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Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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Summary

The federal network of quarantine stations spans ports of entry across the United States, serving as a premier line of defense against the importation of infectious disease threats across the nation’s borders through travelers arriving by air, land, and sea. The United States typically receives nearly 1 million travelers per day into the country, underscoring the need for a rapid, nimble, and effective response when travelers with communicable diseases of public health concern are identified. To help prevent the introduction, transmission, and spread of communicable diseases across and within the country, the Division of Global Migration and Quarantine (DGMQ) within the Centers for Disease Control and Prevention (CDC) operates quarantine stations staffed by public health officers at 20 U.S. international airports and land-border crossings with the highest concentrations of incoming international travelers.

Over the past two decades, the public health, social, and economic threats posed by infectious diseases—particularly due to emerging pathogens of epidemic and pandemic potential—have intensified significantly, compounded by the increasing ease, speed, and range of international travel. Consequently, the DGMQ has faced an increasing number of emergency public health responses during that period, most recently COVID-19. Estimates show that more than 3.4 billion people worldwide may have been infected with SARS-CoV-2 (Barber et al., 2022). Excess mortality resulting from the pandemic could be over 18 million (Wang et al., 2022), highlighting the devastating consequences of limited capacities to mitigate and control the introduction, transmission, and spread of emerging and reemerging infectious pathogens such as novel coronaviruses. Beyond the

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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ongoing COVID-19 pandemic, the world in recent years has had to respond to SARS, MERS (Middle East respiratory syndrome), Zika, West Nile Virus, and multiple Ebola virus disease epidemics and outbreaks.

In 2004, catalyzed by concerns about bioterrorism and emerging infectious disease threats, the CDC requested that the Institute of Medicine (IOM) conduct a consensus study to recommend strategies to strengthen the DGMQ’s quarantine station network, resulting in the report Quarantine Stations at Ports of Entry: Protecting the Public’s Health (Institute of Medicine, 2006). Similarly, in 2021, the CDC called upon the National Academies of Sciences, Engineering, and Medicine (the National Academies) to conduct another evaluation of the DGMQ’s role and the federal quarantine station network in mitigating the risk of onward transmission of microbial threats by drawing upon lessons learned from the response to the COVID-19 pandemic and other recent emergency responses. The National Academies appointed an ad hoc committee of experts to fulfill this request. Specifically, the committee was charged with assessing the role of DGMQ quarantine stations in mitigating the risk of onward communicable disease transmission in light of changes in the global environment, including large increases in international travel, threats posed by emerging infections, and the movement of animals and cargo.

The landscape has changed substantially since the IOM report in 2006, not only in terms of the increasing emergence of novel pathogens and burgeoning international travel, but also in terms of the number of quarantine stations, increases in DGMQ’s responsibilities without commensurate increases in baseline funding and personnel, changes in the legal landscape for emergency responses and national security protections, evolving roles of the World Health Organization (WHO) and other transnational entities, and the advent of a host of new technologies and data sources that could be leveraged to support disease control.

The committee acknowledges that the DGMQ has implemented many successful changes and activities since the earlier report. Yet, extraordinary infectious disease events have occurred in the last 15 years along with their significant impacts on the DGMQ. The findings and recommendations of this report are not a reflection of any failure by the DGMQ and its outstanding staff, but, rather, a reflection of the difficult times and circumstances in which the division has had to work to try to achieve its valuable mission.

The committee’s findings and recommendations span five domains: (1) opportunities to strengthen the DGMQ’s organizational capacity, including its infrastructure; (2) strategies to mitigate the risk of importing infectious threats into the country and to improve response efforts; (3) methods to optimize the use of novel technologies and data systems to detect and track infectious threats; (4) approaches to improve coordination and collaboration

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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to enhance disease control; and (5) ways to modernize the CDC legal and regulatory authority to more effectively respond to public health threats.

ORGANIZATIONAL CAPACITY

Organizational capacity (OC) refers to an institution’s ability to perform critical tasks and fulfill its mission. As the entity responsible for disease surveillance at U.S. ports of entry, the DGMQ’s OC is a critical element of U.S. national health security. The committee identified and evaluated the four key areas that directly influence the DGMQ’s ability to complete its core tasks: infrastructure, finances, workforce, and organizational culture.

The DGMQ’s infrastructure is central to its OC and is a key element in protecting public health as people become increasingly mobile within today’s globally interconnected world. One branch within the DGMQ, the Quarantine and Border Health Services Branch (QBHSB), holds primary responsibility for both monitoring incoming travelers for diseases of public health concern and planning for emergency response. All but two of the twenty quarantine stations are under the jurisdiction of the QBHSB. The committee noted that the DGMQ has a unique set of responsibilities and is one of the few units at the CDC with direct regulatory responsibilities. It is also one of the few CDC divisions that has a network of operational field units, including those with international responsibilities.

Finances are foundational to the other critical elements of OC. Despite the increasing number and complexity of public health emergencies involving the DGMQ over the past decade, the division’s core funding has seen little increase. Rather than increased core funding, surge funding is appropriated for the DGMQ to access in times of emergency: This approach creates a cycle of boom and bust. Although surge funding has been critical to the DGMQ’s response, it often comes too late to allow an efficient response, placing severe stress on existing staff. Because it is a temporary source of funding, there are limitations in how surge funding can be used and what type of personnel can be brought on board and supported. The division is in urgent need of more reliable funding streams than its traditional appropriations and intermittent surge funding. Current base funding is not commensurate with the DGMQ’s responsibilities. Moreover, cycles of surge funding do not support a sustainable, proactive system that is ready to be deployed as soon as a public health emergency is identified. Consistent, reliable streams of funding are required to support this organization in fulfilling its mission of preparedness for public health emergencies.

Public health emergencies, most notably the COVID-19 pandemic, have strained an already limited workforce within the DGMQ. Although the number of approved full-time employee positions has increased since 2019, the majority of personnel at the DGMQ are currently in nonpermanent

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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positions. Heavy reliance on temporary personnel poses several challenges, such as increased work for human resources (e.g., onboarding, badging, medical clearances), competition with other stakeholders for a limited pool of surge staff, and lower experience levels among staff. High vacancy rates among permanent positions have led to increased demands for overtime work, in turn resulting in burnout and high turnover. Combined with challenges in recruiting new hires, workforce issues are a vulnerability within the DGMQ. This is likely to affect not only the functioning of the division but is also likely to impact the culture and morale of the permanent staff. Leveraging technology and different recruitment methods may help meet increased workforce demands. Additionally, assessing the culture of the DGMQ could also address issues of burnout and provide means of supporting staff to reduce turnover.

Recommendation 2-1: The U.S. Department of Health and Human Services (HHS), especially including the Centers for Disease Control and Prevention (CDC), should ensure that the Division of Global Migration and Quarantine (DGMQ) has the necessary financial and personnel resources, an effective organizational structure, and optimal infrastructure to effectively meet its responsibilities, execute its growing volume of work, and achieve its mission.

To implement this recommendation, the DGMQ needs to specifically act and resolve the following issues:

  1. Organizational restructuring
    1. Strong consideration should be given to restructuring the DGMQ to become a standalone unit with a direct reporting line to the CDC director.
  2. Finances
    1. HHS should make a special agreement with the DGMQ to enable the DGMQ to utilize readily accessible funding in future emergencies. The process of acquiring and utilizing surge funds should be streamlined to facilitate greater flexibility during both their acquisition and during the draw-down period post-emergency.
    2. The CDC should explore, along with the administration and Congress, the development of a user fee program to ensure that the division has a consistent and dependable source of revenue to cover the costs of operating quarantine stations.
  3. Workforce
    1. The DGMQ should develop and implement a comprehensive and contemporary personnel plan to address multiple issues of recruitment, retention, skills development, vacancy rates, burnout, and excessive reliance on contract and temporary
Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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    1. staff. This plan should also include a commitment to diversity, equity, and inclusion, and to critical training needs and upskilling to prepare staff to successfully work in a dynamic, rapidly changing, and demanding environment and to stay abreast of evolving technologies. The plan should address the need for all quarantine stations to operate on a two-shift standard.
    2. The DGMQ should develop and launch innovative strategies to support its critical recruitment needs.
      1. The organization should work with academic entities, such as universities and schools of public health, medicine, and law to develop a pipeline of future employees. Creative incentives and a streamlined human resources process should be used to facilitate the recruitment of graduates.
      2. The DGMQ should design, develop, and implement a “Ready Reserve Corps”: a well-trained, experienced, and agile group of personnel with essential competencies who are preapproved and cleared, and thus could be immediately available to rapidly meet personnel needs of the organization during emergencies. This group should be paid a stipend to serve, be on standby status, and engage in training and practice exercises.
    3. DGMQ should leverage opportunities presented through the CDC director’s diversity, equity, and inclusion initiatives while undergoing the division’s workforce study.
  1. Culture

    The DGMQ should assess its organizational culture and climate in association with the personnel and development plan to ensure that the division’s values positively support its mission. This assessment should include a focus on diversity, equity, and inclusion. Corrective actions should be initiated if findings suggest that an adjustment is needed.

Recommendation 2-2: The Division of Global Migration and Quarantine (DGMQ) should create an effective and innovative quarantine-station model that matches the expanding and changing needs of a global, mobile world and augments its work in a progressively challenging infectious disease environment.

To achieve this recommendation, the DGMQ needs to implement these specific steps:

  1. Develop criteria to determine whether a quarantine station should be added, deleted, or upgraded, and adjust the current number of stations accordingly. If a new station is deemed necessary, conduct
Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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  1. a business plan during preplanning to determine (1) the optimal number of staff to support a two-shift standard, (2) requisite staff competencies, (3) necessary support staff, and (4) capacity for routine round-the-clock coverage during emergencies if needed. If a new station is deemed necessary, conduct a business plan during preplanning to (5) determine whether the new site could have multiple uses and (6) identify potential partners that the new site could engage between and during emergencies. Finally, (7) adopt appropriate advanced technology including telemedicine options.
  2. The maritime unit should be permanently housed within the DGMQ so that it can address the unique needs of the cruise industry and maritime-traveling public to enhance collaboration and disease control activities in maritime settings. The maritime quarantine station should have transparent operations and strong partnerships with regulated parties and other relevant entities.
  3. Develop a more robust program for preclearance of passengers, immigrants, and animals, including collaborative actions with other pertinent agencies and organizations. The emphasis would be on upstream locations outside of the United States—to ease workload at entry sites.
  4. Redesign post-entry follow-ups in partnership with local and state agencies, and other federal agencies, in which resources and responsibilities are better shared and modern technology is used for communications, tracking, and surveillance.

DISEASE CONTROL AND RESPONSE EFFORTS

Over the past two decades, the pace and variance of global infectious disease emergence has been accelerating at an alarming rate. This likely reflects a range of factors, including mass travel and migration, close animal/human interchange, and climate change. The DGMQ requires access to resources and tools for disease control that can be tailored to the specific threats. For individual travelers, the DGMQ’s suite of infectious disease control tools includes travel restrictions—specifically the Do Not Board list, the Public Health Lookout, and (in conjunction with HHS and the White House) testing and/or vaccine requirements and restrictions on travel from particular countries experiencing infectious disease outbreaks.1,2 In practice, these strategies have seen mixed success in mitigating disease spread.

Contact investigations are another tool used by the DGMQ to conduct

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1 This text was modified after release of the report to the study sponsor to correct the name of the list. Similar corrections have been made throughout the report.

2 This text was modified after release of the report to the study sponsor to correctly describe the measures undertaken by DGMQ.

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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surveillance and protect the health of those who may have been exposed to infectious diseases during travel, with the aim of preventing further spread. When needed, the federal government can also exercise legal authorities to implement isolation and quarantine measures for individuals who may carry infectious diseases of high public health concern. As a federal agency, the DGMQ’s powers are limited to those needed to prevent the entry of dangerous infectious diseases into the United States and to contain spread across state lines. DGMQ’s mission is to prevent, detect, and respond to the spread of communicable diseases that impact the health of global and domestic travelers, migrants, immigrants, and refugees.

Considerations for ethics and equity must be central to the discussion of disease control measures—especially for interventions such as border closures and isolation and quarantine—and must take into account the variation in the types of travelers who enter the United States. For example, refugees and asylum seekers may need additional assistance to access services, and may be more vulnerable to consequences of border closures and travel restrictions. In addition to these core responsibilities related to international travelers, the DGMQ must respond to numerous other concerns. The DGMQ and CDC’s Vessel Sanitation Program, run by the Center for Environmental Health,3 interface with the maritime industry, responding to disease outbreaks on ships (cargo and cruise) at U.S. ports of entry. The DGMQ also regulates the entry of certain animals and products of animal origin into the United States and restricts animal products that could pose a public health risk.

The DGMQ was heavily involved in the COVID-19 response, collaborating with other CDC entities and other agencies to provide guidance on disease surveillance and mitigation, educate travelers, and work with various partners to implement public health measures. These experiences highlight the importance of scenario planning for the most likely and/or concerning potential disease outbreaks, with the active involvement of key partners. The committee found that the DGMQ could benefit from developing operational plans for emergency response based on lessons learned from recent disease events, such as SARS, MERS, Zika, influenza, COVID-19, and Ebola. The committee also found that disease control measures have not always maximized resource efficiency. For example, once COVID-19 transmission was widespread in the United States, quarantine and active monitoring of all international travelers coming into the United States—regardless of their symptoms or exposure history—was likely not effective in minimizing transmission in the country and diverted public health resources from other critical activities. These and other key lessons learned can be leveraged to guide policy decisions, such as travel restrictions and active

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3 This text was modified after release of the report to the study sponsor to correctly identify the entities responsible for responding to outbreaks at US ports of entry.

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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monitoring of international travelers to minimize risk of disease spread within the United States.

Recommendation 3-1: The Division of Global Migration and Quarantine (DGMQ) should develop detailed operational plans and playbooks based on the most concerning and likely scenarios for transmissible disease threats.

  1. The DGMQ should develop operational plans for the most probable scenarios that are likely to have major impacts requiring disease control interventions based on priority pathogens. These plans should list required partners, enumerate possible response steps, define possible implementation go–no go decision points, and include metrics to assess containment.
  2. The DGMQ should seek input from key agencies and organizations (e.g., the World Health Organization, the Coalition for Epidemic Preparedness Innovations, the U.S Agency for International Development, the new Centers for Disease Control and Prevention (CDC) Center for Forecasting and Outbreak Analytics, the CDC Center for Public Health Preparedness and Response, and the Office of the Assistant Secretary for Preparedness and Response) as well as state and local public health agencies when determining which pathogens and scenarios to prioritize for planning purposes.

Recommendation 3-2: The Division of Global Migration and Quarantine, in coordination with appropriate federal partners for implementation, should develop detailed operational plans for large-scale isolation and quarantine needs for future emergencies. These operational plans should be informed by the lessons learned during the initial response to COVID-19. Critical issues to address include:

  1. Potential sites for large-scale isolation and quarantine facilities should be identified in all Department of Health and Human Services regions. Memoranda of agreement for these facilities should be established prior to any possible need to facilitate rapid setup during a public health emergency. Minimum standards of infrastructure should be established for these facilities including capacity to provide wraparound services, such as health care services, diverse dietary needs, laundry facilities, communication needs, business support services, and entertainment.
  2. Ethical and equity issues that will likely arise, especially when housing/caring for special populations, including families with young children, the elderly, persons with special medical needs,
Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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  1. persons with disabilities, refugees, persons who cross borders on a routine basis for work, and persons with pets. The plans should also address language and incorporate intercultural components, normalizing these needs as an expected component of the public health response.
  2. Those plans also need to include
    1. coordination of legal authority and enforcement;
    2. triage, transport, and assessment of ill persons with nearby health care facilities or onsite, available health care personnel; and
    3. collaboration with state and local public health, law enforcement, and emergency management officials.

Recommendation 3-3: The Division of Global Migration and Quarantine/Centers for Disease Control and Prevention should commission an external formal evaluation and/or a modeling study of the effectiveness of travel restrictions and active screening/monitoring of all international travelers in preventing and mitigating disease transmission in the United States during both the current COVID-19 pandemic and the 2014–2015 Ebola outbreaks in West Africa. The formal evaluation should include psychological benefits, political implications, unintended consequences of screening, resources required, and burden placed on state and local jurisdictions. These findings should be used to inform plans detailing when such measures should be considered in the future and to specify the types of pathogens and scenarios that warrant these measures. The latter criteria might include incubation period, timing of infectiousness related to symptom onset, proportion of asymptomatic infections, size of traveler population that would require monitoring, technological ease and cost of monitoring, severity of illness, and reasonable ability to provide or implement countermeasures.

NEW TECHNOLOGIES AND DATA SYSTEMS

The DGMQ relies on technologies for disease mitigation, diagnostic testing, data collection, and communication. However, the COVID-19 pandemic has revealed striking inadequacies in the existing DGMQ technology infrastructure, even as the pandemic has resulted in the development and implementation of new technologies for health surveillance and communication. Innovative digital technologies for collecting and aggregating data are an essential tool for protecting public health from the introduction of diseases across international borders. These data are needed for contact tracing for individuals potentially exposed to infectious diseases, and for system reporting and monitoring and epidemic intelligence.

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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Technology can also be used to overcome limitations with staffing and to scale up, maximizing the effectiveness of screenings in airports and health departments. Contact tracing, for example, is more efficient when performed digitally rather than manually. However, major technical barriers of interoperability and standardization can limit the effectiveness of innovative digital tools to support the response to an infectious disease outbreak. Furthermore, there are some issues in legal, regulatory, and governance of data collection and sharing that can also pose a barrier to the adoption and effectiveness of innovative digital tools. Interoperability is critical for a strong and effective health care and public health system capable of flexing to respond to a public health emergency. Enhancing data interoperability can lead to improved early warning systems that integrate data from open sources as well as from traditional surveillance methods. Investments in data system interoperability can be lifesaving during a pandemic, improve day-to-day care coordination, and generate financial benefits to the United States. It is critical that the DGMQ update and improve its technology infrastructure in order to meet current and future demands during public health emergencies.

Clear, trustworthy public communication strategies are essential for explaining the need for digital technology, providing justification for the collection and use of personal data. As with all other aspects of disease control, ethics and equity must be central when considering and applying technology for disease mitigation. All technologies need to be used with safeguards for autonomy and privacy. Achieving this will require improved processes for data governance, such as through a CDC ethics committee or a DGMQ advisory committee.

Recommendation 4-1: The Division of Global Migration and Quarantine (DGMQ) should increase and improve the use of innovative technology to aid in outbreak detection and response and to mitigate disease transmission. The DGMQ should improve readiness and develop flexible and targeted strategies for disease control at the border. The DGMQ should incorporate and improve on the use of digital technologies to gather health data from travelers, trace transmission, and alert travelers to exposures. These practices will also allow the development of scalable approaches to disease control strategies for large numbers of incoming travelers.

Recommendation 4-2: The Division of Global Migration and Quarantine (DGMQ) should support the adoption of the Office of the National Coordinator for Health Information Technology (ONC) roadmap by health care and public health practitioners. The DGMQ should work with the ONC to facilitate the ONC roadmap and interoperability net-

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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works. Connectathons—events that allow providers, organizations, or other implementers to learn from developers, conduct testing, and practice exchanging data asynchronously across agencies—are an example of how this could occur. As health information technology developers continue to increase functionality in mobile health applications and electronic health records, the DGMQ should identify gaps and opportunities in legislation and regulation to support the proper use and transfer of information across data systems.

Recommendation 4-3: The Division of Global Migration and Quarantine (DGMQ) should ensure that all uses of digital technologies, novel data streams, and interoperative public health information systems follow a careful consideration of their ethical aspects and that all actions are in accordance with existing regulations for the protection of personal data. In order to achieve this, the DGMQ should put an oversight structure in place.

COORDINATION AND COLLABORATION

Partnerships are critical to the DGMQ’s mission. The division works with both domestic and international partners in government and the private sector, including other nation’s quarantine and disease control organizations; U.S. federal agencies; state, tribal, local, and territorial (STLT) agencies; and private-sector industries. One key example is the collaboration between the DGMQ and health officials in the United States and Mexico at various levels to (1) limit the cross-border spread of infectious diseases, (2) protect the health of people living in the U.S.–Mexico border region, and (3) promote the health of travelers, migrants, and other mobile populations. The DGMQ’s success is highly dependent on its own capacity and that of its partners, including local public health departments and the U.S. Customs and Border Protection (CBP).

Coordination with travel industries is also an important example. The DGMQ’s Quarantine Travel Epidemiology Team responds to reports of illness or exposure to disease that take place on airplanes, cruise ships, and cargo ships. The team works with state and local health departments, as well as with international partners, to facilitate contact investigations. This network of partnerships serves as the organizational and operational framework for implementing policies and activities to prevent and control the onward transmission of communicable diseases.

The COVID-19 pandemic has revealed opportunities to strengthen these relationships to facilitate coordination for future events. Making these relationships ongoing can help to ensure effective collaboration at the outset of an emergency. Regular engagement with jurisdiction-level

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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stakeholders would facilitate clear and effective streams of communication. It will also be important to obtain perspectives from a broad range of stakeholders through a robust engagement process while policies are being developed and before they are finalized. Forming partnerships with academic institutions could also be helpful in analyzing the effectiveness of mitigation measures from previous public health emergencies to better understand the science behind the decisions including the economic cost of pandemic related measures.

Recommendation 5-1: The Division of Global Migration and Quarantine (DGMQ) should strengthen partnerships through defined and planned activities that enhance working relationships and continue to build trust.

To do so, the DGMQ should implement these specific measures:

  1. Improve collaboration with international partners through regularly scheduled forums:
    1. Actively engage in the International Health Regulations (IHR) revision process.
    2. Ensure the continuity of binational collaborations in border areas to facilitate the development of trust between partners. Participate with other agencies and partners in the development and implementation of a harmonized approach to border measures with Mexico and Canada that features common protocols for disease surveillance and response in border areas.
  2. Improve coordination between federal and state, tribal, local (county and city), or territorial (STLT) health agencies and strengthen international collaboration and engagement of quarantine officers.
    1. Develop a Federal Interagency Workgroup with input from STLT partners.
    2. Strengthen isolation and quarantine preparedness planning.
      1. Define federal and STLT roles and responsibilities.
      2. Understand and plan for variation in how STLT entities implement public health legal authorities.
      3. Implement a federal and STLT tabletop exercise program to bring together relevant quarantine stakeholders to practice coordination periodically, especially in regions containing quarantine stations.
    3. Ensure pre-decisional input and engagement from STLT health agencies. It is critically important that DGMQ guidance and documents are informed by ground-level local (county and city) health agencies.
Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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      1. Work to align DGMQ interventions with local public health activities to avoid overburdening the local public health system.
  1. Improve coordination with aviation and maritime industries for border/traveler health issues and mandates:
    1. Build on coordination mechanisms established during the COVID-19 pandemic between aviation and maritime industries with STLT health agencies and the DGMQ. Examples of mechanisms for coordination include an Interagency Federal Workgroup, Memoranda of Agreement (MOA), Standard Operating Procedures (SOPs), emergency planning, drills, and exercises.
    2. Improve DGMQ engagement with regulated industries (e.g., cruise ship lines).
      1. Establish clear and consistent structure for communication.
      2. Develop clear objectives (e.g., safety and relative risk).
      3. Share and evaluate best practices at domestic and international ports.

Recommendation 5-2: The Division of Global Migration and Quarantine (DGMQ) should modernize health communication efforts with and for travelers to improve public understanding of disease control efforts as well as compliance.

  1. Develop standardized communication for travelers, families of travelers, and the general public (e.g., what to expect when traveling to the United States) to ensure that travelers understand and change behaviors to follow disease control and prevention measures.
  2. Establish mechanisms to utilize airlines, airport authorities, and travel agencies to communicate messages and better inform travelers during a pandemic, emerging pandemic, or outbreak.
  3. Collaborate with the aviation industry to provide predeparture education and information sharing prior to flight boarding and during ticket purchase. Incorporate international best practices for communicating with passengers and sharing information regarding quarantine and testing requirements.
  4. Incorporate avenues for the DGMQ to share informative materials with travelers in addition to the DGMQ website.
    1. Consider the use of electronic means of communication—such as flexible text messaging tools—to reach travelers with follow-up instructions and information.
Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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  1. In order to avoid health inequities, make these communications accessible for all travelers, regardless of language, access to technologies (e.g., smartphones), disabilities, and so on.

LEGAL AND REGULATORY AUTHORITY

The CDC has broad regulatory authority to control the introduction and interstate spread of communicable diseases in the United States. During the COVID-19 pandemic, the DGMQ has exercised powers granted to the CDC under the Public Health Service Act of 1944 (PHSA) by taking actions such as (1) testing, detaining, and releasing persons entering the United States who are suspected of carrying certain communicable diseases, (2) issuing federal isolation and quarantine orders, and (3) restricting importation of animals or other items that may pose public health threats. Examples of CDC orders enacted during the COVID-19 pandemic include Federal Quarantine and Isolation Order, No Sail/Conditional Sail Order, Global Testing Order, Safe Resumption of Global Travel, and the Face Mask Order. Many of these CDC actions were challenged in, or even blocked by, the courts. Reform of laws and regulations are needed to modernize the CDC’s authorities, and to implement the committee’s recommended measures on infrastructure, workforce, data systems, as well as important reforms to ensure it has the powers required to safeguard the American public.

Concerns related to CDC regulatory actions during the pandemic are primarily based on the interpretation of the PHSA, specifically the provision that grants the CDC the authority to take “necessary measures” to prevent the introduction into or spread of communicable diseases in the United States and across state borders. It will be critical for Congress to modernize the PHSA, which was enacted before the era of mass travel, migration, trade, and close animal/human interchange. The CDC will also need to undertake rulemaking to clarify its interpretation of the broadly delineated “necessary measures” provision and adopt procedural requirements and substantive standards to govern the use of its powers.

Also relevant to the use of regulatory power is the issue of DGMQ funding. Current large-scale funding methods for public health emergencies (PHEs) are inadequate. There are several options for expediting surge-funding mechanisms, such as (1) establishing a new PHE contingency fund that can be triggered under certain criteria during a PHE and (2) establishing a fund similar to the HHS Federal Emergency Management Agency (FEMA) Disaster Relief Fund.

Recommendation 6-1: Congress should improve the legal authority and flexibility of the Centers for Disease Control and Prevention (CDC) in

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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responding to public health threats by modernizing and improving the 1944 Public Health Service Act in several ways:

  1. Give the CDC authority to effectively act to prevent or mitigate current and future public health threats. The CDC should have the authority it needs but must act consistently with scientific evidence, and only where necessary to prevent the interstate, intrastate, or international spread of infectious diseases. The CDC should also use the least restrictive alternative means that reasonably can be predicted to achieve an important public health objective.
  2. Specifically delegate congressional power to reflect what the CDC needs to carry out its mission through evidence-based measures. These delegations should provide the CDC with robust authority and the necessary flexibility to implement science-based public health measures.
  3. Include protections for individual rights and freedoms including procedural due process, where constitutionally warranted and feasible, to challenge any order under the Act.
  4. Ensure that CDC authorities are fairly and equitably utilized.

REFERENCES

Barber, R. M., R. J. D. Sorensen, D. M. Pigott, C. Bisignano, A. Carter, J. O. Amlag, J. K. Collins, C. Abbafati, C. Adolph, A. Allorant, A. Y. Aravkin, B. L. Bang-Jensen, E. Castro, S. Chakrabarti, R. M. Cogen, E. Combs, H. Comfort, K. Cooperrider, X. Dai, F. Daoud, A. Deen, L. Earl, M. Erickson, S. B. Ewald, A. J. Ferrari, A. D. Flaxman, J. J. Frostad, N. Fullman, J. R. Giles, G. Guo, J. He, M. Helak, E. N. Hulland, B. M. Huntley, A. Lazzar-Atwood, K. E. LeGrand, S. S. Lim, A. Lindstrom, E. Linebarger, R. Lozano, B. Magistro, D. C. Malta, J. Månsson, A. M. Mantilla Herrera, A. H. Mokdad, L. Monasta, M. Naghavi, S. Nomura, C. M. Odell, L. T. Olana, S. M. Ostroff, M. Pasovic, S. A. Pease, R. C. Reiner Jr, G. Reinke, A. L. P. Ribeiro, D. F. Santomauro, A. Sholokhov, E. E. Spurlock, R. Syailendrawati, R. Topor-Madry, A. T. Vo, T. Vos, R. Walcott, A. Walker, K. E. Wiens, C. S. Wiysonge, N. A. Worku, P. Zheng, S. I. Hay, E. Gakidou, and C. J. L. Murray. 2022. Estimating global, regional, and national daily and cumulative infections with SARS-CoV-2 through Nov 14, 2021: A statistical analysis. The Lancet, April 8. https://doi.org/10.1016/S0140-6736(22)00484-6.

Institute of Medicine. 2006. Quarantine stations at ports of entry: Protecting the public’s health. Washington, DC: The National Academies Press. https://doi.org/10.17226/11435.

Wang, H., K. R. Paulson, S. A. Pease, S. Watson, H. Comfort, P. Zheng, A. Y. Aravkin, C. Bisignano, R. M. Barber, T. Alam, J. E. Fuller, E. A. May, D. P. Jones, M. E. Frisch, C. Abbafati, C. Adolph, A. Allorant, J. O. Amlag, B. Bang-Jensen, G. J. Bertolacci, S. S. Bloom, A. Carter, E. Castro, S. Chakrabarti, J. Chattopadhyay, R. M. Cogen, J. K. Collins, K. Cooperrider, X. Dai, W. J. Dangel, F. Daoud, C. Dapper, A. Deen, B. B. Duncan, M. Erickson, S. B. Ewald, T. Fedosseeva, A. J. Ferrari, J. J. Frostad, N. Fullman, J. Gallagher, A. Gamkrelidze, G. Guo, J. He, M. Helak, N. J. Henry, E. N. Hulland, B. M. Huntley, M. Kereselidze, A. Lazzar-Atwood, K. E. LeGrand, A. Lindstrom, E. Linebarger,

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
×

P. A. Lotufo, R. Lozano, B. Magistro, D. C. Malta, J. Månsson, A. M. Mantilla Herrera, F. Marinho, A. H. Mirkuzie, A. T. Misganaw, L. Monasta, P. Naik, S. Nomura, E. G. O’Brien, J. K. O’Halloran, L. T. Olana, S. M. Ostroff, L. Penberthy, R. C. Reiner Jr, G. Reinke, A. L. P. Ribeiro, D. F. Santomauro, M. I. Schmidt, D. H. Shaw, B. S. Sheena, A. Sholokhov, N. Skhvitaridze, R. J. D. Sorensen, E. E. Spurlock, R. Syailendrawati, R. Topor-Madry, C. E. Troeger, R. Walcott, A. Walker, C. S. Wiysonge, N. A. Worku, B. Zigler, D. M. Pigott, M. Naghavi, A. H. Mokdad, S. S. Lim, S. I. Hay, E. Gakidou, and C. J. L. Murray. 2022. Estimating excess mortality due to the COVID-19 pandemic: A systematic analysis of COVID-19-related mortality, 2020–21. The Lancet 399(10334):1513-1536. https://dx.doi.org/10.1016/S0140-6736(21)02796-3.

Suggested Citation:"Summary." 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. doi: 10.17226/26599.
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The U.S. Centers for Disease Control and Prevention (CDC) is responsible for preventing the introduction, transmission, and spread of communicable diseases into the United States. It does this primarily through the Division of Global Migration and Quarantine (DGMQ), which oversees the federal quarantine station network. Over the past two decades, the frequency and volume of microbial threats worldwide have continued to intensify. The COVID-19 pandemic, in particular, has prompted a reevaluation of many of our current disease control mechanisms, including the use and role of quarantine as a public health tool.

The emergence of COVID-19 prompted CDC to request that the National Academies of Sciences, Engineering, and Medicine convene a committee to assess the role of DGMQ and the federal quarantine station network in mitigating the risk of onward communicable disease transmission in light of changes in the global environment, including large increases in international travel, threats posed by emerging infections, and the movement of animals and cargo. The committee was also tasked with identifying how lessons learned during COVID-19 and other public health emergencies can be leveraged to strengthen pandemic response. The report's findings and recommendations span five domains: organizational capacity, disease control and response efforts, new technologies and data systems, coordination and collaboration, and legal and regulatory authority.

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