Embed Size (px)
Citation preview
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)
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
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)
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
Quarantine Basics
Definitions
History
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
Definition: QuarantineSeparation 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
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
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
History of U.S. Quarantine, cont.
11Source: Population Action International 1994
Major Migration Flows: 1960-75
22
4 x increase in volume as compared to 1960-754 x increase in volume as compared to 1960-75Source: Population Action International 1994
Major Migration Flows: 1990s
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
US Average Daily Entry: 1.16 Million (FY06)
176,000 Bus, Train, Walk
240,000 Airline
71,000 Ship
681,000 Private vehicle 154 Land
ports154 Land
ports
113 Airports44 User air
15 Seaports
1.16M People 326 POEs
~80 Staff20 QS
Quarantine Stations
Source: CBP June 2007
San DiegoSan Diego
VTVT
MEME
MAMANYNY
PAPA
NHNH
WVWV
VAVA
MDMD
NJNJ
RIRICTCT
AZAZ
ININ
WIWI
KYKY
MIMI
OHOHIAIA
MNMN
MOMO
ILILNENE
KSKS
SDSD
NDND
ALAL
TNTN
GAGA
SCSC
NCNC
ARAR
LALA
MSMS
OKOK
AtlantaAtlanta
ChicagoChicagoSeattleSeattle
WYWY
IDID
WAWA
AKAK
OROR
MTMT
NVNVUTUT
NMNM
COCO
East TXEast TX
MiamiMiami
FLFL
No.CANo.CA
So.CASo.CA
Los AngelesLos Angeles
San FranciscoSan Francisco
HIHI
HonoluluHonolulu
Washington, D.C.Washington, D.C.
El PasoEl Paso
HoustonHouston
NewarkNewark
New YorkNew York
BostonBoston
GUGU
San JuanSan Juan
MinneapolisMinneapolis
DetroitDetroit
AnchorageAnchorage
West TXWest TX
PRPR
CDC Quarantine StationCDC Quarantine Station
PhiladelphiaPhiladelphia
DallasDallas
North TXNorth TX
CTCT
DEDE
CDC Quarantine Stations 2008 Jurisdictions
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
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
The Quarantine System
Relationships among the Quarantine Core System and Network for U.S. Ports of Entry
Air Transport Assoc. of America
Network
System
CoreQ StationsDGMQ HQ
CDCCBPEMS
Int. Org. for Migration
State PHAs
Hospitals
Health-care providers
Port officials
USFWS
USDA APHIS
PH labs
Air Transport Assoc. of AmericaForeign Gov'ts
Courts
Int. Council of Cruise Lines
Canadian/ Mexican BorderAuthorities
PHAC
DHSFAA
FBI
State Dept.
WHO
News Media CSTE
NACCHO
ASTHO
BIDS
APHL
DOT
Media (general)
Int. Civil Aviation Org.
USCG
FBI (local)
LPHAs
OverseasPanel Physicians
USCG (local)
FDA
Source: IOM Report
Quarantine Station Functions
Illness Surveillance and Response
EMS Collaboration
• 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
Quarantine Station Functions
• Distributing life-saving immunobiologics and investigational drugs
• Providing travelers with essential health information
Quarantine Station Functions, cont.
Quarantine Station Functions, cont.
• Monitoring health and collecting medical information of new– immigrants,
– refugees,
– asylees, and
– parolees • Responding to mass
migration emergencies
Quarantine Station Functions, cont.
• Building partnerships for disease surveillance and control
Quarantine Station Functions, cont.
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.
• Applies to all international 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)
International Travelers (42 Code of Federal Regulations Part 71)
OR
OR
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
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. BushApril 1, 2005
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
1. Identification• Signs or symptoms indicative of
communicable disease• Traveler on international or domestic
conveyance2. Notification
• International traveler: EMS notify CDC Quarantine Station (QS)
• Domestic traveler: EMS notify County Health Department
• Public Health authorities share notification with EMS
3. 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
Notification and Response Protocol at POE
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
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
• Goal of CDC Staff : Determine public health risk and appropriate public health action
• Three possibilities:
CDC Quarantine Station Illness Surveillance and Response Protocol
Recommend seeking medical care and/or delay travel until noninfectious1
Allow travel to continue, if desired3
Require transfer to Memorandum of Agreement Hospital if quarantinable disease suspectedRequire transfer to hospital if quarantinable disease suspected2
EMS Role in Illness Surveillance and Response
• Identification• Notification • Assist CDC on site and by phone
to assess public health risk• Assist with transport
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
Ongoing Activities:
Partner Needs Assessment Project
Public Health Preparedness
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
Partners (and Audience)
• 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)
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
Needs Assessment Topics, cont.
• Preferred formats for timely and effective communications
• Preferred formats for training– Methods used
– Frequency
• Opportunities to work together
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
Aircraft Rescue Firefighting Working Group Annual Meeting
• ~200 attendees from airports around the world
• CDC presentation
• Roundtable discussions with 10 attendees from international airports
Roundtable Discussions
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
Front Back
Training & MaterialsDraft EMS Public Health Card
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
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
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
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!
SummaryEMS 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
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
Questions?
