In an age of rapid global travel and escalating microbial threats, the importation of infectious pathogens of public health significance across national borders poses a substantial threat to the United States. The Centers for Disease Control and Prevention’s (CDC’s) Division of Global Migration and Quarantine (DGMQ) works to mitigate this threat by preventing the introduction, transmission, and spread of communicable diseases. This responsibility is complex and challenging, given that the United States typically receives nearly 1 million travelers per day across the nation’s land, air, and sea ports of entry (CDC, 2021d). A cornerstone of the DGMQ’s efforts to prevent the importation of infectious diseases among this high volume of incoming international travelers is its network of quarantine stations. As of March 2022, quarantine stations were located at 20 U.S. international airports and land-border crossings with the highest concentrations of arriving international travelers. Staffed with medical and public health officers, these quarantine stations are prepared to respond when ill travelers enter the country.
As the scope, volume, and frequency of microbial threats1 have continued to intensify worldwide, the DGMQ has responded to an increasing number of infectious disease outbreaks over the past decade. Most notably, the COVID-19 pandemic—caused by severe acute respiratory syndrome
1 For the purposes of this report, microbes include bacteria, viruses, protozoa, fungi, and prions that can replicate in humans (see the 2006 National Academies report Quarantine Stations at Ports of Entry, https://www.nap.edu/catalog/11435/quarantine-stations-at-ports-of-entry-protecting-the-publics-health, accessed May 19, 2022).
coronavirus 2 (SARS-CoV-2)—emerged as an outbreak in Wuhan, China, in December 2019. Declared a pandemic by the World Health Organization on March 11, 2020, an estimated 3.4 billion people have become infected with SARS-CoV-2 (Barber et al., 2022), resulting in over 18 million excess mortalities worldwide (Wang et al., 2022). COVID-19 has caused over 466 million confirmed cases and over 6 million deaths as of March 2022. The COVID-19 pandemic has starkly demonstrated the breadth of devastating health, social, and economic consequences that an infectious disease can wreak at a global scale. Moreover, it has highlighted the critical importance of identifying and implementing effective strategies and policies to mitigate the spread of infectious diseases of public health significance across national borders.
CHARGE TO THE COMMITTEE
The committee was charged with analyzing the effectiveness of the federal quarantine station network based on lessons from the COVID-19 pandemic. As specified in the committee’s statement of task, the study was requested in order to (1) review how other relevant entities mitigate transmission risks for pathogens from arriving international travelers, (2) identify effective interventions, and (3) examine potential changes to the CDC’s infrastructure and regulatory authorities. The committee was asked to review the DGMQ’s current structure and function, including changes that have been made since the 2006 Institute of Medicine (IOM) report. It was also tasked with identifying how lessons learned during the COVID-19 pandemic and other public health emergencies can be leveraged to strengthen pandemic response. The committee’s expertise comprised health law, ethics, behavioral science, health policy, state and local public health, medicine, global health, infectious diseases, health technology, and community health. The full statement of task for this consensus study is provided in Box 1-1.
This undertaking follows a 2006 IOM report, Quarantine Stations at Ports of Entry: Protecting the Public’s Health, that had also been requested by CDC. The emergence of the COVID-19 global pandemic again prompted CDC to request that the National Academies of Sciences, Engineering, and Medicine convene a committee to conduct an external assessment of 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.
Scope of Work
The committee worked to identify effective interventions and best practices for the context of a U.S.-specific response to a future pandemic. This involved consideration of the complexity and capacity restraints in mitigating disease introduction, safeguarding mobile populations and the travel industry, and implementing innovative data systems and analytics.
Such constraints include (1) scale limitations for health screening and data collection at U.S. airports; (2) challenges for gathering, analyzing, reporting, and validating data; (3) interoperability challenges between agency and partner networks in supporting public health; and (4) law and policy challenges related to the use of federal orders and the management of movement restrictions on large groups.
The committee reviewed needed changes in the CDC’s infrastructure and regulatory authorities pertaining to
- how the DGMQ may leverage innovative approaches to data systems and/or analytical methods to mitigate scale limitations for current processes;
- potential changes to regulations to implement recommended measures;
- the scope of responsibilities and types of partners needed at quarantine stations;
- how best to support health departments and other partners in mitigating disease transmission; and
- optimal types of staff and scheduling at CDC quarantine stations and headquarters.
In developing this report and its recommendations, the committee deliberated for approximately 5 months, from November 2021 through March 2022. Their activities included four virtual meetings of 3 days each and one hybrid meeting of 2 days. Each of the virtual meetings included sessions open to the public; all public meeting agendas can be found in Appendix B. The committee’s recommendations are directed at the CDC—specifically the DGMQ—and other stakeholders relevant to the Division’s mission and operations.
The committee developed an approach for addressing each topic in the statement of task. Comparing international approaches to disease mitigation is an important item in the Statement of Task, and the National Academies commissioned a paper to be written that assessed a variety of disease control strategies implemented globally during the COVID-19 pandemic. International public health leaders were also invited to speak to the committee regarding COVID-19 mitigation measures implemented within their countries. Due to the context-specific nature of these measures and the committee’s charge to develop recommendations specifically for the DGMQ, the committee decided not to include a detailed comparison of international approaches within this report, finding that this would detract from the focus of the report. Chapter 3 contains a description of the evidence presented for various disease control measures.
CURRENT FEDERAL QUARANTINE STATION NETWORK
Currently, the DGMQ operates a network of 20 quarantine stations located in U.S. ports of entry with high international travel volume. Notably, these stations are not physical areas through which incoming travelers pass into the United States. Rather, the term “quarantine station” refers to a group of individuals who perform activities designed to mitigate the risk of microbial and other threats of public health significance entering the United States (Institute of Medicine, 2006). Collaborating with other federal agencies such as Customs and Border Protection (CBP), the quarantine stations cover all 320 CBP U.S. ports of entry.2 This report uses the term “port of entry” to mean any air, land, or seaport through which people, cargo, and conveyances may legally enter the United States from abroad.
The DGMQ is comprised of three branches: (1) Quarantine and Border Health Services; (2) Immigrant, Refugee, and Migrant Health; and (3) Travelers’ Health; and two units: (1) United States–Mexico; and (2) Community Interventions for Infection Control. The Quarantine and Border Health Services Branch—one of the largest branches or units within the CDC in terms of number of federal employees and contractors—oversees 18 quarantine stations located within U.S. international airports as of March 2022 (Brown et al., 2021), The United States–Mexico Unit operates the two quarantine stations serving land-border crossings with Mexico. The stations are located in El Paso, Texas, and San Diego, California. Figure 1-1 depicts the geographic distribution of these quarantine stations across the United States. In addition to the 20 quarantine stations, the DGMQ operates three international field offices in Kenya, Thailand, and Mexico (CDC, 2021a).3,4
Expansion of the Quarantine Station Network
Almost a century after the first quarantine station was built at Philadelphia’s port in 1799 after a yellow fever outbreak, the passage of the National Quarantine Act (1878) shifted some quarantine powers from the state to the federal level.5 In 1944, the federal government’s quarantine
2 CBP’s use of “port of entry” refers to an administrative center whose jurisdiction may include more than one entry facility in a certain geographic area (e.g., the Philadelphia Port of Entry services Philadelphia International Airport, Philadelphia’s seaport, Trenton Mercer Airport, Atlantic City International Airport, and ports in Lehigh Valley, PA) (Institute of Medicine, 2006). Thus, the United States has over 470 literal ports of entry and 320 CBP ports of entry.
3 More information about CDC quarantine stations can be found at https://www.cdc.gov/quarantine/quarantine-stations-us.html (accessed February 26, 2022).
4 This text was modified after release of the report to the study sponsor to correctly reflect the number of international field offices.
5 More information about the history of quarantine in the United States is available from https://www.cdc.gov/quarantine/quarantine-stations-us.html (accessed March 23, 2022).
power was codified in the Public Health Service Act of 1944 (PHSA) and, in 1967, the CDC’s predecessor National Communicable Disease Center assumed federal quarantine functions. Throughout the 1970s, the CDC’s network of quarantine stations was reduced from more than 50 to fewer than 10 based on the presumption that infectious diseases no longer posed a major public health threat. However, anthrax attacks using contaminated letters (2001) and a severe acute respiratory syndrome (SARS) outbreak (2003) renewed concerns about bioterrorism and infectious disease threats and catalyzed the expansion of the federal quarantine station network. In fiscal year 2003, Congress began allocating funds for an expansion to a total of 25 quarantine stations at ports of entry including airports, seaports, and land-border crossings (Institute of Medicine, 2006).
Prior to 2004 the network consisted of quarantine stations located at eight international airports—New York (JFK), Miami, Chicago, Los Angeles, Atlanta, San Francisco, Honolulu, and Seattle—with limited staffing. In 2005, the network expanded to include quarantine stations at the airports in Washington, DC; Houston; Newark; Boston; Detroit; Minneapolis; Anchorage; and San Juan; two stations serving U.S.–Mexico land-border crossings were also created that year in El Paso and San Diego. In 2007, spurred by an IOM consensus study report, quarantine stations in Philadelphia and Dallas were added to the network. The report also recommended five additional locations in Charlotte, New Orleans, Phoenix, Denver, and Kansas City, but those have not yet been established. Thus, the number of quarantine stations increased by almost three-fold in 3 years—from 8 in 2004 to 20 in 2007—but no new quarantine stations have been established since 2007.
The DGMQ’s network of quarantine stations is responsible for executing a range of activities to protect the public’s health at U.S. ports of entry by rapidly responding to sick travelers who arrive in the United States, alerting travelers about disease outbreaks, and restricting the importation of animals and products that may carry disease. The key roles and responsibilities of DGMQ quarantine stations are outlined in Box 1-2. Among those roles is the delegated authority to implement isolation and quarantine for individuals under specific circumstances. Isolation separates individuals who are proven or highly suspected of being sick with a designated infectious disease of consequence from individuals who are not sick. Quarantine separates and restricts the movement of people who were exposed to an infectious disease to see if they become sick. Although quarantine and isolation functions at national borders are critical tools for limiting the importation and spread of infectious disease threats, their effectiveness varies based on the type of threat and the extent of its current spread (Institute of Medicine, 2006).
The federal government has legal authorities6 to implement isolation and quarantine measures to help prevent the public’s exposure to an individual who has or may have specific infectious diseases of great public health risk (CDC, 2021b). An executive order by the president authorizes federal isolation and quarantine for a specific set of infectious diseases; this list can also be revised by the president through executive order. Currently, isolation and quarantine are federally authorized for cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers (i.e., Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named), SARS, influenza caused by novel or
6 The authority for isolation and quarantine derives from the Commerce Clause of the U.S. Constitution. Under section 361 of the Public Health Service Act (42 U.S. Code §264), the U.S. Secretary of Health and Human Services is authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states. Isolation and quarantine also are considered “police power” functions that are derived from the state’s right to take action affecting individuals for the benefit of society. (Source: https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html; accessed March 15, 2022.)
reemergent influenza viruses that are causing—or have the potential to cause—a pandemic, and measles (CDC, 2021b).
The U.S. Department of Health and Human Services (HHS) has delegated its federal authority7 to carry out isolation and quarantine functions to the CDC. Thus, if an individual who arrives at a U.S. port of entry—via air travel, maritime travel, or land-border crossing—has a suspected or confirmed case of a designated quarantinable infectious disease, quarantine station staff have the delegated authority to detain, medically examine, or conditionally release that individual. The CDC’s authority to order that such individuals be medically evaluated can supersede the public health powers of states and localities under specific circumstances (Institute of Medicine, 2006). However, despite these authorities, the CDC has traditionally deferred to state and local public health officials to implement isolation and quarantine in such instances. During the outset of the COVID-19 pandemic, however, the CDC implemented isolation and quarantine for individuals entering the United States from Hubei Province, China, and two cruise ships with identified outbreaks (CDC, 2020).8
2006 IOM REPORT AND SUBSEQUENT DEVELOPMENTS
The 2006 IOM consensus study report Quarantine Stations at Ports of Entry: Protecting the Public’s Health provided a set of recommendations about how the DGMQ’s quarantine station network could strengthen its capacities to mitigate disease importation and its response to infectious threats at the nation’s borders (Institute of Medicine, 2006). Key recommendations from that report include
- increasing U.S. efforts and providing sufficient financial resources to minimize microbial threats from travelers;
- working with partners to harmonize authorities for sufficient contact data;
- enhancing the competencies, number of staff, space, and technological capacity of the quarantine stations with an expansion to 25 stations;
- conducting periodic review of processes and optimal locations of quarantine stations;
7 Under 42 Code of Federal Regulations parts 70 and 71, the CDC is authorized to detain, medically examine, and release persons arriving into the United States and traveling between states who are suspected of carrying these communicable diseases. (Source: https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html; accessed March 15, 2022.)
8 This text was modified after release of the report to the study sponsor to correctly reflect and specify where isolation and quarantine orders were implemented.
- developing proper surge capacity for emergencies with deployment of CDC assets and hiring plans, including locations for isolating travelers and communication plans to interface with health care staff and media;
- developing a research agenda to examine basic public health interventions for use in the system; and
- developing scientifically sound tools to measure the effectiveness and quality of operations at the quarantine stations.
In response to these recommendations, the DGMQ increased the ability to conduct risk assessment for microbial threats. The DGMQ also developed a series of tools and practices including a data system to catalogue all events occurring at quarantine stations and support follow up activities for ill travelers, such as documenting diagnostic test results. However, post-arrival public health follow-up has been limited due to failure to implement an electronic traveler contact data collection system.9 In addition to expanding the number of quarantine stations in the network, the stations have been revamped in response to the recommendations made in the 2006 report. However, not all of the other recommendations have yet been incorporated due to a decision to instead expand additional international locations. Offices in Kenya, Thailand, and Mexico were established to support these activities.
In its work, this committee was asked to further identify effective interventions and best practices to mitigate disease introduction into the United States. This undertaking involves consideration of numerous challenges specific to developments since the 2006 report was published. Chapter 2 outlines the increased responsibilities outbreak mitigation efforts have entailed in recent years. Over the past decade, regular emergencies have become part of normal operations—see Figure 2-2. This reflects a greater need to build preparedness into the structure of the DGMQ. Although operating costs have risen dramatically since 2014, the majority of this funding has come from response-specific and reimbursable funds, while programmatic core funds have been slow to increase. Furthermore, the DGMQ’s staffing needs have grown considerably. While permanent full-time employee positions have seen only modest growth since 2008, the total full-time equivalent—which includes contractors and other nonpermanent positions—has grown more than five-fold in the same time period (Damon, 2022). This study assesses the DGMQ and its needs in the context of the frequent emergence of disease threats.
The COVID-19 pandemic has presented myriad challenges and involved large-scale isolation and quarantine response efforts, some of which
9 This text was modified after release of the report to the study sponsor to correctly describe the tools and practices used by the DGMQ.
had never before been implemented. The committee reviewed the effectiveness of these efforts and highlighted lessons yielded from the pandemic response. They also explored the proliferation of technological developments that have emerged since the 2006 report in order to recommend strategies to leverage and optimize current capabilities.
This study also takes into account critical issues regarding ethics and equity that must be considered when developing and implementing a public health response to emerging threats—particularly given the rapid advancement of technological innovations for disease surveillance and mitigation as well as the existing inequities that have been highlighted by the COVID-19 pandemic. It is increasingly imperative to employ measures that do not further exacerbate these inequities. Ethical risks must also be considered when designing infectious control strategies, especially those that employ novel, powerful digital technologies and data systems. To guide its deliberations, the committee identified a set of key ethical principles: (1) protecting privacy, (2) maintaining autonomy, (3) promoting equity, (4) minimizing the risk of error, and (5) ensuring accountability.
The global impact of the COVID-19 pandemic revealed the broad range of partners with which the DGMQ must engage to effectively execute its roles and responsibilities in mitigating transmissible disease threats, including federal interagency partners; state, tribal, local, and territorial agencies; international partners; and private-sector entities. This study highlights the critical importance of fostering trust and strengthening the DGMQ’s functional working relationships across agencies and sectors to effectively counter future infectious disease threats.
Additionally, the COVID-19 pandemic demonstrated that public health authority designated by legislation enacted before the age of large-scale global travel needs to be modernized. Thus, the committee has recommended a set of policy changes to expand authorities and streamline funding for emergency events.
STRUCTURE OF THE REPORT
This report is organized to reflect five primary factors that determine the effectiveness of the federal quarantine station network, as identified by the statement of task and the expert committee. These factors are organizational capacity; disease control and response efforts; new technologies and data systems; coordination and collaboration; and legal and regulatory authority. Chapter 2 provides an overview of the organizational capacity of the DGMQ, highlighting key issues surrounding workforce, financials, infrastructure, and culture within the division. Chapter 3 describes the DGMQ’s role in infectious disease control and provides an assessment of various disease mitigation measures. Chapter 4 describes the technol-
ogy that has been implemented by the DGMQ and details innovations developed during the COVID-19 pandemic—both in the United States and abroad—that can be adopted to increase the DGMQ’s capacity for surveillance and data sharing. Chapter 5 describes the partnerships with federal, state, and local health authorities that the DGMQ relies on to fulfill its mission. Chapter 6 offers a detailed analysis of the legal and regulatory framework that underpins the DGMQ’s authority, addressing mechanisms for modernizing applicable public health response powers.
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.
Brown, C., F. Alvarado-Ramy, and A. Klevos. 2021. To screen or not to screen? There’s more to border health than interventions at our borders: CDC. Presentation to the National Academies of Sciences, Engineering, and Medicine Committee on Analysis to Enhance the Effectiveness of the Federal Quarantine Station Network.
CDC (Centers for Disease Control and Prevention). 2020. CDC issues federal quarantine order to repatriated U.S. citizens at March Air Reserve Base [Media Statement]. https://www.cdc.gov/media/releases/2020/s0131-federal-quarantine-march-air-reserve-base.html (accessed May 18, 2022).
CDC. 2021a. Laws and regulations. Division of Global Migration and Quarantine (DGMQ). https://www.cdc.gov/ncezid/dgmq/laws-and-regulations.html (accessed May 18, 2022).
CDC. 2021b. Legal authorities for isolation and quarantine. https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html (accessed March 15, 2022).
CDC. 2021c. Quarantine and border health services. Division of Global Migration and Quarantine (DGMQ). https://www.cdc.gov/ncezid/dgmq/focus-areas/quarantine.html (accessed February 28, 2022).
CDC. 2021d. Who we are. Division of Global Migration and Quarantine (DGMQ). https://www.cdc.gov/ncezid/dgmq/who-we-are.html (accessed February 25, 2022).
Damon, J. 2022. Review of budget and staffing—DGMQ funding, staffing, and turnover data 2019–2021: CDC. Presentation to the National Academies of Sciences, Engineering, and Medicine Committee on Analysis to Enhance the Effectiveness of the Federal Quarantine Station Network.
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, 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.
This page intentionally left blank.