Introduction to the U.S. RiskBased Border Strategy RBBS

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Introduction to the U.S. Risk-Based Border
Strategy (RBBS)

• Andrew Plummer, MD, MPH
• David Hunter, MPH, MSW
• Quarantine and Border Health Services Branch
• Division of Global Migration and Quarantine
• Centers for Disease Control and Prevention

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Presentation Outline

• Purpose and strategy
• Risk-Based Screening Procedures
• Primary Screening
• Secondary Screening
• Flight Group Waiting Area (Cohort)
• Cohort Out Processing
• Pre-deployment surge capacity training
• Just in time training

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U.S. Government Strategic Objective and
Principles
Delay the introduction of pandemic influenza
into the United States at ports of entry

• Undertake measures to maintain the flow of U.S.
  citizens, non-citizens, and cargo across the
  border
• Implement scalable, flexible border measures
  during a severe pandemic, including the
  following
• Screening for illness at ports of entry
• Health guidance, isolation, and quarantine to
  limit onward transmission

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Risk-Based Border Strategy (RBBS)

• Potential Benefit of Intervention
• Reduced introduction allows increased level of
  preparedness in U.S. (1-4 weeks)
• Time-Limited
• Effectiveness greatest early in pandemic
• Short duration 1-4 weeks
• Only for severe pandemic can turn on and off
• Scalable

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Risk-Based Border Strategy (RBBS)

• Trigger for implementing for H1N1
• Currently indications are
• H1N1 flu is less severe
• Plans needed for less
• severe pandemic
• Trigger for Stopping
• When no public health
• benefit to screening

Note to date, the novel H1N1 flu outbreak has
not been declared a pandemic.
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Risk-Based Border Strategy (RBBS)

• Limitations
• High leakage rate screening will not detect
  individuals who are infected but asymptomatic
• Will cause delays in travel but can streamline
• Requires significant communications efforts with
  public

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CDC Quarantine Stations by 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 Stations
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Number of Persons Entering theUnited States,
2008
Seaport data is based on 2005 data, the latest
available from the Department of Transportation
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Illness and Death Reportsby Port of Entry,
2006-2008
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Primary Screening
Secondary
Health
Screening
Isolation
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RBBS on Aircraft En Route

• En route activities
• by flight crew

Distribute Health Declarations Play instructional
video Deliver announcements Identify ill
travelers on board Notify airport of ill traveler
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At the Arrival Gate

• If advanced notification of suspect ill traveler
  received

• Ill traveler and travel companions removed from
  aircraft and directly transferred to public
  health secondary screening
• Remaining passengers escorted from aircraft to
  public health primary screening

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Objectives of Public Health Primary Screening
(PHPS)
Screen arriving international travelers and
airline crews in order to

• Efficiently process those passengers who are
  presumed well
• Identify suspect ill passengers and their
  contacts
• Quickly direct suspect ill passengers and their
  long term contacts to Public Health Secondary
  Screening (PHSS) area

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Key Elements of PHPS
Principal responsibility and security and escort
responsibility rests with the Department of
Homeland Security (DHS)
Public health consultation and referral
responsibilities rest with the Department of
Health and Human Services (HHS)

• Conduct rapid screening (30 seconds or less to
  process each passenger)
• Provide accessible interpretation services on site

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Guidelines for Public Health Primary Screening
Operational Guidelines

• Screen 100 of travelers and crew
• Expedite disembarkation
• Utilize mobile PHPS screening units
• Requires 2 DHS staff and 1 HHS staff per gate
• Use two or more processing lines
• Provide interpretation services
• Possible administration of temperature checks

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Layout of Primary Screening Area
From arrival gate
To Flight Group Waiting Area (Cohort)
Public Health Secondary Screening
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Public Health Primary ScreeningAction Sequence

• Visual exam for obvious signs of illness
• Review Health Declaration
• Interview (follow up questions to traveler, if
  indicated)
• Check results of thermal scanning device, if used
• Decide if traveler is suspect ill or if presumed
  well

If traveler is suspect ill
If traveler is presumed well

• Identify long term contacts
• of suspect ill traveler
• Escort suspect ill traveler and
• any long term contacts to Public
• Health Secondary Screening

• Send the presumed well and
• short term contacts to the flight
• group waiting area (cohort area)

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Secondary Public Health Screening
Secondary
Health
Screening
Isolation
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Public Health Secondary Screening Drill (Miami,
November 2008)
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Objectives of Public Health Secondary Screening
(PHSS)
Evaluate risk of potentially ill travelers

• Perform epidemiological and physical exam
• Confirm suspect ill
• Determine who may have been exposed
• Isolate ill persons, if necessary
• Quarantine contacts, if necessary
• Return other travelers to the Flight Group
  Waiting Area (Cohort Area)

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Key Elements of PHSS
Principal responsibility rests with the Centers
for Disease Control and Prevention (CDC) and the
Department of Health and Human Services (HHS)
Security and escort responsibility rests with
the Department of Homeland Security (DHS) and law
enforcement (LE)

• Suspect cases transferred to healthcare
  facilities
• Manage contacts by chosen cohort method
• Critical enabling factor process timeliness

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Guidelines for Public Health Secondary Screening
Operational Guidelines

• One secondary screening site per terminal, close
  to primary screening
• Licensed clinician supervision
• Infection control and social distancing
• Quickly isolate suspect ill
• Exposed passengers - quarantine or conditional
  release
• Rapid processing and communication with cohort
• Patient privacy and confidentiality

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Layout of Secondary Screening Area
Waiting area
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Required Equipment for Triage

• Table
• Chairs for approximately 10 people (spacing apart
  as feasible)
• Appropriate forms
• Pens
• Computer
• Phone
• Trash can
• Supply of purple gloves
• Alcohol hand sanitizer or hand washing area

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Health Declaration Form
1
Country A
Country B
2
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Required Equipment for Exam Area

• Private rooms or screened off areas
• Desks and chairs
• Examination lamps
• Sufficient extension cords
• Thermometers
• Trash cans
• Boxes of gloves
• Boxes of tongue depressors
• Stethoscope
• PPE for travelers and staff
• Alcohol hand sanitizer or hand washing area

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Isolation and Quarantine Waiting Areas

• Provide comfort and attend to medical and
  psychosocial needs
• Create separate waiting areas
• Implement social distancing and infection control
  measures
• Encourage recommended sanitation and hygiene
  measures
• Provide PPE masks

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Cohort and Out Processing
Secondary
Health
Screening
Isolation
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Guidelines for Flight Group Waiting Area

• Keep each flight of travelers separate
• Place all travelers from a single flight together
  and form two lines
• Travelers with connecting flights
• Travelers without connecting flights
• Provide informational materials
• Transfer family members or traveling companions
  of any suspect ill traveler identified to
  Secondary Screening
• Proceed to Out Processing only after all
  travelers on flight have been through primary
  screening

Operational Guidelines
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Key Elements of Flight Group Waiting Area (Cohort
Area)

• Most travelers will go to the Flight Group
  Waiting Area
• Provide information and answer questions
• Travelers contact airlines for rebooking missed
  connections

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Key Elements of Cohort Out Processing
Principal responsibility for out processing
travelers rest with the Department of Health and
Human Services (HHS)
Security and escort responsibility rests with the
Department of Homeland Security (DHS)

• Travelers released from flight group waiting area
  (cohort) via Out-processing
• Public health activities vary depending upon
  determination of findings from Public Health
  Secondary Screening

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Layout of Cohort Out Processing
Lane 1
Lane 2
To Customs and Immigration
Lane 3
Medical Officers
Lane 4
Lane 5
Lane 6
Pharmacist
Lane 7
Lane 8
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Cohort Out-Processing Scenario A
Most travelers will be out-processed under
Scenario A
Scenario A No suspect case on aircraft

• Collect Health Declaration
• Distribute fact sheet
• Release traveler to customs and immigration area

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Cohort Out-Processing Scenario B
Scenario B Suspect case on aircraft

• Review Health Declaration for 24-hour window
• gt24-hours from boarding the plane to final
  destination, refer traveler to PHSS for
  quarantine
• lt24-hours from boarding the plane to final
  destination, continue out-processing
• Review and complete Conditional Release orders
• Distribute anti-virals
• Distribute fact sheet and home care guide
• Release traveler to customs and immigration area

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Cohort Out-processing Health Declaration Review
Suspect ill traveler on board flight

• Review health declaration for 24-hour window from
  boarding plane to final destination

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5
1 4

2 0
3 4
Conditionally Release
lt24 hrs
Quarantine (PHSS)
gt24 hrs

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Deployment for Surge Capacity

• Risk Based Border Strategy requires significant
  staff deployment to operate
• Primary source of staffing will be Commissioned
  Corps and DMAT personnel
• Numbers below assume 12-hour shifts, 6 days per
  week

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Surge Staff Duties and Responsibilities
Surge capacity personnel may be asked to perform
a variety of tasks depending on their skill,
experience and training
These duties include but are not limited to

• Communication and information tasks.
• Medical tasks.
• Epidemiologic tasks.
• Administrative and clerical tasks

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Characteristics of Surge Personnel
Key characteristics to help accomplish mission
Flexibility and team work Readiness for a variety
of tasks Training and security clearance Specializ
ed skills
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Pre-deployment TrainingReady, Set, Surge!

• Purpose Provide an introduction to working at a
  quarantine station or port of entry during a
  public health emergency

Partners Work environment Roles and
responsibilities Tools and systems
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Surge Course Basics
Free, 508 compliant, multi-module course
Continuing education credits available
Pre- and post-tests assess knowledge gain
Using Train.org learning management system
Developed with CDCs Office of Workforce and
Career Development
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Ready, Set, Surge!

• Modules
• Intro to the CDC Quarantine Stations
• Intro to Surge Capacity at Quarantine Stations
• Roles of Surge Capacity Staff and Incident
  Command in a Quarantine Station Operation

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Audiences
Potential sources of surge capacity staff

• CDC
• Commissioned Corps of the Public Health Service
• Department of Health and Human Services (ESF-8)
• State and local health departments
• Volunteer organizations

Other sources of surge capacity staff

• Customs and Border Protection (CBP)
• Transportation Security Administration (TSA)
• Other groups involved in onsite response

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1014648
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Acknowledgements

• Developers and designers
• Amanda McWhorter
• Gaby Benenson
• Allie Cox
• Karen Ngowe

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Acknowledgements, cont.
Content experts, clearance reviewers, and
production assistants
Todd Wilson Shah Roohi Gabe Palumbo Tony Drew
LCDR Andy Plummer CAPT Dan Fishbein CAPT Peter
Houck CDR Francisco Alvarado-Ramy Nabiha
Megateli-Das Ava Navin Clive Brown
Cynthia Corsino John Bateman Danitza
Tomianovic Kirsten Buckley CDR Jason Thomas Jim
Misrahi Stacy Howard Ashley Marrone LaShonda
Pittman Janice Marton John OConnor
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Acknowledgements, cont.
Continuing Education Pilot Testers

• Shannon Bachar
• Robynne Jungerman
• CAPT Jacque Polder
• LT Deborah Forcht
• Chris Swager
• CAPT Peter Houck
• CDR Francisco Alvarado-Ramy
• Nicole Cohen
• Bill Tynan
• Will Schluter
• LT David Hunter
• Lisa Hines
• Erika Cutts
• Amanda Whatley

and 22 additional pilot testers
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Ready to learn?

• Go to quarantine.train.org
• Register in TRAIN
• Search for course 1014648

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Questions?