CRS: Ebola Outbreak – Quarantine v. Isolation, Travel Restrictions, Select Legal Issues

— Domani Spero
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On October 25, WaPo reported that the governors of New York Andrew Cuomo and New Jersey Gov. Chris Christie ordered on Friday the imposition of a mandatory 21-day quarantine for medical workers returning from the countries hit hardest by the ebola epidemic. Illinois later in the day imposed similar restrictions. Today, NYT reported that the Obama administration has expressed deep concerns to the governors and is consulting with them to modify their orders to quarantine medical volunteers returning from West Africa.

Ebola CRS report via Secrecy News (pdf):

On August 8th, the World Health Organization declared the outbreak of the Ebola Virus Disease in West Africa a Public Health Emergency of International Concern. The recent arrival in the United States of several health care workers who contracted the disease, combined with the first diagnosis of a case in the U.S. at a hospital in Dallas, has sparked discussion about the appropriate government response. Aside from the various policy considerations at issue, the outbreak has generated several legal questions about the federal government’s authority to restrict specific passengers’ travel and/or contain the outbreak of an infectious disease. These questions include, inter alia, whether the federal government may: (1) restrict which countries U.S. nationals may travel to in the event of a public health crisis; (2) bar the entry into the United States of people who may have been infected by a disease; and (3) impose isolation or quarantine measures in order to control infectious diseases.

Passport restrictions on which countries U.S. citizens may visit can be imposed by the Secretary of State. Pursuant to the Passport Act, the Secretary of State may “grant and issue passports” according to rules designated by the President, and may impose restrictions on the use of passports to travel to countries “where there is imminent danger to the public health or the physical safety of United States travellers” (sic). The Supreme Court has recognized that the authority to “grant and issue” passports includes the power to impose “area restrictions” – limits on travel to specific countries (restrictions must comply with the Due Process Clause of the Constitution). Although passport restrictions are not criminally enforceable, they may prevent travelers from boarding a flight to a restricted area.

Restrictions may also be imposed on who may enter the United States, though the range of applicable restrictions may differ depending upon whether a person seeking entry into the country is a U.S. national. The government enjoys authority under federal immigration law to bar the entry of a foreign national on specific health-related grounds, including when a particular foreign national is determined to have a “communicable disease of public health significance.” More broadly, section 212(f) of the Immigration and Nationality Act authorizes the President, pursuant to proclamation, to direct the denial of entry to any alien or class of aliens whose entry into the country “would be detrimental to the interests of the United States.”

These restrictions do not apply to U.S. citizens, who may enjoy a constitutional right to reenter the country. Nonetheless, certain travel restrictions may impede the ability of any person – regardless of citizenship – from traveling to the United States in a manner that potentially exposes others to a communicable disease. For example, airlines flying to the U.S. are permitted under Department of Transportation regulations to refuse transportation to passengers with infectious diseases who have been determined to pose a “direct threat” to the health and safety of others. In making this determination, airlines may rely on directives from the CDC and other government agencies. Pilots of flights to the United States are also required to report certain illnesses they encounter during flight before arrival into the U.S.

In addition, the Department of Homeland Security and Centers for Disease Control and Prevention (CDC) maintain a public health “Do Not Board” (DNB) list, which contains the names of people who are likely to be contagious with a communicable disease, may not adhere to public health recommendations, and are likely to board an aircraft. Airlines are not permitted to issue a boarding pass to people on the DNB list for flights departing from or arriving into the United States. People placed on the DNB list are also “assigned a public health lookout record,” which will alert Customs and Border Protection officers in the event the person attempts to enter the country through a port of entry. The CDC’s Division of Global Migration and Quarantine (DGMQ) can conduct exit screening at foreign airports to identify travelers with communicable diseases and alert the relevant local authorities.

Finally, both federal and state governments have authority to impose isolation and quarantine measures to help prevent the spread of infectious diseases. While the terms are often used interchangeably, quarantine and isolation are actually two distinct concepts. Quarantine typically refers to separating or restricting the movement of individuals who have been exposed to a contagious disease but are not yet sick. Isolation refers to separating infected individuals from those who are not sick. Historically, the primary authority for quarantine and isolation exists at the state level as an exercise of the state’s police power in accordance with its particular laws and policies.

However, the CDC is also authorized to take measures “to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession.” In order to do so, the implementing regulations “authorize the detention, isolation, quarantine, or conditional release of individuals.” This authority is limited to diseases identified by an Executive Order of the President, a list which currently includes Ebola. Whether an isolation or quarantine order originates with the federal or state government, such orders will presumably be subject to habeas corpus challenges, and must also comport with the Due Process Clause of the Constitution.

View the original CRS Legal Sidebar here (pdf) includes active links.

And that legal challenge may soon be upon us. On October 26, Kaci Hickox, a nurse placed under mandatory quarantine in New Jersey, went on CNN on Sunday and criticized the “knee-jerk reaction by politicians” to Ebola.  According to CNN, Hickox, an epidemiologist who was working to help treat Ebola patients in Sierra Leone, has tested negative twice for Ebola and does not have symptoms.  Norman Siegel, Hickox’s attorney, and a former director of the New York Civil Liberties Union told CNN that he will be filing papers in court for Hickox to have a hearing no later than five days from the start of her confinement. Siegel told CNN that Hickox’s quarantine is based on fear.

Here is the link to the Executive Order 13295 of April 4, 2003 cited above by the CRS brief via:

[T]he following communicable diseases are hereby specified pursuant to section 361(b) of the Public Health Service Act:

(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

July 31, 2014 Update

“(b) Severe acute respiratory syndromes, which are diseases that are associated with fever and signs and symptoms of pneumonia or other respiratory illness, are capable of being transmitted from person to person, and that either are causing, or have the potential to cause, a pandemic, or, upon infection, are highly likely to cause mortality or serious morbidity if not properly controlled. This subsection does not apply to influenza.”

A side note, the U.S. Ambassador to the United Nations, Samantha Power is currently traveling to the countries in West Africa hardest hit with the ebola outbreak:

 

 

Now, since Ambassador Power is not a medical worker, she probably will not be subjected to the NJ/NY mandatory quarantine when she gets back. However, on October 22, the Centers for Disease Control and Prevention (CDC) announced that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea.  Active post-arrival monitoring, according to the CDC  means that travelers without febrile illness or symptoms consistent with Ebola will be followed up daily by state and local health departments for 21 days from the date of their departure from West Africa. Except that Ambassador Power’s return trip will not be originating from West Africa but from Belgium, the last stop on this West Africa-Europe trip before returning to the U.S.

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State Dept Awards $4.9 Million Contract to Phoenix Air for Air Ambulance Evacuation #Ebola

Domani Spero
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Yahoo News reported on September 9 that “an undisclosed number of people who’ve been exposed to the Ebola virus — not just the four patients publicly identified with diagnosed cases — have been evacuated to the U.S. by an air ambulance company contracted by the State Department.”  The report identified Phoenix Air Group as the provider of the air ambulance services. The VP of the company said medical privacy laws and his company’s contract with the State Department prevented him from revealing how many exposed patients have been flown from West Africa to the U.S.  He did tell the reported that Phoenix Air has flown 10 Ebola-related missions in the past six weeks. The report also says that the State Department confirmed the four known Ebola patient transports but couldn’t provide details on any exposure evacuations to the United States.  An unnamed State Department official told Yahoo News that “every precaution is taken to move the patient safely and securely, to provide critical care en route, and to maintain strict isolation upon arrival in the United States.”(See Ebola evacuations to US greater than previously known).

Public records indicate that the State Department awarded the air ambulance contract on August 18, 2014.  The sole source contract was awarded to Phoenix Air for a period of six (6) months at an estimated cost of $4,900,000.00 under FAR 6.302-2  for “unusual and compelling urgency.” The services include among others, air ambulance evacuation, a dedicated on-call aircraft and flight crew, an aero-biological containment system, and emergency recall and mission preparedness:

This requirement is in response to Department of State’s diplomatic mission overseas to provide movement of emergency response personnel into and out of hazardous/non-permissive environments and medical evacuation of critically ill/injured patients, including those infected with unique and high contagious pathogens. This is an immediate response to the Ebola Virus Crisis.

The contract justification says that the movement of patients infected with highly contagious pathogens, as with the current Ebola Virus epidemic, requires the use of an air-transportable biocontainment unit. A unit was designed and built by the Center for Disease Control in 2006 in collaboration with the Phoenix Air Group in Cartersville, GA. The Aeromedical Biological Containment Shelter (ABCS) is the only contagious patient airborne transportation system in the world which allows attending medical personnel to enter the containment vessel in-flight to attend to the patient, thus allowing emergency medical intervention such as new IV lines, intubation, etc.

Yes, the Pentagon has a transport tube but —

“The U.S. Department of Defense has a transport “tube” which a patient is placed into, but once sealed inside the patient is isolated from medical care. It is admittedly (by the DOD) more designed for battlefield causalities than live human transport, especially over long distances. It is also only certified for DOD aircraft and not by the FAA for commercial aircraft which makes this capability not feasible in meeting the Department’s urgent need for the capability to transport contagious patients world-wide.”

Why is this a sole-sourced contract?

Below is part of the justification statement extracted from publicly available documents:

As a matter of standard business practice, Phoenix Air Group does not provide chartered transport of highly contagious patients outside of a standing government contract. As the only vendor with this unique capability, Phoenix Air Group has never offered this service on a one-off basis to private of government entities. The capability was developed on a multi-year contract with the CDC (2006-2011). When the CDC could no longer to afford to maintain the stand-by capability, the equipment was warehoused. While it is technically true that the movement of two American citizens in late July, 2014, was a private transaction, those missions were conducted after the Department requested that PAG consider a break in their standard business practice on a humanitarian basis, with the assurance that the USG would make all necessary arrangements for landing clearances, public health integration, decontamination, and provide press guidance. Simply put, the transportation of this type of patient requires too much international and inter-agency coordination, and incurs too much corporate risk, for PAG to provide the service outside the protection of a federal contract to do so.

The U.S. Department of State has always been responsible for the medical evacuation of official Americans overseas, regardless of their USG agency affiliation. Because of the unique severity and scope of the current Ebola outbreak, and the complete lack of host nation infrastructure to support victims of EVD infection, the international community is finding recruitment of professional staff very difficult without being able to articulate a sound medical evacuation plan. To that end, the Governments of Mexico, Japan, the United Kingdom, Canada, and the United Arab Emirates, as well as the World Health Organization and the United Nations, have separately approached PAG to establish exclusive contracts for this limited resource. Had the Department not moved very quickly to establish its own exclusive use contract, our negotiating position would have shifted, placing USG personnel and private citizens at significant risk.

The availability of the PAG resource is thus a foreign policy issue, placing the U.S. Department of State as the logical arbiter of international agreements to assure equitable coverage while protecting U.S. national interests. The Department is moving to establish Title 607 agreements with these and other eligible entities, allowing coordinated sharing of the resource on a cost-reimbursable basis under 22 U SC 2357 authorities.

Private American citizens responding to this crisis would lack the resources to privately contract for this service, even if it were available on the open market. By establishing the contract through the Department, additional options are provided to American Citizen Services, allowing them to structure the funding as a form of repatriation loan. This would be very difficult to do if not for a Department-level contract; by bringing the resource in-house, the money flow remains within the Department, spreading the financial risk across a much larger budgeting pool. Foreign governments are being encouraged to take similar steps with their own private citizens through high level dialogue that is only possible when the Department is in the lead on this issue.

Given recent CDC guidelines for the movement of asymptomatic contacts, an unprecedented level of control and coordination is necessary to move these individuals that, despite not being contagious or even clearly infected, are nonetheless quarantined. The USG is left with only two options in supporting a CDC scientist that has a high risk exposure to an EVD patient — use the PAG capability to fly the person back to the US for observation and optimum care should disease develop, or leave the person in place where no care is available if the disease develops. The question, then, is not how many EVD patients will be moved, but rather how many contacts and EVD patients will be moved across the entire international response population (as many as three per month). Finally, from a pragmatic stand point, given the limited options for movement of even asymptomatic contacts, it has become clear that an international response to this crisis will not proceed if a reliable mechanism for patient movement cannot be established and centrally managed.

The “special missions” G-111 aircraft, what is it?

 The ABCS was certified by the Federal Air Administration (FAA) under a Supplemental Type Certification (STC) for use in an aircraft. The STC further lists only two (2) air- craft by serial number as approved for the installation and operation of the ABCS. Both aircraft are owned and operated by Phoenix Air.

The two aircraft listed by serial number in the STC are “special missions” Gulfstream G-III jets owned and operated by Phoenix Air. There are only three “special missions” G-111 aircraft in the world and Phoenix Air owns and operates all three. These are unique aircraft converted in the Gulfstream Aerospace factory during the original manufacturing assembly line from standard “executive” aircraft to “special missions” aircraft which includes a large cargo door forward of the wing measuring 81.5” wide X 61” high thus allowing the large components of the ABCS to be installed in the aircraft and post-flight decontamination to be performed, each aircraft has a heavy duty cargo floor allowing the ABCS floor attachment system to be installed, and each aircraft is certified at the factory for passenger, cargo or air ambulance operations.

Phoenix Air holds various DOD Civil Aircraft Landing Permits (CALP’s) from all U.S DOD service branches allowing its aircraft to land at all U.S. military bases and facilities worldwide. For security reasons, all medical evacuations of patients with highly contagious pathogens must land at military airfields. Recent experience reinforces the importance of using military airfields, especially OCONUS where the host nation governments have refused to allow the aircraft access to civil airports in the Azores, but have conceded to allow the aircraft to refuel on USMIL airfields in their country.

All Phoenix Air flight and medical personnel have the Commission on Accreditation of Medical Transport Systems (CAMTS) required accreditation and CDC recommended inoculations for air ambulance missions as well as missions into disease~prone areas around the world providing DOS a unique capability that may not be available with other aviation vendors.

 

Unlike the outbreak of the highly pathogenic avian influenza (H5N1) virus and fears of a pandemic in 2007, one thing we haven’t heard this time is  “shelter-in-place.” Back then, Americans abroad were advised to identify local sources of healthcare and prepare to “shelter-in-place” if necessary. “In those areas with potentially limited water and food availability, Americans living abroad are encouraged to maintain supplies of food and water to last at least two and as long as 12 weeks.” We remember thinking then about the embassy swimming pool and wondering how long it would last if city water runs out. Or what happens if a mob comes into the compound in search of food and water.

That does not seem to be the case here. At least, this time, there will be an air ambulance equipped to evacuate  Americans back home should it come to that. Note that the  justification statement does not include details of how much of the cost will be accounted for as part of the repatriation loan program (pdf) for private Americans.

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Freaking out over the disease that’s “coming for us”? Watch this!

 

 

 

 

 

 

 

 

U.S. Embassy Dakar Issues Security Message on Ebola Virus Disease (EVD) in Senegal

— Domani Spero
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Today, the U.S. Embassy in Dakar issued a security message to U.S. citizens in Senegal concerning the country’s first confirmed case of Ebola Virus Disease (EVD):

On August 29, the Senegalese Minister of Health and Social Action (MOH) announced the country’s first confirmed case of EVD.  At a press conference, the MOH reported that Guinean authorities reached out to Senegalese authorities to advise them about a young Guinean student who is confirmed to have the virus.  The student is currently placed in isolation at a local hospital and is in stable condition.  At this time, there are no other confirmed cases in Senegal. The Department of State is working with the government of Senegal, the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) to monitor the situation.

 

On August 21, the government of Senegal has closed its borders with Guinea. It has also closed air and sea borders for aircraft and ships from Guinea, Sierra Leone, and Liberia.

The State Department has previously issued travel warnings for two countries in the region – Liberia and Sierra Leone– and warned U.S. citizens against non-essential travel to these countries. Due to the lack of available medical resources in these countries and limited availability of medical evacuation options, the U.S. Department of State ordered the departure of family members residing with Embassy staff in Monrovia and in Freetown. (see U.S. Embassy Sierra Leone Now on Ordered Departure for Family Members #Ebola and U.S. Embassy Liberia Now on Ordered Departure For Family Members, New Travel Warning Issued).

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State Dept Issues Travel Alert on Ebola-Related Screening and Travel Restrictions in West Africa

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

On August 28, the State Department issued a Travel Alert for screening and restrictions related to the Ebola outbreak in parts of West Africa:

The Department of State alerts U.S. citizens to screening procedures, travel restrictions, and reduced aviation transportation options in response to the outbreak of Ebola Virus Disease in Guinea, Liberia, Nigeria, and Sierra Leone.   This Travel Alert will expire on February 27, 2015.

Due to an outbreak of Ebola Virus Disease (EVD) in the West African nations of Liberia, Guinea, and Sierra Leone, the Centers for Disease Control and Prevention (CDC) issued  Level 3 Travel Warnings for those three countries advising against non-essential travel and provided guidance to reduce the potential for spread of EVD.  The CDC also issued a Level 2 Travel Alert for Nigeria to notify travelers of the Ebola outbreak in that country.  The Bureau of Consular Affairs’ website prominently features an Ebola Fact Sheet and links to the CDC Health Travel Warnings, Travel Alert, and general guidance about Ebola.

The World Health Organization (WHO) and CDC have also published and provided interim guidance to public health authorities, airlines, and other partners in West Africa for evaluating risk of exposure of persons coming from countries affected by EVD.  Measures can include screening, medical evaluation, movement restrictions up to 21 days, and infection control precautions.  Travelers who exhibit symptoms indicative of possible Ebola infection may be prevented from boarding and restricted from traveling for the 21-day period.  Please note neither the Department of State’s Bureau of Consular Affairs nor the U.S. Embassy have authority over quarantine issues and cannot prevent a U.S. citizen from being quarantined should local health authorities require it.  For questions about quarantine, please visit the CDC website that addresses quarantine and isolation issues.

The cost for a medical evacuation is very expensive.  We encourage U.S. citizens travelling to Ebola-affected countries to purchase travel insurance that includes medical evacuation for Ebola Virus Disease (EVD).  Policy holders should confirm the availability of medical care and evacuation services at their travel destinations prior to travel.

Some local, regional, and international air carriers have curtailed or temporarily suspended service to or from Ebola-affected countries.  U.S. citizens planning travel to or from these countries, in accordance with the CDC Health Travel Warnings and Health Travel Alert, should contact their airline to verify seat availability, confirm departure schedules, inquire about screening procedures, and be aware of other airline options.

The Department is aware that some countries have put in place procedures relating to the travel of individuals from the affected countries, including complete travel bans.  Changes to existing procedures may occur with little or no notice.  Please consult your airline or the embassy of your destination country for additional information.

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According to the WHO’s Outbreak News, the total number of probable and confirmed cases in the current outbreak of Ebola virus disease (EVD) as reported by the respective Ministries of Health of Guinea, Liberia, Nigeria, and Sierra Leone is 3069, with 1552 deaths.  The World Health Organization reports that the outbreak continues to accelerate with more than 40% of the total number of cases occurring within the past 21 days.  The overall case fatality rate is 52%.

A separate outbreak of Ebola virus disease not related to the four-country outbreak was laboratory-confirmed on  August 26 by the Democratic Republic of Congo (DRC). The DRC’s index case was a pregnant woman from a village who butchered a bush animal that had been killed and given to her by her husband. From July 28- August 18, 2014, a total of 24 suspected cases of haemorrhagic fever, including 13 deaths, have been identified in that outbreak.

As of this writing, Senegal also confirmed its first case of Ebola related to the four-country outbreak in West Africa.

 

 

 

 

 

 

 

U.S. Embassy Sierra Leone Now on Ordered Departure for Family Members #Ebola

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

On August 14, the State Department  announced the ordered departure of family members not employed at U.S. Embassy Freetown from Sierra Leone. This follows the ordered departure of family members from U.S. Embassy Liberia on August 7. No Travel Warning has yet been issued for Sierra Leone as of this writing but we expect one coming out soon. Below is the statement of the U.S. Embassy Freetown ordered departure:

At the recommendation of the U.S. Embassy in Sierra Leone, the State Department today ordered the departure from Freetown of all eligible family members (EFMs) not employed by post. The Embassy recommended this step out of an abundance of caution, following the determination by the Department’s Medical Office that there is a lack of options for routine health care services at major medical facilities due to the Ebola outbreak.

We are reconfiguring the Embassy staff to be more responsive to the current situation. Our entire effort is currently focused on assisting U.S. citizens in the country, the Government of Sierra Leone, international health organizations, local non-governmental organizations (NGOs), and the Sierra Leonean people to deal with this unprecedented Ebola outbreak.

We remain deeply committed to supporting Sierra Leone and regional and international efforts to strengthen the capacity of the country’s health care infrastructure and system — specifically, the capacity to contain and control the transmission of the Ebola virus, and deliver health care.

According to the World Health Organization, a total of 128 new cases of Ebola virus disease (EVD) (laboratory-confirmed, probable, and suspect cases) as well as 56 deaths were reported from Guinea, Liberia, Nigeria, and Sierra Leone between August 10-11, 2014. See the disease update from the WHO:

via WHO

via WHO

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