Transcript Quarantine - StudentsPrepAmerica.org

Quarantine
CDC COCA Conference Call
February 2006
Danitza Tomianovic, MPH
Quarantine Public Health Officer
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Global Migration and Quarantine
Miami Quarantine Station
SAFER • HEALTHIER • PEOPLE
Objectives
• 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: 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: 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
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
SAFER • HEALTHIER • PEOPLE
Quarantine
in 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
SAFER • HEALTHIER • PEOPLE
Quarantine:
Statutory 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)
SAFER • HEALTHIER • PEOPLE
Quarantine:
Statutory 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
SAFER • HEALTHIER • PEOPLE
Foreign Quarantine Regulations:
Title 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)
SAFER • HEALTHIER • PEOPLE
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
President George W. Bush
April 1, 2005
SAFER • HEALTHIER • PEOPLE
Interstate Quarantine Regulations:
42 CFR (Code of Federal
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
SAFER • HEALTHIER • PEOPLE
Public Health Service Act, 1944
• Basis for current federal quarantine authority
• Expanded maritime health service
– Public Health Service hospitals
– Health screening of immigrants
– Illness assessment on vessels and aircraft
SAFER • HEALTHIER • PEOPLE
Quarantine Program, 1960s
• Board aircraft
• Review documents
• Monitor illness
SAFER • HEALTHIER • PEOPLE
Quarantine Program
• 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
SAFER • HEALTHIER • PEOPLE
U.S. Quarantine Program
DHEW 1953
DHHS 2004
•
•
•
•
•
•
•
• 8 airports
• 70 employees
52 seaports
41 airports
17 border stations
33 territory stations
41 U.S. consulates
50 maritime vessels
600 employees
SAFER • HEALTHIER • PEOPLE
Major Migration Flows: 1960-75
Source: Population Action International 1994
SAFER • HEALTHIER • PEOPLE
1
Major Migration Flows: 1990s
4 x increase in volume as compared to 1960-75
Source: Population Action International 1994
SAFER • HEALTHIER • PEOPLE
2
SAFER • HEALTHIER • PEOPLE
CDC Quarantine Stations
Anchorage
Seattle
Minneapolis
Boston
Detroit
New York
Newark
Chicago
San Francisco
Washington DC
Los Angeles
San Diego
Atlanta
El Paso
Houston
Miami
Honolulu
San Juan
Operational Stations (18)
SAFER • HEALTHIER • PEOPLE
Functions of CDC Quarantine Station
• 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
SAFER • HEALTHIER • PEOPLE
Functions of CDC Quarantine
Station (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
Principles of
Modern 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
Civil liberties
SAFER • HEALTHIER • PEOPLE
Purpose 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
SAFER • HEALTHIER • PEOPLE
Legal 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
SAFER • HEALTHIER • PEOPLE
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
SAFER • HEALTHIER • PEOPLE
Principles of Community
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 Community
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
SAFER • HEALTHIER • PEOPLE
Principles of Community
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 Community
Containment (4)
Quarantined persons must be among the
first to receive all available diseasepreventing 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 Community
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
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 Community
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
SAFER • HEALTHIER • PEOPLE
Principles of Community
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 Community
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 Community
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
SAFER • HEALTHIER • PEOPLE
Evaluating the Effectiveness
of Quarantine
Key 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
Response
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
SAFER • HEALTHIER • PEOPLE
Question 2: Level of Response
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
SAFER • HEALTHIER • PEOPLE
Question 3: Case Management
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
SAFER • HEALTHIER • PEOPLE
Question 4: Case Management
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
SAFER • HEALTHIER • PEOPLE
Question 5:
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
SAFER • HEALTHIER • PEOPLE
Question 6:
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?
SAFER • HEALTHIER • PEOPLE
Question 7: Community
Containment 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
SAFER • HEALTHIER • PEOPLE
Question 8: Community
Containment 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
SAFER • HEALTHIER • PEOPLE
Question 9: Containment Strategy:
Border and Travel Responses
• 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
SAFER • HEALTHIER • PEOPLE
Quarantine 2003:
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
SAFER • HEALTHIER • PEOPLE
Acknowledgments
• 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
SAFER • HEALTHIER • PEOPLE
SAFER • HEALTHIER • PEOPLE
Questions?
SAFER • HEALTHIER • PEOPLE