Accessible Version

AIR TRAVEL AND 

COMMUNICABLE 

DISEASES

Comprehensive 

Federal Plan Needed 

for U.S. Aviation 

System’s 

Preparedness

Report to Ranking Member, 

Subcommittee on Aviation, Committee 

on Transportation and Infrastructure, 

House of Representatives

December 2015

GAO-16-127

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-16-127, a report to the 

Ranking Member, Subcommittee on Aviation, 

Committee on Transportation and 

Infrastructure, House of Representatives

December 2015

AIR TRAVEL AND COMMUNICABLE DISEASES

Comprehensive Federal Plan Needed for U.S. Aviation 

System’s Preparedness

Why GAO Did This Study

Past communicable diseases, such as 

the recent Ebola epidemic, have 

resulted in many deaths and highlight 

the potential economic cost of 

disruptions to air travel and the U.S. 

and global economies. 

GAO was asked to review the 

preparedness of the U.S. aviation 

system to respond to communicable 

diseases. This report examines (1) the 

extent to which selected U.S. airports 

and airlines have plans for responding 

to communicable disease threats from 

abroad and to which a national 

aviation-preparedness plan guides 

preparedness, and (2) the challenges 

that U.S. airports and airlines have 

faced when responding to threats and 

any actions taken to address them. 

GAO reviewed available documents 

and interviewed representatives from 

14 U.S. international airports—selected 

to reflect a range of activities and 

facilities—and the 3 major U.S. 

airlines. GAO also reviewed applicable 

federal requirements and international 

obligations and guidance for U.S. 

airports and airlines, and interviewed 

officials and reviewed documents from 

federal agencies and aviation 

stakeholder groups. 

What GAO Recommends

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. GAO 

continues to believe the 

recommendation is correctly directed 

to DOT, as discussed in this report.

What GAO Found

All of the 14 airports and 3 airlines GAO reviewed have plans for responding to 

communicable disease threats from abroad, although the United States lacks a 

comprehensive national aviation-preparedness plan aimed at preventing and 

containing the spread of diseases through air travel. U.S. airports and airlines are 

not required to have individual preparedness plans, and no federal agency tracks 

which airports and airlines have them. Consequently, it is not clear the extent to 

which all U.S. airports and airlines have such plans. The plans GAO reviewed 

generally addressed the high-level components that GAO identified as common 

among applicable federal and international guidance, such as establishment of 

an incident command center and activation triggers for a response. GAO 

identified these components to provide a basis for assessing the breadth of the 

plans. The plans GAO reviewed for each airport were developed by, or in 

collaboration with, relevant airport stakeholders, such as Centers for Disease 

Control and Prevention’s (CDC) airport staff. As provided in Annex 9, the 

Chicago Convention, an international aviation treaty to which the United States is 

a signatory, obligates member states to develop a national aviationpreparedness plan for communicable disease outbreaks. The Department of 

Transportation (DOT) and CDC officials contend that some elements of such a 

plan already exist, including plans at individual airports. However, FAA has 

reported that individual airport plans are often intended to handle one or two 

flights with arriving passengers, rather than an epidemic, which may require 

involvement from multiple airports on a national level. Most importantly, a 

national aviation-preparedness plan would provide airports and airlines with an 

adaptable and scalable framework with which to align their individual plans—to 

help ensure that individual airport and airline plans work in accordance with one 

another. DOT and CDC officials agree that a national plan could add value. Such 

a plan would provide a mechanism for the public-health and aviation sectors to 

coordinate to more effectively prevent and control a communicable disease 

threat while minimizing unnecessary disruptions to the national aviation system. 

Aviation stakeholders GAO spoke with identified multiple challenges in 

responding to communicable disease threats and actions they took or would take 

in response. For example, airline and airport representatives told GAO they 

sometimes experienced difficulties sharing timely and accurate information about 

threats, and some reported that they improved communication by developing 

tools, such as standardized forms, to collect and share relevant information. 

Employees at aviation services firms that GAO spoke with—including contract 

workers who clean aircraft—raised concerns about the availability of training and 

access to equipment to control exposure to communicable diseases. Some 

airports GAO reviewed developed additional mechanisms to ensure adequate 

training and preparation during the Ebola threat. A national aviationpreparedness plan could serve as the basis for testing communication 

mechanisms among responders to ensure those mechanisms are effective prior 

to a communicable disease outbreak as well as to provide the basis for ensuring 

that airport and airline staff receive appropriate training and equipment to reduce 

their risk of exposure to communicable diseases during an outbreak. View GAO-16-127. For more information, 

contact Gerald Dillingham, Ph.D., (202) 512-

2834, DillinghamG@gao.gov. 
Letter 1

Page i GAO-16-127 Air Travel and Communicable Diseases

Background 4

Airports and Airlines That We Reviewed Have Plans, but a 

Comprehensive National Aviation-Preparedness Plan Does Not 

Exist 17

Airports, Airlines, and other Stakeholders Faced Challenges 

Responding to Communicable Disease Threats and Are Taking 

Some Actions as a Result 30

Conclusions 42

Recommendation 43

Agency Comments and Our Evaluation 43

Appendix I: Objectives, Scope, and Methodology 45

Appendix II: Technologies for Responding to Communicable Diseases in Aviation 50

Appendix III: Comments from the Department of Transportation 55

Appendix IV: GAO Contacts and Staff Acknowledgments 56

Appendix V: Related GAO Products 57

Appendix VI: Accessible Data 59

Agency Comment Letter 59

Data Tables 60

Table

Table 1: Selected Airports for Review 46

Figure 3: Top Five U.S. International Arrival Airports for Five Global 

Regions, 2014 60

Figures

Figure 1: Major Epidemic Threats since 2002 5

Figure 2: Potential Response by Flight Stage for Addressing 

Communicable Disease Threats from Abroad 10

Figure 3: Top Five U.S. International Arrival Airports for Five Global 

Regions, 2014 14

Figure 4: U.S. Airports with Centers for Disease Control and Prevention 

Quarantine Stations, 2015 21

Contents
Page ii GAO-16-127 Air Travel and Communicable Diseases

Abbreviations

ACI Airport Council International 

AEP airport-emergency plans 

CAPSCA Collaborative Arrangement for the Prevention and 

 Management of Public Health Events in Civil 

 Aviation 

CARE Check and Report Ebola kit

CBP U.S. Customs and Border Protection 

CDC Centers for Disease Control and Prevention 

CDRP communicable-disease response plan 

Chicago Convention Convention on International Civil Aviation

DHS Department of Homeland Security 

DOT Department of Transportation 

FAA Federal Aviation Administration 

HEPA high-efficiency particulate air 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

IATA International Air Transport Association 

ICAO International Civil Aviation Organization 

IHR International Health Regulations 

MERS Middle East Respiratory Syndrome

MOU memorandum of understanding 

OSHA Occupational Safety and Health Administration 

PPD-8 Presidential Policy Directive 8 

RBBS Risk-Based Border Strategy 

SARPs standards and recommended practices 

SARS severe acute respiratory syndrome 

TB tuberculosis 

WHO World Health Organization

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Page 1 GAO-16-127 Air Travel and Communicable Diseases

441 G St. N.W.

Washington, DC 20548

December 16, 2015

The Honorable Rick Larsen

Ranking Member

Subcommittee on Aviation

Committee on Transportation and Infrastructure

House of Representatives

Dear Mr. Larsen:

In 2014, almost 52-million international air travelers entered the United 

States, and the Federal Aviation Administration (FAA) expects that 

number to continue to increase as the global economy continues to 

develop. The Ebola epidemic in West Africa in 2014 and 2015 renewed 

concerns about the spread of communicable diseases through air travel. 

More than any other mode of transportation, air travel creates the 

potential for an infection to move quickly from one part of the world to 

another.1In response to Ebola there were proposals in the United States to 

restrict travel and trade to and from affected countries, although public health 

officials advised permitting travel to allow access to medical supplies and 

qualified personnel to contain the epidemic. While deaths and illnesses 

may be the most visible effect of an outbreak, communicable disease 

threats also create economic costs. In the case of the 2003 severe acute 

respiratory syndrome (SARS) epidemic, for example, the International Air 

Transport Association (IATA) estimated the overall cost at $33 billion of 

global gross domestic product in 2003. North American airline revenue 

losses alone were estimated at $1 billion, while Asia Pacific airlines lost 

an estimated $6 billion.2

 

1For more information about the interaction of the aviation sector and communicable 

disease threats, see Airport Cooperative Research Program, Transportation Research 

Board, Interagency–Aviation Industry Collaboration on Planning for Pandemic Outbreaks, 

Conference Proceedings 41 (Washington, D.C.: 2008). 

2

IATA, Economic Briefing: Avian Flu (May 2006). 

Letter
We have found—in lessons learned from the response to the 2009 H1N1 

influenza pandemic

Page 2 GAO-16-127 Air Travel and Communicable Diseases

3—that interagency planning and exercises build formal 

networks and informal relationships that are valuable during a response.4

Further, in the aviation area, international guidance for aviation stakeholders—

including guidance for civil aviation authorities such as FAA—points to the 

importance of preparedness plans for communicable disease threats, with 

recommendations designed to reduce exposure to the disease and 

improve the response to health-related emergencies by establishing 

mechanisms for rapid decision-making and action.5

In light of recurring communicable disease threats, the continued growth 

in international air travel, and the need to prepare for future threats, you 

asked us to review issues related to the preparedness of the U.S. aviation 

system to respond to pandemics and other health crises. This report 

examines (1) the extent to which selected airports and airlines have 

preparedness plans to respond to communicable disease threats from 

abroad and the extent to which a national aviation-preparedness plan 

guides preparedness, and (2) what challenges U.S. airports and airlines, 

including their contractors, have faced when responding to communicable 

disease threats and any actions they have taken to respond to those 

challenges.

To conduct this work, we identified and reviewed applicable federal 

requirements, international obligations, as well as federal and 

international guidance for U.S. airports and airlines with international air 

traffic. We interviewed officials and reviewed available documents from 

five federal departments that represent the key federal departments with 

responsibilities for preparing for and responding to communicable disease 

threats from abroad—the Departments of Transportation (DOT), Health 

and Human Services (HHS), Homeland Security (DHS), State, and Labor 

 

3According to the Centers for Disease Control and Prevention (CDC), epidemic refers to an 

increase, often sudden in the number of cases of a disease above what is normally expected in 

that population in that area. Outbreak carries the same definition of epidemic, but is often 

used for a more limited geographic area. Finally, pandemic refers to an epidemic that has 

spread over several countries or continents, usually affecting a larger number of people. 

4GAO, Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future 

Planning, GAO-11-632 (Washington, D.C.: June 27, 2011). 

5Airport Council International (ACI) and International Civil Aviation Organization (ICAO), 

Airport Preparedness Guidelines for Outbreaks of Communicable Disease, Revised (April 

2009); IATA, Emergency Response Plan: A Template for Air Carriers (May 2009). 
and their relevant components, including DOT’s Federal Aviation 

Administration (FAA), HHS’s Centers for Disease Control and Prevention 

(CDC), DHS’s U.S. Customs and Border Protection (CBP), and Labor’s 

Occupational Safety and Health Administration (OSHA). We identified 

high-level components that were common among applicable federal and 

international guidance, as well as corroborating information collected from 

aviation stakeholders whom we spoke with. Then, we developed a list of 

high-level components for airport and airline communicable-disease 

preparedness plans to provide a basis for assessing the breadth of the 

plans. We compared these components against the available plans 

collected from 14 airports and three airlines that we selected for review 

during our study. We did not evaluate the plans for sufficiency or level of 

preparedness. We selected for review 14 airports that met one or more of 

our selection criteria, which included being a large hub airport

Page 3 GAO-16-127 Air Travel and Communicable Diseases

6 with CDC 

staff on-site; receiving the largest and second largest number of international 

passengers from at least one of five world regions; having enhanced 

passenger entry-screening procedures in place for Ebola; and having 

experience with a confirmed Ebola case. We selected for review the three 

U.S. airlines that handle the largest quantity of international travelers.7In 

addition to reviewing the plans, we administered a questionnaire to each of the 14 

airport operators on preparedness at their airport, such as the plans and 

procedures they have in place for a variety of circumstances. We interviewed 

a range of stakeholders to discuss preparedness plans and potential 

opportunities to improve preparedness, as well as to identify challenges 

airports and airlines have faced in responding to communicable disease 

threats, including Ebola, and actions stakeholders have taken to address 

those challenges. These stakeholders include representatives from the 14 

selected airports and their local airport stakeholders—such as first 

responders, local public health officials, CBP officials, and CDC officials, if 

applicable; the three selected U.S. airlines; airport, airline, and flight 

attendant industry associations;8the International Civil Aviation Organization 

(ICAO); the labor union representing airport- and airline-service workers; and 

 

6U.S. commercial service airports accounting for 1 percent or more of total annual U.S. 

passenger enplanements. 49 U.S.C. § 47102(10).

7American Airlines, Delta Air Lines, and United Airlines.

8Airport Council International (ACI) North America, Airlines For America, and Association of 

Flight Attendants.
contracted aviation-services employers and their employees.

Page 4 GAO-16-127 Air Travel and Communicable Diseases

9 We also 

identified challenges and actions through our attendance at an ICAO global 

symposium. Additional detail on the scope and methodology of our review is 

contained in appendix I.

We conducted this performance audit from November 2014 to December 

2015 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

A number of communicable disease threats have raised concern 

regarding international transmission and travel since the 2003 SARS 

epidemic, which was the first major new disease of the 21st century, 

according to the World Health Organization (WHO) of the United Nations. 

WHO described that 2003 epidemic as a watershed event, because it 

revealed how much the world had changed in terms of the impact that 

communicable diseases can have in a highly mobile and closely 

interconnected world.10 Figure 1 provides information about major 

communicable disease epidemics since 2002.

 

9We consulted with representatives from the union that represents these workers to identify 

aviation service employees to speak with, and we conducted interviews with two of the four firms 

that the nine employees identified worked for, as well as three of the four airports where 

they worked.

10WHO, Outbreak Communication: Best Practices for Communicating with the Public during an 

Outbreak, Report of the WHO Expert Consultation on Outbreak Communications held in 

Singapore, September 21–23, 2004. 

Background
Figure 1: Major Epidemic Threats since 2002

Page 5 GAO-16-127 Air Travel and Communicable Diseases

The International Health Regulations (IHR) are an international 

agreement of the World Health Assembly, the governing body of WHO, 

and were originally adopted by the Assembly in 1969 to address certain 

disease threats. The IHR have evolved since then in response to the 

growth in international travel and trade and the emergence of 

international disease threats. Most recently, the IHR were revised in 2005 

following the SARS epidemic.11 WHO implements and oversees the IHR 

and—together with its partners, such as the International Civil Aviation 

Organization (ICAO)—helps member states build response capacities. 

 

11The revised IHR (2005) were adopted by the World Health Assembly on May 23, 2005, and 

became effective in the summer of 2007. 
ICAO takes a key role in coordinating the international aviation response 

to public health risks.

Page 6 GAO-16-127 Air Travel and Communicable Diseases

12 Through the IHR, WHO member states have agreed to 

build core capacities at designated ports of entry,13 such as airports, to limit the 

spread of public health risks—such as communicable disease threats—while at 

the same time minimizing any unnecessary interference with travel and 

trade.

ICAO develops international standards and recommended practices 

(SARPs) for civil aviation systems, in cooperation with its member states 

and global aviation organizations.14 Member states, including the United 

States, are obligated to establish regulations or take other appropriate 

steps to implement the ICAO standards within their own civil aviation 

systems.15 In the United States, different agencies are responsible for different 

aspects of the civil aviation system, as discussed below. The SARPs 

include some health-related standards and recommended practices 

based on the most recent IHR obligations. To encourage member states 

to comply with these health-related SARPs, ICAO has developed a 

template for the development of national aviation public-health 

emergency-preparedness plans, which are obligations under the IHR.16

The Collaborative Arrangement for the Prevention and Management of Public 

Health Events in Civil Aviation (CAPSCA) also works to bring together 

international, regional, national, and local organizations to develop a 

 

12ICAO is a United Nations specialized agency created in 1944 by the Convention on 

International Civil Aviation (Chicago Convention), under which ICAO Member States 

agreed, among other things, “to take effective measures to prevent the spread by means 

of air navigation of cholera, typhus (epidemic), smallpox, yellow fever, plague and such 

other communicable diseases as the [ICAO Member] States shall from time to time decide 

to designate.” Art. 14, Chicago Convention. 

13Article 19 of the IHR. 

14The ICAO Standard contained in paragraph 8.12 of Annex 9 (Facilitation) to the Chicago 

Convention states that “[ICAO Member] States shall comply with the pertinent provisions 

of the IHR. Member states are not obligated to follow the recommended practices, 

although these may also be used to develop regulations or guidance by the relevant 

agency of the member state’s government. 

15Member states are obligated to notify ICAO of a “difference” from the international standard, if 

they find it impractical to fully comply with an international standard or otherwise differ from 

the standard in their regulations or practices. Art. 38, Chicago Convention. 

16ICAO, Template for a National Aviation Public Health Emergency Preparedness Plan, accessed 

December 31, 2014, 

http://www.capsca.org/Documentation/TemplateAviationPHEPNov2010.pdf. 
coordinated approach to preparedness and response. Other international 

organizations, notably Airports Council International (ACI) and IATA, also 

provide assistance to airports and airlines, respectively, in preparing for 

communicable disease threats.

In the United States, a number of federal agencies, aviation stakeholders, 

and others have roles and responsibilities in preparing for, assessing, and 

responding to communicable disease threats in the aviation system. Each 

of the federal agencies involved in preparing for or responding to 

communicable disease threats from abroad have a different mission, 

including those described below, that affects their responsibilities for 

protecting against communicable disease threats. DHS and HHS are the 

lead agencies in a response to a communicable disease threat, and other 

federal agencies provide support as necessary.

· Within DHS, CBP aims to safeguard America’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. CBP officials at ports of entry, including 

airports, conduct the primary inspection of arriving international 

travelers and have authority to permit or deny admission to the United 

States.

Page 7 GAO-16-127 Air Travel and Communicable Diseases

17

· Within HHS, CDC has defined its mission as protecting America from 

health, safety, and security threats, both foreign and domestic. With 

its partners, such as CBP, CDC responds to sick travelers who arrive 

in the United States at major airports, seaports, or land border 

crossings, when warranted. CDC alerts travelers about disease 

outbreaks and steps they can take to protect themselves. CDC also 

has the authority to quarantine passengers traveling from foreign 

 

17CBP possesses broad authority under customs and immigration laws to examine merchandise, 

cargo, conveyances, and persons upon their entry to and exit from the United States. 19 U.S.C. 

§§ 482, 1461, 1496, 1499, 1581, 1582, 1589a, and 1595; 8 U.S.C. §§ 1222, 1225, and 

1357. 
countries, if necessary, to protect the general population and respond 

to disease threats to the United States.

Page 8 GAO-16-127 Air Travel and Communicable Diseases

18

· Within DOT, FAA is responsible for safety of flight in the United States 

and the safe and efficient movement of air traffic in the national 

airspace system, as well as for the safety of U.S. airlines, other U.S. 

operators, and FAA-certificated air crews worldwide. As part of this 

responsibility, the agency regulates and certificates airports, airlines, 

and airmen and provides guidance through advisory circulars and 

other means.

· Within the Department of Labor, OSHA aims to assure safe and 

healthful working conditions for working men and women by setting 

and enforcing standards and by providing training, outreach, 

education, compliance, and assistance.19

· The Department of State (State) has the authority to grant visas, 

which allow foreign citizens to travel to a U.S. port of entry (generally 

an airport) and request permission to enter the United States.20

 

18Under section 361 of the Public Health Service Act (codified at 42 U.S.C. § 264), HHS is 

authorized to make and enforce regulations to prevent the entry and spread of communicable 

diseases from foreign countries into the United States and among states. The authority for 

carrying out these functions on a daily basis has been delegated to CDC, an agency in 

HHS. Under 42 C.F.R. parts 70 and 71, CDC may provide for the detention, medical 

examination, and release of persons arriving into the United States and traveling among 

states who are suspected of carrying these communicable diseases. Quarantinable 

diseases include cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow 

fever, viral hemorrhagic fevers (including Ebola), severe acute respiratory syndromes, and 

flu that can cause a pandemic (Executive Order No. 13674, § 1, 79 Fed. Reg. 45671 (July 

31, 2014)). 

19Several OSHA standards and directives are directly applicable to protecting workers against 

transmission of infectious agents. These include OSHA’s Bloodborne Pathogens standard 

(29 C.F.R. § 1910.1030), which provides protection of workers from exposures to blood 

and body fluids that may contain blood-borne infectious agents; OSHA’s Personal

Protective standard (29 C.F. R. § 1910.132) and Respiratory Protection standard (29 C.F. 

R. § 1910.134) which provide some protection for workers when exposed to infectious 

agents transmitted through routes other than the bloodborne route; and OSHA’s TB 

compliance directive which protects workers to a certain degree against exposure to TB 

through enforcement of existing applicable OSHA standards and the General Duty Clause 

of the OSH Act (29 U.S.C. § 654). 

20A visa does not guarantee entry into the United States. 
Depending on location and threat, these agencies along with aviation 

stakeholders and their partners—including local public health 

authorities,

Page 9 GAO-16-127 Air Travel and Communicable Diseases

21 first responders, contracted aviation-services firms, and others—

may each have a role in preparing for or responding to a communicable disease 

incident. That is, the specific response actions taken by individual entities, 

such as airports and airlines—as well as federal, state, and local 

authorities—will depend on the operating characteristics of the airline or 

airport, disease characteristics, and the type and level of threat that 

exists. Finally, some roles and responsibilities for a response to a threat 

in the aviation system are established in law or by agreement and others 

may be defined in preparedness plans. Airports are required by FAA 

regulations to develop airport-emergency plans (AEP), which must 

address a variety of hazards, including aircraft incidents and accidents, 

acts of terrorism, fires, natural disasters, hazardous materials, power 

failures, or water rescues.22 These plans are not required to address 

communicable disease threats.

The risk of disease transmission in an airport and aboard airlines may be 

heightened during a communicable disease epidemic, although airports, 

airlines, and public health authorities may have to address travelers with 

more common communicable diseases such as tuberculosis or measles 

at any time. The recent Ebola epidemic in West Africa provides an 

example of a regional epidemic that triggered governments and aviation 

stakeholders to take additional precautions during each stage of air travel 

to minimize the spread of the disease. Figure 2 shows routine and 

potential enhanced safety measures that may be taken before, during, 

and after flights by a variety of stakeholders.

 

21For purposes of this report, we refer to state, local, and tribal public health authorities as 

local public health authorities. 

2214 C.F.R. § 139.325. See also FAA, Advisory Circular: Airport Emergency Plan, 150/5200-31C 

(Washington, D.C.: July 19, 2009).
Figure 2: Potential Response by Flight Stage for Addressing Communicable Disease Threats from Abroad

Page 10 GAO-16-127 Air Travel and Communicable Diseases

Before boarding an aircraft, passengers may be prevented from travel if 

they have a communicable disease that could pose a public health threat 

during the flight. For example, in the United States, DHS and HHS can 

identify travelers who are not allowed travel, based on public health 

threats.23 Airlines may only refuse to board a passenger—or otherwise restrict 

or delay travel—with a communicable disease under DOT regulations if that

passenger poses a direct threat to the health and safety of others.24

Additionally, the Department of State can restrict visas for foreign travelers with 

a communicable disease, preventing them from entering the United States. 

Governments in areas experiencing such an outbreak may screen 

passengers exiting the area and restrict or discourage the transport of ill 

 

23When HHS requests DHS assistance, HHS notifies TSA of individuals it has identified as 

public health threats who should be designated “Do Not Board.” The public health “Do Not 

Board” list—created in response to concerns about prior drug-resistant tuberculosistraveler incidents—is designed to ensure that airlines are notified that they should not 

allow the designated individuals on any commercial flights to or from the United States. 

See GAO, Public Health And Border Security: HHS and DHS Should Further Strengthen 

Their Ability to Respond to TB Incidents, GAO-09-58 (Washington, D.C.: Oct. 14, 2008). 

24An airline can refuse to transport a person with a communicable disease to the extent permitted 

by the airline’s contract of carriage and DOT’s disability regulation, 14 C.F.R. Part 382. 

Under DOT nondiscrimination regulations, passengers who have a communicable disease 

or infection may only be prevented from traveling; required to delay travel; subjected to 

any condition, restriction, or requirement not imposed on other passengers; or required to 

provide a medical certificate if the ill passengers pose a direct threat. A direct threat is “a 

significant risk to the health or safety of others that cannot be eliminated by a modification 

of policies, practices, or procedures, or by the provision of auxiliary aids or services.” 14 

C.F.R. §§ 382.3 and 382.19(c). 
or possibly contagious passengers. Under the IHR, these decisions may 

be made based on recommendations from WHO, although states can 

make their own entry- and exit-screening decisions. During the SARS 

epidemic, WHO recommended screening travelers before their departure 

from affected areas on international flights for symptoms associated with 

SARS and advising travelers with symptoms to postpone travel. To date, 

WHO has not recommended screening passengers departing from a U.S. 

airport, and the United States has never instituted such a precaution, 

according to CDC officials. Aviation stakeholders have questioned the 

legal authority by which the United States could implement exit screening. 

According to CDC officials, such screening could be done under HHS’s 

quarantine and isolation authorities.

Page 11 GAO-16-127 Air Travel and Communicable Diseases

25

CDC regulations require pilots to immediately report to CDC any deaths 

or the occurrence of any travelers with signs or symptoms that may 

indicate a communicable disease infection during international flights 

coming to the United States.26 In the case of an ill traveler, CDC guidance 

recommends that the aircraft’s crew take practical measures to protect themselves

and others. These measures may include avoiding direct contact with 

bodily fluids, and if indicated, isolating ill passengers who exhibit specific 

signs or symptoms consistent with a communicable disease, as well as 

providing ill passengers with tissues or a mask. In conducting its 

assessment, CDC may also request that aircraft crewmembers hand out 

information about health risks or collect and report information on a 

suspected ill passenger’s travel history, as done during the recent Ebola 

epidemic in West Africa. According to CDC officials, reporting suspected 

ill travelers before the flight’s arrival gives ground-based responders 

preparation time to provide for medical assessment and treatment of the 

traveler upon arrival, if warranted.

 

2542 U.S.C. § 264. 

26CDC regulations require that “the commander of an aircraft destined for a U.S. airport shall 

report immediately to the quarantine station at or nearest the airport at which the aircraft 

will arrive, the occurrence, on board, of any death or ill person among passengers or 

crew.” 42 C.F.R. § 71.21(b). CDC regulations define “ill person” (42 C.F.R. § 71.1). 42 

C.F.R. Part 70.4 requires reports of suspected cases of communicable disease on 

interstate flights to be made to the local public health authority with jurisdiction for the 

arrival airport. ICAO standards require that notification be made to air traffic control 

authorities. FAA and CDC have an agreement on how notifications are relayed. See 

Memorandum of Agreement between the Federal Aviation Administration and the Centers 

for Disease Control and Prevention, October 26, 2010.
Once an aircraft with a suspected ill passenger approaches an airport, 

decisions about where to park the aircraft, how to respond to the 

suspected ill passenger, and how to deplane other passengers may be 

coordinated among stakeholders, according to ICAO guidance. Federal or 

local public health officials, first responders (e.g., fire or emergency 

medical technicians), airport authorities, air traffic control personnel, or a 

combination of these stakeholders may make these decisions and lead 

certain components of the response based on the situation and available 

response protocols or preparedness plans. If a communicable disease is 

confirmed, CDC is to follow established protocols and work with state and 

local public health authorities to assess and provide interventions to other 

travelers onboard the aircraft, if necessary.

Passengers infected with respiratory, gastrointestinal, or blood-borne 

communicable diseases may contaminate aircraft or airports with bodily 

fluids. Whether any measures beyond routine airline- and airport-cleaning 

practices are necessary will depend upon the characteristics of the 

disease in question, according to CDC guidance. For international flights, 

CDC may require additional cleaning or disinfection to prevent the 

transmission of a communicable disease.

Page 12 GAO-16-127 Air Travel and Communicable Diseases

27 Airline representatives told us 

that they may also opt for a more thorough decontamination as a precaution. 

Decontamination may be carried out by airport or airline staff or by contracted 

aviation-services firms.28 During flights, cabin crew may clean potentially 

infectious material to protect other passengers, and CDC provides 

guidance on how to carry out this targeted cleaning. The occupational 

health and safety of airline, airport, or contracted aviation-service 

employees on the ground is overseen by OSHA, which sets and enforces 

workers’ health and safety standards related to communicable diseases 

and provides guidance on personal protective equipment, 

decontamination, and handling waste contaminated by potentially 

infectious material, with certain exceptions.29 On board an aircraft in 

 

2742 C.F.R. § 71.32. 

28According to FAA officials, any cleaning methods used to address a communicable 

disease threat must not negatively affect the airworthiness of the aircraft.

29OSHA considers occupational health and safety hazards faced by workers when prioritizing its 

inspections, including dangerous situations, fatalities, catastrophes, complaints, or 

referrals, among other criteria. This prioritization does not consider the potential for 

workers to spread occupational health hazards such as communicable diseases to the 

broader public. In the aviation system, the agency conducts new investigations based on 

reported safety incidents or worker allegations, according to agency officials. 
operation, responsibility for the health and safety of employees is divided 

between the FAA and OSHA. FAA is responsible for all working conditions of 

flight crew (i.e., pilots, flight engineers, and flight navigators) and for most, but 

not all, working conditions of cabin crew (e.g., flight attendants).

Page 13 GAO-16-127 Air Travel and Communicable Diseases

30

According to DOT’s origin-and-destination ticketing data, almost 52-

million air passengers entered the United States from other countries in 

2014, including returning U.S. citizens. While the United States does not 

receive non-stop commercial flights from all countries, including the West 

African countries that suffered the recent Ebola outbreak, passengers 

come from every corner of the globe and fly into airports both large and 

small. Figure 3 shows passenger arrivals from five regions of the world 

and the top five airports receiving passengers whose travel originated 

from each of these regions in 2014 (for a total of 12 airports), based on 

the original departure airport in the ticket itinerary. Together, these 12 

airports received about 50 percent of the total number of passengers 

coming into the United States from abroad in 2014—accounting for more 

than 25 million passenger arrivals.

 

30OSHA standards are not applicable to working conditions onboard an aircraft while it is in 

operation, with the exception of OSHA’s standards on hazard communication, blood-borne 

pathogens exposure, and occupational noise exposure under a memorandum of 

understanding (MOU) between the agencies. An aircraft is in operation from the time it is 

first boarded by a crewmember, preparatory to a flight, to the time the last crewmember 

leaves the aircraft after completion of that flight. See Memorandum Of Understanding 

Between The Federal Aviation Administration U.S. Department Of Transportation And The 

Occupational Safety And Health Administration U.S. Department Of Labor, August 26, 

2014.
Figure 3: Top Five U.S. International Arrival Airports for Five Global Regions, 2014

Page 14 GAO-16-127 Air Travel and Communicable Diseases

aCentral and South America region includes the Caribbean.

Even if an ill passenger on an international flight is not detected while 

onboard an aircraft, he or she may be identified after arrival during the 

customs and immigration inspection process. After an international flight 

arrives in the United States, passengers are to undergo routine inspection 

or possibly enhanced screening for communicable diseases under 

authorities held by HHS31 and DHS (by agreement).32 During primary 

inspection, CBP staff are expected to visually observe arriving international 

travelers for certain signs and symptoms of communicable diseases during their 

 

31HHS has statutory responsibility for preventing the introduction, transmission, and spread of 

communicable diseases into the United States and between the states. 42 U.S.C. §§ 264, 265.

32In 2005, DHS and HHS signed an MOU outlining cooperative efforts to enhance the nation’s 

preparedness against the introduction, transmission, and spread of quarantinable and serious 

communicable diseases from foreign countries into the United States and its possessions. 
routine interactions with travelers and then notify CDC, as appropriate.

Page 15 GAO-16-127 Air Travel and Communicable Diseases

33 CBP 

and CDC may investigate further by asking specific questions during 

primary inspection—such as inquiring about travel to affected areas—or 

by conducting additional assessments such as taking body temperatures 

during secondary or tertiary screening.

For passengers who are asymptomatic (not displaying symptoms) but at 

heightened risk for a communicable disease, CDC officials may also 

establish a means of ongoing monitoring.34 For example, asymptomatic 

passengers from Ebola-affected countries—Guinea, Liberia, and Sierra 

Leone35—receive a Check and Report Ebola (CARE) kit upon arriving in the 

United States if they are found to be at heightened risk of exposure. The kit 

contains guidance and tools to measure and report symptoms to local public 

health officials for the 21-day disease incubation period. Local public 

health authorities are responsible for protecting public health within their 

jurisdictions.36 While CDC and state and local public health agencies coordinate 

closely on many issues, state and local public health authorities may, at their 

discretion and based on their legal authority, impose restrictions or 

requirements in their jurisdictions that are more stringent than those 

issued by CDC.37

In certain extraordinary circumstances, passengers or flights from areas 

experiencing a communicable disease outbreak could be redirected to 

designated U.S. airports with the capacity to receive them. This process 

is commonly referred to as “funneling,” and it may involve re-routing 

 

33CBP has jurisdiction over immigration and customs and—together with its DHS partner 

organizations—assists HHS by enforcing quarantine rules and regulations. 42 U.S.C. § 268(b); see 

also 42 U.S.C. § 97 (including quarantines imposed under state laws). CBP officers are 

trained to identify signs and symptoms of communicable disease of public health concern 

in travelers.

34According to CDC officials, implementation of such measures is extremely rare and would 

require cooperation with state and local public health departments.

35Given the spread of the Ebola epidemic, additional screening questions were also directed at 

travelers from Mali and Nigeria for a period of time. 

36In general, state and local public health authorities are responsible for protecting public health 

within their jurisdictions, which may, at times, overlap with federal authority. 

37During the Ebola outbreak, for example, some jurisdictions put limits on the movement of 

asymptomatic travelers returning from affected countries in West Africa. Likewise, monitoring 

ranged from in-person checkups by medical personnel in some jurisdictions to travelers 

from the affected countries entering data themselves through an online portal. 
passengers by changing their itineraries or directing flights to certain 

airports. Beginning in October 2014, for example, CBP directed all flights 

to the United States with passengers whose recent travel included Ebolaaffected countries to be routed to one of the following five designated 

airports where CBP and CDC staff conducted enhanced entry screening 

procedures:

Page 16 GAO-16-127 Air Travel and Communicable Diseases

38

· John F. Kennedy International Airport,

· Newark Liberty International Airport,

· Washington Dulles International Airport,

· Hartsfield-Jackson Atlanta International Airport, and

· Chicago O’Hare International Airport

Prior to passenger re-routing by airlines, these five airports accounted for 

94 percent of existing arrivals from the affected countries in West Africa 

(Guinea, Liberia, and Sierra Leone), according to CBP officials, all of 

which arrived on connecting flights through other countries.39 Travelers 

who might have arrived at a different airport are now re-routed by airlines—or 

“funneled”—to arrive at one of these five designated airports. Any non-military 

U.S. health personnel returning from the Ebola-affected countries also have 

to return via these airports and go through enhanced screening.

Airports that are not designated to receive passengers from areas 

affected by a communicable disease outbreak may still encounter 

individuals who have recently traveled from affected areas even when 

funneling has been put in place. There have been Ebola-related 

responses at airports that were not identified for funneling, for example. 

One way this could happen is by a passenger traveling on a “broken 

ticket”—a separate itinerary for travel between the affected country and 

the United States via an intermediate destination, such as a country in 

Europe. In this instance, a passenger from an affected country may have 

bought two tickets—one to Europe and a separate ticket to the United 

 

38CBP has authority under 19 U.S.C. § 1433(c) and 19 C.F.R. § 122.32 to limit the locations 

where aircraft entering the United States from abroad may land. CBP announced that all 

flights to the U.S. carrying persons who have recently traveled to, from, or through Ebolastricken countries were to arrive at one of these five U.S. airports. 79 Fed. Reg. 63313 

(Oct. 23, 2014).

39As of September 21, 2015, enhanced entry screening was discontinued for travelers coming to 

the United States from Liberia, following two incubation periods (42 days) since the last survivor 

tested negative for Ebola in that country. As of October 20, 2015, funneling was still in 

place for travelers from Guinea and Sierra Leone. 
States, following a layover. Another scenario is that a passenger could 

have transferred to a domestic flight after passing through a designated

airport and developed symptoms of infection on the later flight. In cases 

such as these, CDC officials or local public health authorities, or both, 

may conduct public health assessments and follow-up activities.

Page 17 GAO-16-127 Air Travel and Communicable Diseases

All of the 14 airports and three airlines we reviewed have plans—often 

contained in multiple documents—in place for responding to 

communicable disease threats from abroad. The plans in place for each 

airport and airline generally address the high-level components that we 

identified as common among applicable federal and international 

guidance.40 We identified these components to provide a basis for assessing the 

 

40For airports, we identified six high-level components through review of DOT’s and HHS’s 

National Aviation Resource Manual for Quarantinable Diseases and ACI’s and ICAO’s 

airport preparedness guidelines for outbreaks of communicable disease. After identifying 

these components, we used corroborating information about high-level components for 

communicable-disease preparedness that we obtained from DOT and FAA officials, a 

representative of CAPSCA, and some airport representatives. For airlines, we identified 

four components through review of IATA’s emergency-response plan template for air 

carriers.

Airports and Airlines 

That We Reviewed 

Have Plans, but a 

Comprehensive 

National AviationPreparedness Plan 

Does Not Exist

Airports and Airlines That 

We Reviewed Generally 

Have CommunicableDisease Preparedness 

Plans

Airports and Airlines We 

Reviewed Have Preparedness 

Plans
breadth of the plans, not to evaluate the sufficiency of the plan’s contents or the 

level of preparedness that the plans provide.

We found the plans in place at each of the 14 airports addressed the 

following six high-level components:

1. Establishment of an incident command center.

2. Coordination among various stakeholders.

3. Selection and use of personal protective equipment for various 

stakeholders.

4. Training for various stakeholders.

5. Some protocols for responding to a threat, such as meeting the 

aircraft, maintaining a quarantine area, or transporting a suspected ill 

passenger.

6. Protocols for decontamination.

The plans in place at each airport were developed by, or in collaboration 

with relevant airport stakeholders, including airport operators, first 

responders, state and local public health representatives, and officials 

from CDC and CBP, as applicable. Not all airports had a separate 

communicable-disease preparedness plan that alone addressed all six 

high-level components. For example, when asked about communicabledisease preparedness planning, representatives from 11 of the 14 

airports reported that the procedures for responding to these threats at 

their airport were contained in multiple documents,

Page 18 GAO-16-127 Air Travel and Communicable Diseases

41 ranging from a general 

emergency preparedness plan, such as the airport-emergency plan (AEP)—

required by FAA regulations, but not required to specifically address 

communicable diseases42—to a disease-specific preparedness plan, such as a 

pandemic influenza response plan. Other types of documents included a 

 

41Representatives from the remaining three airports reported that procedures for responding to 

communicable disease threats at their airport were contained in one document. 

4214 C.F.R. § 139.325. FAA provides airport operators guidance, in the form of an Advisory 

Circular, for development and implementation of an AEP. FAA AC 150/5200-31C. The 

Advisory Circular recommends that airports structure their plans using a functional 

approach, which strives to avoid duplication of a planning effort for every hazard and task. 

Thus, it provides some guidance to airports for developing basic emergency response 

procedures, such as assigning responsibilities for emergency operations, which are 

relevant to the response to any type of emergency—including communicable disease 

threats.
checklist for first responders; standard-operating procedures for a specific 

disease, such as Ebola; and CDC’s communicable-disease response 

plans (which are discussed more below). During the Ebola outbreak, 

representatives from eight airports that we reviewed reported developing 

an additional Ebola-specific response plan or adapting an existing plan.

All three of the airlines we reviewed have a preparedness plan for 

responding to communicable disease threats. The plans themselves were 

not available to us because of their proprietary nature; however, based on 

our conversations with airline representatives and a review of summary 

information regarding their plans, we can report that the three airlines’ 

plans addressed the following four high-level components:

1. Establishment of emergency response team and designation of 

emergency response center.

2. Description of the triggers that inform the level and nature of a 

response.

3. Activation triggers for the response team and response center.

4. Identification of roles and responsibilities for relevant stakeholders.

Furthermore, all three airlines stated that they carry universal precaution 

kits that include equipment to respond to suspected communicable 

diseases onboard aircraft flying internationally.

Page 19 GAO-16-127 Air Travel and Communicable Diseases

43

As noted above, some airports have in place a CDC communicabledisease response plan (CDRP)—specifically 18 total airports that 

currently have (or had) a CDC quarantine station on site, 11 of which 

were included in our review. CDRPs fulfill part of WHO’s IHR obligations 

for establishing core capacity at designated points of entry.44 The CDRPs, 

according to CDC officials, were developed in coordination with relevant 

stakeholders and partners at each airport and based on a framework provided 

 

43ICAO provides guidance in Annex 6 to the Chicago Convention on the type, number, location, 

and contents of medical supplies to be carried on aircraft, including the typical contents for a 

universal precaution kit—which may be used to clean up potentially infectious materials and to 

protect cabin crew members who are assisting potentially infectious passengers.

44Core capacities at airports for responding to events that may constitute a public health emergency 

of international concern include providing appropriate public health emergency response by 

establishing and maintaining a public health-emergency contingency plan. WHO, IHR 

(2005) – 2

nd ed., Annex B.
by CDC to airport quarantine stations. The existence of a CDRP at an 

airport does not preclude an airport operator or other airport stakeholders 

from developing and maintaining one or more additional preparedness 

plans or documents. In fact, representatives from all but one of the 

airports that we reviewed that have a CDRP reported having additional 

preparedness documents (10 of 11 airports). Representatives from 3 of 

those 10 airports that reported having plans contained in multiple 

documents do not view the CDRP as the airport’s main preparedness 

plan for communicable diseases. One CDC official from the Quarantine 

and Border Health Services Branch noted that CDRPs at some airports 

are more developed than others and recognized that CDC quarantine 

staff in collaboration with relevant airport stakeholders are continually 

updating and improving the CDRPs. Figure 4 shows the 16 U.S. airports 

that currently have a CDC quarantine station and the 2 airports that 

formerly had one.

Page 20 GAO-16-127 Air Travel and Communicable Diseases

45 Each of these quarantine stations is also responsible for 

enforcing quarantine regulations at all airports within its assigned jurisdiction.

 

45According to CDC officials, the closure of the CDC quarantine stations at Dallas/Fort Worth 

International and Boston Logan International airports is temporary and was a result of 

budget constraints.
Figure 4: U.S. Airports with Centers for Disease Control and Prevention Quarantine Stations, 2015

Page 21 GAO-16-127 Air Travel and Communicable Diseases

DOT officials told us that in 2010, DOT and the aviation industry 

requested that CDC expand its outreach to further the development of 

CDRPs beyond airports with quarantine stations on site to airports without 

them.46 CDC officials told us that since that request, the agency has been 

working to expand the coverage of CDRPs to select U.S. airports. These 

 

46The request resulted from a series of meetings convened by DOT at the request of the aviation 

industry and attended by representatives from HHS, DHS, DOT, and the aviation industry to 

discuss standardized entry and exit screening at airports. According to DOT officials, the 

request did not specify which airports to extend CDC’s outreach, in part because, at that 

time, CDC was resistant to any expansion.
officials told us that they are in the process of identifying priority airports 

using criteria that include the number and origins of arriving international 

passengers. These officials reported that at least three airports (one of 

which was included in our review) without quarantine stations on site 

have already collaborated with CDC to develop an airport preparedness 

plan for communicable disease threats.

Page 22 GAO-16-127 Air Travel and Communicable Diseases

47 According to these officials, 

however, CDC response efforts to disease outbreaks, such as the cholera 

outbreak following the Haiti earthquake in 2010, have slowed these 

outreach efforts. CDC officials said they hope to complete this effort in the 

next several years, but do not have a specific established completion 

date.

FAA officials told us that they encourage airports and airlines to develop 

preparedness plans for communicable disease threats. For example, in 

July 2009, FAA Office of Airport Safety and Standards issued a 

CertAlert48 to FAA airport inspectors to encourage airport operators to either 

update their pandemic flu plans—plans that airports may have developed in 

response to the avian influenza threat of H5N1 that began in 2003—or, for those 

that did not have a plan, to develop such a plan for their airport. In late 

2014, FAA officials told us that they began planning an update of the July 

2009 CertAlert, but it was delayed due to the Ebola response. As of 

August 2015, no updated CertAlert has been issued.

FAA officials told us that they do not track or review airport or airline 

plans—in part because they lack adequate public health expertise, which 

they believe CDC would have, to assess whether an airport’s or airline’s 

plan would be effective at preventing or reducing the spread of 

communicable diseases. FAA officials further noted that communicable 

diseases rarely threaten the safety of flight, which is FAA’s primary 

regulatory jurisdiction. CDC officials in the Division of Global Migration

and Quarantine office told us that they review CDRPs every 2 years at 

the 16 airports with quarantine stations currently on-site, and the CDC 

quarantine station staff at the airport review them during the in-between 

years. However, CDC officials noted that they do not formally track the 

 

47For the purposes of our review, we do not consider these plans to be CDRPs since they are at 

airports that do not currently have—or did not formerly have—a CDC quarantine station on site.

48CertAlert 0912. According to FAA, CertAlerts give FAA’s Airports Safety and Operations 

Division a quick way of providing additional guidance on Airport Certification and related 

issues to FAA inspectors and staff.
development of any preparedness plans for communicable disease 

threats at airports that do not currently have a quarantine station on site.

Airports and airlines are not required to develop and maintain 

preparedness plans for communicable disease threats. And neither FAA 

nor CDC systematically tracks which airports and airlines have such 

plans. Thus, FAA and CDC officials could not tell us the full extent to 

which airports that receive international passengers and airlines that 

operate international flights have preparedness plans in place. The 18 

airports with CDRPs accounted for about 58 percent of the international 

arriving passengers to the United States in 2014. These 18 airports—

together with the 3 airports we reviewed without CDRPs, but with their 

own preparedness plans—accounted for about 65 percent of the 

international arriving passengers in 2014 (or about 34 million of the 

almost 52-million total).

A variety of entities, including FAA, CDC, state and local public health 

entities, and international sources, provide resources to help airports and 

airlines develop communicable-disease preparedness plans. In 2006, 

DOT, in coordination with CDC, published the National Aviation Resource 

Manual for Quarantinable Diseases,

Page 23 GAO-16-127 Air Travel and Communicable Diseases

49 which provides guidance for airports 

and airlines on how to develop a communicable-disease preparedness plan that 

can be adapted and implemented for a variety of sizes and types of 

communicable disease threats. When we asked representatives from three 

airports specifically about DOT guidance for preparedness plans during 

interviews, representatives from two airports were familiar with the 

Manual, but noted that it was outdated. An official from DOT’s Office of 

Intelligence, Security, and Emergency Response told us that DOT has no 

plans to update it, in part, because in DOT’s view, everything contained in 

the document can be found on other websites and doing so might create 

a document that could not be rapidly updated, as might be necessary in 

facing an emerging public health threat.

The guidance for specific disease threats that is published by CDC also 

provides some information for those attempting to develop plans or 

procedures for responding to a specific disease threat. For example, CDC 

published several guidance documents for airport and airline employees 

 

49Oak Ridge Institute for Science and Education, National Aviation Resource Manual for 

Quarantinable Diseases, a report prepared for the Department of Transportation (December 2006).

A Variety of Entities Provide 

Resources to Help Develop 

Plans
regarding Ebola, including guidance for personal protective equipment for 

airport and airline cleaning crews and interim guidance about Ebola 

infection for airline crews, cleaning personnel, and cargo personnel.

Page 24 GAO-16-127 Air Travel and Communicable Diseases

50

Local public health entities also provide resources, such as public health 

advisories, that airports reported using to help develop such plans.

Finally, some international guidance and technical assistance is available 

to airports and airlines in developing communicable disease plans.51 For 

example, in 2009, ACI, in collaboration with ICAO, published the Airport 

Preparedness Guidelines for Outbreaks of Communicable Disease to help 

airports.52 Through CAPSCA, ICAO works to bring international, regional, 

national, and local organizations together to combine efforts and develop 

a coordinated approach to respond to public health risks. CAPSCA’s 

efforts include providing voluntary visits to airports to help them prepare 

for communicable disease threats.

In 2007, ICAO adopted a standard that obligates each ICAO member 

state to establish a national aviation-preparedness plan for communicable 

disease outbreaks that pose a public health risk or public health 

emergency of international concern.53 In 2010, ICAO, by resolution,54 further 

urged member states to ensure that the public health sector and the 

aviation sector collaborate to develop a national preparedness plan for 

 

50http://www.cdc.gov/quarantine/air/managing-sick-travelers/ebola-guidance-airlines.htm. 

51The National Academies’ Aviation Cooperative Research Program also issues guidance, such 

as the Transportation Research Board’s Airport Cooperative Research Program, Report 

91 that recommends mitigation measures at airports and on aircraft, but is not guidance 

for developing a communicable disease preparedness plan.

52ACI and ICAO, Airport Preparedness Guidelines for Outbreaks of Communicable 

Disease, Revised (April 2009).

53Section F of Annex 9, subparagraph 8.16.

54ICAO, International Civil Aviation Organization Assembly, Res. A37-13 (November 2010).

The United States Lacks a 

Comprehensive National 

Aviation-Preparedness 

Plan

ICAO Standard Obligates 

Member States to Establish a 

National AviationPreparedness Plan
aviation to help prevent the spread of communicable diseases through air 

travel, and that member states establish requirements for the involvement 

of stakeholders, such as airport operators and airlines, in the 

development of the plan. In guidance to member states for developing a 

national aviation-preparedness plan, ICAO recommends that such a plan 

include guidance that is generic to all communicable diseases. This 

guidance can then be adapted for specific diseases. Officials from the 

DOT office responsible for coordinating U.S. policy for presentation to 

ICAO told us that it is the responsibility of each member state to either 

implement regulations or other appropriate measures to comply with 

ICAO standards or to file a “difference” with ICAO.

Page 25 GAO-16-127 Air Travel and Communicable Diseases

55

While the United States has not developed a national aviationpreparedness plan for communicable disease outbreaks, DOT and CDC 

officials contend that some elements of such a plan already exist. 

Specifically, officials from DOT’s Office of Intelligence, Security, and 

Emergency Response and FAA’s Office of National Security Programs 

and Incident Response, as well as CDC’s Division of Global Migration 

and Quarantine, told us that some elements of a national aviationpreparedness plan are encompassed in various documents that include 

airports’ individual plans, including CDRPs at airports with quarantine 

stations on site. However, FAA reported to ICAO in 2010—by way of 

answering an ICAO questionnaire on member states’ fulfillment of this 

standard56—that individual airport plans are intended to handle one or two 

flights with inbound passengers and not respond to a full epidemic, which may

require a response involving multiple airports on a national level. Officials 

from CDC’s Division of Global Migration and Quarantine also told us that 

while the United States does not have a national aviation-preparedness 

plan, past planning efforts, such as the 2005 National Strategy for 

Pandemic Influenza and its associated 2006 implementation plan 

 

55A difference filing does not necessarily signify that a member state is in noncompliance; 

for example, a difference filing could signify that a member state’s current regulations are 

different in character, but achieve the same objective by other means.

56International Civil Aviation Organization, State Letter EC 6/22-10/51 (June 22, 2010).
developed in response to the avian influenza threat of H5N1,

Page 26 GAO-16-127 Air Travel and Communicable Diseases

57 as well as 

CDC’s Risk-Based Border Strategy (RBBS),58 helped inform their decision 

making in the national-level response to Ebola as this response pertained 

to the screening and risk assessment of passengers arriving from the 

affected countries. The pandemic influenza national strategy and 

implementation plan, however, are neither aviation-specific nor designed 

to address communicable disease outbreaks of various types (e.g., 

different diseases), as we have found in past work.59 Furthermore, CDC 

officials told us that the RBBS has been superseded by CDRPs, which represent 

the most up-to-date preparedness efforts at U.S. airports.

DOT and CDC officials also told us that while a national aviationpreparedness plan could have value, they do not believe that their 

respective agencies should be the lead in the development of such a 

plan. DOT officials said that a national aviation-preparedness plan for 

communicable disease outbreaks would be valuable to support a unified 

approach where multiple entities, including DOT, have input into the 

plan’s development and can then test and exercise the plan. These 

officials also noted that while DOT’s Office of the Secretary serves as the 

liaison to ICAO for Annex 9 to the Chicago Convention, in which the 

relevant ICAO standard is contained, complying with an ICAO standard 

 

57In 2005, the Homeland Security Council issued the National Strategy for Pandemic Influenza, 

which identified three pillars of the National Strategy including preparedness and communication, 

surveillance and detection, and response and containment. In turn, the 2006 National 

Strategy for Pandemic Influenza Implementation Plan identified actions and expectations 

for federal agencies under each pillar to make effective international and domestic 

transportation decisions in order to maintain infrastructure services, mitigate adverse 

economic impacts, and sustain societal needs in the case of a pandemic influenza threat. 

The implementation plan focuses not only on transportation, but also on protecting human 

and animal health, law enforcement, and institutions, among other areas. Developed in 

response to the avian influenza threat of H5N1 that began in 2003, the strategy has not 

been updated to address other types of communicable diseases. 

58In response to a requirement in the 2006 pandemic influenza implementation plan that 

required federal agencies to develop a strategy for border intervention that could be used 

during pandemics, CDC designed a strategy referred to as the Risk-Based Border 

Strategy (RBBS), which officials described as a flexible and scalable strategy for 

designing appropriate entry-screening at airports. 

59In 2011, following the H1N1 pandemic, we found that the federal government did not activate 

some aspects of the pandemic influenza national strategy and implementation plan in 

response to H1N1 (such as critical infrastructure protection and border and trade 

measures) because they were not relevant given the specific characteristics of the 

disease outbreak. See GAO-11-632. 
could be led by any number of other federal agencies. DOT officials 

believe that while DOT should be a key contributor to the development of 

a national aviation-preparedness plan, HHS should be the lead federal 

agency in developing such a plan, in part because DOT does not have 

sufficient public health expertise, which they believe HHS does. CDC 

officials noted that since communicable disease is just one of many 

threats to the commercial aviation sector, a broader, all-hazards national 

aviation plan that includes communicable disease as a component may 

be more prudent or warranted.

Page 27 GAO-16-127 Air Travel and Communicable Diseases

60 These officials also noted that a stand-alone 

plan may not be necessary, as they believe that the elements currently in place 

are sufficient, as reflected in the successful national Ebola response effort. Yet 

these officials also stated that they could see value in aspects of a national 

aviation-preparedness plan where stakeholders come together to discuss 

preparedness, resulting in a document that is collaborative and likely 

agreed upon by relevant parties. CDC officials told us that if a national 

aviation-preparedness plan were to be developed, DOT would be in the 

best position to lead the effort because FAA and DOT have stronger and 

deeper ties to the relevant stakeholders that would be involved in such a 

broad effort. While the DOT and CDC may not agree on which agency 

should lead the development of a national aviation-preparedness plan, 

DOT’s Office of the Secretary is the liaison to ICAO for Annex 9 to the 

Chicago Convention, in which the relevant ICAO standard is contained,

and is responsible for overseeing the aviation sector.

ICAO’s guidance to member states in developing a national aviationpreparedness plan also recommends that such a plan contain guidance 

that is generic to all communicable diseases and can be adapted to 

specific diseases. It also recommends that specific measures adopted at 

individual airports correspond to defined communicable disease threat 

 

60In 2011, the White House released Presidential Policy Directive 8 (PPD-8) that aims to facilitate 

an integrated, all-of-nation, capabilities-based approach to preparedness. PPD-8 defined five 

mission areas—Prevention, Protection, Mitigation, Response, and Recovery—and directed 

the development of a series of policy and planning documents to enhance national 

preparedness. The White House, Presidential Policy Directive 8 on National Preparedness

(Washington, D.C.: Mar. 30, 2011). Among the planning documents, DHS has included 

several functional and incident-specific annexes, which describe the principles, roles and 

responsibilities, and coordinating structures for delivering the core capabilities to support 

PPD-8. The current annexes are neither targeted to the needs of the aviation sector, nor 

do they provide detailed information on preparing for and responding to human 

communicable disease incidents, specifically. For example, the Biological Incident Annex 

notes that specific operational guidelines, developed by respective organizations to 

address their unique planning considerations, will supplement this annex. 

A National Plan Aims to 

Provide an Adaptable and 

Scalable Framework
alert levels, such as WHO’s pandemic alert phases or a national publichealth authority’s alert levels, to help ensure that procedures are scaled 

up and down as circumstances of the public health threat change. 

Adopting measures that correspond to different risk levels or types of 

diseases would provide individual airports with an adaptable and scalable 

framework with which to align their plans—without which airports could 

find it challenging to prepare for a national response effort. For example, 

representatives from four airports that were not designated to conduct 

enhanced-screening for Ebola reported developing their own Ebolaspecific response plans during the Ebola outbreak—sometimes with and 

sometimes without input from federal stakeholders. The airports did this in 

part because they did not know what their responsibilities would be in the 

long run or to what extent they would need to have procedures in place in 

the event that a suspected ill passenger was traveling on a broken 

ticket.

Page 28 GAO-16-127 Air Travel and Communicable Diseases

61 An adaptable and scalable framework would subsequently improve 

harmonization of individual plans across airports and airlines—helping 

ensure that the individual plans work in accordance with one another for a 

national level response effort—and serve as the basis for training airport 

and airline staff and crew.62 For example, representatives from one airport 

told us that, in their view, many airports had good efforts under way to 

respond to Ebola, but that the efforts were fragmented across airports 

leaving passengers and airlines to deal with differences in how travel is 

handled at each airport.

ICAO guidance to member states for developing a national aviationpreparedness plan for communicable disease outbreaks states that 

implementation of any measures within a preparedness plan should be a 

well-coordinated multi-agency effort to avoid confusion, inconsistencies, 

and duplication of resources, as well as minimize inconvenience to 

travelers. DOT officials reported not being involved in or consulted on the 

decision to funnel passengers from Ebola-affected countries to five 

 

61A broken ticket involves a person traveling on a separate itinerary for travel between the affected 

country and the United States via an intermediate destination, such as from a country in 

Africa to a county in Europe on the way to the United States.

62WHO also states, in guidance to national public-health authorities in preparedness planning at 

designated points of entry, that individual plans need to be aligned with each other in order 

for tasks and actions to flow seamlessly from the national to the local level, particularly 

during response to public health threats at a national level. WHO, International Health 

Regulations (2005): A Guide for Public Health Emergency Contingency Planning at 

Designated Points of Entry (2012).

Public-Health and Aviation 

Sector Coordination Has Been 

Insufficient
airports and implement enhanced entry-screening procedures. And while 

the officials believe that funneling passengers was a good decision in the 

case of the Ebola threat, they expressed concern about what might 

happen during future national-level communicable disease response 

efforts if decisions affecting aviation are made without their input. For 

example, in response to the avian influenza threat of H5N1 that began in 

2003, national efforts included discussions on funneling all international 

passengers through 30 U.S. airports and screening all arriving 

passengers—an option provided under RBBS.

Representatives from three of the four airports that we spoke with about 

this issue, as well as ACI representatives, expressed concern that 

funneling all arriving international passengers to 30 airports and 

screening them was unrealistic due to the resource requirements it would 

impose on airports and delays that could ripple across the national 

airspace system. DOT officials further noted that from an air traffic control 

perspective, many major U.S. airports are already at or near full capacity 

and shifting a significant amount of air traffic to these airports could result 

in gridlock. CDC officials acknowledged that funneling passengers to 30 

airports and screening them all was a worst-case scenario and pointed 

out that RBBS was designed to be flexible and scalable and to serve as 

an adaptable framework for entry-screening at airports, as the RBBS 

framework did for the Ebola outbreak. DOT officials highlighted that 

because the number of passengers coming from the Ebola-affected 

countries is quite small relative to the total number of international 

passengers entering the United States (less than 25,000 out of almost 52-

million total passenger arrivals in 2014), the impact from re-routing

passengers to five airports and the time and resources needed to conduct 

the enhanced screening did not result in an unreasonable impact on the 

national aviation system. This may not be the case if the communicable 

disease threat were to come from China, for example, or another region 

with large numbers of passengers or flights to the United States.

Page 29 GAO-16-127 Air Travel and Communicable Diseases

63

DOT officials also reported that they did not always have the opportunity 

or were provided insufficient time to review or comment on CDC Ebola 

guidance or fact-sheets addressed to aviation stakeholders. For example, 

a DOT official told us that because similar information was often posted in 

multiple places and because documents that the officials had reviewed in 

 

63China accounted for almost 1.5-million passenger arrivals in 2014.
the past got renamed, revised, and re-published, the DOT official had to 

continue to watch out for published CDC guidance that included 

recommendations for the aviation industry. The DOT official highlighted 

that CDC guidance did not always have the DOT issues portrayed 

correctly and that failure to adequately coordinate with DOT could have 

safety consequences in some circumstances. For example, if a 

disinfectant that is used to clean suspected Ebola contamination is not 

compatible with the aircraft materials (e.g., aluminum) or is used in the 

wrong manner, such as using too concentrated a solution, the aircraft 

could be damaged, which could negatively affect its airworthiness. 

Officials from CDC’s Division of Global Migration and Quarantine 

acknowledged that some CDC webpages about Ebola developed prior to 

the beginning of the Ebola outbreak in 2014 contained misinformation 

related to aircraft disinfectants, but noted that the information was 

promptly removed once officials became aware of the problem. These 

officials also told us they sought DOT’s input in guidance relevant to 

aviation, but acknowledged that at times during the Ebola outbreak, 

things moved very quickly and webpages were reorganized to make 

information easier to find.

While aviation stakeholders we spoke with reported having plans that 

address communicable diseases, they also reported facing multiple 

challenges in responding to threats and taking actions to address these 

challenges. Aviation stakeholders that we spoke with reported challenges 

in responding to communicable disease threats including obtaining 

guidance, communicating, coordinating among responders, and assuring 

employees have appropriate training, equipment, and sanitary 

workplaces. To address these challenges, aviation stakeholders reported 

taking actions such as developing communication tools and strategies; 

reviewing, exercising, and improving response plans; and providing 

training, equipment, and cleaning supplies. A national aviationpreparedness plan could serve as the basis for testing communication 

mechanisms among responders to ensure those mechanisms are 

effective prior to addressing a communicable disease outbreak. It could 

also serve as the basis to ensure that airport and airline staff have 

received appropriate training and access to properly maintained 

equipment to reduce the risk of exposure to communicable diseases 

during an outbreak.

Page 30 GAO-16-127 Air Travel and Communicable Diseases

Airports, Airlines, and 

other Stakeholders 

Faced Challenges 

Responding to 

Communicable 

Disease Threats and 

Are Taking Some 

Actions as a Result
Stakeholders at 12 of the 14 airports we spoke with reported challenges 

in obtaining guidance on how to respond to communicable disease 

threats or in communicating during specific incidents. Various 

stakeholders including federal agencies, airports, airlines, and contracted 

aviation-services employers reported taking actions to improve access to 

timely guidance and communication. As we have found in prior work, 

planning efforts and exercises can help develop relationships between 

federal officials and stakeholders that are useful in responding to 

communicable diseases.

Page 31 GAO-16-127 Air Travel and Communicable Diseases

64 Moreover, ICAO recommends that national 

aviation-preparedness plans include a communication system and 

emphasizes the importance of periodically testing this communication 

system.

Representatives at 7 of the 14 airports we spoke with reported difficulties 

obtaining prompt and clear guidance from federal agencies including 

CDC, CBP, and FAA on how to respond to specific communicable 

disease threats including Ebola. According to CDC, CDC Quarantine 

Station officials referred airport questions about the Ebola response to 

CDC headquarters to ensure airports received consistent guidance that 

reflected the most up-to-date information. However, representatives at 3 

of the 10 airports with Quarantine Stations with whom we spoke said that 

CDC headquarters did not provide requested guidance within short time 

frames. Representatives from two airports said the initial federal response 

to Ebola was not clear because it did not correspond to a national plan or 

unified approach with which the representatives were familiar. In addition, 

a representative at another airport reported experiencing confusion 

determining the magnitude of the threat that Ebola posed and what 

guidance to follow given that FAA did not address these issues.

CDC officials we spoke with described inherent challenges to providing 

prompt guidance on the recent Ebola threat, as well as actions the 

agency took to address airports’ and airlines’ information needs during 

the response. Communicable disease outbreaks are unpredictable by 

their very nature. CDC officials told us that information evolved during the 

Ebola response and that answers to particular questions were not always 

readily available. In these instances, CDC formulated responses with the 

assistance of leadership and subject-matter experts. According to 

officials, CDC dedicated additional resources to provide in-depth and 

 

64GAO-11-632.

Guidance and 

Communication 

Challenges

Guidance from Federal 

Agencies
timely Ebola guidance, and met with aviation industry partners both 

collectively and individually.

Airport-emergency responders at 6 of the 14 airports we interviewed told 

us that airlines sometimes do not provide them with information that is as 

complete, accurate, and immediate as they would like when a traveler 

becomes ill during a flight. CDC officials also told us that information 

provided by airlines or air traffic control to CDC was often incomplete or 

inaccurate. While CDC requires pilots on international flights to U.S. 

airports to immediately notify CDC of ill travelers suspected of having a 

communicable disease

Page 32 GAO-16-127 Air Travel and Communicable Diseases

65—as determined by signs and symptoms—flight 

crews must focus on safely operating the aircraft during critical phases of 

a flight such as takeoffs and landings.66 This situation may preclude 

immediate notification, according to CDC officials. Furthermore, CDC officials 

and some responders we spoke with said that ill travelers or their caregivers 

may be reluctant or unable to share information, cabin crew may lack 

expertise in assessing relevant medical conditions, and information may 

develop inaccuracies as it passes from passenger to flight attendant to 

pilot to various ground-based responders. CDC officials also stated that a 

lack of proper equipment (thermometer, for example) on the aircraft may 

limit flight crews from providing a rapid and detailed notification of illness. 

CDC makes available guidance and tools to report traveler death or 

disease that outline reporting requirements and requested information.67

However, airport responders and CDC officials said that airlines do not use a 

common template to record or communicate this requested information. 

Inaccurate or untimely information can slow down an appropriate 

response (such as conducting assessments before travelers have exited 

the aircraft) or trigger precautions unnecessarily. For example, 

representatives at one airport described launching an Ebola response 

after being alerted by an airline of a suspected case, only to discover that 

the passenger was traveling from East Africa—rather than an Ebola-

 

6542 C.F.R. § 71.21(b).

66Under FAA regulations, “No certificate holder shall require, nor may any flight crewmember 

perform, any duties during a critical phase of flight except those duties required for the safe 

operation of the aircraft.” 14 C.F.R. § 121.542.

6742 C.F.R. § 71.21(b). Requested information includes aircraft identification, departure airport, 

destination airport, estimated time of arrival, number of persons on board, number of suspected 

cases on board, and the nature of the public health risk, if known. HHS, Centers for Disease 

Control and Prevention, For U.S. Arrivals: CDC Death and Disease Reporting Tool for 

Pilots (Washington, D.C.: August 2014).

Communications during Flight
affected area in West Africa—and suffering from a fear of flying rather 

than a physical illness.

Airport, airline, and other stakeholders have taken actions to improve 

communication about ill travelers during flights including real-time 

consultations with emergency medicine consultants, evaluating 

telemedicine technologies, and dedicating a radio frequency for 

emergencies to enable communication during flight with ground-based 

medical responders. See appendix II for additional information about 

technologies used to respond to communicable disease threats. In 

addition, CDC officials said that they conduct follow-up investigations 

when they receive reports of suspected communicable disease incidents 

on flights that airlines did not report and that CDC addresses with airlines 

any deficiencies found.

Aviation stakeholders have developed various tools to improve their 

communication about and response to medical problems. For example, 

one U.S. airline uses a checklist form to guide flight attendants in 

collecting and sharing traveler information with emergency medicine 

professionals who are remotely located. Another example comes from the 

AIRSAN Project, a stakeholder network that addresses response at the 

European Union level to public health threats in air transport. The 

AIRSAN Project developed operational tools including a flow chart and 

questionnaires to help cabin crew with decision making and information 

gathering to assess public health risks, communicate with ground-based 

responders (including public health officials who use the same tools), 

apply public health measures during the flight, and minimize interference 

with international traffic.

Representatives at two of the three airlines we spoke with said that CDC 

does not routinely notify airlines of the results of an ill passenger’s 

screening or diagnostic tests unless a positive diagnosis confirms a 

communicable disease. Representatives from one airline stressed that it 

experienced challenges obtaining information about the status of ill 

passengers or passengers who were not ill during flight but screened 

positive for risk of Ebola after leaving the aircraft. Representatives from 

this airline said these challenges impact their operations as well as their 

relationships with employees and customers. CDC officials confirmed that 

CDC does not routinely notify airlines when CDC determines a 

passenger’s condition is not of public health concern or before diagnosing 

passengers suspected of communicable diseases. However, CDC 

protocols call for notifying airlines when a positive diagnosis confirms a 

communicable disease of public health concern. CDC officials also said 

Page 33 GAO-16-127 Air Travel and Communicable Diseases

Communication after Arrival
that if there were suspicions but no diagnosis of a communicable disease, 

CDC might provide airlines with general information when media 

coverage or other concerns arise but would not provide personally 

identifiable information.

Page 34 GAO-16-127 Air Travel and Communicable Diseases

68

All of the employees we spoke with from two contracted aviation-services 

firms that conduct aircraft cabin cleaning said that after incidents when a 

traveler became ill during a flight, the cabin crew does not always notify 

them of potentially infectious bodily fluids that had contaminated the 

aircraft. In its general infection-control guidance to airlines, CDC 

recommends that cabin crews notify cleaning crews of where and how ill 

passengers may have contaminated the aircraft and remind cleaning 

crews that additional personal protective equipment may be required. 

Given that it is typically unclear whether or not an illness that develops 

during a flight is contagious, CDC recommends treating any bodily fluid 

as potentially infectious regardless of whether or not an identified 

communicable disease outbreak threatens to spread to the United States. 

Aircraft cleaners we spoke with said that cleaning crews often have 

limited time to clean an aircraft before the boarding process begins for the 

next flight, and so may need to request additional time to conduct 

additional cleaning necessary to decontaminate the aircraft.

Some of the airlines and the contracted aircraft-cleaning employers we 

spoke with reported taking steps to improve communication about 

travelers’ health status after leaving the aircraft and any contamination 

that cleaners may need to address. For example, a foreign airline has 

developed a paper-based form for cabin crews and public health officials 

to record and share information about potentially contaminated items on 

the aircraft and the disinfection agents the cleaning contractor should use. 

The contracted aircraft-cleaning employer we spoke with reported 

directing employees who clean international flights at one of the five 

enhanced screening airports for Ebola to notify their crew lead of any 

bodily fluids they encounter and to treat these fluids as potentially 

infectious.

 

68CDC officials also noted that illness reporting often occurs after air travel when a passenger is 

diagnosed during a visit to the local health department or doctor’s office. The state and 

local public health departments then report these cases to CDC quarantine stations.
Keeping the traveling public informed about communicable disease risks 

and implications can help manage public anxiety to avoid unnecessary 

social disruption and economic losses, according to the WHO. WHO 

notes that intense public scrutiny may accompany a communicable 

disease incident, and DOT recommends in its National Aviation Resource 

Manual for Quarantinable Diseases that airports plan “how they will 

handle the onslaught of media inquiries and reports from the very outset 

of the communicable disease incident.”

We interviewed airport representatives and their partners, such as 

emergency-management and public-health officials, and found that the 

need to provide public information in the wake of the Ebola outbreak and 

related airport incidents could create a variety of challenges. The 14 

airports we spoke with and their partners provided the following 

examples:

· Responding quickly enough to rapidly developing public concern:

Page 35 GAO-16-127 Air Travel and Communicable Diseases

Some airport representatives said that suspected communicable 

disease incidents could quickly generate public concern. 

Representatives at three airports we spoke with emphasized the need 

to provide information quickly, and representatives at two of these 

airports stated a preference for a proactive rather than reactive 

approach to the media.

· Providing partners useful information: Emergency management 

officials at one airport conducting enhanced screening for Ebola and 

state public health officials working with this airport said they did not 

receive information needed to respond to media requests or inform 

senior public officials. However, representatives at another airport that 

conducts enhanced screening for Ebola noted that sharing information 

about a suspected communicable disease incident too broadly could 

cause unnecessary alarm.

· Addressing the volume of concerns: Representative from two airports 

said that addressing public information requests could require 

significant resources or create a challenging work environment.

Some airport representatives and union representatives also identified 

instances when information was requested that they believe should not 

be made available or could be better secured. For example, union 

representatives for cabin crews expressed concern that co-workers can 

identify crewmembers on a flight with an ill passenger and subsequently 

avoid working with them or even make their identities public via social 

Challenges in Providing 

Information to the Public
media. Union representatives suggested that airlines could do more to 

protect crewmembers’ identities after a potential communicable disease 

incident, but an airline we spoke with said that crewmembers’ identities 

could be discovered by a variety of means outside of the control of the 

airline, including direct observation.

Page 36 GAO-16-127 Air Travel and Communicable Diseases

69

Airport and airline representatives we spoke with identified actions they 

took to provide information about the Ebola threat to better inform the 

public. For example, three airports we spoke with highlighted using social 

media to provide information or respond to concerns in real time. 

Representatives from one of these airports and one of the three airlines 

we spoke with noted that it was useful to disseminate public information 

developed by CDC because of its credibility.

Representatives at 8 of the 14 airports that we interviewed identified 

challenges coordinating various entities’ roles and actions when 

conducting communicable disease responses or exercises. 

Representatives from the 14 airports we spoke with and their partners 

reported challenges with:

· Lines of authority and plan alignment: Representatives from four 

airports we interviewed reported challenges determining lines of 

authority, such as whether CDC or fire department officials lead 

emergency medical services, or aligning stakeholders’ response 

plans, such as airlines’ plans, with the airports’ response plans.

· Unnecessary interference: Representatives from three airports we 

spoke with reported that the actions of one type of responder had 

negative implications for another responder or for airport operations 

and that these complications were avoidable. For example, during the 

response to a passenger suspected of Ebola, responders blocked off 

a road to provide themselves with space to put on personal protective 

equipment. However, in so doing they blocked all baggage-handling 

trucks’ access to the baggage claim area, and in turn, the baggagehandling trucks blocked other responders’ access to the aircraft.

 

69DOT officials told us that DOT’s Office of Aviation Enforcement and Proceedings does not 

enforce any law or regulation that would protect crewmember identifying information from 

being accessed by other airline employees in the event of possible exposure to a 

communicable disease and that unless the issue affects safety, FAA regulations would not 

apply.

Challenges in 

Coordinating Incident 

Response
· Coordinating with contracted aviation-services firms: Representatives 

Page 37 GAO-16-127 Air Travel and Communicable Diseases

at two airports said that after completing the questionnaire we 

provided them, they realized that they likely should do more to 

coordinate with contracted aviation-services firms that operate at the 

airport.

Airport representatives reported taking various approaches to improve 

their coordination during a response. Airport officials reported using 

strategies such as conducting meetings or training with aviation 

stakeholders to provide information and clarify lines of authority in 

responding to communicable diseases, using centralized notification and 

communication hubs, and coordinating response activities through 

emergency operations centers or unified command structures. In addition, 

airport representatives at 2 of the 14 airports we interviewed highlighted 

their practice of reviewing the response plans of each airline operating at 

the airport to understand airlines’ approach and assist with any gaps that 

the airport might identify. Representatives from each of the 14 airports we 

spoke with used some level of exercises and debriefs to improve the 

efficiency and effectiveness of their response, including four airports that 

conducted full-scale exercises that address simulated communicablediseases incidents. In addition, airports debriefed staff involved with 

actual incidents that involve communicable disease response to assess 

and improve their operational capability. However, neither DOT nor HHS 

requires airports to conduct communicable disease exercises and 

debriefs, and the communicable disease exercises conducted by airports, 

varied in comprehensiveness from table-top to full-scale exercises, 

according to airport officials with whom we spoke.

According to an aviation medicine expert at ICAO, collaboration between 

aviation and public health officials presents the biggest challenge in 

managing communicable diseases in the aviation sector. For example, 

under airport all-hazards plans, officials typically isolate aircraft away from 

the terminal in order to minimize suspected threats (e.g., bomb threats), 

but in a public health emergency it may be more appropriate to park an 

aircraft near the terminal to provide emergency responders access, 

according to this expert. Representatives from 3 of the 14 airports we 

interviewed mentioned adapting their practices during the Ebola outbreak 

or recent exercises to park incoming aircraft with ill travelers suspected of 

communicable diseases at or near the gate rather than at a remote 

location.
Contracted aviation-service employees—including airport cleaning, 

aircraft cleaning, and passenger-service employees (e.g., wheelchair 

attendants), and associated union representatives we interviewed—

expressed concern that these service employees did not receive 

adequate communicable disease training and reported challenges 

accessing appropriate personal protective equipment, cleaning 

equipment, and cleaning supplies. Inadequate training, equipment, and 

supplies could lead to employee exposures to pathogens that could in 

turn result in infections. This risk could extend to passengers since they 

share the same aircraft environment. OSHA violations provide some 

evidence for concerns and challenges related to appropriate pathogenexposure-control planning, training, vaccinations, and personal protective 

equipment.

OSHA’s blood-borne pathogens standard requires employers to provide 

employees who encounter blood, certain bodily fluids, and other 

potentially infectious materials while carrying out job duties with:

· Training: initial and annual training—including the opportunity to ask 

Page 38 GAO-16-127 Air Travel and Communicable Diseases

questions of a knowledgeable trainer—on methods to control 

exposures to pathogens and additional training when changes occur 

that affect employees’ occupational exposure to potentially infectious 

materials.70

· Personal protective equipment: appropriate personal protective 

equipment such as gloves, gowns, eye protection, and masks.71

· Sanitary work surfaces: work surfaces that have been noticeably 

contaminated by potentially infectious materials must be 

decontaminated with an appropriate disinfectant immediately or as 

soon as feasible.72

 

7029 C.F.R. § 1910.1030(g)(2).

7129 C.F.R. § 1910.1030(d)(3)(i).

7229 C.F.R. § 1910.1030(d)(4).

Challenges in Training and 

Equipping Contracted 

Aviation-Service 

Employees
· Vaccination and post-exposure evaluation and follow-up: employees 

Page 39 GAO-16-127 Air Travel and Communicable Diseases

must be offered the hepatitis B vaccination and be evaluated and 

provided follow-up after an exposure incident.73

We spoke with nine workers employed by aviation-services firms that 

contract with airports or airlines. Collectively, these nine employees 

worked for four different firms at four separate airports. Employees and 

union representatives we spoke with reported gaps in training, equipment, 

supplies, and time to decontaminate aircraft.

· No routine or outbreak-specific training: Employees from three of the 

four contracted aviation-services firms that we spoke with said that 

employers do not provide formal, hands-on training to understand 

risks and minimize workers’ exposure to potentially infectious 

materials, and that employers did not provide hand-on training to 

respond to specific disease outbreaks such as Ebola.74 For example, 

aircraft cabin cleaners from one firm reported not knowing where to 

dispose of hazardous material and so sometimes simply disposed of it 

with non-hazardous garbage.

· Inadequate personal protective equipment: Aircraft cabin cleaners we 

spoke with from the two firms that conduct cabin cleaning reported 

that the gloves employers provided were too thin and that they could 

not replace gloves immediately if they ripped because of the need to 

clean aircraft quickly.75

· Unsanitary conditions and unavailable resources to clean: Wheelchair 

attendants at both airports where we interviewed passenger-service 

employees reported that wheelchairs were not always 

decontaminated after coming in to contact with potentially infectious 

 

7329 C.F.R. § 1910.1030(f)(1).

74At least one employee of three of the four of the aviation services firms we spoke with said 

employers did post written notices about the Ebola outbreak in their workplace or provided 

copies of these notices to employees directly.

75Aircraft-cleaning employees with one contracted firm reported that their employer began 

providing better quality gloves in May 2015 after employees filed a complaint with a state 

occupational safety and health agency.
materials such as feces.

Page 40 GAO-16-127 Air Travel and Communicable Diseases

76 Employees with each of the three firms that 

conduct airport or aircraft cabin cleaning reported lacking sufficient 

and clean towels. For example, one employee said that cabin 

cleaners sometimes use the same towels to clean potentially 

infectious materials and later to clean food service equipment such as 

coffeemakers. Employees at two of the three firms that conduct 

cleaning reported difficulties accessing cleaning solutions, and 

employees we interviewed from one of the two firms that conduct 

aircraft cabin cleaning said that cleaning solutions sometimes are not 

properly labeled, causing them to use the wrong concentration.

· Insufficient time to clean: A union representative and employees we 

interviewed from one of the two firms that conduct aircraft cabin 

cleaning noted that some cleaning solution instructions indicate that 

the solution should sit for a period of time on potentially contaminated 

surfaces before cleaning, but that this was not always possible when 

cleaners have to quickly prepare the aircraft for another flight.

Violations of state and federal occupational health standards by 

contracted aviation-services employers provide some support to 

employees’ concerns that aviation services’ employers do not always 

ensure that their employees received blood-borne pathogen training and 

personal protective equipment. Union representatives provided us with 

examples of citations between December 2012 and July 2015 resulting 

from complaints aviation-service employees filed with the union’s 

assistance. We used publicly available information from OSHA to confirm 

that at least 11 of these citations resulted in violations of OSHA’s bloodborne pathogens standard or analogous state standards that are at least 

as effective.77 Among these violations were instances when aviation-services 

employers did not provide employees with appropriate pathogen exposure 

 

76A representative from the firm that employs the wheelchair attendants whom we spoke with said 

that while employees typically use anti-microbial wipes to sanitize passenger transport 

equipment such as wheelchairs before they use the equipment, this step does not 

necessarily meet OSHA’s requirements for decontamination. This representative said that 

airport authorities or airlines typically own passenger transport equipment, and a separate 

firm responsible for airport terminal cleaning is typically responsible for cleaning 

passenger transport equipment.

77None of these violations were committed by aviation services employers whose employees we 

spoke with. Two of the four firms with employees we spoke with have open investigations 

into potential violations of OSHA’s blood-borne pathogens standard or analogous state 

standards.
control planning, training, vaccinations, and personal protective equipment. 

Eight of the 11 violations were designated serious violations, which 

indicates a substantial probability that death or serious physical harm 

could result, unless the employer did not, and could not with the exercise 

of reasonable diligence, know of the presence of the violation. In total, 

OSHA found that these 11 violations led to 680 instances when 

conditions did not meet OSHA’s blood-borne pathogens standard, and 

almost all of these instances (676 out of 680) affected over 100 

employees. OSHA records indicate that employers took corrective actions 

to address these violations.

We interviewed representatives from two aviation-services employers that 

contract with airports and airlines, and both said that they comply with 

training, personal protective equipment, and decontamination standards 

required by regulation. Representatives from the firm that conducts 

aircraft cabin cleaning said that airlines provide employees with labeled 

cleaning products that trained managers dilute to ensure that the products 

used are appropriate as indicated by the original-equipment 

manufacturer. In addition to providing employees with required training, 

personal protective equipment, and supplies, representatives from both 

aviation-services firms that we spoke with reported taking additional 

precautions during the Ebola outbreak such as providing employees with 

additional hands-on training, personal bottles of hand sanitizer, and 

information about Ebola on tablet devices that some employees use to 

carry out job duties.

In addition, airports, airlines, and union representatives we spoke with 

reported taking steps to mitigate aviation-service employees’ exposure to 

communicable diseases, especially since the Ebola threat emerged. For 

example, representatives from two airports we spoke with have 

established airport minimum standards—including hazardous material 

training—to qualify or license aviation-services firms that operate at the 

airport. Representatives from all three airlines we spoke with said that 

they provided contracted firms with additional information to help them 

prepare for the Ebola threat and reported taking steps to ensure that 

contracted employers provide employees appropriate training and 

personal protective equipment. Union representatives also reported 

providing training on infection control for aviation-service employees at 

some international airports during the Ebola outbreak.

Page 41 GAO-16-127 Air Travel and Communicable Diseases
Air travel—more than any other mode of transportation—creates the 

potential for infected persons to move quickly from one part of the world 

to another while sharing confined quarters with other travelers. With the 

anticipated growth in international air travel, the recurring threat of 

communicable diseases from abroad, and the potential economic cost of 

disrupting air travel, it is imperative that the U.S. aviation system is 

sufficiently prepared to help respond to any communicable disease threat. 

The 14 airports that we reviewed (11 of which have CDC-developed 

CDRPs) had a plan or plans in place that in combination with one another 

met the six high-level components that we identified as common 

components in federal and international guidance. CDC is working to 

expand development of CDRPs to select U.S. airports that the agency is 

currently identifying, using criteria involving the origins and the total 

volume of international arriving passengers, but it is uncertain when CDC 

will be able to complete this effort. Furthermore, Annex 9 to the Chicago 

Convention obligates member states to establish a national aviationpreparedness plan—a plan intended to provide a mechanism for the 

public health sector to coordinate with the aviation sector in the event of a 

communicable disease threat. Yet 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. Finally, DOT officials expressed concern about 

their lack of involvement in decisions made during the Ebola outbreak that 

involved the aviation sector. Developing and maintaining a national 

aviation-preparedness plan could foster a shared understanding and 

agreement among all relevant stakeholders, and help balance the needs 

of the aviation and public health sectors.

Page 42 GAO-16-127 Air Travel and Communicable Diseases

Conclusions
To help improve the U.S. aviation sector’s preparedness for future 

communicable disease threats from abroad, we recommend that the 

Secretary of Transportation work with relevant stakeholders, such as the 

Department of Health and Human Services, to develop a national 

aviation-preparedness plan for communicable disease outbreaks. Such a 

plan could establish a mechanism for coordination between the aviation 

and public health sectors and provides clear and transparent planning 

assumptions for a variety of types and levels of communicable disease 

threats.

We provided a draft of this product to DOT, HHS, DHS, Labor, and State 

for comment. In its written comments reproduced in appendix III, DOT 

partially concurred with our recommendation. State did not provide 

comments to include in this report. HHS, DHS, and Labor only provided 

technical comments that we incorporated, as appropriate.

With regard to our recommendation, DOT agreed that there is a need for 

a national aviation-preparedness plan for communicable diseases to help 

improve the U.S. aviation sector’s preparedness for future communicable 

disease threats. DOT further proposed that those agencies that have both 

legal authority and expertise for public health take the lead role in 

developing such a plan within the existing interagency framework for 

national-level all-hazards emergency preparedness planning, for which 

DOT stands ready to participate. We agree that public health expertise is 

needed in developing a national aviation-preparedness plan. However, as 

stated in our report, DOT has primary responsibility in overseeing the 

aviation sector and DOT’s Office of the Secretary is the liaison to ICAO 

for the Annex to the Chicago Convention that obligates member states to 

establish a national aviation-preparedness plan. As such, we believe that 

DOT is in the best position to work with its relevant stakeholders, 

including those that have the needed public health expertise, to develop a 

national aviation-preparedness plan. DOT also provided technical 

comments that we incorporated, as appropriate.

We are sending copies of this report to the Secretary of the Department 

of Transportation, the Secretary of the Department of Health and Human 

Services, the Secretary of the Department of Homeland Security, the 

Secretary of the Department of Labor, the Secretary of the Department of 

State, and other interested parties. In addition, the report is available at 

no charge on the GAO website at http://www.gao.gov.

Page 43 GAO-16-127 Air Travel and Communicable Diseases

Recommendation

Agency Comments

and Our Evaluation
If you or your staff have any questions about this report, please contact 

me at (202) 512-2834 or DillinghamG@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix V.

Sincerely yours,

Gerald L. Dillingham, Ph.D.

Director

Physical Infrastructure Issues

Page 44 GAO-16-127 Air Travel and Communicable Diseases
Appendix I: Objectives, Scope, and 

Methodology

GAO was asked to review the preparedness of the U.S. aviation system 

in responding to communicable disease threats from abroad. This report 

examines:

1. The extent to which selected U.S. airports and airlines have 

preparedness plans to respond to communicable disease threats from 

abroad and the extent to which a national aviation-preparedness plan 

guides preparedness.

2. Challenges that U.S. airports and airlines including contractors have 

faced when responding to threats and the actions have they taken to 

help address those challenges.

Characteristics of communicable disease threats from abroad: We 

considered the following characteristics as applicable to the scope of our 

review:

· communicable disease of public significance (e.g., non-routine 

diseases, including Ebola, SARS, and MERS),

· international arriving traveler,

· suspected ill traveler is identified onboard an arriving aircraft, or

· suspected ill traveler is identified in an airport after deplaning aircraft.

We considered the following characteristics as not applicable to the scope 

of our review:

· traveler who is ill with seasonal flu or other routine disease that is not 

of public significance,

· solely domestic travelers,

· threat of communicable disease spread by cargo or animals,

· bioterrorism (i.e., traveler using communicable disease as a weapon),

· continuity of Operations, and

· known medical transport (ill person is identified prior to departing host 

country).

Selected airports and airlines: We selected for review 14 airports—which 

accounted for about 53 percent of total international arriving passengers 

in 2014—that met one or more of the following criteria (see table 1):

· have enhanced passenger entry-screening procedures in place for 

international passengers arriving from the three current or past Ebolaaffected countries in West Africa;

· received the first and second largest number of international 

passengers from each of five world regions in 2014;

Page 45 GAO-16-127 Air Travel and Communicable Diseases

Appendix I: Objectives, Scope, and 

Methodology

Objectives

Scope
Appendix I: Objectives, Scope, and 

Methodology

· large hub airports

Page 46 GAO-16-127 Air Travel and Communicable Diseases

1 with a Centers for Disease Control and Prevention 

(CDC) quarantine station on site at the time of our review;

· large hub airports without a CDC quarantine on site, but still receiving 

a larger number of international passengers relative to other large 

hubs without a CDC quarantine station on site;

· experienced a confirmed Ebola case;

· have a station manager from one of the three U.S. airlines in our 

review; and

· are located within proximity to a GAO office.

Table 1: Selected Airports for Review

Airport 

Centers for Disease Control 

and Prevention (CDC) 

quarantine station on site 

Ebola enhanced

entry screening 

First and second highest 

number of international 

passenger arrivals from one 

or more world regions in 2014 

Dallas/Fort Worth International a No No

Fort Lauderdale-Hollywood 

International

b No No

Hartsfield- Jackson Atlanta 

International Yes Yes Yes

Honolulu International Yes No Yes

John F. Kennedy International Yes Yes Yes

Los Angeles International Yes No Yes

McCarren International (Las 

Vegas)

b No No

Miami International Yes No Yes

Newark Liberty International Yes Yes Yes

O’Hare International (Chicago) Yes Yes Yes

Orlando International b No No

Seattle-Tacoma International Yes No No

San Francisco International Yes No Yes

Washington Dulles International Yes Yes No

Source: CDC and GAO analysis of DOT’s O&D data.

aDallas Fort-Worth formerly had a CDC quarantine station on site.

b

Large hub airports without a CDC quarantine on site, but still receiving a larger number of 

international passengers relative to other large hub airports without a CDC quarantine station on-site.

 

1U.S. commercial service airports accounting for 1 percent or more of total annual U.S. passenger 

enplanements. 49 USC 47102(10)).
Appendix I: Objectives, Scope, and 

Methodology

We selected for review the three U.S. airlines that handle the largest 

quantity of international passengers—American Airlines, Delta Air Lines, 

and United Airlines.

Departments and components: Our review involved five federal 

departments—the Departments of Transportation (DOT), Health and 

Human Services (HHS), Homeland Security (DHS), State, and Labor. We 

selected these departments because they represent the key federal 

departments with responsibilities for preparing for and responding to 

communicable disease threats from abroad. Within these five 

departments we collected and reviewed available documentation and 

interviewed officials from various components that play a key role at their 

respective departments for these matters, principally DOT’s Federal 

Aviation Administration (FAA), HHS’s CDC, DHS’s U.S. Customs and 

Border Protection (CBP), and Labor’s Occupational Safety and Health 

Administration (OSHA).

To examine the extent to which airports and airlines have plans in place 

to respond to communicable disease threats from abroad, we developed 

and administered a questionnaire to airport operators of the 14 selected 

airports on general preparedness at their airport.

Page 47 GAO-16-127 Air Travel and Communicable Diseases

2 The questionnaire 

included questions about communication with local stakeholders about 

communicable diseases, guidance used to develop any plans for 

communicable disease response, and plans or procedures that the airport 

had in place for a variety of situations or stakeholders, such as 

establishing the parking location for an aircraft and training for airport 

employees. We then conducted follow-on interviews with the 14 airport 

operators and relevant local stakeholders, who generally included first 

responders, local public health officials, CBP officials, and CDC officials, if 

applicable, about their preparedness. We also collected from the 14 

selected airports and 3 selected airlines relevant and available 

preparedness plans for communicable disease threats. We identified and 

reviewed applicable federal requirements and international obligations, 

including the International Civil Aviation Organization’s (ICAO) Standards 

and Recommended Practices, and guidance for U.S. airports and airlines 

 

2At one airport where the terminals are owned and operated independent of the airport authority, 

the airport operator suggested that we also administer the questionnaire to an operator of an

international terminal, whose responses, as indicated by the airport authority, would be 

similar to the other international terminals.

Methodology
Appendix I: Objectives, Scope, and 

Methodology

with international air traffic. We identified high-level components that were 

common across applicable federal and international guidance, 

obligations, and requirements, as well as corroborating information 

collected from aviation stakeholders with whom we spoke.

Page 48 GAO-16-127 Air Travel and Communicable Diseases

3 We then 

developed a list of high-level components for airports’ and airlines’

communicable-disease preparedness plans to provide a basis for 

assessing the breadth of the plans. We compared these high-level 

components against the available plans collected from the 14 airports and 

three airlines as a method to assess the breadth of the plans. We then 

reviewed the structure and contents of these plans, but did not evaluate 

the plans for sufficiency or level of preparedness. We reviewed available 

documents from the five selected federal departments and their relevant 

components and interviewed officials from these departments. We also 

interviewed representatives from federal and international airport, airline, 

and flight-attendant industry associations,4and ICAO about preparedness 

plans generally and potential opportunities to improve preparedness.

To examine challenges that U.S. airports and airlines, including 

contractors, have faced when responding to communicable disease 

threats, including Ebola, and the actions they have taken to help address 

those challenges, we first identified challenges through interviews with 

selected airports and airlines as discussed above, as well as interviews 

with representatives from the labor union representing airport- and airlineservice employees, and airport- and airline-contract employers of service 

employees. We consulted with representatives from the union that 

 

3

For airports, we identified six high-level components through review of DOT and HHS’s National 

Aviation Resource Manual for Quarantinable Diseases and ACI and ICAO’s airport 

preparedness guidelines for outbreaks of communicable disease. The six components are 

establishment of an incident command center, coordination among various stakeholders, 

selection and use of personal protective equipment for various stakeholders, training for 

various stakeholders, some protocols for responding to a threat, and protocols for 

decontamination. After identifying these components, we used corroborating information 

about high-level components to communicable preparedness collected from DOT and 

FAA officials, a representative of CAPSCA, and some airport representatives. For airlines, 

we identified four components through review of IATA’s emergency-response plan 

template for air carriers. The four identified components are establishment of an 

emergency response team and designation of an emergency response center, description 

of the triggers that inform the level and nature of a response, activation triggers for the 

response team and response center, and identification of roles and responsibilities for 

relevant stakeholders.

4Airport Council International (ACI), Airlines For America (A4A), and Association of Flight 

Attendants (AFA).
Appendix I: Objectives, Scope, and 

Methodology

represents these employees to identify nine aviation-service employees 

with whom we spoke, and we conducted interviews with two of the four 

firms that these nine employees worked for, as well as three of the four 

airports they worked at. We also identified challenges to responding to 

communicable disease threats and actions taken by stakeholders during 

our attendance at a Global Symposium—convened by ICAO in 

collaboration with the World Health Organization (WHO)—of the 

Collaborative Arrangement for the Prevention and Management of Public 

Health Events in Civil Aviation (CAPSCA) program, which is a global, 

collaborative arrangement that works to bring together international, 

regional, national, and local organizations to develop a coordinated 

approach to preparedness and response. We also collected and reviewed 

available after-action reports that airports used to assess their responses 

to simulated communicable disease incidents. In addition, to corroborate 

comments we heard from airline-service employees (e.g., aircraft cabin 

cleaners or wheelchair attendants) and their union representatives, we 

reviewed summaries of inspections and violations related to OSHA’s 

blood-borne pathogens standard that were initiated by employees with 

the support of their union. The challenges faced by U.S. airports, airlines, 

and contracted aviation-services firms and the actions taken to address 

these challenges that we describe in this report represent information 

provided to us during interviews and site visits, but may not capture all of 

the challenges and actions taken by the airports, airlines, and aviationservices firms we spoke with.

We conducted this performance audit from November 2014 to December 

2015 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Page 49 GAO-16-127 Air Travel and Communicable Diseases
Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

A few technologies have been implemented, or are being developed, to 

identify or mitigate potential outbreaks of communicable diseases through 

air travel. These include screening passengers to detect travelers who 

may have an infectious disease (ill travelers), utilizing temperature 

screening to diagnose ill travelers, and using data analysis to identify 

disease outbreaks and potential traveler movement patterns.

Page 50 GAO-16-127 Air Travel and Communicable Diseases

1

U.S. Customs and Border Protection (CBP) personnel routinely observe 

travelers during their primary inspection and refer those that show 

symptoms of a communicable disease—or those recently traveling from 

an area of concern—for further assessment by Centers for Disease 

Control and Prevention (CDC) staff or other health authorities. Additional 

screening, such as was carried out during the Ebola threat, may include 

more targeted assessments during enhanced screening. According to the 

CBP, there are three main screening methods used for identifying 

passengers entering the United States who may have communicable 

diseases during the Ebola outbreak: (1) collecting advance passenger 

information, (2) visual inspection or taking of temperatures, and (3) 

questioning travelers. All of these methods are used for screening 

airplane passengers arriving in the United States, but only temperature 

measurement is associated with on-site health technology. Temperature 

checks may be conducted with contact or noncontact thermometers, but 

outside of the current Ebola response, this check is typically not common 

and only done in the setting of assessment of a suspected ill traveler 

reported to CDC, according to CDC officials.

Entry screening for Ebola at enhanced screening airports in the U.S. 

includes using non-contact infrared thermometers, under the enhanced 

screening protocols put in place to address the disease threat. Noncontact thermometer-based temperature measurement is a simple 

enough premise, but an agency official suggested it has both low 

sensitivity and specificity for detecting passengers with infectious 

disease.2In other words, such temperature measurement alone has a low chance 

of correctly identifying ill travelers and a low chance of correctly excluding 

healthy travelers. In the case of enhanced screening for Ebola, CDC officials or 

 

1The evaluations and claims of the technologies were not independently assessed by the GAO.

2Targeted populations are typically passengers who were recently in an area of an active 

outbreak.

Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

Temperature-Screening 

Technologies
Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

CBP contractors use thermometers that are commercially available 

following primary inspection by CBP personnel. To date, no mass 

screening of airplane passengers—where every passenger’s temperature 

is taken—has been conducted at a U.S. airport. During the recent Ebola 

outbreak, for example, only passengers with recent travel to, from, or 

through outbreak countries, such as Sierra Leone, were identified for 

temperature screening.

Internationally, both non-contact infrared thermometers as well as thermal 

scanners have been used for entry and exit passenger screening for 

communicable diseases, including Ebola and severe acute respiratory 

syndrome (SARS). For example, in 2009, during the H1N1 influenza 

pandemic, many international airports—but not U.S. airports—

implemented temperature-screening procedures. However, the literature 

reports questionable effectiveness from temperature screening, stemming 

in part from the aforementioned low sensitivity.

Page 51 GAO-16-127 Air Travel and Communicable Diseases

3 Some of the performance 

issues result from variabilities in temperature measurements exceeding the 

threshold for fever indication—variabilities of up to 3 degrees Celsius 

under some circumstances, such as after smoking, whereas fever can be 

indicated by an elevation of 1 degree Celsius for Ebola, for example. 

Temperature variability results from several factors including metabolism, 

medication, environment, and conditions, such as certain cancers, which 

are not quarantinable diseases of concern for airport screening purposes. 

Further, passengers who are in the incubation period of illness may not 

exhibit fevers, given that such periods of several infectious diseases 

typically last longer than most flights. According to scientific literature, 

camera-based thermograms have been used internationally. For 

example, camera-based temperature measurement, followed by earbased temperature measurement, has been tentatively shown to be 

effective for monitoring Dengue Fever in Taiwan. Dengue fever is not a 

U.S. quarantinable disease, and another study indicated uncertainty that 

temperature screening is effective for mitigating community transmission 

of this disease. Generally, however, thermal cameras are more expensive 

 

3A study in the 2013 World Health Organization (WHO) Bulletin suggests that exit screening in 

regions of active outbreak is more efficient than entry screening at all possible destination 

airports. See Khan, K., et al, “Entry and exit screening of airline travelers during the 

A(H1N1) 2009 pandemic: a retrospective evaluation,” Bull World Health Organ, vol. 90 

(2013): 368-376. Our report focuses on entry screening because the United States has 

not carried out exit screening during disease outbreaks within the past decade. However, 

during the Ebola outbreak, exit screening was implemented in Ebola outbreak countries 

with CDC and CBP assistance.
Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

than thermometers and their precision is not better. A possible reason for 

deploying thermal cameras is the eventual capacity to screen large 

numbers of travelers rapidly, but the benefits of this approach have not 

been established.

The CDC has developed a “Big Data” approach for identifying and 

tracking communicable disease outbreaks through data collection and 

analysis.

Page 52 GAO-16-127 Air Travel and Communicable Diseases

4

Information provided by BioMosaic can be used to help 

determine the risk of international spread of disease and to target 

potential CDC intervention by identifying potential threats, although it 

cannot be used to identify specific ill individuals. Launched in 2011 by the 

CDC’s Division of Global Migration and Quarantine, BioMosaic is a data 

analytics tool that works with collections of data, including news sources, 

historical travel information, and public databases to map the health and 

demographics of foreign-born populations within the United States (e.g., 

diaspora), as well as disease outbreaks internationally.5

For example, in 2014, the CDC reported the first confirmed cases of 

Middle East Respiratory Syndrome (MERS) infections in the United 

States and, by using BioMosaic, was able to identify the major points of 

entry into the country, as well as the volume of travelers entering from 

Saudi Arabia and the United Arab Emirates. CDC was able to identify five 

cities within the United States that accounted for 75 percent of arrivals 

from those two countries.

Several technologies are being evaluated for potential use in tracking or 

mitigating disease, including communicable diseases. These technologies 

could potentially be used for air travel. These include (1) telemedicine, (2) 

air circulation control, (3) genetic sequencing of airplane lavatory waste, 

and (4) point-of-care diagnostic technology. These technologies are at 

 

4

“Big Data” and data analytics can refer to analysis of large data sets—typically too large for 

conventional computational methods—to extract meaningful patterns and results.

5BioMosaic (sometimes Bio-Mosaic) entails collaboration among the CDC, several academic 

institutions, and data projects including BioDiaspora (now called BlueDot) and HealthMap 

that track disease trends. The focus on foreign-born persons is to help mitigate existing 

health disparities between them and U.S.-born persons. A comprehensive list of data 

sources is beyond the scope of this report, but includes a variety of sources including 

Google News and the International Air Transport Association (IATA) databases.

BioMosaic

Flight-Related Medical 

Technologies
Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

various stages of development and their effectiveness and cost 

considerations are not established.

Airlines use a variety of approaches in responding to ill passengers during 

flight. United Airlines is currently exploring the use of telemedicine, 

whereby some technology can be used on board an aircraft to provide a 

remotely located doctor with information—such as vital signs—needed for 

diagnosis and determining whether a flight diversion is needed.

Development of altered air circulation devices may also mitigate the 

spread of communicable diseases. Currently, air in an aircraft is filtered 

by high-efficiency particulate air (HEPA) filters, but effectiveness relies on 

the air’s passing through the filters. If a pathogen circulates widely within 

an aircraft cabin prior to being filtered, there may be an increased chance 

of person-to-person transmission of the disease. Air-circulation-altering 

devices may provide more isolated air environments for each passenger, 

but these devices have not yet been developed to the point where they 

have been tested or validated.

Recent research used meta-genomic examination of the content of 

airplane lavatories by sequencing and detecting the relative abundance of 

select pathogens (not quarantinable infectious diseases, however). By 

isolating and determining the sequence from genetic material found in 

passenger bio-waste, the researchers were able to determine the types of 

antibiotic resistance carried by passengers’ microbes. Researchers were 

also able to identify specific pathogens, as well as their relative 

abundance based on the geographic origin of the samples. This method 

is potentially useful for global surveillance of communicable diseases, 

antibiotic resistances, and transmission routes. However, there are 

potential challenges to implementing this approach. For example, the 

researchers identified that implementing this method from all flights on a 

weekly basis would be challenging, given the current state of technology.

Additionally, developments in point-of-care technology—methods that can 

be used in doctor’s offices, hospitals, or on the field (e.g., at an airport), 

instead of a laboratory—are increasing the speed of diagnosis as well as 

the variety of diseases that can be targeted. For example, companies 

have developed FDA-approved tests for human immunodeficiency virus 

(HIV) that do not require laboratory equipment and can provide results in 

as little as 20 minutes. Some tests for communicable diseases, such as 

influenza, have been developed and FDA-approved, but studies have 

indicated the sensitivities can be variable. Future improvements may lead 

Page 53 GAO-16-127 Air Travel and Communicable Diseases
Appendix II: Technologies for Responding to 

Communicable Diseases in Aviation

to feasible screening based on, for example, microfluidics devices that 

can identify multiple concomitant infections.

Page 54 GAO-16-127 Air Travel and Communicable Diseases
Appendix III: Comments from the Department 

of Transportation

Page 55 GAO-16-127 Air Travel and Communicable Diseases

Appendix III: Comments from the 

Department of Transportation
Appendix IV: GAO Contacts and Staff 

Acknowledgments

Gerald L. Dillingham, Ph.D., 202-512-2834, or dillinghamg@gao.gov

In addition to the contact named above, the following individuals made 

important contributions to this report: Paul Aussendorf, Assistant Director; 

David Hooper; Hayden Huang; Molly Laster; David Lysy; Jacob McAuliffe; 

Josh Ormond; Sarah Resavy; Gretchen Snoey; Russell Voth; and Amelia 

Weathers

Page 56 GAO-16-127 Air Travel and Communicable Diseases

Appendix IV: GAO Contacts and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Appendix V: Related GAO Products

Emerging Infectious Diseases: Asian SARS Outbreak Challenged 

International and National Responses. GAO-04-564. Washington, D.C.: 

April 28, 2004.

Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer 

Federal Leadership Roles and an Effective National Strategy. 

GAO-07-781. Washington D.C.: August 14, 2007.

Influenza Pandemic: Opportunities Exist to Address Critical Infrastructure 

Protection Challenges That Require Federal and Private Sector 

Coordination. GAO-08-36. Washington D.C.: October 31, 2007.

National Response Framework: FEMA Needs Policies and Procedures to 

Better Integrate Non-Federal Stakeholders in the Revision Process. 

GAO-08-768. Washington, D.C.: June 11, 2008.

Public Health And Border Security: HHS and DHS Should Further 

Strengthen Their Ability to Respond to TB Incidents. GAO-09-58. 

Washington, D.C.: October 14, 2008.

Influenza Pandemic: Sustaining Focus on the Nation’s Planning and 

Preparedness Efforts. GAO-09-334. Washington D.C.: February 26, 

2009.

Influenza Pandemic: Increased Agency Accountability Could Help Protect 

Federal Employees Serving the Public in the Event of a Pandemic. 

GAO-09-404. Washington D.C.: June 12, 2009.

Influenza Pandemic: Monitoring and Assessing the Status of the National 

Pandemic Implementation Plan Needs Improvement. GAO-10-73. 

Washington D.C.: November 24, 2009.

Disaster Response: Criteria for Developing and Validating Effective 

Response Plans. GAO-10-969T. Washington, D.C.: September 22, 2010.

National Preparedness: DHS and HHS Can Further Strengthen 

Coordination for Chemical, Biological, Radiological, and Nuclear Risk 

Assessments. GAO-11-606. Washington, D.C.: June 21, 2011.

Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be 

Incorporated into Future Planning. GAO-11-632. Washington D.C.: June 

27, 2011.

Page 57 GAO-16-127 Air Travel and Communicable Diseases

Appendix V: Related GAO Products
Appendix V: Related GAO Products

FEMA Has Made Limited Progress in Efforts to Develop and Implement a 

System to Assess National Preparedness Capabilities. GAO-11-51R. 

Washington, D.C.: October 29, 2010.

Influenza Pandemic: Agencies Report Progress in Plans to Protect 

Federal Workers but Oversight Could Be Improved. GAO-12-748. 

Washington, D.C.: July 25, 2012.

Emergency Preparedness: Opportunities Exist to Strengthen Interagency 

Assessments and Accountability for Closing Capability Gaps. GAO-15-20. 

Washington, D.C.: December 4, 2014.

Page 58 GAO-16-127 Air Travel and Communicable Diseases
Appendix VI: Accessible Data

Page 59 GAO-16-127 Air Travel and Communicable Diseases

U.S. Department of Transportation

Office of the Secretary of Transportation

Assistant Secretary for Administration

1200 New Jersey Avenue. SE

Washington. DC 20590

DEC 03 2015

Gerald Dillingham, Ph.D.

Director, Physical Infrastructure

U.S. Government Accountability Office

441 G Street N W

Washington, DC 20548

The Department of Transportation (DOT) is committed to ensuring a fast, 

safe, efficient, accessible and convenient transportation system for the 

American people. We agree that there is a need for a national aviationpreparedness plan for communicable diseases to help improve the U.S. 

aviation sector's preparedness for future communicable disease threats.

However, responding to these threats within the transportation context, as 

well as in other respects, is primarily a matter of public health emergency 

preparedness. We are prepared to support those agencies that, unlike the 

Department of Transportation, have both the legal authority and expertise 

to develop a national aviation preparedness plan for communicable

Appendix VI: Accessible Data

(540285)

Agency Comment 

Letter

Text of Appendix III: 

Comments from the 

Department of Transportation

Page 1
Appendix VI: Accessible Data

diseases and we stand ready to participate in their planning efforts. To be 

effective, these efforts should be conducted within the existing 

interagency framework for national-level all-hazards emergency prep a 

redness planning. As a result, we concur in part with the 

recommendation.

We will provide a detailed response to the recommendation within 60 

days of the report's issuance. We appreciate the opportunity to offer our 

comments on the GAO draft report. Please contact Madeline 

Chulumovich, Director of Program Management and Improvement, at 

(202) 366-65 12 with any questions or if the GAO would like to obtain 

additional detail about these comments.

Sincerely,

Jeff Marootian

Assistant Secretary for Administration

Figure 3: Top Five U.S. International Arrival Airports for Five Global Regions, 2014

Page 60 GAO-16-127 Air Travel and Communicable Diseases

Region Percentage

Central and S America 30

Europe 25

N America 25

Asia and Australasia 16

Africa and Middle East 4

Data Tables
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