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”