Preparing Airports For Communicable Diseases On Arriving Flights (2017)

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Preparing Airports for Communicable Diseases on Arriving Flights
AIRPORT COOPERATIVE RESEARCH PROGRAM
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
S ubscriber C ategories
Aviation • Security and Emergencies • Society
Research Sponsored by the Federal Aviation Administration
2017
Copyright National Academy of Sciences. All rights reserved.

AIRPORT COOPERATIVE RESEARCH PROGRAM ACRP SYNTHESIS 83
Airports are vital national resources. They serve a key role in Project A11-03, Topic S03-12
transportation of people and goods and in regional, national, and ISSN 1935-9187
international commerce. They are where the nation’s aviation sys- ISBN 978-0-309-39008-8
tem connects with other modes of transportation and where federal Library of Congress Control Number 2017942537
responsibility for managing and regulating air traffic operations
intersects with the role of state and local governments that own and © 2017 National Academy of Sciences. All rights reserved.
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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 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 Disease outbreaks have become more visible in an era of mass travel, with air travel serv-
By Gail R. Staba ing as a speedy and powerful means of transmitting communicable disease. Public health
Senior Program Officer and airport responders can act to reduce transmission of illness from arriving flights. This
Transportation synthesis examines current disease preparedness and response practices at U.S. and Cana-
Research Board 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.

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

Preparing Airports for Communicable

Diseases on Arriving Flights
Summary Sick people travel by air every day. They board with common colds, mild cases of influenza, and
sometimes more serious illnesses. This requires that airports and their public health partners be pre-
pared to respond when a sick passenger is on an arriving flight, particularly when a passenger has a
highly contagious illness. An effective response requires an established partnership among airport and
public health authorities and a well-conceived and practiced communicable disease response plan.
Ebola, influenza A virus subtype H1N1 (often called swine flu), Middle East respiratory syndrome
coronavirus (MERS-CoV), influenza A virus subtype H5N1 (sometimes called Asian avian influenza),
influenza virus A subtype H7N9 (an avian influenza), tuberculosis, and Zika—this is only a partial list
of the myriad communicable diseases that have threatened global public health in the past decade.
Disease outbreaks have become more visible in an era of mass travel, with air travel serving as a
powerful means of transmission. The primary strategy of the public health sector—from the World
Health Organization (WHO) to the Centers for Disease Control (CDC), Public Health Agency of
Canada (PHAC), and state, provincial, county, and local health partners—is to mitigate the risks
from a communicable disease to contain its spread within the outbreak area. This involves heighten-
ing awareness among the public, mobilizing risk-mitigation efforts, promoting social distancing, and
applying the use of prophylactic medicines and vaccines. To strengthen these efforts, the aviation
sector can provide support by helping to reduce the likelihood of sick individuals traveling outside
the outbreak area and transmitting illness to others.
This synthesis examines current disease preparedness and response practices among U.S. and
Canadian airports and their public health partners. Recent outbreaks, including those listed previously,
have caused airports and public health agencies and departments to forge strong relationships and
engage in joint planning to protect community health and well-being and ensure business continuity.
In short, the aviation and public health sectors need each other; neither sector can act effectively alone,
and both require the detailed knowledge and expertise of the other as well as numerous additional
stakeholders. Although larger airports that receive international flights are most likely to experience
the challenges associated with these events, the preparedness and response lessons are transferable
more widely to the aviation sector.
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 suggestions for future research.
Effective comprehensive planning is necessary to ensure airport safety and operational continuity
and protect public health. This synthesis presents major conclusions in the following six areas:
• Comprehensive planning
• Partnership and stakeholder engagement
• Legal issues
• Strategic communications
• Exercising, drilling, training, and education
• Evaluation and continuous improvement.

2
The research also identified six areas for future research, which are presented here in the form of
analytical questions:
• What procedures are in place to get prompt passenger information that is timely and complete
to the agencies that need it?
• What security issues face public health responders in an airport setting?
• What additional information on the risk of disease transmission on aircraft and in other aviation
settings is needed, and how is this information obtained?
• What are the sociocultural factors that shape reaction to a communicable disease involving avia-
tion, and how do airports and public health stakeholders use established and emerging media tech-
nologies to inform the public and engage them as partners in response?
• What are the most effective means to disseminate information about communicable disease in
an airport setting to the general population and the traveling public?
• How effective are exit screening and other border exclusion strategies for protecting the public
from disease threats?
The information presented in this synthesis report is intended for use by senior airport leader-
ship, airport responders and emergency planners, airport emergency response partners, public health
officials, other health providers, and airlines.

3
chapter one
Introduction
In the 2011 biomedical thriller Contagion, American filmmaker Steven Soderbergh dramatized the
challenges of communicable disease response. In the film’s opening sequence, we learn that Beth
Emhoff (played by Gwyneth Paltrow) recently has returned to her family in their suburban Minnesota
home after a trip to Hong Kong and brief layover in Chicago, where she reconnected with a former
lover. Although she appears to have contracted a mild influenza virus on her trip, her symptoms rap-
idly worsen after returning home. Within 48 hours she experiences violent seizures and dies of what
appears to be massive hemorrhaging in her brain, which initially is misdiagnosed as meningitis. We
soon learn that she has passed the disease to her son, Clark, who quickly dies.
The film touches on several key themes: the political and economic dimensions of mass quar-
antine and vaccine development, the fear of panic and anomie that often accompany outbreaks of
novel diseases, how news media and social media shape public risk perception, the deeply intercon-
nected nature of the global economy and our anxieties about its effects, and the epidemiological
complexities of contact tracing. The use of high-profile cast members (in addition to Paltrow, the
film stars Matt Damon, Laurence Fishburne, Jude Law, Marion Cotillard, and Kate Winslet) and
the key roles played by senior U.S. public health officials in the script development and promotion
of the film helped ensure its critical reception; Contagion was the top-grossing film in its debut
week, generating $8 million on opening day, and was screened in numerous professional and public
settings, prompting a broader discussion about the complex challenges of dealing with threatening
vector-borne pathogens.
Inspired by real-world experiences with severe acute respiratory syndrome (SARS), Contagion
illustrated how rapid modern air travel can be an efficient vector for the spread of disease and reduces
the time available to public health authorities to prepare for and mount effective interventions
[Airports Council International (ACI) and International Civil Aviation Organization (ICAO) 2009].
When a disease outbreak occurs on an international scale, the readiness of all aspects of the public
health sector and air travel industry will be tested. Airports, airlines, health agencies, and other stake-
holders would do well to cooperate, share resources, and prepare in advance. Such preparations may
not be able to halt the spread of some diseases; however, they may limit their acceleration and make
it possible to reduce the consequences.
Although the film presents the issue of a global pandemic threat in dramatic form, sick people travel
by air every day. Passengers board flights with any number of illnesses, from the common cold to
influenza viruses and more serious infectious diseases. The risk this poses to the public can be serious
and requires an effective response that is appropriate to the nature of the disease. Such a response
requires not only clear policies and guidelines but also established partnerships among airports, local
health departments, national public health agencies, and other stakeholders. This synthesis looks at
how such a partnership can work most effectively to prepare airports to deal with arriving passengers
with communicable diseases and thereby protect populations to the greatest extent possible.

4
chapter two
Air Travel and Communicable Diseases
I view the threat of deadly pandemics right up there with nuclear war and climate change. Innovation,
cooperation, and careful planning can dramatically mitigate the risks presented by each of these threats.
Bill Gates, address to Munich Security Conference, February 18, 2017
The first major global health threat in which modern transportation played a large role was the Spanish
influenza pandemic of 1918, which sickened 30% of the world’s population and killed between
50 and 100 million people (Rodrigue et al. 2017). In that pandemic, travel by steamship and rail, not
air, accelerated the spread of disease. Despite concerns that air travel would spread influenza and other
illnesses, it was not until the outbreak of SARS in 2003 that a pandemic realistically threatened to
spread quickly by global air travel. SARS spread through air passengers who traveled from China to
Singapore, Taiwan, Vietnam, and Canada. By the time the outbreak had been contained, 774 people
had died, and more than 8,000 had been infected worldwide.
The global transmission of SARS illustrates several aspects of air travel that make it a special
challenge for managing disease spread.
1. Air transportation compresses time and space, connecting nearly all points of the globe to every
other point.
2. Modern aircraft move faster than the incubation time of many diseases, especially flu variants,
and therefore can accelerate disease transmission (Rodrigue et al. 2017).
3. The global air transportation system can quickly be shut down in whole or part.
Airline passengers tend to be highly risk averse and will voluntarily avoid flights during serious out-
breaks (Rodrigue et al. 2017).
A rapidly spreading disease not only puts travelers at risk but also can spread to their families
and others in their workplaces and communities, employees at airlines and airports, first responders,
and employees of medical facilities and ambulance services. Such spread of a severe illness or a
pandemic can cause disruptions that cascade throughout society and lead to significant economic loss
and political instability. For example, it is estimated that SARS cost the Canadian economy $722 mil-
lion between 2003 and 2006 (CBC News 2003). In the worst case, the spreading disease becomes an
epidemic in society at large.
International public health efforts, especially those dealing with air travel and communicable disease,
are intensive and collaborative. In this section, key documents are grouped by purpose and described
briefly. Full bibliographic information for retrieving each document is given in the References list.
Diseases of Public Health Significance
Public health agencies at all levels of government within countries and internationally focus on pre-
paring for and responding to communicable disease threats. Diseases that can be spread by passengers
traveling on aircraft pose unique challenges and get special attention. Before the SARS epidemic,
the focus was on lists of specific diseases, but partly in response to a new risk from a novel disease,
the focus has shifted to diseases with certain characteristics. This shift in emphasis has been reflected
in the primary guidance documents of the World Health Organization (WHO) International Health
Regulations 2005, the 2014 revision of U.S. Presidential Executive Order 13295 (White House 2014),

5
and the Canadian Quarantine Act (2005). Appendix A to this report contains the current (February
2017) lists of diseases of public health significance for Canada, the United States, and the world
(as determined by WHO).
An international resource that is applied at the level of a nation state is the Joint External Evalu-
ation (JEE) Tool, the purpose of which is to “assess country capacity to prevent, detect, and rapidly
respond to public health threats independently of whether they are naturally occurring, deliberate, or
accidental” (WHO 2016). JEE looks at a country’s overall preparedness to deal with health threats
but includes all points of entry. It is not airport specific.
Risk Assessment for Communicable Diseases Transmitted on Aircraft
The European Centre for Disease Prevention and Control (ECDC) Risk Assessment Guidelines for
Infectious Diseases Transmitted on Aircraft (2009) provides guidance for public health agencies,
airlines, and potentially airports (A. Khan, personal communication, January 23, 2017). A related
resource is the ECDC web page “Infectious Diseases on Aircraft” (ECDC 2017).
Notification Procedures and Air Traffic Control Roles
The International Health Regulations (WHO 2005) represent the commitment of more than 200 nations
to reporting certain communicable diseases when specified criteria are met. ICAO Document 4444,
which states and disseminates procedures for air navigation services and air traffic manage-
ment, spells out the requirements for the pilot of an international flight to notify air traffic control
en route of suspected communicable diseases or other public health risk on board an aircraft
(ICAO 2007, Para. 16.6). Paragraph 16.6 of Document 4444 is reproduced as Appendix B of this
synthesis.
Paragraph 16.6.3 gives three pathways by which the information is supposed to reach the destina-
tion airport:
1. From the air traffic services (ATS) unit to the public health authority (or appropriate authority
designated by the country), and through established pathways through health agencies to the
airport.
2. From the ATS unit to the aircraft operator (or the operator’s designated representative), and to
the airport.
3. From the ATS unit directly to the destination airport.
The parallel U.S. guidance is the Memorandum of Agreement (MOA) between FAA and the Centers
for Disease Control and Prevention (CDC) (FAA and CDC 2010) that assures that those two key
agencies cooperate to
relay notifications of reports that they receive of deaths, suspected cases of communicable disease, or other
public health risks, on board aircraft and to establish other actions that the Parties agree to take to prepare for
and respond to contingencies involving deaths, suspected cases of communicable disease, or other public health
risks, on board aircraft.
The MOA not only establishes the mechanism for U.S. compliance with Document 4444 but also
sets up the procedures and notification pathways for communicable disease and public health risk
notifications involving passengers on domestic flights within the United States.
In response to the Ebola crisis of 2014–2015, the Department of Homeland Security (DHS)
Customs and Border Protection (CBP) overrode the procedures in the FAA–CDC MOA to change
screening of passengers arriving from, traveling to, or passing through Ebola-stricken countries.
This document announced the decision of the commissioner of CBP to direct all flights to the United
States carrying persons who had recently traveled to, from, or through Ebola-stricken countries to
arrive at one of five U.S. airports where CBP implemented enhanced screening procedures (19 CFR
Part 122, Air Commerce Regulations, October 23, 2014).

6
In 2016, Canada, Mexico, and the United States adopted the Communicable Disease and Public
Health Risk Air Traffic Operational Response Concept of Operations (Trilateral CONOPS), which
refines the notification and air traffic management provisions of Document 4444 to create a coopera-
tive, coordinated system to handle a flight with a suspected communicable disease aboard.
Ideally, an airport and its airline and public health partners will learn in advance of a sick passenger
on an incoming flight.
In addition, the guidance allows for aircraft operators (e.g., airlines) to have designated representa-
tives to deal with health issues. The role of designated health representatives for airlines is examined
in detail in the Dallas/Fort Worth International Airport case example in chapter four.
Airport and public health agency experts who deal with emergency medical services (EMS) note
that despite notifications through these pathways, EMS responders often do not know whether the
situation they will encounter will be worse, better, something different, or nothing at all (CAPSCA
Panel Atlanta August 2016; F. Broom, personal communication, January 23, 2017).
The survey results presented in chapter three and case examples in chapter four allow consider-
ation of how these pathways operate in practice.
Isolation and Quarantine Procedures
Isolation and quarantine are not the same thing. This distinction is critical in planning effective response
to communicable disease at an airport.
Isolation and quarantine help protect the public by preventing exposure to people who have or may
have a contagious disease. Isolation separates sick people with a contagious disease from those who
are not sick, whereas quarantine separates and restricts the movement of people who were exposed
to a contagious disease to see if they become sick (CDC 2017).
In the United States and Canada, quarantine stations, located at ports of entry and land border
crossings, can work with their partners, using isolation and quarantine among other public health
practices as part of a comprehensive strategy that serves to limit the introduction of infectious dis-
eases into the countries and prevent their spread [Public Health Agency of Canada (PHAC) 2015a;
82 CFR §6890 2017; CDC 2017].
The primary international guidance regarding isolation and quarantine in airports is Paragraph 8.15
of Annex 9 (Facilitation) of the Convention on International Civil Aviation (Chicago Convention)
(ICAO 2006). Canada’s Quarantine Act (2005) and the Canadian Pandemic Influenza Preparedness:
Planning Guidance for the Health Sector provide guidance specific to Canada (PHAC 2015b). For the
United States, the primary guidance document is Presidential Executive Order 13295, “Revised List
of Quarantinable Communicable Diseases” (White House 2014).
During the 2014–2015 Ebola outbreak, CDC instituted enhanced Ebola screening that required
all passengers from Ebola-affected countries to enter the United States at one of five designated air-
ports at which special staffing, training, equipment, and facilities had been established (CDC 2014).
The effectiveness of this designated-airport-of-entry procedure has not been evaluated for future
applicability.
Isolation and quarantine put spatial, operational, and logistical demands on airports. Stambaugh
et al. (2008) examined these demands in ACRP Report 5.
Federal authorities balance the need to protect the public’s health with safeguarding people’s
civil liberties and when appropriate use less-restrictive tools, such as the conditional release of pas-
sengers. This shifts considerable responsibility onto the passengers and local health departments.

7
Airport and Airline Roles
TRB convened two conferences that addressed agency–aviation industry collaboration to plan for
pandemic outbreaks, the first in 2007 and the second, which dealt with the transmission of diseases
in airports and aircraft, in 2009 (Turnbull 2008; Gerencher 2010). The scope and purpose of the first
conference are stated in the preface to “TRB Conference Proceedings 41”:
In September 2007, approximately 70 people assembled in Washington, D.C., to participate in a workshop on
Interagency–Aviation Industry Collaboration on Planning for Pandemic Outbreaks. The conference brought
together individuals involved in planning and responding to pandemic events—from both the public sector
(federal agencies and state and local agencies, including public airports) and the private sector (airlines and
consultants with expertise in various facets of aviation).
The workshop goals were to examine (a) the action items included in the section on Transportation and
Borders in the May 2006 National Pandemic Plan that directly or indirectly affect air transportation, (b) the
current state of the practice for pandemic planning by airports and airlines, (c) coordination among various
agencies and the aviation sector to implement these plans, and (d) potential areas for public–private sector
cooperation in pandemic planning (Turnbull, 2008, p. 1).
The scope and purpose of the 2009 conference are stated in the preface to “TRB Conference
Proceedings 47”:
In September 2009, about 100 people assembled in Washington, D.C., to participate in a symposium on research
on the transmission of disease in airports and on aircraft. The symposium brought together individuals from the
public sector (federal, state, and local agencies including public airports), private sector (airlines and consultants
with expertise in various facets of airport emergency response), and research institutions to learn about current
research and to consider ways to conduct and fund future research.
The symposium goals were to examine (a) the status of research on or related to the transmission of disease
on aircraft and in airports, (b) the potential application of research results to the development of protocols
and standards for managing communicable disease incidents in an aviation setting, and (c) areas where addi-
tional research is needed. To plan the event, TRB assembled a committee appointed by the National Research
Council (NRC) to organize and develop the symposium program. The planning committee was chaired by
Katherine B. Andrus, Air Transport Association of America, Inc.
The symposium program was designed to provide an opportunity for the aviation community to share data,
models, and methods; discuss findings and preliminary conclusions of ongoing research; and identify gaps to
inform future research projects. During the symposium, consecutive sessions were organized according to dif-
ferent approaches to research as identified by the planning committee. These approaches included case study
investigations, theoretical modeling, and “bench science” experimental methods. A session discussing different
approaches to policies and planning to minimize the spread of disease along with an open dialog among all
attendees on candidate topics for future research was also conducted.
This summary report contains white papers, authored by the invited speakers to each session, that summarize
the presentations they gave during the symposium. It includes a summary of the discussion of topics for future
research. The planning committee was solely responsible for organizing the symposium, identifying topics,
and choosing speakers. The responsibility for the published symposium summary rests with the symposium
rapporteur and the institution (Gerencher 2010, p. 1).
ACI and ICAO (2009) published Airport Preparedness Guidelines for Outbreaks of Communicable
Disease, which is a comprehensive planning guide for airport communicable disease preparedness.
The airport-specific resource that resembles JEE is the Collaborative Arrangement for the Prevention
and Management of Public Health Events in Civil Aviation (CAPSCA) State and Airport Assistance
Visit. CAPSCA is a partnership led by ICAO with participation by nine other United Nations agen-
cies, including WHO, CDC, the International Air Transport Association, the International Federation
of Air Line Pilots’ Associations, and ACI. The mission of CAPSCA is to bring together international,
regional, national, and local organizations to combine efforts and develop a coordinated approach for
international aviation to respond to public health risks such as pandemics (CAPSCA 2017).
As noted, CDC and other federal agencies worked with five U.S. airports during the Ebola crisis in
2014–2015 to develop specially prepared reception centers to screen passengers coming to the United
States from Ebola-affected countries. This required close coordination and cooperation with airlines
and local health departments and health providers (CDC 2014). This approach eliminated most issues
that might have resulted from passengers with connections to domestic flights and broken itineraries.
In 2013 and 2014, ACRP sponsored two projects that dealt with communicable diseases at airports:
ACRP Report 91: Infectious Disease Mitigation in Airports and on Aircraft (Environmental Health &
Engineering 2013) and ACRP Project 02-20, “The Role of Air Travel in the Transmission and Spread
of Insect-borne Disease” (Mao et al. 2014), which produced a tool for assessing risks and mitigation
measures, along with a user’s guide. The underlying data and models for the tool have been published

8
in a series of three papers. The first provided a web-based GIS tool for vector-borne disease airline
importation risk (Huang et al. 2012). In the second, a model of global passenger flow in 2010 was
provided (Huang et al. 2013). The third modeled monthly flows of global air passengers to provide an
open-access data resource (Mao et al. 2014).
The Civil Aviation Contingency Operations (CACO) Division of Transport Canada (2014) pub-
lished the Plan for Pandemics and Communicable Disease Events that guides the overall response of
Canada’s aviation sector to communicable disease events. It is closely articulated with the Quarantine
Act. A useful source of current information is Transport Canada’s Pre-Flight blog, for example the
post “Pandemic and Communicable Diseases—Spread Prevention” (2014).
A fast-emerging tool that applies to communicable disease response at airports, among other types
of emergencies, is social media for emergency management (SMEM). This is the topic of ACRP
Synthesis Project A11-03/S04-18 (Smith and Kenville in press). The synthesis focuses on SMEM as
a source of situational awareness and intelligence and a means of communicating directly with the
public, passengers, and response partners and stakeholders.
Efforts Under Way to Improve Understanding and Processes
ACRP has two 2017 projects that bear on the issue of airport roles in communicable disease response.
ACRP Legal Project 11-01/Topic 09-01, “Airport Public Health Preparedness & Response: Legal
Rights, Powers & Duties,” deals with the legal duties, responsibilities, and rights of airports regarding
communicable diseases. The “ACRP Forum on Airport Roles in Reducing Communicable Diseases
Transmission,” ACRP Project 11-08, seeks to engage the U.S. aviation industry broadly to consider
research needs in all aspects of airport roles in reducing communicable disease transmission. The final
reports for both projects are expected in 2018.
Caring for the Caregivers
Caring for the caregivers is an emerging issue in emergency response including at airports. ACRP
Report 22: Helping Airport and Air Carrier Employees Cope with Traumatic Events (Kenville et al.
2009) is a comprehensive guide in this area.
In summary, the topic of air travel and communicable diseases has worldwide importance and has
been the focus of intense national and international attention. Guidance and procedures for dealing
with communicable diseases are evolving quickly, and the trend is toward more general guidance on
disease lists and procedures. Finally, the agencies and organizations working in the field indicate that
continuing research is needed to deal with emerging diseases and the associated risks of transmission.
Legal Environment for Response to Communicable Diseases at Airports
A separate ACRP Legal Study (ACRP Project 11-01/Topic 09-01), “Airport Public Health Prepared-
ness & Response: Legal Rights, Powers & Duties,” is scheduled to be published in 2018. Its objective
is to develop best practices for airport lawyers and managers that outline the legal rights, powers, and
duties of an airport in addressing the spread of communicable diseases through air travel. The study
will identify and describe the rights and obligations of additional stakeholders, such as WHO, CDC
and other federal agencies, and state and local health and public safety organizations, in response
to the potential transmittal of disease. The study will set forth options to address such issues under
existing laws and policies, as well as potential opportunities to address inadequacies in the current
legal landscape. The study will include but not be limited to a review of legal issues relating to isola-
tion and quarantine, disease surveillance, screening protocols, contact tracing, and decontamination
procedures, search and seizure, involuntary testing, denial of access (to the airport, to travel, etc.),
and privacy and personal health information. The final product will be a form of playbook that allows
airport attorneys, management, and staff to respond to a public health emergency in real time. Given
the scope and objectives of ACRP Legal Study 09-01, the current synthesis presents a general over-
view of the roles and responsibilities of airports, public health agencies, aircraft operators, and other
stakeholders regarding communicable diseases on arriving flights.

9
Airports Are Expected to Have Preparedness Plans
Air travel–related risk management and preparedness for communicable diseases is the responsibil-
ity of the local/regional/national public health authority and the airport operator (WHO 2005). Each
airport is expected to have its own preparedness plan. International guidelines state that individual
airport preparedness plans should address aspects such as:
(a) communication (especially with the public);

(b) screening;
(c) logistics (transport of travelers to health facilities);
(d) equipment, including personal protective equipment for airport staff;
(e) training;
(f) entry/exit controls; and
(g) coordination with the local/regional/national public health authorities (WHO 2005, §2.2-2.3).
Specific to the United States, FAA Advisory Circular 150/5200-31C Airport Emergency Planning
requires all airports to have an airport emergency plan (AEP). For airports that serve passenger flights,
such plans are required to address communicable disease response. This may be done directly in the
AEP or indirectly by having the AEP reference the communicable disease response plan. In addition,
airports address communicable disease response in their business continuity plans, continuity of busi-
ness plans, recovery plans, and communications plans.
Importance of Relying on Public Health and Medical Expertise
Airports usually have access, either through staffing or EMS partners, to a range of field treatment
skills to triage, describe symptoms, and stabilize the condition of ill persons. However, except for
a few obvious cases of rash illnesses, even an infectious disease specialist would be hard pressed
to make a diagnosis in an air travel–related reported illness. Consequently, airlines, airports, and
airport mutual aid responders are not expected to identify disease. National public health agencies,
such as CDC and PHAC, provide their aviation partners with a list of symptoms they are asked
to report.
A second reason for relying on public health partners is their strong knowledge of the statutory
and regulatory environment surrounding communicable diseases and such issues as sharing medical
information, patient privacy, and appropriate response procedures.
A third reason is that an airport and its response partners rely on public health expertise to ensure
that decisions made by the incident command are medically sound and outgoing communications
are factually based and not speculative.
Relationships of Local, State, or Provincial and National Public Health

Departments in the United States and Canada
In the United States and Canada, public health practice is governed by federal, state/provincial,
and local law. Generally speaking, the authority to control disease spread and compel isolation and
quarantine is a state/provincial/territorial power. Local health departments (also known as health
units in Ontario) assist with implementing state/provincial/territorial laws around disease control.
Federal public health agencies (CDC in the United States and PHAC in Canada) are responsible for
acting when health threats span more than one state/province/territory, region, or the entire nation,
and when response to a public health threat is beyond the jurisdiction of a single state, province, or
territory. For instance, as previously noted, during the Ebola crisis in 2014–15, CDC and DHS-CBP
worked to funnel passengers to five U.S. airports, where they established procedures to screen pas-
sengers coming to the United States from Ebola-affected countries. This required close coordination
and cooperation with airlines and local health departments and health providers (CDC 2014). By
limiting the locations where passengers from Ebola-affected countries could enter the United States,
this approach (funneling) eliminated most of the issues that might have resulted from passengers on

10
open itineraries with connections to domestic flights, including the need for surge staffing at multi
ple airports. The CDC and PHAC also have authority for disease control and quarantine at their
respective country’s (United States or Canadian) ports of entry concerning the entry of persons,
goods, and conveyances from other countries that may spread communicable disease.
United States Airports
The investigation of communicable disease at U.S. airports may fall under the jurisdiction of a state
health department or a local health department depending on how public health practices are struc-
tured in the state where the airport is located. The involvement of CDC will depend on whether the
communicable disease is on a flight entering the United States or if measures are needed to help pre-
vent the spread of disease across states (J. Martin, personal communication, February 1, 2017).
Canadian Airports
As with U.S. airports, the investigation of a communicable disease may fall under a local or national
public health authority, depending on the flight’s point of initiation. This can be more complex when
the airport is close to a local boundary. For example, Toronto Pearson International Airport is geo-
graphically located in Peel Region but is near the border with the city of Toronto. Airport personnel,
including PHAC quarantine offices, deal with the Peel Region Health Department, but individuals
with suspected exposures to communicable pathogens usually are taken to Toronto hospitals for care
and investigation and are reported to Toronto Public Health.
In these circumstances, the Province of Ontario has similar roles as a state health department
in the United States, and PHAC has international and isolation/quarantine roles similar to those of
the CDC. However, in Canada’s federal system, the provinces and territories have considerably
more authority, at least in public health issues, which means that domestic communicable disease
issues involving two or more provinces and territories typically require significant federal/provincial/
territorial collaboration.
The 2003 SARS outbreak revealed problems with public health preparedness and emergency
response in Canada at all levels (Manasan 2015). As a result, many improvements were made: at the
national level with the creation of the PHAC; at the provincial level with, for example, the creation
of Public Health Ontario and the Provincial Infectious Diseases Advisory Committee; at the local
health department level with increased provincial funding; and at the airport level with the creation
of a specific communicable disease plan. Other provinces made similar changes. The government of
Canada amended the Quarantine Act and reorganized agencies as a result of the lessons learned from
SARS. Quarantine officers located in six airports across the country provide a 24/7 response system
that covers all international ports of entry in Canada. Canada Border Services Agency (CBSA) offi-
cers are designated as screening officers in the Quarantine Act. With the guidance of a quarantine
officer, CBSA officers act on their behalf when quarantine officers are not present (S. Jain, personal
communication, December 1, 2016).
In the United States and Canada, public health agencies in all levels of government have respec-
tive duties and responsibilities that may come into play with planning and response to a communi-
cable disease on an arriving international or domestic flight.
Scope of This Study
The objective of this synthesis is to compile current experience and effective practices related to
aviation communicable disease response in the United States and Canada. The report addresses the
following items:
• Clear definition of issues and appropriate governing regulations;

• Roles and responsibilities of airport, public health, and key stakeholders;
• Trigger mechanisms for response;
11
• Defining the step-by-step response process;

• Monitoring, mitigation, and communication strategies; and
• Business continuity and recovery.
Although community reaction to a communicable disease reported or rumored to be at an airport

is important, it lies outside the scope of this study. The report presents case examples and materials
useful to airports and their partners for developing plans and responses to communicable diseases on
arriving flights. The primary audiences for this synthesis are airport leadership, airport emergency
responders and planners, airport emergency response partners, airlines, public health officials, and
other health providers.
Study Methods
Data for this study were collected using a literature review, an online survey, six case examples,
and interviews with senior officials in five health agencies. The consultants also benefited from
the opportunity to observe the public session of the August 2016 Staff Assistance Visit (SAV) by
CAPSCA, WHO, and the Pan American Health Organization at the invitation of Hartsfield-Jackson
Atlanta International Airport, to review the airport’s communicable disease preparedness plan and
provide consultation.
Literature Review
A comprehensive literature review was performed to identify key studies relating to the topic of
communicable disease response and the airport sector. The results of the literature review are listed
in References at the end of this synthesis.
Survey and Response Rates
The survey data were gathered during July through October 2016 using an online tool provided by
TRB. A nonrandom, purposive sample of 57 airports was selected; the sample was made up of
51 U.S. airports of various types and sizes and six large-hub Canadian airports. The sample was based
on the professional knowledge of topic panel and synthesis team members. For the 51 U.S. airports,
survey invitations were sent to the 51 local health departments that serve as local public health pre-
paredness coordinators for the airports. For the six Canadian airports, survey invitations were sent to
their six local health departments and the regional offices of PHAC serving the airports in the sample.
Among the 57 airports invited to participate in the survey, 50 responded, representing a response
rate of 88% (44 of 51 U.S. airports and six of six Canadian airports). The participating airports are
identified in Appendix C. The online survey questions and survey data for airports are reproduced as
Appendix D. One airport chose to respond to the survey by e-mail rather than using the online tool.
Thirty-four of the 51 U.S. local public health preparedness coordinators invited to participate sub-
mitted responses, representing a response rate of 67%. The Canadian response computation is compli-
cated because potentially two levels of health departments (local public health units and the regional
representative for the PHAC, which has particular jurisdictional responsibilities outlined under the
Federal Quarantine Act) could respond for each airport. The actual results were responses for five of
the six Canadian airports coming from one provincial health department, one city health department,
the PHAC East communicable disease response coordinator (two airports: Toronto and Montreal),
and the response coordinator for PHAC West (two airports: Vancouver and Edmonton). If the Cana-
dian health department invitations are viewed as a total of nine potential responses, the response rate is
four responses to nine invitations (44%). Overall, 39 health departments participated, a response rate
of 68%. The analogous situation did not arise with the U.S. surveys because the synthesis team sent
surveys only to local health departments and not to CDC Quarantine Stations.
Because this study focuses on cooperation between airports and public health departments in
preparing for and responding to communicable disease incidents, cases in which an airport and its
public health partner participated in the study have special interest. Thirty-six (63%) airport–health
department pairs responded.
12
Case Examples
Six detailed case examples are presented to highlight processes each airport has implemented since
2003 and the airports’ particular disease response incident. Potential epidemic/pandemic diseases
(SARS, Ebola, and influenza) and nonepidemic communicable diseases (tuberculosis and measles)
are included. The six case examples are:
1. Toronto Pearson International Airport and severe acute respiratory syndrome (2003);
2. Phoenix Sky Harbor International Airport and tuberculosis (2013);
3. Portland International Airport and measles (2014);
4. Dallas/Fort Worth International Airport and Ebola (2014);
5. Boston Logan International Airport and five suspected Ebola cases (2014); and
6. Vancouver International Airport and H7N9 (2015).
These airports, which all have had to respond to actual disease incidents, yield useful, practical,
and scalable lessons about how best to respond to communicable diseases on arriving flights. All six
case examples are large hub airports. Two (Toronto Pearson and Vancouver) have resident quarantine
offices and thus are “ports” in a manner similar to CDC, whereas four (Boston, Phoenix, Dallas/
Fort Worth, and Portland) are “subports” by virtue of not having a quarantine office at the airport. In
addition, these cases trace the evolution of airport planning and responses to communicable diseases
since the SARS outbreak and paint a picture of the most highly evolved communicable disease pre-
paredness and response plans today.
Each case example has been developed from examination of the survey responses from the air-
port (except BOS) and from its public health preparedness coordinator partner, a targeted literature
review, analysis of media coverage, a plans review, and a telephone interview with representatives
of the airport, health agency partner, and other key stakeholders. Unlike the survey portion of this
study, the case examples address the roles of airport personnel, tenants, stakeholders, airlines, clean-
ing crews, response partners (health agencies, law enforcement, emergency managers, and logistics
support entities), communicators/media, and local appointed and elected officials.
Validity
Preliminary conclusions as well as topics for further research were subjected to expert validation that
involved interviews with five senior health officials from U.S., Canadian, and international agencies.
The purpose of these interviews was to test the main findings and identify additional research needs.
The draft conclusions and possible further research needs shown in Appendix D-3 were provided
in advance to the five interviewees. Interviewees were affiliated with the following organizations:
1. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Prepared-
ness and Response;
2. U.S. CDC, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global
Migration and Quarantine;
3. PHAC;
4. New York State Department of Health, Bureau of Communicable Disease Control; and
5. International Civil Aviation Organization, Medical Office.
Data Analysis and Presentation
Most questions are in “check box” format, but open-ended questions allowed respondents to expand or
explain answers not appearing among the check box options. Data gathered by this study are presented
in Appendix D. Qualitative (thematic content) methods are the main analytic tool used. The common
themes discovered are discussed in chapters three and four. The nonrandom nature of the samples and
the relatively small sample sizes prevented the application of quantitative analytical methods other than
determining percentages of respondents in certain categories of answers (descriptive analysis).

13
chapter three
Survey Results
This chapter presents results and observations from the online survey. Detailed aggregated survey data
are presented in Appendices D-1 (Airports) and D-2 (Health Departments). Fifty airports responded to
the data request, with 49 submitting complete survey responses and one responding by e-mail. When
fewer than 49 airports responded to a particular question, the actual number (“n”) is noted. In chapters
three and four, the survey questions, and the data appendix of this report, “international” refers to
flights “arriving from outside the U.S. and Canada.”
Types and Frequency of Arriving Flights
Of the types of flights, not all carry passengers, but all eight types have flight crews. The implication of
this is that airport communicable disease plans need to consider arriving passengers and flight crews.
As noted, there is some variability in how these plans address both types of groups.
More than 60% of the responding airports receive 1,001 or more international flights per month,
which is not surprising given the heavy weighting in the synthesis sample toward large hubs, espe-
cially those that serve international markets (20 of 50 responding airports are large hubs). (Note: The
actual percentage is more accurately 63.1% because Memphis International Airport chose to exclude
FedEx flights from its response to this question.)
The number of international flights arriving per month is a major determinant of staffing size and
facility requirements for processing incoming passengers and flight crews. Of the 49 survey respon-
dents, 40 (81.6%) are a port of entry with U.S. Customs and Border Protection (CBP) or Canada
Border Services Agency (CBSA) on site. The size of the CBP or CBSA staff on site ranged from zero
(seven airports, 14.3%) to more than 30 (23 airports, 46.9%). Ten (20.4%) airports report having one
to five such staffers; five (10.2%) airports report having six to ten staffers; and four airports (8.2%)
report having 11 to 30 staffers. The physical size of CBP or CBSA spaces is an indicator of poten-
tial crowding and flexibility for isolating incoming passengers. The space ranges from less than
500 square feet (four airports, 8.2%) to greater than 5,000 square feet (19 airports, 38.8%), with
17 airports falling in between; in addition, seven airports reported having no CBP/CBSA facility,
and two were uncertain about the size of the area that would be used for passenger isolation.
Experiences with Communicable Disease Responses and Preparations
Table 1 shows the communicable diseases the surveyed airports and health departments have
responded to or prepared to respond to. In the case of nearly every disease, and not surprisingly, the
health departments have experienced or prepared for more kinds of communicable disease incidents
than have the partner airports.
How Airports Expect to Learn of a Potential Communicable Disease

Issue on an Arriving Flight
ICAO Document 4444 Paragraph 16.6 specifies standard procedures for the pilot on an international
flight to notify authorities of a suspected communicable disease onboard the plane. The pilot is
required to notify the air traffic control (ATC) sector in charge of the plane at the moment, and the

14
Table 1
Airport and Health Department Response and Preparation
for Communicable Diseases (since 2003)
Airports Health Departments
Disease (n = 49) (n = 37)
n Percent n Percent
Ebola 21 42.9 28 75.7
H1N1 influenza 20 40.8 24 64.9
SARS 20 40.8 16 43.2
Tuberculosis 19 38.8 22 59.5
Other influenza types (includes bird 20 40.8 12 32.4
flu, swine flu, H5N1)
Measles 15 30.6 23 62.2
Zika 11 22.4 16 43.2
Norovirus 9 18.4 11 29.7
Dengue 5 10.2 6 16.2
Chikungunya 4 8.2 6 16.2
MERS-CoV 3 6.1 1 2.7
Foot and mouth disease 1 2.0 0 0.0
Mad cow disease 1 2.0 0 0.0
Pertussis (whooping cough) 1 2.0 0 0.0
Meningococcal meningitis 1 2.0 1 2.7
Varicella (chicken pox) 0 0.0 2 5.4
Anthrax 0 0.0 1 2.7
Cholera 0 0.0 1 2.7
Mumps 0 0.0 1 2.7
None of the above 17 34.7 2 5.4
Source: Smith and Greenberg data.
ATC sector notifies ATC at the destination and departure point (or other authority designated by the
country) and the airline. ATC at the destination notifies the public health authority at the destination
(in the United States, coordination is through the Domestic Events Network), the aircraft operator,
and the arrival airport. The following hypothetical example, prepared with assistance from Portland
International Airport and CDC, illustrates these dynamics:
If a communicable illness is suspected on a flight from Tokyo to Portland, the pilot contacts the Anchorage
Oceanic Air Traffic Service (ATS) Flight Information Region (FIR) with the required standard information (see
Appendix B, this report) before arrival into the United States. In accordance with U.S. regulations, the pilot
is also required to notify the CDC Quarantine Station of Jurisdiction, however, this is not part of ICAO 4444.
The Anchorage Center would then communicate the information to the Seattle ATC Center and ATS in Japan.
The Seattle ATC Center notifies the Domestic Events Network (DEN), the airline, and Portland International
Airport. The DEN conveys the information to the Centers for Disease Control and Prevention (CDC) Quaran-
tine Stations and other federal response agencies (DHS, CBP, etc.). As a redundant method of communication,
the Seattle ATC may notify the Quarantine Station of jurisdiction, CBP, and EMS response partners directly.
Airport Operations notify EMS and other response partners.
Despite the clear statement of the notification process in ICAO Document 4444 Paragraph 16.6,
there is great variability in how U.S. and Canadian airports receive notification of a potential
communicable disease issue on an arriving flight. Table 2 summarizes the actual responses by
49 airports, annotated by the extent to which they conform to the standard stated in ICAO Docu-
ment 4444. The responses are scored according to how many of the three pathways described in
ICAO Document 4444—direct from ATS, through the public health agency, and/or through the
aircraft operator—appear to be included in the airports’ responses. The scoring is necessarily a rough
15
Table 2
How Airports Say They Learn of a Communicable Disease on an Arriving Flight
ICAO Model: Pilot notifies current ATS; ATS notifies destination and departure ATS, also notifies state health
agency, aircraft operator (or designee), and destination airport. The destination airport ideally receives notice
from the health agency, the aircraft operator, and directly from ATS. Aircraft operator’s designee for medical
issues is often a company such as MedLink.
Match with
Response n
ICAO Model
A report from the pilot to ATC, then through the airline (possibly MedLink) and/or the 19 3/3
national health agency (CDC/PHAC)
CDC/PHAC established process and internal protocols 8 1/3
CBP/CBSA established process and internal protocols 3 2/3
Pilot or Airline operations 2 1/3
911 Comm Center, DOH, CDC, CBP 1 1/3
Airline, public health, or emergency responder agency 1 2/3
Fire Department, airport Operations Center, airport Response Coordination Center 1 1/3
Interaction with CDC, U.S. Dept. of Health, MedLink, Air Carrier, Fire Dispatch (911) 1 2/3
It’s hoped that a flight crew’s discussion with an inflight medical consultant (such as 1 1/3
MedLink) would give us advance notice; however, I’m afraid we may not learn of the
issue until our first responders have already made contact with the ill passenger.
Local Health officials, city or county. CDC—Detroit may call with a heads-up 1 1/3
Notification from either the airline or United States Custom and Border Protection. 1 2/3
Pilot notifies the CDC or Local Health Department who in turn notifies the airport. 1 1/3
Through either the FAA Tower or Airline Operations 1 2/3
Tower communication 1 1/3
Typically, our dispatch center is notified by the airline, by an in-flight medical advice 1 2/3
provider, or CBP. Atypically, we might also be notified by one of four county health
departments.
estimate. However, it is clear that every airport appears to know what the mechanism is for learning
of a communicable disease on an arriving flight. No airport scored zero of three.
Although most airports do not indicate receiving notice of a potential communicable disease by
all three pathways implicit in ICAO Document 4444, every airport reports at least one established
pathway for receiving notice. The survey did not address notification procedures for domestic flights.
Nature of Airport Communicable Disease or Quarantine Plans
Of the 49 airports responding to the survey, 43 (87.8%) have written communicable disease or
quarantine plans. Thirty-eight (77.6%) of these plans are airport centered, and five (10.2%) apply
to the airport but are maintained by the local public health preparedness coordinator. Five (10.2%)
airports, all of which are reliever airports, do not have a written plan, and one airport reported being
unsure whether it has a plan.
The relationship between the communicable disease plans and other major airport plans varies. The
survey did not ask if an airport has a stand-alone plan referenced in its AEP, but current practice is to
have detailed plans separate from AEPs and referenced in the AEPs so that revisions to the detailed
plans do not trigger reviews of entire AEPs, either by the U.S. FAA or Transport Canada.
Twenty (40.8%) airports indicated that their communicable disease response plans are reflected in
the airport’s crisis communications or emergency communications plan; 15 (30.6%) airports reported
16
their plans do not. An additional 14 (28.6%) airports responded that they were unsure. This reflects
the trend uncovered by ACRP Synthesis 73 (Smith et al. 2016b) that showed airports increasingly
seeking to integrate all their communications needs and tools into comprehensive crisis communica-
tions plans; it also reflects what is increasingly a standard to develop strategic integrated plans.
Most airport communicable disease response plans are not categorized as sensitive security infor-
mation (SSI). SSI is a form of access control to sensitive documents. It corresponds to the classifi-
cations of “For Official Use Only” or “Confidential.” Standards for what makes a portion of a plan
SSI vary among airports and depend on the relationship between the TSA/Canadian Air Transport
Security Authority (CATSA) security director and the airport’s management. That most of the plans
are not SSI likely reflects their interest in the widest possible dissemination of the plans among stake-
holders and the public. Thirty-two (65.3%) airport plans are not SSI, and 13 (26.5%) are SSI. Four
(8.2%) reported not knowing if their airport’s plans were classified as SSI. Being able to communi-
cate plans and procedures to stakeholders and the public during a health emergency can be critical to
the success of the response and the protection of the airport’s reputation, as noted in the discussion
of case examples in chapter four of this synthesis.
Other survey questions looked at relationships to other major plans. Twenty-one (42.9%) of the
airports participating in the current study report that U.S. CBP or CBSA has communicable disease/
quarantine plans at those airports, and four (8.2%) have no CBP/CBSA plan. Twenty (40.8%) air-
ports responded they do not know the status of such plans, and four (8.2%) responded that the ques-
tion was not applicable.
Few communicable disease plans differentiate between how an airport handles flight crews who
have been exposed to an infectious illness and how passengers are handled: 12 (24.5%) airports make
this distinction, whereas 29 (59.2%) do not. Five (10.2%) airports indicated that they do not know, and
three (6.1%) say it is not applicable (most often, these respondents were general aviation airports with
no scheduled or charter passenger flights). Among the 32 U.S. health departments responding to this
question, six (18.8%) said flight crews are treated differently, 18 (56.3%) said there was no difference,
two (6.3%) responded not applicable, and six (18.8%) did not know. Among the five Canadian health
agencies that responded, one responded that its plan differentiates the handling of flight crews from
that of passengers, whereas three said there is no difference, and one said not applicable.
Nearly three-quarters of the airport communicable disease plans (36 of 49 airports, 73.5% of sur-
vey respondents) are based on the principles and procedures of the National Incident Management
System (NIMS), whereas seven (14.3%) are not and six (12.2%) reported not knowing.
Most of the airports that participated in this study use social media to communicate with the pub-
lic during communicable disease incidents. In most cases, the messages appear to be worked out
cooperatively between the airport and the local health department and/or quarantine station but are
issued (and presumably monitored) by the airport. Precise numbers are not available for this item
because the question was open ended, with respondents providing a wide variety of answers that do
not support more detailed analysis. ACRP Synthesis Project A11-03 (S04-18), “Using Social Media
to Inform Response and Recovery during Airport Emergencies” (expected publication in mid-2017),
offers related information.
When asked if their plan takes into account the possibility of social media posts by a passenger
about disease on an inbound flight while the flight is en route, 19 (38.8%) airports said yes, 18 (36.7%)
said no, four (8.2%) said not applicable, and eight (16.3%) reported not knowing the answer.
Maintaining and Reviewing Plans
Given how rapidly the public health and communications environments are changing, it might be
expected that airports would commit to regular reviews of and revisions to their plans. Thirty-one
(63.3%) airports reported they perform regularly scheduled reviews and updates of their commu-
nicable disease response plans. When the health departments were asked the same question about
their department’s plan, the results were similar, with 56.3% responding that they perform regularly
scheduled reviews and updates.

17
Training, Drilling, and Exercising Plans
Of the 44 airports that described their training programs for communicable disease response, nearly
all of them (n = 42 or 95.5%) responded that they use exercises (most often tabletop exercises),
training sessions, online training, or some combination of these activities. Several reported that
they train and drill in conjunction with their annual review of their plans. Several of the larger
airports noted they have regularly scheduled briefings with CDC/PHAC partners. Five (11.4%)
airports cited after-action reviews (AARs) following exercises or real-world incidents as their
most valuable training.
When specifically asked how the airport evaluates learning from its communicable disease training,
education, drilling, and exercising program, 17 (38.6%) airports cited AARs or AARs/improvement
programs (IPs). Seven (15.9%) airports reported using formal evaluation surveys after training.
The health departments were asked if they had trained jointly with their partner airport on com-
municable disease response. Of the 37 health departments that participated in the survey, 21 (56.8%)
responded yes, 11 (29.7%) responded no, two (5.4%) responded “not applicable,” and three (8.1%)
did not know whether joint training had been conducted.
The airports and health departments were asked at what intervals or on what occasions they
exercise their plan. Respondents were allowed to include multiple answers in their responses. The
results, reported in Table 3, show that the two occasions cited most often for having an exercise or
Table 3
Intervals and Occasions on Which Plans
Actually Exercised
Health Departments
Airports (n = 49)
Interval or Occasion (n = 37)
n % n %
When we become aware of a
18 36.7 14 41.2
new threat
When new procedures are
15 30.6 9 26.5
introduced
Annually 12 24.5 8 21.6
When regulatory
11 22.4 4 11.8
requirements change
A real-world incident can
10 20.4 15 44.1
substitute for
As part of after-action
10 20.4 8 23.5
review/improvement
Every 2 years 10 20.4 4 11.8
To validate plan revisions 7 14.3 11 32.4
Every 6 months 3 6.1 0 0.0
Every 3 years 2 4.1 13 38.2
Every 3 months or more often 2 4.1 0 0.0
Upon request by stakeholder 1 2.0 4 11.8
Continuous 1 2.0 1 2.9
Monthly 1 2.0 0 0.0
Part of annual AEP review
1 2.0 0 0.0
and update
Not applicable 8 16.3 2 5.9

18
drill—upon learning of a new threat or when new procedures are introduced—are closely linked, and
both probably are associated with risk-based emergency management and safety programs in recent
years. Two serious global public health emergencies (Ebola, Zika) in the past 2 years have intensified
this focus. The fixed time interval data may be confounded because a responding airport could mark
“monthly” without marking every 3 months or 6 six months. What is meant by “continuous” exercise
cannot be determined from the data.
The airports and health departments were also asked what the ideal interval would be for drilling
or exercising a communicable disease response plan. This was an open-ended question, so some
respondents gave answers that included two or more components. There is a consensus among air-
ports and health departments that annual exercises would be ideal. This would represent a significant
increase in exercise frequency compared with what both groups report doing at present. Annual exer-
cises occur only among one in four airports and slightly more than one in five health departments.
Communicable Disease–Related Services Provided

by Health Departments to Airports
The surveys of U.S. and Canadian health departments asked what types of services they expected
to provide at their partner airports related to communicable disease responses. Their responses are
presented in Table 4.
Although Canadian and U.S. responses have been combined, they are not strictly comparable. All
the U.S. responses came from local health departments, whereas the Canadian responses came from
one local health department, one provincial health department, and three PHAC regional offices.
Despite this variability, the most valid message in these data is the range of services an airport can
expect to receive from its public health partner. Also notable is the discrepancy between U.S. and
Canadian health partner organizations regarding public communication during an emergency. All
Canadian respondents indicated this was an area of leadership for them, whereas only 71.9% of U.S.
Table 4
Health Services Provided to Airports during Communicable Disease Responses
U.S. Health Canadian Health
Combined
Department Department
Service (n = 37)
(n = 32) (n = 5)
n % n % n %
Liaising with state/provincial health
department/CDC/PHAC as needed to identify 30 93.8 4 80.0 34 91.9
disease agent and arrange for laboratory testing
Investigating cases and collecting
epidemiological information, including
29 90.6 5 100.0 34 91.9
interviewing ill and exposed individuals
(passengers, flight crew, airport staff, etc.)
Instituting control measures (isolation and
quarantine or other measures necessary to control 27 84.4 5 100.0 32 86.5
disease spread)
Providing guidance regarding treatment or
prophylaxis that may be needed for ill/exposed 27 84.4 2 40.0 29 78.4
individuals
Providing guidance regarding appropriate PPE
26 81.3 2 40.0 28 75.7
and infection control measures
Leading any public information/messaging
23 71.9 5 100.0 28 75.7
efforts in partnership with airport
Providing guidance on environmental cleaning
22 68.8 3 60.0 25 67.6
measures/waste disposal
Collecting environmental samples 14 43.8 3 60.0 17 45.9

19
health departments reported the same. The relationship between the airport and its health prepared-
ness partners is explored further in the six case examples in chapter four.
Dealing with a Surge in Demand for Health Services at an Airport
A surge is a sudden requirement for greatly enhanced staff size to carry out one or more aspects of an
emergency response. The 37 responding health departments reported four basic patterns of dealing
with a surge in demand for services and health personnel for a communicable disease response at an
airport, and in some cases agencies used combinations of these approaches:
1. Reallocation of agency personnel, often nurses with additional specialized training for com-
municable disease functions;
2. Augmentation from regional, state/provincial/territorial, or national resources (e.g., the disaster
medical assistance team, regional EPI team, or regional health care coalition);
3. Hiring of temporary employees; or
4. Use of volunteers such as the Medical Reserve Corps.
Surges in demand for health services, whether in the United States or Canada, typically necessi-
tate a partnership approach. The airport plan would trigger district health plans and coalition plans.
This in turn could trigger the infectious disease network at the state level. The coalition in partner-
ship with public health and emergency management has a surge plan that would be activated, with
communications taking place all the way up the line to the state department of health and including
assistance from the state health care association.
The third of these examples shows the benefit of spelling out the triggers and procedures for a
surge situation in the airport’s communicable health disease plan.
Protective Measures Provided to Airport Employees
Airport communicable disease response plans typically provide special mention of personal protec-
tive equipment (PPE) for employees. Table 5 summarizes the types of PPE provided. There appears
to be a relationship between airport size and the magnitude of a recent communicable disease inci-
dent, on one hand, and the range of PPE provided at an airport, on the other. There appears to be an
issue at many airports regarding who is responsible for the OSHA-required fit testing of personnel
for respirators (L. Slepski, personal communication, April 6, 2017).
Table 5
Protective Measures Provided
to Airport Employees
Measure n %
Training 40 81.6
Personal protective equipment 39 79.6
Equipment 21 42.9
Decontamination facilities 19 38.8
Other clothing 11 22.4
Vaccines 10 20.4
Countermeasures 7 14.3
Medical checks 7 14.3
Counseling 1 2.0
Not applicable 3 6.1
Don’t know 1 2.0

20
Table 6
Comparison of Self-Reported Preparedness Estimates
Local Public Health Preparedness Coordinator Estimate
of Its Preparedness to Respond at the Airport
Very Prepared Somewhat Prepared Not Prepared
Preparedness
Estimate of
Airport
Very Prepared 9 9 —
Somewhat Prepared 2 15 1
Not Prepared 1 — —
Lessons Learned
The airports and health departments were asked to identify the top three lessons they have learned con-
cerning communicable diseases on arriving flights. The question was open ended, allowing respon-
dents to discuss the widest possible variety of experiences. The verbatim or lightly edited lessons
learned that were stated by the airports and local health departments are reproduced in Appendix E.
The most important item revealed by comparing the lessons learned by airports and those learned
by health departments is how much those lessons overlap. The two attention-getting communica-
ble diseases—influenza A virus subtype H1N1 (often called swine flu) in 2009 and Ebola in 2014,
but especially Ebola—that brought airports and public health agencies together to plan their joint
responses probably account for the overlap. The most significant differences come from the airports’
concern with handling an aircraft on the ground compared with the health departments’ greater con-
cern with resource constraints, legal questions, and restrictions or delays on access by public health
officials to planes because of airport security procedures. Both groups are concerned by the gaps in
authority and information sources regarding a passenger who becomes ill on a domestic flight.
Self-Estimates of Preparedness Level
The airports and health departments self-reported their estimated level of preparedness to respond to
a communicable disease on an arriving flight. When data from the 37 matched pairs of airports and
health departments are the only data considered, the two estimates agree in 24 (64.9%) pairs, with
“somewhat prepared” being the most common shared evaluation. In three (8.1%) pairs, the airport
rated itself more prepared than its partner health department rated itself (Table 6). In ten (27.0%)
pairs, the health department rated itself more prepared to respond at the airport than the airport
rated itself. There was only one case in 37 in which the perception of readiness varied widely: one
responded “very prepared,” and the other responded “not prepared.” The examination of answers
to the follow-up question, “What is the one thing you feel your organization could or should do to
enhance its preparedness to respond to a communicable disease on an arriving flight?” suggests that
the two main causes of disagreements and the preponderance of “somewhat prepared” ratings are
failure to exercise or drill together frequently and infrequent review and revision of plans.
When only large hub airports in the surveyed pairs are considered (Table 7), there appears to be a
shift toward a higher level of perceived preparedness, but the small sample size and subjective nature
of the self-reported preparedness estimates limit the generalizability of this observation.
Table 7
Comparison of Self-Reported Preparedness Estimates: Large Hubs
Health Department Estimate of Its Preparedness to Respond at the Airport
Preparedness
Estimate of
Airport
Very Prepared 7 4 0
Not Prepared 0 0 0
n = 16.

21
Table 8
Comparison of Self-Reported Preparedness Estimates: Medium Hubs, Small Hubs,
Non-Hub Primary, and Secondary Commercial Service Airports
Preparedness
Estimate of
Airport
Very Prepared 1 1 0
Not Prepared 0 0 0
n = 14.
Taking a similar look at airports that have commercial passenger service but are not large hubs—
that is, medium hubs, small hubs, nonhub primaries, and secondary commercial service airports—the
most frequently chosen response is “somewhat prepared” (Table 8). Two factors probably account
for the difference from that seen for large hub airports’ estimated preparedness: (1) the airports that
are not large hubs usually have much smaller airport staff sizes, and (2) they lack international flights
that would tend to heighten awareness of communicable disease risks and procedures. Airport–health
department pairs in both size categories report being prepared to some degree, implying that they
are aware of the risks, procedures, and resources available to them. In addition, the members of each
pair in the two groups agree on their preparedness estimates: 12 pairs of 16 (75%) for the large hubs,
and 11 pairs of 14 (79%) for the other airports with passenger service. Airports in these categories,
especially medium hub and small hub airports, are increasingly likely to receive international flights
as low-cost, long-haul airlines establish intercontinental service to the United States and Canada
using airports that have not previously had international flights (see for example Anna.aero 2017).
A reliever airport is a specifically designated general aviation airport that serves to divert general
aviation traffic from nearby commercial passenger airports. The seven reliever airports in the study
and their local health department partners reported a somewhat different pattern (Table 9). Only one
pair of seven (14%) agreed on the estimated level of preparedness. This may perhaps result from
a lower level of interaction and collaboration between the airports and the health departments. In
general, reliever airports are much lower profile in their communities than are airports with commer-
cial service. Six among the seven reliever airports in the surveyed pairs were among the 20 busiest
in terms of flight operations in the United States in 2009, ranking first, third, seventh, 11th, 14th,
and 18th (National Business Aviation Association 2017). All seven airports routinely serve nonstop
international flights by corporate and private jets.
Examining the percentage of airports (not pairs) self-reporting themselves as “very prepared”
shows that the large hub airports (ten of 16, 62%) and reliever airports (five of seven, 71%) are more
similar than either is to the smaller airports with commercial passenger service (two of 14, 14%).
Table 9
Comparison of Self-Reported Preparedness Estimates: Reliever Airports
Preparedness
Estimate of
Airport
Very Prepared 1 4 0
Not Prepared 1 0 0
n = 7.

22
chapter four
Where the Rubber Hits the Tarmac: Six Case Examples
Introduction
Six case examples of communicable disease response planning at U.S. and Canadian airports are
presented here. Each airport has had at least one major incident that caused activation of its commu-
nicable disease response plan and associated activities. All case examples are from large hub airports
served by nonstop passenger flights arriving from outside the United States and Canada and deal
with an incident that has occurred since 2003. Despite the large size and business mixes of these
airports, the synthesis team thinks the principles exhibited in the communicable disease planning and
responses offer practices that can be transferred to smaller airports, domestic airports that receive
connecting international passengers, and airports that receive international passengers and crews on
charter or other nonscheduled flights.
Each case is based on a review of media coverage of each incident, analysis of published litera-
ture, analysis of the survey results from the airport and its local public health preparedness coordinator
(except for Boston Logan International Airport, which did not participate in the survey), and follow-
up correspondence (telephone and e-mail) with the airport, the health partner, and key stakeholders
as identified by the airports. In one case example, a set of documents is presented to illustrate that
airport’s current preparedness posture. With pervasive social media presence, the communication
challenges are magnified (Smith and Kenville in press).
All airport operational statistics in this chapter come from ACI-NA (2016a) or from the airports’
websites.
Case 1: Toronto Pearson International Airport

and Severe Acute Respiratory Syndrome (2003)
Between February and July 2003, Toronto experienced the largest outbreak of SARS outside of
Asia. SARS killed nearly 800 people worldwide, and infected almost 8,000 patients. In Toronto,
225 people became infected; 44 died of complications related to their illness. The outbreak’s
human and economic consequences were significant and took a serious toll on patients and hos-
pital workers and their friends and families. A primarily nosocomial disease, SARS was largely
restricted to persons who were exposed in one of the city’s 19 acute care hospitals and their
household contacts. In April 2003, WHO issued a warning advising against travel to Toronto;
although the advisory lasted less than a week, it contributed to more than $260 million in losses
to the city’s tourism industry and more than CDN $1.1 billion in costs to the provincial (Ontario)
treasury.
This case example is based on the survey results from Toronto Pearson International Airport (YYZ),
the Public Health Agency of Canada (Quarantine Services, Central Region), and Toronto Public Health
(TPH, the city’s health department) and a telephone interview on December 1, 2016.
It is important to note that Pearson International Airport is predominantly in the city of Mississauga,
which as part of the Region of Peel, is served by a different health department than is the City of
Toronto. Major communicable disease incidents likely involve PHAC, the Region of Peel Health
Department, and TPH. All TPH information used in this case study is identified.

23
Pearson International is Canada’s busiest airport in terms of total passengers, international pas-
sengers, total flight operations, and cargo tonnage. In 2002, just before the SARS outbreak, the air-
port served more than 14.5 million international passenger trips [Greater Toronto Airports Authority
(GTAA) 2002]. In 2015, it served 41,036,847 passengers, ranking 15th in North America and 33rd in
the world. In 2015, it had 443,958 total aircraft movements (ranking 16th in the world, ninth in North
America, and first in Canada) and handled 434,777 metric tons of cargo (ranking 56th in the world,
17th in North America, and first in Canada).
Pearson International received more than 7 million international passengers in 2015 (A. Payter,
personal communication, Dec. 21, 2016); this excludes passengers arriving from the United States.
The airport is served by 65 airlines and receives nonstop flights from 100 cities outside the United
States and Canada (Table 10). Passengers can reach more than 67% of the world’s economies through
daily, nonstop flights from Pearson (https://www.torontopearson.com/en/economicimpact/#). Pearson
handles more international passengers than any airport in North America other than John F. Kennedy
International Airport in New York, and ranks 22nd among all world airports for number of international
passengers (ACI-NA 2016b).
In addition, Pearson International receives charter, cargo/freight, and humanitarian support flights
(refugee flights), corporate general aviation flights, and private (noncorporate) general aviation flights
from outside the United States and Canada. It is a port of entry with a resident PHAC quarantine station
and a resident CBSA unit.
Table 10
Airports of Origin Outside United States and Canada
for Toronto Pearson International Airport
Region Number Airports of Origin
East Asia 8 Beijing, Guangzhou, Hong Kong, Manila, Seoul, Shanghai, Taipei, Tokyo
South Asia 4 Delhi, Islamabad, Karachi, Lahore
Southwest 5 Abu Dhabi, Dubai, Jeddah, Riyadh, Tel Aviv

Asia/Mideast
Africa 2 Addis Ababa, Cairo
Europe 23 Amsterdam, Barcelona, Brussels, Copenhagen, Dublin, Frankfurt, Geneva,

Glasgow, Istanbul, Lisbon, London-Gatwick, London-Heathrow, Madrid,
Manchester, Munich, Paris, Ponta Delgada, Porto, Reykjavik, Rome, Vienna,
Warsaw, Zurich
Caribbean, 51 Acapulco, Antigua and Barbuda, Aruba, Barbados, Belize City, Bermuda,
Mexico, and Camaguey, Cancun, Cayo Coco, Cayo Largo, Cienfuegos, Cozumel, Curacao,
Central Exuma, Freeport, Grand Cayman, Grenada, Havana, Holguin, Huatulco,
America Ixtapa, Kingston, La Romana, Liberia, Managua, Manzanillo (Cuba),
Manzanillo (Mexico), Merida, Mexico City, Montego Bay, Nassau, Panama
City, Port of Spain, Providenciales, Puerto Plata, Puerto Vallarta, Punta Cana,
Rio Hato, Roatan, Samana El Catey, San Jose Cabo, San Jose, San Salvador,
Santa Clara, Santiago (Chile), Santiago (Cuba), Santo Domingo, St. Kitts, St.
Lucia, St. Maarten, Varadero
South 6 Bogota, Buenos Aires, Cartagena, Georgetown, Lima, Sao Paulo

America
Oceania 1 Sydney
Total 100
Source: Smith and Greenberg data, derived from www.torontopearson.com (accessed Nov. 27, 2016).

24
In the surveys, Pearson, PHAC, and TPH noted having prepared for or dealt with the diseases shown
in Table 11 in the past 15 years. Under the Quarantine Act, there are 25 diseases of concern; PHAC is
prepared to deal with all 25 (S. Jain, personal communication, December 21, 2016; Appendix A). Of
the diseases in Table 11, all except dengue and norovirus are diseases of concern; however, if PHAC
assesses someone with dengue or norovirus, PHAC helps facilitate the response and care through its
partners (S. Jain, personal communication, December 21, 2016).
During the 2003 SARS outbreak, there was considerable public pressure on airports and health
agencies to screen for symptoms in passengers on arriving flights, especially flights from East Asia.
Soon after WHO lifted its travel advisory, Pearson International introduced screening mecha-
nisms (thermal imaging) for inbound and outbound passengers in an effort to identify passengers
with elevated temperatures and prevent the disease from spreading. These measures were canceled
in late May after complaints from travelers that the actions were unnecessarily intrusive. They also
were costly. A CBC report cited a study published in the journal Emerging Infectious Diseases that
concluded the estimated CDN $7.55 million spent on screening at several Canadian airports failed
to detect a single case of SARS (CBC News 2004). Cities with direct flights to Hong Kong, such as
Toronto, were 25 times more likely to record a SARS case than were cities that were not directly
connected. Cities that required two and more connecting flights to reach Hong Kong did not record a
single case. After the SARS outbreak began, flights in Pacific Asia decreased by 45% compared with
the previous year. During the outbreak, the number of flights between Hong Kong and the United
States fell 69%. This is an example of risk avoidance behavior by travelers (Rodrigue et al. 2017).
The most significant result of SARS was the formation of PHAC. Other changes in practice
since 2003 have been less formal; one of the key successes of the Quarantine Program has been the
networking and relationships which were strengthened among agencies. Expert respondents noted
a strengthening in the relationship between the airport and public health and other stakeholders and
outreach among these parties. One upshot of this development has been that airports now have com-
municable disease plans that are updated on a regular basis. There is a concerted effort to keep up
with the changing dynamics of communicable diseases.
The effectiveness of the efforts since 2003 was demonstrated by Toronto’s experience with the
Middle East respiratory syndrome coronavirus (MERS-CoV) epidemic. In 2015, the Office of Border
Table 11
Communicable Disease Responses or Preparations
at Toronto Pearson International Airport
Disease Airport PHAC TPH
SARS X X X
H1N1 X X X
Measles X X X
Tuberculosis X X X
Ebola X X X
Dengue X
Other influenza types X X X
Norovirus X X
Meningococcal meningitis X X
MERS-CoV X X
PHAC = Public Health Agency of Canada; TPH = Toronto Public Health.


25
and Travel Health (an agency of the PHAC) had a focused public health campaign for MERS-CoV
that included: (1) outreach sessions on MERS-CoV for CBSA officers; (2) working with key airlines
to distribute information to travelers returning from Hajj; and (3) using screens in the CBSA area to
provide travel health information about MERS-CoV to travelers returning to Canada. PHAC’s Travel
Health program (part of the Office of Border and Travel Health) has continued to provide travel
information related to MERS-CoV for Hajj pilgrims through various Muslim associations in Canada.
At the local level, the Ontario Ministry of Health and Long-Term Care created a MERS-CoV docu-
ment that was distributed to all Ontario health departments to ready them for the possible arrival
of the syndrome (Ontario Ministry of Health and Long-Term Care 2016). This document included
case definitions and clear testing protocols. Health departments, including TPH, trained their on-call
teams to appropriately respond to calls from Pearson International and area hospitals identifying
travelers with possible MERS-CoV infection.
The Plans and How Developed
Pearson maintains a communicable disease response plan, which is a stand-alone plan referenced in
the AEP. The airport communicable disease plan is disseminated to stakeholders electronically. The
airport does all plan updates on a regular schedule, and PHAC specifically reviews quarantine proce-
dures. Parts of the airport plan are classified (SSI). The plan is reflected in GTAA’s human resource
policies. The airport plan does not differentiate how it handles passengers from how it handles flight
crews, but the PHAC plan does make this distinction.
Table 12 compares the stakeholder lists given by Pearson, PHAC Central, and TPH.
The Pearson plan incorporates the incident management system and best practices from NIMS
and Incident Command System (ICS) although they are not required in Canada. The airport’s plan
does not involve diverting inbound flights to other airports.
Health Department Services to the Airport
Depending on the specific circumstances, PHAC or the local health department may provide
some or all of the services listed in this section. PHAC in its survey response, interview, and
follow-up correspondence (S. Jain, personal communication, December 21, 2016) reported that it
provides the following services at Pearson International Airport related to communicable disease
responses:
• Assisting in investigating cases and collecting epidemiological information, including interview-

ing ill and exposed individuals (passengers, flight crew, airport staff, etc.).
• Assisting in securing the flight manifests for international flights as outlined by the PHAC
Quarantine Program.
• Supporting the International Health Regulations (IHR) notifications between countries.
• Liaising with provincial health department as needed to identify a disease agent and arrange
for laboratory testing.
• For international travelers entering Canada, enforcing various orders under the Quarantine Act.
Local public health and/or hospitals ensure the orders are implemented.
• Instituting control measures (isolation and quarantine or other measures necessary to control
disease spread).
• Leading any public information/messaging efforts in partnership with the airport.
• Leading public information/messaging efforts (e.g., MERS-CoV).
In its survey response, TPH noted services that likely would be provided by the Peel Region
Health Department:
• Collect environmental samples;

• Each agency (federal) is responsible for obtaining guidance on PPE from its respective occu-
pational health department;

26
Table 12
Stakeholders Involved in Communicable Disease Planning
Process at Toronto Pearson International Airport
Stakeholder Airport PHAC TPH
Airport senior management X X
Airport planning X
Airport media/public relations X X
Airport operations X X X
Airport emergency management X X X
Airport law enforcement
Airport rescue and firefighting X X X
Airport training X
Airport maintenance
Airport human resources
Airlines, air cargo companies, charter operators, and air X X

taxi operators
Concessionaires
Mobility services (wheelchairs, carts)
Airport sponsor/certificate holder
General aviation aircraft owners and pilots
Local health department X X
Provincial health department X X
PHAC–quarantine station X X X
Other public officials (elected officials, etc.)
CATSA
CBSA X X X
Military (airport is joint use)
Transport Canada X
Nonairport law enforcement

National agencies X X
Provincial agencies X X
Local agencies X
Health care coalition
Hospitals and clinics X X
Ambulances/medical transport services X X X
HAZMAT—local fire department X
County emergency management
City emergency management
Provincial emergency management X X
Note: Slash means stakeholder and column entity are the same.

27
• Provide guidance regarding appropriate PPE and infection control measures; and
• Provide guidance regarding treatment or prophylaxis that may be needed for ill/exposed individuals.
For responses to potential health problems with international travelers, PHAC is developing a
surge capacity framework. Recently, PHAC has used nurses from within PHAC to support surge
requirements. In past outbreaks, PHAC used nursing agencies to hire temporary surge staff.
Training, Drilling, and Exercising
Training of fire and emergency services personnel relating to communicable disease is completed on
a regular basis. Training includes practical performance demonstrators, written examinations, and
monthly training drills. The most recent airport communicable disease drill or exercise was in 2010.
There has been a recognized need to expand such drills and training to include external partners and
other frontline employees.
Pearson Airport identifies the need to schedule a drill or exercise
• When regulatory requirements change,

• When new procedures are introduced, and
• When a hazard or deficiency in response to communicable disease is demonstrated.
PHAC recommends a tabletop exercise every year and a full-scale exercise every 3 years.
The airport provides a number of protective measures for its employees: training and counter-
measures for fire and emergency services personnel; PPE for fire and emergency services personnel;
and decontamination facilities.
Communications
The post-SARS reforms have been effective in all areas but particularly in communications. Case
Example 2, regarding Phoenix Sky Harbor International Airport, describes in detail the sort of changes
that Pearson and PHAC achieved.
Greatest Worry
The airport and PHAC worry that there is no federal authority for screening passengers arriving on a
domestic flight. The federal Quarantine Act does not cover domestic flights. This can be illustrated by
a potential situation in which a passenger traveling from Hong Kong to Toronto by way of Vancouver
may not show symptoms until the Vancouver-to-Toronto leg of the trip, and PHAC in Toronto has no
authority over the passenger, who is now arriving as a domestic passenger. The provincial health acts
may or may not have similar authority as the federal Quarantine Act. Historically, Quarantine Officers
have assisted with the assessment; however, they cannot enforce any of the provisions under the Quaran-
tine Act. The provinces are aware of this issue and have initiated action to address it.
Lessons Learned
Pearson International Airport reported:
1. There is a need to work more closely with local public health agencies to understand jurisdic-
tion and the effectiveness of response.
2. When a domestic flight is involved, there may be a challenge in trying to identify a communi-
cable disease and not having authority to send someone to the hospital under a specific legal
act is a challenge.
3. More frequent practice of the communicable disease plan involving all internal and external
stakeholders through to the recovery stage would enhance resilience of the airport community
to communicable diseases.

28
PHAC reported:
1. Challenges of the federal Quarantine Act because it does not pertain to domestic flights;
2. Limited scope of the Quarantine Act;
3. Pressure on partners to deal with communicable disease on domestic flights;
4. Challenges in responding to issues on domestic flights; and
5. Challenges when the quarantine officer is not on site.
TPH reported:
1. Involving all stakeholders is necessary;

2. Having no assumption that everyone understands the basics of communicable disease control;
3. The return on investment for too much detail is difficult to make;
4. Providing information can reduce anxiety;
5. Understanding that prior relationships are the most important thing when initiating a response;
and
6. Planning will take you only so far before improvisation will be necessary.
Greatest Challenge
SARS had a large impact on the number of passengers using Pearson International; traffic dropped
12% in a year. This required major financial adjustments:
The ground rent recorded in the financial statements for 2003 was $125.2 million as compared to $134.5 mil-
lion in 2002. The reduction includes overpayments in 2002, the impact of reduced passenger levels in 2003
below the 25 million passenger cap but does not include the ground rent relief under a program announced by
the Minister of Transport in July 2003. This program was intended to provide ground rent relief for airports in
recognition of the difficulties in the industry, particularly the impact of SARS. For the GTAA the result of the pro-
gram will be a ground rent deferral of approximately $41.6 million over 24 months, commencing on July 1, 2003.
For 10 years commencing in 2006, payments will be increased by approximately $4.2 million each year (GTAA
2003 Annual Report).
Bottom Line
Pearson International Airport’s respondents’ estimate of the level of overall preparedness to deal
with a communicable disease on an arriving international flight was reported as “prepared,” with a
need to improve drill and exercise frequency. Processes are in place for dealing with communicable
disease arriving on a domestic flight; however, more is required to determine the effectiveness of the
current processes.
The TPH respondent’s estimate of the level of overall preparedness to deal with a communicable
disease on an arriving flight was reported as “prepared,” but the following needs were cited: improve
drill and exercise frequency, improve coordination with airlines, and determine the most effective way
to coordinate response to communicable diseases on domestic flights.
The conversation during the interview showed how closely the airport and PHAC work together
and how well they understand each other’s needs and capabilities. Pearson International Airport and
its partners have had direct experience with a passenger getting sick on a flight and a passenger get-
ting sick at home after passing through the airport.
Case 2: Phoenix Sky Harbor International Airport and Tuberculosis (2013)
“We’ve been notified of a health emergency aboard the aircraft.” The pilot’s announcement on US
Airways Flight 2846 hung ominously in the cabin. The plane was on the tarmac of Phoenix Sky
Harbor International Airport (PHX) at the conclusion of its 2-hour leg from Austin, Texas, with a
final destination of Los Angeles International Airport (LAX). As passengers looked nervously at
each other, one of the flight attendants approached a middle-aged male passenger, handed him a

29
medical grade mask, and with emergency personnel in tow, escorted him from the plane. Another
announcement followed a few minutes later, informing passengers that the patient had active
tuberculosis, was highly contagious, and had exposed everyone aboard the flight. “Please contact
your physicians immediately.”
Because of the flight’s short duration, the likelihood of mass tuberculosis (TB) infection aboard
the flight was low; nevertheless, TB is highly contagious and can be deadly. The case also revealed
how vulnerable the air travel industry is to the spread of communicable disease. US Airways spokes-
person Bill McGlashen later revealed there was no warning or flag on the passenger’s record when
he proceeded through security or when he boarded the plane (Avila 2013). Only after the plane
was airborne did CDC notify TDS of a possible risk. TSA then notified the airline to coordinate a
response. In this case, the passenger was not on the CDC’s do-not-board list and did not appear to
present symptoms of serious infection at the time of departure that would lead the ticketing agent to
not issue a boarding pass. Unlike passengers aboard luxury cruise ships, airline passengers are not
legally obligated to notify an airline when they are sick.
This case example is based on the survey results from Phoenix Sky Harbor International Airport and
the Maricopa County Department of Public Health and a telephone interview on December 16, 2016.
Phoenix Sky Harbor International Airport is the 11th busiest airport in North America and
29th busiest in the world, having served 44,003,840 passengers as of 2015. In 2015, Phoenix Sky
Harbor had 369,759 total aircraft movements (ranking 34th in the world, 20th in North America, and
19th in the United States) and handled 283,465 metric tons of cargo (ranking 82nd in the world,
21st in North America, and 20th in the United States). The airport is served by 16 airlines and
receives nonstop flights from 11 cities outside the United States and Canada (Table 13). The City
of Phoenix Aviation Department also owns and operates Phoenix Deer Valley Airport and Phoenix
Goodyear Airport; in addition, the city is a member of the Phoenix–Mesa Gateway Airport Authority.
Phoenix Sky Harbor receives charter, cargo/freight, and corporate general aviation flights from
outside the United States and Canada. The Phoenix area has hosted many large special events, such
as the Super Bowl, College Football Playoff games, political conventions, and large international
conventions, all of which generate many charter and general aviation flights. Phoenix Sky Harbor is
a port of entry, with a resident CBP unit, but there is no CDC Quarantine Station. The airport falls
under the Quarantine Station in San Diego.
In the surveys, Phoenix Sky Harbor and the Maricopa County Department of Public Health noted
having dealt with or prepared to deal with measles, tuberculosis, Ebola, and influenza types in the
past 15 years.
Recent Experiences
As with measles, tuberculosis is a highly contagious communicable disease but does not typically pose
an epidemic threat. According to Dr. Rebecca Sunenshine, medical director of the disease control divi-
sion of the Maricopa County Department of Public Health, the 2013 TB response “enlightened us about
Table 13
for Phoenix Sky Harbor International Airport
Europe 1 London
Caribbean, 10 Culiacan, Cancun, Guadalajara, Hermosillo, Mexico City, Mazatlan, Puerto
Mexico, and Vallarta, Los Cabos, San Jose, Ixtapa
Central
America
Total 11
Source: Smith and Greenberg data, derived from www.skyharbor.com (accessed Nov. 27, 2016).

30
many opportunities to improve our response planning.” It occasioned vast local and national media
attention. The airport’s emergency preparedness coordinator convened every stakeholder to a hot-
wash, an immediate after-action review (AAR) session to discuss and evaluate the response and
review the report that followed. The incident led to a complete revision of the airport’s commu-
nicable disease response plan, with the revision led by the airport. The revision was informed by
the realities of airport, health department, and law enforcement challenges and responsibilities.
The single most important lesson learned from this experience was that if a public health incident
is involved, there is an absolute need to get all stakeholders on the telephone at once and let the
health department be the subject matter expert (SME) to the incident commander and take the lead
in the response. Phoenix Sky Harbor reprogrammed its notification system to reach all the correct
parties in the event of various health-related problems. During 2014, there was a large amount of
partnership/relationship building among partners for agencies involved in health emergencies.
As a group, the stakeholders took the CDC planning template and made it into a local, operational
communicable disease plan.
The efforts undertaken in 2013 and 2014 paid off in 2015. The Maricopa County health depart-
ment notified the airport of a passenger arriving from Liberia through London and coming to a
Phoenix hospital for the diagnosis and treatment of possible Ebola infection. The passenger had
been evaluated in Liberia and London, but the exact illness had not been identified, and the patient
had some but not all Ebola symptoms. The passenger initially had illness classified as “moderate”
risk until being evaluated at a U.S. port of entry, where his illness was reclassified as “low but not
zero” risk. The airport and the health department had several days to prepare. The communications
went well. Advance notice of arrival, no risk to other passengers or airport personnel, and a good
plan allowed the incident to be deescalated in advance. The patient eventually received a diagnosis
of illness other than Ebola.
The airport and health department maintain written communicable disease response plans, but they
coordinate to ensure plan alignment. The airport’s plan is a stand-alone communicable disease/
quarantine plan. The health department has two annexes to its Public Health Emergency Response
Plan—the Infectious Disease Annex and the Disease Containment and Mitigation Annex. The airport
and health department incorporate the principles and practices of NIMS and the ICS in their plans.
Neither plan differentiates how to handle passengers from how to handle flight crews. The airport’s
plan does not involve diverting inbound flights with a reported or suspected communicable disease
to another airport.
The airport’s plan was developed by a group of stakeholders; changes and updates to the plan are
communicated by an e-mail group that includes all stakeholders. Table 14 compares the stakeholder
lists given by Phoenix Sky Harbor and the Maricopa County health department.
The airport and the health department perform regularly scheduled reviews of their communicable
disease response plans and stay familiar with each other’s plans and procedures through numerous
county, regional, and state health and emergency planning committees and meetings.
The Maricopa County health department provides the following services at the airport related to
communicable disease responses:
• Serving as SME—the health department has a staff physician on call 24/7 who is available by
telephone and a provision for an on-site public health liaison (through the Arizona Counter
Terrorism Information Center Terrorism Liaison Officer program);
• Investigating cases and collecting epidemiological information, including interviewing ill and
exposed individuals (passengers, flight crew, airport staff, etc.);

31
Table 14
Process at Phoenix Sky Harbor International Airport
Health
Stakeholder Airport
Department
Airport planning X X
Airport operations X X
Airport emergency management X X
Airport law enforcement X X
Airport rescue and firefighting and EMS X X
Airport maintenance X X

taxi operators
Mobility services (carts, wheelchairs) X
Airport sponsor/certificate holder X
General aviation aircraft owners and pilots X
Local health department X
State health department X X
CDC—Quarantine Station X X
Other public officials (elected officials, etc.) X X
TSA X X
CBP X X
Military (airport is joint use) X
FAA X X
Nonairport law enforcement X
State agencies X X
Local agencies X X
Health care coalition X
Hospitals and clinics X X
Ambulances/medical transport services X
County emergency management X
City emergency management X
State emergency management X

32
• Liaising with state health department/CDC as needed to identify disease agent and arrange for
laboratory testing;
disease spread);
• Collecting environmental samples;
• Providing guidance on environmental cleaning measures/waste disposal;
• Providing guidance regarding appropriate PPE and infection control measures;
• Providing guidance regarding treatment or prophylaxis that may be needed for ill/exposed
individuals; and
The airport carries out regular tabletop and review sessions with stakeholders and public health
partners. The training and exercises are evaluated using real-world observation and feedback con-
firming the effective and efficient response practices of responders. The same methods are applied
to all actual incidents. The airport uses evaluation forms to perform an AAR on every drill and
incident. The most recent drill or exercise was in 2016. The airport holds drills on communicable
disease response at least annually, but it also schedules a drill or exercise:
• When regulatory requirements change;

• When new procedures are introduced;
• To validate plan revisions;
• As part of the AAR/IP process; or
• Upon request from an airline partner or other stakeholder.
A real-world incident can substitute for a drill or exercise required by regulations. The airport pro-
vides a number of protective measures for its employees, including training, PPE, other clothing,
and decontamination facilities.
Communications
When a communicable disease incident occurs at the Phoenix airport, the public relations depart-
ment, working with the county health department, provides regular and timely updates by means
of the airport’s website and all applicable social media options (Facebook, Twitter, and Instagram).
The airport’s plan takes into account the possibility of social media posts by a passenger about
disease on an inbound flight while the flight is in progress.
Accuracy in communication is crucial. Miscommunication can cause a ripple effect in airline

operations. The airport and its partners agree about the importance of sticking to their plan to avoid
allowing an incident to snowball. Maintaining message discipline—a “single voice”—is essential
to ensure the communication of clear, accurate health-risk information. The single voice is achieved
by using a unified public information office (PIO), speaking for the city, county, and airport, that
operates from a joint information center (JIC). This has been a major benefit of the effort put into
building relationships.
When a new disease or other health threat emerges, the health department coordinates with the
airport about signage and other information sharing for passengers and airport employees.
Greatest Worry
In the interview, the health department and the airport both said that their greatest worry is a com-
municable disease incident involving one of the largest aircraft (such as B777, A330, or B747)
because the number of passengers to be interviewed for contact information and screened would
swamp the personnel and space available. The staffing surge required to assist in the screening
and triage of ill and exposed persons at the airport would be addressed through a series of sources

33
activated in sequence or in series, as the situation dictates. The sources include available public
health staff; activation of public health volunteers; requests for staffing assistance through the
health care coalition; requests for staffing assistance through the fire/EMS automatic aid system;
and requests for staffing assistance to adjoining counties and/or the state. In addition, the airport
has arranged with the Arizona Air National Guard for the use of hangar space if the number of
passengers makes it necessary.
Lessons Learned
Phoenix Sky Harbor International Airport reported:
1. Overall planning and the identification of roles and responsibilities among agencies are essential.
2. Effective initial and ongoing communications throughout the incident are paramount.
3. Not all incidents require a full response or isolation of an aircraft; assuring that the flight crew
does not “overdramatize” the event is important.
The Maricopa County Department of Public Health reported:
1. Stakeholder involvement is critical to developing a coordinated plan.

2. Preestablished working relationships with response partners are critical to an effective response.
3. Space to screen/triage/quarantine large numbers of passengers on airport grounds is limited.
4. It takes the full spectrum of stakeholders to respond effectively to an incident with a highly
infectious disease and a large number of potential exposures.
5. Notification of ill persons on aircraft does not always follow the identified communication
channels.
6. Notification of ill persons on aircraft typically is short notice.
7. Information about ill persons typically is limited.
Greatest Challenge
“Our biggest challenge was avoiding miscommunication. We know that when there are numerous
work groups involved in a possible communicable disease type event response, things can easily
go sideways quickly. The outcome could cause major airport and airline operational disruptions.
Therefore, we made sure our established protocols were followed and communicated accurately.
This included making sure the flight crew knew the event was not deemed serious enough by public
health officials to isolate the aircraft” (C. Rausch, e-mail, February 20, 2017).
Bottom Line
Phoenix Sky Harbor International Airport respondents estimated the airport’s level of overall pre-
paredness to deal with a communicable disease on an arriving flight as “very prepared” but reported
there is still room for growth.
The Maricopa County Department of Public Health respondents estimated the agency’s level of
overall preparedness to deal with a communicable disease on an arriving flight as “very prepared”
but reported there is still room for growth.
The conversation during the interview showed how closely the airport and the health department
work together and how well they understand each other’s needs and capabilities.
Case 3: Portland International Airport and Measles (2014)
Thanks to immunization, measles has become a rare disease in North America, but as with other
vaccine-preventable illnesses, it has been making a comeback in recent years because of rising
rates of vaccine hesitancy. Measles remains a common childhood disease in other parts of the
world. For example, in the Philippines, more than 15,000 suspected cases of measles were reported

34
in 2014. By the end of the first quarter of that year, 13 U.S. travelers, most of them unvaccinated
children younger than 2, had been sickened by this highly contagious disease after returning home
from the Philippines.
On March 31, 2014, Multnomah County (Oregon) Health Authorities reported that an unvaccinated
infant who recently traveled to Vietnam and passed through Portland International Airport (PDX) on
March 24 had received a diagnosis of measles. The child was treated at a local primary care clinic,
where additional patient exposure may have occurred.
Portland International Airport became involved through the epidemiological efforts of the county
health department. The health department did contact tracing, working backward on a time line
anchored in the passenger’s disembarkation time and gate. The airport and health department were
able to use the airport’s closed circuit television monitoring system to track the passenger through
the terminal and identify potential social contacts. Such tracking also allowed the health department
to evaluate risk to airport employees, tenants, and other passengers. Portland International worked
with the airline to obtain flight manifests and other information on passengers, and the health depart-
ment contacted adjacent passengers on the flight.
The airport had previous experience with potential measles exposure. In April 2008, airport offi-
cials announced that an unvaccinated female passenger in her 20s had traveled on Northwest Airlines
Flight 33 from Amsterdam to Seattle–Tacoma International Airport, where she then connected to
Portland, where she may have spread the disease to fellow passengers before returning to Amsterdam
by the same route 3 days later. Although she experienced symptoms while in the United States, her
diagnosis of measles was not confirmed until after she returned to the Netherlands.
This case example is based on the survey results from Portland International Airport and the
Multnomah County Health Department and a telephone interview on December 5, 2016. Portland
International Airport is the 30th busiest airport in the United States, 34th busiest in North America,
and 120th busiest in the world, having served 16,850,952 passengers in 2015. In 2015, Portland
Airport had 218,021 total aircraft movements (ranking 92nd in the world, 40th in North America,
and 36th in the United States) and handled 216,187 metric tons of cargo (ranking 95th in the world,
26th in North America, and 24th in the United States).
The airport is served by 16 airlines and receives nonstop flights from six cities outside the United
States and Canada (Table 15). In addition, Portland International receives charter, cargo/freight,
and corporate general aviation flights from outside the United States and Canada. The airport is
a port of entry with a resident CBP unit, but there is no CDC Quarantine Station. The airport falls
under the Quarantine Station in Seattle. In the surveys, the Portland airport and the health department
noted having dealt with or prepared to deal with SARS, H1N1, measles, Ebola, and tuberculosis in
the past 15 years.
Table 15
for Portland International Airport
East Asia 1 Tokyo
Europe 3 Amsterdam, Frankfurt, Keflavik
Caribbean, 2 Guadalajara, Puerto Vallarta
Mexico, and
Central America
Total 6
Source: Smith and Greenberg data, derived from www.flypdx.com/PDX/NonstopDestinations

(accessed Nov. 27, 2016).

35
Portland International maintains a communicable disease response plan, which is a stand-alone plan
referenced in the AEP. The plan was developed in 2001 after 9/11 with help from the airport’s fire
department/EMS, the Multnomah County Health Department, the Port of Portland’s Communication
Center, CDC, and the regional hospital consortium. The airport’s plan has been mostly stable since the
beginning with some expansion and was successfully used in dealing with SARS in 2003 and H1N1 in
2009. The two most significant revisions to the plan were occasioned by changes to how information
regarding an incoming passenger will reach the airport.
Portland International’s plan specifies roles and responsibilities for standardized response proto-
cols for several communicable disease situations. The plan’s stability and durability largely result
from its flexibility and are based on the strong relationship that has been established among the
response partners. Each case of disease response is a little different. The established relationships
allow the plan’s standardized protocols to be flexed.
The airport’s response plan was developed by a group of stakeholders; changes and updates to the
plan are communicated using in-person meetings and exercises. Table 16 compares the stakeholder
lists given by the airport and the health department.
The Portland airport’s plan incorporates NIMS and ICS, differentiates how to handle passengers
from flight crews, and includes provisions for diverting flights to other airports. Although the plan is
reflected in the airport’s crisis communications and business recovery plans, it is not identified in the
Port’s human resources policies. No part of the plan is SSI.
The airport performs regularly scheduled reviews and updates of the communicable disease
response plan, but the health department does not schedule reviews of the airport’s plan. However,
the health department participates in reviews and updates when the airport requests.
The Multnomah County Health Department provides the following services at Portland International
Airport related to communicable disease responses:
• Serving as medical SME;

• Liaising with state health department/CDC as needed to identify a disease agent and arrange
for laboratory testing;
• Providing guidance regarding appropriate PPE and infection control measures;
individuals; and
If there is a surge in demand for these services, the health department activates its Incident Man-
agement Team, which coordinates with the Port of Portland, fire department, and EMS resources to
handle the additional demand for services.
Portland International has several real-world events each year that allow the review of protocols and
training on the plan. In addition, the airport carries out regular tabletop and review sessions with
stakeholders and public health partners. The training and exercises are evaluated using real-world
observation and feedback confirming the effective and efficient practices of responders. The same
methods are applied to all actual incidents. The airport performs an AAR on every drill and incident.
The most recent airport communicable disease drill or exercise was in 2016, and the most recent drill

36
Table 16
Process at Portland International Airport
Health
Stakeholder Airport
Department
Airport senior management
Airport planning X
Airport law enforcement X
Airport maintenance
Airlines, air cargo companies, charter operators, and air X

taxi operators
Concessionaires X
State health department X X
TSA X X
CBP X
FAA
Nonairport law enforcement X
State agencies
Local agencies X
Hospitals and clinics X
Ambulances/medical transport services X
HAZMAT—local fire department
State emergency management

37
in which the health department participated was in 2014. The airport drills on communicable disease
response at least every 2 years, but it also schedules a drill or exercise when regulatory requirements
change; new procedures are introduced; or when the airport authority becomes aware of a new threat,
such as a novel influenza or other communicable illness. Drills and exercises can also occur upon
request from an airline partner or other stakeholder, or can be substituted for real-world incidents
that require a fully tested response.
The health department adds validation of plan revisions and when requested by the CDC Quaran-
tine Station to this list.
Portland International reports the ideal would be to have at least one communicable disease
response drill or exercise each year, whereas the health department reports wanting to see drills or
exercises once every 2 to 5 years.
The airport provides a number of protective measures for airport employees, including training,
PPE, and life-saving medications for Port of Portland employees and their families; the medications
are delivered through the airport’s point of dispensing.
Communications
The Port of Portland is an essential bridge between the health department and airlines and tenants.
Before any health department releases any information to the public, the health departments contact
the airport so that the airport PIO can get involved. For significant incidents, a JIC speaks with a
single voice for the airport, health department, and other stakeholders. The JIC is a central asset in
making the Portland International Airport plan work.
Greatest Worry
In the interview, the health department and the airport responders had different answers to the ques-
tion of what constitutes their greatest worry. The Multnomah County Health Department respondents
said they did not have a great worry because there is a good plan and a good organization based on
strong relationships. However, measles is a serious concern because of vaccine-hesitant populations,
particularly in Europe and Oregon, where the 2013 childhood immunization rate for the measles,
mumps, and rubella vaccine was 89.4%, which is nearly 6% lower than the 95% rate required for
herd immunity and approximately 2% lower than the U.S. National Immunization Survey rate (it
also represents a decline of almost 4% from 2008). This concern is greater than the fear of exotic
illnesses that basically are unknown.
The Portland airport respondents’ greatest worry is airborne illnesses, particularly influenza viruses.
The airport has had to deal with employees’ concerns about real-world exposure versus perceived
threats. This was a major issue among airport and aircraft cleaners. Portland International has dealt
with this worry by expanding its plan for airport employees and other tenants. The role of information
is central; the airport has worked on health-risk messaging internally and externally, using seminars
and tabletop exercises to communicate safeguards and procedures.
Lessons Learned
Portland International Airport reported:
1. If time allows, ensure that all the key pieces of information about the patient have been put
together to formulate the most effective response once the aircraft lands. It is possible to link
local fire department and EMS services with MedLink while the aircraft is airborne to discuss
the medical condition.
2. Get to know your local EMS director and public health partners before an incident. They are
a valuable resource; this includes getting to know their media relations team.
3. There are a lot of assumptions and misinformation about communicable disease; passengers
want information. Ensure someone on your team is prepared to provide basic information about
what is happening and what the passengers can expect.
38
Multnomah County Health Department reported:
1. There are a lot of regulations (federal, airline, port, first responder) that come together at an
airport.
2. The Port of Portland is well structured to handle emergencies; the agency has its own prepared-
ness planners, public information officers, fire and rescue teams, and law enforcement.
3. There is an existing medical support system for planes in flight, and multiple points exist for
connecting with CDC Quarantine Station.
4. It is essential to have a plan and clear points of contact for communications.
5. Port of Portland fire and rescue teams and EMS are fantastic partners.
6. Having a good and professional local plan can meet local needs when Seattle Quarantine
Station is overwhelmed during a national response.
Greatest Challenge
“PR management—if the airport is not involved in the response initially, and a media release goes
out about the ‘measles case’ flying through the airport, then we are in mitigate/reaction mode trying
to quell the fears of the traveling public and our airport employees,” (K. Nobel, personal communica-
tion, February 17, 2017).
Bottom Line
Portland International’s respondent estimated the level of overall preparedness to deal with a com-
municable disease on an arriving flight as “very prepared.” The Multnomah County Health Depart-
ment respondents estimated the level of overall preparedness to deal with a communicable disease
on an arriving flight as “very prepared.”
The conversation during the interview showed how closely the airport and the health department
work together and how well they understand each other’s needs and capabilities. Portland Interna-
tional Airport and its partners have had direct experience with a passenger becoming ill at home after
passing through the airport.
Case 4: Dallas/Fort Worth International Airport and Ebola (2014)
After raging through western Africa, Ebola virus arrived in the United States on September 20, 2014,
when United Flight 822, carrying Liberian national Thomas Eric Duncan, touched down at Dallas/
Fort Worth International Airport (DFW). Mr. Duncan had traveled to Dallas from Monrovia, by
way of Brussels and Washington, D.C., to visit his fiancé and the mother of his 19-year-old son. He
did not realize it at the time of his departure, but Mr. Duncan had become infected with the deadly
virus, which he contracted from his landlord’s daughter in Liberia, whom he had helped carry to the
hospital when she became ill. Although Mr. Duncan might have known that he had been exposed,
his symptoms were not evident before or during his flight.
Within days of his arrival, Mr. Duncan began to experience some of Ebola’s telltale signs: headache,
nausea, and a temperature of 103 degrees. Arriving on his own accord at Texas Health Presbyterian
Hospital, one of the region’s largest medical facilities, he was seen by a physician who provided a
prescription for antibiotics and recommended several days of rest. Although the attending physician
knew that Mr. Duncan had recently traveled to the United States from Liberia, the possibility of an
Ebola infection had not occurred to the physician. Mr. Duncan’s condition began to decline rapidly
over the next few days, until he returned to the hospital. This time, an intake nurse, realizing his path
of travel, notified Dallas County Public Health’s epidemiology department to warn of a possible
domestic case of Ebola.
In its detailed account of America’s harrowing experience with its first Ebola case, Vanity Fair
(Burrough 2015) described a series of breakdowns in communicable disease planning and response.
The article alleged that the city of Dallas had no real plan to handle the outbreak and suggested the

39
federal government was equally unprepared. When calls were placed to the CDC, the agency report-
edly did not initially consider Mr. Duncan a likely Ebola victim. Perhaps numbed to the “Ebolanoia”
that had seized much of the U.S. media at the time, the CDC reportedly advised against any testing:
“There was no indication he’d been to a funeral, no evidence he’d eaten bushmeat, no evidence
of Ebola exposure. All he was was a gentleman from Liberia with a fever.” Only after local health
officials pushed for testing from the Texas Department of State Health Services was a diagnosis
confirmed (5 days later).
This case example is based on the survey results from Dallas/Fort Worth International Airport and
Tarrant County Public Health and a telephone interview on December 21, 2016.
Dallas/Fort Worth International Airport is the fourth busiest airport in North America and 10th busi-
est in the world, having served 64,074,762 passengers in 2015. In 2015, Dallas/Fort Worth Airport
had 681,261 total aircraft movements (ranking third in the world, third in North America, and third in
the United States) and handled 670,029 metric tons of cargo (ranking 40th in the world, 11th in North
America, and 11th in the United States). The airport is served by 23 airlines and receives nonstop
flights from 43 cities outside the United States and Canada (Table 17).
In addition, Dallas/Fort Worth International Airport receives charter, cargo/freights, humanitarian

support, emergency repatriation, corporate general aviation, and private (noncorporate) general avia-
tion flights from outside the United States and Canada. The airport is a port of entry with a large resi-
dent CBP contingent. Although the airport had a Quarantine Station from 2005 until 2008, it currently
is served by the Quarantine Station in Houston, Texas. All of the terminals at the airport are located in
Tarrant County, but much of the airport lies in Dallas County.
In the surveys, Dallas/Fort Worth International Airport and Tarrant County Public Health noted
having dealt with or prepared to deal with the diseases shown in Table 18 in the past 15 years.
September 11, 2001, changed all the plans for Terminal D (the airport’s new international terminal)
that was scheduled to open in 2003. Dallas/Fort Worth International Airport’s EMS Assistant Chief
Broom brought years of experience in EMS to the building of a separate quarantine space with sepa-
rate heating, ventilation, and air conditioning and negative pressure and furnishings and floor cover-
ings that allow for decontamination. The quarantine space is an unfinished in-transit lounge. The CDC
Quarantine Station staffed the space for a while (2006–2008), and a highly effective quarantine offi-
cer brought public health and airport stakeholders together. Monthly disease-related meetings (with
personnel from four counties plus the airport) in the airport’s emergency operations center (EOC) built
relationships and allowed sharing of significant information.
Table 17
for Dallas/Fort Worth International Airport
East Asia 2 Seoul, Tokyo
Southwest 1 Dubai
Asia/Mideast
Europe 4 Frankfurt, London–Heathrow, Madrid, Paris
Caribbean, 28 Aguascalientes, Belize City, Cancun, Chihuahua, Cozumel, Guadalajara,
Mexico, and Guatemala City, Hermosillo, Leon/Guanajuato, Liberia, Montego Bay, Mexico
Central City, Morelia, Monterrey, Mazatlan, Nassau, Puebla, Panama City, Puerto
America Vallarta, Queretaro, Roatan, San Salvador, San Jose del Cabo, San Jose, San
Luis Potosi, Torreon, Veracruz, Zacatecas
South 7 Bogota, Caracas, Ezeiza, Lima, Rio de Janeiro, Santiago, Sao Paulo
America
Oceania 1 Brisbane
Total 43
Source: Smith and Greenberg data, derived from nonostop.com/dallas-fort-worth-dfw (accessed Nov. 27, 2016).

40
Table 18
Communicable Disease Responses or
Preparations at Dallas/Fort Worth
International Airport
Health
Disease Airport
Department
SARS X
H1N1 X
Measles X X
Tuberculosis X X
Ebola X X
Chikungunya X X
Swine flu X
Zika X X
Norovirus X
Recent Experiences
The Ebola outbreak began in West Africa (Guinea, Sierra Leone, Liberia, and Mali) in March 2014
and was declared controlled in mid-2016. By December 8, 2014, Ebola had sickened 17,000 persons
and caused 6,500 deaths. When a patient has symptoms, transmission is by direct contact with body
fluids (Broom 2014b). At the time of writing of this synthesis, there have been more than 21,000 cases
worldwide, including nearly 8,500 deaths.
Dallas/Fort Worth Airport and the Dallas area were actively involved with a response to Ebola
from August 15, 2014, when a TSA screener at the airport who had traveled to Ivory Coast arrived
at the airport, until October 28, 2014, when a third patient was discharged from the hospital and
declared Ebola-free. The entire incident is chronicled in the time line reproduced as Appendix F
(Broom 2014a). The time line shows the intense interactions among airport departments, the health
department, Dallas-area hospitals, CBP, CDC, airlines, and the media.
Federal agencies (U.S. Department of Health and Human Services-CDC and DHS) created the
plan for U.S. airports. The plan focused on
1. Transmission prevention;
2. Exit screening in West Africa;
3. Identifying ill travelers at border entries;
4. Limiting U.S. entries to designated airports where enhanced entry screening and access to spe-
cialized treatment had been established;
5. Connecting travelers with local health departments; and
6. Providing direct support to ill health care workers (Broom 2014a; CDC 2014).
The Ebola experiences caused some changes in the communicable disease plan and planning pro-
cess at Dallas/Fort Worth Airport. The frequency of meetings, training, and exercises was increased,
and these activities mostly involved EMS, medical, and public information officers. Tarrant County
Public Health is the major SME on reassurance measures for workers at the airport and procedures.
Dallas/Fort Worth Airport’s pre-2014 plan addressed the Ebola incident adequately; however, the
airport made additions to the plan to enhance screening and communications by setting up commu-
nications among airports, tracking contacts, and protecting staff and employees.
Both the airport and the health department maintain communicable disease response plans. Dallas/
Fort Worth Airport’s communicable disease response plan is part of its AEP and business continu-
41
ity plan. The plan also is incorporated into the airport’s public safety standard operating procedures
manual. The health department maintains a stand-alone communicable disease/quarantine plan.
Table 19 compares the stakeholder lists provided by Dallas/Fort Worth International Airport and
Tarrant County Public Health.
The Dallas/Fort Worth Airport plan incorporates NIMS and ICS. The airport’s plan does not
involve diverting inbound flights to other airports. Both the airport and the health department have
regularly scheduled reviews and updates for their communicable disease response plans.
Tarrant County Public Health provides the following services at Dallas/Fort Worth Airport related to
communicable disease responses:
• Liaising with state health department/CDC as needed to identify a disease agent and arrange
for laboratory testing;
disease spread);
• Providing guidance on environmental cleaning measures/waste disposal;
• Providing guidance regarding appropriate PPE and infection control measures; and
individuals.
If there is a surge at Dallas/Fort Worth Airport in demand for these services, the health agency
makes a request to the state (known as a STAR request) through the emergency management
chain as well as the state health department office. CBP has a large staff at the airport and the
adjacent foreign trade zone and can surge. CBP is the primary health screener at the airport and
has the legal authority to hold any incoming international passenger. Airport EMS and the health
department get only one opportunity to make the right decision regarding a sick passenger while
the passenger is held by CBP. CBP holds passengers long enough for the airport’s medics to
resolve the issue. If the medics cannot resolve, they call Tarrant County Public Health for advice/
help. The county agency can call on the CDC Quarantine Station for assistance, but problems
sometime arise because CDC’s on-call SME is not fully aware of the airport’s in-house capabili-
ties and introduces inefficiencies by trying to start at the beginning of a standard step-by-step
process.
Dallas/Fort Worth International Airport personnel estimate the airport has two to eight commu-
nicable disease incidents with international passengers per month. The number increases with wide-
spread media reports of an illness, which leads to greater awareness of, and sometimes excessive
anxiety regarding, potential threats.
Dallas/Fort Worth Airport trains on its communicable disease response plan using quarterly briefings
with CDC—Quarantine, CBP, and Tarrant County EMS, tabletop exercises, and AARs of all opera-
tions, with the AAR being the primary evaluation tool. The most recent exercise was in 2015, and
the next regularly scheduled drill will occur in 2017.
Dallas/Fort Worth International Airport schedules a drill or exercise
• Every 2 years;
• When personnel become aware of a new threat; and
• As part of the AAR/IP process.
42
Table 19
Process at Dallas/Fort Worth International Airport
Health
Stakeholder Airport
Department
Airport senior management X
Airport planning
Airport operations X
Airport law enforcement X
Airport training
Airport maintenance
Airport human resources X
Airlines, air cargo companies, charter operators, and air X

taxi operators
Concessionaires X
State health department X
Other public officials (elected officials, etc.) X
TSA
CBP X
FAA
National agencies
State agencies
Local agencies
Health care coalition
Ambulances/medical transport services
Medical and nursing associations and societies
County emergency management X
State emergency management X

43
In addition, a real-world incident can substitute for a drill or exercise required by regulations.
Tarrant County Public Health conducted a drill on its plan in 2016. The agency typically exercises
as a part of the AAR/IP process, but as with Dallas/Fort Worth Airport, a real-world incident can
substitute for a drill or exercise required by regulations.
The airport provides protective measures for airport employees, including training, PPE, other
equipment, vaccines, decontamination facilities, countermeasures, and medical checks.
Communications
The airport communicates its plan to stakeholders by sharing copies, doing exercises, and inviting
feedback to be used in updating the plan. Tarrant County Emergency Management communicates the
county’s plan to stakeholders at the airport. The plan is also distributed through regional emergency
management agencies.
Dallas/Fort Worth Airport no longer has monthly meetings in its EOC with the four surrounding
counties (Tarrant, Dallas, Collin, and Denton) as it did before 2010. However, under Texas law, each
EMS provider is required to have an infection control officer. The Tarrant County Public Health
infection control officer is in touch with Dallas/Fort Worth Airport on an average of once a week, but
the actual frequency varies according to the cyclical nature of health risks and when they present for
attention and response.
One communications method that may be unique to Dallas/Fort Worth Airport involves the pro-
cedure when a new foreign-flag carrier commences operations at the airport. The airline’s station
manager meets with the airport’s public safety and EMS managers and experts to review policies and
procedures for a crash, irregular operations, and communicable diseases. The meeting is followed
that day by a communicable disease tabletop exercise.
Greatest Worry
The Tarrant County Public Health respondents indicated their greatest worry is an airborne disease
such as measles or MERS-CoV. The Dallas/Fort Worth Airport respondents reported worrying that
a patient who has no symptoms but has a contagious disease will pass through and unknowingly
transmit the illness to others. Both the airport and the health department are confident that if they
receive timely information on symptoms, they will secure a good outcome. Airport respondents
would like to see future research leading to better use of emerging communications networks in
rapidly evolving situations—getting the right people to understand what is important or what is not.
Respondents reported that once a situation starts going downhill, it won’t stop going downhill until
it hits the bottom.
Lessons Learned
Dallas/Fort Worth International Airport reported:
1. Prearrival information is suspect and must be verified in person by a competent responder.

2. When dealing with nonmedical or nonpublic safety individuals—that is, when dealing with
the general public, airport employees, and airport business partners—use clear, plain language
and anticipate that deeper explanations will be needed.
3. Be sure to take care of the caregivers.
Tarrant County Public Health reported:
1. Review existing guidelines and determine if additional information can be shared with area
hospitals.
2. Discuss concerns associated with transportation of confirmed or suspected cases.

44
3. Discuss contamination risks and decontamination procedures faced by first responders, public
health, and medical care professionals in the prehospital environment.
4. Ensure communications from airlines to initial response partners occur in a timely manner.
5. Coordinate illness response procedures for Dallas/Fort Worth International Airport and state
response partners.
6. Once on scene, provide initial and ongoing emergency medical coordination.
Greatest Challenge
“Once the initial announcement was made, the communication challenge became one of educating
decision makers in real time. Most executive-level staff do not contemplate communicable diseases
regularly. They need as many hard facts as can be discerned without speculation. This was not a
single episode but an ongoing process” (F. Broom, personal communications, February 28, 2017).
Bottom Line
Dallas/Fort Worth International Airport respondents estimated the airport’s level of overall prepared-
ness to deal with a communicable disease on an arriving flight as “very prepared.” Tarrant County
Public Health respondents estimated the agency’s level of overall preparedness to deal with a com-
municable disease on an arriving flight as “very prepared.”
Case 5: Boston Logan International Airport

and Five Suspected Ebola Cases (2014)
Boston Logan International Airport (BOS) is the 17th busiest airport in the United States and the
19th busiest in North America, having served more than 33 million passengers in 2015. In 2015,
BOS had 372,928 total aircraft movements and handled 684,970 tons of cargo. Served by 40 air-
lines, BOS receives nonstop flights from 48 cities outside the United States and Canada (Table 20).
Its sponsor, the Massachusetts Port Authority (Massport) also operates Worcester Regional Airport
and Hanscom Field.
This case example was added at the request of the topic panel after the airport and local public
health department surveys had been completed, so Boston Logan International Airport and the Boston
Public Health Commission (BPHC) do not have survey results included in this study.
On Monday, October 13, 2014, Boston Logan International Airport was alerted by ATC Boston,
MedLink, and the airline that Emirates Flight 237, a Boeing 777 carrying 187 passengers and 19 crew,
would arrive in 15 minutes with five passengers on board who were coughing, vomiting, and had
Table 20
for Boston Logan International Airport (as of June 2016)
Europe 20 Amsterdam, Cologne, Copenhagen, Düsseldorf, Frankfurt, Istanbul, Lisbon,
London—Gatwick, London—Heathrow, Madrid, Manchester, Munich, Oslo,
Paris, Ponta Delgada, Reykjavik, Rome, Shannon, Terceira, Zurich
Caribbean, 21 Aruba, Bermuda, Bridgetown, Cancun, Fort de France, Grand Cayman,
Mexico, and Guadeloupe, Liberia (CR), Mexico City, Montego Bay, Nassau, Panama City,
Central Pointe-â-Pitre, Port-au-Prince, Providenciales, Puerto Plata, Punta Cana,
America Santiago (DR), Santo Domingo, St. Lucia, St. Maarten
Middle East 3 Doha, Dubai, Tel Aviv
East Asia 4 Beijing, Hong Kong, Shanghai, Tokyo
Total 48
Source: Smith and Greenberg data, derived from www.massport.com/logan-airport (accessed Feb. 28, 2017).

45
fever, all of which are symptoms of Ebola infection (Massport 2014; Tradani and Feathers 2014). At
2:27 p.m., Massport Fire Rescue dispatched equipment that was in position at Terminal E Gate 6
when the plane arrived. Massport Fire Rescue (“Fire Alarm”) notified BPHC and the CDC quaran-
tine station located at JFK. At 2:55 p.m., Boston EMS arrived at Gate 6. A unified command had
been established with Boston EMS/Supervisor, Massachusetts State Police, CBP, airport operations,
and Emirates. The jet bridge was not connected to the plane, and the plane’s doors were not opened,
which effectively put the plane into isolation (R. Barnes, personal communication, February 28, 2017).
The unified command in Terminal E established contact with the pilot and determined that the
five passengers had high fever and had been in contact with persons from Western Africa while
traveling. The five passengers had traveled in seats scattered throughout the plane. The airline pro-
vided passenger information. An incident command post was established at Gate 6 and manned by
four firefighters led by an assistant. An incident action plan was formulated to enter the aircraft and
perform patient assessment and removal. Boston EMS recommended transportation to a hospital.
Hot/warm/cold zones were set up. Using universal precautions (with PPE), the team entered the
plane, and two Boston EMS ambulances were readied for transport. Bleach spray decontamination
was set up, a backup team was positioned, and a safety officer designated. PPE was provided to law
enforcement officers (Massport 2014).
At 3:37 p.m., the team entered the plane to assess the five patients, each of whom was placed
in protective ensemble and removed from the aircraft. The final patient was removed by 4:35 p.m.
Decontamination was performed on the entry team and their PPE, and cleaning materials were
placed in an infectious contents box. The three fire engine crews cleared the scene and returned
to their stations. The unified command was terminated (Massport 2014; R. Barnes, personal com-
munication, February 28, 2017).
The five travelers suspected of having Ebola were transported to two area hospitals for evalu-
ation and diagnosis. By late in the evening, BPHC announced that there appeared to be no Ebola
infection (Tradani and Feathers 2014). The five passengers also were found to not have MERS-CoV,
meningococcal infection, or any other disease of public health concern (Al Arabiya 2014).
At the airport, the entire incident, from alert to stand-down, lasted less than 3 hours, and the inci-
dent, including patient assessment in the hospitals, lasted less than 6 hours. Airport operations were
not significantly disrupted. The short duration, effectiveness of the response, and positive outcomes
for the other passengers on the plane and at the airport appear to have been the result of smoothly
coordinated action based on joint planning, training, and practice among the airport, the local public
health department (BPHC), the state police, and other stakeholders (R. Barnes, personal communica-
tion, February 28, 2017).
Greatest Challenge
“Our biggest challenge was equipping all first responders—fire, State Police and U.S. Customs with
proper PPE. And maintaining the ‘hot zone’ approach to a possible infectious disease approach is
always a top priority. We also had to formulate a proper decontamination procedure. Our second big-
gest challenge was relaying accurate and timely information to our PIO–Massport Media Relations.
In the end, this was done with face to face communications” (R. Barnes, personal communications,
February 28, 2017).
Case 6: Vancouver International Airport and H7N9 (2015)
“There is no doubt. [H7N9] is by far the most worrisome strain [of influenza]. We don’t know what
the reservoir is very well, there’s a bunch of things we don’t know about it and it’s causing a lot of
very, very severe illness” (Dr. Michael Gardam, Director of Infection Prevention and Control, Uni-
versity Health Network, Toronto).

46
On January 26, 2015, North America’s first documented case of H7N9 avian influenza was con-
firmed when a Chinese national living in British Columbia’s Lower Mainland became sick after return-
ing from a trip to China, where she was infected with the virus. Although the risk to other Canadians
was considered low because there is no evidence that H7N9 transmits easily from person to person
(its primary vector of transmission is from infected poultry to humans), passengers aboard Air Canada
Flight 8, which arrived in Vancouver from Beijing, were notified of their possible exposure by PHAC.
This was not the airport’s first experience with a deadly avian influenza. On January 8, 2014,
Canada’s Health Minister Rona Ambrose (now interim leader of Her Majesty’s Loyal Opposition)
announced that an Alberta resident, returning to Canada on December 27, 2013, aboard Air Canada
Flight 030, had fallen ill en route from Beijing to Vancouver, where she waited for more than 2 hours
before boarding Air Canada Flight 244 to Edmonton. The passenger eventually died of her disease
on January 3, 2014. The illness was identified as H5N1 influenza (Vancity Buzz 2014). As with the
more recent H7N9 case, PHAC took the lead in identifying and notifying passengers on both flights
and used contact tracing to notify possible airline passengers who may have been exposed at the gates
and other waiting areas.
This case example is based on the survey results from Vancouver International Airport (YVR)
and the PHAC (Western Region) and a telephone interview on December 2, 2016. Vancouver Inter-
national Airport is the second busiest airport in Canada and the 29th busiest in North America. The
airport served 20,486,935 passengers in 2015. In 2015, Vancouver Airport had 316,182 total aircraft
movements (ranking 43rd in the world, 23rd in North America, and second in Canada) and handled
271,772 metric tons of cargo (ranking 84th in the world, 17th in North America, and second in
Canada). The airport is served by 48 airlines and receives nonstop flights from 38 cities outside the
United States and Canada (Table 21).
In addition, Vancouver Airport receives charter, cargo/freight, industrial aviation (aircraft deliveries;
maintenance and repair operations), humanitarian support (refugee flights), corporate general aviation,
and private (noncorporate) general aviation flights from outside the United States and Canada. The
airport is a port of entry with a resident PHAC quarantine station and a large resident CBSA unit.
In the surveys, Vancouver Airport and PHAC Western respondents reported having dealt with or
prepared to deal with the diseases shown in Table 22 in the past 15 years.
Recent Experiences
Vancouver Airport and PHAC Western Region have had a series of successes in applying their com-
municable disease response plans. In the past few years alone, the partnership has dealt with a pas-
Table 21
for Vancouver International Airport
East Asia 16 Beijing, Chengdu, Guangzhou, Hangzhou, Hong Kong, Kunming, Manila,
Nanjing, Osaka, Qingdao, Seoul, Shanghai, Taipei, Tokyo, Xiamen,
Zhengzhou
South Asia 1 Delhi
Europe 12 Amsterdam, Dublin, Frankfurt, Glasgow, London–Gatwick, London–
Heathrow, Manchester, Munich, Paris, Reykjavik, Rome, Zurich
Caribbean, 10 Cancun, Huatulco, Ixtapa, Manzanillo, Mazatlan, Mexico City, Puerto
Mexico, and Vallarta, San Jose del Cabo, Santa Clara, Varadero
Central
America
Oceania 3 Auckland, Brisbane, Sydney
Total 42
Source: Smith and Greenberg data, derived from www.yvr.ca (accessed Nov. 27, 2016).

47
Table 22
Communicable Disease Responses
or Preparations at Vancouver
Disease Airport PHAC
SARS X X
H1N1 X X
Measles X X
Tuberculosis X X
Ebola X X
Chikungunya X
Zika X X
Dengue X
H5N1 influenza X X
Norovirus X X
Cholera X
Anthrax X
senger with H5N1 influenza and one with H7N9 influenza, another who arrived with untreated TB,
and an outgoing sick 3-year-old child.
The influenza cases were summarized earlier. The incident involving the sick child illustrates the
major benefits of having a good plan and a strong, well-practiced partnership. After the plane of a
foreign-flag carrier pushed back from the gate, the child became ill with fever and rash, appearing
to be clinical. The pilot was not fully aware of the proper procedures under ICAO Document 4444,
but the ATC tower and Vancouver Airport personnel knew what to do. The collaborative response
was timely and effective because of the ongoing relationship building and “testing” of the plan. Per-
sonnel of Vancouver Airport, ATC, PHAC, the local health department, EMS, ambulance services,
CBSA, and CTSA convene several times during the year, which creates cohesiveness and prepared-
ness. Having one clear point of contact with the local health department sped the response and
resolution in this particular case—the child had varicella (chickenpox), which is a communicable
illness but does not pose a serious public health threat. The total delay for the plane’s departure was
about 20 minutes.
Vancouver Airport also has experience in preparing for and responding to Ebola. In early 2014,
public fear about the illness complicated all aspects of communicable disease preparedness and
response. A young student arriving to Canada from West Africa by way of Toronto Pearson Inter
national Airport and continuing to a small airport in British Columbia became ill on the domestic
flight between Toronto and Vancouver. The PHAC quarantine officer at Vancouver Airport had no
jurisdiction under the Quarantine Act because the passenger became ill during a domestic flight but
provided a professional opinion when asked by the medical director of the local health department.
The local health department and Vancouver Airport took the lead in the response with PHAC advis-
ing, all in a highly collaborative approach. Disruption of the plane’s arrival totaled 10 minutes.
From SARS in 2003 to the present, the trajectory of communicable disease planning at Vancou-
ver Airport and PHAC has been toward increasing a focus on prevention to avoid extra work and
costs of epidemiological investigations and follow-up. Vancouver Airport and PHAC have evolving
communicable disease planning documents because both are committed to continuous improve-
ment. Training expands each year. For example, in early December 2016, PHAC hosted a tabletop
exercise derived from the AARs on recent communicable disease incidents. Forty participants from
stakeholders built relationships and learned policies and procedures, and the participants provided
feedback to improve the PHAC and Vancouver Airport plans.

48
Vancouver Airport maintains an airport pandemic plan that includes
• Communicable disease plan,

• Communicable disease response plan,
• Business continuity plan, and
• Quarantine plan.
The pandemic plan and its component plans are part of the AEP and a part of the airport’s busi-
ness continuity plan. The plan is communicated to other stakeholders through regular meetings of
the Airport Emergency Planning Committee, tabletop exercises, and live (full-scale or functional)
exercises with stakeholders. No part of Vancouver Airport’s plan contains SSI. The plan is reflected
in the airport’s crisis communications plan and its business recovery plan, and is identified in the
airport management’s risk profile and its human resources policies. The plan does not differentiate
how to handle passengers from how to handle flight crews. The airport updates the plan on a regular
schedule and when changes are indicated by the AAR of an incident or exercise. CBSA at Vancouver
Airport has its own communicable disease/quarantine plan.
PHAC Western Region maintains a separate communicable disease/quarantine plan that is shared
with all stakeholders (including the airport) for input and review. PHAC does ongoing presentations
that include scenarios based on actual incidents with the various agencies. The close working rela-
tionship and frequent interactions between PHAC and Vancouver Airport make the two plans highly
congruent. The PHAC plan is reviewed on a regular basis and when an AAR indicates a change is
needed. The local health departments are fully engaged in the process; their functions in patient
transport, EMS, and making hospital arrangements are fully reflected in both plans. Table 23 com-
pares the stakeholder lists given by Vancouver Airport and PHAC Western Region.
The Vancouver Airport plan does not incorporate NIMS but is based on ICS structures and
procedures. The airport’s plan does not involve diverting inbound flights to other airports.
PHAC provides the following services at Vancouver Airport related to communicable disease responses:
disease spread);
• Providing guidance on environmental cleaning measures/waste disposal; and
In addition, PHAC Western Region respondents indicated in the interview that the agency works
closely with the local health department to provide other services to Vancouver Airport. See the Toronto
Pearson International Airport case example for a list of these additional services.
If there is a surge at Vancouver Airport in demand for these services, PHAC’s adjustment will
depend on the size of the incident. Initially, PHAC Western Region can move staff to assist other
stations; however, if such action is not sufficient, PHAC Western Region can request PHAC head-
quarters assist by sending more surge capacity staff, such as environmental health officers or nurses
who have had training and enhance that training on the ground with existing quarantine officers.
Vancouver Airport and PHAC—and their stakeholder partners—train jointly on the airport com-
municable disease response plan. Both recommend annual drills. The most recent drill was in 2015.

49
Table 23
Stakeholders Involved in Communicable Disease
Planning Process at Vancouver International Airport
Stakeholder Airport PHAC

Airport planning X X
Airport law enforcement X X
Airport training X
Airport maintenance X
Airport human resources X

taxi operators
Concessionaires X
Caterers X
Airport sponsor/certificate holder X
Local health department
Provincial health department X
PHAC—quarantine station X X
Transport Canada/Nav Canada X
CATSA X
CBSA X X
Military (airport is joint use) X
Red Cross X
Transport Canada X
National agencies X
Provincial agencies X
Local agencies X

Ambulances/medical transport services X X
HAZMAT contractors X
City emergency management X
Provincial emergency management

50
Vancouver Airport schedules a classroom session, seminar drill, tabletop exercise, functional
exercise, or live exercise
1. Monthly (seminars, tabletop exercises);

2. Annually (live, full-scale);
3. When regulatory requirements change;
4. When new procedures are introduced;
5. When personnel become aware of a new threat;
6. To validate plan revisions; and
7. As part of the AAR/IP process.
A real-world incident can substitute for a drill or exercise required by regulations.
PHAC schedules a drill or exercise
• Annually;
• When the airport requests the agency lead an exercise;
• When personnel become aware of a new threat; and
• To validate plan revisions.
An AAR is performed after every drill, exercise, or real incident. This is a written requirement of the
airport’s emergency plan.
The airport provides a number of protective measures for its employees, including training, PPE,
other clothing, equipment, vaccines, decontamination facilities, and medical checks and counseling
services.
Communications
The most important communications link is that between PHAC Western Region and the Vancouver
Airport emergency planning manager. Phone calls and e-mails are used when either partner becomes
aware of a threat or a need to activate the plan. Vancouver Airport’s plan takes into account the pos-
sibility of a passenger posting information on a possible illness from a flight that is in the air—the
airport had this happen around 2010, which triggered its intensive efforts to implement social listen-
ing for emergency management.
Greatest Worry
In the interview for this synthesis, Vancouver Airport and PHAC personnel raised two specific wor-
ries. Both worry about the potential of a major incident occurring on a plane in flight, with the airport
and PHAC being unable to respond in time. Security rules are changing and may not be uniform from
airport to airport. Rules can delay access to a plane to attend to an ill person by as much as 20 minutes.
CATSA recognizes EMS personnel as emergency responders and lets them pass immediately, but
CATSA does not consistently recognize public health (quarantine) staff as having an urgent need for
access to secure areas and a plane when a communicable disease is reported aboard.
Vancouver Airport and PHAC personnel also worry about an undetected communicable disease
getting passed to other passengers and airport employees with the result that enough airport employ-
ees become ill that the airport’s business is affected. Many measures are available to the airport and
PHAC when a communicable disease is known or suspected on an arriving flight. The worst case
would be a pandemic with staff affected by fear or illness.
Lessons Learned
Vancouver Airport reported:
1. Communication across the breadth of stakeholders is fundamental to the success of the plan
but is difficult to do well consistently because of changing personnel and skill levels.
51
2. A clear point of contact (leadership) to liaise with stakeholders and health authorities is needed.
3. An effective training program and protocols for frontline staff are fundamental to a successful
response.
PHAC reported:
1. Gathering and validating information is crucial.

2. Communication with partners is important and can mitigate many challenges, including anxi-
ety if all on the ground are well versed with information and the plan of action because PHAC
personnel usually are first to board the conveyance.
3. Communication with headquarters is vital in the event information is sent to headquarters by
a different source.
4. Proper PPE is needed.
5. It is important to ensure before response that everyone is well versed with the plan so that dur-
ing response the agency has one channel of communication with all stakeholders, including
with the traveler.
6. It is important for everyone on board to remain seated until the assessment is fully conducted
and to reassure and communicate with travelers if necessary.
7. It is important to gather proper information from the traveler to take action if needed.
8. To reduce traveler anxiety, provide information to the traveler as to why personnel are asking
questions.
9. Communicate decisions to the director of the flight and all other partners as required.
Greatest Challenge
“We learned from dealing with the potential impact of H1N1 the following two challenges:
1. Effectively getting all the agencies at the airport aligned with their prevention procedures and
processes.
2. Determining and then mitigating the potential impact on the overall operation if a large num-
ber of personnel within one or more agencies become afflicted” (C. Currie, personal commu-
nication, February 20, 2017).
Bottom Line
Vancouver Airport personnel estimated the level of overall preparedness to deal with a communicable
disease on an arriving flight as “very prepared,” with a need to improve drill and exercise frequency
and gain ability to deal with communicable diseases on domestic flights. PHAC personnel estimated
the level of overall preparedness to deal with a communicable disease on an arriving flight as “some-
what prepared.” This response results from concerns about surge capacity/coordination. Surge capacity/
coordination may be an issue depending on the time of day and day of the week. It may be difficult to
mobilize resources because of a lack of capacity. The alternative is to work with what PHAC has on
the ground in terms of other key partners, which makes remote response protocols become paramount.
For this reason, practicing protocols with other agencies may be needed more frequently than is done
currently. During the interview, PHAC and Vancouver Airport personnel concurred that the level of
preparedness at the airport reaches “very prepared” for communicable disease response.
The conversation during the interview clearly showed how closely the airport and PHAC per-
sonnel work together and how well they understand each other’s needs and capabilities. Vancouver
Airport and its partners have had direct experience with a passenger getting sick on a flight; a pas-
senger getting sick embarking or disembarking at the airport; and a passenger getting sick at home
after passing through the airport (the H5N1 case is an example).
Summary of Common Themes from Case Examples
Table 24 shows the common themes in the answers provided by the six airports that served as case
examples. All six airports had the benefit of 2 to 14 years’ experience since their reported incident
to revise and improve their preparedness. Table 24 indicates current status and cannot be analyzed
52
Table 24
Common Themes in Case Examples
YYZ PHX PDX DFW BOS YVR
Disease Incident SARS TB Measles Ebola Suspected Ebola H5N9 influenza
Year 2003 2013 March 2014 September 2014 October 2014 2015
Common Themes
Scenario(s) 3 1a 3 3 1 3
How airport learned ATC, MedLink,
LHD/PHAC LHD network LHD CDC/LHD LHD, PHAC
of ill passenger airline
Main airport role EMS services;
Assist LHD in
Assist LHD in report symptoms;
epidemiology, Assist LHD in Assist LHD in Assist LHD in
epidemiology; care liaison with LHD;
screening incoming epidemiology epidemiology epidemiology
to caregivers liaison with pilot;
passengers
isolation of plane
Isolation used in
Nob No No Yes Yes No
response at airport
Quarantine used in
No No No No No No
response at airport
Specific airports
designated as points
of entry for
enhanced screening No No No Yes No No
of passengers from
affected countries or
areas
Main LHD role SME, SME, SME, SME,
epidemiology, epidemiology, epidemiology, SME, medical SME, medical epidemiology,
medical medical medical coordination, PIO coordination, PIO medical
coordination, PIO coordination, PIO coordination, PIO coordination, PIO
CDC/PHAC used as
Yes Yes Yes Yes Yes Yes
resource
Airport EOC
? No No Yes Yes No
activated
NIMS principles
used
Mutual aid partners
in addition to LHD ? Yes No Yes Yes PHAC
involved
Social listening
No; Predates YYZ’s
(data scraping) No No No No Yes
SMEM program
applied
Social media used
by airport or by
airport/LHD No; Predates YYZ’s
Yes No Response No Yes Yes
partnership for SMEM program
notices, alerts, and
warnings
Social media
engagement with No No Response Yes Yes Yes
SMEM program
passengersc
Social media
engagement with No No Response No Yes Yes
SMEM program
public
Care for caregivers Yes Yes Yes Yes Yes Yes
Hot wash performed ? Yes Yes Yes Yes Yes

53
Table 24
(continued)
YYZ PHX PDX DFW BOS YVR
AAR performed by
airport
AAR/IP created ? Yes No Response Yes Yes Yes
Airport
communicable
disease response Yes Yes Yes Yes Yes Yes
plan reviewed after
incident
Airport
Very minor for
communicable
airport and one
disease response Major Major Major Major Major
LHD, major for
plan revised after
second LHD
incident
Revised airport
communicable
disease response
plan tested
Communicable
disease
communications
incorporated or
Yes Yes Yes Yes ? Yes
referenced in airport
crisis or emergency
communications
plan
Communicable
disease
communications
incorporated or
Unknown Yes Yes Yes ? Yes
referenced in airport
business continuity
plan and/or risk
profile
Biggest challenge to Loss of passenger Avoiding Public relations Educating PPE, Aligning
airport in response traffic, resulting in miscommunication management decision makers decontamination procedures of
revenue drop among response in real time procedures, and response partners.
partners getting accurate Business continuity
and timely info issues if many staff
to PIO infected
a
Scenario 1 (advance notification that passenger with suspected illness will arrive) was a medical diversion to BOS.
b
Isolation or quarantine is an unlikely part of airport response for a Scenario 3 incident for which epidemiology is a main response element.
c
Social media engagement means two-way conversations, not just outgoing warnings and notices or incoming data scraping results.
for temporal trends across 2003 through 2016. The data were gathered from July 2016 through
February 2017.
1. The most common and challenging communicable disease situation for an airport involves a
passenger who presents symptoms of illness after disembarking and leaving the airport but who
may have contagious disease but no symptoms during flight (Scenario 3). However, the classic
case of a suspected illness reported by the pilot of an aircraft that is en route (Scenario 1) presents
the greatest challenges to the public health community.
2. Airports and public health partners are more likely to successfully manage a communicable
disease incident if they have a long-standing working relationship and have jointly exercised
their communicable disease response plans and activities.

54
3. During communicable disease events, the designated public health partner is the lead to ensure
that the risks to the population are managed as quickly as possible. The public health partner
also is better able to describe the nature of the illness and its risk to the public through all com-
munications channels, including social media. The public health partner usually can provide an
effective public information officer.
4. Effective communication among stakeholders is vital to effective response and depends on a
combination of clearly articulated plans and personal relationships. Emergency response is a
trust-testing exercise, and trust is forged over time and between people.
5. Public health response to a communicable disease on an arriving flight (especially Scenario 1)
necessitates prior planning and coordination for access in secure areas. This may involve the
use of escorts or badges or both.
6. Both airport and public health personnel worry about their capacity to handle the surge demand
that would be placed on them in the event of a major outbreak of communicable disease, such
as a pandemic.

55
chapter five
Findings, Conclusions, and FuRther Research
Findings
Appendix G, Checklist for Airport Communicable Disease Response Planning, presents the major find
ings from the surveys, interviews, case examples, and literature review done for this synthesis. The
checklist is designed to inform the largest airports with passengers arriving on flights from out
side the United States and Canada, but it is scalable and adaptable for use by airports of all types
and sizes.
Existing Issues
Partnerships and Relationships
Strong, respectful preexisting relationships among airports, health agencies (local, state, and national),
and other mutual aid partners and stakeholders characterize effective responses to communicable
disease incidents and preparedness activities for them, including planning, training, drilling, exercis
ing, and evaluation. In such relationships, the partners understand each other’s needs, duties, respon
sibilities, capabilities, resources, strengths, and weaknesses. This allows an effective unified response
that minimizes unnecessary public alarm, operational disruption, and damaging reputational or eco
nomic consequences.
Within the framework of the preparedness and response partnership, an airport manager can stay
calm and follow the plan, thereby giving the public health and first responder experts time for evi
dence collection and fact-based decisions. Similarly, an airport emergency manager manages coordi
nation, collaboration, and communication, both outbound and incoming.
Planning and evaluation are the bookends to the process of building relationships for effective
emergency management, with response and recovery activities being those relationships in action.
Planning, training, drilling, exercising, and evaluating are productive ways to build healthy relation
ships to prepare an airport and its partners to deal with communicable diseases on arriving flights.
Planning Process
Airports and local agencies generally agree that broad-based stakeholder involvement in the plan
ning process for communicable disease response is important. This applies whether the airport and
health agencies have separate plans or share a plan. Experts from airport operations, public informa
tion, first responders, public health, airlines, and medical service providers typically are involved
in drafting airport communicable disease plans, and an even broader list of stakeholders often is
involved in reviewing the draft plan. Good plans usually incorporate schedules for periodic review
or milestones that trigger reviews or both.
Planning for communicable disease response can be a stand-alone process, part of the process to
create or update an airport emergency plan (AEP), or part of another planning process such as conti
nuity of operations planning, business continuity planning, or comprehensive crisis communications
or emergency communications planning. Increasingly, the practice is to create a stand-alone commu
nicable disease plan that is referenced in and coordinated with these other plans (Smith et al. 2016a).

56
Planning Outcomes
The ideal outcome for an effective communicable disease response plan is the one seen in Case 5,
about Boston Logan International Airport, which reports that a well-written, well-practiced plan was
carried out with the result that the incident lasted less than 3 hours, the airport’s operations were
not disrupted, and there was no panic despite the heightened tension around Ebola in October 2014.
Effective Practices
A clear consensus among airports and local health departments points to five effective practices:
1. Establishment and maintenance of healthy relationships among response partners;

2. Respect for each partner’s areas of expertise (for example, the health department as the medi
cal expert);
3. Broad involvement of stakeholders in the development of the plan;
4. Regularly scheduled joint training, drilling, and exercising; and
5. Application of a continuous improvement process that involves hot washes, after-action reviews
(AARs), and IP planning.
Plan Format Options
Provided that the plan is clear and flexible, it can take almost any form as a written document. Other
studies have found that a separate plan that is referenced in the AEP is effective and avoids the need for
FAA review each time the communicable disease response plan is revised. Regardless of the nature of
the written plan, mutual congruence with other airport plans—AEP, airport security program, airport
emergency/crisis communications plan, airport recovery plan, airport business continuity plan, airport
continuity of operations plan, airport irregular operations plan—is important.
Response Strategies and Patterns
Because any of the four scenarios can happen at an airport, the airport’s communicable disease plan
needs response strategies and patterns that can apply effectively. Clear, precise, prompt communica
tion of developments to the partners in the response is essential, as is respect for the role.
Response Triggers/Algorithms for Response
Each of the possible first points of contact (the first person at an airport to receive word of a possible
communicable disease case on an arriving flight) needs adequate training and practice on how, when,
and whom to notify to initiate response. Ideally, an airport’s plan addresses all four scenarios, and
each of the plan sections will be trained and exercised jointly with the local health department and
other response partners so that the algorithms for response become as close to automatic as possible.
The Boston Logan International Airport case example, which reports only 15 minutes’ notice of the
arrival of five possible Ebola cases on a plane with nearly 200 persons onboard, shows the impor
tance of such preparation. An essential part of the triggering phase of the response is the activation
of the emergency operations center (EOC).
Steps and Sequences
Other studies (e.g., Smith et al. 2014; Smith et al. 2016b) have shown that implementation of plans
can be enhanced by breaking the plans into standard operating procedures on cards or in electronic
forms that inform responders of their duties and the sequences of their actions.
Monitoring Response
Monitoring response and recovery is a major duty of the EOC or incident commander. For communi
cable disease incidents, a Unified Command that includes airport operations, EMS, law enforcement,
and the local health department will exercise command and control, which includes monitoring.
57
Mitigation
The key aspects for mitigating the impacts of a communicable disease incident at an airport are isola
tion, clear communications among responders and to the passengers and the public, proper personal
protective equipment (PPE) for airport responders, and a coherent decontamination strategy. Even
more, a strong training and exercise program will mitigate the impacts of an incident.
Communications Strategies
Because an airport’s business and reputation can be damaged by public perception of the effective
ness of a communicable disease response, the airport and its local health department partner can
beneficially work together to optimize the use of each other’s special knowledge and tools. This is
particularly true of communications with the general public, public officials, and airport workers.
One effective practice is to connect the airport communicable disease response plan to the airport’s
crisis communications plan and include strategies and responsibilities for using social media in the
plans (Smith et al. 2016b; Smith and Kenville in press).
Relationships with Airport Emergency Plans and Business Continuity Plans
The Toronto Pearson International Airport case example (Case 1) shows the potentially large finan
cial impacts of a communicable disease incident on an airport. Several airports noted in their survey
responses a concern with having too few workers to operate normally during an epidemic.
Evaluating and Measuring the Effectiveness of Responses
The case examples show several ways of evaluating the effectiveness of response to a communicable
disease incident:
• Extent to which public health was protected;

• Duration of operational disruption;
• Injury to the airport’s reputation; and
• Financial loss.
No metrics were found in the literature for any of these, probably because of the rarity with which
large communicable disease incidents have occurred. However, there are generally accepted ways to
evaluate and measure the effectiveness of responses:
1. Hotwash immediately after the end of the response and recovery;

2. AAR;
3. Improvement plan to create action items to correct deficiencies that were documented in
the AAR;
4. Tracking action on improvements; and
5. Consideration of how many deficiencies show up as uncorrected on subsequent AARs (Smith
2014; Smith et al. 2016a).
Major Conclusions
Recent communicable disease outbreaks and the fears they generated have caused airports and their
local public health coordinators to forge stronger relationships and engage in more joint planning
activities to protect public health and ensure business continuity. Large airports with flights arriving
from outside the United States and Canada are most affected; however, airports of all types and sizes
are increasingly aware of their need for enhanced preparedness. This heightened sense of awareness
led many airports and health departments that participated in this study to rate themselves as “some
what prepared” to respond to a communicable disease on a flight arriving at their airport. Although
many have established robust protocols to deal with prospective threats, greater awareness has led to
a rising of standards. This is reflected in the wide agreement that annual reviews and annual exercises
58
of communicable disease response plans are an ideal to be pursued, despite that fewer than 25% of
airports and barely one in five local health departments test their plans annually.
Preliminary conclusions and topics for future research were subjected to expert validation that
involved interviews with five senior health officials from U.S., Canadian, and international agencies.
The purpose of these interviews was to test the main findings and identify additional research needs.
The draft conclusions and possible future research needs shown in Appendix D-3 were provided in
advance to the five interviewees.
The lessons learned as reported in the survey responses and interviews have been consolidated
into six major thematic conclusions summarized here. In addition to being used to generate the list
of conclusions in this chapter, the entirety of lessons learned is reflected in Appendix G, especially
in the Outline for Model Airport Communicable Disease Response Plans.
This synthesis identified conclusions in six major areas:
1. Comprehensive Planning
a. Effective organizations and partnerships jointly plan to ensure airport safety, operational
continuity, and protecting public health. Airport and public health media experts need to be
involved in the plan’s development.
b. Managing isolation and containing a communicable disease incident at an airport tax scarce
resources. The challenges of isolation involve passengers, locations, duration, issuing orders,
providing basic needs for prolonged holding, legal authority, and public messaging. Space to
screen/triage/isolate large numbers of passengers on airport grounds is limited.
c. Plans need to deal with procedures by airports and public health partners to handle the surge
demand that would be placed on both in the event of a major incident with an arriving flight
or an outbreak of communicable disease, such as a pandemic.
d. Airport and public health media experts need to be involved in the plan’s development.
e. Airport communicable disease response plans work most effectively when coordinated with
the airport’s business continuity plan, AEP, recovery plan, and crisis communications plan.
2. Partnership and Stakeholder Engagement
a. If the airport’s EOC is activated, the Unified Command needs to include a public health
representative.
b. Effective practices include airports using their local public health department as a sub
ject matter expert (SME) and health-related public information expertise used early in the
response.
c. When an illness is detected on board, prearrival information is verified in person by a com
petent responder.
d. Airports and health departments broadly agree on the importance of including an array of
stakeholders in planning and generally agree on the identities of those stakeholders.
e. Airports and public health partners are more likely to manage a communicable disease
incident effectively if they have an established working relationship.
f. A conference call among the responders and key stakeholders as soon as a possible incident
is known to have occurred is highly effective for situational awareness and to clarify roles
and responsibilities.
3. Legal Issues
a. Everyone’s understanding of public health procedures, such as isolation and quarantine, is
different.
b. Many airports are concerned that they may not adequately understand their duties, responsi
bilities, and rights under laws and regulations concerning communicable disease response.
4. Strategic Communications
a. Effective communicable disease responders provide comprehensive, clear, and transparent
communication with stakeholders, the public, and media.
b. Risk communication can provide reassurance to travelers and others affected by communi
cable disease incidents.
c. Clear, coordinated, and consistent messaging is essential to protecting public health and
managing the uncertainty of the incident.

59
d. A joint information center (JIC) is helpful in effectively managing information and

communication.
e. Effective public information officers and counselors communicate with and provide sup
port to passengers, crews, and meeters and greeters.
f. Challenges in communicating with travelers who do not speak a common language or who
may have visual, auditory, or other sensorial conditions may be a barrier to communicable
disease response.
5. Exercising, Drilling, Training, and Education
a. Management of communicable disease works more effectively when public health officials
understand the operational and security needs of airports and when airport and security
managers understand the needs and processes of public health officials.
b. Airports and public health partners are more likely to manage a communicable disease inci
dent effectively if they have jointly trained, drilled, and exercised their communicable dis
ease response plans and activities.
c. Taking care of the caregivers includes providing adequate training, personal protective
equipment (PPE), medical services, and counseling as needed/required.
6. Evaluation and Continuous Improvement
a. Surveyed airports and public health partners report that AARs held after all drills, exer
cises, and real-world incidents are beneficial and need to involve the airport, public health
department/agency, and other defined stakeholders.
b. Tracking corrective actions and using AAR results allow the continuous improvement of
response plans to enhance future responses.
Further Research
The synthesis identified six areas for future research. Those areas are presented here in the form of
analytical questions.
• What procedures are in place to get prompt passenger information that is timely and complete
to the agencies that need it?
• What security issues face public health responders in an airport setting?
• What additional information on the risk of transmission of disease on aircraft and in aviation
settings is needed and how can it be obtained?
• What are the sociocultural factors that shape reaction to a communicable disease involving
aviation, and how do airports and public health stakeholders use established and emerging
media technologies to inform and engage the public as partners in response?
• What are the most effective means for communicating about communicable disease, especially
in an airport setting, to the general population and the traveling public?
• How effective are exit screening and other border exclusion strategies for protecting the public
from disease threats?

60
Glossary
After-action review A professional discussion of an event, such as a disaster exercise, conducted

during or immediately after such event.
After-action review/improvement plan An after action review with a specific plan for correcting
errors or deficiencies.
Air traffic control A service operated by the appropriate authority to promote the safe, orderly,
and expeditious flow of air traffic.
Air traffic control service ICAO term for air traffic control.
Air traffic service A generic term meaning variously flight information service, alerting service,
air traffic advisory service, air traffic control service (area control service, approach control ser-
vice, or aerodrome control service).
Aircraft rescue and firefighting Specially trained and equipped units that deal with aircraft accidents.
Airport emergency plan A concise planning document developed by the airport operator that
establishes airport operational procedures and responsibilities during various contingencies.
Airports Council International A global association representing member airports.
Business continuity plan; business continuity planning Creation of a strategy through the rec-
ognition of threats and risks facing a company, with an eye to ensure that personnel and assets are
protected and able to function in the event of a disaster.
Canada Air Transport Security Authority The Canadian Crown corporation responsible for
securing specific elements of the air transportation system, from passenger and baggage screening
to screening airport workers.
Canada Border Services Agency Agency that ensures Canada’s security and prosperity by facili-
tating and overseeing international travel and trade across Canada’s border.
Centers for Disease Control and Prevention Agency of the U.S. Department of Health and
Human Services that serves to protect the United States from health, safety, and security threats,
both foreign and domestic.
Civil Aviation Contingency Operations A division of Transport Canada and the focal point for
emergency preparedness activities. Responsible for contingency planning and occurrence report-
ing in the national and regional regulatory and operational fields of civil aviation.
Collaborative Arrangement for the Prevention and Management of Public Health Events in
Civil Aviation Voluntary effort sponsored by ICAO to bring together international, regional,
national, and local organizations to combine efforts and develop a coordinated approach to public
health risks, such as pandemics.
Communicable disease A human disease that is caused by an infectious agent or a biological

toxin, poses a risk of significant harm to public health, and is transmissible by direct contact with
an affected individual or by indirect means.
Concept of operations A user-oriented document that describes system characteristics for a pro-
posed system from the viewpoint of the user.

61
Coronavirus The type of virus that causes SARS and MERs-CoV.
Customs and Border Protection U.S. agency with the mission to safeguard the nation’s borders,
thereby protecting the public from dangerous people and materials while enhancing the nation’s
global economic competitiveness by enabling legitimate trade and travel.
Emergency medical services The treatment and transport of people in crisis health situations that
may be life threatening.
Emergency Support Functions Mechanism for grouping functions; most frequently used to pro-
vide federal support to states and federal-to-federal support, both for declared disasters and emer-
gencies under the U.S. Stafford Act and for non-Stafford Act incidents.
Enplanements An enplanement is one revenue passenger boarding an aircraft at an airport.
Epidemic An increase, often sudden, in the number of cases of a disease above what is normally
expected in that population in that area.
Federal Aviation Administration U.S. national authority with powers to regulate all aspects of
civil aviation.
General aviation All civil aviation operations other than scheduled air services and nonscheduled
air transport operations for remuneration or hire.
General aviation airport Public-use airports that do not have scheduled service or have fewer
than 2,500 annual passenger enplanements.
Health Canada The federal department responsible for helping Canadians maintain and improve
their health while respecting individual choices and circumstances.
Incident Command System A management system designed to enable effective and efficient
domestic incident management by integrating a combination of facilities, equipment, personnel,
procedures, and communications operating within a common organizational structure.
International Civil Aviation Organization The United Nations agency that develops and sug-
gests airline safety standards and practices.
International Health Regulations An international legal instrument that is binding for 196 coun-
tries across the globe, including all the member states of WHO, and that requires countries to
report certain disease outbreaks and public health events to WHO.
Isolation Separation of sick people with a contagious disease from people who are not sick.
Joint External Evaluation A voluntary, collaborative process to assess a country’s capacity under
the International Health Regulations (2005) to prevent, detect, and rapidly respond to public health
threats occurring naturally or as the result of a deliberate or accidental event.
Joint information center A location where personnel with public information responsibilities per-
form critical emergency information functions, crisis communications, and public affairs functions.
Large hub airport An airport with 1% or more of total U.S. enplanements.
Local health department The public health presence of local governments.
Local public health preparedness coordinator Qualified person who performs a variety of func-
tions in a public health preparedness program, including program coordination/management, proj-
ect management, policy and procedure development and interpretation, program development,

62
and coordinates program/project evaluation, documentation, technical assistance for and repre-
sentation of the department, and organization networking.
Medium hub airport An airport with at least 0.25% but less than 1% of total U.S. enplanements.
National Airspace System The airspace, navigation facilities, and airports of the United States
along with their associated information, services, rules, regulations, policies, procedures, person-
nel, and equipment.
National Civil Air Transportation System The Canadian equivalent of the U.S. National Air-
space System.
National Incident Management System A systematic, proactive approach to guiding departments

and agencies at all levels of government, nongovernmental organizations, and the private sector
to work together seamlessly and manage incidents involving all threats and hazards, regardless of
cause, size, location, or complexity.
National Plan of Integrated Airport Systems Program to identify existing and proposed U.S.
airports that are significant to national air transportation and thus eligible to receive federal grants
under the Airport Improvement Program.
Nonhub primary airport An airport with more than 10,000 enplanements but less than 0.05%
of total U.S. enplanements.
Pandemic An epidemic occurring worldwide or over a wide area, crossing international boundaries,
and usually affecting a large number of people.
Personal protective equipment Equipment worn to minimize exposure to hazards that cause
serious workplace injuries and illnesses.
Port [of entry] An officially designated location (seaports, airports, or land border locations)
where CBP officers or employees are assigned to accept entries of merchandise, clear passengers,
collect duties, and enforce the various provisions of CBP and related laws.
Public Health Agency of Canada The agency with the mission to promote and protect the
health of Canadians through leadership, partnership, innovation, and action in public health.
Public Health Emergency of International Concern A formal declaration by WHO. The

declaration is promulgated by that body’s Emergency Committee operating under International
Health Regulations.
Public information officer The communications coordinator or spokesperson of certain gov-

ernmental organizations (i.e., city, county, school district, state government, or police/fire
departments).
Quarantine To separate and restrict the movements of people who were exposed to a contagious
disease to see if they become sick.
Quarantine Act (Canada) The Act protects public health by taking comprehensive measures to
prevent the introduction and spread of communicable diseases. The Act authorizes the Minister of
Health to establish quarantine stations and quarantine facilities anywhere in Canada and to desig-
nate various officers, including quarantine officers, environmental health officers, and screening
officers. The Act authorizes measures that can be taken with respect of international travelers, or
other persons at an entry or departure point, who have or might have a communicable disease (one
that poses a risk of significant harm to public health). It also authorizes measures that can be taken
with respect to conveyances arriving in or departing from Canada and cargo on those conveyances
that could be the source of a communicable disease.

63
Reliever airport Airports designated by the U.S. FAA to relieve congestion at commercial service
airports and to provide improved general aviation access to the overall community.
Risk-Based Border Strategy A former CDC program to enhance the capacity of local health
departments to provide risk-based disease screening strategies to reduce the impact of pandemic
influenza and other communicable disease. The primary means of achieving this goal are to
identify, create, and expand opportunities for collaboration among federal, state, and local part-
ners to plan for, respond to, and recover from an influenza pandemic and other communicable
disease incidents.
Security Identification Display Area An area designated by an airport operator in the United
States to comply with FAA requirements directed by Federal Aviation Regulation (FAR)
Part 107.205.
Sensitive security information (SSI) Information that, if publicly released, would be detrimental
to transportation security, as defined by Federal Regulation 49 C.F.R. Part 1520.
Small hub airport An airport with at least 0.05% but less than 0.25% of total U.S. enplanements.
Social media Websites and applications that enable users to create and share content or partici-
pate in social networking.
Standard operating procedure A set of step-by-step instructions compiled by an organization

to help workers carry out operations.
Surge A sudden requirement for greatly enhanced staff size to carry out one or more aspects of an
emergency response.
Tabletop exercise An activity in which key personnel assigned emergency management roles
and responsibilities are gathered to discuss, in a nonthreatening environment, various simulated
emergency situations.
TSA An agency of the U.S. DHS that has authority over the security of the traveling public in the
United States.
U.S. Department of Health and Human Services U.S. federal agency with the mission to enhance
and protect the well-being of all Americans by providing effective health and human services and
fostering advances in medicine, public health, and social services.
U.S. Department of Homeland Security U.S. federal agency designed to protect the United
States against threats. Its wide-ranging duties include aviation security, border control, emergency
response, and cybersecurity.
World Health Organization A specialized agency of the United Nations that is concerned with
international public health.

64
Acronyms
AAR After-action review

AAR/IP After-action review/improvement plan
ACI Airports Council International
AEP Airport emergency plan
ARFF Aircraft rescue and firefighting
ATC Air traffic control
ATS Air traffic service
BOS Boston Logan International Airport
BPHC Boston Public Health Commission
CACO Civil Aviation Contingency Operations (of Transport Canada)
CAPSCA Collaborative Arrangement for the Prevention and Management of Public Health
Events in Civil Aviation
CATSA Canadian Air Transport Security Authority
CBP Customs and Border Protection
CBSA Canada Border Services Agency
CDC Centers for Disease Control and Prevention
CoV Coronavirus
DFW Dallas/Fort Worth International Airport
DHS U.S. Department of Homeland Security
ECDC European Centre for Disease Prevention and Control
EMS Emergency medical services
EOC Emergency operations center
GTAA Greater Toronto Airports Authority
H1N1 Strain of influenza
ICAO International Civil Aviation Organization
ICS Incident Command System
IHR International Health Regulations
JEE Joint External Evaluation
JIC Joint information center
LHD Local health department
MERS Middle Eastern respiratory syndrome
MOA Memorandum of agreement
NIMS National Incident Management System
PHAC Public Health Agency of Canada
PHEIC Public Health Emergency of International Concern
PIO Public information office
PPE Personal protective equipment
SARS Severe acute respiratory syndrome
SAV Staff Assistance Visit
SIDA Security Identification Display Area
SME Subject matter expert
SMEM Social Media for Emergency Management
SSI Sensitive security information
TB Tuberculosis
TPH Toronto Public Health
TTX Tabletop exercise
WHO World Health Organization

65
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69
Appendix A
Diseases of Public Health Significance
Canada
For Canada, the Quarantine Act (2005, c. 20, Sch.; 2007, c. 27, s. 4) includes a Schedule of diseases of
concern. Canada currently has 25 diseases of concern:
• Active pulmonary tuberculosis

• Anthrax
• Argentine hemorrhagic fever
• Bolivian hemorrhagic fever
• Botulism
• Brazilian hemorrhagic fever
• Cholera
• Crimean-Congo hemorrhagic fever
• Diphtheria
• Ebola hemorrhagic fever
• Lassa fever
• Marburg hemorrhagic fever
• Measles
• Meningococcal meningitis
• Meningococcemia
• Pandemic influenza type A
• Plague
• Poliomyelitis
• Rift Valley fever
• Severe acute respiratory syndrome
• Smallpox
• Tularemia
• Typhoid fever
• Venezuelan hemorrhagic fever
• Yellow fever.
If PHAC processes someone with another disease such as dengue and norovirus, PHAC would help facili-
tate the response and care through its partners (S. Jain, personal communication, Dec. 21, 2016).
United States
For the U.S., the list of quarantinable diseases is contained in Presidential Executive Order 13295 (Revised
List of Quarantinable Communicable Diseases, July 31, 2014). The quarantinable diseases for the U.S. are
• Cholera
• Diphtheria
• Infectious tuberculosis
• Plague
• Smallpox
• Yellow fever
• Viral hemorrhagic fevers (such as Marburg, Ebola, and Congo–Crimean)
• Severe acute respiratory syndromes.
Many other illnesses of public health significance, such as measles, mumps, rubella, and chicken pox,
are not contained in the list of quarantinable illnesses, but continue to pose a health risk to the public.
Quarantine Station personnel respond to reports of ill travelers aboard airplanes, ships, and at land border
crossings to make an assessment of the public health risk and initiate an appropriate response.
International—The World Health Organization (WHO)

International guidance is contained in the International Health Regulations (2005) (IHR 2005; WHO
2005). Compared with previous international health regulations, IHR 2005 moved to a process whereby
the scope was not limited to any specific disease or manner of transmission, but instead outlined processes
for reporting to WHO events that could constitute public health emergencies of international concern
(PHEIC). By not limiting the application of the IHR to specific diseases, it then would remain relevant over

70
the years and be applicable for example to emerging or novel diseases (WHO 2005, p. 1). IHR 2005 calls
for reporting as a potential PHEIC, three groups of conditions.
i. Any event of potential international public health concern, including those of unknown causes
or sources
ii. Essentially one case of the following diseases because a case would be unusual or unexpected:
a. Wildtype poliovirus Poliomyelitis
b. Human influenza caused by a new subtype
c. Severe acute respiratory syndrome (SARS).
iii. Diseases that have demonstrated the ability to cause serious public health impact and spread rap-
idly internationally:
a. Cholera
b. Pneumonic plague
c. Yellow fever
d. Viral hemorrhagic fevers (Ebola, Lassa, Marburg)
e. West Nile fever
f. Other diseases that are of special national or regional concern; e.g., dengue fever, Rift Valley
fever, and meningococcal disease.
Note: The Canadian and U.S. lists show how IHR 2005 affects national regulations. In addition, the fol-
lowing observations illustrate how IHR 2005 is applied (CDC, personal communication, Jan. 27, 2017):
I. Each country may face different threats related to volume of travel from specific regions of the
world to that country, etc.; therefore, they may have diseases on their list related to those threats.
II. Countries may also set their own disease elimination goals, in addition to goals set by WHO. TB
is a goal for the U.S., but not for many other countries; that’s why many of our air investigations
involve TB.
III. In the U.S., we don’t expect airlines, or our partners in the airports to identify disease. In fact,
except for a few obvious cases of rash illnesses, even an infectious disease specialist would be hard
pressed to make a diagnosis in an air travel related reported illness. So, we provide our partners
with a list of symptoms that we ask them to report.
IV. The issue for this report is travel related to airports, therefore the diseases of interest should be
communicable either during air travel or in an airport setting. Rabies, though a serious and deadly
disease is not likely communicable in that environment. That said, we have been involved with at
least one potential PHEIC involving air travel and a few air contact investigations. But those were
highly unusual circumstances, one being a bat on a plane. The PHEIC process allows us to do that
without having to list every specific disease.
V. Although WHO has listed some diseases as outlined in 2, each country has to respond based on its
own regulatory authority, not WHO’s. We have learned that it is better to be a bit more general than
specific, that’s why the WHO moved to the PHEIC process. If you look closely, you will notice that
the U.S. list says Severe acute respiratory syndromes and not Severe acute respiratory syndrome.
In July 2014, Executive Order 13295 was amended and replaced with Severe acute respiratory syn-
dromes, because when MERS arose it was clearly different from SARS. In anticipation that there
could be other novel coronavirus infections, it did not make sense to list specific diseases, but rather
to define a term that could encompass a range of similar diseases so we would not need either a rule
change or a new executive order for each new occurrence. That’s the same thinking WHO and the
world public health community had for not listing specific novel influenza virus strains.

71
Appendix B
ICAO Document 4444, Paragraph 16.6
“Notification of Suspected Communicable Diseases, or Other Public Health Risk, on Board an Aircraft”
16.6.1 The flight crew of an en-route aircraft shall, upon identifying a suspected case(s) of com-
municable disease, or other public health risk, on board the aircraft, promptly notify the ATS
[air traffic services] unit with which the pilot is communicating, the information listed below:
a) aircraft identification;
b) departure aerodrome;
c) destination aerodrome;
d) estimated time of arrival;
e) number of persons on board;
f) number of suspected case(s) on board; and
g) nature of the public health risk, if known.
16.6.2 The ATS unit, upon receipt of information from a pilot regarding suspected case(s) of com-
municable disease, or other public health risk, on board the aircraft, shall forward a message
as soon as possible to the ATS unit serving the destination/departure, unless procedures exist to
notify the appropriate authority designated by the State and the aircraft operator or its designated
representative.
16.6.3 When a report of a suspected case(s) of communicable disease, or other public health risk,
on board an aircraft is received by an ATS unit serving the destination/departure, from another ATS
unit or from an aircraft or an aircraft operator, the unit concerned shall forward a message as soon
as possible to the public health authority (PHA) or the appropriate authority designated by the
State as well as the aircraft operator or its designated representative, and the aerodrome authority.
Note 1.—See Annex 9—Facilitation, Chapter 1 (Definitions), Chapter 8, 8.12 and 8.15, and Appen-
dix 1, for relevant additional information related to the subject of communicable disease and public
health risk on board an aircraft.
Note 2.—The PHA is expected to contact the airline representative or operating agency and aero-
drome authority, if applicable, for subsequent coordination with the aircraft concerning clinical
details and aerodrome preparation. Depending on the communications facilities available to the
airline representative or operating agency, it may not be possible to communicate with the aircraft
until it is closer to its destination. Apart from the initial notification to the ATS unit whilst en-route,
ATC communications channels are to be avoided.
19/11/09
No. 2 16-8 Air Traffic Management (PANS-ATM) 22/11/07
Note 3.—The information to be provided to the departure aerodrome will prevent the potential
spread of communicable disease, or other public health risk, through other aircraft departing from
the same aerodrome.
Note 4.—AFTN (urgency message), telephone, facsimile or other means of transmission may
be used.

72
Appendix C
Study Participants
Appendix C lists the airports and health agencies that participated in the surveys. Several additional agen-
cies participated in the case example interviews (chapter four) and the expert validity interviews. Since
Boston Logan International Airport (BOS) was added as the sixth case example several months after the
surveys were completed, it and the Boston Public Health Commission did not participate in the surveys.
Airports
Asterisk (*) indicates part of matched airport-health department pair of respondents.
NPIAS State/
Code Airport Governance Region
(2015) Prov.
* ANC Anchorage International Airport MH City AK AL

* APA Centennial Airport RL Authority CO NM
ASE Aspen–Pitkin County Airport NP County CO NM
Hartsfield–Jackson Atlanta International
ATL LH City GA SO
Airport
Boeing Field/King County International
* BFI NP County WA NM
Airport
BFM Mobile Downtown Airport (Brookley Field) GA Authority AL SO
BOS Boston Logan International Airport LH Authority MA NE
Baltimore–Washington International
BWI LH State MD EA
Thurgood Marshall Airport
Charleston Air Force Base/International
* CHS SH Authority SC SO
Airport
CLT Charlotte/Douglas International Airport LH City NC SO
* DFW Dallas/Fort Worth International Airport LH Authority TX SW
* DVT Phoenix Deer Valley Airport RL City AZ WP
Northwest Florida Beaches International
* ECP SH County FL SO
Airport
* FXE Fort Lauderdale Executive Airport RL Authority FL SO
Westchester County Airport County/
HPN SH NY EA
Privatized
* IAD Washington Dulles International Airport LH Authority VA EA
* IAH Houston Bush Intercontinental Airport LH City TX SW
* JAX Jacksonville International Airport MH Authority FL SO
* JFK John F. Kennedy International Airport LH Authority NY EA
* LAS McCarran International Airport LH County NV WP
* LAX Los Angeles International Airport LH City CA WP
LCK Rickenbacker International Airport CS Authority OH GL
LEX Blue Grass Airport SH Authority KY SO

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NPIAS State/
Code Airport Governance Region
(2015) Prov.
* MCO Orlando International Airport LH Authority FL SO

* MEM Memphis International Airport MH Authority TN SO
* MIA Miami International Airport LH County FL SO
* MKE General Mitchell International Airport MH County WI GL
MMU Morristown Municipal Airport RL Privatized NJ EA
MSP Minneapolis–St. Paul International Airport LH Authority MN GL
OMA Eppley Airfield MH Authority NE CE
* OPF Miami-Opa Locka Executive Airport RL County FL SO
* ORD O’Hare International Airport LH City IL GL
* PDK DeKalb-Peachtree Airport RL County GA SO
* PDX Portland International Airport LH Authority OR NM
* PHL Philadelphia International Airport LH City PA EA
* PHX Phoenix Sky Harbor International Airport LH City AZ WP
* RSW Southwest Florida International Airport MH Authority FL SO
* SAV Savannah-Hilton Head International Airport SH Authority GA SO
* SEA Seattle–Tacoma International Airport LH Authority WA NM
* SFO San Francisco International Airport LH City CA WP
* SJU Luis Muñoz Marín International Airport MH Privatized PR EA
* TEB Teterboro Airport RL Authority NY EA
* TLH Tallahassee International Airport SH City FL SO
* VNY Van Nuys Airport RL City CA WP
* YEG Edmonton International Airport MH* Privatized AB CAN
John C. Munro Hamilton International
YHM NP* Privatized ON CAN
Airport
* YHZ Halifax Stanfield International Airport MH* Privatized NS CAN
YIP Willow Run Airport RL Authority MI GL
Montreal–Pierre Elliott Trudeau
* YUL MH* Privatized PQ CAN
* YVR Vancouver International Airport LH* Privatized BC CAN
* YYZ Toronto Pearson International Airport LH* Privatized ON CAN

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Health Departments
Asterisk (*) indicates part of matched airport-health department pair of respondents.
Health Department Airport Code
Honolulu Department of Health HNL

Marion County Public Health Department IND
* Alberta Health Services YEG
* Bay County Health Department ECP
* Bergen County Department of Health Services TEB
* Chicago Department of Public Health ORD
* Toronto Public Health YYZ
* Coastal Health District SAV
* Dekalb County Board of Health PDK
* Department of Health in Leon County TLH
* Department of Public Health Puerto Rico (Departmento de
SJU
Salud de Puerto Rico)
* Department of Public Health–City of Philadelphia PHL
* Fairfax County Health Department IAD
* Florida Department of Health in Broward County FXE
* Florida Department of Health in Duval County JAX
* Harris County Public Health and Environmental Services IAH
* Honolulu Department of Health HNL
* Lee County Health Department RSW
* Los Angeles County Public Health Department LAX
* Los Angeles County Public Health Department VNY
* Maricopa County Department of Public Health DVT
* Maricopa County Department of Public Health PHX
* Marion County Public Health Department IND
* Miami–Dade County Health Department MIA
* Miami–Dade Health Department OPF
* Milwaukee Department of Health MKE
* Multnomah County DOH PDX
* Municipality of Anchorage/Department of Health and
ANC
Human Services
* New York City Department of Health and Mental Hygiene JFK
* Orange County Health Department MCO

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Health Department Airport Code
* Public Health Agency of Canada Eastern Region YHZ

* Public Health Agency of Canada Eastern Region YUL
* Public Health Agency of Canada Western Region YEG
* Public Health Agency of Canada Western Region YVR
* Public Health—Seattle and King County BFI
* Region 7—Public Health Regional Office CHS
* San Mateo County Public Health Department SFO
* Shelby County Health Department MEM
* Southern Nevada Health District LAS
* Tacoma–Pierce County Health Department SEA
* Tarrant County Health Department DFW
* Tri-County Health Department APA

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Appendix D
Survey Questions and Responses
D-1: Survey Questions and Responses for Airports
1. Name of person completing this section______________________________________________

2. Title of person completing this section _______________________________________________
3. Phone ________________________________________________________________________
4. E-mail ________________________________________________________________________
5. Airport name __________________________________________________________________
6. Airport 3-letter code _____________________________________________________________
7. Is your airport a Joint Use facility with the military? (Y/N)
8. Do you have flights arriving nonstop to your airport from outside the U.S. or Canada? (Y/N)
Of the 49 airports submitting surveys, 40 (81.6%) have flights arriving nonstop from outside the U.S. or
Canada. Table 25 shows the types of such flights arriving at the 40 airports.
Table 25
Types of Flights Arriving from Outside U.S. and Canada
Type of Flight n Percent

Scheduled commercial passenger flights 28 71.8
Charter flights 31 79.5
Cargo/freight flights 29 74.4
Industrial aviation flights (e.g., aircraft) 13 33.3
Humanitarian support flights 17 43.6
Emergency repatriation flights 16 41.0
Corporate general aviation flights 34 87.2
Private (non-corporate) general aviation flights 29 74.4
Smith and Greenberg data (2016)
9. How many monthly international arrivals do you have (rough estimate)?
13.20% 30 or fewer
18.40% 31 to 150
60.50% 1001 or more

5.30% 151 to 500
2.60% 501 to 1000
10. Is your airport a port of entry with CBP or CBSA?

11. How big is the CBP or CBSA staff at your airport?
12. How large (square feet) is the CBP or CBSA facility at your airport?

77
13. What types of communicable disease issues has your airport been involved in responding to?
14. How does your airport expect to learn that it has a potential issue with a communicable disease on
an incoming flight?
[See Table 3 in chapter three for aggregated data for question 14.]
15. Do you have a written communicable disease or quarantine plan for your airport? (Y/N)
16. What form does your communicable disease or quarantine plan take?
Table 26
Relationship of Communicable Disease Plans to Other Major Plans
Title N Percent
Stand-alone communicable disease/quarantine plan maintained by the airport 24 49.0
Communicable disease/quarantine plan is part of the airport emergency plan
18 36.7
(AEP)
Stand-alone or community communicable disease/quarantine plan maintained
9 18.4
by a health department
Communicable disease/quarantine plan is part of the airport business continuity
5 10.2
plan (BCP), also sometimes called the continuity of business plan (COB).
Not applicable—we have no written plan and don’t share in health
3 6.1
department’s plan.
Airport Standard Operating Procedures 1 2.0
Communicable disease/quarantine plan is maintained by CDC Quarantine
1 2.0
Station representatives.
Communicable disease/quarantine plan is maintained as part of county Fire
1 2.0
Rescue Response Plan.
Communicable disease/quarantine plan is part of public safety standard
1 2.0
operating procedure
Plan under development 1 2.0
Note: The total percentage exceeds 100% as some airports have their communicable disease
response plans attached to more than one other plan.
Smith and Greenberg data.
17. How do you communicate your communicable disease plan to other stakeholders?
18. Does CBP or CBSA at your airport have a communicable disease/quarantine plan?
19. Is any part of your communicable disease plan Sensitive Security Information (SSI)?
20. Is your communicable disease plan reflected in your crisis communications plan/emergency
communications plan?
21. Who are the stakeholders in your communicable disease planning process?
Table 27
Stakeholders to Involve in Communicable Disease Response Planning
Airport Health Dept.

Stakeholder
n % n %
Airport operations 43 87.8 23 62.2
Airport senior management 41 83.7 22 59.5
Airport ARFF and EMS 40 81.6 25 67.6
Local health department 38 77.6
Hospitals and clinics 38 78.6 1 2.7
Airport law enforcement 36 73.5 15 40.5
Airport emergency management 35 71.4 28 75.7
Airport media/public relations 35 71.4 21 56.8
(continued on next page)

78
TABLE 27
(continued)
Airport Health Dept.
Stakeholder
n % n %
CBP/CBSA 32 65.3 17 45.9
CDC/PHAC—Quarantine office 31 63.3 30 81.1
Airlines, air cargo companies, charter operators, and air taxi 28 57.1 12 32.4
operators
Local agencies 27 55.1 18 48.6
State health department 25 51.0 27 73.0
Ambulances/medical transport services 22 44.9 28 75.7
TSA/CATSA 22 44.9 13 35.1
FAA/Transport Canada/Nav Canada 21 42.9 3 8.1
Airport human resources 20 40.8 2 5.4
Airport maintenance 20 40.8 5 13.5
American Red Cross/Red Cross of Canada 16 32.7 3 8.1
Airport planning 15 30.6 17 45.9
State agencies 15 30.6 11 29.7
Medical institutions 14 28.6 16 43.2
Sponsor/certificate holder (This is the owner of the airport; 13 26.5 8 21.6
e.g., city, county, state, country, or authority.)
Concessionaires 11 22.4 1 2.7
Other public officials (elected officials, etc.) 11 22.4 9 24.3
National agencies 10 20.4 4 10.8
Airport training 9 18.4 3 8.1
Airport finance 8 16.3 1 2.7
Military (if joint use) 7 14.3 1 2.7
Non-airport law enforcement 7 14.3 9 24.3
General aviation aircraft owners and pilots 6 12.2 2 5.4
Healthcare coalition 6 12.2 21 56.8
Airport IT 5 10.2 1 2.7
HAZMAT contractors 5 10.2 1 2.7
Medical and nursing associations and societies 4 8.2 1 2.7
Fuel services 3 6.1 0 0.0
Mobility services (wheelchairs, carts) 3 6.1 1 2.7
Public media 3 6.1 4 10.8
Caterers 2 4.1 1 2.7
HAZMAT—local fire department 1 2.0 17 45.9
City emergency management 14 37.8
Not asked in
County emergency management 23 62.2
survey
State emergency management 11 29.7
22. Does your plan differentiate how to handle passengers from how to handle flight crews?
23. Does your plan incorporate National Incident Management System (NIMS) principles and
practices?
24. Does your plan incorporate Incident Command Systems (ICS) principles and practices?

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25. Do you review your communicable disease response plan periodically?
[CATEGORY NAME],
4 airports,
[PERCENTAGE]
N/A, 3 airports,
[PERCENTAGE]
[CATEGORY NAME]
11 airports,
[PERCENTAGE]
[CATEGORY NAME]
31 airports,
[PERCENTAGE]
26. How do you train on your communicable disease/quarantine plan?

27. When was your most recent drill or exercise of your airport/arriving flight communicable disease
preparedness plan?
Not applicable
6%
Never 2016
12% 21%
2009 or before
4%
2010
2%
2012
2%
2013
4%
2015
31%
2014
18%
28. What is the role of outbound social media (push social media) regarding communicable disease at
your airport?
29. Does your plan take into account the possibility of social media posts by a passenger about disease
on an inbound flight while the flight is still in progress?

80
30. What protective measures (training, personal protective equipment, other clothing, equipment,
vaccines, countermeasures, medical checks, etc.) do you provide for airport employees?
31. Does your communicable disease/quarantine plan involve diverting inbound flights to other
airports?
32. Can you identify a case at your airport or another airport where the plan or protocol was notably
successful or notably unsatisfactory? (Y/N—this will help identify a potential case example.)
33. What are the top three lessons (positive and/or negative) that you learned concerning communi-
cable diseases on arriving flights? See Appendix E for responses.
34. Overall, how prepared do you consider your organization to be in the event of an airport/arrival
flight communicable disease event?
[CATEGORY
NAME], 3 airports
[PERCENTAGE]
[CATEGORY
NAME], 21 airports,
[PERCENTAGE]
[CATEGORY
NAME], 25 airports,
[PERCENTAGE]
35. If you answered (b) or (c) to the previous question, what is the one thing you feel your organization
should or could do to enhance its airport/arrival flight communicable disease preparedness?
D-2: Survey Questions and Responses for Local Public Health Preparedness Coordinators
1. Name of person completing this section______________________________________________
2. Title of person completing this section ______________________________________________
3. Phone ________________________________________________________________________
4. E-mail _______________________________________________________________________
5. Agency name __________________________________________________________________
6. 3-letter code of nearest airport (e.g., OMA, ATL, YYZ, VNY, ASE, YVR, etc.) ______________
7. Do you have a written communicable disease or quarantine plan for your airport? (Y/N)
8. What form does your communicable disease or quarantine plan take?
Communicable disease/quarantine plans is part of the airport emergency plan.
Stand-alone communicable disease/quarantine plans maintained by the airport.
Stand-alone or community communicable disease/quarantine plans maintained by a health department
Other (Please specify):
Not applicable—we have no written plan.
9. Who are the stakeholders in your communicable disease planning process? See Table 27.
10. Have you trained on your airport/arriving flight communicable disease preparedness plan? (Y/N)
11. Is your agency expected to provide services at the airport?

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12. How does your agency meet requirements to surge for an airport communicable disease response?
(Please mark all that apply.)
Surge staff available
Request surge staff
Re-prioritize existing programs/staff
Temporarily suspend programs/divert staff
Other (Please specify):
13. When was your most recent drill or exercise of your airport/arriving flight communicable disease
preparedness plan?
Table 28
Year Health Department Most
Recently Drilled with Airport
Year n %
2016 12 35.3%
2015 6 17.6%
2014 6 17.6%
2013 1 2.9%
2010 1 2.9%
2009 or before 2 5.4%
Never 4 11.8%
N/A 2 5.4%
n = 34.
14. Overall, how prepared do you consider your organization to be in the event of an airport/arrival
flight communicable disease event?
Very prepared
Somewhat prepared
Not prepared
15. If you answered (b) or (c) to the previous question, what is the one thing you feel your organization
should or could do to enhance its airport/arrival flight communicable disease preparedness?
D-3: Template for Expert Validity Interviews

The senior officials from five health organizations were asked to comment on preliminary conclusions
and further research needs after the completion of data collection and late in the analytical process:
Conclusion 1: Health departments and airports benefit from pre-established relationships and joint
planning efforts for communicable disease response.
Conclusion 2: Miscommunication is a huge risk, so message discipline and use of all forms of com-
munication are essential. A Joint Information Center is very helpful.
Conclusion 3: A unified command with a public health, law enforcement, fire/EMS and airport presence
is the most effective way to manage a communicable disease incident.
Conclusion 4: An airport needs to have quick access to a health department SME.
Conclusion 5: Airports and health departments broadly agree on the importance of including stake-
holders in planning and on who those stakeholders are.
Conclusion 6: The larger the airport, the more likely it and its HD partner are to say it’s Very Prepared.
[65% for large hubs, 22% for medium hubs, 17% for small hubs, 0% for non-hubs, but 56% for
relievers (really big GA airports) and 50% for small GA airports].
Conclusion 7: Looking at the 37 matched pairs of airports and HDs, 24 (about 2/3) agree on level of
preparedness. Overall, the biggest category of agreement is somewhat prepared (16 of 37 airports).
Further Research Topic 1: Information about a sick passenger on an international flight flows, but
similar information is not available for passengers on domestic flights.
Further Research Topic 2: Uniform procedures for getting flight manifests when HD asks airport for
help after a disease is detected.
Further Research Topic 3: Are requirements for screening outgoing passengers coming?
What other areas of further research would you like to see?

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Appendix E
Lessons Learned as Stated by Airports and Local Health Departments
By Airports
General Lessons
• You can never be prepared enough owing to the unique circumstance surrounding each passenger.
• Advanced notification—critical for smooth response.
• Everything takes longer than anticipated.
• Build relationships in advance.
• Respect and use the expertise of CDC/PHAC and CBP/CBSA as well as local health departments.
• Early understanding of potential risk is essential, with adjustment to plan implementation to fit
actual risks.
• Pre-arrival information is suspect and must be verified in person by a competent responder. Accurate
notification of a communicable disease hazard is not often received before the aircraft is already
parked at the terminal building.
• If time allows, ensure that all the key pieces of information about the patient have been put
together to formulate the most effective response once the aircraft lands. It is possible to link your
local Fire/EMT with MedLink while the aircraft is still airborne to discuss the medical condition.
• Contain the incident—minimize the area of the airport affected.
• Public health experts can do onboard evaluation, detention, and isolation of ill passenger.
• The airport needs to manage the expectations of the public health responders.
• Don’t rush into the situation.
Timing
• Engage all agencies before aircraft arrival and have appropriate staff waiting to act.
• The timeliness of testing and who is in charge always is a problem.
• The time of day and day of week of the flight’s arrival matter because of staff availability.
Planning
• Having a solid, tested plan is essential.
• Stakeholder input to planning is essential.
• A good plan should be flexible and scalable—not all communicable disease incidents require the
maximum response.
• Planning is key to safety.
• Review of the plan revealed a strong plan toward treatment but was weak in quarantine, specifi-
cally if control of passengers was weak.
• Plan should be at least evaluated annually.
Roles and Responsibilities

• Stakeholder familiarity with their responsibilities in the Plan is vital.
• Get to know your local EMS director and public health BEFORE an incident. They are an invaluable
resource—this included their media relations team.
• Overall pre-planning and the identification of responsibilities among agencies is essential.
• Let the health department do their job.
Legal Issues
• Know the airport’s legal authority.
• Everyone’s understanding of quarantine issues is different and the fact that an airport cannot quar-
antine a flight or detain anyone.
• Quarantine/Use of force issues.
Coordination
• Interagency coordination is 100% necessary.
• In real incidents, airports, agencies, and organizations work extremely well together.
• Resolve jurisdictional concerns in advance (during planning process).
• Understanding roles and responsibilities of the various local, state and federal agencies to determine
which agency serves as lead agency in incident command.
• Each agency involved needs to predesignate a point of contact and share the information among
the group of potential responders.
• Any issue that may impact business continuity of the day will require EOC activation.

83
Communication
• Accurate, open, and timely communication among partners is essential for the effectiveness of the
response.
• Poor communication between agencies often happens.
• Ensure that airport has notification center that spans all agencies involved.
• Include airlines at airport in communications.
• Follow up with airlines.
• Contact lists and relationships must be kept up to date.
Security
• Include need for law enforcement in all stages of planning, response, and recovery.
• Quarantine areas that are post-security could pose a SIDA issue (bringing passenger through secure
doors without proper credentialing).
• Escort procedures for department of health employees need to be outlined ahead of time to ensure
access to ill passenger on plane or at gate area.
• Arrange police department escorts for a non-stop transport to the destination hospital.

• An effective joint training program is essential.
• You should practice with your mutual aid responders.
• Drilling at least annually is helpful, especially given staff turnover and differing skill levels.
Managing the Media

• Airport media experts need to be involved in plan development.
• Airport media experts must be kept fully informed as an incident evolves.
• If the EOC is activated, the unified command needs to include the health department and needs the
services of a joint information center (JIC).
• When dealing with non-medical or non-public safety, use clear plain language and anticipate deeper
explanations will be needed.
• There is a need to work closer with Local Public Health agencies to discuss how to disseminate
information effectively upon notification of potential CD contact.
• Control media, public perception of safety concern with patient on airport property.
Notification of Ill Passenger on Arriving Flight

• Procedures of notification to smaller airports and of passengers who become ill on domestic flights
are uncertain.
• Broken itinerary can greatly complicate learning information concerning incoming ill patient’s point
of origin.
Managing Aircraft on Ground

• Decisions can be made if aircraft will be allowed to bridge at terminal or off terminal based on risk
assessment of flight.
• Park aircraft remotely, ideally out of view of public and media.
• Have emergency vehicles on standby before aircraft arrives.
• There is a lot of misinformation and assumptions about communicable disease—passengers want
information. Ensure you have someone prepared to provide basic information about what is happen-
ing and what the passengers can expect.
Resources
• Logistical and facilities planning.
• Make provision for additional funding that may be needed.
• Have a facility large enough to hold people for a long period with restrooms, water, and ability to
provide food.
• Request necessary resources before needed.
Disinfection and Cleaning

• Treat all body fluid like it is infectious.
• Clean/disinfect exposed areas and dispose of waste as recommended/required.
Protecting Airport Workers

• Provide PPE for airport employees and train them how to use PPE.
• Be sure to take care of the care givers.

84
Psychological Concerns
• Use of PPE can heighten anxieties among passengers.
• Over-reaction or reduced reaction of staff.
• Difficulties of dealing with uncertainty (Is disease actually present? What disease is it? Have other
passengers been exposed?).
• When the threat is heavily in the public consciousness, almost any illness or any anomalous physical
condition can be reported as that threat.
Business Impact to Airport

• Consider business impact to airport.
• Airport business partners (e.g., tenants and concessionaires) need information, too.
By Health Departments
The health department survey asked two separate questions about top three lessons learned, one about
planning and one about actual responses. The responses overlapped, so they have been consolidated in
this section.
General Lessons
• It takes the full spectrum of stakeholders to effectively respond to an incident with a highly infec-
tious disease with high number of potential exposures.
• It’s complicated—lots of players, multiple priorities, and considerations.
• It’s political—high visibility.
• It is sometimes difficult to work alongside elected officials.
• It’s difficult to get the needed players to the table.
• Evaluation is most effectively done on board the aircraft. Everyone on board remains seated until
the assessment is fully conducted and personnel reassure/communicate to the travelers if need be.
• Gathering and validating information is crucial.
• Information provided by passengers may be inaccurate.
• Don’t assume that everyone understands the basics of communicable disease control.
• The gaps in authority and procedures for handling communicable disease on international flights and
on domestic flights are a major complicating factor for planning and response.
• You need to build relationships with your partners in advance.
• Effective responses are personality and relationship-dependent.
• Difficulty in obtaining flight manifests to conduct contact investigations.
• Airlines destroy their flight manifests very quickly which makes identification of passengers on
the plane difficult to impossible unless the request for the manifest to be retained can be made
immediately.
• Although time frame is essential, safety is more essential.
• Having a real incident can motivate airport, LHD, and other stakeholders to improve collaboration,
communication, planning, and mutual understanding.
Timing
• Challenges occur when Quarantine Officer is not on site.
Planning
• Stakeholder involvement is critical to developing a coordinated plan.
• All stakeholders need to participate.
• Planning team needs to be more robust with multiple partners than previously anticipated.
• It is difficult to coordinate planning among various stakeholders.
• The planning process is necessarily long: be patient, the results are worth it.
• Plan should be flexible: plans will only take you so far before improvisation will be necessary.
• The return on investment for too much detail [in a plan] is difficult to make.
• Having an identified hospital/emergency room that is going to be responsible for receiving individu-
als identified as potentially infected as part of the plan is crucial.
• Health department plans need to track changing business of airport, especially if number of inter
national flights and points of origin are increasing.
• Sharing plans at each agency and ensuring coordination within all documented plans.
• Airport and LHD plans need to be cross walked to ensure agencies are aware of each other’s plans,
roles and responsibilities and expectations clearly defined.
• Generating participation by airlines in planning can be challenging.
• Help airport to include diseases in its risk assessment.
• Critical to have plan for transport from airport to hospital.
• Media involvement/presence can complicate planning meetings.
• Discuss concerns associated with transportation of confirmed or suspected cases.

85
• In the planning, it is important that each partner know their roles so when called to respond they
are familiar with the actions they should take and help put into the plan.
• Smaller industrial airports are very different and we do not plan with them regularly on communi-
cable diseases.
Roles and Responsibilities

• Knowledge of the needs, capabilities, and limitations of your partners is essential.
• Collaborate with regional, state, and other local health departments, and CDC/PHAC partners.
• CDC/PHAC Quarantine Stations and Officers are major resource for local health departments.
• Airport operations vs. public health response needs.
• Partners understand roles and responsibilities as a result of improved communications and training.
• Opportunity to better differentiate the LHD and Quarantine Station roles and responsibilities in
a response.
Legal Issues
• Challenge with domestic versus international flights and jurisdictional authority is unclear.
• Legal issues are barriers.
• There are complex matters with jurisdiction and authority.
• Many different regulations (federal, airline, port, first responder) come together at an airport.
• Airport has certain federal regulations they must operate within that [health agencies] need to
account for.
• Challenges with quarantine of passengers, locations, duration, issuing orders, providing basic needs
for prolonged holding.
• Review existing guidelines and determine if additional information can be shared with area hospitals.
• Multi-jurisdiction response.
• Legal aspects of integration with other agencies.
Coordination
• Know all of your community partners, public and private.
• Clearly identify the lead agency.
• Effective integration into Airport EOC is essential.
• Create a committee around the plan to keep the plan current and ensure it is regularly exercised.
• A response makes it even more complicated—everyone wants a say. Authority must be established
and channels followed.
• When services are provided on a contracted basis, coordination is complicated.
• Generating interest by airport officials in public health issues is challenging.
• More coordination and collaboration is necessary to ensure LHD has information necessary to sup-
port airport response and disease containment.
• Critical to understand chains of communication at airport ahead of time.
• Lack of LHD involvement with national agency (CDC/PHAC).
• LHD needs better tools, information sources and airline, airport assistance to be able to monitor
traveler data to identify plan triggers and to prepare/prevent CD transmission.
• Last minute requests to participate cause undue confusion.
Communication
• Communication with our partners is very important and can mitigate many challenges, including
anxiety if all on the ground are well versed with information and the plan of action as we usually are
first to board the conveyance.
• Contacting the right people early on in the response.
• Have a conference call early on for situational awareness and to clarify roles and responsibilities.
• Critical to understand required notifications at each agency or organization involved.
• Defining triggers for when [local] public health should be notified by the airport.
• Airlines have to be made aware of what communicable diseases are circulating in domestic and
international flight areas.
• Prompt communication of the health decision to the airline, the airport, and other required partners
is essential.
• Process for communication amongst key partners in planning/response.
• Identification of specific individuals responsible for communication between the various federal,
state/provincial and municipal stakeholders is crucial for timely and effective management of the
situation.
• Communication with Headquarters is vital in case information is sent to them by different sources.
• Social media nowadays make communications portion of communicable disease plan very important.
• Maintain up-to-date contact lists.
• Notification of ill persons on aircraft doesn’t always follow the identified communication channels.
• Compatibility of personal (carried) communications device can be an issue during a response.

86
Security
• Transportation security agencies and procedures may delay access of public health officials and
medical responders to patient on plane or in secure area; these need to be resolved in advance.
• Security concerns and access to the facility will be challenging, particularly with surge staffing that
may be identified at the time of the event.

• A plan that is never exercised is not useful because partners forget.
• Ensure prior to response everyone is well versed with the plan so that during response we have one
channel of communication with all stakeholders including with the traveler.
• TTX, drills and training help develop, socialize, and refine plans and procedures, and build trust
among responding agencies.
• There are limited opportunities to exercise for these events as frequently as we would like.
• Have a joint exercise plan.
• Jointly exercise communicable disease response plan annually.
• Joint airport and LHD training and exercises necessary using biological agent scenario. Consider for
future triennial airport exercises or tabletop exercises.
Managing the Media

• Clear communication to the public is needed.
• Manage communications with the public if possible before the event or else be as transparent as
possible.
• Make sure there are clear plans for communication with the public.
Resources
• Additional resources are needed for responding to communicable disease on arriving flights.
• No ear-marked funding for response.
• Funding is limited.
• Identifying and rostering surge staffing for quickly moving events may be problematic in the face
of staffing cuts.
• Pre-identify resources to be used.
• Challenges with quarantine of passengers, locations, duration, issuing orders, providing basic needs
for prolonged holding.
• Space to screen/triage/quarantine large numbers of passengers on airport grounds is limited.
• Airport resources are limited space-wise for quarantine and private interviews.
• Not having a quarantine location at the airport creates a major problem.
• Access to CDC resources may be limited or slow.
• Industrial airports have a reduced capacity to manage and respond to a CD event, need outside help.
(Note: An industrial airport can be a general aviation airport that has an aircraft factory or mainte-
nance facility but no passenger service.)
• Staff/labor intensive because it requires disruption of daily activities.
• Quarantine Station has limited capacity/capabilities
Protecting Health Workers

• Protection of responders is essential.
• Discuss decontamination faced by first responders, public health, and medical care professionals in
pre-hospital environment.
• Proper PPE is essential.
Psychological Concerns
• Mental health counselors should be there waiting for the passengers.
• Providing information can reduce anxiety.
• It is important to keep passengers on arriving flight calm.
• Explaining to passengers why questions are being asked can reduce anxiety.
• Education and time with individual travelers is needed, which is culturally sensitive to various lan-
guages and customs.
Business Impacts
• Working with airlines can be challenging because of different business practices.

87
Appendix F
Ebola Time Line for DFW Cases
Ebola Time Line (Broom 2014a)
Aug. 15 TSA employee with recent travel to Ivory Coast becomes ill in TSA office and is trans-
ported to Baylor Medical Center Grapevine by DFW EMS. Conference call that night.
Sept. 15 Mr. Duncan helps a neighbor get to the hospital. Neighbor later diagnosed with Ebola.
Sept. 19 Mr. Duncan leaves Liberia. He is asymptomatic on exit screening.
Sept. 20 Mr. Duncan arrives at EWR and takes a United domestic flight to DFW.
Sept. 24 Mr. Duncan begins to have fever and GI symptoms.
Sept. 25 Mr. Duncan presented to Texas Health Resources (THR) Presbyterian with symptoms,
but his travel history was not fully appreciated by the entire care team.
Sept. 28 Mr. Duncan returns to THR Presbyterian ER by Dallas Fire Rescue ambulance. CDC and
DHHS are notified.
Sept. 30 CDC passes unofficial warning that a diagnosed Ebola case will be announced. DFW has
about two hours warning.
14:30 EVPs and Public Information office work most of the night in collaboration with Tarrant
County Public Health and CDC to understand Mr. Duncan’s travel itinerary. CDC con-
firms Duncan did not fly on Emirates.
17:00 Dallas County begins operating an EOC to manage the consequences of the diagnosis.
18:52 Tarrant County PH issues media statement.
19:19 Initial Board employee statement transmitted.
Oct. 1 Dallas Fire reports that all its ambulance workers have tested negative for Ebola. They
are sent home, to be monitored for 21 days.
Dallas schools report that five children in four schools may have had contact with Mr. Duncan but are not
showing symptoms. Schools stress to parents that there is “no imminent danger to your child.”
Dallas County health officials say they are watching 10 to 18 people who had close contact with Mr. Duncan,
mainly family and close friends, and would “not be shocked” if a second case surfaces.
Emirates Airways begins A380 service to DFW Airport.
Governor Perry holds noon press conference at THR Presbyterian. Tsunami of conference calls begins.
Oct. 2 Mr. Duncan is listed in serious condition by the hospital.

State health officials say they are looking at about 100 people who may have had contact with Duncan
or his relatives.
Dallas County says 80 people had contact either directly with Mr. Duncan or with people who had contact
with Mr. Duncan.
Duncan’s family is ordered by state health officials to stay home, with no visitors unless health officials
give their approval, until Oct. 19.
The hospital says a software flaw kept a physician from seeing that Mr. Duncan had recently traveled from
Liberia, leading the hospital to initially send him home.
United Airlines says it is trying to notify as many as 400 people who may have been on Mr. Duncan’s
flights to the U.S., referring them to the CDC.
Sanitation of Terminal E areas becomes an issue.
PPE worn (or not) by employees becomes an issue.

88
Oct. 3 Haz-mat crews decontaminate apartment where Mr. Duncan stayed before hospitalization.
The quarantined family members of Mr. Duncan are transported from their apartment to an undisclosed
location. Meanwhile, Mr. Duncan is in critical condition.
CDC rep meets with DPS, EAD, Customer Service, ETAM.
Oct. 4 Duncan receives an experimental drug called Brincidofovir, made by Chimerix, Inc.
A Fort Worth doctor who was diagnosed with Ebola while in West Africa treating patients and later cured
after traveling back to the U.S., says he attempted to donate plasma to help Duncan but their plasma types
didn’t match.
Mr. Duncan’s condition is downgraded from serious to critical.
Oct. 6 Stericycle (waste handler) is given a permit to transport Ebola-contaminated materials for
incineration.
Parking begins frequent cleaning of buses.
Oct. 8 Mr. Duncan pronounced dead at Texas Health Presbyterian Hospital Dallas.
A sheriff’s deputy is transported from a Frisco clinic to Texas Health Presbyterian after experiencing
stomach pains. The deputy went inside Duncan’s apartment days before his death with several other depu-
ties and two health officials.
False alarm on DFW-LAX flight which stopped in Midland, Texas.
Oct. 9 The deputy’s Ebola test comes back negative.

Message sent to Board employees.
Infrared thermometer availability became an issue.
Oct. 10 Patient #2, a 26-year-old nurse at Texas Health Presbyterian takes her temperature and
reports having a fever. She drove herself to the hospital and was in isolation within
90 minutes.
Patient #3 flies to Cleveland on Frontier Airlines.
Parkland shares their training video on donning and doffing of PPE.
House of Representatives Committee on Homeland Security holds a Field Hearing in Terminal D.
Oct. 12 Patient #2 is diagnosed with Ebola. She’s the second person to be diagnosed within the
United States and the first to contract the virus within the country.
Three distinct messages sent for Fire/EMS, Police/Security, and admin DPS employees.
Oct. 13 Patient #3, a 29-year-old nurse who also treated Duncan at Texas Health Presbyterian,
travels from Cleveland to Dallas on Frontier Airlines with a low-grade fever.
Crews transport Patient #2’s King Charles Spaniel, named Bentley, to an undisclosed location. The pet
will be placed under monitoring for 21 days.
Contamination of waste water became an issue.
Oct. 14 Patient #3 reports and is admitted to Texas Health Presbyterian.

DFW holds Pandemic Steering Committee meeting
Oct. 15 Patient #3 is diagnosed with Ebola. Haz-mat crews clean out her apartment at Skillman
Street and Lovers Lane. Patient #3 is the second person to contract the virus on U.S.
soil. Texas Health Presbyterian announced she’ll be transferred to Emory Healthcare in
Atlanta for treatment.
Frontier is notified of Patient #3’s travel on their flights and posts press release.
Subcontractor employee to Bombardier says he lives in same apartment complex as Patient #3 and has
been ordered to DHHS for screening.
Board employees increase questions after Frontier announcement. N-95 masks become an issue.
Oct. 16 Patient #2 is transferred to NIH Bethesda, Maryland, for treatment.

Border entry screening for Ebola concentrated at “the 5” airports.
Employee (subcontractor) who was told to remove gloves and masks goes media.
Message number 3 sent to all Board employees.

89
Oct. 17 Jail intake screening for Ebola set up.

Center for Domestic Preparedness made initial contact about DFW hosting a PPE class at FTRC.
First indication of enhanced screening possibility from Customs and Border Protection.
Oct. 18 CBP indicates enhanced screening of those with travel history or passports begins
immediately.
Oct. 21 Conference call to polish the enhanced screening procedures and expectations was held.
Oct. 23 CDP holds pilot course on PPE for biological events.
Oct. 24 Patient #2 is Ebola-free and is discharged.
Oct. 28 Patient #3 is Ebola-free and is discharged.

90
Appendix G
Checklist for Airport Communicable Disease Response Planning
Applies
CHECKLIST to Our Done
Airport
Plans and Planning
Goals and Objectives:

1. Protection of the public from the spread of communicable diseases.
2. Protection of workers at airport and responders.
3. Care for the care-givers.
4. Respect for the dignity and privacy of all passengers, crew, and
employees.
5. Creation of a relationship among the partners who will be involved

in responding to a communicable disease on an arriving flight or
epidemiological investigation if a passenger passed through the
airport before developing symptoms.
6. Mutual knowledge of roles, responsibilities, needs, and capabilities

between the airport and the local public health preparedness
coordinator. Think of this as exchanging “Airport 101” and “Public
Health 101.”
7. Minimization of operational disruptions at the airport.
8. Management (“ownership”) of the media space.
Pre-Planning Activities:
1. Identify lead or champion for communicable disease planning at
airport.
2. Get senior management buy-in at the airport and at the public health
agency.
3. Identify point of contact in each airport department, public health

agency, or other key stakeholder.
4. Inventory resources available for a response.
5. Structure the planning process.

91
Applies
Airport
Planning Activities:
1. Identify the stakeholders who need to be involved in making the
plan and those who need to review the draft plan.
Airport operations
Airport senior management
Airport ARFF and EMS
Airport law enforcement
Airport emergency management
Airport training
Airport media/public relations
Airport maintenance
Airport planning
Airport human resources
Airport finance
Airport IT
CDC/PHAC—Quarantine station/office
Hospitals and clinics
Ambulances/medical transport services
Healthcare coalition
Medical and nursing associations and societies
American Red Cross/Red Cross of Canada
CBP/CBSA
TSA/CATSA
FAA/Transport Canada/Nav Canada
Air cargo companies
Air charter operators
Air taxi operators
Local agencies
Concessionaires
Caterers
Fuel services
Non-airport law enforcement
HAZMAT contractors

92
Applies
Airport
State agencies
National agencies
Military (if joint use)
Sponsor/certificate holder (This is the owner of the
airport; e.g., city, county, state, country, or authority.)
Public media
State emergency management
2. Convene planning session.
3. Include a tabletop exercise (TTX) in the first planning session to

communicate needs, capabilities, gaps, and roles.
4. Ensure that participants understand each other’s roles and

responsibilities.
5. Set outline for airport’s communicable disease response plan.
6. Write plan.
7. Have plan reviewed by public health partner and all other pertinent
partners such as airlines and maintenance contractors.
8. Distribute plan to all partners, making separate non-SSI version if

necessary.
Outline for Model Airport Communicable Disease Response Plans

1. Goals and objectives of response
2. Identification of likely scenarios at the airport
3. Risk assessment
4. Trigger(s) to activate airport EOC for communicable disease or

potential contagious disease
5. Staged activation of EOC and resources to track evolution of

incident
6. Identification of responders and their roles for each scenario
7. Designation of points of contact
8. Notification procedures including triggers to initiate notifications

93
Applies
Airport
9. Contact lists for airport, public health agencies, and other response
partners
10. Procedure for maintaining accurate and current contact lists
11. Procedures to isolate plane
12. Procedures for screening passengers
13. Isolation procedures
14. Triage procedures and location/facilities
15. Procedure for checked baggage of passengers suspected with

communicable disease
16. Procedure for carry-on items of passengers
17. Patient transport arrangements
18. Staffing plan to handle surge
19. Family Assistance Centers for communicable disease incidents
20. Procedures to communicate with and manage meeters and greeters
21. EOC procedures for communicable disease incidents incorporating

public health representative and a joint information center (JIC)
22. Communications plan perhaps including prescripted social media,

webpage, and press releases. For large international ports of entry,
a shadow website pre-programmed for a communicable disease
incident may be worth considering.
23. Security procedures (emergency temporary badging, pre-badging,

escorts) to allow fast access of public health officials to patient on
plane or in secure area of terminal
24. Protection of airport workers and responders including PPE,

training, counseling, etc.
25. Disinfection, cleaning, and waste disposal
26. Joint training program including topics, participants,

frequency/schedule, and evaluation
27. Joint drill/exercise schedule
28. Resource inventory
29. Requirement for after-action review and improvement plan for each
drill, exercise, and real-world incident

94
Applies
Airport
30. Schedule for regular coordination meetings at least between airport

emergency management, airport operations, public health agency,
and EMS
31. Schedule for review and update of plan to include public health
agency and (as appropriate) other stakeholders
32. Coordination with other major airport plans:
a. Airport Emergency Plan (AEP)
b. Airport Security Program (ASP)
c. Comprehensive Crisis Communications Plan
d. Business Continuity Plan (BCP)
e. Recovery Plan (if separate from AEP)
f. Human Resources policies
After Plan Has Been Distributed

1. Joint training
2. Test contact lists.
3. Test the plan with exercise(s).
4. Perform after-action review (AAR) and create improvement plan

(IP) to give an AAR/IP for all exercises and actual incidents.
5. Track progress on actions items in AAR/IP.
6. Revise the plan as necessary.
7. Test the revised plan.
8. Review and revise plan periodically.
9. Practice continuous improvement.

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
FAST Fixing America’s Surface Transportation Act (2015)
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
TDC Transit Development Corporation
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

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Preparing Airports For Communicable Diseases On Arriving Flights (2017)

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Preparing Airports for Communicable Diseases on Arriving

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National Academies of Sciences, Engineering, and Medicine 2017. Preparing

– Access to free PDF downloads of thousands of scientiﬁc reports

Copyright © National Academy of Sciences. All rights reserved.

AIRPORT COOPERATIVE RESEARCH PROGRAM

A Synthesis of Airport Practice

Research Sponsored by the Federal Aviation Administration

Copyright National Academy of Sciences. All rights reserved.

AIRPORT COOPERATIVE RESEARCH PROGRAM ACRP SYNTHESIS 83

Copyright National Academy of Sciences. All rights reserved.

Learn more about the Transportation Research Board at www.TRB.org.

Copyright National Academy of Sciences. All rights reserved.

Topic Panel S03-12

Synthesis Studies Staff

Cooperative Research Programs Staff

ACRP Committee for Project 11-03

Aircraft Owners and Pilots Association

Airports Consultants Council

Airports Council International–North America

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

4 Chapter Two Air Travel and Communicable Diseases

13 Chapter Three Survey Results

22 Chapter Four Where the Rubber Hits the Tarmac:

55 Chapter Five Findings, Conclusions, and further Research

Copyright National Academy of Sciences. All rights reserved.

69 Appendix A Diseases of Public Health Significance

71 Appendix B ICAO Document 4444, Paragraph 16.6

72 Appendix C Study Participants

76 Appendix D Survey Questions and Responses

82 Appendix E Lessons Learned as Stated by Airports

87 Appendix F Ebola Time Line for DFW Cases

90 Appendix G Checklist for Airport Communicable Disease

Copyright National Academy of Sciences. All rights reserved.

Preparing Airports for Communicable

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Air Travel and Communicable Diseases

Diseases of Public Health Significance

Copyright National Academy of Sciences. All rights reserved.

Risk Assessment for Communicable Diseases Transmitted on Aircraft

Notification Procedures and Air Traffic Control Roles

Copyright National Academy of Sciences. All rights reserved.

Isolation and Quarantine Procedures

Copyright National Academy of Sciences. All rights reserved.

Airport and Airline Roles

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Efforts Under Way to Improve Understanding and Processes

Caring for the Caregivers

Legal Environment for Response to Communicable Diseases at Airports

Copyright National Academy of Sciences. All rights reserved.

Airports Are Expected to Have Preparedness Plans

(a) communication (especially with the public);

Importance of Relying on Public Health and Medical Expertise

Relationships of Local, State, or Provincial and National Public Health

Copyright National Academy of Sciences. All rights reserved.

United States Airports

Scope of This Study

22 Chapter Four Where the Rubber Hits the Tarmac:

82 Appendix E Lessons Learned as Stated by Airports

90 Appendix G Checklist for Airport Communicable Disease