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Human Resources at U.S. Ports of Entry to Protect the Public’s Health

Interim Letter Report

January 13, 2005

Dr. Martin Cetron

Director

Division of Global Migration and Quarantine

National Center for Infectious Disease

Centers for Disease Control and Prevention

1600 Clifton Road, Mailstop E-03 Atlanta, GA 30333

Dear Dr. Cetron:

This interim letter report contains the competencies1 and types of health professionals suggested for the CDC quarantine station system by the Institute of Medicine’s Committee on Measures to Enhance the Effectiveness of CDC Quarantine Station Expansion Plan for U.S. Ports of Entry. These suggestions fulfill the first deliverable requested by the CDC Division of Global Migration and Quarantine (DGMQ) in Contract No. 200-2000-00629, Task Order No. 31.

Form naturally follows function; however, our committee has been challenged to recommend a human-resource structure for the expanding quarantine station system before developing a robust concept of how the system should function. The guidance offered in this report therefore is preliminary and will be revisited in our final report, to be released on 31 May 2005. The final report will contain recommendations that address all items in the committee’s Statement of Task (Box 1-1).

HISTORIC CONTEXT

Dismantling of Quarantine Station System

More than 500 people staffed the 55 federal quarantine stations at U.S. seaports, airports, land-border crossings, consulates, territories, and territorial waters in the late 1960s (Cetron, 2004; DGMQ, 2003a), a period when the medical community generally believed it was “time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease.” This statement, attributed by legend to U.S. Surgeon General William Stewart (The Office of the Public Health Service Historian, 2002), reflected the public’s confidence in the power of antibiotics and vaccines to eradicate such dreaded communicable diseases as yellow fever, plague, and cholera, which the quarantine stations had worked to barricade from the U.S. population for nearly a century.

1  

To be consistent with current workforce terminology, the committee uses the terms “competencies” or “abilities” for skills belonging to individuals and “capacities” or “capabilities” for collections of skills posessed by the human resources of an organization.



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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Human Resources at U.S. Ports of Entry to Protect the Public’s Health Interim Letter Report January 13, 2005 Dr. Martin Cetron Director Division of Global Migration and Quarantine National Center for Infectious Disease Centers for Disease Control and Prevention 1600 Clifton Road, Mailstop E-03 Atlanta, GA 30333 Dear Dr. Cetron: This interim letter report contains the competencies1 and types of health professionals suggested for the CDC quarantine station system by the Institute of Medicine’s Committee on Measures to Enhance the Effectiveness of CDC Quarantine Station Expansion Plan for U.S. Ports of Entry. These suggestions fulfill the first deliverable requested by the CDC Division of Global Migration and Quarantine (DGMQ) in Contract No. 200-2000-00629, Task Order No. 31. Form naturally follows function; however, our committee has been challenged to recommend a human-resource structure for the expanding quarantine station system before developing a robust concept of how the system should function. The guidance offered in this report therefore is preliminary and will be revisited in our final report, to be released on 31 May 2005. The final report will contain recommendations that address all items in the committee’s Statement of Task (Box 1-1). HISTORIC CONTEXT Dismantling of Quarantine Station System More than 500 people staffed the 55 federal quarantine stations at U.S. seaports, airports, land-border crossings, consulates, territories, and territorial waters in the late 1960s (Cetron, 2004; DGMQ, 2003a), a period when the medical community generally believed it was “time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease.” This statement, attributed by legend to U.S. Surgeon General William Stewart (The Office of the Public Health Service Historian, 2002), reflected the public’s confidence in the power of antibiotics and vaccines to eradicate such dreaded communicable diseases as yellow fever, plague, and cholera, which the quarantine stations had worked to barricade from the U.S. population for nearly a century. 1   To be consistent with current workforce terminology, the committee uses the terms “competencies” or “abilities” for skills belonging to individuals and “capacities” or “capabilities” for collections of skills posessed by the human resources of an organization.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report BOX 1-1 Statement of Task The factors to be considered in an assessment of current and future border quarantine functions would include: The current role of quarantine stations as a public health intervention and how the roles should evolve to meet the needs of the 21st century. The role of other agencies and organizations working collaboratively with the CDC’s Division of Global Migration and Quarantine at ports of entry (including federal partners such as Customs and Border Protection, Immigration and Customs Enforcement, U.S. Department of Agriculture, and U.S. Fish and Wildlife Service). The role of state and local health departments as partners for public health interventions at the nation’ s borders (such as activities focused on emergency preparedness and response, disease surveillance, and medical assessment and follow-up of newly arriving immigrants and refugees). Optimal locations for the quarantine stations for efficient and sufficient monitoring and response. Appropriate types of health professionals and necessary skill sets to staff a modern quarantine station. Surge capacity to respond to public health emergencies. The perception that humans had effectively controlled microbial threats led to the dismantling of most of the federal border quarantine system in the 1970s; by the end of that decade, fewer than a dozen active stations remained (Cetron, 2004). In mid-2004 there were 8 stations with 37 full-time equivalent staff (Table 1-1). Run by the Centers for Disease Control and Prevention (CDC), their responsibilities and capabilities have consisted of: TABLE 1-1 Number of Employees and Contractors at Each CDC Quarantine Station at U.S. Ports of Entry, Mid-2004 Quarantine Station No. of Full-Time Equivalents Atlanta 3 Chicago 5 Honolulu 3 Los Angeles 4 Miami 7 New York City (JFK) 8 San Francisco 3 Seattle 4 TOTAL 37   SOURCE: Personal communication, D. Kim, DGMQ, October 13, 2004, M. Remis, DGMQ, January 18, 2005. Responding to ill passengers (international travelers, immigrants, and refugees) with suspected infectious disease. If the passenger arrives at a port with a quarantine station, station staff evaluate the individual for signs,symptoms, and travel history consistent with a quarantinable disease (Box 1-2). If the index of suspicion is high, the individual is sent to a healthcare facility for medical evaluation and diagnosis. If the passenger arrives at port of entry lacking a quarantine station, the station with jurisdic-

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report BOX 1-2 Quarantinable Communicable Diseases By executive order of the President of the United States, federal isolation and quarantine are authorized for the following communicable diseases: Cholera Diphtheria Infectious Tuberculosis Plague Smallpox Yellow Fever Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named) Severe Acute Respiratory Syndrome (SARS) SOURCE: Executive Order 13,295 of April 4, 2003: Revised List of Quarantinable Communicable Diseases. 3 C.F.R. (2003). tion2 over the port consults the physician on call at DGMQ headquarters or alerts the local health department to evaluate the individual for signs and symptoms of a quarantinable disease. If the index of suspicion is high, the individual is sent to a healthcare facility for diagnosis. Meeting arriving refugees and parolees, visually screening them for signs and symptoms of illness, reviewing the results of their oversees medical examinations, giving local health departments notification of their arrival and the results of their oversees exams, and alerting the health departments to arrivals with Class A or B conditions (Box 1-3). Identifying immigrants with Class A or B diseases who arrive at a station’s port or whose oversees medical examinations are forwarded to the station by the U.S. Immigration and Naturalization office at the port of arrival. The station then then sends information to relevant state and local health departments about the immigrants’ final destinations, suspect diseases, and the results of their oversees medical exams. Inspecting plants and animals imported legally or illegally that may pose a public health threat. Inspecting cargo identified as a potential public health threat. (Personal communications: J. Barrow and M. Remis, DGMQ, December 28, 2004; S. Maloney, DGMQ, January 18, 2005) Emergence of Infectious Diseases and the Threat of Bioterrorism Once the border quarantine system had been largely dismantled, new and long-absent infectious diseases emerged, reemerged, and spread in humans; nearly 40 newly emerging infectious diseases were identified during the 30 years between 1973 and 2003 (GAO, 2004). The conver 2   Each quarantine station is responsible for many ports of entry without a quarantine station located within a specific geographic area. For example, Hartsfield International Airport in Atlanta has jurisdiction over all ports in Georgia, Alabama, Arkansas, Louisiana, Oklahoma, Mississippi, North Carolina, South Carolina, and Tennessee. The United States has more than 295 ports of entry (Personal communication, S. Maloney, DGMQ, January 18, 2005).

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report gence of multiple interrelated factors is responsible for this phenomenon (IOM, 2003); they include: rapid, high-volume international and transcontinental travel, commerce, and human migration; mass relocation of rural populations to cities and the prevalence of overcrowded, unsanitary conditions there; exponential growth of population and the number of individuals susceptible to infectious disease; widespread changes in climate, ecology, and land use; more frequent contact between people and wildlife; reduced global investment in public health infrastructure; development of antimicrobial resistance. Numerous scientists, physicians, and public health officers in national and international organizations have voiced concern about these trends and their relationship to such naturally occurring public-health threats as West Nile Virus, SARS, pandemic influenza, and HIV/AIDS. Also within the past two decades, terrorism in general and bioterrorism in particular have become grave concerns to the United States government and its citizens. Consequently, in the late 1990s, BOX 1-3 Class A and Class B Conditions In the context of medical examinations of individuals who seek refuge in the United States or want to immigrate to this country: Class A conditions generally render an alien ineligible for entry into the United States; they include: Communicable diseases of public health significance, including chancroid, gonorrhea, granuloma inguinale, human immunodeficiency virus (HIV) infection, leprosy (infectious), lymphogranuloma venereum, syphilis (infectious stage) and tuberculosis (active). A physical or mental disorder and behavior associated with the disorder that may pose, or has posed, a threat to the property, safety, or welfare of the alien or others. A history of such a disorder and behavior, which is likely to recur or lead to other harmful behavior. Drug abuse or addiction. In certain cases, a waiver may be issued to an individual with a Class A condition for entry into the United States. When this occurs, immediate medical follow-up is required. Class B conditions comprise a “physical or mental abnormality, disease or disability serious in degree or permanent in nature amounting to a substantial departure from normal well-being” (Medical Examination of Aliens. 42 C.F.R. § 34.4 [2004]). Individuals with Class B conditions may enter the United States, but must receive medical follow-up soon after arrival. SOURCES: Medical Examination of Aliens. 42 C.F.R. § 34.1–34.8 (2004); Refugee and Immigrant Health Program, Massachusetts Department of Public Health (2000).

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report DGMQ began to explore ways that the quarantine stations at U.S. ports of entry might help protect U.S. citizens from the unintentional or intentional importation of dangerous infectious agents (Personal communication, D. Kim, DGMQ, October 13, 2004). The outbreak of SARS in 2002 dramatically demonstrated the need for strong, well-coordinated national and international systems for disease surveillance, detection, and response. In the short term, the outbreak led to a modest but significant change at the CDC quarantine stations: the addition of 9 contractors who have master’s degrees in public health. U.S. Government Invests in Biosecurity Coupled with the microbial threats described above, SARS generated enough political will for the U.S. federal government to commit funding to biosecurity initiatives. A portion of the fiscal year 2004 budget appropriation went to DGMQ for the construction of 3 new CDC quarantine stations at U.S. ports of entry: Houston Intercontinental Airport; the Mexico–U.S. land border crossing in El Paso, Texas; and Dulles International Airport, located 26 miles from Washington, D.C. These three new stations are not fully staffed as of this writing. President George W. Bush proposed further expansion of the quarantine station system under the biosecurity umbrella of his fiscal 2005 budget request to Congress3 by calling for another 14 CDC quarantine stations at U.S. ports of entry (Figure 1-1) (Office of Management and Budget, 2004). VISION FOR THE EXPANDED QUARANTINE STATION SYSTEM With its new mandate, DGMQ wants the quarantine stations to do more than respond to and evaluate travelers with suspect or probable illness. It envisions playing an active, anticipatory role in nationwide biosurveillance (DGMQ, 2003b). This move may be broadly viewed as a significant step back to the robustness of the U.S. border quarantine station system before 1970, as well as a step forward toward national biosecurity based on today’s technology and knowledge of microbial threats to human heath. “CDC Quarantine Stations are gearing up to make the transition from the current focus on federal inspection services at airports to become a full partner in public health response,” DGMQ states in a 2003 proposal (DGMQ, 2003b, p.1). “The transformed CDC Quarantine Stations will go beyond evaluating ill passengers to encompass a wide range of responses to infectious disease threats, whether intentional—as in the case of bioterrorism—or related to emerging pathogens…. [They] will bring new expertise to bridge gaps in public health and clinical practice4, emergency services, and response management…. Improved communications networks will enable passengers to be notified promptly of potential exposures to infectious diseases. These expanded services will be integrated into bioterrorism and emergency preparation and response plans and will be grounded in strengthened collaboration [with state and local health departments, the travel industry, and the health-care community, as well as other federal agencies].” DGMQ also would like the CDC quarantine stations to provide a stronger continuum of health support for refugees, whom the division helps prepare for migration to the United States. 3   On December 8, 2004, Congress allocated $80 million to the Department of Health and Human Services, Office of the Secretary, “to support and expand biosurveillance activities” in fiscal year 2005 (U.S. Congress, 2004). As of this writing, it is unclear what portion of the total will go to DGMQ for expanding the quarantine station system. 4   As of January 18, 2005 seven Quarantine Medical Officers (physicians) are on duty or have accepted offers of employment. Offers of employment have been made to two additional Quarantine Medical Officers. Offers of employment for other staff positions are also pending. (Personal communication, M. Remis, DGMQ, January 18, 2005)

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Refugees primarily enter the United States through a port with a quarantine station5, so the stations may be well positioned to monitor the health status of arriving refugees and collaborate with state and local officials on follow-up health evaluations and treatment. FIGURE 1-1 DGMQ’s proposed geographic distribution of the 25 quarantine stations in the expanded system. The New York, Miami, Chicago, and Los Angeles quarantine stations would serve as regional headquarters. The white boxes denote the 8 cities where quarantine stations existed prior to 2004. The shaded boxes with a double border identify the three cities where quarantine stations opened in 2004. The shaded boxes with a single border represent the 14 cities where DGMQ plans to establish more stations beginning in 2005. The existing quarantine stations are located at airports and a land crossing, as indicated in parentheses under the name of each of those cities. Each of the next 14 stations will be located at either a seaport, airport, or land crossing, but most of this information has not been communicated to the committee as of the date of this letter. SOURCE: Adapted from personal communication, M. Remis, DGMQ, October 22, 2004. 5   A large number of refugees enter the United States at Newark Liberty International Airport, which lacks a quarantine station at present. The International Office for Migration does the initial processing of these refugees and provides their documentation to quarantine station staff at John F. Kennedy International Airport in New York City, who notify appropriate health departments. Newark is one of the 14 cities designated for a quarantine station.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Guidance Sought from IOM The pace of the quarantine-station expansion at U.S. ports of entry and the potential for a functional revamping of the sytem led DGMQ to seek guidance from the Institute of Medicine (IOM) on how best to strengthen, improve, and modernize public-health responses and disease surveillance in its quarantine-station system. The pace of the expansion also led DGMQ to request preliminary guidance early in the course of the IOM study on the types of health professionals and competencies needed to meet the stations’ new public health mission and traditional statutory responsibilities. We provide this preliminary guidance below. FUNCTIONS AND COMPETENCIES The committee has preliminarily developed priority functions (Box 1-4) and core competencies necessary for surveillance, detection, and response to public-health threats at U.S. ports of entry. The guidance in this report is based primarily on the expert judgment of the committee. As noted above, we will revisit the question of function in depth in the final report. BOX 1-4 Priority Functions Conduct historic* functions. Plan for public health threats. Conduct surveillance for public health threats. Assess and respond to public health threats. Communicate the nature of diseases, risks, and responses. Create linkages across sectors and jurisdictions. *   Historic functions are the activities, including inspections, that have been carried out by the stations for at least the past decade in accordance with federal regulations. Guiding Framework The competencies should be considered within the following framework: Every station should have access to individuals who posess all the competencies. These individuals could be located either on site or off site. Potential off-site human resources could be based at the regional stations, DGMQ headquarters, the private sector, partner agencies, or elsewhere. In general, using partners as a resource for some of the competencies could help the stations build collaborative relationships that enhance the stations’ overall effectiveness. The competencies in each functional area do not necessarily comprise a job description. Qualified individuals may have competencies in more than one functional area. Many different mixes of professionals could, as a team, have all the requisite competencies.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report A regional station might need staff on site who collectively posess all the competencies necessary to execute all of the priority functions. All staff who conduct the priority functions should be able to demonstrate basic familiarity with infectious diseases of public health concern. All staff of the quarantine station system should have access to and abilities in basic information technology, including the abilities to use e-mail, word-processing software, and the Internet. Specialized Competencies in Information Technology At least some of the technical staff should have more advanced computer skills that enable them to use standard, off-the-shelf software for creating spreadsheets, databases, and communication products. These staff also should be capable of using software for conducting analyses and for exchanging data with partner organizations. For instance, relevant staff should be able to obtain and use airlines’ electronic passenger manifests, when available, to conduct contact tracing. In addition, the stations may need access to technical support should any of their systems fail, especially during a public health emergency. Capacities in Foreign Languages and Cultures The quarantine stations should have access to translators in the languages of the travelers and crew who typically arrive at their port. Staff who conduct any of the priority functions should be able to identify and contact appropriate translators at any time. This competency is critical to individuals who conduct assessment and response, health communication, and risk communication. In addition, the quarantine station staff should be able to demonstrate knowledge of and sensitivity to the cultural norms in interpersonal communication and healthcare of travelers and crew who typically arrive at their port. I. Conduct Historic Functions Historic functions are the routine activities that the quarantine stations have conducted for the past decade or more in accordance with federal regulations. The committee has placed these activities at the top of the list of priority functions to highlight the importance of maintaining them and their associated competencies and human resources during this transitional period and into the future. Today’s quarantine inspectors and officers collectively have nearly three centuries worth of knowledge and experience (Personal communication, D. Kim, DGMQ, October 13, 2004). To preserve this wealth of expertise, these individuals should be involved in the development of training modules for new staff who will carry out historic functions at new stations as the expansion progresses. Historic quarantine station activities include the processing of immigrants, refugees, asylees and parolees; and the inspection of plant items, animal items, and cargo that could pose a potential public health threat. In addition, the stations have a long history of clinically evaluating new arrivals to the United States. As described on pages 2 and 3 of this letter, today’s inspectors carry out that important function in several ways: by responding to ill passengers with suspected infectious disease to determine if the individuals have symptoms and travel history consistent with a quarantinable disease (Box 1-2); by visually screening refugees and parolees for signs and symp-

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report toms of illness; by identifying immigrants with Class A or B conditions (Box 1-3); and by conveying the results of oversees medical examinations and other relevant information to state and local health departments (Personal communications: J. Barrow and M. Remis, DGMQ, December 28, 2004; S. Maloney, DGMQ, January 18, 2005). During its deliberations, the committee decided to consolidate all clinical competencies—including those associated with the historic screening described above—under the priority function, “Assess and respond to public health threats” in part IV below; this placement is reflected in Table 1-2. Although the stations’ regulatory authority for historic functions is longstanding, the ability of the station staff to carry out these functions has greatly diminished due to the tremendous, round-the-clock volume of travelers and imported cargo and the global spread of infectious disease. For instance, the stations have a regulatory responsibility to restrict the importation of items that may pose a human health risk, including but not restricted to dogs, cats, non-human primates, turtles and tortoises, human remains, and etiological agents of various kinds (42 CFR § 71.51–55). However, the way these regulations are carried out varies from station to station and from port to port. In some instances, the quarantine station staff sees a significant number of imported animals or the paperwork documenting them; indeed, the staff relies on paper documentation for much of the inspection it conducts. Some imports are cleared by telephone and some by fax. In other instances, the staff relies on Customs and Border Protection (CBP) officials to perform these duties on their behalf. Even at the ports with quarantine stations, however, some of the at-risk cargo enters the United States without being inspected or cleared by DGMQ field staff (Personal communication, J. Barrow and M. Remis, DGMQ, November 9, 2004). The Trade Act of 2002, slowly being implemented at the ports of entry, is converting to a paperless system. DGMQ is pursuing the possibility of accessing the International Trade Data System with the goal of reviewing incoming cargo at all ports and identifying those items that might need further scrutiny (Personal communication, J. Barrow and M. Remis, DGMQ, November 9, 2004). At any given time, specialized restrictions can be put in place when a risk is perceived. Two contemporary examples are the bans on the importation of civet cats, an important potential source of the SARS coronavirus (Zhong, 2004), and Gambian rats, the probable source of human monkeypox virus that emerged in the United States in 2003 (Di Giulio and Eckburg, 2004). Competencies Needed to Conduct Historic Functions6 Relevant staff members should have the ability to: Understand and carry out federal regulations applicable to the quarantine stations regarding the importation of plants, animals, and biological specimens (Foreign Quarantine. 42 C.F.R. § 71.51–71.56 [2004]). Inspect plant and animal items that may pose a potential public health threat. Collaborate with staff from other federal and state agencies that also have responsibility for the inspection of imported plants and animals, including the USDA Animal and Plant Health Inspection Service, the U.S. Food and Drug Administration, state fish and wildlife agencies, and the Department of Homeland Security. Inspect cargo identified as a potential public health threat. 6   Excluding the clinical aspects of historic functions; these are described in part IV.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Develop knowledge of cargo operations at airports and seaports and keep apprised of changes. Develop and maintain relationships with key individuals at private-sector transport companies that routinely use the port where the quarantine station is based. Develop relationships and maintain frequent communication with key port personnel and with employees of U.S. ports located in offices at major foreign points of origin. Process arriving refugees, immigrants, asylees, and parolees. II. Plan for Public Health Threats Each quarantine station should be prepared to screen for and respond to the detection of microbial threats to health in arriving passengers and crew. For purposes of this report, a microbial threat of public health significance causes serious or lethal human disease and is transmissible from person to person, from animal to person, or has the potential to be transmitted either of these ways; it also may be transmissible from food or water to people. Concern is greatest for those microbes that spread readily from person to person due to their potential for wide dispersal. The stations should develop protocols for responding to possible, probable, and definite diagnostic results, including the identification or construction of isolation units at or near ports of entry. Protocols for screening and response should be updated as new rapid diagnostics become available. Likewise, staff should periodically participate in continuing education courses. In addition, the stations should create emergency-response plans for their personnel in concordance with established emergency-response plans that cover the port where each station is located and other ports in its area of jurisdiction7. These plans should be developed in coordination with relevant partners. The competencies developed by the committee in this section are not inconsistent with the elaborate work done by the Center for Health Policy at Columbia University School of Nursing (Center for Health Policy, 2001, 2002). They are, however, specifically tailored to the immediate needs of quarantine stations at U.S. ports of entry in the context of the planned expansion. Competencies Needed to Plan for Public Health Threats Relevant staff should have the ability to (National Response Team, 2001; Center for Health Policy, 2001): Coordinate (with DGMQ headquarters) the station’s procedures for the monitoring of global health threats. Develop and maintain emergency response plans consistent with local, state, and regional plans for biological, chemical, radiological, and conventional threats. If called upon, collaborate with port personnel, private-sector partners, and public-sector partners in the development of emergency response plans for biological, chemical, or radiological incidents at the port. Develop and maintain routine protocols for the identification of suspect cases, probable cases, and asymptomatically infected individuals. 7   Each quarantine station has responsibility for ports of entry without a quarantine station within a specific geographic area. For example, Hartsfield International Airport in Atlanta has jurisdiction over all ports in Georgia, Alabama, Arkansas, Louisiana, Oklahoma, Mississippi, North Carolina, South Carolina, and Tennessee.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Define and articulate the station’s role in emergency response within the area’s jurisdictional parameters. Work within an incident command structure and the National Incident Management System. Maintain relationships and regular communication with relevant public health and emergency partners.8 Implement notification systems. Conduct emergency preparedness training procedures, including tabletop exercises and regular drills, for station staff and—if requested—port personnel. Participate in practice sessions and drills with local emergency preparedness groups. Evaluate training and incident response results to ensure that all parts of the emergency plan are followed. Develop plans and procedures for educating arriving passengers and crews about the health risks posed by suspected or detected microbial threats in a human traveler or in imported animals, plants, biological specimens, and other substances for which the stations have statutory responsibility. Coordinate and maintain protocols for assessing and responding to the importation of biological specimens from abroad for their potential threat to public health; these include bodily fluids and human and animal tissues. Manage the station’s emergency resources, including contacts, equipment, materials, and facilities. Effectively manage fellow staff members in the coordination and implementation of response plans and routine protocols. Work comfortably with quarantine station staff, DGMQ colleagues, and all relevant partners to coordinate and implement response plans. III. Conduct Surveillance for Public Heath Threats The station system should conduct surveillance for microbial threats of public health significance as defined above. The stations and DGMQ headquarters should anticipate the arrival of infectious disease threats from abroad to the best of their ability by mining the multiple electronic disease-reporting networks and databases at their disposal. These data should be monitored, interpreted, and assessed for situations that call for the screening of at-risk inbound travelers. Since an estimated 75 percent of newly emergent infectious diseases are zoonotic in origin (Taylor et al., 2001), staff should track outbreaks of disease in animals as well as humans. The routine review and analysis of disease diagnoses in travelers and their points of origin could help local public health authorities contain community-level outbreaks of imported diseases and could stimulate the introduction of disease-specific diagnostics and interventions at the ports of entry likely to receive infected passengers. Such new technologies as thermal scans and rapid diagnostic assays may need to be adapted, implemented, and evaluated for surveillance purposes. 8   These partners include area hospitals and emergency responders; community organizations; officials from public health agencies and other branches of state, local, and tribal government; area transportation safety officials; representatives and officers of transportation companies and industry organizations; port and border security personnel; law enforcement agencies; officials from such federal agencies as the Department of Homeland Security, U.S. Department of Agriculture, and U.S. Fish and Wildlife Service; international public health agencies; international transportation organizations; the media; and suppliers of critical products.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Competencies Needed to Conduct Surveillance for Public Health Threats Relevant staff should have the ability to: Design surveillance protocols. Adapt surveillance protocols to the type and severity of perceived threat. Operate newly developed surveillance technology as it becomes available. Follow CDC guidelines for the evaluation of surveillance systems to examine the effectiveness of new surveillance technologies in conjuction with other stations and DGMQ headquarters. Collect, analyze, and interpret relevant data. Use standard epidemiological and statistical software such as Epi-Info and SAS. Undertake outbreak investigations. Report findings to regional stations and DGMQ headquarters. Participate in large-scale contact tracing. Collaborate with public health officials at local, state, tribal, and international levels; with state epidemiologists, CBP partners, private-sector partners (especially transportation companies), and DGMQ staff at headquarters and other stations. Respond to information about outbreaks of infectious diseases of public health concern by conducting disease surveillance and response on appropriate arrivals. IV. Assess and Respond to Public Health Threats At this stage of the study, the committee has approached the dual functions of assessment and response almost entirely from a clinical standpoint. The clinical aspects of the stations’ historic functions are incorporated here for thematic cohesion; all other historic functions are discussed in section I. The quarantine stations need access to a clinician who can diagnose infectious diseases of public health concern, including those that are uncommon or absent in the United States but common in or endemic to other parts of the world. The stations also need access to clinicians who can assess patients exposed to chemical, radiological, or biological agents and who can recommend prophylaxes or treatment. At times, the clinician might need to perform triage; it is unclear whether state medical licensing laws would apply to the quarantine stations in these cases. In addition, the need may arise for mass diagnostic screening of inbound (and potentially outboud) passengers, such as during an influenza pandemic. Quarantine station personnel who do direct clinical evaluation or triage are at risk for infection, so these individuals should have baseline skills in infection control and the use of such personal protective equipment as masks, protective eyewear, gloves, gowns, and containment suits (IOM, 2004), which should be available on site. Strong relationships between the clinician and local hospitals, emergency-room physicians, clinical laboratories, and first responders will facilitate the response to public health threats. Competencies Needed to Assess and Respond to Public Health Threats Relevant staff should have the ability to:

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report Recognize the signs, symptoms, and transmission patterns of infectious diseases of public health concern, especially those that are transmissible from person to person, rapidly progressive, and lethal. This includes diseases rarely seen in the United States but common or endemic to other parts of the world. Perform triage.9 Interview patients and contacts to obtain case histories. Physically examine patients and assess them, report findings to physicians with specialized expertise, make diagnoses when possible, and make decisions regarding patient referral and the need for isolation during transport to a referral facility. Develop comprehensive knowledge of local resources for patient referral. Develop relationships with local hospitals, physicians, first responders, and public health laboratories. Collect specimens for laboratory analysis. Follow appropriate protocols for infection control during direct clinical evaluations, triage, and the collection and transport of laboratory specimens. Such protocols include the use of personal protective equipment and the implementation of isolation precautions. Perform rapid diagnostic tests to screen large numbers of passengers for potential exposure to infectious agents of public health concern. Interpret results of diagnostic tests. By telephone or equivalent, conduct pre-arrival assessments of suspect or probable cases who are aboard airplanes and ships; coordinate responses by instructing crews and deploying personnel and equipment on the ground. Track patients, passengers, crews, and so on. Conduct post-arrival follow-up on the health status of refugees, immigrants, and asylees. Assess biological specimens for their potential to introduce a microbial threat to the public. Recognize epidemiologic and other emergency indicators; interpret and understand related data. V. Communicate the Nature of Diseases, Risks, and Responses We have subdivided the communication function into four categories—general communication, risk communication, health education, and media relations—because the last three areas require specialized knowledge and skills. In practice, however, we expect that two or more of these functions will be integrated. For instance, communicating with the media about travelers diagnosed with an infectious disease would require some discussion of risk and some health education. In all cases, the stations, DGMQ headquarters, or both should coordinate public communications with state and local partners. A) General Communication 9   Triage: The sorting of individuals who are too well to need treatment, too ill to be saved, and those in the middle who would benefit from treatment.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report The quarantine stations routinely interact with multiple partners: port officials, representatives of airlines and cruise ships, federal officials from other agencies, state and local public health officials, hospital officials, emergency responders, and so on. At least one individual at every station should be capable of communicating with these partners in a way that fosters credibility, respect, understanding, collaboration and trust (ATSDR, 1994). Individuals responsible for risk communication, health education and media relations should also have these capabilities. Competencies needed to conduct general communication Relevant staff members should have the ability to: Communicate verbally in an articulate, poised manner with both individuals and groups. Quickly build trust and rapport. Distill complex information into clear, succinct messages. Listen to, comprehend, and respond to diverse audiences. Communicate effectively with individuals in positions of authority among partner organizations. Such individuals include pilots, captains, and officials of transport companies, hospitals, and port authorities. Communicate effectively in writing and through graphics. Create printed and electronic communication products for staff and stakeholders with the goal of helping the stations function more efficiently and effectively. Create and give presentations to stakeholders. Routinely evaluate whether messages achieve their intended outcome. Collaborate effectively with communications officers at partner organizations (e.g., by developing consistent messages about a particular incident). B) Risk Communication Many of the public health threats that the quarantine stations encounter will be characterized at the outset by uncertainty. As the nature of the threat becomes clearer, the facts that emerge will have the potential to cause panic and distress. The stations should all have rapid access to individuals trained to discuss health-related uncertainties, risks, and concerns with individuals and groups (ATSDR, 1994). Competencies needed to communicate the nature of health risks Relevant staff should have the ability to: Understand quantitative and qualitative data on the health risks posed by suspect, probable and confirmed cases of disease and by exposure to biological, chemical, and radiological weapons. Translate quantitative measurements of risk into language that helps affected individuals develop a realistic level of concern and take appropriate actions. Decrease the potential for alarm.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report C) Health Education The diagnosis of an infectious disease in a passenger or crew member often will require that a member of the quarantine station staff discuss the health implications of the diagnosis with the patient, his or her contacts, representatives of the airline or shipping company, and others. In some cases, a staff member of the quarantine station may need to explain a public health matter to a large group of passengers or others. Competencies needed to communicate the nature of diseases and appropriate responses Relevant staff members should have the ability to: Understand the signs, symptoms, prophylaxis, treatment, and infection control measures pertinent to infectious diseases of global health concern, especially those rare or absent in the United States. Understand clinical information communicated by physicians and epidemiologists. Explain medical conditions and provide instructions for self–care in language that is understandable to individuals at all levels of health literacy. Respond to patients’ questions and concerns. Explain risks and proposed responses to governing legal authorities and other individuals in positions of authority (e.g., pilots, captains). D) Media and Public Relations From time to time, the media and the general public may express an interest in an incident managed by a quarantine station, or the station may want to alert the public in response to an incident. An individual representing the individual station, the station system, or DGMQ will need to communicate with reporters or public leaders with accuracy, good judgment, consistency, and media savvy in close coordination with partners such as local and state jurisdictions and transportation companies. Competencies needed to communicate with the media and general public Relevant staff members should have the ability to: Perform well under pressure in a fast-paced environment. Demonstrate good judgment and trustworthiness in all interactions with the public and the media. Understand the news cycle, the meaning and appropriate usage of such terms as “off the record” and “on background,” and the general perspective of reporters, editors, and producers. Formulate messages consistent with the mission of the CDC quarantine station system. Coach senior staff in preparation for interviews with individual reporters and for press conferences.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report VI. Create Linkages across Sectors and Jurisdictions The quarantine stations should develop collaborative relationships with all members of their communities and jurisdictions who respond to public health threats, as well as with relevant private-sector organizations. One example of such a linkage is the development of protocols and agreements with emergency medical services and area hospitals for the transport, care, and isolation of potentially infectious travelers, as well as reporting guidelines and jurisdictions among city, county, tribal, and state officials. Another example is the development of collaborative relationships with employees of U.S. ports who are based at major points of origin of the port’s clients. (For instance, the Port of Seattle maintains permanent offices, staffed by Port employees, at major ports of origin in the Pacific.) In certain situations, it may be appropriate for quarantine station staff to take the lead in collaborative planning and responses based on the applicable incident command structure as well as on state, local, tribal, and regional laws, regulations, and practices. When creating linkages, the station staff must follow privacy laws and practices to protect the confidentiality of patients’ information. Competencies Needed to Create Linkages across Sectors and Jurisdictions The senior staff of each station should have the ability to: Establish credibility, foster relationships, and promote information-sharing with state and local officials in public health and emergency preparedness. Notify state and local public health authorities of clinical, diagnostic, epidemiological, or other investigations that indicate a possible public health threat. Protect the confidentiality of patients’ information. Be conversant in the overlapping and harmonizing functions of traditional public health agencies and other partners in all-hazards preparedness, including law enforcement, fire departments, and emergency medical technicians. Describe how the quarantine station fits into the preexisting incident command structure (Center for Health Policy, 2001) and operate within that structure. Take the lead, when appropriate, in coordinating public health responses within the applicable incident command structure. Understand the legal authorities in public health emergency response and work within those boundaries. Develop and maintain relationships with private-sector partners. TYPES OF HEALTH PROFESSIONALS As noted above, many combinations of health professionals and others could, as a team, have all the competencies necessary to meet the priority functions. To identify the types of professionals who would likely have one or more sets of the competencies outlined above, the committee brought to bear its combined knowledge on workforce issues in public health, medicine, nursing, emergency preparedness and response, epidemiology, and travelers’ health. The results are presented in Table 1-2 below. The selected job titles are common parlance within the U.S. public health community.

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report In addition to the types of professionals listed in Table 1-2, the stations will need clerical workers who perform structured work in support of station operations (Center for Health Policy, 2001). CONCLUDING REMARKS The committee has identified 6 sets of core competencies and 11 types of professionals that could help prevent microbial threats of public health significance from breaching U.S. borders and contain those that are imported either by accident or intentionally. We derived these competencies and professionals from the 6 functions that we identified as priorities for the CDC quarantine station system (Box 1-4). As noted above, the guidance offered in this interim letter report is preliminary and will be revisited as we continue to assess the role of the CDC quarantine station system in the context of our task (Box 1-1). We encourage the reader to refer back to the Statement of Task as a reminder of the breadth of subject matter to be addressed in the committee’s final report. During the next few months, we will visit several quarantine stations to personally see how they function. We will also learn how multiple private- and public-sector organizations presently interact with the stations and what role they envision the quarantine stations playing in the future. These information-gathering activities will likely include a discussion of the role of the quarantine stations within the National Incident Management System and relevant incident command structures. The committee’s deliberations may include consideration of such issues as the degree of centralization or autonomy that the individual stations should have. We look forward to providing DGMQ with recommendations for the development of a quarantine station system capable of meeting current and projected public-health needs at U.S. ports of entry. Georges C. Benjamin, Chair IOM Committee on Measures to Enhance the Effectiveness of CDC Quarantine Station Expansion Plan for U.S. Ports of Entry

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Human Resources at U.S. Ports of Entry to Protect the Public’s Health: Interim Letter Report TABLE 1-2 Types of Workers Who Could Conduct the Priority Functions Necessary for the Surveillance for, Detection of, and Response to Microbial Threats at U.S. Ports of Entry Type of Worker Priority Functions   Historic Functionsa Planning Surveillance (Epidemiological) Assessment & Response (Clinical) Communicationb Creating Linkages Health Education Risk Communication Media & Public Relations   Physician       x x x   x Physician with public health background   x x x x x x x Nurse practitioner   x   x x     x Physician’s assistant       x x x   x Nurse       x x x   x Public health nurse   x x x x x x x Public health advisor   Baccalaureate orequivalent x x     x     x Master’s ordoctoral   Trained in epidemiology x x x   x x   x Nottrained in epidemiology x x     x x   x Infectious disease epidemiologist   x x         x Communication specialist (Master’s or equivalent)   x       x x x NOTE: Any of these individuals could have the ability to manage a quarantine station. No correlation necessarily exists between level of education and rank. a For purposes of this report, the historic clinical capacities of the quarantine stations are encompassed by the priority function of assessment and response. b General communication competencies were intentionally left out of this table.