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55 chapter five Findings, ConClusions, and FuRtheR ReseaRCh Findings Appendix G, Checklist for Airport Communicable Disease Response Planning, presents the major findÂ ings from the surveys, interviews, case examples, and literature review done for this synthesis. The checklist is designed to inform the largest airports with passengers arriving on flights from outÂ side the United States and Canada, but it is scalable and adaptable for use by airports of all types and sizes. existing issues Partnerships and Relationships Strong, respectful preexisting relationships among airports, health agencies (local, state, and national), and other mutual aid partners and stakeholders characterize effective responses to communicable disease incidents and preparedness activities for them, including planning, training, drilling, exercisÂ ing, and evaluation. In such relationships, the partners understand each otherâs needs, duties, responÂ sibilities, capabilities, resources, strengths, and weaknesses. This allows an effective unified response that minimizes unnecessary public alarm, operational disruption, and damaging reputational or ecoÂ nomic consequences. Within the framework of the preparedness and response partnership, an airport manager can stay calm and follow the plan, thereby giving the public health and first responder experts time for eviÂ dence collection and factÂbased decisions. Similarly, an airport emergency manager manages coordiÂ nation, collaboration, and communication, both outbound and incoming. Planning and evaluation are the bookends to the process of building relationships for effective emergency management, with response and recovery activities being those relationships in action. Planning, training, drilling, exercising, and evaluating are productive ways to build healthy relationÂ ships to prepare an airport and its partners to deal with communicable diseases on arriving flights. Planning Process Airports and local agencies generally agree that broadÂbased stakeholder involvement in the planÂ ning process for communicable disease response is important. This applies whether the airport and health agencies have separate plans or share a plan. Experts from airport operations, public informaÂ tion, first responders, public health, airlines, and medical service providers typically are involved in drafting airport communicable disease plans, and an even broader list of stakeholders often is involved in reviewing the draft plan. Good plans usually incorporate schedules for periodic review or milestones that trigger reviews or both. Planning for communicable disease response can be a standÂalone process, part of the process to create or update an airport emergency plan (AEP), or part of another planning process such as contiÂ nuity of operations planning, business continuity planning, or comprehensive crisis communications or emergency communications planning. Increasingly, the practice is to create a standÂalone commuÂ nicable disease plan that is referenced in and coordinated with these other plans (Smith et al. 2016a).
56 Planning Outcomes The ideal outcome for an effective communicable disease response plan is the one seen in Case 5, about Boston Logan International Airport, which reports that a wellÂwritten, wellÂpracticed plan was carried out with the result that the incident lasted less than 3 hours, the airportâs operations were not disrupted, and there was no panic despite the heightened tension around Ebola in October 2014. Effective Practices A clear consensus among airports and local health departments points to five effective practices: 1. Establishment and maintenance of healthy relationships among response partners; 2. Respect for each partnerâs areas of expertise (for example, the health department as the mediÂ cal expert); 3. Broad involvement of stakeholders in the development of the plan; 4. Regularly scheduled joint training, drilling, and exercising; and 5. Application of a continuous improvement process that involves hot washes, afterÂaction reviews (AARs), and IP planning. Plan Format Options Provided that the plan is clear and flexible, it can take almost any form as a written document. Other studies have found that a separate plan that is referenced in the AEP is effective and avoids the need for FAA review each time the communicable disease response plan is revised. Regardless of the nature of the written plan, mutual congruence with other airport plansâAEP, airport security program, airport emergency/crisis communications plan, airport recovery plan, airport business continuity plan, airport continuity of operations plan, airport irregular operations planâis important. Response Strategies and Patterns Because any of the four scenarios can happen at an airport, the airportâs communicable disease plan needs response strategies and patterns that can apply effectively. Clear, precise, prompt communicaÂ tion of developments to the partners in the response is essential, as is respect for the role. Response Triggers/Algorithms for Response Each of the possible first points of contact (the first person at an airport to receive word of a possible communicable disease case on an arriving flight) needs adequate training and practice on how, when, and whom to notify to initiate response. Ideally, an airportâs plan addresses all four scenarios, and each of the plan sections will be trained and exercised jointly with the local health department and other response partners so that the algorithms for response become as close to automatic as possible. The Boston Logan International Airport case example, which reports only 15 minutesâ notice of the arrival of five possible Ebola cases on a plane with nearly 200 persons onboard, shows the imporÂ tance of such preparation. An essential part of the triggering phase of the response is the activation of the emergency operations center (EOC). Steps and Sequences Other studies (e.g., Smith et al. 2014; Smith et al. 2016b) have shown that implementation of plans can be enhanced by breaking the plans into standard operating procedures on cards or in electronic forms that inform responders of their duties and the sequences of their actions. Monitoring Response Monitoring response and recovery is a major duty of the EOC or incident commander. For communiÂ cable disease incidents, a Unified Command that includes airport operations, EMS, law enforcement, and the local health department will exercise command and control, which includes monitoring.
57 Mitigation The key aspects for mitigating the impacts of a communicable disease incident at an airport are isolaÂ tion, clear communications among responders and to the passengers and the public, proper personal protective equipment (PPE) for airport responders, and a coherent decontamination strategy. Even more, a strong training and exercise program will mitigate the impacts of an incident. Communications Strategies Because an airportâs business and reputation can be damaged by public perception of the effectiveÂ ness of a communicable disease response, the airport and its local health department partner can beneficially work together to optimize the use of each otherâs special knowledge and tools. This is particularly true of communications with the general public, public officials, and airport workers. One effective practice is to connect the airport communicable disease response plan to the airportâs crisis communications plan and include strategies and responsibilities for using social media in the plans (Smith et al. 2016b; Smith and Kenville in press). Relationships with airport emergency Plans and Business Continuity Plans The Toronto Pearson International Airport case example (Case 1) shows the potentially large finanÂ cial impacts of a communicable disease incident on an airport. Several airports noted in their survey responses a concern with having too few workers to operate normally during an epidemic. evaluating and Measuring the effectiveness of Responses The case examples show several ways of evaluating the effectiveness of response to a communicable disease incident: â¢ Extent to which public health was protected; â¢ Duration of operational disruption; â¢ Injury to the airportâs reputation; and â¢ Financial loss. No metrics were found in the literature for any of these, probably because of the rarity with which large communicable disease incidents have occurred. However, there are generally accepted ways to evaluate and measure the effectiveness of responses: 1. Hotwash immediately after the end of the response and recovery; 2. AAR; 3. Improvement plan to create action items to correct deficiencies that were documented in the AAR; 4. Tracking action on improvements; and 5. Consideration of how many deficiencies show up as uncorrected on subsequent AARs (Smith 2014; Smith et al. 2016a). MajoR ConClusions Recent communicable disease outbreaks and the fears they generated have caused airports and their local public health coordinators to forge stronger relationships and engage in more joint planning activities to protect public health and ensure business continuity. Large airports with flights arriving from outside the United States and Canada are most affected; however, airports of all types and sizes are increasingly aware of their need for enhanced preparedness. This heightened sense of awareness led many airports and health departments that participated in this study to rate themselves as âsomeÂ what preparedâ to respond to a communicable disease on a flight arriving at their airport. Although many have established robust protocols to deal with prospective threats, greater awareness has led to a rising of standards. This is reflected in the wide agreement that annual reviews and annual exercises
58 of communicable disease response plans are an ideal to be pursued, despite that fewer than 25% of airports and barely one in five local health departments test their plans annually. Preliminary conclusions and topics for future research were subjected to expert validation that involved interviews with five senior health officials from U.S., Canadian, and international agencies. The purpose of these interviews was to test the main findings and identify additional research needs. The draft conclusions and possible future research needs shown in Appendix DÂ3 were provided in advance to the five interviewees. The lessons learned as reported in the survey responses and interviews have been consolidated into six major thematic conclusions summarized here. In addition to being used to generate the list of conclusions in this chapter, the entirety of lessons learned is reflected in Appendix G, especially in the Outline for Model Airport Communicable Disease Response Plans. This synthesis identified conclusions in six major areas: 1. Comprehensive Planning a. Effective organizations and partnerships jointly plan to ensure airport safety, operational continuity, and protecting public health. Airport and public health media experts need to be involved in the planâs development. b. Managing isolation and containing a communicable disease incident at an airport tax scarce resources. The challenges of isolation involve passengers, locations, duration, issuing orders, providing basic needs for prolonged holding, legal authority, and public messaging. Space to screen/triage/isolate large numbers of passengers on airport grounds is limited. c. Plans need to deal with procedures by airports and public health partners to handle the surge demand that would be placed on both in the event of a major incident with an arriving flight or an outbreak of communicable disease, such as a pandemic. d. Airport and public health media experts need to be involved in the planâs development. e. Airport communicable disease response plans work most effectively when coordinated with the airportâs business continuity plan, AEP, recovery plan, and crisis communications plan. 2. Partnership and Stakeholder Engagement a. If the airportâs EOC is activated, the Unified Command needs to include a public health representative. b. Effective practices include airports using their local public health department as a subÂ ject matter expert (SME) and healthÂrelated public information expertise used early in the response. c. When an illness is detected on board, prearrival information is verified in person by a comÂ petent responder. d. Airports and health departments broadly agree on the importance of including an array of stakeholders in planning and generally agree on the identities of those stakeholders. e. Airports and public health partners are more likely to manage a communicable disease incident effectively if they have an established working relationship. f. A conference call among the responders and key stakeholders as soon as a possible incident is known to have occurred is highly effective for situational awareness and to clarify roles and responsibilities. 3. Legal Issues a. Everyoneâs understanding of public health procedures, such as isolation and quarantine, is different. b. Many airports are concerned that they may not adequately understand their duties, responsiÂ bilities, and rights under laws and regulations concerning communicable disease response. 4. Strategic Communications a. Effective communicable disease responders provide comprehensive, clear, and transparent communication with stakeholders, the public, and media. b. Risk communication can provide reassurance to travelers and others affected by communiÂ cable disease incidents. c. Clear, coordinated, and consistent messaging is essential to protecting public health and managing the uncertainty of the incident.
59 d. A joint information center (JIC) is helpful in effectively managing information and communication. e. Effective public information officers and counselors communicate with and provide supÂ port to passengers, crews, and meeters and greeters. f. Challenges in communicating with travelers who do not speak a common language or who may have visual, auditory, or other sensorial conditions may be a barrier to communicable disease response. 5. Exercising, Drilling, Training, and Education a. Management of communicable disease works more effectively when public health officials understand the operational and security needs of airports and when airport and security managers understand the needs and processes of public health officials. b. Airports and public health partners are more likely to manage a communicable disease inciÂ dent effectively if they have jointly trained, drilled, and exercised their communicable disÂ ease response plans and activities. c. Taking care of the caregivers includes providing adequate training, personal protective equipment (PPE), medical services, and counseling as needed/required. 6. Evaluation and Continuous Improvement a. Surveyed airports and public health partners report that AARs held after all drills, exerÂ cises, and realÂworld incidents are beneficial and need to involve the airport, public health department/agency, and other defined stakeholders. b. Tracking corrective actions and using AAR results allow the continuous improvement of response plans to enhance future responses. FuRtheR ReseaRCh The synthesis identified six areas for future research. Those areas are presented here in the form of analytical questions. â¢ What procedures are in place to get prompt passenger information that is timely and complete to the agencies that need it? â¢ What security issues face public health responders in an airport setting? â¢ What additional information on the risk of transmission of disease on aircraft and in aviation settings is needed and how can it be obtained? â¢ What are the sociocultural factors that shape reaction to a communicable disease involving aviation, and how do airports and public health stakeholders use established and emerging media technologies to inform and engage the public as partners in response? â¢ What are the most effective means for communicating about communicable disease, especially in an airport setting, to the general population and the traveling public? â¢ How effective are exit screening and other border exclusion strategies for protecting the public from disease threats?