Quarantine Facilities for Arriving Air Travelers: Identification of Planning Needs and Costs (2008)

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8There are several unique planning features associated with quarantine of the crew and passengers of a commercial aircraft arriving in the United States. The National Aviation Resources Manual for Quarantinable Diseases identifies nine considera- tions for planning in the event that quarantine is needed. That manual recommends the following be addressed in the plan- ning process: 1. Identifying a secure location and requisite lodging for quar- antine. (Space must be adequate and safe). 2. Identifying the staff needed to sustain, enforce, and provide services to quarantined individuals and from where this staff will come. (Food, water, and sanitation are among the basics). 3. Identifying the supplies needed to sustain quarantine and from where these supplies will come. 4. Identifying the medical and mental health needs of the quarantined population and how these needs will be met. (Physical and emotional support may be needed). 5. Identifying the special needs of the quarantined popula- tion (e.g., children, pregnant women, people with disabil- ities, and differing cultures and religions) and how these needs will be met. 6. Identifying the support organizations available to assist in managing quarantine. 7. Identifying the financial needs for managing quarantine. 8. Addressing the legal needs for managing quarantine (e.g., due process protections for quarantined passengers and flight crew). 9. Addressing media and public information issues [e.g., set- ting up a Joint Information Center (JIC)].2 This report addresses the planning considerations specific to an airport quarantine site and the estimated associated costs. For purposes of this analysis, it is assumed that quarantine of 200 people for up to 2 weeks would be established on prop- erty owned or controlled by the airport and away from the terminal. This is not the only potential location where a quar- antine facility could be established and operated. At least two other possible scenarios—quarantine within the airport terminal and an off-site quarantine facility—should be in- vestigated further. The following analysis identifies the major anticipated costs but makes no assumptions or judgments about who would be responsible for them. There are no assumptions made about who would be re- sponsible for all the associated costs of quarantine under these circumstances. This report identifies the major antic- ipated costs without regard for who would pick up the tab. In reality, costs would be spread among various entities de- pending on who is liable for covering what costs. Location There are several possible locations on airport property for establishing a quarantine facility, each of which would present its own challenges. The options include dedicating an existing facility to this purpose such as an unused hangar; identifying a facility used for another purpose that could be shifted to use as a quarantine area (e.g., a portion of a terminal building); or de- termining a site on which temporary facilities could be erected. Trailers, tents, or other types of emergency shelter might be feasible depending on the time of year and the weather. Deter- mining the optimum location from an operational and cost standpoint will depend on the specifics of the airport, but the following factors should be considered. Space Requirements How much space is needed to sustain quarantine for as many as 200 people for up to 14 days? If quarantine is consid- ered a form of “medical sheltering” to protect a community C H A P T E R 3 Planning Considerations for Airport Quarantine 2 National Aviation Resource Manual for Quarantinable Diseases, U.S. Department of Transportation, December 2006.

from the spread of disease, then shelter models can be applied. FEMA guidance for hurricanes (and any event of less than 36 hours duration) is a mere 10 square feet per person. Stan- dards for longer stays are double or triple that number. Thus, at least 4,000 ft2 of space would be needed for personal space at a quarantine site. That amount does not include the space required for eating, recreation, offices, or ancillary services. Transport to the Facility If the site is not directly accessible from the aircraft (either via a jet bridge to the terminal or via mobile stairs from a re- mote parking location), the quarantine plan must include pro- visions for the movement of the passengers and crew. If motor vehicles such as buses are used, this may involve quarantine of the operators and the decontamination of the vehicles. Security People being held in quarantine must be protected from harm, and their personal belongings (including luggage, if re- turned to them) must be secure as well. Basic security measures and secure storage need to be provided. A security force must be in place to ensure that the people being quarantined do not leave and that unauthorized people do not enter the facility. Curious people, the press, politicians, and others will not be permitted to come into the area to observe or interview the people inside the quarantine area. Once in the area, a person re- mains there until released. Perimeter fencing and limited access to the building housing the quarantine area may be required. Impact on Airport Operations The location of the facility, and whether it is a multiple-use or dedicated facility, will have a direct impact on airport oper- ations. Intra-airport transportation may need to be re-routed. It is also possible that cordoning off an area could affect aircraft movements on taxiways and ramp areas. Airport managers and their staff would need to establish a Unified Command operation and mobilize their Emergency Opera- tions Center as the coordination site for additional personnel who will handle the media, help manage a family assistance center, provide security, coordinate incoming volunteers, and manage the logistics of outside (private sector and gov- ernment) assistance. Accommodations Power Source If the building does not have adequate primary and backup power, generators and fuel supplies have to be available to keep the facility operational for the duration of the quarantine. Power requirements will be substantial and will involve more than back-up emergency power to keep exit lights illuminated. Heating, Ventilation, and Air Conditioning A quarantine area must have sufficient heating, ventilation, and air conditioning (HVAC) systems to keep people rea- sonably comfortable. This is more than just for convenience: the old, the very young, and people with particular medical conditions are less tolerant of temperature extremes than the rest of the population. Portable HVAC units may have to be brought to the quarantine site, and ventilation will have to be evaluated by an HVAC expert. Lighting The building must have adequate lighting for daytime and nighttime use. Depending on how the building is used nor- mally, sufficient lighting may already be in place, although it may not provide adequate task light or allow for lower light- ing levels during the evening. Sanitation The sanitary needs of a group of people under quarantine must be addressed. In all likelihood, the building will not have enough toilets for 200 people. The structure or area may not have any facilities for bathing (showers). Between four to five (in-place or portable) toilets are recommended per 100 occu- pants. For 200 people then, a minimum of 8 and preferably 10 toilets would be needed. One ADA-approved handicapped toilet also would be required. If the toilets are portable, plans must include pump out and cleaning. Depending on the facil- ity being used, portable sinks might also need to be provided. Unless the quarantine is of very short duration, (e.g., less than 24 hours), showers will have to be provided. Also, for a quarantine of up to two weeks, provisions must include laun- dry service. Given the circumstances, an off-site service may not be feasible. As an alternative, several washer/dryer units could be pre-deployed in a designated area. Communications Quarantine planners will need to ensure that the site can be set up with communications links (telephone lines, internet, tel- evision, public address system) either through pre-established infrastructure or via wireless capability. Radios, batteries, and power outlets for cell phone recharging will be needed. Animals Some travelers may arrive with pets or service animals (ser- vice animals such as guide dogs are not considered pets and are 9

exempt from most restrictions on travel with pets). Pet dogs and cats are subject to inspection upon arrival in the United States for evidence of disease. In addition, dogs arriving from coun- tries where rabies is reported are required to be immunized against rabies. Dogs and cats that appear to be ill with a disease that may be transmissible to humans are subject to veterinary medical examination, treatment, and/or quarantine (see http://www.cdc.gov/ncidod/dq/faq_animal_importation .htm#dogreqs). Service animals are generally allowed in other shelter situations and should be accommodated in a quarantine facility if possible. Careful consideration should be given to al- lowing pets that are cleared of disease to remain or be reunited with their owners. Allowing pets to be co-located with their owners (instead of housed at an animal shelter or elsewhere on the airport) may provide comfort and psychological support. However, other quarantined individuals may have allergies or aversions to animals, and the noise, mess, and smell associated with some pets may be hard to control in a shelter setting. Supplies Food and Water Food and water are crucial to the operation of a quarantine area. A quarantine plan should include provisions to store a supply of basic foods or to acquire them quickly, for the first 24–48 hours of the quarantine. After that point, if necessary, a food supply system should be in place to provide for needs of the people in quarantine. There may be passengers who have diabetes or other re- lated blood sugar disorders or who are on medication that re- quires it be taken with food. Also, some travelers may have babies or small children with them. It is much harder for babies and small children to ward off hunger. Space for carbohydrate-rich snacks, baby formula, and canned or pack- aged food could be provided at the site. It is not necessary to have accommodations for preparing hot meals as long as they can be purchased for delivery from a supplier. Paper plates, cups, and napkins and plastic utensils can be used. Can and bottle openers should be available as well. The people in quarantine will need water. If the building does not have potable running water, then alternative supplies must be provided. Between a half and 1 gallon of water per day per person may be necessary. Bottled water can be brought in by a public or private supplier or stored on site (or elsewhere on the airport property). If the temperature in the building is warmer than comfortable, then more water may be needed. Other beverages can be provided to supplement water. Clothing and Personal Items Depending on the pathogen involved, passengers and crew may not have access to their baggage until it has been decon- taminated or disinfected. Even if baggage is immediately available, travelers may not have sufficient clothing and per- sonal items for more than a day or so, or might not have ap- propriate clothing for the airport climate. Some quarantined individuals may be able to make arrangements for clothing and personal items to be sent to them by family or friends, while others may need to have these provided. Many volun- teer organizations have or can quickly obtain donations of clothes. Bedding and Other Supplies A projected list of supplies and equipment, per FEMA and Red Cross guidelines, should include the following: • Bedding—a cot, blanket, pillow and sheets for each person. It is a good idea to have a 10% spare capacity as well. • Emergency equipment—flashlights, fire extinguishers, tool kits. • First-aid supplies—tape, safety pins, latex gloves, scissors, antiseptics, antibiotics, smelling salts, splints, thermom- eters, blood pressure gauges, variety of bandages, towels, and ointments. • Sanitary supplies—toilet paper, paper towels, personal hy- giene items, chlorine bleach, disinfectants, trash cans, and plastic bags. • Infant and children supplies—disposable diapers, powders and ointments, moistened towelettes, pacifiers, toys, and blankets. • Social and recreational needs—age-appropriate games, toys, books, and magazines. A quarantine area should have portable partitions to allow family groups to stay together and to allow at least some pri- vacy for sleeping and changing clothes. In addition, partitions will be needed to establish recreational and office space. Staffing The question of staffing the site and providing services re- quires serious consideration. The quarantine area can not run itself, but how can services be provided if staff will potentially expose themselves to contamination as well? The scope of this study does not allow for a sufficient examination of this ques- tion. For the purposes of planning and estimating associated costs, the following assumes that measures will be identified and implemented that minimize the risk of exposure for in- dividuals providing these services (e.g., through the use of personal protective equipment, inoculations and/or prophy- lactic treatment, and/or strategies for avoiding person-to- person contact). The cost of implementing these exposure minimization measures is not included in this analysis. 10

Services Security Security will be essential and law enforcement personnel are likely to be required. Again, consideration must be given to exposure of security personnel. Medical Evaluation and Services Nurses and doctors may be needed to assess quarantined individuals for symptoms of the quarantinable disease as well as to provide evaluation and treatment of pre-existing or newly occurring conditions. The same worker contamination issue as discussed before applies if practitioners are in direct con- tact with exposed individuals. Part of the initial assessment process will be to screen the population for existing medical conditions. For example, some people may have chronic conditions that require med- ical treatment on an ongoing basis (e.g., dialysis every 48 to 72 hours or a continuous supply of supplemental oxygen). Likewise, some people may have daily or frequent medication needs, and may only have enough medications to last for the expected duration of their trip, or may not have immediate access to medication in their checked baggage. Many med- ications require refrigeration or room temperature storage— if bags are subjected to extreme temperatures the medicine may need to be replaced. A quarantine plan must have pro- visions for replacing, storing and dispensing prescription medication and other medical treatment unrelated to the quarantinable disease. Injuries and illness that could occur or develop during quarantine must be treated, too. First aid kits should be part of the inventory of supplies awaiting a group of people being quarantined. In addition, one Automatic External Defibril- lator (AED) per 100 people should be available in the quar- antine area. Arrangements should be made in advance with local medical facilities for referring people subject to quar- antine in the event that more extensive medical treatment is necessary. In the event that there is an outbreak of the disease that necessitated the quarantine or any other disease, treatment plans and the staff needed to implement them are needed. Isolation areas within the quarantine area may be necessary. Mental Health While the majority of the population in quarantine will ad- just to the situation, there may be individuals that do not. There may be passengers with pre-existing mental health issues who require additional care. Part of the medical considerations for a quarantine plan must include provisions for mental health services and the well being of the people in virtual lock down. Counseling should be provided and resources made available after the people are released from quarantine. Mental health issues may overlap with medication needs and become part of the needs to acquire and store medications on site. Special Needs Language and Cultural Needs An international flight will probably include individuals from outside the United States who are not fluent in English. This language barrier will cause communication difficulties be- tween quarantine officials and the foreign nationals, and will require the services of interpreters. Quarantined individuals or airport or airline employees with multi-lingual skills may be of assistance in providing interpretation. If no locally-based in- terpreter is available it may be possible to provide interpreters by phone (note: even on-site interpreters will not be able to have direct contact with the quarantined individuals unless they themselves are quarantined). Embassy contact informa- tion should be provided to quarantined foreign nationals. Dietary Restrictions Whether based on cultural practices, religious beliefs, or health concerns, some people may require special food. For example, several cultures and religions do not eat pork prod- ucts. When acquiring pre-packaged meals for the quarantine area, a chicken meal and a vegetarian meal should be two of the choices. After the dietary needs of the population are known, a variety of foods can be ordered. Religious Needs As with cultural differences, religious needs have to be ad- dressed in a quarantine plan. An area(s) should be designated as “quiet or meditation” zone(s). Certain faiths may ask for religious books such as a Bible or Quran. Pastors or chap- lains or other spiritual leaders may offer or request to be ad- mitted to the area to minister to the needs of the members of their faith. Media Management A quarantine at a U.S. airport would attract extensive media coverage. The challenges for the airport public rela- tions staff include handling media inquiries and requests for interviews, managing (or restricting) access for media on site, and coordinating closely with federal, state, and local agencies as well as with airlines to ensure consistent and accurate information is provided to the public. 11

Under the National Incident Management System (NIMS), a Joint Information Center (JIC) is established and all press briefings are conducted at one time at this designated location. Most airports will have such facilities or locations in place as part of their emergency response plans, but special considera- tion should be given to its location in a quarantine situation. The JIC must be far enough removed from the quarantine fa- cility to avoid the risk of exposure and protect the privacy of quarantined individuals, while still facilitating coordination with those responsible for managing the quarantine. In a JIC all stakeholder agencies provide coordinated press releases to ensure that consistent and accurate information is released. It is important during any emergency to convey complex in- formation clearly and simply. However, it should be anticipated that quarantined individuals may contact the media directly via cell phone or e-mail, or be willing to provide interviews to the media without going through any official communications plan. Providing quarantined individuals with access to the same information that is going out to the media will help to address this issue. Clean-Up and Disinfection (Post-Quarantine) Before the area that is used for quarantine is returned to other service or left in a stand-by mode for future use as a quar- antine facility, it must be cleaned sufficiently to ensure that there is no risk of further contagion from the items or materi- als left behind. Plans should be made for specialized cleaning/ disinfection by individuals trained in the use of appropriate personal protection equipment (PPE) for the quarantinable disease and universal precautions for dealing with materials potentially contaminated by blood and feces. If the quarantine facility serves another purpose at the air- port (e.g., food service), more stringent clean-up standards may be applicable. 12