James Leggett
Dr. Marcellus Grace, R.Ph., Ph.D.
HMLS 6150
October 21, 2013
Potential Exposure to Typhoid Fever on American Airlines Flight from Miami to New Orleans
Introduction
On October 15, 2012, an American Airlines flight from Miami to New Orleans was held for two hours on the tarmac at Louis Armstrong International Airport after a passenger suggested to the flight crew that she might have been exposed to typhoid fever. In my analysis and critique of this event, I will discuss the typhoid fever, its symptoms and effects, the response from both the Louis Armstrong International Airport emergency response personnel and the Centers for Disease Control (CDC), and the “What if?” scenario if it actually was a legitimate typhoid fever diagnosis.
Typhoid Fever Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. In the United States, it is estimated that approximately 5,700 cases occur annually. Most cases (up to 75%) are acquired while traveling internationally. Typhoid fever is still common in the developing world, where it affects about 21.5 million persons each year. (CDC) You can get typhoid fever if you eat food or drink beverages that have been handled by a person who is shedding Salmonella Typhi or if sewage contaminated with Salmonella Typhi bacteria gets into the water you use for drinking or washing food. Therefore, typhoid fever is more common in areas of the world where handwashing is less frequent and water is likely to be contaminated with sewage. (CDC) In addition, a small number of persons, called carriers, recover from typhoid fever but continue to carry the bacteria. Once a person is infected, the body will typically respond with high fever (>103°), stomach pains, and loss of appetite. Unfortunately, the only way to know whether a person has been infected with Salmonella Typhi is with a stool sample. Typhoid fever is common in most parts of the world except in industrialized regions such as the United States, Canada, western Europe, Australia, and Japan. (CDC) The Center for Disease Control and Prevention recommends all United States citizens who regularly travel to less industrialized areas of the world receive the Typhoid Fever vaccination. This vaccination will not prevent all cases of the infection and requires a booster every five years. (CDC) Typhoid fever is treated with antibiotics. Resistance to multiple antibiotics is increasing among Salmonella that cause typhoid fever. Reduced susceptibility to fluoroquinolones (e.g., ciprofloxacin) and the emergence of multidrug-resistance has complicated treatment of infections, especially those acquired in South Asia. Antibiotic susceptibility testing may help guide appropriate therapy. Choices for antibiotic therapy include fluoroquinolones (for susceptible infections), ceftriaxone, and azithromycin. Persons who do not get treatment may continue to have fever for weeks or months, and as many as 20% may die from complications of the infection. (CDC)
Response
The response to this particular medical crisis was adequate to the situation and in the public’s eyes, a non-event. There were actually very few stories covering this situation because the response was seamless and orderly. Typically, in emergency or crisis-type situations, how smooth the response is can be seen via how much publicity it receives. A higher profile situation or one with disorganized response and poor leadership and management will tend to be covered more by media outlets than the ones that are handled with forceful, decisive, and appropriate action and response. This is due, in large part, to the public’s need for mayhem and drama. They want to watch a crisis via television and tell themselves that it could never happen to them or anyone they love. They love to watch the disorder unfold before their eyes while they are comfortably sitting on the couch in their secure home. It gives people a sense of security knowing that they are safe and sound while others are out dealing with the dramatic event as it is occurring. People tend to distance themselves from a catastrophic event that has occurred but will overwhelmingly want to watch what happens and how those “other” people handle the stressful situations unfolding before their eyes. I will, therefore, critique the event as it occurred, but, also discuss what could have happened had this been an actual outbreak of typhoid fever. In this particular case involving a woman on an American Airlines flight displaying flu-like symptoms and informing the flight crew that she could have been exposed to typhoid fever, the first action was the flight crew informing emergency personnel on the ground at Louis Armstrong International Airport in New Orleans. The emergency personnel immediately called the Centers for Disease Control (CDC) to report the potential medical emergency. The flight landed on schedule, and, following taxiing from the runway to a secure location, CDC personnel boarded the flight to retrieve blood samples from the potential victim. (NOLA) More than 45 minutes after arrival, the Captain made an announcement over the intercom announcing the situation and what was taking place. He also added, “ We're all in this together, the flight crew, the attendants, everyone aboard this plane is in the same situation.” (NOLA) Nearly an hour later, the Captain once again spoke over the intercom informing the passengers they were free to go and to be sure to wash their hands upon arrival at the terminal. The ill woman was transported via ambulance to East Jefferson Hospital with an undisclosed illness. (NOLA) This is the end of the story for this event. In this case, the woman who was experiencing these symptoms reacted appropriately by informing the flight crew. The flight crew did what they were trained to do and informed the emergency response team of the situation in the air. The team on the ground immediately notified the CDC, who then sent a team to investigate, and that investigation resulted in the conclusion that there was no serious medical threat to the other passengers on that airline or to the populous at large.
Typhoid Fever Outbreak If the CDC would have drawn the blood sample of the ill woman and the resulting tests indicated a positive result of typhoid fever, the subsequent response would have been dramatically different.

First Responders Upon being informed of a potential victim being infected with Typhoid Fever, the first responders would have to immediately quarantine the aircraft, preventing any personnel from leaving, including the flight crew. Once the first responders have established the necessary baseline information on the extent of the illness and potential for outbreak, the on-scene commander will then determine how to utilize his resources to protect against any additional exposure. At this point, the CDC will most likely arrive on scene, receive a thorough briefing of the situation from the first responders/airport emergency on-scene commander, assume control as the on-scene commander, and begin the arduous process of identifying all potential victims, both on the aircraft and at the previous airport, in this case Miami. They will direct their emergency personnel to don all required Personal Protective Equipment (PPE) for entering a biohazard environment to draw blood for testing from the potential victim. Upon hearing from the testing lab of a positive test result, necessary medical response personnel will be called in to determine the extent of exposure, potential for the disease spreading, and inform the emergency response leadership of the results to disseminate the information to the public. Consideration will be given to ensure enough medication is on hand in the local area and whether or not to request additional medication via nearby stockpiles or through the Strategic National Stockpile (SNS). The SNS would only have to be utilized if the outbreak appeared to be heading towards an epidemic status. (Hogan) In determining the proper response to a typhoid fever outbreak, the leadership will rely on an accurate evaluation from the on-scene commander. This will provide the leadership with valuable information to help determine what, if any, additional resources are required and how quickly they might be needed. Additionally, this initial assessment will provide them with necessary information to help them make an informed decision as to what to address with the public. This type of situation could make the majority of the population start to panic, due largely to their lack of knowledge regarding this particular illness and how it is communicated. As an emergency manager, it is imperative to only inform the public of relevant information and risks associated with the situation to help alleviate the possibility of widespread panic. I would provide the on-scene commander with the following press release:
CONFIRMED CASE OF TYPHOID FEVER ON AIRCRAFT FROM MIAMI FLORIDA
Tuesday, October 15, 2012: Contact: Centers for Disease Control
New Orleans- As of 7:00 p.m. today the New Orleans Fire Department, Louis Armstrong International Airport Emergency Response Crew, and the Center for Disease Control are evaluating the complete situation and extent of potential exposure involving a confirmed case of typhoid fever on an airliner that landed at 4:30 p.m. today. At the time of this press release, there have been no additional cases reported on the aircraft or the originating city of Miami. The remaining passengers and flight crew are currently being quarantined on the aircraft for further evaluation. The CDC believes this to be an isolated case of the illness and does not foresee any additional cases or outbreaks. If you begin to experience a high fever, stomach pains, and loss of appetite, please proceed to your nearest Emergency Room or local health care provider to receive appropriate medical care. For questions or concerns regarding this illness and its symptoms please go to http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/
Conclusion
The initial response to this type of incident should always be to determine if it is a valid diagnosis of a particular communicable illness, total scope of potential exposure, containment or quarantine of those affected, and ensuring the availability of medication or vaccinations. The key for emergency management leadership is a fundamental understanding of available assets, allocation of those assets, and, as is true in any emergency, constant and effective communication up, down, and across all agencies involved in the response. If the emergency response team understands these key components required by the leadership, they will be able to offer informed recommendations and actions to manage the situation in the best possible manner. Together, if these “keys to success” are utilized by everyone involved, the situation will be handled in a timely and appropriate manner and the public will trust that they are safe from any sort of threat and will remain calm.

Works Cited
"Typhoid Fever." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 May 2013. Web. 07 Oct. 2013. http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/
Webster, Richard A. "Greater New Orleans." Editorial. The Times-Picayune [New Orleans] 15 Oct. 2012: The Times-Picayune. Web. 8 Oct. 2013 http://www.nola.com/health/index.ssf/2012/10/no_contagion_feared_after_typh.html Webster, Richard A. "Greater New Orleans." Editorial. The Times-Picayune [New Orleans] 16 Oct. 2012: The Times-Picayune. Web. 8 Oct. 2013 http://www.nola.com/health/index.ssf/2012/10/no_contagion_feared_after_typh.html
Ciottone, Gregory R. Disaster Medicine. Philadelphia, PA: Mosby Elsevier, 2006. Print.
Hogan, David E., and Jonathan L. Burstein. Disaster Medicine. Philadelphia: Lippincott Williams & Wilkins, 2007. Print