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Introduction and Historical Context of Isolation and Quarantine

Allison Hackbarth, MPHHealth Education Unit Manager

Division of Epidemiology and ImmunizationMassachusetts Department of Public Health

June 2008

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Target Audiences

Public health, public safety, healthcare, school and legal professionals seeking an overview of isolation and quarantine

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By the end of this session, participants should be able to:Define and differentiate between isolation and quarantineDescribe the purpose of isolation and quarantineSummarize the history of isolation and quarantineDescribe the legal requirements that govern isolation and quarantineSummarize recent lessons learned and current efforts

The Introductory Module sets the stage for Modules 1 and 2.

Learning Objectives

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Why Do We Isolate or Quarantine?

Simply put: Isolation and quarantine are public health strategies to prevent the spread of dangerous contagious diseases

Isolation and quarantine are not new

Have been used throughout history to contend with disease and outbreaks by reducing the spread to other people

Underlying social precept called the ‘public health contract’: individuals agree to forgo certain rights and liberties, if necessary, to prevent a significant risk of illness to themselves or others

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Isolation and Quarantine: Part of the Larger System

PUBLIC HEALTHINFECTIOUS DISEASE

SURVEILLANCESYSTEM

Reporting

Data analysis

Distributionof Data

Epidemiologic Research

Action orPolicy

Control

Outbreak Investigation

Isolation and Quarantine

Case Investigation

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Definitions of Isolation and Quarantine

Isolation: For people who are illThe separation of persons who have a specific infectious disease from those who are healthy to stop the spread of that disease

Examples:Ill food handler excluded from work due to shigellosisA child excluded from school due to pertussis

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Definitions of Isolation and Quarantine (cont.)

Quarantine: For people who have been exposed but are not yet ill

The separation and restriction of movement of persons who, while not yet ill, have been exposed to a communicable disease and therefore may become infectious and spread the disease to others

Examples:Food handlers who are contacts of other individuals diagnosed with shigellosis are considered the same as a case and handled in the same fashion as on the previous slideContacts are defined as family members, spouse, roommates, significant others, etc.

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HistoryLarge-scale isolation and quarantine were quite common during the epidemics of the 19th and first half of the 20th

centuries

MA has a prominent place in the history of public health and is known for pioneering some of the first laws around isolation and quarantine

CholeraSmallpoxYellow FeverLeprosyTyphoid Fever1918 pandemic flu

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History (cont.)

The Middle Ages:The practice of quarantine as we know it began during the 14th centuryTo protect cities from plague, ships arriving in harbors from infected areas were required to sit for 40 days before landingQuarantine was derived from the Italian quaranta giorni which means 40 daysNote that quarantine is used interchangeably with isolation but is not technically correctPlague Doctor

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History (cont.)

Early America:When the US colonies were first established, little was done to prevent the importation of infectious disease

Individual municipalitiesbegan enacting a variety of regulations for arriving ships

Regulations and enforcement fell under local andstate jurisdiction

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History (cont.)

Early America:1600’s – 1700’s: Boston harbor served as a 1st line of defense against smallpox Ships were quarantined in the harbor on Spectacle Island, moved to Rainsford Island1850: Lemuel Shattuck argued that the state had a greater responsibility to protect the public’s healthThe courts have ruled that states may limit individual liberty in service of well-established public health interventionsJacobson v. Massachusetts, 197 U.S. 11 (1905): smallpox vaccination case

Lemuel Shattuck

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State and local attempts at quarantine were sporadic and inconsistentContinued outbreaks finally prompted Congress to pass federal quarantine legislation in 1878Continued legislation into the 1900’s gave the federal government more authority in imposing quarantine requirementsLocal quarantine stations were gradually turned over to the federal government, and this became nationalized in 1912

History (cont.)

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History (cont.)

“Typhoid Mary”:Mary MallonExtreme example of forced quarantineHealthy carrier of Typhoid FeverWorked as a cook in NYCOutbreaks were traced back to herMary is thought to have transmitted Typhoid to 47 people, with 3 deathsQuarantined 1907–1910 and 1915–1938 until her death on an island in the East River

Part of the New York American article of June 20, 1909, which first identified Mary Mallon as "Typhoid Mary."

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History (cont.)Typhoid Mary

Mary Mallon (right) photographed with bacteriologist Emma Sherman on North Brother Island in 1931 or 1932, over 15 years after she had been quarantined there permanently.

An old file card detailing results from tests on stool specimens from Mary Mallon gives a capsule history of her capture and quarantine.

The cottage on North Brother Island in New York's East River where Mary Mallon was quarantined from 1907 to 1910, and again from 1915 until her death in 1938.

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Federal quarantine authority was transferred to the Public Health Service in 1944. This more clearly established the federal role for responsibility for the introduction and spread of communicable diseases from foreign countries into the US.

History (cont.)

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History (cont.)

Quarantine authority was transferred to CDC in 1967

Today federal quarantine stations are located in 20 cities (including Logan Airport in Boston)

A list of diseases is contained in an Executive Order of the President. Recent additions are SARS, and influenza that is causing or has the potential to cause a pandemic

State and local health departments retain the authority for isolation and quarantine in their state and local jurisdictions

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Although familiarity has faded over time, isolation and quarantine are used routinely in MA to control spread of infectious diseases

Example of Isolation: A foodworker with campylobacter is excluded from work until he or she is clearedExample of Isolation: A school child with chickenpox is excludedfrom school until no longer infectious

Isolation and Quarantine Today

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Isolation and Quarantine Today

Example of Quarantine: A contact of a SARS patient is confined to his/her home until the incubation period passes (quarantined at home)

Advent of SARS, anthrax, other bioterrorism (BT) agents and pandemic flu has brought isolation and quarantine into the limelight, especially in regards to modern human rights and civil liberties

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Infectious Disease Reporting Requirements and Legal Authority in MA

Federal, state and local public health agencies are responsible for protecting the health of citizens

MDPH and local boards of health have legal and regulatory authority to define dangerous diseases, investigate, and implement isolation and quarantine

MA General Law (MGL): Chapter 111, Public Health

MA Regulations: 105 CMR 300.000, Reportable Diseases, Surveillance, and Isolation and Quarantine Requirements

Outlines isolation and quarantine requirements for all the reportable diseases

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105 CMR 300.000

The text of 105 CMR 300.000 can be found on the MDPH website at: www.mass.gov/dph

Conduct a search for “isolation,” “quarantine,” or “reportable disease”

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Isolation and Quarantine Timeframes

There are approximately 70 disease conditions that are reportable through local boards of health to MDPH

Approximately 35 have isolation and/or quarantine requirements

How long isolation or quarantine lasts depends on:

The type of disease and how it’s spread

The severity of the disease

The infectiousness of the disease

The incubation period of the disease

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Isolation and Quarantine Timeframes (cont.)

Example 1: Botulism – No isolation or quarantine because it is not transmitted from person to person.

Example 2: Hepatitis B – No isolation except for exclusion from organ and blood donation. Quarantine involves personal surveillance for high-risk contacts who should receive IG and vaccine.

Example 3: SARS – Isolation for duration of illness and for at least 10 days after resolution of illness. Quarantine for contacts ispersonal surveillance for symptoms for a certain length of time.

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Isolation and Quarantine Timeframes (cont.)

In the past, sometimes the authorities overreacted (used excessive force, excessive measures) or discriminated against minorities or immigrants

Examples: Mary Mallon, San Francisco and plague

Measures were used that led to lack of trust with the government

Because of this, isolation and quarantine have a fearful connotation that still exists today

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Individual Rights vs. The Public Good

Isolation and quarantine require choices involving ethical and human rights, and legal principles; a balancing act

Focus today is on the dignity and rights of the individual person and how to accomplish isolation and quarantine without stigmatization, restriction of liberties, violations of confidentiality and privacy, and meeting the needs of people

Public good Individual liberties

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Isolation and Quarantine Continuum

Health authorities should implement the least restrictive measure that achieves the goal of public health protection; a measure that is least restrictive of individual freedom

Exclusion from School

Exclusion from Work

Isolation in a Hospital

Sick Day

ISOLATION

Isolation at Home

Exclusion from Work

QUARANTINE

Social Distancing

Exclusion from School

Personal Surveillance

MedicalSurveillance

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Implementation Steps

There are 3 main steps to implement isolation and quarantine:

1. Education and persuasion for voluntary compliance (this usually works!)

2. Written order from local board of health (has the force of law).Warns that noncompliance may result in court order

3. Application for court order by local board of health and MDPHAllows removal of a patient (isolation) to a hospital or other facility; or exclusion of a well person from work/school, or requirement to remain at home (quarantine)

Parts 2 and 3 of this training will cover more detail about these steps.

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SARS in 2003: Toronto

What did we learn about isolation and quarantine?Toronto Public Health investigated 2,132 potential cases of SARS, and identified 13,374 contacts as requiring quarantineMore than 99% complied27 formal quarantine orders needed to be served1 formal appeal was processed through the court, but was later withdrawn after the purpose of quarantine was explained more fully

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SARS in 2003: Singapore

Singapore Public Health served quarantine orders for 7,863 persons

Auxiliary police officers served the quarantine orders because there were not enough health officers

They made random checks or called the contacts to ensure they were home, in addition to nursing checks

Persons found guilty of breaking quarantine could be prosecuted by a fine, or imprisonment not to exceed 6 months, or both

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SARS in 2003: Singapore (cont.)

Most people understood the purpose and complied (99%)

26 persons broke quarantine once for invalid or frivolous reasons. They were observed more strictly, issued warnings and given wrist tags

1 person was imprisoned for 6 months for violating quarantine multiple times and flaunting it

2 persons were detained in a facility to serve the remaining part of their quarantine because they broke it on at least 3 occasions

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SARS 2003

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Isolation and Quarantine Today

Many of the Massachusetts laws from the late 1800’s regarding isolation and quarantine are still in effect

SARS in 2003 highlighted the difficulties of interpreting and implementing laws from a different era

Difficulties of older laws:No practical enforcement capacity

Reimbursement of no more than $2/day for isolated patients missing workLocal boards of health can’t enforce across city/town lines

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Lessons Learned in MA

Certain level of education and expertise is needed by all audiences to implement and enforce isolation and quarantine (local public health, first responders, lawyers, judges)

Understanding of diseases, legal process, personal protective equipment, mental health and social issues, risk communication

Don’t underestimate the fear, anxiety and old stereotypes associated with this topic by various audiences

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Lessons Learned in MA (cont.)

Planning efforts and training to date have strengthened local capacity, specifically with routine isolation and quarantine situations

Need to continue to prioritize this topic, specifically in regards to the logistics of food, medicine, pets and larger groups of people

MDPH has developed a “Frequently Asked Questions About Isolationand Quarantine” document that provides more information. It is posted on the MDPH website at www.mass.gov/dph. In the search function, enter the title.

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Current Efforts in MA

MDPH is offering additional training programs on:

Infectious disease surveillance, reporting and control

Personal protective equipment for infection control

More information can be found on the Local Public Health Institute website at: www.masslocalinstitute.org

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Current Efforts in MA (cont.)

Education with the general public

A bill in the Legislature contains many of our goals for amending the laws and regulations

Example: The authority to issue health orders is made explicit, and it adds due process protections