Elaine Cramer, MD, MPH

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Elaine Cramer, MD, MPH Quarantine Medical Officer
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Presentation OutlineNational Quarantine Program

• Brief History
• New Quarantine Act
• Screening program and protocols
• Epidemiology
• Case Studies
• Challenges and Initiatives
• Recommendations

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19th Century Quarantine
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Grosse Isle Quarantine Station
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Quarantine Service Capacity

• 25 Quarantine Officers
• 2 Medical Quarantine Officers
• Coverage of marine ports and remote ports
• 94 of intl flights through 6 airports
• Canada Border Services Agency screening officers

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Revision of Quarantine Act

• Assent May 2005
• In force December 12, 2006
• Compliance with International Health Regulations
• June 2006 voluntary compliance (pandemic)
• June 2007 comes into force
• 2009 capacities must be in place

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Quarantine Act Authority

• Internationally arriving and departing travellers
• Goods
• Cargo
• Conveyances

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Schedule of Quarantinable Diseases(Section 2,
subsections 15(2) and 34(1) and sections 45 and
63)
Measles Meningococcal meningitis Meningococcemia P
andemic influenza type A Plague Poliomyelitis Rift
Valley fever Severe Acute Respiratory
Syndrome Smallpox Tularemia Typhoid
fever Venezualan hemorrhagic fever Yellow fever

• Active pulmonary tuberculosis
• Anthrax
• Argentine hemorrhagic fever
• Bolivian hemorrhagic fever
• Botulism
• Brazilian hemorrhagic fever
• Cholera
• Crimean-Congo hem.fever
• Diphtheria
• Ebola hemorrhagic fever
• Lassa fever
• Marburg hemorrhagic fever

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Enhanced authority under thenew Quarantine Act
(2005)

• Minister can designate quarantine facilities at
  any location
• A QO can require any person to undergo health
  assessment
• Deny a conveyance entry into Canada
• Order a conveyance to divert
• Exit screening
• Public health measures necessary at all ports
• Power to add additional communicable diseases

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Additional Public Health Measures

• Screening based on emerging case definition/risk
  profile
• Canada Border Services Agency screening (E311
  card)
• Health Alert Notices (HAN)
• General Health Declaration, Annex 9 (conveyance
  ops)
• Screening devices (e.g., thermoscanners,
  biomarkers)
• Pre-boarding assessments

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Syndromic Case Definition for reporting ill
travellers to Quarantine Program

• Multiple ill travellers aboard conveyance
• Documentation of disease on Quarantine Schedule
• 3. Traveler or crew member with
• Appearing obviously unwell
• Cough with blood
• Fever (38oC or greater ) with any of the
  following
• Shortness of breath or difficulty breathing
  (recent onset)
• Persistent coughing
• Persistent diarrhea
• Persistent vomiting
• Headache
• Confusion (recent onset)
• Skin rash
• Bruising or bleeding (without previous injury)

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Guidelines for Requirement for Medical
Examination under Canadian Quarantine Act

• Cough with blood
• Cutaneous or mucous membrane hemorrhaging
• Fever of gt 38 C lasting gt 48 hours plus
• one or more of the following symptoms
• Cough with sputum
• New onset rash
• Neck stiffness
• Diarrhea gt 3 episodes in 24 hours
• New onset confusion

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Deplaning Air Passengers, by Canadian Airport
(2006), millions
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Traveller Health Assessments, by Presenting
ComplaintVancouver Intl Airport, 2005-2006, n
219
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Diagnoses associated with Medical Examinations of
Arriving Travellers

• Tuberculosis (M. tuberculosis)
• Gastroenteritis
• Meningitis (N. meningitidis)
• Influenza A
• Sporadic cases/outbreaks
• Meales (rubeola)
• Legionnaires disease (legionella pneumophila)

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Epidemiology of Infectious Diseases Associated
with Cruise Ships
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Top Ten U.S. Cruise Ship Port Embarkations
Vancouver (4.5)
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Pathogens associated with waterborne cruise ship
outbreaks 1970-2003
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Pathogens associated with food borne cruise ship
outbreaks 1970-2003
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• Case Studies

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Case Study 1

• 26 y.o. male arrived Toronto Pearson on Feb
  16,2007
• Asymptomatic
• Found in possession of illegal substance
• Appeared in court, 10-day detention for drug
  possession
• Deportation Order
• Detained in provincial facility (Correctional
  Complex)

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Case Study 1

• 26 y.o. male arrived Toronto Pearson on Feb
  16,2007
• Asymptomatic
• Found in possession of illegal substance
• Appeared in court, 10-day detention for drug
  possession
• Deportation Order
• Detained in provincial facility (Correctional
  Complex)

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Case Study 1
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Case Study 1

• Discussed with Provincial TB Director
• Citizenship Immigration medical detention for 48
  hours
• Sputum induction chamber
• 2 AFBs ve 1 AFB weakly positive M. TB
• AMTD (Amplified Mycobacterium tuberculosis Direct
  Test for M. tuberculosis rRNA)
• Quarantine Detention considered
• AMTD negative
• Traveller deported on Day 13

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Case Study 2 Biologic Importation

• Notified by Canada Border Services Agency
• December 6, 2006
• Briefcase containing vials
• Remedies labelled
• Smallpox, tularemia, typhoid

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Case Study 2 Biologic Importation

• Canadian Dentist
• Returning from US homeopathic convention
• Misplaced case
• Remedies for diagnosing patients
• CBSA requested traveller charged under Qurantine
  Act

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Challenges
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Challenges

• Reliance on regional and provincial diagnostic
  services
• Med exam results relayed to Fed Quarantine
• Surge capacity during pandemics
• Olympics preparedness for 2010 Winter Games
• Training key partners in remote locations
• Denominator data for evidenced-based decision
  making

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Initiatives

• Operations Manual
• Quarantine Database (THAD)
• International Health Regulations
• Border Health Initiatives
• Security and Prosperity Partnership
• Global Public Health Information Network (GPHIN)

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Recommendations

• Quarantine is a net not a shield
• Enhance communication strategies
• Use traveller data to inform syndromic
  definitions
• Create port risk assessment tool
• Identify essential key partners for training
• Border Services
• Cruise Lines and Airlines
• Establish International Quarantine Working Group

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Contact Information

• Elaine Cramer, MD, MPH
• Public Health Agency of Canada
• Quarantine Services 604-317-1720
• Direct line 604-666-2404
• Elaine_cramer_at_phac-aspc.gc.ca