Planning for a public health emergency
Measures to detect and track public health emergencies
Declaring a state of public health emergency
Special powers during a state of public health emergency: control of property
Special powers during a state of public health emergency: control of persons
Public information regarding a public health emergency
Mission and functions
Public health infrastructure
Collaboration and relationships with public and private sector partners
Public health authorities/powers (including quarantine and isolation)
Public health emergencies
Public health information privacy
Administrative procedures, civil and criminal enforcement, and immunities
Per MSEHPA, quarantine is defined as “the restriction of the activities of healthy persons who have been exposed to a case of communicable disease during its period of communicability to prevent disease transmission during the incubation period if infection should occur.”6 Thus, quarantine refers to the physical separation and confinement of an individual or groups of individuals who are or may have been exposed to a contagious or possibly contagious disease but who do not show signs or symptoms of infection. Given that persons can be contagious prior to exhibiting symptoms, the purpose of such separation is to prevent or limit the transmission of the disease to non-quarantined individuals. Thus, for diseases that are not contagious prior to symptom onset, quarantine would not be a scientifically supported public health strategy. Despite this, sociopolitical factors have resulted in forced quarantine in some settings, such as during the 2014 Ebola epidemic.8 Quarantine restrictions can be voluntary or involuntary, the choice of which raises different legal, social, financial, and logistical challenges.9
Isolation is defined in MSEHPA as “the separation, for the period of communicability, of known infected persons in such places and under such conditions as to prevent or limit the transmission of the infectious agent.”6 In this context, isolation refers to the physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infected with a contagious or possibly contagious disease. Its purpose is to prevent or limit the transmission of the disease to non-isolated individuals.
On the global scale, the International Health Regulations (IHR), revised in 2005 by the World Health Assembly (Table 17.2), and implemented on June 15, 2007, serve as the model for global health security. The IHR – containing sixty-six articles organized into ten parts, with nine annexes – is among the world’s most widely adopted treaties, with 194 state parties.10 The IHR reflect enhanced practices in global health, international security, epidemic alert and response, travel restrictions, and use of quarantine. WHO’s strategic plan has evolved to a proactive risk management process focusing on source containment, active surveillance, prompt detection, isolation of new cases, and rapid tracing of contacts. In addition, the plan calls for building capacity to cope with an inevitable pandemic.11 The IHR focuses on early identification and interventions based on appropriate decision making and evidence-based data,12 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.”13
The International Health Regulations (2005)
| Developed by WHO, the IHR is a legally-binding international agreement providing a framework for the coordination of the management of events that may constitute a public health emergency of international concern (PHEIC). It was designed to improve the capacity of countries to detect, assess, notify and respond to public health threats. Member states are urged to build, strengthen, and maintain the required capacities identified in the IHR, collaborate to ensure their effective implementation, and develop the necessary public health capacities and legal and administrative provisions within the regulation. IHR provisions address: |
| Definitions, purpose and scope, principles, and responsible authorities Information and public health response Recommendations Points of entry Public health measures (including quarantine) Health documents Charges General provisions IHR roster of experts, the emergency committee, and the review committee |
Quarantine in Theory and Practice
In theory, separating highly contagious individuals from susceptible persons is a sound method for limiting the spread of infection. Research suggests that quarantine can be effective given a compliant community and appropriately managed resources.14 However, in practice it is difficult to maintain complete separation of individuals or groups during the time of infectivity. While comprehensive containment strategies to limit the impacts of emerging infectious diseases should include elements of physical separation, quarantine alone will not prevent the spread of disease. Effective emergency planning within the larger context of disease outbreak requires multiple approaches. Global travel, enforcement, employment and financial considerations, and population medical needs of a physical or psychological nature can all complicate a quarantine plan. Appropriate logistical support for affected individuals and healthcare workers caring for them are critical to ensure effective quarantine.15
Historically, crude quarantine measures have been largely ineffective. At the turn of the twentieth century, for example, San Francisco’s Board of Health quarantined a predominantly Chinese neighborhood in response to nine reported cases of plague. Although all known infected persons were limited to a seven-block radius, the quarantine reached twelve blocks; implicating thousands of otherwise healthy Chinese-Americans. In a resulting case, Jew Ho v. Williamson, the court opined not only that such action was insufficient to quell disease, but also a direct violation of equal protection principles via the Fourteenth Amendment of the U.S. Constitution.16
Modern examples demonstrate how quarantine can thwart the spread of disease. Flying home from Africa in April 2012, Lisa Sievers reported to her mother about a rash similar to one she noticed on her newly adopted son from Uganda. Concerned, Ms. Sievers’s mother contacted a local hospital.17 Unable to confirm the severity of the rash, the hospital immediately contacted CDC, activating a series of measures to prevent the spread of what was thought to be monkeypox, a rare viral disease with a rash similar in appearance to the rash of smallpox. CDC ordered the plane to land in Chicago, and in collaboration with local public health authorities, temporarily quarantined passengers to determine whether the rash posed a real threat to the public’s health. Ultimately, it was determined that the rash presented no such danger. However, the expeditious resolution of the hazard demonstrates the modern capacity for government to rapidly prevent the spread of disease through quarantine.18
Improved public health responses worldwide, including better sanitation, mass immunization, and skilled epidemiological investigations, have greatly reduced the prevalence of infectious diseases, and therefore their ability to spread. While controversial, countries have employed travel restrictions as a first line of defense against the spread of disease. During the 2003 SARS global outbreak, for example, WHO administered unprecedented travel restriction advisories, halting nearly all non-essential travel in Hong Kong, Guangdong province, Beijing, Shanxi province, Tianjin, Inner Mongolia, Taiwan, and Toronto, Ontario, Canada.19 Similar efforts in select jurisdictions were also deployed by specific countries, including China, in response to the 2009/2010 H1N1 pandemic.20
With increased ability for persons to travel globally, the threat of cross-border spread of disease is high. Figure 17.2 depicts the worldwide spread of H1N1 influenza in an 8-month period from April to November 2009. Notwithstanding some nationally issued travel restrictions (noted previously) and related travel advisories from WHO, the virus reached every continent and caused hundreds of thousands of cases and many deaths. This illustration highlights the potential need for social distancing measures like quarantine to restrict travel of individuals who are exposed and isolation of those who present symptoms of infectious disease to help thwart a global outbreak.
Global Spread of H1N1, 2009.
As noted in a study by Pourbohloul and colleagues, contact network modeling suggests that simultaneous case–patient isolation and quarantine of close contacts can substantially improve disease containment.21 With the addition of ring vaccination –a strategy where individuals who may come into direct contact with an infected person or group are identified and vaccinated–22 quarantine can prevent the spread of disease. Data are conclusive as to the potential to improve public health outcomes by eliminating contacts between infected and susceptible persons. However, study authors note the need for strong surveillance, reliable rapid diagnostic tests, and social acceptance of quarantine measures; all of which may be unavailable or contested in specific countries or settings depending on available resources and commitment to compliance with IHR standards.
In limited instances where vaccines or other countermeasures are not available or capable of thwarting the spread of infectious diseases, quarantine may be needed. Actual separation of infectious persons from noninfectious individuals through social distancing measures, including isolation and quarantine, may be the only major course of public health intervention. Strategies to prevent the spread of disease inevitably include quarantine, but should also focus on augmenting surge capacity to optimize population outcomes. An outbreak is a dynamic type of public health emergency and strategies must be flexible to account for the influx of either more patients or of more resources (e.g., vaccines and other countermeasures).
Healthcare facilities have isolation procedures and methods for separating infectious patients from the general hospital (or other healthcare entity) population. In the United States, The Joint Commission, which accredits healthcare facilities, requires hospitals and other entities to specify facility responsibilities when governmental authorities establish quarantine.23 CDC’s Pandemic Influenza Plan identifies isolation of infectious patients in private rooms or cohort units as a measure of controlling disease transmission in healthcare facilities.24 Coordinating healthcare workers assigned to an outbreak unit is needed, as is consistent training in implementing quarantine measures.25 In addition, caution must be exercised to prevent cohorting that exposes persons without the disease of concern to infected patients who may be contagious.
In 2003, quarantine practices were integral to controlling the spread of SARS. Still, such practices reportedly caused transmission of SARS to healthy individuals in Canada when those without the disease were exposed and confined with infected cohorts.26 Multiple studies have reviewed containment strategies but not quantified the full impact and effectiveness of quarantine alone. Voluntary compliance with quarantine orders during SARS was greater than 90% among most populations; generalized studies indicate that 100% compliance may not be necessary.27
In 2014, while not evidence-based,52 quarantine measures were implemented with varying effectiveness to combat the spread of Ebola virus disease (EVD) in West Africa. Due to the lack of effective EVD treatments and vaccines, public health responses centered on quarantine, isolation, contact tracing, and disinfection.28 Unlike past Ebola outbreaks, researchers suggested that the use of sanitary burial practices alone was insufficient to control transmission rates, requiring the concurrent use of quarantine and other social distancing measures.29 Because EVD symptoms may appear up to 21 days after first exposure,30 quarantine measures had a finite end point. Yet, due to the high morbidity and mortality rates of EVD, some experts suggested they had to be stringently enforced to prove effective. Mandatory enforcement can lead to significant negative consequences on quarantined individuals.8
In September 2014, a Liberian, Thomas Eric Duncan, entered the United States. Despite being asymptomatic for EVD during his air travel, Duncan presented to a Dallas-area hospital with symptoms shortly after arriving in Texas.31 Duncan eventually succumbed to EVD in early October, leaving behind multiple exposed contacts subject to mandatory quarantine including family members, healthcare workers, and emergency medical providers. While none of the contacts contracted Ebola, their lives were significantly impacted by the quarantine through social stigma and public fear, the inability to return to work or school,32 and difficulty in finding suitable housing.33
Legal Issues Underlying the Use and Implementation of Quarantine
Public health powers to quarantine individuals and groups exist at all levels of governance in most countries and many provinces or states. The complexity of governance creates numerous overlaps as well as gaps in containment of disease spread. Cross-jurisdictional issues require clear guidance and defined lines of authority to enable authorities to execute appropriate powers.
The aforementioned IHR’s purpose is achieved at both the national and international level through: 1) routine public health protection – ongoing surveillance and response to disease threats within countries and at their borders; and 2) coordinated and proportionate global detection and control of transnational disease threats. The regulations strive to balance public health with trade and human rights, ensuring that all three are respected.
The IHR require administering states to develop capacities for surveillance and response, including an adequate public health law infrastructure. States have sovereignty to exercise public health powers, such as quarantine, but WHO’s director-general can issue recommendations, such as the appropriateness of containment measures, or declaration of a PHEIC. Member states are required to use a decision instrument to determine whether they have a duty to report cases or outbreaks to WHO (Figure 17.3).34
Decision Instrument for the Assessment and Notification of Events that May Constitute a Public Health Emergency of International Concern, IHR 2005.
On the national level, laws authorizing quarantine can be antiquated and fail to reflect current evidence-based disease management.35 This observation, in part, led to the development of the aforementioned MSEHPA and Turning Point Act to provide modern legislative/regulatory language for the use of quarantine. These models not only define quarantine, but also provide effective language on its proper use, consistent with a balance of individual constitutional rights and other civil liberties.36 More than forty U.S. states and the District of Columbia have adopted some portion of MSEHPA, including twenty-eight states that have updated their quarantine laws.37
Canada updated its national Quarantine Act38 following its experience with SARS. Much like other countries, its legal guidance was dated since its initial enactment in 1872. Influenced by MSEHPA and corresponding draft guidance in the IHR, Canada amended its quarantine legislation on June 22, 2007. Consequently, representatives of the Ministry of Health have broad powers to limit the spread of infectious disease, including the capacity to order treatment39 and detain non-compliant individuals.40
In the United States, protecting the public’s health via quarantine is largely the responsibility of state and local governments. However, the federal government is authorized to engage in quarantine powers.41 Federal legislation authorizes the U.S. surgeon general to direct all national quarantine stations, designate their boundaries, and appoint officers to manage them. The secretary of the Department of Health and Human Services (HHS) is authorized “to make and enforce regulations that in [his or her] judgment are necessary to prevent the introduction, transmission, or spread of communicable diseases.”42 Federal authorities govern the introduction of diseases, both foreign and interstate, pursuant to quarantine rules.43 The federal government can also assist states with execution of their quarantine laws. Although courts have upheld states’ primary responsibility for quarantine,44 the federal government can preempt state power if necessary to control disease spread across state or international borders.45
The U.S. CDC’s Division of Global Migration and Quarantine operates quarantine stations as part of the comprehensive quarantine system network. Stations are located at twenty ports of entry and land-border crossings focused on the arrival of international travelers. CDC health officers determine appropriate measures to address an ill, or potentially ill, person attempting to enter the country. CDC officials may isolate an individual showing symptoms of contagious disease. If diagnosed with a disease subject to quarantine, CDC authorities permit its officers to detain, admit to a hospital, or confine individuals until the threat of spread is contained or averted.46 Although legally clear as to CDC’s power, an Institute of Medicine (IOM) study found that “most practices of the quarantine stations and their surrogates lack a scientific basis” and were based primarily on “experience and tradition.” IOM recommended development of “scientifically sound tools to measure the effectiveness and quality of all operational aspects of the quarantine system.”47
While CDC proposed significant revisions to communicable disease control regulations in late 2005,48 including quarantine powers, at the time of this writing, these proposed rules have not been finalized.49 Specific diseases subject to quarantine must be authorized by Executive Order of the President (Table 17.3),50 thus requiring amendments to the order each time a new disease emerges (e.g., SARS in 2003).51 This is inefficient and potentially catastrophic if the legal process cannot move rapidly enough to formally add a condition to the federal list. A more effective approach would include using language such as “any contagious infectious disease that could be a threat to the public health and safety” (like that used in the IHR and MSEHPA) instead of a specific listing of known conditions.52
