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6 in the United States lies with the CDC; this is not an airport one facility may be used to screen and register individuals who or air carrier decision. The air carrier has a duty to report cer- could then be transported to longer-term accommodations. tain illnesses as explained, but for international travelers, only The passengers and crew of the aircraft would be inter- federal public health officials are legally authorized to imple- viewed to collect basic information and evaluated to assess ment a quarantine. potential exposure. Medical personnel also would access any While CDC has the authority to impose mandatory quar- pre-existing health issues that may exacerbate, complicate, or antine for nine diseases, the agency may choose a less extreme confound symptoms of the quarantinable disease (e.g., pre- measure such as voluntary home quarantine; prophylactic existing respiratory or cardiac conditions that might be wors- treatment where available (e.g., vaccination); or simply col- ened or triggered, or seasonal allergies that might be mistaken lection of contact information and follow-up by public health for or mask symptoms of the quarantinable disease). The officials to determine if anyone exposed develops symptoms stress of being quarantined may exacerbate existing condi- later. The latter was done during the 2003 SARS outbreak. tions and travelers may have medication needs. Phase 2. Establishment Phase 3. Quarantine Operations of Quarantine Once a quarantine location is established and quarantined After the decision to quarantine is made by the CDC, the individuals have been transported there, the site becomes op- next step is to determine where the quarantined passengers erational. The individuals under quarantine will need food, and aircrew would be held and to set up the necessary ac- water, toilet facilities and, depending on the duration of the commodations. Health officials will decide if the ill person(s) quarantine, accommodations for sleeping, bathing, enter- and any others exhibiting symptoms should be referred to a tainment, and communications. Access to medical care will hospital or other medical facility for treatment and isolation. have to be available. Supplies and staffing for food prepara- Others exposed to the illness, though not symptomatic, may tion, medical care, security, cleaning, counseling and so forth need to be detained for hours, days, or even weeks until a di- will have to be mobilized quickly. Personnel from many dif- agnosis is confirmed, the time period for incubation is deter- ferent agencies could be involved in the effort, including CDC mined, and the risk of further spread of the disease is evalu- officials, state and local public health employees, hospitals, ated. For example, exposed individuals may need to be kept airport and airline staff, private sector contractors, local pub- in quarantine until laboratory tests confirm the initial diag- lic safety officials, and non-profit organizations. nosis. If tests are negative, individuals would then be released It will be very important to maintain good records on the from quarantine. If the tests prove positive, quarantine would individuals who are held in quarantine. Also, the operation be extended for the appropriate incubation period. An esti- will require rapid acquisition of goods and services, many of mate of these time frames and decision points should be which ultimately may be reimbursable from disaster response made and conveyed to passengers and crew at this point and funds or other sources. To take advantage of those resources, then updated as needed. and for general accountability, it will be necessary to have Keeping passengers and crew on board the aircraft or in the records of all purchases and receipts. Totals can be organized gate area for any extended period is not desirable and may not and tallied during demobilization after quarantine ends. be feasible; therefore, it probably will be necessary to remove Record keeping is vital in the event of any legal claims and in quarantined individuals to another location on or off the air- preparation for cost reimbursement. port. A procedure for transport to the designated medical An important area for further study is to examine and surveillance area should be made part of an airport's emer- compare specific mandates of federal, state, and local gov- gency plan. If the facility is on the airport property but away ernment with an eye toward determining more precisely the from the terminal, the aircraft may be able to be moved to that responsibilities of each and how the cost should be allocated. facility and a stairway provided for egress from the aircraft. Lift service would need to be available for nonambulatory Phase 4. Demobilization or limited ambulatory passengers, and wheelchairs should be available. Plans for demobilization can begin immediately after quar- If the quarantine site is off the airport property or otherwise antine is underway. A demobilization plan--the controlled, not accessible by moving the aircraft, other vehicles, like buses organized cessation of operations--is a feature of the National or airport shuttles, would have to transfer the passengers and Incident Management System (NIMS). The plan should in- crew to the site. In this case, officials would have to consider clude procedures for finalizing all records, including financial the personal protection of the vehicle operators. Later, the records. Having a system in place helps to reduce the poten- vehicles would need to be decontaminated. In some situations, tial for confusion on billing for rented equipment and per-