Public Health Screening

Public Health
Screening
at Northwest
Ports of Entry

Sandra L. Marvinney

Five to eight times a month, Jenny Ansdell, the officer-in-charge for the U.S. Public Health Service Division of Quarantine at Seattle-Tacoma International Airport, receives a call from an airliner captain that a passenger is ill with symptoms of a possibly quarantinable disease. A quarantine officer meets the plane at the gate and, while other passengers are held on board, examines the ill person and takes a detailed history of symptoms and recent travel.

Foreign quarantine regulations define a passenger as ill if the person has (1) a temperature of 1OO degrees F or greater for two or more days or if the fever is accompanied by a rash, jaundice, or glandular swelling, or (2) diarrhea severe enough to interfere with normal activity The quarantine inspector has the power to detain persons suspected of having cholera, diphtheria, infectious tuberculosis, plague, suspected smallpox, yellow fever, or suspected viral hemorrhagic fevers such as Lassa and Ebola. In difficult cases, the inspector consults by phone with a contract physician/medical officer with the Centers for Disease Control and Prevention (CDC), National Center for Infectious Diseases.

Under a revised protocol effective May 1, 1996, for the Seattle Quarantine Station, the quarantine officer consults with the CDC and the contract physician if a passenger arrives with suspected viral hemorrhagic fever. With their concurrence, the passenger will be transported under strict isolation to the University of Washington Medical Center. Those with symptoms of other quarantinable diseases will be transported to Harborview Medical Center. The quarantine officer then notifies the state epidemiologist and the Seattle-King County Department of Health. Other passengers who had noncasual contact with the ill person will complete a surveillance form, and all passengers receive a notice to monitor specific illness criteria. If circumstances warrant, close contacts may be urged to obtain prophylactic treatment.

If the cause of illness seems to be food poisoning or a medical condition such as diabetes mellitus, the other passengers and crew arc allowed to deplane and the ill person may be released, referred to a physician, or transported to Highline Hospital near SeaTac. Passengers with symptoms of infectious illnesses such as measles or hepatitis will be referred to physician, with notification given to the appropriate units of the local health department and the CDC for followup. In the case of measles, the passengers and crew receive alert notices.

The quarantine inspector completes the initial on-board screening as quickly as possible, usually within five minutes, because "gate time" is expensive to the airlines and the demand for it is intense at this busy airport. Also, passengers tend to be impatient. If the quarantine inspector is paged when the Quarantine Office is closed, however, passengers are held until the inspector or emergency medical technicians on contract to the Public Health Service (PHS) can reach the airport and perform the screening.

Screening of Immigrants and Others

Medical inspection of arriving aliens is another major responsibility All immigrants, refugees, and fiances/fiancees of U.S. citizens and their minor children are required to have a medical examination overseas. Immigration inspectors at the main port and subports advise the quarantine officer when an immigrant arrives with incomplete or no medical documents. The documents of those who have medical conditions are mailed to the Seattle Quarantine Station for notification. All aliens, including those not routinely required to have a medical examination, may be denied entrance if they exhibit symptoms of a physical or mental disorder that may be excludable under immigration law.

All immigrants who arrive with "Class A" conditions such as tuberculosis (TB), Hansen's disease, or infection with HIV, require a waiver with the name and address of the health provider. Those with TB and Hansen's must have completed treatment. Incomplete treatment for syphilis is a "Class B" condition. A class A/B stamp usually is imprinted on the visa. The quarantine officer sends out notification to the state and local health department to follow up. Copies of health papers for immigrants with medical conditions and for all refugees are sent to local health departments and to CDC headquarters.

Sometimes even a departing alien can present a disease control problem. Last March the Tacoma-Pierce County Health Department requested the assistance of the Seattle Quarantine Station because an alien from Southeast Asia had left the country while she was still being treated for active TB. The woman had been living here since 1994. Although the task of determining her departure flight might seem impossible, it was surmised the woman would leave on the same airline to return to her home country An immigration officer was able to obtain her 1994 arrival airline and flight number, and with the airlines assistance, the quarantine officer confirmed the departure flight. Thus, it was possible for the Tacoma-Pierce County Health Department to alert other passengers and crew to potential TB exposure.

Additional airport duties include clearance of animals and etiological agents for import. Dogs three months and older must have current rabies vaccination (unless arriving from a rabies-free country) and all cats and dogs are visually inspected. Nonhuman primates may be imported only for scientific, educational, or zoological exhibition purposes, and may be brought in only by registered importers. Special CDC permits are required for some species. For example, primates shipped as pets are seized, re-exported to the country of origin, donated to CDC-approved facilities, or destroyed. Shipments of aquatic fish and plants are inspected for snails, which may carry schistosomiasis, and turtles, which are usually infected with Salmonella. Certain animal products, for example Haitian goat skins, which may carry anthrax, are banned from import. Etiological agents require a CDC import permit.

By Sea and Land Also

The responsibilities of the PHS Quarantine Station at Sea-Tac range far beyond the airport - and beyond the state. The station monitors activity at all international airports and seaports in Alaska, Oregon, and Washington, and the U.S.-Canadian border crossings from Washington to North Dakota. This enormous task is accomplished through cooperation with immigration and customs officers in those locations and through contracting with local physicians for inspection services as needed. All incidents are reported to the Seattle Quarantine Station.

Jim Bates/The Seattle Times, 1992

As with airline captains, ship captains also are required to notify the station of a death or illness on board. In one case, a cargo ship left a Mediterranean port, put an ill crew member ashore in Fort Lauderdale, Florida, and then headed for Astoria, Oregon. Florida health authorities notified the Miami Quarantine Station, which notified the Seattle station that the ill crew member had been diagnosed with active TB. The Seattle station then alerted the Oregon Health Department TB division so that every member of the crew who had been in contact with the ill crew member could be followed up for testing on arrival in Astoria.

With cargo ships, insect vectors of disease also are a major concern. Containers of used tire casings shipped from foreign ports may be transporting mosquitoes that could spread diseases such as dengue. Regulations require that containers of used casings be treated with methyl bromide, heat, or steam to kill mosquitoes and larvae. Quarantine inspectors examine about 10% of the shipments of tire casings; the Seattle Quarantine Station at present lacks the personnel to conduct more extensive inspections to ensure that regulations are fully met.

Rat infestations are another potentially serious problem, but U.S. ports do not require "derat" certification for cargo ships. Ships headed for countries that require such certification may ask the Seattle Quarantine Station for an inspection if their six-month certification is about to expire or has expired. Contractors handle this inspection work for the station. Ships that fail inspection must eliminate the rats through trapping or fumigation to receive a new certificate.

list of quarantine stations
How Significant Is the Risk of Disease Importation?
Seven to 12 international flights from Asia, Russia, Europe, Mexico, and 30 flights from Canada arrive daily at Sea-Tac. Up to 30 flights a month may arrive with 30 to 50 refugees each. According to the local health department, about 5% of immigrants from some Asian countries have infectious TB, even though their medical documents reported noninfectious status. The introduction of Ebola virus through travelers is unlikely, but plague or dengue could enter via the shipping industry.
The Seattle Quarantine Station performs a critical function in preventing disease introduction into the Northwest, but it might be likened to a giant sieve. The surveillance and quarantine protocols enforced by its vigilant though overextended staff will catch the more obvious problems. Infected but apparently asymptomatic travelers and aliens will flow through and disperse into the region. The lesson, again, is that our best protection is a strong local public health infrastructure.

Public health professionals must be alert for potential disease introduction and prepared to take action to protect the community.

Author

Sandra L. Marvinney, B.A, is managing editor of Washington Public Health.

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Last update: 01/30/97