Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 4. Isolation/Quarantine
Isolation and quarantine are public health measures that historically have been used to control the spread of contagious diseases. Isolation restricts the movement of persons known to have a contagious disease and is currently used by hospitals on patient floors and in emergency departments. Quarantine, used by medical providers and public health authorities, separates persons who have been exposed to but who have not actually developed a contagious disease (Canadian Society for Medical Laboratory Science, 2003). Health professionals who need to successfully implement isolation and quarantine practices must address gaps and shortfalls in current systems and embrace emerging best practices in the field as improvement models.
There are challenges to implementing isolation and quarantine at both the hospital and community levels. Isolation practices in hospital settings are contingent upon the activities of hospital infection prevention and control programs. In addition, there has been debate about the importance of inanimate environmental contamination/decontamination, prevention of airborne agent transmission, and prevention of disease when in contact with moist body substances or body fluids (Jackson and Lynch, 1985). Hospital plans are constantly challenged to find adequate operational space, staffing to support the needs of persons in isolation settings, and the environmental barriers to have the capacity to handle a surge of patients with communicable diseases who could overwhelm such a facility.
The arrival of Severe Acute Respiratory Syndrome (SARS) in 2003 in Asia and Toronto, Canada, introduced the concept of "respiratory etiquette," where health care facilities directed patients with respiratory symptoms to wear surgical masks or cover their nose and mouth with a tissue. There was also increasing attention given to hand washing, the urging of hospitals to separate patients with respiratory illnesses, and posting notices at health care facility entrances requiring persons with respiratory symptoms to inform health officials of their arrival.
The responses to these recommendations were varied, however, even after guidance documents were sent from the U.S. Centers for Disease Control and Prevention (CDC). This added another variable into the matrix of debate, discussion, and practice that exists with health care providers and facilities, and is causing gaps in disease outbreak hospital isolation plans. The absence of rapid and accurate diagnostic testing for SARS and other bioterrorism agents, which could give indication of a need to isolate or quarantine, is another challenge that health care facilities face. They must cast a broad net to include all people at risk in order to protect the public's health.
The increasing threat of rapidly emerging infectious disease and bioterrorism agents that could cause mass casualties has brought renewed attention to the practice of quarantine as a public health measure that could involve large-scale geographic or regional quarantine. Large-scale quarantine was implemented during the 2003 SARS outbreak in Beijing, China, where approximately 30,000 Beijing residents were quarantined in their homes or at sites of known SARS patients. The human resources to manage, implement, and enforce this quarantine process were monumental. To guide future quarantine policy, the Chinese Field Epidemiology Training Program of the Chinese Center for Disease Control and Prevention recommended, as a component of a comprehensive SARS-control program, that quarantine be limited to persons who had contact with an actively ill SARS patient in the home or hospital, allowing for better focus of resources (Centers for Disease Control and Prevention [CDC], July 2003).
The implementation of individual or community-level sustained quarantine in both China and Toronto during the SARS outbreaks brought forth logistical concerns such as income and job protection, disability status, family and dependent care, relief staffing at health care facilities, and the psychological effects of quarantine on patients and health care providers. Uncertainty and stigmatization were prominent, particularly when the presence of law enforcement was added to the quarantine (Maunder et al., 2003). Hospitals and health care facilities that isolated SARS patients or were used for home or work quarantine faced significant financial challenges and social stigma after the resolution of the outbreak and the remediation and decontamination of the facilities.
SARS was an emerging infectious disease, and the technology and science for decontamination was also emerging. The social understanding and acceptance of health care facilities as safe, non-infectious buildings to inhabit was in conflict. The cost of remediation and decontamination of the buildings to public and regulatory agency satisfaction was significant. In Asia and Toronto, the government was largely responsible for costs, with lesser, but still significant costs to the facilities themselves. The U.S.'s experience with the decontamination of Congressional office buildings, U.S. postal facilities, and the American Media Building in Florida after the anthrax incidents of 2001 indicated that significant financial burdens would have to be negotiated between the public and private sectors. Many U.S. hospitals, health care facilities and providers, as well as local, State, and Federal governments, do not have clearly defined mechanisms to address which parties are responsible for incurring costs as a result of a facility being isolated or quarantined during an infectious disease outbreak.
In the United States, States and local jurisdictions have primary responsibility for isolation and quarantine within their borders. The Federal government has residual authority under the Constitution's Commerce Clause to prevent the interstate spread of disease. Also, the Federal government has primary responsibility for preventing the introduction of communicable diseases from foreign countries into the United States.
Because isolation and quarantine are "police power" functions, public health officials at the Federal, State, and local levels may occasionally seek the assistance of their respective law enforcement counterparts to enforce a public health order (CDC January 20, 2004). State and local law enforcement entities will look to State and local health departments for operational guidance in terms of personal protection and the criteria for urgency of action and, in turn, State and local health departments need the proper legal backing to operationally handle a public health emergency such as SARS. However, this delegation of responsibility at the State level creates a patchwork of more than 50 potentially different quarantine laws.
Furthermore, as legal entities and judiciaries are beginning to explore the topics of isolation, quarantine, and civil liberties, the appellate process and operational definitions of the law enforcement process and Federal, State, and local statutes are not being taken into consideration. Legal entities and judiciaries have varying levels of interest and expertise on this topic, and their protocols need to be clearly defined in advance of the first case of a disease requiring isolation.
During the SARS outbreaks in Asia and Toronto, police powers were activated as part of the quarantine process. However, many of the people within these communities did not require intervention by police or law enforcement to enforce the public health quarantine order. In both localities, the "social norm" was to be compliant with the legal order to stay home, partly because of aggressive public education campaigns that emphasized the need to comply with the quarantine order, and partly because many of the affected people had occupations that permitted them to work from home or in the quarantined facility. In the United States, many of the isolation and quarantine laws that have been and are being written allow for varying levels of the appellate process. This may or may not allow for additional time to elapse before a person is forcibly quarantined, which could expose additional people to the contagious agent.
If an infectious disease situation occurs that requires the quarantine of thousands of U.S. citizens, many of the affected persons will not have occupations permitting them to work from home. Therefore, there is the potential for thousands of people to violate the quarantine to maintain continuity of life activities (i.e., earned income or food) and to exercise the appellate process. Many of the isolation and quarantine laws do not address mechanisms to resolve continuity of life activities, which poses a threat within the U.S. if a significant communicable disease outbreak requiring community-wide isolation and quarantine were to occur.
In the public health sector, successful disease containment depends on the public and private health care systems' ability to rapidly detect, recognize, and treat disease while implementing barriers to limit the spread of the disease in question. Private health care providers and hospitals depend on public health departments to provide treatment recommendations and to assist in identifying persons at risk or those actively infected with the disease. Public health departments have a history of conducting contact tracing for diseases; there are reporting mechanisms in place to identify the first case of a potential disease once a case definition is determined. However, the appropriate mechanisms and funding streams to implement staff, procedures, and detection technology for monitoring illnesses with broad communicable spread, in the short and long-term, are not yet in place.
Many challenges are involved in monitoring communicable diseases. State public health departments request and sometimes mandate that private providers and hospitals report suspected diseases. However, health care providers often do not comply. Often, there is a gap in public health departments' capacity to provide real-time or rapid feedback to health care providers due to lack of around-the-clock public health staffing and real-time notification technology. While it is the appearance of a patient at a hospital or other health care facility that begins the process of surveillance and notification, the patient is also the last "responder," since monitoring for long-term effects of a communicable disease continues long after hospital discharge. The lack of funding and technology for the surveillance of long-term health effects may create a system with gaps in disease understanding, treatment, and prevention.
A hallmark of the SARS experience in Toronto was the creation of a SARS Command Center to include a public health department representative, who was in contact with hospitals at all times. The purpose of this constant contact was to provide ongoing communication between the hospitals and local health departments. The capacity of local and State public health departments to maintain this level of epidemiological or disease investigational representation 24 hours a day during an outbreak currently is often only minimally present, even in the largest U.S. cities. In all localities there is a need to train people from within the public health system to provide advice to hospitals, help assess patients, and communicate surveillance data on isolated and quarantined patients to the local health department.
During the SARS outbreaks, thousands of people were quarantined. It was incumbent upon the public health system to conduct twice-daily telephone contact and assess people in quarantine (for 10 or more days at a time) who were at risk for developing the infectious disease. This did not account for people who required quarantine but did have telephones or other communication devices at their disposal. In Asia and Toronto, the public health systems had to monitor those who were quarantined in more regulated government facilities; yet, monitoring was still a labor-intensive enterprise, involving numerous telephone calls, continual monitoring of fever, and the like. It is likely that if a disease outbreak occurred in the U.S. requiring community-wide quarantine, there would be people who would not have telephone access. This would lead to challenges in the public health system to protect the public's health while maintaining personal liberties currently being outlined in State and local isolation and quarantine laws.
A key link to supporting isolation and quarantine at any level, but particularly if it becomes a community-wide need, is to have a well integrated electronic network where public health staff can conduct real-time contact tracing. During the Hong Kong SARS experience, the local public health department placed information on their Web site as to how they integrated their surveillance and contact tracing of isolated and quarantined patients into all aspects of emergency response. The Hong Kong SARS emergency response units included police and fire departments and emergency medical systems.
In the U.S., private and public health system surveillance and contact tracing could be improved by using several means of electronic communication (Web-based, wireless, etc.) for rapid communication. U.S. hospitals need to be able to communicate with the CDC, local and State public health departments, and other responding agencies. The implementation of video conferencing could enhance communications and sharing of important information between hospitals and public health authorities (e.g., transmitting pictures for diagnostic purposes in order to communicate with, and safely monitor, the health of larger numbers of people).
There have been discussions that during a biological incident, hospitals should be reserved for persons who have not been exposed to the virulent agent, and those who have been exposed should be assessed and treated at off-site isolation units. However, until technological advances allow for immediate triage and diagnosis of emerging infectious diseases and bioterrorism agents, people will present to hospitals and health care providers with early forms of transmissible diseases.
Authorities in Asia designated "SARS hospitals" to treat SARS patients; non-SARS infected patients were moved to unaffected facilities. This practice is advocated by some who recommend changes in the U.S. inter-hospital transfer regulations, such as the Emergency Medical Treatment and Active Labor Act (EMTALA). Proposed changes would allow larger communities with multiple hospitals or health care facilities to rapidly identify receiving hospitals and promote community self-triage to those hospitals. However, if this practice were to occur, plans would be needed to consolidate existing hospital patients who were not infected with the particular disease and to direct them to alternate locations, since hospitals are at or near full-bed capacity at all times. On a federal level, the National Disaster Medical System and its patient movement system could be activated; however, regions and jurisdictions need similar, operationally feasible, autonomous planning as well.
Currently, U.S. hospitals are generally overwhelmed with patients but understaffed with providers. Hospitals may have only vague, untested intra-jurisdictional or regional mutual aid agreements and/or alternate patient transfer plans for sending less critically ill patients to non-affected facilities after an infectious disease outbreak. In small communities with one hospital, triage and alternate care facilities (e.g., mobile hospitals) would need to be created to keep the disease out of the hospital.
It should be noted that an alternate scenario would likely appear in the U.S. since many U.S. hospitals are privately owned. If there were a designated hospital for infectious disease treatment during an outbreak in the U.S., this hospital could become bankrupt, since the community's fear of becoming infected would drive the hospital to end all surgeries and other business. The dialogue between public governments that implement a forced isolation or quarantine on a private sector entity would then have to lead to a resolution as to how to deal with economic disruption. U.S. hospitals, other health care facilities, and providers—as well as the U.S. local, State, and Federal governments—do not appear to have clearly defined mechanisms to determine which parties are responsible for incurred costs as a result of a forced isolation or quarantine due to an infectious disease outbreak.
Personal protective equipment (PPE) is available for health care staff if there is the chance that they could be exposed to an infectious disease (i.e., N-95 masks, gowns, gloves, and face and eye protection). While all U.S. healthcare facilities will have at least basic PPE for infectious control needs, the amount of supplies necessary to care for many infected patients for a sustained period of time is not usually on hand. Additionally, some of this equipment is cumbersome, unfamiliar, and untested except for use in case of a disease outbreak. For example, full protective Level C PPE was difficult and stressful for health care workers to use in past SARS outbreaks. Staffs were rotated constantly because they were unable to work 8-hour shifts. This resulted in the need for additional staff.
Health and safety surrounding the work force are important issues, particularly among the currently understaffed public and private health care workforce. It will be difficult to expect and depend upon the workforce to increase the numbers needed to treat large-scale disease outbreaks or outbreaks of unknown diseases, and to treat unknown persons, if there is a lack of institutional support for their physical and mental well-being. Attention to this topic is critical for the maintenance of the workforce, but even more so when diseases such as SARS or hospital-based gastroenteritis outbreaks adversely affect health care workers.
The proper and consistent use of PPE is critical not only to the protection of staff tending to isolated or quarantined patients, but also to prevent further spread of the disease within the facility. Poor adherence to PPE standards and poor compliance to well-known infectious disease contact or universal precautions by health care staff has been shown to prolong outbreaks of norovirus and other pathogens. Furthermore, health care workers may be reluctant to report to duty during a disease outbreak, despite being provided with PPE or even incentive pay; the ethical and legal ramifications of workers subsequently failing to care for infected patients or using financial incentives to mitigate this type of situation have not been clearly defined. Staff might be less afraid to report to work to assist in the treatment of isolated or quarantined persons if they were trained in using PPE. It is essential to educate the public health care workforce so they will feel reassured about their own health and that of their families. Health care workers tend to have the same "it can't happen to me" mentality as the general public.
Finally, appropriate mental health specialists need to be trained to respond to fear and crisis in the health care workforce, both during and after crisis situations. Fears of being socially marginalized by being placed in isolation or quarantine, loss of income, and social stigma as a result of potentially being victims of a disease outbreak, may cause many people—particularly the public health or private health care workforce—to ignore early symptoms of disease that may contribute to their failure to seek timely medical care. Too often, the mental health support for health care workers, public or private, is offered after, not during, the event. Therefore, the stressful emotional effects of isolation and quarantine on the health care workforce—whether they are caring for patients and/or colleagues in these situations or they themselves are in isolation or quarantine—are delayed and more difficult to resolve when they do surface (Arlington County, 2002).
Most State public health laws, including those recently rewritten to provide emergency powers, seem to be a patchwork and of debatable flexibility when it comes to responding to infectious diseases requiring isolation and quarantine. There are minimum standards outlined in the Model State Emergency Health Powers Act, such as the requirement of the government to provide for people in isolation and quarantine a respect for dignity, necessary facilities, and comfort. For example, a quarantine measure for the government at the local level requires people to remain at home for a certain number of days and not interact with other people. However, the fact that there are potentially 50 State public health laws, all addressing various issues, could produce a level of inconsistency that could result in illegal restrictions, improper releases, the lack of development of clear plans for protecting public health and personal liberties, and a lack of clear mechanisms for the actual enforcement of the necessary isolation or quarantine.
If the Beijing SARS experience—in which several thousand people needed to be quarantined—were to occur today in the U.S., it would be a significant challenge to supply enough lawyers, judges, and health care officials to put people in mandatory quarantine, and enough law enforcement officials to monitor homes and communities to enforce it. These segments of the workforce need to be involved in concrete operational planning for public health requests for isolation and quarantine measures. Large-scale community quarantine may involve neighborhoods and entire zip codes. It would be a challenge to erect a "traditional" barricade around all the streets and buildings in an entire neighborhood or town needing to be quarantined.
Unless the public were to heed the warning to stay home if they are infected or potentially infected, there would be an excessive number of people who would break quarantine by leaving their homes. It would be incumbent on the public health community to implement effective and dynamic risk communication plans to meet this challenge. The community would have to create a climate that supports people staying in their homes for the public's welfare. In terms of technology, monitoring bracelets could be a resource to ensure that people stay in their homes, but the community would need to be well educated by health and law enforcement personnel on the importance of quarantines.
Communities need to develop specific, operational-level quarantine plans and implement them in advance of an event to include the needs of special populations such as persons with addictions, the homeless, and those with special health needs or disabilities. In short, specific operating procedures and protocols of law enforcement and legal procedures would need to be put in place prior to an event, and they would have to be practiced. This would have to involve educating the judiciary and city attorneys and any associated regulatory bodies.
All logistical support would need to be in place so that food, medications, repair services, shelter, and maintenance of basic life services could be provided. The number of services that would need to be provided is extraordinary and must be provided for in advance of an outbreak or epidemic, not at the time an event takes place. Regional approaches to this problem should also be considered to minimize the fragmentation that is present with multiple State plans.
In the area of law enforcement of isolation and quarantine, a potentially serious problem to address would be that most law enforcement personnel may not be trained to deal with public health issues, and so would worry about contracting an infectious disease during a quarantine enforcement. To complement their work, they need to have contact training in a public health role (forensic epidemiology). Using law enforcement as the basis for a successful quarantine is rarely effective on a large scale, as seen in Canada and China. Rather, public health officials need to encourage residents to stay home voluntarily. Encouraging compliance with public education and providing support for resilient communities will be more effective than relying on potentially overtaxed law enforcement agencies. Bringing in the Federal government to enforce isolation and quarantine should only be necessary to back up military activity if riots were to take place.
A challenge in terms of legal provisions to successfully implement isolation and quarantine would be to provide for income protection. Some people believe that the Americans with Disabilities Act (ADA) would be an applicable vehicle for anyone under quarantine (personal communication with James G. Hodge, Jr., J.D., L.L.M., Deputy Director, Center for Law and the Public's Health, January 7, 2004). These opinions state that people who might be contagious or exposed can be considered to have a disability. In such situations, employers may have to meet their own needs and employ or reassign other workers; the ADA may not apply.
In the Canadian system, there are possibilities for worker compensation. However, in the U.S., the employer or government does not have to pay for lost salaries if the disability is not job related. However, in the case of a bioterrorism attack, this area could be hotly debated. This problem would require rethinking of our social welfare system because recent Federal catastrophes have demonstrated that there have been problems with providing coherent models for compensation. Current models include the Federal Emergency Management Agency (FEMA) or the September 11 Compensation Funds, but these are last resorts and may (as in the case of the September 11 Compensation Funds) require the recipient not to file any legal action against the government. However, in order to compensate victims and their families in a timely manner, there would need to be a large pool of funds available and set aside for the Nation in preparation for a declared state of emergency.
Rapid and sustained implementation of stringent infection control procedures by health care workers in hospitals have been effective in combating the spread of new, infectious diseases for which there is no vaccine; implementation of such procedures also has been effective in combating known threats and pathogens, and are relatively inexpensive and easy to implement (Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) Bioterrorism Task Force and CDC Hospital Infections Program Bioterrorism Working Group, 1999).
The establishment of "outside-the-facility" triage, medical assessment, mobile medical units, and diversion protocols are options to prevent infectious diseases from entering health care facilities (Farquharson and Baguley, 2003). After the Canadian SARS experience, Canadian authorities retrofitted two long-term care facilities with additional negative pressure rooms to be used for SARS patients. In Taiwan, authorities are building 1,000 new negative pressure rooms, routinely used for patients with tuberculosis, to prevent infectious particles from spreading. They also are converting campsites and military facilities into makeshift SARS isolation areas ("U.S. Anti-SARS Efforts Based on the Nation's Fight Against TB" 2003).
Public Health Reporting
Worldwide lessons learned about suspected disease reporting and contact tracing have helped to stem disease outbreaks and to generate preparedness efforts in the U.S. In addition, cross-training of multiple types of public health staff to assist in the management of large-scale disease tracing was used to combat recent SARS epidemics and is a model to be implemented for training people in other occupations (social workers, teachers, etc.) in advance of an event (personal communication with Daniel Lucey, M.D., Washington Hospital Center, December 23, 2003).
The CDC and national health law centers are developing educational programs for judges on public health law, which cover a varied range of public health issues. The University of Louisville School of Medicine Institute of Bioethics, Health Policy, and Law is developing a program that involves 30 national organizations reaching agreement so they can run their own health law programs to include issues related to isolation and quarantine. The States that are piloting the program include Arizona, Texas, Wisconsin, New York, Mississippi, Michigan, and Indiana (personal communication with Mark Rothstein, J.D., University of Louisville School of Medicine, Institute of Bioethics, Health Policy and Law, January 7, 2004).
Future Research Needs
- Develop real-time disease reporting technology to be used at and between health care facilities. This would allow providers to alert public health authorities of suspicious patient symptoms or actual disease detection at the time of the event. This technology must be easy to use and must have redundant communication outlets (Web, video, wireless). This will enhance communications and sharing of important diagnostic information related to persons involved in isolation and quarantine situations.
- Create and preserve additional funding streams to support an increased number of public health personnel whose role it would be to discern early warning signs of illness.
- Fund and develop technology for the short- and long-term surveillance of persons required to be isolated or quarantined. Systems need to allow public health practitioners to conduct surveillance and monitoring of persons who do not have telephone access, who have language or cultural differences, or who do not have a permanent residence (homeless).
- Develop model templates for health care facilities so they, in turn, can develop intra-jurisdictional and regional mutual aid agreements and alternate patient transfer plans. These plans would allow health care facilities needing to isolate and quarantine patients to transfer less critically ill patients to non-affected facilities. Such plans would also allow for review of existing Emergency Medical Treatment and Active Labor Act (EMTALA) regulations to permit such patient transfers.
- Develop clearly defined regulatory or legal mechanisms to address which parties are responsible for incurred costs of a private facility being isolated or quarantined by local, State, or the Federal government as part of an infectious disease or bioterror outbreak. This should also include recommendations and provisions to resolve financial issues of the private facility.
- Develop PPE and in-house facility barrier protections (room dividers, negative pressure rooms, and the like) that will protect health care personnel and other first responders working in an infectious disease situation while permitting ease of work for the entire normal work shift. Develop PPE such as masks for patients and staff when respiratory or other communicable diseases are suspected. During disease outbreaks, staff shortages are a significant concern; having a diminished staff pool using PPE that makes it difficult for them to perform their tasks is likely to cause gaps in the disease containment process.
- Develop models and practices to address the apprehension and anxiety of the health care workforce in working during an infectious disease or bioterror outbreak situation, including concerns about the use of PPE or other protective measures. These models need to include templates and models for localities, public health, and health care facilities so they will be able to respond to the fears of the health care workforce both during and after crisis situations.
- Review State laws and statutes on isolation and quarantine frequently to address and minimize, where possible, variations in the ability of local and State jurisdictions to declare and enforce isolation and quarantine.
- Develop additional models, templates, and practices from centers of public health law and other ethics institutes to educate and involve the judiciary and law enforcement personnel in concrete operational planning, standard operating procedures, and legal protocols when public health requests for isolation and quarantine measures occur.
- Develop specific, realistic, operational-level quarantine model templates and plans for community level isolation and quarantine that reflect real U.S. resident culture. These models must include the use of home and work quarantine and not assume that telecommuting or "snow days" are a viable option. These plans should be drilled and exercised in advance of an event and include the needs of special populations such as persons with language differences, addictions, special health needs or disabilities, and those who are homeless. These plans must include provisions to maintain continuity of life operations (income protections, job protections, food, shelter, and care for other family members who are not required to be placed in isolation and/or quarantine).
As outlined in the discussion of best practices and further research needs, a best practice model for isolation and quarantine would be built upon the foundation of real-time suspected and actual disease reporting and information sharing between all public health departments and hospitals. Disease reporting frequently depends on having a laboratory-confirmed diagnosis of a particular illness and then having the health care facility report that disease to local or State public health departments. In the absence of rapid confirmatory technology to detect and diagnose infectious diseases such as SARS, or bioterrorist agents such as anthrax or plague, the practice of isolating patients will have to depend on the absolute compliance and adherence to precautions on the parts of both health care providers and patients.
Syndromic surveillance models that identify certain symptom complexes and then refer trends detected at the health care provider level back to public health department show promise. However, until these systems can be adapted to gather data, disseminated to public health departments in real-time, and consistently have public health staff receive, analyze, and respond to this type of information, disease reporting systems will continue to have to depend on astute medical providers to make initial contact with public health departments. Funding for public health departments will have to include cross-training of additional staff to ensure 24 hour a day, seven days a week reporting coverage back to the health care providers.
Once a situation occurs that may require isolation of infected patients or quarantine of persons at risk for infection, facilities should have the capacity to adhere to standards such as those from the Association for Professionals in Infection Control and Epidemiology. Patients should be placed in isolation rooms, cohorted wings or wards of health care facilities, or rooms that have dedicated ventilation systems. The Canadian and Taiwanese models of creating additional surge capacity by building additional negative pressure rooms in their hospitals is a model that could be adapted in U.S. hospitals. Public sector financial supplements would be needed to accomplish this in the U.S. Current Office for Domestic Preparedness (ODP) and other public sector funding grants containing restrictions that do not readily allow for construction of isolation facilities should be revised to allow for increased physical surge capacity for health care facilities.
Models and practical steps for the operational legal aspects of public health departments to isolate and quarantine persons connected to disease situations have been collected at the CDC Public Health Law Program. State and local laws vary and therefore the procedural models to implement them could best be adapted if they followed the guidance steps outlined in the CDC's SARS Legal Planning Fact Sheets of September 2003. The actual standard operating procedures for law enforcement personnel, however, have not been as detailed and should include early notification of potential isolation and quarantine situations. Identification of command center locations and electronic monitoring (e.g., video conferencing, Web site sharing) between public health and law enforcement personnel should be outlined to ensure compliance with isolation and quarantine laws when voluntary compliance is not achieved.
A first-step model for community containment measures, including non-hospital isolation and quarantine, has been outlined in the CDC's Public Health Guidance for Community Level Preparedness and Response to Severe Acute Respiratory Syndrome, Version 2. Supplement D contains five appendices that detail suggested interventions, community containment, frequently asked questions about the use of community containment measures, guidelines for evaluating homes and facilities for isolation and quarantine, threshold determinants for the use of community containment measures, and a preparedness checklist for community containment measures. It is based on "lessons learned" from the community isolation and quarantine situations in the SARS outbreaks in Asia and Canada.
In the absence of having access to the 50 U.S. State laws, the checklist is a productive first step for the operational aspects of implementing community-wide isolation and/or quarantine for hospital and public health staff. However, the checklist does not fully address the gaps identified in this document in terms of U.S. residents' attitudes toward voluntary or mandatory quarantine, particularly if the real-life mental health, income protections, continuity of life, and PPE concerns mentioned in this document are not addressed.
Guidelines for Building the Model
The following areas specify items that should be explored when developing a best practices methodology for dealing with biological terrorism preparedness planning:
Adaptability—Is the best practice suitable for use in any region?
Real-time disease detection, reporting, and surveillance between public health personnel, health care providers, and law enforcement personnel are suitable for use in any region. This type of communication permits rapid identification of the need for isolation and quarantine, and accurate assessment of the process to be used to contain the outbreak. The Hong Kong experience of placing public health disease surveillance information on SARS cases on their Web site and integrating this information into other aspects of the responder community brought critical responders to the disease containment effort and could be replicated in the U.S. Identifying additional physical surge capacity for negative pressure rooms is possible but would require further analysis for funding streams and mechanisms to provide the least disruption of currently used facilities while this revision occurs.
It is possible to establish a common legal standard that protects the community and the health care workforce, as well as one that allows for individual due process. However, there would need to be agreement that protection of the public's health may have to temporarily supercede individual liberties; the person under isolation and quarantine would have the right to contest the order after the period of infectivity has passed.
Throughput—How many victims of a biological attack will the best practice aid?
Providing real-time disease detection and surveillance technology would diminish the transmission of infectious agents by allowing public health personnel and health care providers to quickly and realistically share critical data that would be used to implement isolation or quarantine control measures. Linking and integrating such technology with other responders, such as emergency medicine, law enforcement, and legal partners would further reduce the number of potential victims because additional responders would be able to assist in information dissemination to the public. Providing additional isolation and quarantine facilities would provide capacity to monitor and contain disease outbreak for significant numbers of the U.S. population who would not be able to remain under isolation and quarantine at home.
Cost—How much will it cost regions to implement the best practice?
Depending on the extent of the program adopted by particular regions, the cost for purchasing, maintaining, and staffing real-time disease diagnosis and surveillance technology could be significant. In addition, costs will be incurred for initial and in-service training for health care providers and public health staff using this technology. Although development of such systems is reportedly underway at the Federal level, it is important that creation of real-time reporting systems between local and State public health departments and health care providers occur in the immediate future. Funds should be allocated for this process immediately and its completion designated on a fast track so as not to jeopardize disease containment efforts.
Funds must also be utilized to continually train and hire public health disease detectives and to maintain a strong infrastructure to not only quickly identify disease outbreaks, but to mitigate spread by increasing the distance between well and ill persons identified by real-time technologies. Each jurisdiction that receives Department of Health and Human Services (DHS) or CDC funding should also be able to access and be required to demonstrate access to multiple redundant communication technologies (Web, video conferencing, wireless) for this effort as a condition of funding. There should be sufficient staff to maintain these technologies and all staff must achieve competency in its use, or detection and containment will fail.
Operational Impact—What are the operational considerations of using this best practice?
The operational impact will initially be significant for creating such real-time disease detection and reporting technology. The ability to provide funding to support staff and responders to use it, to retrofit or create surge capacity for additional isolation rooms in health care facilities, and to have operational legal provisions that clearly declare isolation orders, rights of appeal/due process, and standard operating procedures for monitoring community level quarantine will also be significant.
Specialized training is needed in order to participate and function properly in the event of a biological incident. However, by identifying systems, responders, and protocols in advance of a biological incident, training and cross-training multiple types of responders in advance of an outbreak or bioterror attack provides for less attrition of staff during an actual event. Recognition of and attention to various cultural challenges of implementing community quarantine and soliciting community involvement will promote compliance with a public health quarantine order. The government will have to demonstrate the capacity to protect the workforce with sufficient PPE and other job-related supports and protect and support the community.
Training—What level of training does this best practice require?
When real-time disease diagnosis and surveillance technology between health care facilities and public health departments is created, staff will need to be trained in use of the various redundant communication technologies involved in the process (Web, wireless, and video). Training in the importance of information sharing between legal staff, law enforcement, emergency management, public health, and hospital staff is a relatively simple process and inexpensive models for forensic epidemiology currently exist. Forensic epidemiology training programs involve awareness of common practices by each of the provider communities and allow essential team building that will be useful in responding to a potential need for isolation and quarantine. Creation of additional physical locations for isolation or quarantine should require only minimal training of staff.
Community education and training about the concepts of isolation and quarantine and how government and health care facilities can support the community during an outbreak situation or bioterror attack will be a challenge, but utilizing community input to develop risk communication messages in advance will greatly support community acceptance and maximize disease containment efforts. Training should include real-world operational aspects of "how this applies to the public" and should be practiced among all involved parties, public and private.
Resources—Does the practice build on existing practices/infrastructure? Are there available resources to implement the practices?
The practice of using real-time disease detection and reporting practices builds upon current relationships between health care facilities and public health departments. Priority funding from DHS appropriations in this area would foster and strengthen this relationship. Redundant communication devices have already been targeted by other "first responders" as a priority area for funding and training to protect public safety. The challenge is to move the end-point of development of such technology to a "fast track" status so public health personnel, hospital staff, and any other medical responders can act quickly to share information. Guidelines for community isolation and quarantine build upon recent experiences with disease outbreaks but need to be reviewed with respect to recent disasters as well.
The use of distance learning technologies, e.g. video conferencing for supporting large-scale community isolation and quarantine, builds upon distance learning technologies that have been successfully utilized in military field medicine and in disease treatment between urban and rural areas. It is known that most regions do not have an existing procedure for dealing with this issue and if one does exist, minimal equipment and personnel are available to perform necessary functions. This may result in additional challenges in assessing the community's need for isolation and quarantine. Health care facilities should aggressively pursue this type of training and should capitalize on the opportunity to participate in inter-agency training, especially with agencies that offer subject matter expertise in this area.
Morbidity and Mortality—What impact will this practice have on saving lives?
Earlier disease detection results in earlier identification of persons needing treatment and earlier recognition of those at risk for disease. Community education about culturally sensitive plans for isolation and quarantine will promote disease containment practices by both health care providers and the public. In turn, this may result in the least possible restrictive isolation and quarantine procedures and the maximum containment of disease.
Evidence-based Practice versus Theory—Is there a body of professional research supporting this practice or is it theoretical?
A great deal of research has been identified with lessons learned from recent SARS outbreaks and bioterror attacks in the areas of isolation and quarantine. Current research and guidelines use community isolation and quarantine modeling based on cultures and populations that are less likely to challenge government authority than U.S. populations and on success stories from populations that are far less diverse and have less socioeconomic, language, racial, and cultural differences than the U.S.
Regulatory Compliance—Does the practice comply with existing regulations or does it require a regulatory change?
Currently there are no regulations to mandate the use of real-time disease diagnosis and reporting technology; of having a required level of staff capacity to conduct surveillance and monitor isolated or quarantined persons; or of specific legal/law enforcement training to address common statutes in the areas of isolation and quarantine. Health officials at the State and local levels generally have the authority to order isolation or quarantine when health conditions indicate. However, addressing gaps and shortfalls identified in this document's future research section may require regulatory change in the areas of patient transfer and in funding streams such as at the Office of Domestic Preparedness (ODP), Health Resources and Services Administration grants to allow for hospital/health care facility isolation and quarantine protection.
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