Air Travel and Communicable Diseases: Comprehensive Federal Plan Needed for U.S. Aviation System's Preparedness
Published: 2015-12-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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 aviation-preparedness 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 aviation-preparedness 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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. In 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.
We have found—in lessons learned from the response to the 2009 H1N1  influenza pandemic—that interagency planning and exercises build  formal networks and informal relationships that are valuable during a  response. 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.
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  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 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. In 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; the International Civil Aviation Organization (ICAO); the  labor union representing airport- and airline-service workers; and  contracted aviation-services employers and their employees. 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.
subsections: section_title: Background
paragraphs: 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. Figure 1 provides information about major  communicable disease epidemics since 2002.
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. 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.
ICAO takes a key role in coordinating the international aviation response  to public health risks. Through the IHR, WHO member states have  agreed to build core capacities at designated ports of entry, 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. 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. 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. 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 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.
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  countries, if necessary, to protect the general population and respond  to disease threats to the United States.
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.
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.
Depending on location and threat, these agencies along with aviation  stakeholders and their partners—including local public health  authorities, 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. 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.
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. 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. 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 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.
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. 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.
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. 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. 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. On board an aircraft in  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).
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.
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 HHS and DHS (by agreement). During primary  inspection, CBP staff are expected to visually observe arriving  international travelers for certain signs and symptoms of communicable  diseases during their routine interactions with travelers and then notify  CDC, as appropriate. 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. For example, asymptomatic  passengers from Ebola-affected countries—Guinea, Liberia, and Sierra  Leone—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. 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.
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  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 Ebola- affected countries to be routed to one of the following five designated  airports where CBP and CDC staff conducted enhanced entry screening  procedures:
Newark Liberty International Airport,
Washington Dulles International Airport,
Hartsfield-Jackson Atlanta International Airport, and
Chicago O’Hare International Airport  John F. Kennedy 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. 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  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.
section_title: Airports and Airlines That We Reviewed Have Plans, but a Comprehensive National Aviation- Preparedness Plan Does Not Exist
subsections: section_title: Airports and Airlines That We Reviewed Generally Have Communicable- Disease Preparedness Plans
subsections: section_title: Airports and Airlines We Reviewed Have Preparedness Plans
paragraphs: 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. We identified these components to provide a basis for  assessing the 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 communicable- disease 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, 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 diseases—to a disease-specific preparedness  plan, such as a pandemic influenza response plan. Other types of  documents included a 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.
As noted above, some airports have in place a CDC communicable- disease 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. The CDRPs,  according to CDC officials, were developed in coordination with relevant  stakeholders and partners at each airport and based on a framework  provided 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. Each of these quarantine stations is also  responsible for enforcing quarantine regulations at all airports within its  assigned jurisdiction.
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. 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  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. 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  CertAlert 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  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).
section_title: A Variety of Entities Provide Resources to Help Develop Plans
paragraphs: 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, 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  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.  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. For  example, in 2009, ACI, in collaboration with ICAO, published the Airport  Preparedness Guidelines for Outbreaks of Communicable Disease to  help airports. 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.
section_title: The United States Lacks a Comprehensive National Aviation-Preparedness Plan
subsections: section_title: ICAO Standard Obligates Member States to Establish a National Aviation- Preparedness Plan
paragraphs: 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. In 2010, ICAO, by resolution,  further urged member states to ensure that the public health sector and  the aviation sector collaborate to develop a national preparedness plan  for 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.
While the United States has not developed a national aviation- preparedness 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 aviation- preparedness 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  standard—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 developed in response to the avian influenza threat of H5N1, as  well as CDC’s Risk-Based Border Strategy (RBBS), 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. 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 aviation- preparedness 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  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. 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.
section_title: A National Plan Aims to Provide an Adaptable and Scalable Framework
paragraphs: ICAO’s guidance to member states in developing a national aviation- preparedness 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  alert levels, such as WHO’s pandemic alert phases or a national public- health 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 Ebola- specific 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. 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. 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.
section_title: Public-Health and Aviation Sector Coordination Has Been Insufficient
paragraphs: ICAO guidance to member states for developing a national aviation- preparedness 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  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.
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  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.
section_title: Airports, Airlines, and other Stakeholders Faced Challenges Responding to Communicable Disease Threats and Are Taking Some Actions as a Result
paragraphs: 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 aviation- preparedness 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.
subsections: section_title: Guidance and Communication Challenges
paragraphs: 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. Moreover, ICAO recommends that national  aviation-preparedness plans include a communication system and  emphasizes the importance of periodically testing this communication  system.
subsections: section_title: Guidance from Federal Agencies
paragraphs: 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  timely Ebola guidance, and met with aviation industry partners both  collectively and individually.
section_title: Communications during Flight
paragraphs: 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—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. 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. 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-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.
section_title: Communication after Arrival
paragraphs: 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  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.
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.
section_title: Challenges in Providing Information to the Public
paragraphs: 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:  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  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.
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.
section_title: Challenges in Coordinating Incident Response
paragraphs: 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 baggage- handling trucks blocked other responders’ access to the aircraft.
Coordinating with contracted aviation-services firms: Representatives  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 communicable- diseases 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.
section_title: Challenges in Training and Equipping Contracted Aviation-Service Employees
paragraphs: 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 pathogen- exposure-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  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.
Personal protective equipment: appropriate personal protective  equipment such as gloves, gowns, eye protection, and masks.
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.
Vaccination and post-exposure evaluation and follow-up: employees  must be offered the hepatitis B vaccination and be evaluated and  provided follow-up after an exposure incident.
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. 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.
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  materials such as feces. 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 blood- borne pathogens standard or analogous state standards that are at least  as effective. Among these violations were instances when aviation- services employers did not provide employees with appropriate pathogen  exposure 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.
section_title: Conclusions
paragraphs: 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 aviation- preparedness 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.
section_title: Recommendation
paragraphs: 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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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.
section_title: Appendix I: Objectives, Scope, and Methodology
subsections: section_title: Objectives
paragraphs: 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.
section_title: Scope
paragraphs: 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: bioterrorism (i.e., traveler using communicable disease as a weapon), 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,  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 Ebola- affected countries in West Africa;  received the first and second largest number of international  passengers from each of five world regions in 2014;  large hub airports 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.
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).
section_title: Methodology
paragraphs: 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. 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  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. 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, and 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 airline- service employees, and airport- and airline-contract employers of service  employees. We consulted with representatives from the union that  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 aviation- services 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.
section_title: Appendix II: Technologies for Responding to Communicable Diseases in Aviation
paragraphs: 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.
subsections: section_title: Temperature-Screening Technologies
paragraphs: 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. Non- contact 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. In 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 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. 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 ear- based 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  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. 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.
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.
section_title: Flight-Related Medical Technologies
paragraphs: 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  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  to feasible screening based on, for example, microfluidics devices that  can identify multiple concomitant infections.
section_title: Appendix III: Comments from the Department of Transportation
section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.
section_title: Appendix V: Related GAO Products
paragraphs: 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.
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.