Quarantine Regulations in a Disaster

2014 - 6 December - Disaster Management
Maciej Walczyszyn, MD; Bushra Mina, MD, FCCP, FACP
Two experts discuss the nuances of quarantine and isolation.

The concept of quarantine, as we know it, has been around for centuries. The word itself is derived from the Italian words “quaranta giorni,” or “40 days.” This was how long ships arriving in Venice from infected ports were required to stay anchored before docking during the Yersinia pestis pandemic of the 14th century, also  known as the Black Death.  In contemporary history, the World Health Organization (WHO) has taken it upon itself to monitor and aid in controlling the international spread of disease.  WHO defines quarantine as “the compulsory physical separation, including restriction of movement, of populations or groups of healthy people who have been exposed to a contagious disease.  This may include efforts to segregate these persons within specified geographic areas.”(1) This practice often applies to healthy individuals, unlike isolation which usually is “applied to those who have developed the disease.”(1) Although quarantine and isolation are distinctly delineated, they are often used interchangeably in practice.

The advancement of transportation systems, growing populations and the increased movement of products internationally all make communicable disease a global concern and disease management immensely difficult.  During 2002 and 2003, the severe acute respiratory syndrome (SARS) outbreak exposed these global public health uncertainties and highlighted how quickly a disease can spread. From November 2002 to July 2003, 8,098 probable SARS cases were reported to WHO from 29 countries. A total of 774 SARS-related deaths were reported.(2)

Following the aftermath of SARS, in an attempt to reconcile global public health concerns regarding future outbreaks, the World Health Assembly of WHO coordinated an intergovernmental working group to formulate and revise what is now referred to as the International Health Regulations (IHR) (2005).  The “purpose and scope of the IHR (2005) is to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”(3)

The IHR (2005) contain a range of innovations,(3) including:

a) A scope not limited to any specific disease or manner of transmission, but covering “illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans”;
b) State Party obligations to develop certain minimum core public health capacities;
c) Obligations on States Parties to notify WHO of events that may constitute a public health emergency of international concern according to defined criteria;
d) Provisions authorizing WHO to take into consideration unofficial reports of public health events and to obtain verification from States Parties concerning such events;
e) Procedures for the determination by the Director-General of a “public health emergency of international concern” and issuance of corresponding temporary recommendations, after taking into account the views of an Emergency Committee;
f) Protection of the human rights of persons and travelers; and
g) The establishment of National IHR Focal Points and WHO IHR Contact Points for urgent communications between States Parties and WHO.

Although many countries already had functional public health entities, IHR (2005) expanded the regulations’ range of application, set the standard for countries’ obligations in surveillance, response and collaboration, solidified WHO’s authority in these manners, and applied human rights principles to public health interventions.(4)

In the United States, the Centers for Disease Control and Prevention (CDC) has been assigned the accountability for public health. Much of the CDC’s function focuses on inspection and regulation of products (including livestock) imported into the country. Many quarantine and isolation regulations have been put into place to prevent introduction and spread of disease to humans and other domestic animals. For example, the CDC imposed a mandatory quarantine on all imported nonhuman primates, requiring at least three negative tuberculin skin tests administered at two-week intervals prior to releasing the animals.(5) This task becomes more difficult in humans for obvious reasons.

The CDC relies on the commanders of arriving vessels and the pilots of incoming aircraft to report suspicious activity. It has provided a definition list of signs, symptoms and conditions to aid in identifying reportable illnesses that might indicate communicable diseases. By the Executive Order of the President, federal isolation and quarantine are authorized for cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, SARS, and flu that can cause a pandemic (Table 1).(6) The list can be revised by the president at any point.(7)

Detailed protocols are in place to further investigate each incident. Twenty U.S. Quarantine Stations, located at ports of entry and land-border crossings, use public health practices such as quarantine and isolation as part of a comprehensive quarantine system that aims to limit the introduction and spread of infectious diseases. Each station is staffed with medical and public health officers who respond to reports of illnesses at border crossings and on incoming vessels and aircraft, keep track of quarantinable diseases, monitor travelers (as well as refugee migrations), inspect cargo, and in partnership with other agencies, perform disease surveillance.(7)

Isolation and quarantine regulations serve two main functions. The medical function protects the public by preventing exposure to infected or potentially infected persons. The policing function gives the government the authority to take action to maintain that public benefit.(7)

The Commerce Clause of the U.S. Constitution gives the federal government the authority for isolation and quarantine. The Public Health Service Act allows the U.S. Secretary of Health and Human Services to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states.(8) The CDC is the functional authority for this process and has the power to detain, medically examine and release persons arriving in the United States and traveling between states who are suspected of carrying a communicable disease under Title 42 of the Code of Federal Regulations (parts 70 and 71).(7)

§ 71.33 Persons: Isolation and surveillance.
a) Persons held in isolation under this subpart may be held in facilities suitable for isolation and treatment.
b) The Director [of a quarantine station] may require isolation where surveillance is authorized in this subpart whenever the Director considers the risk of transmission of infection to be exceptionally serious.
c) Every person who is placed under surveillance by authority of this subpart shall, during the period of surveillance:
1. Give information relative to his/her health and his/her intended destination and report, in person or by telephone, to the local health officer having jurisdiction over the areas to be visited, and report for medical examinations as may be required;
2. Upon arrival at any address other than that stated as the intended destination when placed under surveillance, or prior to departure from the United States, inform, in person or by telephone, the health officer serving the health jurisdiction from which he/she is departing.

CFR, Title 42, Chapter I, Subchapter F, Part 71, Subpart D, Section 71.33 (2013) (9)

With this power, the CDC can detain passengers and crew to investigate any suspicion of communicable illness on board arriving vessels and aircraft.  Although all 50 states (as well as American Indian tribes) have local laws and policing powers regarding quarantine and isolation, ultimate authoritative control and enforcement comes from the federal government via the CDC. (7)

When it comes to public health in the United States, the standard is not the usual “beyond reasonable doubt.”  A court can impose quarantine or isolation based on “reasonable suspicion” if it decides that such health powers are necessary to prevent progression of communicable disease; no jury trial is required. Furthermore, in many states, an individual’s noncompliance holds a “criminal penalty.”(10)  Historically, utilitarian principles of “social good trump the guarantees of individual rights afforded by the Constitution.”(11) However, the tension between public health and individual rights continues to occupy a prominent place in the law of quarantine. (11)

For quarantine to be effective, three conditions must be met. First, the disease must be efficiently transmissible in its incubation period or very early in its symptomatic stage. Second, it must be possible and practical to identify virtually all people incubating the infection. Third, infected individuals must comply with the quarantine.(12)  Ensuring effective quarantines when necessary to maintain public health is clearly important as evidenced by the current Ebola epidemic, which is larger than all previous outbreaks combined.

References:

1. Barbeschi M, Healing T, eds. Communicable Disease Alert and Response for Mass Gatherings: Key Considerations. World Health Organization. Geneva, Switzerland: WHO Press; 2008. Available at: <http://www.who.int/csr/Mass_gatherings2.pdf?ua=1>. Accessed September 28, 2014.
2. Centers for Disease Control and Prevention. Revised U.S. Surveillance case definition for severe acute respiratory syndrome (SARS) and update on SARS cases — United States and worldwide, December 2003. MMWR Morb Mortal Wkly Rep. 2003:52(49):1202-1206. Available at <http://www.cdc.gov/mmwr/PDF/wk/mm5249.pdf.> Accessed October 3, 2014.
3. World Health Organization. International Health Regulations (2005). Geneva, Switzerland: WHO Press; 2008. Available at: <http://www.who.int/ihr/publications/9789241596664/en/>. Accessed September 28, 2014.
4. Baker MG, Fidler DP. Global public health surveillance under new international health regulations. Emerg Infect Dis. 2006;12(7):1058-1065. Available at: <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291053/>. Accessed October 6, 2014.
5. Roberts JA, Andrews K. Nonhuman primate quarantine: its evolution and practice. ILAR J. 2008;49(2):145-156. Available at:  < http://ilarjournal.oxfordjournals.org/>. Accessed October 5, 2014.
6. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-S164. Available at: <http://www.cdc.gov/hicpac/2007ip/2007ip_appenda.html>. Accessed October 9, 2014.
7. Centers for Disease Control and Prevention. Quarantine and isolation.  Last updated July 10, 2014. Available at:  http://www.cdc.gov/quarantine/.  Accessed September 28, 2014.
8.  The Public Health and Welfare. 42 USC Chap 6A, Subchap  II, Part G – Quarantine and Inspection §264-§272. Available at: http://uscode.house.gov. Accessed November 18, 2014.
9. Code of Federal Regulations. Title 42 Public Health. Chap 1,  Subchap F, Part 71 – Foreign Quarantine. October 1, 2013.. Available at: http://ecfr.gov.  Accessed November 18, 2014.
10. Callan P. Ebola quarantine is perfectly legal.  CNN Justice, October 6,  2014. Available at: <http://www.cnn.com/2014/10/06/justice/callan-law-on-quarantine/>. Accessed November 18, 2014.
11. Contreras JL. Public health versus personal liberty – the uneasy case for individual detention, isolation and quarantine. The SciTech Lawyer.  2011;7(4). Available at: <http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1952707>. Accessed October 2, 2014.
12. Schabas R. Is the Quarantine Act relevant? CMAJ.2007;176(13):1840-1842. Available at: http://www.cmaj.ca/content/176/13/1840.long. Accessed November 18, 2014.