Best Practices in Isolation and Quarantine

1
Best Practices in Isolation and Quarantine
Results of a National Survey of State
Epidemiologists

• Part I Legal Basis for Isolation and Quarantine

2
Have you consulted with a legal adviser to answer
the questions in Part I?
Response Frequency Response Count
Yes 73.2 30
No 26.8 11
3
Do your state isolation and quarantine laws exist
as statutes (written laws passed by legislature)
or as regulations (administrative rules with the
force of law promulgated and enforced by
government agencies)?
Response Frequency Response Count
Statutes 36.6 15
Regulations 0.0 0
Both 63.4 26
Neither- no isolation and quarantine laws exist 0.0 0
4
When were the state's isolation and quarantine
laws last revised?
Response Frequency Response Count
lt 2 years 24.4 10
2 to 5 years 41.5 17
6 to 10 years 7.3 3
gt 10 years 26.8 11
5
Where do the laws and statutes related to
isolation and quarantine reside?
Response Frequency Response Count
State Public Health Code 80.0 32
Other (please specify) 20.0 8
Other CT General Statutes, Ohio Revised Code
Chapters 3701, 3707 and 339 (TB), KSA 65-128,
65-129ato 65-129e, KAR 28-1-5 and KAR 28-1-6
state statutes and 173NAC6 Health and Safety
Code Massachusetts General Laws SDCL 34-22
ARSD 4420
6
Does the code specify a length of time that state
and local public health officials can detain an
individual or groups of persons for quarantine or
isolation? If so, please specify length of time.
Response Frequency Response Count
Yes 60.0 24
No 40.0 16
Yes depends on agent/situation not to exceed
the period of incubation and communicability as
long as needed until disease has been rendered
noncommunicable minimum necessary to accomplish
public health objective 36 hrs- if court order
is granted can detain until no longer contagious
72 hrs not more than 20 days 30 days (4) 180
days 6 months (2)
7
Does the state law provide for due process for
individuals and groups (i.e. procedural
protections requiring a judicial hearing either
before or after quarantine is imposed)?
Individual Groups Response Count
Yes 36 22 36
No 5 13 13
8
Have the state and local health departments
promulgated regulations to implement due process
when isolation and quarantine are ordered?
Response Frequency Response Count
Yes 46.3 19
No 53.7 22
9
Does the state code differentiate isolation and
quarantine procedures and response based on the
number of persons affected (e.g. individual vs.
groups of persons)?
Response Frequency Response Count
Yes 30.8 12
No 69.2 27
10
Do the legal criteria for differentiating
procedures and response based on number of
persons affected reside in statutes or
regulations?
Response Frequency Response Count
Statutes 24.4 10
Regulations 9.8 4
Not Applicable 65.9 27
11
Which of the following persons have independent
legal decision-making authority to declare an
emergency for epidemics or other communicable
disease threats and/or implement isolation and
quarantine of INDIVIDUALS or GROUPS OF PERSONS?
(Check all that apply)
Emergency Declarations Quarantine of Individuals Isolation of Individuals Quarantine of Groups Isolation of Groups Response Count
Governor 39 9 9 9 9 39
State Health Officer 6 35 35 32 33 35
Chief Medical Executive 0 3 3 3 3 3
State Epidemiologist 0 4 4 5 4 5
State Director of Emergency Preparedness 0 0 0 0 0 0
Local Health Officer 2 27 27 23 23 27
Other 3 6 5 7 5 10
Other Municipal and county governments
physician designated by State Health Officer
county or city chief executive official State
Medical Officer local health officer for groups
only with permission of State Health Officer
Dept of Health and Environment on-call
physicians and other disease control staff with
delegated authority Local Board of Supervisors
or designee Deputy Secretary of Health Planning
and Assessment
12
Has the person(s) with legal authority to order
quarantine and/or isolation provided written
formal guidance to state and local public health
officials on how to proceed with implementation
of quarantine/isolation?
Response Frequency Response Count
Yes 65.0 26
No 35.0 14
13
Who has the state public health agency identified
to serve as "legal adviser" to provide
interpretation of quarantine and isolation
authority? (Check all that apply)
Response Frequency Response Count
Attorney General 43.9 18
Health Department Chief Counsel 70.7 29
Other legal counsel (please specify) 29.3 12
Other State public health agency staff
attorneys Assistant Legal Counsel- Health
Department Assistant Attorney General County
attorneys Cabinet for Health Family Services
Legal Counsel Staff Attorney, Public Health
Preparedness and Emergency Response Local Health
Officers Counsel Bureau for Public Health Legal
Counsel Health Department Deputy Counsel
14
Has the legal adviser issued formal guidance on
how to meet individual and group due process
requirements?
Response Frequency Response Count
Yes 47.4 18
No 52.6 20
15
Does the State Health Officer have express
authority to order isolation and quarantine in
the absence of a declared emergency?
Response Frequency Response Count
Yes 90.2 37
No 9.8 4
16
In the event of a legal challenge to an isolation
or quarantine order authorized by the local
public health agency, who has authority to
override the order? (Check all that apply)
Response Frequency Response Count
Governor 20.0 8
State Health Officer 37.5 15
Chief Medical Executive 5.0 2
State Epidemiologist 7.5 3
CDC Official 0.0 0
N/A- no legal authority to override a local order 20.0 8
Other (please specify) 52.5 21
Other Judges/Courts (12) local board of
health state board of health Comments Only the
State Health Department has authority to
establish quarantine or isolation orders by
local agencies are coordinated with state health
officer locals cant order isolation or
quarantine (2) not specified in statute or rule
17
From your state's perspective, does the CDC or
other federal entity have the legal authority to
mandate individual or group isolation or
quarantine?
Response Frequency Response Count
Yes 55.0 22
No 45.0 18
18
If CDC or another federal entity mandates
individual or group isolation or quarantine in
your state, which governmental entity bears the
attendant costs? (Check all that apply)
Response Frequency Response Count
State Health Department 15.0 6
Local Health Department 7.5 3
CDC/Other federal agency 52.5 21
Not applicable- CDC/federal entity has no legal authority to mandate individual or group quarantine in my state 32.5 13
Other (please specify) 25.0 10
Comments CDC has authority at international
border, our attorney is not aware of in-state
authority (3) federal government should fund
federal order but since a formal statement has
not been made, we are assuming state funds may be
necessary determined jointly on a case-by-case
basis CDC can only order isolation and
quarantine when federal declaration of emergency
has been issued not specified by law, rule or
policy dont know
19
Does the state public health agency have
memoranda of understanding (MOU) on isolation and
quarantine with any of the following? (Check all
that apply)
Response Frequency Response Count
Local Health Department 6.3 1
Local Government 6.3 1
Tribal Health Board 0.0 0
Indian Health Center 0.0 0
CDC Quarantine Station 12.5 2
Law Enforcement 12.5 2
Emergency Medical Services 0.0 0
Other (please specify) 75.0 12
Comments All local health departments are in the
state system we have MOUs with some facilities
for use for emergency response purposes but not
specifically iso/quar not required- our statutes
grant that authority only to the state public
health agency has taken education and
informational, rather than legalistic approach,
to outreach to government and private sector
partners
20
Do isolation and quarantine laws in your state
mandate MOUs with law enforcement or Emergency
Medical Services?
Response Frequency Response Count
Yes 0.0 0
No 100.0 39
21
Does state law mandate/provide for the following
quarantine/isolation (QI) procedures? If YES,
identify whether the law exists as a STATUTE,
REGULATION, or BOTH. If NO, choose NO LEGAL
MANDATE.
Statute Regulation Both No Legal Mandate Response Count
Due process for individuals 21 4 8 5 38
Due process for groups 17 4 5 11 37
Drills/exercises for state and local public health to test QI procedures capabilities 0 0 0 39 39
Provision of incentives to private citizens to enhance QI compliance 2 0 0 35 37
Job protection for those placed in Q/I 5 0 0 34 39
Income replacement for those placed in Q/I 0 0 0 38 38
Use of "least restrictive alternative" when ordering QI 12 7 7 10 36
22
Please describe any deficiencies in the legal
authority in ordering or enforcing
isolation/quarantine as identified by the state
public health agency or state Attorney General.

• We need to better define due process for group
  quarantine or isolation. Where there is
  concurrent authority we need MOUs specifying how
  each entity will carry out its authority
• The lack of express due process rights within the
  quarantine and isolation statutes is currently
  being addresses by state legislation
• No appeal from a local QI order no
  administrative procedure
• Need "exercises
• Training local judges on isolation/quarantine
  laws to avoid delays or gaps in an emergency
• Chemical, radiologic, and nuclear events
• Although Massachusetts has adequate legal
  authority, the statutes are archaic. Pending
  legislation would update and modernize law
  regarding IQ

23
Please describe any deficiencies in the legal
authority in ordering or enforcing
isolation/quarantine as identified by the state
public health agency or state Attorney General.
(Continued)

• Not a deficiency but a comment. Our statues do
  not identify "groups" as a unit for IQ. Legal
  department interpretation is that we still need
  to serve orders that identify each person as an
  individual
• Need better statutory clarification on groups-no
  provision for income replacement
• The statute provides for the appointment of
  counsel to represent individuals who are about to
  be quarantined. The provision should be further
  clarified
• Habeas corpus statute (KSA 60-1505) currently
  requires the district court judge to appoint at
  least two competent physicians to examine persons
  under isolation or quarantine and report their
  findings to the judge. We have introduced a bill
  in the current legislative session to strike this
  language from the statute.

24
Best Practices in Isolation and Quarantine
Results of a National Survey of State
Epidemiologists

• Part II Isolation and Quarantine Policies and
  Practice

25
Please indicate the number of times in the last 5
years that your state has invoked isolation or
quarantine policies for INDIVIDUALS or GROUPS.
26
Has state-ordered isolation or quarantine been an
effective disease control tool in your state in
the last 5 years?
Response Frequency Response Count
Yes 70.0 28
No 0.0 0
Not applicable no state-ordered isolation or quarantine in the last 5 years 30.0 12
27
In practice, who is responsible for declaring an
emergency for epidemics or other communicable
disease threats and/or implementing isolation and
quarantine of INDIVIDUALS and GROUPS OF PERSONS?
(Check all that apply)
Emergency Declarations Quarantine of Individuals Isolation of Individuals Quarantine of Groups Isolation of Groups Response Count
Governor 33 3 3 3 3 33
State Health Officer 12 32 32 31 31 33
Chief Medical Executive 0 1 1 1 1 1
State Epidemiologist 2 9 9 8 8 9
Director of Public Health Preparedness 1 1 1 1 1 1
Local Health Officer 4 26 26 23 23 26
Other 5 8 8 8 8 11

• Other designees A State Medical Officer, Local
  executive officer (emergency declarations), State
  disease control program, State public health
  director, secretary of the department of health,
  Deputy/Assistant State Health Officer, Chief
  presiding officer of the local government, Local
  Boards of Supervisors, Deputy Secretary for
  Health Planning and Assessment, Mayor

28
Who is primarily responsible for advising the
state health officer on whether to implement
isolation and quarantine? (Check all that apply)
Quarantine Isolation Response Count
Chief Medical Executive 7 7 7
State Epidemiologist 39 39 39
Director of Public Health Preparedness 6 6 6
Other 7 7 7
Other General Counsel, Regional Directors,
Assistant State Epidemiologist, Disease Control
Program Staff, Local Health Officers, Director of
the Office of Public Health, Deputy Commissioner,
Division of Acute Epidemiology, Deputy Secretary
for Health Planning and Assessment
29
In your state public health agency, which
department/office has primary responsibility for
handling logistics for GROUP isolation and
quarantine?
Response Frequency Response Count
Public Health Preparedness 47.4 18
Administration 2.6 1
Communicable Diseases 31.6 12
Legal Affairs 2.6 1
Other (please specify) 15.8 6
Other Bureau of Health Emergency Preparedness,
Local responsibility, multiple agencies at state
level, shared between Public Health Preparedness
and Communicable Disease Comments No plans for
group isolation/quarantine emergency support
functions as defined in the state plan
30
Which organizational entities have responsibility
for ensuring each of the following components of
isolation and quarantine? (Check all that apply)
State Public Health Local Public Health Law Enforcement Hospitals/clinics NGOs (Red Cross, Salvation Army) Other Response Count
Monitoring compliance 27 34 8 11 1 1 38
Providing basic necessities to people 14 25 1 8 20 13 37
Medical and mental health evaluation and treatment 21 25 0 27 5 11 37
Social support services 10 22 0 4 17 18 37
Systems support (e.g. communications, personnel) 23 23 7 6 6 14 36
Funding support 24 20 0 1 6 14 34
Transport of persons 13 20 14 7 5 16 36
31
Are there provisions made in the state public
health agency's plan (including delegation of
responsibility to local public health) for each
of the following when ordering AT-HOME isolation
or quarantine?
Yes No Response Count
Basic necessities (food, water, etc.) 29 9 38
Physical infrastructure (location, heat, electricity, etc.) 25 12 37
Medical evaluation and treatment 31 7 38
Mental health evaluation and counseling 21 16 37
Social support services 27 10 37
Funding support (funding for personnel, etc.) 11 25 36
Transport (relocation to higher level of care) 25 11 36
32
Are there provisions made in the state public
health agency's plan (including delegation of
responsibility to local public health) for each
of the following when ordering INSTITUTIONAL
(hospital) isolation or quarantine?
Yes No Response Count
Medical evaluation and treatment 29 8 37
Mental health evaluation and counseling 21 15 36
Social support services 23 13 36
Funding support (i.e. all associated costs for hospitalization) 18 18 36
Transport to higher level of care 24 12 36
33
Which of the following has primary responsibility
for covering associated costs for INSURED and
UNINSURED patients in the event of state-ordered
isolation and quarantine in a healthcare
facility? (Check all that apply)
Answer Options Local health department State health department Other state agency Healthcare facility Private insurance Other Response Count
Insured 7 12 6 10 29 8 38
Uninsured 8 18 14 21 1 13 37
34
Does the state ever order isolation and
quarantine without engaging the affected local
public health agencies in the decision-making
process?
Response Frequency Response Count
Yes 7.7 3
No 79.5 31
Not Applicable 12.8 5
35
Which of the following organizations has the
state public health agency engaged to coordinate
roles and responsibilities dealing with isolation
and quarantine? (Check all that apply)
Response Frequency Response Count
Local Health Departments 87.2 34
Local Governments 53.8 21
Tribal Health Board 30.8 12
Indian Health Service 15.4 6
CDC Quarantine Station 64.1 25
Law Enforcement 79.5 31
State Department of Agriculture 53.8 21
National Guard 35.9 14
State Department of Human (Social) Services 43.6 17
State Office on Aging 25.6 10
Emergency Responders 61.5 24
Private Entities 43.6 17
None 0.0 0
Other (please specify) 41.0 16
Other State Department of Homeland Security, Red
Cross, hospitals, Attorney General, Circuit
Courts, Regional Public Health Emergency Planning
Teams, Department of Education, legal
associations, private healthcare, military,
behavioral health, Department of Corrections,
Emergency Management Comments All local health
departments are part of the state system
Isolation/quarantine have been a local
responsibility
36
When were the state's isolation and quarantine
laws/statutes last reviewed by state public
health officials?
Response Frequency Response Count
lt 2 years 61.5 24
2 to 5 years 35.9 14
6 to 10 years 2.6 1
gt 10 years 0.0 0
37
Please rate the level of importance of each of
the following concerns in impacting decisions to
ORDER and TERMINATE isolation or quarantine using
the following scale 1not important 2of little
importance 3moderately important 4important
5very important
1 2 3 4 5 Response Count
Scientific (specific disease, transmission patterns, magnitude, severity, etc.) Scientific (specific disease, transmission patterns, magnitude, severity, etc.) 0 0 1 26 12 39
Resource (available personnel, funding, logistical restrictions, etc.) Resource (available personnel, funding, logistical restrictions, etc.) 2 9 22 3 2 38
Legal (authority, etc.) Legal (authority, etc.) 1 1 5 25 7 39
Political (public pressure, legislative action, media attention, etc.) Political (public pressure, legislative action, media attention, etc.) 8 14 14 1 1 38

TERMINATE TERMINATE TERMINATE TERMINATE TERMINATE TERMINATE TERMINATE TERMINATE
1 2 3 4 5 Response Count
Scientific (specific disease, transmission patterns, magnitude, severity, etc.) Scientific (specific disease, transmission patterns, magnitude, severity, etc.) 0 0 2 25 11 38
Resource (available personnel, funding, logistical restrictions, etc.) Resource (available personnel, funding, logistical restrictions, etc.) 4 8 21 4 2 39
Legal (authority, etc.) Legal (authority, etc.) 2 1 6 24 5 38
Political (public pressure, legislative action, media attention, etc.) Political (public pressure, legislative action, media attention, etc.) 8 13 14 3 1 39
38
Which criteria determine whether
isolation/quarantine for an emergency event can
be ordered by a state agency or by a local
agency? (Check all that apply)
Response Frequency Response Count
Number of people to be isolated/quarantined (individual v. groups) 39.5 15
Geographic spread of event 65.8 25
Media, public, and/or political attention to event 15.8 6
Specific disease involved 71.1 27
Other (please specify) 39.5 15
Other Mode of transmission, legal authority,
insufficient/inappropriate action of local HDs,
threat to public health, syndrome, jurisdictional
considerations, recommendations from CDC
consultants, Comments State HD is sole
authority to order iso/quar (5) not specified by
rule, law, or policy
39
Are there different procedures for implementing
GROUP isolation/quarantine versus INDIVIDUAL
isolation/quarantine?
Response Frequency Response Count
Yes 52.9 18
No 47.1 16
40
Does your state have an isolation and quarantine
electronic tracking system that may be used
independently by local public health agencies?
Response Frequency Response Count
Yes 28.2 11
No 71.8 28
41
Does your state have a case management system for
persons in isolation or quarantine that is
integrated with other electronic systems, such as
a NEDSS-compliant surveillance system?
Response Frequency Response Count
Yes 23.1 9
No 76.9 30
42
Has the state public health agency identified
incentives to enhance compliance of private
citizens in a state-ordered isolation or
quarantine?
Response Frequency Response Count
Yes 22.5 9
No 77.5 31
If an incentive program was developed, has it
ever been employed?
Response Frequency Response Count
Yes 5.0 2
No 15.0 6
Not Applicable 80.0 32
43
How much time would be needed to obtain an
isolation or quarantine order from the state
health department following report of a
physician-diagnosed quarantinable disease?
Response Frequency Response Count
Less than 24 hours 90.0 36
24-48 hours 7.5 3
49-72 hours 0.0 0
4-7 days 0.0 0
More than 7 days 0.0 0
Don't know 2.5 1
44
If the CDC issues a federal order for INDIVIDUAL
or GROUP quarantine in your state, for which of
the following areas would the state be willing
to provide resources to implement and maintain
that order? (Check all that apply)
Individual Group Response Count
Monitoring compliance 28 24 28
Basic necessities 19 16 19
Medical and mental health evaluation and treatment 20 18 20
Social support services 18 17 18
Systems support (e.g. personnel, communications, surge capacity) 21 19 21
General Funding support 9 8 9
Transportation services 18 15 18
None of the above 5 6 6
Other 6 6 7
Comments Unable to respond depends on
situation not specified by statute, rule, or
policy CDC has no legal authority to mandate
individual or group quarantine in my state
without a federal quarantine station, unsure how
federal authority applies in right circumstances
would do all
45
Which of the following areas are too
under-resourced in the state to effectively
implement and maintain an INDIVIDUAL-level or
GROUP-level isolation or quarantine? (Check all
that apply)
Individual Group Response Count
Financial resources 14 25 26
Human resources 13 23 25
Physical infrastructure 14 25 26
None 9 5 9
Other 6 8 8
Comments Situation dependent legal
restrictions- no MOUs in place to accommodate
isolation or quarantine little large scale
capability
46
Which of the following locales is your state
considering for use in group isolation/quarantine?
(Check all that apply)
Response Frequency Response Count
Hospital 62.2 23
Armory 27.0 10
Schools 45.9 17
Other 73.0 27
Other Designated mass care shelters, motels,
hotels, casinos, correctional facilities,
churches, community centers, airport hangars,
colleges, military bases, gyms, homes, vacant
State properties, nursing homes Comments Have
not discussed have not been able to identify we
do not plan to do group isolation/quarantine
47
Has a preparedness checklist specific to
isolation and quarantine been created by your
state public health agency for use by the general
public?
Response Frequency Response Count
Yes 30.0 12
No 70.0 28
48
What percentage of the GENERAL PUBLIC in your
state do you believe is prepared for an event
requiring isolation or quarantine (i.e. plans in
place supplies readied)?
Response Frequency Response Count
0-10 64.1 25
11-25 23.1 9
26-50 12.8 5
51-75 0.0 0
76-100 0.0 0
49
On a scale of 1-10, please rate your state public
health agency's level of preparedness for the
following activities related to isolation and
quarantine. 1 not at all prepared 10 fully
prepared
1 2 3 4 5 6 7 8 9 10 Rating Avg Response Count
Initiation of order 0 0 0 0 1 0 2 11 12 14 8.88 40
Maintenance 0 1 3 3 7 6 5 9 2 1 6.19 37
Termination of order 0 0 0 0 2 2 1 9 14 12 8.68 40
Recovery 0 1 3 1 7 8 7 3 4 2 6.31 36
50
What type of exercises, if any, has the state
public health agency conducted in the last 5
years to test group isolation and quarantine
procedures and/or capabilities? (Check all that
apply)
Response Frequency Response Count
Full-scale 12.5 5
Functional 25.0 10
Tabletop 70.0 28
None 20.0 8
Other (please specify) 15.0 6
Other School closure exercises, participated in
exercises led or co-led by with other
agencies Comments No plans for group
isolation/quarantine
51
Which of the following populations has been
targeted by the state public health agency for a
public education campaign on isolation and
quarantine? (Check all that apply)
Response Frequency Response Count
General public 51.4 19
Children and families 21.6 8
Geriatric population 21.6 8
Physically impaired 13.5 5
Minority groups 21.6 8
Low income population 16.2 6
Non-English speaking 32.4 12
None 43.2 16
Other (please specify) 10.8 4
Other Generic references, health care, law
enforcement, public health
52
If your state public health agency has developed
a public education campaign, which message(s) has
served as the main content? (Check all that apply)
Response Frequency Response Count
Ready.gov Prepare. Plan. Stay Informed. 23.7 9
Pandemicflu.gov Get Informed. Be Prepared. 44.7 17
American Red Cross Get a Kit. Make a Plan. Be Informed. 18.4 7
Not Applicable 39.5 15
Other (please specify) 18.4 7
Other Get 10, Preparedness Today, internally
developed materials