduced new pandemic

influenza preparedness strategies

Public Health Preparedness, cont.

• Developing Comprehensive Communicable Disease Response Plans at major Florida POE’s– Miami International Airport (ongoing)– Ft. Lauderdale-Hollywood International Airport– Orlando International Airport– Sanford International Airport– Next steps: seaports

• Finalizing Public Information, Media and Communications Plan

• Discussions of Pandemic Influenza Planning

• Partnerships are essential!

SummaryEMS is a vital partner in CDC quarantine station efforts to detect and control

communicable disease

• Identification, Notification and Response of:• An international ill traveler (crew or passenger) with any symptoms that meet the federal definition of an ill

person• A death during international travel

• CDC wants to work with EMS to help develop appropriate training and find opportunities for collaboration

More Information

• Contact CDC Miami Quarantine Station

305-526-2910

• Visit www.cdc.gov/ncidod/dq

• Visit www.cdc.gov/travel for health information for international travelers

Questions?