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Transcript of TM A Non-Traditional Role for Dietitians: Centers for Disease Control Quarantine Stations CDR...
TM
A Non-Traditional Role for Dietitians: Centers for Disease
Control Quarantine Stations
CDR Kirsten Warwar, RD, MHA, CAAMA Officer in Charge
CDC Miami Quarantine Station
Quarantine and Border Health Services BranchDivision of Global Migration and Quarantine Centers for Disease Control and Prevention
TM
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
Overview
• History of Quarantine• U.S. Quarantine System • Mission • Federal Legal Authorities • New Regionalized Structure• Quarantine Station Activities • Team Activities
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)
Pre-1967:
• Quarantine Inspectors monitored passengers disembarking from aircraft, ships, and across land borders
History of U.S. Quarantine, cont.
• Expanded staff enabled direct inspection, observation, and response
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
History of U.S. Quarantine, cont.
VTVT
MEME
MAMANYNY
PAPA
NHNH
WVWV
VAVA
MDMD
NJNJ
RIRICTCT
AZAZ
ININ
WIWI
KYKY
MIMI
OHOHIAIA
MNMN
MOMO
ILILNENE
KSKS
SDSD
NDND
ALAL
TNTN
GAGA
SCSC
NCNC
ARAR
LALA
MSMS
OKOK
AtlantaAtlanta
ChicagoChicagoSeattleSeattle
WYWY
IDID
WAWA
AKAK
OROR
MTMT
NVNVUTUT
NMNM
COCO
MiamiMiami
FLFL
No.CANo.CA
So.CASo.CA
Los AngelesLos Angeles
San FranciscoSan Francisco
HIHI
HonoluluHonolulu
New YorkNew York
GUGU PRPR
CDC Quarantine StationCDC Quarantine Station
CTCT
DEDE
CDC Quarantine Stations 2004 Jurisdictions
TXTX
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
Wor
ld P
opul
atio
n in
bill
ions
(
)
Day
s to
Circ
umna
viga
te (
)
th
e G
lobe
Year1850
0
400
350
300
250
200
150
100
50
2000
0
1900 1950
1
2
3
4
5
6
Speed of Global Travel in Relation toWorld Population Growth
Number of Persons Entering the United States, 2005
Conveyance Daily Annual (millions)
Air 219,000 80
Sea 71,000 26
Land 874,000 319
Total 1,164,000 425
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
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
U.S. Quarantine System: A Network of Networks with a Core
Air Transport Assoc. of America
Network
System
CoreQ-StationsDGMQ HQ
CDCCBPEMS
Int. Org. for Migration
State PHAs
Hospitals
Health-care providers
Port officials
USFWS
USDA APHIS
PH labs
Air Transport Assoc. of AmericaForeign Gov'ts
Courts
Intl. Council of Cruise Lines
Canadian/ Mexican BorderAuthorities
PHAC
DHSFAA
FBI
State Dept.
WHO
News Media CSTE
NACCHO
ASTHO
BIDS
APHL
DOT
Media
Int. Civil Aviation Org.
USCG
FBI (local)
LPHAs
OverseasPanel Physicians
USCG (local)
FDA
Source: IOM Report
San DiegoSan Diego
VTVT
MEME
MAMANYNY
PAPA
NHNH
WVWV
VAVA
MDMD
NJNJ
RIRICTCT
AZAZ
ININ
WIWI
KYKY
MIMI
OHOHIAIA
MNMN
MOMO
ILILNENE
KSKS
SDSD
NDND
ALAL
TNTN
GAGA
SCSC
NCNC
ARAR
LALA
MSMS
OKOK
AtlantaAtlanta
ChicagoChicagoSeattleSeattle
WYWY
IDID
WAWA
AKAK
OROR
MTMT
NVNVUTUT
NMNM
COCO
East TXEast TX
MiamiMiami
FLFL
No.CANo.CA
So.CASo.CA
Los AngelesLos Angeles
San FranciscoSan Francisco
HIHI
HonoluluHonolulu
Washington, D.C.Washington, D.C.
El PasoEl Paso
HoustonHouston
NewarkNewark
New YorkNew York
BostonBoston
GUGU
San JuanSan Juan
MinneapolisMinneapolis
DetroitDetroit
AnchorageAnchorage
West TXWest TX
PRPR
PhiladelphiaPhiladelphia
DallasDallas
North TXNorth TX
CTCT
DEDE
CDC Quarantine Station Jurisdictions, 2009
CDC Quarantine Station
HIHI
VTVT
MEME
MAMANYNY
PAPA
NHNH
WVWV
VAVA
MDMD
NJNJ
RIRICTCT
AZAZ
ININ
WIWI
KYKY
MIMI
OHOHIAIA
MNMN
MOMO
ILILNENE
KSKS
SDSD
NDND
ALAL
TNTN
GAGA
SCSC
NCNC
ARAR
LALA
MSMS
OKOK
AtlantaAtlanta
ChicagoChicagoSeattleSeattle
WYWY
IDID
WAWA
AKAK
OROR
MTMT
NVNVUTUT
NMNM
COCO
East TXEast TX
MiamiMiami
FLFL
No.CANo.CA
So.CASo.CA
Los AngelesLos Angeles
San FranciscoSan Francisco
HonoluluHonolulu
Washington, D.C.Washington, D.C.
El PasoEl Paso
HoustonHouston
NewarkNewark
New YorkNew York
BostonBoston
San JuanSan Juan
MinneapolisMinneapolis
DetroitDetroit
AnchorageAnchorage
San DiegoSan Diego
PRPR
PhiladelphiaPhiladelphia
DallasDallas
DEDE
Region 3Region 3
Region 2Region 2
Region 1Region 1
GUGU
CDC Quarantine StationCDC Quarantine Station
West TXWest TX
North TXNorth TX
CDC Quarantine Stations 2009 Regions
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
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
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)
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
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
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
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
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. BushApril 1, 2005
Other Communicable Illness of Public Health Significance*
* 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.
• Malaria• Typhoid• Varicella• Rabies• Meningococcal• Legionellosis• Dengue• Measles
• Polio• Zoonotic poxvirus• Pertussis• Mumps• Rubella• Infectious diarrhea• Other communicable diseases
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
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
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
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)
Epidemiology TeamElaine Cramer, Team Lead
• Mission– Respond to public health
events
– Conduct research to inform public health practice associated with travel on international conveyances
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
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
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
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
Quarantine Training and Education Team (QTET), cont.
• Activities– Internal Training and Education
– Public Communications
– Partner Training, Education, and Communication (PTEC)
CDC Quarantine Stations: Contact Info
Onlinewww.cdc.gov/quarantine
Emergency Phone # CDC Director’s Emergency Operations Center
770-488-7100
TM
Questions?