We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.

A 1-day table-top exercise in San Diego, California, in December 2004 emphasized voluntary compliance with home quarantine to control an emerging infectious disease outbreak. The exercise heightened local civilian-military collaboration in public health emergency management. Addressing concerns about lost income by residents in quarantine was particularly challenging.

The purpose of this study was to cull lessons from Toronto's experiences with large-scale quarantine during the outbreak of Severe Acute Respiratory Syndrome in early 2003. We focused on issues that affected the population's willingness to comply with quarantine. Information was acquired from interviews, telephone polling, and focus groups. Issues of quarantine legitimacy, criteria for quarantine, and the need to allow some quarantined healthcare workers to leave their homes to go to work were identified. Also important was the need to answer questions from people entering quarantine about the continuation of their wages, salaries, and other forms of income while they were not working, and about the means by which they would be supplied with groceries and other services necessary for daily living. The threat of enforcement had less effect on compliance than did the credibility of compliance-monitoring. Fighting boredom and other psychological stresses of quarantine, muting the forces of stigma against those in quarantine, and crafting and delivering effective and believable communications to a population of mixed cultures and languages also were critical. The need for officials to develop consistent quarantine policies, procedures, and public messages across jurisdictional boundaries was paramount.

How to promote transnational collaboration in implementing quarantine was the topic of a January 19–23, 2004, conference sponsored by the Defense Threat Reduction Agency. Fifty invited participants discussed the status of quarantine planning in 13 countries (the Americas, Israel, and several members of the European Union [EU] nations). Held in the Wilton Park Conference Centre, Sussex, United Kingdom, the conference, following an International Biological Weapons Attack: Building Cooperation, Achieving Consistency, also addressed quarantine in response to emerging infectious diseases. Participants first examined the legal foundation for quarantine in their countries. Federal Canadian quarantine law applies only to national ports of entry or exit; provincial laws govern quarantine in the provinces. The U.S. Centers for Disease Control and Prevention has quarantine responsibilities at national ports of entry or departure; this agency may also become involved when a disease is spreading across state borders or even within a state (when invited by the governor of the state or ordered by the U.S. Secretary of Health and Human Services or the U.S. President). In general, however, quarantine in the United States is a local or state government issue. Quarantine laws in these jurisdictions vary, and some public health authorities expressed reluctance to address their shortcomings through legislation for fear that skeptics of quarantine would further weaken the laws. Other nations would turn to the World Health Organization and its International Health Regulations of 1969 (IHR) for guidance. A revised IHR should be available by 2005, but currently it lists only three diseases—plague, cholera, and yellow fever—as subject to quarantine and offers scant help in planning quarantine. Thus, the legal framework for quarantine varies and contributes little to the construction of a consistent approach to quarantine among nations. European public health officials have forged some bilateral cooperative agreements and are discussing establishing a regional disease control center for EU nations. They are not, however, developing and testing national or transnational plans for possible large-scale quarantine. Some participants thought that consistency in developing and implementing quarantine measures was not necessarily desirable, given that each nation must deal with threats in accordance with its own culture, laws, and traditions. Others thought that inconsistencies in response to the same disease threat might encourage persons to question the need for quarantine measures and choose not to comply. The United States also has not developed comprehensive quarantine plans, trained staff, or conducted quarantine exercises in local communities, despite recently issued federal quarantine guidelines. Especially lacking are processes and procedures to clarify decision-making and coordination in communities with multiple jurisdictions. The heightened concern of the United States about bioterrorism was not shared by others at the conference, although all agreed that persons would likely demand a federal response to a health crisis caused by terrorists, including any required quarantine. Other issues discussed included assurances of compensation for income lost while in quarantine (strongly recommended as a component of any quarantine plan) and psychosocial support to reduce the sense of isolation experienced by many persons while in quarantine. Officials with information management experience during health- and nonhealth-related crises commented on the need for caution in making public statements when faced with a new and evolving threat. The conference permitted participants to establish working relationships with one another, but it also highlighted gaps in comprehensive transnational quarantine planning. The complete conference report is available at http://www.dtra.mil/about/ASCO/wpc/wpc.cfm

Because Armed Forces Reserve members, especially combat support units, were rapidly mobilized during Operation Desert Shield/Desert Storm, they were at higher risk for anxiety and stress-related disorders. Personnel in reserve units in the military force structure are at greater risk for psychologic stress due to rapid mobilization and demobilization, which allows minimal time to process adverse experiences or fears. The unexpected disruption of families and careers and resulting financial pressures are magnified in older age groups who have increased personal and family commitments. Personnel in combat support units are at greatest risk when they lack necessary training, cohesion, and leadership. Prevention efforts in reserve units should involve education regarding the potential for activation and associated disruption of family and career plans, Support networks for reserve families should be encouraged, Additional training in an appropriate context regarding risks of biologic and chemical exposure, with the goal of developing confidence in training and equipment, should be stressed. Finally, group processing before demobilization and recall within 90 days of return to emphasize unit cohesion and readjustment to civilian life may be of benefit.