D
Commissioned Paper on U.S. Seaports and the CDC Quarantine Station System

Prepared by

Rex J. Edwards

April 4, 2005

SUMMARY AND CONCLUSIONS

The Centers for Disease Control and Prevention (CDC) has contracted with the Institute of Medicine (IOM) to conduct a study assessing the role of U.S. federal quarantine stations as a public health intervention at U.S. ports of entry. The assessment, titled Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry, is being conducted in the context of numerous partners across sectors, jurisdictions, and national borders.

This paper examines the CDC quarantine station system (QSS) in the context of how it operates at U.S. seaports,1 with emphasis on identifying differences from operations at U.S. airports where all the existing stations are. The information in this paper was gathered mostly through phone and e-mail interviews of personnel at individual QSS stations, federal regulatory or inspection agencies, the local port sector, and local or state health agencies, a summary of which is included in Table D.1.2 This information was

1  

The term “seaport” applies to ports which handle ocean-going vessels, including those on the U.S. Great Lakes and ports on rivers (e.g., Portland on the Columbia River).

2  

The original statement of work anticipated interviewing a standard cross-section of QSS “partners” at a specified list of ports. The initial interviews indicated that knowledge of the QSS at the local level was very limited, as shown by the difficulty of finding port-level contacts that could comment on the system. This is probably a result of the relatively low frequency of incidents requiring QSS notification or response. Subsequently, the interview process was reoriented toward getting input at a national level for federal agencies and from as many local sources as possible without regard to port.



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Quarantine Stations at Ports of Entry: Protecting the Public’s Health D Commissioned Paper on U.S. Seaports and the CDC Quarantine Station System Prepared by Rex J. Edwards April 4, 2005 SUMMARY AND CONCLUSIONS The Centers for Disease Control and Prevention (CDC) has contracted with the Institute of Medicine (IOM) to conduct a study assessing the role of U.S. federal quarantine stations as a public health intervention at U.S. ports of entry. The assessment, titled Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry, is being conducted in the context of numerous partners across sectors, jurisdictions, and national borders. This paper examines the CDC quarantine station system (QSS) in the context of how it operates at U.S. seaports,1 with emphasis on identifying differences from operations at U.S. airports where all the existing stations are. The information in this paper was gathered mostly through phone and e-mail interviews of personnel at individual QSS stations, federal regulatory or inspection agencies, the local port sector, and local or state health agencies, a summary of which is included in Table D.1.2 This information was 1   The term “seaport” applies to ports which handle ocean-going vessels, including those on the U.S. Great Lakes and ports on rivers (e.g., Portland on the Columbia River). 2   The original statement of work anticipated interviewing a standard cross-section of QSS “partners” at a specified list of ports. The initial interviews indicated that knowledge of the QSS at the local level was very limited, as shown by the difficulty of finding port-level contacts that could comment on the system. This is probably a result of the relatively low frequency of incidents requiring QSS notification or response. Subsequently, the interview process was reoriented toward getting input at a national level for federal agencies and from as many local sources as possible without regard to port.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health TABLE D.1 Organizations/Agencies Providing Information for Study   CDC CBP Other Federal Agencies Local/State Health Port Industry Atlanta QS* -Savannah -Atlanta (HDQ)   -GA Office of Public Health (State Epidemiologist) -Port of Charleston (Port Director) -New Orleans Steamship Assn. -Maritime Endeavors Shipping Chicago QS -Chicago*   Los Angeles QS -Los Angeles -USCG (Los Angeles)   Miami QS*   New York QS*   -USCG-New York (Marine Safety Office) -City of New York (Health Dept.) -Port of NY/NJ (Port of Commerce Dept.) San Francisco QS -San Francisco (Agricultural Inspector) -USCG (San Francisco)   Seattle QS -Seattle   -King Co. Health Dept (Infectious Disease, Environmental Health Services)* -Port of Portland National Vessel Sanitation Program   -USCG (National Vessel Movement Center) -USDA (Foreign Agricultural Service)   Acronyms: QS = CDC Quarantine Station; CBP = DHS U.S. Customs and Border Protection, Department of Homeland Security (including legacy customs, immigration, and USDA inspection services); HDQ = Headquaters; USCG = DHS, U.S. Coast Guard *Multiple contacts

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health supplemented with general information concerning the QSS and other federal agencies, information previously gathered by the IOM committee, and other secondary sources. Overview of Results The QSS was a significant presence at U.S. seaports until the 1960s, when foreign passenger travel shifted from sea to air transportation. The current system is oriented toward airports on the basis of priority of perceived threats (i.e., foreign visitors by air), the physical location of all stations at airports, the limited resources available to handle even the airport responsibilities, and most important, the infrequency of incidents at seaports. The current system at seaports is incident-driven and, in some cases, based on informal, ad hoc relationships; it is restricted by the lack of a physical presence and a lack of ability to train and interact with system “partners” over an array of ports that vary geographically and by type of activity. In some of the interviews, there was a perception that the QSS (or, more likely, “public health”), rather than a regulatory or inspection entity, was a resource to be called if there was a concern for the health of port personnel (public and private). In most respects, the scope of threats and the procedures for dealing with them are common to all ports of entry. Similarities and Differences from Airport Environments The primary differences between the airport and seaport systems are based on the following: Source of threats. The primary “human” threats at airports are foreign-origin travelers (and crew) with infectious diseases, mostly arriving from countries with specific disease outbreaks. At seaports, there is a limited level of international visiting passengers, so the human threats derive from returning U.S.-origin cruise passengers and the crews of both cruise and cargo vessels; the latter pose a greater threat because there is less scrutiny of ship sanitation and arrivals are from more distant ports of call. The number of cargo-related incidents at seaports is very limited in both number and scale, primarily since live animals and the other primary threats are more likely to move in small shipments via air. Operating environment. A seaport is a much more open environment than an airport and has higher levels and variety of international cargo and vessel activities. While cruise activity is concentrated at a limited number of U.S. ports and foreign ports of call, the market is expanding to secondary embarkation ports, many seasonal, and to more exotic foreign points (e.g., ecotourism). Over 100 U.S. ports handle import cargo, each

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health with a unique combination of commodities, vessel types, and foreign trade routes. Cargo vessels may operate on a nonscheduled basis, spend weeks at sea, and call at a wide variety of foreign ports. Cargo vessel crews are typically non-English-speaking, their nationalities may be unrelated to the vessel’s trade route, and crew members may be from countries susceptible to disease outbreaks. Unlike airplanes, vessels are typically boarded before they reach the dock and often before federal inspection. Federal agency partners. For the most part, the same federal agency partners apply to both the airport and port systems with the notable exception of the U.S. Coast Guard (USCG), which has primary responsibility for vessel safety within port areas, covering a range of areas (e.g., adequacy of manning and safety equipment). The USCG receives the “notice of arrival” required for all foreign-origin vessels. This document contains information related to vessel itinerary, crew, passengers, and hazardous cargoes that is provided to USCG and other federal personnel at local ports (although not regularly to the QSS). The QSS also works cooperatively with another CDC agency, the Vessel Sanitation Program (VSP), which has primary responsibility for dealing with gastrointestinal illness aboard cruise vessels. With no stations at ports, the QSS relies on agency partners for surveillance and immediate response activities at ports, although they are no different from those at airport “subports” (i.e., those without a station). This is particularly so for “complementary” agencies, such as the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA) that have similar regulatory responsibilities but may have a greater presence at seaports. Health sector partners. QSS relationships with local and state health agencies at seaports are basically the same and may be common to all CDC relationships, e.g., operating under memoranda of agreement (MOAs) with local hospitals. The infrequency of incidents at seaports results in little contact other than for (and sometimes including) the primary ports, many of which are those nearest the airport stations. The limited number of on-site medical staff (until recently, some airport stations had no medical officers) forces dependence on local medical personnel for immediate response for both airport and seaport subports. Private sector partners. Perhaps the greatest differences are based on a private sector that is more decentralized and varied than airports (which are dominated by the airlines and the airport authority, albeit with a limited number of supporting contractors). Most ocean carriers will not have any personnel in most ports of call, especially for the noncontainerized cargo industry. Local port activities are typically managed by a ship agent who may deal with a particular vessel or carrier only infrequently. Responsibility for cargo unloading and certain vessel services may fall to third parties with limited contact with or relationship to the vessel operator. The

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health much wider variety and variability of activities, particularly on the cargo side, make it difficult to ensure that vessel captains and ship agents are aware of reporting requirements for sick or dead persons. Port authority partners. Like airport authorities, the port authorities vary similarly with airport authorities in jurisdictional control (e.g., local, state, and county) and structure (e.g., multiairport), although ports are more likely to have private terminals that are primarily controlled by single carriers or industrial users. (Airports often have third-party-operated cargo and other facilities, but mostly all within the airport “fence” with access controlled by the airport.) In some cases, ports are structured as “landlord ports” (as opposed to “operating ports”), and the port authority itself has few if any facilities but rather leases the land to private operators. These ports have less direct contact with vessel and cargo activities and hence less control and ability to act as a “clearinghouse” for information and cooperation. General System On the basis of interviews with QSS and its partner agencies, several general observations can be made regarding the existing system at U.S. seaports, including: The overall impression gained from the interviews was that the QSS has a very limited profile at individual seaports, even those where the station is at the local airport. Very few chronic incidents have had to be dealt with in recent years (as reported by QSS staff), so there has been little direct contact with QSS by port-level partners, and even less by the general port and health sectors.3 The system could benefit from more “face time” between the QSS staff and the public and private sectors, particularly as the partner agencies are typically much larger and undergo frequent turnover and rotations (exacerbated by significant internal reorganization by these agencies after 9/11). A primary conclusion that resulted from the interviews was that the current system is ad hoc and incident-driven, mostly because there have been few notable incidents at just a few seaports and none of a chronic nature. A general impression was that the stations were stretched just to cover airport responsibilities, and much more to expand their port activities, particularly without any evident threats. The stations have operated 3   The level of contact varied by station; higher levels of contact were seemingly driven by contacts related to airport activities that also apply to local seaports.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health with as few as one full-time person in the past, and it is difficult to provide adequate training to agency partners unless there is a specific threat of high interest (e.g., SARS). Since the system is oriented toward airport threats, the assignment of seaports to the airport systems is geographically based, and individual stations cover wide ranges of both primary and “niche” ports, each with unique profiles of vessel, cruise, and cargo activity. A general impression was that the ad hoc identification system for infrequent incidents leads to inconsistent responses. Most communication was said to occur by telephone, probably because of the infrequency of incidents. The current QSS system mostly depends on a “referral” system whereby partners identify a threat and then communicate it to QSS, possibly through secondary means. There are a variety of ways that a threat could be communicated to QSS, but not necessarily a standard one, particularly in regard to USCG or postvoyage threats identified by local health officials. A general problem is that physical access to the vast array of ports and terminals is difficult in the post-9/11 environment. Different ports having different access standards and private terminals may have different rules for getting on-site when necessary. A response to an incident is based on various factors, including level of threat, timing, location, and involved partners. The level of a threat dictates the type of response, and other factors will determine the extent to which a “joint response” is used, as opposed to a primarily CDC response. Timing and the location of the threat (relative to the station location) are constraints that must be dealt with. A station might also have a postincident diagnostic or policy role. One respondent noted that a key role of the QSS is (or could be) a familiarity with seaport operations (not available to general health personnel) that may useful in handling postcontact situations or response strategies.4 Passenger and Crew Threats The primary source of information on possibly infectious passengers or crew members is the vessel itself, either directly or, more likely, via a ship agent, a cruise line’s medical consultant, or even a partner agency. Ship captains and, by extension, the ocean carriers and their local agents are required by law and international regulations to notify the QSS of “quarantinable” illness on board, but it is unclear whether there is a stan- 4   For example, one station noted that familiarity with the role of various crew members on a cruise ship would be useful in identifying possible on-board contacts.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health dard notification procedure. There were various opinions on how this system works in practice; many stations thought it worked well, while others thought that many agents and captains were unaware of the requirements. Again, this may be a result of the infrequency of incidents, but in any case the vessel personnel must know what to look for, and there is no ability to inform them other than during crisis situations (e.g., SARS). In general, it was thought that the vessel crew have an interest in identifying infectious persons and do a good job of on-board isolation, but the responsibility for dealing with specific on-board situations will differ significantly by type of ship and trade route (beyond its being ultimately the captain’s responsibility). Cruise vessels are much more scrutinized than cargo vessels in terms of on-board sanitation, particularly by CDC’s VSP. Cargo crews are more likely to be on longer voyages from more disease-prone areas and living in cramped conditions. In general, it was thought unlikely that partner agencies would visually identify sick persons, although there were a variety of opinions as to whether partner agencies routinely checked for illness (as opposed to reporting self-identified disease). In particular, the USCG’s vessel tracking system may collect sick crew or passenger information, but this information is not routinely processed by them at the national or local level. Training of partner agencies at subports is ad hoc and differs by port region. Port personnel in both the private and public sectors are concerned about infectious conditions with respect to their own health and may identify sick persons. During the period when SARS was of high concern, some pilots and longshoremen refused to board vessels. The QSS should have a public communication role in these situations, particularly as port safety may be affected, and there is the potential for a widespread shutdown of foreign trade if an outbreak were to occur. The stations’ capability to make medical assessments at seaports is very limited, mostly because of the distance between airports and the covered seaports and the lack of 24-hour medical staffing. The stations rely primarily on local health agencies (including paramedics), although state agencies may have jurisdiction or be better able to deal with situations at smaller ports. The protocols for handling specific situations at all ports seemed to vary, again on the basis of the infrequency of occurrences. Some stations maintained direct contacts with local agencies or a database of health contacts and mentioned MOAs with quarantine-certified hospitals, although this may be a general CDC function. It may be possible to utilize medical staff available through federal partners (e.g., USCG). In terms of possible gaps or shortfalls in the system, no contact provided any high level of concern. The main concern involved the ability to train partner agencies and the shipping community.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Cargo Threats The scope of incidents from cargo at seaports is extremely limited and includes (1) the prohibition of certain live animals (e.g., African rodents, which are more likely to move by air) and (2) some cargo contamination (e.g., mosquito larvae in shipments of “Lucky” bamboo and used tires shipped exposed to standing water) and disease-carrying vessels (e.g., ships from South America with disease in their ballast water), each of which was diagnosed and dealt with on ad hoc basis. Some of the interviewees (including QSS personnel) could not recall a local incident related to cargo. The Department of Homeland Security (DHS) U.S. Customs and Border Protection (CBP) has primary responsibility for clearing all foreign-origin cargo entering the United States (through its legacy U.S. customs function) by all ports of entry. As with airports, the CBP may have authority to clear cargo for the CDC unless a shipment is suspicious, some on a routine basis (e.g., for frequent shipments of medical samples to local hospitals). This supporting role is greatest at ports with no local airport station. A potential source of contacts would be other agencies with responsibility for inspecting and holding cargo at the ports, most important the USDA (for live animals and “unprocessed” foods) and FDA (for food and drugs). These agencies typically have a much larger port presence, and USDA has their inspection personnel within CBP. The QSS or, more likely, the partner agency may identify a threat covered by another agency and then directly contact it. In the case of USDA, this may occur after CBP has referred an issue to its agricultural specialist, who then might contact the QSS. As in an airport situation, the QSS is responsible for dealing with any cargo that is refused entry under its jurisdiction, which may include destroying or reexporting the shipment or ensuring that the cargo is not hazardous. Most of the stations noted that they do not have access to CBP’s Automated Manifest System (AMS), which contains all the relevant information necessary to clear the cargo (origin/destination, shipper/consignee, and commodity). Access would enable them to monitor certain commodities and perhaps identify patterns creating new threats, but there is also concern as to whether they would have the capability to use the system at the local level. One concern was that the protocols for contacting the QSS on the basis of AMS identifications of covered imports may not be clear. Another concern was that CBP requirements for documentation may not meet CDC’s requirements when CBP is responsible for clearing shipments. There were no gaps or shortfalls that were otherwise identified regarding cargo transportation, although logically the greatest threat would

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health be cargoes that are unrelated to the responsibilities of complementary federal agencies (i.e., other than agricultural materials, live animals, food, and drugs). In conclusion, the QSS has developed primarily as an airport system, most important in terms of where the stations are. The relative infrequency and limited severity of seaport incidents have resulted in an incident-driven ad hoc system that is almost entirely dependent on local port partners and, with respect to person-borne illnesses, mostly on a self-identified and referral basis. A more expanded seaport role or the requirement to deal with new more expansive threats would require an increased local port presence at all subports, each of which may present a high level of risk. In particular, the QSS would need to develop better relationships with (1) the local port sector (port authority, carriers, and port service firms), (2) USCG because of its primary role for port safety, and (3) the relevant DHS partner agencies. Most important, the QSS would have to change the perception that it is merely a “public health” response option when there is a concern about infection (mostly as it applies to port personnel), rather than a partner agency for surveillance of and response to foreign-origin threats to the U.S. population. The following section provides an overview of the QSS in terms of the general scope of the system’s responsibilities relative to the seaport environment, contrasting activities with those at U.S. airports. The QSS at seaports is described in general terms relative to the overall sources of threats, activities for surveillance of and response to threats, current protocols and communication patterns, and potential gaps or areas for improvement. The general system is then described in detail for the three primary areas of coverage: (1) cruise passengers, (2) vessel crews, and (3) cargo imports. GENERAL DESCRIPTION OF THE CDC QUARANTINE STATION SYSTEM (QSS) AT SEAPORTS The CDC QSS aims to minimize the risk that microbial threats5 of public health significance originating abroad will enter the United States through official ports of entry. Because of a dramatic reduction in the size and resources of the QSS in the 1970s and 1980s, the stations now rely heavily on partner agencies, especially CBP, to carry out their regulatory 5   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 potentially either way; it also may be transmissible from food or water to people. Because of their potential for wide dispersal, concern is greatest for those microbes that spread readily from person to person.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health responsibilities at the more than 280 ports of entry where CDC quarantine stations do not exist. The QSS has the same jurisdiction over the persons and cargo on vessels as on aircraft: Whenever the Director has reason to believe that any arriving person is infected with or has been exposed to any of the communicable diseases …, he/she may detain, isolate, or place the person under surveillance and may order disinfection or disinfestation as he/she considers necessary to prevent the introduction, transmission, or spread of the listed communicable diseases. (per 42 CFR Part 71.32). The communicable diseases include cholera, diphtheria, infectious TB, plague, smallpox, yellow fever, viral hemorrhagic fevers and SARS (per Executive Order 13295). In general terms, the QSS (including both CDC and its federal partner agencies) is responsible for the surveillance of and response to communicable disease threats that could enter via U.S. seaports. Surveillance activities include specifying the scope of existing and emerging threats and identifying specific threats that might enter via a seaport. Response activities include isolating and assessing specific threats, preventing threats from entering the country (until safe), and taking (or stimulating) actions to eliminate threats (including hospitalization or quarantine of persons or reexport of cargo) and mitigate the impact of threats (identifying contacts). In most respects, the scope of threats and the procedures for dealing with them are common to all ports of entry. The primary differences between the airport and seaport systems are related to the sources of threats, the operating environment, and the roles of and communication with various public and private partners. Source of Threats The QSS covers any person or cargo item arriving on a vessel from a foreign port, including cruise and other passengers, imported cargoes and personal items, crew members on cruise or cargo vessels, and illegal aliens (including stowaways). Cruise Passengers The majority of foreign-origin passengers that enter U.S. seaports arrive via cruise vessels, most of them originating and terminating at a U.S. port on voyages ranging from a few hours (“day cruises”) to 2 weeks or more. Some passengers arrive on cargo vessels, but there are no substantial differences from cruise passengers. Similarly, passengers who arrive from

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Canada or Mexico on passenger ferries receive the same coverage by the QSS. The multiday-cruise industry (which is the highest priority in terms of infectious disease) is defined by a combination of: Vessel type as determined by technology and passengers’ comfort wishes (e.g., luxury or sailing). Destination market(s)—mostly foreign ports of call that are of interest to cruise visitors and can be reached within standard voyage lengths (mostly 7 days). U.S. embarkation port—based on location relative to large population bases and ability to access via air, as well as the ability to accommodate the vessels. There were 184 vessels serving the U.S. cruise market in 2003.6 Cruise vessels can vary from relatively small specialty vessels (e.g., Windjammer sailing vessels) to enormous vessels carrying almost 4,000 persons (e.g., the Queen Mary with 2,620 passengers and a crew of 1,253). The typical vessel carries 2,000 passengers and a crew of 950, creating a large processing problem at U.S. ports on the return voyages. The U.S. cruise industry is oriented mostly toward the Caribbean and Southern California markets, which allow year-round sailing as shown in Table D.2. Vessels from Florida ports—led by Miami, Port Everglades, and Port Canaveral—sail primarily to Caribbean and Mexican Gulf Coast points. These three ports accounted for nearly two-thirds of total U.S cruise passengers in 2003. The Southern California ports serve both the west coast of Mexico and Hawaii (which is not covered by the QSS). Other cruise markets include summer sailings to Alaska, New England, and Great Lakes points and multiweek itineraries (e.g., Panama Canal or trans-Atlantic). In recent years, the originating ports for Caribbean and Gulf of Mexico cruises have expanded to include Galveston, New Orleans, and New York. This trend is expected to continue as the primary ports become more congested and new ports expand or emerge to handle local passengers or new itineraries. Of potential interest for this study is the emergence of nontraditional foreign ports of call (particularly oriented toward ecotourism) that might create exposure to more remote areas. 6   Source: International Council of Cruise Lines.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health station. One USCG respondent referred to a “statement of no SARS” as a part of the NOA, but that might have been a temporary measure. In any case, it was indicated that USCG might make a courtesy call to CDC but had no fixed protocols. One QSS contact indicated receiving USCG vessel tracking information during the SARS crisis, but it was only temporary; others did not mention it. The NVMC indicated that it does not “process” crew-illness information, but if it is reported (although not required), it is attached to the NOA record for the local port’s use; it also noted the local MSO would not process it either. At the local port level, the MSO conducts random inspections (under different responsibilities) of vessels guided by certain risk factors and the availability of vessel information. One MSO respondent thought that there was an item on the NOA about sick crew, although it is not on the standard form. It would be of importance to USCG only if sickness of a crew member results in substandard manning levels or if there were concern about boarding a vessel. An MSO respondent indicated that in some cases, USCG may hold a ship at anchorage with an infectious-disease threat (perhaps under direction of the QSS) and wait out the incubation period. The respondent also indicated that the USCG has a doctor on staff that could assist with a response.10 Most crew notifications involve injuries, not illness, and one respondent indicated that calls to CDC are infrequent. The relationship with USCG as reported by the QSS differed significantly. One station indicated that the MSO had first responsibility for onboard illness or death, that the operations manual provides questions to ask regarding health issues, and that vessels had to make health declarations. USCG can hold a vessel at anchorage, and one station reported that during SARS, it provided on-site surveillance of symptomatic persons. Unlike CBP, CDC does not train USCG personnel at a national level, and local contacts and knowledge are difficult with personnel rotations every 1½ -2 years. One QSS contact suggested more frequent meetings and training for USCG. The NVMC is looking to integrate all the information reported for Immigration, Customs, and USCG; this would provide a single point of contact for vessel reporting. Perhaps CDC can get access or provide data to this expanded system. 10   The USCG medical staff deal primarily with USCG personnel and port or vessel injuries, which are the primary health problems at ports.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Port Industry (Port Authority and Vessel Services) The primary role of the general port sector, other than the vessel operator itself, is to identify any health risks encountered in the course of general business. It is more likely that it would contact CDC (or more likely USCG) to determine whether it is safe to board a vessel. When the SARS epidemic first came out there was a period of time when the pilots requested specific information from the vessels, such as whether they had been to a port that was designated as a high-risk area or whether any crew on board had been diagnosed with SARS. One QSS contact commented that the QSS had a role in communicating the true level of threats during a crisis; the shipping sector could shut down if shore-based personnel refused to assist in the safe operation of vessels entering ports. The primary role of the port authority is providing access for the QSS (or its agents) to restricted port areas, a major concern with the SARS crisis. As noted elsewhere, policies vary by port and even by terminal, and the infrequency of visits may not dictate maintaining badges at all ports. Local and State Health Agencies QSS relationships with local and state health agencies at seaports are basically the same and may be generic for all CDC relationships (e.g., MOAs with hospitals). The infrequency of incidents results in little contact other than for (and sometimes including) the primary ports, many of which are those nearest to the airport stations. The small number of on-site medical staff (until recently, some airport stations had no medical officers) forces dependence on local medical personnel for immediate response for both airport and seaport subports. A station may use designated local hospitals or physicians (often those of the ship agent) when CDC personnel are not available (in a timely manner relative to distance or during off hours).“Quarantinable” illnesses require a higher level of response—they have designated civic hospitals (certified with memo agreements) that are equipped to handle quarantine and isolation. Most contact is via telephone or e-mail, particularly for distant ports. In some cases, the station will work with local health agencies to devise a strategy (one station had a whole crew vaccinated once).The appropriate government contact depends on the port’s location and size; state agencies may be appropriate for certain areas (e.g., smaller remote ports). Passengers will often get sick only after returning home (particularly after cruises of 7 days or less), and local health officials may contact CDC (as they are supposed to) if it is known that a person visited abroad. It was thought that contact could come via headquaraters or directly.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Potential Gaps or Shortfalls No contact showed any high level of concern about gaps or shortfalls in the system. A general concern involved the ability to train partner agencies and the shipping community. One possible gap is the possibility of off-shore contact between vessel crew and shore-based personnel (e.g., port pilots) or between off-shore vessels not calling at a foreign port and other off-shore vessels. That was not considered a concern by the interviewees. It was also noted that even private vessels must process through CBP if leaving U.S. waters. Another possible gap involves illnesses diagnosed after people leave the U.S. that would probably be identified only for ships returning to the United States. One concern offered by a QSS contact involved stowaways, who may pose a problem if infectious disease is suspected and the appropriate agency staff refuse to deal with them until the problem is diagnosed. The general problem of dealing with non-English-speaking crew was also a concern. CDC QSS AT SEAPORTS: CARGO TRANSPORTATION11 General overview Incidents related to cargo at seaports are extremely few (as reported in the interviews): African rodents and “bush meat”: There is a prohibition on these imports, although these commodities are likely to move by air. Lucky bamboo: This plant commodity was shipped from Asia and was packed in a gel that somehow turned to water and contained mosquito larvae. After diagnosis, the import of this commodity was closely monitored. Used tires: Like lucky bamboo, some used tires imported from China were in containers with standing water that contained mosquito larvae. The problem was eventually diagnosed and eliminated. Cholera in South American vessels’ ballast: Ships from South America were discovered to be carrying cholera in their ballast water (sea-water carried on the vessel for weight and other purposes). This discovery occurred after a joint task force (including FDA) inspected incoming vessels. The result was a policy requiring vessels to flush their ballast water at least three times before arriving at a U.S. port. Contaminated equipment: One major port cited some repatriated 11   See Tables D.5 and D.6 for data on levels of cargo traffic at U.S. seaports.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health agricultural machinery that was contaminated and had to be fumigated (as its only cargo-related incident), although it was probably a USDA-related matter not involving the QSS. Other than those incidents, some of the interviewees (including QSS personnel) could not recall a local incident related to cargo (and many of them cited the same incidents occurring in other regions). Based on the infrequency of threats, there was limited input from industry and agency partners. The following sections describe the little information that was gathered regarding cargo imports. CDC In the cases cited above, the QSS was mostly responsible for dealing with a problem once it was identified. No stations cited a case in which it had identified a threat and passed it on to its partners on a local basis. It is assumed that prohibited items are identified at a national level and communicated to CBP at that level. One QSS contact was concerned that this type of contact might not filter down to the local level. As in an airport situation, the QSS is responsible for dealing with any cargo that is refused entry under its jurisdiction, which may include destroying or reexporting the shipment or ensuring that the cargo is not hazardous. CBP (U.S. Customs and Border Protection) CBP has primary responsibility for clearing all foreign-origin cargo entering the United States (through its legacy U.S. customs function) by all ports of entry. As with airports, CBP may have authority to clear cargo for CDC unless a shipment is suspicious, some on a routine basis (e.g., for frequent shipments of medical samples to local hospitals). This supporting role is greatest at ports with no local airport station. The primary process involved includes a review of documentation as now filed via the AMS that contains all the relevant information necessary to clear the cargo (origin and destination, shipper and consignee, and commodity). CBP can also visually inspect or hold cargo suspected to be in violation of U.S. law. CBP contacts whichever agency has primary responsibility for a particular shipment but also has the ex-USDA unit of “agricultural specialists” to which any agricultural issue is probably referred. The general impression was that if there was a suspected problem with a shipment, CBP will contact the “logical” agency: USDA for agriculture, FDA for foods and drugs, and CDC (or “public health”) if there is a perceived possibility of disease.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health TABLE D.5 2003 Containerized Traffic for U.S. Ports Quarantine Station Port 20-Foot Equivalent Units # of Containers Container Weight (MT) Los Angeles (LAX) Los Angeles (CA) 7,148,940 3,951,792 N/A Long Beach (CA) 4,658,124 2,577,080 25,312,306 Houston (TX) 1,243,706 776,403 10,812,558 San Diego (CA) 86,136 43,068 876,669 Freeport (TX) 67,784 N/A 469,132 Hueneme (CA) 24,523 N/A N/A Galveston (TX) 9,911 4,961 62,232   13,239,124 7,353,304 37,532,897 New York (JFK) New York/New Jersey 4,067,812 2,382,639 N/A Hampton Roads (VA) 1,646,279 947,872 12,108,920 Baltimore (MD) 536,078 337,978 4,261,591 Wilmington (DE) 254,191 123,378 1,379,472 Boston (MA) 158,020 88,890 1,077,654 Philadelphia (PA) 147,413 103,156 1,132,134 Richmond (VA) 43,672 NA 386,765 Portland (ME) 3,587 2,109 32,547 Albany (NY) 892 521 4,055   6,857,944 3,986,543 20,383,138 Miami (MIA) San Juan (PR) (fy) 1,665,765 694,069 6,589,677 Miami (FL) (fy) 1,028,565 363,336 7,874,579 Jacksonville (FL) (fy) 692,422 343,568 3,405,386 Port Everglades (FL) (fy) 569,743 324,600 3,298,591 Palm Beach (FL) (fy) 217,558 N/A 1,007,429 Ponce (PR) (fy) 32,497 20,718 205,605 Fernandina (FL) 22,096 14,799 108,264 Manatee (FL) 11,837 N/A 72,809 Tampa (FL) (fy) 8,173 N/A 38,480 Canaveral (FL) (fy) 678 678 N/A   4,249,334 1,761,768 22,600,820 Seattle (SEA) Tacoma (WA) 1,738,068 906,434 11,154,908 Seattle (WA) 1,486,465 852,905 8,814,689 Anchorage (AK) 521,993 208,797 1,522,418 Portland (OR) 339,571 190,639 2,855,128 Everett (WA) 6,815 1,338 18,682 Vancouver (WA) 338 171 N/A   4,093,250 2,160,284 24,365,825

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Quarantine Station Port 20-Foot Equivalent Units # of Containers Container Weight (MT) Atlanta (ATL) Charleston (SC) 1,690,847 N/A N/A Savannah (GA) 1,521,728 848,502 10,045,117 New Orleans (LA) 251,187 159,707 2,769,754 Gulfport (MS) 199,897 107,398 1,434,571 Wilmington (NC) 96,453 54,048 562,568 Mobile (AL) 26,302 14,649 N/A Lake Charles (LA) 19,000 20,000 15,400 Brunswick (GA) 118 59 1,469   3,805,532 1,204,363 14,828,879 San Francisco (SFO) Oakland (CA) 1,923,104 1,079,479 N/A San Francisco (CA) 20,633 13,533 501,000   1,943,737 1,093,012 501,000 Honolulu Honolulu (HI) (fy) 980,840 589,587 4,922,168 Kahului (HI) (fy) 115,556 70,626 777,286 Hilo (HI) (fy) 60,942 37,113 377,594 Kawaihae (HI) (fy) 55,345 32,924 346,675 Nawiliwili (HI) (fy) 42,700 26,430 228,343 Kaunakakai (HI) (fy) 2,152 1,796 12,394 Barbers Point (HI) (fy) 18 18 196   1,257,553 758,494 6,664,656 Overseas Apra (GU) (fy) 144,541 82,310 2,050,951   144,541 82,310 2,050,951 Grand Total   35,591,015 18,400,078 128,928,166   SOURCE: American Association of Port Authorities. Most of the stations noted that they do not have access to the AMS. Access would enable them to monitor certain commodities and perhaps identify patterns creating new threats, but there is also concern about whether they would have the capability to use the system at the local level. One concern was that the protocols within the AMS for contacting the QSS may not be clear. It was very unclear to what extent there are CDC-flagged items in the AMS and what occurs in such a case. One QSS contact indicated that regulations limit the information that can be passed on to CDC and that the AMS protocols may need to be reviewed. (The example

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health TABLE D.6 U.S. Waterborne Imports—Top 100 Ports by Weight and Customs District (2003) Quarantine Station Port Import Weight (Short Tons) Rank LAX Houston, TX 90,335,647 1 Beaumont, TX 63,336,752 3 Corpus Christi, TX 44,758,661 4 Texas City, TX 40,184,521 5 Long Beach, CA 37,969,522 6 Los Angeles, CA 29,962,253 8 Freeport, TX 22,665,591 11 Port Arthur, TX 14,259,432 21 Matgorda Ship Channel, TX 6,451,220 31 San Diego, CA 2,194,448 52 Brownsville, TX 1,865,561 54 Galveston, TX 1,064,833 66 Port Hueneme, CA 910,801 72 LAX Total   355,959,242   JFK New York, NY and NJ 70,251,263 2 Portland, ME 27,133,777 10 Baltimore, MD 18,984,957 13 Philadelphia, PA 18,615,848 15 Paulsboro, NJ 17,908,339 16 Marcus Hook, PA 16,077,374 19 Boston, MA 15,634,152 20 Hampton Roads, VA 10,155,182 24 Providence, RI 4,402,336 36 Portsmouth, NH 4,113,573 40 Camden-Gloucester, NJ 3,764,289 41 Wilmington, DE 3,400,014 43 New Haven, CT 2,954,309 46 Fall River, MA 1,954,888 53 Bridgeport, CT 1,850,626 55 Chester, PA 1,342,801 59 New Castle, DE 1,329,415 60 Albany, NY 1,325,761 61 Penn Manor, PA 1,205,420 64 Searsport, ME 996,205 69 Richmond, VA 288,106 90 JFK Total   223,688,635   ATL South Louisiana, LA, Port of 30,857,319 7 Lake Charles, LA 27,825,176 9 New Orleans, LA 20,889,868 12 Baton Rouge, LA 18,701,796 14 Mobile, AL 17,553,389 17

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Quarantine Station Port Import Weight (Short Tons) Rank   Pascagoula, MS 17,513,754 18 Savannah, GA 13,174,550 22 Charleston, SC 13,041,525 23 Plaquemines, LA, Port of 8,519,740 28 Wilmington, NC 2,739,522 48 Georgetown, SC 2,400,943 50 Gulfport, MS 1,228,417 63 Brunswick, GA 1,056,658 68 Morehead City, NC 703,318 74 ATL Total   176,205,975   MIA Jacksonville, FL 9,878,816 26 Tampa, FL 9,230,682 27 Port Everglades, FL 8,426,945 29 San Juan, PR 5,008,816 33 Miami, FL 4,915,706 35 Ponce, PR 3,266,582 44 Port Manatee, FL 3,189,814 45 Port Canaveral, FL 2,950,340 47 Palm Beach, FL 819,382 73 Panama City, FL 663,660 78 Pensacola, FL 292,732 88 MIA Total   48,643,475   SEA Seattle, WA 6,748,803 30 Tacoma, WA 5,702,602 32 Portland, OR 4,398,499 37 Anacortes, WA 1,492,029 57 Redwood City, CA 915,510 71 Longview, WA 698,574 75 Vancouver, WA 680,736 76 Port Angeles, WA 672,165 77 Grays Harbor, WA 323,006 84 Everett, WA 264,683 92 Nikishka, AK 226,934 94 Kalama, WA 219,889 95 Anchorage, AK 218,233 96 Coos Bay, OR 195,189 98 Olympia, WA 107,924 100 SEA Total   22,864,776  

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Quarantine Station Port Import Weight (Short Tons) Rank ORD Toledo, OH 4,243,476 38 Detroit, MI 3,493,535 42 Cleveland, OH 2,708,093 49 Burns Waterway Harbor, IN 1,269,905 62 Milwaukee, WI 1,119,290 65 Chicago, IL 1,057,337 67 Ashtabula, OH 960,441 70 Marysville, MI 584,298 79 Duluth-Superior, MN and WI 529,060 80 Buffalo, NY 402,376 81 Gary, IN 393,742 82 Lorain, OH 334,244 83 Muskegon, MI 321,516 85 Grand Haven, MI 318,215 86 Indiana Harbor, IN 314,107 87 Green Bay, WI 292,532 89 Marquette, MI 284,738 91 Fairport Harbor, OH 257,575 93 Manistee, MI 196,385 97 Conneaut, OH 177,899 99 ORD Total   19,258,764   SFO Richmond, CA 10,017,014 25 Oakland, CA 4,203,403 39 San Francisco, CA 1,635,880 56 Stockton, CA 1,417,749 58 SFO Total   17,274,046   HNL Honolulu, HI 4,918,596 34 Barbers Point, Oahu, HI 2,357,417 51 HNL Total   7,276,013   Grand Total   871,170,926     SOURCE: American Association of Port Authorities. given concerned a prohibited item that was only generically described and had a “Call CDC” designation that resulted in contact of headquarters rather than the local QSS where the item was entering the United States. Another concern was that CBP requirements for documentation may not meet CDC’s requirements when CBP is responsible for clearing shipments.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health USCG As with passenger concerns, USCG is responsible for the safety of vessels entering a port. The NVMC database of NOAs contains information on “dangerous goods,” but there is no apparent protocol for identifying or handling QSS-related cargoes. Other Federal Agencies A primary source of contacts for the QSS is other agencies with responsibility for inspecting and holding cargo at the ports, especially the USDA (for live animals and “unprocessed” foods) and FDA (for foods and drugs). These agencies typically have a much larger port presence; in the case of USDA, inspection personnel are within CBP. The QSS or more likely the partner agency may identify a threat covered by another agency and then directly contact it. In the case of USDA, that may occur after CBP has referred an issue to its agricultural specialist, who then might contact the QSS. As with other concerns at the port, the priority and awareness of QSS concerns (to the extent that there are any) depend on communications with the other agencies at the local level. In major agricultural areas, local or state agriculture agencies might also monitor and participate in the surveillance and response process. For example, mosquito-abatement agencies in the Los Angeles area will fumigate some containers before USDA inspection, and local agencies are very vigilant about threats to local agriculture. Port Industry (Port Authority, Terminal, Stevedore, and Vessel Services) The port industry and port authorities did not appear to have a major role with QSS cargo threats. None of the interviewees thought it likely that a customs broker would identify a threat unless there was obvious health risk to them. Local and State Health Agencies There were no examples of involvement of local or state health agencies in QSS-related cargo matters. As with passengers, some problems may be identified after entry (e.g., spoiled fish not properly smoked), but it is unclear whether a comprehensive response is necessary in that most are probably another agency’s responsibility (e.g., FDA for spoiled fish). A local health agency involved in one previous incident noted that it had problems in getting timely information that allowed them to prepare for incoming shipments thought to pose a risk.

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Quarantine Stations at Ports of Entry: Protecting the Public’s Health Potential Gaps or Shortfalls Other than the concerns about access to and protocols of the AMS cited above, no gaps or shortfalls regarding cargo transportation were identified. Logically, the greatest threat would be cargoes that are unrelated to the responsibilities of complementary federal agencies (i.e., other than agricultural, live animals, foods, or drugs).