Bridge from Present to Future: Vision and Recommendations
The traditional, primary activities of the quarantine stations run by the Centers for Disease Control and Prevention (CDC) no longer protect the U.S. population sufficiently against microbial threats of public health significance1 that originate abroad, the committee concluded. 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 people 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.
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, the Quarantine System, lacks effec-
tive leadership. No single entity has the responsibility, the authority, and the resources for orchestrating the activities of the 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 and historical activity of inspection to the provision of strategic national public health leadership for Quarantine System activities. Such leadership, carried out in collaboration with the Division of Global Migration and Quarantine (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 Quarantine Core should provide similar strategic leadership to the Quarantine Network. The committee concluded that the stations’ traditional primary activities should continue but should consume only a fraction of their time.
The Core’s leadership role stems naturally from the unique responsibility of federal government to assure2 action for health (IOM, 2003, p. 34) as well as from CDC’s position as a lead federal agency for protecting the health of Americans. The Core alone has the appropriate expertise, resources, and experience to provide strategic national public health leadership to the Quarantine Network. At the same time, the committee recognizes that from both a historical and a constitutional perspective, protecting the public’s health has primarily been a function of the states and their localities3 (IOM, 2003). Accordingly, the Core must take extra care to collaborate with—as well as respect the jurisdictional authorities of—its state and local partners as it assumes this leadership role. In addition, the Core should be careful to respect preexisting systems and infrastructures that states and localities may have already developed and put into place. The committee emphasizes the need for cooperation, flexibility, and partnership among the Core and its partners in the recommendations that follow.
This chapter begins with a vision of a Quarantine Network that reflects the committee’s sense of how best to protect against microbial threats of public health significance at U.S. ports of entry. Subsequently, the committee presents seven recommendations designed to help the quarantine sta-
tions and Quarantine Core effectively lead the System and the Network. Given the desire to transform the CDC quarantine stations into a more robust component of the U.S. public health infrastructure, these recommendations address core functions of public health: assessment, policy development, and assurance (IOM, 2003).
COMMITEE’S VISION OF THE 21ST CENTURY QUARANTINE NETWORK FOR U.S. PORTS OF ENTRY
A multijurisdictional, multisectoral, multinational Quarantine Network protects both travelers entering the United States and the population within U.S. borders from microbial and other threats of public health significance that originate abroad. In so doing, this Network helps protect the health of the global community. Central to the Quarantine Network from a domestic perspective is a System that comprises the people and organizations on the front lines of public health activities at U.S ports of entry. The Core consists of the quarantine stations, DGMQ headquarters, and the national scientific and organizational capacity of CDC. Figure 3.1 illustrates the relationships among the Quarantine Core, System, and Network.
The Quarantine Network will minimize the risk that microbial threats of public health significance may enter the United States.
The Quarantine System will detect and respond to such threats in travelers who are en route to the United States and who arrive at a U.S. port of entry. The System will manage index cases and monitor suspect cases, probable cases, and close contacts.4 The Quarantine System also will participate in public health emergency planning and response activities for biological, chemical, and radiological threats and other disasters.
The Core will anticipate microbial and other threats of public health significance and will collaborate with the other members of the Network to prevent their arrival. The Quarantine Core will routinely measure and evaluate its performance and will adapt and change in response to its findings, as well as to the rapidly changing global environment. The Core will not only carry out statutory responsibilities but also provide strategic public health leadership to the Quarantine Network on matters at the intersection of international travel, global trade, and public health. As noted above, this leadership role stems naturally from the unique responsibility of the federal government to assure action for health (IOM, 2003, p. 34) and from CDC’s position as a lead federal agency for protecting the health of Americans.
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.
Development of a National Strategic Plan by the Quarantine Core
On the basis of its collective experience in public health practice, law, and governance, the committee concluded that a national strategic plan developed by the Core would provide the people of the United States with the best possible framework for protection against importation of microbial threats of public health significance. With its focus on human communicable disease, the Quarantine Core’s national strategic plan would complement those plans formulated by the Department of Homeland Security to protect the American public.
The Quarantine Core should begin developing its strategic plan by conducting a comprehensive assessment of the risks posed at multiple types of ports of entry to this country by microbial and other threats of public health significance. As noted in Appendix D, airports and seaports vary in their physical and institutional structures. The same is true of U.S. land-border crossings (Personal communication, R. St. John, Public Health Agency of Canada, July 5, 2005). The types of imported goods and conveyances and the points of origin of travelers and crew also vary widely from one port to the next. The comprehensive risk assessment should examine the implications of these variations. No such assessment of the Quarantine System has been conducted for at least 10 years (Bozzi, 1995).
Once the risk assessment is complete, the Core should collaborate with its partners in the Quarantine System to develop a strategic plan for mitigating the risks identified in the assessment. The plan should have a set of nationally uniform principles and outcomes as well as malleable elements that localities can shape to their unique circumstances. An important part of this plan will be the development of public health protocols for managing and monitoring persons, goods, and conveyances.
Since colonial times, tension over the control of U.S. quarantine functions has existed between states and localities on one side and the federal government on the other (DGMQ, 2003a; Gostin, 2000; Mullan, 1989). The committee is cognizant of this tension and of the reality that states and
localities carry out most of the public health functions required by federal quarantine laws. By recommending a strategic plan that is uniform only in its principles and outcomes, the committee intends to give states and localities enough latitude to decide on the details of execution.5
The uniformity of the plan will facilitate the flow of essential communication and data among all stations and their System partners nationwide. As an earlier Institute of Medicine report concluded, “a public health system that can assure the nation’s health requires an alignment of policy and practice of governmental public health agencies at the national, state, and local levels” (IOM, 2003, p.96). In addition, a plan that promotes a uniform level of outcomes has the potential to prevent terrorists and some commercial interests from finding ports of entry whose public health protection mechanisms are substandard.
The malleable elements of the strategic plan should help the members of the system, including each of the nearly 3,000 U.S. local public health authorities (NACCHO, 2003), tailor the implementation of the plan to their unique circumstances (Figure 4.1).
Legal Authority and Resources Necessary to Implement the Strategic Plan
The Core will need sufficient legal authority to implement the strategic plan. As the Institute of Medicine noted in an earlier report, U.S. federal and state public health laws are frequently antiquated, fragmented, and inconsistent (IOM, 2003). These broad observations certainly characterize quarantine authority, which may suffer from such deficiencies as the narrow application to specified diseases, lack of clear criteria for implementation, and absence of adequate procedural due process as required under the Constitution (Gostin, 2000).
To help states remedy some of these deficiencies not only in their quarantine authority, but also in their overall legal preparedness for public health, two model laws have been written: the Model State Emergency Health Powers Act (MSEHPA) and the “Turning Point” Model State Public Health Act (MSPHA) (Gostin et al., 2002). MSEHPA was drafted by
the Center for Law and the Public’s Health at the request of the CDC after September 11, 2001. MSPHA was drafted as part of the Robert Wood Johnson “Turning Point” initiative and has detailed provisions for isolation, quarantine, and other health powers. These provisions provide a strong model for states to consider when modernizing their public health legislation.
Thirty-three states and the District of Columbia have passed bills or resolutions that include provisions from or closely related to MSEHPA; 21 of those bills or resolutions include the modernization of isolation and quarantine powers in a public health emergency (http://www.publichealthlaw.net/MSEHPA/MSEHPA%20Surveillance.pdf). The committee encourages all states to examine and modernize their public health laws, particularly for isolation and quarantine.
For the Core to exercise national strategic public health leadership, there is a need for coordination of federal, state, and local authority for the exercise of public health powers. At present, legal and regulatory authority,
as well as practice and implementation, are fragmented at the various levels of government.
Laws at the federal and state level should ensure that the Quarantine Core has clear authority to carry out all its essential functions, including inspection, disinfection, nuisance abatement, medical examination, vaccination, treatment, isolation, and quarantine. In particular, the law should ensure at least the following:
The Core has adequate power and duties to isolate and quarantine with respect to all diseases of public health importance at specific places and times, including enforcement of isolation or quarantine orders in a timely fashion.
There are clear lines of authority within the Quarantine Core and among the various levels of government—among the various federal agencies and among federal, tribal, state, and local governments.
The Core has the authority to obtain all relevant information from domestic and transnational sources to carry out its responsibilities for protecting the public (e.g., electronic passenger manifests).
The Core operates under standards of procedural and substantive fairness as established under the Constitution and applied by the Supreme Court, including the provision of procedural due process.
The Core has the legal authority to track and control the state-to-state spread of disease resulting from international travelers, animals, and cargo arriving at U.S. ports of entry and moving across state lines.
The Quarantine Core must also comply with the United States’ international obligations. This is particularly important because of the expanded role for DGMQ. The revised International Health Regulations, adopted by the World Health Assembly in May 2005, should receive special attention. For a complete discussion of the international laws and obligations relevant to this report, see Appendix F.
Along with sufficient legal authority, the Core should have sufficient funds for both DGMQ HQ and the quarantine station staff to carry out their responsibilities under the strategic plan. The Core also should make every effort to assure that all of its partners are fully aware of and trained to carry out any public health functions delegated to them under the strategic plan. These functions will be discussed in more detail in connection with Recommendation 3, but the allocation of sufficient funds in an effective manner is integral to assuring the capacity and competence of state, tribal,
and local public health authorities, laboratories, and health care providers to carry out their duties under the strategic plan.
Although appropriate levels of funding and methods of allocating funds fall outside the committee’s expertise and scope of work, some general observations about financial allocations are appropriate here. First, all financial arrangements between the Core and states and localities should take into account the structural and functional diversity of the country’s numerous local health departments. In addition, the Core should consider allocating federal funds from the Core to states and localities through a multiyear financing mechanism that gives them adequate “discretion and flexibility to plan and implement multiyear efforts” (IOM, 2000, pp.16–17). The U.S. Government Accountability Office (GAO) recently made similar observations regarding bioterrorism funds (GAO, 2005). GAO noted that state and local administrative processes slowed the obligation and expenditure of bioterrorism funds and urged federal authorities to consider the time-consuming planning process that precedes the obligation and spending of funds at the state and local levels.
Another general observation is that formalized funding arrangements could be useful in strengthening collaboration between the Core and its state and local partners. The provision of funds could be tied to specific performance indicators, such as the regularity of scheduled interaction and partnering activities. Under such arrangements, the quarantine stations should be held just as accountable as the states and localities.
Finally, as the Core implements the strategic plan, it must assure the local health departments’ ability to take on delegated responsibilities while continuing to provide essential public health services. Unfunded mandates will only impose greater financial burdens on localities.
Harmonization of Authorities and Functions
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.
The Quarantine Network is a very complex environment, as Figure 3.1 suggests. The multiplicity of missions, players, skill sets, systems, laws, rules, and regulations at play in the Network appears to reduce its effectiveness. The wide array of potential sources of microbial threats further complicates the Network. This environment would become more effective if
roles were clarified and harmonized, eliminating some of the present breaks in the lines of authority and communication described in Chapter 3.
As a first step toward harmonizing the authorities and functions within the Network, the Core should articulate gaps in authority and function. Some of the gaps identified by the committee or the Quarantine Core are described below. Through the risk assessment described in the strategic plan, the Core could identify additional gaps.
Electronic Passenger Manifests
One gap DGMQ has clearly identified is the difficulty of collecting passenger information in a timely manner in connection with a communicable disease investigation, as discussed in Chapter 3. Local public health authorities and the quarantine stations usually can trace only a fraction of exposed passengers, even with a great effort, increasing the risk of dispersal of microbial threats of public health significance and endangering the health of travelers after they arrive in this country. Although U.S. Customs and Border Protection (CBP) and DGMQ staff working at several ports of entry thought that during an extreme public health emergency such information would likely be made available to DGMQ, this is not assured (Committee, 2005). The Quarantine Core has been working with numerous partners in the System and the Network to overcome the barriers to accessing passengers’ contact information. An interim solution—the targeted use of passenger locator cards—appears to be close at hand.
Identification of Ill Passengers
Another gap in the Network pertains to a mismatch between the responsibility for screening ill travelers and the role of the individuals informally assigned to this task (such as CBP staff). These individuals act as the Core’s surrogates at most U.S. ports of entry, yet CBP does not count microbial threats of public health significance among its principal threats of concern at U.S. borders, as described in Chapter 3. Moreover, the quarantine stations have lacked adequate budgets to routinely visit all subports to train CBP staff and evaluate their effectiveness (Personal communication, M. Becker, DGMQ, March 24, 2005). Consequently, the surveillance conducted for ill travelers (and certain animals) arriving from international points of origin is largely passive in nature at most U.S. ports of entry (Committee, 2005).
Furthermore, as discussed in Chapter 3, pilots and captains of U.S.-bound airplanes and ships do not always notify a CDC quarantine station of ill persons on board, even though the law requires them to do so (42 CFR § 71.21a,b; Committee, 2005; Appendix D).
Continuity of Care for Refugees and Immigrants
Refugee health is another gap in the Network. The U.S. Department of State is responsible for refugees before their resettlement but has limited capacity to cope with their health issues. The Quarantine System is not designed to provide refugees with comprehensive preventive health care abroad. Consequently, many refugees with infectious diseases, some of public health concern, arrive at U.S. ports of entry (Catanzaro and Moser, 1982; CDC, 1998; CDC, 2002; Miller et al., 2000). Local public health authorities—a component of the System—bear the burden of any adverse impact the refugees may have upon the health of their new communities. Because some illnesses of refugees are not typically seen in the United States, their signs and symptoms often fall below the index of suspicion of American clinicians, leading to delays in treatment that may be life-threatening and contributing to the dispersal of microbial threats. Ultimately, the cost of treating such illnesses in the United States could be much greater than effective preventive care administered to refugees before their resettlement in this country.
As pictured in Figure 1.1 and noted in Chapter 3, DGMQ has a distinct branch that is dedicated to immigrant and refugee health. The research portfolio of the Immigrant, Refugee, and Migrant Health Branch aims to improve the health status of or health information regarding some immigrants and refugees prior to their arrival in the United States (DGMQ, 2004a). This work will likely reduce the number of people infected with microbial threats of public health significance who reach U.S. gateways. This work also will likely improve the quality and accuracy of the health information evaluated and processed by quarantine inspectors or their CBP surrogates. In summary, measures that strengthen the Immigrant, Refugee, and Migrant Health Branch are likely to promote and support the goals of the quarantine stations.
The adequacy of animal health screening for zoonotic6 diseases is another weakness in the Quarantine System. No federal agency has a mandate and mission that covers all imported animals and zoonoses (Personal communication, P. Arguin, DGMQ, April 8, 2005). Although the Quarantine Core has the authority to respond to a specific perceived threat of zoonotic disease on a conveyance (42 C.F.R. §71.32), the Core’s standing to screen all imported animals for zoonoses is questionable (Personal communication, P. Arguin, DGMQ, April 8, 2005). Yet an estimated 75 percent of
emerging microbial threats to human health and 61 percent of all human pathogens are zoonotic (Taylor et al., 2001). Newly emergent zoonoses include monkeypox, severe acute respiratory syndrome (SARS), West Nile virus, and mad cow disease (variant Creutzfeldt-Jakob disease in humans). Many predictions about the nature of future novel pathogens anticipate the emergence of zoonoses (IOM, 2004).
Harmonization of Functions and Protocols Among Countries
The revised International Health Regulations will help to ensure harmonization on a global level, especially during crises. For the Network to function most effectively, however, all countries’ approaches and activities should be routinely harmonized and coordinated. Routine cooperation will foster learning and sharing opportunities, ultimately ensuring that countries institute the most effective practices and procedures. For example, the Core’s capacity to perform effective global disease surveillance would be enhance by increased collaboration and information-sharing among countries. In addition, public confidence in the Network will increase as the international community observes similar and coordinated responses taking place across the globe.
The Core should initiate efforts to bridge these and other gaps in the Quarantine Network. To a great extent, the success of these efforts will be contingent upon cooperation from relevant partners. The Core should continue to explore ways to jointly develop with the Department of State a more comprehensive public health approach to managing immigrants and refugees to improve their health, reduce costs, and prevent the spread of infectious disease. Through its relationships with CBP, the U.S. Department of Agriculture (USDA), and the U.S. Fish and Wildlife Service (USFWS), the Core should work toward a comprehensive national strategy for preventing the importation of zoonotic disease. In addition, the highest ranking officials of the Core should continue to highlight the absence of sufficient staff who are qualified, trained, and tasked to inspect arriving travelers and crews for signs of communicable disease of public health significance. Meanwhile, the Core should continue to pursue strategies at all levels to alleviate this shortfall. The Core also should work with appropriate authorities to ensure prearrival notification that sick persons are aboard conveyances and to obtain access to electronic passenger manifests. Effective contact tracing during disease outbreaks will be possible only with the information included in these manifests; access, however must be subject to the high standards of health information privacy and security. These are but a few
examples of the numerous clarifying and harmonizing activities that would improve the Network’s effectiveness and efficiency.
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.
The infrastructure of the Quarantine System is inadequate to support its current role, let alone the role envisioned for it under the expansion plan. Only a limited amount of resources are available to the quarantine stations and their partners in the System for their work in mitigating the risks posed by microbial threats of public health significance at U.S. ports of entry. These limits (and mismatches) in people, tools, training, physical space, and use of technology keep the System far from achieving what is realistically possible in relation to both its present regulatory responsibilities and any sort of expanded public health role. Enhancements in the Quarantine System’s infrastructure will be especially important in today’s dynamic regulatory environments, both domestic and international.
People and Training
One of the most glaring problems with the infrastructure of the System pertains to its human resources. The Core’s field staff numbers approximately 40 (Personal communication, M. Remis, DGMQ, May 11, 2005). By contrast, 120 million people traveled to and from the United States by air in 2003—a ratio of 1 CDC inspector per 3 million travelers (Office of Aviation Policy and Plans, 2005). With its severely limited human resources, the Quarantine Core also is unable to oversee the vast majority of imported cargo either on paper or in person and must accept on faith that most cargo is imported with appropriate permits or is innocuous (Committee, 2005; personal communication, J., Barrow and M. Remis, DGMQ, November 9, 2004; Appendixes D and E).
If the Core expands to 25 stations, DGMQ’s plan calls for a field staff of 158 (DGMQ, 2004b), reducing this ratio to about 1 CDC inspector per 750,000 travelers. Adding the 19,000-some CBP field inspectors approaches a more reasonable balance of 1 federal official per 6,300 travelers (CRS, 2004); however, only those inspectors located at CDC-staffed airports appear to receive adequate training to actually identify ill passengers.
As noted earlier, while port-based CBP officials have a duty to act as surrogates for the CDC quarantine stations, they also have multiple responsibilities of their own that (from their perspective) take precedence over the
duties of the Core (see Boxes 3.1 and 3.2). Furthermore, the committee is concerned that a significant percentage of these CBP officers lack appropriate and sufficient competences, training, and resources to perform this surrogate function. These issues represent serious weaknesses in the Quarantine System. While conducting its risk assessment and developing a national strategic plan, the Quarantine Core should define these deficiencies and assure they are corrected.
The present obstacles to improving training are both internal and external to the Core. Internal obstacles include the small workforce at existing field stations, an insufficient travel budget for visiting subports to conduct training sessions (as noted in Recommendation 2), lack of videoconferencing capabilities among stations and substations, and insufficient security clearance to enter many substations, particularly seaports (Appendix D). External obstacles include the high level of turnover among CBP officials, irregular hours of airline crews, and multiple demands and priorities that compete for the attention of private sector and federal partners (Committee, 2005).
DGMQ should assure that every station has access to individuals who possess all the competences required to carry out the responsibilities of the new and expanded Quarantine System. As discussed in Chapter 1, the committee issued an interim letter report on competences for the Core’s staff. That report was done prior to the committee’s complete analysis of the Network and the development of its vision. However, the competences outlined in the interim letter report, reprinted in Appendix A, remain compelling to the committee.
The CDC quarantine station staff and their colleagues at headquarters require competences to execute historical and statutory functions, to plan, to conduct surveillance for public health threats, to perform clinical and public health assessment and response, to perform health and risk communication, and to develop collaborative relationships with all members of the Network. Several points made in the interim report bear repeating here:
Each station should have access to individuals with the competences outlined by the committee. These individuals could be located either on-site or off-site. Potential off-site human resources could be based at the regional stations, DGMQ headquarters, the private sector, partner agencies, or elsewhere. In general, using partners as a resource for some of the competences could help the stations build collaborative relationships that enhance the stations’ overall effectiveness. A regional station might need staff on-site who collectively possess all the competences necessary to execute all of the priority functions.
Many combinations of health professionals and others could, as a team, have all the competences necessary to conduct the priority functions necessary for the surveillance, detection, and response to microbial threats of public health significance at U.S. ports of entry.
Today’s quarantine inspectors and officers have extensive knowledge about—and experience in—the historical functions of the quarantine stations. As new staff with expanded backgrounds in public health are hired, DGMQ should ensure that the important experiences of its outstanding and long-serving staff are not lost. Because many techniques, practices, and knowledge of the quarantine station staff have not been codified in a serious way, the stations’ continued functioning depends on the people who have fulfilled their roles so well for decades. These experienced individuals should be involved in the development of training modules for new staff who will carry out historical functions at new stations as the expansion progresses.
The quarantine stations should have access to translators in the languages of the travelers and crews who typically arrive at their ports. In addition, the quarantine station staff should be able to demonstrate knowledge of and sensitivity to the cultural norms in interpersonal communication and health care of travelers and crews who typically arrive at their port.
Finally, DGMQ should make as a priority the hiring of clerical support for the quarantine stations. This will allow the quarantine inspectors to perform functions well matched to their competence and to meet the competences laid out by the committee. As the stations, the Core, and the Network evolve, the inspectors will need to take on greater and more complex responsibilities and will need strong clerical support.
While developing this report, the committee learned that none of the Core’s field staff have formal veterinary backgrounds (Appendix E), although they have regulatory responsibility for screening an array of pets, exotic imports of animal origin, and live animals that might harbor a zoonotic disease, as described in Chapter 3. The station staff usually reviews paperwork about these animals and sometimes does brief visual exams, but physical examinations of the animals would be more informative, according to the analysis commissioned by the committee (Appendix E). The Core should examine and rectify this mismatch between competences and statutory responsibilities in the realm of animal inspection.
The location and layout of the quarantine stations are ideal in some airports and suboptimal in others (Committee, 2005). DGMQ has no fi-
nancial leverage to influence where the airport authority places stations, because airports are required by regulation to provide quarantine station space free (42 CFR §71.47). Airport real estate comes at a premium to their landlords, so nonprofit operations, such as DGMQ, are sometimes viewed as an undue burden (Borrone, 2005). The Core should be cognizant of these financial and regulatory issues as it continues to build relationships with its System partners at airports. As more of these partners appreciate the complete role the Core plays, perhaps negotiations over space will become easier and more fruitful.
Use of Technology
DGMQ should attempt to acquire electronic communication and data systems that are more robust, modern, and redundant than those currently in place. Such technological enhancements would facilitate the rapid, effective exchange of electronic information that is integrated with CDC’s headquarters-based systems. DGMQ also should acquire electronic information-gathering and advanced transmission systems to help compensate for its cirumscribed geographic reach. In addition, it should continue to seek access to databases and systems that contain information to protect the public’s health, such as the Automated Manifest System (AMS), Notification of Arrivals, and the Automated Passenger Information System (APIS). Although the stations may need new administrative support as a result of these enhancements, they already need substantial clerical help in their current configuration.
The ability to receive and transmit digital images could yield important public health rewards. Obtaining access to the chest x rays of immigrants and refugees, for instance, can be a slow and difficult process for the Core. The transmittal of these x rays as digital images should, at the very least, expedite the process, and the committee urges the Core to assess the feasibility and benefits of utilizing digital imagery in screening immigrants and refugees for active tuberculosis. Relaying digital images could also be useful in assessing skin lesions and other clinical findings. Furthermore, electronically scanned medical records of immigrant and refugees could be transmitted to the quarantine stations and local public health departments before the individuals arrive in the United States, creating an opportunity to review the records in advance. The electronic transmittal of immigrant and refugee medical records would also reduce the processing delays and errors noted in Chapter 3.
With the ability to transmit and receive digital images throughout the System, more travelers and crews with signs, such as rashes, that might indicate an infection of public health concern could be screened remotely by the quarantine stations, DGMQ HQ, and available physicians. The same technology could increase the number of animals inspected for zoonoses.
The transmission of digital images from off-site locations also would expand the capacity of the geographically confined quarantine station staff to inspect contraband, tissues, etiologic agents, and so on.
The Quarantine Core and its state, tribal, and local partners should develop and maintain shared data and data systems to improve the monitoring of numerous outcomes and processes. In the case of routine screening and management of immigrants and refugees, for instance, shared databases would help the Core oversee
Medical follow-up determined to be medically indicated for individuals with active or inactive tuberculosis.
The administration of necessary vaccinations.
The treatment of parasitic infections.
To cite another example, shared data and data systems would help the Core and local public health authorities exchange surveillance data and information on exposed persons during contact tracing and outbreak management. As noted in Recommendation 2, the sharing of data systems among countries would amplify the Core’s global surveillance capacity.
Location of Stations
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.
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, 2003b). Both the committee’s expertise and the scope and timetable of this study precluded a comprehensive review and analysis of DGMQ’s data and methods for selecting the cities and ports for the new quarantine stations. The committee recommends, however, that DGMQ consider these additional factors in its site-selection process:
Percentage of international flights covered.
Amount of coverage during peak arrival times of international flights.
The cost-benefit ratio of a robust, round-the-clock presence at relatively few, high-risk sites versus a thinner presence at a greater number of sites.
Coverage of high-risk ports of entry identified in the risk assessment described in Recommendation 1.
In addition, the Core should develop virtual or mobile teams to supplement permanent stations, should the need arise, because of resource constraints or changing threat assessments. Finally, the Core should continue to strengthen existing stations as it builds new ones.
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.
The Core should assure that a surge-capacity plan for public health emergencies at U.S. ports of entry is part of the emergency plan of the municipalities that contain such ports. One way to accomplish this could be to make it a prerequisite to the receipt of CDC funds for emergency preparedness and bioterrorism planning at the state level and for those cities that receive direct CDC funds. In addition, DGMQ should consider having its staff participate—as resources allow—in response and planning efforts for local public health emergencies. This would not only help foster closer relationships and stronger partnerships with state and local partners but also ensure that DGMQ staff maintain and develop important emergency response skills.
Tools that would be useful in planning for surges include:
Streamlined protocols for transferring staff from one quarantine station to another.7
Emergency hiring plans.
Contracts and agreements with local hospitals,8 emergency respond-
The ability to transfer staff is a slow and bureaucratic process in general. Furthermore, relocation will be disruptive to the staff members’ personal lives. The protocols should address these challenges.
The committee realizes that some hospitals, fearing stigmatization as “the quarantine facility,” may be hesitant to enter into agreements with DGMQ. The committee encourages DGMQ to take this concern into account as it continues to establish partnerships with local hospitals. As noted in Chapter 3, however, DGMQ has already entered into memoranda of agreement with more than 130 hospitals near ports of entry throughout the United States.
ers (fire and ambulance), social service providers, local public health authorities and laboratories, and airport and seaport authorities (to facilitate rapid security clearance).
Locations to isolate all passengers of a flight for a reasonable period.
Push-packs (cots, blankets, toiletries, and towels) for quarantine support.
Virtual teams, mobile teams, or both that can nimbly shift their attention and resources to any one of numerous ports of entry as risks or real events dictate.9 Such teams could be based at DGMQ headquarters, regional quarantine stations, or other stations. CDC could assemble a team from its emergency command center via videoconference, or a quarantine station could temporarily relocate staff to a port of entry that lacks a permanent station.
Communication plans and designated, trained personnel to interface with the media and health care providers and to communicate to the public.
Furthermore, the Core should build cooperative relationships with other federal agencies that have extensive experience in emergency response, such as the Federal Emergency Management Agency (FEMA) and USDA. Given their experience in assembling personnel and materials during emergencies, such agencies could serve as valuable resources for the Core as it works to strengthen its surge capacity.
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.
Much of the practice of detecting infections and controlling outbreaks of disease in the context of the Quarantine Network has a basis in 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.
Determining the Effectiveness of the Stations’ Practices
The visual screening of arriving international travelers at airports has evolved from laws dating back to 1891 that mandated the medical inspection of all arriving immigrants one person at a time. Then, as now, the public health service was severely understaffed—even at Ellis Island (Mullan, 1989). To cope with multiple duties and huge influxes of hopeful journeyers, the medical officers of the time resorted to cursory visual screening of immigrants for signs of unwanted disease. According to one seasoned public health officer conducting inspections at Ellis Island in 1917, “experience enables [me] in that one glance to take in six details, namely, the scalp, face, neck, hands, gait, and general condition, both mental and physical” (Mullan, 1989, p.45). The system was very inefficient. Fifteen to 20 percent of new arrivals were detained for further medical examination, but less than 1 percent ultimately were found to have an infection that was grounds for refusing entry into the United States (Mullan, 1989).
In today’s fast-paced world, thousands of travelers rush through the international terminals of major U.S. airports every day. The culture is loath to stop or slow its pace for anything that isn’t absolutely necessary. Logically, in this environment, it would seem to be the exception and not the rule for a quarantine inspector with or (more often) without clinical training to successfully spot signs of a serious communicable disease in one or more individuals hurrying by. Only an infected individual whose illness has progressed to a symptomatic stage that severely impairs his or her ability to function precisely during the hours in flight, when disembarking, or shortly after would clearly stand out from the crowd. On the basis of this reasoning and data gathered on site visits, the committee concluded that visual inspections identify a small percentage of travelers who have communicable diseases of public health significance. Therefore, the stations should devote only a small fraction of their time to the visual inspection of disembarking passengers.
Just as consumers and payers of medical care increasingly base their choices on data about the efficacy of drugs and treatment regimens, so the quarantine stations should scrutinize their methods in a scientific, quantitative way. Designing studies to carefully measure the sensitivity and specificity of current techniques will generate data that either validate or debunk the methods in use. Questions to be asked and answered should include:
How effective is the current process for screening the health of immigrants and refugees? Could it be improved, and if so, how?
What is the veracity of self-reported health information?
What are the most effective methods of tracing exposed travelers or possibly infectious animals?
For example, if passenger locator cards are to be used for contact tracing, the Core should evaluate their effectiveness and continue to research alternative methods.
Developing a Forward-Looking Research Agenda
The Core also should formulate a forward-looking research agenda to develop a scientific foundation for decisions that may need to be made in the future. For instance, many countries would have saved money and time during the SARS outbreak had they previously conducted small studies of the efficacy, cost effectiveness, and efficiency of thermal scanners in identifying individuals with a specific, fever-inducing disease. Such studies would have revealed that the predictive value of a positive thermal scan was zero (St. John et al., 2005; personal communication, R. St. John, Public Health Agency of Canada, July 5, 2005). Questions to be asked and answered should include:
Given an array of perceived microbial threats, each of a different nature, which method or methods of exit screening10 would most effectively identify infected individuals? A questionnaire? If so, what questions should be asked? A medical exam? What would be of any use at all?
What are the environmental factors that contribute to or prevent the transmission of infectious agents on airplanes, cruise ships, cargo ships, and other conveyances?
How sensitive, specific, and costeffective are existing rapid diagnostic tests, and how and where should those tests be applied? What basic research is needed to develop new rapid diagnostic tests?
What are the best methods to reduce postarrival diseases, such as tuberculosis, in immigrants and refugees?
In developing this research agenda, the Core should collaborate with its national and international partners to ensure mechanisms for closer cooperation and a better exchange of knowledge and information in the research process.
Developing Data-Collection and Data-Evaluation Plans
In addition, the Core should develop, in advance, data-collection and data-evaluation plans to apply when an incident occurs. The very process of
responding to an incident generates data, but it is extremely difficult to design a data-collection scheme and obtain the necessary clearances (for human-subject studies) in the midst of a crisis. Having such plans and tools at the ready would make it possible to collect and analyze data generated during the crisis. This will be especially important if the incident involves a microbial threat about which many important characteristics are unknown.
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.
As described in Chapter 3, the absence of evidence-based performance standards and measurement in the present Quarantine System made it virtually impossible for the committee to objectively evaluate most of the System’s performance. This weakness in the System would be remedied by the development of scientifically sound metrics for assessing effectiveness and quality.
The Core should catalog all the components of System processes and operations that influence the detection of microbial threats of public health significance at ports of entry. Next, the Core should identify a rational set of measures of the effectiveness and quality of the identified processes and operations. A standard set of tools should be developed for performing measurement. Finally, the Core should use these tools to routinely evaluate its own performance, the performance of individual partner organizations, and the performance of the entire System in concert. The difficulty of conducting objective self-assessments suggests that the Core should consider identifying an unbiased advisory group to perform this activity.
The use of a nationally uniform, evidence-based toolkit to assess the System’s performance will help maintain a consistent level of quality and effectiveness in efforts to mitigate the risk that microbial and other threats of public health significance will enter or affect travelers to the United States. Moreover, consistently high quality and effectiveness across all ports of entry will have the positive externality of boosting public confidence in the federal government’s ability to protect public health. Below are eight examples of the types of questions that the evaluations should answer.
What is the completeness of ascertainment of passengers with conditions of public health concern?
What proportion of refugees receives appropriate immunizations or other indicated disease screening, prevention, and treatment prior to arrival in the United States?
What proportion of immigrants with a notifiable communicable disease identified overseas completes treatment?
What is the quality and effectiveness of the relationships within the Quarantine System?
Are the new stations on track to establish relationships with key System partners within a predefined period?
Does the training given to CBP, emergency medical services (EMS), and port staff enhance their ability to identify and respond to potential infectious disease threats?
How often and completely do members of the System follow response and notification protocols?
Do these protocols reduce morbidity and mortality when applied during drills and tabletop exercises?
Questions 4 and 5 call for further explanation. Informal relationships are the glue that holds the System together—a finding documented by the committee (Committee, 2005) and the commissioned paper titled U.S. Seaports and the CDC Quarantine System (Appendix D). For this reason, DGMQ headquarters should hold new stations accountable for establishing critical relationships with System partners within a defined period; otherwise, the stations are not fully functional. Metrics for evaluating critical relationships may be difficult to formulate; the disciplines of sociology and organizational dynamics may be helpful in this regard. But the task of measuring the quality and effectiveness of relationships is as important as it may be challenging, because their ongoing evaluation and improvement will help assure that the System is fully functional and operating effectively.
Recommendation 3 discusses the infrastructure of the Quarantine System. Given the weaknesses identified by the committee in this area and the significant impact of staffing, technology, and space on operational performance, the Core should also routinely assess the adequacy of the System’s infrastructure and its resources. Through regular evaluation, the Core could better identify, for example, appropriate staffing levels and hours of operation for the quarantine stations.
The U.S. Quarantine Network needs strategic public health leadership. The CDC quarantine stations at U.S. ports of entry should provide this
leadership to the Quarantine System, and the Quarantine Core should provide it to the Network as a whole. In so doing, the Core could assure the flow of essential communication and data among all CDC quarantine stations and their System partners, promoting rapid, effective, nationally coordinated public health responses to microbial threats that originate abroad.
Given sufficient resources and legal authority to exert strategic national public health leadership, the Core could formalize the collaborative relationships it already has and could establish new linkages to assure that the responsibilities of the Network are executed at all ports of entry on both a routine and emergency basis. In particular, the Quarantine System must be capable of preventing, anticipating, preparing for, and responding to foreign-origin microbial threats that reach U.S. ports of entry when and where CDC quarantine station staff are absent. To achieve this capability, the Core needs sufficient financial and human resources to train its surrogates and acquire information technology that permits rapid, real-time communication and data-sharing among the stations and their System partners.
Finally, the Quarantine Core should build for today and for 50 years hence. Microbial threats of public health significance have been increasing in number and severity for decades; this trend will likely continue for the foreseeable future. The nation must prepare—now—to meet future microbial threats at its gates.
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