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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preparing Airports for Communicable Diseases on Arriving Flights. Washington, DC: The National Academies Press. doi: 10.17226/24880.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Preparing Airports for Communicable Diseases on Arriving Flights. Washington, DC: The National Academies Press. doi: 10.17226/24880.
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SubScriber categorieS Aviation  •  Security and Emergencies  •  Society A I R P O R T C O O P E R A T I V E R E S E A R C H P R O G R A M ACRP SYNTHESIS 83 Preparing Airports for Communicable Diseases on Arriving Flights A Synthesis of Airport Practice conSultantS James F. Smith Smith-Woolwine, Inc. Panacea, Florida and Joshua Greenberg Carleton University Ottawa, Ontario, Canada Research Sponsored by the Federal Aviation Administration 2017

AIRPORT COOPERATIVE RESEARCH PROGRAM Airports are vital national resources. They serve a key role in transportation of people and goods and in regional, national, and international commerce. They are where the nation’s aviation sys- tem connects with other modes of transportation and where federal responsibility for managing and regulating air traffic operations intersects with the role of state and local governments that own and operate most airports. Research is necessary to solve common oper- ating problems, to adapt appropriate new technologies from other industries, and to introduce innovations into the airport industry. The Airport Cooperative Research Program (ACRP) serves as one of the principal means by which the airport industry can develop innovative near-term solutions to meet demands placed on it. The need for ACRP was identified in TRB Special Report 272: Airport Research Needs: Cooperative Solutions in 2003, based on a study sponsored by the Federal Aviation Administration (FAA). ACRP carries out applied research on problems that are shared by airport operating agencies and not being adequately addressed by existing federal research programs. ACRP is modeled after the successful National Cooperative Highway Research Program (NCHRP) and Transit Cooperative Research Program (TCRP). ACRP undertakes research and other technical activities in various airport subject areas, including design, construction, legal, mainte- nance, operations, safety, policy, planning, human resources, and administration. ACRP provides a forum where airport operators can cooperatively address common operational problems. ACRP was authorized in December 2003 as part of the Vision 100—Century of Aviation Reauthorization Act. The primary par- ticipants in the ACRP are (1) an independent governing board, the ACRP Oversight Committee (AOC), appointed by the Secretary of the U.S. Department of Transportation with representation from airport operating agencies, other stakeholders, and relevant indus- try organizations such as the Airports Council International-North America (ACI-NA), the American Association of Airport Execu- tives (AAAE), the National Association of State Aviation Officials (NASAO), Airlines for America (A4A), and the Airport Consul- tants Council (ACC) as vital links to the airport community; (2) TRB as program manager and secretariat for the governing board; and (3) the FAA as program sponsor. In October 2005, the FAA executed a contract with the National Academy of Sciences for- mally initiating the program. ACRP benefits from the cooperation and participation of airport professionals, air carriers, shippers, state and local government officials, equipment and service suppliers, other airport users, and research organizations. Each of these participants has different interests and responsibilities, and each is an integral part of this cooperative research effort. Research problem statements for ACRP are solicited periodi- cally but may be submitted to TRB by anyone at any time. It is the responsibility of the AOC to formulate the research program by identifying the highest priority projects and defining funding levels and expected products. Once selected, each ACRP project is assigned to an expert panel appointed by TRB. Panels include experienced practitioners and research specialists; heavy emphasis is placed on including airport professionals, the intended users of the research products. The panels prepare project statements (requests for proposals), select contractors, and provide technical guidance and counsel throughout the life of the project. The process for developing research prob- lem statements and selecting research agencies has been used by TRB in managing cooperative research programs since 1962. As in other TRB activities, ACRP project panels serve voluntarily with- out compensation. Primary emphasis is placed on disseminating ACRP results to the intended users of the research: airport operating agencies, service providers, and academic institutions. ACRP produces a series of research reports for use by airport operators, local agencies, the FAA, and other interested parties; industry associations may arrange for workshops, training aids, field visits, webinars, and other activities to ensure that results are implemented by airport industry practitioners. ACRP SYNTHESIS 83 Project A11-03, Topic S03-12 ISSN 1935-9187 ISBN 978-0-309-39008-8 Library of Congress Control Number 2017942537 © 2017 National Academy of Sciences. All rights reserved. COPYRIGHT INFORMATION Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously published or copyrighted material used herein. Cooperative Research Programs (CRP) grants permission to reproduce material in this publication for classroom and not-for-profit purposes. Permission is given with the understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FRA, FTA, Office of the Assistant Secretary for Research and Technology, PHMSA, or TDC endorsement of a particular product, method, or practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment of the source of any reprinted or reproduced material. For other uses of the material, request permission from CRP. NOTICE The report was reviewed by the technical panel and accepted for publication according to procedures established and overseen by the Transportation Research Board and approved by the National Academies of Sciences, Engineering, and Medicine. The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessari- ly those of the Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; or the program sponsors. The Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; and the sponsors of the Airport Cooperative Research Program do not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the object of the report. Published reports of the AIRPORT COOPERATIVE RESEARCH PROGRAM are available from Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet by going to http://www.national-academies.org and then searching for TRB Printed in the United States of America

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 Board’s 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.

TOPIC PANEl S03-12 K. FORREST BROOM, Dallas/Fort Worth International Airport Fire/EMS, Corinth, Texas CLIVE M. BROWN, U.S. Department of Health and Human Services, Atlanta, Georgia ALI S. KHAN, University of Nebraska Medical Center, Omaha, Nebraska JENNIFER L. MARTIN, Baltimore City Health Department, Baltimore, Maryland LLOYD A. McCOOMB, Oakville, Ontario, Canada DEAN ULRICH, Los Angeles World Airports, Los Angeles, California ALEX NAAR, Federal Aviation Administration (Liaison) LYNN A. SLEPSKI, U.S. Department of Transportation (Liaison) MATT CORNELIUS, Airports Council International–North America (Liaison) JACK HERRMANN, U.S. Department of Health and Human Services (Liaison) SYNTHESIS STudIES STAFF STEPHEN R. GODWIN, Director for Studies and Special Programs JON M. WILLIAMS, Program Director, IDEA and Synthesis Studies MARIELA GARCIA-COLBERG, Senior Program Officer THOMAS HELMS, Consultant JO ALLEN GAUSE, Senior Program Officer GAIL R. STABA, Senior Program Officer TANYA M. ZWAHLEN, Consultant DON TIPPMAN, Senior Editor CHERYL KEITH, Senior Program Assistant DEMISHA WILLIAMS, Senior Program Assistant DEBBIE IRVIN, Program Associate COOPERATIVE RESEARCH PROGRAMS STAFF CHRISTOPHER J. HEDGES, Director, Cooperative Research Programs LORI L. SUNDSTROM, Deputy Director, Cooperative Research Programs MICHAEL R. SALAMONE, Senior Program Officer KAREN NEELEY, Program Associate EILEEN P. DELANEY, Director of Publications ACRP COMMITTEE FOR PROjECT 11-03 CHAIR JOSHUA D. ABRAMSON, Easterwood Airport, College Station, Texas MEMbERS DEBBIE K. ALKE, Montana Department of Transportation, Helena, Montana GLORIA G. BENDER, TransSolutions, Fort Worth, Texas DAVID A. BYERS, Quadrex Aviation, LLC, Melbourne, Florida DAVID N. EDWARDS, JR., Greenville–Spartanburg Airport District, Greer, South Carolina BRENDA L. ENOS, Massachusetts Port Authority, East Boston, Massachusetts LINDA HOWARD, Independent Aviation Consultant, Bastrop, Texas FAA lIAISON PATRICK W. MAGNOTTA AIRCRAFT OwNERS ANd PIlOTS ASSOCIATION ADAM WILLIAMS AIRPORTS CONSulTANTS COuNCIl MATTHEW J. GRIFFIN AIRPORTS COuNCIl INTERNATIONAl–NORTH AMERICA LIYING GU TRb lIAISON CHRISTINE GERENCHER Cover figure: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) virions. Image produced by the National Institute of Allergy and Infectious Diseases using highly magnified, digitally colorized transmission electron microscopic technology. (Public domain photograph.)

FOREWORD Disease outbreaks have become more visible in an era of mass travel, with air travel serv- ing as a speedy and powerful means of transmitting communicable disease. Public health and airport responders can act to reduce transmission of illness from arriving flights. This synthesis examines current disease preparedness and response practices at U.S. and Cana- dian airports in coordination with public health officers and partners. Recent outbreaks, including but not limited to Ebola, H1N1, MERS-CoV, H5N1, H7N9, tuberculosis, and Zika have caused airports and public health agencies and departments to forge strong rela- tionships and engage in joint planning both to protect community health and well-being, and ensure business continuity. While larger airports that receive international flights are most likely to experience the challenges associated with these events, the preparedness and response lessons are transferable to the aviation sector more widely. Smaller airports may be final destinations of those traveling with communicable diseases, so report findings are useful to all airport operators and local public health officers. The findings presented in this report are based on survey responses from a purposive sample of 50 airports and 39 public health departments, a review of peer-reviewed and gray literature, six detailed case examples involving interviews with aviation and public health partners, and interviews with representatives of five leading international, national, and regional airport and public health organizations to provide expert validation of the study’s findings and identify further research. Dr. James F. Smith, Smith-Woolwine, Inc., Panacea, Florida, and Dr. Joshua Greenberg, Carleton University, Ottawa, Ontario, Canada, collected and synthesized the information and wrote the report. The members of the topic panel are acknowledged on the preceding page. This synthesis is an immediately useful document that records the practices that were acceptable within the limitations of the knowledge available at the time of its preparation. As progress in research and practice continues, new knowledge will be added to that now at hand. Airport administrators, engineers, and researchers often face problems for which infor- mation already exists, either in documented form or as undocumented experience and practice. This information may be fragmented, scattered, and unevaluated. As a conse- quence, full knowledge of what has been learned about a problem may not be brought to bear on its solution. Costly research findings may go unused, valuable experience may be overlooked, and due consideration may not be given to recommended practices for solving or alleviating the problem. There is information on nearly every subject of concern to the airport industry. Much of it derives from research or from the work of practitioners faced with problems in their day-to-day work. To provide a systematic means for assembling and evaluating such useful information and to make it available to the entire airport community, the Airport Coop- erative Research Program authorized the Transportation Research Board to undertake a continuing project. This project, ACRP Project 11-03, “Synthesis of Information Related to Airport Practices,” searches out and synthesizes useful knowledge from all available sources and prepares concise, documented reports on specific topics. Reports from this endeavor constitute an ACRP report series, Synthesis of Airport Practice. This synthesis series reports on current knowledge and practice, in a compact format, without the detailed directions usually found in handbooks or design manuals. Each report in the series provides a compendium of the best knowledge available on those measures found to be the most successful in resolving specific problems. PREFACE By Gail R. Staba Senior Program Officer Transportation Research Board

ACkNOwlEdGMENTS The authors are grateful to Dr. Oscar Alleyne, National Association of County and City Health Officials (NACCHO), who coordinated the U.S. local health depart- ment survey requests with outstanding results. Mr. Alex Naar of FAA for facilitating the authors’ attendance in August 2016 at the public sessions of the Staff Assistance Visit (SAV) for Hartsfield–Jackson Atlanta International Airport (ATL) by the Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation (CAPSCA), and for introduc- tions to senior public health officials from CDC, U.S.PHS, U.S.DOT, DHS, HHS, and ICAO. Discussions at CAPSCA were helpful in shap- ing this report. Dr. Ansa Jordaan, International Civil Aviation Organization; Dr. Clive Brown, CDC; Dr. Ali Khan, University of Nebraska Medical School; Mr. Alain Boucard, Public Health Agency of Canada; Mrs. Suchita Jain, Public Health Agency of Canada; Dr. Bryon Backenson, New York State Department of Health; Dr. Jennifer Martin, Baltimore City Health Department; Commander Christopher Perdue, Depart- ment of Health and Human Services; Ms. Christine Gerencher, TRB; and Mr. Jack Herrmann, Department of Health and Human Services, who helped the authors understand the medical and regulatory frame- work under lying the prevention and control of communicable dis- eases, particularly as related to air travel. Drs. Brown, Khan, Martin, and Mssrs. Herrmann and Naar served on the topic panel for this project. For Case 1, Toronto Pearson International Airport and SARS: Mr. Andrew Payter, Manager, Operational Continuity & Emergency Management Programs, Greater Toronto Airports Authority (GTAA); Ms. Dana Franzgrote, Emergency Management Systems Officer, Greater Toronto Airports Authority; and Mrs. Suchita Jain, Manager, Central Region, Quarantine Services, Office of Border and Travel Health, Public Health Agency of Canada (PHAC). For Case 2, Phoenix Sky Harbor International Airport and tuber- culosis: Mr. Christopher Rausch, Emergency Preparedness Manager, City of Phoenix Aviation; Dr. Rebecca Sunenshine, Medical Direc- tor and Administrator, Disease Control Division, Maricopa County Department of Public Health; Mr. Mitchell Lach, Program Manager, Office of Preparedness and Response, Maricopa County Department of Public Health; and Mr. William E. Smith, Epidemiologist, Office of Epidemiology, Maricopa County Department of Public Health. For Case 3, Portland International Airport and measles: Ms. Kori Nobel, Emergency Program Manager, Public Safety and Security, Port of Portland; Dr. Amy Sullivan, Communicable Disease Services, Multnomah County Health Department; and Mr. Uei Lei, Emergency Preparedness and Response Manager, Multnomah County Health Department. For Case 4, Dallas/Fort Worth International Airport and Ebola: Mr. Forrest Broom, Assistant Fire Chief—Emergency Medical Services, Dallas/Fort Worth International Airport; and Mr. Russell Jones, Chief Epidemiologist, Tarrant County Public Health. For Case 5, Boston Logan International Airport and five suspected Ebola cases: Massport ARFF Chief Robert Donahue; Massport ARFF Assistant Chief Robert Barnes; ARFF Assistant Chief Ted Costa; Catherine Obert, Emergency Planner, Massport; and Olga Freger, Para- legal, Massport. For Case 6, Vancouver International Airport and H7N9 influenza: Mr. Cal Currie, Manager, Emergency Planning, Vancouver International Airport Authority; and Ms. Amal Remu, Manager, Western Region, Quarantine Services, Office of Border and Travel Health, Public Health Agency of Canada (PHAC). For the expert validation interviews, the research team thanks the senior officials from the five agencies who graciously and candidly responded to our findings and suggested improvements. The research team thanks the topic panelists and the ACRP senior project manager for their unstinting help and encouragement.

CONTENTS 1 SUMMARY 3 CHAPTER ONE INTRODUCTION 4 CHAPTER TWO AIR TRAVEL AND COMMUNICABLE DISEASES Diseases of Public Health Significance, 4 Legal Environment for Response to Communicable Diseases at Airports, 8 Importance of Relying on Public Health and Medical Expertise, 9 Relationships of Local, State, or Provincial and National Public Health Departments in the United States and Canada, 9 Scope of This Study, 10 Study Methods, 11 13 CHAPTER THREE SURVEY RESULTS Types and Frequency of Arriving Flights, 13 Experiences with Communicable Disease Responses and Preparations, 13 How Airports Expect to Learn of a Potential Communicable Disease Issue on an Arriving Flight, 13 Nature of Airport Communicable Disease or Quarantine Plans, 15 Maintaining and Reviewing Plans, 16 Training, Drilling, and Exercising Plans, 17 Communicable Disease–Related Services Provided by Health Departments to Airports, 18 Dealing with a Surge in Demand for Health Services at an Airport, 19 Protective Measures Provided to Airport Employees, 19 Lessons Learned, 20 Self-Estimates of Preparedness Level, 20 22 CHAPTER FOUR WHERE THE RUBBER HITS THE TARMAC: SIX CASE EXAMPLES Introduction, 22 Case 1: Toronto Pearson International Airport and Severe Acute Respiratory Syndrome (2003), 22 Case 2: Phoenix Sky Harbor International Airport and Tuberculosis (2013), 28 Case 3: Portland International Airport and Measles (2014), 33 Case 4: Dallas/Fort Worth International Airport and Ebola (2014), 38 Case 5: Boston Logan International Airport and Five Suspected Ebola Cases (2014), 44 Case 6: Vancouver International Airport and H7N9 (2015), 45 Summary of Common Themes from Case Examples, 51 55 CHAPTER FIVE FINDINGS, CONCLUSIONS, AND FURTHER RESEARCH Findings, 55 Major Conclusions, 57 Further Research, 59

60 GLOSSARY 64 ACRONYMS 65 REFERENCES 69 APPENDIX A DISEASES OF PUBLIC HEALTH SIGNIFICANCE Canada, 69 United States, 69 International—The World Health Organization (WHO), 69 71 APPENDIX B ICAO DOCUMENT 4444, PARAGRAPH 16.6 72 APPENDIX C STUDY PARTICIPANTS Airports, 72 Health Departments, 74 76 APPENDIX D SURVEY QUESTIONS AND RESPONSES D-1: Survey Questions and Responses for Airports, 76 D-2: Survey Questions and Responses for Local Public Health Preparedness Coordinators, 80 D-3: Template for Expert Validity Interviews, 81 82 APPENDIX E LESSONS LEARNED AS STATED BY AIRPORTS AND LOCAL HEALTH DEPARTMENTS By Airports, 82 By Health Departments, 84 87 APPENDIX F EBOLA TIME LINE FOR DFW CASES 90 APPENDIX G CHECKLIST FOR AIRPORT COMMUNICABLE DISEASE RESPONSE PLANNING Note: Photographs, figures, and tables in this report may have been converted from color to grayscale for printing. The electronic version of the report (posted on the web at www.trb.org) retains the color versions.

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TRB's Airport Cooperative Research Program (ACRP) Synthesis 83: Preparing Airports for Communicable Diseases on Arriving Flights examines current disease preparedness and response practices at U.S. and Canadian airports in coordination with public health officers and partners. While larger airports that receive international flights are most likely to experience the challenges associated with these events, the preparedness and response lessons are transferable to the aviation sector more widely. Smaller airports may be final destinations of those traveling with communicable diseases, so report findings are useful to all airport operators and local public health officers.

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