HHS Should Assess Jurisdictional Planning for Isolation and Quarantine (GAO-24-106705)
Summary
A GAO report to congressional committees, GAO-24-106705, dated July 2024, on public health preparedness. It notes that as of June 2024 over 1.1 million people in the United States had died from COVID-19, according to CDC. It explains that isolation and quarantine are among the first measures available to limit disease spread and that state and territorial governments have primary responsibility for them. All seven selected jurisdictions GAO reviewed used isolation and quarantine for the COVID-19 pandemic, and their officials identified considerations for implementing such measures. Its title states that HHS should assess jurisdictional planning for isolation and quarantine.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
United States Government Accountability Office
Report to Congressional Committees
PUBLIC HEALTH
July 2024
PREPAREDNESS
HHS Should Assess
Jurisdictional Planning
for Isolation and
Quarantine
GAO-24-106705
July 2024
PUBLIC HEALTH PREPAREDNESS
HHS Should Assess Jurisdictional Planning for
Isolation and Quarantine
Highlights of GAO-24-106705, a report to
congressional committees
Why GAO Did This Study What GAO Found
As of June 2024, over 1.1 million When a new disease presents a public health emergency, isolation and
people in the United States have died quarantine are among the first measures available to limit disease spread. All
from COVID-19, according to CDC. seven selected jurisdictions (states and territories) GAO reviewed used isolation
State and territorial (jurisdictional) and quarantine for the COVID-19 pandemic. Officials from these jurisdictions
governments have primary identified considerations for implementing such measures for COVID-19,
responsibility for leading the including difficulty with enforcement and isolation and quarantine facility logistics.
preparation for and response to public
health emergencies, with federal Examples of Selected Jurisdictions’ COVID-19 Isolation and Quarantine Actions
support through guidance and funding
awards. When jurisdictions’ capabilities
are insufficient, HHS is charged with
leading the federal public health and
medical response. GAO added HHS
leadership of public health
emergencies to its High-Risk List in
2022.
The Consolidated Appropriations Act,
2023 included a provision for GAO to
review selected jurisdictions’ isolation
and quarantine planning. Regarding
isolation and quarantine, this report
examines (1) selected jurisdictions’ The selected jurisdictions carried out some isolation and quarantine planning
COVID-19 actions, (2) their planning, before the COVID-19 pandemic. Four had detailed plans based on past
(3) federal agencies’ support to experiences with diseases such as H1N1 influenza, while the remaining three
jurisdictions, and (4) CDC’s efforts to had high-level provisions within emergency plans. In response to COVID-19
assess jurisdictional planning. GAO experiences, the selected jurisdictions have taken steps to strengthen their
reviewed documentation and isolation and quarantine planning, such as updating plans to identify potential
interviewed officials from seven facilities for isolation and quarantine.
jurisdictions selected for geographic
variation and representatives from five
Federal agencies—primarily the Department of Health and Human Services’
national public health associations. (HHS) Centers for Disease Control and Prevention (CDC)—provided guidance
GAO also reviewed documentation and and awarded funding to jurisdictions during the COVID-19 pandemic that could
interviewed officials from HHS and the be used to support isolation and quarantine efforts. However, CDC did not
Federal Emergency Management provide advance notice of isolation and quarantine guidance to jurisdictions
Agency. before publication, which slowed jurisdictions’ implementation of these measures.
CDC has a new process for developing and sharing guidance, and officials told
What GAO Recommends GAO the agency intends to provide advance notice to jurisdictions when
GAO is making two recommendations possible. However, CDC has not documented its intentions to provide advance
to CDC to (1) document its intentions notice. Doing so will help ensure CDC implements its approach as planned and
to share finalized isolation and thereby help jurisdictions prepare for and effectively implement isolation and
quarantine guidance with jurisdictions quarantine when needed.
before publication; and (2) assess Additionally, CDC has not assessed jurisdictions’ planning for isolation and
jurisdictional planning for isolation and quarantine. As a result, CDC is missing information to identify and address gaps
quarantine. HHS agreed with the
in jurisdictions’ planning, including the absence of such plans. The National
recommendations.
Biodefense Strategy directs CDC to determine any gaps in disease mitigation
View GAO-24-106705. For more information, preparedness, including for isolation and quarantine. By assessing jurisdictions’
contact Mary Denigan-Macauley at (202) 512-
7114 or DeniganMacauleyM@gao.gov.
planning, CDC could better fulfill this responsibility and identify and help address
any gaps in jurisdictional planning for future disease outbreaks.
United States Government Accountability Office
Contents
Letter 1
Background 8
Selected Jurisdictions Took a Range of Isolation and Quarantine
Actions for COVID-19 11
Selected Jurisdictions Did Some Isolation and Quarantine
Planning Before the COVID-19 Pandemic and Are Revising
Planning for Future Threats 20
Federal Agencies Supported Jurisdictions’ COVID-19 Isolation
and Quarantine Efforts In Several Ways; CDC Has a New
Process for Developing and Communicating Guidance 27
CDC Has Not Assessed Jurisdictions’ Isolation and Quarantine
Planning 41
Conclusions 43
Recommendations for Executive Action 44
Agency Comments and Our Evaluation 45
Appendix I Comments from the Department of Health and Human Services 46
Appendix II GAO Contact and Staff Acknowledgments 50
Table
Table 1: Examples of Federal Awards That Could be Used for
COVID-19 Isolation and Quarantine 33
Figures
Figure 1: Characteristics of Selected Jurisdictions 4
Figure 2: Examples of Selected Jurisdictions’ COVID-19 Isolation
and Quarantine Actions, 2020 to 2023 12
Figure 3: Examples of Characteristics and Wraparound Services
for Isolation and Quarantine Facilities Identified by
Selected Jurisdictions 15
Figure 4: Examples of Selected Jurisdictions’ Documented
Isolation and Quarantine Planning During the COVID-19
Response 24
Figure 5: Selected Changes to CDC Guidance on Isolation and
Quarantine for COVID-19, 2020-2022 28
Page i GAO-24-106705 Isolation and Quarantine
Figure 6: CDC Guidance on Isolation and Precautions for
Individuals with COVID-19, December 2022 30
Page ii GAO-24-106705 Isolation and Quarantine
Abbreviations
ASPR Administration for Strategic Preparedness
and Response
CDC Centers for Disease Control and Prevention
FEMA Federal Emergency Management Agency
HHS Department of Health and Human Services
PanCAP Adapted Pandemic Crisis Action Plan Adapted: U.S.
Government COVID-19 Response Plan
PHEP Public Health Emergency Preparedness
This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.
Page iii GAO-24-106705 Isolation and Quarantine
Letter
441 G St. N.W.
Washington, DC 20548
July 25, 2024
The Honorable Bernard Sanders
Chair
The Honorable Bill Cassidy
Ranking Member
Committee on Heath, Education, Labor and Pensions
United States Senate
The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
As of June 2024, over 1.1 million people in the United States had died
from COVID-19, according to the Department of Health and Human
Services’ (HHS) Centers for Disease Control and Prevention (CDC).
State and territorial governments—jurisdictions—have primary
responsibility for leading the preparation for and response to public health
threats and emergencies, including those caused by an infectious disease
like COVID-19. 1 HHS awards funds and provides guidance to jurisdictions
to prepare for infectious disease threats and support jurisdictions’
response in times of emergency.
When a new disease presents a public health emergency, isolation,
quarantine, and other non-pharmaceutical interventions, such as
handwashing and social distancing, are the first public health
countermeasures that are readily available to respond to that new
disease, according to CDC and the World Health Organization. 2
Isolation—separating sick people with an infectious disease from people
who are not sick—and quarantine—restricting the movement of people
who were exposed to an infectious disease—are methods for containing
1We refer to states, territories, and the District of Columbia as jurisdictions for the
purposes of this report. According to CDC, Tribes enforce isolation and quarantine law
within tribal lands, if such laws exist. Tribes were outside the scope of this review.
2The Secretary of Health and Human Services may declare a public health emergency
upon a determination that a) a disease or disorder presents a public health emergency; or
b) a public health emergency, including significant outbreaks of infectious disease or
bioterrorist attacks, otherwise exists. 42 U.S.C. § 247d(a).
Page 1 GAO-24-106705 Isolation and Quarantine
and mitigating the spread of infectious diseases like COVID-19 during the
public health emergency, according to CDC.
States and territories are responsible for enforcing isolation and
quarantine within their borders. They also are responsible for developing
plans to prepare for emergencies, such as those needing isolation and
quarantine. Such plans are not required to include isolation and
quarantine measures. CDC—the agency within HHS responsible for
protecting the nation’s health—is authorized to take measures to prevent
the introduction, transmission, or spread of infectious diseases from
foreign countries into the U.S. and between states. 3 These measures
include taking federal actions for isolation and quarantine. CDC also
assists jurisdictions in the prevention and suppression of infectious
diseases. This support can include cooperating with and aiding
jurisdictions in the enforcement of their quarantine regulations. 4
Generally, if jurisdictions’ response capabilities are exceeded, they may
seek support from the federal government.
The Consolidated Appropriations Act, 2023 included a provision for us to
review selected jurisdictions’ isolation and quarantine planning and
related federal assistance. 5 This report is also part of our body of work on
HHS’s leadership of public health emergencies, which we identified as an
area of high risk. 6 We added this topic to our High-Risk List in 2022, citing
the critical need for the nation to be prepared for, and effectively respond
to, future public health threats and emergencies.
This report
1. describes the isolation and quarantine actions selected
jurisdictions took in response to the COVID-19 pandemic;
342 U.S.C. § 264(a).
442 U.S.C. § 243(a).
5Pub. L. No. 117-328, § 2114, 136 Stat. 4459, 5726 (2022).
6See GAO, High-Risk Series: Efforts Made to Achieve Progress Need to Be Maintained
and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20,
2023) and GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief
Funds and Leading Responses to Public Health Emergencies, GAO-22-105291
(Washington, D.C.: Jan. 27, 2022).
Page 2 GAO-24-106705 Isolation and Quarantine
2. describes selected jurisdictions’ planning for isolation and
quarantine;
3. examines the federal support provided for jurisdictions’ isolation
and quarantine efforts; and
4. evaluates the extent to which CDC assesses jurisdictions’
planning for isolation and quarantine.
For three of the objectives, we reviewed documentation and interviewed
health department officials from a nongeneralizable sample of seven of
56 jurisdictions (states, territories, and the District of Columbia) and
representatives from five national associations representing state,
territorial, local, and tribal public health officials. We selected six states
and one territory—which we refer to as selected jurisdictions—to obtain
variation in the following characteristics: geographic location, health
department governance structure (i.e., the relationship between state and
local health agencies), population size and rurality, duration of imposed
travel restrictions for COVID-19, federal funding awarded to jurisdictions
that could have been used for isolation or quarantine activities, and extent
of homeless population. 7 We selected and interviewed health department
officials from the following jurisdictions: American Samoa, Alabama,
Hawaii, New Jersey, Rhode Island, South Dakota, and Texas. (See fig.
1.) Information from selected jurisdictions is not generalizable to other
jurisdictions. Additionally, we selected three national associations that
represent all state, territorial, or local health department officials; one
association that represents all tribal health officials; and one association
that represents all state and territorial political leaders. 8
7We used the following data sources to select a diverse group of jurisdictions: U.S.
Census Bureau 2020 Census, CDC governance health structures listing, CDC COVID-19
Crisis Response Cooperative Agreement Funding Data, Department of Homeland
Security Public Assistance Grants Manager, and Department of Housing and Urban
Development 2020 Annual Homelessness Assessment Report. We assessed the
reliability of these data by reviewing related documentation. Based on this assessment,
we determined that these data were sufficiently reliable for the purposes of selecting
jurisdictions.
8We interviewed representatives from the following national associations: Association of
State and Territorial Health Officials, National Association of County and City Health
Officials, Council of State and Territorial Epidemiologists, National Indian Health Board,
and National Governors Association.
Page 3 GAO-24-106705 Isolation and Quarantine
Figure 1: Characteristics of Selected Jurisdictions
Note: We refer to states and territories as jurisdictions for the purposes of this review.
Page 4 GAO-24-106705 Isolation and Quarantine
aPublic health governance structure indicates the relationship between state health departments and
local public health units, according to CDC. Centralized or largely centralized governance indicates
that local health units are primarily led by employees of the state. Decentralized or largely
decentralized governance indicates that local health units are primarily led by employees of local
governments.
To describe the isolation and quarantine actions selected jurisdictions
took in response to the COVID-19 pandemic, we reviewed documentation
and interviewed health department officials from the selected jurisdictions
for information on actions from January 2020 through May 2023—the
beginning and end of the public health emergency declaration for COVID-
19. We reviewed documentation of actions taken, such as guidance,
planning documents, and other support. For the purposes of this review,
we included actions jurisdictional governments took to promote isolation
or quarantine, including issuing guidance, offering facilities, offering
wraparound services, issuing orders, or enforcing isolation or quarantine. 9
Jurisdictions can use other community mitigation measures in conjunction
with isolation and quarantine, such as travel restrictions or social
distancing. We interviewed jurisdictional health department officials about
isolation and quarantine actions taken for COVID-19 and the challenges
or other considerations that influenced their actions. We also interviewed
representatives from the five national associations to gain a broader
perspective on jurisdictions’—including state, territorial, tribal, and city or
county jurisdictions—isolation and quarantine experiences.
To describe the selected jurisdictions’ planning for isolation and
quarantine, we reviewed their isolation and quarantine planning
documents developed before and in response to the COVID-19
pandemic. 10 We also interviewed officials from the selected jurisdictional
health departments and representatives from national associations to
9Wraparound services refer to supportive services such as delivery of food, medicine, or
transportation to individuals in isolation or quarantine. We limited our review to actions for
the general public isolating or quarantining at home or in facilities specifically for isolation
or quarantine purposes, rather than at other types of institutions such as schools or health
care facilities. Repatriation of individuals from abroad at the outset of the COVID-19
pandemic is outside the scope of this review. For more information on federal repatriation
for COVID-19 see COVID-19: HHS Should Clarify Agency Roles for Emergency Return of
U.S. Citizens during a Pandemic, GAO-21-334 (Washington, D.C.: Apr. 19, 2021). For
information on COVID-19 response at other healthcare facilities, see for example COVID-
19 in Nursing Homes: Outbreak Duration Averaged 4 Weeks and Was Strongly
Associated with Community Spread, GAO-23-104291 (Washington, D.C.: Dec. 15, 2022).
10We define planning prior to the COVID-19 pandemic as any plans or procedures created
before COVID-19 was declared a public health emergency on January 31, 2020. Isolation
and quarantine planning developed in response to the COVID-19 pandemic includes
COVID-19-specific documents and plans and procedures developed since the public
health emergency through April 2024.
Page 5 GAO-24-106705 Isolation and Quarantine
gain further perspective on jurisdictional preparedness planning efforts.
Additionally, to describe isolation and quarantine planning informed by
COVID-19 experiences across all state and territorial jurisdictions, we
reviewed work plans submitted by 50 states, five territories, and the
District of Columbia describing how they would use funding from CDC’s
Public Health Emergency Preparedness (PHEP) cooperative agreement
program for the 2022-2023 budget period. 11
To examine the federal support provided for jurisdictions’ isolation and
quarantine efforts, we reviewed documentation and interviewed officials
from the Administration for Strategic Preparedness and Response
(ASPR) and CDC within HHS, and the Federal Emergency Management
Agency (FEMA) within the Department of Homeland Security. This
included documentation and interviews about technical assistance and
funding awards that the agencies provided to help jurisdictions implement
isolation and quarantine during the COVID-19 public health emergency,
as well as CDC’s plans to provide support in the future. We reviewed
CDC and FEMA COVID-19 award data and associated documentation to
determine which jurisdictions used awards for isolation and quarantine
purposes. 12 We assessed the reliability of these award data by reviewing
documentation and discussing them with agency officials. Based on this
assessment, we determined that these data were sufficiently reliable for
determining which jurisdictions used the awards, but not how much
funding each jurisdiction received.
Further, to examine federal support, we compared a new process CDC
instituted in August 2023 for developing public health guidance, including
for isolation and quarantine, against its responsibilities outlined in federal
strategies for emergency response. These strategies included the
Pandemic Crisis Action Plan Adapted: U.S. Government COVID-19
Response Plan (PanCAP Adapted) and the National Response
11Through the PHEP program, CDC provides annual awards to states and other
jurisdictions to aid capacity building and preparedness for “all hazard” public health
threats, including infectious diseases, extreme weather events, or terrorist threats. For
more information on PHEP funding, see Public Health Preparedness: Building and
Maintaining Infrastructure beyond the COVID-19 Pandemic, GAO-24-105891
(Washington, D.C.: Nov. 7, 2023).
12We examined agency data on CDC Public Health Crisis Response cooperative
agreement funding for 2020 and FEMA Public Assistance grant funding as of June 2023
to identify recipients that reported using the award for isolation or quarantine purposes.
We did not examine or verify reported award amounts.
Page 6 GAO-24-106705 Isolation and Quarantine
Framework. 13 We also assessed CDC’s new public health guidance
development process against selected federal internal control standards
for control environment, implementing control activities, communicating
quality information, and monitoring. 14 Additionally, we interviewed
selected jurisdictional health department officials about their experiences
with federal agencies’ support for isolation and quarantine, including the
technical assistance and awards they received and any challenges they
encountered. We also interviewed representatives from the five selected
national associations to gain a broader perspective on jurisdictions’
experiences.
To evaluate the extent to which CDC assesses jurisdictions’ planning for
isolation and quarantine, we reviewed CDC documentation on
jurisdictional preparedness and response assessments, including CDC’s
guidance on what jurisdictions should submit for these assessments in
2019 through 2024, and interviewed officials. We compared CDC’s efforts
to assess jurisdictional isolation and quarantine planning against its
responsibilities outlined in the National Biodefense Strategy, which directs
CDC to determine gaps in preparedness and response for community
mitigation measures (i.e., nonpharmaceutical interventions). 15
To help ensure the accuracy of the facts and statements presented from
our interviews, we provided relevant excerpts of the draft report to the
jurisdictions we interviewed. We incorporated, as appropriate, their
technical comments. The views of the jurisdictions and national
associations interviewed are not generalizable beyond those entities.
We conducted this performance audit from March 2023 to July 2024 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
13See Department of Health and Human Services, PanCAP Adapted: U.S. Government
COVID-19 Response Plan (Mar. 13, 2020); and Department of Homeland Security,
National Response Framework, Fourth Edition (Oct. 28, 2019).
14GAO, Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: Sept. 10, 2014). We also reviewed CDC’s Public Health Guidance
Development Framework against selected federal internal control standards that our prior
work has identified and applied to federal agencies’ guidance processes. See Regulatory
Guidance Processes: Selected Departments Could Strengthen Internal Control and
Dissemination Practices, GAO-15-368 (Washington, D.C.: Apr. 16, 2015).
15The White House, National Biodefense Strategy and Implementation Plan for
Countering Biological Threats, Enhancing Pandemic Preparedness, and Achieving Global
Health Security (Washington, D.C.: October 2022).
Page 7 GAO-24-106705 Isolation and Quarantine
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
State and territorial governments—jurisdictions—have primary
Background responsibility for leading the preparation for and response to public health
threats and emergencies. Jurisdictional health departments also assist
local health departments and providers in responding to emergencies.
When jurisdictions’ capabilities are insufficient, they may seek additional
support from the federal government. With respect to biological threats
specifically, the National Biodefense Strategy explains how the U.S.
government will manage its activities to more effectively assess, prevent,
prepare for, respond to, and recover from biological threats. The federal
government does so by coordinating its biodefense efforts with those of
state, local, tribal, territorial, and international partners, industry,
academia, nongovernmental entities, and the private sector.
CDC Public Health HHS components award funding to jurisdictions to prepare for infectious
Emergency Preparedness disease and other public health threats through several programs, one of
which includes PHEP cooperative agreements.
Cooperative Agreement
CDC administers the PHEP cooperative agreements, established in 2002,
to jurisdictions with the goal of developing effective public health
emergency management and response programs nationwide. 16 Through
PHEP cooperative agreements, CDC provides annual awards to
jurisdictions to aid capacity building and preparedness for “all-hazard”
public health threats, including infectious disease outbreaks, extreme
weather events, or terrorist threats. As a condition of receiving a PHEP
award, jurisdictions must have an “All-Hazards Preparedness and
Response Plan.” While PHEP recipients are required to address
nonpharmaceutical interventions in these all-hazard plans, according to
CDC, there is no requirement for them to address isolation or quarantine
specifically. 17
As part of PHEP, CDC established public health preparedness capability
standards in 2011 and updated them in 2018. The Public Health
Emergency Preparedness and Response Capabilities: National
16The PHEP cooperative agreement program provides awards to 62 jurisdictions (50
states, four localities, and eight U.S. territories and freely associated states).
17See 42 U.S.C. § 247d-3a(b)(2)(A).
Page 8 GAO-24-106705 Isolation and Quarantine
Standards for State, Local, Tribal, and Territorial Public Health describe
standards for 15 capabilities designed to help jurisdictions prepare for
emergencies. 18 Isolation and quarantine activities are embedded in
capability 11: nonpharmaceutical interventions. CDC defines
nonpharmaceutical interventions as actions that people and communities
can take to help slow the spread of illness or reduce the adverse impact
of public health emergencies. Nonpharmaceutical interventions, also
referred to as community mitigation measures, can include isolation,
quarantine, restrictions on movement, social distancing, external
decontamination, hygiene, or precautionary protective behaviors,
according to CDC.
CDC requires PHEP award recipients to develop and implement work
plans outlining how they will use PHEP awards. Jurisdictional PHEP
recipients must use their PHEP awards to build and sustain their public
health preparedness and response capacity, according to PHEP program
documentation. Recipients develop work plans for each budget period
within a 5-year PHEP performance period, the most recent of which
covered 2019-2024.
Federal Public Health If an emergency is severe enough that jurisdictional response capabilities
Emergency Response and are insufficient, jurisdictional governments may seek support from the
federal government. The PanCAP Adapted describes the structure and
the COVID-19 Pandemic
authorities for the federal government to lead and coordinate the COVID-
19 response. 19
18Specifically, CDC designed the capability standards to advance the emergency
preparedness and response capacity of jurisdictional public health systems. CDC, Public
Health Emergency Preparedness and Response Capabilities: National Standards for
State, Local, Tribal, and Territorial Public Health (Atlanta, Ga.: Oct. 2018). See CDC,
“Public Health Emergency Preparedness and Response Capabilities,”
https://www.cdc.gov/readiness/php/capabilities/index.html, accessed June 27, 2024.
Beginning in 2024, CDC will use a new Public Health Response Readiness Framework
that will focus on 10 priority areas that are essential to our ability to prepare for, respond
to, and recover from health threats, according to CDC’s website.
19The Biological Incident Annex to the Response and Recovery Federal Interagency
Operational Plan provides strategic guidance for interagency coordination during a
response to a biological incident. Department of Homeland Security, Biological Incident
Annex to the Response and Recovery Federal Interagency Operational Plan, May 2023.
The PanCAP, approved in 2018, operationalizes the Biological Incident Annex with a
focus on potential viral pandemic pathogens and the PanCAP Adapted adapts federal
response actions for COVID-19. Specifically, the PanCAP Adapted outlines key federal
decisions, federal actions, and interagency coordination structures that may be used
during the COVID-19 response. Department of Health and Human Services, PanCAP
Adapted: U.S. Government COVID-19 Response Plan (Mar. 13, 2020).
Page 9 GAO-24-106705 Isolation and Quarantine
HHS is required to lead the federal public health and medical response to
public health emergencies and incidents covered by the National
Response Framework, which guides the nation’s response on disasters
and emergencies. 20
Within HHS, the following components are involved in such a response.
• ASPR. ASPR serves as the principal advisor to the Secretary of
Health and Human Services on all matters related to federal public
health and medical preparedness and response to public health
emergencies.
• CDC. CDC has a lead role in addressing public health emergency
preparedness and response, including detecting and responding
to new and emerging disease threats. CDC is authorized to issue
quarantine orders to prevent the spread of infectious diseases
from foreign countries into the United States and between
states. 21 CDC also assists states and localities in the prevention
and suppression of infectious diseases, including cooperating with
and aiding states and localities in the enforcement of their
quarantine regulations. 22
While HHS is the lead for the public health and medical response, FEMA,
an agency within the Department of Homeland Security, coordinates the
overall federal response during Presidentially-declared disasters and
emergencies. HHS and FEMA can also make certain awards available to
jurisdictions to respond to emergencies and disasters.
Under section 319 of the Public Health Service Act, the Secretary of
Health and Human Services may issue a public health emergency
declaration. 23 Such a declaration triggers the availability of certain
2042 U.S.C. § 300hh(a). Department of Homeland Security, National Response
Framework, Fourth Edition (Oct. 28, 2019). The National Response Framework
establishes an all-hazards response structure to coordinate federal resources during
emergencies and disasters and is divided into 15 emergency support functions, which are
functional areas that are most frequently needed during a national response. HHS,
through ASPR, is the lead agency for Emergency Support Function #8: Public Health and
Medical Services Response.
21Under 42 U.S.C. § 264, the Secretary of Health and Human Services may make and
enforce regulations necessary to prevent the introduction, transmission, or spread of
communicable diseases from foreign countries into the United States and between the
states.
22See 42 U.S.C. § 243(a).
2342 U.S.C. § 247d.
Page 10 GAO-24-106705 Isolation and Quarantine
authorities under federal law that may allow the federal government to
increase support to and reduce administrative burdens on jurisdictions.
On January 30, 2020, the Secretary of Health and Human Services
declared a public health emergency for COVID-19, which expired on May
11, 2023.
In addition, on March 13, 2020, the President declared COVID-19 a
nationwide emergency under the Robert T. Stafford Disaster Relief and
Emergency Assistance Act. 24 The President also approved major disaster
declarations under the Stafford Act for all 50 states, the District of
Columbia, five territories, and certain Tribes. These declarations made
available additional authorities to assist jurisdictions. The Stafford Act
incident period terminated on May 11, 2023.
Selected Jurisdictions
Took a Range of
Isolation and
Quarantine Actions
for COVID-19
Selected Jurisdictions’ The seven selected jurisdictions (states and territories) took a range of
COVID-19 Isolation and actions to promote isolation and quarantine and limit the spread of
disease during the public health emergency for COVID-19. Specifically,
Quarantine Actions
isolation and quarantine actions jurisdictional officials reported taking
ranged from issuing public guidance to offering facilities for isolation and
quarantine; providing wraparound services—such as food delivery
services—to encourage compliance; requiring individuals to isolate or
quarantine; and enforcing isolation or quarantine. (See fig. 2.)
2442 U.S.C. § 5191.
Page 11 GAO-24-106705 Isolation and Quarantine
Figure 2: Examples of Selected Jurisdictions’ COVID-19 Isolation and Quarantine
Actions, 2020 to 2023
Note: GAO reviewed documentation and interviewed health department officials from seven selected
jurisdictions: American Samoa, Alabama, Hawaii, New Jersey, Rhode Island, South Dakota, and
Texas.
aFor the purposes of this report we define enforcement to include fines or jail time. Jurisdictions also
monitored compliance of individuals in isolation or quarantine such as by placing phone calls to or
conducting home or facility visits, but without imposing fines or jail time.
Guidance. All seven selected jurisdictions shared guidance about home
isolation and quarantine with the public and stakeholders such as local
health officials. Isolation and quarantine guidance generally
recommended when to isolate or quarantine and for how long. For
example, New Jersey’s guidance as of September 2022 instructed
individuals to isolate for 5 days after testing positive for COVID-19, which
aligned with CDC guidance at the time. The selected jurisdictions used
various means to share isolation and quarantine guidance, such as
website updates, public service announcements, social media posts, and
communication with community sources. Six of the selected jurisdictions
translated the guidance into other languages.
Page 12 GAO-24-106705 Isolation and Quarantine
Examples of COVID-19 Isolation and
Additionally, all of our selected jurisdictions conducted some contact
Quarantine Facilities tracing or helped local health departments conduct contact tracing—
Some jurisdictions, including all those we telephone calls or letters to people that tested positive for COVID-19 and
interviewed, offered facilities for individuals
or family members to isolate or quarantine
their close contacts to inform them of isolation and quarantine guidance.
in when unable to do so at home. The types Officials from two jurisdictions noted they conducted contact tracing as
of facilities, number of facilities, and time resources allowed and staff could keep up with cases.
frames differed across the selected
jurisdictions. Examples of selected
jurisdictions’ COVID-19 isolation and Isolation or quarantine facilities. All selected jurisdictions offered
quarantine facility arrangements include the
following:
facilities for individuals or family members to isolate or quarantine when
• Rhode Island’s centralized health unable to do so at home. Jurisdictions often offered these facilities for
department managed five facilities at certain vulnerable populations such as unhoused individuals, students, or
various times between 2020 and 2023, health care workers. For example, three of the seven jurisdictions
including facilities for individuals and
families. The health department used provided facilities mainly for individuals experiencing homelessness. In
one state-owned facility, contracted with the two island jurisdictions, the government made facilities available to
two hotels, and worked with other
departments and charitable anyone who could not safely isolate or quarantine at home. The type and
organizations to operate some of the number of facilities and time frames for offering facilities varied by
facilities and provide wraparound
services.
selected jurisdiction. (See sidebar.) In some jurisdictions, the state-level
• Hawaii’s centralized state health
public health department supported isolation and quarantine facilities
department contracted with hotels to offered by local (e.g., city or county-level) health departments.
provide facilities in every county from Representatives from national associations representing state, territorial,
2020 through 2021. Anyone without
housing or unable to isolate safely at local, and tribal public health officials also noted use of facilities at each of
home was eligible. The health these levels of government.
department also contracted for
wraparound services such as food and
used case managers to offer care Wraparound services. All selected jurisdictions provided supportive or
coordination and behavioral health “wraparound” services such as delivery of food, laundry, medicine, mental
care.
health care, religious services, entertainment, or transportation to
Source: Hawaii Department of Health, Rhode Island individuals isolating or quarantining at facilities or at home. In some
Department of Health. | GAO-24-106705
places, health officials we interviewed noted the value of offering
wraparound services to promote compliance with isolation and quarantine
guidance. Jurisdictions delivered the services in various ways, such as
contracting with vendors (Alabama, Rhode Island, and Texas) or using
their Medical Reserve Corps volunteers (Hawaii). 25 Additionally, Rhode
Island provided state-funded cash assistance to individuals in isolation or
quarantine who met certain criteria to promote compliance, according to
health officials. Representatives from national associations representing
local and tribal public health officials also noted local and tribal
25The Medical Reserve Corps consists of health care volunteers—medical and public
health professionals—as well as others who donate their time to help strengthen a
response to public health emergencies by augmenting federal, state, and local capabilities
and building community resilience. See generally 42 U.S.C. § 300hh-15. For more
information on the use of Medical Reserve Corps volunteers, see Public Health
Preparedness: Information on the Use of Medical Reserve Corps Volunteers during
Emergencies, GAO-20-630 (Washington, D.C.: Sept. 14, 2020).
Page 13 GAO-24-106705 Isolation and Quarantine
governments offered wraparound services to their residents. For
example, certain Tribes offered food delivery, medication, and other
services, and for one Tribe, a traditional healer to people in isolation,
according to representatives from a national association.
Jurisdictions identified some characteristics and wraparound services as
valuable to include in isolation and quarantine facilities, according to
planning documents. (See fig. 3.)
Page 14 GAO-24-106705 Isolation and Quarantine
Figure 3: Examples of Characteristics and Wraparound Services for Isolation and Quarantine Facilities Identified by Selected
Jurisdictions
Note: GAO reviewed documentation from seven selected jurisdictions: American Samoa, Alabama,
Hawaii, New Jersey, Rhode Island, South Dakota, and Texas.
Page 15 GAO-24-106705 Isolation and Quarantine
Isolation or quarantine orders. Six selected jurisdictions (American
Samoa, Alabama, Hawaii, Rhode Island, South Dakota, and Texas)
issued official isolation or quarantine orders to individuals, though health
officials in all but one jurisdiction said they used orders rarely. 26 One of
the jurisdictions—Alabama—issued quarantine orders for every individual
who tested positive for COVID-19 through late 2022, which was very
resource intensive for the health department, according to officials. The
island jurisdictions—American Samoa and Hawaii—had more widespread
quarantine requirements, though they did not issue quarantine orders for
all individuals. For example, American Samoa required American
Samoans seeking to repatriate to the island to first quarantine for 7 days
in Hawaii then for another 14 days upon arrival in American Samoa.
Enforcement of isolation or quarantine. One of the selected
jurisdictions—Hawaii—engaged law enforcement to enforce isolation or
quarantine orders through fines for certain individuals. Specifically, in
limited cases Hawaii imposed fines on travelers and Hawaiian residents
who were repeatedly noncompliant with isolation or quarantine orders.
Additionally, health officials from both island jurisdictions explained that
they worked with public safety and other departments to monitor
compliance with isolation or quarantine requirements during some of the
response.
Considerations for Selected jurisdictional officials and national public health association
Implementing Isolation representatives identified considerations for, or challenges with, taking
isolation and quarantine actions for COVID-19.
and Quarantine
Enforcement of isolation and quarantine. Officials from five selected
jurisdictions and representatives from two national associations identified
enforcing isolation or quarantine orders or requirements as a challenge.
Officials cited time frames for pursuing legal enforcement before an
individual’s isolation or quarantine period had ended and the reluctance of
law enforcement to pursue the issue as reasons for difficulty with
enforcement.
For example, officials from three jurisdictions noted the need to see a
judge to enforce isolation or quarantine. Officials from one of these
jurisdictions said it would have required dozens of lawyers to enforce
quarantine orders. Moreover, courts in the jurisdiction would have a
26An isolation or quarantine order requires an individual to isolate or quarantine for a
certain amount of time or until they are able to confirm their status through testing,
according to the National Conference of State Legislatures.
Page 16 GAO-24-106705 Isolation and Quarantine
month to hold a hearing once a petition was filed to enforce an isolation
and quarantine order, by which time the individual’s isolation or
quarantine period may have ended before enforcement could occur,
according to officials.
Law enforcement reluctance was another consideration according to
officials in one jurisdiction. These officials said some local sheriffs refused
to deliver isolation and quarantine orders. Representatives from two
national associations confirmed this concern, stating that some states
experienced challenges obtaining buy-in from law enforcement in
enforcing orders, for example, because law enforcement officers might
place themselves at risk of getting COVID-19 during enforcement.
Rather than enforce isolation and quarantine, some selected jurisdictions
generally sought to promote voluntary compliance such as by offering
facilities and culturally relevant wraparound services, according to
jurisdictional officials. For example, by providing needed services and
home comforts, people were more likely to remain at home or a facility,
officials told us.
Logistics of offering quarantine facilities. Health officials from four
selected jurisdictions and representatives from three national associations
identified the logistics of offering isolation and quarantine facilities—such
as identifying hotels willing to house sick people or providing wraparound
services—as an impediment to quickly opening or operating such
facilities. For example, officials from three jurisdictions and
representatives from three national associations noted that many hotels
initially did not want to participate because of concerns about
contaminating rooms or becoming known as a “COVID-19 hotel.”
According to officials from a jurisdiction and a national association, some
selected jurisdictions used government or other facilities in addition to
hotels to house people in isolation or quarantine, which officials told us
also proved difficult.
With respect to offering wraparound services, officials from two
jurisdictions noted the unexpected need for and difficulty identifying
transportation services to transport sick individuals to and from isolation
and quarantine facilities. Again, some of the difficulty was due to
commercial transportation services, such as public buses or ride-hailing
applications, being disinclined to serve sick individuals, officials from one
jurisdiction said. The jurisdictions contracted with ambulance companies
to provide transportation, which was very expensive, according to officials
from one jurisdiction.
Page 17 GAO-24-106705 Isolation and Quarantine
Contracting for hotel rooms and wraparound services was another
difficulty cited by jurisdictional officials. Specifically, officials from two
jurisdictions said the process of contracting for hotel rooms and
wraparound services was difficult due to state procurement procedures.
Financial and staffing strain on jurisdictions. Officials from four
selected jurisdictions and representatives from two national associations
said financial and staffing resources to implement isolation and
quarantine actions were challenges during the pandemic. Standing up
and maintaining facilities as well as offering wraparound services were
costly for jurisdictional governments, according to representatives from
two national associations.
Another challenge for jurisdictions was the strain it put on their human
resources. Officials from a jurisdiction and representatives from two
national associations noted that jurisdictions had few health department
staff to maintain isolation and quarantine facilities or conduct contact
tracing, which in some cases limited the services the jurisdiction could
provide. For example, one jurisdiction did not have enough contact
tracers, which resulted in a lag between when people needed health
department support and when the department became of aware of that
need. Generally, health departments often did not have the resources to
hire new staff and therefore had to reassign existing staff to the COVID-
19 response, causing burnout, according to representatives from two
national associations.
To offset staffing limitations, in one jurisdiction, the behavioral health
office took over management of the isolation and quarantine facility
program and employed case managers to manage it and volunteer health
workers to deliver wraparound services, according to officials.
Communication with public. Isolation and quarantine only work to limit
disease spread if people listen and comply, according to representatives
from one national association. Officials from four jurisdictions and
representatives from four national associations said countering
misinformation or providing clear communication about isolation and
quarantine was a challenge they faced in encouraging compliance with
isolation and quarantine during the COVID-19 pandemic. At the same
time, media and social media spread misinformation about public health
interventions, according to officials from one jurisdiction and
representatives from two national associations. Officials in one jurisdiction
also said the COVID-19 experience had eroded public trust and health
departments’ ability to implement isolation and quarantine in the future.
Page 18 GAO-24-106705 Isolation and Quarantine
To combat difficulty communicating about isolation and quarantine,
jurisdictional public health officials we interviewed said they took various
actions, such as dedicating resources to communication, employing new
communication methods—such as robust social media or website
development—and leveraging community groups. For example, officials
in three jurisdictions told us that partnering with trusted community
leaders—such as village leaders, church leaders, and professional
organizations—helped to effectively communicate the importance of
isolation and quarantine. Officials from two jurisdictions also noted the
importance of translating guidance and materials into culturally relevant
languages to improve communication.
Mental and financial strain on individuals and families. Isolation and
quarantine place restrictions on people’s movement and their ability to
work, go to school, or access normal activities. Jurisdictional public health
officials with responsibility for implementing isolation and quarantine must
consider the trade-offs of limiting disease spread and the effect on these
activities. 27 Officials from four jurisdictions and representatives from two
national associations acknowledged the social, emotional, or financial
consequences of isolation and quarantine on populations, including
children. As officials from one jurisdiction elaborated, the general public
was unprepared for teleworking and distance learning, and isolation and
quarantine policies were generally disruptive.
Selected jurisdictions took action to defray the negative consequences of
isolation and quarantine by offering various supports to people, such as
mental health care, entertainment, or cash assistance. For example, two
jurisdictions made technology services available to connect people in
quarantine with family and friends or behavioral health providers to
decrease feelings of loneliness.
Nature of COVID-19 transmission. Additionally, officials from two
jurisdictions and representatives from one national association noted that
isolation and quarantine is generally a good tool for containing and
mitigating spread of diseases such as Ebola virus disease or tuberculosis.
By contrast, the potentially asymptomatic and fast spread of COVID-19
reduced the effectiveness of isolation and quarantine as a mitigation
27GAO has also reported that the health and economic effects of the COVID-19 pandemic
have intensified concerns about the increasing numbers of people affected by behavioral
health conditions and in need of treatment. See Behavioral Health: Available Workforce
Information and Federal Actions to Help Recruit and Retain Providers, GAO-23-105250
(Washington, D.C.: Oct. 27, 2022).
Page 19 GAO-24-106705 Isolation and Quarantine
method for this disease, they noted. This became particularly true as
COVID-19 spread widely in communities. Moreover, officials from these
two jurisdictions and representatives from two national associations
identified testing capacity or delayed test results, particularly at the
beginning of the pandemic, as limiting jurisdictions’ ability to conduct
timely contact tracing.
Selected Jurisdictions
Did Some Isolation
and Quarantine
Planning Before the
COVID-19 Pandemic
and Are Revising
Planning for Future
Threats
Selected Jurisdictions’ Prior to the COVID-19 pandemic, four of the seven selected jurisdictions
Isolation and Quarantine had operational isolation and quarantine plans that could be applied to
infectious diseases generally, while three did not have such plans,
Planning Before the
according to documents we reviewed from the selected jurisdictions. CDC
COVID-19 Pandemic defines operational plans as describing roles and responsibilities, tasks,
integration, and actions required of a jurisdiction during emergencies. The
documentation we reviewed showed that the three jurisdictions without
operational plans that could be applied to infectious diseases generally
had high-level isolation and quarantine provisions as part of emergency
plans. For the purposes of this review, high level provisions are those
which mention isolation and quarantine as possible nonpharmaceutical
interventions but do not detail practical considerations for implementation.
As a condition of receiving a PHEP award, jurisdictions must have an “All-
Hazards Preparedness and Response Plan”; however, there is no
requirement for these plans to address isolation or quarantine specifically.
Page 20 GAO-24-106705 Isolation and Quarantine
Operational isolation and quarantine plans. Prior to the COVID-19
List of Quarantinable Diseases
pandemic, four selected jurisdictions—American Samoa, Hawaii, New
Jersey, and South Dakota—had detailed, operational isolation and
quarantine plans that could be applied to infectious diseases generally.
For example, American Samoa’s health department officials told us they
used their Isolation and Quarantine Plan, last updated in January 2020,
to respond to other quarantinable infectious diseases prior to the COVID-
19 pandemic, including H1N1 influenza, measles, and chikungunya virus.
Hawaii officials said that the health department used its 2008 Pandemic
Isolation and quarantine help protect the
public by preventing exposure to people who
Influenza Preparedness and Response Plan to respond to the H1N1
have or may have a contagious disease, pandemic. Hawaii, New Jersey, South Dakota, and American Samoa’s
such as COVID-19, according to CDC. CDC operational plans delineated health department responsibilities and
maintains a list of quarantinable diseases for
which the Secretary of Health and Human described isolation and quarantine implementation in detail, among other
Services can authorize isolation and considerations, such as:
quarantine, including:
• Cholera
• Isolation and quarantine facilities. For example, New Jersey’s
• Infectious tuberculosis
2003 Severe Acute Respiratory Syndrome Preparedness and
• Diphtheria
Response Plan acknowledged that a widespread infectious
• Plague
disease threat may require isolation and quarantine outside of
• Smallpox
hospital or healthcare settings. Additionally, Hawaii’s plan
• Yellow fever
indicated that homes or other facilities—such as hotels—may
• Viral hemorrhagic fevers, such as Ebola
virus disease
serve as isolation facilities for individuals unable to isolate at home
• Severe Acute Respiratory Syndromes,
or when hospital isolation beds reached capacity. New Jersey and
such as COVID-19 Hawaii’s plans established site selection criteria for isolation and
• Flu that can cause pandemic quarantine facilities such as food and laundry service, telephone
• Measles and internet access, bathroom facilities, and controlled entry.
• Authorities. Hawaii’s plan documented the health department’s
Source: Centers for Disease Control and Prevention (CDC)
(information), CDC, Alissa Eckert, Dan Higgins (image). | authorities relating to isolation and quarantine, noting the health
GAO-24-106705
department’s ability to require isolation and quarantine, implement
its pandemic plan, and advise and inform the governor on the
progression of the disease threat. New Jersey, South Dakota, and
American Samoa’s plans similarly noted the jurisdictional health
departments’ legal authorities to require individuals to isolate or
quarantine.
• Wraparound services. American Samoa’s plan, for example,
charged the health department with providing for isolated or
quarantined individuals’ needs through services such as meal
preparation, mental and behavioral health support, transportation,
and childcare. Hawaii’s plan similarly instructed the health
department to provide wraparound services to individuals in
quarantine to promote physical and mental health. Specifically,
under the plan, the health department maintained a memorandum
Page 21 GAO-24-106705 Isolation and Quarantine
of agreement with the local American Red Cross chapter to
provide basic necessities and mental health support.
• Enforcement and compliance. For example, Hawaii’s health
department planned to call quarantined individuals twice daily at
random times to ensure compliance with quarantine orders. If
quarantined individuals did not answer such calls, then the plan
charged a health department representative with visiting the
quarantined individual to ensure compliance or confirm non-
compliance with quarantine orders. In the event of non-
compliance, the plan outlined law enforcement’s authority to
locate and confine individuals in violation of the quarantine order.
South Dakota’s 2006 Pandemic Influenza Plan established that
the health department maintain protocols for monitoring
individuals in isolation and quarantine and work with law
enforcement and the Attorney General’s office to enforce
movement restrictions. Additionally, American Samoa planned to
require individuals placed in isolation or quarantine to sign a
document indicating agreement to comply with isolation and
quarantine requirements. It also charged the health department’s
medical director with determining the scope of monitoring
necessary for individuals in isolation or quarantine.
High-level isolation and quarantine provisions in emergency plans.
Three selected jurisdictions mentioned isolation and quarantine at a high
level in their public health emergency preparedness plans prior to the
COVID-19 pandemic. However, they did not have detailed operational
isolation and quarantine plans that could be applied to infectious diseases
generally. For example, one jurisdiction’s Pandemic Influenza Plan
mentioned isolation as a possible consideration for the general public in
the event of an infectious disease threat but did not provide further detail.
Another jurisdiction used its 2015 Respiratory Viruses Having Pandemic
Potential Plan to respond to communicable diseases requiring isolation
such as tuberculosis and H1N1 influenza, according to jurisdictional
officials. This plan detailed operations for pandemic response such as
surveillance activities, communication procedures, and incident command
structures but did not include isolation and quarantine procedures.
Page 22 GAO-24-106705 Isolation and Quarantine
Selected Jurisdictions Are In response to their COVID-19 experiences with implementing isolation
Revising Isolation and and quarantine, six selected jurisdictions planned for isolation and
quarantine by documenting isolation and quarantine processes in new
Quarantine Planning
plans, documenting procedures within plans, or both. Additionally, officials
Based on COVID-19 from four selected jurisdictions, including the remaining jurisdiction that
Experience had not yet documented isolation and quarantine procedures or updated
plans, told us they are planning to further update their isolation and
Operationalizing Isolation and quarantine plans to respond to future threats.
Quarantine during the COVID-19
Pandemic
The Rhode Island Department of Health
Efforts to strengthen isolation and quarantine planning. The selected
developed several documents to jurisdictions engaged in efforts to strengthen their isolation and
operationalize isolation and quarantine quarantine planning during their COVID-19 response, including by
procedures during the COVID-19
pandemic. For example: documenting COVID-19 procedures or updating already existing
preparedness plans (see fig. 4).
Quarantine and Isolation Support Plan
guided officials in determining isolation
and quarantine thresholds, assessing the
need for various services, and discerning
roles and responsibilities.
Food Delivery Protocol established
protocols for meeting urgent food needs
for those in isolation.
Case Investigation, Data Management,
& Operations guided support staff in
managing data, conducting case
investigations, and understanding case
management operations for those in
isolation and quarantine.
First COVID-19 Case Protocol
established isolation and quarantine
procedures for the first confirmed case of
COVID-19 in Rhode Island.
Quarantine and Isolation Cash
Assistance Procedures outlined
procedures for providing cash assistance
to low-income individuals in isolation and
quarantine to promote compliance.
Source: Rhode Island Department of Health documents.
| GAO-24-106705
Page 23 GAO-24-106705 Isolation and Quarantine
Figure 4: Examples of Selected Jurisdictions’ Documented Isolation and Quarantine Planning During the COVID-19 Response
Note: Some selected jurisdictions’ preparedness plans specifically referenced the COVID-19
pandemic, while others were more general. All plans included in this analysis were developed or
updated by jurisdictions during the COVID-19 response based on their COVID-19 experiences. That
is, the plans were updated in 2020 or later.
aContact tracing is telephone calls or letters to people that tested positive for COVID-19 and their
close contacts to inform them of isolation and quarantine guidance. Jurisdictions documented public
health officials responsible for conducting contact tracing.
bJurisdictions planned to provide supportive or “wraparound” services such as food, medicine, or
transportation to individuals isolating or quarantining at home or in a facility.
cThree jurisdictions planned to engage law enforcement if individuals were found to be noncompliant
with isolation and quarantine protocols. The remaining jurisdictions’ plans discussed protocols for
monitoring compliance of individuals in isolation and quarantine.
• Documented COVID-19 procedures. During the COVID-19
public health emergency from January 2020 through May 2023,
five selected jurisdictions—Alabama, Hawaii, Rhode Island, South
Dakota, and Texas—developed and documented COVID-19
isolation and quarantine procedures, such as isolation and
quarantine facility operations and protocols for providing
Page 24 GAO-24-106705 Isolation and Quarantine
wraparound services. 28 For example, Texas’s state health
department developed an Isolation and Quarantine Facility Project
Manual to describe operational procedures for facilities stood up
during the COVID-19 pandemic. Texas regional health
departments used the centralized planning document while
operating isolation and quarantine facilities in the field, rather than
developing their own operations, according to officials.
Selected jurisdictions also revised existing preparedness and
response plans to meet their needs for the COVID-19 response,
according to officials. For example, health department officials
from three jurisdictions—Alabama, New Jersey, and Rhode
Island—told us they referred to existing Ebola virus disease-
specific plans with isolation and quarantine procedures when
responding to the COVID-19 pandemic. Our review of these plans
showed that they did not include considerations for larger-scale
isolation and quarantine implementation, as was needed for the
COVID-19 response. As such, Ebola virus disease-specific
isolation and quarantine procedures were not fully applicable to
the COVID-19 response.
• Updating preparedness plans. During the COVID-19 response,
two selected jurisdictions—American Samoa and Hawaii—
developed or revised operational preparedness plans to codify
isolation and quarantine procedures. Officials from another four
selected jurisdictions told us they intended to update their
preparedness plans to reflect COVID-19 experiences and to
prepare for future emergencies. For example, health department
officials from one jurisdiction told us they planned to draft broad
guidelines for isolation and quarantine that can be customized as
needed based on the disease. Officials from the remaining
selected jurisdiction told us that while they intended to update their
preparedness plans to reflect experiences from the COVID-19
pandemic generally, they are not changing isolation and
quarantine planning. Additionally, representatives from a national
association suggested jurisdictions could develop and maintain
relationships with governmental and non-governmental
organizations, such as hotels or food banks, and consider contract
and payment mechanisms. Jurisdictions could document such
updates in their preparedness plans.
28For the purposes of this review, we define documenting COVID-19 procedures as
memorializing such procedures or processes in planning documents.
Page 25 GAO-24-106705 Isolation and Quarantine
Other considerations for isolation and quarantine planning.
Jurisdictional health department officials also identified factors that could
affect future isolation and quarantine planning, such as the availability of
federal funds to support planning efforts and potential changes to
jurisdictional health department authorities.
• Leveraging PHEP funds for isolation and quarantine planning.
Our review of PHEP work plans for 50 states, five territories, and the
District of Columbia for the 2022-2023 budget period showed that 24
of 56 jurisdictions planned to use PHEP funds for isolation or
quarantine preparedness activities. 29 Nineteen of these 24
jurisdictions intended to update their isolation and quarantine plans
using PHEP funds. Jurisdictions proposed using PHEP awards to
support various strategies for updating their isolation and quarantine
plans. For example, one state’s health department planned to
incorporate feedback from local, state, and tribal partners, as well as
lessons learned from its COVID-19 After Action Review, according to
its PHEP work plan from the 2022-2023 budget period. Other
examples of jurisdictions’ planned activities using PHEP funds
included identifying isolation and quarantine facilities and developing
isolation and quarantine plans for special populations.
• Planning for potential changes to authorities. According to
representatives we interviewed from two national public health
associations, some jurisdictional legislatures have limited health
departments’ isolation and quarantine authorities such that they may
not have the same authority to implement isolation and quarantine as
they did during the COVID-19 response. 30 This may have implications
for isolation and quarantine planning as public health preparedness
capability standards instruct jurisdictions to consider legal authorities
in preparedness planning.
29Jurisdictions receiving PHEP funds submit annual work plans to CDC to document how
they plan to use their PHEP awards in accordance with CDC’s 15 capabilities for public
health emergency management and response. Our review of PHEP work plans included
the 50 states, the five territories, and Washington, D.C. We excluded cities that received
PHEP funding for the 2022-2023 PHEP budget period because our review focused on the
state and territorial level of government.
30For example, see M. Davis, et al., “Emergency Powers and the Pandemic: Reflecting on
Legislative Reforms and the Future of Public Health Response,” Journal of Emergency
Management, vol. 21, no. 7 (2023): 19–35.
Page 26 GAO-24-106705 Isolation and Quarantine
Federal agencies’ support of jurisdictions’ use of isolation and quarantine
Federal Agencies during the COVID-19 pandemic included providing technical assistance,
Supported such as by publishing guidance on isolation and quarantine
recommendations, and awarding funding. However, selected jurisdictional
Jurisdictions’ COVID- officials and national association representatives noted challenges with
19 Isolation and CDC’s isolation and quarantine guidance development and
communication. CDC has created a new process for developing and
Quarantine Efforts In issuing public health guidance, but the agency has not documented its
Several Ways; CDC intention to communicate guidance to jurisdictions in advance of
publication when feasible.
Has a New Process
for Developing and
Communicating
Guidance
ASPR, CDC, and FEMA ASPR, CDC, and FEMA supported jurisdictions’ use of isolation and
Provided Technical quarantine by providing technical assistance and awarding funding during
the COVID-19 pandemic. Officials from our selected jurisdictions and
Assistance and Awarded
national association representatives identified some challenges
Funding to Jurisdictions associated with this federal support.
for COVID-19 Isolation
and Quarantine; Selected Technical assistance. ASPR, CDC, and FEMA provided technical
Jurisdictions Identified assistance on COVID-19 isolation and quarantine by issuing guidance,
answering inquiries, convening partners, and to a lesser extent, deploying
Some Challenges federal staff to support jurisdictions.
• Publishing guidance. CDC provided written COVID-19
isolation and quarantine guidance on its website and
frequently updated guidance as new science emerged. (See
fig. 5.)
Page 27 GAO-24-106705 Isolation and Quarantine
Figure 5: Selected Changes to CDC Guidance on Isolation and Quarantine for COVID-19, 2020-2022
Note: Isolation separates sick people with COVID-19 from people who are not sick, and quarantine
restricts the movement of people who were exposed to COVID-19. We included only selected
changes to CDC guidance on isolation and quarantine, such as changes to duration, in this figure.
Page 28 GAO-24-106705 Isolation and Quarantine
CDC updated COVID-19 isolation and quarantine guidance based on emerging science and its
understanding of the novel virus and new variants, according to CDC officials.
On March 1, 2024, CDC revised its COVID-19 guidance to align with guidance for other respiratory
viruses, such as influenza. As of June 2024, CDC recommended that people with respiratory virus
symptoms stay home and away from others until at least 24 hours after their overall symptoms are
getting better and they have not had a fever. CDC recommended that people take additional
precautions, such as additional steps for cleaner air, hygiene, masks, physical distancing, or testing,
for 5 days after resuming normal activities. See CDC, “Preventing Spread of Respiratory Viruses
When You’re Sick,” https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html,
accessed June 7, 2024.
aSpecifically, in March 2020, CDC recommended discontinuing isolation after at least (a) 72 hours
since recovery (i.e., resolution of fever and improvement in symptoms) and 7 days since first
symptoms; (b) resolution of fever, improvement in symptoms, and two negative tests collected over
24 hours apart; or (c) 7 days after first positive test, for individuals without symptoms.
bCDC recommended that most people with COVID-19 end isolation 10 days after first symptoms or
first positive test, although testing to end isolation may be considered in some instances.
cAt the time of this guidance, CDC counted individuals as being fully vaccinated if they received two
doses on different days (regardless of time interval) of the two-dose vaccines or received one dose of
a single-dose vaccine.
dSpecifically, CDC recommended 5-day quarantine for people who were unvaccinated or more than 6
months out from their second two-dose vaccine (or more than 2 months out from their one-dose
vaccine) and had not yet received a booster vaccine dose.
eAntigen tests, including self-tests or at-home tests, are rapid tests that usually produce results in 15-
30 minutes.
CDC’s guidance included recommendations for who should isolate or
quarantine and for how long. Some guidance applied to the general public
and other guidance was specific to certain settings, such as patients or
providers in healthcare facilities. Officials from our selected jurisdictions
told us that they used CDC’s guidance to help establish their own
guidance on isolation and quarantine. See figure 6 for an example of
CDC guidance on isolation for COVID-19.
Page 29 GAO-24-106705 Isolation and Quarantine
Figure 6: CDC Guidance on Isolation and Precautions for Individuals with COVID-
19, December 2022
Note: On March 1, 2024, CDC revised its COVID-19 guidance to align with guidance for other
respiratory viruses, such as influenza. As of June 2024, CDC recommended that people with
respiratory virus symptoms stay home and away from others until at least 24 hours after their overall
symptoms are getting better and they have not had a fever. CDC recommended that people take
Page 30 GAO-24-106705 Isolation and Quarantine
additional precautions, such as additional steps for cleaner air, hygiene, masks, physical distancing,
or testing, for 5 days after resuming normal activities. See CDC, “Preventing Spread of Respiratory
Viruses When You’re Sick,”
https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html, accessed June 7,
2024.
• Answering inquiries. Federal officials answered jurisdictions’
questions on isolation and quarantine through consultation calls
and emails. CDC received over 675 inquiries from states,
territories, localities, and Tribes related to COVID-19 isolation and
quarantine as of May 2023, according to officials; these included
inquiries from all of the selected jurisdictions in our review. CDC
officials told us they resolved most of these requests by sharing
and clarifying existing guidance. CDC officials also said that they
received a large volume of questions from jurisdictions related to
CDC’s December 2021 guidance change, when it reduced the
recommended isolation period from 10 days to 5 days (see fig. 5).
ASPR also responded to technical assistance requests on
isolation and quarantine, for example, by providing information on
isolation and quarantine for people experiencing homelessness.
Additionally, CDC, ASPR Regional Office, and FEMA Regional
Office officials told us they answered jurisdictions’ questions about
applying for and using federal award funding for supporting
isolation and quarantine.
• Convening partners. CDC and ASPR also convened jurisdictions
and stakeholders in national and regional groups to facilitate
sharing of information on isolation and quarantine, according to
agency officials. For example, CDC officials told us they facilitated
several national Community of Practice webinars where
jurisdictions shared best practices on topics including isolation and
quarantine. ASPR addressed isolation in a number of trainings,
according to officials, including a webinar that discussed
considerations for using hotels for COVID-19 isolation and
quarantine. Additionally, two national public health associations
facilitated calls with CDC officials and jurisdictions to share
information and discuss challenges, according to association
representatives. Selected jurisdictional officials cited information-
sharing calls as particularly helpful. For example, officials from
one jurisdiction said that they learned through CDC calls how
other jurisdictions were contracting with hotels for isolation and
quarantine.
• Deploying staff. CDC deployed teams of CDC staff to
jurisdictions to serve multiple purposes during the COVID-19
pandemic, according to agency officials, but it did not specifically
deploy staff to jurisdictions to assist with isolation and quarantine.
Page 31 GAO-24-106705 Isolation and Quarantine
Officials from four selected jurisdictions told us that federal staff
deployed for other purposes did assist with isolation and
quarantine. For example, CDC officials told us that their deployed
staff helped one selected jurisdiction develop wraparound services
for people in isolation and quarantine. Additionally, a few
jurisdictions leveraged federally-supported staffing resources for
isolation and quarantine. For example, officials in two jurisdictions
told us that individuals in the Medical Reserve Corps—a volunteer
program overseen by ASPR—assisted with isolation and
quarantine. 31
Awards. CDC and FEMA awarded funding to jurisdictions that could be
used to support isolation and quarantine for COVID-19. Specifically, CDC
awarded funding through the Cooperative Agreement for Emergency
Response: Public Health Crisis Response and the Epidemiology and
Laboratory Capacity for Prevention and Control of Emerging and
Infectious Diseases Cooperative Agreement, and FEMA awarded funding
through the Public Assistance grant. These funding sources each
permitted, but did not require, jurisdictions to use these funds to support
isolation and quarantine for COVID-19. 32 (See table 1.) For example, 40
of 56 jurisdictions that received CDC’s Cooperative Agreement for
Emergency Response: Public Health Crisis Response funding in 2020,
including five of our seven selected jurisdictions, requested to use their
award for activities related to isolation and quarantine in their initial work
plans, according to CDC documentation. 33 Additionally, FEMA’s Public
Assistance grant program awarded funding to eligible entities in all 56
jurisdictions to support projects involving isolation and quarantine as of
June 2023, according to agency data.
31ASPR oversees the Medical Reserve Corps program and supports the units by
providing communications, grants and contract oversight, and information for communities
to establish, implement, and maintain Medical Reserve Corps units, among other things.
32CDC and FEMA did not require award recipients to use their awards for isolation or
quarantine activities or track expenditures for isolation and quarantine, according to
officials. Officials from selected jurisdictions noted that they may have used other federal
funding for isolation and quarantine as well.
33For the purposes of this review, jurisdictions included 50 states, five territories, and the
District of Columbia.
Page 32 GAO-24-106705 Isolation and Quarantine
Table 1: Examples of Federal Awards That Could be Used for COVID-19 Isolation and Quarantine
Award Purpose Examples of allowed use for isolation
and quarantine during COVID-19
pandemic
CDC Cooperative Agreement for Supports surge needs of public health Award could be used for identifying and
Emergency Response: Public Health Crisis programs responding to a significant public securing safe housing for isolation and
Response health emergency. quarantine and providing lodging and
wraparound services such as food,
cleaning, waste management, and clinical
care for individuals in isolation and
quarantine.
CDC Epidemiology and Laboratory Provides financial support and technical The Enhancing Detection Expansion
Capacity for Prevention and Control of assistance to the nation’s health COVID-19 supplemental award could be
Emerging Infectious Diseases Cooperative departments to detect, prevent, and used for wraparound services such as
Agreement respond to emerging infectious diseases. hoteling, food, and mental health services.
Recipients could also use some setting-
specific awards to support isolation and
quarantine, such as in homeless shelters.
FEMA Public Assistance Grant Provides supplemental grants to Award could be used for non-congregate
jurisdictional governments and certain sheltering for isolation and quarantine—
types of private non-profits so communities locations where each individual or
can quickly respond to and recover from household has living space that offers
major disasters or emergencies. some level of privacy. Grant could be used
to support facilities, staff, and supplies,
among other services.
Source: GAO analysis of documents from Centers for Disease Control and Prevention (CDC) and Federal Emergency Management Agency (FEMA). | GAO-24-106705
Note: These awards allowed recipients to fund a wide variety of other activities in addition to isolation
and quarantine. CDC and FEMA did not require award recipients to use their awards for isolation and
quarantine activities, according to officials. Our data were not sufficiently reliable to determine how
much award funding recipients received or used to support isolation and quarantine.
Challenges identified by selected jurisdictions and national
associations. Officials from six selected jurisdictions and representatives
from the five national associations told us that they experienced one or
more challenges with federal technical assistance—publishing guidance,
answering inquiries, convening partners, or deploying federal staff—or
federal award funding for COVID-19 isolation and quarantine. These
challenges could have delayed jurisdictions’ isolation and quarantine
response. As our prior work has highlighted, rapid response during public
health emergencies is essential. 34
34See for example GAO-23-106203 and COVID-19: Pandemic Lessons Highlight Need for
Public Health Situational Awareness Network, GAO-22-104600 (Washington, D.C.: June
23, 2022).
Page 33 GAO-24-106705 Isolation and Quarantine
Isolation and quarantine guidance. Our selected jurisdictions experienced
challenges implementing federal guidance on isolation and quarantine,
according to jurisdictional health department officials. National association
representatives said this was true for their members as well. For example:
• Officials from six jurisdictions and representatives from four
national associations told us that jurisdictions experienced
challenges understanding, communicating, and quickly
implementing isolation and quarantine guidance because CDC did
not share guidance changes with them in advance of issuing the
guidance publicly. Instead, CDC communicated finalized guidance
changes via its website, emails, and calls to jurisdictions upon
guidance publication, according to officials from CDC and selected
jurisdictions. Officials from five jurisdictions and representatives
from three national associations said that jurisdictions sometimes
learned about new isolation and quarantine guidance through
news media, rather than from CDC. Therefore, they learned about
changes at the same time as the public.
Selected jurisdictional officials and national association
representatives said that this situation affected jurisdictions’ ability
to effectively implement isolation and quarantine because it did
not allow them enough time to prepare for implementation, for
example, by informing and training staff, updating their websites,
adapting communications, and preparing for questions from the
public. For example, jurisdictions sometimes had to answer
questions about changes to the guidance that they had not yet
seen or had only very recently become aware of, according to
officials from two jurisdictions and representatives from three
national associations. Officials from five jurisdictions also told us
that CDC’s approach contributed to confusion and misinformation
and decreased the public’s trust in federal and jurisdictional health
officials, which may have affected compliance with isolation and
quarantine guidance.
• Officials from two jurisdictions and representatives from three
national associations said that CDC did not consistently seek input
or feedback from jurisdictions when developing isolation and
quarantine guidance. As a result, guidance was not necessarily
practical for jurisdictions to implement, according to
representatives from two national associations. CDC officials told
us that they generally collected input during guidance
development from national associations representing jurisdictional
entities, such as the Association of State and Territorial Health
Page 34 GAO-24-106705 Isolation and Quarantine
Officials, but not from jurisdictional health departments
themselves. CDC officials told us that the agency did not share
guidance with jurisdictions in advance of publication during the
COVID-19 pandemic to avoid leaked information and public
confusion.
• Officials from three jurisdictions and representatives from four
national associations told us they experienced challenges getting
linguistically (i.e., translated) and culturally relevant information on
isolation and quarantine from the federal government to meet their
populations’ needs. For example, federal isolation and quarantine
guidance did not always reflect cultural sensitivity for some tribal
populations that tended to live in smaller, multigenerational
homes, according to representatives from one national
association.
• Officials from one jurisdiction and representatives from one
national association noted challenges with inconsistent messaging
across federal agencies’ guidance on isolation and quarantine.
For example, national association representatives said that
jurisdictions experienced challenges reconciling CDC’s setting-
specific guidance with the HHS Health Resources and Services
Administration’s guidance for the health centers that it funds.
Awards. Our selected jurisdictions experienced challenges using federal
awards for isolation and quarantine, according to jurisdictional officials;
national association representatives echoed these concerns for their
members. These challenges are similar to challenges identified in our
prior work examining federal awards provided in response to public health
emergencies, including the COVID-19 pandemic. 35 For example:
• Officials from six jurisdictions and representatives from four
national associations told us that federal awards were not always
flexible enough to allow use for isolation and quarantine. For
example, officials from one jurisdiction said they were unable to
use federal awards for certain wraparound services such as
transportation and providing medications.
• Officials from five jurisdictions and representatives from three
national associations cited the timing of federal awards as a
challenge. For example, two jurisdictions said that they had
35See GAO-24-105891 and COVID-19 Relief Funds: State Experiences Could Inform
Future Federal Relief Funding, GAO-24-106152 (Washington, D.C.: Nov. 15, 2023).
Page 35 GAO-24-106705 Isolation and Quarantine
already stood up isolation and quarantine activities by the time
federal awards became available for this purpose.
CDC Created a Process to CDC has developed a new process to standardize how the agency
Improve Guidance creates and disseminates public health guidance to the public, health
care providers, and jurisdictional health departments. According to CDC,
Development and
this new process will be used to develop and issue any future guidance
Communication, But It Has on isolation and quarantine. CDC has documented this process in its
Not Documented Its Plans Public Health Guidance Development Framework (the framework),
for Providing Advance instituted in August 2023 as part of the CDC Moving Forward
Notice to Jurisdictions modernization initiative, and in related implementation materials. The
framework is designed to increase uptake of public health guidance that
people and communities need to protect their health, prevent disease,
and prepare for new health threats, according to CDC. 36
The framework represents a five-step process, according to CDC
documentation: forecast and document the rationale for new or updated
guidance, plan external engagement, formulate the guidance, release and
disseminate the guidance, and evaluate the guidance. The framework
calls for ongoing external engagement with the public and key partners
throughout the guidance development process and considers contextual
factors that influence guidance implementation. National association
representatives we spoke with said that this framework addresses some
of their—and jurisdictions’—concerns about guidance communication.
Specifically, the framework incorporates the following elements:
• Partner engagement during guidance development. The
framework established processes to collect internal (e.g., CDC
subject matter experts and policy staff) and external (e.g.,
jurisdictional health departments and national public health
associations) input during guidance development as well as to
collect feedback on published guidance to inform future
revisions. 37 For example, for public health guidance that is likely to
form the basis of national, state, or local policy—including isolation
and quarantine guidance for the general public, according to
officials—the framework recommends a public input process, such
36Public health guidance includes any statement by CDC recommending action that an
external entity (e.g., public health programs, employers, workers, healthcare providers, or
the public) could take to prevent, control, or treat illness, disease, or injury, according to
CDC.
37For more information on important considerations for federal agencies’ guidance
development processes, see GAO-15-368.
Page 36 GAO-24-106705 Isolation and Quarantine
as by holding a public meeting or webinar. 38 Representatives from
one national association we spoke to believed that CDC’s new
process sufficiently addressed concerns about collecting
jurisdictional input during guidance development, and these
representatives told us that they communicated extensively with
CDC before the agency released new COVID-19 isolation
guidance in March 2024. 39 CDC also received input on the March
2024 guidance from a small group of jurisdictional officials,
according to agency officials and national association
representatives.
• Contextual considerations. The framework also calls for CDC to
consider context for guidance, such as its expected impact on
health equity and human rights and any barriers to
understandability, acceptability, and feasibility. For example, the
framework includes actions such as developing guidance in
multiple languages, using plain language, and avoiding
stigmatizing language. It also calls for CDC to enhance the
guidance’s understandability by clearly indicating how it aligns
with or departs from previous or current related guidance.
• Communication of finalized guidance. The framework calls for
CDC to follow established agency procedures to communicate
guidance to key audiences, for example, by holding an advance
briefing with key public health partners before information is
published. For isolation and quarantine guidance changes, CDC
officials told us that this would involve briefing relevant national
associations, such as the Association of State and Territorial
Health Officials, but the agency would not brief jurisdictional
officials directly in advance of guidance publication. CDC officials
38The framework notes that CDC may not collect external input during the development of
public health guidance that needs to be released quickly to protect health. When this is the
case, the framework calls for CDC to engage with external groups as soon as practical
after dissemination to refine and revise the guidance as appropriate. CDC officials also
told us that, in non-emergency circumstances, CDC might issue isolation and quarantine
guidance with various options that jurisdictions can consider, which could require less
public comment.
39On March 1, 2024, CDC revised its COVID-19 guidance to align with guidance for other
respiratory viruses, such as influenza. This guidance recommended that people with
respiratory virus symptoms stay home and away from others until at least 24 hours after
their overall symptoms are getting better and they have not had a fever. CDC also
recommended that people take additional precautions, such as additional steps for
cleaner air, hygiene, masks, physical distancing, or testing, for 5 days after resuming
normal activities. See CDC, “Preventing Spread of Respiratory Viruses When You’re
Sick,” https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html,
accessed June 7, 2024.
Page 37 GAO-24-106705 Isolation and Quarantine
told us that they often brief jurisdictional officials on guidance after
publication.
With respect to communicating finalized guidance, CDC officials told us
that it is now their preferred practice to share information with
jurisdictional officials in advance of publication whenever possible to allow
them to prepare for implementation. For example, CDC shared its March
2024 isolation guidance, talking points, and answers to frequently asked
questions with jurisdictional members of national associations
approximately 4 hours prior to public release, according to agency
officials and national association representatives. CDC officials
acknowledged the need for jurisdictional officials to receive advance
notice of guidance given their key role in implementing it, particularly for
isolation and quarantine. CDC officials told us their goal is to share
finalized guidance with jurisdictions at least 24 hours in advance, and
representatives from a national association agreed that jurisdictions
should receive at least 24-hour notice prior to public release.
However, CDC has not documented its intentions to share guidance with
jurisdictions in advance of publication, despite officials recognizing the
importance of this practice. As noted earlier in this report, selected
jurisdictional officials and national association representatives told us that
not receiving advance notice of CDC isolation and quarantine guidance
during the COVID-19 pandemic adversely affected jurisdictions’ ability to
implement the guidance. Similarly, an internal HHS review conducted in
2022 as part of CDC Moving Forward—CDC’s modernization initiative—
echoed concerns about CDC’s COVID-19 communications. 40 This review
found that CDC’s absence of regular communications and consistent
channels or methods for sharing information affected its ability to
effectively communicate internally and externally during the COVID-19
pandemic. To address this concern, HHS’s review recommended that
CDC formalize roll-out procedures and processes for guidance
documents, including tailored pre-release materials for key external
partners, in a “no surprises communication operating posture.”
CDC officials told us that they have not documented their intentions to
provide advance notice of forthcoming guidance to jurisdictions because
strategies for sharing information ahead of publication can vary based on
circumstances, such as the urgency of the release or the extent of prior
40See Centers for Disease Control and Prevention, CDC Moving Forward Summary
Report (Atlanta, Ga.: Sept. 1, 2022). HHS conducted this review to identify ways to
improve and institutionalize how CDC develops and deploys its science and gather
feedback on agency processes to inform CDC’s Moving Forward modernization initiative.
Page 38 GAO-24-106705 Isolation and Quarantine
engagement with jurisdictions. Additionally, CDC must sometimes
coordinate the release of guidance with other federal partners, which
could influence when and whether the agency can share guidance with
jurisdictions ahead of publication, according to officials. We recognize that
circumstances can vary. However, CDC can document its intended
process in, for example, the framework or related implementation
materials, and include provisions for various types of situations that allow
for flexibility. For example, CDC could document intended dissemination
methods, such as an email directly to jurisdictional officials or through
national associations; document ideal time frames, such as providing 24-
hour notice of forthcoming guidance under circumstances when this is
possible; and document exceptions, such as circumstances that call for
expedited release.
CDC could better accomplish the Moving Forward review
recommendation that the agency adopt a “no surprises communication
operating posture,” by documenting its intentions to share isolation and
quarantine guidance with jurisdictions in advance. 41 This would also align
with HHS’s communication responsibilities in the National Response
Framework. 42 Additionally, these actions would align with CDC’s
responsibilities in the PanCAP Adapted, which charged CDC with
providing guidance on COVID-19 mitigation strategies, such as isolation
and quarantine, to jurisdictions and coordinating and refining these
strategies with jurisdictions prior to implementation. 43 Moreover,
documenting its intentions would be consistent with federal internal
control standards that highlight the importance of documentation, such as
41CDC Moving Forward Summary Report.
42National Response Framework, Fourth Edition. The National Response Framework
requires regular and clear communication between response partners, including
governments at all levels, to ensure that accurate, accessible, and actionable information
is available in response to emerging threats.
43The Biological Incident Annex to the Response and Recovery Federal Interagency
Operational Plan provides strategic guidance for interagency coordination during response
to a biological incident. The PanCAP, approved in 2018, operationalizes the Biological
Incident Annex with a focus on potential viral pandemic pathogens, and the PanCAP
Adapted adapts federal response actions for COVID-19.
Page 39 GAO-24-106705 Isolation and Quarantine
maintaining written policies and procedures to establish and communicate
processes as well as retain institutional knowledge. 44
Documenting its intentions to share isolation and quarantine guidance
with jurisdictions in advance of publication whenever possible will help
CDC more consistently implement this action across the agency.
Moreover, if documented, CDC would be positioned to maintain this
practice even as CDC staff change positions or retire. In turn, receiving
advance notice of guidance should help jurisdictions plan for—and
effectively implement—isolation and quarantine guidance to address
public health developments and emerging threats. This advance notice
could also help eliminate confusion during an emergency, such as
jurisdictions experienced during the COVID-19 pandemic, that could slow
response efforts. Jurisdictions need to be able to quickly implement
isolation and quarantine guidance and communicate that guidance to
other key parties in their area, such as local health departments and
health care providers, to slow the spread of future infectious disease
threats.
44GAO-14-704G. While we identified this deficiency in internal control standards for
documentation, we found that CDC’s new framework incorporated other selected internal
controls by establishing processes to collect internal and external input during guidance
development as well as to collect feedback on published guidance to inform future
revisions. For more information on internal controls’ application to federal agencies’
guidance development processes, see GAO-15-368.
Page 40 GAO-24-106705 Isolation and Quarantine
Our review found that CDC is missing key information on jurisdictions’—
CDC Has Not states’ and territories’—isolation and quarantine planning. In particular,
Assessed CDC is missing information on whether and which jurisdictions have
sufficient planning to implement isolation and quarantine in response to
Jurisdictions’ Isolation widespread infectious diseases. This includes missing information on any
and Quarantine gaps in planning that could impede jurisdictional use of such measures
and potentially require assistance from the federal government. For
Planning example, CDC officials did not know how many or which jurisdictions had
isolation and quarantine plans in place prior to the COVID-19 pandemic.
Further, CDC officials did not have current information on such plans as
of December 2023.
CDC is missing this information because the agency does not assess
jurisdictions’ planning for implementing isolation and quarantine. While
CDC has assessed some aspects of jurisdictions’ planning for public
health threats through PHEP Operational Readiness Reviews, such as
preparedness for a large-scale vaccination campaign, officials told us the
agency has not included isolation and quarantine planning in its
assessments as of 2024. 45 Further, a new PHEP evaluation strategy for
2024, which aligns with the agency’s Public Health Response Readiness
Framework, will also not assess isolation and quarantine planning,
according to officials. 46
45CDC, PHEP Operational Readiness Review Guidance (Atlanta, Ga.: March 2022).
According to the guidance, the Operational Readiness Review includes three sections: (1)
jurisdictional descriptive information; (2) an evaluation of jurisdictional plans aligned with
the 15 capability standards; and (3) operational activities including drills, exercises,
incidents, and events. According to CDC’s Operational Readiness Review guidance, the
information CDC evaluated for the 2019-2024 PHEP performance period changed from
year to year. For example, in 2022, CDC used the Operational Readiness Review to
evaluate jurisdictions’ preparedness for a COVID-19 vaccination campaign, including the
ability to transport and store vaccines, manage volunteers, and more.
46CDC’s PHEP 5-year performance period beginning July 2024 is focused on the
agency’s new Public Health Response Readiness Framework. The framework includes a
priority focus on threat-specific planning and PHEP recipients may elect to plan for
isolation and quarantine within relevant threat areas, according to CDC officials.
Page 41 GAO-24-106705 Isolation and Quarantine
CDC Operational Readiness Reviews
CDC officials told us the agency has not prioritized an assessment—as
The Public Health Emergency part of PHEP or otherwise—of isolation and quarantine planning because
Preparedness (PHEP) cooperative these measures are not technically difficult to implement. CDC officials
agreement program is CDC’s primary
mechanism for supporting jurisdictional
told us they do not specifically review PHEP recipients’ preparedness
preparedness for “all-hazard” public health plans to determine whether they include planning for isolation and
threats. CDC provides jurisdictions with quarantine. Instead, CDC officials told us that they have a general
standards for preparedness planning,
including for isolation and quarantine as understanding of jurisdictional preparedness for isolation and quarantine
well as other nonpharmaceutical based on their close working relationships with jurisdictions. However, our
interventions, through the PHEP program.
Jurisdictions are not required to plan for
review of documentation from selected jurisdictions found that three of the
isolation and quarantine as a condition of seven selected jurisdictions did not have operational isolation and
receiving PHEP funding, according to CDC. quarantine plans that could be generally applied to infectious diseases
CDC established the PHEP Operational
Readiness Review process in 2012 and
prior to the COVID-19 pandemic. For example, two of these selected
conducted its first national review in 2015- jurisdictions had isolation and quarantine plans for specific diseases that
2016 to evaluate preparedness of experienced more limited spread, but the plans did not account for
jurisdictional public health agencies. These
reviews evaluate jurisdictional isolating and quarantining individuals outside of healthcare settings, as
preparedness efforts against CDC was required for the COVID-19 response.
preparedness and response standards and
identify gaps, strengths, promising
practices, and opportunities for CDC Additionally, CDC officials said that infrastructure for isolation and
technical assistance. CDC requires PHEP quarantine implementation, such as jurisdiction-owned isolation and
recipients to submit various deliverables to
demonstrate their preparedness as part of quarantine facilities, is a costly and rarely used capability to maintain.
this process. However, jurisdictions can take other actions to plan for isolation and
The assessment has changed over time quarantine without purchasing facilities. For example, CDC’s notice of
and was originally established to assess
preparedness for distribution of medical funding opportunity for the PHEP cooperative agreement program
countermeasures—products such as recommends that jurisdictions document applicable jurisdictional, legal,
vaccines that may be used in the event of a
potential public health emergency. In 2020,
and regulatory authorities to implement isolation and quarantine. 47
CDC expanded the PHEP Operational
Readiness Review to evaluate planning and The National Biodefense Strategy directs CDC to determine gaps in
operational functions aligned with the
agency’s 15 preparedness and response preparedness and response for community mitigation measures (i.e.,
standards. However, the COVID-19 nonpharmaceutical interventions), including isolation and quarantine. To
pandemic disrupted CDC’s plans to conduct
a full assessment in alignment with this meet this directive, CDC established a new Division of Readiness and
guidance, according to officials. Response Science in October 2023 that will research and improve the
Source: Centers for Disease Control and Prevention
(CDC). | GAO-24-106705
47See CDC, Public Health Emergency Preparedness (PHEP) Cooperative Agreement,
CDC-RFA-TP19-1901. See also capability standards outlined in CDC, Public Health
Emergency Preparedness and Response Capabilities: National Standards for State,
Local, Tribal, and Territorial Public Health (Atlanta, Ga.: October 2018). PHEP recipients
are not required to “meet” these standards to receive funding, but they are required to use
them as they plan, operationalize, and evaluate their ability to prepare for, respond to, and
recover from public health emergencies, according to CDC officials. Capability 11 covers
nonpharmaceutical interventions, including isolation and quarantine.
Page 42 GAO-24-106705 Isolation and Quarantine
impact of community mitigation measures, according to officials. 48
However, CDC officials said at the time of our review this Division does
not intend to assess jurisdictions’ planning for or capacity to implement
community mitigation measures such as isolation and quarantine.
By assessing jurisdictions’ planning for implementing isolation and
quarantine, such as identifying which jurisdictions have plans and
whether those plans are sufficient to implement large-scale isolation and
quarantine, CDC would be better able to understand what preparedness
gaps, if any, jurisdictions have and which gaps CDC might need to help
fill. CDC could accomplish such an assessment through its PHEP
evaluation processes or through other means that CDC determines
feasible, such as a survey or structured conversations with jurisdictional
officials. To respond to any gaps CDC identifies as part of this
assessment, the agency could develop updated planning guidance or
resources to help jurisdictions better prepare to respond to future threats.
Further, such an assessment would help CDC fulfill its responsibilities to
determine gaps in preparedness and response for community mitigation
measures in the National Biodefense Strategy.
We also learned from CDC officials in April 2024 that HHS and the
Department of Homeland Security are developing an interagency plan to
identify operational requirements, roles, and responsibilities for isolation
and quarantine. CDC anticipates completing this plan by the end of 2024,
according to officials. Our review suggests that a CDC assessment of
jurisdictions’ planning for implementing isolation and quarantine would
likely complement development of this interagency plan. Together, these
efforts would better prepare the nation to use isolation and quarantine,
should they be needed to protect against future threats.
Isolation and quarantine are key strategies jurisdictional governments can
Conclusions use to contain and mitigate the spread of infectious disease, particularly
for new diseases such as COVID-19. CDC played a crucial role in
supporting jurisdictions’ COVID-19 response, including through guidance,
technical assistance, and awarding funding for isolation and quarantine
actions. However, jurisdictional officials and an internal HHS review noted
that CDC could improve its guidance communication to better enable
48CDC’s Division of Readiness and Response Science develops and implements the
science of readiness and response; builds scientific expertise to address health disparities
and community mitigation; evaluates state, tribal, local, and territorial readiness and
response; and informs a broader framework for evaluating CDC’s and partners’ readiness
status, according to CDC’s website.
Page 43 GAO-24-106705 Isolation and Quarantine
jurisdictions to implement isolation and quarantine measures within their
borders. CDC has instituted a new public health guidance development
process that addresses some of these concerns, but the agency has not
documented its intentions to share finalized isolation and quarantine
guidance with jurisdictions prior to publication, when feasible, to allow
them to prepare to implement such guidance. By documenting such
intentions, CDC can be more consistent in its actions and retain
institutional knowledge about these intentions. In turn, this should help
jurisdictions quickly understand and implement new isolation and
quarantine guidance, which is essential to slowing the spread of future
disease threats.
As key implementers of isolation and quarantine, jurisdictions need to be
prepared to respond to infectious disease threats, including by using
nonpharmaceutical interventions such as isolation and quarantine.
However, we found that not all selected jurisdictions had isolation and
quarantine plans prior to or following the COVID-19 pandemic. CDC plays
a key role in assisting jurisdictions in their use of isolation and quarantine
by providing support to help them respond in times of emergency.
Because CDC has not assessed jurisdictional planning for isolation and
quarantine, it is missing information on which jurisdictions have sufficient
planning to implement isolation and quarantine when another emergency
arises. Assessing jurisdictional planning for isolation and quarantine and
determining whether federal actions are needed to help jurisdictions close
any gaps would allow CDC to better fulfill its responsibilities outlined in
the National Biodefense Strategy to enhance preparedness for future
emerging and deliberate biological threats facing the nation.
We are making two recommendations to CDC:
Recommendations for
Executive Action The Director of CDC should document the agency’s intentions to share
finalized isolation and quarantine guidance with jurisdictions in advance of
publication to allow them to prepare to implement such guidance.
(Recommendation 1)
The Director of CDC should assess jurisdictional planning for isolation
and quarantine and determine whether federal actions are needed to help
jurisdictions close any gaps. (Recommendation 2)
Page 44 GAO-24-106705 Isolation and Quarantine
We provided a draft of this report to HHS and the Department of
Agency Comments Homeland Security for review and comment. In its written comments,
and Our Evaluation reproduced in appendix I, HHS concurred with our recommendations and
identified steps to implement them. Regarding our first recommendation,
HHS stated CDC will add a statement in the next iteration of its Public
Health Guidance Development Framework to document its intentions to
share finalized isolation and quarantine guidance with jurisdictions in
advance of publication.
For our second recommendation on assessing jurisdictional planning for
isolation and quarantine, HHS said CDC plans to review and update its
public health preparedness capability standards—including those related
to nonpharmaceutical interventions like isolation and quarantine—based
on COVID-19 and other recent responses. HHS believes this effort could
potentially inform future assessments of jurisdictional planning for
isolation and quarantine. HHS also noted several challenges and
limitations to jurisdictions implementing isolation and quarantine including
restrictions on jurisdictional public health authorities and workforce
challenges. Additionally, HHS noted that jurisdictions often need federal
support to carry out large-scale isolation and quarantine. These
challenges make it all the more important that CDC understand
jurisdictional preparedness for isolation and quarantine and determine
whether federal actions are needed to help jurisdictions close any gaps.
HHS and the Department of Homeland Security also provided technical
comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the Secretary
of Homeland Security, and other interested parties. In addition, the report
is available at no charge on the GAO website at http://www.gao.gov.
If you or your staff members have any questions about this report, please
contact me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs may
be found on the last page of this report. GAO staff who made key
contributions to this report are listed in appendix II.
Mary Denigan-Macauley
Director, Health Care
Page 45 GAO-24-106705 Isolation and Quarantine
Appendix I: Comments from the Department
Appendix I: Comments from the Department of
Health and Human Services
of Health and Human Services
Page 46 GAO-24-106705 Isolation and Quarantine
Appendix I: Comments from the Department of
Health and Human Services
Page 47 GAO-24-106705 Isolation and Quarantine
Appendix I: Comments from the Department of
Health and Human Services
Page 48 GAO-24-106705 Isolation and Quarantine
Appendix I: Comments from the Department of
Health and Human Services
Page 49 GAO-24-106705 Isolation and Quarantine
Appendix II: GAO Contact and Staff
Appendix II: GAO Contact and Staff
Acknowledgments
Acknowledgments
Mary Denigan-Macauley, (202) 512-7114 or
GAO Contact: DeniganMacauleyM@gao.gov
In addition to the contact named above, Tom Conahan (Assistant
Staff Director), Rebecca Abela (Analyst-in-Charge), Alanna Miller, Jennifer
Acknowledgements: Natoli, and Rachel Weingart made key contributions to this report. Kaitlin
Farquharson, Monica Perez-Nelson, Roxanna Sun, and Cathy Hamann
Whitmore also made important contributions.
Page 50 GAO-24-106705 Isolation and Quarantine
The Government Accountability Office, the audit, evaluation, and investigative
GAO’s Mission arm of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of the
federal government for the American people. GAO examines the use of public
funds; evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make informed
oversight, policy, and funding decisions. GAO’s commitment to good government
is reflected in its core values of accountability, integrity, and reliability.
The fastest and easiest way to obtain copies of GAO documents at no cost is
Obtaining Copies of through our website. Each weekday afternoon, GAO posts on its website newly
GAO Reports and released reports, testimony, and correspondence. You can also subscribe to
GAO’s email updates to receive notification of newly posted products.
Testimony
Order by Phone The price of each GAO publication reflects GAO’s actual cost of production and
distribution and depends on the number of pages in the publication and whether
the publication is printed in color or black and white. Pricing and ordering
information is posted on GAO’s website, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card, MasterCard,
Visa, check, or money order. Call for additional information.
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Connect with GAO Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
Contact FraudNet:
To Report Fraud,
Website: https://www.gao.gov/about/what-gao-does/fraudnet
Waste, and Abuse in
Automated answering system: (800) 424-5454 or (202) 512-7700
Federal Programs
A. Nicole Clowers, Managing Director, ClowersA@gao.gov, (202) 512-4400, U.S.
Congressional Government Accountability Office, 441 G Street NW, Room 7125, Washington,
Relations DC 20548
Sarah Kaczmarek, Acting Managing Director, KaczmarekS@gao.gov, (202) 512-
Public Affairs 4800, U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Stephen J. Sanford, Managing Director, spel@gao.gov, (202) 512-4707
Strategic Planning and U.S. Government Accountability Office, 441 G Street NW, Room 7814,
External Liaison Washington, DC 20548
File and source
- File
- gao-24-106705.pdf
- Size
- 4,688,514 bytes
- SHA-256
- 143df3babdf55f8e5cec529fdc060d37dbffa5902a4c8a44dec4a7e9982cf22c
- Our copy
- gao-24-106705.pdf
- Original
- www.gao.gov