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A Non-Traditional Role for Dietitians:  Centers for Disease

Control Quarantine Stations

CDR Kirsten Warwar, RD, MHA, CAAMA Officer in Charge

CDC Miami Quarantine Station

Quarantine and Border Health Services BranchDivision of Global Migration and Quarantine Centers for Disease Control and Prevention

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From Nutrition to Quarantine?

• B.S. Dietetics• USAF Internship• 1st Assignment – officer in charge, nutritional

medicine department• Educational Opportunities – AF advocates

leadership, supervision, in addition to primary medical profession

• Master’s Degree – Healthcare Administration• Protocol officer, executive officer• Transfer to USPHS

– HSA, ICE Detention Center Medical Facility– CDC Quarantine Station

Overview

• History of Quarantine• U.S. Quarantine System • Mission • Federal Legal Authorities • New Regionalized Structure• Quarantine Station Activities • Team Activities

History of U.S. Quarantine

• Quarantine laws passed and executed by state or local authorities

• Marine Hospital Service began to administer quarantine regulations in 1878

• National quarantine system by 1921

• Field office personnel expansion peaks with staff at every port of entry (1967)

Pre-1967:

• Quarantine Inspectors monitored passengers disembarking from aircraft, ships, and across land borders

History of U.S. Quarantine, cont.

• Expanded staff 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 in

quarantine staff

History of U.S. Quarantine, cont.

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CDC Quarantine Stations 2004 Jurisdictions

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U.S. Quarantine System Expansion

Precipitating Events

• Speed and high-volume of global travel• Bioterrorism risks and 9/11• SARS and Monkeypox• Avian influenza and risk for pandemic• MDR-TB Incident in 2007

Wor

ld P

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Speed of Global Travel in Relation toWorld Population Growth

Number of Persons Entering the United States, 2005

Conveyance Daily Annual (millions)

Air 219,000 80

Sea 71,000 26

Land 874,000 319

Total 1,164,000 425

Source: U.S. Customs and Border Protection. 2006. Securing America’s Borders at Ports of Entry, 2007-2011. Available at: http://www.cbp.gov/linkhandler/cgov/border_security/port_activities/securing_ports/entry_points.ctt/entry_points.pdf

Quarantine Stations at Ports of Entry: Protecting the Public’s Health, 2005

Institute of Medicine (IOM) Report

• Expansion to 25 quarantine stations recommended

• Response and preparedness at ports of entry necessary

• Capacity to conduct surveillance, epidemiology, and research

U.S. Quarantine System: A Network of Networks with a Core

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

Intl. Council of Cruise Lines

Canadian/ Mexican BorderAuthorities

PHAC

DHSFAA

FBI

State Dept.

WHO

News Media CSTE

NACCHO

ASTHO

BIDS

APHL

DOT

Media

Int. Civil Aviation Org.

USCG

FBI (local)

LPHAs

OverseasPanel Physicians

USCG (local)

FDA

Source: IOM Report

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HoustonHouston

NewarkNewark

New YorkNew York

BostonBoston

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MinneapolisMinneapolis

DetroitDetroit

AnchorageAnchorage

West TXWest TX

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PhiladelphiaPhiladelphia

DallasDallas

North TXNorth TX

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CDC Quarantine Station Jurisdictions, 2009

CDC Quarantine Station

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El PasoEl Paso

HoustonHouston

NewarkNewark

New YorkNew York

BostonBoston

San JuanSan Juan

MinneapolisMinneapolis

DetroitDetroit

AnchorageAnchorage

San DiegoSan Diego

PRPR

PhiladelphiaPhiladelphia

DallasDallas

DEDE

Region 3Region 3

Region 2Region 2

Region 1Region 1

GUGU

CDC Quarantine StationCDC Quarantine Station

West TXWest TX

North TXNorth TX

CDC Quarantine Stations 2009 Regions

Quarantine and Border Health Services Branch Mission

To protect the health of the public from

communicable diseases through

science, partnerships, and response at

U.S. ports

Quarantine and Border Health Services Branch (QBHSB)

- Responsible for CDC Quarantine Stations and the U.S. Quarantine System

- Implements federal

authority for quarantine and surveillance of infectious diseases at U.S. ports

Federal Authorities*

• Reporting and Surveillance

– Oversee screening of international travelers for symptoms of illness that could be of public health significance and respond to reports of illness on board arriving aircraft

• Quarantine and Isolation

– Detain, medically examine, or conditionally release persons suspected of carrying a communicable disease

* Section 361 Public Health Service Act (42 U.S. Code, Section 264) Title 42 Code of Federal Regulations (CFR) Part 71 (Foreign Quarantine) 42 CFR Part 70 (Domestic Quarantine)

CDC Quarantine Station Activities

– Respond to reports of illnesses on airplanes, maritime vessels, and at land-border crossings

– Inspect animals, cargo, and other items that pose a potential threat to human health

– Distribute life-saving immunobiologics and investigational drugs

– Provide international travelers with important health information

CDC Quarantine Station Activities, Contd

– Monitor the health of and collect medical information about new immigrants, refugees, asylees, and parolees

– Respond to mass migration emergencies

– Plan and prepare for emergency response

– Enter data into electronic surveillance and data reporting systems

– Build strategic partnerships for communicable disease surveillance and control

Definition of Isolation and Quarantine

Isolation:

Quarantine:

The separation of ill persons who have a specific infectious illness from those who are healthy and the restriction of their movement to stop the spread of that illness

The separation and restriction of movement of well persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious

Responding to an Ill Traveler

The captain of an aircraft or ship is required by federal law to report any communicable illness of public health significance or death on board prior to arrival at the port of entry

42 Code of Federal Regulations Part 71.21

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

Other Communicable Illness of Public Health Significance*

* Based on potential to a) cause significant morbidity and spread within the US; b) spread among passengers; c) be controlled by pharmaceutical and/or non-pharmaceutical interventions.

• Malaria• Typhoid• Varicella• Rabies• Meningococcal• Legionellosis• Dengue• Measles

• Polio• Zoonotic poxvirus• Pertussis• Mumps• Rubella• Infectious diarrhea• Other communicable diseases

Do Not Board List

• Department of Homeland Security places a person on Do Not Board travel restriction list at CDC’s request – List managed by Transportation Security Administration

• Person not allowed to obtain boarding pass for commercial flights inbound to, outbound from, or flights within the United States

• Patient must meet all of the following criteria: Infectious public health threat

Documented or potential treatment noncompliance

Potential to fly commercially while infectious

CBP adds person into national Treasury Enforcement Communications System (TECS) to alert CBP that a traveler should be referred to secondary for public health reasons

Look Out List

• Helps identify infectious individual who attempts to enter the U.S. to prevent transmission and ensure follow up care

– All persons placed on the Do Not Board list are also added to the Look out list

– Especially useful in international ground crossings

– Traveler is held provisionally pending case review by a quarantine medical officer

CBP may contact CDC to determine if any traveling companions have been examined and found to be free of TB

Preparedness TeamShah Roohi, Team Lead

• Mission– Prepare for and respond to urgent public health threats by

providing strategic direction and coordination

– Safeguard health and save lives by providing a flexible, robust platform for public health emergency preparedness and response by the U.S. Quarantine System

Preparedness Team, cont.

• Activities– Port Preparedness and

Risk-Based Border Strategy

– Community Preparedness and Mitigation

– Travel-Related Interventions (Do Not Board/Lookout)

– Goal-5 (Investigate to decrease time needed to identify causes, risks, and interventions for those affected by pandemic influenza)

Epidemiology TeamElaine Cramer, Team Lead

• Mission– Respond to public health

events

– Conduct research to inform public health practice associated with travel on international conveyances

Epidemiology Team, cont.

• Activities– Conduct research on quarantinable diseases and their

prevention and transmission on international conveyances

– Investigate and respond to communicable diseases of public health interest

– Build quarantine station capacity in case response, management, and communications with conveyance operators

– Collaborate with key partners for epidemiologic data collection, response, and research

– Inform quarantine-related informatics development regarding epidemiologic data collection and analysis

Surveillance TeamMary Agocs, Team Lead

• Mission– Expand capacity to limit the

importation of infectious disease by:

• detecting situations of public health interest among travelers, immigrants, refugees, and imported products;

• collaborating with binational public health agencies along our shared borders; and

• systematically collecting and disseminating pertinent information to partners

Surveillance Team, cont.• Activities

– Develop a standardized, tiered structure for illness response and subsequent data collection

– Develop a list of diseases of public health interest to U.S. ports and along land borders

– Develop a plan to expand surveillance capacity of the U.S. Quarantine System

– Ensure the proper public health processing of immigrants and refugees at U.S. ports

– Ensure surveillance capacity at land borders

Quarantine Training and Education Team (QTET)

David Hunter, Team Lead (acting)

• Mission– Train Quarantine and Border

Health Services Branch staff to increase their knowledge and skills to accomplish the branch mission

– Train partner agencies and organizations at U.S. ports of entry in their public health role

– Enhance the capacity of branch staff to train and educate partners and the public and to communicate more effectively

Quarantine Training and Education Team (QTET), cont.

• Activities– Internal Training and Education

– Public Communications

– Partner Training, Education, and Communication (PTEC)

CDC Quarantine Stations: Contact Info

Onlinewww.cdc.gov/quarantine

Emergency Phone # CDC Director’s Emergency Operations Center

770-488-7100

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Questions?