World Health Organization. Meeting of the informal Transportation Working Group to develop guidance for implementation of IHR(2005) at points of entry

Transcription

1 World Health Organization Meeting of the informal Transportation Working Group to develop guidance for implementation of IHR(2005) at points of entry Hosted by the International Civil Aviation Organization (ICAO) Montreal, Canada April 2006 Geneva, 1 June 2006

2 TABLE OF CONTENTS EXECUTIVE SUMMARY 1. BACKGROUND 1.1 Outcomes of meeting 2. Discussion arising from Agenda 2.1 Training/public health awareness 2.2 Compliance 2.3 Maritime and aircraft health declarations 2.4 Model ship sanitation control/exemption certificates 2.4 Cruise ship inspection process 2.5 Role of other international organizations, non-governmental organizations 2.6 Additional SOPs proposed during meeting 2.7 Passenger locator card 3. PRESENTATIONS 3.1 Model passenger locator card - Dr Claude Thibeault (IATA) Outcomes from meeting, Avian Influenza Preparedness Planning (Aviation Aspects) Guidelines for States, Singapore, 7-10 February - Introductory remarks by Dr Anthony Evans 3.2 General guidelines for States / Airports and Airlines - Dr Anthony Evans (ICAO) 3.3 Detailed guidelines for airports - Mr David Gamper (ACI) 3.4 Detailed guidelines for airlines - Dr Claude Thibeault (IATA) Appendices 1. List of SOPs and protocols to be developed 2. Draft template for completing SOPs 3. List of members of working groups 4. Preliminary guidance developed by airports working group (including quarantine break-out group) 5. Preliminary guidance developed by ports working group 6. Preliminary guidance developed by ground crossings working group 7. Model passenger locator card 8. General guidelines for States / Airports and Airlines - Dr Anthony Evans (ICAO) 9. Detailed guidelines for airports - Mr David Gamper (ACI) 10. Detailed guidelines for airlines - Dr Claude Thibeault (IATA) 11. Agenda 12. Participants' list - 2 -

3 EXECUTIVE SUMMARY The purpose of the Montreal meeting was to review existing standard operating procedures at selected points of entry and to identify those procedures and any additional procedures that could be considered core capacities for all Member States under Annex 1(b) of the International Health Regulations (2005). After opening remarks by Dr Anthony Evans of ICAO and Mr. William Cocksedge of the World Health Organization, the participants watched a short DVD on the how the Baiyun International Airport in China is equipped to handle public health emergencies of a communicable disease nature. The Baiyun airport is a fully integrated purpose built system going well beyond what would be considered basic capacities, but it provides a good overview of what the working group should consider as it goes about its work. The group agreed that while an integrated system is important, coordination of all players is more important than just having the facilities. The group examined a list of 20 standard operating procedures culled from submissions by several Member States in advance of the meeting. After a broad discussion on the standard operating procedures, three more protocols were added to the list. With a new list of 23 standard operating procedures, the group then split into three subgroups (airports, ports and ground crossings), nominated the Chairs and began the work of developing the SOPS for each point of entry. The working group also developed and approved a template proposal to which all standard operating procedures for points of entry would conform. The groups agreed to continue working on the SOPS in a virtual forum, working towards a deadline of June 30th to complete their work. Dr Claude Thibeault of IATA presented the model passenger locator card for use on board aircraft, to be completed when recommended by WHO or when public health authorities suspect the presence of a communicable disease. The card was developed over time by IATA and ICAO in conjunction with the transportation working group and reviewed by WHO/LEG. It was the considered opinion of those present that the model locator card should be posted on the WHO website. Dr Anthony Evans (ICAO) reported on outcomes from the avian influenza preparedness planning meeting which was held in Singapore in 7-10 February This was followed by ICAO's general preparedness planning guidelines for States at airports and for airlines and detailed guidelines for a pandemic planning at airports (David Gamper/ACI) and for airlines (Dr Claude Thibeault/IATA). 1. BACKGROUND The informal transportation group is made up of public health regulatory and common carrier experts from national governments, the international transportation industry and WHO staff who gather periodically to discuss and propose solutions to issues concerning international travel and transport and the International Health Regulations. The group has provided valuable advice to guide the formulation of the Regulations in areas such as preventing disease spread through vector control, water quality and food safety, etc. on board ships and aircraft and at ports and airports. Five meetings of this group have been held to date (January 2002, November 2003 and January 2005 in Geneva, October 2003 and June 2004 in Montreal) to provide input into the direction and eventual adoption of the Regulations

4 With the adoption of the IHR (2005) in May 2005, WHO Member States agreed to a framework to strengthen surveillance and response measures to prevent disease from spreading internationally. Member States requested further guidelines to accompany the Regulations in the following areas: At international ports, airports and ground crossings: Criteria and inspection protocols for conveyances, public facilities, examination, isolation and quarantine facilities for persons, conveyances, goods, cargo, postal parcels and animals (where applicable). Certification protocols for ports and airports 1.1 OUTCOMES OF MEETING complete list of 23 standard operating procedures of the IHR (2005) for implementation at points of entry (Appendix 1) standardized format (draft template) for standard operating procedures (Appendix 2) working groups to develop of point of entry specific standard operating procedures (Appendices 4, 5, 6) with a finished draft by June 30th schedule of planned activities and field testing, including establishing a date for a final meeting to review the SOPs and target date of May 2007 for finished product The outcomes of the Montreal meeting were reported the following week to an international WHO meeting on strengthening national capacities for epidemic preparedness and response in support of national implementation of the IHR (2005). The meeting was held 2 5 May 2006 in Lyon, France. 2. DISCUSSION ARISING FROM AGENDA 2.1 Training/public health awareness Clarify responsibilities of key players, e.g. airport operators, conveyance operators. Public health authorities must understand role, responsibilities, and limitations. Member States should ensure that ports meet Annex 1B requirements as soon as possible, e.g. space for triage. Ensure that people are adequately trained to make public health decisions regarding conveyance operations. Make sure that forms that are being requested have public health value. Member states need a listing of ports or airports where disinsection is required. This was addressed in the IHR and WHO needs to follow up with the listing. 2.2 Compliance SOPs will help harmonize actions by Member States and may assist bilateral agreements. Important to agree to key SOPs and guidelines as soon as possible in order to avoid conveyance operators doing lowest common denominator shopping. Commercial pressure for POE to comply is a positive driver. External auditor would add credibility to compliance requirements. Value of certification for food and water. Would form a basis for reciprocal acceptance and avoid duplication. Competent authorities should be involved in certification and audit procedures

5 2.3 Maritime and aircraft health declarations These declarations are after the fact. Pilot or captain should have radioed ahead with case of unusual sickness onboard. Aircraft declaration Why not a box that can be ticked confirming that pilot has radioed ahead case of illness? Master of vessel cannot make a medical determination, that is why it is important to radio ahead. Reporting system must take precedence. ISF concern: Do States continue to have the obligation to assess illness onboard vessels? (Cites cases of refusal to enter, refusal to allow ill crew to disembark, etc.) - ACTION: Raise this point with WHO Legal 2.4 Model ship sanitation control/exemption certificates Consistency and credibility of these declarations is key. Propose a similar sanitation certificate for aircraft, although it would be logistically more difficult. Cannot call it a certificate because of the nature of the IHR negotiation process. Member States have right to board international aircraft and do ad hoc inspections as needed. Audit of ships can be carried out using model sanitation certificate against ship logs. Follow up measure could be refusal of free pratique for future visits. Audit should not unduly interfere with ship operations. Ships can choose where they get their inspections. Bottom line: A valid ship sanitation certificate should be accepted by the country and there should be no need for re-inspection. If a ship has a certificate from a non-listed port, WHO will contact the port concerned and report back. 2.4 Cruise ship inspection process WHO not in a position to broker reciprocity 2.5 Role of other international organizations, non-governmental organizations Possible synergies with ILO regarding health and safety onboard. International Hydrographic Organization can relay urgent public health messages to ships at sea. Possibility of ICAO adding public health designation to list of designated airports. 2.6 Additional SOPs proposed during meeting # 21- roles and responsibilities re reporting illness on board for POE staff and conveyance crew: # 22 - container traffic: # 23- recovery of isolation/quarantine costs 2.7 Passenger locator card Post on WHO website - 5 -

6 3. PRESENTATIONS 3.1 Passenger locator card - Dr Claude Thibeault (IATA) The model passenger locator card is the end product of a series of meetings involving IATA, ICAO, WHO and members of this transportation working group over a number of years. The purpose of the card is to aid health authorities to trace passengers who may have been exposed to a communicable disease. The card is intended to be used when recommended by WHO (during public health emergencies) or when public health authorities suspect the presence of a communicable disease. It has long been the opinion of the working group that WHO, as a neutral party, was best positioned to recommend this card to its Member States. Airlines would be interested in using this card in the interests of international harmonization. There was some discussion on how the card would be stocked. It was the general consensus of those present that: Member States are responsible for printing the cards Airport public health authorities should maintain a supply of the cards at the airport.. Airlines carry a small number of cards to be distributed onboard when needed WHO should post the model passenger locator card on its website immediately following this meeting 3.2 General guidelines for States / Airports and Airlines - Dr Anthony Evans (ICAO) Dr Anthony Evans provided information on the outcomes of the ICAO hosted workshop Avian Influenza Preparedness Planning (Aviation Aspects) Guidelines for States, held in Singapore, 7-10 February The purpose of the Singapore meeting was to develop generic aviation preparedness guidelines which can be adapted to any communicable disease threat of international scope, including pandemic flu. Dr Evans stressed the need for a consistent message to be provided to the public and relevant stakeholders by national governments, airports and the airline industry. ICAO has proposed the establishment of a small group with WHO, the Airports Council International and the International Air Transport Association, to try and ensure that this reliable, consistent information is available globally with respect to air transport. (See Appendix 8) 3.3 Detailed guidelines for airports - Mr David Gamper (ACI) ACI outlined a list of goals for airports during a major health-related event, with the overriding concern of keeping the airport running. Airports should expect to operate with at most, 85% of staff during a pandemic and during the peak three weeks that figure would be revised downward to % staff capacity. Using as a real life example, the suspected SARS case at Frankfurt Airport (March 15, 2003), the presentation outlined what worked and what problems emerged from that incident. A series of case scenarios for dealing with a pandemic were presented, with a range of possible responses and the intended effect of those responses. Detailed emergency procedures for dealing with a highly infectious disease were presented as flow charts. The presentation highlighted the importance of personal protective equipment and replacement clothing, quarantine stations. (See Appendix 9) 3.4 Detailed guidelines for airlines - Dr Claude Thibeault (IATA) IATA has developed, in consultation with its medical advisory group and the Centers for Disease Control Atlanta, a comprehensive series of guidelines when there is a case of suspected communicable on board an aircraft. These guidelines are intended for cabin crew, check-in agents, cleaning crew and maintenance crew. WHO has reviewed the guidelines and provided input into the recommendations. IATA has also created guidelines in the event of a bird strike. (See Appendix 10)

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8 Appendix 1 Points of Entry - List of SOPs and Protocols to be developed Inspection of PoE and conveyances Contingency Plans for PoE Qualifications for persons carrying out pest/environment audits/inspections 1. International passenger & cargo aircraft inspections - no example 2. International vessel inspections, including cargo ships and large passenger vessels - UK, USA & Canadian examples 3. Inspection of ports and port facility requirements - no example 4. Inspection of airports and airport facility requirements - Canadian example for flight kitchens 5. Inspection of ground crossings and ground crossing facility requirements - Canadian example 6. Inspection of trains (off board & onboard Canadian example) Isolation/quarantine of persons/animals/conveyances 1. Airport "rest centre" (public health area at airport for non-emergency examinations, including office space & equipment/instrument storage and use - no example 1. Model contingency plan for ports - no direct example, airport plans should assist development 2. Model contingency plan for airports - ICAO example 3. Model contingency plan for ground crossings - airport example can assist development Disinsection/disinfection of conveyances 1. Disinsection methods for conveyances, cargo and goods - WHO, NZ examples 1. Qualifications for persons carrying out public health inspection and environmental audits - no international example 2. Qualifications for persons carrying out pest control services and for pest control audit - no international example Reporting 1. Reporting illness on board

9 2. Quarantine facilities off airport for suspects (persons) - no example 3. Quarantine facilities off airport for suspect animals (OIE) - OIE plus possible example from CAREC 4. Isolation facilities for persons (off airport) - no example 5. Isolation facilities for animals (OIE) - no example 6. Quarantine area for conveyances, goods, cargo, postal parcels - no example 2. Disinfection and decontamination of conveyances, goods, baggage, postage parcels, persons, animals - old WHO aircraft example only 2. Reporting on containers - type and extent of contamination and disinsection/ disinfection measures carried out 3. Recovering cost Other Designated hospital and clinic - minimum requirements, including agreement content - no international example - 9 -

10 WHO IHR Appendix 2 Meeting of the informal Transportation Working Group for implementation of IHR(2005) at points of entry MONTREAL April 26 th to 28 th, 2006 DRAFT GROUP FOR SOP TEMPLATE Coordinator: Andre Basse Rapporteur: Daniel L. Menucci Participants: Patricia Lemay, Dennis Brodie TEMPLATE PROPOSAL 1. Introduction 1.1. background 1.2. scope 2. Goal and Objectives 2.1. Goal: means a broad/general approach 2.2. Objective: Specific/measurable for each guideline 3. Legal and Policy Framework 3.1. Rights and General Obligations for the State Party under IHR and related international instruments (Declarations, Regulations, Conventions, Treaties, Agreements, Codes, Recommendations.) 3.2. Domestic Legal and Policy instruments related to IHR and public health (Legislative, Regulatory, policies) 4. Roles and Responsibilities 4.1. Role of Competent Authorities Community level Intermediate level National level Between National IHR Focal Point and WHO IHR contact points 4.2. Role of Operators, Administrators, Service Providers conveyances facilities 5. MEASURES & PROCEDURES Planning and adopting specific measures, procedures, precesses, systems, personnel, equipment, facilities, communications, reporting, records, trainning, compliance and corrective actions, monitoring and auditing, compliance measurements, testing & other compliance methods, identification of critical areas and type and frequency for inspections or others measures, including joint inspections through national and international agreements or arrangements, communication and results. 6. References 7. Annexes 8. Glossary of terms

11 Appendix 3 Airports Ports Ground Crossings Leads shown in "red" Leads shown in "red" Leads shown in "red" David Gamper (ACI) overall Natalie Wiseman (ship André Basse (LEAD) lead for airports inspections) Angela Tanner Sandra Westacott (port facilities) Patricia Lemay Ockert Jacobs Sally van Boheemen Dennis Brodie Alyson Baker David Forney Daniel Lins Menucci Henry Kong James Gibson Xue Yonglei Kiren Mitruka Elaine Cramer Angela Plott (will coordinate ports and feed back to Natalie) Claude Thibeault Steve Williams David Bennitz Grant Tarling Susan Courage Colin Browne Helen Gannon Tony Evans Christie Reed Aircraft inspections (Angela) Quarantine facilities off-site (Alyson, Christie, Elaine) Aircraft operations (David Bennitz, Susan, David Gamper, Claude, Tony Contingency plans for communicable disease and public health space (Susan) Airport and aircraft operations and contingency planning (Xue, Henry)

12 Appendix 4 AIRPORTS GROUP Participants: Dave Bennitz; Alyson Baker; Susan Courage; Elaine Cramer; Anthony Evans; David Gamper; Helen Gannon; Henry Kong; Kiren Mitruka; Christie Reed; Claude Thibeault; Yonglei Xue SOPs Policy and legislation Member states legislation, based on IHR Work procedures and guidelines (Standards, minimum requirements) Training and education Includes competencies for operators and inspectors Equipment required Facilities Records analysis Inspection, procedures (inspectors) Auditing and monitoring Bibliography Guide to hygiene and sanitation in aviation (WHO, 1977 to be rewritten) Glossary of terms General Comments Should serve all contracting states, that require varying degrees of prescription or equivalent useful phrase 1. Aircraft inspection (passenger) Guide to hygiene and sanitation in aviation (WHO, 1977 to be rewritten) Frequency? Every 6/12, annual, what % of aircraft. Restaurants inspected 4-6 times per year Internationally valid Aircraft Sanitation Certificate. Onus on airline to have such a certificate and request a revalidation. UK developing tools for this national only at present. Different requirements for food cooked on board and cooked elsewhere and uploaded. Who can inspect? No international standard for inspectors. Needs to include all types, food, water, waste disposal. Food, unless cooked on board is covered off-aircraft already Vector Food/water kitchen inspection Droplet/airborne disease ventilation system inspecton A/C cleaning is done at end of long flight or at end of day (short haul) Still not clear how to interpret IHR. Thursday a.m. comments During regular maintenance would not involve observing working crew Voluntary compliance works better if using same ports Storage of food on board is impt V. large nos of aircraft involved certificate may be impracticable Capacity to inspect is already available at airports ad hoc at present. Reactive Wording should be prescriptive Don t go below PH requirement (but minimise time required) Records should be available, as required, even if not a complete check? in different languages. Cruise liner one/two inspection per year 4. Airports facilities and inspection Food, water, waste, gen. sanitation, pax. education Guide to hygiene and sanitation in aviation (WHO, 1977 to be rewritten)

13 Airport food serving premises under PH authority Quarantine pax/cargo Problem is not sick passenger (who goes to hospital) but how to cope with remaining passengers. Delay in making assessment should be minimised Education of flight crew important Include consultation with the airport operator Quarantine break-out Participants; Kiren Mitruka; David Gamper; Susan Courage; Elaine Cramer; Claude Thibeault; Christie Reed; Yonglei Xue; Henry Kong; Alyson Baker; Ockbert Jacobs; Jitu Thaker Short-term quarantine (holding) at airport then move to longer term facility Space? hotel hotels are not keen, even if whole hotel taken over Govt premises needed with individual rooms/toilets for families Food/water/communication/newspaper/entertainment Medical surveillance + treatment Access PR Quarantined people not happy use cell phones to contact media Charges? public health Handwashing Linen cleaning Stockpile of equipment/drugs Ready-to-go packs Identify Refer to staged holding Crew and pax together? Minors travelling alone? Detaining pax against will communication reduces tension Airport quarantine for few hours OK The following accommodation standard is being proposed by the WHO for use at airports for the provision of public health services: CONSIDERATIONS: General: Private Assessment Area with direct access to the Customs Hall (for arriving passengers) and preferably close to the Primary Inspection Line (to limit potentially infected travellers exposure to other people). Access to a handwash station (ideally access to showers) Contact surfaces suitable for easy disinfection Access to a toilet Ventilation to avoid contamination of other passengers A contingency area to accommodate, inside or outside the airport terminal building, a potentially large number of passengers with facilities to include: Handwashing Food Water Toilets Similar facilities should be provided for departing passengers as for arriving passengers if exit

14 screening is required Administration Operations Space Ready access to the airport s public area and to the Private Assessment Area as mentioned above. Capability to communicate privately Adequate communication facilities (IT, telephone) Adequate storage space Thursday am comments Staff toilet required Dedicated toilet for suspected case(s) Not intended for treatment a triage area. Not for isolation? minimum time for transport to health care facility important to call ahead Minimise delay to aircraft on ground

15 A. Preamble - Designated Port of Entry Appendix 5 WHO INFORMAL TRANSPORTATION MEETING PORT HEALTH WORKING GROUP Identified Public Health Need Public Health Assessment Area. Arriving cargo ships, ferries, cruise ships and other sea-going vessels may, from time to time, identify passengers or crew who they suspect may be unwell with a disease or illness that could be a communicable disease or illness of public health concern. Such patients may present with symptoms of fever, rash, respiratory or influenza-like illness, neurological illness or gastro-enteritis. These symptoms may be seen individually or in combination. There is also the possibility that passengers or crew members may have had access to, or been exposed to biological and chemical agents or radiological materials, possibly released as part of a terrorist incident, that will pose a public health hazard. Under these circumstances, it would be necessary to disembark the passenger or crew member for more extensive medical examination and care than is available on board. The physical circumstances of a ship, isolation from land-based medical care and advanced diagnostic resources, mean that management of a communicable disease or an illness of public health concern is extremely difficult, particularly in the absence of a on-board physician, nurse or medical provider. At times of heightened public health concern, such as the emergence of new pathogens or the threat of pandemic influenza, public health agencies may adopt a pro-active surveillance or screening program at ports of entry to mitigate the spread of such diseases. Additionally at times of heightened public health awareness, the operators of cruise ships may also elect to provide pre-embarkation health screening of passengers to reduce the risk of the introduction of a communicable disease onto the ship. The provision of a Port Health Assessment Area will enable the timely provision of public health screening examination, for both embarking and disembarking passengers or crew members. It will further provide an opportunity to isolate a potentially infectious patient, until such time as a determination is made that the passenger or crew member is fit to return to the ship or vessel, continue their travels, or is transferred to an appropriate medical facility for the investigation and treatment of any communicable disease or illness of public health significance. B. OBJECTIVE The establishment at all ports of entry, of a Port Health Assessment Area within the port security boundary that can provide; a) Physical separation of person or persons suspected of having a communicable disease or illness of public health significance. b) An area appropriate for a designated public health professional to conduct an initial patient screening examination to identify those persons who may pose a public health risk. C. GOAL a) The ability for member states to mitigate the possibility of the introduction of communicable diseases and illnesses of public health concern through ports of entry and the promotion of biosecurity measures designed to protect resident communities from the spread of international diseases. b) The worldwide development of surveillance points at ports of entry to enhance the likelihood of early detection by WHO and other national and international public health agencies of new and emerging pathogens, or the spread of a communicable disease or illness of public health concern.

16 D. LEGISLATIVE CONTEXT International Health Regulations (2005) Part IV Points of Entry Annex 1, Part B :Core Capacity Requirements for Designated Airports, Ports and Ground Crossings. UN Safety of Life at Sea (SOLAS) UN Convention LOS E. STANDARD OPERATING PROCEDURE 1. Each State Party shall determine who shall be the competent authority to establish and supervise the Port Health Assessment Area (PHAA). The competent authority should then supervise the provision, by an appropriate public health professional, of a Port Health Assessment on a person or persons arriving suspected of having a communicable disease or illness of public health significance. 2. The Port Health Assessment Area should be located in an area that is within the port of entry security zone, but not connected to other buildings or is environmentally isolated from the other buildings. The PHAA should have a climate controlled environment where the exhausted air is passed through a HEPA filter or some other method of reducing the likelihood of output and transmission of potentially harmful pathogens. 3. There should be provision of basic diagnostic equipment, such as a patient exam table, blood pressure measuring equipment, personal protective equipment (PPE) and where available, specific disease screening tools or diagnostic aids. 4. The Port Health Screening Area should also provide adequate toilets and sanitation systems to safely dispose of excreta and other body fluids generated within the screening area. 5. The competent authority shall enter an agreement or memorandum of understanding with an appropriate local health care facility for the transport to, and further evaluation or treatment of, a person or persons, who upon completion of the initial screening examination are suspected of having a communicable disease or illness of public health concern. Such agreement shall also outline the process for emergency transfer of a passenger or crew member, suspected of having a communicable disease or illness of public health significance, who has an acute emergency medical condition, that requires immediate hospital-level care. 6. The competent authority shall ensure that the appropriate local health care facility has a Standard Operational Procedure to accept and isolate a person or persons with a communicable disease or illness of public health concern. 7. The competent authority shall select the appropriate public health professional to conduct port health screening exams and develop protocols and procedures designed to address the clinical issues that may arise during the performance of port health screening exams. Such protocols should include, but are not limited to, the delineation of clinical decision making responsibilities, criteria for determining the presence or absence of possible communicable diseases or illnesses of public health significance and notification procedures to local, state and national public health authorities as appropriate. Thursday am comments Cross reference with ISBS code Some ports have minimal facilities 7 year period to implement minimum requirements Security pre-clearance for officials

17 Appendix 6 GROUND CROSSING GROUP (11 th floor conf.rm.) Coordinator: Andre Basse Rapparteur: Daniel L. Menucci Participants: Discussion: a) SOP/Guidelines List The group proposes to re-group the SOP/Guidelines List into 7 major areas of interests. The group also identify 5 of them related to ground crossing. [LIST OF THE 7 MAJOR AREAS/GUIDELINES RE-GROUPING IT] b) Guidelines Format The group proposes the following formats for 5 of the SOP/Guidelines related to ground crossing. I- INSPECTION OF GROUND CONVEYANCES (trains, lorries, coaches) 1. Introduction a. background b. purpose c. scope 2. Rights and General Obligations for the State Party at Point of Entry 3. Role of Competent Authorities 4. Role of Operators, Administrators, Service Providers a. conveyances b. facilities 5. Planning Inspection Program a. Public health situation analysis at the point of entry i. Epidemiological analysis ii. Existing care facilities iii. Vector and reservoirs iv. Environmental health a) Waste b) Water c) Food d) Air quality b. Conveyance frequency, type, volume and route c. Identify, elaborate and adopt appropriate protocols d. Define personnel qualifications and training, equipment and facilities for inspections 2. Critical Areas, Systems and Services for Inspections a. Potable water b. Food c. Solid waste d. Liquid waste e. Vector and reservoirs

18 f. Air conditionning systems g. Toillets h. Cargo & passenger compartments 3. Conducting Inspections a. Type of inspection/frequency i. Routine ii. Follow-up iii. Emergency iv. Targetted v. Simulation vi. Other (outbreak verification, justice requirements, complaints verification.) b. Joint inspections through international agreements or arrangements c. Reporting and records i. Report preparation ii. De-brief operator iii. Record keeping [and information systems?] 4. Compliance and Corrective Action 5. References 6. Annexes a. Statement of corrective action b. Publication of inspections results [?] II - POINTS OF ENTRY FACILITIES (health care, critical areas, systems and services for other sanitary measures (cargo, animals, etc.) and for HEALTH CARE FACILITIES RELATEDE TO POINTS OF ENTRY (INSIDE: travellers information, assessment, interviews, examination, transportation; OUTSIDE or INSIDE: observation, treatment, isolation, quarantine, prophylasis, vaccine, transportation) 1. Introduction a. background b. purpose c. scope 2. Rights and General Obligations for the State Party at Point of Entry 3. Role of Competent Authorities 4. Role of Operators, Administrators, Service Providers a. conveyances b. facilities 5. Planning Inspection Program a. Public health situation analysis i. Epidemiologic analysis ii. Existing care facilities iii. Vector, environment, and health iv. Waste, water, food, sanitation b. Frequency, tupe, vlume, route c. Identify, elaborate, adopt appropriate protocols d. Define personnel qualifications and training, equipment and facilities for inspections 7. Critical Areas, Systems and Services for Inspections 8. Conducting Inspections a. Type of inspection/frequency i. Routine/follow-up ii. Emergency iii. Targetted iv. Simulation

19 v. Other b. Joint inspections through international agreements or arrangements c. Reporting and records i. Report preparation ii. De-brief operator 9. Compliance and Corrective Action a. Statement of corrective action b. Publication of inspections results 10. STATE PARTIES SHARING COMMON BORDER POINTS OF ENTRY FACILITIES 11. References 12. Annexes III- METHODS FOR SANITARY MEASURES AT POINTS OF ENTRY 1. Introduction a. background b. purpose c. scope 2. Rights and General Obligations for the State Party at Point of Entry 3. Role of Competent Authorities a. Community level b. Intermediate level c. National level 4. Role of Operators, Administrators, Service Providers 5. FOR TRAVELLERS, PERSONNEL AND ANIMALS: a. Isolation b. Quarantine c. Observation d. Prophylaxis e. Vaccination 6. FOR CONVEYANCES: a. Isolation b. Deratification c. Disinfection d. Decontamination e. cargo/baggage distruction f. quarantine g. refuse entry/departure 7. FOR THE POINTS OF ENTRY FACILITIES a. Isolation b. Deratification c. Disinfection d. Decontamination e. Others (?) 8. References 9. Annexes IV - REPORTING AND COMMUNICATIONS [and coordination?]

20 1. Introduction d. background e. purpose f. scope 2. Rights and General Obligations for the State Party at Point of Entry 3. Role of Competent Authorities 4. Role of Operators, Administrators, Service Providers a. conveyances b. point of entry facilities c. health care services and health profissionals 5. Reporting and communications a. Community level b. Intermediate level c. National level d. Between National IHR Focal Point and WHO IHR contact points 6. References 7. Annexes V CONTINGENCY PLAN FOR A PHEIC - GROUND CROSSING PREPARENESS AND RESPONSE 1. Introduction a. background b. purpose c. scope 2. Rights and General Obligations for the State Party at Point of Entry 3. Role of Competent Authorities a. Community level b. Intermediate level c. National level 4. Role of Operators, Administrators, Service Providers a. conveyances b. point of entry facilities c. health care services and health profissionals 5. [VERIFY WITH THE WHO GUIDELINES FOR INFLUENZA PREPARATION PLAN] a. Logistics (equipament, stockpile for drugs & medical devices & biosafety & sampling, etc.) b. Monitoring and strategic health information c. Dealing with the midia & information to the public d. Coordination with others partners and authorities e. Tranning and simulation programs f. Verification & suport for immediate control measures: i. Community level ii. Intermediate level iii. National level iv. WHO IHR contact points v. Others partners and authorities 6. References 7. Annexes

21 Appendix 7

22 Appendix 8 ICAO PREPAREDNESS PLANNING GUIDELINES (AVIATION ASPECTS) FOR A COMMUNICABLE DISEASE POSING A SERIOUS PUBLIC HEALTH RISK DRAFT Version 7 Clean (18 April 2006) Preface These guidelines are written to assist States in developing an aviation related plan for any communicable disease posing a serious public health risk, such as an influenza virus with human pandemic potential. This information is written primarily for States; further information may be found on the websites of the Airports Council International (ACI) and the International Air Transport Association (IATA). The preparedness guidelines will be developed over time, as the preparedness planning process evolves. They should be incorporated into national preparedness plan guidelines. GENERAL PREPAREDNESS In order to respond to a communicable disease with the potential to pose a serious public health risk, States should establish a national plan, in accordance with any relevant preparedness guidance available from the World Health Organization (WHO) ( including: a) a clear contact point, with identified individual(s), at national aviation level for policy formulation and operational organization of preparedness; b) a contact point that is integrated into the general national preparedness plan; c) national bilateral and regional level linkages (networks) to exchange expertise and share resources; d) a national preparedness plan that effectively links all relevant aviation stakeholders; e) guidance that is generic to all communicable diseases, which can be adapted for specific diseases; f) guidance that is based on information provided by WHO, to ensure global harmonization of information; g) at the stage of trip planning and booking of tickets, methods to inform the public of any relevant personal and public health risks. Such information should be incorporated into national public health, airline and travel agent websites and may also be provided through the media and telephone contact; h) consistent advice by the national public health authority to advise passengers to postpone travel, or seek medical advice, if they have signs or symptoms of a communicable disease with the potential to pose a serious public health risk; Note. Routine public health measures as outlined in the International Health Regulations (2005) ( are considered of importance with regard to the potential for international spread of disease. Such measures should be emphasized by the public health authority to the public and relevant worker groups. i) consistent health requirements for entry, or denial of entry into a State, in accordance with WHO recommendations; and, j) a communication system to facilitate the above. For implementation of the national plan in the event of an increase in the public health risk, States should further establish:

23 a) a position (or positions with adequate lines of communication) having responsibility for the operational implementation of the national aviation preparedness plan, having reasonable autonomy/flexibility for rapid policy and decision making; b) a national rapid communication network involving: i) key stakeholders in the aviation industry e.g. airport authorities, air traffic control, airlines and general aviation; ii) other stakeholders e.g. public health agencies, security, police, ground transport, retail etc; and iii) the public; c) in association with other States, regional networks of aviation and public health experts for the benefit of aviation stakeholders in the region; d) an information system for rapidly accessing such experts in times of public health emergencies; e) a method of testing preparedness by means of drills/exercises involving all relevant stakeholders, especially public health agencies, airports and airlines. Note. If medication is being stockpiled by contracting States for treatment or preventative purposes in the event of an outbreak, airline and airport workers, as well as air traffic controllers, should be given appropriate priority in the distribution plan

24 Appendix 9 AIRPORT PREPAREDNESS (to be included in ACI website) DRAFT, Version 7, Clean (18 April) The primary issue with respect to airport preparedness planning is to protect the health and welfare of passengers, staff and the public. To achieve this, the airport preparedness plan should address aspects such as communication (especially with the public), screening, logistics (transport of passengers to health facilities), equipment, entry/exit controls and coordination with the local public health authority. A particularly important requirement is for adequate supplies of appropriate personal protective equipment (including handwashing facilities or sanitizing gels) to be available for airport staff. They should be adequately trained in aspects of preparedness planning relevant to their specific role. The following guidance may serve to facilitate the development of an airport specific plan. They are not designed to be adopted as written but to be modified to the local situation as necessary. Communication Airports should establish: a) a clear contact point for policy formulation and operational organization of preparedness; and, b) a position with responsibility for the operational implementation of the airport preparedness plan, having reasonable autonomy/flexibility for rapid policy and decision making. Communication links should be established, directly or indirectly, with the following entities: 1) Internal airlines handling agents air traffic management local public health agency local hospital(s) police customs immigration security travel agents airport retailers information/customer relations services other stakeholders as necessary 2) External passengers: before reaching the airport in the terminal building other airports in same State/region other airports outside State/region media Communication with departing passengers in the event of a communicable disease outbreak Before arrival at the airport terminal building, information can be provided to passengers by means of an airport web site (or by electronic link to a public health web site) by recorded telephone message or by printed media. A telephone message may give health information directly and possibly refer the listener to further sources of information. Passengers and health professionals should have access to consistent information about postponing travel if the potential passenger has an illness prior to arrival at the airport and whether screening measures may be in place at the airport. Such information will usually be taken from a public health information site or developed in close collaboration with the public health authority. Passengers who have medical conditions that will not prevent travel should have their attending physician complete the International Air Transport Association

25 Medical Information MEDIF Form (or the form in use by the airline) and discuss the situation with airline medical staff should they have questions. When in the airport, information can be given by posters or electronic displays, and by public address. A sample text is: o This airport has XXXX (name of disease) screening in place. Passengers that may be suffering from XXXX will not be permitted to board any flight. The main symptoms of XXXX are.. The text would be adjusted according to the information to be conveyed. The WHO will provide the o information on symptoms. Public announcements should be provided in the languages used by persons most frequently travelling through the airport, including English, as well as the State s own language(s). The media can play a useful role in informing passengers of the situation at an airport and links with the media should be established so that journalists can obtain information at short notice. Screening Screening of travellers on departure will vary according to the nature of the communicable disease in question. The most appropriate screening method will be determined by the current scope of the outbreak, the characteristics of the targeted population, how effective screening is likely to be, the quality of the science on which a decision to screen is taken, and the cost. A toolbox of screening methods is available, including visual inspection, questionnaire and temperature measurement (using thermal scanners or other suitable methods). Details of requirements cannot be determined in advance of an outbreak and will be advised by the WHO, based on the symptoms and signs of the disease, its epidemiology and possible exposure history of individuals being screened. Consequently, public health agencies, in collaboration with the World Health Organization, may recommend airport screening, including temperature measurement and questionnaires about symptoms and travel history. Screening is likely to be of most value for departing passengers It should be undertaken as soon as possible after passengers have arrived at the airport, and before passengers pass through to airside. Certain entry (arrival) screening may also be useful: for geographically isolated infection free areas (islands) when epidemiological data indicates the need to do so if departure screening is deemed inadequate for passengers arriving from defined outbreak areas If the public health authority determines that screening is to be employed, airport operators should discuss the issues with the local public health authority in order to develop acceptable plans. Costs associated with providing screening equipment and airport space and infrastructure support would normally be met by the public health authority. Passengers thought to be at increased risk of having a communicable disease posing a potentially serious public health risk should undergo secondary screening by a qualified individual e.g. medical practitioner. If the assessment is positive i.e. the passenger is thought to be suffering from a communicable disease which poses a serious public health risk he/she should not be permitted to depart. Measures should be taken to refer the individual for appropriate diagnosis, treatment, if available, and appropriate case management, in accordance with the IHR (2005) ( with a view to protecting the public from potential infection i.e. by isolation. In the event of negative secondary screening the passenger should be allowed to continue on his/her way. A private isolation area where a passenger with symptoms can be personally distanced from transmitting any potential disease to other individuals needs to be pre-identified. Passengers arriving or departing from an at risk area should be provided with information about symptoms and safeguards to take, as appropriate to the disease. They should be given guidance on when to contact a health professional and with appropriate public health contact telephone numbers, if available. Inbound aircraft carrying a sick passenger with a communicable disease which may pose a serious public health risk A number of considerations must be taken into account when an aircraft arrives carrying a suspected case of a communicable disease which may pose a serious public health risk. There follows some guidance on possible action to take:

26 The pilot in command (PIC) needs to be advised of where to park the aircraft such information will normally be communicated to the PIC by air traffic control. The decision will normally be taken by the public health agency in consultation with airline and airport authorities. This may be on a remote stand, or, depending on the situation, on the apron, not attached to a jetway, or in a stand with a jetway attached. Action should be taken to disembark the passengers as soon as possible after the situation has been evaluated and a public health response has been instituted, if needed Flight and ground crew need to be advised concerning the opening of aircraft doors, disembarkation and what information should be given to passengers prior to the arrival of the medical team Public health officials need quick and efficient access to the aircraft Personal protective equipment (PPE) appropriate to the suspected communicable disease, the mode of transmission and the nature of duties being performed by aviation personnel, should be worn. For many communicable diseases, disposable gloves and good hand hygiene (at times in combination with surgical masks) are sufficient unless otherwise specified by the national public health authority. A passenger having a respiratory disease should wear a surgical mask unless the passenger is unable to tolerate it. If a mask is worn consistently by the ill passenger this obviates the need for others to wear a mask. All disposable materials in potential contact with a sick passenger need to be disposed of with biohazard precautions All surfaces potentially contaminated by the sick passenger should be cleaned and disinfected (a list of suitable cleaning agents/disinfectants will be included when available) A sick passenger should be taken, by a medical escort, from the aircraft to an area for further assessment/treatment. He/she should use appropriate infection control measures e.g. a mask if coughing, and be isolated from other passengers and staff Passengers and crew on the same aircraft as the sick passenger should be segregated until contact information has been obtained and they have been advised by public health authority staff of the precautionary measures necessary Procedures need to be in place for obtaining baggage, customs and security clearance of a sick passenger, and the other passengers and crew A procedure for transporting a sick passenger to hospital needs to be in place Drills/Exercises Airports should establish a method of testing preparedness by means of drills/exercises involving all relevant stakeholders, especially public health authorities, airports and airlines. Summary A schematic summary of some of the possible communication links is shown in Figure 1. Figure 1 - Airport preparedness plan schematic example of summary of actions [note: view in print layout not normal or outline to see the figure] Normal situation communicable disease not regarded as a major risk Minimal requirements Periodic review of plan and exercises Reduce risk of transmission APPEARANCE OF TRIGGERS TO ACTIVATE PLAN Level of response as determined by trigger(s) Advice- WHO (global) Regional National Some or all elements of preparedness plan activated Situational assessment