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Suggested Citation:"Chapter 2 - Phases of Quarantine." National Academies of Sciences, Engineering, and Medicine. 2008. Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs. Washington, DC: The National Academies Press. doi: 10.17226/13989.
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Suggested Citation:"Chapter 2 - Phases of Quarantine." National Academies of Sciences, Engineering, and Medicine. 2008. Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs. Washington, DC: The National Academies Press. doi: 10.17226/13989.
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Suggested Citation:"Chapter 2 - Phases of Quarantine." National Academies of Sciences, Engineering, and Medicine. 2008. Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs. Washington, DC: The National Academies Press. doi: 10.17226/13989.
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5Quarantine can be broken down into a series of sequen- tial actions or phases: (1) the decision process to quarantine, (2) the establishment of a quarantine area with registration and assessment of the population going into quarantine, (3) the operational aspects of maintaining quarantine, (4) demobi- lization, and (5) recovery. This section will discuss each of the phases and identify areas for further study. Phase 1. Decision to Quarantine What situation would require a quarantine action at an air- port? There are several scenarios that could initiate a quaran- tine action, but many of the procedures for carrying that out are undergoing revision or under development. The follow- ing procedures provide a general idea of how a quarantine might proceed. CDC could receive a report of a potentially quarantinable disease on board an aircraft in flight. The airline, in particu- lar the captain or person in command of an international flight landing in the United States, is required under federal law (42 CFR 71.21) to report illness meeting certain criteria to a CDC Quarantine Station. Notification can be done via the air carrier’s operations center or through air traffic con- trol. (A separate regulation found at 42 CFR 70.4 applies to flights within the United States). The criteria for an “ill per- son” as defined by the regulation are: • A fever, defined as a temperature of 38°C or 100°F or greater, accompanied by one or more of the following: rash, jaundice, glandular swelling, or temperature persisting for two or more days. and/or • Diarrhea severe enough to interfere with normal activity or work (defined as three or more loose stools within 24 hours or a greater than normal number of loose stools). Any traveler(s) who meets the criteria would be assessed by a public health official, as well as by airline medical consult- ants or by airport emergency medical personnel who would determine if the traveler required medical treatment. Nearly all airlines have in-house medical personnel or a contract with a service to provide medical advice on the ground to the aircraft crew handling an in-flight medical incident. These medical professionals may also be able to coordinate with the CDC Quarantine Station personnel or other public health officials by providing them with additional information prior to landing that would expedite assessment of the traveler. Generally, the arriving aircraft would proceed to its assigned gate at the scheduled airport, where it would be met by pub- lic health officials and the airport emergency medical response team. If a preliminary assessment identified the potential for a quarantinable illness on board, the aircraft might be directed to a more remote area of the airport or to a gate closer to the CDC Quarantine Station. The plane may even be diverted to another airport. The decision would be made by federal authorities, with CDC taking the lead. If the airline does not identify and report a potential com- municable disease in flight but requests medical assistance upon landing, the airport medical emergency response team may de- termine that the situation involves a potential quarantinable ill- ness and the CDC Quarantine Station covering that airport would arrange for further assessment by CDC personnel or by local public health officials. In such circumstances, other pas- sengers and crew members may be requested to provide contact information for possible follow-up or to remain on the aircraft or in the gate area until their status is determined. CDC may opt to have Quarantine Station personnel meet flights that have originated or stopped over in a country or re- gion where an outbreak of a communicable disease is known to be occurring. CDC has the authority to observe and inter- view passengers as they leave the aircraft. Regardless of how the process is initiated, the decision to impose a quarantine order on international travelers arriving C H A P T E R 2 Phases of Quarantine

6one facility may be used to screen and register individuals who could then be transported to longer-term accommodations. The passengers and crew of the aircraft would be inter- viewed to collect basic information and evaluated to assess potential exposure. Medical personnel also would access any pre-existing health issues that may exacerbate, complicate, or confound symptoms of the quarantinable disease (e.g., pre- existing respiratory or cardiac conditions that might be wors- ened or triggered, or seasonal allergies that might be mistaken for or mask symptoms of the quarantinable disease). The stress of being quarantined may exacerbate existing condi- tions and travelers may have medication needs. Phase 3. Quarantine Operations Once a quarantine location is established and quarantined individuals have been transported there, the site becomes op- erational. The individuals under quarantine will need food, water, toilet facilities and, depending on the duration of the quarantine, accommodations for sleeping, bathing, enter- tainment, and communications. Access to medical care will have to be available. Supplies and staffing for food prepara- tion, medical care, security, cleaning, counseling and so forth will have to be mobilized quickly. Personnel from many dif- ferent agencies could be involved in the effort, including CDC officials, state and local public health employees, hospitals, airport and airline staff, private sector contractors, local pub- lic safety officials, and non-profit organizations. It will be very important to maintain good records on the individuals who are held in quarantine. Also, the operation will require rapid acquisition of goods and services, many of which ultimately may be reimbursable from disaster response funds or other sources. To take advantage of those resources, and for general accountability, it will be necessary to have records of all purchases and receipts. Totals can be organized and tallied during demobilization after quarantine ends. Record keeping is vital in the event of any legal claims and in preparation for cost reimbursement. An important area for further study is to examine and compare specific mandates of federal, state, and local gov- ernment with an eye toward determining more precisely the responsibilities of each and how the cost should be allocated. Phase 4. Demobilization Plans for demobilization can begin immediately after quar- antine is underway. A demobilization plan—the controlled, organized cessation of operations—is a feature of the National Incident Management System (NIMS). The plan should in- clude procedures for finalizing all records, including financial records. Having a system in place helps to reduce the poten- tial for confusion on billing for rented equipment and per- in the United States lies with the CDC; this is not an airport or air carrier decision. The air carrier has a duty to report cer- tain illnesses as explained, but for international travelers, only federal public health officials are legally authorized to imple- ment a quarantine. While CDC has the authority to impose mandatory quar- antine for nine diseases, the agency may choose a less extreme measure such as voluntary home quarantine; prophylactic treatment where available (e.g., vaccination); or simply col- lection of contact information and follow-up by public health officials to determine if anyone exposed develops symptoms later. The latter was done during the 2003 SARS outbreak. Phase 2. Establishment of Quarantine After the decision to quarantine is made by the CDC, the next step is to determine where the quarantined passengers and aircrew would be held and to set up the necessary ac- commodations. Health officials will decide if the ill person(s) and any others exhibiting symptoms should be referred to a hospital or other medical facility for treatment and isolation. Others exposed to the illness, though not symptomatic, may need to be detained for hours, days, or even weeks until a di- agnosis is confirmed, the time period for incubation is deter- mined, and the risk of further spread of the disease is evalu- ated. For example, exposed individuals may need to be kept in quarantine until laboratory tests confirm the initial diag- nosis. If tests are negative, individuals would then be released from quarantine. If the tests prove positive, quarantine would be extended for the appropriate incubation period. An esti- mate of these time frames and decision points should be made and conveyed to passengers and crew at this point and then updated as needed. Keeping passengers and crew on board the aircraft or in the gate area for any extended period is not desirable and may not be feasible; therefore, it probably will be necessary to remove quarantined individuals to another location on or off the air- port. A procedure for transport to the designated medical surveillance area should be made part of an airport’s emer- gency plan. If the facility is on the airport property but away from the terminal, the aircraft may be able to be moved to that facility and a stairway provided for egress from the aircraft. Lift service would need to be available for nonambulatory or limited ambulatory passengers, and wheelchairs should be available. If the quarantine site is off the airport property or otherwise not accessible by moving the aircraft, other vehicles, like buses or airport shuttles, would have to transfer the passengers and crew to the site. In this case, officials would have to consider the personal protection of the vehicle operators. Later, the vehicles would need to be decontaminated. In some situations,

sonnel costs. Documentation of medical conditions that may have developed during the quarantine should be part of the records management planning. A demobilization plan should cover the following items in depth: • Final medical checkout of detainees by medical staff • Planned release times for travelers and crew • Coordination with air carrier for travelers to finish their journey if additional flights are needed • Ground transportation to the destination of choice for travelers if needed • Shutdown of service items such as food delivery, trash pickup and so forth • Documentation of all costs incurred by the operation • Any logs, reports or diaries of the course of the quarantine have to be collected and collated • Critical Incident Stress Management intervention for personnel held in quarantine and those supporting the operation off-site • Final press releases • Clean-up and recovery plans Phase 5. Recovery Recovery can be defined as the restoration of services and the environment to the state they were in prior to the event. In the case of quarantine at an airport, it would address the restoration of the space used for the quarantine. The aircraft that carried the passengers to the airport could be decontam- inated and disinfected as soon as the passengers, crew and baggage are removed. However, if it is suspected that the in- cident was deliberate, the plane would be off limits until it was released by the appropriate law enforcement agency involved in the investigation. Aircraft, equipment, and space clean up require specific cleaning and clearance procedures depending on the charac- teristics of the biological agent involved. The work will need to done by specially trained personnel and equipment. Vehicles and equipment, such as buses, carts, wheelchairs, and so forth, also will need to be cleaned to a level where they are considered safe to return to service. Equipment that can not be cleaned to required standards would have to be disposed of and those costs would have to be covered. The costs of clean up will vary according to the type of disease involved. Some disease-causing pathogens can be de- activated through procedures consisting of fairly simple clean- ing with a standard disinfectant. Others may require more ex- pensive and time-consuming procedures. It should be noted that none of the quarantinable diseases would be likely to re- quire the type of intensive decontamination process required to deactivate anthrax spores, which are hardy and extremely persistent in the environment. The potential psychological effects of quarantine on an air- port and its employees have not been studied, but it is certain that workers in and around the airport will require reassur- ance that their work area is safe and their health will not be en- dangered. Part of the demobilization and recovery is prepar- ing the staff to return to routine duties. 7

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TRB’s Airport Cooperative Research Program (ACRP) Report 5: Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs explores facility issues, security considerations, and estimated costs (including operating costs) that airport operators and policymakers may want to consider when planning for the potential quarantine of arriving air travelers.

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