Another Opportunity to Prepare for Quarantines

An article published in 2013 discussed the considerable challenges of quarantine order implementation and enforcement during a future pandemic or other serious threats to public health. That discussion was after the emergence of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), but before the re-emergence of the Ebola virus in West Africa. The level of preparedness for the rapid execution of federal quarantines has not greatly improved since 2013. The nation’s readiness may have even diminished during the current pandemic due to social, political, and organizational discord.

The article, Black Swans – Preparing for Pandemic & Biological Threats, proposed that, if the novel coronavirus MERS, H7N9 influenza, or another serious pathogen were to arrive in the United States, it would trigger a response in many critical sectors – especially medical services, public health, and law enforcement. It was predicted that it would test medical detection and surge capacity capabilities to a level that may demonstrate insufficient planning and preparedness in an all-hazards environment. One of the first lines of defense and possible failure points, according to the article, was the initial screening and identification of the virus in time to utilize designated quarantine and isolation procedures and practices to contain the spread of the virus. If possible, swift containment would be the most effective response to assess and control the exposure of the emerging threat.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the novel virus that caused the COVID-19 pandemic – confirmed numerous concerns regarding national planning and preparedness for a pandemic or bioterrorism attack. Even though actual quarantine orders were not largely implemented for COVID-19 in the United States, the vast and various restrictions for social movement, education, and commerce may have affected the ability to properly plan and prepare for the implementation of formal quarantines in the future. Quarantine orders are very different from stay-at-home directions.

Despite polarization over the freedom of movement and commerce, specific quarantine orders can be essential tools – when timely and wisely executed – to stop or mitigate an evolving novel or weaponized pathogen. The recent stay-at-home or shelter-in-place requests or orders may not be as useful to contain a serious public health threat as official quarantine orders, especially if the next disease is a man-made pathogen that requires an immediate and suitable response.

Quarantine and Isolation

The definitions of quarantine and isolation can be confused with each other. A person exposed to a contagious disease can be quarantined to separate them from others and restrict their movement pending confirmation of exposure or illness. If the person becomes ill from the exposure, they can be isolated from others who are not sick while they receive medical treatment. Broader and informal variations of this concept have been implemented since the arrival of SARS-CoV-2 in the United States.

A federal or state quarantine order may be issued to force compliance with the process. For a noncompliant person, the quarantine order functions similarly to a public health detention to control their movement. The compliant and those too ill to resist may not require legal restrictions. A quarantine order is often specific and directed at a person or persons arriving at a border or hospital with a highly pathogenic disease to control an outbreak before it spreads to others.

On the federal level at a border or between states, the Centers for Disease Control and Prevention (CDC) possesses the authority to quarantine individuals. In February 2020, CDC developed a generic quarantine order for persons returning from China. The order declared:

CDC may legally detain you until it finds that you are no longer at risk of becoming ill and spreading the disease to others. This is commonly referred to as the incubation period for the disease. The incubation period for COVID-19 is currently believed to be up to 14 days. You will be reassessed while you are detained. CDC will count the beginning of the incubation period from when you left Hubei Province, China.

The quarantine order was specific to a person rather than a group, city, state, or region. It was legally and functionally different than the assortment of governmental directions or guidance issued since the arrival of SARS-CoV-2 across the United States.

Other Than Quarantine Orders

The wide-ranging social distancing/shelter-in-place requests, instructions, orders, and other guidance versions issued since the arrival of COVID-19 ranged from state to state and city to city over time. Most directions did not include formally executed quarantine orders as per existing laws and previous practices, but a broader adaptation or lesser variation of the concept.

The federal quarantine orders, as seen above, involved people returning from China in the early days of the outbreak. These quarantine activities, conducted mostly at military bases, were apparently less demanding to implement since the limited number of subjects were apparently content to comply to receive swift transportation back to the United States from China or depart an unexpectedly extended stay on a cruise ship.

However, the nation has not completely resolved the massive quarantine challenges at the international border. Enforcing specific or larger general quarantines at the border or functional equivalent of the border (airports and other entry locations) may be more challenging to accomplish for compliance and proper execution. The screening and quarantining of noncompliant passengers or illegal border crossers shall result in a myriad of new challenges, issues, and lawsuits. There would be unexpected and unmet surge capacity issues for resources for numerous agencies and organizations, not to mention sensitive and precarious subjects such as use of force guidance to enforce legal orders and other supporting laws. The tremendous increase in illegal border entries on the southern border in 2021 demonstrated the monumental response challenges and the resource-depleting consequences of attempting to manage the substantial surge – especially during a pandemic.

Requests, instructions, or orders to stay-at-home or shelter-in-place, outside formal quarantine orders, can be problematical to enforce. Interstate and intrastate quarantines would be even more difficult. They were not easy to execute in the 1800s and early 1900s with a smaller less mobile population. However, this does not mean that they should be ignored. No- or short-notice federal quarantines shall be required at some time to control an exceptionally dangerous pathogenic threat from spreading across the county, state, nation, or world.

Federal Quarantine Enforcement

The U.S. Secretary of Health and Human Services is authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states under the federal statute 42 U.S. Code § 264. The authority to execute these functions was delegated to CDC.

Federal law identifies the federal officers responsible for quarantine enforcement and associated activities during a public health emergency. The federal officials with legal authority, and at times mandate, to enforce federal and state quarantines are identified within the foundational 2006 National Strategy for Pandemic Influenza – Implementation Plan; by specific federal statutes (42 U.S. Code § 97, 42 U.S. Code § 268) and by CDC guidance.

According to federal policies, plans, strategies, and statutes, designated customs officers are responsible for the enforcement of federal quarantine orders. The CDC identified U.S. Customs and Border Protection (CBP) and U.S. Coast Guard (USCG) officers as those authorized to help enforce federal quarantine orders. In addition to CBP and USCG, U.S. Immigration and Customs Enforcement (ICE) employs thousands of designed customs officers that would be required to support the enforcement at border or interior locations. Customs officers are the personnel within CBP, USCG, and ICE with legally designated customs authority. The number of officers with delegated customs authority within the agencies has expanded since the creation of the Department of Homeland Security in 2003 – providing a larger pool of deployable resources but still extremely limited for the vast mission.

As identified by CDC, public health authorities at the federal, state, local, and tribal levels may sometimes seek help from police or other law enforcement officers to enforce a public health order. Violating a federal quarantine order is punishable by fines and imprisonment, which expands responsibilities to other departments and agencies.

The National Strategy for Pandemic Influenza – Implementation Plan states that the federal government has statutory authority to order a quarantine to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the United States or from one state or possession into another state or possession. The plan provides additional guidance for federal quarantines and other movement restrictions.

Customs and Coast Guard officers are required to aid in the enforcement of Federal quarantine rules and regulations. Furthermore, Customs and Coast Guard officers and “military officers commanding in any fort or station upon the seacoast” are required to aid in the enforcement of State quarantines.

Customs and Coast Guard officers may assist in enforcing State quarantines at the direction of the Secretary of Health and Human Services.

CDC does not have the law enforcement capability for the execution of this unique mission thus requiring outside resources. This additional responsibility assigned to customs officers was not well-known by the public or many of the customs officers. It was not a standard mission that was sufficiently funded and exercised by the agencies, and was often viewed as a CDC, National Guard (under Title 32), or state public health responsibility. The customs officers in CBP, USCG, and ICE are already consumed by their primary responsibilities and duties along with other unexpected taskings and events.

The discussion and planning for federal quarantine enforcement may not be a practical one at this time. It was a challenge to plan and train for this unique responsibility in 2006 to support the new implementation plan long before the current pandemic.

Threats Over the Horizon

The concerns for a possible pandemic threat from a novel coronavirus were not new. In 2012, the coronavirus of concern was MERS with its mortality rate of approximately 30-40%. The international concern a decade ago was that MERS would travel and spread around the world like SARS in 2003 with its mortality rate of approximately 15%. The feared pandemic would turn out to be the novel SARS-CoV-2 in 2019 with a mortality rate of approximately 1%. The mortality rate was significantly lower, but the impact for the nation and world was immense. The mortality rate of the next pathogen may be closer to SARS and MERS or even much worse.

The White House released American Pandemic Preparedness: Transforming Our Capabilities in September 2021. The document described the work needed to transform capabilities to respond to any future pandemic or high-consequence biological threat. The document declared that there will be an increasing frequency of natural – and possibly human-made – biological threats in the years ahead. The document stated:

As devastating as the COVID-19 pandemic is, there is a reasonable likelihood that another serious pandemic that may be worse than COVID-19 will occur soon – possibly within the next decade. Unless we make transformative investments in pandemic preparedness now, we will not be meaningfully prepared.

The document also addressed the areas of biosecurity, biosafety, and prevention of catastrophic biological events by expanding capabilities to identify safety and security risks to deter and detect the development and use of bioweapons.

Bioterrorism or biowarfare may be a more serious threat than a naturally occurring zoonotic pathogen. A novel man-made pathogen resulting in enhanced levels of transmissibility, morbidity, and mortality through gain-of-function experimentation could make the current pandemic issues appear manageable and even preferable.

Opportunities Lost

It is critical to identify and stop highly pathogenic threats, such as multidrug-resistant tuberculosis, viral hemorrhagic fevers (Ebola, Lassa, and Marburg), Nipah, and a novel influenza A virus before entry into the county. Effective and efficient screening, quarantine, and isolation procedures could make the difference between a public health concern and catastrophe during an encounter or emergence.

With the increasing politicization and polarization over face masks, vaccines, therapeutics, and other pandemic-related restrictions and directions, it becomes less likely that subjects such federal quarantine orders and enforcement shall be thoughtfully analyzed and addressed for the next inevitable public health threat. The topic of legally enforced federal quarantines may continue to be overlooked due to the current optics and politics.

At this time in the COVID-19 pandemic, the frank discussion of forceful quarantine orders and their proper execution may not be feasible. Not many may be overly interested in entering the societal and political debate with limited resources for the perceived return on investment. Even though quarantine orders are intrusive, they sometimes are a necessary tool to contain pathogens or other direct public health threats.

Containing the Next Threat

SARS-CoV-2 may be just another warning shot to caution the nation and world about the ramifications of the failure to plan and prepare for a serious pathogen that leads to another more perilous epidemic or pandemic. During the past two decades, SARS, MERS, Ebola, and several influenza viruses provided the world with warnings that faded away as quickly as the outbreaks themselves.

Another more serious public health threat, naturally occurring or man-made, will happen. It is critical to be prepared to identify it as soon as possible to block or slow it from spreading. The appropriate and legal use of quarantine orders can provide the ability to contain the early spread of an emerging pathogen. However, the execution of a quarantine order is not the same as a wide-ranging request for citizens to stay-at-home or social distance. It is a powerful authority and resource demanding an established process that can reap great benefits if properly executed by knowledgeable and trained personnel. Quarantines can also create confusion and resistance if not fully understood by the implementing officials and the public.

It is time to address the formal quarantine issue or more ground shall be lost – thus increasing vulnerabilities and cascading consequences. Public health threats can get much worse than SARS-CoV-2, especially in the realm of an engineered bioterror or biowarfare attack. The nation’s level of preparedness for the execution of federal quarantines is not where it needs to be to stop or slow the next outbreak, epidemic, or pandemic. There is another opportunity to prepare for quarantines.