Quarantine Stations At Ports of Entry Protecting The Public’s Health

Global Health Security: Public Health Interventions at Ports-of-Entry

Center for Science Technology & Security Policy

American Association for the Advancement of Science &

U.S. House of Representatives Committee on Homeland Security

Georges C. Benjamin, MD, FACP,FACEP(E)Executive Director

American Public Health AssociationJuly 23, 2007

At the Gates – Our Safety Depends On Eternal Vigilance

Historic Roots of Quarantine

Biblical accounts of quarantine practices for persons with leprosy

Epidemic plague in 14th C. Europe had profound impact on commerce 1485: Venice established 40-day (Lat. Quadragina)

harbor detention, i.e., quarantine 1626: First Quarantine Station, Marseille The Quarantine Flag: Became the “Q” flag in the

international maritime code of flag signals Quarantine in Colonial America (17th C.) handled locally by

each colony 1647- Massachusetts Bay Colony (Plague) 1796 - Congress pass law allowing Feds to help states 1798 - Yellow Fever Outbreak in Philadelphia: Governor

declared cordon sanitaire

Public Health Service Act, 1944 (42 USC §§201)

Basis for current federal quarantine authority Expanded maritime health service (55 stations and 500+ staff)

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

Quarantine Program, 1960s

Board aircraft Review documents Monitor illness Quarantine stations to CDC,

1967

“The war against infectious diseases has been won” - WH Stewart, US Surgeon General, 1969

Functions of CDC Quarantine Station

Respond to reports of illnesses on maritime vessels (cruise & cargo) & airplanes

Emergency planning and preparedness

Inspecting animal & human products posing threat to human health

Monitoring health, and collecting, distributing and managing medical information of new immigrants, refugees & parolees

Functions of CDC Quarantine Stations

Perform inspections of cargo & hand-carried items for potential vectors of human infectious diseases

Distribute immunobiologics & investigational drugs

Provide travelers with essential health information

Respond to mass migration emergencies

Overarching Vision

Washington Post

U.S. to Triple Airport Quarantine Stations

Health Program Aims to Prevent Infectious Diseases From Entering Country

By Justin GillisWashington Post Staff WriterSunday, August 28, 2005; A16

The government plans to more than triple the number of quarantine stations at airports around the country an d hire scores of health officers as part of a broad plan to try to stop deadly infectious diseases from entering the United States. Ten new stations, at airports stretching from Alaska to Puerto Rico, are already open or nearing completion, and about 50 new health officers are undergoing training.

The Centers for Disease Control and Prevention plans to build an additional seven stations as soon as it can get the money. Eight stations that have existed for years are gaining staff, so that when the plan is complete, the country will be blanketed by a network of 25 centers designed as a first-line of defense against a global disease pandemic.

From Inspection to Strategic Leadership

Quarantine Core System & 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

The Central Challenge

Ports of entry52 seaports

41 airports

17 border stations

33 territory stations

41 U.S. consulates

~474 Plane

Boat

Boarder crossing

People entering US Few million 425 million (CY2005)

Number of

Q Stations

Over 55 stations

600 people

20 stations*

133 people

Infectious Diseases No bioterrorism > 40 new ones since 1973 & bioterrorism

1953 (DHEW) 2007 (HHS/CDC)

*Was 8 stations & 40 people in 2005

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

Number of Persons Entering the United States, 2005

Port Daily Annual (millions)

Air 219,000 80

Sea 71,000 26

Land 874,000 319

Total 1,164,000 425

Source: Securing America’s Borders at Ports of Entry;Office of Field Operations Strategic Plan FY 2007-2011;Customs and Border Protection. Accessed at: www.cbp.gov

IOM Statement of Task Assess the role of federal quarantine stations in light

of the emerging new environment for 21st Century

Look at the current role of quarantine stations and how they should evolve

Evaluate the role of other agencies and organizations that work in collaboration with the CDC’s DGMQ

Assess role of state & local health departments

Evaluate optimal locations for the quarantine stations

Recommend the appropriate types of health professionals and necessary skill sets for staffing

Address surge capacity to respond to public health emergencies

Seven Recommendations

1. Strategic Leadership

2. Harmonization of Authorities & functions

3. Infrastructure

4. Location of stations

5. Surge capacity

6. Research

7. Measuring performance

VT

ME

MANY

PA

NH

WV

VA

MD

NJ

RICT

AZ

IN

WI

KY

MI

OHIA

MN

MO

ILNE

KS

SD

ND

AL

TN

GA

SC

NC

AR

LA

MS

OK

AtlantaAtlanta

ChicagoChicagoSeattleSeattle

WY

ID

WA

AK

OR

MT

NVUT

NM

CO

East TX

MiamiMiami

FL

No.CA

So.CA

Los AngelesLos Angeles

San FranciscoSan Francisco

CDC Quarantine Stations & Jurisdictions*, 2007

HI

HonoluluHonolulu

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

El PasoEl Paso

HoustonHouston

NewarkNewark

New YorkNew York

BostonBoston

GU San JuanSan Juan

MinneapolisMinneapolis

DetroitDetroit

AnchorageAnchorage

San DiegoSan Diego

West TX

PR

CDC Station

PhiladelphiaPhiladelphia

DallasDallas

DEDE

*Note: Regional jurisdictions have not been finalized

Quarantinable & Other Communicable Illness of Public Health Significance*

Communicable diseases specified in Executive Orders of the President Recommendation of the Secretary HHS Revised on April 4, 2003 (Exec. Order 13295)

• Cholera or suspected cholera, diphtheria, infectious tuberculosis, plague, suspected smallpox, yellow fever, suspected viral hemorrhagic fevers, severe acute respiratory syndrome, novel influenza virus (pandemic potential)

Public Health Significance* Malaria, typhoid, varicella, rabies, meningococcal,

legionellosis, dengue, measles, polio, zoonotic poxvirus, pertussis, mumps, rubella, infectious diarrhea

* Based on potential to a) cause significant morbidity and spread within the US; b) spread among passengers; c) be controlled by pharmaceutical and/or non-pharmaceutical interventions.

Disease Detection / Surveillance

Pre-arrival Detectors passengers, crew, medical personnel, others Surveillance data or specific information from sources

At time of arrival Customs and Border Protection, quarantine station staff,

emergency responders, other airport partners, others Medical records, obvious illness, deaths, technology like

fever screeners (Under evaluation), experience, risk based screens, others

Post-arrival Off-site providers, state and local public health, others Post arrival illness or deaths

Vary by Port and Conveyance; Air, Sea, Land

Surveillance at Ports of Entry, Conceptual Framework

All illness at port of entry

Quarantinable & Illness of public health significance

Illness detected by surveillance

Underdeveloped Detection Opportunity

Pre-departure evaluations State Department & HHS Thousands of individuals

involved Review of any required

medical immigration forms Best opportunity to detect

disease Big gap here

Significant occurrence of disease

Social Distancing Strategies

Voluntary home curfew

Suspend group activity

Cancel public events

Close public places

Suspend public travel

Restrict travel

Snow days

Non-essential workers off

Work quarantine

Cordon sanitaire

IsolationSeparation of infected persons

Usually in a hospital setting (Other settings may be difficult)

QuarantineRestriction of persons presumed exposed

Community or individual level

Disease Control by Quarantine or Isolation

Voluntary or legally compelled action

Isolation Separation of infected persons Usually in a hospital setting

(Other settings may be difficult) Quarantine

Restriction of persons presumed exposed

Usually at community or population level

Designed to meet two objectives

Facilitate early recognition of symptoms of a contagious disease, should they develop

Reduce risk of transmission before progression to disease has been recognized

Cordon Sanitaire (a.k.a. geographic quarantine)

Sanitary barrier erected around an area

Purpose is to control communicable disease

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

Public good Civil liberties

Principles of Modern Quarantine

Key Questions before Decision to Quarantine

Is there public health and medical justification? Infectious agent, communicability, risk of fatality

Are implementation and maintenance of quarantine feasible? Define who is to be quarantined and for how long, and

availability of resources

Do potential benefits of quarantine outweigh adverse consequences? Determine health risks for those quarantined,

consequences of quarantine disobedience, and effect on commerce

JAMA, Dec 5,2001-vol 286, No 21:2711-2717

Plan To Care For Sequestered Persons

Food & Water

Housing

Hygiene & sanitation

Social support systems

Treatment & prophylaxis for disease

Disease monitoring

Dependent care

Compensation & liability issues

Quarantine Stations At Ports of Entry Protecting The Public’s Health

Georges C. Benjamin, MD,FACP, FACEP(E)Executive Director

American Public Health Association

“Protect, Prevent, Live Well”