CSTE Surveillance Presentation Draft

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: 

Disease Surveillance U.S. Ports of Entry Francisco Averhoff, MD, MPH Centers for Disease Control and Prevention Division of Global Migration and Quarantine Quarantine and Border Health Services Branch

U.S. Quarantine History : 

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

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

U.S. Quarantine System Expansion: 

U.S. Quarantine System Expansion Precipitating events Bioterrorism 9/11 SARS Monkeypox Avian influenza and risk for pandemic

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Institute of Medicine Report Quarantine Stations at Ports of Entry: Protecting the Public’s Health, 2005 Expansion to 25 Quarantine Stations Response (Preparedness) at Ports of Entry Capacity to do conduct surveillance, epidemiology & research

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“To protect the health of the public from communicable diseases through science, partnerships and response at U.S. ports” Mission of Quarantine Stations

Number of Persons Entering the United States, 2005: 

Number of Persons Entering the United States, 2005 Source: Securing America’s Borders at Ports of Entry; Office of Field Operations Strategic Plan FY 2007-2011; Customs and Border Protection. Accessed at: www.cbp.gov

Quarantine Core System and Network for U.S. Ports of Entry: 

Quarantine Core System and Network for U.S. Ports of Entry

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VT ME MA NY PA NH WV VA MD NJ RI CT AZ IN WI KY MI OH IA MN MO IL NE KS SD ND AL TN GA SC NC AR LA MS OK Atlanta Chicago Seattle WY ID WA AK OR MT NV UT NM CO East TX Miami FL No.CA So.CA Los Angeles San Francisco CDC Quarantine Stations & Jurisdictions*, 2007 HI Honolulu Washington, D.C. El Paso Houston Newark New York Boston GU San Juan Minneapolis Detroit Anchorage San Diego West TX PR CDC Station Philadelphia Dallas DE *Note: Regional jurisdictions have not been finalized

Federal Authority*: 

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);

Quarantinable and Other Communicable Illness of Public Health Significance*: 

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.

Quarantine Activity Reporting System (QARS): 

Quarantine Activity Reporting System (QARS) Operational, June 2005 Quarantine Stations Report Illness Deaths Other

Surveillance at Ports of Entry, Conceptual Framework: 

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

Surveillance Opportunities: 

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

Illness and Death Reports*, by Arrival Status, 2006: 

Illness and Death Reports*, by Arrival Status, 2006 * Provisional data only

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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

Illness and Death Reports, by Source of Report, QARS, 2006: 

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.

Illness and Death Reports by Port of Entry, 2005 – 07*: 

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.

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* Provisional data; 2005 data includes June – December only; 2007 data reported through April 30, 2007.

Illness & Death Reporting, QARS, by Syndrome*, 2005- 2007** (n=2528): 

Illness & Death Reporting, QARS, by Syndrome*, 2005- 2007** (n=2528) * < 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.

Illness & Death Reporting, QARS, 2005- 2007*: 

Illness & Death Reporting, QARS, 2005- 2007* Provisional data; 2005 data includes June – December only; 2007 data reported through April 30, 2007.

Illness of Public Health Significance and Quarantinable, by POE, 2005- 2007*: 

Illness of Public Health Significance and Quarantinable, by POE, 2005- 2007* ** Includes unspecified; total may exceed Air + Sea + Land *** Includes: encephalitis, fever unspecified, ILI/Influenza, hepatitis, Legionella, Mumps, pertussis, rubella, typhoid * Provisional data; 2005 data includes June – December only; 2007 data reported through April 30, 2007.

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Post-Arrival Air Investigations, Tuberculosis and Other, 2006 – 2007* /----------------------2006-------------------------------------/---------2007------------/

Tuberculosis and Influenza (ILI), and Other Disease of PH Significance, QARS, 2005- 2007*: 

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.

Surveillance Challenges: 

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!

Surveillance Future: 

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

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END

Dx/Dz of Importance by Conveyance, QARS, 2005- 2007*: 

Dx/Dz of Importance by Conveyance, QARS, 2005- 2007* Provisional data; 2005 data includes June – December only; 2007 data reported through April 30, 2007.

Illness & Death Reporting, QARS by Mode of Entry, 2005- 2007*: 

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.

Source Country of Illness Reported, QARS (Sample): 

Source Country of Illness Reported, QARS (Sample)

Intervention to improve reporting: 

Intervention to improve reporting Rachel jervis

Air Travel – Investigations: 

Air Travel – Investigations April 14, 2006 / 55(14);401-402

Challenges: 

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

Future: 

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

Acknowledgements: 

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

Illness & Death Reporting, by Arrival Status, QARS, 2005- 2007*: 

Illness & Death Reporting, by Arrival Status, QARS, 2005- 2007* Provisional data; 2005 data includes June – December only; 2007 data reported through April 30, 2007.

Illness & Death Reporting, QARS, by Syndrome or System Involved, 2005- 2007*: 

Illness & Death Reporting, QARS, by Syndrome or System Involved, 2005- 2007*

Quarantine System Summary, 2007: 

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