Infectious Disease Mitigation in Airports and on Aircraft (2013)

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24 Airport Operators and Airlines Should Consider Implementing a “Healthy Traveler” Campaign Highly Recommended Rationale. Public relations campaigns, such as a “Healthy Traveler” campaign, can be an effective way to provide passengers with recommendations for staying healthy during their travels. A “Healthy Traveler” cam- paign encompasses many important mitigation measures that are included elsewhere in this document, such as wash your hands and cover your cough, but also includes the establishment of a unified program to raise awareness of these public health measures. A single checklist of the items included in the campaign could be developed and provided to all airport and airline managers to distrib- ute appropriately. A coordinated campaign with similar images and messages across all airports and within an air- port would be ideal for reinforcing these actions, as it would provide consistency for the passengers traveling through various airports during their trip. If the city or district an airport is located in has a similar public health campaign already in place, then it would be encouraged to collaborate with their local DPH and look to their campaign for guidance as well. Points to Consider for Implementation 1. Encourage passengers to be aware of what diseases they may be exposed to at their travel des- tination, so they can prepare accordingly. Include reference to the CDC Traveler’s Health for foreign travel as a way to encourage passengers to consider disease exposure. 2. Encourage passengers to rebook their flight for a later date if they are feeling ill. 3. Provide a checklist of recommendations, with specific examples, for what passengers should do prior to and during airline travel (e.g., get a good night’s sleep the night before, stay hydrated, keep your hands clean). Best practices and other reference materials used in the health care field could be used as a template for this checklist. 4. Use multiple means of disseminating information to passengers, such as the airport website, mobile applications (apps), video screens at the airport, and airport signage. 5. Suggest the use of a mask if a passenger suspects that they have a respiratory illness but are not able to alter their travel plans. 6. Issue traveler health notices to keep passengers up to date on information regarding infec- tious diseases of concern and provide them with recommendations. 7. Implement the campaign at all times of the year, but heighten the campaign during flu season and during outbreaks. C h a p t e r 4 People

people 25 8. Recommend a “Healthy Traveler Kit” as part of this campaign. The kit would consist of any or all of the following: masks, gloves, alcohol hand wipes, hand sanitizer. Passengers would also be made aware of their responsibilities if they are traveling with young children, such as to monitor their health as they travel and ensure that they have proper vaccinations. As part of this campaign, it should also be encouraged that the passenger should provide the airline with accurate contact information for their own safety, in case there is the unlikely need for contact tracing. 9. Provide information in multiple languages. “Healthy Traveler” campaigns promote public health recommendations for protecting yourself and others from infectious agents. One example of an effective campaign is the “Got a cough? Cover it” health education campaign sponsored by the Infectious Disease Bureau of the Boston Public Health Commission. The campaign is based on the well-known “Got Milk?” advertisements and can be deployed around the airport to raise awareness of simple measures to protect individual and public health.

26 Infectious Disease Mitigation in airports and on aircraft Airport Operators and Airlines Should Consider Implementing a “Healthy Worker” Campaign Highly Recommended Rationale. A universal “Healthy Worker’’ campaign is a valuable means to encourage healthy behaviors of airport and airline workers. Many airport and airline workers come into contact with hundreds or thousands of passengers every day, and some also handle passengers’ food and beverage. Therefore, it is important for these employees to remain in good health. All airport and air- line workers working in all parts of the airport environ- ment would be targeted. Points to Consider for Implementation 1. Develop Human Resource policy to ensure workers are not penalized for being out sick if a similar policy does not already exist. 2. Reinforce that sick airport/airline employees should remain at home until they are completely recovered (e.g., for flu, fever free for at least 24 hours). 3. Provide vaccinations under the scope of wellness benefits of medical plans (e.g., influenza and all routine vaccinations, to include on-site influenza vaccination clinics). 4. Communicate through multiple modalities in easy to understand documents and signage that include recommendations, such as the importance of hand washing. 5. During an outbreak, provide information (e.g., employer specific FAQs) based on guidance provided by the CDC and other reputable sources that will allow airport/airline workers to recognize symptoms and seek out appropriate treatment. Airport Operators Should Consider Implementing a Seasonal Influenza Vaccination Campaign and Make the Vaccination Available to All Populations in the Airport Environment Highly Recommended Rationale. The implementation of an influenza vac- cination campaign in airports would allow passengers and airport and airline employees easy access to the vaccina- tion during the flu season and provide an important pub- lic health benefit to the traveling community, airport, and airline employees and the non-traveling population. While similar campaigns could be implemented in other congre- gate settings, such as hospitals and schools, the airport serves as a single point of contact for millions of passen- gers every year during the flu season. High-priority groups (pregnant women, children, young adults) can be specifi- cally targeted in the event of a pandemic. Points to Consider for Implementation 1. Establish vaccination stations throughout the airport, including each terminal because targeting passengers during downtime prior to boarding may increase the response rate.

People 27 2. Distribute information to passengers at ticketing areas and airport entryways to promote the campaign. 3. Develop an airport-wide public relations campaign (e.g., signage, digital signage, video) to make passengers aware of the campaign. Airport Operators and Airlines Should Consider Participating in Pandemic Planning Highly Recommended Rationale. The establishment of a pandemic plan would provide information for all members of the air- port community about their roles and responsibi lities in the event of a pandemic. Having a plan already in place during an outbreak greatly increases the control the airport/airline community has over the transmission of the disease. The International Health Regulations (IHR) issued in 2005 focus on serious public health threats with the potential to spread beyond a country’s borders. Such events are defined as a Public Health Emergency of International Concern (PHEIC). IHR outline assessment, management, and information sharing for PHEICs. They aim to prevent, protect against, control and provide a public health response to the international spread of disease and provide guidelines and recommendations for the prevention of disease transmission through air travel that is meant to be used in the development of this type of plan. The develop- ment of a pandemic plan provides an important opportunity for all stakeholders to meet and understand their various roles in event of a pandemic. The group of stakeholders may also play a role in other recommendations in this document, including the development of “Healthy Traveler” and “Healthy Worker” campaigns. Airport operators and airlines should be aware of federal government initiatives such as Risk Based Border Strategies (RBBS). RBBS is a strat- egy that involves screening international passengers during initial phases of a pandemic. The pandemic plan should include provisions for guidance and/or direction from federal agencies during a pandemic. Points to Consider for Implementation 1. Assign one position or group within airport operations as being responsible for maintaining the pandemic plan. 2. For those with existing pandemic plans, review the plan annually to ensure the document remains current, including contact information of the stakeholders. 3. When developing or reviewing plans, ensure all stakeholders participate in the development of the pandemic plan for the airport environment (e.g., local boards of health, local hospitals, fire and police). 4. Hold training courses to inform all airport and airline employees about their duties and responsibilities within the plan. 5. In addition to annual meetings to review pandemic plans, broaden the scope of these meet- ings to discuss other issues related to employee and traveler health, such as access to vaccina- tions and “Healthy Worker” and “Healthy Traveler” campaigns. 6. When reviewing pandemic plans, consider workloads that a pandemic can create in the initial phase of disease mitigation efforts.

28 Infectious Disease Mitigation in airports and on aircraft 7. Incorporate the pandemic plan into the overall Airport Emergency Response Plan as a way to ensure the document is considered annually and available to the necessary constituents. 8. Review CDC information for the latest information on pandemic plans, risk assessments, and governmental involvement. 9. Consider how to exercise the pandemic plan to ensure that all stakeholders are important contributors to the exercise. Airport and Airline Operators Should Consider Implementing a Hand Hygiene/ Cough/Sneeze Etiquette Campaign as a Method to Reduce the Transmission of Respiratory Infections and Infections Transmitted Via Direct Contact Highly Recommended Rationale. Most controlled studies show a protec- tive effect of hand washing at reducing upper respira- tory infections. The U.S. Centers for Disease Control and Prevention (CDC) state that “hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others.” Points to Consider for Implementation 1. Encourage passengers, airport and airline employ- ees, passengers, and guests to wash hands frequently and effectively and to use proper cough/sneeze etiquette to minimize transmission and prevent exposure to respiratory organisms and organisms transmitted via the fecal/oral route through a unified campaign of highly visible signage in the rest rooms, public address announcements, and other means. 2. Develop guidance for airport staff and airline crew for social distancing of obviously ill and potentially infectious passengers (e.g., locate the passenger away from other passengers if possible). Airport Operators and Airlines Should Consider Establishing and Maintaining Contact with Their Local Department of Health (DPH) and CDC Representatives Recommended Rationale. Local CDC and DPH offer great support in handling infectious disease prevention and response in airports, whether it is on a day-to-day basis, during the seasonal flu period, or during a pandemic. With a strong relationship between airports/airlines and these agencies in place, information pertaining to infectious diseases would be easily shared. Both organizations could also be valuable resources in the event of a pan- demic. Communication between airports/airlines and the agencies is essential to controlling the spread of disease if such an event was to occur, and this commu- nication would be greatly facilitated if airports/airlines

People 29 have already been maintaining good relations with these agencies. A number of other recom- mended mitigation measures can be easily implemented once relationships with contacts at both organizations have been developed, such as the development and review of a pandemic plan. Partnerships with these organizations may also aid in the implementation of the “Healthy Worker” and “Healthy Traveler” campaigns, as these organizations could provide professional marketing counsel to get the campaigns’ messages across in the most effective manner. Points to Consider for Implementation 1. Assign one position or group within airport operations and airlines as the responsible party for maintaining contact with local DPH and CDC representatives. 2. Monitor CDC website for guidance and suggestions for best practices. 3. Ensure that processes are in place for the release of information pursuant to a proper public health agency request Airport Operators and Airlines Should Consider Creating a Committee on Infectious Diseases That Includes All Agencies That Are Active Within the Airport Environment Recommended Rationale. The creation of an airport agencies com- mittee would have implications for all passengers, guests, and employees. This group would be the information resource and advisor for any and all actions pertaining to infectious disease control. This committee would allow for all of the different parts of the airport community to easily transfer information to one another and facili- tate the identification of airport-wide concerns regard- ing disease transmission. The goal of the committee is to ensure that programs and plans like “Healthy Worker” plans are implemented successfully. Representatives from each agency that were involved in the development of the plans would be able to effectively communicate them to other members of their respective teams. The committee on infectious disease could be established as a subcommittee of a larger committee (e.g., airport Health and Safety). Points to Consider for Implementation 1. Ensure committee membership represents all groups within the airport community in order to reduce the risk of unforeseen problems that could arise if only one or few groups were involved. 2. Ensure a broad scope for the committee by not targeting a specific disease or transmission pathway. Instead, focus on public health campaigns.

Abbreviations and acronyms used without definitions in TRB publications: A4A Airlines for America AAAE American Association of Airport Executives AASHO American Association of State Highway Officials AASHTO American Association of State Highway and Transportation Officials ACI–NA Airports Council International–North America ACRP Airport Cooperative Research Program ADA Americans with Disabilities Act APTA American Public Transportation Association ASCE American Society of Civil Engineers ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials ATA American Trucking Associations CTAA Community Transportation Association of America CTBSSP Commercial Truck and Bus Safety Synthesis Program DHS Department of Homeland Security DOE Department of Energy EPA Environmental Protection Agency FAA Federal Aviation Administration FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FRA Federal Railroad Administration FTA Federal Transit Administration HMCRP Hazardous Materials Cooperative Research Program IEEE Institute of Electrical and Electronics Engineers ISTEA Intermodal Surface Transportation Efficiency Act of 1991 ITE Institute of Transportation Engineers MAP-21 Moving Ahead for Progress in the 21st Century Act (2012) NASA National Aeronautics and Space Administration NASAO National Association of State Aviation Officials NCFRP National Cooperative Freight Research Program NCHRP National Cooperative Highway Research Program NHTSA National Highway Traffic Safety Administration NTSB National Transportation Safety Board PHMSA Pipeline and Hazardous Materials Safety Administration RITA Research and Innovative Technology Administration SAE Society of Automotive Engineers SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (2005) TCRP Transit Cooperative Research Program TEA-21 Transportation Equity Act for the 21st Century (1998) TRB Transportation Research Board TSA Transportation Security Administration U.S.DOT United States Department of Transportation