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82 By Airports General Lessons â¢ You can never be prepared enough owing to the unique circumstance surrounding each passenger. â¢ Advanced notificationâcritical for smooth response. â¢ Everything takes longer than anticipated. â¢ Build relationships in advance. â¢ Respect and use the expertise of CDC/PHAC and CBP/CBSA as well as local health departments. â¢ Early understanding of potential risk is essential, with adjustment to plan implementation to fit actual risks. â¢ Pre-arrival information is suspect and must be verified in person by a competent responder. Accurate notification of a communicable disease hazard is not often received before the aircraft is already parked at the terminal building. â¢ If time allows, ensure that all the key pieces of information about the patient have been put together to formulate the most effective response once the aircraft lands. It is possible to link your local Fire/EMT with MedLink while the aircraft is still airborne to discuss the medical condition. â¢ Contain the incidentâminimize the area of the airport affected. â¢ Public health experts can do onboard evaluation, detention, and isolation of ill passenger. â¢ The airport needs to manage the expectations of the public health responders. â¢ Donât rush into the situation. Timing â¢ Engage all agencies before aircraft arrival and have appropriate staff waiting to act. â¢ The timeliness of testing and who is in charge always is a problem. â¢ The time of day and day of week of the flightâs arrival matter because of staff availability. Planning â¢ Having a solid, tested plan is essential. â¢ Stakeholder input to planning is essential. â¢ A good plan should be flexible and scalableânot all communicable disease incidents require the maximum response. â¢ Planning is key to safety. â¢ Review of the plan revealed a strong plan toward treatment but was weak in quarantine, specifi- cally if control of passengers was weak. â¢ Plan should be at least evaluated annually. Roles and Responsibilities â¢ Stakeholder familiarity with their responsibilities in the Plan is vital. â¢ Get to know your local EMS director and public health BEFORE an incident. They are an invaluable resourceâthis included their media relations team. â¢ Overall pre-planning and the identification of responsibilities among agencies is essential. â¢ Let the health department do their job. Legal Issues â¢ Know the airportâs legal authority. â¢ Everyoneâs understanding of quarantine issues is different and the fact that an airport cannot quar- antine a flight or detain anyone. â¢ Quarantine/Use of force issues. Coordination â¢ Interagency coordination is 100% necessary. â¢ In real incidents, airports, agencies, and organizations work extremely well together. â¢ Resolve jurisdictional concerns in advance (during planning process). â¢ Understanding roles and responsibilities of the various local, state and federal agencies to determine which agency serves as lead agency in incident command. â¢ Each agency involved needs to predesignate a point of contact and share the information among the group of potential responders. â¢ Any issue that may impact business continuity of the day will require EOC activation. Appendix e Lessons Learned as Stated by Airports and Local Health departments
83 Communication â¢ Accurate, open, and timely communication among partners is essential for the effectiveness of the response. â¢ Poor communication between agencies often happens. â¢ Ensure that airport has notification center that spans all agencies involved. â¢ Include airlines at airport in communications. â¢ Follow up with airlines. â¢ Contact lists and relationships must be kept up to date. Security â¢ Include need for law enforcement in all stages of planning, response, and recovery. â¢ Quarantine areas that are post-security could pose a SIDA issue (bringing passenger through secure doors without proper credentialing). â¢ Escort procedures for department of health employees need to be outlined ahead of time to ensure access to ill passenger on plane or at gate area. â¢ Arrange police department escorts for a non-stop transport to the destination hospital. Training, Drilling, and Exercising â¢ An effective joint training program is essential. â¢ You should practice with your mutual aid responders. â¢ Drilling at least annually is helpful, especially given staff turnover and differing skill levels. Managing the Media â¢ Airport media experts need to be involved in plan development. â¢ Airport media experts must be kept fully informed as an incident evolves. â¢ If the EOC is activated, the unified command needs to include the health department and needs the services of a joint information center (JIC). â¢ When dealing with non-medical or non-public safety, use clear plain language and anticipate deeper explanations will be needed. â¢ There is a need to work closer with Local Public Health agencies to discuss how to disseminate information effectively upon notification of potential CD contact. â¢ Control media, public perception of safety concern with patient on airport property. Notification of Ill Passenger on Arriving Flight â¢ Procedures of notification to smaller airports and of passengers who become ill on domestic flights are uncertain. â¢ Broken itinerary can greatly complicate learning information concerning incoming ill patientâs point of origin. Managing Aircraft on Ground â¢ Decisions can be made if aircraft will be allowed to bridge at terminal or off terminal based on risk assessment of flight. â¢ Park aircraft remotely, ideally out of view of public and media. â¢ Have emergency vehicles on standby before aircraft arrives. â¢ There is a lot of misinformation and assumptions about communicable diseaseâpassengers want information. Ensure you have someone prepared to provide basic information about what is happen- ing and what the passengers can expect. Resources â¢ Logistical and facilities planning. â¢ Make provision for additional funding that may be needed. â¢ Have a facility large enough to hold people for a long period with restrooms, water, and ability to provide food. â¢ Request necessary resources before needed. Disinfection and Cleaning â¢ Treat all body fluid like it is infectious. â¢ Clean/disinfect exposed areas and dispose of waste as recommended/required. Protecting Airport Workers â¢ Provide PPE for airport employees and train them how to use PPE. â¢ Be sure to take care of the care givers.
84 Psychological Concerns â¢ Use of PPE can heighten anxieties among passengers. â¢ Over-reaction or reduced reaction of staff. â¢ Difficulties of dealing with uncertainty (Is disease actually present? What disease is it? Have other passengers been exposed?). â¢ When the threat is heavily in the public consciousness, almost any illness or any anomalous physical condition can be reported as that threat. Business Impact to Airport â¢ Consider business impact to airport. â¢ Airport business partners (e.g., tenants and concessionaires) need information, too. By Health Departments The health department survey asked two separate questions about top three lessons learned, one about planning and one about actual responses. The responses overlapped, so they have been consolidated in this section. General Lessons â¢ It takes the full spectrum of stakeholders to effectively respond to an incident with a highly infec- tious disease with high number of potential exposures. â¢ Itâs complicatedâlots of players, multiple priorities, and considerations. â¢ Itâs politicalâhigh visibility. â¢ It is sometimes difficult to work alongside elected officials. â¢ Itâs difficult to get the needed players to the table. â¢ Evaluation is most effectively done on board the aircraft. Everyone on board remains seated until the assessment is fully conducted and personnel reassure/communicate to the travelers if need be. â¢ Gathering and validating information is crucial. â¢ Information provided by passengers may be inaccurate. â¢ Donât assume that everyone understands the basics of communicable disease control. â¢ The gaps in authority and procedures for handling communicable disease on international flights and on domestic flights are a major complicating factor for planning and response. â¢ You need to build relationships with your partners in advance. â¢ Effective responses are personality and relationship-dependent. â¢ Difficulty in obtaining flight manifests to conduct contact investigations. â¢ Airlines destroy their flight manifests very quickly which makes identification of passengers on the plane difficult to impossible unless the request for the manifest to be retained can be made immediately. â¢ Although time frame is essential, safety is more essential. â¢ Having a real incident can motivate airport, LHD, and other stakeholders to improve collaboration, communication, planning, and mutual understanding. Timing â¢ Challenges occur when Quarantine Officer is not on site. Planning â¢ Stakeholder involvement is critical to developing a coordinated plan. â¢ All stakeholders need to participate. â¢ Planning team needs to be more robust with multiple partners than previously anticipated. â¢ It is difficult to coordinate planning among various stakeholders. â¢ The planning process is necessarily long: be patient, the results are worth it. â¢ Plan should be flexible: plans will only take you so far before improvisation will be necessary. â¢ The return on investment for too much detail [in a plan] is difficult to make. â¢ Having an identified hospital/emergency room that is going to be responsible for receiving individu- als identified as potentially infected as part of the plan is crucial. â¢ Health department plans need to track changing business of airport, especially if number of inter- national flights and points of origin are increasing. â¢ Sharing plans at each agency and ensuring coordination within all documented plans. â¢ Airport and LHD plans need to be cross walked to ensure agencies are aware of each otherâs plans, roles and responsibilities and expectations clearly defined. â¢ Generating participation by airlines in planning can be challenging. â¢ Help airport to include diseases in its risk assessment. â¢ Critical to have plan for transport from airport to hospital. â¢ Media involvement/presence can complicate planning meetings. â¢ Discuss concerns associated with transportation of confirmed or suspected cases.
85 â¢ In the planning, it is important that each partner know their roles so when called to respond they are familiar with the actions they should take and help put into the plan. â¢ Smaller industrial airports are very different and we do not plan with them regularly on communi- cable diseases. Roles and Responsibilities â¢ Knowledge of the needs, capabilities, and limitations of your partners is essential. â¢ Collaborate with regional, state, and other local health departments, and CDC/PHAC partners. â¢ CDC/PHAC Quarantine Stations and Officers are major resource for local health departments. â¢ Airport operations vs. public health response needs. â¢ Partners understand roles and responsibilities as a result of improved communications and training. â¢ Opportunity to better differentiate the LHD and Quarantine Station roles and responsibilities in a response. Legal Issues â¢ Challenge with domestic versus international flights and jurisdictional authority is unclear. â¢ Legal issues are barriers. â¢ There are complex matters with jurisdiction and authority. â¢ Many different regulations (federal, airline, port, first responder) come together at an airport. â¢ Airport has certain federal regulations they must operate within that [health agencies] need to account for. â¢ Challenges with quarantine of passengers, locations, duration, issuing orders, providing basic needs for prolonged holding. â¢ Review existing guidelines and determine if additional information can be shared with area hospitals. â¢ Multi-jurisdiction response. â¢ Legal aspects of integration with other agencies. Coordination â¢ Know all of your community partners, public and private. â¢ Clearly identify the lead agency. â¢ Effective integration into Airport EOC is essential. â¢ Create a committee around the plan to keep the plan current and ensure it is regularly exercised. â¢ A response makes it even more complicatedâeveryone wants a say. Authority must be established and channels followed. â¢ When services are provided on a contracted basis, coordination is complicated. â¢ Generating interest by airport officials in public health issues is challenging. â¢ More coordination and collaboration is necessary to ensure LHD has information necessary to sup- port airport response and disease containment. â¢ Critical to understand chains of communication at airport ahead of time. â¢ Lack of LHD involvement with national agency (CDC/PHAC). â¢ LHD needs better tools, information sources and airline, airport assistance to be able to monitor traveler data to identify plan triggers and to prepare/prevent CD transmission. â¢ Last minute requests to participate cause undue confusion. Communication â¢ Communication with our partners is very important and can mitigate many challenges, including anxiety if all on the ground are well versed with information and the plan of action as we usually are first to board the conveyance. â¢ Contacting the right people early on in the response. â¢ Have a conference call early on for situational awareness and to clarify roles and responsibilities. â¢ Critical to understand required notifications at each agency or organization involved. â¢ Defining triggers for when [local] public health should be notified by the airport. â¢ Airlines have to be made aware of what communicable diseases are circulating in domestic and international flight areas. â¢ Prompt communication of the health decision to the airline, the airport, and other required partners is essential. â¢ Process for communication amongst key partners in planning/response. â¢ Identification of specific individuals responsible for communication between the various federal, state/provincial and municipal stakeholders is crucial for timely and effective management of the situation. â¢ Communication with Headquarters is vital in case information is sent to them by different sources. â¢ Social media nowadays make communications portion of communicable disease plan very important. â¢ Maintain up-to-date contact lists. â¢ Notification of ill persons on aircraft doesnât always follow the identified communication channels. â¢ Compatibility of personal (carried) communications device can be an issue during a response.
86 Security â¢ Transportation security agencies and procedures may delay access of public health officials and medical responders to patient on plane or in secure area; these need to be resolved in advance. â¢ Security concerns and access to the facility will be challenging, particularly with surge staffing that may be identified at the time of the event. Training, Drilling, and Exercising â¢ A plan that is never exercised is not useful because partners forget. â¢ Ensure prior to response everyone is well versed with the plan so that during response we have one channel of communication with all stakeholders including with the traveler. â¢ TTX, drills and training help develop, socialize, and refine plans and procedures, and build trust among responding agencies. â¢ There are limited opportunities to exercise for these events as frequently as we would like. â¢ Have a joint exercise plan. â¢ Jointly exercise communicable disease response plan annually. â¢ Joint airport and LHD training and exercises necessary using biological agent scenario. Consider for future triennial airport exercises or tabletop exercises. Managing the Media â¢ Clear communication to the public is needed. â¢ Manage communications with the public if possible before the event or else be as transparent as possible. â¢ Make sure there are clear plans for communication with the public. Resources â¢ Additional resources are needed for responding to communicable disease on arriving flights. â¢ No ear-marked funding for response. â¢ Funding is limited. â¢ Identifying and rostering surge staffing for quickly moving events may be problematic in the face of staffing cuts. â¢ Pre-identify resources to be used. â¢ Challenges with quarantine of passengers, locations, duration, issuing orders, providing basic needs for prolonged holding. â¢ Space to screen/triage/quarantine large numbers of passengers on airport grounds is limited. â¢ Airport resources are limited space-wise for quarantine and private interviews. â¢ Not having a quarantine location at the airport creates a major problem. â¢ Access to CDC resources may be limited or slow. â¢ Industrial airports have a reduced capacity to manage and respond to a CD event, need outside help. (Note: An industrial airport can be a general aviation airport that has an aircraft factory or mainte- nance facility but no passenger service.) â¢ Staff/labor intensive because it requires disruption of daily activities. â¢ Quarantine Station has limited capacity/capabilities Protecting Health Workers â¢ Protection of responders is essential. â¢ Discuss decontamination faced by first responders, public health, and medical care professionals in pre-hospital environment. â¢ Proper PPE is essential. Psychological Concerns â¢ Mental health counselors should be there waiting for the passengers. â¢ Providing information can reduce anxiety. â¢ It is important to keep passengers on arriving flight calm. â¢ Explaining to passengers why questions are being asked can reduce anxiety. â¢ Education and time with individual travelers is needed, which is culturally sensitive to various lan- guages and customs. Business Impacts â¢ Working with airlines can be challenging because of different business practices.