# Transportation Systems Casebook/Disease
## Summary

In recent years there has been an upswing in diseases crossing international borders, often at alarming speeds. While much attention presently is devoted to Ebola, let us remind you of some of the other more recent outbreaks: Middle East respiratory syndrome (MERS), Swine Flu (H1N1), Severe Acute Respiratory Syndrome (SARS), Avian Flu (H7N9), and many earlier diseases that were once thought to be controlled through vaccination or eliminated entirely: Poliovirus, Cholera, Yellow Fever, and Measles.
Globalization and advances in technology continue to expand our horizons and bring international borders and continents closer in time than ever before. As air travel has increased so has the risk that an infectious disease could be spread to multiple destinations in a matter of hours. In fact SARS, reached pandemic level by reaching four continents in three days. In light of the recent outbreak of Ebola this case study evaluates the viability of infectious disease screening at airports, specifically within the context of Ebola, and other policy proposals to contain diseases in aviation.

## Annotated List of Actors

* Centers for Disease Control and Prevention (CDC): National public health institute of the United States. Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability.
* Customs and Border Control (CBP): Agency responsible for regulating and facilitating international trade, collecting import duties, and enforcing U.S. regulations, including trade, customs, and immigration.
* Ohio Department of Health: Instituted a mandatory 21 day quarantine for health care workers and travelers arriving from Sierra Leone, Liberia, and Guinea whether or not they have symptoms.
* Texas Health Presbyterian Hospital: This is the hospital that treated the first diagnosed Ebola patient in the U.S. outside of patients transported to the U.S. for treatment. Two nurses that worked at this hospital and cared for that patient later contracted the disease.
* United States Department of Health and Human Services: The U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.
* World Health Organization (WHO): Directs and coordinates authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends.

## Timeline of Events

* 1976 - September 1: Ebola was first diagnosed in Zaire now the Democratic Republic of Congo.
* 1976 – 2013 Sporadic outbreaks of less than 1800 reported human infections with 64% mortality.
* 2013 – December 6: A Guinean toddler who passed away is believed to be “Patient Zero” in current Ebola outbreak.
2014
* March 22: Guinea confirms Ebola.
* March 30: Liberia reports two Ebola cases.
* Aug. 2: First U.S. citizen (a missionary physician) infected with Ebola in is flown to Atlanta for treatment. Treated w/experimental drug. Released Aug 19 disease free.
* Aug. 5: Second U.S. missionary infected with Ebola in is flown to Atlanta for treatment. Treated w/experimental drug and released Aug 21 disease free.
* Sept. 20: A Liberian citizen (Thomas Eric Duncan) attempted to help woman infected with Ebola to seek medical attention, she died from the disease. Mr. Duncan boarded a flight from Liberia to Dallas, TX with connecting flights in Brussels Belgium and Dulles International.
* Sept. 25: Duncan goes to Dallas hospital with fever, abdominal pain and was released. He returns via ambulance on Sept. 28th
* Sept. 30: CDC confirms Duncan has Ebola; first case diagnosed in the U.S.
* Oct. 8: Duncan, dies in Dallas hospital.
* Oct. 11: J.F.K. begins screening operation.
* Oct. 9: Britain announces intent to screen passengers entering country through London's two main airports and Eurostar rail link with Europe. Begins screening at Heathrow, on Oct 14th.
* Oct. 12: Nurse who treated Duncan tests positive for Ebola, becoming first person to contract the virus in the United States.
* Oct. 15: Second Texas nurse who treated Duncan tests positive.
* Oct. 21: U.S. announces that starting Oct. 22 travel from Liberia, Sierra Leone and Guinea will be restricted entry into one of five designated airports for enhanced screening. These include: John F. Kennedy International airport, Dulles, Chicago O’Hare, Newark Airport, and Hartsfield-Jackson. Screening will include monitoring for symptoms of the virus for 21 days.
* Oct. 23: New York reports health care worker returning for Guinea infected. CDC confirms Oct. 24th.
* Oct. 24: The governors of New York and New Jersey order the quarantine of all medical workers returning from these countries.
* Oct. 25: Illinois orders the quarantine of all medical workers returning from these countries
* Oct. 26: Florida will monitor for 21 days people returning from these countries.
* Oct. 27: U.S. military begins isolating personnel returning from Ebola missions in West Africa.
* Australia closes its borders by restricting visas for citizens of Sierra Leone, Liberia and Guinea.
* Oct. 29: infections have occurred in 8 countries total 13,567 cases accounting for 4,960 deaths.

## Background

On August 7th, 2014, Ebola was declared by the World Health Organization (WHO) “public health emergency of international concern”. A part of this decision was based on the death rate, lack of treatments available, and lack of licensed vaccinations.
The Ebola virus is a type of hemorrhagic fever. Hemorrhagic refers to severe bleeding. The symptoms
of this disease are bleeding, fever, nausea, vomiting, diarrhea, bruising, and many other symptoms. Bleeding normally occurs from the eyes, though those near death will also bleed from the nose, ears, and rectum.The WHO estimates the death rate of those infected with Ebola at 50%.
Currently there is not a cure for Ebola. The treatments are supportive such as intravenous fluids and drugs that only treat symptoms. Various potential treatments are in the development process. Also, there are not any licensed vaccines available. The vaccines are in the final stages of gaining licensing approval.
Patient zero of this current Ebola outbreak is believed to be a two year old from Guinea. He died on December 6, 2013. The disease then spread to his mother, sister, and grandmother. Those that attended their funerals then took the disease back to their villages. As of October 27th, 2014 there have been 13,703 Ebola cases with 4,920 deaths.
The first patient with Ebola to arrive in the United States, Thomas Eric Duncan, highlights some of the policy issues. He flew from Liberia to Brussels, and then Brussels to Washington Dulles Airport, and then from Washington Dulles Airport to Dallas Fort-Worth. After arriving in Dallas, Duncan went to Texas Health Presbyterian Hospital for a fever and vomiting. While in triage it was noted that Duncan had recently travelled from Liberia. It is not known if this information was appropriately communicated to the healthcare team. The physical examination found abdominal tenderness and nasal congestion. He was given an antibiotic and pain reliever, then sent home. Three days later Duncan returned to Texas Health Presbyterian Hospital and was admitted. Ten days later Duncan was pronounced dead.
Two nurses contracted Ebola while caring for Duncan. Exactly how the two contracted the virus is unknown. The first nurse to be diagnosed with Ebola, Nina Pham, did not travel after treating Duncan. The second nurse, Amber Vinson, travelled to Cleveland after Duncan had died. While in Cleveland Amber was not exhibiting any signs or symptoms of disease until the final day. Before she boarded a flight from Cleveland to Dallas she called the CDC and reported a 99.5 degree fever. This was below the limit set by the CDC which is 100.4. She was told it was acceptable to board the flight and return to Dallas.
Entry screening began at five U.S. airports in October for travelers from affected areas of West Africa. Entry screening at JFK began on October 12, 2014. The other four airports are Washington Dulles, Chicago’s O’Hare, Atlanta Hartsfield jackson, and Dallas Love Field; they started entry screening on October 16, 2014. As major international hubs, these screenings initially covered over 90 percent of flights involving travelers from West Africa. With continued concerns, a new policy requiring all travelers from West Africa to enter through these hubs was adopted October 21st.Exit screening in Sierra Leone, Guinea, and Liberia was also adopted, but with concerns regarding their effectiveness based on the truthfulness of travelers.
Dr. Craig Allen Spencer is the most recent case of Ebola to be diagnosed on US soil. He was diagnosed on October 23, 2014. The doctor worked with Doctors Without Borders in West Africa and returned to the United States on October 17. He was not required to be under quarantine and went about normal life in New York City. He was self monitoring his temperature per the guidelines given to him by Doctors Without Borders. Between 10 a.m. and 11 a.m. the doctor found that he had a fever of 100.3. He notified Doctors Without Borders which arranged for his transportation to Bellevue Hospital. The doctor had gone through the mandatory screening point at JFK International Airport which involved a temperature check and travel survey.
In response to Dr. Craig Allen Spencer’s Ebola case the governors of New York and New Jersey have implemented a mandatory 21 day home quarantine for health care workers that had contact with Ebola patients and other arriving travelers that had contact with Ebola infected people. On October 31, 2014 Ohio adopted the same quarantine rules. A nurse in Maine was battling a quarantine order in court, which a Maine judge rejected.

## Clear Identification of Policy Issues

A number of policies have been either implemented or advocated for in addressing the potential spread of Ebola from West Africa. Airport screenings involving temperature checks and heightened questioning have been adopted, in addition to travel restrictions funneling West African travelers through key airports where they are subject to screenings.
- Airport Screenings
Exit screenings have been adopted for travelers leaving affected countries in West Africa, however there are concerns that travelers may not be honest in answering questions about their exposure to Ebola. Even when truthful, temperature scans are not effective earlier during the disease before temperature spikes. Similar screenings were found to be ineffective during an earlier outbreak of Swine Flu. Entry screenings into the United States have also been adopted, along with requirements for travel through certain airports as part of travel restrictions.
- Travel Restrictions & Bans
A restriction on entry to the United States has been adopted for travelers originating from West Africa, funneling travelers through five major international hubs where entry screenings have been expanded. These entry screenings have the same challenges as exit screenings in West Africa, leading some to advocate for outright travel bans for travelers from West Africa or beyond. However, there are few direct flights from West Africa to the United States, with most travelers having a layover in London or Brussels. A travel ban would have to determine the original point of origin for a traveler, which may be challenging and require additional resources if the traveler does not cooperate. Such a ban would also impact international travelers, including humanitarian workers, and undermine the effort to control Ebola within West Africa.
An outright ban of all people with passports from the affected countries may impact students and international workers with visas who have not been back home for extended periods of time. A travel ban would significantly reduce flights in West Africa, reducing the ability of humanitarian workers to continue to not only visit the countries, but also operate within the countries where roads and other infrastructure may be poor. The U.S. humanitarian response, including Pentagon travel, currently depends on private contractors with the Pentagon working to deploy their own planes for transport in January.

## Discussion Questions

* Is it feasible to establish infectious disease screenings at airports? If yes, which airport – origin or destination?
* Should medical workers who volunteer (or are ordered to the infected area – as in the military) and come in direct contact with the virus be involuntarily confined (quarantined) for a defined period upon their return from the infected areas? If yes, should they be compensated? Should there be different regulations for medical volunteers versus members of the military?
* Are travel restrictions or travel bans about protecting against the spread of a disease, or security theater to calm public concerns?
* While this study asks about airports, should screening procedures include other ports (sea) or points of entry?

## Additional Readings

* Ebola - Signs and Symptoms. http://www.cdc.gov/vhf/ebola/symptoms/index.html
* Ebola - How is it transmitted? http://www.cdc.gov/vhf/ebola/transmission/index.html
* Ebola - Treatment. http://www.cdc.gov/vhf/ebola/treatment/index.html
* Questions and Answers about CDC’s Ebola Monitoring & Movement Guidance. http://www.cdc.gov/vhf/ebola/exposure/qas-monitoring-and-movement-guidance.html
* These scientific studies show that airport Ebola screenings are largely ineffective. http://www.washingtonpost.com/blogs/federal-eye/wp/2014/10/31/these-scientific-studies-show-that-airport-ebola-screenings-are-largely-ineffective/
* Why a travel ban wouldn't work. http://www.politico.com/story/2014/10/travel-ban-flights-ebola-111961.html
* Why an Ebola flight ban wouldn't work. http://fivethirtyeight.com/datalab/why-an-ebola-flight-ban-wouldnt-work/

## References

* ↑ Gaber, W., Goetsch, U., Diel, R., Doerr, H, & Gottschalk. (2009) Screening for Infectious Diseases at International Airports: The Frankfurt Model. [Electronic Version]. Aviation, Space and Environmental Medicine, 80(7), 595-600.
* ↑ Oatis, J. (October 28, 2014). Chronology – Worst Ebola outbreak on record tests global response. Retrieved on October 31, 2014 from http://www.reuters.com/article/2014/10/28/health-ebola-idUSL2N0SG2FH20141028.
* ↑ Centers for Disease Control (October 2014). Ebola Outbreak in West Africa – Case Counts. From http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html.
* ↑ Centers for Disease Control (October 2014). 2014 Ebola Outbreak in West Africa – Outlook Distribution Map. From http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html
* ↑ World Health Organization (November 2014). Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. From http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/
* ↑ Centers for Disease Control and Prevention (November 2014). Ebola (Ebola Virus Disease). From http://www.cdc.gov/vhf/ebola/index.html
* ↑ Mayo Clinic (November 2014). Ebola virus and Marburg virus Symptons. From http://www.mayoclinic.org/diseases-conditions/ebola-virus/basics/symptoms/con-20031241
* ↑ World Health Organization (November 2014). Ebola virus disease. From http://www.who.int/mediacentre/factsheets/fs103/en/
* ↑ World Health Organization (November 2014). Ebola virus disease. From http://www.who.int/mediacentre/factsheets/fs103/en/
* ↑ Park, Madison. CNN (October 2014). Report: Ebola outbreak probably started with 2-year-old in Guinea. From http://www.cnn.com/2014/08/11/health/ebola-patient-zero/
* ↑ World Health Organization (October 2014). Ebola Response Roadmap Situation Report. From http://apps.who.int/iris/bitstream/10665/137376/1/roadmapsitrep_29Oct2014_eng.pdf?ua=1
* ↑ Botlho, Greg. CNN (October 2014). U.S. Ebola patient: The travels and travails of Thomas Eric Duncan. From http://www.cnn.com/2014/10/01/health/us-ebola-patient/
* ↑ Corcoran, Kiernan. Associated Press (October 2014). How Ebola victim Thomas Eric Duncan's organs slowly failed and he begged to be put in a diaper as he lay dying. From http://www.dailymail.co.uk/news/article-2791171/ebola-victim-thomas-eric-duncan-s-organs-slowly-failed-begged-diaper-lay-dying.html
* ↑ Snow, Kate, and Hasani Gittens. NBC News (October 2014). Ebola Nurse Amber Vinson Checked With CDC Before Flight: Source. From http://www.nbcnews.com/storyline/ebola-virus-outbreak/ebola-nurse-amber-vinson-checked-cdc-flight-source-n226961
* ↑ Centers for Disease Control and Prevention (October 2014). Enhanced Ebola Screening to Start at Five U.S. Airports and New Tracking Program for all People Entering from Ebola-affected Countries. From http://www.cdc.gov/media/releases/2014/p1008-ebola-screening.html
* ↑ Berman, Mark. Washington Post (October 2014). All travelers from countries with Ebola must now fly through U.S. airports with stricter screening. http://www.washingtonpost.com/news/post-nation/wp/2014/10/21/all-travelers-from-countries-with-ebola-must-now-fly-through-u-s-airports-with-stricter-screening/
* ↑ Christensen, Jen; Joe Sutton, and Ray Sanchez. CNN (October 2014). Ebola screenings begin at JFK, four more airports start next week. From http://www.cnn.com/2014/10/11/health/ebola/
* ↑ Centers for Disease Control and Prevention. (October 2014). Ebola Virus Disease (Ebola) Pre-Departure/Exit Screening at Points of Departure in Affected Countries. From http://wwwnc.cdc.gov/travel/pdf/ebola-exit-screening.pdf
* ↑ ABC News (October 2014). From Soffee Stand to Bowling Alley: Retracing Steps of Doctor Who Tested Positive for Ebola. From http://abcnews.go.com/Health/retracing-steps-dr-craig-spencer-ebola-diagnosis/story?id=26418093
* ↑ CBS News (October 2014). New York City Doctor Tests Positive for Ebola. From http://newyork.cbslocal.com/2014/10/23/cbs-2-officials-looking-into-possible-ebola-case-in-new-york-city/
* ↑ Marchione, Marilynn. Associated Press (October 2014). Mandatory Ebola quarantines in New York and New Jersey. http://www.myfoxny.com/story/26887903/mandatory-ebola-quarantines
* ↑ Crane, Misti. Columbus Dispatch (November 2014). Ohio adopts mandatory Ebola quarantine for exposed workers. http://www.dispatch.com/content/stories/local/2014/11/01/ohio-adopts-mandatory-ebola-quarantine-for-exposed-workers.html
* ↑ Sanchez, Ray; Catherine Shoichet, and Faith Karimi, CNN (November 2014). Ebola update: Main judge rejects quarantine for nurse Kaci Hickox. From http://www.cnn.com/2014/10/31/health/us-ebola/index.html
* ↑ Hicks, Josh. Washington Post (October 2014). Studies show airport Ebola screenings largely ineffective. From http://www.washingtonpost.com/blogs/federal-eye/wp/2014/10/31/these-scientific-studies-show-that-airport-ebola-screenings-are-largely-ineffective/
* ↑ Silver, Nate. FiveThirtyEight (October 2014). Why An Ebola Travel Ban Wouldn't Work. From http://fivethirtyeight.com/datalab/why-an-ebola-flight-ban-wouldnt-work/
* ↑ Cohn, Jonathan. The New Republic (October 2014). The CDC's New Ebola Plan Is Better Than a Travel Ban. From http://www.newrepublic.com/article/119937/cdc-announces-active-monitoring-ebola-better-travel-ban
* ↑ Berman, Mark. Washington Post (October 2014). Why new airport screening still can’t prevent more Ebola cases in the U.S. From http://www.washingtonpost.com/news/post-nation/wp/2014/10/07/why-new-airport-screening-still-cant-prevent-more-ebola-cases-in-the-u-s/
* ↑ Zoroya, Gregg. USA Today (October 2014). Pentagon builds units to transport Ebola patients. From http://www.usatoday.com/story/news/world/2014/10/26/ebola-transport-military-patients-aircraft-phoenix-air/17669025/