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19 APPENDIX C Resources Identified During Presentations Smith, J. F., and J. Greenberg. 2017. ACRP Synthesis of Air- port Practice 83: Preparing Airports for Communicable Diseases on Arriving Flights. Washington, D.C.: Transpor- tation Research Board. http://www.trb.org/Publications/ Blurbs/176419.aspx. Vonnahme, L. A., M. R. Jungerman, R. K. Gulati, P. Illig, and F. Alvarado-Ramy. 2017. U.S. Federal Travel Restrictions for Persons with Higher-Risk Exposures to Communica- ble Diseases of Public Health Concern. Emerging Infec- tious Diseases, Volume 23(13). https://wwwnc.cdc.gov/ eid/article/23/13/17-0386_article. WHO. 2005. Strengthening Health Security by Implementing the International Health Regulations: About IHR. World Health Organization. http://www.who.int/ihr/about/en/. WHO. 2009. Guide to Hygiene and Sanitation in Aviation: Module 1: Water, Module 2: Cleaning and Disinfection of Facilities. Geneva: World Health Organization. http:// www.who.int/ihr/ports_airports/guide_hygiene_sanitation_ aviation_3_edition_wcov.pdf. WHO. 2014. WHO Interim Guidance for Ebola Virus Disease: Exit Screening at Airports, Ports and Land Crossings. Geneva: World Health Organization. http://apps.who.int/iris/ bitstream/handle/10665/139691/WHO_EVD_Guidance_ PoE_14.2_eng.pdf. WHO. 2015. Handbook for the Management of Public Health Events in Air Transport: Updated with Information on Ebola Virus Disease and Middle East Respiratory Syndrome Coronavirus. Geneva: World Health Organization. http:// www.who.int/ihr/publications/9789241510165_eng/en/. WHO. 2016. Vector Surveillance and Control at Ports, Air- ports, and Ground Crossings. Geneva: World Health Organization. http://www.who.int/ihr/publications/ 9789241549592/en/. CDC. 2007. Interim Pre-pandemic Planning Guidance: Com- munity Strategy for Pandemic Influenza Mitigation in the United StatesâEarly, Targeted, Layered Use of Non- pharmaceutical Interventions. Atlanta, Ga.: CDC. https:// www.cdc.gov/flu/pandemic-resources/pdf/community_ mitigation-sm.pdf. CDC. 2018. CDC Yellow Book 2018: Health Information for International Travel. Centers for Disease Control and Prevention. Atlanta, Ga.: CDC. https://wwwnc.cdc.gov/ travel/page/yellowbook-home. Code of Federal Regulations, Title 42, Chapter I, Subchapter F, Part 70, Interstate Quarantine. Updated Jan. 29, 2017. Code of Federal Regulations, Title 42, Chapter I, Subchapter F, Part 71, Foreign Quarantine. Updated Jan. 29, 2017. Cohen, N. J., C. M. Brown, F. Alvarado-Ramy, H. Bair-Brake, G. A. Benenson, T.-H. Chen, A. J. Demma, N. K. Holton, K. S. Kohl, A. W. Lee, D. McAdam, N. Pesik, S. Roohi, C. L. Smith, S. H. Waterman, and M. S. Cetron. 2016. Travel and Border Health Measures to Prevent the International Spread of Ebola. Morbidity and Mortality Weekly Report, Supplements; 65 (Suppl-3):57â67. https:// www.cdc.gov/mmwr/volumes/65/su/su6503a9.htm. FEMA. 2017. National Incident Management System, 3d ed. Washington, D.C.: U.S. Department of Home- land Security. https://www.fema.gov/media-library-data/ 1508151197225-ced8c60378c3936adb92c1a3ee6f6564/ FINAL_NIMS_2017.pdf. GAO. 2015. Air Travel and Communicable Diseases: Com- prehensive Federal Plan Needed for U.S. Aviation Systemâs Preparedness. Washington, D.C.: U.S. Gov- ernment Accountability Office. https://www.gao.gov/ assets/680/674224.pdf.
TRANSPORTATION RESEARCH BOARD 2018 EXECUTIVE COMMITTEE* OFFICERS CHAIR: Katherine F. Turnbull, Executive Associate Director and Research Scientist, Texas A&M Transportation Institute, College Station VICE CHAIR: Victoria A. Arroyo, Executive Director, Georgetown Climate Center; Assistant Dean, Centers and Institutes; and Professor and Director, Environmental Law Program, Georgetown University Law Center, Washington, D.C. EXECUTIVE DIRECTOR: Neil J. Pedersen, Transportation Research Board MEMBERS Scott E. Bennett, Director, Arkansas Department of Transportation, Little Rock Carlos Braceras, Executive Director, Utah Department of Transportation, Salt Lake City Ginger Evans, President, Tower Consulting, LLC, Arlington, VA Nathaniel P. Ford Sr., Executive DirectorâCEO, Jacksonville Transportation Authority, Jacksonville, FL A. Stewart Fotheringham, Professor, School of Geographical Sciences and Urban Planning, Arizona State University, Tempe Susan Hanson, Distinguished University Professor Emerita, Graduate School of Geography, Clark University, Worcester, MA Steve Heminger, Executive Director, Metropolitan Transportation Commission, San Francisco, CA Chris T. Hendrickson, Hamerschlag University Professor of Engineering, Carnegie Mellon University, Pittsburgh, PA Jeffrey D. Holt, Managing Director, BMO Capital Markets, NY S. Jack Hu, Vice President for Research and J. Reid and Polly Anderson Professor of Manufacturing, University of Michigan, Ann Arbor Roger B. Huff, President, HGLC, LLC, Farmington Hills, MI Geraldine Knatz, Professor, Sol Price School of Public Policy, Viterbi School of Engineering, University of Southern California, Los Angeles Melinda McGrath, Executive Director, Mississippi Department of Transportation, Jackson Patrick K. McKenna, Director, Missouri Department of Transportation, Jefferson City Brian Ness, Director, Idaho Transportation Department, Boise James P. Redeker, Commissioner, Connecticut Department of Transportation, Newington Leslie Richards, Secretary, Pennsylvania Department of Transportation, Harrisburg Mark L. Rosenberg, Executive Director, The Task Force for Global Health, Inc., Decatur, GA Gary C. Thomas, President and Executive Director, Dallas Area Rapid Transit, Dallas, TX Pat Thomas, Senior Vice President of State Government Affairs, United Parcel Service, Washington, D.C. (Retired) James M. Tien, Distinguished Professor and Dean Emeritus, College of Engineering, University of Miami, Coral Gables, FL Dean H. Wise, Consultant, Dean Wise LLC, Winchester, MA Charles A. Zelle, Commissioner, Minnesota Department of Transportation, Saint Paul EX OFFICIO MEMBERS Ronald Batory, Administrator, Federal Railroad Administration, U.S. Department of Transportation Mary R. Brooks, Professor Emerita, Dalhousie University, Halifax, Nova Scotia, Canada, and Chair, TRB Marine Board Mark H. Buzby (Rear Admiral, U.S. Navy), Administrator, Maritime Administration, U.S. Department of Transportation Steven Chalk, Deputy Assistant for Secretary for Transportation, U.S. Department of Energy Steven Cliff, Deputy Executive Officer, California Air Resources Board, Sacramento Howard R. Elliott, Administrator, Pipeline and Hazardous Materials Safety Administration, U.S. Department of Transportation Daniel K. Elwell, Acting Administrator, Federal Aviation Administration, U.S. Department of Transportation Audrey Farley, Associate Administrator for Administration, Pipeline and Hazardous Materials Safety Administration, Washington, D.C. LeRoy Gishi, Chief, Division of Transportation, Bureau of Indian Affairs, U.S. Department of the Interior, Washington, D.C. John T. Gray II, Senior Vice President, Policy and Economics, Association of American Railroads, Washington, D.C. Brandye Hendrickson, Acting Administrator, Federal Highway Administration, U.S. Department of Transportation Nikola Ivanov, Director of Operations, Center for Advanced Transportation Technology Laboratory, University of Maryland, College Park, and Chair, TRB Young Members Council Donald Jackson (Major General, U.S. Army), Deputy Commanding General for Civil and Emergency Operations, U.S. Army Corps of Engineers, Washington, D.C. Heidi King, Deputy Administrator and Acting Administrator, National Highway Traffic Safety Administration, U.S. Department of Transportation Raymond Martinez, Administrator, Federal Motor Carrier Safety Administration, Washington, D.C. Keith Nelson, Senior Advisor to the Secretary, Office of the Assistant Secretary for Research and Technology, U.S. Department of Transportation Craig A. Rutland, U.S. Air Force Pavement Engineer, U.S. Air Force Civil Engineer Center, Tyndall Air Force Base, FL Karl Schultz (Admiral, U.S. Coast Guard), Commandant, U.S. Coast Guard Karl Simon, Director, Transportation and Climate Division, U.S. Environmental Protection Agency Paul Skoutelas, President and CEO, American Public Transportation Association, Washington, D.C. Daniel Sperling, Professor of Civil Engineering and Environmental Science and Policy; Director, Institute of Transportation Studies, University of California, Davis K. Jane Williams, Acting Administrator, Federal Transit Administration, U.S. Department of Transportation Frederick G. (Bud) Wright, Executive Director, American Association of State Highway and Transportation Officials, Washington, D.C. * Membership as of October 2018.
TRANSPORTATION RESEARCH BOARD 500 Fifth Street, NW Washington, DC 20001 www.TRB.org ADDRESS SERVICE REQUESTED NON-PROFIT ORG. U.S. POSTAGE PAID COLUMBIA, MD PERMIT NO. 88 Airport Roles in Reducing Transmission of Communicable Diseases PROCEEDINGS OF A WORKSHOP
TRANSPORTATION RESEARCH BOARD 2018 EXECUTIVE COMMITTEE* OFFICERS CHAIR: Katherine F. Turnbull, Executive Associate Director and Research Scientist, Texas A&M Transportation Institute, College Station VICE CHAIR: Victoria A. Arroyo, Executive Director, Georgetown Climate Center; Assistant Dean, Centers and Institutes; and Professor and Director, Environmental Law Program, Georgetown University Law Center, Washington, D.C. EXECUTIVE DIRECTOR: Neil J. Pedersen, Transportation Research Board MEMBERS Scott E. Bennett, Director, Arkansas Department of Transportation, Little Rock Carlos Braceras, Executive Director, Utah Department of Transportation, Salt Lake City Ginger Evans, President, Tower Consulting, LLC, Arlington, VA Nathaniel P. Ford Sr., Executive DirectorâCEO, Jacksonville Transportation Authority, Jacksonville, FL A. Stewart Fotheringham, Professor, School of Geographical Sciences and Urban Planning, Arizona State University, Tempe Susan Hanson, Distinguished University Professor Emerita, Graduate School of Geography, Clark University, Worcester, MA Steve Heminger, Executive Director, Metropolitan Transportation Commission, San Francisco, CA Chris T. Hendrickson, Hamerschlag University Professor of Engineering, Carnegie Mellon University, Pittsburgh, PA Jeffrey D. Holt, Managing Director, BMO Capital Markets, NY S. Jack Hu, Vice President for Research and J. Reid and Polly Anderson Professor of Manufacturing, University of Michigan, Ann Arbor Roger B. Huff, President, HGLC, LLC, Farmington Hills, MI Geraldine Knatz, Professor, Sol Price School of Public Policy, Viterbi School of Engineering, University of Southern California, Los Angeles Melinda McGrath, Executive Director, Mississippi Department of Transportation, Jackson Patrick K. McKenna, Director, Missouri Department of Transportation, Jefferson City Brian Ness, Director, Idaho Transportation Department, Boise James P. Redeker, Commissioner, Connecticut Department of Transportation, Newington Leslie Richards, Secretary, Pennsylvania Department of Transportation, Harrisburg Mark L. Rosenberg, Executive Director, The Task Force for Global Health, Inc., Decatur, GA Gary C. Thomas, President and Executive Director, Dallas Area Rapid Transit, Dallas, TX Pat Thomas, Senior Vice President of State Government Affairs, United Parcel Service, Washington, D.C. (Retired) James M. Tien, Distinguished Professor and Dean Emeritus, College of Engineering, University of Miami, Coral Gables, FL Dean H. Wise, Consultant, Dean Wise LLC, Winchester, MA Charles A. Zelle, Commissioner, Minnesota Department of Transportation, Saint Paul EX OFFICIO MEMBERS Ronald Batory, Administrator, Federal Railroad Administration, U.S. Department of Transportation Mary R. Brooks, Professor Emerita, Dalhousie University, Halifax, Nova Scotia, Canada, and Chair, TRB Marine Board Mark H. Buzby (Rear Admiral, U.S. Navy), Administrator, Maritime Administration, U.S. Department of Transportation Steven Chalk, Deputy Assistant for Secretary for Transportation, U.S. Department of Energy Steven Cliff, Deputy Executive Officer, California Air Resources Board, Sacramento Howard R. Elliott, Administrator, Pipeline and Hazardous Materials Safety Administration, U.S. Department of Transportation Daniel K. Elwell, Acting Administrator, Federal Aviation Administration, U.S. Department of Transportation Audrey Farley, Associate Administrator for Administration, Pipeline and Hazardous Materials Safety Administration, Washington, D.C. LeRoy Gishi, Chief, Division of Transportation, Bureau of Indian Affairs, U.S. Department of the Interior, Washington, D.C. John T. Gray II, Senior Vice President, Policy and Economics, Association of American Railroads, Washington, D.C. Brandye Hendrickson, Acting Administrator, Federal Highway Administration, U.S. Department of Transportation Nikola Ivanov, Director of Operations, Center for Advanced Transportation Technology Laboratory, University of Maryland, College Park, and Chair, TRB Young Members Council Donald Jackson (Major General, U.S. Army), Deputy Commanding General for Civil and Emergency Operations, U.S. Army Corps of Engineers, Washington, D.C. Heidi King, Deputy Administrator and Acting Administrator, National Highway Traffic Safety Administration, U.S. Department of Transportation Raymond Martinez, Administrator, Federal Motor Carrier Safety Administration, Washington, D.C. Keith Nelson, Senior Advisor to the Secretary, Office of the Assistant Secretary for Research and Technology, U.S. Department of Transportation Craig A. Rutland, U.S. Air Force Pavement Engineer, U.S. Air Force Civil Engineer Center, Tyndall Air Force Base, FL Karl Schultz (Admiral, U.S. Coast Guard), Commandant, U.S. Coast Guard Karl Simon, Director, Transportation and Climate Division, U.S. Environmental Protection Agency Paul Skoutelas, President and CEO, American Public Transportation Association, Washington, D.C. Daniel Sperling, Professor of Civil Engineering and Environmental Science and Policy; Director, Institute of Transportation Studies, University of California, Davis K. Jane Williams, Acting Administrator, Federal Transit Administration, U.S. Department of Transportation Frederick G. (Bud) Wright, Executive Director, American Association of State Highway and Transportation Officials, Washington, D.C. * Membership as of October 2018.
C O N F E R E N C E P R O C E E D I N G S 5 5 Airport Roles in Reducing Transmission of Communicable Diseases Summary of a Workshop of the Airport Cooperative Research Programâs 2018 Insight Event John Wilhelmi Rapporteur March 6â7, 2018 National Academy of Sciences Building Washington, D.C. Organized by the Airport Cooperative Research Program Transportation Research Board 2019
Transportation Research Board Conference Proceedings 55 ISSN 1073-1652 ISBN 978-0-309-48007-9 Subscriber Categories Aviation; security and emergencies; terminals and facilities Transportation Research Board (TRB) publications are available by ordering individual publications directly from the TRB Business Office, through the Internet at www.TRB.org or national-academies.org/trb, or by annual subscription through organizational or individual affiliation with TRB. Affiliates and library subscribers are eligible for substantial discounts. For further information, contact the Transportation Research Board Business Office, 500 Fifth Street, NW, Washington, DC 20001 (telephone 202-334-3213; fax 202-334-2519; or e-mail TRBsales@nas.edu). © 2019 National Academy of Sciences. All rights reserved. Printed in the United States of America. NOTICE: This report has been reviewed by a group other than the authors according to the procedures approved by a Report Review Committee consisting of members of the National Academies of Sciences, Engineering, and Medicine. The members of the committee responsible for the project were chosen for their special competencies and with regard for appropriate balance. This conference was supported by Eastern Research Group, Inc. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. Suggested citation: Transportation Research Board. Conference Proceedings 55: Airport Roles in Reducing Transmission of Communicable Diseases. Summary of a Workshop of the Airport Cooperative Research Programâs 2018 Insight Event. Washington, D.C.: National Academies of Sciences, Engineering, and Medicine, 2019.
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, non-governmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to increase the benefits that transportation contributes to society by providing leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Boardâs varied committees, task forces, and panels annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. Learn more about the Transportation Research Board at www.TRB.org.
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Planning Committee for the Insight Event: Airport Roles in Reducing Transmission of Communicable Diseases Jeral Ahtone, American Airlines Paulo Magalhaes Alves, MedAire, Inc. Clive Brown, Centers for Disease Control and Prevention Edward Bushman, Los Angeles World Airports James M. Crites, James M. Crites LLC Kristen Rosdahl Ehresmann, Minnesota Department of Health Augustus Hudson, HartsfieldâJackson Atlanta International Airport Julie Morita, Chicago Department of Public Health Mary Wilson, University of California, San Francisco Eastern Research Group, Inc. Breanna Detweiler Ian Todreas Maxwell Unterhalter John Wilhelmi Transportation Research Board Staff Marci A. Greenberger, Senior Program Officer Brittany Summerlin-Azeez, Program Coordinator CRP Publications Staff for Conference Proceedings 55 Eileen P. Delany, Director of Publications Natalie Barnes, Associate Director of Publications Linda A. Dziobek, Senior Editor Cover design by Beth Schlenoff, Beth Schlenoff Design
Contents Acronyms ................................................................................................................................................ ix Preface .................................................................................................................................................... xi CHAPTER 1: CHALLENGE: AIRPORTS AND COMMUNICABLE DISEASE TRANSMISSION .......... 1 CHAPTER 2: DISCUSSIONS: WHAT WE LEARNED ........................................................................... 3 Risk Management ................................................................................................................................ 3 Stakeholders ......................................................................................................................................... 7 Communications .................................................................................................................................. 9 Infrastructure ..................................................................................................................................... 11 Resources ........................................................................................................................................... 12 CHAPTER 3: LOOKING FORWARD .................................................................................................. 13 APPENDICES A. PROGRAM ....................................................................................................................................... 14 B. INVITED SPEAKERS AND ATTENDEES ....................................................................................... 15 C. RESOURCES IDENTIFIED DURING PRESENTATIONS ............................................................... 19 v i i
ACRP Airport Cooperative Research Program AOC ACRP Oversight Committee CDC Centers for Disease Control and Prevention CDRP Communicable Disease Response Plan DFW DallasâFort Worth International Airport DGMQ Division of Global Migration and Quarantine EMS emergency medical services ERG Eastern Research Group, Inc. FEMA Federal Emergency Management Agency ICAO International Civil Aviation Organization MERS Middle East respiratory syndrome OSHA Occupational Safety and Health Administration PDX Portland (Oregon) International Airport PHX Phoenix Sky Harbor International Airport PIO public information officer PPE personal protective equipment SARS severe acute respiratory syndrome TSA Transportation Security Administration WHO World Health Organization Acronyms i x
x i transmission of communicable diseasesâ is a highly com- plex topic that spans a wide range of issues, including different diseases and transmission modes, many pre- paredness and response actions, legal issues, and public relations approaches to addressing public perception of risk. Faced with this challenge, the planning committee planned the Insight Event to address the primary topic broadly rather than focus on a few specific matters, expe- riences, or issues. The planning committee identified four general subtopics for the Insight Event to address. They were risk management, stakeholders, communications, and infrastructure. Chapter 2 presents definitions of these subtopics and discussions of the subtopics during the 2-day Insight Event. ACRP and its Insight Event contractor, Eastern Research Group, Inc. (ERG), then developed a pro- gram based on the concepts outlined by the planning committee. Specifically, ACRP and ERG identified can- didate speakers, developed the Insight Event program and agenda, and promoted the Insight Event to airports, public health agencies, and other stakeholders. The 2-day Insight Event occurred on March 6 and 7, 2018, in Washington, D.C. Close to 100 individuals attended. The 2-day Insight Event included ⢠Presentations from 13 invited speakers (listed in Appen- dix A), including a keynote address from Capt. Martin Cetron, M.D., Director of the Centers for Disease Con- trol and Preventionâs (CDCâs) Division of Global Migra- tion and Quarantine. The other speakers represented domestic and foreign airports, local public health agen- cies, an international aviation organization, and aca- demia. Appendix B lists invited speakers and attendees. The Airport Cooperative Research Program (ACRP) within the Transportation Research Board (TRB) of the National Academies of Sciences, Engineer- ing, and Medicine carries out applied research on prob- lems and issues that are of interest to airports and that are not being addressed by other federal research pro- grams. As the primary governing body of the program, the ACRP Oversight Committee (AOC) sets the agenda for the programâs annual research activities. In 2015, AOC decided to hold a series of Insight Events on topics of significance to airports. Insight Events are forums that foster dialogue among profes- sionals across sectors, institutions, and industries. Insight Events convene airport industry leaders and subject matter experts in various fields to encourage discussion and promote broader and deeper insight on topics of sig- nificance to airport operators. These in-depth, face-to- face gatherings are designed to promote communication and collaboration, foster innovation, and help identify areas of future interest and research, especially for topics of emerging importance. The decision to hold this event occurred toward the end of the 2014â2016 Ebola virus disease outbreak in West Africa. Concern about this outbreakâs implications for air travel, among other possible outbreaks, led AOC to have its first Insight Event focus on airport roles in reducing transmission of communicable diseases. Building on AOCâs idea, ACRP convened a planning committee of nine airport and public health officials to design and plan the Insight Event. This committee met in June 2017 to advise ACRP on how to proceed. The principal challenge before the planning committee was the breadth of the topic. âAirport roles in reducing Preface
x i i P R E F A C E ⢠Dr. Julie Morita, Commissioner of the Chicago Department of Public Health, facilitated audience question-and-answer sessions and panel discussions. ⢠Emergency management officials from two airports facilitated an interactive exercise, during which audi- ence members evaluated a hypothetical disease out- break scenarioâpassengers on an arriving flight with an unknown illness. ⢠Multiple activities outside the official program included a screening of the documentary Unseen Enemy, a fire- side chat with the filmâs creative director Janet Tobias, and a reception to facilitate networking between participants. The program for the event is available online at http:// www.trb.org/ACRP/ACRP-Insight-Event-Diseases.aspx. This conference proceedings highlights key discussion points at the Insight Event. The proceedings capture com- mon themes from the presentations and discussions, but this summary is not a transcript and does not elaborate on points beyond those made by invited speakers and attendees. While public health agencies, law enforce- ment, and various other stakeholders may respond to communicable disease outbreaks involving airports, these proceedings focus largely on strategies, best practices, and suggestions that pertain specifically to airports, as identi- fied by the invited speakers. Readers who are interested in more information about this Insight Event and other Insight Events and in the broader array of ACRP research activities are encouraged to ⢠Visit the ACRP Insight Event website at http:// www.trb.org/ACRP/ACRP-Insight-Events.aspx. ⢠E-mail Marci Greenberger, the ACRP project manager for this event, at mgreenberger@nas.edu. ⢠Sign up to receive ACRP publications at http:// www.trb.org/ACRP/PubNotify.aspx. John Wilhelmi, Eastern Research Group, Inc., the rapporteur, prepared this proceedings, which is a compilation of the presentations and a factual summary of the ensuing discussions at the event. The planning com- mittee was responsible solely for organizing the Insight Event, identifying speakers, and overseeing activities during the event. The views contained in the proceedings are those of individual Insight Event participants and do not necessarily represent the views of all participants, the planning committee, TRB, or the National Academies of Science, Engineering, and Medicine. This conference proceedings was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by a Report Review Committee consisting of members of the National Academies of Sciences, Engi- neering, and Medicine. The purposes of this indepen- dent review are to provide candid and critical comments that will assist the institution in making the published proceedings as sound as possible and to ensure that the publication meets institutional standards for objectivity, evidence, and responsiveness to the project charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the process. TRB thanks the following individuals for their review: Leila Barraza, University of Arizona, Tucson; Heidi Benaman, Faith Group, LLC, Portland, Oregon; Nicole Cohen, Division of Global Migration and Quarantine, Centers for Disease Control and Preven- tion, Atlanta, Georgia; Elizabeth Hall-Lipsey, University of Arizona, Tucson; Julie Morita, Chicago Department of Public Health; and Tim Riecker, Emergency Prepared- ness Solutions, Utica, New York. Although the reviewers listed above provided many constructive comments and suggestions, these reviewers did not see the final draft of the proceedings before its release. Robert Sproull of the University of Massachu- setts at Amherst and Susan Hanson of Clark University (emerita) oversaw the review of the final draft. They were responsible for making certain that an indepen- dent examination of this proceedings was performed in accordance with standards of the National Academies of Sciences, Engineering, and Medicine and that all review comments were carefully considered. Respon- sibility for the final content rests entirely with the rapporteur and the National Academies of Sciences, Engineering, and Medicine.
1 CHAPTER 1 Challenge Airports and Communicable Disease Transmission todayâs world tremendously interconnected: Dr. Cetron noted that travelers can now move from isolated rural villages to virtually any major city worldwide in less than 36 hours. Thus, a contagious traveler from an area with a disease outbreak can quickly spread dis- ease to other regions and countries, as demonstrated by localized transmission of Ebola virus disease in Nigeria, Middle East respiratory syndrome (MERS) in South Korea and Hong Kong, and severe acute respiratory syndrome (SARS) in Toronto. In each of these cases, localized disease transmission was traced to a single passenger infected with the disease arriving on an inter- national flight from an affected country. Complicat- ing matters, the incubation period for some diseases is longer than the time that it takes to travel worldwide; and, in some cases, infected passengers can travel on airplanes and pass through airports before they show symptoms or even know they are sick. Moreover, con- firmation of illness is not immediate because many diseases do not have rapid diagnostic tests. For these and other reasons, Dr. Cetron, the Insight Eventâs key- note speaker, stated that âA health threat anywhere is a health threat everywhere.â However, as the threats for communicable disease transmission have grown, so have prevention, prepared- ness, and response efforts among air travel interests and the public health community. At the national level, CDC works to prevent the introduction, transmission, and spread of communicable diseases, whether through regulation, research, preparedness, and response. The agencyâs Division of Global Migration and Quarantine (DGMQ) focuses on preventing importation and spread of communicable diseases, in part by building systems and programs to prevent, detect, and respond to disease transmission between immigrants, refugees, travelers, expatriates, and other globally mobile populations. Dr. Cetron discussed DGMQâs previous and ongoing work with air travel interests and public health part- ners, with examples ranging from responding to com- municable disease inquiries to disease investigations with contact tracing. As is noted in this proceedings, a much broader network of local, regional, national, Air travel is vital in todayâs world, as underscored by statistics and anecdotes shared by Dr. Cetron of CDC and Dr. Kamran Khan of the University of Toronto. In 2016, the total distance traveled world- wide by commercial flights was 6.7 trillion kilometers, with half of that travel accounted for by flights originating in just 10 countries. This statistic is part of a continuing trend: in a recent 10-year period, the total distance trav- eled in domestic and international travel increased by more than 50%. Air travel has indeed made the world an increasingly interconnected place, as recent statistics suggest that more than 100 million passengers arrive on international flights at U.S. airports every year. Sustained operations at airports are critical for many reasons. Not only do airports help move travelers and goods but they also deliver direct and indirect economic benefits to local communities. For instance, large airports support thousands of jobs, and arriv- ing travelers spend money at hotels, restaurants, rental car companies, entertainment venues, tourist attrac- tions, and numerous other local businesses. By some estimates, large domestic airports can deliver billions of dollars of economic benefits each year to their host metropolitan areas. Moreover, as underscored by Dr. Petra Illig of Aviation Medical Services, during dis- ease outbreaks, sustained air travel to affected regions is essential for delivering humanitarian assistance. Even short-term interruptions at major hubs can have substantial ripple effects throughout the commercial aviation sector: Dr. Walter Gaber of the Frankfurt International Airport indicated that a 3-hour shutdown at his airport would cause more than 25,000 passengers to miss flights and more than 4,000 tons of freight to be delivered late. These observations underscore the fact that continuity of operations at airports is essential. Communicable disease outbreaks have the potential to affect air travel and public health interests. Concerns about travel and spread of communicable disease are not new, as documented outbreaks of cholera, yellow fever, and other diseases associated with marine travel date back hundreds of years. What has changed in recent decades is how transportation modesâespecially air travelâmake
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 and international stakeholders works to prevent, pre- pare for, and respond to communicable diseases as they relate to air travel. Reducing transmission of communicable diseases pre- sents an important challenge for airports, airlines, and other air travel interests. At the same time, a large commu- nity of stakeholders actively works to prevent, prepare for, and promptly respond to disease outbreaks. Dr. Cetron summed up this apparent dichotomy by saying that âThe world is safer than ever from global health threats; and the world is at greater risk than ever from global health threats.â The rest of this conference proceedings expands on the risks of communicable disease outbreaks and air travel and reviews efforts to manage those risks.
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. airportsâDeb 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)âemphasized 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 airportsâ plans differ due to site-specific considerations, According to Ms. Deb Helton of DallasâFort 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 âpro- 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 complexityâ (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 2014â2016 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 âcall-down listsâ 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 airportâs 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 2014â2016 Ebola virus disease outbreak indicated that some medical facilitiesâincluding certain hospitalsâwere 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 diseasesâ 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 âPush Partner Registry.â 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 âhigh-touchâ 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 regionâs 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 Internationalâ 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 âfalse alarmsâ or âno-caseâ 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 airportâs CDRP. These responses, which were essentially unplanned and unscripted drills, had many benefits, including assuring the public of the airportâs 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 âfalse alarmâ 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 CDCâs 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 âat riskâ travelers, especially when people are motivated to hide their exposure historyâand 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 âin the path ofâ 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 airportsâ 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. CDCâs 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 todayâs 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 Eventâs 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 âcontact information cardâ 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 âownâ 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., âIs it safe to fly?â âShould I come to the airport?â âAre there any travel restrictions?â âHow do you disinfect the terminal?â) but also know which questions should be deferred to public health officials (e.g., âWhat should I do if I think I might have a communicable disease?â). 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 passengerâs activities in the terminal. Closed-circuit television footage often helped provide detailed information on the ill passengerâs 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 airportâs 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 airportsâand the practices used to operate and maintain the built environmentâ 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 passengerâs 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 Organizationâs 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 workersâfirst responders, public health officials, aircraft cleaning crews, and othersâare 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 workersâ 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 speakersâ 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.
13 CHAPTER 3 Looking Forward to have, or suspected of having, communicable dis- eases; to hold an event to assess the utility and fea- sibility of entry and exit screening at airports; and to conduct regional workshops to allow for greater participation from airports and other stakeholders nationwide. ⢠Throughout the 2-day Insight Event, invited speakers and attendees identified numerous resources from government agencies, airports and the aviation sector, and other parties that present best practices on airport roles in reducing transmission of commu- nicable diseases. Having a consolidated, searchable inventory of best practices would be highly ben- eficial to those who are developing and updating CDRPs. ⢠All attendees received a post-event evaluation survey. Of the 29 attendees who completed the survey, 93% indicated that attending the Insight Event was a valuable use of their time and 86% said they met and networked with attendees from industries other than their own. Individual attendees offered several sugges- tions for future Insight Events. These included using a webinar or other means for allowing remote participa- tion; incorporating a broader array of stakeholders in future Insight Events on this topic (e.g., airlines or pub- lic health emergency response personnel); having more opportunities for audience engagement; conducting a full table-top exercise as an optional session; and bring- ing more international perspectives into the agenda. ⢠ACRP also encouraged attendees to use IdeaHub (accessed at https://crp.trb.org/ideahub/) to submit additional feedback and propose research topics. This web-based portal allows the airport community and other stakeholders to present ideas, view ideas and suggestions from other like-minded practitio- ners, and see which initial ideas transform into qual- ity problem statements for further research. Air travel has the potential to rapidly spread communicable diseases both domestically and worldwide but airportsâin coordination with many other stakeholdersâcan help reduce transmis- sion through effective preparedness and response. The Insight Event identified opportunities for enhancing risk management, engaging with a broad stakeholder community, developing and implementing effective communication strategies, and ensuring airport infra- structure accommodates unique needs during disease outbreak scenarios. Although the Insight Event was not designed to iden- tify and prioritize future research topics on airport roles in reducing transmission of communicable disease, sev- eral participants offered suggestions to ACRP. The sug- gestions follow in order of presentation: ⢠While the Insight Event focused on airport roles, many other stakeholders beyond the airport boundary are involved with minimizing the broader impacts of disease outbreaks linked to air travel. Many individual attendees thought that ACRPâs future activities on this topic would be valuable as they would facilitate greater involvement from the broader public health commu- nity, the aviation sector, selected trade associations (e.g., the Aerospace Medical Association or Airline Medical Directors Association), and other stakeholders. ⢠By design, the Insight Event addressed airport roles in reducing transmission of communicable disease at a broad conceptual level. Within this broad topic are numerous specific issues that could be the focus of future ACRP Insight Events or research activity. Some participants suggested the following events. They were to convene a future event between PIOs from airports and public health agencies to discuss communications and messaging during disease out- break scenarios; to hold a session to review jurisdic- tional authorities for detaining passengers known
14 APPENDIX A Program Collaboration and Communication: Airport Roles in Reducing Transmission of Communicable Diseases Russ Jones, MPH, Tarrant County Public Health, Fort Worth, Texas DallasâFort Worth International Airport 2014 Ebola Response Deb Helton, DallasâFort Worth International Airport Dustin Jaynes, DallasâFort Worth International Airport High Infectious Diseases at an International Airport 2003â2018 Walter Gaber, M.D., Frankfurt International Airport Partnerships and Other Practical Measures to Manage the Risk of Disease Transmission Through Air Travel Ansa Jordaan, M.D., Aviation Medicine Section, International Civil Aviation Organization PHX and Maricopa County Public HealthâPartners in Preparedness Rebecca Sunenshine, M.D., FIDSA, Maricopa County Public Health, Phoenix, Arizona Christopher Rausch, ACE, Sky Harbor International Airport, Phoenix, Arizona Airport & Public Health Partnerships: Success in Communicable Disease Response Planning Amy Sullivan, Washington State Department of Health Kori Nobel, Port of Portland, Oregon AIRPORT ROLES IN REDUCING TRANSMISSION OF COMMUNICABLE DISEASES Organized by the Airport Cooperative Research Program Transportation Research Board March 6â7, 2018 National Academy of Sciences Building Washington, D.C. SUMMARY Airport and public health professionals addressed key challenges and issues facing the aviation sector to reduce the transmission of communicable diseases. The program for the event is available online at http://www.trb.org/ ACRP/ACRP-Insight-Event-Diseases.aspx. PRESENTATIONS Delaying the Inevitable: Lessons Learned from Ebola Airport Screening Petra Illig, M.D., Aviation Medical Services Public Health Perspectives: Coordinating the Response to Imported Infectious Disease Threats in New York City Marcelle Layton, M.D., New York City Department of Health and Mental Hygiene Interconnected and Independent: Anticipating Infectious Disease Risks in an Increasingly Mobile World Kamran Khan, M.D., University of Toronto
15 APPENDIX B Invited Speakers and Attendees Emily Bailey Duke University Durham, North Carolina Utpala Bandy Rhode Island Department of Health Providence, Rhode Island Ibrahim Bani Emory University Leesburg, Virginia Leila Barraza Mel and Enid Zuckerman College of Public Health Tucson, Arizona Pat Baylis United Airlines Chicago, Illinois Richard Bonnett Metropolitan Washington Airports Authority, Fire and Rescue Department Washington, D.C. Jinny Bromberg Bromberg & Associates Hamtramck, Michigan Clive Brown Centers for Disease Control and Prevention Atlanta, Georgia Edward Bushman Los Angeles World Airports Sharon Carr Occupational Safety and Health Administration Washington, D.C. Christina Chommanard Alexandria Health Department Alexandria, Virginia INVITED SPEAKERS Capt. Martin Cetron, M.D., Centers for Disease Control and Prevention Dr. Petra Illig, Aviation Medical Services of Alaska Dr. Marcelle Layton, NYC Department of Health and Mental Hygiene Dr. Kamran Khan, University of Toronto Russ Jones, MPH, Tarrant County Public Health Deb Helton, DallasâFort Worth International Airport Dustin Jaynes, DallasâFort Worth International Airport Dr. Walter Gaber, Frankfurt International Airport Dr. Ansa Jordaan, Aviation Medicine Section, International Civil Aviation Organization Dr. Rebecca Sunenshine, FIDSA, Maricopa County Public Health Christopher Rausch, ACE, Sky Harbor International Airport Dr. Amy Sullivan, Washington State Department of Health Kori Nobel, Port of Portland ATTENDEES Jeral Ahtone American Airlines Meredith Allen Association of State and Territorial Health Officials Arlington, Virginia Francisco Alvarado-Ramy Centers for Disease Control and Prevention Atlanta, Georgia Paulo Magalhaes Alves MedAire, Inc. Phoenix, Arizona Senanu Ashiabor IML Consulting Centreville, Virginia
1 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 Andrew Chou Consultant Vancouver, British Columbia, Canada Jim Chung Air Canada Mississauga, Ontario, Canada Kathryn Como-Sabetti Minnesota Department of Health Saint Paul, Minnesota Matt Cornelius Airports Council InternationalâNorth America Washington, D.C. James M. Crites James M. Crites LLC Fort Worth, Texas Terrence Daley Transportation Public Health Preparedness Consultants LLC Lithonia, Georgia Gary Davis Reagan National Airport Washington, D.C. Kristin DeBord U.S. Department of Health and Human Services Washington, D.C. Breanna Detwiler Eastern Research Group (ERG) Arlington, Virginia Daniel Early Booz Allen Hamilton Washington, D.C. Kristen Rosdahl Ehresmann Minnesota Department of Health Saint Paul, Minnesota Bart Elias Congressional Research Service Washington, D.C. Hussein Ezzeldin Food and Drug Administration, Center for Biologics Evaluation and Research, Office of Biostatistics and Epidemiology Silver Spring, Maryland Barent Fake Executive Advisors/IDEA Fairfax Station, Virginia Todd Felix Harrisburg, Pennsylvania Christopher Gay DallasâFort Worth International Airport Emma Fine National Academies of Sciences, Engineering, and Medicine Washington, D.C. Adriana Glenn George Washington University/Alexandria Health Department Fairfax, Virginia Paul Greiner AustinâBergstrom International Airport Austin, Texas Matthew Griffin Airport Consultants Council Alexandria, Virginia Matthew Grossman Affiliation not available Rebecca Hall Centers for Disease Control and Prevention Atlanta, Georgia Elizabeth Hall-Lipsy University of Arizona College of Pharmacy Tucson, Arizona Regina Hawkins Association of State and Territorial Health Officials Arlington, Virginia Chad Heflin International Air Transport Association Washington, D.C. Jonathan Hill Centers for Disease Control and Prevention Atlanta, Georgia Augustus Hudson HartsfieldâJackson Atlanta International Airport Atlanta, Georgia
A P P E N D I X B : I N V I T E D S P E A K E R S A N D A T T E N D E E S 17 Gina Jayawan University of Maryland College Park, Maryland Bruce Jeffries Georgia Department of Public Health Atlanta, Georgia Robynne Jungerman Centers for Disease Control and Prevention Atlanta, Georgia Candace Kolander Air Line Pilots Association, International Herndon, Virginia Barbara Kostuk Airlines for America (A4A) Washington, D.C. Ellen Laine Minnesota Department of Health Saint Paul, Minnesota Molly Laster U.S. Government Accountability Office Seattle, Washington Gabriel Lemarc Affiliation not available Tamara Mahal Chicago Department of Aviation Chicago, Illinois Geoff Manaugh Freelance writer Los Angeles, California Angie Maxted New York State Department of Health Albany, New York Katie McCoy DallasâFort Worth International Airport Page Miller Shoreland/Travax Arlington, Virginia Julie Morita Chicago Department of Public Health Chicago, Illinois Stephanie Murphy Tidal Basin Government Consulting Alexandria, Virginia Alex Naar Federal Aviation Administration Washington, D.C. Amy Nevel Office of the Assistant Secretary for Planning and Evaluation Department of Health and Human Services Washington, D.C. Kate Huggins Nicholson Ikana Media New York, New York Miguel Ocana Division of Global Migration and Quarantine Centers for Disease Control and Prevention Washington, D.C. Arlene Pericak George Washington University Fairfax, Virginia Roger Porocott Affiliation not available Greg Principato National Aeronautic Association Washington, D.C. Vincenzo Procopio Department of Health and Human Services Washington, D.C. Daniela Quilliam Rhode Island Department of Health Providence, Rhode Island Timothy Riecker Emergency Preparedness Solutions LLC Utica, New York Carol Rogers United Airlines Chicago, Illinois Kimberly Rogers Division of Global Migration and Quarantine Centers for Disease Control and Prevention Atlanta, Georgia
1 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 Audilis Sanchez Centers for Disease Control and Prevention Dulles, Virginia Ramon Sanchez Harvard T. H. Chan School of Public Health Boston, Massachusetts Jon Shriber Affiliation not available Jarnail Singh Civil Aviation Authority of Singapore Benjamin Sipiora Chicago Department of Aviation Chicago, Illinois Denise Sockwell Virginia Department of Health Fairfax, Virginia Carlos E. Staff Civil Aviation Authority of Panama Amethyst Clare Surpris Karna LLC Sterling, Virginia Ian Todreas Eastern Research Group (ERG) Boston, Massachusetts Wagahta Tsadik Passport Health Washington, D.C. Naomi Tucker Columbus Public Health Columbus, Ohio Nicola Twilley Self-employed Los Angeles, California Maxwell Unterhalter Eastern Research Group (ERG) Boston, Massachusetts Rusty Tyson RTCPA Rochester, New York Juliana Urrego Shoreland/Travax Arlington, Virginia Bethany Vance Shoreland/Travax Arlington, Virginia Dagmar Vitek Salt Lake County Health Department Salt Lake City, Utah Matthew Walter Department of Homeland Security Washington, D.C. John Wilhelmi Eastern Research Group (ERG) Boston, Massachusetts Mary Wilson University of California, San Francisco Naoki Yanagisawa Harvard T. H. Chan School of Public Health Boston, Massachusetts
19 APPENDIX C Resources Identified During Presentations Smith, J. F., and J. Greenberg. 2017. ACRP Synthesis of Air- port Practice 83: Preparing Airports for Communicable Diseases on Arriving Flights. Washington, D.C.: Transpor- tation Research Board. http://www.trb.org/Publications/ Blurbs/176419.aspx. Vonnahme, L. A., M. R. Jungerman, R. K. Gulati, P. Illig, and F. Alvarado-Ramy. 2017. U.S. Federal Travel Restrictions for Persons with Higher-Risk Exposures to Communica- ble Diseases of Public Health Concern. Emerging Infec- tious Diseases, Volume 23(13). https://wwwnc.cdc.gov/ eid/article/23/13/17-0386_article. WHO. 2005. Strengthening Health Security by Implementing the International Health Regulations: About IHR. World Health Organization. http://www.who.int/ihr/about/en/. WHO. 2009. Guide to Hygiene and Sanitation in Aviation: Module 1: Water, Module 2: Cleaning and Disinfection of Facilities. Geneva: World Health Organization. http:// www.who.int/ihr/ports_airports/guide_hygiene_sanitation_ aviation_3_edition_wcov.pdf. WHO. 2014. WHO Interim Guidance for Ebola Virus Disease: Exit Screening at Airports, Ports and Land Crossings. Geneva: World Health Organization. http://apps.who.int/iris/ bitstream/handle/10665/139691/WHO_EVD_Guidance_ PoE_14.2_eng.pdf. WHO. 2015. Handbook for the Management of Public Health Events in Air Transport: Updated with Information on Ebola Virus Disease and Middle East Respiratory Syndrome Coronavirus. Geneva: World Health Organization. http:// www.who.int/ihr/publications/9789241510165_eng/en/. WHO. 2016. Vector Surveillance and Control at Ports, Air- ports, and Ground Crossings. Geneva: World Health Organization. http://www.who.int/ihr/publications/ 9789241549592/en/. CDC. 2007. Interim Pre-pandemic Planning Guidance: Com- munity Strategy for Pandemic Influenza Mitigation in the United StatesâEarly, Targeted, Layered Use of Non- pharmaceutical Interventions. Atlanta, Ga.: CDC. https:// www.cdc.gov/flu/pandemic-resources/pdf/community_ mitigation-sm.pdf. CDC. 2018. CDC Yellow Book 2018: Health Information for International Travel. Centers for Disease Control and Prevention. Atlanta, Ga.: CDC. https://wwwnc.cdc.gov/ travel/page/yellowbook-home. Code of Federal Regulations, Title 42, Chapter I, Subchapter F, Part 70, Interstate Quarantine. Updated Jan. 29, 2017. Code of Federal Regulations, Title 42, Chapter I, Subchapter F, Part 71, Foreign Quarantine. Updated Jan. 29, 2017. Cohen, N. J., C. M. Brown, F. Alvarado-Ramy, H. Bair-Brake, G. A. Benenson, T.-H. Chen, A. J. Demma, N. K. Holton, K. S. Kohl, A. W. Lee, D. McAdam, N. Pesik, S. Roohi, C. L. Smith, S. H. Waterman, and M. S. Cetron. 2016. Travel and Border Health Measures to Prevent the International Spread of Ebola. Morbidity and Mortality Weekly Report, Supplements; 65 (Suppl-3):57â67. https:// www.cdc.gov/mmwr/volumes/65/su/su6503a9.htm. FEMA. 2017. National Incident Management System, 3d ed. Washington, D.C.: U.S. Department of Home- land Security. https://www.fema.gov/media-library-data/ 1508151197225-ced8c60378c3936adb92c1a3ee6f6564/ FINAL_NIMS_2017.pdf. GAO. 2015. Air Travel and Communicable Diseases: Com- prehensive Federal Plan Needed for U.S. Aviation Systemâs Preparedness. Washington, D.C.: U.S. Gov- ernment Accountability Office. https://www.gao.gov/ assets/680/674224.pdf.
TRANSPORTATION RESEARCH BOARD 2018 EXECUTIVE COMMITTEE* OFFICERS CHAIR: Katherine F. Turnbull, Executive Associate Director and Research Scientist, Texas A&M Transportation Institute, College Station VICE CHAIR: Victoria A. Arroyo, Executive Director, Georgetown Climate Center; Assistant Dean, Centers and Institutes; and Professor and Director, Environmental Law Program, Georgetown University Law Center, Washington, D.C. EXECUTIVE DIRECTOR: Neil J. Pedersen, Transportation Research Board MEMBERS Scott E. Bennett, Director, Arkansas Department of Transportation, Little Rock Carlos Braceras, Executive Director, Utah Department of Transportation, Salt Lake City Ginger Evans, President, Tower Consulting, LLC, Arlington, VA Nathaniel P. Ford Sr., Executive DirectorâCEO, Jacksonville Transportation Authority, Jacksonville, FL A. Stewart Fotheringham, Professor, School of Geographical Sciences and Urban Planning, Arizona State University, Tempe Susan Hanson, Distinguished University Professor Emerita, Graduate School of Geography, Clark University, Worcester, MA Steve Heminger, Executive Director, Metropolitan Transportation Commission, San Francisco, CA Chris T. Hendrickson, Hamerschlag University Professor of Engineering, Carnegie Mellon University, Pittsburgh, PA Jeffrey D. Holt, Managing Director, BMO Capital Markets, NY S. Jack Hu, Vice President for Research and J. Reid and Polly Anderson Professor of Manufacturing, University of Michigan, Ann Arbor Roger B. Huff, President, HGLC, LLC, Farmington Hills, MI Geraldine Knatz, Professor, Sol Price School of Public Policy, Viterbi School of Engineering, University of Southern California, Los Angeles Melinda McGrath, Executive Director, Mississippi Department of Transportation, Jackson Patrick K. McKenna, Director, Missouri Department of Transportation, Jefferson City Brian Ness, Director, Idaho Transportation Department, Boise James P. Redeker, Commissioner, Connecticut Department of Transportation, Newington Leslie Richards, Secretary, Pennsylvania Department of Transportation, Harrisburg Mark L. Rosenberg, Executive Director, The Task Force for Global Health, Inc., Decatur, GA Gary C. Thomas, President and Executive Director, Dallas Area Rapid Transit, Dallas, TX Pat Thomas, Senior Vice President of State Government Affairs, United Parcel Service, Washington, D.C. (Retired) James M. Tien, Distinguished Professor and Dean Emeritus, College of Engineering, University of Miami, Coral Gables, FL Dean H. Wise, Consultant, Dean Wise LLC, Winchester, MA Charles A. Zelle, Commissioner, Minnesota Department of Transportation, Saint Paul EX OFFICIO MEMBERS Ronald Batory, Administrator, Federal Railroad Administration, U.S. Department of Transportation Mary R. Brooks, Professor Emerita, Dalhousie University, Halifax, Nova Scotia, Canada, and Chair, TRB Marine Board Mark H. Buzby (Rear Admiral, U.S. Navy), Administrator, Maritime Administration, U.S. Department of Transportation Steven Chalk, Deputy Assistant for Secretary for Transportation, U.S. Department of Energy Steven Cliff, Deputy Executive Officer, California Air Resources Board, Sacramento Howard R. Elliott, Administrator, Pipeline and Hazardous Materials Safety Administration, U.S. Department of Transportation Daniel K. Elwell, Acting Administrator, Federal Aviation Administration, U.S. Department of Transportation Audrey Farley, Associate Administrator for Administration, Pipeline and Hazardous Materials Safety Administration, Washington, D.C. LeRoy Gishi, Chief, Division of Transportation, Bureau of Indian Affairs, U.S. Department of the Interior, Washington, D.C. John T. Gray II, Senior Vice President, Policy and Economics, Association of American Railroads, Washington, D.C. Brandye Hendrickson, Acting Administrator, Federal Highway Administration, U.S. Department of Transportation Nikola Ivanov, Director of Operations, Center for Advanced Transportation Technology Laboratory, University of Maryland, College Park, and Chair, TRB Young Members Council Donald Jackson (Major General, U.S. Army), Deputy Commanding General for Civil and Emergency Operations, U.S. Army Corps of Engineers, Washington, D.C. Heidi King, Deputy Administrator and Acting Administrator, National Highway Traffic Safety Administration, U.S. Department of Transportation Raymond Martinez, Administrator, Federal Motor Carrier Safety Administration, Washington, D.C. Keith Nelson, Senior Advisor to the Secretary, Office of the Assistant Secretary for Research and Technology, U.S. Department of Transportation Craig A. Rutland, U.S. Air Force Pavement Engineer, U.S. Air Force Civil Engineer Center, Tyndall Air Force Base, FL Karl Schultz (Admiral, U.S. Coast Guard), Commandant, U.S. Coast Guard Karl Simon, Director, Transportation and Climate Division, U.S. Environmental Protection Agency Paul Skoutelas, President and CEO, American Public Transportation Association, Washington, D.C. Daniel Sperling, Professor of Civil Engineering and Environmental Science and Policy; Director, Institute of Transportation Studies, University of California, Davis K. Jane Williams, Acting Administrator, Federal Transit Administration, U.S. Department of Transportation Frederick G. (Bud) Wright, Executive Director, American Association of State Highway and Transportation Officials, Washington, D.C. * Membership as of October 2018.
TRANSPORTATION RESEARCH BOARD 500 Fifth Street, NW Washington, DC 20001 www.TRB.org ADDRESS SERVICE REQUESTED NON-PROFIT ORG. U.S. POSTAGE PAID COLUMBIA, MD PERMIT NO. 88 Airport Roles in Reducing Transmission of Communicable Diseases PROCEEDINGS OF A WORKSHOP
