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Quarantine

Donna Barbisch and Lawrence O. Gostin

OVER V IEW

Quarantine has been used for centuries to sequester potentially infectious individuals, plants, and animals until they are deemed safe for reintroduction to the rest of society. Criteria for the use of quarantine have often been subjective or based on dis- criminatory practice; individuals and entire communities were often cast from society and denied access to essential services. Crude efforts have been largely ineffective.1 Definitive protocols on time and distance necessary to contain the disease are often missing, and the efficacy of differing levels of separation is not well documented. The legal authority to quarantine exists within many jurisdictions worldwide, under many state laws in the U.S. Clear and convincing evidence to support the action is, how- ever, frequently difficult to establish, creating significant concerns over civil liberties.2 When quarantine is instituted, enforcement poses significant challenges. In addition, there are limited effec- tive plans on how to provide or pay for the secondary effects of quarantine: lost wages, impact on business and services, and logistical support such as food, water, and medical services for those individuals in confinement.

The overall objective of quarantine is to prevent the introduc- tion, transmission, and spread of communicable diseases. The World Health Organization (WHO) has determined that crude methods of quarantine are ineffective. Current guidelines diverge from quarantine and predetermined measures concentrated at borders alone to containment strategies focused on real-time epidemiology and evidence-based data.1

Establishing an optimal containment strategy is essential to reduce the progressive adverse outcomes due to person-to- person spread of highly infectious disease. The impact of any quarantine-related activity has the potential to significantly affect a society. Clarifying objectives, defining terms, and establishing realistic policies can effectively reduce the impact of an outbreak of contagious disease.

In a world integrally linked through international travel, questions remain as to whether or not government can effec- tively separate populations in a timely fashion. How will popu- lations manage when children are separated from their parents?

How will essential services be delivered and maintained? Are the existing legal guidelines adequate? Can they be enforced? Is the evidence-based data sufficient to counter the impact on civil liberties caused by an involuntary quarantine? This chapter will review the complexities of quarantine related to three sepa- rate but tightly linked perspectives: efficacy; legal authority; and ethical, as well as logistical, challenges in implementation.

CURRENT STATE OF THE AR T

Defining Quarantine

Defining and appropriately using terms may resolve some of the ambiguity related to quarantine. Quarantine has often been used interchangeably with isolation and civil commitment. The concept refers to separating the healthy from those with disease and has been seen in Biblical and Koranic references dating back to isolation of lepers. The term quarantine was used in the 14th century when ships were detained for 40 days to protect against “foreign” diseases. The word is derived from the Italian quaranta meaning “forty.”1

The U.S. Centers for Disease Control and Prevention (CDC) provides a fact sheet that distinguishes quarantine from isolation and provides additional data on legislative authorities, enforce- ment, and historical uses of quarantine within the United States (Figure 15.1).3 In short, quarantine is applied to exposed (poten- tially infected) persons whereas isolation is the term used to denote the process of separation of people who are ill (with confirmed contagious infectious diseases).

Several guidance documents exist to help define or rede- fine public health emergency issues focused on containment strategies such as quarantine and isolation. In the United States, two model public health laws, the Model State Emergency Health Powers Act (MSEHPA)4 and the Turning Point Model State Pub- lic Health Act acknowledge that traditional public health pow- ers such as surveillance, quarantine, and isolation are among the most outdated provisions in existing state laws (Table 15.1). From an international perspective, the International Health Reg- ulations 2005 (IHR-2005) addressed the need for revising and

203 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 08:54:52.

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204 ■ D O N NA BA R B I S C H A N D LAW R E N C E O. GO S T I N

Isolation and quarantine

Federal law

By Executive Order of the President, federal isolation and quarantine are authorized for these communicable diseases:

The President can revise this list by Executive Order.

CDC , s role

Legal Authorities for Isolation and Quarantine

Fact Sheet – December 2007 – 1 of 2

Continued...

Figure 15.1. Legal Authorities for Isolation and Quarantine.

updating the IHR on global health security, epidemic alert and response, and the need to ensure global public health (Table 15.2).

MSEHPA specifically distinguishes the word quarantine from the word isolation. Quarantine refers to the physical separa- tion and confinement of an individual or groups of individuals who are or may have been exposed to a contagious or possi- bly contagious disease but who do not show signs or symptoms

of infection. The purpose of such separation is to prevent or limit the transmission of the disease to nonquarantined individ- uals. Isolation is the physical separation and confinement of an individual or groups of individuals who are infected or reason- ably believed to be infected with a contagious or possibly conta- gious disease. The purpose of this isolation is to prevent or limit the transmission of the disease to nonisolated individuals. The

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 08:54:52.

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QUA R A N T I N E ■ 205

Legal Authorities, cont.

State, local, and tribal law

Who is in charge

Enforcement

Federal quarantine rarely used

For more information, visit : www.cdc.gov/ncidod/dq

Fact Sheet – December 2007 – 2 of 2

Figure 15.1. Legal Authorities for Isolation and Quarantine.

MSEHPA defines quarantine as “the restriction of the activities of healthy persons who have been exposed to a case of communica- ble disease during its period of communicably to prevent disease transmission during the incubation period if infection should occur.” Isolation is defined as “the separation, for the period of communicability, of known infected persons in such places and under such conditions as to prevent or limit the transmission of

the infectious agent.” Finally, civil commitment is “the detention (usually in a hospital or other specially designated institution) for the purposes of care and treatment.”2 The definitions imply that quarantine applies to the healthy population, and that in the strict interpretation of the term “quarantine,” there may be minimal application to patients within healthcare facilities. Dur- ing the severe acute respiratory syndrome (SARS) outbreak, a

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Table 15.1: The Model State Emergency Health Powers Act and the Turning Point Model State Public Health Act are U.S.-based tools developed to assist state and local governments in assessing their public health laws

The Model State Emergency Health Preparedness Act developed in 2001 provides guidance in refining state policy. Developed after the anthrax incidences of 2001, the guidance was offered to assist states in updating antiquated public health law. It addresses:

Purposes and Definitions Planning for a Public Health Emergency Measures to Detect and Track Public Health Emergencies Declaring a State of Public Health Emergency Special Powers During a State of Public Health Emergency: Control of

Property Special Powers During a State of Public Health Emergency: Control of

Persons Public Information Regarding a Public Health Emergency

The Turning Point Model State Public Health Act contains templates and checklists designed to assist in public health law reform. It adopts a systematic approach to the implementation of public health responsibilities and authorities, presents a broad mission for state and local public health agencies, and balances the protection of the public’s health with the respect for the rights of individual and groups. It addresses:

Purposes and Definitions Mission and Functions Public Health Infrastructure Collaboration and Relationships with Public and Private Sector

Partners Public Health Authorities/Powers Public Health Emergencies Public Health Information Privacy Administrative Procedures, Civil and Criminal Enforcement and

Immunities

number of civil confinement strategies were used. They included medical isolation, home quarantine, work quarantine, travel- ers quarantine, institutional quarantine, and cordon sanitaire (Table 15.3).5

Quarantine has also been referred to as a “contact manage- ment strategy that consists of active monitoring plus activity restrictions.” Such restrictions can be voluntary or involuntary. The use of quarantine raises legal, social, financial, and logistical challenges that require effective planning and implementation.6

Travel restrictions and criteria for quarantine and isolation are identified in the WHO International Health Regulations. As recently as 1994, countries often implemented excessive travel restrictions to thwart the spread of disease resulting in undue economic hardship.1 The WHO strategic plan has evolved to a proactive risk management process focusing on containment at the source, active surveillance, prompt detection, isolation of new cases, and rapid tracing of contacts. In addition, the plan calls for building capacity to cope with an inevitable pandemic.1

The IHR were revised in 2005 with an emphasis on evidenced- based data, taking a strategic approach to the public’s health.7

IHR-2005 are designed to “prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference

Table 15.2: The International Health Regulations (2005) (IHR-2005)

Developed by the World Health Organization, the IHR-2005 is a legally-binding agreement providing a framework for the coordination of the management of events that may constitute a public health emergency of international concerns. It was designed to improve the capacity of countries to detect, assess, notify and respond to public health threats. Member States are urged to build, strengthen and maintain the required capacities identified in the IHR-2005 and to collaborate to ensure their effective implementation and to develop the necessary public health capacities and legal and administrative provisions within the regulation. Specifically, the IHR-2005 addresses:

Definitions, purpose and scope, principles and responsible authorities Information and public health response Recommendations Points of entry Public health measures Health documents Charges General provisions IHR roster of experts, the emergency committee, and the review

committee Final provisions

with international traffic and trade.”8 The IHR-2005 were imple- mented on June 15, 2007. As of February 5, 2008, 194 States were parties to it.9 The WHO believes that the strategic shift from “control at the borders to containment at the source; from a list of diseases to all public health threats; from preset measures to an adapted response – will require a shift in understanding that will take time to assimilate.”1 The IHR-2005 focuses on early identi- fication and intervention based on appropriate decision making. Annex II of the IHR-2005 depicts the decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern (Figure 15.2).

The concept of separating highly contagious individuals from those susceptible is a sound principle for limiting the spread of infection; however, the execution of policies to maintain the separation during the time of infectivity is riddled with critical points of failure. Research suggests that quarantine can be effec- tive given a compliant community and appropriately managed resources.1

A comprehensive containment strategy should include ele- ments of quarantine, but must acknowledge that quarantine alone will not prevent the spread of disease. Operational short- falls exist if planning is done without considering the larger con- text of the disease outbreak; the execution of limited strategies will result in critical points of failure. Global travel, quarantine enforcement, employment and financial considerations, and the population’s medical needs have the potential to obviate a quar- antine plan. In addition, a host of logistical support issues affect- ing those confined, as well as the impact on individuals who rely on confined personnel for life support, must be considered when projecting the efficacy of quarantine.10

Historically, it has been noted that crude quarantine mea- sures were largely ineffective. No data exist to discern the impact of modern quarantine methods in realistic environments. More recently, quarantine implementations have occurred in an envi- ronment associated with improved public health responses. As such, quarantine has been accompanied by improvements in san- itation, mass immunization, and epidemiological investigation.

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QUA R A N T I N E ■ 207

Table 15.3: Efficacy of Differing Civil Confinement Strategies

Type Pros Cons Efficacy Control

Isolation ■ Known infectious patient ■ Closely monitored

■ Lack of capacity for large scale events

Widely accepted as effective

Compulsory or voluntary

Home quarantine also called:

■ self quarantine ■ sheltering in place ■ snow days

■ Less onerous ■ Logistically simpler ■ Socially and politically

acceptable

■ Difficult to monitor and enforce ■ May place family members at

risk ■ Requires significant logistical

support, e.g., for medical care, heating, food, and water

Thought to be effective Voluntary but could be compulsory

Work Quarantine (generally for healthcare workers: permitted to work, but restricted to home when not working)

■ Keeps essential employees at their jobs

■ Closely monitored

■ Risk of transmission of infection to vulnerable patients congregated together

Unknown Voluntary but could be compulsory

Travelers Quarantine ■ Addresses the risk of transmission from areas with suspected disease

■ Population is confined to the transport vehicle

■ Confines unexposed without confirmation of suspected disease

■ Cohorting may expose susceptible individuals to disease

Unknown Compulsory

Institutional Quarantine (applies to institutions or geographic areas)

■ Cohorting is easier than assessing individuals

■ Rapid spread of disease in confined and crowded areas

Unknown Compulsory

Cordon Sanitaire also called:

■ Perimeter quarantine ■ Geographic quarantine

■ Restricts travel into or out of an area

■ May restrict unnecessarily Unknown Compulsory

WHO workshops on preparedness have included containment strategies, recognizing that containment alone may be ineffective in stopping or impeding a pandemic.

The challenges created by today’s global travel can be seen in Figure 15.3. The model, developed by the Center for National Preparedness at the University of Pittsburgh, depicts the locations of travelers within 4 hours of arrival based on flights from Europe to North America.11 The model suggests potential exposure from infectious individuals to susceptible individuals will occur nearly simultaneously across the U.S. within hours; the probability of stopping a highly infectious disease at the border is limited at best. Even in known cases, noncompliant individuals can travel worldwide before they can be curtailed. In 2007, a man with drug- resistant tuberculosis boarded a plane in Atlanta.12 He ignored travel restrictions and flew from Atlanta to Paris, Greece, Italy, Prague, and Montreal exposing more than 600 individuals before authorities detained him after his 12-day trek.13

Contact network modeling can predict the impact of quaran- tine. The models suggest that simultaneous case–patient isolation and quarantine of close contacts substantially improves contain- ment. With the addition of ring vaccination, quarantine can prevent the spread of diseases. The data are conclusive in iden- tifying the impact of eliminating contacts between infected and susceptible persons; however, the study identifies a requirement for a strong surveillance infrastructure, reliable rapid diagnostic tests, and social acceptance, all of which may not be available.14

So what can be done if quarantine in and of itself is inef- fective? It must be understood that quarantine is a measure of last resort. It is used after an infectious and highly contagious

disease is introduced into society. Without immunity, separation of infectious from noninfectious individuals is the only course of action. As identified in the IHR-2005, the objective is to stop the disease at the point of origin. When travelers become vec- tors, the public’s health will be compromised. Mass casualties should be expected. The strategy to prevent spread of disease will include quarantine, however strategies to augment surge capac- ity must also be implemented in order to optimize population outcomes.

Healthcare facilities have isolation procedures and methods for separation of infectious patients from the general popula- tion. Therefore, a review of internal infection control procedures is warranted to identify current capability and capacity to opti- mally prevent or limit transmission of an infectious agent. The U.S. CDC Pandemic Influenza Plan identifies isolation of infec- tious patients in private rooms or cohort units as a measure to control transmission in healthcare facilities. It also identifies cohorting healthcare workers assigned to an outbreak unit.15

This practice, however, has been reported to have caused trans- mission of SARS to healthy individuals when those without the disease were exposed and confined with the cohort.16

During the SARS events of 2003, quarantine was an inte- gral part of the control strategy. Multiple studies have reviewed containment strategies but the full impact and effectiveness of quarantine alone in a realistic environment has not been quanti- fied. Voluntary compliance during SARS was greater than 90% in most settings; generalized studies indicate that 100% compliance may not be necessary.17 Studies on the use of quarantine con- sistently identify the challenges in managing and controlling the

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ANNEX 2

Figure 15.2. Decision Instrument for the Assessment and Notification of Events that May Constitute a Public Health Emergency of International Concern International Health Regulation 2005. World Health Organization. The World Health Report 2007: A Safer Future, Global Public Health Security in the 21st Century. Geneva: WHO.

restrictions in movement. This is resource intensive and logisti- cally challenging and raises legal, financial, and social issues.

Legal Issues of Quarantine

Public health powers for quarantine exist at all levels of gover- nance. Every nation, state, and local government has responsibil-

ity for its respective jurisdiction. The complexity of governance creates numerous overlaps as well as gaps in containment of the disease spread. The cross-jurisdictional issues require clear guidance and defined lines of authority to execute appropriate powers.

The WHO addresses the legal issues of quarantine and out- lines a collective defense strategy. It published legal guidance in

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QUA R A N T I N E ■ 209

Locations of travelers within four hours of arrival from Europe to North America Each circle indicates one hour Dots are commercial airports (total 486 across USA) Airplanes indicate international airports (116 across USA)

Developed by Dr. Ken Sochats, University of Pittsburgh, Center for National Preparedness

• • •

Figure 15.3. Potential Exposure Across the U.S. within 4 hours.

the IHR-2005. The 2005 changes to the IHR address not only the diseases subject to quarantine, but also an inclusive approach of proactive risk management. The IHR-2005 requires states that are parties to the IHR to establish policies and procedures to address containment strategies that include quarantine. The regulations urge states to develop the necessary public health capacities and legal and administrative provisions of the IHR. They should ini- tiate the process for creating a decision instrument designed to ascertain when to notify the WHO of events that may constitute a public health emergency of international concern.18

Many laws governing quarantine are old; they do not reflect current evidence-based disease management.19 The Center for Law and the Public’s Health at Georgetown and Johns Hopkins universities drafted model acts to modernize U.S. public health law. The models guide states in the development of legal powers to respond as well as provisions for due process to protect civil liberties.20 More than 37 U.S. states have adopted some portion of the MSEHPA and updated their laws governing quarantine at the time of this writing.4

Canada updated its Quarantine Act in 2004 as a result of its experience with SARS. Much like other countries, their legal guidance had been largely unchanged since initially enacted in 1872. Influenced by guidance in the IHR-2005, Canada intro- duced a bill amending the recently revised Quarantine Act on December 12, 2006 and immediately implemented this legisla- tion.21

In the United States, public health and safety are primarily state and local responsibilities. The federal government does have some jurisdiction over this area and its guidance is found within U.S. Code: Title 42.22 Federal authorities govern the introduction of diseases, both foreign and interstate, and have the power to enact and enforce quarantine rules.23 The federal government also has the responsibility to assist states in the execution of their quarantine laws. Although the state’s responsibility for quaran- tine has been upheld by the courts,24 the federal government can

preempt state power if necessary to control disease at interna- tional borders or during interstate commerce.25

Under Title 42, the Secretary of the Department of Health and Human Services (HHS) has the responsibility for prevent- ing the introduction, transmission, and spread of communicable diseases from foreign countries into the United States. HHS has assigned the responsibility for federal quarantine to the CDC. Specific diseases subject to quarantine must be authorized by Executive Order of the President (Table 15.4).26 This means that each time a new disease emerges, the Executive Order must be amended to add it to the list of quarantinable diseases. A more effective approach might be to revise the policy to include any contagious infectious disease that could be a threat to the public

Table 15.4: U.S. Diseases Subject to Quarantine∗

■ Cholera ■ Diphtheria ■ Infectious tuberculosis ■ Plague ■ Smallpox ■ Yellow fever ■ SARS ■ Viral hemorrhagic fevers

– Lassa – Marburg – Ebola – Crimean-Congo – South American – Others not yet isolated or named

■ Influenza (caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic)

* Defined in Executive Order 13295

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210 ■ D O N NA BA R B I S C H A N D LAW R E N C E O. GO S T I N

health and safety and avoid listing each one. To update the current antiquated federal quarantine rules, the CDC proposed com- municable disease control regulations in late 2005,27 but these proposed rules have never been finalized.28

Empowering authority for a quarantine order is found in federal regulations. They provide specific guidelines authorizing the Secretary of HHS, “to make and enforce regulations that in his judgment are necessary to prevent the introduction, trans- mission, or spread of communicable diseases.” The authority extends to individuals coming into a state or possession from a foreign country or possession, or from state to state for infected individuals. Title 42 requires the President, upon recommenda- tion of the National Advisory Health Council and the Surgeon General of the United States, to define, by Executive Order, those diseases subject to quarantine.

The Secretary of HHS is authorized to support state and local authorities in enforcing their quarantine and health regulations. State quarantine laws remain valid until displaced by federal law. The responsibility to protect the public’s health must not unduly infringe on personal freedom to travel. There must be a compelling argument that clearly demonstrates travel to or from an infected area puts the greater population in danger.

In 2007, during the well-publicized Andrew Speaker case, the CDC issued the first federal quarantine order since a suspected smallpox carrier was quarantined in 1963.29 Quarantine author- ity under Title 42 was initially the responsibility of the Treasury Department. It was transferred to the Federal Security Agency in 1939. Subsequently, in 1953, it was transferred to the Department of Health, Education and Welfare, later redesignated HHS.

HHS assigned border control containment issues to the CDC, Division of Global Migration and Quarantine, which operates quarantine stations as part of the U.S. comprehensive quaran- tine system network. The stations are located at 20 ports of entry and land border crossings focused on the arrival of interna- tional travelers. Health officers determine the appropriate mea- sures to use if they identify an ill person attempting to enter the United States. If diagnosed with a disease subject to quarantine, the CDC has the legal authority to detain, admit to a hospi- tal, or confine individuals to a home for a certain amount of time to prevent the spread of disease.30 An Institute of Medicine study found that “most practices of the quarantine stations and their surrogates lack a scientific basis.” It also found that the practice of quarantine was based primarily on “experience and tradition.” The Institute of Medicine recommended the devel- opment of “scientifically sound tools to measure the effective- ness and quality of all operational aspects of the quarantine system.”31

The Center for Law and the Public Health at Georgetown and Johns Hopkins universities, in collaboration with the CDC, the National Governors Association, and other public health associations proposed the MSEHPA. The Act suggests that failure to obey a quarantine or isolation restriction shall constitute a misdemeanor. As a misdemeanor, the level of force appropriate to ensure enforcement is a potential challenge.

Other guidelines regarding healthcare facilities and the con- trol of the spread of infectious diseases can be found in the U.S. CDC Guidelines for Environmental Infection Control in Health- care Facilities, 2001.32 Isolation guidelines recommend at least one room equipped to house patients with infections communi- cable through airborne routes, and further identify engineering standards for healthcare facilities. Smallpox and hemorrhagic

fevers are specifically referenced with regard to their airborne transmissibility and potential for infectious waste. The guide- lines do not, however, address policies aimed at managing large numbers of contagious patients.

The Joint Commission, which provides accreditation stan- dards for healthcare facilities in the United States (and some other countries through its Joint Commission International division), issues additional guidance as a deeming authority for Medicare. The Joint Commission standards require leaders and managers to comply with applicable laws and regulations and spell out spe- cific responsibilities of the facility when governmental authorities establish quarantine.33

Ethical Issues of Quarantine

Limited definitive guidance exists on requirements to effectively stop the spread of highly contagious disease. Without evidence- based data to support the efficacy of quarantine, ethical issues will arise. Government policies that restrict individual rights and impact financial security impose hardship on individuals. His- torically, punitive actions and deprivation of liberty have been associated with quarantine. Civil commitment is seen, especially in the United States, as a “massive curtailment of liberty.”34 Gov- ernmental bodies have a responsibility to establish that a sig- nificant risk of transmission exists before detaining individuals against their wills.35

If it can be determined that quarantine is warranted, govern- ments have the responsibility to provide for life-sustaining sup- port such as food and water, medical support, and appropriate sanitary conditions. If a government plan includes quarantine, it is imperative that the plan provide logistical support for the detained population.1 Containment strategies should focus on the “human rights principles: the least restrictive alternative, safe and habitable environments, and fulfilling individual needs for medical treatment and necessities of life.”2 In reality, the magni- tude of large-scale events often makes adequate support nearly impossible.

RECOMMENDATIONS FOR FUR THER RESEARCH

Quarantine is a tool used in conjunction with other medical countermeasures to curtail the spread of highly contagious dis- eases. There are limited evidence-based data on effectiveness. Recommendations for further research must focus on realistically achievable results. The following identify critical areas of study that would contribute to the adoption of effective strategies.

■ Improved modeling is necessary in the context of operational challenges for managing large numbers of displaced individ- uals. The basic elements of delivery of food and water, and medical support are missing. Additional needs for financial support and family integrity have not been addressed.

■ Timelines must be developed to reflect the duration of opti- mal separation to reduce contagion. Criteria must be devel- oped to determine whether the potentially infected popu- lation can be identified soon enough to achieve physical separation and limit transmission.

■ Metrics must be developed to measure quarantine as an effec- tive strategy within a society that has rapid global movement opportunities.

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■ Reporting and communication algorithms are required to assist clinicians in recognizing who to report and when, where, and how to report suspicious activity.

■ Clearly delineated authorities must be developed that enable clinicians to act and political figures (e.g., governors, mayors) to make decisions.

■ Other containment strategies should be assessed for efficacy with or without a state of quarantine.

■ A realistic assessment should be developed regarding the impact of school closure and other activities initiated to facil- itate separation on the population. Researchers should model the second- and third-order effects.

■ Enforcement options in different societies should be identi- fied.

■ Jurisdictional authority issues when federal enclaves or other jurisdictions exist within a state should be deconflicted. This would include determining how a country would manage travel of embassy personnel when no authority exists over those sovereign entities.

In summary, quarantine is an important tool in the arma- mentarium for protection of the public health from contagious infectious diseases. Its efficacy, the legal authorities, and the logis- tical and ethical challenges in its implementation require more study to optimize the probability that quarantine will decrease morbidity and mortality in the global environment.

REFERENCES

1. World Health Organization. The World Health Report 2007: A Safer Future, Global Public Health Security in the 21st Century. Geneva: WHO.

2. Gostin LO., Public Health Law: Power, Duty, Restraint, 2nd ed. Berkeley: University of California Press; Berkeley, CA; 2008.

3. Centers for Disease Control and Prevention. Smallpox Response Plan. March 2003. Available at: http://www.bt.cdc.gov/agent/ smallpox/response-plan/files/guide-c-part-2.pdf. Accessed Jan- uary 14, 2009.

4. Gostin LO, Sapsin J, Teret SP, Burris S, Mair JS, Hodge JG, Vernick J, et al. The Model State Emergency Health Powers Act: Planning and response to bioterrorism and naturally occurring infectious diseases. JAMA. 2002;288:622–688.

5. Gostin LO, Bayer R, Fairchild, AM. Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats. JAMA. 2003;290: 3229–3237.

6. U.S. Centers for Disease Control and Prevention. Public Health Guidance of Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2, Supple- ment D: Community Containment Measures, Including Non- Hospital Isolation and Quarantine. January 8, 2004. Avail- able at: http://www.cdc.gov/ncidod/sars/guidance/D/pdf/d.pdf. Accessed January 14, 2009.

7. Fidler DP, Gostin LO. The New International Health Regula- tions: An historic development for international law and public health. J Law Med Ethics. 2006;33(4):85–94.

8. World Health Organization. “Frequently asked questions about the International Health Regulations (2005)” Avail- able at: http://www.who.int/csr/ihr/howtheywork/faq/en/index .html#whatis. Accessed January 14, 2009.

9. World Health Organization, “States Parties to the Interna- tional Health Regulations (2005).” Available at: http://www.who .int/csr/ihr/states parties/en/index.html. Accessed January 14, 2009.

10. Barbera J, Macintyre A, Gostin L, et al. Large-scale quaran- tine following biological terrorism in the United States: scien- tific examination, logistic and legal limits, and possible conse- quences. JAMA. 2001;286: 2711–2717.

11. Sochats K, Model for global travel. University of Pittsburgh, Center for National Preparedness; 2007.

12. Fidler DP, Gostin LO, Markel H. Through the quarantine look- ing glass: Drug-resistant tuberculosis and public health gover- nance, law, and ethics. J Law Med Ethics. 2007;35:526–533.

13. Hitti M. WebMD Medical News. Drug-resistant TB patient in isolation. Available at: WebMD Medical News. http:// www.medicinenet.com/script/main/art.asp?articlekey=81465. Accessed January 14, 2009.

14. Pourbohloul B, Meyers LA, Skowronski DM, Krajden M, Patrick DM, Brunham R, Modeling control strategies of respiratory pathogens. Emerg Infect Dis. 2005;11:1249–1256.

15. U.S. Department of Health and Human Services. Pandemic Influenza Plan Supplement 4 Infection Control. Available at: http://www.hhs.gov/pandemicflu/plan/sup4.html. Accessed January 14, 2009.

16. World Health Organization. Weekly Epidemiological Record. 30 May 2003. Available at: No 22, 2003, 78. http://www .who.int/docstore/wer/pdf/2003/wer7822.pdf. Accessed January 14, 2009.

17. U.S. Centers for Disease Control and Prevention. Public Health Guidance of Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2, Supple- ment D: Community Containment Measures, Including Non- Hospital Isolation and Quarantine. January 8, 2004.

18. World Health Organization. International Health Regula- tions (2005), Annex 2. Available at: http://www.who.int/ csr/ihr/WHA58-en.pdf. Accessed January 14, 2009.

19. Gostin, Burris, and Lazzarini. “The Law and the Public’s Health: A Study of Infectious Disease Law in the United States;” Daniel S. Reich, “Modernizing Local Responses to Public Health Emer- gencies: Bioterrorism. Epidemics, and the Model State Emer- gency Health Powers Act,” Journal of Contemporary Health Law and Policy, 19 (2003):379–414.

20. Hodge JG, Gostin LO, Gebbie K, Erickson DL. Transforming public health law: The turning point model state public health act. J Law, Med & Ethics. 2006;33(4):77–84.

21. Canada Library of Parliament. Bill C-42: An Act to amend the Quarantine Act. September 25, 2007. Available at: http://www.parl.gc.ca/common/bills ls.asp?lang=E&ls=c42 &source=library prb&Parl=39&Ses=1. Accessed January 14, 2009.

22. U.S. Code, Title 64. Available at: http://www.publichealthlaw .net/Resources/ResourcesPDFs/4quarantine.pdf. January 14, 2009.

23. “An Act Granting Additional Quarantine Powers and Impos- ing Additional Duties upon the Marine Hospital Service.” See Compagnie Francaise de Navigation a Vapeur v. State Board of Health, Louisiana, 186 U.S. 380, 395–96 (1902).

24. Hennington v. Georgia, 163 U.S. 299 (1896) (holding that state police power regulation affecting commerce is valid until super- seded by Congress); see also William H. Cowles WH., “State quarantine laws and the federal constitution.,” American Law Review. 1891;25:45–73.

25. Gibbons v. Ogden, 22 U.S. 1, 205–206 (1824) (“congress may control the state [quarantine] laws . . . for the regulation of

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commerce.”); Compagnie Francaise De Navigation a Vapeur v. Louisiana State Board of Health, 186 U.S. 380 (1902); United States v. Shinnick, 219 F. Supp. 789 (1963).

26. Executive Order 13295 as amended, Revised List of Quarantin- able Communicable Diseases. Code of Federal Regulations, title 3 (2003); Executive Order 13,375 of April 1, 2005: Amendment to Executive Order 13, 295 Relating to Certain Influenza Viruses and Quarantinable Communicable Diseases. Code of Federal Regulations, title 3 (2005).

27. Public Health Service Act §§361–368 (42 U.S.C. 264–271) (authorizing the Secretary to make and enforce regulations to prevent the introduction or transmission of communicable dis- eases from foreign countries and from one state into another); Department of Health and Human Services, Control of Com- municable Diseases (Proposed Rule), 42 CFR Parts 70 and 71 (November 30, 2005).

28. Gostin LO, Federal executive power and communicable disease control: CDC Quarantine Regulations., Hastings Center Report. 2006;36(2):10–11.

29. Fidler DP, Gostin LO, Markel H, Through the Quarantine Looking Glass: Drug-Resistant Tuberculosis and Public Health Governance, Law, and Ethics, J Law, Med & Ethics. 2007;35: 526–533.

30. Centers for Disease Control and Prevention. U.S. Quar- antine Stations Fact Sheet. Dec 2007. Available at: http://

www.cdc.gov/ncidod/dq/resources/Quarantine Stations Fact Sheet.pdf. Accessed January 14, 2009.

31. Institute of Medicine. Quarantine Stations at Ports of Entry Protecting the Public’s Health, Executive Summary. September 2005. Available at: http://www.iom.edu/CMS/ 3783/22845/29602.aspx. Accessed January 14, 2009.

32. Centers for Disease Control and Prevention, the Hospital Infec- tion Control Practices. Advisory Committee (HICPAC). Rec- ommendations for isolation precautions in hospitals. Am J Infect Control. 1996;24:24–52.

33. Joint Commission, Standing Together: An Emergency Planning Guide for America’s Communities. Joint Commission, 2005. Available at: http://www.jointcommission.org/NR/rdonlyres/ FE29E7D3–22AA-4DEB-94B2–5E8D507F92D1/0/planning guide.pdf. Accessed January 14, 2009.

34. Vitek v. Jones 445 U.S. 480, 491 (1980) (holding that an inmate was entitled to due process before transfer to mental institution); see Addington v. Texas, 441 U.S. 418, 425 (1979) (holding that civil commitment is a “significant deprivation of liberty”).

35. Scott Burris S., “Fear itself: AIDS, herpes and public health decisions.” Yale Law and Policy Review, 1985;3 (1985):479–518. See Kansas v. Crane, 534 U.S. 407 (2002) (holding that, in order to commit repeat sex offenders, the state must demonstrate “proof of serious difficulty in controlling behavior” which can distinguish a committable offender from a typical recidivist).

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