QUARANTINE STATIONS AT PORTS OF ENTRY

Protecting the Public’s Health

Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry

Laura B. Sivitz, Kathleen Stratton, and Georges C. Benjamin, Editors

Board on Global Health

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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Quarantine Stations at Ports of Entry: Protecting the Public’s Health QUARANTINE STATIONS AT PORTS OF ENTRY Protecting the Public’s Health Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry Laura B. Sivitz, Kathleen Stratton, and Georges C. Benjamin, Editors Board on Global Health Board on Population Health and Public Health Practice INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health THE NATIONAL ACADEMIES PRESS 500 FIFTH STREET, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2000-00629, Task Order No. 31 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry. Quarantine stations at ports of entry : protecting the public’s health / Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry, Board on Global Health, Board on Population Health and Public Health Practice ; Laura B. Sivitz, Kathleen Stratton, and Georges C. Benjamin, editors. p. ; cm. “This study was supported by Contract No. 200-2000-00629, Task Order No. 31 between the National Academy of Sciences and the Centers for Disease Control and Prevention”—Galley. Includes bibliographical references. ISBN 0-309-09951-X (pbk. book) 1. Quarantine—United States. 2. Bioterrorism—United States—Prevention. [DNLM: 1. Quarantine—United States. 2. Bioterrorism—prevention & control—United States. WA 234 I58 2005] I. Sivitz, Laura. II. Stratton, Kathleen R. III. Benjamin, Georges. IV. Title. RA665.I57 2005 363.34′97—dc22 2005033697 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: The cover incorporates images from a colorized transmission electron micrograph taken by C. Goldsmith (CDC) of Avian influenza A H5N1 viruses (seen in gold) grown in MDCK cells (green). Executive Order 13,375 of April 1, 2005, added to the list of quarantinable communicable diseases influenza caused “by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.”

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health COMMITTEE ON MEASURES TO ENHANCE THE EFFECTIVENESS OF THE CDC QUARANTINE STATION EXPANSION PLAN FOR U.S. PORTS OF ENTRY GEORGES C. BENJAMIN, M.D. (Chair), Executive Director, American Public Health Association JOAN M. ARNOLDI, D.V.M.,1 Retired, Associate Administrator, Animal and Plant Health Inspection Service, U.S. Department of Agriculture BARBARA A. BLAKENEY, M.S., R.N., President, American Nurses Association LAWRENCE O. GOSTIN, J.D., L.L.D., Professor of Law, Georgetown University Law Center; Professor of Public Health, Johns Hopkins University; and Director, Center for Law & the Public’s Health MARGARET A. HAMBURG, M.D., Senior Scientist, Nuclear Threat Initiative FARZAD MOSTASHARI, M.D., M.S.P.H., Assistant Commissioner, Bureau of Epidemiology Services, New York City Department of Health WILLIAM A. PETRI, JR., M.D., Ph.D., Wade Hampton Frost Professor of Epidemiology, Professor of Medicine, Microbiology, and Pathology, and Chief, Division of Infectious Diseases and International Health, University of Virginia Health System ARTHUR L. REINGOLD, M.D., Professor of Epidemiology, School of Public Health, University of California at Berkeley RONALD K. ST. JOHN, M.D., M.P.H., Director General, Centre for Emergency Preparedness and Response, Public Health Agency of Canada KATHLEEN E. TOOMEY, M.D., M.P.H.,2 Director, Division of Public Health, Georgia State Health Department MARY E. WILSON, M.D., Associate Professor of Population and International Health, Harvard School of Public Health and Associate Clinical Professor of Medicine, Harvard Medical School STUDY STAFF KATHLEEN STRATTON, Ph.D., Study Director LAURA B. SIVITZ, M.S.J., Research Associate DAVID W. GILES, Research Assistant SHEYI LAWOYIN, M.P.H., Senior Program Assistant NORMAN GROSSBLATT, ELS (D), Senior Editor PATRICK KELLEY, M.D., Dr.P.H., Director, Board on Global Health ROSE MARIE MARTINEZ, Sc.D., Director, Board on Population Health and Public Health Practice 1   Dr. Arnoldi resigned from the committee on December 21, 2004. 2   Dr. Toomey resigned from the Georgia State Health Department effective January 15, 2005, and from the committee on March 16, 2005.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Donald S. Burke, M.D., Bloomberg School of Public Health, Johns Hopkins University Kathleen F. Gensheimer, M.D., M.P.H., Maine Department of Health and Human Services David Heymann, M.D., World Health Organization Ann Marie Kimball, M.D., School of Public Health, University of Washington Bonnie J. Kostelecky, R.N., M.S., M.P.A., Multnomah County Health Department, Portland, OR Aileen Plant, Ph.D., M.P.H., Curtin University of Technology, Perth, Australia K.W. Wheeler, D.V.M., Retired, Animal and Plant Health Inspection Service, U.S. Department of Agriculture

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, Ph.D., R.N., Columbia University. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The committee’s letter report released in January 2005 (Appendix A) was also subject to independent review. We wish to thank the following individuals for their review of the letter report: Ruth L. Berkelman, M.D., M.P.H., Rollins School of Public Health, Emory University Donald S. Burke, M.D., Bloomberg School of Public Health, Johns Hopkins University Kathleen F. Gensheimer, M.D., M.P.H., Maine Department of Health and Human Services Ann Marie Kimball, M.D., School of Public Health, University of Washington Bonnie J. Kostelecky, R.N., M.S., M.P.A., Multnomah County Health Department, Portland, OR Monitor appointed by IOM: Hugh H. Tilson, M.D., Dr.P.H., School of Public Health, University of North Carolina.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Contents 1   EXECUTIVE SUMMARY          Strategic Public Health Leadership at the Nation’s Gateways,   2      Background and Framework,   3      Recommendations for the Quarantine Core,   9      References,   13 1   INTRODUCTION   14      Study Methods,   18      Framing the Issue,   23      Structure of This Report,   26      References,   26 2   CONTEXT AND CONTENT OF THE CDC QUARANTINE STATION EXPANSION PLAN   28      The Emergence of New Infectious Diseases and the Threat of Bioterrorism,   28      Expansion Plan for CDC Quarantine Stations at U.S. Ports of Entry,   29      References,   34 3   TODAY’S CDC QUARANTINE STATIONS AT U.S. PORTS OF ENTRY   36      Statutory and Regulatory Foundation of CDC Quarantine Station Activities,   36

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health      Quarantine Core, System, and Network,   37      Identification of and Response to Ill Passengers and Crew,   40      Immigrants and Refugees: Role of the Quarantine Core,   55      Inspection of Animals and Animal Products, Etiologic Agents, Hosts, and Vectors,   59      Conclusion,   66      References,   67 4   BRIDGE FROM PRESENT TO FUTURE: VISION AND RECOMMENDATIONS   70      Committee’s Vision of the 21st Century Quarantine Network for U.S. Ports of Entry,   72      Recommendations,   73      Conclusion,   91      References,   92     APPENDIXES         A  HUMAN RESOURCES AT U.S. PORTS OF ENTRY TO PROTECT THE PUBLIC’S HEALTH: INTERIM LETTER REPORT   97      Historical Context,   98      Vision for the Expanded Quarantine Station System,   103      Functions and Competences,   105      Types of Health Professionals,   117      Concluding Remarks,   117      References,   119     B  AGENDAS OF OPEN SESSIONS OF COMMITTEE MEETINGS   121     C  METHODOLOGY USED BY THE DIVISION OF GLOBAL MIGRATION AND QUARANTINE TO SELECT SITES FOR NEW QUARANTINE STATIONS   124      Proposal for CDC Quarantine Station Distribution,   124     D  COMMISSIONED PAPER ON U.S. SEAPORTS AND THE CDC QUARANTINE STATION SYSTEM   128      Summary and Conclusions,   128      General Description of the CDC Quarantine Station System (QSS) at Seaports,   136      Current Operating Environment of CDC QSS at Seaports,   144

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health      CDC QSS at Seaports: Passenger and Crew Transportation,   153      CDC QSS at Seaports: Cargo Transportation,   160     E  MICROBIAL THREATS OF PUBLIC HEALTH SIGNIFICANCE ORIGINATING IN ANIMALS OR ANIMAL PRODUCTS AT U.S. PORTS OF ENTRY   169      Introduction,   169      Legal Framework for Inspections at U.S. Ports of Entry,   170      Agencies at U.S. Ports of Entry—Roles and Responsibilities,   172      Resources and Budgets,   181      Day-to-Day Reality of Work,   181      Interagency Communication and Referrals,   187      Issues and Concerns,   190      References,   194      Abbreviations,   198     F  INTERNATIONAL LEGAL CONSIDERATIONS FOR THE QUARANTINE STATION EXPANSION   199     1.  Introduction,   201     2.  Basic Dynamics of International Law with Respect to Public Health Protection,   201     3.  The International Health Regulations,   203     4.  International Trade Law,   217     5.  International Human Rights Law,   221     6.  International Legal Considerations Concerning “Forward Deployment” of the Expanded NQS,   225     G  EXCERPTS FROM A STANDARED MEMORANDUM OF AGREEMENT BETWEEN CDC AND LOCAL HOSPITALS   305     H  COMMITTEE BIOGRAPHIES   310

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Tables, Figures, and Boxes TABLES 1.1   Locations, Jurisdictions, and Staffing of CDC Quarantine Stations at U.S. Ports of Entry (Established and Nascent), May 2005 and October 2005 Forecast,   16 3.1   Number of Ports of Entry to the United States Compared with Number of Official Ports of Entry (POEs) Defined by U.S. Customs and Border Protection, 2005,   41 3.2   All Cases of Illness Reported to or Found by DGMQ in 2003 and Medical Control Measures Taken,   49 3.3   Number of Immigrants, Refugees, and Asylees Accepted into the United States, 2003,   55 3.4   Communicable Diseases of Public Health Concern Diagnosed in Immigrants and Refugees to the United States by Panel Physicians, 1999–2003,   57 A.1   Number of Employees and Contractors at Each CDC Quarantine Station at U.S. Ports of Entry, Mid-2004,   99 A.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,   118 C.1   Summary Table,   127 D.1   Organizations/Agencies Providing Information for Study,   129 D.2   2002-2003 Cruise Passengers at U.S. Ports,   139

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health D.3   Seaport coverage by CDC Quarantine Station,   146 D.4   Partners in CDC Quarantine Station System at Seaports,   149 D.5   2003 Containerized Traffic for U.S. Ports,   162 D.6   U.S. Waterborne Imports—Top 100 Ports by Weight and Customs District (2003),   164 E.1   Legal Authorities for Inspections at U.S. Borders,   173 E.2   DHS, Border and Transportation Security, U.S. Customs and Border Protection, and Components Addressing Animal Diseases,   178 E.3   Level of Funding,   182 E.4   CBP’s Inspection Staff for All POE Locations, FY 2001–2004,   183 E.5   Resources at CDC Quarantine Stations at Major U.S. Airports,   184 F.1   Public Health-Related Civil and Political Rights in the ICCPR,   223 F.2   Summary Table of Important Positive and Negative Obligations the United States Has Under International Law Relevant to the Expansion of the National Quarantine System,   227 F.3   Analysis of the Revised International Health Regulations: Implications for Plans to Expand the National Quarantine System,   235 F.4   Analysis of the WTO’s Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement): Implications for Plans to Expand the National Quarantine System,   283 FIGURES ES.1   The relationships among the Quarantine Core, System, and Network for U.S. ports of entry,   5 1.1   The relationships among the members of the Quarantine Core and their partner organizations in the Department of Health and Human Services,   19 2.1   The proposed geographic distribution of the 25 quarantine stations in the expanded system,   31 3.1   The relationships among the Quarantine Core, System, and Network for U.S. ports of entry,   39 3.2   CDC Health Alert Notice,   54 3.3   Algorithm for screening prospective immigrants, refugees, and asylees to the United States for tuberculosis (TB),   56

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health 4.1   The geographic boundaries of the United States’ 3,066 counties,   75 A.1   DGMQ’s proposed geographic distribution of the 25 quarantine stations in the expanded system,   103 BOXES ES.1   Class A and Class B Conditions,   7 ES.2   Quarantinable Communicable Diseases,   8 1.1   Statement of Task,   15 1.2   Class A and Class B Conditions,   22 1.3   Quarantinable Communicable Diseases,   23 3.1   The Role of U.S. Ports of Entry as Defined by the Department of Homeland Security,   45 3.2   Mission Statement of U.S. Customs and Border Protection,   46 3.3   Immigration Inspection Program: Mission and Role,   47 A.1   Statement of Task,   98 A.2   Quarantinable Communicable Diseases,   100 A.3   Class A and Class B Conditions,   101 A.4   Priority Functions,   105 F.1   The Revised IHR’s Decision Instrument (Annex 2),   206

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Abbreviations AII airborne infection isolation AMS Automated Manifest System APHIS Animal and Plant Health Inspection Service, U.S. Department of Agriculture APHL Association of Public Health Laboratories APIS Automated Passenger Information System AQI Agriculture Quarantine and Inspection, Animal and Plant Health Inspection Service ASTHO Association of State and Territorial Health Officials ATA Air Transport Association of America Inc. BIDS Border Infectious Disease Surveillance Project, Centers for Disease Control and Prevention CBP U.S. Customs and Border Protection CDC Centers for Disease Control and Prevention CSTE Council of State and Territorial Epidemiologists DGMQ Division of Global Migration and Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention DHHS U.S. Department of Health and Human Services DHS U.S. Department of Homeland Security DOT U.S. Department of Transportation

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health DQ Division of Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention EMS emergency medical services FAA Federal Aviation Administration, U.S. Department of Transportation FBI Federal Bureau of Investigation FDA Food and Drug Administration FTEs full-time equivalents GAO Government Accountability Office HIPAA Health Insurance Portability and Accountability Act HIV human immunodeficiency virus ICD-CM International Classification of Diseases, Clinical Modification ICU intensive-care unit IOM Institute of Medicine LPHA local public health authority MOA memorandum of agreement MSEHPA Model State Emergency Health Powers Act MSPHA Model State Public Health Act NACCHO National Association of County and City Health Officials NACO National Association of Counties NCID National Center for Infectious Diseases, Centers for Disease Control and Prevention NHP nonhuman primates NIH National Institutes of Health OIS Office of Immigration Statistics, U.S. Department of Homeland Security PHAC Public Health Agency of Canada POEs Ports of Entry SARS severe acute respiratory syndrome State PHA state public health agency

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health USCG U.S. Coast Guard USDA U.S. Department of Agriculture USFWS U.S. Fish and Wildlife Service, U.S. Department of the Interior WHO World Health Organization

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health QUARANTINE STATIONS AT PORTS OF ENTRY

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