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CDC Division of Global Migration CDC Division of Global Migration and Quarantineand Quarantine
IOM Committee: Measures to Enhance Effectiveness IOM Committee: Measures to Enhance Effectiveness of Qof Q--Station Expansion PlanStation Expansion Plan
Martin S. Cetron, MDMartin S. Cetron, MDDirector, DGMQDirector, DGMQ
DGMQ MissionDGMQ Mission
•• Prevent importation, transmission, or spread Prevent importation, transmission, or spread of communicable diseases from foreign of communicable diseases from foreign countries into the United Statescountries into the United States
(Statutory responsibility to make and enforce (Statutory responsibility to make and enforce regulations as necessary)regulations as necessary)
•• Decrease morbidity and mortality among Decrease morbidity and mortality among globally mobile populations entering the globally mobile populations entering the United StatesUnited States
(Public health responsibility)(Public health responsibility)
Immigration and Nationality Act
Refugee Act42 CFR
CDC Role in Overseas Migrant Health EvaluationCDC Role in Overseas Migrant Health Evaluation
•Required health evaluation •Inadmissible conditions
•Diseases of public health significance•Monitor quality of health screening •Meet at ports of entry•Notify state/local health dept
•Prevent importation and spread
HIV, TB, Hansen’s disease, STDs, harmful behavior, drug abuse•Waivers
Executive Order 13295:Revised List Of Quarantinable Communicable Diseases
(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers(Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).
(b) Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to person predominantly by the aerosolized or droplet route, and, if spread in the population, would have severe public health consequences.
President George W. BushApril 4, 2003
History of Quarantine & History of Quarantine & U.S. Public Health ServiceU.S. Public Health Service
•• Quarantine preceded Quarantine preceded CDCCDC
•• Legislation 1Legislation 1stst
enacted at turn of enacted at turn of 2020thth cent as spread cent as spread of disease perceived of disease perceived as resulting from as resulting from travel (immigration)travel (immigration)
The Public Health Service & The Rise of The Public Health Service & The Rise of QuarantineQuarantine
•• Prevent introduction Prevent introduction of diseases such as of diseases such as yellow fever, yellow fever, smallpox, cholera, smallpox, cholera, and plague into USand plague into US
•• No mandate to No mandate to address health address health issues of those issues of those leaving USleaving US
U.S. Quarantine ProgramU.S. Quarantine Program
DHEW 1953DHEW 1953•• 52 seaports52 seaports•• 41 airports41 airports•• 17 border stations17 border stations•• 33 territory stations33 territory stations•• Panama CanalPanama Canal•• 41 U.S. consulates41 U.S. consulates•• 50 maritime vessels50 maritime vessels
CDC 1967CDC 1967--70 RIF70 RIF-- 6 airports6 airports
DGMQ 2004DGMQ 2004-- 8 airports8 airports
Charge to IOM:Charge to IOM:Assist DGMQ in strategic planning to reAssist DGMQ in strategic planning to re--build Qbuild Q--station infrastructure in order to accomplish missionstation infrastructure in order to accomplish mission
•• How should the current role of the QS evolve to meet 21How should the current role of the QS evolve to meet 21stst century century challengeschallenges
•• What are the types & numbers of public health professionals and What are the types & numbers of public health professionals and appropriate skill sets necessaryappropriate skill sets necessary
•• What are the optimal locations for efficient and sufficient moniWhat are the optimal locations for efficient and sufficient monitoring and toring and responseresponse
•• How do we ensure surge capacity for PH emergencies (e.g. SARS, How do we ensure surge capacity for PH emergencies (e.g. SARS, Pandemic Flu, Mass migrations)Pandemic Flu, Mass migrations)
•• How should QS staff best collaborate with partnersHow should QS staff best collaborate with partners-- State and Local Health Dept.State and Local Health Dept.-- Other Federal Agencies and Inspection ServicesOther Federal Agencies and Inspection Services-- International partners e.g. WHO, MOH and NGOsInternational partners e.g. WHO, MOH and NGOs
Prior to 1996Division of Quarantine, CPS/CDC
QUARANTINESTATIONS (7)- MEDICAL
SCREENINGHEALTH
ASSESSMENT
MEDICAL SCREENING AND HEALTH ASSESSMENT BRPROGRAM OPERATIONS BR
TRAVELERS'HEALTH
OFFICE OFTHE DIRECTOR
1997-2003Division of Global Migration and Quarantine
OFFICE OFTHE DIRECTOR
SURVEILLANCE ANDEPIDEMIOLOGY BRANCH
ADMINISTRATIVESECTION
FIELD OPERATIONS BRANCH
TRAVELERS'HEALTHSECTION
INFORMATIONMANAGEMENT
SECTION
SURVEILLANCESECTION
EPIDEMIOLOGY &SPECIAL STUDIES
SECTION
QUARANTINESECTION-Quarantine
Stations
MEDICALSCREENING &
HEALTHASSESSMENT
NONHUMANPRIMATEACTIVITY
Division of Global Migration and QuarantineReorganization (2003-4)
Travelers’ Health
ZoonosesTeam
Surveillance & Epidemiology
8- Quarantine Stations (25)D. Kim
Program & Evaluations
L. Ortega
R. Koppaka
M. Weinberg
J. Ward
P. Arguin
P. Kozarsky
CetronBarrowSimone
P. Simone S. Maloney
J. Barrow
Division of Global Migration and QuarantineProposed Reorganization (2003-4)
Travelers’ Health
ZoonosesTeam
Surveillance & Epidemiology
Quarantine Stations11 POEs 25 POEs?International Ports?
Program & Evaluations
Quarantine StationsQuarantine StationsCurrent and Proposed
CA
OR
NV
NM
WA
AZ
UT
ID
CO
WY
NDMT
NE
SD
MN
OK
IA
TX
KS
AR
MO
WI
IL
GAMSALLA
TNSC
FL
OHIN
WV
VA
NC
NYMIPA
ME
KY
Seattle
San Francisco
Los Angeles
El Paso
Chicago
Miami
Atlanta
New York
HonoluluHI
AK
San Juan, PRChristiansted, VI Cruz Bay, VI
Existing Station - 8Station Opening FY2004 - 3Proposed Station FY2005+ - 14
VTNH
San Diego
Anchorage
Denver
PhoenixDallas
New Orleans
KansasCity
Minneapolis
Detroit
Washington, DC
Newark, NJ
Boston, MA
Houston
Charlotte
Philadelphia
Airports: > 1 million travelersSeaports: >100k travelersLand Borders: >5 million crossings
Tier 1 City - 83
Immigrants:Immigrants:Percent of U.S. PopulationPercent of U.S. Population
0
2
4
6
8
10
12
14
16
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
*Camarota SA January 2001. Center for Immigration Studies
Number of ForeignNumber of Foreign--Born Born Persons Living in the U.S.Persons Living in the U.S.
0
5
10
15
20
25
30
1900 1920 1940 1960 1980 2000Mill
ions
of F
orei
gn-b
orn
Pers
ons
Source: Center for Immigration Studies, 2001
Estimated Annual International Arrivals , U.S.A.Estimated Annual International Arrivals , U.S.A.
International Travelers Foreign 60 M / U.S. 60 M
Immigrants1,000,000
Refugees70-90,000
U.S.-Mexico Border Crossings 400M?
Source: U.S. Department of Homeland Security, 2003 (2002 data)
Status adjusters in U.S.679,305
Immigrants and refugees 411,266
Undocumented migrants ~ 275,000 ????
Non-immigrant visas27,907,139
N= ~ 60 million / Yr
Visitors without visas~ 30,000,000
Annual Estimate Migrants “Entering” U.S.Annual Estimate Migrants “Entering” U.S.
Wor
ld P
opul
atio
n in
bill
ions
(
)
Day
s to
Circ
umna
viga
te (
)
th
e G
lobe
Year1850
0
400
350
300
250
200
150
100
50
2000
0
1900 1950
1
2
3
4
5
6
Speed of Global Travel in Relation toWorld Population Growth
From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994
22
4 x increase in volume as compared to 1960-754 x increase in volume as compared to 1960-75Source: Population Action International 1994
Major Migration Flows: 1990s
The Cruise Ship The Cruise Ship
A unique environment for disease transmission,A unique environment for disease transmission,amplification, and dispersal amplification, and dispersal
= 500,000 passenger bed-days= New destinations (<500,000 passenger bed-days)
Expanding Cruise Destinations, 1997
AlaskaYukon Territory
British Columbia
Washington
DenaliNational
Park
Arctic Circle
FairbanksFairbanks
AnchorageAnchorage
SewardSeward
DawsonDawsonWhitehorseWhitehorse
TokTokHealyHealy
SitkaSitka KetchikanKetchikan
SkagwaySkagwayJuneauJuneau
VancouverVancouver
SeattleSeattle
ValdezValdez
Alaska Cruise Ship Sailing Routes
Cruise ship routes along coast
A Decade of Global InfectiousDisease Challenges
Hantavirus pulmonary syndrome (USA)
Plague (India)
Ebola hemorrhagic fever (Zaire)
New variant Creutzfeldt-Jakob disease (UK)
H5N1 influenza (Hong Kong) Vancomycin-intermediate Staphylococcus aureus
(Japan, USA)
Nipah virus encephalitis (Malaysia, Singapore)
1993
1994
1995
1996
1997
1998
A Decade of Global Infectious Disease Challenges (cont.)
West Nile encephalitis (Russia, USA)
Rift Valley fever (Kenya, Saudi Arabia, Yemen) Ebola hemorrhagic fever (Uganda)
Foot and mouth disease (UK)Anthrax (USA)
Vancomycin-resistant S. aureus (USA)
SARS (>25 countries) Monkeypox (Midwestern US)
Avian Influenza (H5N1) (9 Asian countries)
1999
2000
2001
2002
2003
2004
Infectious DiseasesNew Public Health Perspective
Infectious disease outbreaks can impact national security and global economy Local outbreaks/problems now recognized as having much wider implicationsRapid and collaborative response essential and expected
“SARS has become the new paradigm for the global havoc that can be produced by emerging infectious diseases.”
Guangdong Province,
China
A
A
Hotel MHong Kong
Chain of transmission among guests at Hotel M—Hong Kong, 2003
B
J
H
C D
E
I
K †
FG †
Hospital 2Hong Kong
H
J
B
Hospital 3 Hong Kong
Hospital 1 HK
Hospital 4 Hong Kong
C D EB
Singapore
United States
I
Vietnam
IrelandK †
Canada
G †
F
A
4 other Hong Kong Hospitals
2 family members
34 HCWs
HCW
Germany
Bangkok
L§
M§
37 HCWs
HCW
0 HCWs
28 HCWs
156 close contacts of HCWs and
patients
4 family members 10 HCWs
37 close contacts
99 HCWs (includes 17 medical students)
4 HCWs*
3 HCWs
HCW
HCW
2 family members
Unknown number
close contacts
2 close contacts
* Health-care workers; † All guests except G and K stayed on the 9th floor of the hotel. Guest G stayed on the 14th floor, and Guest K stayed on the 11th floor; § Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at the hotel during the same times as Guests G, H, and I, who were ill during this period.Data as of March 28, 2003
Isolation* For people who are ill
Quarantine* For people who have been exposed but are not ill
New
swee
k4/
28/0
3
*Measures usually voluntary, but can be mandatory; legal quarantine authority covers “isolation” and “quarantine” tools.
21st Century Quarantine
A collective action for the common good predicated on aiding individuals infected or exposed to infectious agents while protecting others from the dangers of inadvertent exposure
Public good Individual liberties
10 Contact tracing
Early detection& isolation
Home quarantine
Isolate and Contain StrategyIsolate and Contain Strategy
Quarantine Quarantine -- Definition Definition The restriction of movement of a person who has been exposed to The restriction of movement of a person who has been exposed to an infectious disease for a period of time not longer than the lan infectious disease for a period of time not longer than the longest ongest incubation period of the disease to prevent effective contact wiincubation period of the disease to prevent effective contact with th those who have not been exposed to the infective agentthose who have not been exposed to the infective agent
Secondary Cases of SARS by Number of Days to Isolation of the Source Case
Singapore*
*Reported as of April 15, 2003. Available at: http://www.who.int/csr/sars/en/index.html
Range of Responses to SARS at the National, State, and Community Level
Public Health Criteria for Community Response
• Number of cases/exposed• Exposure category
•Known•Travel•Close contact
•Health care-related•Household
•Unknown (unlinked)•Type of transmission
• Generations of transmission• Morbidity and mortality• Ease/ rapidity of spread • Movement in /out of community• Resources• Need urgent public health action• Risk of public panic
No restrictions
•Voluntary general movement restrictions •“Shelter in Place” or “Snow Day”
•Closing of public places•Suspension of public gatherings•Restriction of mass transit schedules
•Compulsory movement/activity restrictions•Curfews on activities•Closing of mass transit •Closing access routes
•Roads, Airports,Seaports•Closing borders
•Border surveillance/monitoring•“SARS checkpoints”•Travel permits
Targeted restrictions•Population-specific
(i.e., congregate settings or group gatherings)
Range of Responses to SARS at Borders
Public Health Criteria for Border Response
• Number of global cases/exposed• Adequacy of global surveillance/control• Volume of travel • Morbidity and mortality• Ease/ rapidity of spread • Characteristics of local outbreaks • Community response levels• Border and local resources• Need urgent public health action• Risk for public panic
• Travel alerts, advisories, press releases• Meet all SARS-affected arriving flights
• Visual inspection• Disembarkation notices• HAN distribution
• Triage ill passengers•Contact follow-up and surveillance
• Intensified arrival screening • Questionnaire• Temperature monitoring• Active registration with local health department• Health certification
• Pre-departure screening
•Restrict departures and flights •Suspend travel and other visa issuance•Quarantine any arrivals from affected areas
•Close borders?
Travel Measures to Prevent Spread1. Pre-departure Screening
2. Suspected SARS Aboard Conveyances3. Disembarkation Notices
22 (18.3)120Fever/cough (1)7373 hrs
No. (%) Infected
No. on FlightIllnessAircraftDuration
Olsen SJ, et al. N Engl J Med 2003;349:2416-22.
Distributed to 2.7 million airline passengers; also cruise line and cargo ships, select land borders
Travel Alerts and Advisories for SARS, March–July 2003
Region Advisory Started Advisory Stopped Alert Started Alert Stopped Mainland China 3/13/03 6/17/03 6/17/03 7/3/03 Beijing, China 6/17/03 6/25/03 6/25/03 7/11/03 Taiwan 6/25/03 6/25/03 6/25/03 7/15/03 Hong Kong 5/1/03 6/25/03 6/25/03 7/1/03* Hanoi, Vietnam 3/13/03 4/29/03 4/29/03 5/15/03 Toronto Never had an advisory Never had an advisory 4/23/03
restarted: 5/23/035/20/03 restopped: 7/8/03
Singapore 3/13/03 5/4/03 5/4/03 6/4/03 *This change was posted on 7/9/03, retroactive to 7/1/03.
Documents Viewed from Travelers’ Health Website, 1995-2003
* Includes travel related documents from SARS website
0
5,000,000
10,000,000
15,000,000
20,000,000
1995 1996 1997 1998 1999 2000 2001 2002 2003*
Himalayan palm civetPaguma larvata
Chinese Ferret-BadgerMelogale moschata
Raccoon-dog Nyctereutes procyonoides
Animal photos courtesy of Dr. Yi GuanHong Kong University, and badgers.org.uk
Science. July 18, 2003
Infectious Disease Mortality in the U. S., 1900 to 1996
0
200
400
600
800
1000
1900 1920 1940 1960 1980
Year
Mor
talit
y R
ate
per 1
00,0
00
0
20
40
60
80
1970 1980 1990
Source: Armstrong, et al., JAMA ;1999