Who Will Manage Quarantines?

Who is in charge in case of a flu pandemic?

Earlier this week, President Bush, in a press conference, brought up the possibility of using the military to enforce quarantines within the US if there is an outbreak of avian flu:

The policy decisions for a President in dealing with an avian flu outbreak are difficult. One example: If we had an outbreak somewhere in the United States, do we not then quarantine that part of the country, and how do you then enforce a quarantine? When -- it's one thing to shut down airplanes; it's another thing to prevent people from coming in to get exposed to the avian flu. And who best to be able to effect a quarantine? One option is the use of a military that's able to plan and move,” he said.

While US law forbids the military from engaging in domestic law enforcement, and first response to disasters is the responsibility of local and state authorities, the recent hurricane disasters on the gulf coast have raised a shadow of uncertainty over the ability of states to react in an effective manner.

Still, some states are moving forward. In early October, the state of Colorado announced a draft plan to deal with a possible flu pandemic.

According to an article in the Colorado Springs Gazette, the plan calls for 10 executive orders that would go into effect with the governor’s signature and include quarantines that could cancel the state's schools or isolate a neighborhood, authorize rapid burial of epidemic victims without regard to funerals or religious practices and without death certificates in all cases.

Additionally, it would allow the state health department to order hospitals to cease admissions or transfer patients, including moving mentally ill patients out of medical facilities to make room for flu patients, and allow physicians and nurses licensed by another state to practice in Colorado.

Additionally, the Gazette said the state has 13 caches of medical equipment stockpiled around the state that can transform a gymnasium or large hall into a 500-bed hospital within hours.

Short History of Quarantines

The concept of quarantine in public health came from the plague and dates to 1377 when the rector of the Venetian repubic of Ragusa ordered a 30-day isolation period for ships, and 40 days for land travelers. Over the next century, other quarantine laws were introduced in Italian and French ports, according to a paper by Gensini et al, in the Journal of Infectious Diseases, November 2004. The authors conclude that the concept is “still fully valid.”

Meir Oren, general director of the Hillel-Yaffee Medical Center in Israel, writing in the Israel Medical Association Journal within the context of a bioterror attack, speaks to the importance of containing an outbreak at the start rather than than reacting to it once it has spread.

Additionally, he recommends “the implemention of isolation and control measures to lower the risk of further transmission of the disease while assuring the safety of medical teams and laboratory workers. Strategic contingency plans should incorporate well-defined procedures for hospitalization and isolation of patients, providing regional backup of medical personnel and equipment and maintaining close cooperation between the various bodies in the healthcare system.”

Quarantine is an effective containment measure, especially if voluntarily imposed,” he writes.

The Model Act

Following the 9/11 events of 2001, the Bush administration asked the Center for Law and the Public's Health, a joint program at Georgetown and Johns Hopkins Universities,to draft a model law to address health care needs during a national emergency. The center released its "Model State Emergency Health Powers Act" on October 23, 2001. According to the American Academy of Emergency Medicine, the model law is under review in all states. (Click here to read the AAEM's guidance to members on the model law).