Medical Preparedness at Suvarnbhumi Airport, AOT Company Profile of Thailand Public Company Limited or AOT is a state enterprise under the Ministry of Transport. AOT is

ท่าอากาศยานสุวรรณภูมิ (BKK) / responsible for all airport operation ท่าอากาศยานดอนเมือง (DMK) / ท่าอาศยานภูเก็ต (HKT) and airport-related businesses which includes six international airports.

ท่าอากาศยานเชียงใหม่ (CNX) / ท่าอากาศยานแม่ฟ้าหลวงเชียงราย (CEI) / ท่าอาศยานหาดใหญ่ (HDY)

Mae Fah Luang Chiang Rai airport

Chiang Mai Airport

Suvarnabhumi airport Don Mueang airport

Phuket airport Hat Yai airport Airport

• Over all area 8,000 acres • Main terminal building area 563,000 square metres. • There are 120 stands : - 51 contact gates - 69 bays - 6 gates for A380 • 2 runways • Flight 900 flights per day • 55 million passengers per year or 150,000/day Medical service at airport Medical service at airport Legislations and Regulations

• Thai law - Air Navigation Act B.E. 2497 - The Infectious Disease Act B.E.2558 - Public Health Act B.E.2535 • International - WHO , IHR 2005 - ICAO : Annex 9 Facilitation Annex 12 Search and Rescue Annex 14 Aerodromes Annex 18 The Safe Transport of Dangerous Goods by Air Doc 9137 part 7 IHR implementation at ports, airports and ground crossings

PREVENTION EARLY WARNING RESPONSE Responding to Containing known Detecting relevant public health public health risks health events emergencies

Routine control of “Sanitary conditions” at Support to investigation Inspection, Information and and contingency plans to points of entry and verification conveyances adopt control measures Risk management Risk assessment Event management Conveyances inspection programmes and control measures cr.Dr.Daniel Manuci, WHO Authorities and responsibilities

AOT

DDC Coordination in POE (Point Of Entry)

Aviation sec. Health sec. AOT FDA, MOPH

Airlines SVB Airport (BKK) Port health AOC CAAT Provincial health AEROTHAI Hospitals Police Service providers

Custom bureau Immigration bureau

ETC. ETC.

Communication for Medical Emergency

ATC

Airlines Med clinic Port health office

Co-evaluation

NO YES

Hospital Designated hospital Traveller advisory

. Airports of Thailand

• Medical Department - medical responses to aircraft and airport emergency including medical preparedness in airport emergency exercises and drills at airports. - provides medical services at airports for passengers and staffs. - regulates medical clinics of airports . - gives medical advise to airlines and passenger about traveling by air and issue medical certificate “ fit to fly ” for sick passengers. - transfers medical case from aircraft to/from ambulance ( TARMAC ). - facilitates port health officers in communicable disease suspected case. - others : BLS and AED training AOT and frontline airport and airlines staffs, routine check up for AOT staffs, medical certificate for airside driving license and etc. Airport clinics

• All airports provide airport clinic or first aid clinic Suvarnabhumi Airport clinic Don Mueang Airport clinic Phuket Airport clinic Airport clinic Mae Fah Luang Chiang rai Airport clinic Hat Yai Airport first aid clinic Suvarnabhumi airport clinic Overall patients of 2016

40000 35411 35000 30000 25000 20000 14260 15000 9532 10000 6851 3714 5000 2130 0 VTBS VTBD VTSP VTSS VTCC VTCT

Total 71898 VTBS patients

0% 1% 3% AOT STAFF

20% AOT FAMILY MEMBERS 43% PASSENGERS

AIRLINES STAFF 23%

COOPERATE 10% ENTERPRISE Suvarnabhumi Airport Clinic

• Medical clinics at Suvarnabhumi airport Monday – Friday 0800-1700hr operated by AOT Monday – Friday 1700-0800hr next day ,24hr on weekend and public holiday operated by Samitivej Suvarnabhumi (private hospital) clinic under AOT policy. • Response time to scene is 10 mins , at main terminal building the response time is 7 mins. • CPR 20 cases/year • Dead on arrival 6 cases/year • Medical emergency calls at airport 900 cases/year • Minor disease: Common cold , Acute gastroenteritis , Allergic rhinitis • Emergency : Cardiac arrest , CVA , Psychiatric patient , Suicidal attempt Suvarnabhumi Airport Clinic

AOT clinic Samitivej Suvarnabhumi clinic Physicians 7 3 Nurses 14 9 EMTs 6 6 Ambulances 4 3

EMT-B

• Emergency Medical Technician – Basic (EMT-B) certified by National Institute of Emergency Medicine Arrival screening

Measure Traveler’s body temperature using hand held thermometer Public Health Measures at International Points of Entry

- Thailand’s Quarantine diseases: smallpox, cholera, pneumonic plaque, Yellow fever, SARS, Ebola and MERS (The Infectious Disease Act B.E. 2558)

- Any traveler from the affected areas will be screened at point of entry before immigration (required by law)

- “Affected areas” mean a geographical location specifically for which health measures have been recommended by WHO under IHR. • Airlines consults for a sick passenger who is • Temperature above 38.5 Celsius degree • Cough and shortness of breaths • Rash or hemorrhagic rash • Severe diarrhea • Jaundice • Or other significant symptoms • Or suspected infectious disease that by law of communicable disease act B.E. 2558 Flow chart : Medical emergency (Non-PHEIC)

ATC

Port health Airlines Med clinic office Co-evaluation

NO YES

hospital Designated hospital

Follow up Suvarnabhumi medical clinic

• MoU hospitals for aircraft and airport accidents • Samitivej Srinakharin Hospital • medical center • Chularat 9 Hospital • Thai nakarin Hospital • Piyavate Hospital • Vejthani Hospital • Praram 9 Hospital • Vipharam Hospital • Government hospital : national emergency service 1669 Suvarnabhumi airport clinic • If the disease is suspected serious communicable disease , medical emergency is acted immediately • Notify port health office at port health office. • For communicable disease • Contacts Bamrasnaradura infectious disease institute by port health office coordination. • If not communicable diseases , referred sick passengers to general or private hospital. Contact tracing

• Pulmonary TB • Contact tracing :Two rows front and two rows back • Influeza • No specific guidelines but there was evidence of transmission up to 10 rows • Advise the patient to wear surgical mask and personal hygiene and also advise the contacted crew to wear mask. • contact tracing is advisable only if the index case is symptomatic during flight. • Ebola • No evidence base of transmission during the flight . • Highly recommended contact tracing even all crew due to highly infectious • most airplane contacts pose a low to moderate risk of exposure. Contact tracing

• WHO recommends that suspected SARS cases should be separated from other passengers during the flight. • WHO defines a ‘contact’ of a suspected SARS case as • a passenger seated in the same row as the suspected SARS case • a passenger two rows in front or behind the suspected SARS case • a person providing care for the suspected SARS case • a person having intimate contact with the suspected SARS case • a person having contact with respiratory secretions of the suspected SARS case • a person living in the same household with the suspected SARS case • all crew members. Aircraft accident emergency box Medical emergency box PPE level C PPE. Training for Health Control officers. AED ( automatic external defibrillators) at AOT airports Personal hygiene awareness at airports Personal hygiene awareness at airports Airport emergency response Suvarnabhumi Airport Emergency Response • Suvarnabhumi airport emergency plan consist of 13 sections - section 1 Aircraft accident - section 5 Dangerous goods - section 9 Bomb threat on aircraft - section 13 Medical emergency – infectious diseases • Full scale exercise once a year Medical emergency planning exercise : infectious diseases

Suvarnabhumi Airport • SEMEX - 12 full scale exercise : chapter 13 medical emergency and infectious disease , H5N1 infection • Partial scale exercise 2014 : MERS • Tabletop exercise 2016 : MERs Flow chart : infectious disease (PHEIC)

ATC Med clinic

Port health Med clinic VP MED SECURITY Airlines office

Co-evaluation

YES NO

Designated hospital hospital

Follow up

Partial scale exercise : MERS- CoV

• Aim : walk-in case and transportation to designated hospital Tabletop exercise 2016 :MERS-CoV

• Aim : communication and third parties involvement. Tabletop exercise 2016 :MERS-CoV

Hazardous material management

• Held up by Washington state military department , USA with JUSMAG Thai : train as provider and also as HAZMAT train for the trainers. • Drills by Rescue and Fire fighter department once a year. Patient decontaminate drills

INTERESTING CASE Interesting Case

• Called from ATC at 0300UTC +7 , ETA 0500UTC +7 • Flight MS960 from Cairo to Bangkok • There was dead on arrival case on board. He is a Thai man. • What would you do ? Any cause of death to think of ? Interesting Case

• An old Thai man , 85 years old . • He was found collapse in a toilet on the aircraft at 0200 UTC +7 • His relatives called for help. Aircrew called for medical personnel on board. • There was a doctor on board Interesting Case • No pulse , pupil 4 mm fixed dilate both eyes. DTX 283mg/dl • Start CPR and put on AED : NO SHOCK ADVISED . Doctor and aircrew continue CPR rate 120min , 30:2 • They did CPR for 30 mins . His relatives called for terminate CPR at 0230UTC +7 • Anymore information do you need from PIC or airlines ? Or just regular dead on arrival management . Details of in-flight treatment Interesting Case

• He went to Saudi Arabia for Umrah Muslim pilgrimage about 3 weeks ago with his family : wife and niece. • He developed cough fever with productive cough and gradually dyspnea about 1 week ago . He also lost of appetite and got runny nose . He took his medicines including antibiotic that he brought from home and didn’t seek medical treatment while he was in Cairo . • Before the flight , he was fatigue but denied chest pain or shortness of breath . • His wife and niece also has got flu-like symptoms. Interesting case

• differential diagnosis. • Non infectious • Infectious Interesting case Interesting Case

• The aircraft arrived at 0530UTC +7 , The doctor and nurse asked information from aircrew and his relatives with universal precaution as N95 mask . • Medical personnel put on PPE level C for examination. Interesting Case

• All the passengers were hold on the flight for triage as serious communicable disease by Thai the infectious disease Act B.E. 2558. • Minor risk ( Green ) passengers were advised , filled out health declaration form and got through normal immigration and customs . • Intermediate risk ( Yellow ) passengers were advised, filled out health declaration form and self-quarantined . • Major risk ( Red ) passengers his wife and his niece were transferred to hospital for investigation and quarantine at designated hospital. • The index case were full body packed by nurse with PPE level C and transferred for forensic investigation and autopsy . Problem list • Information from PIC? Can we get more information ? - sometimes the details is only “ unknown illness or symptoms” • Designated contact or isolated parking ? - Remote parking bay is enough. • Triage. - 2 row in the fronts and 2 row in the back and around index case , including aircrew and passengers who take care of the index case. Problem list

• Quarantine the passengers ? Or self quarantine? - Red zone : at hospital , Yellow zone : also hospital or home quarantine but report every day , Green zone : home quarantine but report when they are sick . • Transferring the corpse - The certified foundation but has to wear PPE and transfer the corpse to forensic examination . PCR Results

• Influenza type B : positive • Rhinovirus : positive • Moraxella catarrhalis : positive • Klebsiella pneumoniae : positive • Haemophilus influenza : positive • Coronavirus NL63 , 229E , OC43 , HKU1 : negative