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SAFER • HEALTHIER • PEOPLE
QuarantineQuarantine
CDC COCA Conference CallFebruary 2006
Danitza Tomianovic, MPHQuarantine Public Health Officer
Centers for Disease Control and PreventionNational Center for Infectious Diseases
Division of Global Migration and QuarantineMiami Quarantine Station
SAFER • HEALTHIER • PEOPLE
ObjectivesObjectives• Basics of quarantine
– Definitions– History– Legal basis and authority
• Functions of U.S quarantine stations
• Principles of modern quarantine as containment measure
SAFER • HEALTHIER • PEOPLE
SAFER • HEALTHIER • PEOPLE
Definitions: QuarantineDefinitions: 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
SAFER • HEALTHIER • PEOPLE
Definitions: IsolationDefinitions: 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
SAFER • HEALTHIER • PEOPLE
Historic Roots of Historic Roots of QuarantineQuarantine
• 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
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Quarantine Quarantine in the United Statesin the United States
• Quarantine in Colonial America (17th C.) handled locally by each colony – 1647--Massachusetts Bay Colony– 1798--Yellow Fever Outbreak in
Philadelphia
•Governor declared cordon sanitaire
• 1878: National Quarantine Act – Shift of quarantine powers from state to
federal government• 1944: Public Health Service Act: Basis for
current federal quarantine powers
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Quarantine: Quarantine: Statutory AuthorityStatutory Authority
• Intrastate quarantine power – Local or state public health officials
have authority for quarantine when an infectious disease outbreak confined within state border
– Considered a police power-- an inherent authority to protect health and welfare of citizens
– Reserved to states (10th Amendment)
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Quarantine: Quarantine: Statutory AuthorityStatutory Authority
• Foreign and interstate quarantine– Considered essential in regulation of
foreign and interstate commerce– Federal authority (Commerce clause)– Executive decision by the President of U.S.– 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
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Foreign Quarantine Foreign Quarantine Regulations:Regulations:
Title 42 CFR Part 71Title 42 CFR Part 71 • Reporting of “ill persons” defined by
– Fever (≥100º F or 38º C) persisting ≥48 hours and
– Rash or glandular swelling, or jaundice or– 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 Executive Order signed by the President)
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Executive Order 13295: Revised List Of Executive Order 13295: Revised List Of Quarantinable Communicable DiseasesQuarantinable 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 pandemicPresident George W. Bush
April 1, 2005
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Interstate Quarantine Interstate Quarantine Regulations: 42 CFR (Code of Regulations: 42 CFR (Code of Federal Regulations) Part 70Federal Regulations) 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 • Intrastate federal intervention only if
local control inadequate
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Public Health Service Act, Public Health Service Act, 19441944
• Basis for current federal quarantine authority• Expanded maritime health service
– Public Health Service hospitals – Health screening of immigrants– Illness assessment on vessels and aircraft
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Quarantine Program, Quarantine Program, 1960s1960s
• Board aircraft• Review documents• Monitor illness
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Quarantine Quarantine ProgramProgram
• 1970s – Smallpox eradicated; less fear of infectious
disease– Smaller stations closed– Oversee refugee screening
• 1980s– Mass migration emergencies– Health information for international travel– Distribute emergency immunobiologics
• 1990s– Cholera, Plague, Ebola– Refugee arrivals
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U.S. Quarantine U.S. Quarantine ProgramProgram
DHEW 1953• 52 seaports• 41 airports• 17 border stations• 33 territory stations• 41 U.S. consulates• 50 maritime vessels• 600 employees
DHHS 2004• 8 airports• 70
employees
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11Source: Population Action International 1994
Major Migration Flows: 1960-75
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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
SAFER • HEALTHIER • PEOPLE
SAFER • HEALTHIER • PEOPLE
CDC Quarantine StationsCDC Quarantine Stations
Honolulu
San Francisco
Los Angeles
San Diego
SeattleAnchorage
El Paso Houston
Atlanta
Miami
San Juan
Minneapolis
Chicago
Detroit
Boston
New York
Newark
Washington DC
Operational Stations (18)
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Functions of CDC Quarantine Functions of CDC Quarantine StationStation
• Responding to reports of illnesses on maritime vessels (cruise and cargo) and airplanes
• Emergency planning and preparedness
• Inspecting animal and human products posing threat to human health
• Monitoring health, and collecting, distributing and managing medical information of new immigrants, refugees, and parolees
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Functions of CDC Functions of CDC Quarantine Station Quarantine Station
(continued)(continued) • Performing inspections of cargo
and hand-carried items for potential vectors of human infectious diseases
• Distributing immunobiologics and investigational drugs
• Providing travelers with essential health information
• Responding to mass migration emergencies
SAFER • HEALTHIER • PEOPLE
SAFER • HEALTHIER • PEOPLE
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 Principles of Modern QuarantineModern Quarantine
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Purpose of QuarantinePurpose of Quarantine
• Range of community containment strategies for infectious diseases
• Applied to persons exposed but not ill, i.e., 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
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Legal AuthorityLegal Authority
• Legal right to take a particular action based on statute, regulation, or other legal precedent
• Authority does not necessarily equal policy
• Important tool, but not a substitute for– Resources– Planning– Communication
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Key Questions before Key Questions before Decision to QuarantineDecision 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
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Principles of Principles of Community Community
Containment (1)Containment (1)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
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (2)Containment (2)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
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Principles of Principles of Community Community
Containment (3)Containment (3)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 preventive
interventions, including vaccination or prophylactic antibiotics, PPE
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (4)Containment (4)Quarantined persons must be among
the first to receive all available disease-preventing interventions• Vaccination (e.g., smallpox)• Antibiotics (e.g., plague)• Early, rapid diagnostic testing and
symptom monitoring• Early treatment if symptoms appear
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (5)Containment (5)• 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
SAFER • HEALTHIER • PEOPLE
Principles of Community Principles of Community Containment (6)Containment (6)
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
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (7)Containment (7)Containment measures are more likely
to be applied to small numbers of
exposed persons in focused settings:
– Exposed persons on conveyance containing ill passenger(s)
– Exposed persons in a theater where an intentional release has been announced
– Close contact with a case
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Principles of Community Principles of Community Containment (8)Containment (8)
Implementation of containment measures requires:– A clear understanding of public
health roles at local, state, and federal levels
– Well-understood legal authorities at each level
– Cooperation between public and private health-care sectors
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (9)Containment (9)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
SAFER • HEALTHIER • PEOPLE
Principles of Principles of Community Community
Containment (10)Containment (10)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
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Evaluating the Evaluating the Effectiveness of Effectiveness of
QuarantineQuarantineKey Questions:
• Was quarantine applied to the appropriate population? (efficiency)
• Did use of quarantine limit progression of the outbreak? (efficacy)
• Was the implementation of quarantine humane?
SAFER • HEALTHIER • PEOPLE
SAFER • HEALTHIER • PEOPLE
Question 1: Elements of Question 1: Elements of ResponseResponse
What were the elements of response to SARS containment? Was quarantine used alone?
• Elements of SARS containment:– Case management– Contact management– Hospital/facility infection control– Community containment such as
quarantine•Border responses
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Question 2: Level of Question 2: Level of ResponseResponse
What were deciding factors for the levels of containment response?
• Two levels of response: Basic and enhanced response, depending on:– Magnitude and scope of outbreak– Pattern of transmission– Resources available for response– Community cooperation and trust
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Question 3: Case Question 3: Case ManagementManagement
What is correct term for separation of cases? What were some basic methods of isolation (during
minimal community transmission or fatality)?
• Isolation• Home isolation
–Suitable for providing adequate care–Adequate infection control measures possible
• Hospital isolation if medically necessary
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Question 4: Case Question 4: Case ManagementManagement
What were some possible enhanced methods of isolation for cases (if greater community transmission occurred)?
• Community-based facility isolation– Facility must meet patient care and
infection control requirements
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Question 5: Question 5: Contact Management Contact Management
What is the correct term for separation of those who are contacts? What were some basic activities in contact management in the U.S?
• Quarantine• Monitoring without activity restrictions
–Assessment for signs and symptoms in well person(s) exposed to a contagious disease
–Passive or active
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Question 6: Question 6: Contact Management Contact Management
• Describe some of the enhanced activities for restriction of movement of contacts in Canada and Asia– Home quarantine– Working quarantine– Facility-based quarantine
• What was monitored daily in those under quarantine?– Clinical monitoring (Fever and respiratory
symptoms)• Duration of quarantine?
– Quarantine should not be longer than incubation period (for SARS, 10 days from exposure)
• What resources need to be provided to those in quarantine?
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Question 7: Community Question 7: Community Containment measuresContainment measures
Discuss some basic activities of community containment measures utilized around the world?
• Public information and education• Promote “respiratory hygiene” and hand washing
Describe some enhanced activities of community
containment in Canada and Asia?
• Cordon sanitaire• Widespread community quarantine• Measures to increase social distance
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Question 8: Community Question 8: Community Containment MeasureContainment Measure
What are ways to increase social distance?
• Implement “Snow Day” restrictions– Close schools, day-care centers, etc.– Cancel large public gatherings (concerts,
theaters)– Minimize other exposures (markets,
churches, public transit)• Other measures
– Distribution of surgical masks– Temperature screening in public venues– Scaling back transportation services
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Question 9: Containment Question 9: Containment Strategy: Border and Travel Strategy: Border and Travel
ResponsesResponses • Describe some basic activities towards
border and travel response in the U.S?– Travel advisories and alerts– Distribution of health alert notices– Visual inspection of passengers from SARS-
affected areas– Responding to ill passengers
• Enhanced activities would have included…?– Pre-departure and arrival screening – Quarantine of travelers from areas with SARS– Restriction of nonessential travel
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Quarantine 2003: Quarantine 2003: Lessons LearnedLessons 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
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AcknowledgmentsAcknowledgments
• Division of Global and Migration and Quarantine– Marty Cetron, MD, Chief, Division of Global
Migration and Quarantine– Ram Koppaka, MD, PhD, Acting Branch Chief,
Quarantine and Border Health Services– Marty Remis: Deputy Branch Chief,
Quarantine and Border Health Services
• CDC Miami Quarantine Staff
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SAFER • HEALTHIER • PEOPLE
Questions?Questions?