Although the term quarantine is familiar to most physicians, nurses, and emergency medical services (EMS) personnel from their core training, it may mean many different things depending on where, to what level, or from which discipline or perspective someone was trained. The meanings of quarantine and isolation are quite often different between first responders and first receivers (i.e., those who work in hospitals). Within each first responder discipline (e.g., emergency medical technician [EMT] and paramedic, firefighter, and police officer), there are different roles to play and connections or responsibilities, as determined by position, training, and/or experience. Confusion often occurs between the terms isolation and quarantine; many people use the term quarantine to mean either isolation or quarantine. Both are public health measures used to control the spread of contagious disease:
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Isolation is used to separate and restrict the movement of those who are ill with a communicable disease.
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Quarantine is used to separate and restrict the movement of those who are still well but who may have been exposed to a communicable disease.
For the purpose of this chapter we will be using the term quarantine to refer to both isolation and quarantine because we will discuss quarantine in terms of both biological and nonbiological exposures.
The quarantine of any population is a troublesome matter for both the society involved and the government agencies overseeing the containment efforts. At a moment’s notice a nation must mobilize significant resources to help triage, treat, and contain any communicable and potentially epidemic diseases or exposures. Making the decision to identify and then contain individuals certainly cannot be taken lightly and will have both political and logistical repercussions. For the purposes of this chapter the idea of quarantine will include the management of those exposed to chemical, biological, radiological, and nuclear (CBRN) disasters. In particular this chapter will examine and discuss processes to help control the spread of societal hazards, giving particular attention to medical triage and containment.
In the event of a terrorist attack or growing natural epidemic, a rapid quarantine effort can certainly help to mitigate the damage. Proper deployment and specific targeting will be of critical importance to successfully reduce the overall number of casualties by preventing secondary cases. Obtaining data by examining and monitoring exposed individuals can help to predict the clinical trajectory of future cases and also help medical providers rapidly identify any new cases. This information could also be of tremendous significance should the exposure be more occult in nature to help epidemiologists determine the origins of a previously undetected initial event.
As with any government-mandated health care policy, quarantines of any variety will certainly raise questions regarding ethics. Although restrictive measures discussed in this chapter may be of significant benefit to the afflicted society as a whole, they may meet resistance and raise ethical dilemmas. This may be alleviated by attempting to induce voluntary compliance by always proposing restrictive measures that are proportional to a given threat and providing transparency at all stages of a restrictive quarantine. In the United States in particular, balancing personal liberties with societal benefit rapidly becomes an ethical dilemma without a clear resolution. The word quarantine often carries a stigma and negative connotation—to restrict movement, isolate, and maintain a safe distance from “contaminated” individuals. This becomes especially problematic when a rapid quarantine is clearly the safest option for the nation as a whole following a significant communicable exposure event.
The purpose of quarantine is clearly to prevent additional spread of contagious disease or environmental toxins within a specific population. Quarantine success demands tailoring preventative measures to specific features of a given exposure. With the overall goal of quarantine being a significant reduction in total casualties, a successful quarantine will look to accomplish the following:
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Identify what and who has been exposed
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Determine which exposed people, animals, and/or goods are likely to be contaminated or infected
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Prevent transmission by managing those who are contaminated or infected
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Prevent subsequent exposures and contaminations
Frequently employed measures to accomplish the above goals include the following:
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Identification of potentially infected or contaminated persons, animals, and goods
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Initiation of protective measures to prevent further transmission of infectious agents
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Initiation of protective measures to prevent exposed persons from becoming infected
CBRN incidents are those due to weaponized or nonweaponized CBRN materials that have the ability to cause significant harm to life, health, or the environment. Traditionally in the United States and Canada, nonweaponized materials are referred to as dangerous goods (DG) or hazardous materials (HazMat) and can also include items such as contaminated food, livestock, and crops. The term CBRN includes DG or HazMat plus the same materials weaponized into explosive threats. Typically spills or accidental releases or leakages are considered DG or HazMat, whereas intentional spills, releases, or leakages (whether explosive or not) are considered terrorist incidents. Although the approach to dealing with the consequences of both types of incidents may be similar, the terrorist incident will involve additional agencies as well as concerns for public and national security and safety.
Advances in technology and training, years of planning, and billions of dollars spent on that training and equipping response agencies has advanced domestic preparedness for an incident requiring quarantine. This level of training and preparedness has dramatically changed current strategies and tactics in the management of incidents that may require quarantine. Countless lives could thus be saved.
Historical perspective
The popular media have shaped lay public perceptions of quarantine. Dramatic portrayals of military personnel in personal protective equipment (PPE) and armored vehicles patrolling city streets create a sense of fear and anxiety. If not managed properly, this anxiety can evolve into panic and chaos.
For thousands of years humankind has recognized the need to isolate from the general population persons, animals, and goods that have been exposed to contagious elements. As early as 583 ad , authorities restricted the association of lepers and healthy people, building on the biblical sources in Leviticus. History reveals that the use of the term quarantine only recently entered the first responder lexicon despite its having been in practice back to biblical times.
In the fourteenth century, Europe endured repeated episodes of the plague, with an estimated loss of one third of the population. The plague spread rapidly throughout Europe, beginning in the south in 1347, and reaching England, Germany, and Russia within 3 years. Fear, combined with the severe impact of the plague, led to the development of intense measures to attempt to control the spread of the disease—measures we would currently call infection control. Some of the more severe measures include the abandonment of the ill in the fields outside Reggio, Italy, in 1374. By order of Viscount Bernabo, patients were left in the fields to recover or die on their own.
Similarly, in the area currently occupied by the modern city of Dubrovnik, Croatia, the chief physician of the city, Jacob of Padua, advocated the establishment of an area outside of the city walls for those needing treatment for the “black death.” This separation was motivated by an early theory of contagion; however, the efforts were only modestly effective. It was this lack of effectiveness that prompted the Great Council of the city to develop more aggressive methods to prevent the spread of future epidemics.
In 1377 the Great Council established a four-pillared approach to a trentino , or 30-day isolation period. The four pillars include the following:
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The exclusion of citizens or visitors from plague-endemic areas from the city of Ragusa until they had been in isolation for 30 days
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The restriction that no person from Ragusa could go to the isolation area without remaining there for 30 days
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That any person who was not assigned by the Great Council to care for those in quarantine was not permitted to bring food or other items to someone in isolation without having to remain there for 30 days
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That anyone who did not follow these regulations would be fined and subjected to isolation for 30 days
Similar laws were introduced in Marseilles, Venice, Pisa, and Genoa during the following 80 years, although during this time the period of isolation was extended from 30 to 40 days. This 40-day period was known as a quarantino , which was derived from the Italian quaranta or forty. Although the rationale for extending the period to 40 days is not known, it has been suggested that the shorter trentino period of 30 days was found to not be long enough to prevent the spread of the plague. Others have suggested that the change was related to the 40-day period of the Christian observance of Lent or the 40-day period associated with many other significant biblical events (the great flood, Moses’ time on Mount Sinai, or Jesus’ time in the desert). Still others have suggested that the foundation for the quarantino came from the Greek doctrine of “critical days,” which stated that contagious disease occurs within 40 days of exposure. Regardless of the rationale, the duration embodied within quarantino provides the fundamental concept for our present-day quarantine.
The identification of the pathogenic agents of epidemic diseases between the nineteenth and twentieth centuries led to a turning point in the history and development of more modern quarantine. Cholera, plague, and yellow fever began to be thought of as individual pathogenic agents to be considered separately in the development of regulations. International regulations were rewritten in 1903 by the Eleventh Sanitary Conference, at which the convention of 184 articles was signed. Modern planning, identification, and response to individual pathogenic agents of concern comes out of this historical separation. Additionally with the emergence of severe acute respiratory syndrome (SARS) in the twenty-first century, traditional measures were once again utilized because a global public health crisis arose as a result of international travel of people and goods.
Current practice
First responders now have tools to rapidly and accurately identify the nature of an incident (e.g., chemical, biological, or radiological). As a result, the strategies and tactics (policies and procedures) have dramatically evolved from those of the past. First responders can rapidly test potential exposures and determine preliminary information on the nature of the offending agent. Often these rapid tests are definitive. However, most standard operating procedures call for confirmatory testing and follow-up identification procedures in specialized laboratories in order to increase accuracy and specificity. This strategy allows first responders to rapidly determine whether the incident is of a biological, chemical, or radiological/nuclear etiology and adjust quarantine recommendations accordingly. Although the first responder community continues to educate themselves, broad knowledge of signs and symptomatology has become a baseline for education and identification, even without the use of these technologies as a backup.
Quarantine is technically for those incidents involving biological exposures. However, in modern practice, the term also applies to detention, in holding areas, following exposures and prior to decontamination for chemical and radiological or nuclear events. Modern quarantine may be initiated whenever an individual or group is known or suspected to have contracted, or been exposed to, a highly contagious or dangerous disease or a chemical contamination. Public health authorities must ensure that there are resources available to provide care for those in quarantine and to implement and maintain the quarantine. It is also imperative that authorities provide for the expeditious provision of health care for those in quarantine, including coordination with the local health care delivery system, heightened surveillance and monitoring, expedited diagnosis and treatment, and preventive treatment (vaccination, prophylactic antibiotics, and PPE).
Within any potential circumstance in which a modern quarantine might be issued, the primary goal is to reduce disease transmission by increasing the “social distance” between persons (i.e., reducing the number of people each person comes into contact with). To accomplish this there are a wide variety of strategies for disease control that may be implemented individually or in combination with one another. These strategies include shelter-in-place, short-term voluntary home curfew, restrictions on public gatherings and events (including travel and mass transit restrictions), and cordoning off an area with a sanitary barrier. Modern quarantine can be effective in some cases even when it is only partial quarantine (i.e., where many or most, but not all, exposed persons are quarantined). This partial or “leaky” quarantine, particularly when combined with a program of vaccination, has been effective in slowing the rate of the spread of disease, including SARS and smallpox.
Distance and duration of exposure are commonly found to be important predictors of transmission. Accordingly public health authorities employ modern quarantine procedures that involve limited numbers of exposed persons in small areas. These small areas or zones are designed as “rings” or concentric circles drawn around individual disease cases. Only those who fall within the ring of exposure duration or distance would be quarantined along with the individual disease case, with the most intensive disease control activities in the inner ring.
Implementation of modern quarantine also requires the trust and participation of the public. Compliance with quarantine is lowest in areas with little to no experience with quarantine in their recent past. In the United States, obstacles to compliance include difficulties with PPE and preventive measures, issues with compensation for lost income because of missed work, and lack of communication from trusted public officials. The public must be informed about the dangers of contagious diseases subject to quarantine before an outbreak or intentional release of biological agents occurs and throughout an actual event.
Authority for Quarantine
Whereas all aspects of the first responder community provide a rapid response to 911 emergencies when called upon, state and federal governments have enormous resources and jurisdictional laws, rules, and regulations that are utilized to protect and respond to incidents throughout the United States. They also respond in support of first responders, as needed. These federal, state, and local jurisdictional laws govern the specifics of incident command and control in response to a biological incident.
Federal Law
The Commerce Clause of the U.S. Constitution provides the authority for utilization of quarantine and isolation by the federal government. The U.S. Secretary of Health and Human Services is also authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states, as stated in section 361 of the Public Health Service Act (42 U.S. Code § 264). The authority to carry out these functions is delegated to the Centers for Disease Control and Prevention (CDC), including the authority to detain, medically examine, and release persons who are suspected of carrying a communicable disease and are arriving into the United States or traveling between states (42 CFR, parts 70 and 71). Twenty U.S. quarantine stations are located at ports of entry and land border crossings, enabling the CDC to routinely monitor people at these locations for signs or symptoms of communicable disease. When necessary the CDC can institute public health practices to stop or limit the spread of disease through the use of isolation and quarantine.
Although isolation and quarantine are well understood as medical functions, they are less well known as “police power” functions. These police power functions come from the right of the state to take actions affecting individuals for the benefit of society and empower the government to detain or constrain people who may be contagious with a communicable disease.
Federal isolation and quarantine are authorized by executive order of the president and currently exists for the following communicable diseases (this list may be revised by executive order of the president):
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Cholera
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Diphtheria
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Infectious tuberculosis
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Plague
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Yellow fever
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Smallpox
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Viral hemorrhagic fevers (e.g., Ebola)
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SARS
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Pandemic influenza
State, Local, and Tribal Law
Similar to the federal government, individual states have police power functions to protect the health, safety, and welfare of people within their jurisdiction and to enforce the administration of isolation and quarantine. Laws vary between states, and the authority to enforce state law can be at the state or local level, although breaking quarantine is a criminal offense in most states. In the United States, Indian tribes also have police power authority to take actions to establish and enforce their own isolation and quarantine laws within tribal lands.
Who Is in Charge?
In a quarantine situation the federal government has authority over the states and tribal lands and likewise the states have authority over local governments. In addition federal authorities may either assist state and local authorities in infection control operations or request assistance from state and local authorities in enforcing federal isolation and quarantine.
It is possible for federal, state, local, and tribal health authorities to each have legal quarantine power over the same incident at the same time. Whenever this occurs, however, federal law and authority supersede all others.
Federal Enforcement
When a communicable disease that is authorized for quarantine is suspected or identified, the CDC may issue a federal isolation or quarantine order. Enforcement of such a public health order may require assistance from police or other law enforcement. The issuing authorities may request domestic law enforcement assistance at any time in the quarantine process. U.S. Customs and Border Protection and the U.S. Coast Guard are also authorized to assist with the enforcement of federal quarantine orders. Failure to follow a federal quarantine order is punishable by fines and imprisonment, although federal law does allow for conditional release from quarantine when possible if the individuals agree to comply with medical monitoring and surveillance. Although federal authorities have the capability to declare such events, large-scale isolation and quarantine have not been initiated since the influenza (“Spanish Flu”) pandemic in 1918-1919.
State and Local Enforcement
State and local authorities respond in a similar manner to federal authorities with regard to the issuance of a quarantine order. Assistance with enforcement may be requested from local law-enforcement agencies and from the federal level, when necessary. Failure to follow quarantine orders can lead to fines and/or detention, depending on the local or state statutes.
First Responders
First responders will be early on the scene and expected to initiate a response. It is critical that as they arrive, first responders have the capability to properly assess the situation and recognize the signs and indications that a potential CBRN incident has occurred. First responders have to rely on the strength of their training to guide them in their next decisions about the incident. Standard operating guidelines and procedures will likely provide the basis for much of these decisions, including a predetermined level of response to suspected or confirmed CBRN incidents, when to initiate a public health response, how to assess the extent of damage and risk, how to determine exposure pathways and the need for mutual aid, and criteria for activating an emergency operations center (EOC) and incident command post (ICP).
Once determinations are made that there is a CBRN incident requiring the activation of an EOC/ICP and involving public health, the local resources will continue to operate using the incident command system (ICS) and remain in control of the scene for rescue and public safety. The incident commander should coordinate with local and state emergency management officials to request additional resources from state or federal assets in the event that quarantine becomes necessary. First responders may be called upon by the incident commander to assist with provision of needed services throughout the duration of the incident and/or quarantine. Scene management for the first responder requires an understanding of quarantine for potentially contaminated or infected persons, establishment of decontamination and triage areas, and isolation of contaminated areas. For each of these items, it is critical that the first responder understands the signs, symptoms, and effects of CBRN substances (weaponized or nonweaponized CBRN materials that can cause significant harm) and is familiar with HazMat management.
Under control of their respective governor, each state possesses assets that may be deployed to assist in the event of an incident. The National Guard Civil Support Teams (CSTs) are one of the most critical components for quarantine responses. A state’s Office of Emergency Services coordinates the request for and deployment of the CSTs. When an incident exceeds the states’ capabilities, they may request federal assets through their Federal Emergency Management Agency (FEMA) Regional Operations Center.
Training and Response of First Responders: Quarantine
Agencies and organizations, such as the Occupational Safety and Health Administration (OSHA), Environmental Protection Agency (EPA), National Fire Protection Agency (NFPA), and FEMA, have many different levels of training on this topic, ranging from basic awareness courses up through specialist and advanced formal courses. Current guidelines and training emphasize the need to be knowledgeable of all types of HazMat and their management. Recognition is the first line of defense in an incident. Recognition not only protects each individual and other first responders, but also enables first responders to initiate the system-wide responses necessary to manage these incidents. Most training also emphasizes the adherence to established protocols designed to detect hazardous agents on a minute level by the first arriving units. One aspect of these protocols establishes the criteria for involving the highly advanced capabilities of specialized HazMat and weapons of mass destruction (WMD) teams and state and federal resources, if necessary. Recognition that an incident is beyond the management capability of local resources and involves HazMat or WMD would be an initial reason for an incident commander to reach out through an EOC for state or federal resources. This is particularly true when combined with patients exhibiting signs and symptoms of exposure to HazMat or WMD. State resources that may be called upon include agencies such as CSTs. Federal assistance may be requested by the incident commander in coordination with an EOC at the local and state levels through the proper channels. State and federal authorities throughout a state’s Office of Emergency Management and Department of Homeland Security (DHS) monitor incidents of significance and of larger magnitudes. This includes fusion centers, which serve as focal points within the state and local environment for the receipt, analysis, gathering, and sharing of threat-related information between the federal government and state, local, tribal, territorial (SLTT), and private sector partners.
Further knowledge of protocols and procedures provides guidance on protection of the scene for the purpose of limitation and/or reduction of further injuries and illness through limiting ongoing or subsequent exposure and contamination. Finally first responders’ knowledge of their own agency-specific guidelines and those of other related agencies will assist in the speed of implementation of these protocols. It is this knowledge of protocols and procedures that provides a first responder with the ability to take the initial actions toward isolation and quarantine procedures. These actions must be guided by stated policies and procedures and supported by training guidelines and principles.
When referring to CBRN incidents, there are continual changes in the management of these incidents based on improvements in education, training, experience, and, most significant of all, technology. Best practices have also led to advances in management. However, the United States is a diverse country, and scenarios in different parts of the country have to be managed based on their locale and its related procedures. Many different factors, such as weather, population, location, infrastructure, and nature of the incident, come into play in different locations. However, the basic facts of exposure and contamination remain constant. Below is a short summary of exposures and contaminations that have relevance to quarantine and isolation.
Types of Quarantine
Following an exposure or contamination, the greatest concern for the first responder is to limit the number of people already affected or who could potentially be affected. The nature of the agents and the methods of exposure determine the risk level and the actions necessary to mitigate that risk. Quarantine and isolation are the most extreme actions for risk mitigation. Technically quarantine most closely fits biological exposures due to the method of transmission, incubation, and infection by biological agents. However, quarantine is also used when detaining exposed or contaminated personnel for decontamination following a chemical, radiological, or nuclear exposure ( Boxes 82-1 to 82-4 ).
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