Preparing Airports for Communicable Diseases on Arriving Flights (2017)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

22 chapter four Where the rubber hits the tarmac: six case examples introduction Six case examples of communicable disease response planning at U.S. and Canadian airports are presented here. Each airport has had at least one major incident that caused activation of its commu- nicable disease response plan and associated activities. All case examples are from large hub airports served by nonstop passenger flights arriving from outside the United States and Canada and deal with an incident that has occurred since 2003. Despite the large size and business mixes of these airports, the synthesis team thinks the principles exhibited in the communicable disease planning and responses offer practices that can be transferred to smaller airports, domestic airports that receive connecting international passengers, and airports that receive international passengers and crews on charter or other nonscheduled flights. Each case is based on a review of media coverage of each incident, analysis of published litera- ture, analysis of the survey results from the airport and its local public health preparedness coordinator (except for Boston Logan International Airport, which did not participate in the survey), and follow- up correspondence (telephone and e-mail) with the airport, the health partner, and key stakeholders as identified by the airports. In one case example, a set of documents is presented to illustrate that airport’s current preparedness posture. With pervasive social media presence, the communication challenges are magnified (Smith and Kenville in press). All airport operational statistics in this chapter come from ACI-NA (2016a) or from the airports’ websites. case 1: toronto pearson international airport and severe acute respiratory syndrome (2003) Between February and July 2003, Toronto experienced the largest outbreak of SARS outside of Asia. SARS killed nearly 800 people worldwide, and infected almost 8,000 patients. In Toronto, 225 people became infected; 44 died of complications related to their illness. The outbreak’s human and economic consequences were significant and took a serious toll on patients and hos- pital workers and their friends and families. A primarily nosocomial disease, SARS was largely restricted to persons who were exposed in one of the city’s 19 acute care hospitals and their household contacts. In April 2003, WHO issued a warning advising against travel to Toronto; although the advisory lasted less than a week, it contributed to more than $260 million in losses to the city’s tourism industry and more than CDN $1.1 billion in costs to the provincial (Ontario) treasury. This case example is based on the survey results from Toronto Pearson International Airport (YYZ), the Public Health Agency of Canada (Quarantine Services, Central Region), and Toronto Public Health (TPH, the city’s health department) and a telephone interview on December 1, 2016. It is important to note that Pearson International Airport is predominantly in the city of Mississauga, which as part of the Region of Peel, is served by a different health department than is the City of Toronto. Major communicable disease incidents likely involve PHAC, the Region of Peel Health Department, and TPH. All TPH information used in this case study is identified.

23 Pearson International is Canada’s busiest airport in terms of total passengers, international pas- sengers, total flight operations, and cargo tonnage. In 2002, just before the SARS outbreak, the air- port served more than 14.5 million international passenger trips [Greater Toronto Airports Authority (GTAA) 2002]. In 2015, it served 41,036,847 passengers, ranking 15th in North America and 33rd in the world. In 2015, it had 443,958 total aircraft movements (ranking 16th in the world, ninth in North America, and first in Canada) and handled 434,777 metric tons of cargo (ranking 56th in the world, 17th in North America, and first in Canada). Pearson International received more than 7 million international passengers in 2015 (A. Payter, personal communication, Dec. 21, 2016); this excludes passengers arriving from the United States. The airport is served by 65 airlines and receives nonstop flights from 100 cities outside the United States and Canada (Table 10). Passengers can reach more than 67% of the world’s economies through daily, nonstop flights from Pearson (https://www.torontopearson.com/en/economicimpact/#). Pearson handles more international passengers than any airport in North America other than John F. Kennedy International Airport in New York, and ranks 22nd among all world airports for number of international passengers (ACI-NA 2016b). In addition, Pearson International receives charter, cargo/freight, and humanitarian support flights (refugee flights), corporate general aviation flights, and private (noncorporate) general aviation flights from outside the United States and Canada. It is a port of entry with a resident PHAC quarantine station and a resident CBSA unit. TABLE 10 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR TORONTO PEARSON INTERNATIONAL AIRPORT Region Number Airports of Origin East Asia 8 Beijing, Guangzhou, Hong Kong, Manila, Seoul, Shanghai, Taipei, Tokyo South Asia 4 Delhi, Islamabad, Karachi, Lahore Southwest Asia/Mideast 5 Abu Dhabi, Dubai, Jeddah, Riyadh, Tel Aviv Africa 2 Addis Ababa, Cairo Europe 23 Amsterdam, Barcelona, Brussels, Copenhagen, Dublin, Frankfurt, Geneva, Glasgow, Istanbul, Lisbon, London-Gatwick, London-Heathrow, Madrid, Manchester, Munich, Paris, Ponta Delgada, Porto, Reykjavik, Rome, Vienna, Warsaw, Zurich Caribbean, Mexico, and Central America 51 Acapulco, Antigua and Barbuda, Aruba, Barbados, Belize City, Bermuda, Camaguey, Cancun, Cayo Coco, Cayo Largo, Cienfuegos, Cozumel, Curacao, Exuma, Freeport, Grand Cayman, Grenada, Havana, Holguin, Huatulco, Ixtapa, Kingston, La Romana, Liberia, Managua, Manzanillo (Cuba), Manzanillo (Mexico), Merida, Mexico City, Montego Bay, Nassau, Panama City, Port of Spain, Providenciales, Puerto Plata, Puerto Vallarta, Punta Cana, Rio Hato, Roatan, Samana El Catey, San Jose Cabo, San Jose, San Salvador, Santa Clara, Santiago (Chile), Santiago (Cuba), Santo Domingo, St. Kitts, St. Lucia, St. Maarten, Varadero South America 6 Bogota, Buenos Aires, Cartagena, Georgetown, Lima, Sao Paulo Oceania 1 Sydney Total 100 Source: Smith and Greenberg data, derived from www.torontopearson.com (accessed Nov. 27, 2016).

24 In the surveys, Pearson, PHAC, and TPH noted having prepared for or dealt with the diseases shown in Table 11 in the past 15 years. Under the Quarantine Act, there are 25 diseases of concern; PHAC is prepared to deal with all 25 (S. Jain, personal communication, December 21, 2016; Appendix A). Of the diseases in Table 11, all except dengue and norovirus are diseases of concern; however, if PHAC assesses someone with dengue or norovirus, PHAC helps facilitate the response and care through its partners (S. Jain, personal communication, December 21, 2016). During the 2003 SARS outbreak, there was considerable public pressure on airports and health agencies to screen for symptoms in passengers on arriving flights, especially flights from East Asia. Soon after WHO lifted its travel advisory, Pearson International introduced screening mecha- nisms (thermal imaging) for inbound and outbound passengers in an effort to identify passengers with elevated temperatures and prevent the disease from spreading. These measures were canceled in late May after complaints from travelers that the actions were unnecessarily intrusive. They also were costly. A CBC report cited a study published in the journal Emerging Infectious Diseases that concluded the estimated CDN $7.55 million spent on screening at several Canadian airports failed to detect a single case of SARS (CBC News 2004). Cities with direct flights to Hong Kong, such as Toronto, were 25 times more likely to record a SARS case than were cities that were not directly connected. Cities that required two and more connecting flights to reach Hong Kong did not record a single case. After the SARS outbreak began, flights in Pacific Asia decreased by 45% compared with the previous year. During the outbreak, the number of flights between Hong Kong and the United States fell 69%. This is an example of risk avoidance behavior by travelers (Rodrigue et al. 2017). The most significant result of SARS was the formation of PHAC. Other changes in practice since 2003 have been less formal; one of the key successes of the Quarantine Program has been the networking and relationships which were strengthened among agencies. Expert respondents noted a strengthening in the relationship between the airport and public health and other stakeholders and outreach among these parties. One upshot of this development has been that airports now have com- municable disease plans that are updated on a regular basis. There is a concerted effort to keep up with the changing dynamics of communicable diseases. The effectiveness of the efforts since 2003 was demonstrated by Toronto’s experience with the Middle East respiratory syndrome coronavirus (MERS-CoV) epidemic. In 2015, the Office of Border Disease Airport PHAC TPH SARS X X X H1N1 X X X Measles X X X Tuberculosis X X X Ebola X X X Dengue X Other influenza types X X X Norovirus X X X Meningococcal meningitis X MERS-CoV X X PHAC = Public Health Agency of Canada; TPH = Toronto Public Health. Source: Smith and Greenberg data. TABLE 11 COMMUNICABLE DISEASE RESPONSES OR PREPARATIONS AT TORONTO PEARSON INTERNATIONAL AIRPORT

25 and Travel Health (an agency of the PHAC) had a focused public health campaign for MERS-CoV that included: (1) outreach sessions on MERS-CoV for CBSA officers; (2) working with key airlines to distribute information to travelers returning from Hajj; and (3) using screens in the CBSA area to provide travel health information about MERS-CoV to travelers returning to Canada. PHAC’s Travel Health program (part of the Office of Border and Travel Health) has continued to provide travel information related to MERS-CoV for Hajj pilgrims through various Muslim associations in Canada. At the local level, the Ontario Ministry of Health and Long-Term Care created a MERS-CoV docu- ment that was distributed to all Ontario health departments to ready them for the possible arrival of the syndrome (Ontario Ministry of Health and Long-Term Care 2016). This document included case definitions and clear testing protocols. Health departments, including TPH, trained their on-call teams to appropriately respond to calls from Pearson International and area hospitals identifying travelers with possible MERS-CoV infection. the plans and how developed Pearson maintains a communicable disease response plan, which is a stand-alone plan referenced in the AEP. The airport communicable disease plan is disseminated to stakeholders electronically. The airport does all plan updates on a regular schedule, and PHAC specifically reviews quarantine proce- dures. Parts of the airport plan are classified (SSI). The plan is reflected in GTAA’s human resource policies. The airport plan does not differentiate how it handles passengers from how it handles flight crews, but the PHAC plan does make this distinction. Table 12 compares the stakeholder lists given by Pearson, PHAC Central, and TPH. The Pearson plan incorporates the incident management system and best practices from NIMS and Incident Command System (ICS) although they are not required in Canada. The airport’s plan does not involve diverting inbound flights to other airports. health department services to the airport Depending on the specific circumstances, PHAC or the local health department may provide some or all of the services listed in this section. PHAC in its survey response, interview, and follow-up correspondence (S. Jain, personal communication, December 21, 2016) reported that it provides the following services at Pearson International Airport related to communicable disease responses: • Assisting in investigating cases and collecting epidemiological information, including interview- ing ill and exposed individuals (passengers, flight crew, airport staff, etc.). • Assisting in securing the flight manifests for international flights as outlined by the PHAC Quarantine Program. • Supporting the International Health Regulations (IHR) notifications between countries. • Liaising with provincial health department as needed to identify a disease agent and arrange for laboratory testing. • For international travelers entering Canada, enforcing various orders under the Quarantine Act. Local public health and/or hospitals ensure the orders are implemented. • Instituting control measures (isolation and quarantine or other measures necessary to control disease spread). • Leading any public information/messaging efforts in partnership with the airport. • Leading public information/messaging efforts (e.g., MERS-CoV). In its survey response, TPH noted services that likely would be provided by the Peel Region Health Department: • Collect environmental samples; • Each agency (federal) is responsible for obtaining guidance on PPE from its respective occu- pational health department;

26 Stakeholder Airport PHAC TPH Airport senior management X X Airport planning X Airport media/public relations X X Airport operations X X X Airport emergency management X X X Airport law enforcement Airport rescue and firefighting X X X Airport training X Airport maintenance Airport human resources Airlines, air cargo companies, charter operators, and air taxi operators X X Concessionaires Mobility services (wheelchairs, carts) Airport sponsor/certificate holder General aviation aircraft owners and pilots Local health department X X Provincial health department X X PHAC–quarantine station X X X Other public officials (elected officials, etc.) CATSA CBSA X X X Military (airport is joint use) Transport Canada X Nonairport law enforcement National agencies X X Provincial agencies X X Local agencies X Health care coalition Hospitals and clinics X X Ambulances/medical transport services X X X HAZMAT—local fire department X County emergency management City emergency management Provincial emergency management X X Note: Slash means stakeholder and column entity are the same. Source: Smith and Greenberg data. TABLE 12 STAKEHOLDERS INVOLVED IN COMMUNICABLE DISEASE PLANNING PROCESS AT TORONTO PEARSON INTERNATIONAL AIRPORT

27 • Provide guidance regarding appropriate PPE and infection control measures; and • Provide guidance regarding treatment or prophylaxis that may be needed for ill/exposed individuals. For responses to potential health problems with international travelers, PHAC is developing a surge capacity framework. Recently, PHAC has used nurses from within PHAC to support surge requirements. In past outbreaks, PHAC used nursing agencies to hire temporary surge staff. training, drilling, and exercising Training of fire and emergency services personnel relating to communicable disease is completed on a regular basis. Training includes practical performance demonstrators, written examinations, and monthly training drills. The most recent airport communicable disease drill or exercise was in 2010. There has been a recognized need to expand such drills and training to include external partners and other frontline employees. Pearson Airport identifies the need to schedule a drill or exercise • When regulatory requirements change, • When new procedures are introduced, and • When a hazard or deficiency in response to communicable disease is demonstrated. PHAC recommends a tabletop exercise every year and a full-scale exercise every 3 years. The airport provides a number of protective measures for its employees: training and counter- measures for fire and emergency services personnel; PPE for fire and emergency services personnel; and decontamination facilities. communications The post-SARS reforms have been effective in all areas but particularly in communications. Case Example 2, regarding Phoenix Sky Harbor International Airport, describes in detail the sort of changes that Pearson and PHAC achieved. Greatest Worry The airport and PHAC worry that there is no federal authority for screening passengers arriving on a domestic flight. The federal Quarantine Act does not cover domestic flights. This can be illustrated by a potential situation in which a passenger traveling from Hong Kong to Toronto by way of Vancouver may not show symptoms until the Vancouver-to-Toronto leg of the trip, and PHAC in Toronto has no authority over the passenger, who is now arriving as a domestic passenger. The provincial health acts may or may not have similar authority as the federal Quarantine Act. Historically, Quarantine Officers have assisted with the assessment; however, they cannot enforce any of the provisions under the Quaran- tine Act. The provinces are aware of this issue and have initiated action to address it. lessons learned Pearson International Airport reported: 1. There is a need to work more closely with local public health agencies to understand jurisdic- tion and the effectiveness of response. 2. When a domestic flight is involved, there may be a challenge in trying to identify a communi- cable disease and not having authority to send someone to the hospital under a specific legal act is a challenge. 3. More frequent practice of the communicable disease plan involving all internal and external stakeholders through to the recovery stage would enhance resilience of the airport community to communicable diseases.

28 PHAC reported: 1. Challenges of the federal Quarantine Act because it does not pertain to domestic flights; 2. Limited scope of the Quarantine Act; 3. Pressure on partners to deal with communicable disease on domestic flights; 4. Challenges in responding to issues on domestic flights; and 5. Challenges when the quarantine officer is not on site. TPH reported: 1. Involving all stakeholders is necessary; 2. Having no assumption that everyone understands the basics of communicable disease control; 3. The return on investment for too much detail is difficult to make; 4. Providing information can reduce anxiety; 5. Understanding that prior relationships are the most important thing when initiating a response; and 6. Planning will take you only so far before improvisation will be necessary. Greatest challenge SARS had a large impact on the number of passengers using Pearson International; traffic dropped 12% in a year. This required major financial adjustments: The ground rent recorded in the financial statements for 2003 was $125.2 million as compared to $134.5 mil- lion in 2002. The reduction includes overpayments in 2002, the impact of reduced passenger levels in 2003 below the 25 million passenger cap but does not include the ground rent relief under a program announced by the Minister of Transport in July 2003. This program was intended to provide ground rent relief for airports in recognition of the difficulties in the industry, particularly the impact of SARS. For the GTAA the result of the pro- gram will be a ground rent deferral of approximately $41.6 million over 24 months, commencing on July 1, 2003. For 10 years commencing in 2006, payments will be increased by approximately $4.2 million each year (GTAA 2003 Annual Report). bottom line Pearson International Airport’s respondents’ estimate of the level of overall preparedness to deal with a communicable disease on an arriving international flight was reported as “prepared,” with a need to improve drill and exercise frequency. Processes are in place for dealing with communicable disease arriving on a domestic flight; however, more is required to determine the effectiveness of the current processes. The TPH respondent’s estimate of the level of overall preparedness to deal with a communicable disease on an arriving flight was reported as “prepared,” but the following needs were cited: improve drill and exercise frequency, improve coordination with airlines, and determine the most effective way to coordinate response to communicable diseases on domestic flights. The conversation during the interview showed how closely the airport and PHAC work together and how well they understand each other’s needs and capabilities. Pearson International Airport and its partners have had direct experience with a passenger getting sick on a flight and a passenger get- ting sick at home after passing through the airport. case 2: phoenix sky harbor international airport and tuberculosis (2013) “We’ve been notified of a health emergency aboard the aircraft.” The pilot’s announcement on US Airways Flight 2846 hung ominously in the cabin. The plane was on the tarmac of Phoenix Sky Harbor International Airport (PHX) at the conclusion of its 2-hour leg from Austin, Texas, with a final destination of Los Angeles International Airport (LAX). As passengers looked nervously at each other, one of the flight attendants approached a middle-aged male passenger, handed him a

29 medical grade mask, and with emergency personnel in tow, escorted him from the plane. Another announcement followed a few minutes later, informing passengers that the patient had active tuberculosis, was highly contagious, and had exposed everyone aboard the flight. “Please contact your physicians immediately.” Because of the flight’s short duration, the likelihood of mass tuberculosis (TB) infection aboard the flight was low; nevertheless, TB is highly contagious and can be deadly. The case also revealed how vulnerable the air travel industry is to the spread of communicable disease. US Airways spokes- person Bill McGlashen later revealed there was no warning or flag on the passenger’s record when he proceeded through security or when he boarded the plane (Avila 2013). Only after the plane was airborne did CDC notify TDS of a possible risk. TSA then notified the airline to coordinate a response. In this case, the passenger was not on the CDC’s do-not-board list and did not appear to present symptoms of serious infection at the time of departure that would lead the ticketing agent to not issue a boarding pass. Unlike passengers aboard luxury cruise ships, airline passengers are not legally obligated to notify an airline when they are sick. This case example is based on the survey results from Phoenix Sky Harbor International Airport and the Maricopa County Department of Public Health and a telephone interview on December 16, 2016. Phoenix Sky Harbor International Airport is the 11th busiest airport in North America and 29th busiest in the world, having served 44,003,840 passengers as of 2015. In 2015, Phoenix Sky Harbor had 369,759 total aircraft movements (ranking 34th in the world, 20th in North America, and 19th in the United States) and handled 283,465 metric tons of cargo (ranking 82nd in the world, 21st in North America, and 20th in the United States). The airport is served by 16 airlines and receives nonstop flights from 11 cities outside the United States and Canada (Table 13). The City of Phoenix Aviation Department also owns and operates Phoenix Deer Valley Airport and Phoenix Goodyear Airport; in addition, the city is a member of the Phoenix–Mesa Gateway Airport Authority. Phoenix Sky Harbor receives charter, cargo/freight, and corporate general aviation flights from outside the United States and Canada. The Phoenix area has hosted many large special events, such as the Super Bowl, College Football Playoff games, political conventions, and large international conventions, all of which generate many charter and general aviation flights. Phoenix Sky Harbor is a port of entry, with a resident CBP unit, but there is no CDC Quarantine Station. The airport falls under the Quarantine Station in San Diego. In the surveys, Phoenix Sky Harbor and the Maricopa County Department of Public Health noted having dealt with or prepared to deal with measles, tuberculosis, Ebola, and influenza types in the past 15 years. recent experiences As with measles, tuberculosis is a highly contagious communicable disease but does not typically pose an epidemic threat. According to Dr. Rebecca Sunenshine, medical director of the disease control divi- sion of the Maricopa County Department of Public Health, the 2013 TB response “enlightened us about TABLE 13 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR PHOENIX SKY HARBOR INTERNATIONAL AIRPORT Region Number Airports of Origin Europe 1 London Caribbean, Mexico, and Central America 10 Culiacan, Cancun, Guadalajara, Hermosillo, Mexico City, Mazatlan, Puerto Vallarta, Los Cabos, San Jose, Ixtapa Total 11 Source: Smith and Greenberg data, derived from www.skyharbor.com (accessed Nov. 27, 2016).

30 many opportunities to improve our response planning.” It occasioned vast local and national media attention. The airport’s emergency preparedness coordinator convened every stakeholder to a hot- wash, an immediate after-action review (AAR) session to discuss and evaluate the response and review the report that followed. The incident led to a complete revision of the airport’s commu- nicable disease response plan, with the revision led by the airport. The revision was informed by the realities of airport, health department, and law enforcement challenges and responsibilities. The single most important lesson learned from this experience was that if a public health incident is involved, there is an absolute need to get all stakeholders on the telephone at once and let the health department be the subject matter expert (SME) to the incident commander and take the lead in the response. Phoenix Sky Harbor reprogrammed its notification system to reach all the correct parties in the event of various health-related problems. During 2014, there was a large amount of partnership/relationship building among partners for agencies involved in health emergencies. As a group, the stakeholders took the CDC planning template and made it into a local, operational communicable disease plan. The efforts undertaken in 2013 and 2014 paid off in 2015. The Maricopa County health depart- ment notified the airport of a passenger arriving from Liberia through London and coming to a Phoenix hospital for the diagnosis and treatment of possible Ebola infection. The passenger had been evaluated in Liberia and London, but the exact illness had not been identified, and the patient had some but not all Ebola symptoms. The passenger initially had illness classified as “moderate” risk until being evaluated at a U.S. port of entry, where his illness was reclassified as “low but not zero” risk. The airport and the health department had several days to prepare. The communications went well. Advance notice of arrival, no risk to other passengers or airport personnel, and a good plan allowed the incident to be deescalated in advance. The patient eventually received a diagnosis of illness other than Ebola. the plans and how developed The airport and health department maintain written communicable disease response plans, but they coordinate to ensure plan alignment. The airport’s plan is a stand-alone communicable disease/ quarantine plan. The health department has two annexes to its Public Health Emergency Response Plan—the Infectious Disease Annex and the Disease Containment and Mitigation Annex. The airport and health department incorporate the principles and practices of NIMS and the ICS in their plans. Neither plan differentiates how to handle passengers from how to handle flight crews. The airport’s plan does not involve diverting inbound flights with a reported or suspected communicable disease to another airport. The airport’s plan was developed by a group of stakeholders; changes and updates to the plan are communicated by an e-mail group that includes all stakeholders. Table 14 compares the stakeholder lists given by Phoenix Sky Harbor and the Maricopa County health department. The airport and the health department perform regularly scheduled reviews of their communicable disease response plans and stay familiar with each other’s plans and procedures through numerous county, regional, and state health and emergency planning committees and meetings. health department services to the airport The Maricopa County health department provides the following services at the airport related to communicable disease responses: • Serving as SME—the health department has a staff physician on call 24/7 who is available by telephone and a provision for an on-site public health liaison (through the Arizona Counter Terrorism Information Center Terrorism Liaison Officer program); • Investigating cases and collecting epidemiological information, including interviewing ill and exposed individuals (passengers, flight crew, airport staff, etc.);

31 TABLE 14 STAKEHOLDERS INVOLVED IN COMMUNICABLE DISEASE PLANNING PROCESS AT PHOENIX SKY HARBOR INTERNATIONAL AIRPORT Stakeholder Airport Health Department Airport senior management X X Airport planning X X Airport media/public relations X X Airport operations X X Airport emergency management X X Airport law enforcement X X Airport rescue and firefighting and EMS X X Airport maintenance X X Airlines, air cargo companies, charter operators, and air taxi operators X X Mobility services (carts, wheelchairs) X Airport sponsor/certificate holder X General aviation aircraft owners and pilots X Local health department X State health department X X CDC—Quarantine Station X X Other public officials (elected officials, etc.) X X TSA X X CBP X X Military (airport is joint use) X FAA X X Nonairport law enforcement X State agencies X X Local agencies X X Health care coalition X Hospitals and clinics X X Ambulances/medical transport services X HAZMAT—local fire department X County emergency management X City emergency management X State emergency management X Source: Smith and Greenberg data.

32 • Liaising with state health department/CDC as needed to identify disease agent and arrange for laboratory testing; • Instituting control measures (isolation and quarantine or other measures necessary to control disease spread); • Collecting environmental samples; • Providing guidance on environmental cleaning measures/waste disposal; • Providing guidance regarding appropriate PPE and infection control measures; • Providing guidance regarding treatment or prophylaxis that may be needed for ill/exposed individuals; and • Leading any public information/messaging efforts in partnership with the airport. training, drilling, and exercising The airport carries out regular tabletop and review sessions with stakeholders and public health partners. The training and exercises are evaluated using real-world observation and feedback con- firming the effective and efficient response practices of responders. The same methods are applied to all actual incidents. The airport uses evaluation forms to perform an AAR on every drill and incident. The most recent drill or exercise was in 2016. The airport holds drills on communicable disease response at least annually, but it also schedules a drill or exercise: • When regulatory requirements change; • When new procedures are introduced; • To validate plan revisions; • As part of the AAR/IP process; or • Upon request from an airline partner or other stakeholder. A real-world incident can substitute for a drill or exercise required by regulations. The airport pro- vides a number of protective measures for its employees, including training, PPE, other clothing, and decontamination facilities. communications When a communicable disease incident occurs at the Phoenix airport, the public relations depart- ment, working with the county health department, provides regular and timely updates by means of the airport’s website and all applicable social media options (Facebook, Twitter, and Instagram). The airport’s plan takes into account the possibility of social media posts by a passenger about disease on an inbound flight while the flight is in progress. Accuracy in communication is crucial. Miscommunication can cause a ripple effect in airline operations. The airport and its partners agree about the importance of sticking to their plan to avoid allowing an incident to snowball. Maintaining message discipline—a “single voice”—is essential to ensure the communication of clear, accurate health-risk information. The single voice is achieved by using a unified public information office (PIO), speaking for the city, county, and airport, that operates from a joint information center (JIC). This has been a major benefit of the effort put into building relationships. When a new disease or other health threat emerges, the health department coordinates with the airport about signage and other information sharing for passengers and airport employees. Greatest Worry In the interview, the health department and the airport both said that their greatest worry is a com- municable disease incident involving one of the largest aircraft (such as B777, A330, or B747) because the number of passengers to be interviewed for contact information and screened would swamp the personnel and space available. The staffing surge required to assist in the screening and triage of ill and exposed persons at the airport would be addressed through a series of sources

33 activated in sequence or in series, as the situation dictates. The sources include available public health staff; activation of public health volunteers; requests for staffing assistance through the health care coalition; requests for staffing assistance through the fire/EMS automatic aid system; and requests for staffing assistance to adjoining counties and/or the state. In addition, the airport has arranged with the Arizona Air National Guard for the use of hangar space if the number of passengers makes it necessary. lessons learned Phoenix Sky Harbor International Airport reported: 1. Overall planning and the identification of roles and responsibilities among agencies are essential. 2. Effective initial and ongoing communications throughout the incident are paramount. 3. Not all incidents require a full response or isolation of an aircraft; assuring that the flight crew does not “overdramatize” the event is important. The Maricopa County Department of Public Health reported: 1. Stakeholder involvement is critical to developing a coordinated plan. 2. Preestablished working relationships with response partners are critical to an effective response. 3. Space to screen/triage/quarantine large numbers of passengers on airport grounds is limited. 4. It takes the full spectrum of stakeholders to respond effectively to an incident with a highly infectious disease and a large number of potential exposures. 5. Notification of ill persons on aircraft does not always follow the identified communication channels. 6. Notification of ill persons on aircraft typically is short notice. 7. Information about ill persons typically is limited. Greatest challenge “Our biggest challenge was avoiding miscommunication. We know that when there are numerous work groups involved in a possible communicable disease type event response, things can easily go sideways quickly. The outcome could cause major airport and airline operational disruptions. Therefore, we made sure our established protocols were followed and communicated accurately. This included making sure the flight crew knew the event was not deemed serious enough by public health officials to isolate the aircraft” (C. Rausch, e-mail, February 20, 2017). bottom line Phoenix Sky Harbor International Airport respondents estimated the airport’s level of overall pre- paredness to deal with a communicable disease on an arriving flight as “very prepared” but reported there is still room for growth. The Maricopa County Department of Public Health respondents estimated the agency’s level of overall preparedness to deal with a communicable disease on an arriving flight as “very prepared” but reported there is still room for growth. The conversation during the interview showed how closely the airport and the health department work together and how well they understand each other’s needs and capabilities. case 3: portland international airport and measles (2014) Thanks to immunization, measles has become a rare disease in North America, but as with other vaccine-preventable illnesses, it has been making a comeback in recent years because of rising rates of vaccine hesitancy. Measles remains a common childhood disease in other parts of the world. For example, in the Philippines, more than 15,000 suspected cases of measles were reported

34 in 2014. By the end of the first quarter of that year, 13 U.S. travelers, most of them unvaccinated children younger than 2, had been sickened by this highly contagious disease after returning home from the Philippines. On March 31, 2014, Multnomah County (Oregon) Health Authorities reported that an unvaccinated infant who recently traveled to Vietnam and passed through Portland International Airport (PDX) on March 24 had received a diagnosis of measles. The child was treated at a local primary care clinic, where additional patient exposure may have occurred. Portland International Airport became involved through the epidemiological efforts of the county health department. The health department did contact tracing, working backward on a time line anchored in the passenger’s disembarkation time and gate. The airport and health department were able to use the airport’s closed circuit television monitoring system to track the passenger through the terminal and identify potential social contacts. Such tracking also allowed the health department to evaluate risk to airport employees, tenants, and other passengers. Portland International worked with the airline to obtain flight manifests and other information on passengers, and the health depart- ment contacted adjacent passengers on the flight. The airport had previous experience with potential measles exposure. In April 2008, airport offi- cials announced that an unvaccinated female passenger in her 20s had traveled on Northwest Airlines Flight 33 from Amsterdam to Seattle–Tacoma International Airport, where she then connected to Portland, where she may have spread the disease to fellow passengers before returning to Amsterdam by the same route 3 days later. Although she experienced symptoms while in the United States, her diagnosis of measles was not confirmed until after she returned to the Netherlands. This case example is based on the survey results from Portland International Airport and the Multnomah County Health Department and a telephone interview on December 5, 2016. Portland International Airport is the 30th busiest airport in the United States, 34th busiest in North America, and 120th busiest in the world, having served 16,850,952 passengers in 2015. In 2015, Portland Airport had 218,021 total aircraft movements (ranking 92nd in the world, 40th in North America, and 36th in the United States) and handled 216,187 metric tons of cargo (ranking 95th in the world, 26th in North America, and 24th in the United States). The airport is served by 16 airlines and receives nonstop flights from six cities outside the United States and Canada (Table 15). In addition, Portland International receives charter, cargo/freight, and corporate general aviation flights from outside the United States and Canada. The airport is a port of entry with a resident CBP unit, but there is no CDC Quarantine Station. The airport falls under the Quarantine Station in Seattle. In the surveys, the Portland airport and the health department noted having dealt with or prepared to deal with SARS, H1N1, measles, Ebola, and tuberculosis in the past 15 years. TABLE 15 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR PORTLAND INTERNATIONAL AIRPORT Region Number Airports of Origin East Asia 1 Tokyo Europe 3 Amsterdam, Frankfurt, Keflavik Caribbean, Mexico, and Central America 2 Guadalajara, Puerto Vallarta Total 6 Source: Smith and Greenberg data, derived from www.flypdx.com/PDX/NonstopDestinations (accessed Nov. 27, 2016).

35 the plans and how developed Portland International maintains a communicable disease response plan, which is a stand-alone plan referenced in the AEP. The plan was developed in 2001 after 9/11 with help from the airport’s fire department/EMS, the Multnomah County Health Department, the Port of Portland’s Communication Center, CDC, and the regional hospital consortium. The airport’s plan has been mostly stable since the beginning with some expansion and was successfully used in dealing with SARS in 2003 and H1N1 in 2009. The two most significant revisions to the plan were occasioned by changes to how information regarding an incoming passenger will reach the airport. Portland International’s plan specifies roles and responsibilities for standardized response proto- cols for several communicable disease situations. The plan’s stability and durability largely result from its flexibility and are based on the strong relationship that has been established among the response partners. Each case of disease response is a little different. The established relationships allow the plan’s standardized protocols to be flexed. The airport’s response plan was developed by a group of stakeholders; changes and updates to the plan are communicated using in-person meetings and exercises. Table 16 compares the stakeholder lists given by the airport and the health department. The Portland airport’s plan incorporates NIMS and ICS, differentiates how to handle passengers from flight crews, and includes provisions for diverting flights to other airports. Although the plan is reflected in the airport’s crisis communications and business recovery plans, it is not identified in the Port’s human resources policies. No part of the plan is SSI. The airport performs regularly scheduled reviews and updates of the communicable disease response plan, but the health department does not schedule reviews of the airport’s plan. However, the health department participates in reviews and updates when the airport requests. health department services to the airport The Multnomah County Health Department provides the following services at Portland International Airport related to communicable disease responses: • Serving as medical SME; • Investigating cases and collecting epidemiological information, including interviewing ill and exposed individuals (passengers, flight crew, airport staff, etc.); • Liaising with state health department/CDC as needed to identify a disease agent and arrange for laboratory testing; • Providing guidance regarding appropriate PPE and infection control measures; • Providing guidance regarding treatment or prophylaxis that may be needed for ill/exposed individuals; and • Leading any public information/messaging efforts in partnership with the airport. If there is a surge in demand for these services, the health department activates its Incident Man- agement Team, which coordinates with the Port of Portland, fire department, and EMS resources to handle the additional demand for services. training, drilling, and exercising Portland International has several real-world events each year that allow the review of protocols and training on the plan. In addition, the airport carries out regular tabletop and review sessions with stakeholders and public health partners. The training and exercises are evaluated using real-world observation and feedback confirming the effective and efficient practices of responders. The same methods are applied to all actual incidents. The airport performs an AAR on every drill and incident. The most recent airport communicable disease drill or exercise was in 2016, and the most recent drill

36 TABLE 16 STAKEHOLDERS INVOLVED IN COMMUNICABLE DISEASE PLANNING PROCESS AT PORTLAND INTERNATIONAL AIRPORT Stakeholder Airport Health Department Airport senior management Airport planning X Airport media/public relations X X Airport operations X X Airport emergency management X X Airport law enforcement X Airport rescue and firefighting and EMS X X Airport maintenance Airlines, air cargo companies, charter operators, and air taxi operators X Concessionaires X Mobility services (wheelchairs, carts) Airport sponsor/certificate holder General aviation aircraft owners and pilots Local health department X State health department X X CDC—Quarantine Station X X Other public officials (elected officials, etc.) TSA X X CBP X Military (airport is joint use) FAA Nonairport law enforcement X State agencies Local agencies X Health care coalition X Hospitals and clinics X Ambulances/medical transport services X HAZMAT—local fire department County emergency management City emergency management State emergency management Source: Smith and Greenberg data.

37 in which the health department participated was in 2014. The airport drills on communicable disease response at least every 2 years, but it also schedules a drill or exercise when regulatory requirements change; new procedures are introduced; or when the airport authority becomes aware of a new threat, such as a novel influenza or other communicable illness. Drills and exercises can also occur upon request from an airline partner or other stakeholder, or can be substituted for real-world incidents that require a fully tested response. The health department adds validation of plan revisions and when requested by the CDC Quaran- tine Station to this list. Portland International reports the ideal would be to have at least one communicable disease response drill or exercise each year, whereas the health department reports wanting to see drills or exercises once every 2 to 5 years. The airport provides a number of protective measures for airport employees, including training, PPE, and life-saving medications for Port of Portland employees and their families; the medications are delivered through the airport’s point of dispensing. communications The Port of Portland is an essential bridge between the health department and airlines and tenants. Before any health department releases any information to the public, the health departments contact the airport so that the airport PIO can get involved. For significant incidents, a JIC speaks with a single voice for the airport, health department, and other stakeholders. The JIC is a central asset in making the Portland International Airport plan work. Greatest Worry In the interview, the health department and the airport responders had different answers to the ques- tion of what constitutes their greatest worry. The Multnomah County Health Department respondents said they did not have a great worry because there is a good plan and a good organization based on strong relationships. However, measles is a serious concern because of vaccine-hesitant populations, particularly in Europe and Oregon, where the 2013 childhood immunization rate for the measles, mumps, and rubella vaccine was 89.4%, which is nearly 6% lower than the 95% rate required for herd immunity and approximately 2% lower than the U.S. National Immunization Survey rate (it also represents a decline of almost 4% from 2008). This concern is greater than the fear of exotic illnesses that basically are unknown. The Portland airport respondents’ greatest worry is airborne illnesses, particularly influenza viruses. The airport has had to deal with employees’ concerns about real-world exposure versus perceived threats. This was a major issue among airport and aircraft cleaners. Portland International has dealt with this worry by expanding its plan for airport employees and other tenants. The role of information is central; the airport has worked on health-risk messaging internally and externally, using seminars and tabletop exercises to communicate safeguards and procedures. lessons learned Portland International Airport reported: 1. 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 local fire department and EMS services with MedLink while the aircraft is airborne to discuss the medical condition. 2. Get to know your local EMS director and public health partners before an incident. They are a valuable resource; this includes getting to know their media relations team. 3. There are a lot of assumptions and misinformation about communicable disease; passengers want information. Ensure someone on your team is prepared to provide basic information about what is happening and what the passengers can expect.

38 Multnomah County Health Department reported: 1. There are a lot of regulations (federal, airline, port, first responder) that come together at an airport. 2. The Port of Portland is well structured to handle emergencies; the agency has its own prepared- ness planners, public information officers, fire and rescue teams, and law enforcement. 3. There is an existing medical support system for planes in flight, and multiple points exist for connecting with CDC Quarantine Station. 4. It is essential to have a plan and clear points of contact for communications. 5. Port of Portland fire and rescue teams and EMS are fantastic partners. 6. Having a good and professional local plan can meet local needs when Seattle Quarantine Station is overwhelmed during a national response. Greatest challenge “PR management—if the airport is not involved in the response initially, and a media release goes out about the ‘measles case’ flying through the airport, then we are in mitigate/reaction mode trying to quell the fears of the traveling public and our airport employees,” (K. Nobel, personal communica- tion, February 17, 2017). bottom line Portland International’s respondent estimated the level of overall preparedness to deal with a com- municable disease on an arriving flight as “very prepared.” The Multnomah County Health Depart- ment respondents estimated the level of overall preparedness to deal with a communicable disease on an arriving flight as “very prepared.” The conversation during the interview showed how closely the airport and the health department work together and how well they understand each other’s needs and capabilities. Portland Interna- tional Airport and its partners have had direct experience with a passenger becoming ill at home after passing through the airport. case 4: dallas/Fort Worth international airport and ebola (2014) After raging through western Africa, Ebola virus arrived in the United States on September 20, 2014, when United Flight 822, carrying Liberian national Thomas Eric Duncan, touched down at Dallas/ Fort Worth International Airport (DFW). Mr. Duncan had traveled to Dallas from Monrovia, by way of Brussels and Washington, D.C., to visit his fiancé and the mother of his 19-year-old son. He did not realize it at the time of his departure, but Mr. Duncan had become infected with the deadly virus, which he contracted from his landlord’s daughter in Liberia, whom he had helped carry to the hospital when she became ill. Although Mr. Duncan might have known that he had been exposed, his symptoms were not evident before or during his flight. Within days of his arrival, Mr. Duncan began to experience some of Ebola’s telltale signs: headache, nausea, and a temperature of 103 degrees. Arriving on his own accord at Texas Health Presbyterian Hospital, one of the region’s largest medical facilities, he was seen by a physician who provided a prescription for antibiotics and recommended several days of rest. Although the attending physician knew that Mr. Duncan had recently traveled to the United States from Liberia, the possibility of an Ebola infection had not occurred to the physician. Mr. Duncan’s condition began to decline rapidly over the next few days, until he returned to the hospital. This time, an intake nurse, realizing his path of travel, notified Dallas County Public Health’s epidemiology department to warn of a possible domestic case of Ebola. In its detailed account of America’s harrowing experience with its first Ebola case, Vanity Fair (Burrough 2015) described a series of breakdowns in communicable disease planning and response. The article alleged that the city of Dallas had no real plan to handle the outbreak and suggested the

39 federal government was equally unprepared. When calls were placed to the CDC, the agency report- edly did not initially consider Mr. Duncan a likely Ebola victim. Perhaps numbed to the “Ebolanoia” that had seized much of the U.S. media at the time, the CDC reportedly advised against any testing: “There was no indication he’d been to a funeral, no evidence he’d eaten bushmeat, no evidence of Ebola exposure. All he was was a gentleman from Liberia with a fever.” Only after local health officials pushed for testing from the Texas Department of State Health Services was a diagnosis confirmed (5 days later). This case example is based on the survey results from Dallas/Fort Worth International Airport and Tarrant County Public Health and a telephone interview on December 21, 2016. Dallas/Fort Worth International Airport is the fourth busiest airport in North America and 10th busi- est in the world, having served 64,074,762 passengers in 2015. In 2015, Dallas/Fort Worth Airport had 681,261 total aircraft movements (ranking third in the world, third in North America, and third in the United States) and handled 670,029 metric tons of cargo (ranking 40th in the world, 11th in North America, and 11th in the United States). The airport is served by 23 airlines and receives nonstop flights from 43 cities outside the United States and Canada (Table 17). In addition, Dallas/Fort Worth International Airport receives charter, cargo/freights, humanitarian support, emergency repatriation, corporate general aviation, and private (noncorporate) general avia- tion flights from outside the United States and Canada. The airport is a port of entry with a large resi- dent CBP contingent. Although the airport had a Quarantine Station from 2005 until 2008, it currently is served by the Quarantine Station in Houston, Texas. All of the terminals at the airport are located in Tarrant County, but much of the airport lies in Dallas County. In the surveys, Dallas/Fort Worth International Airport and Tarrant County Public Health noted having dealt with or prepared to deal with the diseases shown in Table 18 in the past 15 years. September 11, 2001, changed all the plans for Terminal D (the airport’s new international terminal) that was scheduled to open in 2003. Dallas/Fort Worth International Airport’s EMS Assistant Chief Broom brought years of experience in EMS to the building of a separate quarantine space with sepa- rate heating, ventilation, and air conditioning and negative pressure and furnishings and floor cover- ings that allow for decontamination. The quarantine space is an unfinished in-transit lounge. The CDC Quarantine Station staffed the space for a while (2006–2008), and a highly effective quarantine offi- cer brought public health and airport stakeholders together. Monthly disease-related meetings (with personnel from four counties plus the airport) in the airport’s emergency operations center (EOC) built relationships and allowed sharing of significant information. TABLE 17 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR DALLAS/FORT WORTH INTERNATIONAL AIRPORT Region Number Airports of Origin East Asia 2 Seoul, Tokyo Southwest Asia/Mideast 1 Dubai Europe 4 Frankfurt, London–Heathrow, Madrid, Paris Caribbean, Mexico, and Central America 28 Aguascalientes, Belize City, Cancun, Chihuahua, Cozumel, Guadalajara, Guatemala City, Hermosillo, Leon/Guanajuato, Liberia, Montego Bay, Mexico City, Morelia, Monterrey, Mazatlan, Nassau, Puebla, Panama City, Puerto Vallarta, Queretaro, Roatan, San Salvador, San Jose del Cabo, San Jose, San Luis Potosi, Torreon, Veracruz, Zacatecas South America 7 Bogota, Caracas, Ezeiza, Lima, Rio de Janeiro, Santiago, Sao Paulo Oceania 1 Brisbane Total 43 Source: Smith and Greenberg data, derived from nonostop.com/dallas-fort-worth-dfw (accessed Nov. 27, 2016).

40 recent experiences The Ebola outbreak began in West Africa (Guinea, Sierra Leone, Liberia, and Mali) in March 2014 and was declared controlled in mid-2016. By December 8, 2014, Ebola had sickened 17,000 persons and caused 6,500 deaths. When a patient has symptoms, transmission is by direct contact with body fluids (Broom 2014b). At the time of writing of this synthesis, there have been more than 21,000 cases worldwide, including nearly 8,500 deaths. Dallas/Fort Worth Airport and the Dallas area were actively involved with a response to Ebola from August 15, 2014, when a TSA screener at the airport who had traveled to Ivory Coast arrived at the airport, until October 28, 2014, when a third patient was discharged from the hospital and declared Ebola-free. The entire incident is chronicled in the time line reproduced as Appendix F (Broom 2014a). The time line shows the intense interactions among airport departments, the health department, Dallas-area hospitals, CBP, CDC, airlines, and the media. Federal agencies (U.S. Department of Health and Human Services-CDC and DHS) created the plan for U.S. airports. The plan focused on 1. Transmission prevention; 2. Exit screening in West Africa; 3. Identifying ill travelers at border entries; 4. Limiting U.S. entries to designated airports where enhanced entry screening and access to spe- cialized treatment had been established; 5. Connecting travelers with local health departments; and 6. Providing direct support to ill health care workers (Broom 2014a; CDC 2014). The Ebola experiences caused some changes in the communicable disease plan and planning pro- cess at Dallas/Fort Worth Airport. The frequency of meetings, training, and exercises was increased, and these activities mostly involved EMS, medical, and public information officers. Tarrant County Public Health is the major SME on reassurance measures for workers at the airport and procedures. Dallas/Fort Worth Airport’s pre-2014 plan addressed the Ebola incident adequately; however, the airport made additions to the plan to enhance screening and communications by setting up commu- nications among airports, tracking contacts, and protecting staff and employees. the plans and how developed Both the airport and the health department maintain communicable disease response plans. Dallas/ Fort Worth Airport’s communicable disease response plan is part of its AEP and business continu- TABLE 18 COMMUNICABLE DISEASE RESPONSES OR PREPARATIONS AT DALLAS/FORT WORTH INTERNATIONAL AIRPORT Disease Airport Health Department SARS X H1N1 X Measles X X Tuberculosis X X Ebola X X Chikungunya X X Swine flu X Zika X X Norovirus X Source: Smith and Greenberg data.

41 ity plan. The plan also is incorporated into the airport’s public safety standard operating procedures manual. The health department maintains a stand-alone communicable disease/quarantine plan. Table 19 compares the stakeholder lists provided by Dallas/Fort Worth International Airport and Tarrant County Public Health. The Dallas/Fort Worth Airport plan incorporates NIMS and ICS. The airport’s plan does not involve diverting inbound flights to other airports. Both the airport and the health department have regularly scheduled reviews and updates for their communicable disease response plans. health department services to the airport Tarrant County Public Health provides the following services at Dallas/Fort Worth Airport related to communicable disease responses: • Investigating cases and collecting epidemiological information, including interviewing ill and exposed individuals (passengers, flight crew, airport staff, etc.); • Liaising with state health department/CDC as needed to identify a disease agent and arrange for laboratory testing; • Instituting control measures (isolation and quarantine or other measures necessary to control disease spread); • Providing guidance on environmental cleaning measures/waste disposal; • Providing guidance regarding appropriate PPE and infection control measures; and • Providing guidance regarding treatment or prophylaxis that may be needed for ill/exposed individuals. If there is a surge at Dallas/Fort Worth Airport in demand for these services, the health agency makes a request to the state (known as a STAR request) through the emergency management chain as well as the state health department office. CBP has a large staff at the airport and the adjacent foreign trade zone and can surge. CBP is the primary health screener at the airport and has the legal authority to hold any incoming international passenger. Airport EMS and the health department get only one opportunity to make the right decision regarding a sick passenger while the passenger is held by CBP. CBP holds passengers long enough for the airport’s medics to resolve the issue. If the medics cannot resolve, they call Tarrant County Public Health for advice/ help. The county agency can call on the CDC Quarantine Station for assistance, but problems sometime arise because CDC’s on-call SME is not fully aware of the airport’s in-house capabili- ties and introduces inefficiencies by trying to start at the beginning of a standard step-by-step process. Dallas/Fort Worth International Airport personnel estimate the airport has two to eight commu- nicable disease incidents with international passengers per month. The number increases with wide- spread media reports of an illness, which leads to greater awareness of, and sometimes excessive anxiety regarding, potential threats. training, drilling, and exercising Dallas/Fort Worth Airport trains on its communicable disease response plan using quarterly briefings with CDC—Quarantine, CBP, and Tarrant County EMS, tabletop exercises, and AARs of all opera- tions, with the AAR being the primary evaluation tool. The most recent exercise was in 2015, and the next regularly scheduled drill will occur in 2017. Dallas/Fort Worth International Airport schedules a drill or exercise • Every 2 years; • When regulatory requirements change; • When new procedures are introduced; • When personnel become aware of a new threat; and • As part of the AAR/IP process.

42 TABLE 19 STAKEHOLDERS INVOLVED IN COMMUNICABLE DISEASE PLANNING PROCESS AT DALLAS/FORT WORTH INTERNATIONAL AIRPORT Stakeholder Airport Health Department Airport senior management X Airport planning Airport media/public relations X X Airport operations X Airport emergency management X X Airport law enforcement X Airport rescue and firefighting and EMS X X Airport training Airport maintenance Airport human resources X Airlines, air cargo companies, charter operators, and air taxi operators X Concessionaires X Mobility services (wheelchairs, carts) Airport sponsor/certificate holder General aviation aircraft owners and pilots Local health department X State health department X CDC—Quarantine Station X X Other public officials (elected officials, etc.) X TSA CBP X Military (airport is joint use) FAA Nonairport law enforcement National agencies State agencies Local agencies Health care coalition Hospitals and clinics X Ambulances/medical transport services Medical and nursing associations and societies HAZMAT—local fire department County emergency management X City emergency management State emergency management X Source: Smith and Greenberg data.

43 In addition, a real-world incident can substitute for a drill or exercise required by regulations. Tarrant County Public Health conducted a drill on its plan in 2016. The agency typically exercises as a part of the AAR/IP process, but as with Dallas/Fort Worth Airport, a real-world incident can substitute for a drill or exercise required by regulations. The airport provides protective measures for airport employees, including training, PPE, other equipment, vaccines, decontamination facilities, countermeasures, and medical checks. communications The airport communicates its plan to stakeholders by sharing copies, doing exercises, and inviting feedback to be used in updating the plan. Tarrant County Emergency Management communicates the county’s plan to stakeholders at the airport. The plan is also distributed through regional emergency management agencies. Dallas/Fort Worth Airport no longer has monthly meetings in its EOC with the four surrounding counties (Tarrant, Dallas, Collin, and Denton) as it did before 2010. However, under Texas law, each EMS provider is required to have an infection control officer. The Tarrant County Public Health infection control officer is in touch with Dallas/Fort Worth Airport on an average of once a week, but the actual frequency varies according to the cyclical nature of health risks and when they present for attention and response. One communications method that may be unique to Dallas/Fort Worth Airport involves the pro- cedure when a new foreign-flag carrier commences operations at the airport. The airline’s station manager meets with the airport’s public safety and EMS managers and experts to review policies and procedures for a crash, irregular operations, and communicable diseases. The meeting is followed that day by a communicable disease tabletop exercise. Greatest Worry The Tarrant County Public Health respondents indicated their greatest worry is an airborne disease such as measles or MERS-CoV. The Dallas/Fort Worth Airport respondents reported worrying that a patient who has no symptoms but has a contagious disease will pass through and unknowingly transmit the illness to others. Both the airport and the health department are confident that if they receive timely information on symptoms, they will secure a good outcome. Airport respondents would like to see future research leading to better use of emerging communications networks in rapidly evolving situations—getting the right people to understand what is important or what is not. Respondents reported that once a situation starts going downhill, it won’t stop going downhill until it hits the bottom. lessons learned Dallas/Fort Worth International Airport reported: 1. Prearrival information is suspect and must be verified in person by a competent responder. 2. When dealing with nonmedical or nonpublic safety individuals—that is, when dealing with the general public, airport employees, and airport business partners—use clear, plain language and anticipate that deeper explanations will be needed. 3. Be sure to take care of the caregivers. Tarrant County Public Health reported: 1. Review existing guidelines and determine if additional information can be shared with area hospitals. 2. Discuss concerns associated with transportation of confirmed or suspected cases.

44 3. Discuss contamination risks and decontamination procedures faced by first responders, public health, and medical care professionals in the prehospital environment. 4. Ensure communications from airlines to initial response partners occur in a timely manner. 5. Coordinate illness response procedures for Dallas/Fort Worth International Airport and state response partners. 6. Once on scene, provide initial and ongoing emergency medical coordination. Greatest challenge “Once the initial announcement was made, the communication challenge became one of educating decision makers in real time. Most executive-level staff do not contemplate communicable diseases regularly. They need as many hard facts as can be discerned without speculation. This was not a single episode but an ongoing process” (F. Broom, personal communications, February 28, 2017). bottom line Dallas/Fort Worth International Airport respondents estimated the airport’s level of overall prepared- ness to deal with a communicable disease on an arriving flight as “very prepared.” Tarrant County Public Health respondents estimated the agency’s level of overall preparedness to deal with a com- municable disease on an arriving flight as “very prepared.” case 5: boston loGan international airport and Five suspected ebola cases (2014) Boston Logan International Airport (BOS) is the 17th busiest airport in the United States and the 19th busiest in North America, having served more than 33 million passengers in 2015. In 2015, BOS had 372,928 total aircraft movements and handled 684,970 tons of cargo. Served by 40 air- lines, BOS receives nonstop flights from 48 cities outside the United States and Canada (Table 20). Its sponsor, the Massachusetts Port Authority (Massport) also operates Worcester Regional Airport and Hanscom Field. This case example was added at the request of the topic panel after the airport and local public health department surveys had been completed, so Boston Logan International Airport and the Boston Public Health Commission (BPHC) do not have survey results included in this study. On Monday, October 13, 2014, Boston Logan International Airport was alerted by ATC Boston, MedLink, and the airline that Emirates Flight 237, a Boeing 777 carrying 187 passengers and 19 crew, would arrive in 15 minutes with five passengers on board who were coughing, vomiting, and had TABLE 20 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR BOSTON LOGAN INTERNATIONAL AIRPORT (AS OF JUNE 2016) Region Number Airports of Origin Europe 20 Amsterdam, Cologne, Copenhagen, Düsseldorf, Frankfurt, Istanbul, Lisbon, London—Gatwick, London—Heathrow, Madrid, Manchester, Munich, Oslo, Paris, Ponta Delgada, Reykjavik, Rome, Shannon, Terceira, Zurich Caribbean, Mexico, and Central America 21 Aruba, Bermuda, Bridgetown, Cancun, Fort de France, Grand Cayman, Guadeloupe, Liberia (CR), Mexico City, Montego Bay, Nassau, Panama City, Pointe-â-Pitre, Port-au-Prince, Providenciales, Puerto Plata, Punta Cana, Santiago (DR), Santo Domingo, St. Lucia, St. Maarten Middle East 3 Doha, Dubai, Tel Aviv East Asia 4 Beijing, Hong Kong, Shanghai, Tokyo Total 48 Source: Smith and Greenberg data, derived from www.massport.com/logan-airport (accessed Feb. 28, 2017).

45 fever, all of which are symptoms of Ebola infection (Massport 2014; Tradani and Feathers 2014). At 2:27 p.m., Massport Fire Rescue dispatched equipment that was in position at Terminal E Gate 6 when the plane arrived. Massport Fire Rescue (“Fire Alarm”) notified BPHC and the CDC quaran- tine station located at JFK. At 2:55 p.m., Boston EMS arrived at Gate 6. A unified command had been established with Boston EMS/Supervisor, Massachusetts State Police, CBP, airport operations, and Emirates. The jet bridge was not connected to the plane, and the plane’s doors were not opened, which effectively put the plane into isolation (R. Barnes, personal communication, February 28, 2017). The unified command in Terminal E established contact with the pilot and determined that the five passengers had high fever and had been in contact with persons from Western Africa while traveling. The five passengers had traveled in seats scattered throughout the plane. The airline pro- vided passenger information. An incident command post was established at Gate 6 and manned by four firefighters led by an assistant. An incident action plan was formulated to enter the aircraft and perform patient assessment and removal. Boston EMS recommended transportation to a hospital. Hot/warm/cold zones were set up. Using universal precautions (with PPE), the team entered the plane, and two Boston EMS ambulances were readied for transport. Bleach spray decontamination was set up, a backup team was positioned, and a safety officer designated. PPE was provided to law enforcement officers (Massport 2014). At 3:37 p.m., the team entered the plane to assess the five patients, each of whom was placed in protective ensemble and removed from the aircraft. The final patient was removed by 4:35 p.m. Decontamination was performed on the entry team and their PPE, and cleaning materials were placed in an infectious contents box. The three fire engine crews cleared the scene and returned to their stations. The unified command was terminated (Massport 2014; R. Barnes, personal com- munication, February 28, 2017). The five travelers suspected of having Ebola were transported to two area hospitals for evalu- ation and diagnosis. By late in the evening, BPHC announced that there appeared to be no Ebola infection (Tradani and Feathers 2014). The five passengers also were found to not have MERS-CoV, meningococcal infection, or any other disease of public health concern (Al Arabiya 2014). At the airport, the entire incident, from alert to stand-down, lasted less than 3 hours, and the inci- dent, including patient assessment in the hospitals, lasted less than 6 hours. Airport operations were not significantly disrupted. The short duration, effectiveness of the response, and positive outcomes for the other passengers on the plane and at the airport appear to have been the result of smoothly coordinated action based on joint planning, training, and practice among the airport, the local public health department (BPHC), the state police, and other stakeholders (R. Barnes, personal communica- tion, February 28, 2017). Greatest challenge “Our biggest challenge was equipping all first responders—fire, State Police and U.S. Customs with proper PPE. And maintaining the ‘hot zone’ approach to a possible infectious disease approach is always a top priority. We also had to formulate a proper decontamination procedure. Our second big- gest challenge was relaying accurate and timely information to our PIO–Massport Media Relations. In the end, this was done with face to face communications” (R. Barnes, personal communications, February 28, 2017). case 6: vancouver international airport and h7n9 (2015) “There is no doubt. [H7N9] is by far the most worrisome strain [of influenza]. We don’t know what the reservoir is very well, there’s a bunch of things we don’t know about it and it’s causing a lot of very, very severe illness” (Dr. Michael Gardam, Director of Infection Prevention and Control, Uni- versity Health Network, Toronto).

46 On January 26, 2015, North America’s first documented case of H7N9 avian influenza was con- firmed when a Chinese national living in British Columbia’s Lower Mainland became sick after return- ing from a trip to China, where she was infected with the virus. Although the risk to other Canadians was considered low because there is no evidence that H7N9 transmits easily from person to person (its primary vector of transmission is from infected poultry to humans), passengers aboard Air Canada Flight 8, which arrived in Vancouver from Beijing, were notified of their possible exposure by PHAC. This was not the airport’s first experience with a deadly avian influenza. On January 8, 2014, Canada’s Health Minister Rona Ambrose (now interim leader of Her Majesty’s Loyal Opposition) announced that an Alberta resident, returning to Canada on December 27, 2013, aboard Air Canada Flight 030, had fallen ill en route from Beijing to Vancouver, where she waited for more than 2 hours before boarding Air Canada Flight 244 to Edmonton. The passenger eventually died of her disease on January 3, 2014. The illness was identified as H5N1 influenza (Vancity Buzz 2014). As with the more recent H7N9 case, PHAC took the lead in identifying and notifying passengers on both flights and used contact tracing to notify possible airline passengers who may have been exposed at the gates and other waiting areas. This case example is based on the survey results from Vancouver International Airport (YVR) and the PHAC (Western Region) and a telephone interview on December 2, 2016. Vancouver Inter- national Airport is the second busiest airport in Canada and the 29th busiest in North America. The airport served 20,486,935 passengers in 2015. In 2015, Vancouver Airport had 316,182 total aircraft movements (ranking 43rd in the world, 23rd in North America, and second in Canada) and handled 271,772 metric tons of cargo (ranking 84th in the world, 17th in North America, and second in Canada). The airport is served by 48 airlines and receives nonstop flights from 38 cities outside the United States and Canada (Table 21). In addition, Vancouver Airport receives charter, cargo/freight, industrial aviation (aircraft deliveries; maintenance and repair operations), humanitarian support (refugee flights), corporate general aviation, and private (noncorporate) general aviation flights from outside the United States and Canada. The airport is a port of entry with a resident PHAC quarantine station and a large resident CBSA unit. In the surveys, Vancouver Airport and PHAC Western respondents reported having dealt with or prepared to deal with the diseases shown in Table 22 in the past 15 years. recent experiences Vancouver Airport and PHAC Western Region have had a series of successes in applying their com- municable disease response plans. In the past few years alone, the partnership has dealt with a pas- TABLE 21 AIRPORTS OF ORIGIN OUTSIDE UNITED STATES AND CANADA FOR VANCOUVER INTERNATIONAL AIRPORT Region Number Airports of Origin East Asia 16 Beijing, Chengdu, Guangzhou, Hangzhou, Hong Kong, Kunming, Manila, Nanjing, Osaka, Qingdao, Seoul, Shanghai, Taipei, Tokyo, Xiamen, Zhengzhou South Asia 1 Delhi Europe 12 Amsterdam, Dublin, Frankfurt, Glasgow, London–Gatwick, London– Heathrow, Manchester, Munich, Paris, Reykjavik, Rome, Zurich Caribbean, Mexico, and Central America 10 Cancun, Huatulco, Ixtapa, Manzanillo, Mazatlan, Mexico City, Puerto Vallarta, San Jose del Cabo, Santa Clara, Varadero Oceania 3 Auckland, Brisbane, Sydney Total 42 Source: Smith and Greenberg data, derived from www.yvr.ca (accessed Nov. 27, 2016).

47 senger with H5N1 influenza and one with H7N9 influenza, another who arrived with untreated TB, and an outgoing sick 3-year-old child. The influenza cases were summarized earlier. The incident involving the sick child illustrates the major benefits of having a good plan and a strong, well-practiced partnership. After the plane of a foreign-flag carrier pushed back from the gate, the child became ill with fever and rash, appearing to be clinical. The pilot was not fully aware of the proper procedures under ICAO Document 4444, but the ATC tower and Vancouver Airport personnel knew what to do. The collaborative response was timely and effective because of the ongoing relationship building and “testing” of the plan. Per- sonnel of Vancouver Airport, ATC, PHAC, the local health department, EMS, ambulance services, CBSA, and CTSA convene several times during the year, which creates cohesiveness and prepared- ness. Having one clear point of contact with the local health department sped the response and resolution in this particular case—the child had varicella (chickenpox), which is a communicable illness but does not pose a serious public health threat. The total delay for the plane’s departure was about 20 minutes. Vancouver Airport also has experience in preparing for and responding to Ebola. In early 2014, public fear about the illness complicated all aspects of communicable disease preparedness and response. A young student arriving to Canada from West Africa by way of Toronto Pearson Inter- national Airport and continuing to a small airport in British Columbia became ill on the domestic flight between Toronto and Vancouver. The PHAC quarantine officer at Vancouver Airport had no jurisdiction under the Quarantine Act because the passenger became ill during a domestic flight but provided a professional opinion when asked by the medical director of the local health department. The local health department and Vancouver Airport took the lead in the response with PHAC advis- ing, all in a highly collaborative approach. Disruption of the plane’s arrival totaled 10 minutes. From SARS in 2003 to the present, the trajectory of communicable disease planning at Vancou- ver Airport and PHAC has been toward increasing a focus on prevention to avoid extra work and costs of epidemiological investigations and follow-up. Vancouver Airport and PHAC have evolving communicable disease planning documents because both are committed to continuous improve- ment. Training expands each year. For example, in early December 2016, PHAC hosted a tabletop exercise derived from the AARs on recent communicable disease incidents. Forty participants from stakeholders built relationships and learned policies and procedures, and the participants provided feedback to improve the PHAC and Vancouver Airport plans. TABLE 22 COMMUNICABLE DISEASE RESPONSES OR PREPARATIONS AT VANCOUVER INTERNATIONAL AIRPORT Disease Airport PHAC SARS X X H1N1 X X Measles X X Tuberculosis X X Ebola X X Chikungunya X Zika X X Dengue X H5N1 influenza X X Norovirus X X Cholera X Anthrax X Source: Smith and Greenberg data.

48 the plans and how developed Vancouver Airport maintains an airport pandemic plan that includes • Communicable disease plan, • Communicable disease response plan, • Business continuity plan, and • Quarantine plan. The pandemic plan and its component plans are part of the AEP and a part of the airport’s busi- ness continuity plan. The plan is communicated to other stakeholders through regular meetings of the Airport Emergency Planning Committee, tabletop exercises, and live (full-scale or functional) exercises with stakeholders. No part of Vancouver Airport’s plan contains SSI. The plan is reflected in the airport’s crisis communications plan and its business recovery plan, and is identified in the airport management’s risk profile and its human resources policies. The plan does not differentiate how to handle passengers from how to handle flight crews. The airport updates the plan on a regular schedule and when changes are indicated by the AAR of an incident or exercise. CBSA at Vancouver Airport has its own communicable disease/quarantine plan. PHAC Western Region maintains a separate communicable disease/quarantine plan that is shared with all stakeholders (including the airport) for input and review. PHAC does ongoing presentations that include scenarios based on actual incidents with the various agencies. The close working rela- tionship and frequent interactions between PHAC and Vancouver Airport make the two plans highly congruent. The PHAC plan is reviewed on a regular basis and when an AAR indicates a change is needed. The local health departments are fully engaged in the process; their functions in patient transport, EMS, and making hospital arrangements are fully reflected in both plans. Table 23 com- pares the stakeholder lists given by Vancouver Airport and PHAC Western Region. The Vancouver Airport plan does not incorporate NIMS but is based on ICS structures and procedures. The airport’s plan does not involve diverting inbound flights to other airports. health department services to the airport PHAC provides the following services at Vancouver Airport related to communicable disease responses: • Investigating cases and collecting epidemiological information, including interviewing ill and exposed individuals (passengers, flight crew, airport staff, etc.); • Instituting control measures (isolation and quarantine or other measures necessary to control disease spread); • Providing guidance on environmental cleaning measures/waste disposal; and • Leading any public information/messaging efforts in partnership with the airport. In addition, PHAC Western Region respondents indicated in the interview that the agency works closely with the local health department to provide other services to Vancouver Airport. See the Toronto Pearson International Airport case example for a list of these additional services. If there is a surge at Vancouver Airport in demand for these services, PHAC’s adjustment will depend on the size of the incident. Initially, PHAC Western Region can move staff to assist other stations; however, if such action is not sufficient, PHAC Western Region can request PHAC head- quarters assist by sending more surge capacity staff, such as environmental health officers or nurses who have had training and enhance that training on the ground with existing quarantine officers. training, drilling, and exercising Vancouver Airport and PHAC—and their stakeholder partners—train jointly on the airport com- municable disease response plan. Both recommend annual drills. The most recent drill was in 2015.

49 TABLE 23 STAKEHOLDERS INVOLVED IN COMMUNICABLE DISEASE PLANNING PROCESS AT VANCOUVER INTERNATIONAL AIRPORT Stakeholder Airport PHAC Airport senior management X X Airport planning X X Airport media/public relations X X Airport operations X X Airport emergency management X X Airport law enforcement X X Airport rescue and firefighting and EMS X X Airport training X Airport maintenance X Airport human resources X Airlines, air cargo companies, charter operators, and air taxi operators X X Concessionaires X Caterers X Mobility services (wheelchairs, carts) Airport sponsor/certificate holder X General aviation aircraft owners and pilots Local health department Provincial health department X PHAC—quarantine station X X Other public officials (elected officials, etc.) Transport Canada/Nav Canada X CATSA X CBSA X X Military (airport is joint use) X Red Cross X Transport Canada X Nonairport law enforcement National agencies X Provincial agencies X Local agencies X Health care coalition X Hospitals and clinics X Ambulances/medical transport services X X HAZMAT—local fire department X HAZMAT contractors X County emergency management City emergency management X Provincial emergency management Source: Smith and Greenberg data.

50 Vancouver Airport schedules a classroom session, seminar drill, tabletop exercise, functional exercise, or live exercise 1. Monthly (seminars, tabletop exercises); 2. Annually (live, full-scale); 3. When regulatory requirements change; 4. When new procedures are introduced; 5. When personnel become aware of a new threat; 6. To validate plan revisions; and 7. As part of the AAR/IP process. A real-world incident can substitute for a drill or exercise required by regulations. PHAC schedules a drill or exercise • Annually; • When the airport requests the agency lead an exercise; • When regulatory requirements change; • When new procedures are introduced; • When personnel become aware of a new threat; and • To validate plan revisions. An AAR is performed after every drill, exercise, or real incident. This is a written requirement of the airport’s emergency plan. The airport provides a number of protective measures for its employees, including training, PPE, other clothing, equipment, vaccines, decontamination facilities, and medical checks and counseling services. communications The most important communications link is that between PHAC Western Region and the Vancouver Airport emergency planning manager. Phone calls and e-mails are used when either partner becomes aware of a threat or a need to activate the plan. Vancouver Airport’s plan takes into account the pos- sibility of a passenger posting information on a possible illness from a flight that is in the air—the airport had this happen around 2010, which triggered its intensive efforts to implement social listen- ing for emergency management. Greatest Worry In the interview for this synthesis, Vancouver Airport and PHAC personnel raised two specific wor- ries. Both worry about the potential of a major incident occurring on a plane in flight, with the airport and PHAC being unable to respond in time. Security rules are changing and may not be uniform from airport to airport. Rules can delay access to a plane to attend to an ill person by as much as 20 minutes. CATSA recognizes EMS personnel as emergency responders and lets them pass immediately, but CATSA does not consistently recognize public health (quarantine) staff as having an urgent need for access to secure areas and a plane when a communicable disease is reported aboard. Vancouver Airport and PHAC personnel also worry about an undetected communicable disease getting passed to other passengers and airport employees with the result that enough airport employ- ees become ill that the airport’s business is affected. Many measures are available to the airport and PHAC when a communicable disease is known or suspected on an arriving flight. The worst case would be a pandemic with staff affected by fear or illness. lessons learned Vancouver Airport reported: 1. Communication across the breadth of stakeholders is fundamental to the success of the plan but is difficult to do well consistently because of changing personnel and skill levels.

51 2. A clear point of contact (leadership) to liaise with stakeholders and health authorities is needed. 3. An effective training program and protocols for frontline staff are fundamental to a successful response. PHAC reported: 1. Gathering and validating information is crucial. 2. Communication with partners is important and can mitigate many challenges, including anxi- ety if all on the ground are well versed with information and the plan of action because PHAC personnel usually are first to board the conveyance. 3. Communication with headquarters is vital in the event information is sent to headquarters by a different source. 4. Proper PPE is needed. 5. It is important to ensure before response that everyone is well versed with the plan so that dur- ing response the agency has one channel of communication with all stakeholders, including with the traveler. 6. It is important for everyone on board to remain seated until the assessment is fully conducted and to reassure and communicate with travelers if necessary. 7. It is important to gather proper information from the traveler to take action if needed. 8. To reduce traveler anxiety, provide information to the traveler as to why personnel are asking questions. 9. Communicate decisions to the director of the flight and all other partners as required. Greatest challenge “We learned from dealing with the potential impact of H1N1 the following two challenges: 1. Effectively getting all the agencies at the airport aligned with their prevention procedures and processes. 2. Determining and then mitigating the potential impact on the overall operation if a large num- ber of personnel within one or more agencies become afflicted” (C. Currie, personal commu- nication, February 20, 2017). bottom line Vancouver Airport personnel estimated the level of overall preparedness to deal with a communicable disease on an arriving flight as “very prepared,” with a need to improve drill and exercise frequency and gain ability to deal with communicable diseases on domestic flights. PHAC personnel estimated the level of overall preparedness to deal with a communicable disease on an arriving flight as “some- what prepared.” This response results from concerns about surge capacity/coordination. Surge capacity/ coordination may be an issue depending on the time of day and day of the week. It may be difficult to mobilize resources because of a lack of capacity. The alternative is to work with what PHAC has on the ground in terms of other key partners, which makes remote response protocols become paramount. For this reason, practicing protocols with other agencies may be needed more frequently than is done currently. During the interview, PHAC and Vancouver Airport personnel concurred that the level of preparedness at the airport reaches “very prepared” for communicable disease response. The conversation during the interview clearly showed how closely the airport and PHAC per- sonnel work together and how well they understand each other’s needs and capabilities. Vancouver Airport and its partners have had direct experience with a passenger getting sick on a flight; a pas- senger getting sick embarking or disembarking at the airport; and a passenger getting sick at home after passing through the airport (the H5N1 case is an example). summary oF common themes From case examples Table 24 shows the common themes in the answers provided by the six airports that served as case examples. All six airports had the benefit of 2 to 14 years’ experience since their reported incident to revise and improve their preparedness. Table 24 indicates current status and cannot be analyzed

52 TABLE 24 COMMON THEMES IN CASE EXAMPLES YYZ PHX PDX DFW BOS YVR Disease Incident SARS TB Measles Ebola Suspected Ebola H5N9 influenza Year 2003 2013 March 2014 September 2014 October 2014 2015 Common Themes Scenario(s) 3 1a 3 3 1 3 How airport learned of ill passenger LHD/PHAC LHD network LHD CDC/LHD ATC, MedLink, airline LHD, PHAC Main airport role Assist LHD in epidemiology, screening incoming passengers Assist LHD in epidemiology; care to caregivers Assist LHD in epidemiology Assist LHD in epidemiology EMS services; report symptoms; liaison with LHD; liaison with pilot; isolation of plane Assist LHD in epidemiology Isolation used in response at airport Nob No No Yes Yes No Quarantine used in response at airport No No No No No No Specific airports designated as points of entry for enhanced screening of passengers from affected countries or areas No No No Yes No No Main LHD role SME, epidemiology, medical coordination, PIO SME, epidemiology, medical coordination, PIO SME, epidemiology, medical coordination, PIO SME, medical coordination, PIO SME, medical coordination, PIO SME, epidemiology, medical coordination, PIO CDC/PHAC used as resource Yes Yes Yes Yes Yes Yes Airport EOC activated ? No No Yes Yes No NIMS principles used Yes Yes Yes Yes Yes Yes Mutual aid partners in addition to LHD involved ? Yes No Yes Yes PHAC Social listening (data scraping) applied No; Predates YYZ’s SMEM program No No No No Yes Social media used by airport or by airport/LHD partnership for notices, alerts, and warnings No; Predates YYZ’s SMEM program Yes No Response No Yes Yes Social media engagement with passengersc No; Predates YYZ’s SMEM program No No Response Yes Yes Yes Social media engagement with public No; Predates YYZ’s SMEM program No No Response No Yes Yes Care for caregivers Yes Yes Yes Yes Yes Yes Hot wash performed ? Yes Yes Yes Yes Yes

53 for temporal trends across 2003 through 2016. The data were gathered from July 2016 through February 2017. 1. The most common and challenging communicable disease situation for an airport involves a passenger who presents symptoms of illness after disembarking and leaving the airport but who may have contagious disease but no symptoms during flight (Scenario 3). However, the classic case of a suspected illness reported by the pilot of an aircraft that is en route (Scenario 1) presents the greatest challenges to the public health community. 2. Airports and public health partners are more likely to successfully manage a communicable disease incident if they have a long-standing working relationship and have jointly exercised their communicable disease response plans and activities. AAR performed by airport Yes Yes Yes Yes Yes Yes AAR/IP created ? Yes No Response Yes Yes Yes YYZ PHX PDX DFW BOS YVR Airport communicable disease response plan reviewed after incident Yes Yes Yes Yes Yes Yes Airport communicable disease response plan revised after incident Major Major Very minor for airport and one LHD, major for second LHD Major Major Major Revised airport communicable disease response plan tested Yes Yes Yes Yes Yes Yes Communicable disease communications incorporated or referenced in airport crisis or emergency communications plan Yes Yes Yes Yes ? Yes Communicable disease communications incorporated or referenced in airport business continuity plan and/or risk profile Unknown Yes Yes Yes ? Yes Biggest challenge to airport in response Loss of passenger traffic, resulting in revenue drop Avoiding miscommunication among response partners Public relations management Educating decision makers in real time PPE, decontamination procedures, and getting accurate and timely info to PIO Aligning procedures of response partners. Business continuity issues if many staff infected aScenario 1 (advance notification that passenger with suspected illness will arrive) was a medical diversion to BOS. bIsolation or quarantine is an unlikely part of airport response for a Scenario 3 incident for which epidemiology is a main response element. cSocial media engagement means two-way conversations, not just outgoing warnings and notices or incoming data scraping results. Source: Smith and Greenberg data. TABLE 24 (continued)

54 3. During communicable disease events, the designated public health partner is the lead to ensure that the risks to the population are managed as quickly as possible. The public health partner also is better able to describe the nature of the illness and its risk to the public through all com- munications channels, including social media. The public health partner usually can provide an effective public information officer. 4. Effective communication among stakeholders is vital to effective response and depends on a combination of clearly articulated plans and personal relationships. Emergency response is a trust-testing exercise, and trust is forged over time and between people. 5. Public health response to a communicable disease on an arriving flight (especially Scenario 1) necessitates prior planning and coordination for access in secure areas. This may involve the use of escorts or badges or both. 6. Both airport and public health personnel worry about their capacity to handle the surge demand that would be placed on them in the event of a major outbreak of communicable disease, such as a pandemic.