New CDC Regulations for Domestic and Foreign Travel
On Feb. 21, CDC will implement newly revised rules for issuing federal public health orders (e.g., orders for quarantine, isolation, or conditional release) for both domestic and foreign travel. CDC revised the rules to improve and clarify its role in preventing the introduction, transmission, and spread of communicable diseases in the United States.
The new rules are intended to complement the power and authority of states to respond to communicable diseases. This summary of key provisions is aimed at assisting ASTHO’s members in gaining a deeper understanding of the revised rule.
Federal, State, and Local Roles and Relationships
The revisions to CDC’s rules are meant to apply to all travelers in the United States and are intended to be part of a comprehensive federal, state, and local public health system. With regards to the jurisdictional relationships, CDC retains the authority to take measures to prevent the interstate spread of communicable diseases when it is determined that state or local actions are insufficient. Also, a new provision requires pilots of domestic flights to report any onboard deaths or ill persons directly to the CDC instead of to the local health authority.
In its overview of public comments to the rule changes, CDC recognizes the need for coordination with states when transferring a person who is under a federal public health order to state custody, taking into account the state’s willingness to assume custody. If a state assumes custody of an individual, the state may conduct its own independent assessment of the individual state policies and procedures. Also, once custody is transferred, state law and standards of due process will apply to the individual.
Based on the underlying statutory authority, new provisions clarify CDC’s ability to conduct non-invasive, public health prevention measures (e.g., inspection, fumigation, disinfection, sanitation, pest extermination, etc.) to detect the presence of communicable diseases at United States airports, seaports, railway stations, bus terminals, and other locations used to gather people for interstate travel. The prevention measures may also require providing contact information such as United States and foreign addresses, telephone numbers, email addresses, information about a person’s intended destination, health status, known or possible exposure history, and travel history. These new provisions apply broadly to communicable diseases and are not limited to the “quarantinable communicable diseases” as specified by a presidential executive order and which form the basis for issuing federal public health orders.
Apprehension of Individuals with Case or Suspected Case of Quarantinable Communicable Disease
In regards to domestic travel, the revised rules clarify when the CDC Director can apprehend, medically examine, quarantine, isolate, or conditionally release a person in order to prevent the introduction, transmission, and spread of a quarantinable communicable disease, as specified by a presidential executive order. Quarantinable communicable diseases are currently limited to cholera, diphtheria, infectious tuberculosis (TB), plague, smallpox, yellow fever, and viral hemorrhagic fevers (such as Marburg, Ebola, Lassa fever, and Crimean-Congo), severe acute respiratory syndromes, and influenza caused by novel or re-emergent influenza viruses that are causing or have the potential to cause a pandemic. See Executive Order 13295 (April 4, 2003), as amended by Executive Order 13375 (April 1, 2005) and Executive Order 13674 (July 31, 2014).
Apprehension, medical examination, quarantine, isolation, or conditional release may occur when, with reasonable belief, a person is infected and within a qualifying stage of a quarantinable communicable disease and is in the process of moving from one state to another. Action from the CDC Director may also occur if a person is infected and within a qualifying stage of a quarantinable communicable disease and is a probable source of infection to others who may be moving from state to state. A new provision requires the CDC Director to arrange ancillary support for a person under a federal public health order (e.g., adequate food and water, appropriate accommodation, appropriate medical treatment, and means of necessary communication).
Issuance of Federal Public Health Order
Within 72 hours of apprehension, the federal order authorizing quarantine, isolation, or conditional release must be served to the individual or group. The order must set out the factual basis, provide notice that the order will be reassessed, and provide notice of the rights to request a medical review. Translation or interpretive services are also to be provided as needed.
Mandatory Reassessment of Federal Public Health Order
A mandatory reassessment of the federal public health order must occur no later than 72 hours of the order being served with translation or interpretative services being provided. The reassessment is a review of the records considered when issuing the order, as well as any new information. It provides an opportunity to consider and determine whether less restrictive alternatives would protect the public’s health and concludes with the order being continued or rescinded. If the order continues, the apprehended individual has the right to request a medical review. Translation or interpretive services are to be provided as needed.
Medical Review of the Federal Public Health Order
A person under a federal public health order may request a medical review after the order’s mandatory reassessment. The medical review is used to determine whether there is reasonable belief that the individual is infected with a quarantinable communicable disease in a qualifying stage. At the review, medical and other evidence may be presented and recommendations are issued as to whether the order should be continued, modified, or rescinded. The person under the order has the right to present witnesses and testimony, and be represented by an advocate (e.g., an attorney, family member, or physician) at one’s own expense. If a person is indigent, he or she is entitled to both medical and legal representatives who are appointed at the government’s expense. Translation or interpretive services are also to be provided as needed.
Payment for Care and Treatment
Payment for the care and treatment of individuals subject to federal public health orders may be authorized by CDC. Payment is at CDC’s discretion, subject to available funds, and CDC is to be the payer of last resort. Payment for quarantinable communicable diseases should cover costs from the time the person is referred to a hospital or medical facility to when the order expires. Payment for other diseases is limited to the time between the referral and the diagnosis of the condition as an illness other than a quarantinable communicable disease.
Rescinding a Federal Public Health Order
In the overview of the public comments, CDC touches on the procedures to be used to rescind a federal public health order. CDC indicates that it would issue a written order rescinding the isolation, quarantine, or conditional release to the detained individual. The rescission would be based on either the individual no longer posing a public health threat or the individual being transferred to the custody of a state or local public health authority.
To see all revisions, the final rule, and CDC’s reply to public comments regarding the proposed revisions, please click here.
Disclaimer: The legal information provided above does not constitute legal advice or legal representation. For legal advice, please consult your legal counsel.
Andy Baker-White, JD, MPA, is senior director of state health policy at ASTHO.