Disease Surveillance U'S' Ports of Entry Francisco Averhoff, MD, MPH Centers for Disease Control and

1
Disease Surveillance U.S. Ports of
EntryFrancisco Averhoff, MD, MPHCenters for
Disease Control and PreventionDivision of Global
Migration and QuarantineQuarantine and Border
Health Services Branch
2
U.S. Quarantine History

• Yellow fever, cholera, smallpox, plague
• State and local control
• Marine Hospital Service
• State/local to federal control
• Public Health Service Act of 1944 (42 USC 201)
• PHS/Quarantine grows to 55 stations and 500
  staff
• Quarantine stations to CDC, 1967
• The war against infectious diseases has been
  won - WH Stewart, US Surgeon General, 1969

3
CDC Quarantine Stations and Jurisdictions, 1996
AK
ME
Seattle
Chicago
VT
NH
WA
MA
ND
MT
NY
MN
CT
RI
MI
WI
New York
NJ
OR
PA
SD
ID
WY
MD
DE
IA
OH
NE
IN
WV
No.CA
IL
NV
VA
San Francisco
UT
KY
CO
MO
KS
NC
TN
SC
OK
So.CA
AR
Atlanta
NM
AZ
Los Angeles
AL
GA
MS
TX
LA
FL
Miami
Honolulu
HI
PR
4
U.S. Quarantine System Expansion

• Precipitating events
• Bioterrorism
• 9/11
• SARS
• Monkeypox
• Avian influenza and risk for pandemic

5

• Institute of Medicine Report
• Quarantine Stations at Ports of Entry Protecting
  the Publics Health, 2005
• Expansion to 25 Quarantine Stations
• Response (Preparedness) at Ports of Entry
• Capacity to do conduct surveillance, epidemiology
  research

6

Mission of Quarantine Stations

• To protect the health of the public from
  communicable diseases through science,
  partnerships and response at U.S. ports

7
Number of Persons Entering the United States,
2005
Source Securing Americas Borders at Ports of
Entry Office of Field Operations Strategic Plan
FY 2007-2011 Customs and Border Protection.
Accessed at www.cbp.gov
8
Quarantine Core System and Network for U.S.
Ports of Entry
9
CDC Quarantine Stations Jurisdictions, 2007
AK
ME
Minneapolis
Seattle
Chicago
Anchorage
VT
NH
WA
Boston
MA
ND
MT
Detroit
RI
NY
MN
CT
MI
WI
New York
NJ
PA
OR
SD
ID
Newark
DE
WY
MD
Philadelphia
IA
OH
NE
IN
WV
No.CA
IL
Washington, D.C.
NV
VA
San Francisco
UT
KY
CO
MO
KS
NC
TN
Dallas
SC
OK
So.CA
AR
Atlanta
NM
AZ
Los Angeles
AL
GA
MS
San Diego
East TX
LA
West TX
El Paso
FL
Houston
Miami
Honolulu
PR
HI
GU
San Juan
CDC Station
Note Regional jurisdictions have not been
finalized
10
Federal Authority

• Reporting 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 Isolation
• Detain, medically examine, or conditionally
  release persons suspected of carrying a
  communicable disease

• Section 361, PHS Act (42 U.S. Code, Section 264)
  
• Title 42 CFR , Part 71 (Code of Federal
  Regulation)

11
Quarantinable and Other Communicable Illness of
Public Health Significance

• Quarantinable Diseases
• Smallpox, Cholera, Plague, Viral Hemorrhagic
  Fevers, Infectious Tuberculosis, Yellow Fever,
  Diphtheria, SARS, Novel Influenza Virus (pandemic
  potential)
• Public Health Significance
• Malaria, typhoid, varicella, rabies,
  meningococcal, legionellosis, dengue, measles,
  polio, zoonotic poxvirus, pertussis, mumps,
  rubella, infectious diarrhea

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.
12
Quarantine Activity Reporting System (QARS)

• Operational, June 2005
• Quarantine Stations Report
• Illness
• Deaths
• Other

13
Surveillance at Ports of Entry, Conceptual
Framework
Quarantinable Illness of public health
significance
Illness detected by surveillance
All illness at port of entry
14
Surveillance Opportunities

• Pre- arrival
• Passengers, crew, medical personnel, other
• At Time of arrival
• Emergency responders, airport partners (eg
  Customs and Border Protection), other
• Post-arrival
• Off-site providers, state and local public
  health, other

Vary by Port and Conveyance Air, Sea, Land
15
Illness and Death Reports, by Arrival Status,
2006
Provisional data only
16
Ill Travelers and Deaths Reported by Quarantine
Stations, by Week, Quarantine Reporting System
(QARS), 2006 07
Data provisional 2007 data Includes reports
received through April 30, 2007
17
Illness and Death Reports, by Source of Report,
QARS, 2006
Provisional data 2005 data includes June
December only 2007 data reported through April
30, 2007.
18
Illness and Death Reports by Port of Entry, 2005
07
Provisional data 2005 data includes June
December only 2007 data reported through April
30, 2007.
19
Provisional data 2005 data includes June
December only 2007 data reported through April
30, 2007.
20
Illness Death Reporting, QARS, by Syndrome,
2005- 2007 (n2528)
lt 100 Reports received Allergy, Injury,
Chronic Disease, Dehydration, Other/Unk
Provisional data 2005 data includes June
December only 2007 data reported through
April 30, 2007.
21
Illness Death Reporting, QARS, 2005- 2007

• Provisional data 2005 data includes
• June December only
• 2007 data reported through April 30, 2007.

22
Illness of Public Health Significance and
Quarantinable, by POE, 2005- 2007
Provisional data 2005 data includes June
December only 2007 data reported through April
30, 2007.
Includes unspecified total may exceed Air
Sea Land Includes encephalitis, fever
unspecified, ILI/Influenza, hepatitis,
Legionella, Mumps, pertussis, rubella, typhoid
23
Post-Arrival Air Investigations, Tuberculosis
and Other, 2006 2007
/----------------------2006---------------------
----------------/---------2007------------/

24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
Tuberculosis and Influenza (ILI), and Other
Disease of PH Significance, QARS, 2005- 2007
Provisional data 2005 data includes June
December only 2007 data reported through
April 30, 2007.
28
Surveillance Challenges

• Passive
• Significant amount of noise
• Non-standardized practices and reporting across
  stations partners
• Lack of (syndromic) case definitions
• Lack of diagnostics
• QARS complex
• Competing priorities at Quarantine Stations
• Value

Preliminary analysis, all data presented are
provisional!
29
Surveillance Future

• Standardize practices
• On-sight investigation
• Reporting from partners
• Reporting to QARs (surveillance data)
• Simplify reporting
• single after-hours phone number
• Electronic reporting (Cruise Industry)
• Active ILI surveillance at POEs (Preparedness)
• Research and investigations (evidence based)
• Analyze and disseminate findings
• Coordinate with CSTE

30
END
31
Dx/Dz of Importance by Conveyance, QARS, 2005-
2007

• Provisional data 2005 data includes
• June December only
• 2007 data reported through April 30, 2007.

32
(No Transcript)
33
Illness Death Reporting, QARS by Mode of
Entry, 2005- 2007

• Provisional data 2005 data includes
• June December only
• 2007 data reported through April 30, 2007.

34
Source Country of Illness Reported, QARS (Sample)
35
(No Transcript)
36
(No Transcript)
37
Intervention to improve reporting

• Rachel jervis

38
Air Travel Investigations
April 14, 2006 / 55(14)401-402
39
Challenges

• Sustainable Quarantine System
• Demonstrate value
• Preparedness focus
• Evidence-based practices
• Competing Priorities
• Response and Reporting (Surveillance)
• Standardize
• Simplify
• Analyze and Disseminate Findings
• Geographically Dispersed Staff
• Customer/Partner Satisfaction
• Industry
• Federal/State/Local
• Public

40
Future

• Protecting nations borders
• All-hazards approach
• Evidence based
• Surveillance (ILI)
• Research and investigations
• Technical support and collaboration
• Community Mitigation
• Training
• Partners
• Staff
• Epidemic Intelligence Service (EIS), Council of
  State and Territorial Epidemiologists (CSTE),
  others

41
Acknowledgements

• V Moody
• W Morril
• G Benenson
• D Meadows
• D Hunter
• M Remis
• C Dykewicz
• C Lawson
• L Brooke
• K Mitruka
• K Marieneau

• L Kirk
• S Waterman
• T Wilson
• J Polder
• D Fishbein
• J Brooks
• S Blumensaadt
• S Harris
• P Edelson

42
Illness Death Reporting, by Arrival Status,
QARS, 2005- 2007

• Provisional data 2005 data includes
• June December only
• 2007 data reported through April 30, 2007.

43
(No Transcript)
44
Illness Death Reporting, QARS, by Syndrome or
System Involved, 2005- 2007
45
Quarantine System Summary, 2007

• Preparedness at Ports of Entry Partnerships
• Training, Planning, Exercises, Other
• Surveillance
• Ports of entry (air, sea, land)
• Conveyance Epidemiology (State and Local
  Partners)
• Infectious disease investigations (mumps,
  measles, TB, etc) during air travel
• Infectious Diseases (legionella, rubella,
  measles, TB, etc) on cruise ships Norovirus
  transmission on Riverboat
• Land Borders TB, VPDs ICE Detention Facilities
• Pre-pandemic Planning Community Mitigation
  (State, Local, CDC/Federal)
• Pre-pandemic planning guidance
• EPI-AID investigations
• ILI Surveillance
• Research