Measles Outbreak Underscores Importance of Communicable Disease Response Plans

As confirmed reports of measles continue to emerge in pockets throughout the United States, airport operators throughout the country face the prospect of receiving contagious passengers and visitors. 

John F. Kennedy International Airport (JFK) experienced the swirl last fall regarding Middle East Respiratory Syndrome (MERS), a communicable disease that had killed more than one-third of the people who had contracted it at the time. Prior to landing, the pilot of an Emirates Airline flight from Dubai notified the tower that a large number of people on board were complaining of flu-like symptoms such as coughing and fevers. Airport authorities quickly contacted the Centers for Disease Control and Prevention (CDC), and local health services and laboratories prepared for the plane’s arrival.

Health officials met the flight on the tarmac, and all onboard were held for evaluation (see Editor’s Note on Pg 46.). After medics and Customs agents took temperatures and assessed symptoms, 11 people were sent to the hospital for further evaluation and treatment. Ultimately, none had MERS.

Although the incident was frightening for many, airport and health officials say it was actually reassuring evidence about the efficacy of detailed preparedness plans that have been in place for decades and are updated regularly.

“There have been port preparedness plans for years that have been written and revised and iterated in partnership with state and local health departments, with other federal partners at ports, with the local [emergency medical services] response system, with communications officers,” and other stakeholders, Martin Cetron, director of CDC’s Division of Global Migration and Quarantine, told Stat News, a health-oriented website.

Just one day after the incident at JFK, 250 passengers arriving at Philadelphia International Airport (PHL) on two flights from Europe were evaluated and held for medical review after a dozen passengers complained of flu-like symptoms. Aside from the sick passengers, everyone else was eventually allowed to leave. And again, preparedness plans worked exactly as they are designed, Cetron says.

With international air travel at record levels and continuing to climb, airports are under additional pressure and scrutiny. Health experts say that air travel, more than any other mode of transportation, creates the potential for an infection to move rapidly from one part of the world, because passengers share confined quarters with other travelers.

The International Air Transport Association (IATA) reports that 3.8 billion people traveled by air in 2016, and it predicts that will balloon to 7.2 billion passengers by 2035.

In 2014 and 2015, the Ebola epidemic in West Africa renewed concerns about the spread of communicable diseases through air travel. There were proposals in the United States to restrict travel and trade to/from affected countries.

While deaths and illnesses may be the most visible effects of an outbreak, communicable diseases also create economic costs. For example, a report from the U.S. Government Accountability Office (GAO) states that during the 2003 severe acute respiratory syndrome (SARS) epidemic, IATA estimated the overall cost at $33 billion of global gross domestic product. North American airline revenue losses alone were estimated at $1 billion, while Asia Pacific airlines lost an estimated $6 billion.

What Preparedness Looks Like

In addition to its FAA-required airport emergency plan, San Francisco International Airport (SFO) also maintains a communicable disease response plan, which it shares with the CDC.

“This plan is not a required document under federal regulations, but we find this helpful, as it adds further clarity to who does what, and covers illness response processes in greater detail,” says Doug Yakel, public information officer at the airport’s External Affairs Office. “This document is reviewed as needed, based on changing information and new sources of concern. We’re currently in the process of reviewing it again, as we’ll be drawing from this in our annual full-scale emergency exercise in the fall.”

SFO also has concept of operations (con-ops) documents specifically developed for managing a health concern. Yakel notes that during the Ebola outbreak, the airport gathered its stakeholders together to review and clarify roles and responsibilities, review threat information and create a strategic plan that personnel could practice in a tabletop exercise. “Although we never were a location for screening activities, this was a good way to ensure our readiness had anything developed,” he explains.

In certain extraordinary circumstances, passengers or flights from areas experiencing the outbreak of a communicable disease can be redirected to designated U.S. airports with special capabilities to receive them. For example, in October 2014, during the height of the Ebola crisis, the CDC initiated enhanced screening at five U.S. airports: JFK, Washington-Dulles International (IAD), Newark Liberty International (EWR), Chicago O’Hare International (ORD) and Hartsfield-Jackson Atlanta International (ATL). Passengers whose recent travel included Ebola-affected countries were routed to one of these airports, where U.S. Customs and Border Protection personnel and CDC staff conducted enhanced entry screening procedures.

Measles Scare        

Recently, a resurgence of measles has been the main concern in the U.S. In late May, the CDC reported 940 confirmed cases of measles in 26 states since January–the highest number reported since 2000, when the virus was declared eliminated in the U.S..

Most current cases have been linked to international travel. Unvaccinated travelers come to the U.S. from countries with ongoing outbreaks and expose people who are not vaccinated.

A CDC spokesperson says the agency is working with its partners to consider some measles response options that could be implemented at airports; but no new policies or procedures had been announced as of late May.

For now, standing orders for airport personnel and government officials stationed at U.S. airports is to be aware. A spokesperson for U.S. Customs and Border Protection told the told the Atlanta Journal-Constitution that CBP personnel at ATL, the world’s busiest airport, review all travelers entering the U.S. for “overt signs of illness.” The prescribed process includes visual observation, verbal questioning and notifying the CDC as appropriate.

Awareness & Communication

Airlines workers and airport personnel are trained to recognize and respond to symptoms of communicable diseases in passengers. However, that only works when symptoms are evident during travel. It is possible for infected travelers not to show signs of illness until a day or more after flying, notes Clive Brown, chief of CDC’s Quarantine and Border Health Services Branch. In such cases, CDC depends on state and local health departments to develop a travel history for each sick person and, with help from airlines, attempt to notify other passengers identified to be potentially exposed.

Annually updated airport emergency plans required by the FAA include specific response strategies for medical scenarios such as communicable disease events. Such plans outline the notification process, integration of multiple agencies, command and control, response efforts, mutual aid and staging. Every preparedness plan should go into great detail about the chain of communication needed to effectively respond to an infectious disease incident, says SFO’s Yakel. “Communication and coordination with all first responders, medical health facilities and responding agencies is critical,” he emphasizes. “Ensuring that a threat is identified correctly is the basis for a good response and guides how an airport will communicate with health officials.”

Yakel reports that SFO’s plan includes a detailed communication process to respond quickly if the airport receives information of a credible threat. “The jurisdictions and notifications are clear,” he explains. “The two agencies that will make the determination are the health department of our local county (San Mateo) for domestic flights or CDC for international. These are the primary jurisdictions, although we expect they will always work together to diagnose and make a call to enact a plan.”

Perry Cooper, senior manager of media relations at Seattle-Tacoma International Airport (SEA), says it works much the same way there. If CDC officials determine that a planeload of passengers must be detained for medical evaluation, SEA would block off the far end of one terminal for health officials. 

Cooper says SEA personnel are trained to take direction from the CDC or local health departments in such situations. “We don’t make the decisions to hold someone,” he explains. “We are there for management of space if that is needed.”

National Plan Needed

In a 2015 report, the U.S. Government Accountability Office emphasized the need for a national aviation-preparedness plan for responding to communicable diseases. Personnel interviewed officials at 14 airports and three major U.S. airlines during their research. While all 14 airports had individual emergency preparedness plans in place, the GAO report notes that the United States lacks a comprehensive national plan aimed at preventing and containing the spread of diseases through air travel. 

It also addressed preliminary steps for improvements: “GAO recommends that DOT work with relevant stakeholders, such as the Department of Health and Human Services, to develop a national aviation-preparedness plan for communicable diseases. DOT agrees a plan is needed, but suggests public health agencies lead the effort.

“DOT and CDC officials acknowledge that only certain ‘elements’ of a national aviation-preparedness plan are in place. Such a plan could help maximize an effective response to a public health threat, while minimizing potential inefficiencies in the national response effort and unnecessary disruptions to the national aviation system. A national aviation-preparedness plan that is generic to all communicable diseases and can be adapted for specific diseases would provide individual airports and airlines with an adaptable and scalable framework with which to integrate their individual plans and promote harmonization of individual plans across airports and airlines. As such, the plan could also serve as the basis for testing communication mechanisms among responders to help ensure those mechanisms are effective. In addition, it could help ensure that airport and airline staff have received appropriate training and access to properly maintained equipment during an outbreak to reduce the risk of exposure to communicable diseases.”

Editor’s Note: While most media reports about affected flights mention passengers being quarantined, Airport Improvement magazine adheres to the CDC definitions:

Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. Passengers and crewmembers suspected of exposure are often simply held for medical evaluation and/or isolated from others who are not sick.