CDC Division of Global Migration CDC Division of Global Migration and Quarantineand Quarantine

IOM Committee: Measures to Enhance Effectiveness IOM Committee: Measures to Enhance Effectiveness of Qof Q--Station Expansion PlanStation Expansion Plan

Martin S. Cetron, MDMartin S. Cetron, MDDirector, DGMQDirector, DGMQ

DGMQ MissionDGMQ Mission

•• Prevent importation, transmission, or spread Prevent importation, transmission, or spread of communicable diseases from foreign of communicable diseases from foreign countries into the United Statescountries into the United States

(Statutory responsibility to make and enforce (Statutory responsibility to make and enforce regulations as necessary)regulations as necessary)

•• Decrease morbidity and mortality among Decrease morbidity and mortality among globally mobile populations entering the globally mobile populations entering the United StatesUnited States

(Public health responsibility)(Public health responsibility)

Immigration and Nationality Act

Refugee Act42 CFR

CDC Role in Overseas Migrant Health EvaluationCDC Role in Overseas Migrant Health Evaluation

•Required health evaluation •Inadmissible conditions

•Diseases of public health significance•Monitor quality of health screening •Meet at ports of entry•Notify state/local health dept

•Prevent importation and spread

HIV, TB, Hansen’s disease, STDs, harmful behavior, drug abuse•Waivers

Executive Order 13295:Revised List Of Quarantinable Communicable Diseases

(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers(Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

(b) Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to person predominantly by the aerosolized or droplet route, and, if spread in the population, would have severe public health consequences.

President George W. BushApril 4, 2003

Cholera in New York City, 1892Cholera in New York City, 1892

Typhus Fever Epidemic, 1892

History of Quarantine & History of Quarantine & U.S. Public Health ServiceU.S. Public Health Service

•• Quarantine preceded Quarantine preceded CDCCDC

•• Legislation 1Legislation 1stst

enacted at turn of enacted at turn of 2020thth cent as spread cent as spread of disease perceived of disease perceived as resulting from as resulting from travel (immigration)travel (immigration)

The Public Health Service & The Rise of The Public Health Service & The Rise of QuarantineQuarantine

•• Prevent introduction Prevent introduction of diseases such as of diseases such as yellow fever, yellow fever, smallpox, cholera, smallpox, cholera, and plague into USand plague into US

•• No mandate to No mandate to address health address health issues of those issues of those leaving USleaving US

U.S. Quarantine ProgramU.S. Quarantine Program

DHEW 1953DHEW 1953•• 52 seaports52 seaports•• 41 airports41 airports•• 17 border stations17 border stations•• 33 territory stations33 territory stations•• Panama CanalPanama Canal•• 41 U.S. consulates41 U.S. consulates•• 50 maritime vessels50 maritime vessels

CDC 1967CDC 1967--70 RIF70 RIF-- 6 airports6 airports

DGMQ 2004DGMQ 2004-- 8 airports8 airports

Charge to IOM:Charge to IOM:Assist DGMQ in strategic planning to reAssist DGMQ in strategic planning to re--build Qbuild Q--station infrastructure in order to accomplish missionstation infrastructure in order to accomplish mission

•• How should the current role of the QS evolve to meet 21How should the current role of the QS evolve to meet 21stst century century challengeschallenges

•• What are the types & numbers of public health professionals and What are the types & numbers of public health professionals and appropriate skill sets necessaryappropriate skill sets necessary

•• What are the optimal locations for efficient and sufficient moniWhat are the optimal locations for efficient and sufficient monitoring and toring and responseresponse

•• How do we ensure surge capacity for PH emergencies (e.g. SARS, How do we ensure surge capacity for PH emergencies (e.g. SARS, Pandemic Flu, Mass migrations)Pandemic Flu, Mass migrations)

•• How should QS staff best collaborate with partnersHow should QS staff best collaborate with partners-- State and Local Health Dept.State and Local Health Dept.-- Other Federal Agencies and Inspection ServicesOther Federal Agencies and Inspection Services-- International partners e.g. WHO, MOH and NGOsInternational partners e.g. WHO, MOH and NGOs

Prior to 1996Division of Quarantine, CPS/CDC

QUARANTINESTATIONS (7)- MEDICAL

SCREENINGHEALTH

ASSESSMENT

MEDICAL SCREENING AND HEALTH ASSESSMENT BRPROGRAM OPERATIONS BR

TRAVELERS'HEALTH

OFFICE OFTHE DIRECTOR

1997-2003Division of Global Migration and Quarantine

OFFICE OFTHE DIRECTOR

SURVEILLANCE ANDEPIDEMIOLOGY BRANCH

ADMINISTRATIVESECTION

FIELD OPERATIONS BRANCH

TRAVELERS'HEALTHSECTION

INFORMATIONMANAGEMENT

SECTION

SURVEILLANCESECTION

EPIDEMIOLOGY &SPECIAL STUDIES

SECTION

QUARANTINESECTION-Quarantine

Stations

MEDICALSCREENING &

HEALTHASSESSMENT

NONHUMANPRIMATEACTIVITY

Division of Global Migration and QuarantineProposed Reorganization (2003-4)

Division of Global Migration and QuarantineReorganization (2003-4)

Travelers’ Health

ZoonosesTeam

Surveillance & Epidemiology

8- Quarantine Stations (25)D. Kim

Program & Evaluations

L. Ortega

R. Koppaka

M. Weinberg

J. Ward

P. Arguin

P. Kozarsky

CetronBarrowSimone

P. Simone S. Maloney

J. Barrow

Division of Global Migration and QuarantineProposed Reorganization (2003-4)

Travelers’ Health

ZoonosesTeam

Surveillance & Epidemiology

Quarantine Stations11 POEs 25 POEs?International Ports?

Program & Evaluations

Quarantine StationsQuarantine StationsCurrent and Proposed

CA

OR

NV

NM

WA

AZ

UT

ID

CO

WY

NDMT

NE

SD

MN

OK

IA

TX

KS

AR

MO

WI

IL

GAMSALLA

TNSC

FL

OHIN

WV

VA

NC

NYMIPA

ME

KY

Seattle

San Francisco

Los Angeles

El Paso

Chicago

Miami

Atlanta

New York

HonoluluHI

AK

San Juan, PRChristiansted, VI Cruz Bay, VI

Existing Station - 8Station Opening FY2004 - 3Proposed Station FY2005+ - 14

VTNH

San Diego

Anchorage

Denver

PhoenixDallas

New Orleans

KansasCity

Minneapolis

Detroit

Washington, DC

Newark, NJ

Boston, MA

Houston

Charlotte

Philadelphia

Airports: > 1 million travelersSeaports: >100k travelersLand Borders: >5 million crossings

Tier 1 City - 83

Immigrants:Immigrants:Percent of U.S. PopulationPercent of U.S. Population

0

2

4

6

8

10

12

14

16

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

*Camarota SA January 2001. Center for Immigration Studies

Number of ForeignNumber of Foreign--Born Born Persons Living in the U.S.Persons Living in the U.S.

0

5

10

15

20

25

30

1900 1920 1940 1960 1980 2000Mill

ions

of F

orei

gn-b

orn

Pers

ons

Source: Center for Immigration Studies, 2001

Estimated Annual International Arrivals , U.S.A.Estimated Annual International Arrivals , U.S.A.

International Travelers Foreign 60 M / U.S. 60 M

Immigrants1,000,000

Refugees70-90,000

U.S.-Mexico Border Crossings 400M?

Source: U.S. Department of Homeland Security, 2003 (2002 data)

Status adjusters in U.S.679,305

Immigrants and refugees 411,266

Undocumented migrants ~ 275,000 ????

Non-immigrant visas27,907,139

N= ~ 60 million / Yr

Visitors without visas~ 30,000,000

Annual Estimate Migrants “Entering” U.S.Annual Estimate Migrants “Entering” U.S.

Wor

ld P

opul

atio

n in

bill

ions

(

)

Day

s to

Circ

umna

viga

te (

)

th

e G

lobe

Year1850

0

400

350

300

250

200

150

100

50

2000

0

1900 1950

1

2

3

4

5

6

Speed of Global Travel in Relation toWorld Population Growth

From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994

WHO Report on Infectious Diseases 1999“Removing Obstacles to Healthy Development”

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

Cruise ship passengers 2000:

7 million/year, North America

Grand Princess and U.S. CapitolGrand Princess and U.S. Capitol

The Cruise Ship The Cruise Ship

A unique environment for disease transmission,A unique environment for disease transmission,amplification, and dispersal amplification, and dispersal

Cruise Ship ParadigmCruise Ship Paradigm

Amplification

Dissemination

Convergence

= 500,000 passenger bed-days

Cruise Destinations, 1987

= 500,000 passenger bed-days= New destinations (<500,000 passenger bed-days)

Expanding Cruise Destinations, 1997

AlaskaYukon Territory

British Columbia

Washington

DenaliNational

Park

Arctic Circle

FairbanksFairbanks

AnchorageAnchorage

SewardSeward

DawsonDawsonWhitehorseWhitehorse

TokTokHealyHealy

SitkaSitka KetchikanKetchikan

SkagwaySkagwayJuneauJuneau

VancouverVancouver

SeattleSeattle

ValdezValdez

Alaska Cruise Ship Sailing Routes

Cruise ship routes along coast

National Geographic, Feb. 2002

WHO Report on Infectious Diseases 1999“Removing Obstacles to Healthy Development”

A Decade of Global InfectiousDisease Challenges

Hantavirus pulmonary syndrome (USA)

Plague (India)

Ebola hemorrhagic fever (Zaire)

New variant Creutzfeldt-Jakob disease (UK)

H5N1 influenza (Hong Kong) Vancomycin-intermediate Staphylococcus aureus

(Japan, USA)

Nipah virus encephalitis (Malaysia, Singapore)

1993

1994

1995

1996

1997

1998

A Decade of Global Infectious Disease Challenges (cont.)

West Nile encephalitis (Russia, USA)

Rift Valley fever (Kenya, Saudi Arabia, Yemen) Ebola hemorrhagic fever (Uganda)

Foot and mouth disease (UK)Anthrax (USA)

Vancomycin-resistant S. aureus (USA)

SARS (>25 countries) Monkeypox (Midwestern US)

Avian Influenza (H5N1) (9 Asian countries)

1999

2000

2001

2002

2003

2004

Recent Infectious Threats

Infectious DiseasesNew Public Health Perspective

Infectious disease outbreaks can impact national security and global economy Local outbreaks/problems now recognized as having much wider implicationsRapid and collaborative response essential and expected

“SARS has become the new paradigm for the global havoc that can be produced by emerging infectious diseases.”

Guangdong Province,

China

A

A

Hotel MHong Kong

Chain of transmission among guests at Hotel M—Hong Kong, 2003

B

J

H

C D

E

I

K †

FG †

Hospital 2Hong Kong

H

J

B

Hospital 3 Hong Kong

Hospital 1 HK

Hospital 4 Hong Kong

C D EB

Singapore

United States

I

Vietnam

IrelandK †

Canada

G †

F

A

4 other Hong Kong Hospitals

2 family members

34 HCWs

HCW

Germany

Bangkok

L§

M§

37 HCWs

HCW

0 HCWs

28 HCWs

156 close contacts of HCWs and

patients

4 family members 10 HCWs

37 close contacts

99 HCWs (includes 17 medical students)

4 HCWs*

3 HCWs

HCW

HCW

2 family members

Unknown number

close contacts

2 close contacts

* Health-care workers; † All guests except G and K stayed on the 9th floor of the hotel. Guest G stayed on the 14th floor, and Guest K stayed on the 11th floor; § Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at the hotel during the same times as Guests G, H, and I, who were ill during this period.Data as of March 28, 2003

Isolation* For people who are ill

Quarantine* For people who have been exposed but are not ill

New

swee

k4/

28/0

3

*Measures usually voluntary, but can be mandatory; legal quarantine authority covers “isolation” and “quarantine” tools.

21st Century Quarantine

A collective action for the common good predicated on aiding individuals infected or exposed to infectious agents while protecting others from the dangers of inadvertent exposure

Public good Individual liberties

10 Contact tracing

Early detection& isolation

Home quarantine

Isolate and Contain StrategyIsolate and Contain Strategy

Quarantine Quarantine -- Definition Definition The restriction of movement of a person who has been exposed to The restriction of movement of a person who has been exposed to an infectious disease for a period of time not longer than the lan infectious disease for a period of time not longer than the longest ongest incubation period of the disease to prevent effective contact wiincubation period of the disease to prevent effective contact with th those who have not been exposed to the infective agentthose who have not been exposed to the infective agent

Secondary Cases of SARS by Number of Days to Isolation of the Source Case

Singapore*

*Reported as of April 15, 2003. Available at: http://www.who.int/csr/sars/en/index.html

Range of Responses to SARS at the National, State, and Community Level

Public Health Criteria for Community Response

• Number of cases/exposed• Exposure category

•Known•Travel•Close contact

•Health care-related•Household

•Unknown (unlinked)•Type of transmission

• Generations of transmission• Morbidity and mortality• Ease/ rapidity of spread • Movement in /out of community• Resources• Need urgent public health action• Risk of public panic

No restrictions

•Voluntary general movement restrictions •“Shelter in Place” or “Snow Day”

•Closing of public places•Suspension of public gatherings•Restriction of mass transit schedules

•Compulsory movement/activity restrictions•Curfews on activities•Closing of mass transit •Closing access routes

•Roads, Airports,Seaports•Closing borders

•Border surveillance/monitoring•“SARS checkpoints”•Travel permits

Targeted restrictions•Population-specific

(i.e., congregate settings or group gatherings)

Range of Responses to SARS at Borders

Public Health Criteria for Border Response

• Number of global cases/exposed• Adequacy of global surveillance/control• Volume of travel • Morbidity and mortality• Ease/ rapidity of spread • Characteristics of local outbreaks • Community response levels• Border and local resources• Need urgent public health action• Risk for public panic

• Travel alerts, advisories, press releases• Meet all SARS-affected arriving flights

• Visual inspection• Disembarkation notices• HAN distribution

• Triage ill passengers•Contact follow-up and surveillance

• Intensified arrival screening • Questionnaire• Temperature monitoring• Active registration with local health department• Health certification

• Pre-departure screening

•Restrict departures and flights •Suspend travel and other visa issuance•Quarantine any arrivals from affected areas

•Close borders?

Travel Measures to Prevent Spread1. Pre-departure Screening

2. Suspected SARS Aboard Conveyances3. Disembarkation Notices

David Fitzsimmons, Arizona Daily Star, 4/22/03

Pre-departure Screening:Symptoms

Temperature

Scott Stantis, The Birmingham News, 4/2/03

22 (18.3)120Fever/cough (1)7373 hrs

No. (%) Infected

No. on FlightIllnessAircraftDuration

Olsen SJ, et al. N Engl J Med 2003;349:2416-22.

Distributed to 2.7 million airline passengers; also cruise line and cargo ships, select land borders

Travel Alerts and Advisories for SARS, March–July 2003

Region Advisory Started Advisory Stopped Alert Started Alert Stopped Mainland China 3/13/03 6/17/03 6/17/03 7/3/03 Beijing, China 6/17/03 6/25/03 6/25/03 7/11/03 Taiwan 6/25/03 6/25/03 6/25/03 7/15/03 Hong Kong 5/1/03 6/25/03 6/25/03 7/1/03* Hanoi, Vietnam 3/13/03 4/29/03 4/29/03 5/15/03 Toronto Never had an advisory Never had an advisory 4/23/03

restarted: 5/23/035/20/03 restopped: 7/8/03

Singapore 3/13/03 5/4/03 5/4/03 6/4/03 *This change was posted on 7/9/03, retroactive to 7/1/03.

Documents Viewed from Travelers’ Health Website, 1995-2003

* Includes travel related documents from SARS website

0

5,000,000

10,000,000

15,000,000

20,000,000

1995 1996 1997 1998 1999 2000 2001 2002 2003*

“The summer now is gone”

Himalayan palm civetPaguma larvata

Chinese Ferret-BadgerMelogale moschata

Raccoon-dog Nyctereutes procyonoides

Animal photos courtesy of Dr. Yi GuanHong Kong University, and badgers.org.uk

Science. July 18, 2003

USA

Today 9-8-03

AJC 7-18-04

Avian Influenza H5N1 Activity in Asia*

Infect Dis News March 2004

Infectious Disease Mortality in the U. S., 1900 to 1996

0

200

400

600

800

1000

1900 1920 1940 1960 1980

Year

Mor

talit

y R

ate

per 1

00,0

00

0

20

40

60

80

1970 1980 1990

Source: Armstrong, et al., JAMA ;1999

USAMRIID practices evacuation of contagious patient

The more things change….The more things change….Uganda, 2001Europe, 1350