Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs (2008)

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20 A P P E N D I X A CDC Disease Quarantines

21 Disease / References Symptoms in Early Stage (prodrome stage) Symptoms for Full Blown Illness (fulminant stage) Incubation Period (average and range for 95% of cases) Mechanism of Contagiousness Method for Diagnosis in Early Stage Method for Diagnosis during Incubation Diphtheria 1-4 Malaise, sore throat, loss of appetite, moderate fever, and barking cough. Adherent, gray membrane forms over the mucous membrane of the tonsils and/or pharynx. 2-5 days (range 1-10 days). respiratory and physical contact. Cutaneous lesions are important in transmission. Detection of the lethal and potent toxin produced by the bacteria that causes the disease (C. diphtheriae) is the definitive test for making a diagnosis of diphtheria. Also, testing the levels of two enzymes (pyrazinamidase and cystinase) may aid diagnosis. None established by CDC. Infectious TB 5-10 Prolonged recurrent fever, chronic cough, anorexia, fatigue, and weight loss. Coughing blood from the lungs, Chronic Obstructive Pulmonary Disease, abnormal stretching and enlarging of the respiratory passages caused by mucus blockage, fluid in the lungs. Average incubation period 21 weeks, 95% of cases will develop within 15-28 weeks. Airborne route. Extended period of close contact. specimens smear or culture positive. Tuberculin Skin Test (TST) or Quantiferon®-TB Test positive. Symptoms based: combination of chronic cough (>2 weeks), weight loss, and fatigue. Quantiferon®-TB Test. Cholera 11-14 <20% of Cholera patients will show any symptoms before full onset Copious, painless, watery diarrhea. Vomiting also occurs in most patients. Short incubation period, from less than one day to five days. Ingesting contaminated water or food; person-to-person transmission is rare. Diagnosis is confirmed by identification of the organism in a stool specimen. None established by CDC. Smallpox 15-21 High fever, back pain, headaches, vomiting, malaise, and prostration. Maculopapular rash that progresses to papules, then vesicles, and then pustules and scab lesions. Incubation period averages about 12 to 14 days but can range from 7 to 17 days. Spread by inhalation of air droplets or aerosols. Direct (within 6-7 feet) and fairly prolonged (approximately 3 hours) face-to-face contact is required to spread smallpox from one person to another. Characteristic rash and symptoms (fever, abdominal pain, etc). Electron microscopic (EM) visualization. RT- PCR. Confirmation. Close contact of case, virus found in throat during incubation. Hemorrhagic Fever Viruses 22-24 Fever, aching muscles, dizziness, neck pain, stiffness, backache, headache, sore eyes and sensitivity to light. Nausea, vomiting, sore throat, diarrhea, and generalized abdominal pain. Liver enlargement. Fast heart rate, enlarged lymph nodes, and a rash caused by bleeding into the skin. Bleeding in the mouth and throat, the upper bowel, and the gums. Hepatitis. Liver and kidney and pulmonary failure. Ebola: 2-21 days. Length of incubation may depend on the mode of acquisition (Crimean- Congo HV): tick bite, 1 to 3 days, with a maximum of 9 days; infected blood or tissues is usually 5 to 6 days, with a documented maximum of 13 days. Direct contact with blood or other infected tissues from livestock or tick bite. Human to human close contact. After 6 days of illness, antibodies can be detected (IgG or IgM). Prior to that, virus must be isolated from blood or tissue specimens and grown in host cells. Viral DNA may also be detected in the blood. Virus can be isolated from blood or tissue specimens in the first five days of illness, and grown in cell culture. Likely to find virus in throat swabs, nasal swabs, blood, lymph, and sputum/lungs. Plague 25-31 Fever, chills, headache, malaise, aching muscles, nausea, and prostration. Bubonic plague: painful, swollen lymph nodes. Pneumonic plague: cough, breathing difficulties. Bubonic: draining the site of the flea bite. Pneumonic plague: bloody sputum. Bubonic: 2-6 days. Pneumonic: 2-4 days with range of 1-6 days. Flea bites. Direct contact with infectious animals or other materials or inhalation of infective respiratory droplets. Ingestion. The swollen gland called a "bubo." F1 Ag immunocapture ELISA. Culture lysed by specific bacteriophage. None established by CDC. Bacteria likely found by throat swab or in lymph. APPENDIX A. CDC DISEASE QUARANTINES Direct person-to-person transmission by intimate Abnormal chest radiograph. Respiratory of disease. (continued on next page)

22 SARS 32-35 High fever, headache, body aches. Mild respiratory symptoms at the outset. About 10 percent to 20 percent of patients have diarrhea. Dry cough. Most patients develop pneumonia. Average is 4 days. 95% of cases will develop within 12 days. Close person-to-person contact. Most readily transmitted by respiratory droplets. People occasionally may become infected by touching a surface with influenza virus on it and then touching their mouth, nose or eyes. RT-PCR and ELISA antibody assays are the most commonly used. Isolation in cell culture, electron microscopy for CoV-like particles, and immunohistologic or in situ probe hybridization studies on tissue specimens (not recommended). None established by CDC. Yellow Fever 36-37 Fever, muscle pain (with prominent backache), headache, shivers, loss of appetite, nausea and/or vomiting. Fever, relative slow heart beat, jaundice, renal failure, and hemorrhagic complications. Mosquito bite. No recorded human to human3-6 Days. transmission. Blood tests (serology assays) can detect yellow fever antibodies. None established by CDC. Pandemic Influenza 38-41 Fever, headache, tiredness, cough, sore throat, runny or stuffy nose, body aches. Diarrhea and vomiting (among children). Pneumonia, acute respiratory distress, respiratory failure, and life-threatening complications. Typically 1-4 days, with an average of 2 days. Person to person in respiratory droplets when people who are infected cough or sneeze. People occasionally may become infected by touching a surface with influenza virus on it and then touching their mouth, nose or eyes. Immunofluorescence tests. Rapid antigen detection (ELISA), virus isolation and reverse transcription-polymerase chain reaction (RT-PCR). Embryonic egg culture (not recommended). None established by CDC. References: 1. http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=dtp.htm 2. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/diptheriat.htm 3. Efstratiou et al. 2000. Current Approaches to the Laboratory Diagnosis of Diphtheria. J. Infect. Dis. Vol 181. Suppl: p 138. 4. Efstratious and George. 1996. Screening Tests for the Presumptive Identification of Corynebacterium diphtheriae in a Diagnostic Laboratory. J. Clin. Microbiol. Vol. 34. No. 12: p 3251 5. http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?obj=tb.htm&section=dis 6. ten Asbroek et al. 1999. Estimation of serial interval and incubation period of tuberculosis using DNA fingerprinting. Int. J. Tuberc. Lung Dis. Vol. 3. No. 5: p 414 7. Ismail. 2004. Pulmonary tuberculosis-- a review of clinical features and diagnosis in 232 cases. Med J. Malaysia. Vol 59. No. 1: p 56 8. http://www.cdc.gov/tb/pubs/LTBI/diagnosis.htm 9. Marais et al. 2006. A refined symptom-based approach to diagnose pulmonary tuberculosis in children. Pediatrics. Vol. 118. No. 5:e1350 10. Harada. Characteristics of a diagnostic method for tuberculosis infection based on whole blood interferon-gamma assay. Kekkaku. Vol. 81. No. 11: p 681. 11. http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=cholera.htm 12. http://www.who.int/mediacentre/factsheets/fs107/en/ 13. http://www.who.int/topics/cholera/about/en/ 14. Keen and Bujalski. 1992. The diagnosis and treatment of cholera. Nurse Pract. Vol. 17. No. 12: p 53. 15. www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp. 16. Lofquist et al. 2003. “Smallpox: a review of clinical disease and vaccination.” Am. J. Health Syst. Pharm. Vol. 60. No. 8: p749. 17. http://www.bt.cdc.gov/agent/smallpox/disease/faq.asp 18. Sarkar et al. 1973. “Virus excretion in smallpox: excretion in the throats of household contacts.” Bull. WHO. Vol 48: p 523. 19. Henderson et al. 1999. "Smallpox as a Biological Weapon: Medical and Public Health Management.” JAMA. Vol. 281: p 2127 20. http://www.bt.cdc.gov/agent/smallpox/diagnosis/rashtestingprotocol.asp 21. http://www.bt.cdc.gov/agent/smallpox/lab-testing/pdf/em-rash-protocol.pdf 22. http://www.who.int/mediacentre/factsheets/fs208/en/ 23. http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/vhf.htm 24. Borio et al. 2002. Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management. JAMA. Vol. 287: p 2391 25. http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=plague.htm&cssNav=browseoyb 26. http://www.bt.cdc.gov/agent/plague/trainingmodule/3/02.asp 27. http://www.bt.cdc.gov/agent/plague/trainingmodule/3/09.asp 28. http://www.cdc.gov/ncidod/dvbid/plague/diagnosis.htm 29. http://www.cdc.gov/ncidod/dvbid/plague/lab-test-criteria.htm 30. Rahalis et al. 2000. Diagnosis of Bubonic Plague by PCR in Madagascar under Field Conditions. J Microbiol. Vol. 38. No. 1: p 260. 31. “Distribution of Biological Agents in Medical Samples.” Dec. 20, 2005. Report by Gryphon Scientific. Prepared for Jeff Grotte, Institute for Defense Analyses. 32. Meltzer. 2004. "Multiple Contact Dates and SARS Incubation Periods." Emerging Infectious Diseases. Vol. 10. No. 2: p 207. 33. http://www.cdc.gov/ncidod/sars/factsheet.htm 34. http://www.cdc.gov/ncidod/sars/guidance/F/assays.htm 35. http://www.cdc.gov/ncidod/sars/guidance/F/app7.htm 36. Borio et al. 2002. Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management. JAMA. Vol. 287: p 2391 37. http://www.cdc.gov/ncidod/dvbid/yellowfever/ 38. http://www.cdc.gov/flu/symptoms.htm 39. http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm 40. http://www.influenzareport.com/ir/lab.htm 41. http://www.cdc.gov/flu/professionals/diagnosis/ Disease / References Symptoms in Early Stage (prodrome stage) Symptoms for Full Blown Illness (fulminant stage) Incubation Period (average and range for 95% of cases) Mechanism of Contagiousness Method for Diagnosis in Early Stage Method for Diagnosis during Incubation APPENDIX A. CDC DISEASE QUARANTINES