The U.S. Department of Health and Human Services, especially including the Centers for Disease Control and Prevention, should ensure that the 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 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 (HR) 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 CDC Director’s diversity, equity and inclusion initiatives while undergoing the division’s workforce study.
4. Culture
1. 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.

The 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 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.

The 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, U.S.AID, the new CDC Center for Forecasting and Outbreak Analytics, the CDC Center for Public Health Preparedness and Response, and ASPR) as well as state and local public health agencies when determining which pathogens and scenarios to prioritize for planning purposes.

The DGMQ, 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 HHS 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 medical special needs, 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.
3. 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.

The DGMQ/CDC 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.

The 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.

The DGMQ should support the adoption of the Office of the National Coordinator for Health Information (ONC) roadmap by health care and public health practitioners. The DGMQ should work with the ONC to facilitate the ONC roadmap and interoperability networks. 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.

The 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.

The 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, 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.
   1. Work to align DGMQ interventions with local public health activities to avoid overburdening the local public health system.
3. 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.

The 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.
5. 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.

Congress should improve the legal authority and flexibility of the CDC in 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.