Preparing Airports for Communicable Diseases on Arriving Flights (2017)

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4 chapter two Air TrAvel And CommuniCAble diseAses I view the threat of deadly pandemics right up there with nuclear war and climate change. Innovation, cooperation, and careful planning can dramatically mitigate the risks presented by each of these threats. Bill Gates, address to Munich Security Conference, February 18, 2017 The first major global health threat in which modern transportation played a large role was the Spanish influenza pandemic of 1918, which sickened 30% of the world’s population and killed between 50 and 100 million people (Rodrigue et al. 2017). In that pandemic, travel by steamship and rail, not air, accelerated the spread of disease. Despite concerns that air travel would spread influenza and other illnesses, it was not until the outbreak of SARS in 2003 that a pandemic realistically threatened to spread quickly by global air travel. SARS spread through air passengers who traveled from China to Singapore, Taiwan, Vietnam, and Canada. By the time the outbreak had been contained, 774 people had died, and more than 8,000 had been infected worldwide. The global transmission of SARS illustrates several aspects of air travel that make it a special challenge for managing disease spread. 1. Air transportation compresses time and space, connecting nearly all points of the globe to every other point. 2. Modern aircraft move faster than the incubation time of many diseases, especially flu variants, and therefore can accelerate disease transmission (Rodrigue et al. 2017). 3. The global air transportation system can quickly be shut down in whole or part. Airline passengers tend to be highly risk averse and will voluntarily avoid flights during serious out- breaks (Rodrigue et al. 2017). A rapidly spreading disease not only puts travelers at risk but also can spread to their families and others in their workplaces and communities, employees at airlines and airports, first responders, and employees of medical facilities and ambulance services. Such spread of a severe illness or a pandemic can cause disruptions that cascade throughout society and lead to significant economic loss and political instability. For example, it is estimated that SARS cost the Canadian economy $722 mil- lion between 2003 and 2006 (CBC News 2003). In the worst case, the spreading disease becomes an epidemic in society at large. International public health efforts, especially those dealing with air travel and communicable disease, are intensive and collaborative. In this section, key documents are grouped by purpose and described briefly. Full bibliographic information for retrieving each document is given in the References list. diseAses of PubliC HeAlTH signifiCAnCe Public health agencies at all levels of government within countries and internationally focus on pre- paring for and responding to communicable disease threats. Diseases that can be spread by passengers traveling on aircraft pose unique challenges and get special attention. Before the SARS epidemic, the focus was on lists of specific diseases, but partly in response to a new risk from a novel disease, the focus has shifted to diseases with certain characteristics. This shift in emphasis has been reflected in the primary guidance documents of the World Health Organization (WHO) International Health Regulations 2005, the 2014 revision of U.S. Presidential Executive Order 13295 (White House 2014),

5 and the Canadian Quarantine Act (2005). Appendix A to this report contains the current (February 2017) lists of diseases of public health significance for Canada, the United States, and the world (as determined by WHO). An international resource that is applied at the level of a nation state is the Joint External Evalu- ation (JEE) Tool, the purpose of which is to “assess country capacity to prevent, detect, and rapidly respond to public health threats independently of whether they are naturally occurring, deliberate, or accidental” (WHO 2016). JEE looks at a country’s overall preparedness to deal with health threats but includes all points of entry. It is not airport specific. risk Assessment for Communicable diseases Transmitted on Aircraft The European Centre for Disease Prevention and Control (ECDC) Risk Assessment Guidelines for Infectious Diseases Transmitted on Aircraft (2009) provides guidance for public health agencies, airlines, and potentially airports (A. Khan, personal communication, January 23, 2017). A related resource is the ECDC web page “Infectious Diseases on Aircraft” (ECDC 2017). notification Procedures and Air Traffic Control roles The International Health Regulations (WHO 2005) represent the commitment of more than 200 nations to reporting certain communicable diseases when specified criteria are met. ICAO Document 4444, which states and disseminates procedures for air navigation services and air traffic manage- ment, spells out the requirements for the pilot of an international flight to notify air traffic control en route of suspected communicable diseases or other public health risk on board an aircraft (ICAO 2007, Para. 16.6). Paragraph 16.6 of Document 4444 is reproduced as Appendix B of this synthesis. Paragraph 16.6.3 gives three pathways by which the information is supposed to reach the destina- tion airport: 1. From the air traffic services (ATS) unit to the public health authority (or appropriate authority designated by the country), and through established pathways through health agencies to the airport. 2. From the ATS unit to the aircraft operator (or the operator’s designated representative), and to the airport. 3. From the ATS unit directly to the destination airport. The parallel U.S. guidance is the Memorandum of Agreement (MOA) between FAA and the Centers for Disease Control and Prevention (CDC) (FAA and CDC 2010) that assures that those two key agencies cooperate to relay notifications of reports that they receive of deaths, suspected cases of communicable disease, or other public health risks, on board aircraft and to establish other actions that the Parties agree to take to prepare for and respond to contingencies involving deaths, suspected cases of communicable disease, or other public health risks, on board aircraft. The MOA not only establishes the mechanism for U.S. compliance with Document 4444 but also sets up the procedures and notification pathways for communicable disease and public health risk notifications involving passengers on domestic flights within the United States. In response to the Ebola crisis of 2014–2015, the Department of Homeland Security (DHS) Customs and Border Protection (CBP) overrode the procedures in the FAA–CDC MOA to change screening of passengers arriving from, traveling to, or passing through Ebola-stricken countries. This document announced the decision of the commissioner of CBP to direct all flights to the United States carrying persons who had recently traveled to, from, or through Ebola-stricken countries to arrive at one of five U.S. airports where CBP implemented enhanced screening procedures (19 CFR Part 122, Air Commerce Regulations, October 23, 2014).

6 In 2016, Canada, Mexico, and the United States adopted the Communicable Disease and Public Health Risk Air Traffic Operational Response Concept of Operations (Trilateral CONOPS), which refines the notification and air traffic management provisions of Document 4444 to create a coopera- tive, coordinated system to handle a flight with a suspected communicable disease aboard. Ideally, an airport and its airline and public health partners will learn in advance of a sick passenger on an incoming flight. In addition, the guidance allows for aircraft operators (e.g., airlines) to have designated representa- tives to deal with health issues. The role of designated health representatives for airlines is examined in detail in the Dallas/Fort Worth International Airport case example in chapter four. Airport and public health agency experts who deal with emergency medical services (EMS) note that despite notifications through these pathways, EMS responders often do not know whether the situation they will encounter will be worse, better, something different, or nothing at all (CAPSCA Panel Atlanta August 2016; F. Broom, personal communication, January 23, 2017). The survey results presented in chapter three and case examples in chapter four allow consider- ation of how these pathways operate in practice. isolation and Quarantine Procedures Isolation and quarantine are not the same thing. This distinction is critical in planning effective response to communicable disease at an airport. Isolation and quarantine help protect the public by preventing exposure to people who have or may have a contagious disease. Isolation separates sick people with a contagious disease from those who are not sick, whereas quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick (CDC 2017). In the United States and Canada, quarantine stations, located at ports of entry and land border crossings, can work with their partners, using isolation and quarantine among other public health practices as part of a comprehensive strategy that serves to limit the introduction of infectious dis- eases into the countries and prevent their spread [Public Health Agency of Canada (PHAC) 2015a; 82 CFR §6890 2017; CDC 2017]. The primary international guidance regarding isolation and quarantine in airports is Paragraph 8.15 of Annex 9 (Facilitation) of the Convention on International Civil Aviation (Chicago Convention) (ICAO 2006). Canada’s Quarantine Act (2005) and the Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector provide guidance specific to Canada (PHAC 2015b). For the United States, the primary guidance document is Presidential Executive Order 13295, “Revised List of Quarantinable Communicable Diseases” (White House 2014). During the 2014–2015 Ebola outbreak, CDC instituted enhanced Ebola screening that required all passengers from Ebola-affected countries to enter the United States at one of five designated air- ports at which special staffing, training, equipment, and facilities had been established (CDC 2014). The effectiveness of this designated-airport-of-entry procedure has not been evaluated for future applicability. Isolation and quarantine put spatial, operational, and logistical demands on airports. Stambaugh et al. (2008) examined these demands in ACRP Report 5. Federal authorities balance the need to protect the public’s health with safeguarding people’s civil liberties and when appropriate use less-restrictive tools, such as the conditional release of pas- sengers. This shifts considerable responsibility onto the passengers and local health departments.

7 Airport and Airline roles TRB convened two conferences that addressed agency–aviation industry collaboration to plan for pandemic outbreaks, the first in 2007 and the second, which dealt with the transmission of diseases in airports and aircraft, in 2009 (Turnbull 2008; Gerencher 2010). The scope and purpose of the first conference are stated in the preface to “TRB Conference Proceedings 41”: In September 2007, approximately 70 people assembled in Washington, D.C., to participate in a workshop on Interagency–Aviation Industry Collaboration on Planning for Pandemic Outbreaks. The conference brought together individuals involved in planning and responding to pandemic events—from both the public sector (federal agencies and state and local agencies, including public airports) and the private sector (airlines and consultants with expertise in various facets of aviation). The workshop goals were to examine (a) the action items included in the section on Transportation and Borders in the May 2006 National Pandemic Plan that directly or indirectly affect air transportation, (b) the current state of the practice for pandemic planning by airports and airlines, (c) coordination among various agencies and the aviation sector to implement these plans, and (d) potential areas for public–private sector cooperation in pandemic planning (Turnbull, 2008, p. 1). The scope and purpose of the 2009 conference are stated in the preface to “TRB Conference Proceedings 47”: In September 2009, about 100 people assembled in Washington, D.C., to participate in a symposium on research on the transmission of disease in airports and on aircraft. The symposium brought together individuals from the public sector (federal, state, and local agencies including public airports), private sector (airlines and consultants with expertise in various facets of airport emergency response), and research institutions to learn about current research and to consider ways to conduct and fund future research. The symposium goals were to examine (a) the status of research on or related to the transmission of disease on aircraft and in airports, (b) the potential application of research results to the development of protocols and standards for managing communicable disease incidents in an aviation setting, and (c) areas where addi- tional research is needed. To plan the event, TRB assembled a committee appointed by the National Research Council (NRC) to organize and develop the symposium program. The planning committee was chaired by Katherine B. Andrus, Air Transport Association of America, Inc. The symposium program was designed to provide an opportunity for the aviation community to share data, models, and methods; discuss findings and preliminary conclusions of ongoing research; and identify gaps to inform future research projects. During the symposium, consecutive sessions were organized according to dif- ferent approaches to research as identified by the planning committee. These approaches included case study investigations, theoretical modeling, and “bench science” experimental methods. A session discussing different approaches to policies and planning to minimize the spread of disease along with an open dialog among all attendees on candidate topics for future research was also conducted. This summary report contains white papers, authored by the invited speakers to each session, that summarize the presentations they gave during the symposium. It includes a summary of the discussion of topics for future research. The planning committee was solely responsible for organizing the symposium, identifying topics, and choosing speakers. The responsibility for the published symposium summary rests with the symposium rapporteur and the institution (Gerencher 2010, p. 1). ACI and ICAO (2009) published Airport Preparedness Guidelines for Outbreaks of Communicable Disease, which is a comprehensive planning guide for airport communicable disease preparedness. The airport-specific resource that resembles JEE is the Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation (CAPSCA) State and Airport Assistance Visit. CAPSCA is a partnership led by ICAO with participation by nine other United Nations agen- cies, including WHO, CDC, the International Air Transport Association, the International Federation of Air Line Pilots’ Associations, and ACI. The mission of CAPSCA is to bring together international, regional, national, and local organizations to combine efforts and develop a coordinated approach for international aviation to respond to public health risks such as pandemics (CAPSCA 2017). As noted, CDC and other federal agencies worked with five U.S. airports during the Ebola crisis in 2014–2015 to develop specially prepared reception centers to screen passengers coming to the United States from Ebola-affected countries. This required close coordination and cooperation with airlines and local health departments and health providers (CDC 2014). This approach eliminated most issues that might have resulted from passengers with connections to domestic flights and broken itineraries. In 2013 and 2014, ACRP sponsored two projects that dealt with communicable diseases at airports: ACRP Report 91: Infectious Disease Mitigation in Airports and on Aircraft (Environmental Health & Engineering 2013) and ACRP Project 02-20, “The Role of Air Travel in the Transmission and Spread of Insect-borne Disease” (Mao et al. 2014), which produced a tool for assessing risks and mitigation measures, along with a user’s guide. The underlying data and models for the tool have been published

8 in a series of three papers. The first provided a web-based GIS tool for vector-borne disease airline importation risk (Huang et al. 2012). In the second, a model of global passenger flow in 2010 was provided (Huang et al. 2013). The third modeled monthly flows of global air passengers to provide an open-access data resource (Mao et al. 2014). The Civil Aviation Contingency Operations (CACO) Division of Transport Canada (2014) pub- lished the Plan for Pandemics and Communicable Disease Events that guides the overall response of Canada’s aviation sector to communicable disease events. It is closely articulated with the Quarantine Act. A useful source of current information is Transport Canada’s Pre-Flight blog, for example the post “Pandemic and Communicable Diseases—Spread Prevention” (2014). A fast-emerging tool that applies to communicable disease response at airports, among other types of emergencies, is social media for emergency management (SMEM). This is the topic of ACRP Synthesis Project A11-03/S04-18 (Smith and Kenville in press). The synthesis focuses on SMEM as a source of situational awareness and intelligence and a means of communicating directly with the public, passengers, and response partners and stakeholders. efforts under Way to improve understanding and Processes ACRP has two 2017 projects that bear on the issue of airport roles in communicable disease response. ACRP Legal Project 11-01/Topic 09-01, “Airport Public Health Preparedness & Response: Legal Rights, Powers & Duties,” deals with the legal duties, responsibilities, and rights of airports regarding communicable diseases. The “ACRP Forum on Airport Roles in Reducing Communicable Diseases Transmission,” ACRP Project 11-08, seeks to engage the U.S. aviation industry broadly to consider research needs in all aspects of airport roles in reducing communicable disease transmission. The final reports for both projects are expected in 2018. Caring for the Caregivers Caring for the caregivers is an emerging issue in emergency response including at airports. ACRP Report 22: Helping Airport and Air Carrier Employees Cope with Traumatic Events (Kenville et al. 2009) is a comprehensive guide in this area. In summary, the topic of air travel and communicable diseases has worldwide importance and has been the focus of intense national and international attention. Guidance and procedures for dealing with communicable diseases are evolving quickly, and the trend is toward more general guidance on disease lists and procedures. Finally, the agencies and organizations working in the field indicate that continuing research is needed to deal with emerging diseases and the associated risks of transmission. legAl environmenT for resPonse To CommuniCAble diseAses AT AirPorTs A separate ACRP Legal Study (ACRP Project 11-01/Topic 09-01), “Airport Public Health Prepared- ness & Response: Legal Rights, Powers & Duties,” is scheduled to be published in 2018. Its objective is to develop best practices for airport lawyers and managers that outline the legal rights, powers, and duties of an airport in addressing the spread of communicable diseases through air travel. The study will identify and describe the rights and obligations of additional stakeholders, such as WHO, CDC and other federal agencies, and state and local health and public safety organizations, in response to the potential transmittal of disease. The study will set forth options to address such issues under existing laws and policies, as well as potential opportunities to address inadequacies in the current legal landscape. The study will include but not be limited to a review of legal issues relating to isola- tion and quarantine, disease surveillance, screening protocols, contact tracing, and decontamination procedures, search and seizure, involuntary testing, denial of access (to the airport, to travel, etc.), and privacy and personal health information. The final product will be a form of playbook that allows airport attorneys, management, and staff to respond to a public health emergency in real time. Given the scope and objectives of ACRP Legal Study 09-01, the current synthesis presents a general over- view of the roles and responsibilities of airports, public health agencies, aircraft operators, and other stakeholders regarding communicable diseases on arriving flights.

9 Airports Are expected to Have Preparedness Plans Air travel–related risk management and preparedness for communicable diseases is the responsibil- ity of the local/regional/national public health authority and the airport operator (WHO 2005). Each airport is expected to have its own preparedness plan. International guidelines state that individual airport preparedness plans should address aspects such as: (a) communication (especially with the public); (b) screening; (c) logistics (transport of travelers to health facilities); (d) equipment, including personal protective equipment for airport staff; (e) training; (f) entry/exit controls; and (g) coordination with the local/regional/national public health authorities (WHO 2005, §2.2-2.3). Specific to the United States, FAA Advisory Circular 150/5200-31C Airport Emergency Planning requires all airports to have an airport emergency plan (AEP). For airports that serve passenger flights, such plans are required to address communicable disease response. This may be done directly in the AEP or indirectly by having the AEP reference the communicable disease response plan. In addition, airports address communicable disease response in their business continuity plans, continuity of busi- ness plans, recovery plans, and communications plans. imPorTAnCe of relying on PubliC HeAlTH And mediCAl exPerTise Airports usually have access, either through staffing or EMS partners, to a range of field treatment skills to triage, describe symptoms, and stabilize the condition of ill persons. However, except for a few obvious cases of rash illnesses, even an infectious disease specialist would be hard pressed to make a diagnosis in an air travel–related reported illness. Consequently, airlines, airports, and airport mutual aid responders are not expected to identify disease. National public health agencies, such as CDC and PHAC, provide their aviation partners with a list of symptoms they are asked to report. A second reason for relying on public health partners is their strong knowledge of the statutory and regulatory environment surrounding communicable diseases and such issues as sharing medical information, patient privacy, and appropriate response procedures. A third reason is that an airport and its response partners rely on public health expertise to ensure that decisions made by the incident command are medically sound and outgoing communications are factually based and not speculative. relATionsHiPs of loCAl, sTATe, or ProvinCiAl And nATionAl PubliC HeAlTH dePArTmenTs in THe uniTed sTATes And CAnAdA In the United States and Canada, public health practice is governed by federal, state/provincial, and local law. Generally speaking, the authority to control disease spread and compel isolation and quarantine is a state/provincial/territorial power. Local health departments (also known as health units in Ontario) assist with implementing state/provincial/territorial laws around disease control. Federal public health agencies (CDC in the United States and PHAC in Canada) are responsible for acting when health threats span more than one state/province/territory, region, or the entire nation, and when response to a public health threat is beyond the jurisdiction of a single state, province, or territory. For instance, as previously noted, during the Ebola crisis in 2014–15, CDC and DHS-CBP worked to funnel passengers to five U.S. airports, where they established procedures to screen pas- sengers coming to the United States from Ebola-affected countries. This required close coordination and cooperation with airlines and local health departments and health providers (CDC 2014). By limiting the locations where passengers from Ebola-affected countries could enter the United States, this approach (funneling) eliminated most of the issues that might have resulted from passengers on

10 open itineraries with connections to domestic flights, including the need for surge staffing at multi- ple airports. The CDC and PHAC also have authority for disease control and quarantine at their respective country’s (United States or Canadian) ports of entry concerning the entry of persons, goods, and conveyances from other countries that may spread communicable disease. united states Airports The investigation of communicable disease at U.S. airports may fall under the jurisdiction of a state health department or a local health department depending on how public health practices are struc- tured in the state where the airport is located. The involvement of CDC will depend on whether the communicable disease is on a flight entering the United States or if measures are needed to help pre- vent the spread of disease across states (J. Martin, personal communication, February 1, 2017). Canadian Airports As with U.S. airports, the investigation of a communicable disease may fall under a local or national public health authority, depending on the flight’s point of initiation. This can be more complex when the airport is close to a local boundary. For example, Toronto Pearson International Airport is geo- graphically located in Peel Region but is near the border with the city of Toronto. Airport personnel, including PHAC quarantine offices, deal with the Peel Region Health Department, but individuals with suspected exposures to communicable pathogens usually are taken to Toronto hospitals for care and investigation and are reported to Toronto Public Health. In these circumstances, the Province of Ontario has similar roles as a state health department in the United States, and PHAC has international and isolation/quarantine roles similar to those of the CDC. However, in Canada’s federal system, the provinces and territories have considerably more authority, at least in public health issues, which means that domestic communicable disease issues involving two or more provinces and territories typically require significant federal/provincial/ territorial collaboration. The 2003 SARS outbreak revealed problems with public health preparedness and emergency response in Canada at all levels (Manasan 2015). As a result, many improvements were made: at the national level with the creation of the PHAC; at the provincial level with, for example, the creation of Public Health Ontario and the Provincial Infectious Diseases Advisory Committee; at the local health department level with increased provincial funding; and at the airport level with the creation of a specific communicable disease plan. Other provinces made similar changes. The government of Canada amended the Quarantine Act and reorganized agencies as a result of the lessons learned from SARS. Quarantine officers located in six airports across the country provide a 24/7 response system that covers all international ports of entry in Canada. Canada Border Services Agency (CBSA) offi- cers are designated as screening officers in the Quarantine Act. With the guidance of a quarantine officer, CBSA officers act on their behalf when quarantine officers are not present (S. Jain, personal communication, December 1, 2016). In the United States and Canada, public health agencies in all levels of government have respec- tive duties and responsibilities that may come into play with planning and response to a communi- cable disease on an arriving international or domestic flight. sCoPe of THis sTudy The objective of this synthesis is to compile current experience and effective practices related to aviation communicable disease response in the United States and Canada. The report addresses the following items: • Clear definition of issues and appropriate governing regulations; • Roles and responsibilities of airport, public health, and key stakeholders; • Trigger mechanisms for response;

11 • Defining the step-by-step response process; • Monitoring, mitigation, and communication strategies; and • Business continuity and recovery. Although community reaction to a communicable disease reported or rumored to be at an airport is important, it lies outside the scope of this study. The report presents case examples and materials useful to airports and their partners for developing plans and responses to communicable diseases on arriving flights. The primary audiences for this synthesis are airport leadership, airport emergency responders and planners, airport emergency response partners, airlines, public health officials, and other health providers. sTudy meTHods Data for this study were collected using a literature review, an online survey, six case examples, and interviews with senior officials in five health agencies. The consultants also benefited from the opportunity to observe the public session of the August 2016 Staff Assistance Visit (SAV) by CAPSCA, WHO, and the Pan American Health Organization at the invitation of Hartsfield-Jackson Atlanta International Airport, to review the airport’s communicable disease preparedness plan and provide consultation. literature review A comprehensive literature review was performed to identify key studies relating to the topic of communicable disease response and the airport sector. The results of the literature review are listed in References at the end of this synthesis. survey and response rates The survey data were gathered during July through October 2016 using an online tool provided by TRB. A nonrandom, purposive sample of 57 airports was selected; the sample was made up of 51 U.S. airports of various types and sizes and six large-hub Canadian airports. The sample was based on the professional knowledge of topic panel and synthesis team members. For the 51 U.S. airports, survey invitations were sent to the 51 local health departments that serve as local public health pre- paredness coordinators for the airports. For the six Canadian airports, survey invitations were sent to their six local health departments and the regional offices of PHAC serving the airports in the sample. Among the 57 airports invited to participate in the survey, 50 responded, representing a response rate of 88% (44 of 51 U.S. airports and six of six Canadian airports). The participating airports are identified in Appendix C. The online survey questions and survey data for airports are reproduced as Appendix D. One airport chose to respond to the survey by e-mail rather than using the online tool. Thirty-four of the 51 U.S. local public health preparedness coordinators invited to participate sub- mitted responses, representing a response rate of 67%. The Canadian response computation is compli- cated because potentially two levels of health departments (local public health units and the regional representative for the PHAC, which has particular jurisdictional responsibilities outlined under the Federal Quarantine Act) could respond for each airport. The actual results were responses for five of the six Canadian airports coming from one provincial health department, one city health department, the PHAC East communicable disease response coordinator (two airports: Toronto and Montreal), and the response coordinator for PHAC West (two airports: Vancouver and Edmonton). If the Cana- dian health department invitations are viewed as a total of nine potential responses, the response rate is four responses to nine invitations (44%). Overall, 39 health departments participated, a response rate of 68%. The analogous situation did not arise with the U.S. surveys because the synthesis team sent surveys only to local health departments and not to CDC Quarantine Stations. Because this study focuses on cooperation between airports and public health departments in preparing for and responding to communicable disease incidents, cases in which an airport and its public health partner participated in the study have special interest. Thirty-six (63%) airport–health department pairs responded.

12 Case examples Six detailed case examples are presented to highlight processes each airport has implemented since 2003 and the airports’ particular disease response incident. Potential epidemic/pandemic diseases (SARS, Ebola, and influenza) and nonepidemic communicable diseases (tuberculosis and measles) are included. The six case examples are: 1. Toronto Pearson International Airport and severe acute respiratory syndrome (2003); 2. Phoenix Sky Harbor International Airport and tuberculosis (2013); 3. Portland International Airport and measles (2014); 4. Dallas/Fort Worth International Airport and Ebola (2014); 5. Boston Logan International Airport and five suspected Ebola cases (2014); and 6. Vancouver International Airport and H7N9 (2015). These airports, which all have had to respond to actual disease incidents, yield useful, practical, and scalable lessons about how best to respond to communicable diseases on arriving flights. All six case examples are large hub airports. Two (Toronto Pearson and Vancouver) have resident quarantine offices and thus are “ports” in a manner similar to CDC, whereas four (Boston, Phoenix, Dallas/ Fort Worth, and Portland) are “subports” by virtue of not having a quarantine office at the airport. In addition, these cases trace the evolution of airport planning and responses to communicable diseases since the SARS outbreak and paint a picture of the most highly evolved communicable disease pre- paredness and response plans today. Each case example has been developed from examination of the survey responses from the air- port (except BOS) and from its public health preparedness coordinator partner, a targeted literature review, analysis of media coverage, a plans review, and a telephone interview with representatives of the airport, health agency partner, and other key stakeholders. Unlike the survey portion of this study, the case examples address the roles of airport personnel, tenants, stakeholders, airlines, clean- ing crews, response partners (health agencies, law enforcement, emergency managers, and logistics support entities), communicators/media, and local appointed and elected officials. validity Preliminary conclusions as well as topics for further research were subjected to expert validation that involved interviews with five senior health officials from U.S., Canadian, and international agencies. The purpose of these interviews was to test the main findings and identify additional research needs. The draft conclusions and possible further research needs shown in Appendix D-3 were provided in advance to the five interviewees. Interviewees were affiliated with the following organizations: 1. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Prepared- ness and Response; 2. U.S. CDC, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine; 3. PHAC; 4. New York State Department of Health, Bureau of Communicable Disease Control; and 5. International Civil Aviation Organization, Medical Office. data Analysis and Presentation Most questions are in “check box” format, but open-ended questions allowed respondents to expand or explain answers not appearing among the check box options. Data gathered by this study are presented in Appendix D. Qualitative (thematic content) methods are the main analytic tool used. The common themes discovered are discussed in chapters three and four. The nonrandom nature of the samples and the relatively small sample sizes prevented the application of quantitative analytical methods other than determining percentages of respondents in certain categories of answers (descriptive analysis).