\S
CDC0520.03\
I'M DR. JIM HUGHES, DIRECTOR OF CDC'S
IN ADDITION, FROM
GLOBAL EFFORT IN WHICH INTERNATIONAL COLLABORATION IS ABSOLUTELY
ESSENTIAL AND
MUTUALLY BENEFICIAL.THANK YOU FOR SHARING IN THIS IMPORTANT WORK
AND FOR JOINING
THIS BROADCAST TODAY.
HELLO, EVERYONE.
I'M KYSA DANIELS. WELCOME TO PUBLIC HEALTH COMMUNITY PREPAREDNESS
FOR
SEVERE ACUTE RESPIRATORY SYNDROME, OR SARS.
WE ARE COMING TO YOU LIVE FROM
THE CENTERS FOR DISEASE CONTROL AND
PREVENTION IN
THE GOAL OF TODAY'S PROGRAM IS TO PROVIDE THE PUBLIC HEALTH COMMUNITY
INFORMATION AND GUIDANCE ON CONTAINMENT OF SARS. WE HAVE FOUR KEY OBJECTIVES.
BY THE END OF THE PROGRAM, WE WANT YOU TO BE ABLE TO, NUMBER ONE,
DESCRIBE KEY STRATEGIES FOR CONTAINING THE SPREAD OF SARS, TWO, EXPLAIN THE
CURRENT
GUIDELINES FOR INSTITUTING QUARANTINE AND/OR ISOLATION STRATEGY,
THREE, DETERMINE APPROPRIATE ACTION STEPS NEEDED TO CARRY OUT SARS-RELATED
ISOLATION OR QUARANTINE MEASURES. AND FINALLY, DETERMINE APPROPRIATE
SUPPORT SYSTEMS NEEDED TO CARRY OUT SARS-RELATED ISOLATION OR QUARANTINE MEASURES.
IF YOU'RE HAVING TECHNICAL TROUBLE RECEIVING OUR SIGNAL, YOU CAN
CALL US HERE AT CDC AND THE NUMBER TO DIAL IS 800-728-8232.
CONTINUING EDUCATION CREDIT WILL BE OFFERED FOR A VARIETY OF PROFESSIONS
BASED ON ONE HOUR OF INSTRUCTION. A CERTIFICATE OF CREDIT OR A CERTIFICATE OF
ATTENDANCE WILL BE AWARDED TO PARTICIPANTS WHO COMPLETE THE EVALUATION.
AND FOR THE PURPOSE OF DISCLOSURE, TODAY'S SPEAKERS HAVE STATED
THEY HAVE NO
FINANCIAL INTEREST OR OTHER RELATIONSHIP
WITH ANY COMMERCIAL PRODUCTS OR SERVICES. I'LL GIVE YOU MORE REGISTRATION INFORMATION LATER IN THE
BROADCAST. DURING THE DAY OF THE BROADCAST,
SUBMITTED TO OUR PANELISTS VIA TELEPHONE AT 800-793-8598, TTY AT
800-815-8152
OR YOU CAN FAX YOUR QUESTIONS TO 800-553-6323. LET'S BEGIN TODAY'S
BROADCAST BY WELCOMING OUR PANEL.WE HAVE WITH US DR. JOHN JERNIGAN, GENE MATTHEWS,
DR. MARTY CETRON, DR. ART LIANG AND FROM
WELCOME TO YOU AGAIN, DR. CETRON. THANK YOU. QUARANTINE AND
ISOLATION ARE ANCIENT TOOLS USED TO PREVENT THE SPREAD OF CONTAGIONS. “QUARANTINE”
DERIVES FROM THE 40 DAYS THE SHIPS WERE REQUIRED TO STAY AT HARBOR BEFORE
DISEMBARKATION TO PREVENT THE SPREAD OF PLAGUE. QUARANTINE HAS BEEN USED FOR CENTURIES,
BUT NOT MUCH IN THE MODERN ERA.WE MUST BE COGNIZANT OF THE HISTORICAL LESSONS
OF QUARANTINE INCLUDING ITS MISUSE AND MISAPPLICATION, ITS UNETHICAL USE AND DISCRIMINATION.
THESE LESSONS WE NEED TO REMEMBER AS WE USE THESE TOOLS AGAIN TO CONFRONT A
21st CENTURY EPIDEMIC, SARS. I WOULD LIKE TO START BY PROVIDING DEFINITIONS. THE
TERM “ISOLATION” REFERS TO THE RESTRICTION OF MOVEMENT AND A SEPARATION OF
SICK, INFECTED PERSONS WITH A CONTAGIOUS DISEASE. WHILE THIS USUALLY OCCURS ON
AN INDIVIDUAL BASIS IN A HOSPITAL SETTING, IT MAY ALSO OCCUR AT HOME OR IN A
DEDICATED ISOLATION FACILITY. QUARANTINE, ON THE OTHER HAND, REFERS TO THE RESTRICTION
OF MOVEMENT OR SEPARATION OF WELL PERSONS, PRESUMED EXPOSED TO A CONTAGIOUS
DISEASE. THIS CAN USUALLY OCCUR AT HOME, BUT ALSO MAY BE IN A DEDICATED QUARANTINE
FACILITY, AND IT, TOO, CAN BE APPLIED ON AN INDIVIDUAL
OR A POPULATION LEVEL.I THINK IT'S IMPORTANT TO POINT OUT THAT
QUARANTINE MEASURES AND ISOLATION MEASURES ARE USUALLY UNDERTAKEN IN A
VOLUNTARY
MANNER. BUT THEY CAN BE MANDATORY OR COMPULSORY.
THE LEGAL QUARANTINE AUTHORITIES ON THE OTHER HAND, COVER BOTH PUBLIC HEALTH
TOOLS OF ISOLATION
AND QUARANTINE. SO FAR, FOR THE INTERNATIONAL CONTAINMENT OF SARS,
WE HAVE
SEEN THE THREE MEASURES SHOWN HERE
ON THIS SLIDE APPLIED IN VARYING DEGREES. IN EACH INSTANCE, COUNTRIES HAVE CHOSEN TO ISOLATE SYMPTOMATIC INDIVIDUALS
IN A COMMUNICABLE PHASE OF THEIR DISEASE. THIS HAS FREQUENTLY BEEN DONE IN
DEDICATED SARS HOSPITALS, OR SARS WARDS IN
PARTICULAR HOSPITALS. BUT ISOLATION CAN ALSO OCCUR AT HOME FOR THOSE WHO ARE
NOT SICK ENOUGH TO BE IN A HOSPITAL, OR
CAN OCCUR AT HOME DURING A RECOVERY PERIOD WHEN THE ILLNESS HAS
RESOLVED TO THE DEGREE THAT IT NO LONGER REQUIRES HOSPITALIZATION, BUT STILL
MAY BE COMMUNICABLE.QUARANTINE HAS ALSO BEEN APPLIED IN MANY INTERNATIONAL
COUNTRIES
FOR THE CONTAINMENT OF SARS.THIS IS MEANT DURING CONTACT TRACING
FOR CLOSE CONTACTS OF FOLKS WHO ARE STILL ASYMPTOMATIC BUT IN CLOSE CONTACT
WITH SARS
CASES.QUARANTINE HAS BEEN USED BOTH AT HOME AND IN DEDICATED RESIDENTIAL
FACILITIES. DURING THE PERIOD OF QUARANTINE MOST CASES ARE UNDER CLOSE FEVER
SURVEILLANCE AND BEING CHECKED UP REGULARLY BY PUBLIC HEALTH OFFICIALS.
A THIRD AND IMPORTANT STRATEGY FOR CONTAINMENT OF SARS APPLIES TO
THE COMMUNITY CONTROL MEASURES, WHICH ARE GENERALLY TARGETED TO DECREASE SOCIAL
INTERACTION AND SOCIAL CONTACTS.THESE HAVE INCLUDED THE CANCELLATION OF PUBLIC
GATHERINGS, CLOSURE OF SCHOOLS AND WORKPLACES, AND CANCELLATION OF
LARGE SPORTING EVENTS.IN ADDITION, TRAVEL RESTRICTIONS HAVE BEEN USED AS A
LARGE-SCALE COMMUNITY MEASURE TO LIMIT
THE TRANSLOCATION OF SARS CASES TO OTHER COUNTRIES. SOME OF THE NEXT SLIDES SHOW SOME
PICTURES OF THE WAY
ISOLATION AND QUARANTINE HAVE BEEN USED. IN SOME CASES, THERE HAS
BEEN A
VERY DRAMATIC REACTION, AND THE EPIDEMIC OF FEAR SOMETIMES EXCEEDS
THE ACTUAL EPIDEMIC OF DISEASE.A PICTURE HERE SHOWS WHAT SOME MAY CONSIDER
EXCESSIVE
TECHNIQUES TO ISOLATE A PATIENT IN
IN ADDITION, BECAUSE QUARANTINE AS A TOOL AND SARS AS A DISEASE HAVE
NOT REALLY COME TOGETHER FOR A LONG TIME, THERE IS THE EXPECTED LARGE AMOUNT OF
MEDIA
ATTENTION AND INTEREST FOR THOSE WHO HAVE BEEN ISOLATED OR UNDER QUARANTINE,
AS DEPICTED HERE IN THIS SLIDE. AND WE MUST BE CAREFUL NOT TO STIGMATIZE THOSE
IN
QUARANTINE THROUGH THE FASCINATION OF THE MEDIA. I THINK ONE OF
THE MOST
IMPORTANT LESSONS THAT WE CAN TAKE HOME FROM THIS SATELLITE CONFERENCE
IS THAT QUARANTINE AS A PUBLIC HEALTH TOOL REPRESENTS A COLLECTIVE ACTION FOR
THE
COMMON GOOD, AND REPRESENTS A DELICATE BALANCE FOR PUBLIC GOOD ON
THE ONE HAND AND CIVIL LIBERTIES ON THE OTHER. ONE OF THE LESSONS OF HISTORY FROM
QUARANTINE IS THAT 21st CENTURY APPLICATION OF THIS TOOL REQUIRES
OUR
TO MEET THE NEEDS OF INDIVIDUALS INFECTED AND THOSE EXPOSED INSIDE
THE RING OF QUARANTINE AND ISOLATION. IT IS OUR ETHICAL RESPONSIBILITY TO
SEPARATE THE SICK FROM THE EXPOSED, WHICH HAS NOT ALWAYS BEEN THE CASE IN THE
USE OF
QUARANTINE IN ANCIENT TIMES. WE MUST DISTINGUISH CASES THAT ARE
PROBABLE CASES FROM THOSE THAT ARE SUSPECT, FROM THOSE THAT ARE POSSIBLE EARLY
IN
THEIR DISEASE EVOLUTION AND AGAIN SEPARATE THE EXPOSED WELL PERSONS
SO THAT WE DON'T INADVERTENTLY CAUSE INCREASED TRANSMISSION IN THE QUARANTINE RING.
WE ALSO MUST BE ABLE TO EVALUATE AND RAPIDLY TRIAGE AND MOVE PEOPLE BETWEEN
THESE SEGMENTS.WE NEED TO MEET NOT ONLY THE MEDICAL NEEDS OF THOSE IN QUARANTINE
AND ISOLATION, BUT ALSO THEIR GENERAL HUMAN NEEDS, FEEDING, CARING AND SHELTERING,--
OF THOSE UNDER ISOLATION AND QUARANTINE WHO ARE SACRIFICING THEIR OWN FREEDOMS OF
MOVEMENT FOR THE PUBLIC GOOD. AND FINALLY, AS WE'LL HEAR LATER IN THE
BROADCAST, IT IS KEY TO PREVENT STIGMATIZATION THAT QUARANTINE AND ISOLATION
CAN SOMETIMES ENTAIL. IT IS NOTABLE THAT ON APRIL 4th, PRESIDENT GEORGE BUSH
ADDED SARS TO THE LIST OF THE SEVEN OTHER QUARANTINEABLE DISEASES FOR WHICH OUR
CURRENT QUARANTINE
LAWS IN THE UNITED STATES ALLOW THE RESTRICTION OF HUMAN MOVEMENT.THE
OTHER SEVEN DISEASES ARE SHOWN IN THE TOP OF THIS SLIDE.I THINK IT IS VERY
IMPORTANT TO UNDERSTAND THE BASIC PRINCIPLES AND CONCEPTS OF THE EPIDEMIC DYNAMICS
AND WHY ISOLATION AND QUARANTINE CAN BE SUCH EFFECTIVE TOOLS AT QUENCHING AN
EPIDEMIC. THE GOAL IS TO REACH A REPRODUCTIVE RATE THAT IS LESS THAN ONE, SO
THE EPIDEMIC WILL EXTINGUISH ITSELF.THERE ARE TWO SITUATIONS IN WHICH THE
UTILITY OF QUARANTINE CAN BE FOUND IN ACCOMPLISHING THIS GOAL.THE FIRST IS MOST
COMMONLY
THOUGHT OF, AND THAT IS, IF PEOPLE ARE CONTAGIOUS DURING THEIR
ASYMPTOMATIC INCUBATION PERIOD. IN THIS CASE, IT IS VERY CLEAR THAT ONE MAY
NEED TO ISOLATE OR QUARANTINE THE ASYMPTOMATIC EXPOSED FOLKS, BECAUSE THERE MAY
BE A RISK OF SPREADING DISEASE TO OTHERS. BUT THERE IS ANOTHER SITUATION IN
WHICH QUARANTINE CAN BE EFFECTIVE, AND THIS IS SHOWN IN THIS SLIDE BY LOOKING
AT THE
PERIOD OF COMMUNICABILITY IN RED,
AND THE PROPAGATION THAT'S IN PINK.
HOW RAPIDLY CAN WE ACTUALLY ISOLATE SYMPTOMATIC PEOPLE? HOW
RAPIDLY CAN WE IDENTIFY THEM, RECOGNIZE THEM, AND ISOLATE THEM APPROPRIATELY SO
THAT THEY NO
LONGER POSE A RISK FOR SECONDARY SPREAD? IF THIS TIME IS
PROLONGED, THEN
SIMPLFY COMMUNICABILITY CAN CAUSE A
FEVER IN THIS PERIOD CAN ALLOW THAT PERIOD OF RISK FOR EPIDEMIC PROPAGATION
TO BE REDUCED TO ZERO, SO THAT THE MINUTE THE PERSON BECOMES SYMPTOMATIC AND
COMMUNICABLE, THEY WILL ALREADY BE ISOLATED FROM OTHERS. THIS SHORTENS THE PERIOD OF RISK AND SERVES TO
QUENCH THE EPIDEMIC. THIS SLIDE SHOWS THE FRAMEWORK THAT'S BEEN PROPOSED FOR ISOLATION
AND QUARANTINE MEASURES AS THEY'VE BEEN USED IN THE CONTAINMENT OF SARS WORLDWIDE.
ONE WILL NOTE THAT, DEPENDING ON
THE CIRCUMSTANCES OF THE EPIDEMIC, INDIVIDUAL COUNTRIES HAVE FOUND
THEMSELVES AT
DIFFERENT LEVELS IN THE DEGREES OF
ESCALATING RESTRICTION OF MOVEMENT. ON THE LEFT-HAND SIDE IS THE INDIVIDUAL CASE RESPONSE. AS WE MENTIONED, THIS HAS
LARGELY INVOLVED THE ISOLATION OF
INFECTED INDIVIDUALS ONCE THEY FIRST SHOW SIGNS OF SYMPTOMS. AND ALSO, THE
MONITORING AND ACTIVE SURVEILLANCE OF ASYMPTOMATIC CONTACTS, THROUGH CONTACT TRACING.
BUT ON A POPULATION LEVEL, ONE CAN IMAGINE A SERIES OF RESTRICTED MOVEMENTS
THAT INCREASE IN THEIR RESTRICTIONS AS THE NEED OF THE EPIDEMIC DICTATES. SOME
OF THE DETERMINANTS FOR THE PUBLIC HEALTH THRESHOLD FOR MOVING BETWEEN THESE
LEVELS ARE SHOWN IN THE BOX IN THE MIDDLE,AND THESE INCLUDE THE NUMBER OF NEW
CASES, AND EXPOSED PERSONS, THE MORBIDITY AND MORTALITY OF THE DISEASE, THE
EASE AND SPEED WITH WHICH THE DISEASE IS SPREADING THROUGHOUT THE COMMUNITY, AS
WELL AS THE MOVEMENT OF PERSONS IN AND OUT OF THE COMMUNITY, THE INTENSE RESOURCES
THAT ARE NEEDED FOR CONTACT TRACING AND PUBLIC HEALTH RESPONSE, THE NEED FOR
URGENT PUBLIC HEALTH ACTION FOR CONTAINMENT, AND THE RISK FOR PUBLIC PANIC. THE
LEVELS THAT ARE SHOWN ON THE RIGHT GO FROM LEVEL 1, IN WHICH THE PREDOMINANT
FOCUS OF EDUCATION AND INFORMATION AND INCREASING SURVEILLANCE AND A ALERTNESS. THIS
INCLUDES
TRAVEL ALERTS, ADVISORIES, PRESS INFORMATION AND PRESS RELEASES, AND
INTERAGENCY PARTNER NOTIFICATION, AS WELL AS SATELLITE CONFERENCES LIKE THE ONE
WE'RE HAVING
RIGHT NOW. IN LEVEL 2, THIS INCREASES ONE STEP
FURTHER TO THE ISSUANCE OF TRAVEL ADVISORY AND THE VOLUNTARY MOVEMENT OF PUBLIC
GATHERINGS. IN LEVEL 3 WE SEE COMPULSORY LIMITATIONS AND CURFEWS OR CANCELING
TRANSPORTATION SCHEMES OR PUBLIC EVENTS. LEVEL 4 IS THE MOST HIGHLY RESTRICTIVE,
AND IT INCLUDES ENFORCEMENT OF THESE ACTIVITIES UP TO THE TYPICAL RINGING A GEOGRAPHIC
AREA FOR QUARANTINE
AND PREVENTING MOVEMENT IN OR OUT
OF THIS AREA. SHOWN
ON THIS SLIDE IS AN
EXAMPLE OF THE TRAVEL ADVISORIES THAT HAVE BEEN ISSUED FOR SARS TO
DEFER NONESSENTIAL TRAVEL IN AN OUTBOUND DIRECTION TO THE AREAS THAT ARE
EXPERIENCING
WIDESPREAD COMMUNITY TRANSMISSION.THE LOCATIONS HIGHLIGHTED IN YELLOW
INDICATE THOSE TO WHICH THERE IS AN ONGOING TRAVEL ADVISORY ISSUED BY CDC, AND THESE
CORRESPOND TO ONGOING RECOMMENDATIONS FROM W.H.O. TO RESTRICTING NONESSENTIAL
TRAVEL AS WELL. THE TWO HIGHLIGHTED BELOW,
THERE WERE TRAVEL
EDUCATE AND PROVIDE INFORMATION ON RISK REDUCTION. THIS IS TO
ENHANCE OUR AWARENESS AND OUR SURVEILLANCE FOR EARLY DETECTION AND RAPID
RESPONSE. WE CURRENTLY HAVE A TRAVEL ALERT IN PLACE FOR SINGAPORE, HAVE DROPPED
THE TRAVEL ALERT FOR
BE TAKEN LIGHTLY, AS THEY COULD HAVE MAJOR ECONOMIC CONSEQUENCES, AS
SHOWN HERE IN THIS SLIDE. THIS IS A PICTURE OF A
SARS COUNTRIES WERE ASKED TO NOT ATTEND AND PARTICIPATE. SOMETIMES
THIS TYPE OF OVERREACTION COMES FROM THE EPIDEMIC OF FEAR, WHICH NEEDS TO BE
QUENCHED. SOMETIMES THE POTENTIAL FOR ADVERSE PUBLIC HEALTH OUTCOME, AS WE WILL
HEAR FROM DR. LIANG, IN TERMS OF SUPPRESSING THE REPORTING WHEN TRAVEL RESTRICTIONS
ARE APPLIED TOO LIBERALLY. IN ADDITION, AS I MENTIONED, COMMUNITY MEASURES TO
PREVENT TRANSLOCATION OF DISEASE IN THE MODERN ERA OF GLOBALIZATION ARE KEY.
SHOWN ON THIS SLIDE ARE THREE CLASSIC MEASURES THAT HAVE BEEN USED TO PREVENT
TRAVEL-ASSOCIATED TRANSLOCATION OF SARS. THE FIRST IS PRE-DEPARTURE SCREENING,
FROM QUESTION BASED TO TEMPERATURE-BASED MONITORING OF THOSE WHO HAVE HAD
RECENT CLOSE CONTACT. THIS TARGETS ONLY THOSE AT GREATEST RISK OF TRANSLOCATING
DISEASE.IN ADDITION, BOTH CDC AND W.H.O.HAVE DEVELOPED PROTOCOLS AND GUIDELINES
FOR THE SAFE, EFFECTIVE AND RAPID RESPONSE TO THOSE WHO DEVELOP SYMPTOMS
CONSISTENT WITH SARS IN TRANSIT, AND THESE INCLUDE MOVING THE AFFECTED PERSON
TO THE ISOLATED PART OF THE AIRCRAFT AND USING BARRIER PRECAUTIONS, AS WELL AS
RAPIDLY BRINGING THEM TO THE ATTENTION OF PUBLIC HEALTH AND MEDICAL AUTHORITIES
SO THEY CAN BE EVALUATED UPON LANDING.ONE NEEDS TO BE AWARE, HOWEVER, OF THE
WIDESPREAD USE OF MASKS THAT HAS OCCURRED IN THE SETTING OF SARS. THIS DOES NOT
NECESSARILY ELIMINATE THE RISK.ILL-FITTED OR INAPPROPRIATE MASKS
ARE OFTEN NOT USEFUL AND MAY CONTRIBUTE TO A FALSE SENSE OFSECURITY. CDC
GUIDELINES FOR THE USE OF MASKS FOCUS ON HIGH-RISK ENCOUNTERS IN PATIENT CARE
SETTINGS, AND THE USE OF APPROPRIATELY FITTED (AND 95) RESPIRATORS.HOWEVER, AS
WE CAN SEE FROM THESE LAST TWO SLIDES, MASKS HAVE BECOME QUITE POPULAR AS A
FASHION STATEMENT, AND PERHAPS NOT AS USEFUL AS A PERSONAL PROTECTION
MEASURE.THIS IS A SLIDE FROM THE HONG KONG AIRPORT. IN ADDITION, ON
DISEMBARKATION, WE HAVE USED THE PROCESS OF YELLOW HEALTH ALERT NOTICES TO
INFORM THE TARGETED TRAVELERS ARRIVING TO OUR
COUNTRY FROM AREAS WITH COMMUNITY
TRANSMISSION OF SARS THAT THEY MAY HAVE RECENTLY BEEN EXPOSED. THUS FAR WE HAVE DISTRIBUTED OVER
1 MILLION HEALTH ALERT
NOTICES IN THE UNITED STATES SINCE MARCH 15th.OVER 5,000 AIRLINE
FLIGHTS HAVE
BEEN MET, AND OVER 6,000 SEA VESSELS HAVE BEEN TARGETED FOR THE
DISTRIBUTION OF THESE HEALTH ALERT NOTICES.IN ADDITION, DURING THE PERIOD OF
CONCERN IN TORONTO, 16 LAND CROSSINGS BETWEEN ONTARIO AND THE UNITED STATES
WERE ALSO POSTED, AND 65,000 CONVEYANCES WERE ISSUED HEALTH ALERT NOTICES.THIS
PROVIDES INFORMATION TO ENHANCE AWARENESS AMONG THE TRAVELER AND TO INDICATE
THE SIGNS AND SYMPTOMS OF SARS TO ALLOW FOR RAPID DETECTION AND EARLY
ISOLATION.IT ALSO REMINDS THE TRAVELER TO CALL AHEAD TO THE MEDICAL FACILITY TO
ENSURE SAFE TRANSPORT AND EVALUATION, EVEN IN THE OUTPATIENT SETTING BEFORE THE
PERSON ARRIVES.THERE'S ALSO A MESSAGE ON HERE FOR PHYSICIANS AND WAYS TO
CONTACT THE PUBLIC HEALTH SYSTEM AND CDC.DISEMBARKATION NOTICES OVER THE LAST
TWO MONTHS HAVE BEEN DISTRIBUTED AT THE FOLLOWING PORTS OF ENTRY THROUGHOUT THE
UNITED STATES: 22 AIRPORTS OF ENTRY FOR FLIGHTS ARRIVING FROM SOUTHEAST ASIA, AND
50 ADDITIONAL POINTS OF ENTRY FOR ARRIVALS FROM TORONTO.IN ADDITION, WE HAVE
TARGETED OUR SURVEILLANCE IN THE UNITED STATES AT THESE POINTS OF ARRIVAL AND
HAVE USED AN AGGRESSIVE APPROACH FOR EARLY DETECTION, RAPID RECOGNITION AND
ISOLATION. SHOWN HERE ARE THE LOCATION OF PROBABLE CASES IN RED, AND SUSPECT
CASES IN BLUE FOR THE U.S. CASES OF SARS.IT'S IMPORTANT TO POINT OUT THAT IN OUR
EXPERIENCE WITH THIS EPIDEMIC IN THE UNITED STATES SO FAR, 95% OF THE CASES
HAVE BEEN TRAVEL-RELATED TRANSLOCATIONS. WE HAVE BEEN FORTUNATE NOT TO
EXPERIENCE THE DEGREE OF LOCAL TRANSMISSION AS OTHER COUNTRIES HAVE. HERE ARE SOME
FINAL MEASURES TO THINK ABOUT IN TERMS OF COMMUNITY CONTROL AND CONTAINMENT
JUST COMING ONTO THE HORIZON AS WE LEARN MORE ABOUT THE ENVIRONMENTAL RISKS OF
SARS. THIS IS A PICTURE OF DISINFECTION AND DECONTAMINATION IN THE STREETS OF (GWON JO) AND THIS IS THE RAPID
BUILDING OF A DEDICATED SARS HOSPITAL IN BEIJING, WHICH WAS ACCOMPLISHED IN
UNDER A WEEK'S TIME.OUR LESSONS OF PREPAREDNESS HAVE TAUGHT US THAT WE NEED TO
IDENTIFY IN ADVANCE ADEQUATE MEDICAL RESOURCES AND MEDICAL FACILITIES FOR BOTH
ISOLATION AND QUARANTINE IF WE ARE TO CONTAIN AN EPIDEMIC IN THIS COUNTRY. WE
NEED TO FIND AND IDENTIFY
THANK YOU VERY MUCH.AND THANK YOU, DR. CETRON
JUST A QUICK REMINDER: WE WILL ANSWER YOUR QUESTIONS ABOUT SARS LATER
IN THE BROADCAST, SO HERE ARE OUR CONTACT NUMBERS TO DO THAT YOU MAY CALL
800-793-8598 OR TTY AT 800-815-8152OR YOU CAN FAX YOUR QUESTIONS TO 800-553-6323.
WE CERTAINLY LOOK FORWARD TO HEARING
FROM YOU. NOW, I'D LIKE TO INTRODUCE GENE MATTHEWS.GENE MATTHEWS IS THE CHIEF
LEGAL ADVISER TO THE CDC FROM THE OFFICE OF THE GENERAL COUNSEL.MR. MATTHEWS
WILL TALK TO US ABOUT THE LEGAL ISSUES SURROUNDING CONTAINMENT OF SARS.
MR. MATTHEWS
WELL, THANK YOU.
I APPRECIATE THE
EPIDEMIC.WE NOW USE THE TERM “LEGAL PREPAREDNESS” AS PART OF THE BROADER
CONCEPT OF THIS BROADCAST, WHICH IS COMMUNITY PREPAREDNESS AND IN THIS BRIEF
OVERVIEW, I
WOULD LIKE TO DISCUSS THREE TOPICS
-- THE HISTORICAL CONTEXT, THE CURRENT SITUATION, AND THEN FUTURE EXPECTATIONS. I'D LIKE TO BEGIN WITH DR.
CETRON'S SLIDES FROM A FEW MINUTES AGO ABOUT THE BALANCING OF PUBLIC GOOD AND
PUBLIC
LIBERTIES.I FIND IT VERY INTERESTING TO NOTE THAT IN THIS
MORNING'S "NEW
OBLIGATIONS, AND THE NEED TO RESTRICT
INDIVIDUAL LIBERTIES TO PREVENT THE SPREAD OF DISEASE? SO THERE'S A LOT OF
ENERGY CURRENTLY GOING ON WITH RESPECT TO THIS ISSUE, AND THE REASON INVOLVES A
HISTORICAL CONTEXT. IN THIS PRESENTATION, I HAVE TWO VISUAL METAPHORS TO USE: ONE
IS THE CONCEPT OF SHIPS PASSING IN THE NIGHT, AND A LITTLE BIT LATER I WILL
TALK ABOUT CONNECTING THE SILOS WITH RESPECT TO THE SHIPS PASSING IN THE NIGHT.
IN THIS COUNTRY, SOMEWHERE IN THE 1950s, I WOULD ARBITRARILY PIN 1954 AS THE YEAR,
WITH THE POLIO VACCINE MARKING THE END OF THE NEED FOR U.S. COMMUNITY-WIDE
PUBLIC HEALTH CONTROL MEASURES WHICH PREVIOUSLY WENT BACK NEARLY 300 YEARS IN
THIS COUNTRY. ABOUT THE SAME TIME,YOU CAN LOOK AT THE
SUPREME COURT EVOLUTION BEGINNING WITH THE CASE OF BROWN VERSUS BOARD OF EDUCATION.
THIS MARKED THE BEGINNING OF PROCEDURAL PROTECTIONS OF INDIVIDUAL LIBERTIES
AGAINST GOVERNMENT ACTION. THE PARADOX THAT WE HAVE WITH RESPECT TO ISOLATION
AND QUARANTINE IS, BECAUSE OF THIS HISTORICAL COINCIDENCE, WE NEVER REALLY
CONNECTED THE QUARANTINE SHIP, WHICH WAS SAILING INTO PORT IN 1954, WITH THE INDIVIDUAL
RIGHTS AND LIBERTIES SHIP THAT WAS BEGINNING TO SAIL OUT IN 1954.SO WE HAVE NOT
CONNECTED TOGETHER THIS RICH LEGAL TEXTURE OF PROCEDURAL DUE PROCESS, AND STRICT
JUDICIAL SCRUTINY, AND A LOT OF OTHER THINGS THAT THE JUDICIARY, THE
LEGISLATURES, AND THE EXECUTIVE BRANCH HAVE EVOLVED IN THIS CULTURE IN THE PAST
50 YEARS. SO IT'S IMPORTANT TO KEEP THIS PARADOX IN MIND. HISTORICALLY, THE
PUBLIC HEALTH IS A POLICE POWER AND UNDER THE TENTH AMENDMENT OF THE U.S.
CONSTITUTION, MOST POLICE POWER IS RESERVED TO THE STATES.THE FEDERAL FUNCTIONS
AS NOTED ON YOUR SCREEN ARE FOR INTERNATIONAL SITUATIONS, FOR INTERSTATE, AND
ALSO THE ISSUE OF FEDERAL FUNDING AND ASSISTANCE PROVIDED PARTICULARLY WITH
RESPECT TO SARS TO STATE AND LOCAL GOVERNMENTS. THE SECOND METAPHOR THAT I WANT
TO LAY OUT IS THE CONCEPT OF THE SILOS THAT HAVE EVOLVED IN THIS COUNTRY.WE
HAVE A WHOLE SET OF SILOS,PUBLIC HEALTH, LAW ENFORCEMENT,EMERGENCY MANAGEMENT,
HEALTH CARE SERVICES, THE JUDICIARY, AND THESE ALL OPERATE ON THE FEDERAL, THE
STATE AND THE LOCAL LEVEL. PART OF THE IMPORTANCE OF WHAT WE'RE DOING TO
CONNECT TOGETHER THOSE SHIPS, THE TWO HISTORICAL THINGS THAT OCCURRED IN THIS
COUNTRY, IS TO CONNECT TOGETHER THE VARIOUS CELLS IN THE SILOS, SO THAT WE ARE UNDERSTANDING
WHAT THE OTHER CULTURES OR SUBCULTURES ARE DOING WITH RESPECT TO PUBLIC HEALTH
AND LAW ENFORCEMENT, AND THE JUDICIARY, SO IN AN EMERGENCY, WE KNOW BEST HOW TO
USE ASSETS THAT ARE AVAILABLE. TAKES US UP TO THE CURRENT SITUATION, WHICH IS
GENERALLY THAT INDIVIDUAL STATES ARE RESPONSIBLE FOR THE INTRASTATE PUBLIC
HEALTH CONTROL MEASURES USING THEIR LAWS. YOU SHOULD NOTE THAT THERE IS
SIGNIFICANT VARIATION AMONG STATE LAWS, AND SOME LOCAL JURISDICTIONS MAY HAVE
PUBLIC HEALTH CONTROL PROVISIONS THAT ARE EASIER TO USE THAN THE STATE PROVISIONS.SO
AGAIN, THE -- CONNECTING THE SILOS COMES INTO PLAY.ALSO, STATE, LOCAL AND
PUBLIC HEALTH OFFICERS DO HAVE EXPERIENCE DEALING IN INDIVIDUAL CONTROL
MEASURES SUCH AS ISOLATING OF INFECTIOUS TB PATIENTS, DEALING WITH SCHOOL ATTENDANCE
AND IMMUNIZATIONS, OR DEALING WITH MENTAL HEALTH COMMITMENTS.BUT GENERALLY, WE
DON'T HAVE A LOT OF EXPERIENCE DEALING WITH COMMUNITY PREVENTION MEASURES.NOW,
WITH RESPECT TO THE FEDERAL GOVERNMENT, THE FEDERAL GOVERNMENT HAS CONCURRENT
POWER TO APPREHEND, DETAIN OR CONDITIONALLY RELEASE INDIVIDUALS TO PREVENT
EITHER
INTERSTATE SPREAD OR INTERNATIONAL
IMPORTATION OF CERTAIN DISEASES. THOSE FEDERALLY QUARANTINED DISEASES MUST BE LISTED IN AN EXECUTIVE
ORDER SIGNED BY THE PRESIDENT. AS DR.
CETRON MENTIONED A MINUTE AGO, THOSE QUARANTINEABLE
DISEASES WERE UPDATED ON APRIL 4th BY ADDING SARS TO THE LIST AS A
PRUDENT PUBLIC HEALTH PREPAREDNESS MEASURE.THE OTHER SEVEN DISEASES HAD BEEN
FINALLY, ON THE ENFORCEMENT ISSUE, WE NEED TO REMEMBER THAT EACH
LEVEL OF PUBLIC HEALTH MUST EFFECTIVELY CONNECT WITH THEIR RESPECTIVE
LAW ENFORCEMENT COUNTERPARTS TO ASSIST
IN THE NECESSARY CARRYING OUT OF A COMPULSORY PUBLIC HEALTH ORDER. THIRD, NOW, LET'S
TALK FOR A MINUTE ABOUT FUTURE EXPECTATIONS. ONE IMPORTANT ACTION STEP THAT NEEDS
TO BE WORKED OUT IS THE
NEED TO LOOK AT THE ISSUE OF DUE PROCESS FOR QUARANTINE AND ISOLATION.
STATE PROCEDURES WILL VARY, OR MAY NOT EVEN DIRECTLY ADDRESS THE
DUE PROCESS ISSUES FOR QUARANTINE AND ISOLATION ORDERS.BUT REMEMBER THAT COURTS
MAY
ULTIMATELY REVIEW QUARANTINE AND ISOLATION ORDERS, AND REMEMBER THAT
DUE PROCESS IS A FLEXIBLE CONCEPT. WE GO BACK TO DR. CETRON'S SLIDE ABOUT THE
BALANCING
TO AGREE ON, THAT SHOULD BE THOUGHT THROUGH AS WE GO FORWARD WITH
THIS, ARE THE NEED FOR ADEQUATE NOTICE TO THE PERSON,THAT IS, A WRITTEN ORDER;
THE
RIGHT FOR THE PERSON TO BE HEARD SOMEWHERE IN THIS PROCESS, THAT IS,
TO PRESENT EVIDENCE AND WITNESSES; AND TO CONFRONT THE EVIDENCE OF THE
GOVERNMENT IN
ISSUING THE QUARANTINE OR ISOLATION ORDER TO PROVIDE ACCESS TO
LEGAL COUNSEL
AND A FINAL DECISION THAT A COURT CAN THEN REVIEW. JUST LOOKING AT
THE VISION FOR THE FUTURE OF WHERE WE'RE TRYING TO GO WITH THIS, IT IS
IMPORTANT THAT THE HEALTH OFFICERS BE IN CLOSE COMMUNICATION WITH THEIR PUBLIC
HEALTH LEGAL ADVISORS -- BOTH PARTIES NEED TO BE IN TOUCH WITH THEIR RESPECTIVE
LAW ENFORCEMENT COUNTERPARTS AS WE GO FORWARD. ON THAT NOTE, I CALL TO YOUR
ATTENTION THAT CDC, WITH THE HELP OF THE DEPARTMENT OF JUSTICE AND
A
EPIDEMIOLOGY TRAINING COURSE FOR BOTH
LAW ENFORCEMENT AND PUBLIC HEALTH OFFICIALS IN RESPONDING TO BIOTERRORISM
INVESTIGATIONS.
THIS IS PART OF THE
CONNECTIONS THAT WE'RE TRYING TO
K DANIELS: ALL RIGHT, SO BALANCING TEST, HISTORICAL REALITY AND
CONNECTING THE SILOS. THANK YOU, MR. MATTHEWS. RIGHT NOW I WANT TO ONCE AGAIN REMIND
OUR VIEWERS THAT WE WILL HAVE A QUESTION-AND-ANSWER SEGMENT LATER IN THIS
BROADCAST,AND WE CERTAINLY WELCOME YOUR QUESTIONS.YOU
MAY PHONE US AT 800-793-8598 OR USE OUR TTY SERVICE AT 800-815-8152 OR YOU MAY
FAX YOUR QUESTION TO 800-553-6323. THE QUESTION-AND-ANSWER
SEGMENT WILL BEGIN AFTER TODAY'S FINAL PRESENTER. OUR NEXT PANELIST IS
DR. ART LIANG, WHO WILL SPEAK TO US ABOUT STEPS CDC IS TAKING TO ADDRESS THE
IMPACT OF QUARANTINE AND ISOLATION MEASURES AT THE COMMUNITY LEVEL AND WELCOME
TO YOU, DR. LIANG. THANK YOU.
GOOD AFTERNOON.
A PROFESSOR OF MINE ONCE SAID THAT EVERY MEDICATION HAS TWO EFFECTS,
THE ONE YOU WANT AND THE ONE YOU DON'T WANT, AND AS WE'VE ALREADY HEARD FROM SOME
OF THE SPEAKERS TODAY, WE'VE ITEMIZED NOT ONLY THE INTENT OF OUR PUBLIC HEALTH
INTERVENTION IN THIS CASE, BUT ALSO
SOME OF THE POSSIBLE SIDE EFFECTS. WELL, AT LEAST SOME OF US AT THE TABLE ARE NOT LAWYERS, WE'RE NOT
ECONOMISTS, WE'RE NOT SOCIAL WORKERS, SO ONE MIGHT WONDER WHY WE CARE ABOUT THIS.
THE QUICK ANSWER IS THAT WE CARE BECAUSE THIS IS A REALLY PUBLIC HEALTH ISSUE. HISTORY
HAS SHOWN THAT IF OUR INTERVENTIONS HAVE UNDULY, PUNISHING CONSEQUENCES, EITHER
BY PERCEPTION OR IN REALITY, THIS UNDERMINES THE EFFECT OF THE INTERVENTIONS.
IN THIS CASE, WE CAN ACTUALLY DRIVE THOSE WHO SHOULD BE REPORTING ILLNESS UNDERGROUND, AT LEAST THAT WOULD BE THE CONCERN. IN FACT, IN
THIS OUTBREAK, WE ACTUALLY HAVE HEARD, AND AS MANY OF YOU IN THE AUDIENCE HAVE
AS WELL, DISTURBING COMMENTS. HERE ARE A COUPLE OF THE COMMENTS THAT THE CDC
RECEIVED THROUGH ITS HOTLINE AND, OF COURSE, WE'VE SEEN ARTICLES IN THE PAPER
ABOUT THE IMPACT ON BUSINESSES IN VARIOUS CHINESE COMMUNITIES. SO IN ORDER TO
GET A HANDLE ON THIS – WAS REALLY A PROBLEM? AND HOW BIG WAS IT?-, WE ACTUALLY
CONDUCTED MORE THAN (60 INTERVIEWS -- ACTUALLY, NOW EIGHT DISCUSSIONS)
INVOLVING KEY INFORMANTS FROM WITHIN AND FROM OUTSIDE THE ASIAN COMMUNITY REPRESENTING
NATIONAL, STATE AND LOCAL ORGANIZATIONS, STATE AND LOCAL HEALTH DEPARTMENTS,
PEOPLE FROM BOTH PRIVATE SECTORS, AS WELL AS THE PUBLIC SECTOR, ACADEMIA,
FOR-PROFIT AS WELL AS NONPROFIT. IN ADDITION, KNOWING THAT OTHER GROUPS ARE
SUBJECT TO UNREASONABLE STIGMATIZATION, WE ALSO SAT IN ON MEETINGS THAT DR.
JERNIGAN AND OUR OCCUPATIONAL TEAMS HAD WITH THE AIRLINE WORKERS AS WELL AS HEALTH
CARE WORKERS. WE ALSO GATHERED MORE SYSTEMATIC INFORMATION FROM THE CDC HOTLINE
AS WELL AS OBTAINED SOME INFORMATION FROM A
SURVEY. IT WAS NOT SPECIFICALLY DIRECTED AT
ISSUES OF STIGMA OR DISCRIMINATION PER SE, BUT WAS REALLY A CROSS-SECTION OF QUESTIONS
TRYING TO GAUGE THE
KNOWLEDGE BASE OF THE GENERAL PUBLIC. AGAIN, YOU CAN SEE THAT THERE ARE
AT LEAST SOME NOTIONS BEING HELD BY THE PUBLIC THAT DON'T QUITE GIBE, AT LEAST
WITH THE DATA THAT WE HAVE IN THE UNITED STATES ABOUT THE NATURE OF THIS
OUTBREAK.IN GENERAL, PULLING ALL THESE BITS OF DATA TOGETHER, I THINK WE
CONCLUDED THAT THE FEAR ACTUALLY IN THE GENERAL POPULATION WAS NOT
SUBSTANTIAL.EVEN IF THE KNOWLEDGE WAS A LITTLE BIT SHORT ON THE OTHER HAND – IT
WOULD SEEM THAT THIS KNOWLEDGE GAP DID TRANSLATE INTO SOME SUBSTANTIAL CONCERNS
ON THE PART OF THE ASIAN-AMERICAN COMMUNITY, SOME HEALTH CARE WORKERS AND SOME
WORKING IN THE TRAVEL INDUSTRY. IT DID SEEM THAT THERE WAS NOT A GOOD SENSE OF
THE ACTUAL RISK, AT LEAST IN THE
THAT CAN BRING US IN CONTACT WITH THE VIRUS. SPECIFICALLY,
INFORMATION IS THE INTERVENTION. AS THIS SLIDE SHOWS, THERE ARE ACTUALLY OVER 90
DOCUMENTS ON THE CDC WEB SITE, THAT ARE THE
NATURE OF QUESTIONS THAT PEOPLE MIGHT HAVE ABOUT RISK AND
PREVENTION. THESE ARE JUST A FEW EXAMPLES I
PICKED OUT, MAINLY TO DEMONSTRATE THE NEED TO ADDRESS PEOPLE'S REAL CONCERNS AND
TO BE VERY CLEAR ABOUT WHAT PEOPLE SHOULD WORRY ABOUT, AS WELL AS WHAT THEY
DON'T NEED TO WORRY ABOUT, - TO TRY TO GIVE SIMPLE, CLEAR MESSAGES ON WHAT THEY
CAN DO ABOUT IT. AS I MENTIONED FROM OUR QUICK ASSESSMENT, WE DID FIND THAT THERE
WAS A LOT OF FEAR WITHIN THE ASIAN COMMUNITY ITSELF AND HERE WE HAVE TO GIVE SOME
THANKS TO THE COMMUNITY-BASED ORGANIZATIONS AND STATE AND LOCAL HEALTH DEPARTMENTS
WITH WHOM WE SPOKE.
THEY ACTUALLY HELPED US COME TO THE REALIZATION THAT THE – THAT THESE
COMMUNITIES NEEDED TARGETED MESSAGES, - SIMPLE, AND STRAIGHTFORWARD, AND OF
COURSE, HAVING THEM IN LANGUAGE WAS A BENEFIT. FINALLY, THE LAST STRATEGY IS
SUPPORTING THOSE GROUPS THAT MAY BE STIGMATIZED.HERE ARE A LIST OF SOME OF THE ACTIVITIES
THAT WE'VE EITHER UNDERTAKEN OR ARE PLANNING TO UNDERTAKE. I JUST WANTED TO
POINT OUT THE LAST BULLET, WHICH IS TO NOT FORGET ABOUT THE OCCUPATIONAL GROUPS
THAT MIGHT ALSO BE SUBJECT TO FEAR WITHIN THE GROUP AS WELL AS FROM WITHOUT. --
IN A DAY FULL OF BALANCING ACTS, THERE ARE A COUPLE OF POINTS TO REMBEMBER:
ONE, OF COURSE IS THAT -- OUR INFORMATION IS EVOLVING, THINGS ARE CHANGING. WE'RE
LEARNING NEW THINGS EVERY DAY. AND NUMBER TWO, SOMETHING WE LEARNED ALONG THE
WAY, IT'S OFTEN TEMPTING TO RESPOND TO SOME OF THESE OUTRAGEOUS STATEMENTS IN A
VERY
ALTHOUGH THESE FOLKS CAN OVERREACT, THIS OVERREACTION CAN BE
CONTAGIOUS IN A MANNER OF SPEAKING. THE SOLUTION TO THIS, OF COURSE, IS TO
COMBAT THE FEAR WITH GOOD INFORMATION DELIVERED THROUGH PUBLIC HEALTH, COMMUNITY
CLINICIANS, THROUGH ALL OUR PUBLIC HEALTH PARTNERS. THANK YOU
VERY MUCH.
AND THANK YOU, DR. LIANG.
A KEY PHRASE, INFORMATION IS THE INTERVENTION. I'D LIKE TO REMIND
OUR VIEWERS
THAT WE WILL HAVE A QUESTION-AND-ANSWER
SEGMENT AFTER THIS NEXT PRESENTATION. YOU MAY SUBMIT YOUR QUESTIONS VIA TELEPHONE. THE NUMBER TO DIAL
IS
800-793-8598 OR, USE TTY AT 800-815-8152 OR YOU MAY FAX YOUR
QUESTIONS TO
800-553-6323. OUR FINAL PRESENTER COMES TO US LIVE FROM
DR. D'CUNHA, DR. COLIN D'CUNHA IS THE COMMISSIONER OF PUBLIC HEALTH,
CHIEF MEDICAL OFFICER OF HEALTH FOR THE
DR. D'CUNHA. THANK YOU.
GOOD AFTERNOON, LADIES AND GENTLEMEN
I AM GOING TO APPROACH MY PRESENTATION FROM THREE PERSPECTIVES: FIRST
AND FOREMOST THE PUBLIC HEALTH PRINCIPLES. THE SECOND IS THE LEGAL FRAMEWORK AND
FINALLY, IMPLEMENTATION ISSUES.WHEN WE LOOK AT THE EPIDEMIOLOGY OF SARS, WE HAD 136 PROBABLE CASES, 23 DEATHS INVOLVING SIX DIFFERENT
LOCAL HEALTH PROBLEMS. A POPULATION OF ABOUT 5 MILLION IN
VAST MAJORITY OF
FACT THAT NOT MUCH WAS KNOWN ABOUT SARS AT THAT POINT IN TIME AND
THAT WE WERE ABSOLUTELY DETERMINED TO SET ABOUT CONTROLLING THIS DISEASE, WE
USED THE PUBLIC HEALTH PRINCIPLES OF CASE FINDING, CONTACT ISOLATION, AND
STRICT QUARANTINE TO BRING THE RING OF CONTROL AROUND, - I BELIEVE WE SUCCEEDED.
SIMPLY PUT, IF SOMEONE WAS A PERSON UNDER INVESTIGATION, MET THE CASE
DEFINITION OF SUSPECT,
OR WAS A PROBABLE CASE, THEY WERE IMMEDIATELY ISOLATED. DEPENDING
ON THEIR CLINICAL CIRCUMSTANCES, THEY WERE EITHER ISOLATED AT HOME, WHICH WAS
THE
VAST MAJORITY OF PEOPLE, OR ISOLATED IN A HOSPITAL UNDER APPROPRIATE
RESPIRATORY
ISOLATION PRECAUTIONS. BECAUSE THAT WAS OUR UNDERSTANDING
OF THE SPREAD OF
DISEASE AT THAT STAGE, AND SOMETHING
THAT WE HAVE NO REASON TO DOUBT TODAY. WHEN IT CAME TO CONTACTS, WE PUT THE CONTACTS IN HOME ISOLATION, AND
WE DID HAVE TO DEAL WITH A FEW SOCIAL SITUATIONS THAT I WILL DISCUSS IN A FEW
MINUTES LATER
IN MY PRESENTATION. IN TERMS OF ITS IMPACT, WE ARE STILL
TOTALING UP THE ECONOMIC IMPACT OF SARS ON US HERE IN
ORGANIZATION TO PLACES AS FAR AWAY AS
COMMUNITY-ACQUIRED PNEUMONIA THAT
WAS SUBSEQUENTLY INVESTIGATED AND THOUGHT NOT TO BE SARS. IN TERMS OF SETTING THE LEGAL CONTEXT,
I NEED FIRST TO MAKE VERY CLEAR THAT IN
AND HAVING RESPONSIBILITY FOR THE QUARANTINE
ACT. HEALTH CARE
IS PREDOMINANTLY THE
BUSINESS OF THE PROVINCES, WHICH ARE EQUIVALENT TO THE STATES IN THE
QUARANTINE INTERCHANGEABLY, EXCEPT IN THE LEGAL SENSE, IN WHICH
CASE IF IT'S THE FEDERAL ACT THAT'S INVOKED AT A BORDER CROSSING. IF IT'S
WITHIN THE PROVINCE, THE
TO RECOMMEND ACTIONS, OR TO FORCE
PEOPLE TO TAKE ACTIONS TO PREVENT THE SPREAD OF COMMUNICABLE DISEASE. PRIOR TO SARS
COMING UNDER THE ACT. - SARS WAS NOT KNOWN AS SUCH UNTIL THE MIDDLE OF
MARCH – ACT. ALLOWS THE MINISTER OR THE CHIEF MEDICAL OFFICER TO DEAL WITH THE INFECTION
USE DISEASE. RECOGNIZING WHAT WE WERE GETTING INTO, I MADE A RECOMMENDATION TO
THE MINISTER OF HEALTH, WHO TOOK FIVE MINUTES TO AGREE, AND WORKING
WITH OUR LEGAL COUNSEL WE DRAFTED THE NECESSARY PAPERWORK TO MAKE SARS A
REPORTABLE COMMUNICABLE DISEASE. MAKING IT “REPORTABLE” ALLOWED HEALTH CARE
PROVIDERS TO REPORT THE DISEASE TO LOCAL PUBLIC HEALTH AUTHORITIES WITH THE FORCE
OF LAW. MAKING IT “COMMUNICABLE” GAVE OUR 37 MEDICAL OFFICES THE POWER TO
REQUIRE PEOPLE SUSPECTED OF HAVING SARS TO TAKE OR NOT TAKE CERTAIN ACTIONS.
MAKING IT A REPORTABLE COMMUNICABLE DISEASE MEANT THAT PEOPLE WHO DID NOT
FOLLOW THE LEGAL POWER OF THE MEDICAL OFFICER WOULD BE SUBJECTED TO A COURT
AUTHORITY, THUS ALLOWING OUR ACTIONS IN PUBLIC HEALTH TO BE SUBJECTED TO REVIEW
PROCESS. BECAUSE ANY PERSON WHO IS IN RECEIPT OF SUCH AN ORDER - AS I REPORTED,
43 PEOPLE DID RECEIVE SUCH ORDERS - DID HAVE RECOURSE TO THE COURTS AS THEY
DESIRED. AS BEST AS I UNDERSTAND IT, NONE OF THEM CHOSE TO GO TO JUDICIAL REVIEW,
BECAUSE I SUSPECT THEY UNDERSTOOD THE CONSEQUENCES OF THE ORDER AND FELT THEIR
POINT OF VIEW WAS TAKEN INTO ACCOUNT BEFORE THE ORDER WAS IN FACT FOLLOWED
THROUGH. IN TERMS OF WORKING WITH SOME OF THE PRACTICAL ISSUES, WE WORKED VERY
CLOSELY WITH LAW ENFORCEMENT OFFICIALS. ONE OF THE REASONS WHY WE DECLARED A
PROVINCIAL HEALTH EMERGENCY WAS THAT OUR EXISTING PUBLIC HEALTH INFORMATION
SYSTEM DID NOT HAVE GOOD ELECTRONIC DATABASES THAT COULD COPE WITH THE HUGE
NUMBER OF CONTACTS THAT WE POTENTIALLY HAD TO FOLLOW. SO WE TAPPED INTO THE LAW
ENFORCEMENT CONTACT MANAGEMENT ELECTRONIC
INFORMATION SYSTEM.
WE USED THAT TO VERY SUCCESSFULLY TRACK AND TO PLAN HOW TO INTEGRATE THIS INTO
OUR PUBLIC HEALTH INFORMATION. WE RAN INTO A WHOLE VARIETY OF SOCIAL SUPPORT
ISSUES VERY SPECIFICALLY, ADDRESSING THE ESSENTIALS OF LIFE, SUCH AS WHETHER
IT'S BUYING GROCERIES, WHETHER IT'S PAYING BILLS, AND OTHER DAY-TO-DAY, MUNDANE
TASKS
THAT WE ALL TAKE FOR GRANTED THAT BECOME A CHALLENGE WHEN GOING
INTO QUARANTINE. WE RAN INTO ISSUES INVOLVING PERSONS WHO WERE IN
AND NOT BE PENALIZED. THIS INVOLVED ALL THREE LEVELS OF GOVERNMENT
IN THE
COUNTRY WORKING VERY CLOSELY TOGETHER AND FINALLY, WE RAN INTO COMPENSATION
ISSUES. IN THE EARLY DAYS, THROUGH THE EMPLOYMENT INSURANCE PROGRAM FOR
FOLKS WHO HAD EMPLOYMENT INSURANCE, WHICH IS ANYBODY WHO'S
EMPLOYED AND PAYS A FIXED SMALL AMOUNT OF THEIR NOMINAL SALARY, THEY HAD SOME
COVERAGE. FOR PEOPLE WHERE IT WAS RELATED TO THEIR WORKPLACE, AND THE WORKPLACE
WAS COVERED BY WORKER'S COMPENSATION, THAT WAS ADDRESSED. BUT WE RECOGNIZED A
VARIETY OF OUR HEALTH CARE PROVIDERS AND PHYSICIANS ARE IN GENERAL SELF-EMPLOYED.
THE GOVERNMENT IS WORKING THROUGH THE APPLICATION OF FAIR POLICIES TO ADDRESS
ALL THE COMPENSATION ISSUES. I'D LIKE TO CLOSE, AND WOULD BE DELIGHTED TO TAKE
QUESTIONS.THANK YOU.
>> AND THANKS TO YOU, DR. D'CUNHA, TALK BG HOW OFFICIALS ARE
CONTAINING THE
SPREAD OF SARS IN
THE NUMBERS ONCE AGAIN ARE BY PHONE, 800-793-8598 TTY,
800-815-81526789 AND THEN
BY FAX, 800-553-6323.
DR. JERNIGAN, A CO-LEADER FOR THE SARS CLINICAL AND INFECTION CONTROL
TEAM AT CDC, WILL ANSWER YOUR QUESTIONS, ALONG WITH THE REST OF OUR PANEL. WE WELCOME DR. JERNIGAN;
NOW LET'S BEGIN RIGHT OFF THE TOP WITH A QUESTION FROM
WASHINGTON.DR. JERNIGAN, WHAT CAN CDC DO TO HELP WITH QUARANTINE
AND ISOLATION AT THE LOCAL LEVEL? ACTUALLY, THAT'S A QUESTION THAT I'LL DIRECT
TO
DR. CETRON. SURE. I THINK IT'S IMPORTANT THAT THERE ARE SEVERAL
WAYS IN WHICH
THROUGH PARTNERSHIPS, CDC TOGETHER WITH LOCAL AND STATE GOVERNMENTS
CAN HELP DEAL WITH THIS ISSUE IN THE PREPAREDNESS REALM. ONE OF THEM IS TO
SHARE THE
LESSONS LEARNED GLOBALLY THAT OUR FIELD FOLKS HAVE GLEANED FROM
BEING ON THE FRONT LINES WITH W.H.O. IN SOME OF THE HARD-HIT AREAS AFFECTED BY
SARS.
SOME OF THOSE IMPORTANT LESSONS YOU HEARD FROM DR. D'CUNHA, INCLUDING
THAT THE VAST MAJORITY OF PERSONS WILL VOLUNTARILY DO THE RIGHT THING, AND DO
NOT NEED
TO BE SERVED ANY LEGAL ORDERS, ONLY HAS TO APPLY IN THE MINORITY
OF INSTANCES. IN ADDITION, WE CAN
PROVIDE TECHNICAL ASSISTANCE ON STRATEGIC PLANNING BY DEFINING THE REQUIREMENTS
FOR SARS WARDS OR HOSPITALS, AS WELL AS DEDICATED RESIDENTIAL FACILITIES. WE
CAN PROVIDE--AND HAVE ALREADY DONE SO THROUGH LEADERSHIP IN MR. MATTHEWS' SHOP--
MODELS, STATE LAWS THAT WILL HELP STATES UNDERSTAND AND KNOW THEIR ROLES AND RESPONSIBILITIES,
AND WHAT KIND OF TOOLS THEY NEED TO HAVE IN THEIR POSSESSION. IN ADDITION, I
THINK THAT THE FINANCIAL ASSISTANCE, TOGETHER THROUGH THE GRANTS PROCESS OF THE
FEDERAL GOVERNMENT, IS ANOTHER WAY THAT WE CAN ENHANCE OUR PREPAREDNESS AND
PLANNING. ALL RIGHT.
DR. CETRON, THANK YOU FOR THAT RESPONSE. THIS QUESTION IS FROM LINDA, IN
OR TO A CREW MEMBER. IN FACT, GIVEN THE MILLIONS OF FOLKS WHO HAVE
FLOWN OVER THE COURSE OF THE PAST TWO MONTHS, THE ACTUAL NUMBER OF CASES THAT
HAVE BEEN ASSOCIATED WITH TRANSMISSION IN FLIGHT IS QUITE SMALL, BUT THIS DOES
NOT MEAN THAT THE RISK IS ZERO. THERE ARE CLEARLY MEASURES THAT CAN BE TAKEN TO
MITIGATE OR REDUCE THIS RISK. CERTAINLY IN THE PRIMARY ONE THAT W.H.O. AND
OTHERS HAVE RECOMMENDED IS THE PREVENTING OF SICK PERSONS FROM EMBARKING AND GETTING
ON AIRPLANES TO TRANSLOCATE DISEASE IN THE FIRST PLACE.IT'S ALSO IMPORTANT TO
NOTE THAT SINCE THE INSTITUTION OF THESE AIRPORT SCREENING RECOMMENDATIONS,
BOTH BY QUESTION-BASED DEFERRAL AS WELL AS THERMAL SCANNING AND TEMPERATURE
MONITORING, THERE HAVE BEEN NO ADDITIONAL REPORTED CASES OF TRANSMISSION AS
BOTH THE CONTROL AND CONTAINMENT MEASURES HAVE TAKEN PLACE RIGOROUSLY WITHIN
THOSE COUNTRIES. AT THE PORTS OF EMBARKATION, WE REALLY SEEM TO BE ADDRESSING
THIS ISSUE IN LARGE PART. THE RISK IS NOT ZERO, BUT IT IS APPARENTLY VERY LOW, AND
WITH CONTAINMENT AND CONTROL MEASURES THAT
THIS QUESTION IS FROM
DETAINEES WHO ARE ARRIVALS FROM HIGH-RISK
AREAS. DO YOU
HAVE RECOMMENDATIONS FOR
REDUCING THE POTENTIAL FOR TRANSMISSION IN A CORRECTIONAL INSTITUTION?
DR. CETRON, THERE ARE FOLKS FROM OUR QUARANTINE, GLOBAL MIGRATION
AND QUARANTINE AREA, TOGETHER WITH DR. JERNIGAN'S INFECTION ANDCONTROL TEAM WHO
ARE COMING UP WITH GUIDANCE. AND AS WE'VE SEEN FROM OTHER COMMUNICABLE
DISEASES, DETENTION CENTERS AND JAILHOUSES ARE NOT THE KINDS OF PLACES WHERE
--THAT WE WOULD CONSIDER APPROPRIATE ISOLATION OR QUARANTINE FACILITIES.IN PART
OF THE GUIDANCE, WE TALKED ABOUT DEFINING WHAT ARE APPROPRIATE FACILITIES.THESE
CLOSE CROWDING, HIGH-RISK SITUATIONS IN WHICH PATHOGENS CAN GO BOTH UNRECOGNIZED
AND AMPLIFY AND ARE SPREAD ARE NOT GOOD SETTINGS AT ALL. WE WOULD HIGHLY
RECOMMEND AGAINST THOSE APPROACHES.
>> OKAY.YOU HAVE SOMETHING TO ADD?>> MR. MATTHEWS YES,
IF I COULD JUST ADD, THE CASE THAT WAS CITED ON THE SLIDE, THE CALIFORNIA CASE,
IT WAS A CALIFORNIA STATE APPEALS COURT TAKING A VERY DIM VIEW OF THE WAY A
TUBERCULOSIS PATIENT WAS ISOLATED IN A COUNTY JAIL FACILITY IN
CALIFORNIA.THAT'S THE 2002 DECISION.SO IT'S VERY TIMELY. I AGREE WITH WHAT DR.
CETRON SAID ON THE MATTER. DR.DANIELS THIS NEXT QUESTION IS FROM NEW
JERSEY.DOES THE CDC RECOMMEND TAKING TEMPERATURES OF PEOPLE RETURNING FROM
SARS-INFECTED COUNTRIES? IF SO, HOW OFTEN SHOULD THE TEMPERATURE BE TAKEN? DR.
JERNIGAN. OUR RECOMMENDATIONS HAVE INCLUDED THE ACTIVE SURVEILLANCE OF PEOPLE
THAT -- WHO ARE AT RISK. FOR THOSE WHO HAVE HAD CLOSE CONTACT WITH PROBABLE
CASES OF SARS. NOW, SIMPLY RETURNING FROM THE AFFECTED AREA WOULD NOT NECESSARILY
CONSTITUTE A NEED FOR ACTIVE SURVEILLANCE IN THE UNITED STATES, AS WE CURRENTLY
ARE IMPLEMENTING THAT AND THAT SIMPLY MONITORING YOUR OWN HEALTH, AS IS
INDICATED ON THE YELLOW CARD, AND MONITORING YOUR OWN TEMPERATURE FOR THE DEVELOPMENT
OF A FEVER WOULD BE VERY USEFUL AND IMPORTANT. AND IN GENERAL, FEVER LOGS ARE SOMETIMES
KEPT ABOUT TWICE A DAY. IT IS IMPORTANT TO POINT OUT THAT WE HAVE SEEN
SITUATIONS OF COMMUNICABILITY OF SARS, EVEN IN THE STAGE AFTER FEVER HAS EMERGED.
SO CHECKING YOUR TEMPERATURE, PERHAPS TWICE A DAY. WHICH
YOU CAN DO IT ON YOUR OWN, AND CALLING AHEAD IF YOU DEVELOP FEVER OR SYMPTOMS
OF SARS, TO GET FURTHER ADVICE AND PROVIDE SAFE TRANSPORT. DR. DANIELS. I THINK DR. D'CUNHA WANTS TO WEIGH
IN ON THIS SUBJECT. GO AHEAD. >> DR. D’CUNHA. TO COMPLEMENT WHAT WAS JUST
SAID, WHAT I WANT TO STRESS IS THAT IT'S KEY THAT INCOMING TRAVELERS HAVE THEIR
TEMPS TAKEN --PARTICULARLY IF THEY COME FROM HIGH-RISK AREAS. SECOND, NOT JUST
KEEPING A TEMPERATURE LOG, BUT LOOKING OUT FOR THE OTHER SIGNS AND SYMPTOMS. OUR
EXPERIENCE WAS IT'S NOT FEVER THAT NECESSARILY WAS THE START,
IT'S ONE OF THE EARLY PROGRAMMABLE SIGNS. AND KEEP CLOSE TOUCH WITH ONE'S HEALTH
CARE PROVIDER AND LOCAL HEALTH AUTHORITY, DEPENDING ON HOW THINGS ARE ORGANIZED
FROM STATE TO STATE.>> DR. DANIELS AND DR. D'CUNHA, ANOTHER QUESTION FOR
YOU, OR A QUESTION FOR YOU FROM ILLINOIS. HOW DID CANADA KEEP TRACK OF 19,000
PERSONS IN QUARANTINE, AND THEN THE OTHER PART OF THE QUESTION IS, DID SOMEONE
WATCH THEM, OR DID THEY JUST TAKE THEIR WORD THAT THE PERSONS FOLLOWED THE
QUARANTINE ORDER? DR.
D’CUNHA SURE. ESSENTIALLY, AS I POINTED OUT, PUBLIC HEALTH IS DELIVERED
BY THE 37 MEDICAL OFFICERS OF HEALTH. THE BULK OF THESE 19,000 INDIVIDUALS WHO
WERE IN QUARANTINE WERE LOCATED ACROSS EIGHT JURISDICTIONS, WITH A COUPLE IN
THREE OTHER OUTLYING AREAS.THE WAY THE HEALTH QUARANTINE WAS MONITORED WAS, FOR
LOWER SITUATIONS, TWO PHONE CALLS A DAY. WE DID GET OTHERS THAT I'LL SPEAK ABOUT IN A
MINUTE. IF WE HAD DOUBT THAT SOMEONE WAS EITHER COMPLYING OR THAT A STORY WAS
BEING SPUN, A DOOR KNOCKING WAS ACTUALLY UNDERTAKEN AND WHERE APPROPRIATE,
POLICE WERE DISPATCHED.BECAUSE WE WERE IN A STATE OF A PROVINCIAL HEALTH
EMERGENCY. ONE THAT WE WERE FOOLED WAS AN UNIDENTIFIED SITUATION WHERE THE SPOUSE
INDICATED THAT THE INDIVIDUAL WAS AT HOME IN QUARANTINE, ALONG WITH THE SPOUSE.
IT TURNED OUT THAT THE INDIVIDUAL NOT ONLY ENDED UP GOING TO WORK, BUT INFECTED
ANOTHER WORKER; ALL OF THIS CAME OUT AFTER THE FACT. BUT BY FAR AND LARGE, I
WOULD LIKE TO STRESS, AND AS THE PREVIOUS SPEAKER CORRECTLY NOTED, THE VAST MAJORITY
OF PEOPLE WHO WERE ASKED TO GO INTO QUARANTINE COMPLIED WITH THE
RECOMMENDATIONS TO THE BEST OF THEIR ABILITY.
>> DR. DANIELS, DR. D'CUNHA, FROM SPOKANE, WASHINGTON,
SOMEONE WANTS TO KNOW WHO PAID FOR THE HOSPITAL COSTS AND OTHER EXPENSES OF ISOLATION
AND QUARANTINE?>> DR. D’CUNHA ESSENTIALLY WHEN IT CAME TO HOSPITALIZATION,
THESE COSTS WERE FULLY PICKED UP BY THE PROVINCE OF ONTARIO.CANADA DOES HAVE A
FREE MEDICAL CARE PROGRAM RIGHT ACROSS THE COUNTRY.WE DID HAVE A SITUATION
WHERE A
FEW PEOPLE DIDN'T HAVE STATUS, OR A FEW ILLEGALS, AND WE MADE SPECIAL
ARRANGEMENTS AND GOT APPROPRIATE REGULATORY AMENDMENTS TO BE SURE THAT THESE
PEOPLE WOULD GET CARE WITHOUT THE FINANCES BEING AN ISSUE.AS IT
PERTAINS TO HOME ISOLATION, WE'RE RIGHT IN THE MIDDLE
OF DEVELOPING OUR FINAL COMPENSATION PROGRAM. IT'S MY UNDERSTANDING THAT ONE WILL
HAVE TO APPLY.WE'RE CERTAINLY NOT GOING TO PAY PEOPLE $1 MILLION, BUT, YOU KNOW
WHAT WOULD BE DEEMED REASONABLE
AND THE POLICY WOULD BE ENTERTAINED FOR PURPOSES OF REIMBURSEMENT
FROM A
COMPENSATION STANDPOINT. >> DR. DANIELS THANK YOU,
DR. D'CUNHA.I'LL ADDRESS THIS QUESTION TO THE ENTIRE PANEL.FROM OHIO, HOW CLOSE
ARE WE TO HAVING A VACCINE, AND WILL WE NEED TO INSTITUTE A MASS VACCINATION
PLAN?>> DR. JERNIGAN I'D BE HAPPY TO TAKE THAT ONE.OBVIOUSLY
THERE'S GREAT INTEREST IN DEVELOPING A VACCINE FOR THIS ILLNESS.THERE ARE
VACCINES AVAILABLE FOR SOME OF THE CORONAVIRUSES THAT
INFECT ANIMALS, BUT THERE ARE SOME ISSUES.THERE ARE SOME
DIFFICULTIES IN
DEVELOPING EVEN THESE VACCINES. SOME OF THE LIVE VACCINES HAVE THE
PROPERTY OF ACTIVELY RECOMBINING WITH SOME OF THE WILD-TYPE VIRUSES AND LOSING
THEIR EFFICACY. WITH SOME OF THE VACCINES, THERE'S
ACTUALLY CONCERN ABOUT
ANTIBODY ENHANCEMENT OF ILLNESS AND THIS IS OF GREAT CONCERN.I
THINK THAT WE'RE QUITE SOME TIME AWAY FROM A VACCINE IN HUMANS. ALTHOUGH I CAN
TELL YOU THAT CDC
IS IN COLLABORATION WITH THE NATIONAL INSTITUTES OF HEALTH AND
OTHERS TO ACTIVELY INVESTIGATE THIS ISSUE, AND DEVELOP NEW VACCINES.BUT WE'RE
SOME TIME AWAY FROM A VACCINE THAT WILL BE AVAILABLE FOR HUMANS.OBVIOUSLY IF WE
GET AN EFFECTIVE AND SAFE VACCINE, IT WILL PLAY AN IMPORTANT ROLE IN THE
CONTROL
OF THIS DISEASE.>> DR. DANIELS, DR.
JERNIGAN, THANK YOU. THIS NEXT QUESTION COMES TO US FROM WASHINGTON.I'M
TRAVELING TO KOREA.WHAT ARE THE CONCERNS IN TRAVELING THERE, STAYING THERE, AND
QUARANTINE WHEN RETURNING?>> DR. CETRON I THINK
I'LL PROBABLY TAKE THAT ONE. RIGHT NOW,
THERE'S
AND AS FAR AS COMING BACK TO THE UNITED STATES, AS I'VE INDICATED THERE
IS NO -- CURRENTLY NO PROCESS, OR NEED FOR USE OF THE QUARANTINE TOOL WITHIN
THE
UNITED STATES WITH THE EXTENT OF THE EPIDEMIC AS WE CURRENTLY HAVE
IT.
SO NO TRAVELERS RETURNING TO THE UNITED STATES, REGARDLESS OF WHICH
COUNTRY THEY'RE RETURNING FROM, ARE ASKED TO BE QUARANTINED FOR ANY PERIOD OF
TIME.>> DR. DANIELS, DR. D'CUNHA,
WE HAVE A QUESTION FOR YOU FROM
IN DEALING WITH SARS.A WHOLE BUNCH OF PEOPLE IN THE SOCIAL FRONT, SUCH
AS THE
SALVATION ARMY. AND I'M GOING TO GUESSTIMATE AND SAY
PROBABLY A NUMBER OF ALL
THESE OTHER AGENCIES AS IT PERTAINS TO ISOLATION OUT IN THE COMMUNITY
SETTING ON THE ORDER OF ABOUT 5,000 TO 6,000 PERSONS. BASICALLY, FOR ABOUT 20,000
PEOPLE IN THE POPULATION – WHO WERE PUT INTO QUARANTINE, WE SAW A WORK FORCE OF
ABOUT 6,000 INDIVIDUALS MAKING THAT HAPPEN.>> DR. DANIELS, THIS NEXT
QUESTION COMES TO US FROM NORTH CAROLINA: SHOULD WASTE WATER MANAGEMENT WORKERS
DO ANYTHING EXTRA TO PROTECT AGAINST SARS? I SEE A HAND RAISED BY DR. JERNIGAN.
>> DR. JERNIGAN, IT'S A GOOD QUESTION, KYSA. OF COURSE, THERE'S BEEN SOME
CONCERN ABOUT THIS, BECAUSE AS WE'VE LEARNED, INDIVIDUALS WITH SARS CAN SHED
THE CORONAVIRUS IN THEIR STOOL FOR SOME PERIOD OF TIME AFTER THEY BECOME
INFECTED. WE DON'T REALLY UNDERSTAND YET
WHAT THIS PROLONGED SHEDDING, WHAT IMPLICATIONS THIS SHEDDING HAS FOR
TRANSMISSION OF THE ILLNESS. WE ARE LOOKING CAREFULLY AT THE ISSUE OF HOW OUR
WASTE STREAM IS MANAGED. EPIDEMIOLOGICALLY, THERE'S NO EVIDENCE TO DATE THAT
THIS IS A SOURCE OF TRANSMISSION. WE HAVE REASON TO BELIEVE THAT THE WAY OUR
WASTE WATER AND WASTE IS TREATED IN THIS COUNTRY SHOULD BE ADEQUATE IN CONTROLLING
THE RISK OF TRANSMISSION. SO FOR NOW, I DON'T THINK THERE ARE ANY ADDITIONAL
PRECAUTIONS, OTHER THAN THE USUAL PERSONAL PROTECTIVE EQUIPMENT AND PRECAUTIONS
THAT ARE TAKEN.THERE'S NO NEED FOR ADDITIONAL PRECAUTIONS AT THIS TIME. OF
COURSE, WERE CONTINUE OF MONITORING AND LOOKING AT THE EPIDEMIOLOGY, IF THERE'S
ANY EVIDENCE TO SUGGEST THAT ADDITIONAL PRECAUTIONS SHOULD BE TAKEN, WE WILL
MAKE THAT INFORMATION AVAILABLE.FOR RIGHT NOW, I DON'T THINK ANYTHING EXTRA OR
SPECIAL NEEDS TO BE DONE. DR. DANIELS, OKAY. WE'RE GETTING CALLS FROM ALL OVER.
THIS ONE IS FROM
PARTICULAR GUIDANCE FOR BUSINESSES AND EMPLOYERS TO DEAL WITH
EMPLOYEES RETURNING FROM SARS-AFFECTED AREAS.THE SHORT ANSWER AND THE BOTTOM LINE
IS, NO, WE DO NOT FEEL IT IS APPROPRIATE TO FURLOUGH A WORKER RETURNING FROM A
SARS
AFFECTED AREA. OUR STRATEGY AND APPROACH HAS BEEN
TO TARGET ONLY THOSE FOLKS
WHO DEVELOP SYMPTOMS OR WHO HAD CLOSE CONTACT WITH PROBABLE CASES
OF SARS THAT WOULD BE MONITORED – MONITORING THEMSELVES.WE DO NOT FEEL IT IS
APPROPRIATE
FOR BUSINESSES TO FURLOUGH WORKERS
OR EXCLUDE PEOPLE SIMPLY ON THE BASIS OF A TRAVEL HISTORY ALONE. DR. DANIELS SOMEWHAT OF A LEGAL
QUESTION HERE NOW FROM MARYLAND.CAN PEOPLE WITHOUT SARS SYMPTOMS BE FORCED TO
BE IN QUARANTINE? MR. MATTEHEWS SURE, I'LL TAKE A SHOT AT THAT. THE QUARANTINE
BY DEFINITION IS ISOLATION OF PEOPLE WHO ARE CLEARLY EXPOSED TO SARS. SO IN THE
DEFINITIONS THAT DR. CETRON GAVE EARLY ON, IT IS POSSIBLE FOR THOSE WHO ARE IN DIRECT
CONTACT WITH SOMEONE IDENTIFIED AS AN ACTIVE CASE OF SARS TO NEED TO BE
ISOLATED, THEY'RE NOT -- OR REALLY, THEY NEED TO BE QUARANTINED BECAUSE THEY'RE
NOT, SHOWING SYMPTOMS.SO YES, IT CAN BE DONE UNDER THE LAWS IN ALL THE STATES
AND BY THE FEDERAL GOVERNMENT. DR. DANIELS AND I BELIEVE THAT DR. D'CUNHA HAS
SOMETHING TO ADD TO THIS. DR. D’CUNHA, SURE. MY
COMMENT IS NOT GOING TO BE FROM A LEGAL PERSPECTIVE. I'M GOING TO COME AT IT
FROM A PUBLIC HEALTH PERSPECTIVE. KEEPING IN MIND THAT THE WHOLE REASON FOR
ISOLATING ASYMPTOMATIC CONTACT, ONE CANNOT PREDICT WHICH ONE OF THESE CONTACTS,
IF THEY'RE TRUE DIRECT CONTACTS, OR KNOWN PROBABLE CASES OF SARS, WHEN THEY
WILL BE SYMPTOMATIC AND CONSEQUENTLY INFECTIOUS. THAT'S THE PURPOSE FOR ASKING THEM
TO GO INTO ISOLATION. AND THEN YOU DEVELOP THE LEGAL MECHANISMS IN WHICH ONE IS
OPERATING TO ENSURE THAT RECOMMENDATION HAS BEEN MET. DR. DANIELS, DR. D'CUNHA,
ANOTHER QUESTION FOR YOU FROM
AN EPIDEMIOLOGIC EXPOSURE AND SYMPTOMS, TO BE APPROPRIATELY
ISOLATED.FOR THOSE WITH CLOSE CONTACT, TO BE MONITORED FOR SYMPTOMS. BUT WE CURRENTLY
DO NOT RECOMMEND NOR SEE THE NEED FOR AT THE CURRENT TIME WITH THE STATUS OF
THE EPIDEMIC IN THE UNITED STATES, FOR ANY TYPE OF QUARANTINE FOR STUDENTS ARRIVING
FROM
THERE ARE A
AUDIO INFORMATION. AGAIN, WE'VE HEARD THAT THERE ARE
SOME LOCALITIES THAT DO HAVE HOTLINES AND TRANSLATIONS. IF YOU'D LIKE, WE CAN
TRY TO DO SOME MORE RESEARCH AND IDENTIFY THEM FOR YOU, IF YOU NEED SOME FOLLOW-UP
ON THAT PARTICULAR QUESTION.>> DR. DANIELS THANK YOU, DR. LIANG.I THINK
DR. D'CUNHA WHO IS IN CANADA HAS IS SOMETHING TO SAY ABOUT THIS AS
WELL.>> D’CUNHA I WOULD LIKE TO TELL ALL THE VIEWERS THAT THE TORONTO OUTBREAK
PEAKED IN MARCH AND APRIL.AROUND MARCH 26th IS THE BULK OF OUR STUDENTS WHO
WERE VISITING IN THEIR TRIPS, AND WE MADE A CONSCIOUS DECISION THAT WE WERE NOT
GOING TO ASK THEM TO GO INTO ISOLATION, BECAUSE AS IT'S BEEN CORRECTLY POINTED
OUT, THAT UNLESS ONE HAD EPIDEMIOLOGICAL LINKAGE, THIS ACTION MADE NO SENSE. WE
HAD CONTRADICTORY ADVICE THAT WE PUT OUT, WAS PARENTS GOING TO CHINA TO ADOPT
CHINESE BABIES.OUR FEELING WAS, WHEN YOU BRING A CHILD IN WHO'S UNDER A YEAR OF
AGE, AS PART OF THE ADJUSTMENT TO A NEW SOCIAL MILIEU, THE CRYING THAT A BABY
MAY MANIFEST HAS TO BE SORTED OUT FROM A CRYING POSSIBLY RELATED TO SIGNS AND
SYMPTOMS OF SARS. IN FACT, WE DID HAVE A COUPLE SUSPECT CASES OF SARS IN
ADOPTEES. SO ALTHOUGH WE STAYED WITH THE GENERAL ADVICE PROVIDED BY CDC, WE STRAYED
A LITTLE FROM THEIR ADVICE AS IT PERTAINED VERY SPECIFICALLY TO THE ADOPTION-RELATED
GROUP. AND OUR CONCERN WAS, WHEN A PARENT BRINGS IN AN ADOPTED CHILD, YOU GET A
WHOLE BUNCH OF FRIENDS AND RELATIVES VISITING, AND IF ONE OF THESE CHILDREN TURNED
OUT TO HAVE SARS, THERE WOULD NOT BE AN END TO OUR OUTBREAK. DR.DANIELS THE
NEXT QUESTION FROM
THE HAND HYGIENE IS CRITICALLY IMPORTANT, THAT IF THESE SAME MEASURES
ARE FOLLOWED, THE SAME MEASURES THAT WOULD PREVENT TRANSMISSION OF OTHER
INFECTIOUS
DISEASES SHOULD BE ADEQUATE FOR THIS PARTICULAR ILLNESS. DR.
DANIELS OKAY. FROM
VIOLATION. AND LAW ENFORCEMENT OFFICIALS CAN
BE -- CAN ASSIST, AS DR. D'CUNHA INDICATED IN HELPING CARRY OUT THE
ENFORCEMENT.I THINK IT'S IMPORTANT TO
REMEMBER, THOUGH, THAT WE HAVE BEEN VERY PLEASED AT THE PUBLIC COOPERATION
IN DEALING WITH THE QUEST FOR VOLUNTARY ISOLATION AND VOLUNTARY QUARANTINE.\E
I THINK IT'S IMPORTANT THAT THIS CULTURAL GAP THAT WE HAVE OVER THE
PAST 50 YEARS HAS NOT REALLY RESULTED IN ANY DEMONSTRABLE DROP-OFF IN THE
SPIRIT OF PUBLIC COOPERATION THAT WAS PRESENT 50 YEARS AGO, OR 100 YEARS AGO. SO
I THINK IT'S SOMETHING WORTH CONTINUING TO MONITOR. AND I THINK THE DATA FROM
QUESTION IS DIRECTED AT THE STUDY THAT YOU CONDUCTED.AND THE
PERSON FROM
AND QUARANTINE TOOLS AS WE HAVE HERD SO ELOQUENTLY FROM DR. D'CUNHA
AND OTHERS, AND AS WE HAVE WITNESSED IN VIETNAM, SINGAPORE, IS GOING ON IN TAIWAN.SO
I THINK THAT ACTIVELY ENGAGING IN THE LESSONS LEARNED AND DEVELOPING AN
OPERATIONAL
PLAN AT THE LOCAL AND THE STATE LEVEL IS GOING TO BE VERY IMPORTANT
AS WE MOVE FORWARD. DR.DANIELS AND DR. D'CUNHA, I BELIEVE YOU HAVE SOMETHING TO
ADD TO THIS? DR. D’CUNHA YES. JUST TO REINFORCE WHAT WAS SAID, WHAT WE HAVE TO
BE VERY CLEAR IS WE DON'T HAVE IT -- AN EPIDEMIC OR ONGOING TRANSMISSION IN
NORTH AMERICA, NOW THAT WE'VE SUCCESSFULLY PUT THE CAT BACK IN THE BOX, IF I
CAN PUT IT SIMPLY.
WE HAVE TO BE PREPARED FOR THE IMPORTATION OF CASES AS LONG AS THE
SARS IS SEEN IN ANY PART OF THE WORLD. WE HAVE TO HAVE THE HEALTH CARE PROVIDERS
ON THE GROUND TO SUSPECT SARS AND IN PARTICULAR TO TAKE A GOOD TRAVEL EPIDEMIOLOGICAL
HISTORY. WE'VE GOT TO BACK IT UP WITH A GOOD HEALTH SURVEILLANCE SYSTEM. AND,
AS HAS BEEN CORRECTLY POINTED OUT, WE VERY CLEARLY NEED TO HAVE OUR PLANS TO
DEAL WITH ISOLATION AND CONTAINMENT IF THAT'S WHERE WE END UP HAVING
TO GO. DR.DANIELS I WOULD LIKE TO REMIND EVERYONE
THAT DR. D'CUNHA IS JOINING US FROM
AND QUARANTINE FOR FOLKS THAT ARE NOT SICK ENOUGH TO REQUIRE HOSPITALIZATION,
BUT ARE NOT IN A SITUATION WHERE THEY CAN BE HOME -- ISOLATED OR QUARANTINED
AT HOME. THAT IS, THE PERSON IN TRANSIT OR
THE PERSON FOR WHOM THEIR HOME IS NOT AN APPROPRIATE FACILITY FOR ISOLATION AND
QUARANTINE.SO, YEAH, WE REALLY NEED TO BE DOING THAT.AND WE'VE SEEN, AS BUDGET CUTBACKS
AND THINGS HAVE OCCURRED, THE SORT OF CLOSURE OF SOME OF THESE TYPES OF FACILITIES
FOR MANAGING TUBERCULOSIS PATIENTS WHO ARE IN A RECOVERY MODE OR SOMETHING IN THE
PAST.AND WE HAVE TO THINK CREATIVELY ABOUT FINDING NEW PLACES FOR THESE TYPES
OF FACILITIES.
DR.DANIELS WE WANT TO BRING TO THE VIEWERS' ATTENTION THAT WE ARE RUNNING
A LITTLE LONG. LONGER FOR THIS BROADCAST. AND YOU'RE
CERTAINLY WELCOME TO STAY WITH US. WE WANT TO GIVE EVERYONE WHO ASKS A QUESTION
AN
OF 500 IN BOTH OF THEM, AND SUCCESSFULLY ISOLATED PEOPLE THERE.SO
IT'S ABSOLUTELY CRITICAL, AS THE PREVIOUS SPEAKER SAID, THAT WE DRAW THE
ON-THE-GROUND PLANS FOR HOSPITAL ISOLATION, AND HOME ISOLATION AND FACILITY ISOLATION.
DR.DANIELS THIS QUESTION IS FROM LOUISIANA.IS THE UNITED STATES
PERFORMING ANY MANDATORY QUARANTINING OF TRAVELERS? DR.CETRON NO.THE ANSWER TO
OUR VIEWERS IS THAT WE ARE NOT PERFORMING ANY MANDATORY QUARANTINING OF TRAVELERS
FROM SARS AFFECTED AREAS OR OTHER AREAS AT THIS TIME.AND SO FAR, THE STRATEGY
OF RAPID DETECTION AND ISOLATION WITHOUT THE NEED FOR FULL-SCALE QUARANTINE HAS
BEEN EFFECTIVE IN THE UNITED STATES, RECOGNIZING WE'VE HAD A VERY DIFFERENT EXPERIENCE
THAN THE TORONTO EXPERIENCE THAT DR. D'CUNHA MENTIONED.AND THOSE OF SOME OF THE
OTHER COUNTRIES.IN ADDITION, WERE WE TO USE QUARANTINE, IT WOULD NOT BE SORT OF
LOOSELY TAILED TO ALL RETURNING TRAVELERS.WE WOULD TRY TO TARGET THIS KIND OF
RESTRICTED MOVEMENT TO ONLY CLOSE CONTACTS OF PROBABLE CASES WHERE WE WERE
REALLY CONCERNED ABOUT THE RISK OF EXPOSURE.SO IT WOULD BE MORE NARROWLY
APPLYING THE TOOLS WERE WE TO CONDITION TEMPLATE ITS USE. DR. DANIELS FROM
SITUATIONS IN WHICH AIRBORNE
INVESTIGATION IN CONJUNCTION WITH CANADA OF A CLUSTER OF INFECTIONS
AMONG HEALTH CARE WORKERS SURROUNDING AN AEROSOL GENERATING EVENT THAT WAS DESCRIBED
IN OUR LAST WEEK'S MMWR, THAT IT'S POSSIBLE THAT FIT TESTING COULD HAVE BEEN AN
ISSUE IN THAT REGARD.SO WE THINK THAT EVERY PRECAUTION SHOULD BE
TAKEN TO
PREVENT ANY POTENTIAL MODE OF TRANSMISSION FOR THIS PARTICULAR ILLNESS,
ESPECIALLY IN THE SETTING OF AEROSOL GENERATING PROCEDURES.THAT'S WHY WE'RE
RECOMMENDING THAT WE CONTINUE AIRBORNE PRECAUTIONS, PART OF WHICH INCLUDES A
COMPREHENSIVE FIT TESTING PROGRAM. DR.DANIELS WE WANT TO PITCH IT TO
AND THE OTHER INSTANCE THAT IS AN ANECDOTE TO THE SCIENTIFIC PART
IS WE HAD A SITUATION WE HAD OVER THE EASTER WEEKEND, – WHERE A BUNCH OF OUR HEALTH CARE
WORKERS SUBSEQUENTLY CAME DOWN WITH PROBABLE SARS, WHO HAD
OTHERWISE FOLLOWED ALL THE RECOMMENDATIONS. THIS LED US TO CONCLUDE THAT WHILE
WE STILL BELIEVE IT'S NOT AIRBORNE TRANSMISSION, DROPLET SPREAD; CLEARLY THE
FACE SHIELD OR PROPER EYE-FITTING WEAR AND TESTING OF THE MASK ARE CRITICAL. DR. DANIELS OKAY, DR. D'CUNHA. THANK YOU. I
THINK THIS IS GOING TO BE OUR FINAL QUESTION: WE'RE HEARING NEWS REPORTS THAT SARS
IS SLOWING DOWN, THAT THE EMERGENCY IS OVER. IS THIS TRUE?
WELL, IT IS TRUE THAT WE ARE OVER THE LAST DAYS, MANY OF THE CENTERS
AROUND THE WORLD ARE REPORTING A DECREASE IN THE NUMBER OF REPORTED CASES.THIS
IS NOT UNIVERSALLY TRUE.I THINK IN TAIWAN, THEY'RE STILL SEEING QUITE A BIT OF TRANSMISSION,
AND IT'S A BIT TOUGH TO TELL WHERE THEY ARE IN THE COURSE OF THEIR EPIDEMIC CURVE.WHILE
ENCOURAGING IN MANY PARTS OF THE WORLD, I THINK WE HAVE TO REMAIN VIGILANT.WE
DON'T KNOW WHAT THE FUTURE HOLDS FOR THIS PARTICULAR VIRUS.
AS I MENTIONED, THERE'S POTENTIAL FOR SEASONALITY. EVEN THOUGH HERE
IN THE UNITED STATES, WE'VE SEEN FEWER CASES OF, AS OF LATE, IN
FUTURE. I THINK WE HAVE TO ASSUME THAT COULD
BE THE CASE.AND THAT MAKES THE ISSUE OF PREPAREDNESS SO CRITICALLY IMPORTANT.I
THINK IF THE CASES ARE GOING DOWN, WE SHOULD VIEW THIS AS A GOOD OPPORTUNITY TO
LOOK AT THE
LESSONS LEARNED FROM WHAT'S JUST HAPPENED, AND TURN THAT INTO ACTIVE
PREPARATION, ASSUMING THAT WE SHOULD HAVE A PROBLEM IN THE FUTURE, SO THAT
WE'LL BE WELL PREPARED AND BE ABLE TO CONTROL THAT. DR. JERNIGAN LET ME JUST
ADD ONE FINAL COMMENT.I THINK THAT ONE OF THE CLEAR LESSONS LEARNED IN ALL OF
THE AREAS THAT HAVE BEEN BATTLING SARS AND CONTAINING IT IS THAT IT HAS
REQUIRED BOLD AND SWIFT ACTION WITH PRUDENCE AND MEASURED RESPONSE TARGETED TO THE
VIRUS AND THE BEHAVIORS THAT CAN CONTAIN THIS EPIDEMIC. AND THE SUCCESS IN MANY
PLACES SPEAKS TO OUR NEED TO BE PREPARED TO IMPLEMENT THOSE BOLD AND SWIFT
MEASURES WHILE MAINTAINING THE BALANCE AND PREVENTING STIGMATIZATION. DR.DANIELS
THANK YOU VERY MUCH AND WE ARE OUT OF TIME OR JUST
ABOUT OUT OF TIME. BUT IF YOU HAVE ADDITIONAL QUESTIONS THAT YOU WOULD LIKE TO HAVE
ANSWERED, PLEASE SUBMIT YOUR QUESTIONS BY FAX TO 800-553-6323 OR E-MAIL US AT
PHTN AT CDC.GOV. FOR OTHER QUESTIONS, REMEMBER TO VISIT THE CDC AND WORLD
HEALTH
ORGANIZATION WEB SITES FOR THE LATEST INFORMATION ON SARS.THOSE
ADDRESSES, AGAIN, ARE, FIRST AT THE WORLD HEALTH ORGANIZATION. THEIR WEB SITE
IS
WWW.WHO.INT, AND THEN THE WEB ADDRESS FOR THE CDC IS WWW.CDC.GOV.PARTICIPANTS
OF THIS BROADCAST ARE ENCOURAGED, BUT NOT REQUIRED TO REGISTER AND EVALUATE THE
PROGRAM ON THE CDC TRAINING AND CONTINUING
EDUCATION ONLINE SYSTEM. THAT ADDRESS IS WWW.PHPPO.CDC.GOV/PHTNONLINE.PARTICIPANTS’
REGISTRATION AND
EVALUATION WILL BEGIN
JUNE 20th, 2003.HERE ARE THE COURSE NUMBERS THAT YOU'LL NEED.THE
NUMBER FOR THE SATELLITE BROADCAST IS SB 0133.THE WEB CAST NUMBER, WC
0033.QUESTIONS ABOUT REGISTRATION SHOULD BE DIRECTED TO 800-41-TRAIN,
404-639-1292.OR E-MAIL CE AT CDC.GOV AND WHEN E-MAILING A REQUEST, PLEASE
INDICATE SARS 3 IN THE SUBJECT LINE. THIS CERTAINLY HAS BEEN MY PLEASURE BEING
YOUR MODERATOR FOR THIS BROADCAST. WE WANT TO THANK DR. CETRON ONCE AGAIN. WE
WANT TO THANK MR. GENE
MATTHEWS. WE WANT TO THANK DR. LIANG, DR. JERNIGAN, AND IN
DR. D'CUNHA.THANK YOU SO MUCH FOR BEING WITH US AND GOOD-BYE TO
ALL OF YOU FROM ALL OF US AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION
IN