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22 C H A P T E R 4 Public health departments (local, state, federal) will likely provide guid- ance on specific measures that transportation organizations should imple- ment during a pandemic. These measures are initiated in coordination with public health agencies before explosive growth of the epidemic and, in the case of severe pandemics, are maintained consistently during an epidemic wave(s) in a community. This guidance will be transmitted either directly or through a controlling body such as a county commission, city council, or parent organization. Specific measures transportation organizations may implement based on public health recommendations at the time of a pandemic are designed to help prevent the transmission of communicable diseases (see Exhibit 15). To effectively implement these measures requires: â¢ Coordination with and advice from technical experts in the community (e.g., physicians, environmental health experts) who understand how to interpret recommendations and address related challenges â¢ Supplies and equipment purchased prior to a pandemic â¢ Policies outlining what measures will and will not be taken â¢ Protocols for taking extraordinary measures to prevent the spread of disease â¢ Workforce training and education Public health agencies at the federal, state, and local level have wide ability to determine what actions people must take to protect the public welfare. These police powers can have a significant impact on transportation systems, including ordering the cessation of service. At the local level, especially in rural areas, public health may not have extensive resources nor experience in emergency manage- ment and the exercise of those police powers. Transportation organizations should consult with local public health and emergency management officials and be able to articulate specific infor- mation and direction and control requirements for the transportation organization. Exhibit 16 describes a checklist with specific activities for preventing the spread of disease. Non-Pharmaceutical Interventions The CDC coordinates a surveillance system internationally with the World Health Organiza- tion and domestically with state and territorial health departments. The state health depart- ments coordinate data and information with local (e.g., county, city, tribal) health departments Preventing the Spread of Disease This chapter discusses the public health disaster containment strategies and how transportation organizations can adopt and adapt them internally. Exhibits in this Chapter 15 Measures that Prevent the Spread of Disease 16 Preventing the Spread of Disease Checklist 17 Three Types of Control Measures 18 Characteristics that Determine the Effectiveness of Non-Pharmaceutical Community Mitigation Activities 19 Non-Pharmaceutical Containment Measures: Definitions, Examples, and Considerations 20 Additional Resources for Preventing the Spread of Disease
Preventing the Spread of Disease 23 and healthcare providers. It is through this system of reporting cases, conducting disease (epidemiological) investigations and performing laboratory tests that agencies can predict and understand new pandemic diseases. Non-pharmaceutical community mitigation activities will be the principal means of mitigat- ing the progression and impact of the pandemic until adequate supplies of vaccine or medica- tions are available (which may be 6 to 8 months). The non-pharmaceutical mitigation activities that may be implemented during a pandemic and that are addressed in this chapter are isola- tion and treatment, voluntary home quarantine, dismissal of students from school, canceling events of social congregation (e.g., theater, sporting events), social distancing, and infection prevention and control measures (e.g., hand hygiene, cough etiquette). Exhibit 17 provides an overview of these control measures. Exhibit 16. Preventing the spread of disease checklist. This tool is included on page 46 of Chapter 7. Purpose: Provide a checklist of disease prevention actions transportation agencies should address during the planning phase for pandemics. This checklist is designed to provide a starting point and is not exhaustive of all possible actions. Directions: Use this checklist to chart the organizationâs progress. Exhibit 15. Measures that prevent the spread of disease. Measures Examples Engineering Controls Separate people from the contamination (e.g., Plexiglas barriers for drivers and ticket sellers) Administrative Controls Training, plans, policies, and procedures that articulate and enforce means to reduce infection Personal Protective Equipment Gloves and respiratory protection to reduce contamination Hand hygiene Hand washing, waterless hand sanitizer Environmental hygiene Cleaning (e.g., steam cleaning, disinfectants) of stations, vehicles, and workplaces to minimize surface contamination (fomites) Social distancing Maintain a space of 3 6 feet between persons to minimize contamination from aerosol and droplets (e.g., sneezing and coughing); canceling church, schools, declaring âsnow daysâ when everyone stays home. (It is important to note that social distancing decisions must be made in collaboration with all organizations that will be impacted. For example, if a small town is signiï¬cantly impacted, a collaborative decision may be made to close schools, shopping centers, churches, non critical medical facilities and government oï¬ces. This in turn would have direct impacts on the extent of need for transit. Ventilation Control heating, ventilation, and air conditioning to reduce the spread of contamination
24 A Guide for Public Transportation Pandemic Planning and Response Decisions about non-pharmaceutical community mitigation activities will be made amid considerable scientific uncertainty. Non-pharmaceutical community mitigation activities must be adapted to the epidemiologic (the study of disease) context of each phase of the pandemic. The effectiveness of non-pharmaceutical community mitigation activities is unknown and depends on characteristics of the evolving disease-causing microorganism (see details in Exhibit 18). Non-medicated community mitigation interventions represent a cornerstone of pandemic response, particularly early in a pandemic when a vaccine is unlikely to be available. Public health agencies will institute various combinations of pharmaceutical measures as part of a comprehen- sive strategy to address the immediate and possible long-term shortage of pharmaceutical solutions to a pandemic. Each of the three strategies (case containment, social distancing, and infection prevention and control) will impact how transportation organizations manage and communicate with their workforce during a pandemic. Exhibit 19 provides details on several non-pharmaceutical containment measures and the relevant considerations for transportation organizations. Case Containment Measures â¢Voluntary case isolation â¢Voluntary quarantine of members of households with ill persons â¢Antiviral treatment/ prophylaxis Social Distancing Measures of Children and Adults â¢Dismissal of students from classrooms â¢Social distancing of adults in the community and at work Infection Prevention and Control Measures â¢Hand hygiene â¢Cough etiquette â¢Personal protection (gloves, masks, etc.) Exhibit 17. Three types of control measures. Characteristic Description Pathogenicity How much of the germ causes disease, including how much of the virus, bacteria, or other microorganism is needed to make someone sick Virulence How sick the disease makes someone Principal mode of transmission Modes may include direct contact, indirect contact, droplet or aerosol Onset and duration of shedding How much a person gives oï¬ disease causing particles Attack rate in diï¬erent groups Infectivity of the microorganism Proportion of asymptomatic infections People who carry the disease but do not exhibit the disease symptoms Clinical presentation Observed signs or symptoms of the disease in a clinical setting (i.e., by a health practitioner) Compliance among the targeted populations An unpredictable percentage of the population will not comply with health department guidelines to reduce social interactions for a variety of social, economic, cultural, personal need, and potentially political reasons Exhibit 18. Characteristics that determine the effectiveness of non- pharmaceutical community mitigation activities.
Preventing the Spread of Disease 25 Measure Deï¬nition Considerations for Transportation Organizations Isolation The separation of infected persons from other persons for the period of communicability in conditions that will prevent the transmission of the disease. In strict isolation, the individual is conï¬ned to a room with a separate bed, with direct contact only with designated caretakers. Employees should stay home when sick. Protocols may be needed to address employees who report for work sick or become sick while on shift. Additionally, organizations should have protocols in place for sick passengers expecting to use transportation services. Quarantine The limitation of freedom of movement of persons or animals that have been exposed to a communicable disease for a period of time equal to the longest usual incubation period of the disease, in such manner as to prevent eï¬ective contact with those not so exposed. Employees and/or their family members may be placed in quarantine by public health authorities. Individual level containment measures Measures applied to individuals, as opposed to groups or communities. Encourage family preparedness measures; maintain supplies of food, water, other necessities in case of home quarantine. Quarantine of close contacts The quarantine of individuals exposed to patients with communicable diseases; the individual should remain separated from others for a speciï¬c period. During that time, the individual should be regularly assessed for signs and symptoms of disease. Employees or their family members may be placed in quarantine by public health authorities. Community based activity restrictions Measures applied to groups of people or communities. Measures that may be beneï¬cial and practical when there is a larger number of cases and more extensive viral transmission. In such settings, individual level measures may no longer be eï¬ective or practical. Public health may recommend changes to how people are transported, directly impacting a transportation agency. These may impact routes, seating arrangements, or boarding protocols. These measures may limit ridership. Focused measures to increase social distance and decrease social interactions Measures applied to speciï¬c groups (as opposed to individuals or whole communities), designed to reduce interactions and thereby transmission risk within the group. Focused measures apply to groups or persons in speciï¬c settings, most, but not necessarily all, of whom are at risk of exposure. Includes quarantine of groups of exposed persons and measures that apply to the use of speciï¬c sites or buildings. Public health may recommend changes to how people are transported, directly impacting the transportation agency. These may impact routes, seating arrangements, or boarding protocols. These measures may limit ridership. Restricting the use of speciï¬c sites or buildings or public events A type of focused measure that may involve restricting entrance to a building or other site or requiring fever screening before entrance. Cancelation of public events; closure of oï¬ce buildings, schools, shopping malls; closure of public transportation such as rail or bus lines. Exhibit 19. Non-pharmaceutical containment measures: definitions, examples, and considerations. Adapted from U.S. Department of Health and Human Services Pandemic Influenza Plan, November 2005 (http://www.flu.gov/ planning-preparedness/federal/hhspandemicinfluenzaplan.pdf) (continued on next page)
26 A Guide for Public Transportation Pandemic Planning and Response Cleaning and Disinfection of Transportation Assets Maintaining safety in transportation locations and vehicles will require stringent cleaning and disinfection of transportation assets. The basic components of effective environmental management of pandemics include: â¢ Having a policy and appropriate EPA-registered disinfectants, personal protective equip- ment (PPE), and cleaning protocols for vehicles, stationary public areas, and work areas (contact county health department or public health agencies for recommended supplies and storage recommendations). â¢ Routine cleaning with soap or detergent in water to remove soil and organic matter, followed by the proper use of chemicals and steps that can reduce the chances of hand transfer of a disease, such as limiting physical contact with persons and surfaces, frequent hand washing, use of waterless hand cleaners, and the use of gloves. â¢ Reducing the aerosolization of disease-causing microorganisms during the cleaning process. â¢ Training and equipping workers to use disinfectants appropriately for their protection and safety. Transportation organizations should have a policy of when and how to implement altered cleaning activities in response to a disease outbreak. Workers must be appropriately trained and equipped, including respiratory protection from chemicals used in the disinfection. (Note: Filters that are effective for protection from diseases may not be effective for chemical protection; check manufacturerâs specifications.) Guidance on cleaning and disinfecting is available from flu.gov (see Exhibit 20). Medical Interventions Local and state public health prioritization schemes for vaccines, antivirals, and other medi- cal countermeasures may or may not include frontline transportation workers. It is important that transportation agencies work with public health entities to ensure their essential workers are included in local plans for community vaccinations and medical support and receive an appropriate priority. Measure Deï¬nition Considerations for Transportation Organizations Coordinated community and business closures Voluntary measures that coordinate simultaneous closure of oï¬ces, schools, transportation systems and other non essential community activities, services, and businesses for a speciï¬ed period of time. All non-essential service personnel and community members are urged to stay at home. Transit organizations need to coordinate with external organizations to alter services to meet community needs. Staï¬ng within the transit organization may be altered to minimize non essential personnel exposure. Infection prevention and control measures Use of physical barriers and hygiene measures to limit the risk of transmission. Includes respiratory hygiene, cough etiquette, hand washing and hand hygiene, use of gloves, masks, and general hygiene and disinfection. Exhibit 19. (Continued).
Preventing the Spread of Disease 27 Exhibit 20. Additional resources for preventing the spread of disease. Transportation Planning > Seasonal Flu Guidance Disinfectants marketed in the United States are required to be registered by the U.S. EPA. These products must be used in accordance with their label instructions; following label instructions is necessary to achieve adequate eï¬cacy and to avoid unreasonable adverse eï¬ects. Flu.gov provides guidance for the transportation industry on managing the close-contact environments in travel settings and for proper cleaning/disinfecting of stations, cargo, and passenger vehicles. Access the most up-to-date guidance online at: http://www.ï¬u.gov/planning-preparedness/transportation Antimicrobial Products Registered for Use Against the H1N1 Flu and Other Inï¬uenza A Viruses on Hard Surfaces When cleaning and preventing the spread of disease, it is important to use appropriate disinfectants and to use them properly. For example, using alcohol based hand cleaners is eï¬ective against many germs, but is not considered appropriate for preventing the spread of clostridium diï¬cile (known as c. dif). The manner in which these products are used is important. For example, while bleach and ammonia both are potent cleaners, mixing the two products can generate dangerous vapors. Access the most up-to-date guidance online at: http://www.epa.gov/oppad001/inï¬uenza-disinfectants.html Interim Guidance for Passenger Railcar (Transit Vehicle) Cleaning When a Passenger or Crewmember is Visibly Ill During an Inï¬uenza Pandemic Flu.gov provides interim guidance for passenger railcar (transit vehicle) cleaning when a passenger or crewmember is visibly ill during an inï¬uenza pandemic. Access the most up-to-date guidance online at: http://www.ï¬u.gov/planning- preparedness/transportation/cleaning_railcar.html# Interim Guidance for Cleaning Transit Stations During an Inï¬uenza Pandemic Flu.gov provides interim guidance for cleaning transit stations during inï¬uenza pandemic. Access the most up-to-date guidance online at: http://www.ï¬u.gov/planning- preparedness/transportation/cleaning_transit_stations.html#