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Prevention and Management of High Threat Pathogen Incidents in Transport Hubs

Final Report Summary - PANDHUB (Prevention and Management of High Threat Pathogen Incidents in Transport Hubs)

Executive Summary:
Efficient transport systems are of vital importance for modern, urban societies all over the world. They can, however, also play an important role in the spread of infectious diseases. The continuously growing air traffic facilitates the quick and uncontrollable long-distance spread of person-to-person transmissible pathogens around the world, as was the case for SARS in 2002/03 and influenza A(H1N1)pdm09 in early 2009. Ground mass transportation systems may in turn offer an effective way of accelerating the spread of infectious diseases locally within communities. This is due to the large number of passengers using mass transport for commuting, crowded areas and high contact rates, especially during peak hours.

The main objective of the PANDHUB project was to create an integrated toolbox to aid operators and relevant actors in major transport hubs in the development of their current pandemic and dangerous pathogen preparedness and response plans. The project covers the extraordinary aspects specific to serious natural or man-made pathogen threats in the transport environment by providing accurate, reliable and validated information for the threat assessment, preparedness, response and recovery phases.
The specific aims were to
- deepen the understanding of disease transmission mechanisms and control measures in transport environments thus allowing effective mitigation strategies to be developed
- create a toolbox to prepare for and efficiently respond to an intentional release of pathogens in a major transport hub
- as part of the toolbox, develop guidelines for first responders and transport operators to prepare for and efficiently respond to pandemic situations in transport hubs.

The scope and content of the toolbox was developed in close cooperation with transport operators, end-users and authorities responsible for public health emergency management.

A Stakeholder Liaison Group (SLG) was established with members from the European Centre for Disease Prevention and Control (ECDC), World Health Organization (WHO), airport and mass transit operators as well as from the security sector and a related project to help guide the work and give periodic feedback.
Project Context and Objectives:
PROJECT CONTEXT
Pandemics
Transportation plays an important role in the spread of infectious diseases. The continuous growth of global travel around the world facilitates the quick and sometimes uncontrollable spread of naturally or intentionally released person-to-person transmissible pathogens around the world. As was the case for SARS in 2002/03 and influenza A(H1N1)pdm09 in early 2009, air travel will be the key to the spreading of such pathogens internationally, while mass transportation systems offer an effective way of accelerating the spread of infectious diseases within communities. This is mainly because of the high density of passengers in enclosed spaces, and high contact rates. The presence of infectious agents and infectious individuals in large transport hubs (railway stations, bus stations, airports etc.) could affect large populations travelling across the world and have a major concurrent impact in several Member States.

Urban Mass transport systems (UMTS) provide an ideal environment for the spread of disease. During rush hours especially, the crowd density is high and the number of person-exchanges (synonymous with contact rates) is very high (because stops are frequent and crowd turnover is high at each stop – the pool of potential new susceptible subjects is therefore refreshed very frequently). Sneezing, coughing, talking or even tidal breathing produces large numbers of pathogenic respiratory viruses exposing nearby passengers. Moreover, commonly touched surfaces may be contaminated with pathogens, and microbes from these surfaces can be transferred to other persons hands and
thereafter to portals of entry into the body (mucosal surfaces of the eyes, nose, mouth) when touching face. The only mitigating factor is that children, who are known to be the highest emitters of respiratory viruses, in fact use UMTS less than adults.

Although it is difficult to perform studies that definitively link the spread of infectious organisms to transportation systems, a substantial body of literature nevertheless exists. It should also be noted that because of the distances people move away from a particular hub and number of potential contacts, that the identified case may not themselves be aware of, there are serious public health challenges if for example contact tracing is required to mitigate the disease spread.

Intentional dispersal of pathogens in transport hubs
In addition to naturally occurring infectious diseases, threats also exist from the intentional use of biological agents. Transport sector is critical to our society and any disturbances in the major hubs can have wide-spread consequences. In general, air transport has addressed the possibility of terrorism to greater extent than mass transport but has not fully eliminated the problems caused by unconventional weapons.

Public transport is an attractive terror target, a reality that is unlikely to change any time soon. The vulnerabilities of public transportation include:
· Attacks on mass transportation targets have been almost twice as lethal as terrorist attacks overall. This is mainly because of the high density of people, and because in enclosed spaces the effects of explosions and dispersal of toxic agents are more serious than in open areas,
· Spreading of panic and perception of insecurity of passengers,
· Targeting mass transport can deter people from everyday travel, causing serious economic disruption,
· Continuous attacks on mass transport targets can severely undermine government authority,
· Terrorists prefer transportation targets because they are essentially a feature of large population centres
· Open and accessible by design and necessity, ground transport is a soft target that provides the terrorists with almost an infinite number of options for operations with a high probability of success and a low level of risk.

There is an additional vulnerability from a public health point of view where identifying potentially affected individuals retrospectively will be very challenging because people may travel far from the transport hub before the health response is triggered. This will mean targeting countermeasures whether prophylactically or for treatment purposes will be difficult and so there may be additional mortality and morbidity than expected from a release scenario involving a localised population.

Pandemic preparedness
The World Health Organization (WHO) has produced a six-stage classification that describes the process by which a novel influenza virus moves from the first few infections in humans through to a pandemic. This starts with the virus mostly infecting animals, with a few cases where animals infect people, then moves through the stage where the virus begins to spread directly between people, and
ends with a pandemic when infections from the new virus have spread worldwide.

Although the Member States have responsibility for managing public health crises at national level, no single country can tackle a cross-border public health crisis on its own. In the current financial climate, especially, it is more important than ever to focus on actions in areas where the added value is evident, such as minimising the negative effects of a potential public health crisis.

At EU level, the legal basis for addressing serious cross-border health threats has been reinforced with the Lisbon Treaty. The EU can now take action in this field, except for any harmonisation of the laws and regulations of the Member States. Also, the Treaty stipulates that the EU must complement and support national policies and encourage cooperation between Member States, without superseding their competence in that field.

So far, EU legislation in this area only addresses threats related to communicable diseases. The EU network for surveillance and control of communicable diseases has specific mechanisms for monitoring communicable diseases, giving alerts and coordinating the EU response. Because its scope is limited to communicable diseases, however, a new Decision covering all types of serious cross-border threats will replace the older one. The previously informal body, the Health Security Committee, would be established on a formal basis. This would make it possible to facilitate a coherent coordination of preparations for and responses to serious cross-border health threats. Also,
crisis communication would be improved for all serious cross-border health threats. Communication with the public is an integral part of the response, since the public’s acceptance of measures taken for public-health purposes is vital if such measures are to be effective.

Guidelines for transport operators have also been developed. They are mostly for air transport by Airport Council International (ACI) and the International Air Transport Association (IATA) with the aim to reduce exposure to infectious agents and improve the response to health emergencies.

International Civil Aviation Association (ICAO) introduced a system to provide earlier warning of public health events which would increase the window for mounting a public health response by reporting suspected cases of communicable disease via air traffic control services. A related project is Collaborative Arrangement for the Prevention and management of public health events in Civil Aviation (CAPSCA) to provide guidance for all public-health related events. The project is managed by ICAO, in close collaboration with the WHO and additional partners including the ACI and IATA, and is directed towards devising and amending ICAO Annexes and facilitating their implementation.

The American Public Transportation Association (APTA) has also created preparedness guidelines to mass transport for outbreaks of
communicable disease. These include phased responses and they give guidance on information sharing, disinfection of assets, sanitary aids, medication and measures during service reduction, shutdown and restoration.

PANDHUB OBJECTIVES
The aim of the project is to aid transport operators and relevant actors in transport hubs in the development of their current pandemic and dangerous pathogen preparedness and response plans. The project is intended to cover the extraordinary aspects specific to pathogen threats in the transport environment by providing accurate, reliable and validated information for the incident threat assessment, preparedness and response phases. Such information can only be produced from a deep and solid knowledge about the underlying phenomena of the various aspects of the threats and their propagation.

PANDHUB provides the most recent knowledge and technologies available to improve the prevention and management of pandemics by providing a toolbox to support the current plans for managing serious health bio-threats in transport hubs. The objective of the toolbox is also to support prevention measures and related preparedness, as well as to accelerate and improve the possible response.

The specific aims are to
· deepen the understanding of disease transmission mechanisms and control measures in transport environments thus allowing effective mitigation strategies
· create a toolbox to prepare for and efficiently respond to an intentional release of pathogens in a major transport hub
· develop Guidelines for first responders and transport operators to prepare for and efficiently respond to pandemic situations in transport hubs.

For these purposes, the toolbox includes the following tools to support
· threat and vulnerability assessment
· early detection
· improving the efficiency and the rapidity of the response
· Improving the communication between all the actors (and including with the public).

The project has specified the needs and the requirements for the toolbox in close cooperation with
transport operators and end-users. The tools were also evaluated during the piloting phase.

The project took full advantage of the technologies and results of previous EU funded and national projects in this area. In this way the project avoided overlapping work and could concentrate on the essential elements. On the other hand, liaison with the other relevant project offered an opportunity to effectively disseminate the findings of PANDHUB.

Project Results:
1. Main Scientific and Technical Results

1.1 Threat and vulnerability assessment (WP2)
The overall aims of this work package were to review current knowledge on disease transmission in the context of transport hubs; to develop and describe appropriate scenarios; and to develop a risk and vulnerability assessment tool. The results are presented in four deliverable reports.

Reference set of scenarios (D2.1)
The objective was to select scenarios to describe potential pathogen threats within hubs, (one set for pandemic agents and one for deliberate release agents) to encompass a range of measures across scale and clinical and psychosocial impact. As for potential deliberate release the scenario agents were agreed on as pneumonic plague and inhalation anthrax while Ebola Virus Disease (EVD) and pandemic influenza were selected as diseases with pandemic potential.

Inhalational anthrax and pneumonic plague are examples of deliberate release events where the transport hub may act as the source of initial infections. These are both defined as category A agents by CDC and both have severe outcomes for untreated cases. Inhalational anthrax is not person-to-person transmissible but requires a substantial course of antimicrobial prophylaxis. Pneumonic plague exhibits the potential for person-to-person spread.

EVD and pandemic influenza are examples of diseases with pandemic potential where the transport hub might play a role in mitigation or amplification of the event. Both diseases have recently impacted on the EU (the 2014-2015 EVD outbreak and 2009 influenza pandemic). Ebola virus disease requires close physical contact and has severe patient outcomes. Pandemic influenza is a mild infection for most cases and people may have mild or no symptoms whilst still shedding virus, therefore being a source of infection to others.

The selected scenarios provided a framework for all the PANDHUB work. This choice of pathogens/ infections ensured coverage of a broad range of different disease characteristics, such as transmissibility, treatment, incubation period etc. Consequently, these pathogens pose different public health challenges and require different responses within a hub.

Hot spot analysis (D2.2)
The objective was to gather information to enable identification of critical points on the passenger journey or sites in hubs where transmission risk is increased.

Pathogens can spread naturally or through deliberate release. Transport hubs are potentially important for both of these, because of the large number and turnover of passengers in close proximity to each other in a confined space, common facilities intensely used, and frequently touched surfaces favour the transmission of a number of microbes.

There are a number of mechanisms for transmission of infections. In the context of transport hubs, relevant mechanisms include airborne, droplet and contact, both direct contact between persons and indirect contact through e.g. surfaces, as well as contaminated food and water. As food and water borne infections in the hubs are covered by standard regulations and procedures, infections related to these sources were not addressed in this project.

For preventing and controlling transmission of infections in hubs, the hot spots, ie points or sites within a traffic hub environment where the risk for transmission of microbes is at least periodically increased due to favourable conditions or human behaviour, need to be identified. The hot spots were identified by the characteristics of microbes with potential for transmission in the hubs, the characteristics of the hub structures facilitating survival of microbes and transmission, as well as those features of human behaviour while in the hubs, which are conducive to transmission.

Literature review revealed that there is little published information on the environmental contamination of transport hubs by respiratory viruses. To fill the knowledge gap extensive measurements were made to investigate the presence of respiratory viruses in the passenger environment of a major airport during the seasonal influenza epidemic. Taking into account the results of the microbial contamination assessments, the characteristics of the PANDHUB pathogens, knowledge of passenger flows, structural considerations the risk points could be identified. These were generally areas of high passenger density (for infections transmitted by the droplet and airborne route) and surfaces touched frequently by multiple people (for infections transmitted by an indirect contact route). Depending on the specific properties of a microbe, the potential sites for hot spots within a hub will vary in accordance with the microbe. For example, influenza potential hot spots, at least periodically, are formed by high density of passengers, as well as frequently touched surfaces. The output linked with several other PANDHUB pieces of work, including Guidelines for threat assessment (D2.4) Rapid Detection (D3.2) Disinfection and Decontamination (D4.4) Protection of People and Infrastructure (D4.5).

Disease spread in transport environments (D2.3)
The objective was to systematically gather evidence regarding transmission events in transport hub environments. A systematic review of the evidence for air, sea and ground transport hubs or systems having a role in the transmission of EVD, pneumonic plague and inhalation anthrax (including deliberate release) was undertaken. Similar work on influenza conducted just prior to PANDHUB was incorporated. SARS and MERS-CoV coronaviruses were also included.

Overall, the literature reviewed for disease spread in transport environments was limited in quantity and epidemiological quality. Confirmed influenza transmission has been documented to occur on board aircraft and ships, and transmission of influenza-like illness has been documented on board ships and on trains. Air transport accelerates the importation of influenza and SARS to new areas. Air travel also seeded the outbreak of MERS-CoV in South Korea and accelerated the importation of EVD. However we found no documented evidence of transmission of influenza, coronaviruses, EVD or pneumonic plague in transport hubs for travel by air, land or sea, nor of deliberate release with regards to plague or anthrax in such settings. However, modelling studies illustrated the potential for transmission of influenza at airports.

Despite the paucity of relevant data, a set of common control principles were identified that can be applied in hubs, namely: exclusion of symptomatic persons; interpersonal distancing measures; ventilation controls; separation of international and domestic passenger streams and measures to reduce indirect contact transmission. Practical measures, which incorporate these principles were developed elsewhere in the PANDHUB project. (see WP4, response)

Guidelines for threat assessment (D2.4)
The objective was to provide a mechanism to facilitate threat assessment for infection risk in a transport environment.

Guidelines for threat (risk) assessment were developed with the aim of providing a tool that can be used in transport hubs to rapidly aid threat assessment both in routine circumstances in order to minimise risks in advance, or as part of the response to an event. This tool is informed by and links with other deliverables, such as the hot spot analysis.

Because the pathogens differ from each other and the situations in transport hubs vary it is very challenging to give detailed guidance which systematically would cover different situations. Therefore, a method to analyse the situation systematically was proposed, which is based on the systematic identification of potential sites, where the person-to-person disease transmission could occur.

The assessment method offers a comprehensive mechanism and framework to identify and assess the threat of exposure to high-risk pathogens in a transport hub. As a result of the assessment, exposure threats are ranked to help guide preparedness, mitigation and response planning. The developed threat assessment method can be used in a number of different situations, e.g. in the design phase of a hub, in a normal operating situation, and in case of an epidemic or a high threat pathogen incidence. The assessment is intended to be carried out by experts who have the background knowledge to consider the extent of each type of risk.

1.2 Preparedness (WP3)
The overall aim was to provide a suite of tools to contribute to preparedness activities (incorporating detection, awareness, prevention, and resilience) for a potential biological hazard event in, or linked to, a transport hub.

Surveillance tools (D3.1)
The objective was to identify which systems are most likely to pick up signals related to a public health event at a Points of Entry (PoE) and other transport hubs.

The rapid detection of new or emerging infections is essential to mounting an effective public health response. Since most introductions of novel agents are likely to occur via air travel, the efficiency and speed of any public health response is likely to be improved if: a) such disease introductions are detected as close as possible to ports (or points) of entry; b) the port itself has effective procedures in place so that it does not serve as a disease amplification point – that is to say minimising dissemination and secondary spread.

The main aims of public health surveillance are twofold: firstly to measure disease burden, and secondly prompt detection of public health events to enable swift control. The discipline of public health surveillance has rapidly evolved to take advantage of changes in the generation and availability of data, and in response to the changing threats to public health. Traditional public health surveillance includes laboratory surveillance, hospital surveillance (such as antimicrobial resistance surveillance, and surveillance for healthcare associated infections), sentinel surveillance, environmental hazard monitoring, mortality surveillance, and surveillance via cancer and other disease registers etc. There are surveillance systems in place for monitoring for specific pathogens and for notifiable diseases, locally, nationally, and internationally.

PoE pose a challenge for surveillance and the public health response because of the wide and rapid dispersal of disembarked passengers. A scoping review of existing surveillance systems was done to identify which systems (and statistical methods) most likely to pick up signals related to a public health event at a PoE and other transport hubs. The systematic review, which was structured by categorising relevant systems and networks according to the frameworks of event-based surveillance and indicator based surveillance, identified 78 diverse surveillance networks and surveillance systems. Of networks identified, the most pertinent to PoE was the Ports, Airports and Ground Crossings Network (PAGNet) that enables partners to share information regarding international travel and transport. However, no surveillance systems were identified that focus on the detection of threats at transport hubs. Of the available Indicator-based surveillance systems, Emergency Department systems are likely to be the best placed to detect events that occur in transport hubs because they are timely and gather syndromic data on serious disease. The data generated through telephone helplines may also be useful to supplement local surveillance efforts to detect events at transport hubs. However, whilst some surveillance systems have relevance to transport hub incidents, none are specifically linked to transport hubs, or can be certain of picking such signals up quickly. Using more than one system and integrating data sources together would be likely to increase the detection of events in transport hubs.

Rapid detection (D3.2)
The objective was to identify available options for the identification of deliberate release pathogens, and pathogens that cause communicable disease.

Microbiological detection methods are needed at hubs to define areas with heavy loads, to trace contamination source and routes, and verify safety following decontamination. A literature review was undertaken to identify options available for the identification of both a deliberate release pathogenic agent, and the best methods available for identifying pathogens that cause communicable disease, particularly those with pandemic potential.

The report on rapid detection defines the suitability of detection methods that can be used at transport hubs and discusses the challenges of sampling in such environments. The advantages and limitations of traditional culture-based detection and molecular biology based methods (hybridization, polymerase chain reaction (PCR), and other options) used for microbiological detection and identification are detailed. Out of the reviewed methods, ethidium monoazide (EMA) / propidium monoazide (PMA) in combination with quantitative PCR (qPCR) are likely to be a good option for detection of specific high threat pathogens since distinguishing between non-live and live pathogens is important. EMA/PMA treatment would enable the specific amplification of viable (membrane-intact) bacteria whilst qPCR would allow rapid and specific quantification of a selected pathogen.

To find out the background “peacetime” microbial levels, sampling was undertaken in three Finnish airports. The main goal was to analyse the bacterial population profiles from different commonly touched surfaces like security screening trays, tables, railings and touch screens. For this, a new generation sequencing of 16S rRNA gene amplicon was used. The bacterial communities varied between the samplings. At Helsinki airport actinobacteria dominated in most of the sample. In the samples from Oulu and Kuopio airports, the relative amount of actinobacteria varied from 8% to 56% of the whole microbiota. The major actinobacteria in almost all the samples were propionibacteria (genus Propionibacterium), micrococci (genera Kocuria, Micrococcus and Rothia) and corynebacteria (genus Corynebacterium). Most of the genera were identified to be human associated: the identified groups are dominant in healthy adult skin microflora. Corynebacterium is also frequently found in the nose.

The results may be useful for testing biological threat agent detectors in realistic conditions by simulating complex real-life environments.

Simulation of passenger flows (D3.3)
This report describes modelling frameworks for simulating passenger infection from transmission events involving the scenario diseases, whether pandemic or deliberate release, and considers the role of transient contact and movement.

Mathematical models can be viewed as conceptual tools used for explaining real world systems and predicting future outcomes and consequently they increase our understanding of a system. No single model is “correct” so it is important to assess what mathematical approach is most appropriate for each situation. A good model should be suited to its purpose and parametrised by available data. A scoping review was conducted to identify techniques which have been employed to model the global spread of a pandemic potential disease and what data are available to parameterise these models. Validation is important because it indicates how well a model represents the real-world situation. We identified whether the models were validated and, if so, which data were used to do this.

The search terms for the scoping study included terminology for established modelling types. We searched explicitly for influenza as, from experience, many global disease spread models are for pandemic influenza. We also included a more general global disease spread term, along with terms ‘global’ and ‘pandemic’. The databases Embase, PubMed and Scopus, yielded 799 records after all duplicates were removed. All 799 records were screened first on title and abstract. After full text screening and citation checking of included articles, 79 articles remained to be reviewed. The majority of these 79 articles did not have any validation data and population-level metapopulation models were the most common model type. Nine metapopulation model records reported validation data. This highlights that models currently exist and can be parameterised and validated: we do not consider it necessary to construct a new global disease spread model for the PANDHUB project.

Given that pandemic infections will spread globally, importation to European countries is likely, though the numbers may be low depending on international public health efforts and the disease transmission characteristics in question. This report presents a model for calculating the probability of an infected individual becoming infectious or symptomatic during transit. This can be used to assess whether major transport hubs might have a role in mitigation by detecting imported cases.

For a deliberate release of biological pathogens, case numbers can be estimated using dispersion modelling and passenger movements. Considerations needs to be given to the mechanism of delivery, the airborne dissemination, characteristics of the hub environment, and the effect of the material on humans in the vicinity. A relatively simple eddy diffusion model can be used to calculate the exposure of occupants following a puff type release. The model’s performance in predicting time-dependent concentrations was examined experimentally. Critical to the model is the interaction between the eddy diffusion parameter, air exchange rates and dwelling time. For a detailed risk assessment of a bio-aerosol release in a transport hub, computational fluid dynamics simulations could be conducted. However, given the mismatch in apparent precision between the fluid flow calculations and individual location and movement patterns in a hub and the high computational costs it is sufficient to use the coarser scale modelling with sensitivity analysis conducted around other parameters.

Assessing exposure to people moving nearby from a release of aerosol material may involve custom-built models in a full agent-based modelling system or a highly simplified estimate of passenger volumes and flows. From the number of exposed individuals, and the deposited dose for those individuals, characteristics of the disease outbreak may be calculated. Among these characteristics are the number of patients exhibiting different classes of symptoms, the time to onset of symptoms, and the expected number of deaths (perhaps with the inclusion of particular intervention strategies).
Modelling of disease transmission was challenging as there is very limited evidence of transmission in any hub type. In addition, data on contact patterns in hubs is required –such data gaps limit the use of the models. The hot spot analysis and rapid detection work highlighted security screening trays as a potential risk for transmission hence they were identified as a hot spot.

In general, the time to onset of symptoms will be of the order of days for the diseases considered here so it is likely that patients will seek healthcare away from the location of the transport hub. This dispersion of cases from a large transport hub, possibly across many countries, complicates the detection and intervention aspects of any response, which are considered in D3.4 and D3.5.

Risk maps (D3.4)
Based on the framework for modelling the passenger flows and interactions between users of the hub developed in D3.3 D3.4 is built on this basis by parameterising the models and showing the spatial impact, both within the hub and external to the hub, of the pandemic and deliberate release infections.

This deliverable considers “risk maps” for threat scenarios developed so far on the PANDHUB project. We consider the deliberate exposure of users of a transport hub to aerosolized Bacillus anthracis or Yersinia pestis, which may cause anthrax or pneumonic plague. Analytical frameworks are developed and data analysis performed for risk mapping and determining infection chance at three spatial scales: within the hub, nationally, and internationally. We present results for a major airport to illustrate the use of Wi-Fi connections offered by hub operators to users to track the location of users within the hub.

It is recommended that data collection exercises on passenger and staff movements in transport hubs be performed with the requirements of public health work driving the study design. Simulation models may assist with quantifying exposure but these need careful adaptation to model disease transmission and infection. Once a person has been exposed to an infectious agent they are likely to travel elsewhere, either by air over long distances or by other means regionally. Datasets reportedly showing international connections of transport hubs exist (IATA, OAG) are available. Recent work has shown very limited attempts by studies to validate the use of such datasets. The choice of connection measure must be evaluated carefully within each context it is applied. Movement to the community from the transport hub may be measured in a number of ways: by survey data, by ticketing data, by assessment of the catchment area of a hub or more recently by analysis of social media posts.

We provide risk maps which illustrate the potential use of social media (Twitter) data to evaluate the spatial extent of onward travel from a specific hub. This may inform contact tracing in any event.

Contingency planning (D3.5)
In deliverable D3.5 the effects of mitigation, such as body temperature screening, are considered further. The influences on behaviour, such as improved communication, and person to person contact reduction are also considered; outputs from which may support stakeholders in their preparedness and contingency planning for an infectious disease event in a transport hub.

Deliverable 3.5 considers contingency planning on specific scenarios related to geographic dispersal of cases (cross-border) and longer-term impacts, these scenarios were created in Deliverable 2.1 (Reference set of scenarios) and are based around hypothetical incidents of Ebola virus disease, pandemic influenza, pneumonic plague and anthrax. Models have been developed within the work package to consider:
• Infection of humans with disease
- Quantitative microbial risk assessment
- Person to person transmission
- Airport security trays infection risk
• Border control options
- Potential detection of cases by screening
- Staffing required to support screening.

If the agent is pathogenic, there is a risk of infection before recognition of the event and initiation of a public health response. Person to person transmission model then considers the infection processes and was mostly reported in Deliverable 3.3 (Simulation of passenger flows) but is extended in this report where a potential model for person to person spread is presented to calculate secondary cases. As an example of transmission of infection via surfaces, a model for assessing infection risk from handling airport security trays has been developed. This work has arisen from the results of other work packages and from PANDHUB stakeholder discussion and allows potentially the assessment of the burden of infection at or near the hub. Interventions to mitigate the events are likely to be outside of the hub using public health agencies and local primary and secondary care systems. However, one intervention, namely temperature screening, is considered due to its deployment during the Ebola virus disease outbreak of 2014. To this effect, work is concluded, begun in Deliverable 3.3 and 3.4 on the probability of case detection at a hub and then the number of staff required to serve border screening is assessed in a separate model.

The probability of an individual becoming symptomatic during transit was examined for each scenario agent. The chance of travellers developing symptoms between departure screening and entry screening given they were infected prior to departure was calculated using parameters including incubation period and journey length. For the scenario agents, the likelihood (probability) of detection of symptom onset and thus clinical diagnosis through body temperature screening varied from 1 in every 3.3 cases for influenza to one in every 28 cases for anthrax (and one in 26 for Ebola), thus illustrating that screening was unlikely to be effective. The calculated probability illustrates the maximum chance, in reality the probability may be smaller. The findings for Ebola was in keeping with other studies.

The scenarios referring to pathogen release and pandemic events at transport hubs indicate that there may be circumstances where containment is not possible or practical due to the exposed groups of people traveling away from the transport hub before local treatment/prophylaxis to these cases has been taken place. A risk map of the likely spread of people for each scenario, using data from the transport hubs on, for example throughput rates of people and their likely destinations, provided a key contextual basis for mitigating the event.

The psychosocial aspects of a planned response and the longer term health/infection risks and measures to counteract these were also explored.

Outputs from these tools could help support hub operators and public health officials to prepare for infectious disease events.

1.3 Response (WP4)
The overall aims of WP4 were to provide guidance to emergency responders and other transport hub staff in the event of a biological hazard incident; to provide a data collection system to facilitate rapid data sharing and analysis within and between countries; and to identify tools and guidance that might be of operational use to hubs for preparedness and response in the context of multi-country investigations of cross border threats.

Contact tracing and epidemiological investigation tools (Merger of D4.1 and D4.2)
The objective was to develop a user friendly modular IT (Information Technology) tool that would cater for both contact tracing requirements and for epidemiological investigation. The developed IT system is easy to use and supports fixed and mobile electronic data collection and a wealth of features including: user-friendly interface, rapid questionnaire development, multi-user functionality and basic analysis tools to support contact tracing and epidemiological investigation activities.

The PANDHUB project had first-hand experience gained by the Department of Health (DH) with data collection and data management during Ebola screening in 2014. These experiences highlight the need for a pre-existing electronic data collection system in the face of a public health emergency. During the Ebola emergency, screening of potentially exposed individuals was put in place in the UK airports and Eurostar over a short period of time. Since no electronic system was available, screening data were collected via paper forms. These paper forms were regularly updated (seven versions) and for each version, new paper forms had to be printed out and sent to the screening teams. After each screening session, a lot of time was required to transcribe the data into an electronic system for data analysis. Following the Ebola crisis, DH expressed the desire to have a system that could quickly create a bespoke electronic system to collect the screening data. Additionally, a system with a mobile application for data collection would enable direct data entry at the screening sites. By avoiding the data processing time required to transcribe data from paper into a database, and/or fax or email essential information to incident investigators, data would immediately be available for analysis. Such a system would also enable questionnaires to be revised during the course of an emergency and made immediately available for download and use. This is the type of form that the PANDHUB IT system should be able to manage and to convert into an easy to use electronic questionnaire.

A user-friendly IT system was developed with key capacities around epidemiological investigation and contact tracing to respond to the identified needs. The system is customizable (i.e. it is easy to build questionnaires specific to requirements), accessible and flexible, providing a bank of template questionnaires that can be used as provided or adapted. The system is designed to complement rather than replace existing systems. Once data is in the system there is the capacity to export it to other programs for analysis if desired, but also the capacity to produce simple charts of the data inputted. Two major advantages of the system are that it is possible to collect data using the program on a computer or on a mobile device, and that it is a system that is designed not to require on-going IT support.

The envisioned context in which these tools would be used is when a public health risk is identified in a transport hub and health authorities need to organise an efficient and timely public health response. For this, they need to collect information about this event for epidemiological investigation and for contact tracing. For that purpose, epidemiologists/investigators will need to develop data collection tools e.g. questionnaires for analysis and contact tracing and employ incident management strategies. Such an Information System has to be deployed quickly to enable timely, good quality data collection and sharing. It should be customizable (in terms of questionnaire development and data access) so that it can address the specific event that is encountered. It should be flexible so that it can be updated easily depending on the evolution of the event, and be accessible by all actors of the event in whatever situation they are (fixed or mobile).

Infectious disease or deliberate release incidents occurring in a transport hub will present complex challenges: large numbers of transient individuals moving and congregating together, often with connections to other transport hubs and multiple locations. Faster characterisation of an incident and identification of key incident parameters will help accelerate public health investigation, limiting public health impacts.

Analysis is essential for interpreting and communicating data. Early (basic) descriptive assessment and visualisation of collected data will be possible within the PANDHUB IS itself. More epidemiological and advanced data analyses and visualisations will be available by exporting data into additional software tools.

Questionnaire data collected within the IS can be exported, using standard, recognised file formats (csv), to free analysis software tools, such as EpiData Analysis2. EpiData software is widely used by public health organisations including: Public Health England (PHE), European Centre for Disease Prevention and Control (ECDC) and the World Health Organisation (WHO). The software is free, easy to install, and does not require specialised training to use. It can be used to perform a wide range of analyses on questionnaire datasets, both descriptive (for example, Frequency, Cross and Summary Statistics Tables) and basic graphs and significance testing (for example, ANOVA, t-test, chi-square, Fisher’s exact tests of association). Data can also be managed in this software, i.e. recoding of data, label values and variables.

Since the data repository and the system applications will be hosted by the organisation which owns the system, it is this organization that will have to manage the legal and ethical aspects related to the storage of personal data. They will have to follow the rules that apply for their country. Health-related data are subjected to an even higher level of security. In practice, the health organisation which hosts this type of data has to take any useful precautions to prevent data being modified, erased by mistake, or accessed by unauthorized third parties. It thus has to implement, within its premises, measures of physical security (such as the controlled access to the rooms hosting the servers and/or defining a list of the people who are authorized to access these rooms) and techniques (such as secure servers).

Data security is ensured at several levels. For data access, each user is authenticated via a login and a password so that only authorized users can access the web and mobile data collection applications. Moreover, when logging into the applications, a given user will only be able to access the projects they have been assigned to. Finally, each user is given one/several profile(s) so that a specified user can only access the questionnaires and questions that they are allowed to access. On the mobile application, the local database only receives/stores the data that the user is allowed to access. For data transmission, data are transmitted via HTTPS. It consists of communications over HTTP within a connection encrypted by TLS/SSL. TLS/SSL are cryptographic protocols that provide communications security over a computer network. The security measures applied to prevent direct access to the data repository will be under the responsibility of the hosting organization which owns the system.

In summary, the developed IT system is easy to use and supports fixed and mobile electronic data collection and a wealth of features including: user-friendly interface, rapid questionnaire development, multi-user functionality and basic analysis tools to support contact tracing and epidemiological investigation activities. The questionnaires can be translated into different languages allowing internationalisation of the activities and consistency of the survey results.

In parallel, additional analysis and visualisation tools have been evaluated in order to select those most appropriate for advanced epidemiological data analysis and social network analysis during a disease incident occurring in a transport hub.

The system has been reviewed in consortium meetings and with the SLG. It has also been presented and tested at a number of workshops where it reviewed very well. It is being prepared as a commercial product.

Multi-country investigations (D4.3)
The objectives were to increase the understanding of the characteristics specific to transport hubs as an infectious disease event setting; assess the potential impact of the setting on cross-border outbreak investigation and identify tools and guidance that might be of operational use to hubs for preparedness and response.

Literature was reviewed exploring common themes around preparedness and response for serious threats with cross border potential, and a series of consultations held with transport operators and public health experts.

The needs of transport operators for preparedness and contingency planning for serious biological incidents varied, e.g. by hub type (ground transport or airport), presence of onsite first aid and medical care at individual hubs, or whether they directly connect with international PoE. The extent of these individual needs might also reflect the level of operational involvement operators had during the Ebola outbreak and how well they felt the situation was handled within their hubs.

One of the main findings from the consultations was the desire for stronger connections between transport operators and public health practitioners, to support both business continuity and incident response. These connections focus on clarity for the access to Public Health; the provision of public health information either before, and/or during the acute stage of a serious biological incident; and best practice strategies around communicating risk to staff and stakeholders. Included in this document are tools and guidance suggested by operators and other stakeholders to help address these points.

This work highlights the lack of European-level cross-sector transport preparedness guidance to aid hub operators with development of operational pandemic or serious biological threat contingency plans. Additionally, despite the development of communication platforms, such as those for ports (SHIPSAN) and airports (AIRSAN), there is no evidence of a Europe-wide cross-sector transport communications system.

Disinfection and decontamination guide (D4.4)
The objective was to develop guidelines to assist hub operators in the selection of decontamination methods in the event of a high threat pathogen or other biohazard contamination. This work linked with the microbiological sampling carried out in a transport hub and also with detection methods reviewed in the preparedness work package.

In transport hub environments, high impact microbial contamination may be triggered intentionally by the dispersion of biological agents, or caused unintentionally by infectious passengers or other human or animal agents. Following such an incident there may be a need to clean facilities before use to reduce the risk of spread of dangerous pathogens. Potential cleaning and disinfection/decontamination methods depend on the type of pathogen and scale of the contamination. Other factors to consider are that disruptions need to be kept to an operational minimal while restoring the facilities safely and efficiently, and that public concerns need to be addressed. There are a number of remediation options for dealing with biological contamination which vary in duration, cost, and application. Possible routes of infection transmission that might occur at transport hubs are
• inhalation of infectious aerosols
• direct contact with microbe containing material such as blood, faeces, vomit, and respiratory secretions
• indirect contact with infectious material on surfaces.

This deliverable reviews suitable options for disinfection and decontamination following a high threat pathogen/biohazard contamination event. The information is summarized and presented in a way to provide understanding and allow useful comparison of available methods that can be readily utilized by transport hub operators, health authorities, cleaning personnel, maintenance workers, and health emergency managers. The guide facilitates the selection of the most appropriate approach for specific types of incident, taking into account the target microbe and extent of the contamination and considers personal protection.

The most promising decontamination method for large spaces and sensitive equipment was also tested in field conditions using Bacillus atrophaeus spores as anthrax simulants. These experiments provided valuable information of the required exposure time and decontaminant concentration as well as experience in performing demanding decontamination in practice. Similarly, disinfection tests were run in laboratory conditions to find out suitable disinfection methods for much less resistant microorganisms than the spores used in the decontamination tests.

Protection of people and infrastructure (D4.5)
The objective was to develop customised guidance to assist hub operators with the management of communicable disease public health events by providing pragmatic advice on infection prevention and control and providing benchmarks to optimise preparedness. An additional aim is to provide advice and evidence in a consolidated format that may potentially be a useful resource to public health authorities as well as to hub operators.

Guidance was developed around principles of infection control to make it flexible enough to address routine requirements, but also relevant for particular circumstances such as an influenza pandemic. The work involved reviewing existing infection prevention and control guidance for PoE to identify best practice (and gaps). Transmission routes were also reviewed. A review of preparedness guidance in the context of communicable disease events was also included. Bespoke guidance was generated for communicable disease events and high threat pathogen events in a transport hub, built around five common control principles, namely: 1) ventilation controls, 2) exclusion of symptomatic persons, 3) separation of international and domestic travellers, 4) interpersonal distancing, and 5) measures to reduce indirect contact transmission. The guidance takes into consideration transmission routes, virulence of the pathogen, the types of control that are practical and available, and high risk areas where control is most important. Sector specific (including airports, maritime ports and land transport hubs) principle-based infection prevention and control guidance is provided for each step of the passenger journey for routine circumstances, together with guidance for specific communicable disease threats for a number of staff groups within transport hubs including first responders, cleaning staff, passenger service agents and operators.

For infection prevention and control the objective is to provide hub operators with simple, practical, operational advice regarding appropriate precautions and actions, proportional to risk, which will help minimise the risk and incidence of communicable disease transmission events in transport hubs, and thus reduce the risk of spreading diseases nationally and internationally. The advice is for the protection of staff and passengers and is intended to help prevent transmission of common communicable diseases as well as communicable diseases of greater public health significance such as Ebola and pandemic influenza.

The guidance comprises of three elements:
1. Guidance to address ‘routine’ infection risks at points in the passenger journey through the hub, i.e. at hotspots for transmission of infection. The risks at each point on the passenger journey are summarised in table format with recommendations and additional points for consideration provided. This advice by journey point will be most useful those concerned with operational management. Tables have been provided for a passenger journey in a typical airport and in a typical sea port. The same principles can be applied to the simpler journey through a land transport hub, and the tables adapted to suit the local context.
2. Guidance in the format of ACTION CARDS specific to three key types of communicable disease that pose a serious public health risk: respiratory infections, particularly those with the potential to cause a pandemic; Ebola as an example of viral haemorrhagic fever; and guidance for pneumonic plague (or other high risk respiratory infections). The latter was a late addition in the light of the increase in cases in Madagascar in the second half of 2017. The ACTION CARDS are targeted at key groups (hub operators, passenger service agents, cleaning personnel, baggage handlers, customs personnel, and first responders) for the infection types outlined.
3. Principle based infection prevention and control guidance for hub design and renovation.

The aim of the preparedness checklist element of this document is to provide a means for hub managers responsible for emergency preparedness and response to assess the status of their current preparedness in the context of communicable disease events.

The main target audiences for this document are hub operators, especially those with responsibility for preparedness and response, and public health authorities. It is also largely relevant to other hub employees (it includes some personnel group specific guidance), as well as transport operators and employees e.g. airline/train operators and employees. The secondary target audience is passengers (the travelling public).

1.4 Coordination, communication and co-operation (WP5)
The overall aim of this work package was to provide tools to improve coordination between stakeholders involved in an incident. Addressing communication with the general public was also an important factor.

Communication flows (D5.1):
The document aims at reviewing the communication flows and the organisation to manage pandemic risk in transport hubs. Findings were that the health crisis management information flows and the various actors are already well defined and organised thanks to the implementation of International Health Regulations (IHR) at all levels from the national level up to the European and international level. The operational management of the health crisis stays under the responsibility of the members states. European and international bodies are informed in case of potential serious cases and in case of potential serious cross border issues.

The IHR are a framework aimed at helping countries to minimize the impact and spread of public health threats. As an international treaty, the IHR is legally binding on all state parties, including all the EU member states. The revised IHR introduced the concept of public health emergencies of international concern in order to cover existing, new, and old diseases, including health crises due to non-infectious diseases. Countries are using the IHR framework to prevent and control global health threats while keeping international travel and trade as open as possible.

The IHR requires state parties to meet specific core capacity requirements for surveillance and response in order to early detect, investigate and respond to all public health risks. This mechanism, known as Early Warning and Response (EWAR), is based on the collection and the dissemination of pertinent information to competent authorities who can take appropriate measures.

At national level, each identified point of entry has to appoint a specific focal point referring to the national IHR focal point. The information flow and the logic of alert triggering are well described for ports and airports. Regarding urban transportation however, the information flow is less clear, the transport organizations usually have their own crisis management cells. But regarding specific potential health crisis, they directly rely on the national health authorities.

At European level, these communication exchanges are especially relying on the Early Warning Response System (EWRS) operated by ECDC. Additional tools have recently been developed through two specific European networks resulting from the European projects AIRSAN and SHIPSAN. It is not clear however if there are specific information exchanges at European level between transport hubs, especially for instance between the main European train stations.

Communication tools (D5.2)
The findings of the scoping review were that in general, real-time communication tools are seen as a positive factor for increasing the effectiveness of communication with the public during outbreaks. This is largely due to the increased speed, reach and transmission of these tools. Social media has been the most heavily studied communication tool during disasters and pandemics, and a number of novel applications for its use have been tested and implemented. Literature relating to the use of real-time communication tools to disseminate information to members of the public at transport hubs specifically during pandemics was very limited. (It is acknowledged that such communication regarding infectious disease events is not the responsibility of the hub.) Due to the increased transmission effects and risk potential associated with transport hubs, and the need for better communication with the public, researchers should focus on addressing this research gap.

Improvement of communication tools (D5.3):
A report was compiled on supporting tools to improve the communication flows between the decision makers and actors managing prevention and response. Suggestions include the use of pre-prepared messages, and using social media as a communication tool for improving communication with the general public.

Key points for an effective communication are:
Provide facts, not reassurance - Members of the public will want information about the nature of the incident, and the actions that emergency responders and the authorities are taking. Avoid providing generic reassurance, without providing facts. Reassurance that is not supported by evidence, or is not in line with official actions, can reduce public trust in authorities. Avoid ‘myth-busting’, which can have the effect of perpetuating the myths that it is attempting to address.

Provide sufficient practical information - Members of the public should be provided with sufficient practical information to enable them to effectively take recommended actions. Providing sufficient practical information ensures that people are able to take protective actions, generates a sense of agency and control, and therefore helps to reduce public anxiety.

Communicate in a timely way - Communication with the public about the nature of the incident and actions that are being taken should begin as soon as possible following an incident, and regular updates on the incident and the actions that people should take should be provided. The public should be told when the next update will be provided, and an update should be provided at this time, even if no new information is known. Be clear on when information is not communicated because it is not yet known, and when information is not being shared for security reasons.

Communicate honestly - Authorities should communicate openly and honestly with members of the public about the nature of the incident and the actions that are being taken. This includes communicating where information is uncertain or unknown; members of the public understand that incidents are continually evolving, and that there is often a delay before all information becomes available. This is acceptable, as long as this uncertainty is communicated.
Ensure consistency, between different sources of information, and between actions and deeds - Information provided should be consistent between organisations, and over time. Information should also be consistent with actions that are being taken; where advice given is perceived to contradict actions being taken, this results in reduced public trust. An example of potentially contradictory actions and information would be seeing emergency responders dressed in personal protective equipment, at a time when the public are being reassured that there is no risk to their health. This apparent contradiction should be clearly explained in communications.

Provide health-focused explanations about why certain actions are necessary - It is important to explain not only what actions people should take, but also why such actions will be effective. Responders and authorities should therefore provide health-focused explanations about why recommended protective actions are necessary. This will help people to understand why it is important to take action, enhancing perceived efficacy of the actions, and potentially increasing public compliance.

These principles could be used to construct a message from transport hub operators to the public, also encompassing main points that could be expanded upon for use in other communication scenarios such as electronic communication and cross-border communication. In terms of electronic communications, evidence for the use of websites, social networking sites, and mobile applications has been considered.

We consider that common preparedness and communication plans between transport hub operators within European Union Member States could improve cross-sector communication and consider best practices when planning for cross-border threats. Communication plans involving the use of electronic communication may require standard operating procedures as this communication form is not one-way. Alternative approaches may be needed for groups who don’t use electronic communication. The severity of the infectious disease outbreak will determine the level of psychological first aid that might need to be administered. It is suggested that a communication expert is appointed to ensure information communicated regarding the outbreak and response measures continues to be of high-quality, requiring an effective communication strategy.

1.5 Piloting (WP6)
The purpose of piloting was to evaluate and refine the tools developed during the course of the work. This was done by engaging through the stakeholder liaison group and also with other national and international contacts. The participants for the workshops were invited from different countries to ensure that local and national particularities and experiences were taken into account.

Exercise database (D6.1)
The exercise database was populated throughout the project as a living document updated as and when further exercise opportunities relevant to the scope of the PANDHUB programme were identified. Unfortunately in reality few suitable exercises were identified.

Individual task trialling (D6.2)
Task trialling took place for the evaluation of suitable methods for both disinfection and decontamination of surfaces at transport hubs. The evaluations were performed by experimentation using suitable model microbes. The tested disinfectants had a widely varying efficacy depending on the surface material, the decontaminant but also on the detection method.

The efficacy of commonly-used sanitation solutions (disinfectants) used to disinfect ‘high-touch’ hard surfaces in transport hubs.

Pieces of glass, hard plastic, soft plastic and wood representing materials mainly found in high-touch areas were used in this experiment. Glass, mainly found in ATMs and ticket vending machines; hard plastics found in trays for luggage and other personal items; soft plastics mainly found in arm rests, escalator rails as well as in toys, and wood which are mainly the table surface materials and chairs found in transportation hubs. Bacillus licheniformis and Staphylococcus aureus strains were used as model microorganisms; Staphylococcus being sensitive and Bacillus, a spore forming bacterium, being a resistant strain.

Disinfectants used in the tests were common liquid cleaning agents used in cleaning indoor environments. These included
• 70% alcohol
• 0.2 % chlorine
• 5% hydrogen peroxide solution
• an all surface detergent
• a combination of an all surface detergent and UV radiation using UVC (121 μW/cm2 at 254 nm wavelength at a distance of 7.5 cm).

Microbial inactivation efficacy of various material surfaces varied with different disinfectants. Although all the disinfectants were able to reduce the microbial load by more than 1 order of magnitude, hydrogen peroxide showed the highest reduction in microbial amounts on almost all the material surfaces with more than 3 orders of magnitude.

In the decontamination tests Bacillus atrophaeus spores were used as simulants for B. anthracis. For the tests a spore suspension was spread and dried on different surfaces before placing the samples in the test area. After decontamination microbes from the steel surfaces were collected using cotton-tipped swabs and cultured for calculation.

The hydrogen peroxide vapour designed for decontamination of hardy microbes showed high inactivation efficacy when the concentration and exposure time were sufficient. Up to 6-log spore reduction were achieved within exposure time of 40 min when the hydrogen peroxide vapour concentration was about 500 ppm in the decontamination space. The advantages of the gaseous hydrogen peroxide include its potent and broad spectrum antimicrobial activity, rapid efficacy, compatibility with surface materials and limited toxicity concerns.

Workshops (D6.3)
Workshops were held during the later phase of the PANHDUB project to present and evaluate the tools developed in the project. Relevant stakeholders were invited to familiarise with the tools and provide feedback. Responses were collated to evaluate and refine the tools.

The following exercises were eventually organised:
• Threat and vulnerability analysis workshop including an analysis of previous incidents, as well as the possibilities of modelling tools, Helsinki, Sept 2017
• Preparedness and response workshop, London, Oct 2016
• Coordination, communication, cooperation workshop, London June 2017

Live exercise (D6.4)
An exercise named as Chequered Flag was designed to exercise a multi-agency response to a serious infectious disease incident in a transport hub in which PANDHUB tools were available be used by the participants. This live exercise took place at Helsinki airport. It was built around a scenario of a person falling ill in a transport hub and involved the injection of scenario updates at intervals. Testing all PANDHUB tools was limited by time constraints therefore the exercise focussed on:
• Disinfection and Decontamination guidance
• Protection of People and Infrastructure guidance
• Risk communication using real-time ICT tools
• Threat Assessment guidelines/tool
• IT tool

The IT tool was also evaluated more fully at a separate half-day workshop just prior to the full exercise. Participants were representatives from public health, the hosting airport (hub operator and transport operator), emergency responders, and a Ministry of Health. External observers were also present.

This was a one day exercise delivered at a venue within the airport at Vantaa, Helsinki. The exercise comprised of three sessions of response: 1) response to a standard situation; 2) response to a heightened situation; and 3) response to a confirmed case of infectious disease. In Session 3, participants were asked to consider the potential use of the PANDHUB tools as part of their response activities and this also formed part of the facilitated plenary.

There was full agreement that the exercise achieved its aim; that the scenario and injects generated useful discussions; that the exercise generated important issues and lessons identified; and that the exercise was well organised. The results show that the aim and objectives of Exercise Chequered Flag were achieved. Plenary feedback indicated where PANDHUB tools could be used in a multi-agency response and evaluation form responses gathered end-user comment on their utility. Analysis of the feedback from the plenary session and the tool evaluation form suggests that all the tools presented were of interest and potential use by the end users in their emergency response actions. Plenary and exercise evaluation form feedback also showed that there was notable value to the participants in coming together to exercise a serious infectious disease incident, with participants noting that there were areas for improvement in communication flows between agencies and, in some instances, a need to update and revise their emergency response protocols.

1.6 Dissemination (WP 7)
The aim of the dissemination work package was to guarantee that the project outcomes efficiently reach the target audience. Wide dissemination of the results was ensured through:
• network communication methods
• the forming of and liaising with a Stakeholder Liaison Group
• conferences and workshops
• linking with ongoing relevant projects
• holding a final symposium

Online communications (D7.1)
The PANDHUB website for the dissemination of the findings was set up early in the project. A project work site was created to store, track, and manage public electronic documents during development, and in final version. This site also hosts links to relevant publications or web sites.

Formation of Stakeholder Liaison Group (D7.2)
Similarly the SLG was one of the early tasks undertaken to facilitate communication and liaison between the project and the Group members’ organisations. The SLG includes members participating the Collaborative Arrangement for the Prevention and Management of Public Health events in Civil Aviation (CAPSCA) and Coordinated Action in the Aviation Sector to control public health threats (AIRSAN) projects.

Stakeholder input report (D7.3)
Bi-annual face to face meetings took place with the SLG to present project progress, and glean the opinion and guidance of SLG members on deliverables, discussing ways in which the outputs and results could potentially be strengthened, disseminated and utilised.

The practical collaboration with the SLG took place via face-to-face meetings twice a year and all the project partners actively participated in the meetings. The group’s involvement ensured that different perspectives are taken into account, and thus all relevant issues are covered sufficiently and in a timely manner. The key recommendations can be summarised as related to three main areas:
• Focus of the project: It was recommended that the focus of the project is on the built environment, excluding vehicles, and the work priority is as follows: mass transport, aviation, trains and ports. Also, mass gathering experiences would be beneficial in the PANDHUB project. The current refugee aspect should be taken into consideration where relevant.
• Communication and cooperation: Communication with and involvement of stakeholders is important throughout the project. Cooperation with stakeholders and other interested parties ensures that the project fills existing gaps, different perspectives are taken into account, and duplication of work is avoided. The group provided valuable feedback, advice and references to relevant information and expertise to support the project.
• Dissemination and exploitation of project results: The sustainability of the project results should be taken into consideration. The involvement of the SLG supports the wide dissemination of the project results, which allows for the project findings to be considered in EU policy making. It was recommended that key terms are to be defined in the deliverables, and interconnections between work packages are ensured.

Final Symposium (D7.4)
The PANDHUB Final Symposium was held on 6th of March 2018 in Brussels and covered a comprehensive overview of the main topics addressed and activities undergone throughout the project lifetime. The project results were presented following the logic of management of high threat pathogen incidents, which consists of several different phases: threat assessment, preparedness, prevention and protection, detection, response, recovery (including disinfection and decontamination), and conclusions and lessons learnt. The PANDHUB project has produced tools for each phase specifically suited for transport hubs. The applicability of the tools was discussed from different stakeholder perspectives during the Final Symposium.


Potential Impact:
POTENTIAL IMPACT
Health threats in transport hubs could have severe impacts disrupting travel, causing fear and undermining public confidence in governments and authorities’ ability to handle such threats. The PANDHUB project set out to enhance the resilience of European urban mass transport and air traffic against pandemics and other high threat pathogen incidents in transport hubs. These enhancements can be achieved through the measures in the ‘toolbox’. These include tools for threat assessment, preparedness and response, taking into consideration the specific features of transmissible diseases and transport hub environment. The toolbox includes also modelling tools for disease spread, and epidemiological and contact tracing tools. In addition, the project identifies cost-effective measures for mitigation of hazardous (biological) incidents on the site.

The infection prevention advice in Protection of People and Infrastructure pulls together the best of existing evidence-based advice from several institutions and organisations, thus optimising the focus on hub needs. The guidance offers a means to strengthen knowledge, supporting prevention. It provides principle-based advice which if adopted routinely will have an impact on transmission events for many pathogens in transport hubs. While the prevention of pandemics or outbreaks is likely beyond the control of transport hubs, simple and small actions could help to decrease or slow the global spread of communicable diseases, and on a personal level reduce the risk of getting infected in a hub. For example, the guidance includes practical steps that should be taken during an influenza pandemic such as more frequent cleaning, and the use of signage to promote hand and respiratory hygiene.

Decision support tools have been presented through modelling and simulation exercises. Detailed modelling regarding specific countermeasures enhances existing knowledge and demonstrates the effect of specific actions that will reduce the impact of the event; for example the effectiveness using hand hygiene after contact with security screening trays at airports is depicted. Although the impact of measures can be demonstrated in this way, there are many factors influencing decision making. For example, despite evidence and simulations suggesting screening control of infected air passengers is not effective, political factors may be a powerful driver in the decision whether to put such measures in place.

Through conducting exercises PANDHUB has raised the profile of communicable disease as a threat that hubs should be preparing themselves against. In terms of societal impacts of PANDHUB, the key impact of PANDHUB is in raising awareness of disease and risks. Also associated with societal impacts are the psychological aspects of affected passengers and staff in incident response.

It is also useful to consider the impacts of the PANDHUB toolbox at each step of the security cycle: threat assessment, prevention, preparedness, response (and mitigation), and recovery.

Threat assessment
The impact of using the PANDHUB Threat Assessment methodology is to systematically identify and rank the risks caused by pathogens. This can help reduce unnecessary disruption by taking a rational approach proportional to the threat, minimising disruption when the threat is low but conversely when the threat is assessed as high, actions can be taken to reduce the risk for passengers and staff, protecting their health. Contributing to this was the hot spots review which systematically identified sites within a traffic hub environment where the risk for microbial transmission is at least periodically increased due to favourable conditions or human behaviour.

Prevention
The Protection of People and Infrastructure guidance provides a ready prepared guide for communicable disease events, intended to be used by hub operators and public health professionals to encourage the use of rational and evidence based actions. It includes advice regarding routine measures such as hand hygiene and respiratory hygiene, which, when followed, will reduce even every-day transmission events such as common colds and gastrointestinal infections. It also includes advice regarding protecting the infrastructure/environment in terms of survival of pathogens and appropriate and effective cleaning agents for different pathogens. More so, it includes advice to protect people during a pandemic, and in the event of other high-threat bioagents.

Prevention includes not only taking measures to prevent the transmission of infection, but also elements of pre-planning to limit contamination, such as ensuring the maintenance of ventilation systems, and the availability of decontamination capabilities for various biocontamination events. The Disinfection and Decontamination guidance is intended to supplement existing organisational protocols, enhancing routine cleaning advice as well as providing guidance for mitigation and control in the event of a contamination incident, thus impacting on the magnitude and reach of transmission events.

Also relevant to prevention is improving information flow and exchange and risk communication, addressed by PANDHUB.

Preparedness
Preparedness involves planning for an emergency situation to reduce its impact on life and health (and also business continuity although this is not a focus of PANDHUB). Modelling countermeasures, as carried out as part of PANDHUB, informs and strengthens decision making regarding contingency planning and effective responses. For example, one model generated assesses the appropriateness of traveler temperature screening to reduce disease transmission (likely to be ineffective) and the staffing required if such screening were instigated. Capability is also part of preparedness, for example ensuring capacity for rapid detection and means for disinfection and decontamination in advance; this is addressed through Rapid Detection and Disinfection and Decontamination. Preparedness checklists also feature in the Protection of People and Infrastructure guidance. The impact of PANDHUB here includes the potential provision of PANDHUB outputs as pre-prepared advice available for hubs to hold on site in readiness for a biological hazard incident.

Exercises are part of preparedness and these have an impact on improving the response to an event. They provide an opportunity to share lessons learned and improve working relationships between different organisations.
A further impact is around improving information flows for health emergency management. The consultations that occurred as part of the Communication Coordination and Cooperation work provided valuable opportunities for range of different users to present their different perspectives, define their needs and suggest areas for improvement to information flow both nationally and internationally. Addressing these needs would enable a more effective and streamlined response to communicable disease events.

Response
A swift and effective response is required to protect the health of hub workers, passengers and those that come into contact with infectious agents or persons with infectious diseases. The rapid deployment of tools specific to the environment (i.e. hubs) will help with this, as will having relevant and accessible information to hand. Examples where PANDHUB addresses these include the use of Rapid Detection methods and the Protection of People and Infrastructure guidance which, for example, includes guidance on the use of personal protective equipment (PPE).
Response is generally a complex multi-agency operation that requires close coordination between the agencies and responders. The impact of PANDHUB has been to contribute to strengthening this by reviewing needs of agencies through consultation and providing the developed IT tool for rapid data collection and sharing.

Recovery
Decontamination following a high threat pathogen incident is important to a swift return to normal operations. This is addressed by the Disinfection and Decontamination guidance which may help mitigate the consequences of a communicable disease or intentional event by providing clear instructions for handling various biocontamination events. The Protection of People and Infrastructure also addresses elements of decontamination, particularly with regard to high threats such as Ebola.

WIDER SOCIETAL IMPLICATIONS
In 2017, the number of people traveling by air reached just over 4 billions. Although this figure includes a large number of people who travel multiple times per year, it is equivalent to 53 percent of the world’s population. The number of passengers in global air traffic has continued to increase at an average 5 percent annual rate over four decades. Part of the reason for this trend are large declines of real cost of air travel and increases in living standards and disposable incomes over time. With a projected 400 million people in emerging and developing countries joining the middle class in the coming years, IATA expects this long-term upward trend to continue over the next two decades. It is now possible to travel between most places in the world in less time than the incubation period for many infectious diseases. This poses great challenges to containment and mitigation strategies to prevent disease importation and spread. The PANDHUB results may help provide rationale pandemic control plans causing less severe economic impact on airports during pandemics.

In the European Union, over 80% of the population lives in urban areas and around one third in cities with population over one million people. Cities and urban areas are the economic motors that generate the wealth of the citizens, and public transport plays an important role in this. The PANDHUB outputs may help keep the important public transport sector running in the event of pandemics or outbreaks of high threat pathogens thus helping maintain stability, social order and security.

DISSEMINATION ACTIVITIES AND EXPLOITATION OF RESULTS
The aim was to maximise the impact of PANDHUB by adopting an overarching strategy of cooperation. There was liaison and cooperation with other parties through selection of the SLG, which included representation from WHO, ECDC and hub operators. Key to the consultation exercise of Multi-country investigations/cross border working and workshop invitations was the need to gain input from hub operators, first responders, (such as the emergency services) public health experts, and Ministries of Health who were able to both identify gaps (via the consultations) and provide expert feedback on the usefulness of the tools in emergency management (via workshops and the final exercise).

Dissemination has been very active throughout the PANDHUB project. The results have been presented in scientific journals, conferences and in the PANDHUB Final Symposium held in Brussels in March 2018. Moreover, there have been media releases, several general level arti-cles and news in the media. The PANDHUB public reports are available at the project’s web-site at http://pandhub-fp7-security.eu/.

Information sharing is also important for exploitation of results. There has been liaison and sharing between PANDHUB and other EU programs, for example between PANDHUB and PANDEM (Pandemic Risk and Emergency Management), PANDHUB and SHIPSAN, and PANDHUB and EUSTO providing opportunities to network and add value each other’s projects, and opportunities to potentially address areas identified as gaps in other projects. Related to this was ensuring that outputs complement existing tools, and complement outputs from other projects. For example, the PANDHUB IT system is intended to complement rather than replace other IT systems. The IT tool has the potential to impact upon situational awareness. It also holds potential for improved information sharing at all levels, including multi-national. The flexible system not only facilitates coordinated contact tracing and epidemiological data collection, it also provides an effective option for conducting routine surveillance.

The developed PANDHUB IT tool for data collection during health incidents and contact tracing has proven useful in the workshops and exercises. Its technical features were tested by Assistance Publique during the Hajj pilgrimage 2017, and in a tabletop exercise organised in Paris in spring 2018, participated by the French health authorities. The tool has been presented in several occasions for possible end-users like ECDC, Ministry of Health, ESA and other potential target groups.



List of Websites:
Website address: http://pandhub-fp7-security.eu/

Contact details:
Teknologian tutkimuskeskus VTT Oy, Finland: Ilpo Kulmala
ASSISTANCE PUBLIQUE - HOPITAUX DE PARIS, France: Nicolas Poirot
Department of Health, UK: Emma Bennett
MEDES-INST MEDECINE PHYSIOLOGIE SPATIALE, France: Audrey Berthier
ITA-SUOMEN YLIOPISTO, Finland: Pertti Pasanen
THE UNIVERSITY OF NOTTINGHAM, UK: Jonathan Nguyen-Van-Tam

Project coordinator:
Dr Ilpo Kulmala
VTT Oy
PO Box 1300
33101 Tampere, Finland
tel +358-405811310
email: ilpo.kulmala@vtt.fi