1. Introduction to Quarantine and the EMS Public Health Role
Danitza Tomianovic, MPH
Assistant Officer in Charge, CDC Miami Quarantine Station
Division of Global Migration & Quarantine (DGMQ)
National Center for the Preparedness, Detection, and Control of Infectious Diseases (NCPDCID)
Centers for Disease Control and Prevention (CDC)

2. Overview Intro to DGMQ Basics of quarantine
Our mission
Basics of quarantine
Definitions
History
Quarantine Station functions
Illness surveillance and response
EMS collaboration
Ongoing activities
Partner Needs Assessment Project
Public Health Preparedness
Summary

3. Department of Health and Human Services (DHHS)
Federal Structure
Department of Health and Human Services (DHHS) ↓
Centers for Disease Control and Prevention (CDC) ↓
Coordinating Center for Infectious Diseases (CCID) ↓
Here is the structure for the location of the Quarantine and Border Health Services Branch within the federal government, starting with the Department of Health and Human Services…
Slide Action:
Click 1– CDC flies in from top
Click 2– CCID flies in from top
Click 3– DGMQ flies in from top
Click 4– QBHSB flies in from top and pulses
Division of Global Migration and Quarantine (DGMQ) ↓
Quarantine and Border Health Services Branch (QBHSB)

4. Quarantine and Border Health Services Branch (QBHSB) Mission
To protect the health of the public from communicable diseases through science, partnerships, and response at U.S. ports
The quarantine stations at our ports of entry are part of CDC’s Quarantine and Border Health Services Branch.
The mission of the Quarantine and Border Health Services Branch is to protect the health of the public from communicable diseases through science, partnerships, and response at U.S. ports.
Our partnership with EMS is invaluable – we included the term, “partnerships” in our mission statement because Quarantine Station personnel rely on the assistance of partner agencies to achieve the mission of protecting the health of the public. In particular, EMS is one of several partners at ports of entry that recognize and notify CDC of public health events.
Photo description: A Quarantine Public Health Officer responds to a call in San Francisco.
Photo credit: Ramesh Krishnamurthy, courtesy of the San Francisco Quarantine Station

5. Quarantine Basics
Definitions
History

6. Definition: 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
Now that you know about some of our functions, it is important to understand the distinction between the terms “isolation” and “quarantine.” The word isolation refers to the separation and restricted movement of ill persons with contagious disease. These persons have symptoms of the infectious disease.
Isolation is often in a hospital setting.
It is usually applied at the individual level, but may be applied to populations.
It is often voluntary, but may be mandatory.
Overall, isolation is a fundamental, commonly used public health practice, especially in healthcare facilities.

7. Definition: 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
In contrast to “isolation,” the word “quarantine” refers to the separation and restriction of movement of well persons (i.e. those without symptoms) presumed to have been exposed to contagion. Quarantine can be accomplished at home or in a residential facility and may be voluntary or mandatory.
Photo Note: Atlanta EMS responding to ill person in quarantine during Atlanta live exercise.
Photo Credit: George Clark

8. History of U.S. Quarantine
Before 1967
Quarantine Inspectors monitored passengers disembarking from aircraft, ships, and across land borders
Large workforce enabled direct inspection, observation, and response
[This slide contains automated animation]
Up until 1967, with a large workforce of Quarantine Inspectors, passengers were visibly screened and examined on board and as they disembarked from aircraft and ships, and crossed land borders. [mouse click] The Quarantine Inspectors looked for symptoms of illness, most notably telltale signs of smallpox infection, other rash illnesses, and jaundice, a yellowing of the skin and whites of the eyes. Passengers would be routed down segregated hallways and processed by U.S. Customs and Immigration agents separately from other arriving passengers.
Photo description: This photo illustrates the visual screening of disembarking passengers by a Quarantine Inspector, highlighted by the red oval.
Photo credit: Courtesy of the National Library of Medicine (reference number A018018)

9. History of U.S. Quarantine, cont.
Reorganization of quarantine station system reduced staff and facilities
Reorientation of quarantine staff roles
2003-present
Newly emerging threats initiated an expansion of quarantine system
Beginning in 1967, the quarantine system underwent a reduction in size and presence at ports of entry. Guided by a new perspective on the threat of communicable diseases (U.S. Public Health thought communicable diseases were no longer a threat), the reorganization of the program generated a reduction in stations and staff, and prompted a revision of quarantine roles and activities. Rather than conducting direct observation of arriving travelers, Quarantine Inspectors shifted to a passive response role, where they relied upon reports from other federal agencies to initiate a response.
The emergence of new illnesses such as SARS and the threat of bioterrorism, combined with an evaluation of the current capacity of the quarantine station system, sparked a revision of operations and an expansion of stations, staff, and resources in 2003.

10. This slide shows major human migration flow patterns during 1960 through 1975.
Source: Population on Action International 1994.

11. By the 1990s, global migration had increased 4-fold since the 1960s and 1970s. Just imagine the increase today where air travel time between any two cities in the world is typically less than 36 hours. Circumnavigation of the globe takes less than 3 days. This is less time than the incubation period of many infectious diseases.
This, in turn, makes our ports of entry even more vulnerable to the introduction, spread, and dissemination of communicable diseases. Because of this, port preparedness planning, surveillance, early detection, and rapid response are essential in containment of infectious diseases. This is where your part of the partnership is especially important to our mission: you are notified of illness more often than quarantine stations are notified, therefore with your help in notifying us, we can respond more rapidly to make a public health assessment and better protect our ports of entry.
Source: Population on Action International 1994.

12. Not to mention the global challenges of emerging infx diseases such as SARS
During this outbreak it became obvious that the Quarantine program can no longer rely on our history, as proud and distinguished as it is, if we wish to continue to play a role in and contribute to the safekeeping of public health in the United States today.
Quarantine stations faced challenges in manpower while responding at ports (visual screening) and contact tracing
Partnerships were important
QS were “rediscovered” as public health partners

13. U.S. Quarantine Program HEW 1953 HHS 2004 HHS 2008 52 seaports
41 airports
17 border stations
33 territory stations
41 U.S. consulates
50 maritime vessels
600 employees
HHS 2004
8 airports
70 employees
HHS 2008
18 airports
2 border stations
~100 employees
In 1953, there were…[read from slide].
Contrast that with 2004 when these numbers were reduced to…[read from slide].
And now in 2007 we are expanding our quarantine system to include…[read from slide].
Note: The Department of Health, Education, and Welfare (HEW) was formed in 1953, and CDC and the Public Health Service became part of this department. HEW became the Department of Health and Human Services (HHS) in 1979.

14. US Average Daily Entry: 1.16 Million (FY06)
1.16M People
Quarantine Stations
326 POEs
681,000 Private vehicle
154 Land
ports
176,000 Bus, Train, Walk
~80 Staff
20 QS
240,000 Airline
113 Airports
44 User air
1.16 million passengers and pedestrians enter the U.S. daily. This includes:
240,000 air passengers at 133 airports, 44 user fee airports;
681,000 travelers that arrive by private vehicle;
and 176,000 people arriving via bus, train, foot, or boat to the 154 land ports.
Maritime cargo is the largest method of trade movement for the U.S.
Source: Slide was modified from DHS CBP June 2007
71,000 Ship
15 Seaports
Source: CBP June 2007

15. CDC Quarantine Stations
2008 Jurisdictions AK ME
Seattle
Minneapolis
Anchorage
Chicago VT NH WA MT ND
Detroit MA
Boston MN NY RI CT CT WI MI
New York OR ID SD PA NJ
Newark WY MD DE IA
Philadelphia OH NE
No.CA IN WV IL NV
Washington, D.C.
San Francisco VA UT CO KS MO KY NC TN
So.CA OK
Dallas SC AR
Atlanta
Los Angeles AZ NM
(Note to presenter: The map with contact list can be printed out as handouts from
To date, there are 326 ports of entry in the United States: 157 airports, 154 land ports, and 15 sea ports. We share 5,000 miles of border with Canada, 1,900 miles of border with Mexico, and have 95,000 miles of shoreline. Keeping this level of operation in mind, there are only 20 quarantine stations, with close to 100 staff at 18 airports and 2 land border crossings.
This map shows the 20 quarantine stations and their corresponding, color-coded jurisdictions, as redefined in Dallas and Philadelphia are our newest stations; they opened in Note that Texas is broken up by county lines; there are three areas that encompass this vast state – North, East, and West Texas, respectively. North Texas is managed by the Dallas station, East Texas is managed by the Houston station, and West Texas is managed by the El Paso station.
Note: If participants would like a copy of this map and contact information, they can locate it on the Internet at:
North TX AL MS GA
San Diego
West TX
East TX LA
El Paso FL
Houston
Miami
Honolulu GU HI PR
San Juan
CDC Quarantine Station

16. Quarantine Station Staff Roles
Officer in Charge (OIC)/ Assistant OIC
Oversees the administration and management of the station
Quarantine Medical Officer (QMO)
Oversees the clinical and medical activities and scientific research
Quarantine Public Health Officer (QPHO)
Handles daily operative functions
U.S. quarantine stations have staff in three types of positions/job categories. [Read from slide]
(Note to presenter: If possible, insert a picture of your quarantine station staff. If you don’t include a photo of the Quarantine Station staff, use this slide as an opportunity to introduce the names of the your staff.)

17. CDC Miami Quarantine Station
Jurisdiction:
State of Florida, Mississippi, Alabama, and Bahamas Pre-clearance port
Located:
Miami International Airport (MIA)
Concourse E, 3rd Floor FIS Area
Staff:
1 ROIC/OIC + 1 AOIC + 1 QMO (in Atlanta) + 3 QPHO’s + 2 Admin Assistants
24-hour Phone Number:

18. Air Transport Assoc. of America
The Quarantine System
Air Transport Assoc. of America
Network
System
Core
Q Stations DGMQ HQ CDC
CBP
EMS
Int. Org. for Migration
State PHAs
Hospitals
Health-care providers
Port officials
USFWS
USDA APHIS
PH labs
Foreign Gov'ts
Courts
Int. Council of Cruise Lines
Canadian/ Mexican Border Authorities
PHAC
DHS
FAA
FBI
State Dept.
WHO
News Media
CSTE
NACCHO
ASTHO
BIDS
APHL
DOT
Media (general)
Int. Civil Aviation Org.
USCG
FBI (local)
LPHAs
Overseas Panel Physicians
USCG (local)
FDA
Source: IOM Report
Relationships among the Quarantine Core System and Network for U.S. Ports of Entry

19. Quarantine Station Functions
Illness Surveillance and Response
EMS Collaboration

20. Quarantine Station Functions
Responding to reports of illnesses on maritime vessels (cruise, cargo), airplanes, and at land border crossings
Performing inspections of animals, cargo, and hand-carried items
Emergency planning and preparedness
Quarantine stations achieve the mission of protecting the public from communicable diseases through a number of activities.
The primary activity of quarantine public health officers is responding to reports of illnesses on ships, aircraft, and at land border crossings.
Quarantine staff inspect hand-carried items, certain animals, and animal products for possible risks to human health.
Quarantine station personnel work closely with other federal agencies, airport authorities, health departments, and other organizations to prepare for public health emergencies, such as pandemic influenza. The training exercise depicted in this photograph is an example of interagency collaboration in preparing for emergency situations. This exercise in Atlanta involved more than 60 different partner groups and accurately reflects the critically important aspect of partnerships in responding effectively to public health threats.
Note: Although the Quarantine Public Health Officer shown here is wearing an N-95 respirator; the use of a respirator is extremely rare. Respirators are almost never worn when boarding an aircraft. More commonly, the officer will provide the patient with a surgical mask to contain respiratory droplets, if necessary.
Photo description: This photo shows a Quarantine Public Health Officer boarding an aircraft during a live action exercise in Atlanta.
Photo credit: George Clark

21. Quarantine Station Functions, cont.
Distributing life-saving immunobiologics and investigational drugs
Providing travelers with essential health information
Quarantine staff also distribute special immunobiologic agents and drugs through the CDC Drug Service, Division of Scientific Resources. These limited supply agents and drugs are distributed only through eight quarantine stations nationally and are used solely for emergency immunobiologic therapy and/or prophylaxis. For example, someone may be suffering from botulism poisoning and CDC can send botulism antitoxin quickly to the health care provider requesting it. EMS may assist with this at some quarantine stations.
Staff also provide travelers with essential health information. CDC’s Travelers’ Health Web site provides detailed health information for international travelers. Public information campaigns around specific issues, such as an illness outbreak, are often conveyed through the use of posters, such as the measles poster for travelers returning from Germany during the 2006 Soccer World Cup.

22. Quarantine Station Functions, cont.
In addition, Travel Health Alert Notices (T-HANs) may be provided. These are small cards distributed to international travelers who may have been exposed to an ill person during travel. The cards provide valuable health information, such as the symptoms of the illness, vaccination, treatment and provide instructions for monitoring health and seeking medical care if select symptoms appear. The image on the slide shows the T-HAN for measles and alerts the traveler that he or she may have been exposed to measles. The backside of the card includes information for doctors who may provide follow-up care for the traveler.

23. Quarantine Station Functions, cont.
Monitoring health and collecting medical information of new
immigrants,
refugees,
asylees, and
parolees
Responding to mass migration emergencies
Eight quarantine stations serve at U.S. ports of entry that receive refugees and asylees. World conflict causes many people to seek refuge in the United States. The quarantine public health officers meet each plane containing refugees, check their temperature, and review their medical paperwork.
(Note to Presenter: If you are one of the 8 QSs that receive refugees, give recent examples of arrivals, such as: Somali refugees arrived from Kenya and Ethiopia, asylees arrived from Iran, etc.)
Quarantine staff also respond to mass migration emergencies. In these situations, staff monitor the health of migrating populations and assist with reviewing and managing the health information as part of their entrance to the United States.
Photo notes/credits:
Somali refugees in Kenya (Photo courtesy of the White House,
Glossary Notes:
Immigrant: An alien admitted to the United States as a lawful permanent resident.
Refugee: Any person who is outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution based on race, religion, nationality, particular social group, or political opinion. Refugees are subject to ceilings by geographic area set annually by the President in consultation with Congress and are eligible to adjust to lawful permanent resident status after 1 year of continuous presence in the United States. (Persons who seek U.S. refugee status must apply for admission to the U.S. Refugee Program while overseas. )
Asylee: Same as a refugee, except that an asylee applies for asylum status either upon arrival at a U.S. port of entry or after entry into the United States. Students, visitors, and other nonimmigrants who fear to return home sometimes have no alternative but to apply for asylum after arrival in the United States.
Parolee: An alien who appears to be inadmissible to the inspecting officer, but are allowed into the United States for urgent humanitarian reasons or when that alien’s entry is determined to be for significant public benefit. Parole does not constitute a formal admission to the United States and confers temporary status only, requiring parolees to leave when the conditions supporting their parole cease to exist.
For a glossary of terms, see: ,

24. Quarantine Station Functions, cont.
Building partnerships for disease surveillance and control
Each quarantine station has very few staff members (some have only one person), so we rely on our partners to serve as our eyes and ears to work with us to protect the health of the public from communicable diseases.
Photo note:
Photo on left, shown here are Danitza Tomianovic and Thomas George, Miami Quarantine Public Health Officers, with a Customs and Border Protection officer.
Photos on right taken during a live action exercise in Atlanta.
Photo credit:
Photo on left taken by David Hunter
Photos on right taken by George Clark

25. Responding to an Ill Traveler on a Conveyance
The captain of a plane, ship, or other conveyance is required by federal law to report any “illness” or death on board to a public health authority (i.e. quarantine station or local health department) prior to arrival at the port of entry.
As mentioned earlier, one of a quarantine station’s many functions is responding to illnesses of public health threat on incoming international conveyances. Our function of responding to reports of illnesses on maritime vessels and airplanes is defined in 42 Code of Federal Regulations Part 71. The regulations to prevent the introduction, transmission, and spread of communicable diseases from foreign countries into the United States are codified in Part 71 of Title 42 of the Code of Federal Regulations. The interstate part is found at Part 70 and addresses illnesses on domestic flights. CFR 42 part mandates that the “master of a ship destined for a U.S. port shall report immediately to the quarantine station at or nearest the port at which the ship will arrive, the occurrence, on board, of any death or any ill person among passengers or crew” during the 15 days before arrival or during the period since departure from a U.S. port.
Photo Credit: Microsoft Clip Gallery

26. International Travelers (42 Code of Federal Regulations Part 71)
Applies to all international travelers: crew and passengers; U.S. citizens and non-U.S. citizens
Definition of “ill person”:
Fever ≥100°F persisting for >48 hours
Fever and certain other symptoms:
Fever ≥100°F AND rash, or
Fever ≥100°F AND swollen glands, or
Fever ≥100°F AND jaundice
Severe diarrhea (with or without fever) OR
The definition of an ill person – which applies to ALL travelers, crew, and passengers, U.S. citizens or non-U.S. citizens – is someone who has fever of greater than or equal to 100 degrees for more than 48 hours OR someone with these specific symptoms:
Fever and rash OR
Fever and swollen glands OR
Fever and jaundice OR
Severe diarrhea (with or without fever)
The list of reportable syndromes is being revised and will be expanded to include respiratory symptoms.
In the case that these symptoms are not easily detected, we look for anyone who appears very sick with fever. We ask EMS to report any traveler, crew, or passenger with any of these symptoms of illness or death to the quarantine station. OR

27. Additional Reportable Syndromes
Current regulations being revised
Proposed regulations will have additional reportable syndromes (“requested” reporting for now)
Fever and any one of the following:
Difficulty breathing or suspected/ confirmed pneumonia
Cough of more than 2 weeks’ duration or cough plus bloody sputum
Headache with neck stiffness
Reduced level of consciousness
Unexplained bleeding
Timeline of new regulations unknown. Currently open for comment.
In addition to previous syndromes also include…

28. Executive Order 13295
Revised List of Quarantinable Communicable Diseases
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)
Severe acute respiratory syndrome (SARS)
Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic
Only in the case of these nine illnesses listed in the Executive Order signed by the President of the United States does CDC have the authority to quarantine. SARS and novel or reemergent influenza viruses, such as avian influenza, are the most recent additions.
CDC Quarantine Station staff has the authority to detain pax/crew for conducting public health assessment. CBP and MDPD are our law enforcement arms in enforcing this authority.
President George W. Bush
April 1, 2005

29. Domestic Travelers (42 Code of Federal Regulations Part 70)
Applies to all domestic travelers: crew and passengers; U.S. citizens and non-U.S. citizens
“Domestic travel”: From any State to a point of destination in any other State; or Between points in the same State
“Ill person”: a case or suspected case of a communicable disease

30. Notification and Response Protocol at POE
Identification
Signs or symptoms indicative of communicable disease
Traveler on international or domestic conveyance
Notification
International traveler: EMS notify CDC Quarantine Station (QS)
Domestic traveler: EMS notify County Health Department
Public Health authorities share notification with EMS
Response
International traveler:
CDC QS staff not on-site communicate by phone and obtain the EMS assessment or CDC QS staff in-person with EMS
In airport settings, the following notification and response protocol is followed:
1. Notification
We receive notification of arriving death or “ill” passenger or crew (defined in 42 CFR Part 71.1) by airline, EMS, or CBP, either before flight landing or after landing. If we receive notification from a partner agency other than EMS, then we will notify EMS, accordingly. 
If we receive notification before landing or disembarkation, we instruct the pilot or lead flight attendant to have everyone remain seated until a public health evaluation can be completed.
2. Response
If CDC quarantine station staff are on site, we will board the aircraft with EMS and conduct a public health assessment after an EMS assessment has been completed. If quarantine station staff are not on site we will obtain the EMS assessment and communicate with EMS by phone.
Photo Note: Chicago Quarantine Public Health Officer (Shannon Bachar) interviewing an ill passenger on board an airplane.
Photo Credit: David Hunter

31. Public Health Information Needed
Medical Information
Signs, symptoms, complaints, history
Itinerary
Method of travel, from where, U.S. entry
Exposure history and demographics
Contact with ill person or livestock or poultry
Travel history in last 10 days
Occupation
Date of Birth, country of residency
Traveler contact information
The notification and response protocol varies based on the port environment. As mentioned before, there are 20 quarantine stations at various locations across the country. There will be times in which we’ll need EMS to complete a public health assessment if quarantine staff are not on site, are unavailable, or if EMS responds first.
The assessment, if done by EMS when quarantine station staff are off-site/unavailable, will be supported by CDC over the phone; we may prompt EMS staff with questions, or ask for specific information when they call. The following information, which differs from the standard information typically collected during an EMS assessment, is needed for effective quarantine station communication and public health assessment:
The demographics and contact information of the ill traveler(s).
The traveler’s itinerary – that is, his or her departure country, intended destination, airline or cruise ship, flight number, seat or cabin number, and their date and time of entry into the United States.
The signs, symptoms and complaints of the ill traveler.
The past medical history and known diagnosis of the ill traveler.
The traveler’s exposure history –
Who’s been in contact with the ill person?
Has this person been in contact with livestock or poultry?
Has this person visited farms or poultry markets?
What does the traveler do – what is their occupation?
What’s the ill person’s travel history in the past 10 days?
(Note to presenter: The goals/purpose of an EMS assessment and a public health assessment are very different. EMS assessments focus solely on life threatening, acute care vs. public health assessments which focus solely on communicable disease suspicion, epidemiology and clinical care/treatment. Inasmuch, the information they normally collect is very different than what we need to conduct our PH assessment.)

32. Health Insurance Portability and Accountability Act (HIPAA)
45 CFR (b)
Allows for disclosure, without individual authorization, protected health information to public health authorities
CDC authorized by law to collect or receive protected health information for:
Preventing or controlling disease, injury, or disability
Reporting of disease, injury, vital events
Conducting public health surveillance, investigations, and interventions
Because we ask EMS to share information with us, it’s important to understand that CDC is covered by HIPAA. The Health Insurance Portability and Accountability Act (HIPPA) governs disclosure of protected health information to public health authorities. CDC quarantine stations are considered public health agencies and therefore can collect protected health information without individual authorization for purposes of prevention and control of disease, surveillance, public health investigations, and interventions.
Note: Examples of vital events: births or deaths.
Note: The Privacy Act of 1974 governs disclosure by federal agencies of certain personally identifiable information on U.S. citizens and lawful permanent residents. The privacy act should be considered prior to action being requested or taken under these operational protocols. Covered agencies may legally disclose for public health purposes protected health information to CDC, which should include disclosures of medical information on persons suspected or known to have a quarantinable disease or other communicable disease constituting a public health threat.

33. CDC Quarantine Station Illness Surveillance and Response Protocol
Goal of CDC Staff : Determine public health risk and appropriate public health action
Three possibilities:
Recommend seeking medical care and/or delay travel until noninfectious 1
Require transfer to Memorandum of Agreement Hospital if quarantinable disease suspected
Require transfer to hospital if quarantinable disease suspected 2
Our goal during surveillance and response is to assist you in determining if the illness is a public health threat and, if so, that appropriate public health actions are taken.
Three possible outcomes follow our assessment:
We recommend that the ill traveler seek medical care and/or delay travel until noninfectious if they have a communicable disease, but not one of the nine quarantinable disease, or
Require the ill traveler to transfer to a Memorandum of Agreement Hospital if they are suspected of having a quarantinable disease, or
The ill traveler may resume travel if desired, if the illness is not a public health threat.
Note: a Memorandum of Agreement Hospital is a hospital that agreed to receive patients with communicable diseases, per the Memorandum of Agreement. EMS may be advised to transport to this type of hospital, but only specific state or local health department personnel and quarantine station Staff know which are MOA hospitals.
Allow travel to continue, if desired 3

34. EMS Role in Illness Surveillance and Response
Identification
Notification
Assist CDC on site and by phone to assess public health risk
Assist with transport
The overall objective of EMS in assisting CDC in illness surveillance and response is to help CDC determine if the traveler’s illness is a public health threat and, if so, to assist in providing immediate response.
EMS typically takes on the following roles:
Notification
Quarantine stations receive reports of illness and death most commonly through EMS and CBP. Because of daily interaction with all travelers, EMS and CBP are the “eyes and ears” for public health issues at our ports of entry.
Assist CDC on-site and by phone to assess public health risks.
EMS assesses traveler based on standard EMS protocol, in addition to conducting a public health assessment (if necessary).
Help transport ill travelers to a specialized hospital or other public health facility.

35. Primary EMS* and Total QARS† Reports, by Quarantine Station, Jan 2006- Sep 2007
Primary EMS Calls
Total Illness
Percent primary EMS
ANC 16
155
10%
ATL 4 78 5%
HNL 3
490 1%
MIA 20
181
11%
SFO
137 3%
IAD 57
JFK 89
BOS 2 38
HOU
103 2%
MSP 1 85
SEA 7 83 8%
Total 65
1496 4%
*Primary EMS is when QS first informed by EMS
† Exclude other information reports
‡ Quarantine Stations not listed had no primary EMS reports

36. Partner Needs Assessment Project Public Health Preparedness
Ongoing Activities:
Partner Needs Assessment Project
Public Health Preparedness

37. Goals of Needs Assessment Project
Build and strengthen relationships with key partners at ports of entry
Develop appropriate training and education content and communication messages
Deliver through preferred and effective formats
A large scale needs assessment project is being done with 10 port partners to address our training and education needs. The goals of the current Needs Assessment Project are:
To build and strengthen relationships with key partners at ports of entry
To develop appropriate training and education content and communication messages
To deliver valuable training through preferred and effective formats
QTET carries out the goals of the needs assessment thru the formation of workgroups, interviews with people involved in training and education, and roundtable discussions and surveys with frontline personnel.

38. Partners (and Audience)
U.S. Customs and Border Protection (CBP)
Airlines
Cruise lines
EMS
Customs Brokers
Border Patrol
U.S. Department of Agriculture (USDA)
U.S. Fish & Wildlife
U.S. Transportation Security Administration (TSA)
This is a list of our needs assessment partners and audiences. Representatives from each agency are part of a workgroup to guide the direction of the needs assessment. We also have a representative from NASEMSO.

39. Needs Assessment Topics
Knowledge, attitudes, and beliefs related to
Health issues
Public health roles
Barriers to fulfilling public health role
Current training related to public health issues
Topics for which staff want training
To position ourselves to be able to build and strengthen relationships as well as develop appropriate training for key partners such as EMS, QTET has been focused on learning more about these specific topics:
Knowledge, attitudes, and beliefs related to:
Health issues
Public health roles – How does EMS feel about taking part in surveillance and response; are there barriers to understanding the role/purpose of public health; is public health a priority?
Barriers to fulfilling public health role – what are those barriers and how can we overcome them?
Current training related to public health issues – what training is required of EMTs; where does this training take place; how often?
Topics for which staff want training – would EMS staff prefer training on specific topics (e.g., TB, malaria, etc); how would these trainings be best delivered (online, in person, at conferences)?

40. Needs Assessment Topics, cont.
Preferred formats for timely and effective communications
Preferred formats for training
Methods used
Frequency
Opportunities to work together
Preferred formats for timely and effective communications – what are the preferred formats for communication; what has proven effective for this audience and what hasn’t?
Preferred formats for training
Methods used – what methods/technologies do EMS staff work well with and/or have access to?
Frequency – how often are EMS staff trained?
Opportunities to work together

41. Roundtable Discussions EMS & CDC Collaborative Meeting
70 participants from EMS and CDC
Presentations and roundtable discussions
Purpose
Strengthen the partnership between CDC and EMS
Identify ways to improve reporting of illnesses to CDC
Identify opportunities to collaborate in training and education
Identify opportunities for sharing data
In July and September, QTET members had the opportunity to get feedback on the job aids that were drafted for the EMS audience. In July, CDC hosted an EMS/CDC Collaborative meeting in Atlanta, Georgia.
There were 70 participants from EMS and CDC present
Presentations and roundtable discussions took place with the purpose of:
Strengthen the partnership between CDC and EMS
Identify ways to improve reporting of illnesses to CDC
Identify opportunities to collaborate in training and education
Identify opportunities for sharing data
The roundtable discussions were very successful.

42. Aircraft Rescue Firefighting Working Group Annual Meeting
Roundtable Discussions
Aircraft Rescue Firefighting Working Group Annual Meeting
~200 attendees from airports around the world
CDC presentation
Roundtable discussions with 10 attendees from international airports
In September, Aircraft Rescue and Fire Fighting Working Group (ARFF) held their annual meeting.
There were around 200 attendees from airports around the world.
CDC presentation on agenda
Roundtable discussions with nine attendees who work in airport settings.

43. Training & Materials Draft EMS Public Health Card
In development
Size of ID card
Consultation with Miami-Dade Fire Rescue
Need for quick assessment of communicable diseases
Need to know triggers for contacting CDC Quarantine Station
Need 24-hour contact telephone number
QTET began drafting training and materials to appropriately address key partners. The EMS Public Health Card is a quick reference job aid developed for EMS staff. Its designed to be the size of an ID card for EMTs, to carry and reference when they are working.
A consultation with Miami-Dade Fire Rescue showed us:
There is a need for materials that will help with the quick assessment of communicable diseases
There is a need to know triggers for contacting CDC Quarantine Station
EMTs still will need contact information, including 24-hour contact telephone number

44. Training & Materials Draft EMS Public Health Card
Front
Back

45. Roundtable Discussion Results
Identified needs for
Clear protocols for responses to public health situations
Job aids to support protocols
Include algorithms and diagrams
Use sticker format instead of card
Training and education (signs and symptoms)
Active outreach by Quarantine Stations
Training opportunities = conferences and certification programs
State Medical Director plays pivotal role

46. Public Health Preparedness
MIA Communicable Disease and Bioterrorism Response Plan
Developed in collaboration with Miami-Dade County Health Department, CBP, Airport Authorities, MD Police Department, MD EMS & Fire rescue, TSA, Red Cross
Surge capacity training for Florida Department of Health employees
Trainings and regular communication with EMS partners

47. Public Health Preparedness, cont.
Full-scale exercise at MIA (2005)
SARS and Smallpox on aircraft
Lead to refining MIA CDR Plan
Tabletop exercise at POM (2005)
Cruise arriving with avian flu and plague
Identified major gaps in resources and surge capacity
Tabletop exercise at MIA (2007)
Avian Influenza on aircraft
Quarantine entire flight
Introduced new pandemic influenza preparedness strategies
We’re hoping a plan similar (mimic) that were doing with airport can be developed in seaport
(97 participants)

48. Public Health Preparedness, cont.
Developing Comprehensive Communicable Disease Response Plans at major Florida POE’s
Miami International Airport (ongoing)
Ft. Lauderdale-Hollywood International Airport
Orlando International Airport
Sanford International Airport
Next steps: seaports
Finalizing Public Information, Media and Communications Plan
Discussions of Pandemic Influenza Planning
Partnerships are essential!
In addition, we’ve been providing input to RCCL and ICCL for dvlpmt of standard industry pan flu plan. Kiren is at WHO meeting with maritime and airport partners, implementation of revised WHO IHR.
Trying to dvelop ed matieral for maritmie on reporting reqrmts. Process developing standards mechinism reporting and repsonse. One is to work with VSP in getting reporting. Exploring mechanisms. If look at illness reponse sheet, formatted to fax. Hope to make electronic perhaps with collaborations with VSP
Revised dear capt leter
If don’t know
(97 participants)

49. Summary
EMS is a vital partner in CDC quarantine station efforts to detect and control communicable disease
Identification, Notification and Response of:
An international ill traveler (crew or passenger) with any symptoms that meet the federal definition of an ill person
A death during international travel
CDC wants to work with EMS to help develop appropriate training and find opportunities for collaboration
In summary, the EMS partnership with CDC quarantine stations is necessary for communicable disease surveillance and control.
Please call your local CDC quarantine station if you become aware of:
An ill traveler (crew or passenger) with any symptoms that meet the federal definition of an ill passenger, or
A recently deceased traveler.

50. More Information Contact CDC Miami Quarantine Station 305-526-2910
Visit
Visit for health information for international travelers
For more information or for area-specific questions, please contact your local quarantine station.
You will also find useful information on CDC’s Quarantine Web site at
In addition, if you are looking for health information for travelers, visit

51. To conclude, the potential for an explosion of a communicable disease is always lurking given our highly mobile global population. Our division and Q stations are in the forefront in preventing the importation, transmission and spread of communicable illnesses from foreign countries into the United States.
We rely on cooperation from EMS in meeting our mission.

52. Questions?