Quarantine and Border Health Services Stories

100 years since the great influenza pandemic: CDC updates regulations for a modern era

Black and white image of a large parade in downtown Philadelphia, circa 1918

The word quarantine comes from the Italian words quaranta giorni, meaning 40 days. Quarantine practices began in the 14th century to protect coastal cities like Venice from plague. Ships arriving from places known to have infections were required to anchor for 40 days before landing and letting people off.

In 1798, President John Adams and Congress created the US Marine Hospital Service. This service established a network of hospitals and quarantine staff along the coast to protect our young country against the spread of disease.

This network of quarantine staff screened sailors and immigrants arriving from foreign ports for signs of disease. They isolated and treated sick people, and quarantined those who had been exposed. Eventually, this network became the US Public Health Service.

Painting of boats at sea, with caption “View of The New York Quarantine, Staten Island.”

One hundred years ago, history’s worst influenza pandemic devastated communities and left millions of survivors, friends, and family to bear the heavy burden of loss.

As World War I was coming to a close, US cities held Liberty Loan parades to help pay for the war effort, drawing thousands of spectators. With the flu pandemic at its peak, St. Louis decided to cancel its parade, while Philadelphia chose to continue. The next month, more than 10,000 people in Philadelphia died from pandemic flu, while the death toll in Saint Louis did not rise above 700. This deadly example shows the benefit of canceling mass gatherings and employing social distancing measures during pandemics.

Regulatory updates guided by advances in science, public health, and civil rights

A lot has changed since the 1917-1918 flu pandemic. Public health practices have come a long way over the past hundred years. For example, nonpharmaceutical interventions, border health and importation, vaccination, and laboratory systems have improved with each lesson learned from outbreak responses, like

DGMQ scientists, public health officers, and policy experts worked diligently for more than ten years to update quarantine regulations belonging to a previous era. “With each new outbreak response, we faced policy and legal challenges because some of our regulations had become archaic. Our old regulations didn’t include all the knowledge gained about infectious diseases, how modern-day travel spreads them faster, and what the most effective ways are to prevent them now,” said Martin Cetron, MD, director of CDC’s Division of Global Migration and Quarantine (DGMQ).

Many public health practitioners and policy experts welcomed the updates. However, tens of thousands of citizen comments showed that a significant number of people did not understand that the changes proposed were meant to codify existing public health practices and inform the public of DGMQ’s role in protecting US communities during a public health emergency.

When DGMQ staff began receiving public comments on the proposed rule update, they quickly realized that there was confusion about when, where, and how CDC uses its authority to protect public health. DGMQ Policy and Regulatory Affairs Specialist, Ashley Altenburger, JD, explained, “the confusion reflected an underlying fear that we were overstepping our boundaries, which stemmed from a lack of understanding of the authority Congress has granted to us in statute.  Our biggest challenge in addressing these concerns and crafting language for the final rule was to make explicit that CDC does, and will continue to, use the least restrictive approach possible to protect public health. Many people also didn’t realize that our federal isolation and quarantine authority is limited to only nine very serious diseases and that a change of Executive Order by the President is required to modify this list—it is not something that CDC can do on a whim.”

Perseverance pays off with an updated Final Rule 42 CFR 70 and 71

Newspaper article - “Typhoid Mary” article from the early 1900s

Quarantine and public health practices have come a long way from the 1900s “Typhoid Mary” tabloids to today.

DGMQ based regulatory updates on lessons learned from outbreak responses and input from lawmakers, migration and public health experts, biomedical ethicists, civil rights advocates, and public citizens. “Collaborating to refine and update the regulations was a Herculean task. I am proud of the perseverance demonstrated in publishing the updated Final Rule for Control of Communicable Diseases: Interstate and Foreign. It took meticulous effort and thoughtfulness to craft language to address 15,800 partner and public comments,” Cetron said. The updated final rule enhances CDC’s ability to prevent the introduction, transmission, and spread of communicable diseases (like pandemic flu) into and throughout the United States. The updates clarify how to define an ill person, report communicable diseases, trace contacts, protect civil rights, collect data, and monitor or restrict the movement of those who have or were exposed to a communicable disease.

The final rule update balances protecting public health, American communities, commerce, and an individual’s civil rights. Cetron emphasized, “Quarantine in the 14th century through the early 20th century really focused on the protection of the community at the expense of the victims of illness…victims who were seen as little more than vectors. For example, recall the way ‘Typhoid Mary’ was demonized. In the last 50 years, the civil rights movement in the United States brought to the forefront human rights and the dignity of vulnerable populations. The final rule provides an authoritative framework for controlling communicable diseases in a way that’s based on the latest science, hundreds of years of public health experience, and the ethics expected in these modern times.”

For more information about the final rule, go to the Office of the Federal Register’s websiteExternal.

Keeping the Madagascar Plague Outbreak from Spreading Through International Points of Entry

Man using a non-contact thermometer to take a motorcyclists temperature.

In August 2017, Madagascar health authorities began reporting significantly more bubonic plague cases* than in previous annual outbreaks. Bubonic plague is endemic in rural parts of the country. People can get bubonic plague when bitten by fleas carried by rodents. Often considered a dreaded disease of the past, outbreaks of bubonic plague still occur in parts of the world where rodents frequently come into close contact with people.

As autumn arrived, alarm grew as, in addition to bubonic plague, a mounting number of pneumonic plague cases were discovered in cities. Pneumonic plague is much rarer and deadlier and, unlike bubonic plague, can be spread from person to person. On October 6, CDC Travelers’ Health issued an Alert Level 2 Travel Notice for Madagascar. With the sheer numbers of travelers and merchandise crossing borders, the international community was concerned that flights and ships leaving Madagascar could carry plague to other countries.

*The increase in cases may have been due in part to a sensitive case definition and retaining “non-cases” that were still classified as suspected cases.

The bubonic plague pandemic widely known as the “Black Death” or the Great Plague, originated in China in 1334 and spread along the great trade routes to Constantinople and then to Europe, where it claimed the lives of an estimated 60% of the European population.

DGMQ provides expertise in port-of-entry surveillance, preparedness, and travel medicine

Two men from the back representing the World Health Organization. The two men in the foreground are carrying travel bags, wearing blue WHO vests, and walking across the tarmac towards a prop plane. There are four other people and mountains with a hazy skyline in the distance.

Fellow World Health Organization exit screening team members preparing to board flight from Ivato International Airport in Madagascar.

The public health risks associated with pneumonic plague led the World Health Organization (WHO) to request CDC’s technical assistance. With substantial expertise in how travel can spread infectious diseases to other countries, DGMQ staff quickly deployed to join plague experts from the Division of Vector-Borne Disease Branch to evaluate the situation on the ground in Madagascar. DGMQ’s expertise in exit and entry screening, cross-sector collaboration at ports of entry for public health response, and global partner engagement strategies is rooted in years of infectious disease prevention, travel medicine, and border health protection practice as well as lessons learned from responding to the recent Ebola and Zika epidemics.

Shortly after being called upon, DGMQ staff teamed up with WHO and Madagascar health officials to evaluate exit screening activities at the island nation’s seven ports of entry (including airports and seaports). As a follow-up to the evaluation, DGMQ staff provided onsite training and technical assistance at the Ivato International Airport. Non-contact thermometer and personal protective equipment recommendations were shared with airport authorities and screeners. The DGMQ team also advised on how to monitor the outbreak’s evolution and adjust exit screening measures according to the number of cases reported in the community.

Program impact

DGMQ staff offered expert evaluation and guidance that carefully balanced different stakeholder needs while protecting people from getting or spreading plague as they traveled to and from Madagascar. On November 25, 2017, WHO announcedExternal that the Madagascar Ministry of Health declared that the outbreak of acute pneumonic plague had been contained.

Teamwork Conquers Ebola Stigma

For Derek Sakris, assistant officer-in-charge of CDC’s Chicago Quarantine Station, it was all in a day’s work.

Group of people sitting at a table

CARE Ambassadors, left, greet travelers from West Africa who have been cleared by Customs and Border Protection staff in the entry screening area of the airport.

Sakris and David Johnson crossed paths in late 2014. Sakris was working at the quarantine station at Chicago’s O’Hare International Airport, participating in a regular morning call to discuss airport entry screening for Ebola with colleagues at CDC. An officer from Customs and Border Protection (CBP) from next door told Sakris that a traveler who had been screened the previous day was back and needed assistance. The traveler was Johnson.

CDC works closely with key partners like CBP at US ports of entry (primarily international airports) to recognize signs of infectious disease in travelers. The partners notify CDC’s quarantine stations to respond to important public health events. Since October 2014, CDC has been working with the Department of Homeland Security to conduct enhanced entry screening at five US airports, including O’Hare, as part of a layered approach to prevent the spread of Ebola to the United States.

Johnson didn’t have an infectious disease, but was suffering from the stigma of one just the same. He had just returned to the United States after a year in West Africa where he was searching for family members who were separated during the civil war and living in refugee camps. A native of Liberia, Johnson had immigrated to the United States and become a citizen before he set out to find his siblings.

The journey back to West Africa was marked by fear and uncertainty. However, Johnson’s hopes were realized when he located his brothers and sisters in Sierra Leone. He headed back to the United States to work on immigration papers that would allow them to come live with him in Chicago.

Unfortunately for Johnson, the largest Ebola epidemic in history had occurred during his trip. His return to America would be complicated by stigma. Johnson returned virtually penniless, only to find that the landlord had moved his belongings out of the apartment he was renting; the landlord didn’t think Johnson was coming back from West Africa. Friends refused to house him because they feared he might have Ebola, he hadn’t eaten for two days. With nowhere else to turn, Johnson spent the night at the airport.

The next morning, when Sakris heard about the stranded traveler’s plight, he quickly mobilized resources. He contacted CDC partner agencies to secure basic life necessities for Johnson. CBP officers had personally bought him food to ease his immediate hunger. Then the Chicago Department of Public Health and American Red Cross provided lodging and meal vouchers for Johnson during his 21-day active monitoring period.

Active monitoring means that public health workers check a person’s health every day for 21 days from the time of his or her exposure. In this case, it would be 21 days from the time Johnson left Liberia.

Ebola Care Kit

CARE Kits contain information and tools for checking for and reporting Ebola symptoms.

CDC developed the CARE (Check and Report Ebola) Program in late 2014 to support travelers undergoing active monitoring for Ebola in the United States. After returning from West Africa and going through entry screening at O’Hare, Johnson received a CDC CARE Kit with information on how to monitor his health and report Ebola symptoms for 21 days, a pictorial description of symptoms, a thermometer with instructions for how to use it, a symptom log, and a wallet-sized card that reminds travelers to monitor their health and provides information about who to call if they have symptoms.

He also was given a CARE cell phone with three weeks of unlimited talk and text service to make sure he could stay in touch with the local health department every day during that time.

Meanwhile, to provide for his long-term needs, CBP enlisted Travelers Aid Chicago. The social service program helps travelers in crisis, offering social and emotional support. A case manager helped Johnson find a job and long-term housing.

“In public health work, it is rare that you get to observe someone getting immediate help like this. You don’t always witness the impact of your help, but this was one of those nice occurrences,” Sakris reflected recently at the CDC Quarantine Station.

He credits great communication and coordination between CDC, CBP, the Chicago Department of Public Health, Travelers Aid, Red Cross, and the State of Illinois for helping Johnson get back on his feet. Ironically, Johnson secured a job at the airport, driving a loading truck.

“This success story is a reminder of the importance of maintaining partnerships,” said Sakris. “Each agency brings special resources to the table in times of crisis.”

On a personal note, Sakris was glad to be able to help someone down on his luck. After all, he went into public health to make a difference in people’s lives. Seeing the power of teamwork to support travelers like David Johnson, he knows that he has.

Measles Travels from Malaysia to 10 States

Time is of the essence when measles is concerned. Responding to a measles outbreak can involve working 24/7. Measles is a highly contagious disease and can cause severe illness, even death.

Keysha Ross and Kimberly Crocker, public health officers at the Los Angeles Quarantine Station, review flight information.

Keysha Ross and Kimberly Crocker, public health officers at the Los Angeles Quarantine Station, review flight information. Credit: CDC Foundation / David Snyder

What started as a routine call to the Los Angeles Quarantine Station (LAQS) involving one teenage refugee with measles quickly unfolded into an event where exposed passengers and refugees traveled to many states. Refugee travel from Malaysia to the United States was suspended for several weeks.

Located at 20 U.S. airports, seaports, and land border crossings, the U.S. Centers for Disease Control and Prevention (CDC) Quarantine Stations serve on CDC’s frontlines to protect the public’s health at U.S. ports of entry. These stations connect locally with state and local health departments and globally with the ministries of health in various countries.

Staff at the quarantine stations work with partners to protect the health of communities from contagious diseases that are just a flight, cruise, or border crossing away. One of their many duties includes conducting investigations when an ill person onboard an airplane or ship may have infected others who need to be notified about their exposure.

One call takes on a life of its own, as a measles outbreak ripples out across the country.

“You never know when you get these calls. It’s amazing how within 24 hours a call can take on a life of its own,” said Kimberly Crocker, Officer in Charge of LAQS. “With the speed of travel and breadth of disease spread, one infected person can very quickly become 35. Picture a ripple effect.”

Seating diagram for notifying passengers exposed to measles, rubella, or tuberculosis.  The red seat indicates the index case.

Seating diagram for notifying passengers exposed to measles, rubella, or tuberculosis. The red seat indicates the index case.

How it all began

The initial call on August 26, 2011, came from a California Department of Public Health officer who said that a refugee had been hospitalized with measles the day before. The teenager had just traveled from Malaysia on August 24. The health officer called the quarantine station because other passengers on the plane may have been exposed (contacts), and they needed to be notified. Juliana Berliet, quarantine public health officer, hung up the phone and initiated a flight contact investigation. She became the lead, coordinating the station staff and partners in this event.

Berliet called the airline to confirm where the ill teenager (index case) sat and requested the flight manifest, which provides passenger information. Thirty-five people who sat on the same row and two rows in front and back of the ill teenager were considered contacts. In addition, thirty refugees, who traveled from Malaysia as part of the same group as the teenager, were considered “travel companions” and therefore also exposed. The 35 passengers traveled on to 10 states, and the refugees traveled to 8.

Multistate investigation started

The CDC investigation crossed three time zones and involved several states: California, Washington, Texas, Oklahoma, Wisconsin, Iowa, Illinois, Indiana, Virginia, North Carolina, Maryland, New York, and New Hampshire. LAQS worked with 27 staff members at 3 CDC Quarantine Stations, Quarantine and Border Health Services Branch headquarters, the CDC Immigrant and Refugee Migrant Health Branch, CDC measles experts in Atlanta, and 12 state and county health departments. Notices went out to state health departments through Epi-X, a secure system CDC uses to notify states of people who have been exposed to diseases.

These agencies worked together to prevent further spread of measles in U.S. communities. All the contacts had to be evaluated quickly to make sure they were protected against measles and didn’t expose their families or members of their communities.

“It’s the crux of our program—unvaccinated travelers can spread disease,” said Crocker. “We worked closely with our partners throughout this event to ensure this didn’t happen.”

Other partners in this response included the airlines on which the ill teenager traveled, the Los Angeles County health department’s immunization program, and the International Organization for Migration (IOM), which coordinates the relocation of refugees. IOM was surprised that the ill teenager was not noticed before travel—it is rare for an ill refugee to be missed.

Recommendations provided

Map of the United States that shows states receiving notifications.  Three different shades highlight specific states.  The first is shade shows ill refugee arrive - this is California.  The next shade shows exposed to refugees traveled.  These states are Oregon, Oklahoma, Texas, Wisconsin, North Carolina, Maryland, and New Hampshire.  The last shade shows states with exposed passangers traveled.  These states are California, Oklahoma, Texas, Iowa, Wisconsin, Illinois, Indiana, North Carolina, Maryland, and New York.

Six people in four states who were exposed to the ill teenager subsequently developed measles: three unvaccinated refugee children, two unvaccinated children who were passengers on the flight, and one unvaccinated Customs and Border Protection (CBP) officer, who processed the flight. In addition, on September 7, 2011, the Wisconsin Department of Health notified the Chicago Quarantine Station of a measles case in an unvaccinated 23-month-old refugee from Malaysia who also traveled on August 24, but on a different flight.

To prevent further importation and transmission of measles from arriving Malaysian refugees, Martin S. Cetron, MD, Director of CDC’s Division of Global Migration and Quarantine, issued a letter of recommendations to IOM and the Bureau of Population, Migration, and Refugees at the Department of State. He recommended temporarily stopping the refugee movement from Malaysia while U.S.-bound refugees were vaccinated for measles. The recommendation also included screening refugees for symptoms of measles before travel.

Training delivered

Because an unvaccinated CBP officer who processed the flight got sick with measles and was hospitalized, the LAQS staff trained CBP officers in recognizing the signs and symptoms of measles, as well as the importance and methods of minimizing exposure and spread. LAQS staff also provided a job aid on what to do if a CBP officer may have been exposed.

“You spend all this time developing relationships with partners, and at the end it really worked well,” said Crocker. “My own staff were incredibly responsive and flexible; they provided excellent coordination and worked late hours for conference calls and training. We all wanted to be here to answer questions asked by our partners.”

“Now, on to the next thing,” Crocker said with a smile.

How CDC’s Quarantine Stations Welcome New Arrivals to the United States and Protect the Health of U.S. Communities

With 1 billion people crossing international borders each year, there is nowhere in the world from which we are remote and no one from whom we are disconnected. That is why the U.S. Centers for Disease Control and Prevention’s (CDC) Quarantine Stations, often called Q-stations, are so important. U.S. Quarantine Stations are part of a broad system that serves to limit the introduction and spread of infectious diseases into the United States.

Arnold Vang standing next to two flags.

Arnold Vang at the Minneapolis Q-Station

U.S. Quarantine Stations are located at airports and land-border crossings where 85% of international travelers arrive. They are staffed with quarantine medical and public health officers from CDC. These health officers decide whether ill persons can enter the United States and what measures should be taken to prevent the spread of infectious diseases. Quarantine officers are responsible for many activities, including responding to reports of illnesses, examining cargo, inspecting animals and animal products, and monitoring the health and collecting medical information of new immigrants, refugees, asylees, and parolees. To find out more about CDC’s quarantine stations, please visit www.cdc.gov/quarantine.

Through their understanding of the sensitive circumstances faced by immigrants and refugees, and the challenges encountered these individuals before arriving in the United States, Q-station officers are uniquely equipped to handle many of the obstacles immigrants and refugees face.

An Officer and a Refugee

Arnold Vang is one of the CDC’s quarantine officers at the Minneapolis-St. Paul Quarantine Station, and he knows firsthand what it is like to be a refugee. Arnold, along with some of his family, came to the United States in 1976 from Laos.

“It was dangerous for us to stay in Laos because my father had worked with the United States. When the country fell to the communists, we knew we had to leave.”

With just the clothes on their backs, Arnold and his family left in the middle of the night, got into a small boat, and crossed into Thailand. They took refuge at a Buddhist temple, where they were picked up by the United States military personnel and moved to a military base. A year later, Arnold and his family moved to a camp with 100,000 refugees. They were given pots and pans, but had no water or wood. Food was scarce and crime was rampant.

Eventually, Arnold and his family were chosen to come to the United States. They arrived not knowing how to use the stove or the thermostat, and they woke up to a new world on the morning of their arrival when they saw their first snow.

“My experience as a refugee made me want to work in public health, especially with refugees. A lot of refugees are silent out of fear and are afraid to talk about health issues,” Arnold says. “It’s important to inquire but also to be respectful.”

Arnold feels very fortunate to have been chosen to come to the United States. He was the first person in his family to go to high school and college. Every day at work, Arnold expresses his gratitude, “If I can make the transition easier, then I’ve done something to help a refugee.” Having people in place at Q-stations who understand and respect the many emotions, challenges, and transitions experienced by refugees and immigrants helps facilitate the work that CDC must do to welcome these new arrivals and protect the health of U.S. communities.

Working with Immigrants and Refugees

Each year, close to 75,000 refugees and 500,000 immigrants come to the United States from around the world. When immigrants and refugees arrive in the United States, they are sometimes met by CDC’s quarantine officers, or their medical documents are referred to a quarantine officer by U.S. Customs and Border Protection Officers when public health follow-up is required. This is particularly important for newly arriving refugees and immigrants, who often experience a higher burden of disease than U.S.-born populations. For example, tuberculosis (TB) rates in foreign-born persons remain higher than those in the U.S.-born population. From 1990 through 2010, the percentage of TB cases occurring in foreign-born persons increased from 26% to 60%.

A quarantine officer processing paperwork.

Perry Camagong, Quarantine Officer at the Los Angeles Quarantine Station, processing immigrant paperwork

In addition to their activities at Q-stations, officers also serve a vital role in promoting the health of refugees and immigrants, while protecting the health of U.S. communities. Q-station officers notify state and local health departments in the areas where refugees and immigrants resettle about any health issues that need follow-up care. One example is the Chicago Quarantine Station’s referral program for arriving immigrants with TB conditions. Q-station officers counsel refugees and immigrants with infectious TB and other communicable diseases on the importance of follow-up medical treatment and provide them with referrals and linkages to state and local health departments. An evaluation of this program demonstrated a 400% increase for refugees and immigrants starting medical follow-up and improved timeliness in getting to a state or local health department. As a result, a standard referral program is being developed for all entry points into the United States.

CDC’s quarantine officers take their role very seriously and want to make sure all migrants have a positive experience. For someone new to this country, it can often be frightening. Because of the experiences they had prior to arriving in the United States, they may fear government officials and people in uniforms. Some immigrants and refugees may never have flown on an airplane before, and the clothing, language, and food may all be new and different. John Bateman, quarantine officer at the Newark Quarantine Station says, “in addition to protecting our public health, I think it is my duty to make the process as comfortable and stress free as possible.”

Quarantine officers also work closely with volunteer organizations, along with airport, federal, and local partners. Volunteer organizations often ensure that refugees get the help they need, including jobs and education. Local health departments ensure immigrants and refugees have necessary follow-up health care. To find out more about immigrant and refugee health, please visit www.cdc.gov/immigrantrefugeehealth.

As U.S. demographics change and new public health needs emerge, the CDC’s quarantine officers are determined to welcome new arrivals, while also protecting the public’s health.

From One Baby with Measles to Exposing 270 International Students

Measles can easily become a stowaway on a flight to the United States.

This highly contagious and serious disease continues to be common throughout the world, including Europe. Because of decades of measles vaccination in the United States, most cases of measles that occur in the United States are linked to cases imported from another country by U.S. residents and visitors. Measles outbreaks in Europe during 2010–2011 caused an increase in the number of measles cases imported to the United States. In 2011, the United States had more measles cases than any other year since 1996.

Vaccination is the best possible prevention.

This measles exposure started in July 2010 with one contagious infant on a flight from Zurich to Boston and ended with exposing measles to 270 students from around the world.

The infant had a rash and fever during the flight and was diagnosed with measles the following day. Because measles is a disease that doctors have to report to public health, the hospital notified the Massachusetts Department of Public Health (MDPH). Because the patient had recently traveled, MDPH contacted the U.S. Centers for Disease Control and Prevention’s (CDC) Boston Quarantine Station.

A short window of time

A public health officer on his mobile phone at the airport.

Andrew Klevos, a CDC quarantine public health officer, learns about an illness on a flight. Photo credit: Jonathan Hill, CDC

Andrew Klevos, a public health officer at the CDC Boston Quarantine Station, received the call. He immediately started the contact investigation by reaching out to the airline for the manifest of the Zurich flight and cross-referencing that passenger information with information from Customs Declaration forms and the Customs and Border Protection (CBP) database.

As Klevos explained, “Passenger contact information is crucial and is rarely correct 100 percent of the time. With measles, we only have a short window of time to reach the exposed passengers and stop the continued spread of measles. So, we’re working against the clock on limited information.”

While requesting the passenger information, he alerted the airline and CBP officials so they could notify the flight crew and CBP officers who were potentially exposed to the infant with measles.

According to the CDC contact investigation protocol, 31 people were considered exposed to the infant. State and local health authorities were able to reach 29 of the 31 to notify them of their exposure, find out if they had had measles in the past or a vaccine, or recommend that they get tested to check if they were immune to measles. One person from that flight declared he had had measles as a child, which at the time was considered acceptable proof of immunity—so no blood test was taken.

A big deal

Travelers: Get Your Vaccines!

Protect yourself before you travel:

  1. See your doctor before you travel overseas.
  2. Make sure your vaccines are up to date.
  3. Find out about travel vaccines for your destination at CDC Travelers’ Health.

Three weeks later, the New York State Department of Health called the CDC Boston Quarantine Station and Massachusetts Department of Public Health to inform them that one of the 29 contacts had developed measles and was being treated in a New York City hospital. This patient turned out to be the passenger who said he had measles as a child. Unfortunately, while he was contagious with measles, he was a chaperone at a party for more than 270 international students who had attended a summer English-language camp.

Making the situation worse, these exposed students were scheduled to fly home to a dozen different countries from three major airports within the next 24 hours.

“This was a big deal,” said Klevos. “Unfortunately, the camp did not require proof of immunity to measles, so we had to get this information directly from the students’ parents and doctors who lived throughout the world in places such as Egypt, China, Russia, and France. We had to work quickly and collaboratively to prevent others from being exposed, not just within the United States, but throughout the world. Furthermore, because this exposure stemmed from self-reported immunity, we had to quickly raise our standards for acceptable proof of immunity.”

“Self-reporting was not going to count this time,” he emphasized. “We had to get and verify all medical documentation within 24 hours before the students started to fly home.”

Calling all over the world

CDC Quarantine Stations in Boston, New York, and Newark worked collaboratively with several state departments of health, and several countries’ ministries of health to request vaccination or disease history records from students’ parents and doctors. Most of these documents also had to be translated. These calls were made well into the early morning hours, and records were faxed to the United States from around the world.

Fortunately, of the 270 students, only 2 didn’t have evidence of immunity and were not cleared to fly home as scheduled. The CDC Boston Quarantine Station worked with the airlines to reschedule the two students’ flights at no additional cost. The students were able to extend their stay with their U.S. host families (who were already vaccinated) until the end of the measles incubation period (21 days), when it was safe for them to travel home.

Making a positive impact

“Vaccines are important and this case highlights why,” said Klevos. “I speak for all my colleagues, that we enjoy being able to make a positive impact and assist our partners to improve the public’s health. This is government service—this is what we’re here for. We have the tools to act quickly to impact people’s health and well-being.”

From U.S. Borders to Your Community – Saving Lives 24/7

A response always starts with a call, no matter what time of day or night.

Located at 20 U.S. airports, seaports, and land border crossings, the U.S. Centers for Disease Control and Prevention (CDC) Quarantine Stations serve on CDC’s frontlines to protect the public’s health at U.S. ports of entry. These stations connect locally with state and local health departments and globally with the ministries of health in various countries.

Staff at the quarantine stations work with partners to protect the health of communities from contagious diseases that are just a flight, cruise, or border crossing away. Their many duties include responding to reports of ill passengers arriving from international travel, sending life-saving drugs to patients with certain conditions, and conducting investigations when an ill person onboard an airplane or ship may have infected others who need to be notified about their exposure.

It’s all part of our 24/7 work at CDC…

CDC Quarantine Station and State Troopers Team Up to Help Save Lives

A CDC public health officer enlists partners to get life-saving drugs to patients.

Looking forward to a relaxing weekend with her family, Lisa Poray took the train home on a cold January Friday night—an hour’s ride from her work as a quarantine public health officer at the Chicago O’Hare International Airport. The minute she walked in her door at 7 p.m. she got a call from CDC’s Emergency Operations Center (EOC). That night, she was on call for the CDC Chicago Quarantine Station.

Than Lerner inspects drugs stored at CDC's Seattle Quarantine Station.

Than Lerner, Quarantine Public Health Officer, inspects drugs stored at CDC’s Seattle Quarantine Station. Photo Credit: CDC / Gaby Benenson

The urgent call on January 21, 2011, was a request to ship diphtheria antitoxin—an essential treatment for this rare but life-threatening infection—to Madison, Wisconsin.

When authorized, select CDC Quarantine Stations release emergency drugs, such as artesunate for malaria and antitoxins for botulism and diphtheria. Because the stations are located at airports, they are well situated to get the drugs out as soon as possible on the next available flight. In 2011, CDC Quarantine Stations released 153 drug shipments.

Making connections

Officer Poray turned on her computer to look for the earliest flight to Madison: no more flights that night. The earliest flight was at 7:15 a.m. the next morning. The shipment would have to be prepared and given to the airline 45 minutes before flight time at another terminal.

She talked to the doctor at the hospital handling the case and the hospital pharmacist who arranged for pick-up at the airport. Since these antitoxins are rarely used, the professional staff often have questions. Poray made sure the doctor and pharmacist knew how to reach the CDC specialists on call for diphtheria so they could discuss the case and the dosage, and how to prepare and administer the treatment.

Next, Poray had to schedule a babysitter for her two children, aged 8 and 11, since she would have to leave at 5:00 am. Her children knew the drill whenever their mom had to respond to emergencies.

She had just drifted off to sleep when she got another call at 10:10 p.m. A shipment of artesunate was needed for a patient with malaria in Merrillville, Indiana.

No flight available

The major airlines had no flights to Merrillville. She looked up the closest airport: Indianapolis. How to get the package to its final destination?

State police, she thought.

Poray got authorization from the station’s assistant officer in charge to request help from the state police. Illinois state police would coordinate with Indiana state police.

Unfortunately, the state police 24/7 emergency number shown on the Internet was unstaffed and responded with only a recording. She was not getting anywhere. Poray called CDC’s Emergency Operations Center (EOC).

“Can you help me?” she asked the EOC duty officer.

“No problem. That’s what we do,” Lee Miller reassured her, and he found all the numbers needed.

Four degrees of separation

Lisa Poray wraps a shipment of life saving drugs.

Lisa Poray, Quarantine Public Health Officer in Chicago, wraps a shipment of life saving drugs. Photo Credit: CDC / Shannon Bachar

From there, it was four degrees of separation to get a human chain to deliver the drugs to the patient’s hospital. The Illinois Emergency Management Agency Communications Center contacted the Illinois Department of Public Health duty officer, who got the Illinois State Police Emergency Operation Center liaison, who connected with the Indiana state troopers.

Miller arranged a conference call with everyone in the chain. They discussed how to relay the drugs securely. A packing slip would be designed so every party could sign it, hand it off to the next person, and fax it back to Poray, who would keep track of the relay. The conference call ended at midnight.

Poray left for the airport at 4 a.m., so she would have time to prepare the shipments for both Wisconsin and Indiana. At 6:00 a.m., the Illinois state trooper met her at the airport to pick up the artesunate. At 8:08 a.m., he transferred the package to the Indiana trooper. By 9:00 a.m., the package reached the hospital in Merrillville. Meanwhile at 6:30 a.m., Poray dropped off the diphtheria antitoxin at United Airlines for the 7:13 a.m. flight to Madison, Wisconsin.

Poray got home in time to take her kids to their Saturday morning ice-skating lessons.

“These calls seem to come at the worst possible time, but it gives me a good feeling that I’m helping someone. My kids are proud of me for my work, and they know when that call comes in, it’s important.”