3

Policy and Procedures

In the workshop’s second session, four speakers discussed policy changes that could be implemented to expedite a return to safe travel with as few restrictions as possible and to help prepare for future pandemics. The topics of discussion included who should be allowed on airplanes (e.g., should vaccinations be required); should there be changes in seating configuration; should changes be made to embarkation, debarkation, and movement through terminals; and what should be done about uncooperative passengers.

The four panelists were: Marty Cetron of the Centers for Disease Control and Prevention (CDC), Arjun Garg of Hogan Lovells, Lauren Beyer of Airlines for America (A4A), and Steven Mayers, airport director of customer experience at Atlanta’s Hartsfield-Jackson International Airport. Each provided a brief presentation and took part in a panel discussion moderated by workshop planning committee member Vicki Hertzberg of Emory University.

CONTEXT: WHAT MAKES COVID-19 DIFFERENT

Introducing his presentation, Cetron said that he was not going to discuss policy questions, but instead would provide context for policy issues by discussing what makes COVID-19 different from other infectious diseases. His perspective, he said, comes from his approximately 30 years at the CDC, during which time he has seen a number of global outbreaks and pandemics, participating in the response to many of them. From that perspective, the COVID-19 pandemic is “distinctly unique,” with a collection of characteristics that make it like no other pandemic since perhaps the 1918 global influenza pandemic.

COVID-19 is a “supervirus,” Cetron said, with five distinct superpowers. The first is its highly contagious nature. The original virus that appeared in Wuhan, China, had an estimated R₀—the average number of people that an infected person will pass the virus to—of about 3 in a typical setting. Because R₀ for flu is typically between 1 and 2, that means that the original virus was significantly more transmissible than influenza. Even worse, as new variants emerged, the transmissibility increased. The Italian variant is more contagious than the original version; the alpha variant, which was originally described in the United Kingdom, is about 60 percent more contagious than the Italian variant; and the delta variant, which was originally reported in India and is rapidly becoming the dominant variant worldwide, is about 60 percent more contagious than the alpha variant. The delta variant has an R₀ that is close to 6, making it very highly contagious.

A second distinguishing feature is that COVID-19, which is typically expelled from a person’s lungs through coughing or simply breathing, spreads both by aerosol transmission—small droplets that hang in the air—and by larger droplets that quickly fall and land on a surface.

Third, COVID-19 is a ribonucleic acid (RNA) virus, Cetron noted. Like most RNA viruses, it has the capacity to mutate, but the variants of concern are emerging in a setting of intense global viral circulation. “Even prior to the pressures of countermeasures, whether they be treatment or vaccine use,” he said, “the virus itself is figuring out ways to become particularly more contagious by altering its spike protein, which it uses to stick to human cells by the ACE2 receptor.” The increased contagiousness means that an infection can be caused by a lower dose of the virus and that more viral replication occurs so that the viral load in people with the new variants tends to be higher. Furthermore, the accumulation of mutations has led to a reduced efficacy in some countermeasures, such as the monoclonal antibodies used for treatment and some of the vaccines intended to protect individuals from infection. In particular, he said, the efficacy of vaccines against infection and against the severity of the disease, varies according to the type of vaccine—that is, according to whether it is, for example, a messenger RNA (mRNA) vaccine, a one-dose or two-dose vaccine, a vaccine applied through an adenovirus vector, or a vaccine made in a more traditional way. All these platforms have different efficacies against infection, transmission, and morbidity and mortality, depending on which variant one is exposed to. “That’s a really unique challenge,” he said.

The fourth superpower is the tremendous amount of infectious transmission from people who are either pre-symptomatic or asymptomatic. “This means that people don’t even know they’re sick when they may be highly contagious and transmissible,” Cetron said. Ebola, for example, for which contagiousness increases over the course of the illness, may reach a maximum at the time of death. However, COVID is maximally contagious before most people even know they are sick, or at least before they are sick enough to curtail their travel and interactions with others.

Fifth, COVID presents very differently, with effects ranging from no symptoms whatsoever to rapid death within 2 weeks owing to respiratory and multi-organ failure. The angiotensin-converting enzyme 2 (ACE2) receptor that the virus’s spike protein binds to is found not just in the airways of the lungs but also on the insides of blood vessels, which run throughout all the organs of the body, As such, COVID can manifest in a wide variety of ways, from blood clots in the brain, brain fog, strokes, heart inflammation, gastrointestinal tract disease, and many others. Thus, it is not always clear that a patient has COVID, making it more likely that an infected person will pass it along. Additionally, an overexuberant inflammatory response in some people, both children and adults, can lead to symptoms that persist long after the initial recovery, including autoimmune problems.

The COVID pandemic cycle is also unusual because of these superpowers. Most recent pandemics have had relatively short durations, Cetron noted, while this one has lasted a year and a half and is still going. “I know it’s very popular to think in the West that we’re at the beginning of the end,” he said. “I actually would say globally … we’re probably at the end of the beginning, and this virus is likely to be wreaking havoc around the globe with us for some time to come, in part owing to the inadequate supply, globally, of vaccines.”

The pandemic has three acts. The first act was when it first emerged and was geographically limited. The second act is the long middle game where the virus is being fought with nonpharmaceutical measures. The closing act is when countries have countermeasures, including good vaccine programs and effective treatments. “But in fact,” he said, “these three acts are repeated in multiple cycles across the globe through a series of waves, and sometimes the clock is reset when a new variant emerges, like delta or others, and almost make the virus appear as a new virus, causing new susceptibility in people who previously had already been infected.”

So how can this supervirus be fought? Cetron likened a good pandemic response to a fine diamond, which excels in four characteristics: clarity, cut, carat, and color. For a pandemic response, the first characteristic is the public health perspective—carrying out risk assessments and determining ways to mitigate risk, limit transmission, and reduce morbidity and mortality. The second characteristic is the political response, he said. Countries around the world have managed the virus in different ways, depending on the country’s political considerations. The third characteristic is the private-sector response, which is more likely to take into account the economic aspects of the pandemic’s effects on business and industry. The fourth characteristic is the population perspective and how people understand the virus, how they perceive risk, and what they are willing to do and tolerate in terms of mitigation. Too often, Cetron said, one or another of these characteristics of the response to the pandemic is skewed or given too much weight, preventing a response that is effective in all four of these areas.

A particular challenge is that the COVID virus is changing rapidly over time. This means, Cetron said, that if the response to the virus is to be effective, the science and the tools related to it must be constantly revisited. “The virus is far more nimble than most of our large-scale policies and bureaucracies can adapt to,” he said, “and so sometimes we get stuck in dealing with a phase of the virus that is out of sync with really what the pandemic is presenting us.” In that situation, he said, an effective strategy is what fighter pilots refer to as OODA loops—observe, orient, decide, act. Then one loops back to see the results of the action and starts the process again, adjusting the response according to the outcome. “Too often,” he said, “we are not able to achieve the nimbleness of a fighter pilot fighting this existential threat.”

To deal with the pandemic effectively, Cetron continued, it will be necessary to balance the intended consequences with the unintended consequences, some of which can be anticipated but others of which cannot. The unintended consequences include such things as effects on mental health, on the economy, on other parts of the healthcare systems, and on vulnerable populations. Finding a good balance between risks and benefits is difficult, particularly when the tools at one’s disposal are only partially effective.

There is also variability in the way the tools are used. The different approaches can be carried out voluntarily through encouragement and incentives or through mandates. There have been more regulatory actions taken in response to the COVID pandemic, both in the United States and around the globe, compared to any other pandemic Cetron has seen in his 30 years in the field. One needs to go back to the 1918 flu epidemic to find anything like it.

In closing, he said that it will be crucial to adjust COVID-related policies in response to new knowledge and new situations. Early on, the responses were generally crude country-level responses based on aggregate perceptions of risk. Many of these responses, such as border restrictions or closings, had tremendous downsides for the economy and other areas. Moving forward, the goal should be to have more tightly focused responses on localized risks. However, given the various social and political pressures it may be difficult carry this out effectively.

THE ROLE OF FEDERAL AGENCIES IN RESPONDING TO THE COVID PANDEMIC

In the next talk, Garg described how the roles of federal agencies’ responses to the COVID pandemic evolved over time. Garg then offered some suggestions for making more effective federal COVID policies. However, he warned, future pandemics are likely to be different from this one in meaningful ways, and “we don’t want to be caught fighting the last battle.” As such, the specific solutions developed for COVID may not make sense for the next pandemic. Still, some general lessons can be learned, and one in particular, he said, is “you want to be nimble and responsive and flexible to whatever might come up.”

With that preface, he offered a brief history of how federal agencies responded once it became clear that COVID was going to be a problem. It was January 2020 when COVID first came onto his radar as he was working at the Federal Aviation Administration (FAA). It “quickly became an all-consuming, top-of-mind agenda item,” he said, “and very soon that became true for the entire world.” At the time, however, it was a struggle to figure out exactly who was going to do something about it. A number of federal agencies recognized the coming pandemic as a problem, and each saw that it overlapped with the agency’s mission to a certain extent. However, there was no one agency positioned to take it on directly, and the different agencies all struggled to determine what legal authority, resources, and expertise they had to bring to bear.

Fast forward to December 2020, he said, and a Runway to Recovery document was put out jointly by three departments: the Department of Transportation (DOT), the Department of Health and Human Services (HHS), and the Department of Homeland Security (DHS). To get to that point, however, there was a lot of work that had to be done, relationships that had to be built, and processes that had to develop in order to get the different entities working together on a solution, he said, “but that’s not where we started.”

In the early days, there was little consensus on who had responsibility for dealing with COVID. In terms of COVID and air travel, Garg said, many people pointed to the FAA as the natural agency. However, legally the FAA’s mandate concerned air travel safety, and that had traditionally been interpreted as keeping planes from crashing.

It was not clear that taking steps to prevent transmission of a virus on a plane fit into that mandate. Furthermore, the FAA had little expertise in the area of public health. So, there was an internal debate at FAA as to whether this was the agency’s problem. Other agencies had similar issues, he added.

As an example of a significant policy intervention that did not arise from FAA authority, Garg explained that the mask mandates that were eventually imposed on air passengers were under the legal authority of HHS and DHS. “FAA’s legal authority has actually never been used to any significant extent in tackling these problems.” The CDC and HHS also provided the science behind the mandates.

Yet, the scientific considerations are only part of the overall problem, he continued. There are economic, social, and political considerations. Neither the CDC nor the FAA has the expertise or the authority to address these issues. Furthermore, the agencies that are equipped to deal with these issues are typically not public health experts. The bottom line, Garg said, was that there was a “nonalignment” of the resources, expertise, and mandates among the various agencies relevant to dealing with the pandemic, and the agencies needed to figure out what their various roles should be. “Everyone knew this was a huge problem, everyone wanted to jump in as public servants and help solve it,” he said, but no one knew exactly who should be doing what.

At the time, Garg said, he began thinking that perhaps the right approach would be the establishment of a Transportation Health Administration parallel to the Transportation Security Administration (TSA) that was established after 9/11. The goal would be to have one government entity that had all the resources, expertise, and mandates to tackle such problems as COVID in air transportation. Even if that entity was a good idea in the months following the appearance of COVID, he continued, politically the time for it had probably passed. At this point, a number of agencies, including the FAA, CDC, and TSA had developed a strong day-to-day working relationship with each of the agencies responsible for particular parts of the problem. Still, there remains some ongoing movement in that direction, such as the Healthy Flights Act of 2021 introduced in the House of Representatives. This act makes it clear that the FAA has legal authority to take public health interventions relevant to aviation. It tasks DOT with developing an aviation preparedness plan for pandemics and performing studies on disease transmission in airplane cabins.

At this point, Garg said, he is not sure that the necessary capabilities exist in any one agency to competently and comprehensively attack a pandemic such as COVID. It is important to keep thinking about whether the federal government has its agencies set up in such a way that they can effectively respond to the next pandemic.

Another item to think about, he continued, is the question of how to keep track of which policies are ineffective and shut them down. In the early days of the pandemic, a number of interventions were implemented that seemed to make sense at the time. However, not all of them remained useful, given changing circumstances and the evolving understanding of COVID. There is a natural inertia that keeps such interventions in place even once it is clear that they are no longer needed. It would make sense to set out some metrics at the beginning by which the effectiveness of programs could be judged, and programs that are no longer needed could be clearly identified.

Garg pointed to the situation of international flights forced to land in one of 11 U.S. airports as an example of a policy that stayed in place long past sensible time. This example included returning U.S. citizens who had been in certain countries of concern. The policy made sense at one time—the goal was to make sure these people were going to airports where they could be appropriately screened. However, the policy stayed in place until September 2020 before it was finally lifted. At that point, there was already uncontrolled spread of COVID in the United States as well as in many countries that were not on the original list of countries of concern. It made little sense to be spending resources on this program when they could be better spent elsewhere. Furthermore, by routing all of these flights to just 11 airports, the program was creating a huge disruption to global airline operations. If there had been some metric in place and stated goals for the program, Garg said, the cancellation of the program might have happened much earlier. As it was, the government program was disrupting a global industry without actually helping the problem. That is the worst kind of government action.

In conclusion, Garg said it would be useful to consider the issues he had described in order to make it more likely that the government responds more nimbly and effectively to pandemics and other crises in the future.

THE U.S. AIRLINES’ PERSPECTIVE ON MOVING BEYOND THE COVID PANDEMIC

In the next presentation, Beyer spoke about what it will take to get the airline industry back to near-normal after the pandemic. She urged that certain steps be taken toward that end.

Beyer began by showing a graph of U.S. airline passenger volumes since the beginning of 2020. As had been noted by earlier speakers, the number of passengers flying on U.S. airlines dropped precipitously in March 2020, to less than 5 percent of the normal volume. Since that time, the number of passengers has slowly and steadily rebounded up to the week of June 15, 2021, the last week for which there were data available before the workshop. U.S. airline passenger volumes were down only 23 percent compared with the pre-pandemic numbers. However, Beyer continued, that average number obscures some major weakness in passenger volume. Passenger numbers for flights inside the United States were down only about 20 percent from before the pandemic. Additionally, the numbers for flights between the United States and Mexico were actually up by about 15 percent compared with 2019. However, there was still relatively little air travel between the United States and the rest of the world. Overall, passenger volume on international flights was down 46 percent.

Furthermore, the revenues from air passenger travel on U.S. airlines are still down 45 percent compared with 2019. This is largely because corporate and international travel—which have outsized importance to the bottom line of airlines—are still greatly depressed, Beyer said. For example, in May 2021 air travel between the United States and the United Kingdom was down 96 percent from its May 2019 level; for United States-China travel, it was a 98 percent decrease, and for United States-Canada, it was 97 percent. Indeed, air travel is still down more than 90 percent for 13 of the 25 largest markets for U.S. airlines.

For that reason, Beyer said, U.S. airlines strongly advocate developing a harmonized approach to restoring international travel, “and we continue to urge the U.S. government to develop a risk-based and data-driven roadmap to reopening these markets.”

In reopening these markets, ensuring the well-being of the traveling public should be a top priority, she said. The airline industry was encouraged when the Biden administration decided a few weeks before the workshop to establish working groups tasked with determining a pathway for the safe reopening of international air travel markets. “We believe these working groups should act really quickly to endorse a policy that’s backed by science; that will allow travelers who are fully vaccinated or who have presented a negative COVID-19 test to travel to the United States,” she said. “The science clearly and consistently affirms that international air travel is safe for vaccinated passengers as well as those who have been tested, and numerous academic studies have shown that the risk of transmission in air travel is extremely low.”

Many of the U.S. air travel industry’s key international markets have some of the highest vaccination rates around the world, Beyer said. In the United Kingdom, for example, 65 percent of the population has received at least one shot, and 47 percent are fully vaccinated. The United States has also achieved relatively high vaccination rates. Still, however, there are a number of U.S. travel restrictions that apply to passengers who have been present in the United Kingdom and the European Union, and the Canadian government is still imposing travel restrictions for passengers from the United States. According to a recent Mayo Clinic study, she said, the chances of a person infected with COVID boarding a plane traveling from the United States to the United Kingdom is approximately 1 in 10,000, while the chance of a passenger contracting COVID on a flight from the United States to the United Kingdom is about 1 in 1 million.

The successful vaccination efforts in the United States, the United Kingdom, and other countries can serve as the foundation for the U.S. government to take the lead and demonstrate how to safely reopen these crucial air corridors, Beyer stated. U.S. airlines have been encouraged by the decisions of other countries to allow entry to U.S. travelers who are vaccinated, can provide proof of a negative COVID test, or can provide proof of recovery from COVID. The airlines are urging the U.S. government to implement a reciprocal policy that allows individuals who are fully vaccinated or who present negative test results to travel to the United States from countries with similarly successful vaccination programs. This would be in line, Beyer said, with what Cetron had urged in his presentation. He said it made sense to move away from broad-brush policies that are indiscriminately applied, and instead institute COVID-related policies based on individual situations.

Beyer went on to discuss what some U.S. airline policies might be. One priority for the U.S. airline industry, she said, is the development of voluntary digital health credentials that can be used to easily validate an individual’s COVID status. An increasing number of countries are requiring proof of vaccination or negative COVID test results for entry to the country (or at least, to avoid mandatory quarantines upon entry). Currently, this means that international air passengers must travel with pieces of paper, either proof of vaccination or a negative test result. These forms of proof can be extremely difficult to validate in another country. A number of apps for digital health credentials have been developed and are available to consumers. However, it would be valuable, Beyer said, if the U.S. government were to set standards for these apps, particularly concerning privacy and security. “By doing so,” she continued, “we believe they can create a more seamless and touchless travel experience for passengers, while protecting their privacy and ensuring the legitimacy of results.”

Despite their support for digital health credentials, Beyer cautioned, A4A and its member carriers do not believe that vaccinations should be required for domestic or international air travel. Furthermore, they believe that there should always also be alternative options for those who cannot or choose not to use these apps. “That’s why we stress voluntary,” she said. “But we also believe that a key component of providing public confidence to get back on that plane, to get back out and travel, whether domestically or internationally, is a standardized experience. The bottom line is that requiring travelers to carry these paper cards is simply not a 21st century solution.”

Looking to the future, Beyer said that one priority for U.S. airlines will be to continue investing in technology and creating an increasingly touchless and seamless travel experience. The emphasis on science and research can make travel safer and help instill confidence in the traveling public as they return to the air.

As an example of this approach, she pointed to the “quick and voluntary actions” taken by U.S. airlines to implement multiple layers of protective measures, including mask requirements, pre-flight health acknowledgement forms, enhanced disinfection protocols, and excellent ventilation systems. All of these actions are aimed at mitigating the risk of COVID transmission. This layered approach has proved effective, Beyer said, pointing to a Harvard University study that concluded that there is a very low risk of viral transmission on board a commercial airliner. Indeed, because of the multiple layers of protection, the risk is no greater than—and often less than—the risk for many other activities that individuals willingly take part in, such as grocery shopping or going out to eat. Other studies have come to similar conclusions, she said, particularly concerning the value of onboard ventilation in reducing the risk of viral transmission.

Even once air travel returns to near-normal, she continues, she expects U.S. airlines to continue implementing the safety practices they have developed in response to the pandemic. These practices include an increased focus on air filtration and enhanced disinfection protocols. Even before the pandemic, the U.S. airline industry was working to develop and put into practice various touchless technologies, with the goals of enhancing security and creating a more convenient customer experience. The pandemic accelerated that work. Once the pandemic is over, U.S. airlines will continue to emphasize the implementation of touchless devices for such tasks as passenger check-in and boarding. Additionally, both the TSA and U.S. Customs and Border Protection have been involved in and collaborated with the airlines on the development of touchless technologies in airports.

As for airline passengers, A4A and its member airlines have been working on messaging to encourage the use of touchless technologies in airports, Beyer said. Surveys indicate that passengers are clearly receptive. Indeed, she added, “we actually have data that that tells us that there’s an enormous appetite from travelers to utilize these technologies.” The data indicate that well over 50 percent of travelers have used an electronic boarding pass at the gate and that 80 percent of passengers who are not checking bags check in electronically.

In closing, Beyer said, “these are just some of the lessons learned from the U.S. airline industry that I believe are going to carry forward long past COVID. As we move forward, we remain really committed to investing in these kinds of technologies from check-in to deplaning because we know that the value of that more seamless, more touchless experience helps everyone, all the way around.”

AN AIRPORT’S RESPONSE TO THE COVID PANDEMIC

The session’s final speaker, Mayers, described the policies that Atlanta’s Hartsfield-Jackson International Airport implemented in response to the COVID pandemic. First, he offered some basic details about the airport itself.

Before the pandemic, Hartsfield-Jackson was the world’s busiest airport. It is located within a 2-hour flight of 80 percent of the U.S. population. In 2020, it was ranked as the top airport in the United States in terms of customer satisfaction. Additionally, with five parallel runways, Mayers said, it has been rated as the world’s most efficient airport for 16 years in a row. The airport has 63,000 employees.

When the COVID pandemic hit, passenger traffic took a nosedive, dropping from 8 million passengers in January 2020 to 453,000 passengers in April 2020. Since then, it has progressively increased, but the airport is still nowhere near where it was in terms of numbers of passengers or flights. On the other hand, the amount of cargo handled by the airport has increased to the degree that some cargo has to be turned away owing to lack of capacity.

When the pandemic hit, the airport’s focus was on protecting the passengers and the airport’s employees, Mayers said. The City of Atlanta enacted rules requiring that masks be worn in all Atlanta facilities, including the airport. The airport created a program to provide masks to passengers who did not have them. The airport’s emergency management team also put together policies for social distancing, personal protective equipment (PPE), hand sanitizing, and other approaches to limiting transmission of the virus. Even before the pandemic, he added, the airport emergency management team regularly rehearsed responses to various emergencies, including outbreaks of infectious diseases.

It is the responsibility of an airport, Mayers stated, to educate the public on why it has certain rules, policies, or standards in place. There will always be a segment of the traveling public that does not trust the science and does not appreciate the rules, and it is particularly important to reach out to them. About 25 percent of the people who come through the airport, for instance, are resistant to wearing a mask.

The airport’s responses to the COVID pandemic included such things as an increased frequency of cleaning and disinfection of surfaces. The response also included the provision of various touchless technologies for passengers to avoid contact with surfaces and airport employees as much as possible. The airport put up 4,200 stickers throughout the facility reminding people to maintain a social distance of 6 feet. However, many people did not comply with this distancing, particularly when standing in lines. Stickers on seating in the gate area asking people to not sit in certain seats were more effective in preventing people from getting too close to one another. Plexiglass was installed in the check-in area. The additional costs associated with dealing with the pandemic were borne by the airport as well as by the airlines that use the airport.

The airport also closed off large sections, such as most of concourses C, E, and F. Now, as passenger volume has picked up, the airport is opening most of its facilities, including its parking facilities. These parts of the airport will have the COVID-related items, added before they open, such as signage, hand sanitizers, and so on. The airport has also increased the number of public service announcements it makes, providing passengers with guidance on airport policies and practices. That is not likely to change going forward, Mayers said. Even once the pandemic has receded, the airport will likely keep emphasizing safety to its passengers.

Just as the airport worries about passenger health and safety, it should pay attention to the health and safety of its employees, he said. Even before the pandemic there was discussion of creating an airport medical facility geared toward employees, and the pandemic has given additional impetus to that plan.

Hartsfield-Jackson plans to continue requiring facemasks for its employees through the end of the year even if the federal government relaxes its facemask regulations. The airport is also encouraging the use of touchless equipment for ordering in its food and beverage areas as well as in its retail locations. The airport is encouraging airport concessionaires, such as off-airport regional shuttles, to follow the same types of COVID-related practices that the airport employs.

DISCUSSION

Hertzberg opened the question-and-answer period with a question from the public: Should the FAA create standards for aircraft cabin air circulation in order to control disease spread? Garg answered first, saying that it is an intriguing idea. He noted that one of the provisions of the proposed Healthy Flights Act of 2021 mentioned in his talk would include the FAA performing a study to decide whether it makes sense to put standards in place. At this point, however, it is difficult to determine whether such a standard should be set up.

Beyer added that the jets flown by commercial airliners today already have air circulation that meets a very high standard, to the degree that the risk of transmission on a commercial aircraft is less than the risk of transmission in an operating room.

Commenting on what Beyer said, Cetron pointed out that the air travel experience is more than just the time spent on a plane. It begins when you leave home and does not end until you reach your destination. Because it is clear that travel does lead to the spread of COVID, as shown by the infection peaks that followed Thanksgiving, Christmas, and New Year’s last year, it would make sense to focus on limiting transmission risks outside the flight itself. One possibility might be simply to have the plane’s circulation system on during boarding and deplaning. Such circulation would keep the cabin air flowing through the high-efficiency particulate absorbing (HEPA) filters and remove as many viral particles as possible.

Responding to that, Beyer said that after the Harvard study came out, A4A members recognized the value of keeping an aircraft’s filtration system on whenever passengers were on the plane, and not just during flight. They have committed to doing that.

Workshop chair John-Paul Clarke then asked a question about regulatory authority. It seemed to him, he said, that during the pandemic the airlines and airports have all the regulatory authority they needed to respond. Is that true? More importantly, will they have the requisite regulatory authority to respond to future pandemics? Because democracies are not particularly fast in responding to crises through legislative processes, airlines, airports, and other relevant stakeholders will need the regulatory authority ahead of time so that they can respond to a future pandemic as quickly as possible.

Mayers answered that the general manager of Hartsfield-Jackson has certain powers according to the airport’s lease agreement. However, he does not have emergency powers to make the airlines and other of the airport’s partners behave in a certain way. As he described in his talk, the Atlanta city council can pass legislation in response to a crisis, and that is how a mask mandate was created for the airport. There is the possibility, he continued, of giving the airport manager certain powers that could be used in an emergency. That might be worth looking into. One consideration, he added, is that it can cause confusion if each airport has its own set of emergency rules. As such, there should be some method to standardize the approach across airports.

Cetron elaborated on Mayers’s last point. Airports and transportation corridors are very complex overlapping jurisdictions, with local, state, regional, national, and even international bodies playing a role. Rivalries and disagreements between the different players can slow down decisions, confuse passengers, and even give ammunition to those who wish to resist evidence-based rules. Aligning the overlapping jurisdictions is thus an important task and often a difficult one.

In the case of the airlines, Beyer responded, A4A worked with its members to put measures in place that were the same across the industry. The goal was to institute effective measures that would not confuse the public by having the rules of one airline differ from those of another.

Hertzberg next asked another audience question: Why is there so much focus on fomite transfer?¹ After all, the CDC has reported that each contact with a contaminated surface has less than a 1-in-10,000 chance of causing infection.

Cetron answered that much of this is owing to a sort of scientific inertia. Stephen Hawking said that the enemy of knowledge is not ignorance, it is the illusion of knowledge, and this illusory knowledge can drive regulations. In the case of fomites, the original understanding that there was a sort of dichotomy in viral transmission between aerosol particles that hang in the air and large droplets that fall onto surfaces had been found to be too simplistic.

___________________

¹ Fomite transmission refers to the spread of disease via contaminated surfaces and objects such as door handles, chairs, and tables.

There really is a continuum of modes of transmission. “We’ve learned that over time,” he said, “but it’s been very difficult to let go of preexisting ideas or that illusory knowledge about what what’s true.” So, some people are still focused on an understanding of COVID transmission that is not necessarily in sync with the most recent scientific picture.

Carlos del Rio, one of the previous session’s keynote speakers, then posed a question. The world seems to be separating into two types of places, those where the epidemic is being brought under some sort of control and those where it is not. Will that have repercussions for the policies put into play on different flights? Might there, for instance, be certain areas where everyone on the flight must be tested while for other areas testing would not be required? Similarly, might some flights accept proof of vaccination in lieu of proof of a negative test?

Cetron first responded to the second question. While countries with a significant percentage of their populations vaccinated do seem to be doing a better job of getting the pandemic under control, he would not suggest moving completely to a check of vaccination status. There are just too many complications, such as the emergence of variants that may not be as responsive to the vaccine, and the likelihood that certain vaccinated individuals will still be susceptible to infection. Thus, it makes sense to layer the approach to limiting transmission risk, with vaccinations, negative tests, and even masking.

Mayers added that a requirement for a negative test result, compared with a vaccination requirement, may be more palatable to travelers, particularly international travelers. After all, there are already requirements in place for medical examinations for people receiving a visa to travel in the United States.

del Rio agreed that testing is very important, which led him to ask why no testing infrastructure has been developed within U.S. airports. Airports in many other countries have testing facilities. Why not the United States? Mayers answered that part of the reason is political, owing to the contentiousness surrounding COVID, its vaccines, and even testing in the United States. On the other hand, Delta Airlines does offer COVID testing at its facilities within the Atlanta airport. This is a service for its international passengers, many of whom must show a negative test result to travel to the country of their choice. Cetron added that there are ways to solve the problems of the politics or the bureaucracies to create testing centers in airports or next to airports. However, it requires partnerships and collaboration between different parties—government agencies, corporations, and others. On that same subject, Beyer reported that U.S. airlines have been collaborating with the CDC and a number of testing providers to offer testing for passengers.

Next, Hertzberg, referring to the concept of “known unknowns” and “unknown unknowns,” asked the panelists what some of the major known unknowns would be that relate to research needs for aviation and future pandemics. Cetron answered that there are a number of typical known unknowns related to emerging pandemics, such as what the modes of transmission are and how best to diagnose the infection. A major issue, he added, is often a lack of humility, which can lead researchers to assume that they understand the new threat because it bears similarities to something they have already studied. As an example from the COVID pandemic, he said that there was a time soon after the emergence of the virus that researchers overestimated the incubation period. They did not realize how much pre-symptomatic or asymptomatic transmission there was. They initially believed the incubation period was 28 days because the connections between known cases were too far apart. Eventually, they realized that they were missing the asymptomatic carriers in the middle who were responsible for that transmission.

Garg took a different approach to answering the question about known unknowns. “I’m curious to see what the social appetite is going to be for an ongoing permanent prophylactic posture,” he said. After 9/11, there was agreement that changes had to be made in how aviation is done, but there was no such consensus after, for example, the Ebola outbreak. So, will COVID have the same sort of long-term impact on the aviation system as 9/11 did? Will people put up with various inconveniences as a necessary cost of ensuring the health of the system? The answers are not yet known.

Another set of known unknowns involves how different groups of people will respond to a pandemic, Mayers added. Which groups need to be targeted to overcome resistance to measures aimed at fighting the pandemic? What approaches will work best with these groups? One way to get data that could help answer these questions would be to include questions on airport customer satisfaction surveys. Such questions would be aimed at understanding the concerns and beliefs of the different types of air travel passengers.

Beyer echoed Mayers’s comments and suggested it would be valuable to carry out research on how to encourage better behavior in compliance with public health requirements. It is very hard to break human habits, she elaborated. As an example, Beyer described the difficulties airlines faced in trying to get passengers to follow new boarding and deplaning procedures. Despite instructions, passengers tended to behave as they always did, especially in getting off an airplane.

Reading another audience question, Hertzberg asked whether increasing the amount of surface cleaning in airports and on airplanes might lead to resistant pathogens. It is a complicated topic, Cetron answered, and there is a growing field to examine what works and what does not work in fighting microorganisms. Perhaps instead of using antimicrobials for surface decontamination, it would make sense to use other tools, such as ultraviolet light, that would not risk the development of resistance.