Help stop the spread, get the world moving by Global Health @ Mott MacDonald

Help stop the spread, get the world moving How infrastructure epidemiology can help reduce the risks of Covid-19 and restart the aviation industry

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Aviation: An unwitting vector in the global pandemic The industry can help get the world moving while reducing the spread of Covid-19. Like it or not, the aviation industry accelerated the global spread of Covid-19. Without air travel the virus would have been limited to a localised epidemic – still of concern, but at least a manageable outbreak.

Infrastructure epidemiology: A unique discipline to tackle the crisis We have combined our aviation expertise, through our work on many of the world’s biggest airport projects, with our health services expertise, where we have 20 years’ experience working on infectious diseases and epidemiology. This enables us to look at the building blocks of disease mitigation and how they apply to aviation settings. Using this lens of infrastructure epidemiology – unique in our industry – we are able to define key goals to reduce the spread of the virus.

“We have to put health science at the heart of our efforts to kickstart the global economy. Our focus on infrastructure epidemiology helps to reduce risk in air travel, getting people flying again.”

Many recommend getting back to ‘business as usual’ – with some modifications. However, this is not enough as it doesn’t deal with the root causes of the pandemic or provide science-led remedies. It risks a second lockdown – which many industry players would struggle to survive. As the unwitting vector in this global pandemic, the aviation industry must play an active role in reducing the further spread of the virus. It can do this through effective interventions which enable travel, while reducing the risk of a second wave of infection and the devastating impact this would have on people’s lives and the global economy.

Mike Haigh Executive chair, Mott MacDonald

Our vision for the industry The journey through the airport should minimise the risk of spreading Covid-19. Ideally, the risk would be no greater than it would be if doing any normal day-to-day activity where others are present. Our core goals are:

The risk of a traveller’s journey through the airport should not extend beyond their flight (ie no matter how many flights are handled at an airport, risk to individual travellers should be no greater than if the terminal only handled their flight).

Airports and airlines should reduce overall risk to passengers by streamlining processes and interventions both on the aircraft and on the ground.

Measures should contribute to a safe working environment by reducing risk to employees.

Airports should be equipped to become one of several lines of defence in controlling the spread of serious communicable disease.

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Reducing the risk Ideally, journeys through terminals should be modified so that passengers from different flights have minimal contact with each other. This contact can be through close physical proximity, actual person-to-person contact, or common touchpoints. Reducing contact limits passenger exposure risk and cuts cross-contamination between flights. Where contact cannot be avoided, then greater attention to hygiene controls should be implemented. So long as Covid-19 or any infectious disease remains in the public realm, there will always be a risk of transmission and infection.

Historic business as usual • Common use facilities

A three-step process Aviation leaders should follow a three-step process to re-open their facilities while properly managing contagion risk. Step one relates to the immediate future and includes operational interventions using existing technologies and equipment with an overlay of new procedures to reduce the risk of transmission. Step two brings in new solutions, with a likely bias towards technology and hygiene to further reduce the risk until an immunisation is effective (likely to be 18–24 after an outbreak). Step three puts in place permanent changes to operations and infrastructure to reduce the risk of transport infrastructure aiding the spread of infectious disease.

Stage 1: What needs to be done to get the world flying again (operational interventions) Stage 2: What can then be introduced to improve the journey (operations, Capex and revenues) Stage 3: The longer term implications to minimise aviation infrastructure contributing to the occurence of another pandemic (operations, Capex and revenues)

Reduced risk – minimising the spread • Dedicated facilities • Focus on essential services • Re-engineered retail and food and beverage offer

Key Possible contamination P

Additional contamination Infected passenger Other passengers

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Reduce the spread Epidemiology principles Fundamentally, we need to reduce exposure risk for Covid-19 by: • Reducing proximity between people to limit the transmission of the disease through microdroplets in the air • Reducing direct contact, such as hand-to-hand contact, to limit direct transmission from person to person • Increasing/improving cleaning and hygiene to reduce the risks from fomites – transmission via handles and surfaces

International vs domestic As countries emerge from lockdown, decisions on what is opened up and when will be determined by the ability of health services to handle new infections and the need to kickstart economic activity without having to revert to stringent lockdowns. Opening up domestic aviation would be part of the same risk analysis, so ensuring a risk-controlled environment is critical both to allowing widespread travel and to giving passengers confidence that risks are as low as possible. Restriction of international aviation is one of the primary controls on the spread of the virus across borders – and one that can be turned on or off on a unilateral basis. Aviation needs to demonstrate that it has controlled risks both to receiving countries and to passengers. The industry can reduce risks further if certain non-pharmaceutical interventions are adopted.

How intense interventions should be depends on underlying transmission rates, locally or in the area of origin for arrivals. Risk is determined by: • The time spent in the facility itself • The degree of social mixing/person-density • The level of hygiene and sanitation If exposure can be sufficiently reduced using evidencebased measures, the public can be reassured that the risk of travel is no greater (or could even be lower) than the risk of normal daily tasks in public places.

Guiding principles of non-pharmaceutical interventions (NPIs)

• Keep passengers informed, so they can carry out any necessary preparation before travelling to the airport

• Screen out symptomatic passengers prior to entry • Reduce time in the terminal: the less time spent in the airport, the less time exposed

• Reduce the density and contact points in the terminal • Provide what is necessary to minimise transmission risk, such as hand sanitiser, face masks and personal protective equipment (PPE) for staff • Reduce potential for cross-flight contamination in the terminal • Remove non-essential staff, processes and access to facilities • Do the ‘brilliant basics’ of cleaning, process and maintenance thoroughly • Include all key stakeholders in core decision-making • Use the latest evidence, as it emerges, to refine interventions and select those (or combinations) are most effective

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Simplifying the journey

A root and branch review of the total passenger journey will reduce the risk of cross-contamination between flights. Every process and touchpoint must be critically assessed. If it can be removed, then it will not be touched and will not need to be cleaned. This allows focus on how to reduce the risk from essential facilities. Restarting business as usual may add to the cross-contamination and not provide the necessary controls. The arrivals and transfer passenger process may also include screening of passengers, dependent on origin. Facilities will need to be provided to handle those that test positive and to inform those that have come into close contact with them – contact tracing. The less process and ‘less to process’ also makes for faster, more efficient journeys.

Staff and the broader community Workload for frontline staff is likely to be more intense. Rest areas and PPE for staff (in particular when food and beverage outlets are not available) will need particular attention as will the handling of passengers who test positive, with facilities for paramedics and their vehicles as well as medical waste handling being necessary. Customer services Travelling will be more stressful, so customer services and customer experience will be even more important. A particular focus is needed on: • Safety – demonstrating all the additional levels of safety protection • Efficiency – passengers do not want to be in the terminal longer than necessary • Everyone doing their job exceptionally well – this includes visibility and assistance with necessary distancing • Small tokens of happiness that will go a long way Strategies should be continuously adapted based on operational evidence and to keep up with rapidly evolving national and regional circumstances.

Reduce touchpoints Covid-19 and other contaminants are difficult to remove from surfaces, so the focus should be on minimising touchpoints to reduce risk. Non-essential touchpoints can be removed altogether. For those that are needed, then a risk analysis should be carried out to show how contamination can be minimised. Most touchpoints were not designed to limit the spread of disease, so some may never return, and others may need to be replaced. There are also multiple points of contact in the aircraft. Some airlines are providing new guidelines, such as minimising hand baggage to under-theseat size to limit contact from passengers constantly repositioning luggage to fit in overhead lockers. Boarding from the back with the first rows first, and disembarking from the front, should also be considered to reduce the risk of cross-contamination.

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“We need to get it into our heads that our lives have changed.”

Planning for the future

Time, 29 April 2020

Evidence-based approach to safely opening the gateways

Going forward

Applying our approach to infrastructure epidemiology – utilising epidemiological evidence married with process mapping, passenger flow models, and other modelling tools – enables us to understand the issues much better. While the nature of each airport means there is no ‘one size fits all’ solution, the goals and objectives remain the same.

Reverting to ‘business as usual’ enhances risk to travellers, may prolong the pandemic and will ultimately lead to greater social and economic costs. New NPIs will change the risk profile of flying, allowing for a step-by-step pathway to a ‘new normal’. This has to follow a risk-based approach rather than blind faith in others.

The industry should aim to get things right before restarting commercial flights and introducing continuous improvement as traffic returns to prior levels: • Align goals and objectives across all primary stakeholders • Review the NPIs (non-pharmaceutical interventions) available before and during the journey, as well as risk reduction efficacy • Continuously review the evidence to inform options and, where appropriate, conduct operational research • Carry out a thorough ‘touchpoint check-up’ analysis looking at all touch (or proximity points), transmission risk, hygiene factors and whether they are essential or can be removed or modified • Fully understand the demand on facilities and processes for airport staffing and other stakeholders • Analyse operations and capacity optimisation in the light of all interventions • Analyse impact on profits, revenue and operational costs with a range of traffic – not against business as usual, but in the context of current circumstances • Revise operational and customer services plans

The aviation industry was a key vector in turning a local disease into a global pandemic, so industry leaders have to go the extra mile to reduce the spread of infection.

• Dedicated serviced bag drop for each flight • Allow only checked bags and carry-on bags small

Existing plans to embed smarter, more efficient journeys (such as the NEXTT initiative or single token journeys) should be implemented sooner. Extensive use of technology with personal devices used for most transactions will become standard quickly. However, that alone will not get us flying safely more quickly. It has to be matched by what we call the ‘brilliant basics’ of enabling passengers to journey efficiently through the airport onto their flights, minimising mixing between those from different flights, cutting unnecessary processes and touchpoints, and a strong focus on hygiene.

• Use stagger gates to promote social distancing • Board from the back row of the aircraft • Disembark by row number • Provide PPE, physical barriers, sanitisers and

Key points: • Understand and quantify the risks across the journey • Minimise access to the system except for those who are fit to fly • Minimise time spent in the terminal, especially in common use areas • Minimise contact with other passengers, in particular those from other flights • Optimise hygiene and give it the same importance as security

• Encourage check-in before travel and health declarations

• Travellers to bring their own PDA and be tracked • Travellers to bring their own water bottles • Encourage ‘drive and park’ or ‘drive and drop-off’ until other modes of transport have reduced their risk

• Implement health check controls before entry to the terminal or airport transit system enough to fit under seats

• Maximise ‘click and collect’ facilities at commercial outlets

enhanced staff support • Appoint an infection control officer linked to national and international institutions • Focus efforts on customer service through consistent communications before and during the journey • Increase frequency of cleaning regimen

Don’t

• Allow non-travellers into the terminal • Provide common use facilities • Provide self-service touchpoints • Encourage high density queuing • Increase dwell time – take travellers straight to the gate

• Provide unnecessary touchpoints, such as ‘happy or not’ customer service indicators

• Hold travellers for long periods of time in the departure lounge before the call to the gate

• Provide commercial activities (until safe to do so) • Concentrate flights together • Allow unnecessary belongings into the aircraft cabin • Pack people together to increase capacity • Treat hygiene as a cost • Rely on others (including travellers, contracted staff or your supply chain) to understand and manage risk

• Rely on passengers to understand all safety measures when they get to the terminal without additional support • Operate facilities that add unnecessary workload

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Opening opportunities with connected thinking. Authors: Chris Chalk Global sector leader for Aviation chris.chalk@mottmac.com Dr Toby Leslie Mott MacDonald expert on epidemiology and infectious disease control toby.leslie@mottmac.com

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