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7 SESSIONÂ 2Â HealthÂ UpdateÂ Â Rhonda Hamm-Niebruegge, St. Louis International Airport and Chair, ACRP Oversight Committee, Moderator PresentersÂ Hilary Godwin, University of Washington School of Public Health Baruch Fischhoff, Carnegie Mellon University Rhonda HammâNiebruegge introduced Session 2, a health update by Hilary Godwin, Dean of the University of Washington School of Public Health, who presented on health, safety, and travel during the ongoing COVID-19 pandemic, and Baruch Fischhoff, Howard Heinz University Professor in the Department of Engineering and Public Policy and Institute for Politics and Strategy at the Carnegie Mellon University, who presented on passenger risk perception, confidence, and behavior. Hilary Godwin presented an overview of COVID-19. There is a shortage of tests, reagents, supplies, and personal protective equipment (PPE) that poses risks and challenges to the population and health care workers. For workplace interventions, it is important to provide screening and maintain a clean environment. For air travel, it is important to maintain social distancing, both in airports and on aircraft, wear facial coverings, keep surfaces clean, and maintain good high-efficiency particulate air (HEPA) filtering systems. Protecting public health and safety is a state-level function, although federal guidance is sought. Baruch Fischhoff presented an overview of passenger risk perception. Behavioral science and the practice of risk communication are key areas to attend to, as many are facing stressful situations with misinformation on a new and unknown environment. It is important to have both process and content matter, show concern for people, and be collaborative and adaptive to keep up with changes in a virus. Health,Â Safety,Â andÂ TravelÂ duringÂ theÂ COVIDâ19Â PandemicÂ Hilary Godwin, University of Washington School of Public Health Hilary Godwin stated her goal was to provide an overview of what is known about COVID-19 and how this pertains to the airline industry. She stated that it is important to remember that COVID-19 is a new virus, meaning that the majority of the population is still susceptible to infection, and that there currently is no vaccine for it. She stated that it is important to keep in mind that the typical timeline for producing a vaccine for a new disease is many years, and the world record at this point is 4 years. So even with speeding up production and discovery of a vaccine, it will be at least 12 to 18 months until a vaccine
8 is developed. She also stated that with any new disease, it takes a little while to develop tests for it, and this one is no exception. Godwin went on to say that even now, when there are tests available, there are still shortages in terms of reagents and supplies and PPE that healthcare workers need to use when they are collecting samples from patients. This has posed a challenge to knowing who is currently infected and to the ability to help prevent the spread of the disease. She added that 80% of the population that gets infected with COVID-19 experiences either mild or moderate symptoms or no symptoms at all. She stated that it is really challenging that there are people walking around who are infected but are not so sick that they have to stay in bed. Then there is a significant percentage of the population that may not even know they have COVID-19. She said, âThis really challenges our ability to identify those people who are infected and to use normal quarantine and isolation procedures to prevent spread.â Godwin stated that, on the flip side, of the 80% who experience either mild or moderate symptoms when they are infected, 20% (which is a high percentage), experience more severe symptoms than someone infected with the seasonal flu and need intense hospitalization and care, often for many weeks. Such levels of hospitalizations have the potential to overload the healthcare system. She stated that was visible in New York City, but it was true of other places, including Seattle, Washington, where the curve was flattened significantly. Seattle and New York City also saw a huge impact on their health care systems and their ability to provide services for people with heart attacks and for car accident victims who needed immediate care. She added that people were still less likely to get their routine medical care from their physician and that their last resorts were to switch to community-level interventions. She then indicated that the limitations of the tests were becoming more widespread and explained the two different kinds of tests. The first test is to see whether someone is currently infected and is only effective if the person has enough virus in his or her body to show up on the test. One of the challenging things about COVID-19 is the long lag time. However, for some people, there is a period between when they are exposed and when they start to exhibit symptoms or have a high viral load during which they could show up negative, even though they might end up testing positive a few days later. She added that this means the testing is really just a snapshot in time and does not give as much information as we would like. Godwin further elaborated on the other kind of test, the antibody-based test, which is for people who have previously been infected. These tests also have inherent limitations. She explained that it takes a little while before a personâs immune system develops antibodies that can be detected through testing. Godwin stated that it could be a couple of weeks before someone tests positive, and that COVID-19 is really challenging because it is new. She said that doctors and researchers do not know whether or not a positive result on this test means that a person is protected from a future infection. This is a challenge inherent to COVID-19 that makes it really difficult for individuals to know what to do when the result of their antibody-based test is positive. It also makes it hard to make decisions about whether employee interventions could be done selectively. Godwin observed,
9 What we know right now about transmission of COVID-19 is that the highest risk is due to droplets from someone who is coughing or sneezing or speaking loudly, who has that large amount of virus in their body and those droplets can hang out in the air for about 6 feet. So being in close proximity within 6 feet of someone who is infected for an extended period of time, which would be approximately 10 to 15 minutes or moreâthat is where we see the highest risk for infection. Keep in mind that that person may not even know that theyâre infected. Godwin stated that a lower risk, but one that is relevant to the airline industry and other workplaces, is that the droplets can also fall on surfaces, such as the person who had coffee in his or her hands, then touched a door knob, where the virus could be picked up. She added, âAnd if you touch your face, then you could become infected that way, but thatâs the lower-risk event.â She added, Of the measures that we know that reduce risk of transmission of COVID-19, the best one is to stay away from other people outside their household. People who are sick must stay home and in bed. But as weâve seen with the virus, what people refer to as lockdowns or âstay-at-home, stay healthy,â weâve encouraged people, even if they arenât experiencing symptoms, to try and avoid close contact for prolonged periods of time with people who are outside their household. . . . [I]f you do need to go outside your home and interact with people from outside your household, we ask that you try to stay 6 feet away from those people and wear a face covering, and that safe covering isnât just to protect you, itâs mainly to protect other people, just in case you have COVID-19 and donât know it. Godwin noted that in terms of workplace interventions, it is really important to do screening to make sure employees are not coming to work if they have symptoms and to send them home if they do. Routine cleaning of high-touch surfaces and encouraging people to wash their hands regularly or use hand sanitizer to prevent them from getting infected via surfaces are also important. Godwin stated that it is important to remember that there are individuals who are at higher risk for severe symptoms, and so it is important that people in those risk groups try to stay away from people who are outside their household and may have COVID-19. That includes people over the age of 65, people with prior heart and lung disease or diabetes, and those who are morbidly obese, which, she stated, is a significant segment of the U.S. population. As this relates to air travel, Godwin explained that, as airports start to reopen with more passengers, it is important to put in constraints to maintain social distancing, both in the airports and on planes. She added that it is very important to require employees and travelers to wear face coverings, particularly because it is not possible to know whether people may have COVID-19 if they are asymptomatic. She emphasized that that all planes have HEPA filtration systems and frequent disinfecting of high-touch surfaces and access to hand sanitizers throughout airports and on planes. She further stated that it is important to thoroughly disinfect planes between flights and provide clear additional warnings for those high-risk individuals.
10 Godwin also stated that it is important to remember that under federalism in the United States, the power to protect the public health and safety is reserved to the state, so there are going to be a lot of different reactions on how to deal with COVID-19 as each governor and each state health department make their own decisions. She cited an example in Washington State about how people were aware and had clear guidance about when they could do different things, which is not true for every state. She explained that each state has different phases, guidelines, and metrics, so it can be very confusing once people start traveling across borders. Godwin stated that since there are critical roles for the federal government to play during this time, national guidance is needed, and it is important that the federal government manage the supply chain for essential items like test kits, face coverings, gloves, cleaning materials, and disinfectant materials with issue guidance for interstate and international travel. National standards are needed, and tools should be available for contact tracing and associated data collection and sharing. She added that it is important that such standards focus on issuing protections for the nationâs most vulnerable and that it is important there is fiscal relief for state local governments, businesses, and individuals. She stated that it is important that there is national guidance for safe practices in airports and on airplanes, so that travelers can expect consistently safe experiences as they travel across the United States. Godwin concluded that a national repository for flight manifests is needed, including contact information for all travelers. This should be information that could be accessed by local health jurisdictions when they are doing contact tracing, just in case someone who was on a plane that came into their jurisdiction ends up testing positive. Finally, she added that a national communications campaign about the importance of adhering to preventative measures, both in airports and on planes, would be beneficial for airline employees, airport employees, and travelers. Hamm-Niebruegge then introduced Baruch Fischhoff. PassengerÂ RiskÂ Perception,Â ConfidenceÂ andÂ BehaviorÂ Baruch Fischhoff, Carnegie Mellon University, Presenter Baruch Fischhoff started by discussing the science and the practice of risk communication. Fischhoff noted that many people are facing stressful decisions, including making ends meet, doing their jobs, and safely taking care of loved ones at home. Other decisions include those that people make related to finding food supplies and medication, supporting the vulnerable people in their communities, interpreting their own health, and navigating healthcare. He added that many are making travel decisions and that sources of information are imperfect, may be biased, and may include unqualified evidence. Fischhoff stated that the mental models used for dealing with diseases and travel may lead many astray, as there could be confusion from jargon and vague terms. He said further that he hopes that there is going to be a vaccine soon and to recognize that there are nonscientists with inadequate information and contradictory claims. He added that this a very difficult
11 information environment and reiterated Godwinâs statement that this is new and there is a lot to learn. Fischhoff continued by asking, âWhat do we need to know about any of our decisions, whether itâs travel or health care or going to the playground with our kids? How big are the risks, what actions cause and reduce those risks, and how good is the evidence? How confidently, can we take different actions? What is likely to change either in the world or in the evidence and, finally, whom can you trust?â Fischhoff said, âWithout that knowledge, we are left to guess, drawing on our own imperfect mental models about how various parts of the world work.â Fischhoff stated that people are vulnerable to misinformation and disinformation and would find information online if there is no good information from authorities. Furthermore, Fischhoff said that it is important to have both the process and the content matter in getting the communication right. He explained that the process must demonstrate concern for people and be collaborative to convey a shared faith of safety. The process also needs to be adaptive because the world is changing in terms of the virus and what institutions of science say. He added that the content needs to be relevant and reflect an analysis of peopleâs decisions in what they need to know, not what they think they need to know or what we want to tell them. Content needs to be comprehensible, and it is important to draw on behavioral research, particularly when things are not intuitive, such as how exponential processes grow and how diseases disseminate through populations. Fischhoff outlined a strategic approach to process, referring to a diagram from the Canadian Standards Association dated from 20 years earlier that was first implemented by the Canadian Aviation Authority. He described the elements in a risk management process, where there is two-way risk communication that does not start until it is established with the public to determine importance and ensure there are no surprises. He added that while the world changes and there is reliance on your partners to help alert you to those changes, this demonstrates commitment by senior leadership to this two-way communication with the public. Fischhoff explained how a strategic approach to content has three stages: the first stage is analysis, which is to figure out what decisions people face; the second stage is to find out how they are currently dealing with those decisions without any communication; and the third stage is intervention, which is to consider how people can be helped to make better decisions. He added that this general process can be applied to just about any decision where there is risk or technical information. He described what decisions people face using a decision tree, which starts a decision with various sources of uncertainty and outcomes, and how versatile these tools are. A second tool, summarizing the quality of the evidence, is done by using a method that has been used by the Bank of England. This method was used in stress testing of the British economy since the 2007â2009 collapse and involves presenting the uncertainty surrounding projections for the British economy and determining how there needs to be an understanding of uncertainty and risk when making a decision. He stated that often people need to know how a decision was modeled in order for them to trust the conclusions.
12 Fischhoff stated that evidence can be created from old and new sources, citing the National Academiesâ Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats that is doing work on COVID-19. This committee is chaired by Harvey Fineberg, a former president of the National Academy of Medicine. Fischhoff said that he is a member of this standing committee, which has produced consensus reports reviewed through the National Academiesâ rigorous peer review process and said what was known about these various topics. He added that these reports can be found online. He added that in the past, the National Academies has taken maybe 18 months to do these reports and recently they have been done much quicker. There is a list of early reports on unrelated topics that provide an information base that can then be adapted to the specific properties of COVID-19. Fischhoff continued that there is a large research base going back a century on how to communicate information to people, emphasizing that the National Academies of Sciences, Engineering, and Medicine has organized good resources, including special issues of the Proceedings of the National Academy of Sciences of the United States of America on the science of communication. Most of these reports, he added, are publicly available as free downloads. Fischhoff also added that he and his colleagues have done work on pandemic diseases such as papers on H5N1 as well as a survey of people during the Ebola virus. They found similar problems in the degree of public understanding. Often, the public is viewed as, or treated as, hysterical or emotional. Said Fischhoff, â[I]f you have peopleâs attention and if we do our job and communicate, the public will be there for us.â Fischhoff indicated that in the science of judgment and decision-making, his area of expertise, there are people who work on each of the topics of principles of judgement. He described that judgment is how people assess their world and that people are very good at tracking what they see. Researchers who study this say they automatically calculate how often things are seen, but they are not very good at detecting sample bias or things that are overpublicized. People tend to overestimate things that are underpublicized and tend to neglect that which is correctable. He added that it is understood that this is how people work, and there are people who spend their lives working on the details of each element of judgment. He further described principles of choice that involve how people combine what they believe with what they want. There is also the cognitive process, which is how people think, and there also psychologists who study social and emotional processes. He said, Emotions can both cloud and focus thinking, which are both good and bad. We know the poor communications can needlessly increase anxiety and can generate hostile emotions and undermine trust if we donât do our job right. And then finally, social pressure can lead people to act against their own best judgment. . . . Perhaps [such social pressure was] most easily seen or felt when we were teenagers, but it happens when we get pulled along in the things that we know we shouldnât do. There are people who study when this works and can help when this is going to happen in different situations.
13 Fischhoff stated that people who study individual differences say that it appears that there are some people who are better decision-makers than others as a function of their upbringing, which is reflected in the decisions that they make. He added that there are differences in peopleâs decision-making styles, which he cited are important to respect in a diverse workforce and in members of the public but are hard to measure. He indicated that it is hard to say that people are like this or like that, but it turns out to be harder to measure than competence. The National Academy of Sciences has been a leader in interventions on helping people make better decisions. He added that while we have antivirals, we hope to have vaccines; it is important to make certain people know what they can and cannot do and have a science base for all of these things. Fischhoff further said that applying this science requires several things, including substantive expertise from experts such as Godwin and her colleagues so as to get the facts right. People such as those in the National Academiesâ COVID-19 community are synthesizing the research, which is currently very scattered. To get the right facts, it is important to have a dialogue with your partners, know what the issues are, and have a process for rapid message testing so that what is heard is what was intended to be said. He added that there is no excuse for not doing message testingâit is neither expensive nor time-consuming and everybody needs to test their messaging. Often psychology shows that everybody exaggerates how well they understand other people. Lastly, he said that a strategic commitment to risk communication cannot be at the end of the pipeline. It needs to be integral with the risk management process. Fischhoff concluded with a proposal to create a resource center that will provide publication-quality support in developing communications, because getting this right is as important as getting the scientific record right. Common templates and terms are needed, as is framing problems in the same way and getting everybody to be speaking from the same page. Finally, it is important to extend an organizationâs absorptive capacity when there is not in-house expertise. Having a resource center for the aviation industry would enable work with internal communications staff, human resources, and safety staff, in order to provide complimentary communication skills. HealthÂ UpdateÂ Q&AÂ Fischhoff was asked to provide a further explanation of an influence diagram that comes from Bayesian decision-making as a way of organizing data. He said that it is a model for doing computational simulations of how complicated systems work, their health effects in the air, and what health effects to predict. He cited an example of the intrusion of a cryptosporidium parasite into the domestic water supply and how it will depend on the factors that flow into the effects on health. Questions to consider include
14 â¢ What is the measure of contamination? â¢ How well is that contamination picked up so it will go from contamination to routine testing and then flow through the process of measuring contamination? â¢ How well-coordinated is the water utility with the public health officials? He added that final questions concern who drinks the water and what people have done to protect their water. Fischhoff explained that as he understood the science, cryptosporidium is something that someone cannot test by themselves. Therefore, if people test positive, they have probably put themselves at greater risk than had they not been tested. If people boil water appropriately, then they are probably at less risk than they would have been had they not boiled water. On the other hand, if they do not boil the water appropriately, they may have a false sense of security. Fischhoff indicated that this is a Baysian model taking into consideration varied forms of information. One central question of using the model is, âWhat is the transmission rate within the system and how often are people tested within the systemâ? He explained that it is just a class of modeling technique that enables inputs of diverse data to estimate risk. HammâNiebruegge then asked both presenters: âWhat is the panelâs opinion about conducting COVID-19 tests physically at airports across the country if the test can be a rapid result?â Â Godwin responded by stating that it is necessary to hear the perspective of those who are working in airports, specifically, about what their constraints are. Godwin stated that âfrom a public health perspective, we are not ready to do that at this point, regardless of how feasible it is for airports, because the rapid results tests do not tend to have very good levels of false positives and false negatives right now, and testing could create unmanageable lines, which is not a good use of resources.â Conversely, she stated that at the University of Washington, they have been using what they call âaccess stations,â but in the airport setting, she described that when you check in and indicate that you do not have hazardous materials in your bag, you might also need to test that you do not have symptoms associated with COVID-19. It is a good way to remind people that they are not supposed to be flying if they have those symptoms. She added that it is still an honor system, but, just as it works for keeping people from carrying hazardous materials, it might be worth considering. Fischhoff responded that it is very important to get authoritative estimates of the sensitivity and specificity and the performance properties of the test. Doing so would likely require somebody from either a university or an industry body to estimate the rate of false negatives and false positives and the possible liabilities if the tests are not as good as they are billed. He further indicated that as stated in the news, there have been problems with the reported numbers and actual performance standards of the tests. The next question posed by an attendee was, âWhat should the FAA regulate or mandate to bring back the public confidence to fly again?â
15 Fischhoff responded that these are economic political questions. He said he believed that the whole system would fail if people do not believe what is said about the safety of flying again and if information is not consistent with the facts. He added that it is important that the expectations that are being communicated are consistent and justifiable. He said, âThat in this country, there are places that are opening up but people arenât going out. They are afraid since they havenât seen the kind of reassurances and suspect that people in many of those areas have not had a [disciplined] approach to communication, getting the analysis, getting the testing right, making sure that you draw on the science that communicates things that are not inherent and that can be tricky.â The moderator asked the next question: âHow long do you expect the social distancing recommendations to remain in place?â Godwin responded that each of the 50 states is already starting to list some social distancing restrictions. She said that this varies from state to state because it is under state jurisdiction, and so depends upon where people live. Each governor and state health officer are weighing in on not just public health considerations but also on economic and political considerations to make those decisions. Fischhoff replied that how well this works will again depend on how effective the communication is. For instance, the two neighboring states of Pennsylvania and Ohio seem to have a nice division of labor between the governor and the secretary of health. Fischhoff said that âa governor who gives the policy doesnât pretend to know the science and hands it over to the secretary of health, who is a dedicated physician and public health official,â which he indicated was a good model. Fischhoff added, âThe more that model is followed, the more stable our situation will be and the better [we will be] able to maintain an upper course.â Godwin was asked if she could address the modest change CDC made to the surface transmission risk. Godwin responded, that, on the basis of looking at the CDC documentation, this was just a clarification. She said, As weâve moved from guidance that was based upon what we knew about other respiratory pathogens and other coronaviruses to information specifically about this coronavirus in real-world settings, . . . what we know is that the main route, the highest risk for transmission, is through droplets, and that is why it is so important to maintain that 6 foot distance and not to stay in close contact with people for extended periods of time. . . . Public health officials werenât saying people couldnât get the virus from surfaces, so it is important to clean surfaces and for people to do the hand-washing with soap and water or use hand sanitizer. Godwin added that health officials were just trying to clarify that touching surfaces is a lower risk than close contact for extended periods of time. HammâNiebruegge added that she believed there was a recommendation that only people who have COVID-19 should wear the face mask. Then that also changed and health officials suggested that everyone should be wearing a mask other than children under two.
16 Godwin added that the change to recommend face masks was really due to new information, which was the component of people who are asymptomatic being responsible for a significant amount of the transmission. In addition, it was the realization that although cloth face coverings do not provide fantastic protection for the wearer, they actually provide pretty good protection for other people nearby. She added that âsince we have a significant number of people who have COVID-19 but donât even know it, wearing a mask is a way of protecting other people from yourself.â Fischhoff added that he worked on the National Academies COVID-19 committee to produce a report on handmade face masks (adding this was not a major topic of research by the biomedical establishment). He stated that the report was clear that some of the contradictory recommendations were made because there were issues with solving different problems about what is known and unknown regarding inhaling, exhaling, protecting yourself, and protecting others, but people have alternative intuitive psychological theories without any support. He said that, âwhile we wouldnât speculate about aerosols, people shouldnât speculate about human behavior without evidence.â HammâNiebruegge posed another question to Godwin: âCan you address the problems with some of the testing results? How much confidence should we have in the data that is currently published?â Godwin responded that âthe data that we have is incomplete and we can assume that there are more people who have been infected with COVID-19 than the number of cases that have been detected.â She added, Over time, we will end up having better data as we end up doing more testing as we understand the disease better. Itâs really hard in the midst of a pandemic to have high-quality data available in real time. Nonetheless, there are still basic things that we know about how to reduce risk of transmission that are really important. It is also really important for people to make sure that theyâre doing what they can to reduce their own risk and not place people with vulnerabilities at risk.â HammâNiebruegge asked, âSo the ultraviolet lighting is currently marketed as a tool to disinfect aircraft. Can you share any insights on the viability of the ultraviolet lighting?â Godwin responded that she would like to first see some actual data for COVID-19 itself in the settings being discussed and how the people who would disinfect airplanes would use that product. Fischhoff agreed and said that, âWe have this situation where we have a strong need for trusted regulatory bodies, and there are unfortunately lots of people taking advantage of the situation and selling things that donât really work so are costing lives.â He added, âBecause people think they have protection and they donât, it undermines faith in everything. Citizens canât tell what has been proven and what hasnât been proven. So it is very tough, if we canât get it from the gut.â He added that there needs to be tough standards for certifying potential solutions.
17 HammâNiebruegge asked, âHow long will practicing social distancing need to be done on an aircraft, and what is the reality and financial impact of trying to keep social distancing onboard? What is the economic viability in the long term? Should it be a requirement on aircraft?â Godwin responded that there are so many other factors that play into the decision-making. She added that from a public health perspective, seeing people distance by 6 feet and wear face coverings is ideal, knowing that sitting in close proximity to someone from outside your household for an extended period of time would count as a high-risk activity. She added that how long people can maintain social distancing guidelines and how realistic those guidelines are is in terms of the economics, is something the industry is going to have to figure out. She hoped that with the current low demand for flights, there is consideration in terms of seat assignments and trying to create space where possible, but she reiterated that this will need to be figured out. Fischhoff added that he would like to see people like Godwin and her colleagues do modeling with the HEPA filters, and, while there is a lot of concern for air quality in planes, there are assumptions made about disease load and screening. He indicated that often these models, similar to the one he showed earlier, can have unintuitive results. Sometimes it turns out that the prevalence is lower in the population. People wearing a face mask with a certain amount of self-discipline ultimately stay home to avoid getting infected. He added that these dynamic interactive nonlinear models have unintended effects.