Executive Summary

The millions of people and goods that daily traverse the globe disperse microbial threats in their wake, usually without intent to harm. Living things get infected along the way, and the lag time before signs and symptoms appear can be days, weeks, or months. These phenomena and other forces intrinsic in modern technology and ways of life favor the emergence of new diseases and the re-emergence or increased severity of known diseases. Meanwhile, the risk of bioterrorism has become a pressing national security issue. Taken together, these factors have stimulated calls for greater vigilance about microbial threats of public health significance at U.S. gateways. Some of those calls have focused attention on the number and—more important—the role of quarantine stations for human disease at U.S. ports of entry.

The Centers for Disease Control and Prevention (CDC) has quarantine stations at 8 of the 474 U.S. ports of entry (CRS, 2004; DGMQ, 2003). Unlike their namesakes, today’s quarantine stations are not stations per se, but rather small groups of individuals located at major U.S. airports. Their core mission remains similar to that of old: mitigate the risks to residents of the United States posed by infectious diseases of public health significance originating abroad. These quarantine station staff, their offices, and their patient isolation rooms are run by CDC’s Division of Global Migration and Quarantine (DGMQ).

In fiscal 2003, Congress began to allocate funds for the establishment of new quarantine stations at 17 major U.S. ports of entry that comprise airports, seaports, and land-border crossings. In a significant departure



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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Executive Summary The millions of people and goods that daily traverse the globe disperse microbial threats in their wake, usually without intent to harm. Living things get infected along the way, and the lag time before signs and symptoms appear can be days, weeks, or months. These phenomena and other forces intrinsic in modern technology and ways of life favor the emergence of new diseases and the re-emergence or increased severity of known diseases. Meanwhile, the risk of bioterrorism has become a pressing national security issue. Taken together, these factors have stimulated calls for greater vigilance about microbial threats of public health significance at U.S. gateways. Some of those calls have focused attention on the number and—more important—the role of quarantine stations for human disease at U.S. ports of entry. The Centers for Disease Control and Prevention (CDC) has quarantine stations at 8 of the 474 U.S. ports of entry (CRS, 2004; DGMQ, 2003). Unlike their namesakes, today’s quarantine stations are not stations per se, but rather small groups of individuals located at major U.S. airports. Their core mission remains similar to that of old: mitigate the risks to residents of the United States posed by infectious diseases of public health significance originating abroad. These quarantine station staff, their offices, and their patient isolation rooms are run by CDC’s Division of Global Migration and Quarantine (DGMQ). In fiscal 2003, Congress began to allocate funds for the establishment of new quarantine stations at 17 major U.S. ports of entry that comprise airports, seaports, and land-border crossings. In a significant departure

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health from the recent past, both the preexisting 8 quarantine stations and the new 17 are expected to play an active, anticipatory role in nationwide biosurveillance (DHS, 2004; Gerberding, 2005). Consequently, CDC asked the Institute of Medicine (IOM) to convene an expert committee to assess the present CDC quarantine stations and recommend how they should evolve to meet the challenges posed by microbial threats at the nation’s gateways.1 IOM convened the Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry in October 2004; this is the committee’s final report to CDC. STRATEGIC PUBLIC HEALTH LEADERSHIP AT THE NATION’S GATEWAYS The traditional, primary activities of the CDC quarantine stations no longer protect the U.S. population sufficiently against microbial threats of public health significance that originate abroad, the committee concluded. In 2004, for example, a man suffering from fever, chills, severe sore throat, and diarrhea flew from Sierra Leone to Newark, NJ. By the time he died from Lassa fever less than a week after arrival, he had exposed 188 persons to the disease (CDC, 2004). Another recent failure of the U.S. quarantine system to prevent the importation of serious communicable disease occurred in 2003, when several infected rodents imported from Africa apparently caused a multistate outbreak of human monkeypox (CDC, 2003). Many of the stations’ legacy activities focus on the detection of disease in persons, animals, cargo, and conveyances during the window of time shortly before and during arrival at U.S. gateways. Yet the pace of global trade and travel has narrowed that window dramatically. Consequently, infected individuals and animals do not necessarily develop signs of disease while in transit or by the time of arrival, and available noninvasive diagnostics cannot always identify infected travelers with reasonable sensitivity, specificity, and speed. With 120 million people traveling to and from the United States by air annually (Office of Aviation Policy and Plans, 2005), the quarantine stations face a daunting task in adequately screening arriving passengers and protecting the country from microbial threats of public health significance. Moreover, the consequences of globalization and the development of the U.S. homeland security infrastructure have increased the complexity of the organizational environment in which the CDC quarantine stations function. This organizational environment, called the Quarantine System in this report, comprises entities that span sectors and jurisdictions. Yet the Quarantine System lacks effective leadership. No entity has principal responsibil- 1   Contract No. 200-2000-00629, Task Order No. 31.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health ity, authority, and resources for orchestrating the activities of the Quarantine System to protect the U.S. population from microbial threats of public health significance that originate abroad. To fill this void, the primary activities of the CDC quarantine stations should shift from the legacy activity of inspection to the provision of strategic national public health leadership for Quarantine System activities. Such leadership, carried out in collaboration with DGMQ and the scientific and organizational capacity of CDC, would improve national preparedness for crises caused by microbial threats of public health significance that originate abroad. The triad of (1) the CDC quarantine stations, (2) DGMQ headquarters, and (3) the scientific and organizational capacity of CDC form a functional unit in the context of this report. To refer to this unit, the committee coined the term “Quarantine Core.” (Additional terminology developed by the committee is presented in the following section). The Quarantine Core should provide strategic public health leadership for the broad, international network of organizations whose actions and decisions affect the CDC quarantine stations at U.S. ports of entry. BACKGROUND AND FRAMEWORK Quarantine is the separation and restriction of movement of apparently healthy people or animals that may have been exposed to a microbial threat and therefore may become infectious (DGMQ, 2004). CDC quarantine stations and many of their public health partners have the legal authority to quarantine specific individuals and animals to protect the public’s health. In addition, a CDC quarantine station may assure2 the isolation of specific individuals or animals that are reasonably believed to be carrying a communicable disease of public health significance. Through isolation, the infected persons or animals are separated from the population at large, and their movement is restricted to prevent the microbial threat from spreading (DGMQ, 2004). Quarantine and isolation at national borders are nonmedical components of the public health toolkit for limiting and containing the spread of microbial threats. Their utility varies, however, depending on the nature of the threat and the extent to which it has spread. The microbes of concern to the Quarantine Network are bacteria, viruses, protozoa, fungi, and prions that can replicate in humans. A microbial threat of public health significance causes serious or lethal human 2   In this report, “to assure” means to make sure that necessary public health services are provided to all members of society by encouraging the requisite actions, requiring them, or providing the services directly. For an in-depth description of the assurance function in public health, see The Future of Public Health, pp. 45-47 (IOM, 1988).

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health disease and is transmissible from person to person, from animal to person, or potentially both; it also may be transmissible from food or water to people. Because of their potential for wide dispersal, concern is greatest for microbes that spread rapidly from person to person. A microbial threat may be introduced intentionally—as in bioterrorism—or unintentionally. Additional threats of public health significance of concern to the quarantine stations include the release of chemical or radiological substances and of biological substances other than microbes (e.g., microbial toxins). The Quarantine Core, System, and Network As suggested above, the CDC quarantine stations are one component of a large, complex network of organizations whose collective actions provide limited protection to residents of and travelers to the United States from microbial threats of foreign origin. It became apparent to the committee that understanding the role of the CDC quarantine stations in this network would be essential to developing realistic conclusions and recommendations. Consequently, the committee developed a conceptual diagram and vocabulary to visualize and articulate the interrelationships among the stations, the network, and other key actors. The following text describes this diagram, Figure ES.1, as well as the corresponding set of terms coined by the committee for use throughout the report. Quarantine Core At the center of the diagram is what the committee has dubbed the “Quarantine Core.” As noted above, the Core consists of the CDC quarantine stations, DGMQ headquarters, and the organizational and scientific capacity of CDC. The quarantine stations lie at the center of this diagram because they are the only members of the network whose primary purpose is the mitigation of imported microbial threats at U.S. ports of entry. Any meaningful change in the quarantine stations, however, will involve the resources of DGMQ and the organizational and scientific capacity of CDC. Therefore, the committee’s recommendations address the Quarantine Core as a whole. Quarantine System In the ring around the Core lies the group of organizations that have (or should have) especially close ties to the Core. Together, this group and the Quarantine Core form what the committee calls the “Quarantine System.” The organizations in the System are responsible for performing the critical quarantine functions of planning, surveillance, assessment and response,

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health FIGURE ES.1 The relationships among the Quarantine Core, System, and Network for U.S. ports of entry. The circle around the Core is a dotted line to reflect the interdependence of the quarantine stations and their partners in the System. CBP, EMS, LPHAs and State PHAs are bolded to reflect the especially close collaboration of those entities with the stations on virtually a daily basis. Some organizations interact with the quarantine stations at the System level as well as with CDC or DGMQ at the Network level; these organizations appear in both places in the diagram.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health and communication to mitigate the risks posed by microbial threats of foreign origin to residents of and travelers to the United States. In addition to the entities within the Core, the Quarantine System includes local emergency responders and hospitals, local health care providers, local and state health departments, state public health laboratories, port authorities, port staff, airlines, cruise lines, shipping companies, shipping agents, the International Organization for Migration, overseas panel physicians, the U.S. Coast Guard, the Federal Bureau of Investigation, and federal inspectors from U.S. Customs and Border Protection (CBP),3 U.S. Fish and Wildlife Service, and the Food and Drug Administration. As will be seen in Chapter 4, the consistency and quality of relationships within the System are the subject of several conclusions and recommendations. Quarantine Network In the outermost ring lie the organizations and people that interact with DGMQ leadership and the organizational and scientific capacity of CDC, not with individual stations. Together, these entities plus the Quarantine System and Quarantine Core form a multijurisdictional, multisectoral, multinational “Quarantine Network” that protects both travelers entering the United States and the population within U.S. borders from microbial threats of public health significance that originate abroad. In so doing, this Network helps protect the health of the global community. The members of the Network that lie outside the System include the national-level staff of federal agencies active at the System level, the U.S. Department of State and its embassies, the Department of Homeland Security, national and international transportation industry associations, Mexican and Canadian officials responsible for border activities and disease control, the World Health Organization, and the news media. Although these organizations do not interact with the CDC quarantine stations on a daily basis, they are essential partners whose actions and decisions affect the functioning of the CDC quarantine stations at U.S. ports of entry. Today’s CDC Quarantine Stations at U.S. Ports of Entry Today, the CDC quarantine station staff at U.S. ports of entry primarily perform the following activities (Committee, 2005;4 Appendixes D and E): 3   CBP includes veterinary and animal health inspectors from the U.S. Department of Agriculture Animal and Plant Health Inspection Service, as well as the staff of the former Immigration and Naturalization Service and Immigration and Customs Enforcement. 4   Committee members visited five quarantine stations over the course of the study. This series of site visits, which included meetings with DGMQ field staff as well as federal and

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health BOX ES.1 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 that 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 followup soon after arrival. SOURCES: Medical Examination of Aliens. 42 C.F.R. §34.1–34.8 (2004); Massachusetts Department of Public Health, 2000. Reviewing shipping manifests to identify cargo that may pose a public health threat; ensuring that the shipment is inspected by a quarantine inspector or, more frequently, an inspector from a partner federal agency; ensuring that identified threats are contained, eliminated, or both. Obtaining and reviewing the results of immigrants’ overseas medical examinations, identifying immigrants who have Class A or B diseases (Box ES.1), and mailing those results to the state and local health departments with jurisdiction at the immigrants’ final destinations.     local partners, served as a major means of data collecting for the committee and as an evidence base in writing the report. The citation “Committee, 2005”, which appears throughout the report, refers to the committee’s notes from these visits. The notes are available in the study’s public access file.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health BOX ES.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). Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic. SOURCES: Executive Order 13,295 of April 4, 2003: Revised List of Quarantinable Communicable Diseases. Code of Federal Regulations, title 3 (2003); Executive Order 13,375 of April 1, 2005: Amendment to Executive Order 13, 295 Relating to Certain Influenza Viruses and Quarantinable Communicable Diseases. Code of Federal Regulations, title 3 (2005). Meeting arriving refugees and parolees, visually screening them for signs and symptoms of illness, reviewing the results of their overseas medical examinations, giving local health departments notification of their arrival and the results of their overseas examinations, and alerting the health departments to arrivals with Class A or B conditions. Responding to calls from port-based inspectors from other federal agencies about cargo that may pose a public health threat. Visually screening passengers of airplanes arriving from foreign points of origin for signs or symptoms consistent with a quarantinable disease (Box ES.2). Responding to ill passengers (international travelers, immigrants, and refugees) and crew reported by pilots, ship masters, and others. Developing and maintaining relationships with local public health authorities and other System partners at ports within the station’s jurisdiction. Overseeing the importation of nonhuman primates to ensure that the process is performed according to a protocol designed to prevent the transmission of zoonotic disease to humans if the nonhuman primates were infected.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Inspecting plants and animals that may pose a public health threat and are imported by passengers. The committee concluded that these activities have public health benefits of various degrees and should continue but should consume only part of quarantine stations’ time, for the activities are insufficient in themselves to meet the challenges posed by microbial threats at the nation’s gateways. RECOMMENDATIONS FOR THE QUARANTINE CORE Strategic Leadership The United States needs a single entity to exert national strategic public health leadership for the Quarantine Network to successfully protect the U.S. population from microbial threats that originate abroad. Recommendation 1: The committee recommends that the Quarantine Core strategically lead the United States in its efforts to minimize the risk that microbial threats of public health significance will enter or affect travelers to this country. The Core should have the financial resources and legal authority, consistent with the Constitution and international obligations, to exert this leadership. As the public health leader for the nation’s gateways, the Core should conduct a comprehensive national assessment of the risks posed by microbial threats that have the potential to reach U.S. ports of entry. The Core should then develop a national strategic plan with uniform principles and outcomes designed to mitigate the risks identified in the assessment. If followed, such a plan would help the members of the Quarantine System set priorities for their activities and focus their resources on the people, animals, goods, and conveyances from abroad that pose the greatest risks to the health of the U.S. population. The committee concluded that the Core alone has the capacity to provide the necessary national public health leadership to the Quarantine Network. Protecting the public’s health has traditionally been a function of the states and their localities, however, and the Core should take extra care to collaborate with its state and local partners as it exerts this leadership. Accordingly, as the Core implements its strategic plan, it must assure the local health departments’ ability to take on newly delegated responsibilities while continuing to provide essential public health services. In matters not of direct public health concern or in matters of national security, the relevant agency should continue to assume the lead.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Harmonization of Authorities and Functions Many members of the System appear to lack a clear understanding of the authorities and channels of communication that should be followed to respond to a known or suspect microbial threat of public health significance. Moreover, gaps and overlaps in authority and communication among partners in the System reduce its effectiveness in such areas as identifying cases of zoonotic disease, assuring continuity of care for refugees and immigrants, identifying ill passengers, and conducting contact tracing. Given sufficient resources and legal authority to exert strategic leadership, the Core could formalize the collaborative relationships that already exist with certain Network partners and establish similar relationships with the remaining Network partners to assure that the responsibilities of the Quarantine Network are executed at all ports of entry on both a routine and emergency basis. The Core also could assure in advance that the responders to microbial threats from abroad would know who is in charge at each location and point in time. Recommendation 2: The committee recommends that, on the basis of its strategic plan, the Quarantine Core work with its partners in the Quarantine Network (and with appropriate agencies in other countries) to delineate or redefine each partner’s role, authority, and channel of communication at all locations and specific times in order to minimize the risk that microbial threats of public health significance will enter or affect travelers to the United States. Infrastructure The Quarantine Core relies heavily on port-based inspectors from other federal agencies to identify and report travelers, crew, animals, and cargo that may pose a public health threat at the more than 400 ports that lack quarantine stations and at hours when the quarantine stations are closed. These activities are an official sidebar to the main duties of the port-based officers of the Department of Homeland Security’s U.S. Customs and Border Protection (CBP). Although CBP officers receive training for these public health activities during their job orientation and when new diseases emerge, the activities lie outside the domain for which CBP personnel are hired and do not necessarily have high priority for CBP (or other partners of the Core). Further, the quarantine station staff lack the resources to provide CBP with ongoing public health training and reinforcement. The Core will remain reliant on CBP even after the quarantine station expansion is complete, however, because DGMQ will receive insufficient funds to have in-person, round-the-clock coverage at every U.S. port of entry—or even at the most active 10 percent of those ports. Accordingly, the Core

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health should have more opportunities to train its surrogates in the Quarantine System. In addition, it should have up-to-date technology with the capacity for rapid, real-time communication and data-sharing. At present, the infrastructure of the Quarantine System is inadequate to support its current role. Recommendation 3: The committee recommends enhancements in competences, number of people, training, physical space, and utilization of technology to meet the System’s evolving, expanding role. Location of Stations DGMQ selected the locations of the 17 new quarantine stations with several goals in mind. Primary among them is to place stations at U.S. ports of entry that receive the greatest volumes of air, sea, and land travelers (DGMQ, 2003). While the committee’s expertise and the scope and the timetable of this study precluded a comprehensive review and analysis of DGMQ’s plans, the committee offers a set of additional factors DGMQ should consider in its site-selection process, including percentage of international flights covered, amount of coverage during peak arrival times of international flights, coverage of high-risk ports of entry, and the cost-benefit ratio of a robust around-the-clock presence at relatively few, high-risk sites versus a thinner presence at a greater number of sites. Recommendation 4: The committee recommends that the Core periodically revisit its methodology to ascertain whether the stations are optimally located and staffed and relocate stations or staff as needed. While a volume-based risk assessment seems reasonable, based on available data, the Core should periodically evaluate changes in patterns of global travel and trade, as well as models of infectious disease outbreaks, international spread, and efficacy of interventions. Surge Capacity As noted earlier, the quarantine stations’ staff currently perform nine primary activities on a routine basis. Although public health emergencies occur sporadically, the committee concluded that the Core should be equally prepared to respond to emergencies as to carry out routine duties. Recommendation 5: The committee recommends that the Quarantine Core have plans, capacity, resources, and clear and sufficient legal authority to respond rapidly to a surge of activity at any single U.S. port of entry or at multiple U.S. ports simultaneously.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health In developing its surge-capacity plans, the Core should collaborate with relevant state and local authorities, many of whom may have already developed emergency response plans for their respective jurisdictions. Furthermore, the committee recommends that the Core build cooperative relationships with agencies that already have extensive experience in emergency response, such as the Federal Emergency Management Agency (FEMA) and U.S. Department of Agriculture (USDA). Research The committee found that most practices of the quarantine stations and their surrogates lack a scientific basis. Indeed, much of the practice of detecting infections and controlling outbreaks of disease in the context of the Quarantine Network is based on experience and tradition. It is important that these practices be the subject of systematic research to determine their validity and cost-effectiveness. Further, in the context of new technologies and changing microbial threats, new practices should be developed and tested. Recommendation 6: The committee recommends that the Core define and devote resources to a research agenda that examines basic public health interventions used or to be developed for use in the System. The Core should formulate a forward-looking research agenda and should develop plans and protocols for data collection and evaluation during a crisis. This would enable the Core to determine the effectiveness of its practices for containing microbial threats of public health significance. Measuring Performance The scientific mindset described above should extend to operational performance. Recommendation 7: The committee recommends that the Quarantine Core develop scientifically sound tools to measure the effectiveness and quality of all operational aspects of the Quarantine System. The Core should routinely assess the performance of critical quarantine functions by individual CDC quarantine stations, DGMQ headquarters, partner organizations, and the System as a whole. Identified shortfalls should be remedied promptly. The development and application of measurable standards of effectiveness and quality would yield multiple benefits. It would give members of the System, other policymakers, and the general public clear indicators of

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health the degree to which the U.S. public is protected from microbial threats of public health significance that originate abroad. If the recommended performance metrics become widely accepted, they could stimulate members of the System to strive for operational excellence. Within the Core, performance metrics could set a national standard for the geographically dispersed quarantine stations, especially as new stations are established. REFERENCES CDC (Centers for Disease Control and Prevention). 2003. Update: multistate outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep 52(27): 642–646. CDC. 2004. Imported Lassa fever—New Jersey, 2004. MMWR Morb Mortal Wkly Rep 53(38): 894–897. Committee (IOM Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry). 2005. Unpublished. Notes on Site Visits to DGMQ Quarantine Stations . CRS (Congressional Research Service, The Library of Congress). 2004. Border Security: Inspection Practices, Policies, and Issues. [Online] Available: http://fpc.state.gov/documents/organization/33856.pdf [accessed April 7, 2005]. DGMQ (Division of Global Migration and Quarantine, National Center for Infectious Diseases, Centers for Disease Control and Prevention). 2003. Reinventing CDC Quarantine Stations: Proposal for CDC Quarantine Station Distribution. Proposal, September 16, 2003. DGMQ. 2004. Fact Sheet: Isolation and Quarantine. [Online] Available: http://www.cdc.gov/ncidod/dq/sars_facts/isolationquarantine.pdf [accessed May 6, 2005]. DHS (U.S. Department of Homeland Security). 2004. Bio-Surveillance program initiative remarks by Secretary of Homeland Security Tom Ridge and Secretary of Health and Human Services Secretary Tommy Thompson. [Online] Available: http://www.dhs.gov/dhspublic/display?theme=43&content=3093 [accessed October 4, 2004]. Gerberding J, Director, Centers for Disease Control and Prevention. 2005. A Hearing on the Centers for Disease Control and Prevention. Statement at the Apr. 6, 2005 hearing of the Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Committee on House Appropriations, U.S. House of Representatives. IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press. Office of Aviation Policy and Plans, Federal Aviation Administration, U.S. Department of Transportation. 2005. FAA Aerospace Forecasts: Fiscal Years 2005-2006: Table 7 (U.S. and Foreign Flag Carriers: Total Passenger Traffic To/From the United States). [Online] Available: http://www.api.faa.gov/forecast05/Table7.PDF [accessed April 6, 2005].