Introduction to Quarantine and the EMS Public Health Role

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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)

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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

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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)
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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
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Quarantine Basics

• Definitions
• History

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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

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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

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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

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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

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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

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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
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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
PA
OR
SD
ID
Newark
DE
WY
MD
Philadelphia
IA
OH
NE
IN
WV
No.CA
IL
Washington, D.C.
NV
VA
San Francisco
UT
KY
CO
MO
KS
NC
TN
Dallas
SC
OK
So.CA
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
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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

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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
  QPHOs 2 Admin Assistants
• 24-hour Phone Number
• 305-526-2910

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The Quarantine System
Relationships among the Quarantine Core System
and Network for U.S. Ports of Entry
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Quarantine Station Functions

• Illness Surveillance and Response
• EMS Collaboration

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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

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Quarantine Station Functions, cont.

• Distributing life-saving immunobiologics and
  investigational drugs
• Providing travelers with essential health
  information

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Quarantine Station Functions, cont.
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Quarantine Station Functions, cont.

• Monitoring health and collecting medical
  information of new
• immigrants,
• refugees,
• asylees, and
• parolees
• Responding to mass migration emergencies

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Quarantine Station Functions, cont.

• Building partnerships for disease surveillance
  and control

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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.
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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 100F persisting for gt48 hours
• Fever and certain other symptoms
• Fever 100F AND rash, or
• Fever 100F AND swollen glands, or
• Fever 100F AND jaundice
• Severe diarrhea (with or without fever)

OR
OR
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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

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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
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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

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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

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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

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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

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CDC Quarantine Station Illness Surveillance and
Response Protocol

• Goal of CDC Staff Determine public health risk
  and appropriate public health action
• Three possibilities

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EMS Role in Illness Surveillance and Response

• Identification
• Notification
• Assist CDC on site and by phone to assess public
  health risk
• Assist with transport

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Primary EMS and Total QARS Reports, by
Quarantine Station, Jan 2006- Sep 2007
Quarantine Station 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 4 137 3
IAD 3 57 5
JFK 3 89 3
BOS 2 38 5
HOU 2 103 2
MSP 1 85 1
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
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Ongoing Activities

• Partner Needs Assessment Project
• Public Health Preparedness

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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

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Partners (and Audience)

• U.S. Department of Agriculture (USDA)
• U.S. Fish Wildlife
• U.S. Transportation Security Administration (TSA)

• U.S. Customs and Border Protection (CBP)
• Airlines
• Cruise lines
• EMS
• Customs Brokers
• Border Patrol

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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

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Needs Assessment Topics, cont.

• Preferred formats for timely and effective
  communications
• Preferred formats for training
• Methods used
• Frequency
• Opportunities to work together

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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

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Aircraft Rescue Firefighting Working Group Annual
Meeting
Roundtable Discussions

• 200 attendees from airports around the world
• CDC presentation
• Roundtable discussions with 10 attendees from
  international airports

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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

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Training MaterialsDraft EMS Public Health Card
Front
Back
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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

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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

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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

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Public Health Preparedness, cont.

• Developing Comprehensive Communicable Disease
  Response Plans at major Florida POEs
• 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!

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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

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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

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Questions?