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10 C H A P T E R 2 Airport Operators Should Consider Implementing the Use of Hand Sanitizer Stations in Strategic Locations Throughout the Airport Highly Recommended Rationale. Use of hand sanitizer has been dem- onstrated to reduce infectious disease transmission by reducing microbial loads on hand surfaces. Data from schools, extended care facilities, and acute care facili- ties show a reduction in absenteeism and infection rates with increased use of hand sanitizer. While hand sanitizer stations are commonly used in many airports, locations of the stations should be considered fully such that the intended user (e.g., passengers, employees) travel experi- ence is incorporated into the placement of the stations. For example, place stations (and appropriate signage) at check-in counters and immediately after the security line are two locations where passengers come in contact with frequently touched items (e.g., touch- screen kiosks and bins for screening carry-on bags). Hand sanitizers are to be used in addition to, and not to replace, soap and water hand washing. Points to Consider for Implementation 1. Use hand sanitizers that contain at least 60% alcohol, per the recommendation by the Centers for Disease Control and Prevention (CDC). 2. Consider the passenger experience in determining strategic locations for hand sanitizer stations. 3. Ensure highly visual signage near hand sanitizer stations to encourage use. 4. Appoint staff as responsible person or group to maintain stations and ensure adequate supplies of sanitizer product. Airport and Airline Operators Should Consider Using Broad-Spectrum U.S. Environmental Protection Agency (EPA)-Registered Disinfectants Highly Recommended Rationale. Frequently touched surfaces (e.g., railings and chairs) and floors become con- taminated with microorganisms from settling airborne bacteria, by contact with hands, shoes, wheels, and other objects, and occasionally by spills and or splashes of human blood or bodily fluids (e.g., vomit). Studies conducted in healthcare facilities have shown that mopping with soap and water (80% reduction) was less effective in reducing the numbers of bacteria than was a Buildings
Buildings 11 phenolic disinfectant (94%-99.9% reduction). Other studies have shown that with normal use, detergents become contaminated and can increase the bacterial load on multiple surfaces after âcleaning.â Studies also have shown that, in situations where the cleaning procedure failed to eliminate contamination from the surface and the cloth is used to wipe another surface, the contamina- tion is transferred to that surface as well as the hands of the person holding the cloth. The EPA requires that all disinfectants be registered, which includes conducting standardized organism spe- cific efficacy studies. The efficacy study data is submitted to the EPA and used to support claims for disinfection. Substantiated efficacy claim information is available on an EPA website (http://www.epa.gov/oppadOOl/ chemregindex.htm). Studies have shown that products with limited efficacy can lead to increased transfer of microorganisms from one surface to another. Therefore, it is important to ensure the disinfectant products that are used are proven to be effective against the organisms of interest that are transmitted via contaminated surfaces, such as norovirus and influenza. Appropriate disinfectants have been demonstrated to reduce microbial loads. Disinfectants must be used according to manufacturerâs instructions for the intended purpose. To ensure proper use, a standard operating procedure (SOP) should be developed that includes key information such as how to make up working solutions from concentrate, the length of time the working solutions should be used before they lose effectiveness, the contact time for the dis- infectant, and any safety precautions that should be taken when working with the disinfectant. Staff should be trained on the SOP. Points to Consider for Implementation 1. Ensure that broad-spectrum, EPA-registered disinfectants are used for the general cleaning of frequently touched surfaces and floors, even in areas other than bathrooms. 2. Regularly clean and disinfect high-touch surfaces with EPA-registered, intermediate-level disinfectants. 3. Frequency of cleaning should be based on cleaning audits, such as visual assessments. 4. To ensure effectiveness, make certain that disinfectantâs manufacturerâs instructions are followed for preparation (e.g., appropriate dilution) and use (e.g., contact time). 5. During periods of heightened concern for infectious diseases that are transmitted via surfaces (e.g., influenza, norovirus) ensure that the frequency of disinfection on frequently touched surfaces is increased. EPA-Registered Disinfectants In the United States, liquid disinfectants that are used on environmental surfaces are regulated by the US EPA in the Antimicrobials Division, Office of Pesticide Pro- grams, under the authority of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) of 1947, as amended in 1996. Under FIFRA, any substance or mixture of substances intended to prevent, destroy, repel, or mitigate any pest, including microorganisms but excluding those in or on living humans or animals, must be registered before sale or distribution.
12 Infectious Disease Mitigation in Airports and on Aircraft To obtain a registration, a manufacturer must submit to the EPA specific data regarding the safety and the effectiveness of each product. As part of the registra- tion process, manufacturers are required to submit data on microbicidal activity, along with proposed labeling. If EPA concludes a product may be used without caus- ing unreasonable adverse effects, the product and its labeling are given an EPA reg- istration number, and the manufacturer may then sell and distribute the product in the United States. FIFRA requires users of products to follow the labeling directions on each product explicitly. Not following the specified dilution, contact time, method of application, or any other condition of use is considered misuse of the product. Both the EPA and CDC classify disinfectants. While the EPA classifies disinfectants based on the microbiocidal activity claims (e.g., effective against norovirus or Mycobacterium tuberculosis), the US Centers for Disease Control and Prevention (CDC) uses terms such as âlow-levelâ and âhigh-levelâ disinfectants. CDC desig- nates any EPA-registered disinfectant without a tuberculocidal claim (i.e., ability to kill Mycobacterium tuberculosis) as a low-level disinfectant and any EPA- registered disinfectant with a tuberculocidal claim as an intermediate-level dis- infectant. A general guide is included below, but as a rule, manufacturerâs label claims and instructions should always be followed. More information, including lists of EPA-registered disinfectants and their labels, can be found at http://www. epa.gov/oppad001/chemregindex.htm Organism Processing Level Required Bacterial spores FDA sterilant/high-level disinfectant Geobacillus stearothermophilus (= CDC sterilant/high-level disinfectant) Bacillus atrophaeus Mycobacteria Mycobacterium tuberculosis Nonlipid or small viruses Polio virus Coxsackie virus Rhinovirus Fungi Aspergillus Candida Vegetative bacteria Staphylococcus species Pseudomonus species Salmonella species Lipid or medium-sized viruses Human immunodeficiency virus Herpes simplex virus Hepatitis B and hepatitis C Coronavirus EPA hospital disinfectant with Tuberculocidal claim (= CDC intermediate-level disinfectant) EPA hospital disinfectant (= CDC low-level disinfectant) Airport Operators Should Consider Ensuring That Biohazard Kits Are Available to Employees in Airport Terminals Highly Recommended Rationale. Infectious diseases, such as norovirus, can be transmitted through vomit. Bloodborne pathogens like hepatitis and HIV can be transmitted through contact of broken skin with contaminated blood. Workers who encounter any biological fluid, including phlegm,
Buildings 13 blood, and vomit, do not know if it came from a con- tagious person and should therefore treat the fluid as potentially infectious. It is important to minimize the risk of transmitting infectious diseases through bodily fluids by donning appropriate personal protective equipment and promptly and effectively cleaning and disinfecting the area following a release. Case reports have demonstrated that inadequate responses to pas- sengers who have vomited can result in transmission of infectious illnesses to others in the area. Any person- nel involved with cleaning/disinfecting areas should be properly trained (including training on how to report an occupational bloodborne pathogen exposure event and obtain immediate medical evaluation) and equipped with appropriate personal protective equip- ment to ensure their safety. Points to Consider for Implementation 1. Biohazard kits should be available throughout the airport to ensure a timely response to a release. 2. Biohazard kits should include: gloves, face shield, biohazard bags, towels or other absorbent material, disposable scoops, disinfectant, training materials (or short step by step guide for cleaning up vomit and other bodily fluids). 3. Ensure disinfectant in biohazard kit has a long shelf life. 4. Designated personnel who perform cleaning of bodily fluids should be trained on blood- borne pathogens and cleaning procedures on an annual basis. 5. Ensure that training includes all required elements of U.S. Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, including how to report an expo- sure event and obtain a medical evaluation. 6. Airport procedures for disposal of waste containing bloodborne pathogens should include typical and atypical quantities. Biohazard Kit All biological fluids (for example: phlegm, blood, vomit) should be treated as potentially infectious. Biohazard kits are convenient clean up kits, allowing for quick action in an event where bodily fluids have been released from a sick passenger or employee. Kits include: â¢ Alcohol towelettes â¢ Gloves â¢ Disposable scoops â¢ Aprons â¢ Masks â¢ Surface disinfectant spray bottles â¢ Towels/Other absorbent material â¢ Sharps containers â¢ Thermometer â¢ Face shield â¢ Biohazard bag When properly trained, flight attendants and airport staff can respond to situations where biological fluids need to be cleaned from surfaces while keeping both themselves and travelers safe from infectious diseases and limiting the possibility of sustained transmission or cross-contamination of other areas.
14 Infectious Disease Mitigation in Airports and on Aircraft Airport Operators Should Consider Increasing the Use of Hands-Free Bathroom Appliances and Transaction Tools Recommended Rationale. Many infectious diseases are transmit- ted via contact with contaminated surfaces. Surfaces that are frequently touched by a large number of indi- viduals are most likely to be contaminated. Examples of high-touch surfaces in bathrooms include door handles, faucets, toilets, urinals, and soap dispensers. Other examples of high-touch surfaces include ticket- ing kiosks and counter tops. Minimizing high-touch surfaces will reduce the risk of exposure to infectious microorganisms. Points to Consider for Implementation 1. Incorporate hands-free appliances, such as toilets, soap dispensers, paper towel dispensers, faucets and hand dryers, into design requirements for new construction and renovations of bathroom facilities. 2. Expand and encourage the use of mobile devices for ticketing and printing ticketing outside the airport to avoid touching ticketing kiosks. Airport Facility Personnel Should Consider Ensuring That Their Buildings and Building Modification Projects Include Commissioning Activities to Ensure That the HVAC Systems Serving the Space Are Operated Appropriately and Provide All of the Benefits of Proper Building Design Such as Pressurization, Air Filtration, Outdoor Air Ventilation, and Air Circulation Recommended Rationale. Among other things, the airportâs mech- anical systems control filtration and ventilation, two important indoor environmental parameters that can influence disease transmission. In addition, a properly commissioned building HVAC system ensures that the system that is designed, installed, and operated in the building is functioning properly, which provides many collateral benefits, including: (1) the build- ing will be properly pressurized; (2) the air supplied by the HVAC system to the occupied space is from an air intake location that has been chosen to minimize introduction of outdoor pollut- ant sources, and has passed through the HVAC system filters, dehumidification coils, and other components; (3) the HVAC systemâs economizer cycle will supply more than the code required minimum amount of outdoor air when outdoor air thermal conditions allow it; and (4) the HVAC systems will operate in an energy efficient manner while maintaining thermal comfort for the building occupants.
Buildings 15 Points to Consider for Implementation 1. VentilationâThe goal is to ensure that the HVAC systemâs supply air is (a) sufficient in volume to effectively dilute the concentration of generated aerosols, and (b) efficiently mixed in the occupied zones of the building to minimize the extent to which indoor air pollutants, includ- ing bacteria and viruses, concentrate in localized areas of the building. This is particularly important in high-density, low-volume areas (e.g., security screening queues). 2. FiltrationâMany filters are capable of capturing airborne bacteria and viruses. Effective design, review and commissioning of the systems will increase the overall performance of the system as a whole, including the effective filtration. If Commissioning Is Not Performed, Airport Operators Should Consider Evaluating Their Facilities to Ensure That High-Occupant Density Areas Meet Minimum Ventilation Requirements Recommended Rationale. Ventilation is an important determinant of exposure to airborne pollutants, including bacteria and viruses. A facility in which all occupied areas meet current ventilation codes and guidelines better assures that the air quality is maintained in the space. Areas that are not meeting these guidelines may have amplified risk for airborne pathogen transmission. Changes in security procedures may have impacted the locations and densi- ties of high-occupant areas in the airport. These current high-density areas may not have existed at the time the facility was first opened. Points to Consider for Implementation 1. Conduct a design review to assess the ventilation of the facility as it is currently operating, making note of high-density locations such as security screening areas. 2. An occupant-generated tracer such as carbon dioxide (CO) may provide a useful indicator of the ability of high-density areas to meet appropriate ventilation guidelines. 3. For those areas that do not meet the code required ventilation guidelines, adjustments should be made to the minimum outdoor air flow rates; the ventilation air distribution system; the ventilation system operating sequence (i.e., consideration of demand control ventilation); or some combination of all of these. An architect and engineer may be required to design the appropriate changes and adjustments. If Commissioning Is Not Performed, Airport Operators Should Consider Evaluating Their Facilities to Ensure That the Filters Installed in HVAC Systems Are Appropriately Maintained Recommended Rationale. Filtration can be an effective means of controlling airborne pollutants, including bacteria and viruses. Proper maintenance of HVAC air filtration systems in a building can provide significant benefits to the building owner in terms of improved indoor air quality for building occupants and reduced maintenance. Filters that are not appropriately maintained can become excessively resistant to airflow, which will reduce air flow performance of the HVAC system. This will reduce the systemâs ability to heat, cool, de-humidify, ventilate and properly mix air in the
16 Infectious Disease Mitigation in Airports and on Aircraft occupied space. Filters that are severely clogged can collapse, causing air to bypass the filter. During the col- lapse, the filter can release materials that were collected on the filter into the airstream, which can then be dis- tributed onto the components downstream of the filter in the HVAC system and possibly be delivered into the occupied space. Points to Consider for Implementation 1. Use the filter with the highest MERV rating that does not create unacceptable pressure drop in the system. 2. Ensure the filters are changed based on either a reg- ular schedule or on a measured maximum pressure drop. 3. Facility personnel should incorporate the inspec- tion and maintenance of the filters into the regularly scheduled maintenance program. Filters and other equipment should be inspected according to manu- facturerâs instructions or more frequently if deemed to be appropriate by the facility or carrier. Airport Operators Should Consider Using HEPA-Filtered Vacuums When Cleaning Carpets and Upholstery Suggested Rationale. Typical vacuums have been shown to not only collect, but to also aerosolize large amounts of surface dust, which may contain infectious microorgan- isms or more commonly, allergens, such as fungal spores. The regular use of vacuums in good repair and that are equipped with HEPA filters will minimize secondary dust dispersion. Points to Consider for Implementation 1. Ensure that the use of HEPA-filtered vacuums is specified in contracts with organizations responsible for cleaning airport waiting areas and other carpeted areas used by passengers and guests. Airline Operators Should Consider Working Together to Implement Standardized Cleaning and Disinfecting Practices Within the Airport Suggested Rationale. Multiple groups may be responsible for cleaning various locations within an airport. For example, the airport operations may be responsible for the cleaning contractor that cleans general areas
Buildings 17 of the terminal (such as the waiting areas); the airlines may be responsible for cleaning at the check-in areas including kiosks; while a third group may be responsible for cleaning at food service areas. This may lead to a lack of consistency in cleaning and disinfecting practices between areas in an airport. Points to Consider for Implementation 1. Convene a working group of representatives from organizations responsible for cleaning and disinfecting to review cleaning practices and areas cleaned. 2. Coordinate cleaning with appropriate cleaning/disinfecting products to enhance overall dis- infection at airports. 3. Perform a coordinated and detailed review to ensure that all high-touch surfaces are included in the appropriate responsible partyâs inventory of areas to clean. Airport and Airline Operators Should Consider Implementing Cleaning Audits to Validate That Cleaning and Disinfection Protocols Are Effective at Reducing Bacteria/Loads on High-Touch Surfaces Suggested Rationale. Cleanliness of high-touch surfaces, such as airport bathrooms, is typically assessed visually. While visual assessment audits are important to ensure clean- ing is performed adequately and at sufficient frequency, healthcare based studies have shown that visual assess- ments are not good indicators of microbial contami- nation. Additional studies have shown that infectious microorganisms can be detected on visibly clean surfaces following the use of detergent based clean- ers. Alternative methods to visual assessments, such as microbial sampling and bioluminescence testing, which is used in the food preparation industry, have been used to assess the efficacy of cleaning protocols. The use of microbial sampling and/or bioluminescence testing to evaluate the disinfection of high-contact sur- faces would reduce risk of exposure to infectious organisms by ensuring effective cleaning has been performed. Points to Consider for Implementation 1. Conduct systematic, unannounced audits to assess cleaning group performance. 2. Explore the possibility of the use of limited microbial sampling and/or bioluminescence test- ing to supplement visual assessments with groups responsible for cleaning/disinfecting. Airport Operators Should Consider Conducting an Analysis of Their Passenger Data to Identify Potential High-Risk Time Periods and Locations Suggested Rationale. A prudent first step in attempting to mitigate disease transmission in airports is to determine the populations and micro-environments at risk. Once established, the next step needs to be an analysis of temporal patterns to determine time periods of potential higher risk. This Expert Committee has performed the first step by defining at risk populations and
18 Infectious Disease Mitigation in Airports and on Aircraft micro-environments that are generalizable to most, if not all, airport environments. The temporal component, however, is not generalizable and is therefore the respon- sibility of each airport operator. By identifying time periods of maximum passenger densities, airport operators can target mitigation efforts to these time periods. Maximum passenger loads will also likely vary by terminal type (e.g., international v. domestic); airport location (e.g., east cost v. west coast); time of day; and week of year due to regional events (e.g., NASCAR event, Disneyworld during winter break). Points to Consider for Implementation 1. Evaluate location-specific flight data (i.e., terminals) to identify highest density areas by time (day of week, time of day, week of year). 2. Align cleaning frequency with passenger density. Airport Operators Should Consider Installing and Operating Upper-Room 254 Nm (UVC) Light to Minimize Transmission of Aerosol-Transmitted Microorganisms in High-Risk Locations Throughout the Airport Suggested Rationale. Air disinfection using upper-room 254 nm (UVC) light can lower the airborne concentra- tions of microorganisms in the lower part of the room, and thereby control the spread of airborne infections among room occupants without exposing occupants to a significant amount of UVC. Upper-room UVC may be an effective option for high-risk locations, such as quarantine or isolation areas, and other high-density queuing areas, where high-filtration HVAC systems may not be an option. This can also be implemented during high-risk time periods (e.g., pandemics) for infectious diseases that are transmitted through inha- lation of aerosols. UVC fixtures must be installed properly to ensure that the UVC exposure risk from upper-room fixtures to airport guests and workers is minimal. Points to Consider for Implementation 1. UVC is only effective for microorganisms that are transmitted exclusively or predominately through the airborne route, such as Mycobacterium tuberculosis. 2. UVC requires dedicated, specialized resources to monitor lower-room UVC levels and chang- ing and cleaning lamps. Additionally, training is required for all staff that are anticipated to need access to equipment in the upper-room to prevent occupational exposures. 3. UVC can be implemented in high-risk locations (e.g., isolation rooms) and/or during high- risk time periods (e.g., pandemics). 4. Each facility must make its own determination as to its utility and cost effectiveness.