Improving the CDC
Quarantine Station
Network’s Response
to Emerging Threats

_____

Committee on the Analysis to Enhance
the Effectiveness of the Federal
Quarantine Station Network based on
Lessons from the COVID-19 Pandemic

Board on Global Health

Board on Population Health and Public
Health Practice

Health and Medicine Division

Consensus Study Report

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and U.S. Centers for Disease Control and Prevention (75D30121F0010). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-68969-4
International Standard Book Number-10: 0-309-68969-4
Digital Object Identifier: https://doi.org/10.17226/26599
Library of Congress Catalog Number: 2022943211

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Improving the CDC Quarantine Station Network’s response to emerging threats. Washington, DC: The National Academies Press. https://doi.org/10.17226/26599.

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COMMITTEE ON THE ANALYSIS TO ENHANCE THE EFFECTIVENESS OF THE FEDERAL QUARANTINE STATION NETWORK BASED ON LESSONS FROM THE COVID-19 PANDEMIC

GEORGES C. BENJAMIN (Chair), Executive Director, American Public Health Association

ANA ABRAÍDO-LANZA, Vice Dean and Professor, Department of Social and Behavioral Sciences, School of Global Public Health, New York University

MICHELE BARRY, Drs. Ben and A. Jess Shenson Professor of Medicine and Tropical Diseases and Senior Associate Dean for Global Health, Stanford University

IETZA BOJORQUEZ, Professor, Department of Population Studies, El Colegio de la Frontera Norte, Mexico

BRADLEY DICKERSON, Senior Manager, Chemical and Biological Security, Sandia National Laboratories

LAWRENCE O. GOSTIN, Founding Linda D. & Timothy J. O’Neill Professor of Global Health Law; and Director, WHO Collaborating Center on National and Global Health Law

MOON KIM, Medical Epidemiologist, Los Angeles County Department of Public Health Acute Communicable Disease Control Program

LONNIE KING, Academy Professor and Dean Emeritus, College of Veterinary Medicine, The Ohio State University

MARCELLE LAYTON, Chief Medical Officer, Council of State and Territorial Epidemiologists

STEPHEN OSTROFF, Adjunct Professor, University of Pittsburgh Graduate School of Public Health

EDWARD T. RYAN, Director of Global Infectious Diseases, Massachusetts General Hospital; Professor, Harvard University

ALESSANDRO VESPIGNANI, Sternberg Family Distinguished Professor and Director, Network Science Institute, Northeastern University

C. JASON WANG, Professor of Pediatrics and Health Policy, Stanford University

RUEBEN WARREN, Professor of Bioethics and Director of the National Center for Bioethics in Research and Health Care, Tuskegee University

Study Staff

TEQUAM WORKU, Study Director

ELIZABETH ASHBY, Associate Program Officer

ELIZABETH FERRÉ, Research Associate

EMILIE RYAN-CASTILLO, Research Assistant

JULIE PAVLIN, Senior Director, Board on Global Health

ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice

Consultants

NIXON ARAUZ, Mirzayan Fellow, Virginia Commonwealth University

BENJAMIN BURK, American University, School of Public Affairs

GENIE GROHMAN, Editor

TAMARA HAAG, Science Writer

WASAN KUMAR, Stanford University School of Medicine

ANNA NICHOLSON, Science Writer

LINDSAY WILEY, UCLA School of Law

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, 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 thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or

recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by MARLA SALMON, University of Washington, and TERRY McELWAIN, Washington State University.

They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

This report would not be possible without the sponsorship of the Centers for Disease Control and Prevention Division of Global Migration and Quarantine, whose affiliates were instrumental in conceptualizing the study’s statement of task. The committee wishes to extend its immense gratitude to the many experts who lent their time to presentations during public sessions and who provided invaluable insights to the study. Their names and affiliations can be found in the committee meeting agendas in Appendix B.

The National Academies staff wish to acknowledge Tina Seliber, Leslie Sim, and Taryn Young, for their coordination during the review process, as well as to Lauren Shern for providing guidance throughout the course of the project. The staff also thank Victor Stewart for managing the contract throughout the life cycle of the study. The staff also extend their gratitude to Chloe O’Connor from the Research Center for her assistance with fact checking.

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Preface

The concept of quarantine has been around since the 14th century. When used appropriately, it has been a proven strategy for mitigating the impact of various contagious diseases. Back then, the quarantine process primarily consisted of holding an arriving ship at sea for 40 days to prevent nearby communities from contracting the plague or another infectious disease. This concept has survived through the ages and in 1878 the U.S. Congress passed the first federal quarantine law. Over the years, the federal government became more concerned about infectious disease control at our borders and between states. In 1944 it passed the Public Health Service Act, which modernized the U.S. Public Health Service and with it enhanced its ability to address disease control including infectious diseases. It also gave it the prime responsibility for controlling onward transmission of communicable diseases.

The U.S. Centers for Disease Control and Prevention (CDC) now has oversight for preventing the entry, transmission, and spread of communicable diseases of public health concern into the United States from other nations. It does this primarily through its Division of Global Migration and Quarantine (DGMQ). This division has undergone major changes through the years, both on the scope of its responsibility and its approach to disease control. In 2004 the DGMQ asked the Institute of Medicine of the National Academies of Sciences, Engineering, and Medicine (the National Academies) 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. The 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.”

The Institute of Medicine (IOM) committee charged with the assessment did a comprehensive review and made several recommendations in its 2006 report titled Quarantine Stations at Ports of Entry: Protecting the Public’s Health which the DGMQ believes helped it guide and improve its functions and prepare for the future. In many ways, the DGMQ believes the federal quarantine station network has improved its service delivery as well as the scientific basis of its decision making in addressing the disease threats the country has experienced in recent years.

The 2006 report came in the aftermath of the severe acute respiratory syndrome (SARS) epidemic of 2003–2004.¹ Since then, the world has experienced multiple public health emergencies of international concern, including from the Zika and Ebola viruses and H1N1 influenza (influenza A virus subtype H1N1, also known as swine flu). In December 2019 a novel coronavirus outbreak began in Wuhan, China, and has become the worst pandemic of a respiratory virus since the influenza pandemic of 1918. Known as the COVID-19 pandemic, it is caused by a newly evolved coronavirus—SARS-CoV-2. The COVID-19 pandemic, which as of this writing is ongoing, has had a profound impact throughout the world and has challenged the public health systems of every country. It has also led to a reevaluation of many of our current disease control mechanisms, including the use and role of quarantine as a public health tool.

The COVID pandemic, as of May 23, 2022, has caused over 520,000,000 reported cases worldwide and over 6,200,000 reported deaths, including over 83,345,820 documented cases and 1,002,283 deaths in the United States alone. However, these figures are a great underestimate of the true burden. The quarantine system of the United States has been tested like never before. The use of isolation and quarantine authority during the COVID-19 pandemic in the United States has included international border closures, limits to transportation, and even suspension of the cruise industry. Physical distancing recommendations by public health authorities resulted in wide-scale implementation of isolation and quarantine practices. Emerging technologies for the identification of febrile individuals and the tracking of potentially exposed or infected individuals, using cellular phones and COVID-19 testing as a requirement for international travelers, were used as a component of the quarantine function in various nations. The science and evidence for the effectiveness of these measures remains under study today. As of this writing, the COVID-19 pandemic appears to

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¹ This text was modified after release of the report to the study sponsor to correct the dates of SARS epidemic.

be slowly transitioning to another phase, possibly an endemic phase. The DGMQ must not only continue its current activities, but must also learn from the federal quarantine station network’s response to the pandemic in order to evolve and be better prepared to provide the strategic leadership and operations necessary to protect the nation.

Because of the need to be forward leaning for significant threats like COVID-19 in the future, in 2021, the DGMQ has again asked the National Academies to evaluate the effectiveness of the Federal Quarantine Station Network based on lessons from the COVID-19 pandemic. Once again, a committee of the Academies looked at the operating environment, organizational structure, and legal framework; the workforce and its culture; functional relationships and partnerships; and supporting resources. This assessment was informed by the domestic and international response to COVID-19 and by what is known to date about the successes and failures of the U.S. Federal Quarantine Network and other international disease control efforts. This pandemic is rapidly moving with a pathogen that is ever evolving. With that understanding, the committee focused on strategic and systemic issues and partnerships that we believe will survive the test of time, and strengthen the DGMQ network for the future.

This report was further informed by a committee of expert practitioners who brought their experience and knowledge base to ask probing questions and seek a better understanding of the information presented to us that informed our analysis. I also want to recognize the National Academies’ dedicated professional staff, whose advice, expert background research, and gentle guidance was essential and without whom evidence-based reports of this type could not be produced.

Georges C. Benjamin, M.D., Chair
Committee on Analysis to Enhance the Effectiveness of the Federal Quarantine Station Network Based on Lessons Learned from the COVID-19 Pandemic

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Contents

ACRONYMS AND ABBREVIATIONS

SUMMARY

1 INTRODUCTION

Charge to the Committee

Current Federal Quarantine Station Network

2006 IOM Report and Subsequent Developments

Structure of the Report

References

2 ORGANIZATIONAL CAPACITY

DGMQ Infrastructure

DGMQ’S Financial Landscape

Workforce

Culture

Conclusions and Recommendations

References

3 DISEASE CONTROL AND RESPONSE EFFORTS

The DGMQ’s Roles and Responsibilities in Communicable Disease Control

Improving Strategic Planning for Potential Disease Outbreaks

Border Measures and Active Monitoring of International Travelers during COVID-19: Evaluation

Conclusions and Recommendations

References

4 NEW TECHNOLOGIES AND DATA SYSTEMS

COVID-19 Detection Technologies

Use of Innovative and Integrative Digital Technologies

Leveraging Novel Digital Data Streams to Improve Situational Awareness

Interoperability of Data Systems

Balancing Ethical Risks with Public Health Benefits

Conclusions and Recommendations

References

5 IMPROVING COORDINATION AND COLLABORATION

Collaboration with Key Partners

Best Practices for Improving Coordination and Collaboration

Elements of Effective Coordination and Collaboration

Conclusions and Recommendations

References

6 LEGAL AND REGULATORY AUTHORITY

The CDC’s Legal and Regulatory Authority during Outbreaks: Overview

Recent Court Interpretations of the CDC’s Authority

Modernizing the CDC’s Pandemic Prevention and Response Authority

Surge Funding for Outbreak Response

Conclusions and Recommendations

References

APPENDIXES

A BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND STAFF

B AGENDAS: OPEN COMMITTEE MEETINGS

Boxes, Figures, and Tables

BOXES

1-1 Statement of Task

1-2 Roles and Responsibilities of DGMQ Quarantine Stations

3-1 Responsibilities of the Immigrant, Refugee, and Migrant Health (IRMH) Branch

3-2 The DGMQ Emergency Response Activities during the COVID-19 Pandemic

3-3 The CDC Center for Forecasting and Outbreak Analytics

4-1 Connectathons of the Integrating the Healthcare Enterprise

6-1 Proposed Quarantining of Diamond Cruise Ship Passengers

FIGURES

1-1 CDC quarantine stations and their jurisdictions

2-1 Organizational chart, Quarantine and Border Health Services Branch (QBHSB)

2-2 DGMQ’s 10-year budget trends

2-3 Quarantine and Border Health Services Branch (QBHSB) total staffing, 2008–2022

2-4 Focus areas for DGMQ culture

5-1 Federal governmental regulatory agencies for animal importation at ports of entry

5-2 Complementary missions of the Department of Homeland Security and the Division of Global Migration and Quarantine

TABLES

3-1 Potential Prioritization Scheme for Categorization of Pathogens

4-1 Proximity and Location Awareness Technologies Used in Digital Contact Tracing and Tracking

5-1 Recommendations from Council of State and Territorial Epidemiologists to CDC on Outbreak Response

6-1 Powers Granted to the CDC by the Public Health Service Act of 1944

6-2 Orders Issued by the DGMQ since COVID-19

Acronyms and Abbreviations

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