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Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

QUARANTINE STATIONS AT PORTS OF ENTRY

Protecting the Public’s Health

Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry

Laura B. Sivitz, Kathleen Stratton, and Georges C. Benjamin, Editors

Board on Global Health

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. 200-2000-00629, Task Order No. 31 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry.

Quarantine stations at ports of entry : protecting the public’s health / Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry, Board on Global Health, Board on Population Health and Public Health Practice ; Laura B. Sivitz, Kathleen Stratton, and Georges C. Benjamin, editors.

p. ; cm.

“This study was supported by Contract No. 200-2000-00629, Task Order No. 31 between the National Academy of Sciences and the Centers for Disease Control and Prevention”—Galley.

Includes bibliographical references.

ISBN 0-309-09951-X (pbk. book)

1. Quarantine—United States. 2. Bioterrorism—United States—Prevention.

[DNLM: 1. Quarantine—United States. 2. Bioterrorism—prevention & control—United States. WA 234 I58 2005] I. Sivitz, Laura. II. Stratton, Kathleen R. III. Benjamin, Georges. IV. Title.

RA665.I57 2005

363.34′97—dc22

2005033697

Additional copies of this report are available from the
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Copyright 2006 by the National Academy of Sciences. All rights reserved.

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

COVER: The cover incorporates images from a colorized transmission electron micrograph taken by C. Goldsmith (CDC) of Avian influenza A H5N1 viruses (seen in gold) grown in MDCK cells (green). Executive Order 13,375 of April 1, 2005, added to the list of quarantinable communicable diseases influenza caused “by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.”

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

COMMITTEE ON MEASURES TO ENHANCE THE EFFECTIVENESS OF THE CDC QUARANTINE STATION EXPANSION PLAN FOR U.S. PORTS OF ENTRY

GEORGES C. BENJAMIN, M.D. (Chair), Executive Director,

American Public Health Association

JOAN M. ARNOLDI, D.V.M.,1 Retired, Associate Administrator,

Animal and Plant Health Inspection Service, U.S. Department of Agriculture

BARBARA A. BLAKENEY, M.S., R.N., President,

American Nurses Association

LAWRENCE O. GOSTIN, J.D., L.L.D., Professor of Law,

Georgetown University Law Center;

Professor of Public Health,

Johns Hopkins University; and

Director,

Center for Law & the Public’s Health

MARGARET A. HAMBURG, M.D., Senior Scientist,

Nuclear Threat Initiative

FARZAD MOSTASHARI, M.D., M.S.P.H., Assistant Commissioner,

Bureau of Epidemiology Services, New York City Department of Health

WILLIAM A. PETRI, JR., M.D., Ph.D., Wade Hampton Frost Professor of Epidemiology, Professor of Medicine, Microbiology, and Pathology, and Chief,

Division of Infectious Diseases and International Health, University of Virginia Health System

ARTHUR L. REINGOLD, M.D., Professor of Epidemiology,

School of Public Health, University of California at Berkeley

RONALD K. ST. JOHN, M.D., M.P.H., Director General,

Centre for Emergency Preparedness and Response, Public Health Agency of Canada

KATHLEEN E. TOOMEY, M.D., M.P.H.,2 Director,

Division of Public Health, Georgia State Health Department

MARY E. WILSON, M.D., Associate Professor of Population and International Health,

Harvard School of Public Health and

Associate Clinical Professor of Medicine,

Harvard Medical School

STUDY STAFF

KATHLEEN STRATTON, Ph.D., Study Director

LAURA B. SIVITZ, M.S.J., Research Associate

DAVID W. GILES, Research Assistant

SHEYI LAWOYIN, M.P.H., Senior Program Assistant

NORMAN GROSSBLATT, ELS (D), Senior Editor

PATRICK KELLEY, M.D., Dr.P.H., Director,

Board on Global Health

ROSE MARIE MARTINEZ, Sc.D., Director,

Board on Population Health and Public Health Practice

1  

Dr. Arnoldi resigned from the committee on December 21, 2004.

2  

Dr. Toomey resigned from the Georgia State Health Department effective January 15, 2005, and from the committee on March 16, 2005.

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
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Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

Reviewers

This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Donald S. Burke, M.D., Bloomberg School of Public Health, Johns Hopkins University

Kathleen F. Gensheimer, M.D., M.P.H., Maine Department of Health and Human Services

David Heymann, M.D., World Health Organization

Ann Marie Kimball, M.D., School of Public Health, University of Washington

Bonnie J. Kostelecky, R.N., M.S., M.P.A., Multnomah County Health Department, Portland, OR

Aileen Plant, Ph.D., M.P.H., Curtin University of Technology, Perth, Australia

K.W. Wheeler, D.V.M., Retired, Animal and Plant Health Inspection Service, U.S. Department of Agriculture

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, Ph.D., R.N., Columbia University. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

The committee’s letter report released in January 2005 (Appendix A) was also subject to independent review. We wish to thank the following individuals for their review of the letter report:

Ruth L. Berkelman, M.D., M.P.H., Rollins School of Public Health, Emory University

Donald S. Burke, M.D., Bloomberg School of Public Health, Johns Hopkins University

Kathleen F. Gensheimer, M.D., M.P.H., Maine Department of Health and Human Services

Ann Marie Kimball, M.D., School of Public Health, University of Washington

Bonnie J. Kostelecky, R.N., M.S., M.P.A., Multnomah County Health Department, Portland, OR

Monitor appointed by IOM: Hugh H. Tilson, M.D., Dr.P.H., School of Public Health, University of North Carolina.

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×
   

 Quarantine Core, System, and Network,

 

37

   

 Identification of and Response to Ill Passengers and Crew,

 

40

   

 Immigrants and Refugees: Role of the Quarantine Core,

 

55

   

 Inspection of Animals and Animal Products, Etiologic Agents, Hosts, and Vectors,

 

59

   

 Conclusion,

 

66

   

 References,

 

67

4

 

BRIDGE FROM PRESENT TO FUTURE: VISION AND RECOMMENDATIONS

 

70

   

 Committee’s Vision of the 21st Century Quarantine Network for U.S. Ports of Entry,

 

72

   

 Recommendations,

 

73

   

 Conclusion,

 

91

   

 References,

 

92

 

 

APPENDIXES

 

 

   

A  HUMAN RESOURCES AT U.S. PORTS OF ENTRY TO PROTECT THE PUBLIC’S HEALTH: INTERIM LETTER REPORT

 

97

   

 Historical Context,

 

98

   

 Vision for the Expanded Quarantine Station System,

 

103

   

 Functions and Competences,

 

105

   

 Types of Health Professionals,

 

117

   

 Concluding Remarks,

 

117

   

 References,

 

119

   

B  AGENDAS OF OPEN SESSIONS OF COMMITTEE MEETINGS

 

121

   

C  METHODOLOGY USED BY THE DIVISION OF GLOBAL MIGRATION AND QUARANTINE TO SELECT SITES FOR NEW QUARANTINE STATIONS

 

124

   

 Proposal for CDC Quarantine Station Distribution,

 

124

   

D  COMMISSIONED PAPER ON U.S. SEAPORTS AND THE CDC QUARANTINE STATION SYSTEM

 

128

   

 Summary and Conclusions,

 

128

   

 General Description of the CDC Quarantine Station System (QSS) at Seaports,

 

136

   

 Current Operating Environment of CDC QSS at Seaports,

 

144

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×
Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

Tables, Figures, and Boxes

TABLES

1.1

 

Locations, Jurisdictions, and Staffing of CDC Quarantine Stations at U.S. Ports of Entry (Established and Nascent), May 2005 and October 2005 Forecast,

 

16

3.1

 

Number of Ports of Entry to the United States Compared with Number of Official Ports of Entry (POEs) Defined by U.S. Customs and Border Protection, 2005,

 

41

3.2

 

All Cases of Illness Reported to or Found by DGMQ in 2003 and Medical Control Measures Taken,

 

49

3.3

 

Number of Immigrants, Refugees, and Asylees Accepted into the United States, 2003,

 

55

3.4

 

Communicable Diseases of Public Health Concern Diagnosed in Immigrants and Refugees to the United States by Panel Physicians, 1999–2003,

 

57

A.1

 

Number of Employees and Contractors at Each CDC Quarantine Station at U.S. Ports of Entry, Mid-2004,

 

99

A.2

 

Types of Workers Who Could Conduct the Priority Functions Necessary for the Surveillance for, Detection of, and Response to Microbial Threats at U.S. Ports of Entry,

 

118

C.1

 

Summary Table,

 

127

D.1

 

Organizations/Agencies Providing Information for Study,

 

129

D.2

 

2002-2003 Cruise Passengers at U.S. Ports,

 

139

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

D.3

 

Seaport coverage by CDC Quarantine Station,

 

146

D.4

 

Partners in CDC Quarantine Station System at Seaports,

 

149

D.5

 

2003 Containerized Traffic for U.S. Ports,

 

162

D.6

 

U.S. Waterborne Imports—Top 100 Ports by Weight and Customs District (2003),

 

164

E.1

 

Legal Authorities for Inspections at U.S. Borders,

 

173

E.2

 

DHS, Border and Transportation Security, U.S. Customs and Border Protection, and Components Addressing Animal Diseases,

 

178

E.3

 

Level of Funding,

 

182

E.4

 

CBP’s Inspection Staff for All POE Locations, FY 2001–2004,

 

183

E.5

 

Resources at CDC Quarantine Stations at Major U.S. Airports,

 

184

F.1

 

Public Health-Related Civil and Political Rights in the ICCPR,

 

223

F.2

 

Summary Table of Important Positive and Negative Obligations the United States Has Under International Law Relevant to the Expansion of the National Quarantine System,

 

227

F.3

 

Analysis of the Revised International Health Regulations: Implications for Plans to Expand the National Quarantine System,

 

235

F.4

 

Analysis of the WTO’s Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement): Implications for Plans to Expand the National Quarantine System,

 

283

FIGURES

ES.1

 

The relationships among the Quarantine Core, System, and Network for U.S. ports of entry,

 

5

1.1

 

The relationships among the members of the Quarantine Core and their partner organizations in the Department of Health and Human Services,

 

19

2.1

 

The proposed geographic distribution of the 25 quarantine stations in the expanded system,

 

31

3.1

 

The relationships among the Quarantine Core, System, and Network for U.S. ports of entry,

 

39

3.2

 

CDC Health Alert Notice,

 

54

3.3

 

Algorithm for screening prospective immigrants, refugees, and asylees to the United States for tuberculosis (TB),

 

56

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

4.1

 

The geographic boundaries of the United States’ 3,066 counties,

 

75

A.1

 

DGMQ’s proposed geographic distribution of the 25 quarantine stations in the expanded system,

 

103

BOXES

ES.1

 

Class A and Class B Conditions,

 

7

ES.2

 

Quarantinable Communicable Diseases,

 

8

1.1

 

Statement of Task,

 

15

1.2

 

Class A and Class B Conditions,

 

22

1.3

 

Quarantinable Communicable Diseases,

 

23

3.1

 

The Role of U.S. Ports of Entry as Defined by the Department of Homeland Security,

 

45

3.2

 

Mission Statement of U.S. Customs and Border Protection,

 

46

3.3

 

Immigration Inspection Program: Mission and Role,

 

47

A.1

 

Statement of Task,

 

98

A.2

 

Quarantinable Communicable Diseases,

 

100

A.3

 

Class A and Class B Conditions,

 

101

A.4

 

Priority Functions,

 

105

F.1

 

The Revised IHR’s Decision Instrument (Annex 2),

 

206

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

Abbreviations


AII

airborne infection isolation

AMS

Automated Manifest System

APHIS

Animal and Plant Health Inspection Service, U.S. Department of Agriculture

APHL

Association of Public Health Laboratories

APIS

Automated Passenger Information System

AQI

Agriculture Quarantine and Inspection, Animal and Plant Health Inspection Service

ASTHO

Association of State and Territorial Health Officials

ATA

Air Transport Association of America Inc.


BIDS

Border Infectious Disease Surveillance Project, Centers for Disease Control and Prevention


CBP

U.S. Customs and Border Protection

CDC

Centers for Disease Control and Prevention

CSTE

Council of State and Territorial Epidemiologists


DGMQ

Division of Global Migration and Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention

DHHS

U.S. Department of Health and Human Services

DHS

U.S. Department of Homeland Security

DOT

U.S. Department of Transportation

Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
×

DQ

Division of Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention


EMS

emergency medical services


FAA

Federal Aviation Administration, U.S. Department of Transportation

FBI

Federal Bureau of Investigation

FDA

Food and Drug Administration

FTEs

full-time equivalents


GAO

Government Accountability Office


HIPAA

Health Insurance Portability and Accountability Act

HIV

human immunodeficiency virus


ICD-CM

International Classification of Diseases, Clinical Modification

ICU

intensive-care unit

IOM

Institute of Medicine


LPHA

local public health authority


MOA

memorandum of agreement

MSEHPA

Model State Emergency Health Powers Act

MSPHA

Model State Public Health Act


NACCHO

National Association of County and City Health Officials

NACO

National Association of Counties

NCID

National Center for Infectious Diseases, Centers for Disease Control and Prevention

NHP

nonhuman primates

NIH

National Institutes of Health


OIS

Office of Immigration Statistics, U.S. Department of Homeland Security


PHAC

Public Health Agency of Canada

POEs

Ports of Entry


SARS

severe acute respiratory syndrome

State

PHA state public health agency

Page xvii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2006. Quarantine Stations at Ports of Entry: Protecting the Public's Health. Washington, DC: The National Academies Press. doi: 10.17226/11435.
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USCG

U.S. Coast Guard

USDA

U.S. Department of Agriculture

USFWS

U.S. Fish and Wildlife Service, U.S. Department of the Interior


WHO

World Health Organization

Page xviii Cite
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QUARANTINE STATIONS AT PORTS OF ENTRY

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To mitigate the risks posed by microbial threats of public health significance originating abroad, the Centers for Disease Control and Prevention (CDC) places small groups of staff at major U.S. airports. These staff, their offices, and their patient isolation rooms constitute quarantine stations, which are run by CDC's Division of Global Migration and Quarantine (DGMQ).

Congress began to allocate funds in fiscal 2003 for the establishment of new quarantine stations at 17 major U.S. ports of entry that comprise airports, seaports, and land-border crossings. In a significant departure from the recent past, both the preexisting 8 quarantine stations and the new 17 are expected to play an active, anticipatory role in nationwide biosurveillance. Consequently, DGMQ asked the Institute of Medicine (IOM) to convene an expert committee to assess the present CDC quarantine stations and recommend how they should evolve to meet the challenges posed by microbial threats at the nation's gateways. DGMQ specifically requested "an assessment of the role of the federal quarantine stations, given the changes in the global environment including large increases in international travel, threats posed by bioterrorism and emerging infections, and the movement of animals and cargo." To conduct this assessment and provide recommendations, IOM convened, in October 2004, the Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry.

At the sponsor's request, the committee released the interim letter report Human Resources at U.S. Ports of Entry to Protect the Public's Health in January 2005 to provide preliminary suggestions for the priority functions of a modern quarantine station, the competences necessary to carry out those functions, and the types of health professionals who have the requisite competences (Appendix A). This, the committee's final report, assesses the present role of the CDC quarantine stations and articulates a vision of their future role as a public health intervention.

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