1. Quarantine TM Quarantine and the Emerging Influenza Pandemic Steven L Harris, MD, MSc Quarantine Medical Officer CDC / Houston Quarantine Station 30 March 2007 Steven L Harris, MD, MSc Quarantine Medical Officer CDC / Houston Quarantine Station 30 March 2007

2. Quarantine TM 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 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

3. Quarantine TM 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 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

4. Quarantine TM 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 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

5. Quarantine TM 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 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

6. Quarantine TM 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 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

7. Quarantine TM 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 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

8. Quarantine TM 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 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

9. Quarantine TM Quarantine: Statutory Authority Intrastate quarantine power –Considered a police power -- an inherent authority to protect health and welfare of citizens –Reserved to states (10 th Amendment) –Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border Intrastate quarantine power –Considered a police power -- an inherent authority to protect health and welfare of citizens –Reserved to states (10 th Amendment) –Local or state public health officials have authority for quarantine when an infectious disease outbreak confined within state border

10. Quarantine TM 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 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

11. Quarantine TM 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 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

12. Quarantine TM Foreign Quarantine Regulations: 42 CFR Part 71 Reporting of “ ill persons ” defined by –Fever (≥100 º F or 38 º 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 Reporting of “ ill persons ” defined by –Fever (≥100 º F or 38 º 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

13. Quarantine TM Executive Order 13295: Revised List of Quarantinable Communicable Diseases 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 (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 President George W. Bush April 1, 2005

14. Quarantine TM 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 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

15. Quarantine TM 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 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

16. Quarantine TM VT ME MA NY PA NH WV VA MD NJ RI CT AZ IN WI KY MI OH IA MN MO IL NE KS SD ND AL TN GA SC NC AR LA MS OK Atlanta Chicago Seattle WY ID WA AK OR MT NV UT NM CO East TX Miami FL No.CA So.CA Los Angeles San Francisco Jurisdictions of CDC Quarantine Stations DE HI Honolulu Washington D.C. El Paso Houston Newark New York Boston GU San Juan Minneapolis Detroit Anchorage San Diego West TX PR CDC Quarantine Station

17. Quarantine TM 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

18. Quarantine TM 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 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 U. S. planning assumptions

19. Quarantine TM 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 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

20. Quarantine TM Layered interventions ↓ cases ↑ household & community transmission ↓ cases ↑ household & community transmission Close schools Household (HH) quarantine Household (HH) quarantine ↓ cases ↑ relative importance of workplace & community ↓ cases ↑ relative importance of workplace & community Social distancing Social distancing ↓ cases Keep kids home ↓ HH & community transmission ↑ relative importance of HH & workplace transmission ↓ HH & community transmission ↑ relative importance of HH & workplace transmission

21. Quarantine TM 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 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

22. Quarantine TM 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 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

23. Quarantine TM 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 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

24. Quarantine TM Principles of Community Containment 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 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

25. Quarantine TM 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 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

26. Quarantine TM 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 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

27. Quarantine TM 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 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

28. Quarantine TM 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 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

29. Quarantine TM 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 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

30. Quarantine TM Principles of Community Containment 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 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

31. Quarantine TM 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 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

32. Quarantine TM 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 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

33. Quarantine TM http://www.pandemicflu.gov/ plan/community/commitigati on.html