Introduction to Quarantine and the EMS Public Health Role

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 • 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. Federal Structure Department of Health and Human Services (DHHS) ↓ Centers for Disease Control and Prevention (CDC) ↓ Coordinating Center for Infectious Diseases (CCID) ↓ 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

5. Quarantine Basics Definitions History

6. Definition: Isolation Separation and restricted movement of illpersons 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

7. Definition: Quarantine Separation and restriction of movement of wellpersons presumed to have been exposed to contagion • often at home or residential facility • may be voluntary or mandatory

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

9. History of U.S. Quarantine, cont. 1967-2003 • 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

13. U.S. Quarantine Program HEW 1953 • 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

14. US Average Daily Entry: 1.16 Million (FY06) Quarantine Stations 1.16M People 326 POEs 681,000 Private vehicle 154 Land ports 176,000 Bus, Train, Walk ~80 Staff 20 QS 113 Airports 44 User air 240,000 Airline 71,000 Ship 15 Seaports Source: CBP June 2007

15. CDC Quarantine Stations 2008 Jurisdictions AK ME Minneapolis Seattle Chicago Anchorage VT NH WA Boston MA ND MT Detroit RI NY MN CT CT MI WI New York NJ OR PA ID SD Newark DE WY MD Philadelphia IA OH NE IN No.CA WV IL Washington, D.C. NV VA San Francisco UT KY CO MO KS NC TN Dallas SC So.CA OK AR Atlanta NM AZ Los Angeles AL North TX GA MS San Diego East TX LA West TX El Paso FL Houston Miami Honolulu PR HI GU 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

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: • 305-526-2910

18. Air Transport Assoc. of America Courts Media (general) Network Foreign Gov'ts DOT Air Transport Assoc. of America FAA DHS System USCG FDA WHO Port officials USDA APHIS PHAC FBI BIDS Health-care providers Canadian/ Mexican BorderAuthorities PH labs LPHAs Int. Civil Aviation Org. Core USFWS State PHAs USCG (local) State Dept. Q StationsDGMQ HQCDC OverseasPanel Physicians APHL Hospitals CSTE News Media CBP FBI (local) NACCHO EMS Int. Org. for Migration ASTHO Source: IOM Report Int. Council of Cruise Lines The Quarantine System 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

21. Quarantine Station Functions, cont. • Distributing life-saving immunobiologics and investigational drugs • Providing travelers with essential health information

22. Quarantine Station Functions, cont.

23. Quarantine Station Functions, cont. • Monitoring health and collecting medical information of new • immigrants, • refugees, • asylees, and • parolees • Responding to mass migration emergencies

24. Quarantine Station Functions, cont. • Building partnerships for disease surveillance and control

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.

26. International Travelers (42 Code of Federal Regulations Part 71) • Applies to allinternational 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 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

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 President George W. Bush April 1, 2005

29. Domestic Travelers (42 Code of Federal Regulations Part 70) • Applies to alldomestic 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

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

32. Health Insurance Portability and Accountability Act (HIPAA) • 45 CFR 164.512(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

33. 1 Recommend seeking medical care and/or delay travel until noninfectious 2 Require transfer to hospital if quarantinable disease suspected Require transfer to Memorandum of Agreement Hospital if quarantinable disease suspected 3 Allow travel to continue, if desired CDC Quarantine Station Illness Surveillance and Response Protocol • Goal of CDC Staff : Determine public health risk and appropriate public health action • Threepossibilities:

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

35. Primary EMS* and Total QARS† Reports, by Quarantine Station, Jan 2006- Sep 2007 *Primary EMS is when QS first informed by EMS † Exclude other information reports ‡ Quarantine Stations not listed had no primary EMS reports

36. 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

38. 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) Partners (and Audience)

39. 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 Needs Assessment Topics

40. Needs Assessment Topics, cont. • Preferred formats for timely and effective communications • Preferred formats for training • Methods used • Frequency • Opportunities to work together

41. Roundtable DiscussionsEMS & 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

42. 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

43. Training & MaterialsDraft 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

44. Training & MaterialsDraft EMS Public Health Card Back Front

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

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!

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

50. More Information • Contact CDC Miami Quarantine Station 305-526-2910 • Visit www.cdc.gov/ncidod/dq • Visit www.cdc.gov/travel for health information for international travelers