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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2013. Infectious Disease Mitigation in Airports and on Aircraft. Washington, DC: The National Academies Press. doi: 10.17226/22512.
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A I R P O R T C O O P E R A T I V E R E S E A R C H P R O G R A M ACRP REPORT 91 TRANSPORTAT ION RESEARCH BOARD WASHINGTON, D.C. 2013 www.TRB.org Research sponsored by the Federal Aviation Administration Subscriber Categories Aviation • Environment Infectious Disease Mitigation in Airports and on Aircraft EnvironmEntal HEaltH & EnginEEring, inc. Needham, MA

AIRPORT COOPERATIVE RESEARCH PROGRAM Airports are vital national resources. They serve a key role in trans­ portation of people and goods and in regional, national, and inter­ national commerce. They are where the nation’s aviation system connects with other modes of transportation and where federal respon­ sibility for managing and regulating air traffic operations intersects with the role of state and local governments that own and operate most airports. Research is necessary to solve common operating problems, to adapt appropriate new technologies from other industries, and to introduce innovations into the airport industry. The Airport Coopera­ tive Research Program (ACRP) serves as one of the principal means by which the airport industry can develop innovative near­term solutions to meet demands placed on it. The need for ACRP was identified in TRB Special Report 272: Airport Research Needs: Cooperative Solutions in 2003, based on a study spon­ sored by the Federal Aviation Administration (FAA). The ACRP carries out applied research on problems that are shared by airport operating agencies and are not being adequately addressed by existing federal research programs. It is modeled after the successful National Coopera­ tive Highway Research Program and Transit Cooperative Research Pro­ gram. The ACRP undertakes research and other technical activities in a variety of airport subject areas, including design, construction, mainte­ nance, operations, safety, security, policy, planning, human resources, and administration. The ACRP provides a forum where airport opera­ tors can cooperatively address common operational problems. The ACRP was authorized in December 2003 as part of the Vision 100­Century of Aviation Reauthorization Act. The primary participants in the ACRP are (1) an independent governing board, the ACRP Oversight Committee (AOC), appointed by the Secretary of the U.S. Department of Transportation with representation from airport operating agencies, other stakeholders, and relevant industry organizations such as the Airports Council International­North America (ACI­NA), the American Associa­ tion of Airport Executives (AAAE), the National Association of State Aviation Officials (NASAO), Airlines for America (A4A), and the Airport Consultants Council (ACC) as vital links to the airport community; (2) the TRB as program manager and secretariat for the governing board; and (3) the FAA as program sponsor. In October 2005, the FAA executed a contract with the National Academies formally initiating the program. The ACRP benefits from the cooperation and participation of airport professionals, air carriers, shippers, state and local government officials, equipment and service suppliers, other airport users, and research orga­ nizations. Each of these participants has different interests and respon­ sibilities, and each is an integral part of this cooperative research effort. Research problem statements for the ACRP are solicited periodically but may be submitted to the TRB by anyone at any time. It is the responsibility of the AOC to formulate the research program by iden­ tifying the highest priority projects and defining funding levels and expected products. Once selected, each ACRP project is assigned to an expert panel, appointed by the TRB. Panels include experienced practitioners and research specialists; heavy emphasis is placed on including airport pro­ fessionals, the intended users of the research products. The panels pre­ pare project statements (requests for proposals), select contractors, and provide technical guidance and counsel throughout the life of the project. The process for developing research problem statements and selecting research agencies has been used by TRB in managing cooper­ ative research programs since 1962. As in other TRB activities, ACRP project panels serve voluntarily without compensation. Primary emphasis is placed on disseminating ACRP results to the intended end­users of the research: airport operating agencies, service providers, and suppliers. The ACRP produces a series of research reports for use by airport operators, local agencies, the FAA, and other interested parties, and industry associations may arrange for work­ shops, training aids, field visits, and other activities to ensure that results are implemented by airport­industry practitioners. ACRP REPORT 91 Project 02­20A ISSN 1935­9802 ISBN 978­0­309­28349­6 Library of Congress Control Number 2013946258 © 2013 National Academy of Sciences. All rights reserved. COPYRIGHT INFORMATION Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously published or copyrighted material used herein. Cooperative Research Programs (CRP) grants permission to reproduce material in this publication for classroom and not­for­profit purposes. Permission is given with the understanding that none of the material will be used to imply TRB or FAA endorsement of a particular product, method, or practice. It is expected that those reproducing the material in this document for educational and not­for­profit uses will give appropriate acknowledgment of the source of any reprinted or reproduced material. For other uses of the material, request permission from CRP. NOTICE The project that is the subject of this report was a part of the Airport Cooperative Research Program, conducted by the Transportation Research Board with the approval of the Governing Board of the National Research Council. The members of the technical panel selected to monitor this project and to review this report were chosen for their special competencies and with regard for appropriate balance. The report was reviewed by the technical panel and accepted for publication according to procedures established and overseen by the Transportation Research Board and approved by the Governing Board of the National Research Council. The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessarily those of the Transportation Research Board, the National Research Council, or the program sponsors. The Transportation Research Board of the National Academies, the National Research Council, and the sponsors of the Airport Cooperative Research Program do not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the object of the report. Published reports of the AIRPORT COOPERATIVE RESEARCH PROGRAM are available from: Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet at http://www.national­academies.org/trb/bookstore Printed in the United States of America

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. On the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, on its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. The Transportation Research Board is one of six major divisions of the National Research Council. The mission of the Transporta- tion Research Board is to provide leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Board’s varied activities annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individu- als interested in the development of transportation. www.TRB.org www.national-academies.org

C O O P E R A T I V E R E S E A R C H P R O G R A M S CRP STAFF FOR ACRP REPORT 91 Christopher W. Jenks, Director, Cooperative Research Programs Crawford F. Jencks, Deputy Director, Cooperative Research Programs Michael R. Salamone, ACRP Manager Joseph D. Navarrete, Senior Program Officer Terri Baker, Senior Program Assistant Eileen P. Delaney, Director of Publications Maria Sabin Crawford, Assistant Editor ACRP PROJECT 02-20A PANEL Field of Environment Paul Meyer, Hartsfield-Jackson Atlanta International Airport, Atlanta, GA (Chair) Matthew D. Crosman, Metropolitan Washington Airports Authority—Washington Dulles International Airport, Washington, DC Mark A. Gendreau, Lahey Hospital and Medical Center, Burlington, MA Grace M. Hwang, MITRE Corporation, McLean, VA Barbara T. Martin, Delta Air Lines, Atlanta, GA J. Michael Muhm, The Boeing Company, Woodinville, WA Renee D. Spann, Port Authority of New York & New Jersey, Newark, NJ Shamira Brown, FAA Liaison Francisco Alvarado-Ramy, Centers for Disease Control and Prevention Liaison Deborah C. McElroy, Airports Council International - North America Liaison Christine Gerencher, TRB Liaison

ACRP Report 91: Infectious Disease Mitigation in Airports and on Aircraft provides prac­ tical guidance for mitigating the risk of disease spread via droplet, airborne, and contact transmission modes. The easy­to­use guidebook identifies 24 recommended actions to mitigate disease transmission at airports and aboard aircraft that are classified into three broad categories to assist managers with identifying actions that are specific to their area of oversight: buildings, airplanes, and people. The transmission of disease through air travel is an important public health concern. In general, the risk of disease transmission at airports and on aircraft is similar to risks asso­ ciated with other highly dense public settings and activities. Airports and aircraft afford opportunities for disease transmission due to close human contact (e.g., queuing areas, aircraft cabins); sharing of communal spaces (e.g., restrooms, waiting areas, dining tables); and a high number of touched surfaces (e.g., kiosks, handrails, security bins). In addition, however, air travel also highlights the unique factors resulting from the interaction of large numbers of individuals from geographically diverse regions, with differing immunity and endemic diseases. These additional factors represent unique challenges for airports and aircraft operators. The research, led by Environmental Health & Engineering, Inc., began with a review and synthesis of available literature. The team then identified exposure opportunities within airports and aboard aircraft, and considered transmission­relevant behavior of passengers, visitors, and employees. The relative risks associated with three transmission modes (i.e., droplet, airborne, and contact) were then determined. Working with an expert committee comprising infectious disease specialists, microbiologists, epidemiologists, building engi­ neering specialists, and public health experts, the team developed a list of mitigation mea­ sures. Based upon this research, the team then prepared the guidebook. The guidebook begins with an introduction that describes how infectious diseases are commonly transmitted, discusses the unique aspects of air travel that can affect how dis­ eases are transmitted, and reviews the role of HVAC systems and surface cleaning practices in mitigating disease spread. The guidebook then provides three sections of mitigation mea­ sures focused on buildings (i.e., terminals and other facilities); airplanes; and people (i.e., measures that organizations and individuals can undertake to reduce disease transmission risk). In turn, these measures are prioritized based on the strength of supportive evidence­ based research. Each recommended action includes a brief rationale for the recommenda­ tion. The guidebook also includes a glossary of infectious disease­related terms. In addition to the guidebook, the research team prepared a technical report detailing the research steps and findings. This technical report is available online at http://apps.trb.org/ cmsfeed/TRBNetProjectDisplay.asp?ProjectID=3028. F O R E W O R D By Joseph D. Navarrete Staff Officer Transportation Research Board

P R E F A C E Environmental Health & Engineering, Inc., conducted the following research on behalf of the Transportation Research Board (TRB) of the National Academies to complete Proj­ ect 02­20A of the Airport Cooperative Research Program (ACRP). The objectives of ACRP Project 02­20A were the following: • To determine high­risk areas and activities conducive to human disease spread via drop­ let, airborne, and contact transmission modes (i.e., exposure opportunities) at airports and on aircraft; • To identify mitigation measures to address those risks; and • To provide practical guidance to help airports and aircraft operators use these measures to develop targeted strategies to respond to various types and levels of disease threats. This document is intended for use by airport operators and airline operators and not necessarily the flying public. Further, due to the charge by the ACRP to provide a guidance document with a focus on implementable actions, scientific references and lengthy sup­ porting documentation are not provided here; a complete report for this project, including details of each task and outcome is available on the Project website at http://apps.trb.org/ cmsfeed/TRBNetProjectDisplay.asp?ProjectID=3028. This research was conducted from July 2011 through December 2012, by a multi­ disciplinary team of experts (Table P­1). The scope of work was limited to identify­ ing mitigation measures for U.S. airline and airport operators (including international, domestic and regional airports). Mitigation measures also had to be within the purview of the airline and airport operators for implementation, and therefore excluded consid­ eration of potential measures such as travel restrictions, quarantine, and contact tracing after an outbreak. Furthermore, the contract dictated that research pertaining to air cargo operations, zoonotic, food­borne, water­borne, and vector­borne diseases, and agents related to bioterrorism, was outside the scope of this project. See Table P­2 for a glossary of terms included in this report.

Table P-1. List of experts who contributed to the project through participation in expert panel discussions, report writing and/or report review. (Note: listing here does not imply authorship of this document). Contributor Affiliation(s) Title John McCarthy, SeD Environmental Heath & Engineering (EH&E) Principal Investigator / President John Spengler, PhD Harvard School of Public Health (HSPH) Akira Yamaguchi Professor of Environmental Health and Human Habitation Joseph Allen, DSc EH&E HSPH Principal Scientist Research Associate David Macintosh, SeD EH&E HSPH Chief Science Officer Adjunct Associate Professor Theodore Myatt, SeD Brigham and Women’s Hospital (BWH) EH&E Director of Partners Healthcare Institutional Biosafety Committee Senior Scientist James McDevitt, PhD HSPH Instructor of Exposure, Epidemiology and Risk Lisa Saiman, MD, MPH Columbia University Medical Center Professor of Clinical Pediatrics and Pediatric Infectious Diseases Patricia Fabian, SeD Boston University School of Public Health Research Assistant Professor Edward Nardell, MD HSPH, BWH Associate Professor in the Departments of Environmental Health and lmmunology and Infectious Diseases Jerry Ludwig, PhD, PE EH&E Director of Engineering Christopher Zevitas Volpe National Transportation Center Research and Innovative Technology Administration

Table P-2. Glossary of terms (in relation to infectious disease). Aerosols droplets containing an infectious agent that may become airborne and be transmitted through inhalation Biological agents any microorganism, including bacteria and viruses, that cause disease in humans Bloodborne refers to indirect transmission of an infectious agent by blood-to-blood contact Broad spectrum refers to disinfectant activity against a wide range of disease causing microorganisms Contact time the length of time that the disinfectant is to remain in contact with a potentially con- taminated surface to be effective Endemic describes a disease that is always present in a certain population or region Exposure pathway the complete course by which an infectious agent is transmitted from its source to an- other person Exposure the condition of being subjected to an infectious agent Fomite an inanimate object that may be contaminated with an infectious agent Germicide a substance or agent that kills germs Host an individual who has been infected with a disease-causing microorganism Index case the first identified patient in a group of related cases of a particular disease Infectious dose the smallest quantity of an infectious agent that produces an infection in the host MERV minimum efficiency reporting value; a measure of filter efficiency and performance Microbial load the total number of living microorganisms on a particular surface or contained on vari- ous media Microbiocide a disinfectant used on inanimate objects to kill microorganisms Microorganism a microscopic organism such as bacterium or virus Pandemic a widespread outbreak of an infectious disease that spreads through human popula- tions across a large region Pathogenicity the capability of an agent to cause disease Relative risk a quantitative value of the likelihood of acquiring an infectious disease relative to expo- sure within a particular environment Secondary infection a state of health that occurs when the host is infected by an agent that makes him/her susceptible to additional infections Susceptible individuals capable of being infected, due to lack of immunity or resistance Vector-borne indirect transmission of an infectious agent from one host to another by organisms such as insects Virulence the relative capacity of a pathogen to overcome body defenses Water-borne refers to indirect transmission of an infectious agent by water Zoonotic an infectious agent or disease that can be transmitted from animals to humans

1 Summary 2 Chapter 1 Introduction 2 Infectious Disease Risk 3 Routes of Transmission 4 Research Directions for Infectious Disease Transmission in the Air Travel Industry 4 Transportation Hubs and Disease Transmission: The Airport and Airplane Environments 8 Process for Selection of Mitigation Measures 9 Additional Information 10 Chapter 2 Buildings 19 Chapter 3 Airplanes 24 Chapter 4 People C O N T E N T S

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TRB’s Airport Cooperative Research Program (ACRP) Report 91: Infectious Disease Mitigation in Airports and on Aircraft offers guidance for mitigating the risk of disease spread via droplet, airborne, and contact at airports and aboard aircraft.

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