Improving Coordination and Collaboration
The Centers for Disease Control and Prevention (CDC) Division of Global Migration and Quarantine (DGMQ) accomplishes its duties through a mixture of regulatory authorities as well as operating partnerships. Because of the nature of the quarantine function, these partnerships are with both domestic and international partners in government and the private sector—other nation’s quarantine and disease control organizations; U.S. federal agencies; state, tribal, local and territorial (STLT) agencies; and private sector aviation and maritime industries. Any industry that moves people or goods is a potential partner of the DGMQ because of the disease control nature of their mission. Together, this constellation of partnerships serves as the organizational and operational framework for implementing policies and activities to prevent and control the onward transmission of communicable diseases. There is an opportunity to strengthen these working relationships to achieve better operational efficiencies and improve overall disease control efforts. By strengthening these working relations through predefined strategies, the DGMQ can improve accomplishing its core missions. As with all partnerships, the goal is achieving the mission while optimizing the outcomes for partners.
The COVID-19 pandemic has also revealed a wide range of partners with whom the CDC, and specifically the DGMQ, ought to have significant functional relationships. While some work is accomplished through the DGMQ’s regulatory authority, most of the division’s work is accomplished through working relationships with both governmental and predominantly nongovernmental partners. These relationships are best nurtured by regular formal engagement to solve problems and address issues before a serious emergency occurs, not in the midst of one. The pandemic has also revealed
opportunities to strengthen relationships with STLT agencies as well as international and private industry partners. This chapter synthesizes approaches for improving coordination and collaboration among federal, state, local, and international partners and systems to protect communities across the United States from infectious disease threats.
COLLABORATION WITH KEY PARTNERS
Collaboration with Federal Interagency Partners
The CDC’s DGMQ partners with a range of federal interagency partners—both within HHS and across other departments, including
- U.S. Department of Health and Human Services (HHS)
- Office of the Assistant Secretary for Preparedness and Response (ASPR)
- Office of Global Affairs (OGA)
- Administration for Children and Families (ACF)
- Office of Refugee Resettlement (ORR)
- Food and Drug Administration (FDA)
- U.S. Department of Homeland Security (DHS)
- Countering Weapons of Mass Destruction Office (CWMD)
- U.S. Customs and Border Protection (CBP)
- U.S. Coast Guard (USCG)
- Transportation Security Administration (TSA)
- U.S. Citizenship and Immigration Services (USCIS)
- DHS/CBP-National Targeting Center (NTC)
- Immigration and Customs Enforcement (ICE)
- U.S. Department of Defense (DoD)
- U.S. Department of Transportation (DOT)
- Federal Aviation Administration (FAA)
- Federal Transit Administration
- Federal Railroad Administration
- U.S. Department of State (DOS)
- Bureau of Population, Refugees, and Migration
- Bureau of Consular Affairs
- American Citizens Services and Crisis Management1
- Department of Justice (DOJ)
- U.S. Department of Agriculture (USDA)
- Animal and Plant Health Inspection Service (APHIS)
1https://www.usa.gov/federal-agencies/american-citizens-services-and-crisis-management (accessed April 15, 2022).
U.S. Department of the Interior (DOI)
- U.S. Fish and Wildlife Service (FWS)
For example, Figure 5-1 shows the agencies involved in importation of animals at ports of entry.
Collaboration with the Department of Homeland Security
The missions of DHS and the DGMQ intersect in terms of protecting the public, safeguarding borders, enabling legitimate trade and travel, and providing services to immigrants, refugees, and travelers (see Figure 5-2). DHS and the CDC partnered in supporting the U.S. government response to COVID-19,2 information sharing, and providing operational support to enhance screening and testing for COVID-19 and for Ebola during the 2014–2016, 2019, and 2021 outbreaks (Rasicot, 2021). DHS interagency coordination during the COVID-19 pandemic led to a number of international travel orders, including a mask mandate, vaccine order, global testing order, and contact data collection. Other interagency coordination efforts include the Runway to Recovery framework, which provides guidance to airports and airlines to mitigate the effects of COVID-19 on travel. Developed by DHS, DOT, and HHS,3 Runway to Recovery includes steps
2 More information about the CDC Strategy for Global Response to COVID-19 can be found at https://www.cdc.gov/coronavirus/2019-ncov/global-COVID-19/global-response-strategy.html (accessed March 6, 2022).
3 More information about the Runway to Recovery guidance can be found at https://www.transportation.gov/sites/dot.gov/files/2022-02/Runway_to_Recovery_1.1_DEC2020_Final-508.pdf (accessed March 6, 2022).
for complying with CDC guidance regarding COVID-19 and encourages data collection to support the CDC’s contact tracing activities. The USCG coordinated efforts with CDC to facilitate the Conditional Sailing Order.4 Gary Rasicot, acting assistant secretary of the CWMD at DHS, identified steps needed to enhance the partnership between DHS and the DGMQ: longer term solutions that do not rely on emergency funding; memorializing the CWMD Operational Support to the DGMQ; and augmenting feedback and adaptation (Rasicot, 2021).
DHS and the DGMQ partner in safeguarding national borders from the introduction and spread of infectious diseases. The United States has more than 320 ports of entry, 20 of which have CDC quarantine stations (Division of Global Migration and Quarantine, 2021). These quarantine stations are staffed with CDC medical and public health officers who coordinate medical treatment or cases and contact investigations with local public health and medical officials. DHS’s CBP does initial screening of all travelers at all of the ports of entry including at preclearance ports located in a few other countries, for visible signs of illness. If CBP identifies a traveler that meets predetermined health risk criteria provided by the CDC, they refer those travelers to the CDC quarantine station staff. At the ports of entry where there are quarantine stations the DGMQ staff may sometimes perform this activity in person, and for all of the other points of entry (POEs) they support CBP remotely by telephone. While the 20 CDC quarantine stations cover all of the POEs, CBP officers serve as “eyes, ears, and hands for CDC and HHS.” The DGMQ trains CBP officers to identify overt signs of quarantinable and other communicable diseases, which allows CBP officers to make an initial determination that a traveler may be ill. The CDC also provides job aids (RING cards) to support this function. The traveler is then referred to the CDC or a local public health official qualified to make a diagnosis. CBP staff do not diagnose illness; they only determine whether a traveler may be ill based on overtly identifiable signs or travel history (HHS and CDC, 2016; CRS, 2014). The DGMQ also collaborates with the CBP National Targeting Center to obtain passenger records to support contact tracing on flights where a traveler may have been ill (CBP, n.d.; DHS, 2020). The DGMQ also works with CBP to identify CDC-regulated animals, animal products, biologics, and human remains that pose a potential threat to human health and to ensure that CDC regulatory requirements are met (CBP, n.d.; DHS, 2020, 2022; Gursky and Batni, 2012; HHS and CDC, 2016; Seghetti, 2014).
4 More information about the Conditional Sailing Order can be found at https://www.cdc.gov/quarantine/cruise/COVID19-cruiseships.html (accessed March 6, 2022).
Collaboration with the Transportation Security Administration
The DGMQ also coordinates with the TSA, which has responsibility for the security of private and commercial aviation. The TSA partners with the CDC/DGMQ in two important areas: by administering the Do Not Board list (CDC, 2022b) for certain infectious travelers who are noncompliant with local public health advice not to travel, and by issuing Security Directives and Emergency Amendments to impel commercial air carriers to implement measures consistent with CDC directives like a mask mandate. For individuals to be placed on the Do Not Board list, they have to be actively infectious, demonstrate they are noncompliant with public health isolation orders, and have an intent to board a commercial aircraft. If these criteria are met the DGMQ requests that the TSA put those individuals on a list that prevents them from obtaining a boarding pass.
The DGMQ also works with the TSA to implement certain public health measures in commercial aviation, such as the federal mandate requiring masking in airports and on all flights (CDC, 2022a; TSA, 2022). Additionally, the DGMQ works with USCIS to provide technical instructions and assistance for Civil Surgeons who perform required medical examinations for individuals seeking to change their immigration status within the United States (i.e., to become lawful permanent residents). Figure 5-2 illustrates the complementary missions of the DHS and the DGMQ.
Collaboration with the U.S. Department of Health and Human Services
The DGMQ works with the ORR to support refugee health programs for newly arrived refugees and it provides technical assistance regarding health programs for individuals staying at emergency intake sites while seeking asylum in the United States. The division also collaborates with the OGA on preparedness and response to pandemics and emerging threats and in addressing travel policies as part of the Global Health Security Initiative including the activities to strengthen U.S.–Mexico land border preparedness. The DGMQ also meets with Canadian counterparts monthly or more frequently (as has been the case during the COVID-19 pandemic) to engage in bilateral discussions, exchange information, or plan joint exercises (e.g., for an ill passenger on a train or bus). Additionally, it coordinated with the ACF to support individuals under federal quarantine or isolation orders after being repatriated from Wuhan, China, and during Operation Allied Welcome movement of persons from Afghanistan to the United States.
Collaboration with the U.S. Department of State
The DGMQ works with the DOS to support the required overseas immigrant and refugee medical examinations conducted by panel physicians. The DGMQ provides technical instructions and support to the panel physicians to conduct the exam. The DGMQ also works with the DOS on exemptions to COVID-related travel requirements (e.g., testing and vaccination requirements). The DGMQ also works with the DOS on preventive health programs (screening, vaccination, and presumptive treatment) for U.S.-bound refugees. The DGMQ provides information to the DOS to share with travelers via U.S. embassies regarding diseases of public health concern that may impact travelers and their pets.
Collaboration with Other Federal Partners
The DGMQ is responsible for regulating animals or animal products that pose a public health risk and restricting their entry to the United States (CDC, 2021c). In so doing, the DGMQ coordinates with other regulatory entities. Before the restriction of an animal or article is issued, the CDC must coordinate with other federal partners, including the USDA, the FDA (another partner within HHS), and the FWS (within DOI). The DGMQ works with the USDA and, specifically, APHIS to coordinate changes to animal and animal product importation regulations and to respond to importation events that result in denials of entry to the United States. This coordination aims to balance public health issues with private property rights, implications for the global economy and foreign relations, and
public interests such as the availability of service animals for people with disabilities (HHS and CDC, 2016).
Collaboration with State, Local, Tribal, and Territorial Partners
Like its coordinated efforts with federal interagency partners, the DGMQ collaborations with various STLT partners are critical in preventing onward transmission of infectious diseases. Local and state jurisdictional health departments contribute to preventing and responding to infectious disease outbreaks in a range of invaluable ways, from surveillance activities to the deployment of immunizations to the delivery of screening, care, and treatment.
The HHS ASPR coordinates the overall public health response to a disease outbreak. If a public health event requires a federal response, the ASPR leads the National Response Framework Emergency Support Function (ESF) #8 (Public Health and Medical Services) (FEMA, 2008) on behalf of the HHS secretary. The ASPR spearheaded the medical countermeasure program through personnel deployment to support medical and quarantine facilities and provided needed equipment for surge demands in 2020 to protect the American population from COVID-19 spread (HHS, 2021). Through regular ESF8 conference calls and messages, ESF8 provides assistance to STLT partners. The National Association of County and City Health Officials (NACCHO) works to strengthen the capacities of local health departments to prevent and control the transmission of infectious diseases.5 The Association of State and Territorial Health Officials (ASTHO) supports state and territorial public health agencies in outbreak response and prevention through the provision of immunization services and infectious disease prevention programs; its programmatic and policy work has a strong focus on improving health equity in the realm of infectious disease prevention and control.6 The Council of State and Territorial Epidemiologists (CSTE) is also a key partner, particularly in the areas of developing public health policy and strengthening epidemiological capacity.7 The Association of Public Health Laboratories (APHL) is also another important partner in building laboratory systems for detecting
5 More information about NACCHO’s work in infectious disease prevention and control is available from https://www.naccho.org/programs/community-health/infectious-disease (accessed March 8, 2022).
6 More information about ASTHO’s work in infectious disease prevention and control is available from https://www.astho.org/topic/infectious-disease (accessed March 8, 2022).
7 More information about CSTE is available from https://www.cste.org/page/about-cste (accessed March 8, 2022).
public health threats across the nation and globally.8 Although coordination and collaboration occur between federal and STLT partners, the CDC does not have legal authority over these entities for many of the needed public health responses.
Collaboration with International Partners
In working to mitigate the public health risks associated with global travel, the DGMQ collaborates with international partners. Much of this collaboration takes place in the division’s Immigrant, Refugee, and Migrant Health (IRMH) branch, which strives to strengthen health systems at country borders and improve the health of immigrants, migrants, and refugees bound for the United States (CDC, 2021b). The IRMH branch’s international partners include the World Health Organization (WHO); the United Nations Refugee Agency; the International Organization for Migration; and country governments, customs, immigration, and security agencies. International partners support the IRMH branch in conducting mandatory overseas medical examinations of immigrants and refugees, transmitting examination records to U.S. partner agencies and organizations, and facilitating continuity of care for these mobile populations. Additionally, the IRMH branch collaborates with international partners in border areas to develop technical capacities, including the development of tools to improve the collection and use of data to monitor population movement and disease spread. The United States–Mexico Unit (U.S. M.U.) of the DGMQ partners with Mexico’s ministry of health to address multiple binational health issues related to the border region and maintains a field office in Mexico (CDC, 2019, 2021d).
International collaboration is highlighted in the CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) 2018–2023 strategic plan, which includes the strategy to “improve international collaboration and capacities for emerging infectious disease prevention, surveillance, control and research” (NCEZID, 2018, pg. 11). Given its focus on international mobility, the DGMQ stands to play an important role in achieving this goal. Although international collaboration is essential in responding to global health risks, it is not easily achieved and involves tradeoffs during a crisis (Bump et al., 2021; Fry et al., 2020). The COVID-19 pandemic response demonstrated challenges to international collaboration that include (1) patterns of self-interested nationalism, particularly with regard to vaccine and medication access; (2) politicization of the pandemic response; (3) varying levels of collaboration between countries and WHO and other
8 More information about APHL is available from https://www.aphl.org/aboutAPHL/Pages/default.aspx (accessed March 8, 2022).
multilateral agencies; (4) mistrust regarding data sharing; (5) institutional fragmentation; and (6) budgetary manipulation of WHO by some nations (Bump et al., 2021). Additionally, the time-sensitive nature of COVID-19 policy and research led to a prioritization of efficiency over collaboration (Fry et al., 2020).
The International Health Regulations (IHR) of 2005 are a mechanism for enhancing global collaboration for improved public health. The IHR are a legally binding framework of rights and obligations pertaining to public health events that have the potential to cross borders. These regulations outline the criteria of a “public health emergency of international concern” and include the requirements that countries establish and maintain surveillance and response capacities, report public health events, and comply with WHO communications expectations (WHO, n.d.).9 Although the IHR have been adopted by 196 countries, their implementation requires substantial modifications in order to realize their potential (Gostin and Katz, 2016). The NCEZID 2018–2023 strategic plan underscored the importance of advancing the adoption of IHR and other global health policies in strengthening the global capacity to prevent, detect, and respond to international outbreaks of public health concern (NCEZID, 2018). The Committee received presentations indicating that many countries did not act in ways consistent with their IHR requirements, a further indication of the need for the IHR to be updated (Hoffman and Poirier, 2022). The U.S. government designated CDC quarantine stations as the competent authority to support the implementation of the IHR at U.S. POEs (CDC, 2021a). The quarantine stations are charged with preventing unwarranted restrictions on traffic and trade—thereby avoiding unnecessary disruptions—as they fulfill the responsibility of IHR implementation.
A special case of collaboration with international partners is the required interaction of the quarantine stations with agents across U.S. international land borders. This includes Mexican and Canadian public health agencies, ministries of health, and migration and travel-related authorities in those countries. Interactions occur regularly at the local level, but also include exchanges of information and other activities in agreement with the federal/national levels of those agencies and authorities. These public health and migration partnerships across the U.S.–Mexico and U.S.–Canada land borders allow the DGMQ to identify and respond to potential threats to public health. It also enables the DGMQ to locate people with confirmed cases of infectious diseases who need to be followed up once they enter U.S. territory.
9 More information about the International Health Regulations is available from https://www.who.int/health-topics/international-health-regulations#tab=tab_1 (accessed March 9, 2022).
In the case of the Mexico–U.S. border, multiple cross-border coordination efforts are already in place, including initiatives such as the Binational Infectious Disease Surveillance (BIDS), the U.S.–Mexico Health Commission, and other ad hoc or sporadic activities such as capacity building, conferences, and public health investigation activities. The strength of collaboration between the CDC and its international partners in the region is thus based on a long-established relationship of the public health community on both sides of the border area. Still, according to public health experts who took part in a recent seminar on the impact of the COVID-19 pandemic on the border region, some challenges remain: (1) ensuring the sustainability of collaborations by ensuring that coordination mechanisms in both sides of the border have an adequate budget to continue operating; (2) moving forward toward the establishment of common protocols for surveillance and other public health actions at the border crossings and in the border regions; and (3) ensuring that the federal levels of each country understand and respond to the unique needs of border areas (Bojorquez-Chapela, in press; Fernández De Castro et al., in press).
Coordination with Airline and Maritime Industries
The DGMQ’s role in preventing the introduction and transmission of infectious diseases into the United States involves coordination with airline and maritime industries. The Division’s Quarantine Travel Epidemiology Team works with staff at the quarantine stations to respond to reports of illness or exposure to disease related to air or maritime travel when contact investigations are indicated. Its aviation activity works with STLT health departments, as well as with international partners, to facilitate aircraft contact investigations (Brown et al., 2021). Its Maritime Activity works with quarantine stations staff and maritime industry partners to respond to illnesses and outbreaks on ships as well as facilitate contact investigations among ship travelers. The majority of these illnesses—80 percent—take place on cruise ships, with the remaining 20 percent reported from cargo ships. The team facilitates maritime contact investigations among ship crew and passengers.10 The DGMQ participated during the COVID-19 pandemic in industry calls coordinated by the FAA for airlines or by the DOT for surface transport to help industries remain informed about COVID-19 public health guidance and requirements and to provide a forum for engaging these industries.
Currently, the CDC collects information about airline passengers from CBP through the Advance Passenger Information System (APIS) and Passenger Name Records (PNR). Additionally, the airline industry is required
10 This text was changed after release of the report to the study sponsor to clarify the role of DGMQ in maritime contact investigations.
to provide HHS and the CDC with any requested passenger data, according to the 2017 “Final Rule for Control of Communicable Diseases: Interstate and Foreign.”11 The final rule does not impose any new burdens on the airline industry. Instead, it codifies the current practice of HHS/CDC receiving a passenger manifest, if needed, and being provided with any data in an airline’s possession.
The COVID-19 pandemic response required increased screening measures. In January 2020 the CDC instituted an enhanced screening program to reduce the importation of COVID-19 into the United States and slow its spread (Dollard et al., 2020). With support from DHS, the CDC screened passengers arriving from countries with widespread transmission of SARSCoV-2 or with symptoms of the virus. The CDC and the FAA issued joint occupational health and safety guidance for airline crew members.12 This guidance delegated post-arrival management of crew members to airline occupational health programs.
The COVID-19 pandemic posed multiple challenges to the airline and maritime industries. A study that examined international governance, communication, and response found that the travel health system did not provide early and appropriate risk warnings and alerts concerning cruise ship travel during the COVID-19 pandemic, and that this led to increasing numbers of infections on cruise ships (Zhou et al., 2020). The study concluded that multilateral coordination, cooperation, and collaboration mechanisms are needed between governments, organizations, and industry to improve travel health. The DGMQ has an important role to play in the development of a better international approach to maritime and aviation systems infectious disease control.
Collaboration with Academic Partners
Lessons from past pandemic response efforts provide key insights for evaluating the effectiveness of measures and outcomes. Various quarantine and isolation measures were implemented during the 1918 influenza pandemic, which present an opportunity for understanding and forecasting the impact of similar measures in the current and future pandemics. Conduct-
11 The 2017 Final Rule is codified at 42 CFR Part 70 (interstate spread) and Part 71 (spread from foreign countries into the United States). More information is available from https://www.govinfo.gov/content/pkg/FR-2017-01-19/pdf/2017-00615.pdf (p. 6919) (accessed March 9, 2022).
12 More information about FAA and CDC guidance can be found at https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2020/SAFO20009.pdf and at https://www.cdc.gov/quarantine/air/managing-sick-travelers/ncov-airlines.html (accessed March 8, 2021).
ing studies on these past events will be critical to better understand the science behind the decisions including the economic cost of pandemic-related measures. Collaborating with academic institutions for research or establishing “Centers of Excellence” can play an important role in generating scientific evidence that will help inform political decisions around disease control activities for migration and quarantine activities.
BEST PRACTICES FOR IMPROVING COORDINATION AND COLLABORATION
Coordination between Federal and STLT Systems
Developing and implementing best practices for improving coordination between federal and STLT systems can help to bolster infectious disease response efforts. For instance, through collaboration with federal and STLT stakeholders, the CSTE has identified multiple opportunities to strengthen communication and coordination between the DGMQ, the Quarantine and Border Health Services Branch (QBHSB), and jurisdictional health departments. A 2019 CSTE evaluation identified strategies to improve the processes through which STLT epidemiologists report ill travelers with diseases of public health concern to the QBHSB (CSTE, 2019). The report recommends that the DGMQ (1) develop standardized protocols and algorithms for jurisdictional reporting to quarantine stations, (2) provide clarity and justification for all data requested for reporting cases, (3) convene annual meetings between jurisdictions and quarantine stations, (4) develop training and reference materials regarding jurisdictional reporting to the DGMQ/QBHSB, and (5) explore further opportunities to strengthen communication with STLT health departments. Recommendations specific to jurisdictional health departments include (1) onboarding and training new key staff on reporting cases to the QBHSB, (2) verifying that jurisdictions have accurate contact information for their respective quarantine stations, and (3) ensuring that the CDC’s Emergency Operations Center is accessible to all staff for reporting outside of normal operational hours. As noted in Chapter 3, there is also substantial variation in jurisdictional capacity to offer resources for large scale isolation and quarantine measures that needs to be taken into consideration (Allen, 2022).
A subsequent CSTE study conducted in 2021 evaluated jurisdictional and federal public health responses to past and current outbreaks (e.g., Ebola, measles, SARS-CoV-2) to identify best practices and areas for improvement (CSTE, 2021). This evaluation found that standardizing processes, clarifying communications, and building relationships across the federal and STLT levels are foundational to improving public health responses to outbreaks; an overview of the report’s key recommendations is provided in Table 5-1.
TABLE 5-1 Recommendations from Council of State and Territorial Epidemiologists to CDC on Outbreak Response
|Reduce multiple instances of communication by requesting all missing data elements for infectious traveler notifications at one time.||CDC|
|Build a strong working relationship with jurisdictions and quarantine stations through regular communication and check-in meetings.||CDC|
|Ensure that information sent to jurisdictions for follow-up is sent within the actionable period.||CDC|
|Outbreak Response||Ensure call center surge staff are cross trained on other outbreaks.||CDC|
|Develop shorter, on-demand webinar training for various outbreak response topics including awareness of HD local realities.||CDC|
|Develop clear protocols, requirements, and data collection tools for jurisdictional health departments in the Do Not Board process.||CDC|
|Address delays partners face when calling EOC call center.||CDC|
|CSTE Notification Protocol||Add link to CSTE Notification Protocol and Optional Form to DGMQ website.||CDC|
|Create a secure, bidirectional portal for submitting/sharing information to improve timeliness and efficiency, especially for data that requires public health action.||CDC|
|Information Sharing||Develop a standardized data dictionary to allow jurisdictions to export data directly from their case management systems instead of manually completing the form for large volumes.||CDC|
|Ensure there is ability to submit infectious traveler notifications in “batch” notifications for large volumes.||CDC|
|Identify minimum data requirements and review current forms health departments use to submit multiple cases.||CDC|
SOURCE: CSTE, 2021. https://cdn.ymaws.com/www.cste.org/resource/resmgr/crosscuttingi/Evaluation_of_Jurisdictional.pdf (accessed March 20, 2022).
Communication with Jurisdictions
To ensure clear and effective communication during emerging or ongoing outbreaks, the DGMQ needs to engage with jurisdiction-level stakeholders on a regular basis. An example of a successful partnership in outbreak response spanning the international, federal, and jurisdictional levels is Operation Allies Welcome (OAW), which was executed
during the COVID-19 pandemic (Brown et al., 2021). On August 29, 2021, President Biden directed DHS to lead a humanitarian mission across multiple federal agencies to safely resettle vulnerable Afghans and U.S. citizens/legal permanent residents in the United States (DHS, 2021). DHS established a Unified Coordination Group (UCG) to coordinate the implementation of a large suite of services, including initial processing, COVID-19 testing, isolation of COVID-positive individuals, vaccinations, and additional medical services. The CDC staff supported OAW at three points of entry: Philadelphia (PHL), Washington Dulles (IAD), and Chicago O’Hare (ORD). During OAW Phase 1 (August 17–September 10, 2021), an estimated 63,430 travelers were supported in PHL and IAD. The operation paused after the identification and confinement of a measles outbreak in September, then resumed on October 4 to support 59 unaccompanied minors. During Phase 2, which began on October 5 and remains ongoing, an estimated 14,150 travelers had been supported as of October 31, 2021 (Brown et al., 2021).
The success of OAW has depended on communication and coordination across a range of international, federal, and STLT partners. State and local health departments assisted with mission coordination early on, as well as supporting the processes of testing, isolation, and quarantine. For the first 1–2 weeks, before DHS took over, the Office of Emergency Affairs of the Commonwealth of Virginia provided mission coordination.13 During Phase 1, all Afghan evacuees (aged > 2 years) who arrived at IAD or PHL received onsite SARS-CoV-2 testing performed by the Virginia Department of Health (VDH) and Philadelphia Department of Public Health (PDPH), respectively, with support from a contracting agency. During Phase 2, only symptomatic travelers were tested. The VDH and PDPH also facilitated isolation and quarantine measures, as well as providing follow-up for all positive cases (limited to U.S. citizens/legal permanent residents) and their families. To enhance communication, evacuees were provided with educational materials in their native languages of Dari and Pashto (Brown et al., 2021).
ELEMENTS OF EFFECTIVE COORDINATION AND COLLABORATION
Robust coordination and collaboration at the national, regional, and local levels provide the foundation for timely and effective public health response to an emerging or ongoing outbreak of infectious disease. At the outset of the COVID-19 pandemic, Taiwan implemented a strategy
13 This text was modified after release of the report to the study sponsor to correctly identify the partner.
of “collaborative governance” that underpinned the nation’s successful collective response effort, which resulted in relatively low rates of SARSCoV-2 infection and COVID-19 mortality compared to neighboring countries (Huang, 2020). Key elements of the collaborative governance model include cooperation between central and local governments, coordination with nongovernmental organizations and associations, and collaboration across sectors.
A 2021 study of the Dallas–Fort Worth public health and emergency management response to the 2014 Ebola outbreak identified essential components of effective coordination at the regional level (Soujaa et al., 2021). These components include an identifiable lead agency that coordinates policy, manages a network of organizations, and is authorized by a higher-level entity to use leverage and incentives to shape local action. A formal statement from local authorities regarding efforts made to address the health emergency was found to enhance efficacy of coordination. An environment conducive to informal communications—which can exist concurrently with formal structures—was found to generate flexibility and adaptation for effective coordination. The study also identified the following communication activities as essential for coordination: informing professionals of important developments and operations relevant to the crisis response, connecting professionals with one another, and involving the appropriate responders in decision-making processes.
To improve effectiveness of the federal policies before they are handed down, it is essential to actively engage with STLT public health partners to seek and incorporate their input when developing those policies. For example, in conjunction with CDC and DGMQ experts, the CSTE developed and updated a Notification Protocol and Data Collection Guidance to support health departments in notifying infectious persons with recent travel to the CDC’s quarantine stations.14 This process of seeking input from stakeholders at all levels should be continual throughout the cycle of response to an outbreak, beginning in the preparation phase before an outbreak occurs, then extending throughout the acute response and recovery stages. Existing mechanisms can be leveraged to facilitate this engagement. Predecisional input from the NACCHO, ASTHO, CSTE, and APHL before public health guidance policies, protocols, and documents would help to ensure that the final materials are realistic, practical, and effective.
In order to improve international collaboration to fulfill the DGMQ’s goals, some elements proven to be relevant for successful partnerships should be considered. A commitment to common, measurable goals
14 The most recent version of the Notification ProtocolandData Collection Guidance is available from https://cdn.ymaws.com/www.cste.org/resource/resmgr/crosscuttingi/CSTE_Notification_Protocol_a.pdf (accessed March 8, 2022).
serves as the foundation for the partnership (Bertolo et al., 2018). The scope, objectives, and strategies of effective partnerships are clearly defined and tailored to current need (Druce and Harmer, 2004). Components of scope in the public health context include disease, geography, population, and activities. Partnerships should have clear governance—with roles of all partners defined—and should feature inclusivity and representation of all stakeholders. Partnership processes should be respectful of cultural differences and flexible to allow for responsiveness to political, economic, and other changes in the environment. Trust and transparency foster consensus generation within partnerships. Efficient and effective partnerships align methodologies, share data, and utilize evidence-based approaches (Bertolo et al., 2018). A data-driven systems approach to global collaboration can ensure scientific integrity and improve efficiency (Ros et al., 2021).
Communication of Information to Travelers at Ports of Entry
Communication with travelers at U.S. POEs is a critical component of controlling the spread of infectious disease, both across and within national borders. The committee has identified a set of best practices to improve clarity and effectiveness in communicating information about ongoing or emerging infectious disease threats to incoming travelers at POEs. Key components of these best practices include predecisional collaboration and regular communication among international, federal, and STLT partners to ensure smooth operations on the ground at the jurisdictional level.
Predecisional collaboration is foundational to infectious disease prevention and control efforts. As with policy and protocol development, perspectives and input from the full range of stakeholders and partners should be obtained through a robust and collaborative engagement process before any decisions or policies are finalized. This is especially critical for STLT partner agencies, as the implementation of prevention and control measures mostly occur at the state and local levels. Predecisional input can be coordinated through the major public health partner organizations, including the ASTHO, NACCHO, CSTE, and APHL. During other infectious disease outbreaks prior to the COVID-19 pandemic, this engagement process was conducted through existing mechanisms during the initial stages of the outbreaks. However, as those outbreaks progressed, this engagement process was either absent or inconsistently executed.
CONCLUSIONS AND RECOMMENDATIONS
Conclusion 5-1: To ensure that policies developed at the federal level are effective, it is important to incorporate input from state, tribal, local (county and city), and territorial health agencies and private sector entities.
Conclusion 5-2: Coordination and harmonization between localities will be critical in managing emergencies and outbreaks.
Conclusion 5-3: More effective and sustained engagement with regulated industries, such as maritime and aviation industries, is clearly needed.
Conclusion 5-4: International collaboration is an important component of the DGMQ’s activities. The main framework for international collaboration regarding disease control and prevention are the International Health Regulations (IHR). However, the COVID-19 pandemic has demonstrated the need for the IHR to evolve in order to respond to future public health emergencies on a global scale. Since the DGMQ is the division within the CDC responsible for implementing the IHR, the DGMQ needs to play a major role in the ongoing revision of the IHR.
Conclusion 5-5: Interactions with international partners at the borders comprise another major element of the DGMQ’s international collaboration. Successful collaboration requires the development of trust between partners, which is most effectively achieved through ongoing contact and opportunities to exchange views and define common goals. Different collaboration initiatives have already been developed in this region. However, increasing the continuity of those initiatives is important in fostering the development of trust over time, in making information exchange more regular and standardized, and in establishing common protocols. The DGMQ could play a major role in better understanding the unique needs of border regions at the federal level and the potential impact of these needs on the ability to detect and contain the spread of disease.
Conclusion 5-6: Promoting university/academic partnerships for collaborative research and evaluation, including establishing “Centers of Excellence in Global Migration and Quarantine,” would enhance the
knowledge base for disease control activities for migration and quarantine activities.
Conclusion 5-7: The DGMQ would benefit from the establishment of a formal federal advisory committee to provide external input on quarantine and border health issues on a regular and ongoing basis. Committee membership could include state and local officials, international partners, representatives from regulated industries, academic and private sector experts, professional societies, nongovernmental organizations and have ex-officio membership from other federal agencies.
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:
Improve collaboration with international partners through regularly scheduled forums:
- Actively engage in the International Health Regulations (IHR) revision process.
- 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.
Improve coordination between federal, state, tribal, local (county and city) and territorial (STLT) health agencies and strengthen international collaboration and engagement of quarantine officers.
- Develop a Federal Interagency Workgroup with input from STLT partners.
Strengthen isolation and quarantine preparedness planning.
- Define federal and STLT roles and responsibilities.
- Understand and plan for variation in how STLT entities implement public health legal authorities.
- Implement a federal and STLT tabletop exercise program to bring together relevant quarantine stakeholders to practice coordination periodically, especially in regions containing quarantine stations.
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.
- Work to align DGMQ interventions with local public health activities to avoid overburdening the local public health system.
- 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.
Improve coordination with aviation and maritime industries for border/traveler health issues and mandates:
- 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.
Improve DGMQ engagement with regulated industries (e.g., cruise ship lines).
- Establish clear and consistent structure for communication.
- Develop clear objectives (e.g., safety and relative risk).
- 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.
- 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.
- Establish mechanisms to utilize airlines, airport authorities, and travel agencies to communicate messages and better inform travelers during a pandemic, emerging pandemic, or outbreak.
- Collaborate with the aviation industry to provide pre-departure 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.
Incorporate avenues for the DGMQ to share informative materials with travelers in addition to the DGMQ website.
- Consider the use of electronic means of communication—such as flexible text messaging tools—to reach travelers with follow-up instructions and information.
- 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.
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