Transcript Quarantine and the E.. - Texas Society of Infection Control

Quarantine
and the Emerging
Influenza Pandemic
Steven L Harris, MD, MSc
Quarantine Medical Officer
CDC / Houston Quarantine Station
30 March 2007
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Quarantine
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
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Quarantine
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
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Quarantine
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
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Quarantine
Quarantine 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
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Quarantine
Purpose 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
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Quarantine
Quarantine 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
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Quarantine
Legal 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
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Quarantine
Quarantine: 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
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Quarantine
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
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Quarantine
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
– 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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Quarantine
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
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Quarantine
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
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Quarantine
Functions 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
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Quarantine
Functions 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
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Quarantine
Jurisdictions of CDC Quarantine Stations
AK
ME
Minneapolis
Seattle
Anchorage
Chicago
WA
ND
MT
ID
NY
MI
WI
WY
No.CA
IN
IL
UT
CO
WV
VA
KY
MO
KS
OK
AZ
Los Angeles
Washington D.C.
NC
TN
So.CA
DE
OH
NV
San Francisco
New York
Newark
MD
IA
NE
Boston
CT RI
NJ
PA
SD
NH
MA
Detroit
MN
OR
VT
SC
AR
Atlanta
NM
AL
MS
GA
San Diego
El Paso
West TX
East TX
LA
FL
Houston
Honolulu
Miami
San Juan
HI
PR
GU
CDC Quarantine Station
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Quarantine
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
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Quarantine
U. S. planning assumptions
• 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
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Quarantine
Non-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
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Quarantine
Layered interventions
Close schools
Keep kids home
Household (HH)
quarantine
Social
distancing
↓ cases
↑ household & community
transmission
↓ HH & community transmission
↑ relative importance of
HH & workplace transmission
↓ cases
↑ relative importance of
workplace & community
↓ cases
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Quarantine
Potential 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
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Quarantine
Considerations 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
JAMA, Dec 5, 2001: 286, 21: 2711-2717
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Quarantine
Principles 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
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Quarantine
Principles of Community Containment
Containment measures encompass a range
of strategies:
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“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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Quarantine
Principles 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
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Quarantine
Principles 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
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Quarantine
Principles 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
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Quarantine
Principles 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
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Quarantine
Principles 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
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Quarantine
Principles of Community Containment
Implementation of containment
measures requires coordinated
planning by many partners:
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Public health practitioners
Health-care providers/facilities
Transportation authorities
Emergency response teams
Law enforcement
Security/Credentialing personnel
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Quarantine
Principles 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
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Quarantine
Quarantine: 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
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Quarantine
http://www.pandemicflu.gov/
plan/community/commitigati
on.html
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Quarantine