Introduction to the U.S. Risk-Based Border Strategy RBBS

1. Introduction to the U.S. Risk-Based Border Strategy (RBBS) Andrew Plummer, MD, MPH David Hunter, MPH, MSW Quarantine and Border Health Services Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention

2. Presentation Outline Purpose and strategy Risk-Based Screening Procedures Primary Screening Secondary Screening Flight Group Waiting Area (Cohort) Cohort Out Processing Pre-deployment surge capacity training Just in time training

3. Undertake measures to maintain the flow of U.S. citizens, non-citizens, and cargo across the border Implement scalable, flexible border measures during a severe pandemic, including the following: Screening for illness at ports of entry Health guidance, isolation, and quarantine to limit onward transmission

4. Potential Benefit of Intervention Reduced introduction allows increased level of preparedness in U.S. (1-4 weeks) Time-Limited Effectiveness greatest early in pandemic Short duration: 1-4 weeks Only for severe pandemic: can turn on and off Scalable

5. Trigger for implementing for H1N1 Currently indications are H1N1 flu* is less severe Plans needed for less severe pandemic Trigger for Stopping When no public health benefit to screening

6. Limitations High leakage rate – screening will not detect individuals who are infected but asymptomatic Will cause delays in travel but can streamline Requires significant communications efforts with public

8. To give some context to our work, it useful to consider the number of persons entering the US; you note that daily there are over 1 million persons entering the US legally, over 400 million persons per year. These person enter through over 300 POEs We have currently 20 Q-stations and approximately 80 staff in the field. Clearly, to accomplish our mission, we need to leverage our relations with partners. Source: Securing America’s Borders at Ports of Entry; Office of Field Operations Strategic Plan, 2007-2011. U.S. Customs and Border Protection. Accessed at: www.cbp.gov To give some context to our work, it useful to consider the number of persons entering the US; you note that daily there are over 1 million persons entering the US legally, over 400 million persons per year. These person enter through over 300 POEs We have currently 20 Q-stations and approximately 80 staff in the field. Clearly, to accomplish our mission, we need to leverage our relations with partners. Source: Securing America’s Borders at Ports of Entry; Office of Field Operations Strategic Plan, 2007-2011. U.S. Customs and Border Protection. Accessed at: www.cbp.gov

9. This slide demonstrates the illness and death reporting by type of POE, air, sea or land, for 2005 through 2007. You see that the bulk of reporting is from illness arriving at air POEs, 85%, and only about a small fraction from land POEs, although over 1 million persons legally enter the US daily through land POE. Many fewer enter through our sea and air POEs This apparent inconsistency is a result of a many factors, including the fact that the majority of land border enterers enter by foot or vehicle with minimal contact with authorities and no contact with other reporting partners, such as airline crews or cruise ship physicians Further, a there is greater quarantine presence at our air POEs than land or sea ports. * Data from 2007 are provisional. This slide demonstrates the illness and death reporting by type of POE, air, sea or land, for 2005 through 2007. You see that the bulk of reporting is from illness arriving at air POEs, 85%, and only about a small fraction from land POEs, although over 1 million persons legally enter the US daily through land POE. Many fewer enter through our sea and air POEs This apparent inconsistency is a result of a many factors, including the fact that the majority of land border enterers enter by foot or vehicle with minimal contact with authorities and no contact with other reporting partners, such as airline crews or cruise ship physicians Further, a there is greater quarantine presence at our air POEs than land or sea ports. * Data from 2007 are provisional.

10. Primary Screening

11. RBBS on Aircraft En Route En route activities by flight crew

12. At the Arrival Gate If advanced notification of suspect ill traveler received

13. Efficiently process those passengers who are presumed well Identify suspect ill passengers and their contacts Quickly direct suspect ill passengers and their long term contacts to Public Health Secondary Screening (PHSS) area Objectives of Public Health Primary Screening (PHPS) Cohort = holding area for passengers awaiting final clearance for out-processing. Cohort = holding area for passengers awaiting final clearance for out-processing.

14. Conduct rapid screening (30 seconds or less to process each passenger) Provide accessible interpretation services on site Key Elements of PHPS Suspect Case of Pandemic InfluenzaSuspect Case of Pandemic Influenza

15. Guidelines for Public Health Primary Screening “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing. “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing.

17. Layout of Primary Screening Area

18. Public Health Primary Screening with passengers gathering in gateway.Public Health Primary Screening with passengers gathering in gateway.

19. Public Health Primary Screening with thermal scanner running “hot”Public Health Primary Screening with thermal scanner running “hot”

20. Public Health Primary Screening:Action Sequence Visual exam for obvious signs of illness Review Health Declaration Interview (follow up questions to traveler, if indicated) Check results of thermal scanning device, if used Decide if traveler is suspect ill or if presumed well

21. Secondary Public Health Screening

22. Medical consultation in Public Health Secondary ScreeningMedical consultation in Public Health Secondary Screening

23. Perform epidemiological and physical exam Confirm suspect ill Determine who may have been exposed Isolate ill persons, if necessary Quarantine contacts, if necessary Return other travelers to the Flight Group Waiting Area (Cohort Area) Objectives of Public Health Secondary Screening (PHSS) Cohort = holding area for passengers awaiting final clearance for out-processing. Cohort = holding area for passengers awaiting final clearance for out-processing.

24. Suspect cases transferred to healthcare facilities Manage contacts by chosen cohort method Critical enabling factor – process timeliness Key Elements of PHSS Suspect Case of Pandemic InfluenzaSuspect Case of Pandemic Influenza

25. Guidelines for Public Health Secondary Screening “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing. “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing.

26. Layout of Secondary Screening Area

27. Required Equipment for Triage Table Chairs for approximately 10 people (spacing apart as feasible) Appropriate forms Pens Computer Phone Trash can Supply of purple gloves Alcohol hand sanitizer or hand washing area

29. Private rooms or screened off areas Desks and chairs Examination lamps Sufficient extension cords Thermometers Trash cans Boxes of gloves Boxes of tongue depressors Stethoscope PPE for travelers and staff Alcohol hand sanitizer or hand washing area Required Equipment for Exam Area

30. Isolation and Quarantine Waiting Areas

31. Cohort and Out Processing

32. Guidelines for Flight Group Waiting Area “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing. “Short-term contacts” will be defined as a passenger exposed to a confirmed or suspect case of pandemic influenza who can arrive at home or another destination for quarantine within 24 hours of the initial exposure. Most international flights are less than 24 hours in duration “Long-term contacts” will be identified as travelers who do not identify themselves as ill or are not visibly ill and whose time from first exposure to an ill passenger to their final travel destination is > 24 hours. Signs and symptoms are diagnostic "tools" which help the assessor determine the condition of the passenger. “Signs” are objective evidence of disease perceptible to the examiner (measurement of body temperature) and “symptoms” are self-reported, subjective evidence of disease perceived by the passenger (sore throat, feeling feverish). In layman's terms, "signs" are those "things" that we can see, and "symptoms" are those "things" that the patient tells us. Cohort = holding area for passengers awaiting final clearance for out-processing.

33. Key Elements of Flight Group Waiting Area (Cohort Area) Most travelers will go to the Flight Group Waiting Area Provide information and answer questions Travelers contact airlines for rebooking missed connections

34. Key Elements of Cohort Out Processing Travelers released from flight group waiting area (cohort) via Out-processing Public health activities vary depending upon determination of findings from Public Health Secondary Screening

35. Layout of Cohort Out Processing

36. Cohort Out-Processing: Scenario A Collect Health Declaration Distribute fact sheet Release traveler to customs and immigration area

37. Cohort Out-Processing: Scenario B

38. Cohort Out-processing: Health Declaration Review Review health declaration for 24-hour window from boarding plane to final destination

39. Deployment for Surge Capacity Risk Based Border Strategy requires significant staff deployment to operate Primary source of staffing will be Commissioned Corps and DMAT personnel Numbers below assume 12-hour shifts, 6 days per week

40. Surge Staff Duties and Responsibilities Some of the important communication and information tasks during a public health emergency response include: Distribute health screening forms and assist passengers and crew members with completion of forms. Provide JIT training to arriving staff. Distribute T-HANs or other communication materials to passengers and crew. Provide information updates and answer questions from partners, passengers, and crew. Coordinate updates and situational reports to CDC headquarters staff on operational activities. Work as a liaison between federal, state, and local public health partners. Only staff with professional medical training or a public health background may be asked to perform the following medical tasks: Check the temperatures of arriving passengers and crew members. Conduct public health or medical assessments of passengers and crew members. Collect diagnostic specimens from passengers and crew members. Implement a rapid diagnostic test of travelers and crew members. Distribute antivirals to exposed travelers if available. Other trained staff may be asked to perform these tasks: Review medical documentation. Conduct triage. Address issues relating to ill passengers. Surge capacity staff may assist in the following epidemiologic tasks: Identify and trace contacts of ill person(s) arriving at the port of entry. Collect passenger-locating information. Conduct surveillance. Conduct visual screening and interviews of passengers and crew members. Collect, analyze, interpret, and evaluate epidemiologic data. Monitor, forecast, and manage the epidemiologic aspects of the public health emergency. Coordinate the testing of specimens from passengers and crew members. Isolate any ill travelers identified. Operate thermal scanning equipment, if necessary. Surge capacity staff may assist in administrative and clerical roles by performing the following tasks: Monitor schedule of arriving flights. Enter and process data. Review health declaration forms. Triage phone calls. Work at airport entry gates using electronic communication. Recruit supplemental surge capacity staff. Arrange for transport of ill or exposed travelers to appropriate facilities.Some of the important communication and information tasks during a public health emergency response include: Distribute health screening forms and assist passengers and crew members with completion of forms. Provide JIT training to arriving staff. Distribute T-HANs or other communication materials to passengers and crew. Provide information updates and answer questions from partners, passengers, and crew. Coordinate updates and situational reports to CDC headquarters staff on operational activities. Work as a liaison between federal, state, and local public health partners. Only staff with professional medical training or a public health background may be asked to perform the following medical tasks: Check the temperatures of arriving passengers and crew members. Conduct public health or medical assessments of passengers and crew members. Collect diagnostic specimens from passengers and crew members. Implement a rapid diagnostic test of travelers and crew members. Distribute antivirals to exposed travelers if available. Other trained staff may be asked to perform these tasks: Review medical documentation. Conduct triage. Address issues relating to ill passengers. Surge capacity staff may assist in the following epidemiologic tasks: Identify and trace contacts of ill person(s) arriving at the port of entry. Collect passenger-locating information. Conduct surveillance. Conduct visual screening and interviews of passengers and crew members. Collect, analyze, interpret, and evaluate epidemiologic data. Monitor, forecast, and manage the epidemiologic aspects of the public health emergency. Coordinate the testing of specimens from passengers and crew members. Isolate any ill travelers identified. Operate thermal scanning equipment, if necessary. Surge capacity staff may assist in administrative and clerical roles by performing the following tasks: Monitor schedule of arriving flights. Enter and process data. Review health declaration forms. Triage phone calls. Work at airport entry gates using electronic communication. Recruit supplemental surge capacity staff. Arrange for transport of ill or exposed travelers to appropriate facilities.

41. Characteristics of Surge Personnel Flexibility and Team work examples: Have a positive attitude and good interpersonal skills. Be flexible and willing to adapt to changing situations. Be team players who can work in close proximity with others and without much privacy. Work potentially long and varying shifts, which may require spending days at a time away from home and family. Provide good customer service to diverse populations despite high-stress conditions. Be willing to work with potentially ill persons and accept the risk of potential exposure to disease. Transition easily between tasks. Readiness for a variety of tasks: Work outside, in noisy environments, or in small spaces. Respond quickly and efficiently to direction in a distracting environment. Walk quickly or stand for long periods of time. Perform clerical and data entry tasks. Training and Security clearance examples: Undergo proper training and fit testing for personal protective equipment (PPE), such as an N95 respirator. Receive necessary vaccines to be up-to-date on recommended standard adult immunizations. Complete a National Agency Check with Inquiries (NACI) background check. Specialized Skills: Professional medical education or experience. Public health education or experience. Pharmaceutical licensure. Epidemiology training or experience. Ability to speak and interpret a foreign language. Training or experience in social work, mental health, or counseling. Federal employee status. Flexibility and Team work examples: Have a positive attitude and good interpersonal skills. Be flexible and willing to adapt to changing situations. Be team players who can work in close proximity with others and without much privacy. Work potentially long and varying shifts, which may require spending days at a time away from home and family. Provide good customer service to diverse populations despite high-stress conditions. Be willing to work with potentially ill persons and accept the risk of potential exposure to disease. Transition easily between tasks. Readiness for a variety of tasks: Work outside, in noisy environments, or in small spaces. Respond quickly and efficiently to direction in a distracting environment. Walk quickly or stand for long periods of time. Perform clerical and data entry tasks. Training and Security clearance examples: Undergo proper training and fit testing for personal protective equipment (PPE), such as an N95 respirator. Receive necessary vaccines to be up-to-date on recommended standard adult immunizations. Complete a National Agency Check with Inquiries (NACI) background check. Specialized Skills: Professional medical education or experience. Public health education or experience. Pharmaceutical licensure. Epidemiology training or experience. Ability to speak and interpret a foreign language. Training or experience in social work, mental health, or counseling. Federal employee status.

42. Pre-deployment Training:Ready, Set, Surge! Purpose: Provide an introduction to working at a quarantine station or port of entry during a public health emergency

43. The web-based course will be a no cost, Federal Government Section 508 compliant training application accessible via an internet portal consisting of three core modules that all learners will complete, plus additional modules tailored to each role (e.g. entry and exit screening). Continuing educational credits for some disciplines may be available (CEU, CHES, CME, CNE, CPE, AAVSB). To assess knowledge gain, learners will encounter knowledge checks embedded in each module as well as a test before and after the course. Contact information and geographic location details will be collected from each learner who successfully completes the course. This information can be used by the QS to track potential surge capacity response staff in their regions and invite them to participate in part II of the training plan, the on-site QS orientation, and may be used to reach out to trained staff during a public health emergency. Training Services Division (TSD) Office of Workforce and Career Development (OWCD) The web-based course will be a no cost, Federal Government Section 508 compliant training application accessible via an internet portal consisting of three core modules that all learners will complete, plus additional modules tailored to each role (e.g. entry and exit screening). Continuing educational credits for some disciplines may be available (CEU, CHES, CME, CNE, CPE, AAVSB). To assess knowledge gain, learners will encounter knowledge checks embedded in each module as well as a test before and after the course. Contact information and geographic location details will be collected from each learner who successfully completes the course. This information can be used by the QS to track potential surge capacity response staff in their regions and invite them to participate in part II of the training plan, the on-site QS orientation, and may be used to reach out to trained staff during a public health emergency. Training Services Division (TSD) Office of Workforce and Career Development (OWCD)

44. Ready, Set, Surge! Modules Intro to the CDC Quarantine Stations Intro to Surge Capacity at Quarantine Stations Roles of Surge Capacity Staff and Incident Command in a Quarantine Station Operation

45. Department of Health and Human Services -National Disaster Medical System (NDMS) -Regional Emergency Coordinators (REC) -HHS Regional and CDC HQ Volunteer orgs - Medical Reserve Corps -Red Cross??Department of Health and Human Services -National Disaster Medical System (NDMS) -Regional Emergency Coordinators (REC) -HHS Regional and CDC HQ Volunteer orgs - Medical Reserve Corps -Red Cross??

49. Module 1- testing online, here is a screen shot of what it looks like. Point out: Flag image in background of GUI (Graphical User Interface) Link to other information (websites, fact sheets) Status bar on bottom Links to glossary, resources, table of contents Navigation buttonsModule 1- testing online, here is a screen shot of what it looks like. Point out: Flag image in background of GUI (Graphical User Interface) Link to other information (websites, fact sheets) Status bar on bottom Links to glossary, resources, table of contents Navigation buttons

51. Acknowledgements Developers and designers Amanda McWhorter Gaby Benenson Allie Cox Karen Ngowe

52. Acknowledgements, cont.

53. Shannon Bachar Robynne Jungerman CAPT Jacque Polder LT Deborah Forcht Chris Swager CAPT Peter Houck CDR Francisco Alvarado-Ramy Nicole Cohen Bill Tynan Will Schluter LT David Hunter Lisa Hines Erika Cutts Amanda Whatley Acknowledgements, cont.

55. Questions?