Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs (2008)

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2Introduction This report discusses facility issues, security considera- tions, and estimated costs, including operating costs, that would need to be considered by airport operators and policy- makers in determining how to plan for the potential quaran- tine of arriving air travelers, whether facilities for this purpose should be located on airport property, and who should bear the cost of providing such facilities. The physical require- ments of setting up a quarantine area are established along with an estimation of the costs for operations and then for re- covery. Planning considerations for the diverse needs of a population of 200 travelers are incorporated as part of the standard of care addressed in this report. This report also includes the following information: • A bibliography of research for existing quarantine studies and potential applications • Background information on quarantine laws • Locations of Federal Quarantine Stations • Listing and describing the diseases that qualify for quaran- tine under Executive Orders • A literature review and bibliography of related publications • Information needed for airport quarantine site identifica- tion and support • Labor requirements for quarantine operations • Information on costs, standards of care, planning consid- erations, and physical accommodations What Is Quarantine? According to the Centers for Disease Control and Preven- tion (CDC), quarantine is the “separation and restriction of movement of persons, who, while not yet ill, have been ex- posed to an infectious agent and therefore may become in- fectious.” Quarantine is effective in preventing the spread of a contagious illness and can be carried out voluntarily or ordered by government public health authorities. Isolation is different from quarantine, though many peo- ple wrongly use the terms interchangeably. Isolation, as de- fined by the CDC, applies to people who have a specific in- fectious illness. Their movements are restricted and they are separated from individuals who are healthy (or at least not symptomatic yet). Someone in isolation may be cared for at home, in hospitals, or at another healthcare facility. Though almost always voluntary, isolation can be mandated by the federal, state, or local government in order to protect the pub- lic from disease. For example, a person arriving at an inter- national airport who is exhibiting symptoms of one of nine designated diseases may be taken to an offsite medical facility for treatment and isolation. The remainder of the passengers and crew may then be quarantined to ensure that they do not, in turn, become symptomatic and spread the disease. Here is an explanation about the terms “infectious” and “communicable”: an infectious disease is caused by a virus or bacteria that enters the body through one of a number of dif- ferent transmission modes. For example, harmful bacteria could be present in food that is eaten and which then causes “food poisoning.” A communicable disease is an infectious illness that is spread from one person to another. For exam- ple, inhalation anthrax (as used in the 2001 terrorist at- tacks) is an infectious disease but is not communicable. Smallpox, on the other hand, is both infectious and commu- nicable because it is spread from person to person. Laws Related to Quarantine Quarantine laws have a long history in this country. In 1796 the 4th Congress passed legislation authorizing the ex- ecutive branch to provide assistance to states in enforcing state health laws.1 Federal, state, and local government all have the power to order and enforce quarantine. Federal C H A P T E R 1 Background 1 CRS Report for Congress, “Federal and State Quarantine and Isolation Authority” Library of Congress, August 16, 2006 page 3.

authority derives from the U.S. Constitution, which provides that “Congress shall have the power to regulate commerce with foreign nations and among the several states.” This is the basis of the Public Health Service Act, which authorizes the Surgeon General “to make and enforce such regulations as in his judgment are necessary to prevent the introduction, transmission, or spread of communicable diseases from for- eign countries into the States or possessions, or from one State or possession into any other State or possession.” The Public Health Service Act also authorizes the “appre- hension, detention, or conditional release of individuals” for the purpose of preventing the introduction, transmission, or spread of communicable diseases specified by Executive Orders of the President. Under Executive Order 13295 the federal govern- ment currently can declare quarantine for persons suspected of being ill with the following diseases: 1. Cholera 2. Diphtheria 3. Infectious Tuberculosis 4. Plague 5. Smallpox 6. Yellow Fever 7. Viral Hemorrhagic Fevers 8. SARS (Severe Acute Respiratory Syndrome) 9. Influenza, from a novel or re-emergent source A detailed description of these communicable diseases, in- cluding their respective symptoms, incubation period, mode of transmission, and methods of diagnosis can be found in Appendix A. The types of diseases on the list can be amended in response to emerging diseases. For example, in 2003, SARS was added, and, more recently, influenza that has the poten- tial to trigger a pandemic joined the list. Other illness such as mumps, measles and chicken pox, while contagious and rec- ognized as serious public health threats, are not listed as quar- antinable in the Executive Order. Other federal regulations, such as the airline reporting requirement discussed below, may apply to these diseases and state or local laws may exceed the federal requirements and require different actions, but the nine diseases listed in the Executive Order are the only ones under which the federal government can order a quarantine. State and local governments have the authority to under- take quarantine measures per their “police powers” to protect the welfare of their citizens, including managing outbreaks of communicable diseases. This authority, which derives from the inherent sovereignty of governments, was recognized in the 10th Amendment to the U.S. Constitution that reserves powers not specifically granted to the federal government to the state government. Some states require court orders before quarantine is permitted while others may limit quarantine to a single disease. The length of time for quarantine may also differ from state to state. Travelers crossing state or international borders may be legally detained and isolated for purposes of preventing the spread of a quarantinable disease under the provisions of state law and the Public Health Service Act. International travelers, including U.S. citizens, are under federal authority and con- trol and must go through a federal clearance process before they re-enter the country. The CDC can issue a federal iso- lation order to keep a person under their observation. Law enforcement officers can assist in the detention of the per- son(s) to permit health officials to make an assessment. Local and state law enforcement officers have similar authority to enforce local health codes or public health orders. Neither the federal government nor any state has issued an enforceable quarantine in the past 50 years. In November 2005, CDC proposed new regulations that would allow CDC to order a “provisional quarantine,” lasting up to 3 business days. The proposed regulations would give CDC time to determine if the suspected disease was present. Lab tests are required to confirm the diseases and generally that takes 3 working days. If more time was needed or if lab tests came back positive for one of the quarantinable illnesses listed above, a formal quarantine order would be issued by state authorities. It is unclear at this time whether the federal or state gov- ernment would have primary authority to quarantine air travelers on a domestic flight (i.e., entirely within the United States). Therefore, for planning purposes, this report assumes that the arriving flight subject to quarantine would be an in- ternational flight (i.e., originating outside the United States) which would be clearly under the primary authority of the federal government. Federal Quarantine Stations The CDC, through its Division of Global Migration and Quarantine (DGMQ) operates quarantine stations at 19 air- ports and one land crossing (El Paso, TX). These airports are the following: • Anchorage • Atlanta • Boston • Chicago • Dallas/Ft. Worth • Detroit • Honolulu • Houston • Los Angeles • Miami • Minneapolis • New York (JFK) • Newark • Philadelphia 3

• San Diego • San Francisco • San Juan • Seattle • Washington, D.C. (Dulles) Each CDC Quarantine Station is responsible for all of the ports of entry in their assigned region. Therefore, these 20 sta- tions cover all 130 of the international airports in this coun- try. Customs and Border Protection (CBP) agents are the lead federal agents at international airports that do not have a CDC Quarantine Station. Appendix B provides a listing of the airports served by the CDC Quarantine Stations and includes contact information. A CDC Quarantine Station is not a large quarantine facility in the classic sense of a place where scores or hundreds of peo- ple are screened and detained, like Philadelphia’s Lazaretto, San Francisco’s Angel Island, or New York City’s infamous “contagion facility” on North Brother Island (arriving ships in 19th century New York City were screened at a quarantine sta- tion off Staten Island; only those with nonquarantinable dis- eases on board were permitted to go to Ellis Island). A “Q Sta- tion,” as they are sometimes called today, is more likely to be an office space housing a small staff, perhaps with an examin- ing room and facilities to accommodate one or two people held for observation for short periods. These facilities are pro- vided by the airport at no charge to the federal government under the same law that requires airports to provide space for customs and other federal inspection facilities. A CDC Quarantine Station is staffed during the working day by one to seven CDC employees (or full time equivalents). The Officer in Charge (OIC) is a Senior Public Health Advisor who supervises the activities of the station. The Quarantine Medical Officer (QMO) assists the OIC and is lead medical consultant. The remainder of the staff is classified as Quarantine Public Health Officers (QPHO). Contractors, researchers and other employees may supplement this staff. The typical staff total ranges from four to ten people. During off duty hours, each quarantine station has a 24-hour on-call service and can be contacted directly, in addition any quarantine station, and the Quarantine and Border Health Services Duty Officer at CDC- HQ can be contacted 24/7 through the CDC’s Emergency Operations Center. Role of State and Local Health Departments Most of the international airports in this country do not have a CDC Quarantine Station on the premises. If a flight ar- rives at one of these airports with a potential case of a quar- antinable disease on board, CDC may ask the local health de- partment, whether it is a state or municipal entity, to evaluate a sick passenger or crewmember and take the lead in the re- sponse until a CDC official arrives. The CDC looks upon the relationship between the federal and local health agencies as a partnership, and each of the CDC Quarantine Stations is re- sponsible for developing strong ties to the local and state pub- lic health and medical community. The relationship between state and federal authorities is in flux and is ambiguous under current law. In its proposed reg- ulations, the CDC envisions turning over responsibility to a local health department at some point in the quarantine process. In current practice, CDC works closely with state and local agencies to identify air travelers who may have been ex- posed to a communicable disease and follow up with them re- garding possible treatment. 4