CDC changing rules affecting travelers to help contain infectious diseases

December 2005

ATLANTA — Federal authorities recently proposed changes affecting travelers that authorities believe would make it easier for public health officials to keep infectious diseases out of the United States, they announced at a teleconference held late last month.

“We would like to use this opportunity to formally put forward that CDC today proposed some critical updates to existing regulations, which will allow our agency and HHS to move more swiftly to control potential outbreaks of infectious disease that may result from international importation or interstate movement,” said Martin Cetron, MD, director of the division of global migration and quarantine at the CDC.

Maintain manifests

Under the new rules, airlines and ship operators would be required to report passengers who have certain symptoms of infectious diseases and to maintain passenger lists, including name, seat location and emergency contact information, for at least 60 days after arrival into the United States, according to the CDC. If requested, this information must be submitted quickly and electronically to the CDC. The new rules pertain to international travel, as well as travel between larger cities, he said.

“These will enable a more rapid advance notification of ill passengers upon arrival and prior to arrival,” Cetron said.

In the past, notification of significant public health events occurred after passengers disembarked from planes and ships, leaving investigators to reconstruct an itinerary, a manifest, a seating chart and any contact information based on scant information. Because of the volume of international travel, some of the early electronic records of those manifests were purged within 24 or 48 hours. So the records were often reconstructed by hand.

“It wouldn’t include sufficient contact information for public health authorities to actually find that person and intervene within the incubation period,” Cetron explained.

Often, investigators used handwritten customs declaration forms to identify contact information. “This was an extremely time-consuming process even for a single flight and almost hopelessly unsuccessful when we had to deal with large multiple fights and large volume contact tracing as occurred during SARS,” he added.

“So the specific changes are requirements that passenger manifests be maintained by airlines in electronic format for 60 days after the final destination of that journey; that at the request of public health that information needs to be turned over in less than a day, by and large in 12 hours of that request; and that the information be turned over to public health authorities electronically and that specific fields be included to allow for effective contact tracing,” he said.

This would enable public intervention if someone needed postexposure vaccination or medication, or needed to be isolated or quarantined to prevent the spread of disease.

Symptoms to be reported

The proposed rules also expand the definition of ill travelers that must be reported. This includes those with fever and influenzalike illness, such as cough and sore throat. However, Cetron said they were looking for serious illnesses, not everyone with a cold

“We’re not talking about quarantining anybody for a sniffle or a cough alone. That’s really not going to be the case and it has not occurred,” Cetron said.

The Department of Health and Human Services has authority to isolate and quarantine anyone against the importation of nine infectious diseases: pandemic influenza, cholera, yellow fever, plague, smallpox, infectious tuberculosis, diphtheria, severe acute respiratory syndrome (SARS) and viral hemorrhagic fevers. The proposed rules empower authorities to hold a person for up to three days. Thereafter, they must decide whether to quarantine the person. In addition, the person has a right for a hearing before an independent arbiter.

“These tools have been long used as part of the public health toolbox for centuries, and typically public health recommendations are made as recommendations and are requested on a voluntary basis for compliance. In the vast majority of cases, whether it is individuals or in population groups, voluntary compliance with public health recommendations is all that is needed to assure public safety.

“In rare circumstances, public health authorities principally at the state and local level have the legal power through state regulations to compel or to order compulsory compliance with isolation or quarantine as a public health tool,” Cetron said.

Cetron added that the new proposals result from the SARS pandemic in 2003, when the CDC had difficulty finding and alerting passengers who had been on flights with suspected case-patients. Cetron said it “highlighted our global gaps as well as our global strengths and abilities to respond to these threats.”

The electronic manifests would make it easier to perform trace-backs.

“In the United States where the impact of this disease was minimized, we had a policy of rapid isolation of suspect cases that met a compatible case definition for SARS as defined by the World Health Organization, which was the illness profile in conjunction with an epidemiologic link with a transmission area, and we very much used rapid detection and rapid isolation along with heightened surveillance through passenger notifications.

“During this period, CDC staff were present at 25 points of entry, meeting every flight arriving from an impact area directly or one stop indirectly and handing out yellow notification cards in what symptoms to look for and how to rapidly respond to the emergence of those symptoms over the incubation period of SARS,” Cetron said. “So the general policy was early detection, rapid isolation and containment, and we did not have a federal policy of using quarantine of contacts as part of our containment strategy at the federal level during the SARS epidemic in 2003.”

The proposals are being published in the Federal Register and will be open for public comment. The public comment period will last 60 days from Nov. 30.