QuarantineTM

Quarantine and the Emerging

Influenza Pandemic

Quarantine and the Emerging

Influenza Pandemic

Steven L Harris, MD, MScQuarantine Medical Officer

CDC / Houston Quarantine Station

30 March 2007

Steven L Harris, MD, MScQuarantine Medical Officer

CDC / Houston Quarantine Station

30 March 2007

QuarantineTM

DefinitionsDefinitions

Quarantine• Separation and restriction of movement of well

persons presumed to have been exposed to contagion– often at home or residential facility– may be voluntary or mandatory

Quarantine• Separation and restriction of movement of well

persons presumed to have been exposed to contagion– often at home or residential facility– may be voluntary or mandatory

QuarantineTM

DefinitionsDefinitions

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

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

QuarantineTM

Historic roots of QuarantineHistoric 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

• 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

QuarantineTM

Quarantine in the United StatesQuarantine in the United States

• Quarantine in Colonial America handled locally by each colony – Massachusetts Bay Colony (1647)– Yellow Fever outbreak in Philadelphia (1793)

• Governor declared cordon sanitaire

• National Quarantine Act (1878)– Shift of quarantine powers from state to federal

government

• Public Health Service Act (1944)– Basis for current federal quarantine powers

• Quarantine in Colonial America handled locally by each colony – Massachusetts Bay Colony (1647)– Yellow Fever outbreak in Philadelphia (1793)

• Governor declared cordon sanitaire

• National Quarantine Act (1878)– Shift of quarantine powers from state to federal

government

• Public Health Service Act (1944)– Basis for current federal quarantine powers

QuarantineTM

Purpose of QuarantinePurpose of Quarantine

• Range of community containment strategies for infectious diseases

• Applied to persons exposed but not ill, ie, contacts (not cases)

• Designed to meet two objectives:– Facilitate early recognition of symptoms of a

contagious disease, should they develop– Reduce risk of transmission before progression

to disease has been recognized

• Range of community containment strategies for infectious diseases

• Applied to persons exposed but not ill, ie, contacts (not cases)

• Designed to meet two objectives:– Facilitate early recognition of symptoms of a

contagious disease, should they develop– Reduce risk of transmission before progression

to disease has been recognized

QuarantineTM

Quarantine DichotomyQuarantine Dichotomy

• Quarantine is a “dirty” word– Black Death, yellow fever, Pandemic

influenza– Detention camps equate disease with crime– Stigmatizes victims (e.g., foreign born)– Historical abuses of power

• Quarantine works– Effective tool to prevent spread of contagion– As good or better than other tools in the box

• Quarantine is a “dirty” word– Black Death, yellow fever, Pandemic

influenza– Detention camps equate disease with crime– Stigmatizes victims (e.g., foreign born)– Historical abuses of power

• Quarantine works– Effective tool to prevent spread of contagion– As good or better than other tools in the box

QuarantineTM

Legal AuthorityLegal Authority

• Legal right to take a particular action based on statute, regulation, or other legal precedent

• Important tool, but not a substitute for– Resources– Planning– Communication

• Authority does not necessarily equal policy

• Legal right to take a particular action based on statute, regulation, or other legal precedent

• Important tool, but not a substitute for– Resources– Planning– Communication

• Authority does not necessarily equal policy

QuarantineTM

Quarantine: Statutory AuthorityQuarantine: Statutory Authority

• Intrastate quarantine power – Considered a police power -- an inherent

authority to protect health and welfare of citizens

– Reserved to states (10th Amendment)

– Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border

• Intrastate quarantine power – Considered a police power -- an inherent

authority to protect health and welfare of citizens

– Reserved to states (10th Amendment)

– Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border

QuarantineTM

Interstate Quarantine Regulations: 42 CFR Part 70

Interstate Quarantine Regulations: 42 CFR Part 70

• Report of communicable disease to local health authority

• Provision for Federal travel permit requirement– Written permit for travel from one state to another – Written permit for operators of conveyances– Must comply with applicable state travel permits

• Intrastate federal intervention only if local control inadequate

• Report of communicable disease to local health authority

• Provision for Federal travel permit requirement– Written permit for travel from one state to another – Written permit for operators of conveyances– Must comply with applicable state travel permits

• Intrastate federal intervention only if local control inadequate

QuarantineTM

Quarantine: Statutory AuthorityQuarantine: Statutory Authority

• Foreign and interstate quarantine– Considered essential in regulation of foreign and

interstate commerce– Federal authority (Commerce clause)– Executive decision by the President– CDC manages federal quarantine, with possible

utilization of assets from other agencies– CDC may intervene in intrastate incidents if

requested by state or if local control efforts considered inadequate

• Foreign and interstate quarantine– Considered essential in regulation of foreign and

interstate commerce– Federal authority (Commerce clause)– Executive decision by the President– CDC manages federal quarantine, with possible

utilization of assets from other agencies– CDC may intervene in intrastate incidents if

requested by state or if local control efforts considered inadequate

QuarantineTM

Foreign Quarantine Regulations:42 CFR Part 71

Foreign Quarantine Regulations:42 CFR Part 71

• Reporting of “ill persons” defined by

– Fever (≥100º F or 38º C) persisting ≥48 hours– Fever and rash, glandular swelling, or jaundice– Diarrhea (≥3 stools in 24 hours or greater than normal

amount)

• Medical surveillance of arriving persons • Sanitary measures over inbound carriers, cargo• Quarantine of arriving persons with diseases listed

in the Presidential Executive Order

• Reporting of “ill persons” defined by

– Fever (≥100º F or 38º C) persisting ≥48 hours– Fever and rash, glandular swelling, or jaundice– Diarrhea (≥3 stools in 24 hours or greater than normal

amount)

• Medical surveillance of arriving persons • Sanitary measures over inbound carriers, cargo• Quarantine of arriving persons with diseases listed

in the Presidential Executive Order

QuarantineTM

Executive Order 13295: Revised List of Quarantinable Communicable Diseases 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)

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

(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)

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

President George W. Bush

April 1, 2005

President George W. Bush

April 1, 2005

QuarantineTM

Functions of Quarantine StationsFunctions of Quarantine Stations

• Respond to reports of illnesses on cruise ships, cargo ships, and airplanes

• Inspect animal and human products posing threat to human health

• Monitor health and collect, distribute, and manage medical information for new immigrants, refugees, and parolees

• Respond to reports of illnesses on cruise ships, cargo ships, and airplanes

• Inspect animal and human products posing threat to human health

• Monitor health and collect, distribute, and manage medical information for new immigrants, refugees, and parolees

QuarantineTM

Functions of Quarantine StationsFunctions of Quarantine Stations

• Inspect cargo and hand-carried items for potential vectors of human infectious diseases

• Distribute immunobiologics and investigational drugs

• Provide travelers with essential health information

• Respond to migration emergencies• Planning for emergency response

• Inspect cargo and hand-carried items for potential vectors of human infectious diseases

• Distribute immunobiologics and investigational drugs

• Provide travelers with essential health information

• Respond to migration emergencies• Planning for emergency response

QuarantineTM

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

Jurisdictions of CDC Quarantine StationsJurisdictions of CDC Quarantine Stations

DE

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 Quarantine Station

QuarantineTM

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

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 QuarantinePrinciples of Modern Quarantine

QuarantineTM

• Without intervention, expect international spread in one month and U.S. cases in 1 - 2 months

• Failed containment may still delay international spread by one month

• Severe travel restrictions may delay U.S. cases by 1 - 4 weeks

• Without intervention, expect international spread in one month and U.S. cases in 1 - 2 months

• Failed containment may still delay international spread by one month

• Severe travel restrictions may delay U.S. cases by 1 - 4 weeks

U. S. planning assumptionsU. S. planning assumptions

QuarantineTM

Non-pharmaceutical interventionsNon-pharmaceutical interventions

• Depend on virus transmission characteristics and illness severity

• Measures at borders (international or within countries) - limited early focus, phase 5-6a Health alert notices Entry screening of international travelers Exit screening from affected countries is

recommended, especially if most countries not yet affected

• Depend on virus transmission characteristics and illness severity

• Measures at borders (international or within countries) - limited early focus, phase 5-6a Health alert notices Entry screening of international travelers Exit screening from affected countries is

recommended, especially if most countries not yet affected

QuarantineTM

Layered interventionsLayered interventions↓ cases↑ household & community transmission

↓ cases↑ household & community transmission

Close schoolsClose schools

Household (HH)quarantineHousehold (HH)quarantine

↓ cases↑ relative importance of workplace & community

↓ cases↑ relative importance of workplace & community

Socialdistancing

Socialdistancing ↓ cases↓ cases

Keep kids homeKeep kids home↓ HH & community transmission↑ relative importance of HH & workplace transmission

↓ HH & community transmission↑ relative importance of HH & workplace transmission

QuarantineTM

Potential tools in our toolboxPotential tools in our toolbox

• Our best countermeasure – vaccine – will probably be unavailable during the first wave of a pandemic

• Anti-viral treatment may improve outcomes but will have only modest effects on transmission

• Anti-viral prophylaxis may have more substantial effects on reducing transmission

• Infection control and social distancing should reduce transmission, but strategy requires clarification

• Our best countermeasure – vaccine – will probably be unavailable during the first wave of a pandemic

• Anti-viral treatment may improve outcomes but will have only modest effects on transmission

• Anti-viral prophylaxis may have more substantial effects on reducing transmission

• Infection control and social distancing should reduce transmission, but strategy requires clarification

QuarantineTM

Considerations for a decision to quarantineConsiderations for a 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

• 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: 286, 21: 2711-2717

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Containment measures are appropriate when:• A person or group of people has been exposed to a

highly dangerous and contagious disease• Exposed well-persons are separated from ill cases• Resources are available to implement and support

interventions– Provide essential goods and services– Monitor health status (active vs. passive)– Provide immediate triage & medical care/isolation

Containment measures are appropriate when:• A person or group of people has been exposed to a

highly dangerous and contagious disease• Exposed well-persons are separated from ill cases• Resources are available to implement and support

interventions– Provide essential goods and services– Monitor health status (active vs. passive)– Provide immediate triage & medical care/isolation

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Containment measures encompass a range of strategies:• “Snow days” or “shelter-in-place”• Suspension or restrictions on group assembly• Cancellation of public events• Closure of mass public transit• Closing of public places • Restriction or scaling back of nonessential travel • Cordon sanitaire

Containment measures encompass a range of strategies:• “Snow days” or “shelter-in-place”• Suspension or restrictions on group assembly• Cancellation of public events• Closure of mass public transit• Closing of public places • Restriction or scaling back of nonessential travel • Cordon sanitaire

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Containment measures are used in

combination with other interventions:• Enhanced disease surveillance and symptom

monitoring

• Rapid diagnosis and treatment for those who become ill

• Primary and secondary prevention interventions, including vaccination or prophylactic antibiotics, PPE

Containment measures are used in

combination with other interventions:• Enhanced disease surveillance and symptom

monitoring

• Rapid diagnosis and treatment for those who become ill

• Primary and secondary prevention interventions, including vaccination or prophylactic antibiotics, PPE

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Quarantined persons must be among the

first to receive all available disease

prevention interventions• Vaccination (eg, smallpox)• Antibiotics (eg, plague)• Early, rapid diagnostic testing and symptom

monitoring• Early treatment if symptoms appear

Quarantined persons must be among the

first to receive all available disease

prevention interventions• Vaccination (eg, smallpox)• Antibiotics (eg, plague)• Early, rapid diagnostic testing and symptom

monitoring• Early treatment if symptoms appear

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

• Modern quarantine lasts only as long as necessary to ensure that quarantined persons do not become ill

• Maximum quarantine duration related to the incubation period of disease

• “Due process” rights for those subjected to quarantine restrictions

• Modern quarantine lasts only as long as necessary to ensure that quarantined persons do not become ill

• Maximum quarantine duration related to the incubation period of disease

• “Due process” rights for those subjected to quarantine restrictions

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Modern quarantine does not have to be

absolute to be effective

• Even partial or “leaky” quarantine can reduce disease spread

• Partial quarantine can be an effective supplement to vaccination

Modern quarantine does not have to be

absolute to be effective

• Even partial or “leaky” quarantine can reduce disease spread

• Partial quarantine can be an effective supplement to vaccination

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Implementation of containment measures requires:– A clear understanding of public health

roles at local, state, and federal levels

– Cooperation between public and private health-care sectors

– Well-understood legal authorities at each level

Implementation of containment measures requires:– A clear understanding of public health

roles at local, state, and federal levels

– Cooperation between public and private health-care sectors

– Well-understood legal authorities at each level

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

Implementation of containment measures requires coordinated planning by many partners:

• Public health practitioners• Health-care providers/facilities• Transportation authorities• Emergency response teams• Law enforcement• Security/Credentialing personnel

Implementation of containment measures requires coordinated planning by many partners:

• Public health practitioners• Health-care providers/facilities• Transportation authorities• Emergency response teams• Law enforcement• Security/Credentialing personnel

QuarantineTM

Principles of Community ContainmentPrinciples of Community Containment

To achieve trust and cooperation, the

public must be informed of• The dangers of “quarantinable” infectious

diseases before an outbreak occurs

• The justifications for quarantine when outbreak is in progress

• Anticipated duration and endpoints of control measures

To achieve trust and cooperation, the

public must be informed of• The dangers of “quarantinable” infectious

diseases before an outbreak occurs

• The justifications for quarantine when outbreak is in progress

• Anticipated duration and endpoints of control measures

QuarantineTM

Quarantine: Lessons learnedQuarantine: Lessons learned

• Clear messages about need for quarantine increased public acceptance

• Quarantine can be voluntary

• Mental health support is a critical need for those in quarantine

• Implementation of large-scale quarantine is complex and resource-intensive

• Clear messages about need for quarantine increased public acceptance

• Quarantine can be voluntary

• Mental health support is a critical need for those in quarantine

• Implementation of large-scale quarantine is complex and resource-intensive

QuarantineTM

http://www.pandemicflu.gov/plan/community/commitigation.html