1. TM A Non-Traditional Role for Dietitians: Centers for Disease Control Quarantine Stations CDR Kirsten Warwar, RD, MHA, CAAMA Officer in Charge CDC Miami Quarantine Station Quarantine and Border Health Services Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention

2. TM From Nutrition to Quarantine? B.S. Dietetics USAF Internship 1 st Assignment – officer in charge, nutritional medicine department Educational Opportunities – AF advocates leadership, supervision, in addition to primary medical profession Master’s Degree – Healthcare Administration Protocol officer, executive officer Transfer to USPHS –HSA, ICE Detention Center Medical Facility –CDC Quarantine Station

3. Overview History of Quarantine U.S. Quarantine System Mission Federal Legal Authorities New Regionalized Structure Quarantine Station Activities Team Activities

4. History of U.S. Quarantine Quarantine laws passed and executed by state or local authorities Marine Hospital Service began to administer quarantine regulations in 1878 National quarantine system by 1921 Field office personnel expansion peaks with staff at every port of entry (1967)

5. Pre-1967: Quarantine Inspectors monitored passengers disembarking from aircraft, ships, and across land borders History of U.S. Quarantine, cont. Expanded staff enabled direct inspection, observation, and response

6. 1967-2003: Reorganization of quarantine station system reduced staff and facilities Reorientation of quarantine staff roles 2003-present: Newly emerging threats initiated an expansion in quarantine staff History of U.S. Quarantine, cont.

7. 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 Miami FL No.CA So.CA Los Angeles San Francisco HI Honolulu New York GU PR CDC Quarantine Station CT DE CDC Quarantine Stations 2004 Jurisdictions TX

8. U.S. Quarantine System Expansion Precipitating Events Speed and high-volume of global travel Bioterrorism risks and 9/11 SARS and Monkeypox Avian influenza and risk for pandemic MDR-TB Incident in 2007

9. Speed of Global Travel in Relation to World Population Growth

10. Number of Persons Entering the United States, 2005 ConveyanceDaily Annual (millions) Air219,00080 Sea71,00026 Land874,000319 Total1,164,000425 Source: U.S. Customs and Border Protection. 2006. Securing America’s Borders at Ports of Entry, 2007-2011. Available at: http://www.cbp.gov/linkhandler/cgov/border_security/port_activities/securing_ports/entr y_points.ctt/entry_points.pdf

11. Quarantine Stations at Ports of Entry: Protecting the Public’s Health, 2005 Institute of Medicine (IOM) Report Expansion to 25 quarantine stations recommended Response and preparedness at ports of entry necessary Capacity to conduct surveillance, epidemiology, and research

12. U.S. Quarantine System: A Network of Networks with a Core 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 Air Transport Assoc. of America Foreign Gov'ts Courts Intl. Council of Cruise Lines Canadian/ Mexican Border Authorities PHAC DHS FAA FBI State Dept. WHO News Media CSTE NACCHO ASTHO BIDS APHL DOT Media Int. Civil Aviation Org. USCG FBI (local) LPHAs Overseas Panel Physicians USCG (local) FDA Source: IOM Report

13. San Diego 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 HI Honolulu Washington, D.C. El Paso Houston Newark New York Boston GU San Juan Minneapolis Detroit Anchorage West TX PR Philadelphia Dallas North TX CT DE CDC Quarantine Station Jurisdictions, 2009 CDC Quarantine Station

14. HI 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 Honolulu Washington, D.C. El Paso Houston Newark New York Boston San Juan Minneapolis Detroit Anchorage San Diego PR Philadelphia Dallas DE Region 3 Region 2 Region 1 GU CDC Quarantine Station West TX North TX CDC Quarantine Stations 2009 Regions

15. Quarantine and Border Health Services Branch Mission To protect the health of the public from communicable diseases through science, partnerships, and response at U.S. ports

16. Quarantine and Border Health Services Branch (QBHSB) - Responsible for CDC Quarantine Stations and the U.S. Quarantine System - Implements federal authority for quarantine and surveillance of infectious diseases at U.S. ports

17. Federal Authorities* Reporting and Surveillance –Oversee screening of international travelers for symptoms of illness that could be of public health significance and respond to reports of illness on board arriving aircraft Quarantine and Isolation –Detain, medically examine, or conditionally release persons suspected of carrying a communicable disease * Section 361 Public Health Service Act (42 U.S. Code, Section 264) Title 42 Code of Federal Regulations (CFR) Part 71 (Foreign Quarantine) 42 CFR Part 70 (Domestic Quarantine)

18. CDC Quarantine Station Activities –Respond to reports of illnesses on airplanes, maritime vessels, and at land-border crossings –Inspect animals, cargo, and other items that pose a potential threat to human health –Distribute life-saving immunobiologics and investigational drugs –Provide international travelers with important health information

19. CDC Quarantine Station Activities, Contd –Monitor the health of and collect medical information about new immigrants, refugees, asylees, and parolees –Respond to mass migration emergencies –Plan and prepare for emergency response –Enter data into electronic surveillance and data reporting systems –Build strategic partnerships for communicable disease surveillance and control

20. Definition of Isolation and Quarantine Isolation: Quarantine: The separation of ill persons who have a specific infectious illness from those who are healthy and the restriction of their movement to stop the spread of that illness The separation and restriction of movement of well persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious

21. Responding to an Ill Traveler The captain of an aircraft or ship is required by federal law to report any communicable illness of public health significance or death on board prior to arrival at the port of entry 42 Code of Federal Regulations Part 71.21

22. 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 President George W. Bush April 1, 2005

23. Other Communicable Illness of Public Health Significance* * 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. Malaria Typhoid Varicella Rabies Meningococcal Legionellosis Dengue Measles Polio Zoonotic poxvirus Pertussis Mumps Rubella Infectious diarrhea Other communicable diseases

24. Do Not Board List Department of Homeland Security places a person on Do Not Board travel restriction list at CDC’s request –List managed by Transportation Security Administration Person not allowed to obtain boarding pass for commercial flights inbound to, outbound from, or flights within the United States Patient must meet all of the following criteria:  Infectious public health threat  Documented or potential treatment noncompliance  Potential to fly commercially while infectious

25. CBP adds person into national Treasury Enforcement Communications System (TECS) to alert CBP that a traveler should be referred to secondary for public health reasons Look Out List Helps identify infectious individual who attempts to enter the U.S. to prevent transmission and ensure follow up care –All persons placed on the Do Not Board list are also added to the Look out list –Especially useful in international ground crossings –Traveler is held provisionally pending case review by a quarantine medical officer CBP may contact CDC to determine if any traveling companions have been examined and found to be free of TB

26. Preparedness Team Shah Roohi, Team Lead Mission –Prepare for and respond to urgent public health threats by providing strategic direction and coordination –Safeguard health and save lives by providing a flexible, robust platform for public health emergency preparedness and response by the U.S. Quarantine System

27. Preparedness Team, cont. Activities –Port Preparedness and Risk-Based Border Strategy –Community Preparedness and Mitigation –Travel-Related Interventions (Do Not Board/Lookout) –Goal-5 (Investigate to decrease time needed to identify causes, risks, and interventions for those affected by pandemic influenza)

28. Epidemiology Team Elaine Cramer, Team Lead Mission –Respond to public health events –Conduct research to inform public health practice associated with travel on international conveyances

29. Epidemiology Team, cont. Activities –Conduct research on quarantinable diseases and their prevention and transmission on international conveyances –Investigate and respond to communicable diseases of public health interest –Build quarantine station capacity in case response, management, and communications with conveyance operators –Collaborate with key partners for epidemiologic data collection, response, and research –Inform quarantine-related informatics development regarding epidemiologic data collection and analysis

30. Surveillance Team Mary Agocs, Team Lead Mission –Expand capacity to limit the importation of infectious disease by: detecting situations of public health interest among travelers, immigrants, refugees, and imported products; collaborating with binational public health agencies along our shared borders; and systematically collecting and disseminating pertinent information to partners

31. Surveillance Team, cont. Activities –Develop a standardized, tiered structure for illness response and subsequent data collection –Develop a list of diseases of public health interest to U.S. ports and along land borders –Develop a plan to expand surveillance capacity of the U.S. Quarantine System –Ensure the proper public health processing of immigrants and refugees at U.S. ports –Ensure surveillance capacity at land borders

32. Quarantine Training and Education Team (QTET) David Hunter, Team Lead (acting) Mission –Train Quarantine and Border Health Services Branch staff to increase their knowledge and skills to accomplish the branch mission –Train partner agencies and organizations at U.S. ports of entry in their public health role –Enhance the capacity of branch staff to train and educate partners and the public and to communicate more effectively

33. Quarantine Training and Education Team (QTET), cont. Activities –Internal Training and Education –Public Communications –Partner Training, Education, and Communication (PTEC)

34. CDC Quarantine Stations: Contact Info Online www.cdc.gov/quarantine Emergency Phone # CDC Director’s Emergency Operations Center 770-488-7100

35. TM Questions?