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From Nutrition to Quarantine?

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From Nutrition to Quarantine?

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  1. A Non-Traditional Role for Dietitians:  Centers for Disease Control Quarantine Stations CDR Kirsten Warwar, RD, MHA, CAAMA Officer in ChargeCDC Miami Quarantine StationQuarantine and Border Health Services BranchDivision of Global Migration and Quarantine Centers for Disease Control and Prevention

  2. From Nutrition to Quarantine? B.S. Dietetics USAF Internship 1st Assignment – officer in charge, nutritional medicine department Educational Opportunities – AF advocates leadership, supervision, in addition to primary medical profession Master’s Degree – Healthcare Administration Protocol officer, executive officer Transfer to USPHS HSA, ICE Detention Center Medical Facility CDC Quarantine Station

  3. Overview • History of Quarantine • U.S. Quarantine System • Mission • Federal Legal Authorities • New Regionalized Structure • Quarantine Station Activities • Team Activities

  4. History of U.S. Quarantine • Quarantine laws passed and executed by state or local authorities • Marine Hospital Service began to administer quarantine regulations in 1878 • National quarantine system by 1921 • Field office personnel expansion peaks with staff at every port of entry (1967)

  5. History of U.S. Quarantine, cont. Pre-1967: • Quarantine Inspectors monitored passengers disembarking from aircraft, ships, and across land borders • Expanded staff enabled direct inspection, observation, and response

  6. History of U.S. Quarantine, cont. 1967-2003: • Reorganization of quarantine station system reduced staff and facilities • Reorientation of quarantine staff roles 2003-present: • Newly emerging threats initiated an expansion in quarantine staff

  7. CDC Quarantine Stations 2004 Jurisdictions AK ME Seattle Chicago VT NH WA MA ND MT RI NY MN CT CT MI WI New York NJ OR PA ID SD DE WY MD IA OH NE IN No.CA WV IL NV VA San Francisco UT KY CO MO KS NC TN SC So.CA OK AR Atlanta NM AZ Los Angeles AL GA MS TX LA FL Miami Honolulu PR HI GU CDC Quarantine Station

  8. U.S. Quarantine System Expansion Precipitating Events • Speed and high-volume of global travel • Bioterrorism risks and 9/11 • SARS and Monkeypox • Avian influenza and risk for pandemic • MDR-TB Incident in 2007

  9. Speed of Global Travel in Relation to World Population Growth

  10. Number of Persons Entering the United States, 2005 Source: U.S. Customs and Border Protection. 2006.Securing America’s Borders at Ports of Entry, 2007-2011. Available at: http://www.cbp.gov/linkhandler/cgov/border_security/port_activities/securing_ports/entry_points.ctt/entry_points.pdf

  11. Quarantine Stations at Ports of Entry: Protecting the Public’s Health, 2005 Institute of Medicine (IOM) Report • Expansion to 25 quarantine stations recommended • Response and preparedness at ports of entry necessary • Capacity to conduct surveillance, epidemiology, and research

  12. Air Transport Assoc. of America Courts Media Network Foreign Gov'ts DOT Air Transport Assoc. of America FAA DHS System USCG FDA WHO Port officials USDA APHIS PHAC FBI BIDS Health-care providers Canadian/ Mexican BorderAuthorities PH labs LPHAs Int. Civil Aviation Org. Core USFWS State PHAs USCG (local) State Dept. Q-StationsDGMQ HQCDC OverseasPanel Physicians APHL Hospitals CSTE News Media CBP FBI (local) NACCHO EMS Int. Org. for Migration ASTHO Source: IOM Report Intl. Council of Cruise Lines U.S. Quarantine System: A Network of Networks with a Core

  13. CDC Quarantine Station Jurisdictions, 2009 AK ME Minneapolis Seattle Chicago Anchorage VT NH WA Boston MA ND MT Detroit RI NY MN CT CT MI WI New York NJ OR PA ID SD Newark DE WY MD Philadelphia IA OH NE IN No.CA WV IL Washington, D.C. NV VA San Francisco UT KY CO MO KS NC TN Dallas SC So.CA OK AR Atlanta NM AZ Los Angeles AL North TX GA MS San Diego East TX LA West TX El Paso FL Houston Miami Honolulu PR HI GU San Juan CDC Quarantine Station

  14. CDC Quarantine Stations 2009 Regions AK Region 2 ME Minneapolis Seattle Chicago Anchorage VT NH WA Boston MA ND MT Detroit RI NY CT MN MI WI New York NJ OR PA ID SD Newark DE WY MD Philadelphia IA OH NE IN No.CA WV IL Washington, D.C. NV VA San Francisco UT KY CO MO KS NC Region 3 TN Dallas SC So.CA OK AR Atlanta NM AZ Los Angeles AL North TX GA MS Region 1 San Diego East TX LA West TX El Paso FL Houston Miami Honolulu PR HI GU San Juan CDC Quarantine Station

  15. Quarantine and Border Health Services Branch Mission To protect the health of the public from communicable diseases through science, partnerships, and response at U.S. ports

  16. Quarantine and Border Health Services Branch (QBHSB) - Responsible for CDC Quarantine Stations and the U.S. Quarantine System - Implements federal authority for quarantine and surveillance of infectious diseases at U.S. ports

  17. Federal Authorities* • Reporting and Surveillance • Oversee screening of international travelers for symptoms of illness that could be of public health significance and respond to reports of illness on board arriving aircraft • Quarantine and Isolation • Detain, medically examine, or conditionally release persons suspected of carrying a communicable disease * Section 361 Public Health Service Act (42 U.S. Code, Section 264) Title 42 Code of Federal Regulations (CFR) Part 71 (Foreign Quarantine) 42 CFR Part 70 (Domestic Quarantine)

  18. CDC Quarantine Station Activities • Respond to reports of illnesses on airplanes, maritime vessels, and at land-border crossings • Inspect animals, cargo, and other items that pose a potential threat to human health • Distribute life-saving immunobiologics and investigational drugs • Provide international travelers with important health information

  19. CDC Quarantine Station Activities, Contd • Monitor the health of and collect medical information about new immigrants, refugees, asylees, and parolees • Respond to mass migration emergencies • Plan and prepare for emergency response • Enter data into electronic surveillance and data reporting systems • Build strategic partnerships for communicable disease surveillance and control

  20. Definition of Isolation and Quarantine Isolation: Quarantine: The separation of ill persons who have a specific infectious illness from those who are healthy and the restriction of their movement to stop the spread of that illness The separation and restriction of movement of well persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious

  21. Responding to an Ill Traveler The captain of an aircraft or ship is required by federal law to report any communicable illness of public health significance or death on board prior to arrival at the port of entry 42 Code of Federal Regulations Part 71.21

  22. Executive Order 13295: Revised List Of Quarantinable Communicable Diseases • Cholera; diphtheria; infectious tuberculosis; plague; smallpox; yellow fever; and viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named) • Severe acute respiratory syndrome (SARS) • Influenza caused by novel or reemergent influenza viruses that are causing or have the potential to cause a pandemic President George W. Bush April 1, 2005

  23. Other Communicable Illness of Public Health Significance* • Malaria • Typhoid • Varicella • Rabies • Meningococcal • Legionellosis • Dengue • Measles • Polio • Zoonotic poxvirus • Pertussis • Mumps • Rubella • Infectious diarrhea • Other communicable • diseases * Based on potential to a) cause significant morbidity and spread within the US; b) spread among passengers; c) be controlled by pharmaceutical and/or non-pharmaceutical interventions.

  24. Do Not Board List • Department of Homeland Security places a person on Do Not Board travel restriction list at CDC’s request • List managed by Transportation Security Administration • Person not allowed to obtain boarding pass for commercial flights inbound to, outbound from, or flights within the United States • Patient must meet all of the following criteria: • Infectious public health threat • Documented or potential treatment noncompliance • Potential to fly commercially while infectious

  25. CBP adds person into national Treasury Enforcement Communications System (TECS) to alert CBP that a traveler should be referred to secondary for public health reasons Look Out List • Helps identify infectious individual who attempts to enter the U.S. to prevent transmission and ensure follow up care • All persons placed on the Do Not Board list are also added to the Look out list • Especially useful in international ground crossings • Traveler is held provisionally pending case review by a quarantine medical officer CBP may contact CDC to determine if any traveling companions have been examined and found to be free of TB

  26. Preparedness TeamShah Roohi, Team Lead • Mission • Prepare for and respond to urgent public health threats by providing strategic direction and coordination • Safeguard health and save lives by providing a flexible, robust platform for public health emergency preparedness and response by the U.S. Quarantine System

  27. Preparedness Team, cont. • Activities • Port Preparedness and Risk-Based Border Strategy • Community Preparedness and Mitigation • Travel-Related Interventions (Do Not Board/Lookout) • Goal-5 (Investigate to decrease time needed to identify causes, risks, and interventions for those affected by pandemic influenza)

  28. Epidemiology TeamElaine Cramer, Team Lead • Mission • Respond to public health events • Conduct research to inform public health practice associated with travel on international conveyances

  29. Epidemiology Team, cont. • Activities • Conduct research on quarantinable diseases and their prevention and transmission on international conveyances • Investigate and respond to communicable diseases of public health interest • Build quarantine station capacity in case response, management, and communications with conveyance operators • Collaborate with key partners for epidemiologic data collection, response, and research • Inform quarantine-related informatics development regarding epidemiologic data collection and analysis

  30. Surveillance TeamMary Agocs, Team Lead • Mission • Expand capacity to limit the importation of infectious disease by: • detecting situations of public health interest among travelers, immigrants, refugees, and imported products; • collaborating with binational public health agencies along our shared borders; and • systematically collecting and disseminating pertinent information to partners

  31. Surveillance Team, cont. • Activities • Develop a standardized, tiered structure for illness response and subsequent data collection • Develop a list of diseases of public health interest to U.S. ports and along land borders • Develop a plan to expand surveillance capacity of the U.S. Quarantine System • Ensure the proper public health processing of immigrants and refugees at U.S. ports • Ensure surveillance capacity at land borders

  32. Quarantine Training and Education Team (QTET)David Hunter, Team Lead (acting) • Mission • Train Quarantine and Border Health Services Branch staff to increase their knowledge and skills to accomplish the branch mission • Train partner agencies and organizations at U.S. ports of entry in their public health role • Enhance the capacity of branch staff to train and educate partners and the public and to communicate more effectively

  33. Quarantine Training and Education Team (QTET), cont. • Activities • Internal Training and Education • Public Communications • Partner Training, Education, and Communication (PTEC)

  34. CDC Quarantine Stations: Contact Info Online www.cdc.gov/quarantine Emergency Phone # CDC Director’s Emergency Operations Center 770-488-7100

  35. Questions?

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