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Airport Roles in Reducing Transmission of Communicable Diseases (2019)

Chapter: Chapter 2 - Discussions: What We Learned

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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
×
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
×
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
×
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
×
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Suggested Citation:"Chapter 2 - Discussions: What We Learned." National Academies of Sciences, Engineering, and Medicine. 2019. Airport Roles in Reducing Transmission of Communicable Diseases. Washington, DC: The National Academies Press. doi: 10.17226/25367.
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3 CHAPTER 2 Discussions What We Learned or regions experiencing disease outbreaks. Multiple speakers encouraged airport officials to appreciate both the value of being prepared for communicable disease outbreaks and the risk of not being prepared. Airport Risk Management Activities Invited speakers from U.S. airports—Deb Helton and Dustin Jaynes of DFW; Christopher Rausch of Phoenix Sky Harbor International Airport (PHX); and Kori Nobel of the Port of Portland, which is the authority that oversees the Portland (Oregon) International Airport (PDX)—emphasized the importance of developing, test- ing, and continuously improving communicable disease response plans (CDRPs). The plans should be designed to prevent the introduction and spread of communicable diseases via air travel throughout the event. These air- port officials presented many examples of communicable disease concerns associated with air travel, ranging from localized disease transmission occurrences (e.g., tubercu- losis transmission on flights or measles transmission in gate areas) to regional and international transmission facilitated by air travel (e.g., SARS or pandemic influenza). Discussions about airport risk management centered on three aspects of CDRPs: • Developing a communicable disease response plan. • Testing the communicable disease response plan. • Reevaluating and revising the communicable disease response plan. Developing a Communicable Disease Response Plan The intent of the Insight Event was not to provide com- prehensive guidance on developing CDRPs. However, the four invited speakers from airports discussed their planning efforts, and this section reviews key points from the presentations. Although it is expected that details in airports’ plans differ due to site-specific considerations, According to Ms. Deb Helton of Dallas–Fort Worth International Airport (DFW), airports throughout the United States and worldwide differ in many regards: their size, the number and variety of domestic and international flight routes they serve, their relation- ship with local and county governments, their public health partners for international and domestic flights, and whether they have dedicated professional emergency managers. Nonetheless, a common theme that individual participants discussed is that airports can help reduce transmission of communicable diseases by preparing for and responding to outbreaks, thus helping to ensure the health of communities in a globally mobile world. This chapter summarizes the Insight Event discussions on the four key subtopics identified by the planning committee and lists some resources available to airports for their communicable disease planning efforts. Risk ManageMent The planning committee suggested that the Insight Event address the importance of risk management. Airports, public health agencies, and various other stakeholders are encouraged to assess and manage communicable disease risks before outbreaks occur, particularly for diseases of greater public health significance (e.g., diseases with airborne person-to-person transmission that cause serious illness). Dr. Cetron emphasized that a collabora- tive approach to preparedness and response is consistent with goals outlined in the National Incident Manage- ment System. The System was developed to help “pro- vide a consistent framework for Federal, State, and local governments to work effectively and efficiently together to prepare for, respond to, and recover from domes- tic incidents, regardless of cause, size, or complexity” (FEMA 2017). Dr. Illig noted that an adequately prepared airport can help reduce disease transmission while ensuring continu- ity of operations throughout outbreak scenarios. This is a much-preferred and realistic option to more severe reactions, like attempting to isolate individual airports

4 R E D U C I N G T R A N S M I S S I O N O F C O M M U N I C A B L E D I S E A S E S they will likely share some common features. These fea- tures include establishing an incident command post or emergency operations center, identifying a unified com- mand team, coordinating stakeholders, training stake- holders, selecting and providing appropriate personal protective equipment (PPE) to involved parties, establish- ing processes and protocols for responding to threats of varying scale and complexity, and describing the facility infrastructure (e.g., isolation areas or designated aircraft parking areas) related to disease outbreaks (GAO 2015). When developing plans, Ms. Helton and Mr. Jaynes encouraged airport officials to prepare for a broad range of communicable disease threat scenarios, not just those of greatest risk or consequence. As one example, during the 2014–2016 Ebola virus disease scare, some airports largely prepared for infected passengers arriving on international flights. However, one of the known cases of an Ebola-infected passenger on a flight in the United States occurred on a domestic flight. Further, airports should be prepared for the fact that communicable dis- ease events do not always originate with traveling pas- sengers, as demonstrated by an incident in which an airport responded to a Transportation Security Admin- istration (TSA) agent with travel history to West Africa who became suddenly ill while on the job during a time of heightened concern about Ebola virus disease. In this case, a response was necessary even though it was later confirmed that the TSA employee did not have Ebola virus disease. Airports therefore were encouraged to pre- pare for local transmission of disease even when illness had been documented elsewhere. Finally, speakers from public health agencies, including Dr. Marcelle Layton of the New York City Department of Health and Mental Hygiene and Russell Jones of Tarrant County Public Health (Fort Worth, Texas), noted that some response actions will be pathogen specific. Alternatively, they will be at least specific to the mode of transmission (e.g., air- borne versus droplet versus contact with bodily fluids) and duration of pre-infectious and infectious stages. The planning would ideally also consider the different means by which airports learn of specific communicable disease threats. In some cases, airports learn of sick trav- elers on arriving flights, and this notification typically comes through air traffic control, airport operations, or airline medical teams. However, Dr. Rebecca Sunenshine of Maricopa County Public Health (Phoenix, Arizona) said airports should also be prepared for notifica- tion coming from unexpected channels. Planning for in-flight notifications should consider the possibility of airports receiving notification of ill travelers with limited advance warning before the estimated time of arrival and the possibility that notifications may come with few medical details on the ill passenger. Alterna- tively, and more commonly, airports may learn from public health authorities that a traveler who previously passed through the airport had onset of communicable disease symptoms after arrival, and the traveler might have been infectious while at the airport. Dr. Sunenshine continued that airport plans should be prepared for both scenarios and described appropriate response actions regardless of the notification source. Communicable disease response efforts typically require contributions from multiple individuals, from initial threat assessment to full execution of the response plan. Invited speakers, as described below, shared strate- gies for collaborating among the many different parties involved in response activities. For instance, Mr. Rausch and Dr. Sunenshine explained why critical response actions should never rely on a single individual, because outbreaks may occur when primary contacts are on vacation or otherwise unavailable. From airport first responders to local public health departments, plans should establish clear lines of authority and notifica- tion protocols based on the nature of the events. Every person mentioned by name in CDRP contact lists should be aware of their specific roles and responsibilities referenced in the plans. According to Mr. Rausch and Dr. Sunenshine, for all key stakeholders, CDRP contact lists should include multiple contact options (e.g., office phone number, cell phone number, and e-mail address), including preferred method of contact to use outside business hours and on weekends and holidays. Backup contacts, alternate contacts, or “call-down lists” were encouraged in case primary contacts are unavailable. Contacts for interpreters and translators are important for communicating with passengers who do not speak English. Ideally, all contact lists should be annually reviewed to ensure they remain up-to-date. Many strategies are available for sharing information among key stakeholders. Mr. Rausch described how all stakeholders post the airport’s CDRP in electronic for- mat to a secure web-based portal that is accessible. He stressed the importance of information sharing between stakeholders during all stages of response: as soon as possible after notification of a communicable disease concern, after completing the initial threat assessment, and so on. Conference calls and in-person meetings between all parties are an effective means for ensuring that stakeholders are fully informed and can quickly implement actions assigned to them. Use of commer- cially available emergency mass notification systems can facilitate these notifications and interactions. In some cases, airports might be asked to share video camera footage of passenger activity at gates, within terminals, at baggage claim carousels, and in other locations to assess the extent to which potentially contagious pas- sengers interacted with other travelers and to identify areas requiring disinfection. Dr. Layton emphasized the need to know in advance which ambulance services are willing to transport patients

D I S C U S S I O N S 5 suspected of having high-risk communicable diseases and which local medical facilities are equipped and willing to accept, evaluate, and treat those patients. In many cases, the hospital best suited to accept, evaluate, and treat is not the nearest medical facility to the airport. (Note: Know- ing the closest hospital is still important when traveling passengers are clinically unstable and in need of immedi- ate care, even if the individual is suspected of having a communicable disease of public health concern.) Experi- ence during the 2014–2016 Ebola virus disease outbreak indicated that some medical facilities—including certain hospitals—were not willing to accept patients suspected of having the disease. CDC has information on hospi- tals that have agreed to accept patients suspected of hav- ing communicable diseases of public health concern and have appropriate infection control protocols and other protective measures for doing so. Dr. Layton also encour- aged emergency planners to memorialize agreements with ambulance carriers and hospitals in memoranda of understanding or some other mechanism. Airports were also encouraged to consider employee preparedness in their CDRPs. Ms. Nobel recommended establishing contingencies for a high percentage of employee absences, even among essential employees. This scenario may occur during certain disease outbreaks (e.g., pandemic influenza) due to illnesses among employ- ees and their family members. Employees may also miss work for fear of exposure to communicable diseases— an issue that education and training on infection con- trol measures can help address (see the Resources section at the end of this chapter). Coordination with human resources may be needed to implement new vaccination programs, clarify sick leave policies, or develop guidelines and protocols for issues of concern (e.g., whether and under what circumstances employees may wear masks to work). Ms. Nobel described a strategy adopted by the Port of Portland to foster employee preparedness: par- ticipation in the “Push Partner Registry.” This program provides for rapid distribution of medication and other health-related services to employees and their families in the event of a communicable disease outbreak, bioter- rorism attack, or similar event. Reduced absences among employees are anticipated when the workers are assured that their entire families are cared for. Speakers shared many additional considerations for communicable disease response planning. An issue dis- cussed throughout the Insight Event was the jurisdic- tional authority to detain passengers who are confirmed to have, or who are suspected of having, a commu- nicable disease. Chapter 2 summarizes this discussion. Some simple infection control strategies, mentioned by Dr. Amy Sullivan (now with the Washington State Department of Health) and others, include implement- ing various measures during periods of heightened con- cern about communicable disease transmission such as increased cleaning of “high-touch” areas and place- ment of hand sanitizer dispensers throughout terminals. Dr. Ansa Jordaan from the International Civil Aviation Organization (ICAO) encouraged airports to consider whether their geographic region’s climate might sustain seasonal or year-round mosquito populations presenting risks for certain diseases (e.g., Zika virus). This is a topic the ICAO is in the process of addressing through the Airport Vector Control Register and a risk assessment and decision-making tool regarding aircraft disinsec- tion. Finally, Dr. Gaber discussed approaches for triag- ing passengers on arriving flights when a passenger is suspected of having a highly contagious communicable disease. One approach Dr. Gaber adopted was the use of color-coded cards to categorize passengers based on risk. Red-colored cards were used to denote the index passen- ger, who is immediately isolated and, if necessary, trans- ported to a local hospital. Yellow-colored cards were used for close contacts and flight attendants who served the index passenger, and those individuals were directed to health screening. Green-colored cards were used for all other passengers and flight crew, and those individuals were given informational leaflets and allowed to pro- ceed with their travels. Invited speakers identified several resources for further information on emergency management needs in the con- text of communicable diseases. The American Association of Airport Executives, Airports Council International– North America, the International Association for Emer- gency Managers, and other professional organizations can provide technical information and guidance. Additionally, smaller airports seeking to enhance their emergency management capability can learn from experiences at larger airports. Ms. Helton noted that DFW, for exam- ple, is establishing an Emergency Management Academy of Aviation at its Fire Training Research Center that will offer various emergency management courses, includ- ing a course specific to public health issues. See Appen- dix C for more information on the resources available to airports. Testing the Communicable Disease Response Plan Dr. Cetron emphasized the value of CDRPs and urged colleagues against accessing these plans only during out- break scenarios. Rather, because CDRPs establish criti- cal processes with roles and responsibilities assigned to numerous stakeholders, airports must ensure that the plans undergo routine testing. Emergency or crisis sce- narios are not appropriate times to implement plans or to meet stakeholders for the first time. Nearly every airport has tests, drills, and exercises to prepare for responding to mass causality incidents,

6 R E D U C I N G T R A N S M I S S I O N O F C O M M U N I C A B L E D I S E A S E S natural disasters, and manmade events (e.g., bomb threats). However, fewer airports have similar activities for communicable disease responses. Ms. Helton, Mr. Rausch, Ms. Nobel, and Dr. Gaber all emphasized that tabletop exercises, drills, and functional and full- scale exercises are invaluable in identifying vulnerabilities, improving overall preparedness, and fostering collabo- ration among stakeholders. The stakeholders involved in responding to communicable disease concerns differ from the stakeholders with typical responses to accidents or mass casualty incidents. These speakers said airports should consider different scenarios when conducting exercises, such as responding to an incoming aircraft with passengers suspected of having communicable diseases and learning from a public health authority that a traveler with a communicable disease recently passed through the airport. The exercises should be conducted routinely and test all activities from ini- tial threat assessment to the broader public health response. Walking through every step of the response will help ensure that seemingly minor details do not become major impediments during an actual event. Such details can include ensuring public health depart- ment officials know exactly where to access the airport, whether they know to access airside or landside, and ensuring that all key players have access to PPE and have been trained on how to use. Designated observ- ers can evaluate performance during the exercises and recommend improvements. Even “false alarms” or “no-case” scenarios can be viewed as opportunities to evaluate and improve plans. During times of heightened alert for communicable diseases, false alarms become increasingly common. Dr. Sullivan cited several examples of hypersensitivity among the traveling public during the Ebola and SARS outbreaks, in which even the slightest health concern of an airline passenger would trigger activation of an airport’s CDRP. These responses, which were essentially unplanned and unscripted drills, had many benefits, including assuring the public of the airport’s prepared- ness and allowing the airport to conduct post hoc evalu- ations of their response. Reevaluating and Revising the Communicable Disease Response Plan Ms. Helton and Mr. Rausch encouraged airports to view their CDRPs as living documents to be frequently evalu- ated and continuously improved. Every training pro- gram, exercise, drill, disease outbreak, and even “false alarm” of outbreaks can be viewed as an opportunity to reflect on and reevaluate plans and improve them. Plans may need to be revised to address challenges associated with new emerging infectious diseases. Invited speakers listed many events that led them to reevaluate their CDRPs. For example, Mr. Jaynes explained how DFW updated its plan to integrate les- sons learned from a recent tabletop exercise to assess pre- paredness for MERS outbreaks, and Mr. Rausch noted how Phoenix revisited its plan after identifying vulner- abilities when responding to an incoming flight with a passenger who was suspected of having infectious tuberculosis. In both cases, debriefings and after-action meetings among the key stakeholders were used to iden- tify improvements. Another airport reported conduct- ing quarterly case reviews to assess activities during the previous 3 months (e.g., what worked, what did not work, or what can be improved). Finally, airports were encouraged to check elements of their CDRPs against standard operating procedures and plans adopted by other airports to the extent they are available. Through these and other activities, airports can ensure that their CDRPs incorporate best practices from throughout the industry. Other Perspectives on Risk Management Activities At the federal level, many agencies have responsibili- ties for reducing transmission of communicable disease via air travel and in airports. Discussions at the Insight Event largely addressed CDC’s role, though agency offi- cials acknowledged their coordination with other gov- ernment agency partners (see the Stakeholders section that follows). While CDC has a much broader role than addressing airport-specific issues, this summary focuses on topics specific to airports and air travel that were mentioned during the Insight Event. Drs. Cetron, Layton, Sullivan, and Sunenshine shared many examples of preparedness activities for reducing communicable disease transmission associated with air travel. They explained that CDC and other agen- cies monitor emerging infectious diseases worldwide to assess those that pose the greatest risk for spread into and within the United States, thus allowing the public health community to be prepared for imported cases from affected regions. They further noted that CDC maintains 20 quarantine stations at ports of entry nation- wide, where medical and public health officers work to limit introduction of communicable diseases into the United States, prevent spread of disease through travel, and coordinate with airport and public health partners to enhance their preparedness. Finally, these speakers indicated that, in 2017, CDC led six communicable dis- ease exercises with various domestic and international partners, reviewed and updated more than 20 CDRPs, and held workshops to educate partners on developing effective CDRPs.

D I S C U S S I O N S 7 In terms of communicable disease response, much of the Insight Event discussions addressed the Ebola virus disease outbreak in West Africa, where the response from CDC and other agencies was multifaceted. Dr. Illig explained that the general response activities included sup- porting the local public health system to ensure cases were promptly identified, isolated, monitored, and cared for. General response activities also included identification and tracking of close contacts and education and support for the health care delivery system (i.e., clinicians, hospitals, urgent care facilities, and other medical care providers). The priority issues for domestic airports and air travel interests during the Ebola virus disease outbreak were to prevent spread of disease from affected areas to other locations, whether through diagnosed patients seeking treatment abroad or through undiagnosed travelers. Dr. Cetron listed specific measures to be considered for implementation. These measures included the following: limiting all incoming air travel passengers from Ebola- affected regions to the United States to a few selected airports with CDC quarantine stations and building fur- ther public health response capacity at those airports; implementing primary exit screening in the affected regions with visual inspections, temperature readings, and questionnaires about exposure history; conducting additional assessment by trained public health profes- sionals (secondary screening) for those identified with signs or symptoms compatible with Ebola virus disease or those who reported potential exposure to Ebola; and implementing targeted entry risk assessment with differ- ent actions taken for all travelers from outbreak areas and for those travelers who have reported symptoms or other risk factors for Ebola virus disease exposure. The overall response did not stop at the airport, as CDC further ensured that state and local health departments implemented ongoing monitoring of passengers arriv- ing from Ebola-affected regions to ensure cases did not develop in the United States. The recent Ebola virus disease experience from 2014 to 2016 provided valuable lessons learned on how to implement these strategies. Dr. Illig shared examples of lessons learned about passenger-screening strategies such as careful planning so that exit screening does not interfere with commerce and travel itineraries, balancing protection of public health against respect for personal liberties, ensuring screening is conducted in a manner that does not raise fear among passengers, and apply- ing screening to all passengers and crew members (i.e., no exclusions). Another lesson learned was that even highly effective exit screening measures will not identify all infected or “at risk” travelers, especially when people are motivated to hide their exposure history—and this lesson underscores the importance of preparedness at airports that receive these passengers. Invited speakers also discussed how contributions from the academic and research community are informing communicable disease preparedness. Dr. Khan described one such contribution: a modeling analysis used data on air travel, climate, ecological habitats, and other fac- tors to predict which regions worldwide might eventu- ally see local transmission of Zika virus, whether on a seasonal or ongoing basis. The grander vision of these data-driven models is to inform airports and health care workers when they appear to be “in the path of” certain disease outbreaks. While the available models account for an impressive array of factors that affect communi- cable disease transmission, they do not yet fully capture the underlying complexities regarding emergence, trans- mission, and broader spread of communicable diseases. Drs. Khan and Cetron supported further development and refinement of these models, but they emphasized that air- ports and other stakeholders must continue to prepare for communicable disease outbreaks, regardless of the threat level suggested by predictive or anticipatory models. The aviation sector is another component of the broader communicable disease preparedness efforts. An attendee noted that most major airlines have pandemic response teams that work in parallel with airports to prevent transmission of communicable diseases. The air- lines routinely address related issues of concern, such as use of appropriate PPE for aircraft cleaning crews, strat- egies for disinfecting aircraft, and whether to provide fee waivers to passengers who are scheduled to travel to areas affected by disease outbreaks and wish to change or cancel their itineraries. Dr. Sullivan relayed an expe- rience of coordinating with airlines to learn about the specific technologies and strategies that they implement to prevent disease transmission. stakeholdeRs Many different stakeholders contribute to airports’ role in reducing the spread of communicable disease transmission. These include individuals and organiza- tions who prepare and help execute preparedness and response plans and those whose jobs and activities are affected by these plans. Addressing communicable dis- ease risks involves coordination among experts from numerous disciplines and therefore requires multisector and multipartner collaboration, sharing of information and best practices, and regularly scheduled meetings and joint exercises. The Insight Event presentations identified different stakeholders for communicable disease issues and discussed their roles, jurisdictional responsibilities, and opportunities for collaboration. Airport Perspectives Ms. Helton, Mr. Jaynes, Mr. Rausch, and Ms. Nobel listed the various stakeholders involved with their

8 R E D U C I N G T R A N S M I S S I O N O F C O M M U N I C A B L E D I S E A S E S communicable disease response planning efforts. The primary airport department identified as a key stake- holder is emergency management, given the existing relationships with many other stakeholders of interest. Other airport departments or organizations involved with communicable disease response issues include emergency medical services (EMS), operations, public information officers (PIOs), executive management, law enforcement, and customer care teams. Airlines, other onsite employers, contractors, and unions also were identified as stakeholders. These speakers listed numer- ous external stakeholders, both at the local level (e.g., public health departments, health care delivery system establishments, or emergency management officials from surrounding jurisdictions) and at the national level (e.g., CDC, U.S. Customs and Border Protection, or TSA). Airport officials described how they interacted and engaged with various stakeholders, emphasizing the need to delineate roles, responsibilities, and jurisdic- tional authorities clearly. For example, Mr. Jaynes and Mr. Rausch emphasized the importance of knowing who has the responsibility and authority for deciding when to isolate, quarantine, or conditionally release travelers on flights with concerns about communicable diseases, and how those responsibilities and authorities vary for inter- national and domestic flights. Understanding this author- ity, as well as whether anyone has authority to hold an entire departing flight due to communicable disease con- cerns, will lead to a more coordinated response. No single approach was discussed, because stakeholder roles are ultimately expected to vary from one airport to the next airport based on site-specific issues (e.g., whether airports are run independently by port authorities or a similar organization or have oversight by cities, counties, states, or even multiple states or whether the airport has a CDC quarantine station). The appropriate stakeholders from state and local public health departments vary by jurisdiction. Dr. Julie Morita, Planning Committee Chair for the Insight Event, explained that public health agencies typically have mul- tiple specialties within their organizations that could be involved with communicable disease threats and air travel. These specialties include emergency preparedness, infectious diseases, immunizations, public relations, and others. Airport officials would benefit by ensuring that their stakeholder engagement efforts target the appropri- ate specialties within their public health agency partners. Merely identifying stakeholders is not enough to ensure effective communicable disease response. Several invited speakers emphasized the need for emergency manage- ment officials to engage regularly with key stakeholders, as the first contact with a key stakeholder should never occur during a crisis scenario. Dr. Layton noted the value of holding periodic in-person meetings with key stake- holders, at frequencies ranging from quarterly to annu- ally, in addition to interactions that occur during planned exercises and drills. There may be a need for more fre- quent meetings following revisions of CDRPs, staff turn- over, and other circumstances. A common issue addressed in multiple presentations, particularly the presentations pertaining to New York, Phoenix, and Portland, is jurisdictional authority for detaining and isolating passengers due to concerns of communicable disease transmission, which is an issue that underscores the balance that airport and govern- ment officials must strike between the need to simulta- neously protect public health and also individual civil liberties. In several incidents reviewed during the Insight Event, airport officials, public health agencies, and law enforcement officials voiced uncertainty about the spe- cific circumstances under which they can temporarily detain passengers out of concern of communicable dis- ease transmission and how this authority varies based on traveler location (e.g., while still at the airport or after having left the airport). Dr. Sunenshine recalled a specific experience, in which public health officials had concerns about a potentially contagious passenger, but documen- tation had not yet arrived to confirm this concern and local law enforcement was not comfortable detaining the passenger under those circumstances. While federal regulation authorizes isolation, quar- antine, and conditional release for travelers confirmed or reasonably believed to have or to have been exposed to a quarantinable communicable disease (as defined by executive order) and recent updates to federal regu- lation have added clarity to this issue, such as specific provisions for due process, questions remained about these authorities among participants. Mr. Jones and other speakers encouraged parties involved with emer- gency management efforts to be aware of federal agency authority and state and local authority, if any, to isolate cases and quarantine contacts. Dr. Sunenshine encour- aged emergency planners to consider nuances in these respective authorities. These nuances include how the authority situation changes if the case is confirmed as opposed to the case only being suspected; the recog- nition that laboratory confirmation of actual disease among suspected cases can take several hours or days; and whether local public health departments must visu- ally inspect a passenger before issuing an isolation order in cases in which they have that authority or whether they can issue an isolation order by phone based on details provided by EMS. CDC’s website on legal authorities for isolation provides more information on this topic (see https://www.cdc.gov/quarantine/aboutlawsregulations quarantineisolation.html). National Perspectives Dr. Cetron described the various CDC communicable dis- ease planning, preventive measures, and response efforts

D I S C U S S I O N S 9 that occur at the national level and noted the many part- nerships the agency has developed pertaining to airport roles in reducing transmission of communicable diseases. While CDC has a leadership position on this topic, CDC frequently engages with a number of other organizations: • International organizations, such as the World Health Organization (WHO), ICAO, the International Flight Services Association, and ministries of health in numerous countries. • Numerous federal agency partners, such as the U.S. Department of Homeland Security and agencies within that department (e.g., TSA, U.S. Customs and Border Protection), the Federal Aviation Administra- tion, the Occupational Safety and Health Administra- tion (OSHA), the Food and Drug Administration, and the Department of Agriculture. • State and local partners, including airport authorities, public health agencies, fire departments, law enforce- ment, and EMS. • Various other groups, including airlines, trade associa- tions, and nongovernmental organizations. CoMMuniCations The planning committee advised that effective commu- nications between various airport stakeholders is critical for ensuring that concerns about communicable diseases and air travel do not become pandemics of fear and mis- information. Effective communication strategies have many components. They address both internal airport communications and interactions with external parties (e.g., airlines, inflight medical consultation services, the media, or government officials), health education mes- sages that airports need from medical authorities, and information and data sharing with public health agen- cies. The invited speakers addressed many communica- tions challenges, such as the need to dispel myths, address public perceptions of risk, and issue clear and consistent messaging, especially during disease outbreaks. Insight Event discussions addressed three types of communica- tions: with travelers and the public, with various airport personnel, and with the media and through social media. Communicating with Travelers and the Public Ms. Helton and Dr. Sullivan emphasized the need to ease fears about travel during times of disease outbreaks among traveling passengers and the broader public. Fail- ure to do so can lead to concerned passengers cancel- ing flights with subsequent impacts on tourist revenue, which was demonstrated by the considerable economic impacts that some areas experienced during the SARS outbreak (as reported by Dr. Khan). However, in today’s highly interconnected digital world, with many aircraft now equipped with wireless connections, it is possible that misinformation, rumors, and sensational accounts of risks can travel faster than the aircraft themselves. The Insight Event’s invited speakers discussed many strate- gies for ensuring effective communications about com- municable disease concern to travelers and the public: • Ms. Nobel and Dr. Sullivan shared experiences from the Portland International Airport. Specifically, an ill airline passenger requiring emergency medical atten- tion for suspected communicable disease can be frightening to other passengers on the same aircraft. Whenever possible, potentially exposed passengers should receive health information before leaving the airport or at least receive an informational leaflet and contact information for designated public health offi- cials in case passengers have additional questions in the ensuing days. Failure to provide this information may result in hundreds of passengers seeking medical advice from their individual physicians, who may not be aware of the specific communicable disease concerns from the flight. One example shared by Dr. Sullivan was a “contact information card” that the Portland International Airport provided to all passengers on an aircraft with concern for communicable disease trans- mission. This particular card is designed to be torn into two pieces, and these pieces serve different pur- poses. First, on one part of the card, passengers enter their contact information and relative position on the aircraft and return the completed information to the public health authority, allowing for prompt follow up should subsequent testing of the ill passenger reveal a communicable disease of concern. Second, the other part of the card includes contact information for the local and state public health departments, which pas- sengers retain and are encouraged to use should they develop illness shortly after arrival. • When communicating with a general audience of pas- sengers regarding communicable disease threats, Ms. Helton noted that airport officials typically rely on public health agencies to develop talking points and messaging. Information must be disseminated effec- tively and quickly such that airports “own” the nar- rative before other parties (e.g., the media or bloggers) define messages and circulate them through social media or other channels. These communications can achieve multiple goals, like raising awareness among airport customers of a communicable disease threat, inform- ing traveling passengers of signs and symptoms to look for, and reminding them of basic personal hygiene prac- tices. Many different methods are available to dissemi- nate messages from conventional handouts of health

1 0 R E D U C I N G T R A N S M I S S I O N O F C O M M U N I C A B L E D I S E A S E S advisories and travel health notices to broadcasting public health messages on airport monitors. • Ms. Nobel, Mr. Rausch, and Ms. Helton emphasized that airport PIOs play an essential role when commu- nicating health messages to the public, because PIOs are trained in the nuances and sensitivities associated with communicating effectively to the public. Airport PIOs understand the need to deliver consistent mes- saging that is calming and clear and reassures that an entire airport is not contaminated. • Outreach and communications during a communica- ble disease outbreak scenario, especially one involving international travel into large metropolitan areas, must be culturally sensitive and in languages appropriate for the travelers and affected areas of interest. Dr. Layton noted that messaging should be conducted in a man- ner that does not place a stigma on people known or suspected to have a disease or on entire communities that might be associated with a disease. Compliance with federal accessibility requirements will ensure that outreach messages are accessible to people who are blind or visually impaired, deaf or hard of hearing, or have other disabilities. • Invited speakers shared two specific examples of health communications messaging for airport customers dur- ing a period of heightened concern about the Ebola virus disease. First, Dr. Cetron noted that CDC has developed Check and Report Ebola Kits (CARE Kits) that offered detailed information specific to Ebola virus disease and included information and tools to help travelers participate in the required postarrival monitoring. CDC ensured that all incoming travelers who were in a country with an Ebola virus disease outbreak received these kits. Second, Ms. Helton and Mr. Jaynes explained how DFW received health edu- cation messages from Mr. Jones and other local pub- lic health officials and shared them with the airline operations center, 911 operators, and other airport stakeholders that serve as the first line of commu- nication with the traveling public. This preparation helped the airport to respond to an increasing amount of inquiries from the public (e.g., “Is it safe to fly?” “Should I come to the airport?” “Are there any travel restrictions?” “How do you disinfect the terminal?”) but also know which questions should be deferred to public health officials (e.g., “What should I do if I think I might have a communicable disease?”). Communicating with Various Airport Personnel Larger airports in the United States sustain thousands of jobs, including airline and airport employees, secu- rity personnel, fuel services workers, concessionaires, caterers, mobility providers, and others. During com- municable disease outbreak scenarios, continuity of air- port operations can be jeopardized if employees do not report for work. Dr. Illig noted that increased worker absences among airlines serving airports in Ebola- affected countries led some airlines operating in West Africa to recruit volunteers for certain airport positions during the outbreak. Communications strategies, there- fore, should also aim to provide information and aware- ness to all workers at airports, regardless of employer. Example strategies for effective communications to workers included the following: • During the Ebola virus disease scare, Mr. Jaynes explained how DFW used health education materials developed by CDC to inform first responders about Ebola virus disease transmission modes and how to recognize the earliest symptoms of disease. The air- port also consulted with expert medical professionals, Doctors Without Borders, public health agencies, and other organizations to provide informational materi- als to first responders. The airport ensured that all workers who might have direct contact with affected passengers received these precautions, as even workers who specialized in emergency medical services needed assurances and education about handling potentially infected travelers. • Although first responders come into closest contact with potentially contagious passengers, airports typi- cally have hundreds or thousands of other workers who also are at risk for communicable disease trans- mission. Ms. Nobel described several instances where an infected passenger passed through the airport but was not symptomatic or did not report to public health officials until several days later. In those cases, the airport worked with the affected airline and local public health department to research thoroughly the ill passenger’s activities in the terminal. Closed-circuit television footage often helped provide detailed information on the ill passenger’s movements and contacts with other travelers and airport workers. This research allowed the public health department to issue highly detailed health education messages to workers that specified the precise locations where, and the times when, the ill passenger was in the ter- minal. Such detailed information was well received by workers because they could then better under- stand their risk. In this case, workers in different concourses or on different shifts were assured that their risk was minimal, and the remaining workers were provided educational information about the disease of interest. • Ms. Nobel also emphasized that all workers directly involved with communicable disease response activi-

D I S C U S S I O N S 11 ties, both at airports and with key stakeholders, would benefit from being trained and educated on the CDRP and how it relates to their positions. Emer- gency planners would then benefit from considering what training to give, to whom, and how often, as well as the optimal means of training delivery. The remaining airport workers (e.g., concessionaires, res- taurant workers, or shuttle bus drivers) can benefit from educational messaging about communicable disease transmission, particularly during periods of heightened concern about outbreaks. Airport news- letters, flyers, and educational signs in worker lounges can remind workers of basic personal hygiene prac- tices and other infection control measures that will help protect them from pathogens. Airports were also encouraged to adopt messages issued by public health agencies regarding when sick workers should stay at home, such as during periods of widespread influenza activity in an airport’s metropolitan area. Communicating with the Media and Through Social Media As illustrated by a newsreel shown at the 2-day Insight Event, the traditional news media have reported on pre- vious communicable disease outbreaks within the con- text of air travel and sometimes in an overly sensational fashion. Some discussions addressed the extent to which airport PIOs and other stakeholders can coordinate with traditional news media in advance of outbreaks to ensure that future reporting is done responsibly, thus making the media more of an asset than an adversary during crisis situations. Dr. Cetron indicated that CDC has previously engaged health reporters across different news media outlets to educate them on emergency pre- paredness and response efforts in the hopes that report- ing during future outbreak situations will be based on facts and not hyperbole. Regardless of the extent of advanced coordination with the traditional news media, invited speakers acknowledged that effective messaging to media outlets is critical, especially considering how quickly media can become involved. Dr. Sunenshine, for example, relayed an example of a local public health department receiving its first media inquiry about an arriving passenger suspected of having infectious tuber- culosis approximately 2 hours after the aircraft landed. Dr. Sullivan shared a similar example in which media outlets deployed reporters to cover Ebola concerns for an incoming passenger at approximately the same time that public health officials began responding. Communications with the media should not be limited to traditional news outlets. Mr. Jones emphasized that a large segment of the population, particularly younger people, obtain news and information largely, if not entirely, through social media. Mr. Jones, Ms. Helton, Dr. Cetron, and other speakers encouraged PIOs to leverage social media to educate the public about com- municable disease threats associated with air travel. This education can occur both by issuing messages through social media outlets and by monitoring social media for misinformation and rumors, recognizing that accounts of potentially ill air travelers can spread rapidly on social media even before an arriving aircraft lands. In short, social media allows rapid distribution of messages to large audiences and can be monitored for inaccurate information and alternate story lines that airports and public health officials might need to address. infRastRuCtuRe The built environment at airports—and the practices used to operate and maintain the built environment— can affect potential communicable disease transmission. Examples include allowing for adequate, designated space for passenger evaluation and isolation and imple- menting effective housekeeping, custodial, and infection control practices. Insight Event discussions pertaining to infrastructure addressed the following topics: • The extent to which airports have infrastructure to triage and isolate sick passengers greatly varies. Air- ports with CDC quarantine stations, for example, have infrastructure to temporarily isolate and evalu- ate ill passengers. Dr. Cetron showed a photograph of a typical setup, which includes a negative pressure isolation room with enough space to accommodate an ill passenger, the passenger’s family members, and public health officers and an anteroom stocked with PPE and medical supplies. The stations are sited near the U.S. Customs and Border Protection fed- eral inspection service facilities and are accessible to the airport apron to facilitate EMS transport from aircraft but are not large enough to isolate numer- ous passengers and do not have the equipment for performing advanced diagnostics and medical treat- ment. However, many ports of entry nationwide have inadequate designated isolation and quarantine facili- ties, and some ports of entry lack this infrastructure altogether. Airports were encouraged to consider this infrastructure issue when developing their CDRPs. • Disinfection of surfaces in airport terminals and air- craft can help reduce communicable disease transmis- sion. Ms. Nobel encouraged airport officials to research their current disinfection protocols and practices and update them as necessary, both for routine disinfec- tion and for targeted decontamination (e.g., cleaning areas where passengers recently vomited). Janitorial,

1 2 R E D U C I N G T R A N S M I S S I O N O F C O M M U N I C A B L E D I S E A S E S custodial, and other staff with responsibility for dis- infecting surfaces should be trained and equipped with sufficient supplies and, where necessary, PPE. More- over, airports were also encouraged to be prepared to adjust their disinfection practices during disease outbreak scenarios or at the request of public health authorities and to consult with hazardous materials units when concerned about the presence of high- consequence pathogens. Aircraft disinfection faces these same issues, and the additional challenge for airlines in selecting disinfectants is ensuring they do not compromise aircraft structure or the performance of critical components. Dr. Jordaan noted that further information on this topic can be found in the World Health Organization’s 2009 Guide to Hygiene and Sanitation in Aviation. (Note: the concepts in this para- graph also apply to the selection and use of insecticides as part of strategies for aircraft and airport vector con- trol. This is an issue that has received increased atten- tion in recent years as concerns grow about Zika virus and other vector-borne diseases and as some countries outside the United States implement mandatory air- craft disinsection requirements for in-bound flights.) • Many workers from multiple employers respond to communicable disease threats at airports, and Ms. Nobel addressed the need for protecting work- ers from contracting diseases through performing their job responsibilities. These workers—first responders, public health officials, aircraft cleaning crews, and others—are provided PPE to ensure that they are not exposed to pathogens and to ensure that their response activities do not lead to further disease transmission. Per OSHA regulation, employers are required to assess their workers’ PPE needs, provide the PPE, and train the workers on use. PPE selection should balance the needs of protecting workers against ensuring workers are comfortable, able to communicate effectively with colleagues, and perform tasks that require manual dexterity. All employers involved with planning for and responding to communicable disease incidents involving air travel were encouraged by Ms. Nobel to routinely monitor their inventories of PPE, medical supplies, and other related equipment. ResouRCes Throughout the 2-day Insight Event, invited speakers referred to resources available to airports and other stakeholders to enhance their communicable disease response efforts. Appendix C presents bibliographic information for the specific documents referenced and shown during the invited speakers’ presentations. This list is not a comprehensive bibliography of all informa- tion resources related to airport roles in reducing trans- mission of communicable diseases, because the list only includes documents and other information resources mentioned by invited speakers. Websites for govern- ment agencies and other organizations (e.g., CDC or ICAO) and the published literature include numerous additional documents that are topically relevant.

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TRB's Conference Proceedings 55: Airport Roles in Reducing Transmission of Communicable Diseases summarizes a 2-day Insight Event convened by the Airport Cooperative Research Program and its Insight contractor, Eastern Research Group, Inc., March 6 and 7, 2018, in Washington, D.C. The event addressed four subtopics: risk management, stakeholders, communications, and infrastructure. Discussions centered on the roles of airports in reducing transmission of communicable diseases. Speakers represented the federal government, domestic and foreign airports, local public health agencies, an international aviation organization, and academia. The conference proceedings focused largely on strategies, best practices, and suggestions that pertain specifically to airports and transmission of communicable diseases, as identified by the invited speakers.

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