Improving the CDC Quarantine Station Network's Response to Emerging Threats (2022) / Chapter Skim
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3 Disease Control and Response Efforts
3 Disease Control and Response Efforts
Pages 69-106
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From page 69... ...
THE DGMQ'S ROLES AND RESPONSIBILITIES IN COMMUNICABLE DISEASE CONTROL The DGMQ has a range of domestic and international roles in its responsibility for controlling the spread of communicable diseases at both international air and maritime ports of entry and at land-border crossings.1 The DGMQ's day-to-day responsibilities focus on responding to travelers, animals, human remains, and products that may have specific communicable diseases of public health concern upon their entry to the United 1 More information about the DGMQ's roles and responsibilities is available from https:// www.cdc.gov/ncezid/dgmq/how-we-serve.html (accessed March 15, 2022)
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From page 70... ...
When quarantine station staff are notified of an ill traveler, they communicate with quarantine medical officers, who guide staff on the actions necessary to appropriately mitigate communicable diseases risks. The appropriate steps to mitigate this risk will depend on 2 This text was modified after release of the report to the study sponsor to correctly represent the division's responsibilities.
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Quarantine stations may also receive reports, typically from health departments, for travelers who were diagnosed with communicable diseases after travel. Quarantine station staff will work with quarantine medical officers to determine whether a contact investigation should be initiated.
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From page 72... ...
Additionally, to facilitate public health notification, these individuals are also issued a Public Health Lookout to allow them to be identified if they seek entry to the United States at an airport, land, or sea port of entry.6 In cases where an individual who poses a public health risk intends to travel, local and state public health authorities can request assistance from the CDC to ensure that the individual does not travel while still infectious.7 Individuals may be placed on the DNB list and issued a Lookout if they are 4 See Protecting Travelers' Health from Airport to Community: Investigating Contagious Diseases on Flights | Quarantine | CDC https://www.cdc.gov/quarantine/contact-investigation. html (accessed April 3, 2022)
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From page 73... ...
These authorities can also be utilized to restrict travel by individuals with other suspected or confirmed infectious diseases that could threaten public health during travel. Before the COVID-19 pandemic, most uses of federal public health travel restrictions were for people with infectious TB; however, the tools have also been used for measles, MERS, Ebola virus disease, and Lassa fever.8 When an individual on the Public Health Lookout enters the United States, the CDC is notified by CBP officers at the point of entry; a public health evaluation is then performed prior to the individual's release (DeSisto et al., 2015)
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. Health screenings also occur at quarantine stations to assess passengers for illness who may not be on a DNB or Public Health Lookout.
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. Contact Investigations Contact investigations are another tool used by the CDC and DGMQ to protect the health of individuals who have been exposed to an infectious disease during air travel and to prevent the forward spread of that disease in communities.11 Historically, most flight contact investigations are conducted by the CDC in close coordination with state and local public health authorities for cases of infectious TB, measles, rubella, pertussis, meningococcal disease, and more recently for COVID-19.
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Across the DGMQ's network of quarantine stations, infectious TB was the most frequently occurring infectious disease for 15 The authority for isolation and quarantine derives from the Commerce Clause of the U.S. Constitution.
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ports of entry, the DGMQ is also responsible for preventing the importation of infectious diseases into the United States by protecting the health of incoming U.S.-bound immigrants, refugees, and asylum seekers (CDC, 2021e) .17 The DGMQ's Immigrant, Refugee, and Migrant Health (IRMH)
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state and local health departments and screening clinics along with notifications of the arrival of all refugees and the subset of immigrants with health conditions for which medical follow-up is recommended.20 As of 2012, four quarantine stations at U.S. ports of entry were responsible for meeting and providing a TB-clinic referral to immigrants who had been diagnosed with admissible TB conditions during their pre-immigration medical examination.
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From page 79... ...
in host countries when the outbreak may cross an international border • Developing technical instructions and training health care providers who per form mandatory overseas predeparture medical exams to ensure that health conditions are documented and treated as required • Overseeing the required medical examination of refugee and immigrant visa applicants before they travel to the United States • Promoting, monitoring, and improving the health of children adopted outside of the United States • Educating immigrant and refugee groups and partners about disease preven tion and good health practices • Coordinating with domestic health departments, foreign health agencies, and nongovernmental organizations to develop, implement, and evaluate pro grams that improve health outcomes in globally mobile populations • Partnering with other governments to provide technical assistance at points of entry, along informal cross-border movement, and for cross-border collabora tion building to strengthen surveillance, preparedness, and response among mobile populations • Promoting preventive treatments for and vaccination of refugees and immi grants before departure for several communicable diseases • Providing technical assistance and training to regional medical and public health officials allowing them to identify, treat, and track diseases that threaten the health of refugees, immigrants, and U.S. residents SOURCE: CDC, 2021e.
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From page 80... ...
The QBHSB is responsible for preventing the transmission of communicable diseases across the nation's northern border crossings along the U.S.–Canadian border. Although the QBHSB does not have staff physically present along the northern border, these activities are executed remotely by the airport-based quarantine stations located in Boston, MA (BOS)
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. Between 2010 and 2014, the DGMQ's quarantine stations received almost 3,000 individual maritime case reports of illnesses (77 percent of reports)
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. Quarantine stations are charged with inspecting CDC-regulated animals and animal products that pose a potential threat to human health.
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demand. Therefore, continued vigilance will be essential with the possibility of new zoonotic disease threats emerging beyond canine rabies.
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. Emergency Response and Active Monitoring for Ebola Epidemic in West Africa As part of the CDC's response to the Ebola epidemic in West Africa -- a major global health emergency -- the DGMQ and its quarantine station 29 More information about CDC's emergency response activities is available from https:// www.cdc.gov/ncezid/dgmq/emergency-response.html (accessed March 16, 2022)
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. From 2014 to 2016, 36,059 travelers arriving into the United States from three West African countries -- Sierra Leone, Guinea, and Liberia -- underwent active monitoring for 21 days after a monitoring system was put in place by the CDC in partnership with state and local health departments (CDC, 2015b)
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IMPROVING STRATEGIC PLANNING FOR POTENTIAL DISEASE OUTBREAKS Experiences during recent emergency response efforts highlight the importance of scenario-based planning for the most likely and/or concerning potential disease outbreaks, with the active involvement of key partners. The committee identified multiple opportunities to improve strategic planning for potential disease outbreaks in the domains of (1)
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From page 87... ...
Quarantine Stations to support the program. • Worked with CBP on traveler contact data collection and shared info with STLT partners for follow-up.
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: • "Develop standardized protocols/algorithms for jurisdiction report ing to quarantine stations. • Provide clarity and justification for each piece of data requested for reporting a case.
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For instance, the responses to the Ebola virus disease outbreaks in Western Africa (2014–2016) , as well as the COVID-19 pandemic, were undermined by lack of planning to identify potential sites and operational needs to support the large-scale isolation and quarantine measures required for effective management of international passengers with illness and/or exposures.
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BORDER MEASURES AND ACTIVE MONITORING OF INTERNATIONAL TRAVELERS DURING COVID-19: EVALUATION The committee evaluated research on the effectiveness of border measures and active monitoring of international travelers during COVID-19. Overall, the effectiveness of border measures, including pretravel testing, is unclear, and additional research is needed to determine the factors that contribute to successful screening measures.
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Observational studies reported a wide range of positive cases detected -- between 0 to 100 percent -- with the majority of studies reporting fewer than 54 percent of cases detected. For screening based on testing rather than on symptoms or potential exposure, modeling studies reported that testing travelers reduced both imported or exported cases and cases detected.
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In California, barriers to effective COVID-19 monitoring and screening of travelers included incomplete traveler information transmitted to federal officials and states, the number of travelers requiring follow-up, and potential presymptomatic and asymptomatic transmission (Myers et al., 2020) .35 This suggests that during an outbreak, health departments have to be cautious about devoting their often-limited resources to these types of monitoring efforts, rather than channeling those resources into more effective mitigation strategies.
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From page 93... ...
. A study of international travelers arriving by air in Alberta, Canada, in January–February 2021 found that 0.02 percent of travelers who were fully or partially vaccinated against COVID-19 tested positive for the virus, in comparison with 1.42 percent of unvaccinated travelers, although both were relatively low.
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. Travel restrictions, border closures, and active monitoring of
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For diseases like SARS and Ebola, these interventions are more effective when measures can be more directly targeted to those with known risk exposures, as opposed to targeting all travelers from a country or region. Quarantine with active monitoring of persons at risk and/or exposed works best when most secondary cases become symptomatic after they are separated from others; this helps to prevent ongoing transmission to others (i.e., tertiary cases)
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From page 96... ...
Moreover, once COVID-19 transmission was established in the United States, the role of active monitoring of all international travelers from countries deemed at higher risk -- many of whom were not symptomatic or likely infected -- probably had questionable impact on transmission levels in the United States. However, diverting state and local health department resources to monitor international travelers impacted other local infection control priorities, including vaccination, testing, and outbreak response.
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Conclusion 3-2: Planning for larger-scale isolation and quarantine op erations has been insufficient -- as evidenced in the initial response to COVID-19 in spring 2020 -- in addressing the need for mass repatria tion of U.S. citizens traveling overseas, as well as travelers on cruise ships when COVID-19 outbreaks occur.
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. Conclusion 3-4: Quarantine and active monitoring of all international travelers coming into the United States -- regardless of their symptom status or exposure history -- once COVID-19 transmission was occur ring nationwide was likely not effective in minimizing transmission in the United States.
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Recommendation 3-3: The Division of Migration and Quarantine/ Centers for Disease Control and Prevention should commission an external formal evaluation and/or a modeling study of the effective ness of travel restrictions and active screening/monitoring of all inter national 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 evalua tion should include psychological benefits, political implications, un intended consequences of screening, resources required, and burden placed on state and local jurisdictions.
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2022. Enhancing the Federal Quarantine Station network - A state perspective: ASTHO.
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2015b. The road to zero: CDC's response to the West African Ebola epidemic 2014– 2015.
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2020. Notification protocol and data col lection guidance: Health department notification to CDC quarantine stations of infec tious persons with recent travel.
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BMC Infectious Diseases 21(1)
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Presentation to the National Academies of Sciences, Engineering, and Medicine Committee on Analy sis to Enhance the Effectiveness of the Federal Quarantine Station Network. Myers, J
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The Lancet Infectious Diseases 16(6)
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