Circumstances exist that call for the aeromedical evacuation high-level containment transport (AE-HLCT) of patients with highly hazardous communicable diseases. A small number of organizations maintain AE-HLCT capabilities, and little is publicly available regarding the practices. The time is ripe for the development of standards and consensus guidelines involving AE-HLCT

Achutan, Chandran

Beam, Elizabeth L.

Carter, Gary W.

Cieslak, Theodore J.

Gibbs, Shawn G.

Herstein, Jocelyn J.

Kopocis-Herstein, Kelli R.

Lawler, James V.

Le, Aurora B.

Lowe, John J.

Santarpia, Joshua L.

Stentz, Terry L.

English

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University of Nebraska - Lincoln 
DigitalCommons@University of Nebraska - Lincoln 
Architectural Engineering -- Faculty Publications Architectural Engineering and Construction, Durham School of 
2019 
Need for Aeromedical Evacuation High-Level Containment 
Transport Guidelines 
Shawn G. Gibbs 
Indiana University School of Public Health 
Jocelyn J. Herstein 
University of Nebraska Medical Center, jocelyn.herstein@unmc.edu 
Aurora B. Le 
Indiana University School of Public Health 
Elizabeth L. Beam 
University of Nebraska Medical Center, ebeam@unmc.edu 
Theodore J. Cieslak 
University of Nebraska Medical Center, ted.cieslak@unmc.edu 
See next page for additional authors 
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Gibbs, Shawn G.; Herstein, Jocelyn J.; Le, Aurora B.; Beam, Elizabeth L.; Cieslak, Theodore J.; Lawler, 
James V.; Santarpia, Joshua L.; Stentz, Terry L.; Kopocis-Herstein, Kelli R.; Achutan, Chandran; Carter, Gary 
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(2019). Architectural Engineering -- Faculty Publications. 159. 
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Authors 
Shawn G. Gibbs, Jocelyn J. Herstein, Aurora B. Le, Elizabeth L. Beam, Theodore J. Cieslak, James V. 
Lawler, Joshua L. Santarpia, Terry L. Stentz, Kelli R. Kopocis-Herstein, Chandran Achutan, Gary W. Carter, 
and John J. Lowe 
This article is available at DigitalCommons@University of Nebraska - Lincoln: https://digitalcommons.unl.edu/
archengfacpub/159 
 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 25, No. 5, May 2019 1033
RESEARCH LETTERS
Need for Aeromedical  
Evacuation High-Level  
Containment Transport 
Guidelines
Shawn G. Gibbs, Jocelyn J. Herstein,  
Aurora B. Le, Elizabeth L. Beam,  
Theodore J. Cieslak, James V. Lawler,  
Joshua L. Santarpia, Terry L. Stentz,  
Kelli R. Kopocis-Herstein, Chandran Achutan, 
Gary W. Carter, John J. Lowe
Author affiliations: Indiana University School of Public Health, 
Bloomington, Indiana, USA (S.G. Gibbs, A.B. Le); University of 
Nebraska Medical Center College of Public Health, Omaha,  
Nebraska, USA (J.J. Herstein, T.J. Cieslak, C. Achutan,  
J.J. Lowe); University of Nebraska Medical Center College of 
Nursing, Omaha (E.L. Beam); University of Nebraska Medical 
Center College of Medicine, Omaha (J.V. Lawler, J.L. Santarpia); 
National Strategic Research Institute, Omaha (J.V. Lawler,  
J.L. Santarpia, G.W. Carter); University of Nebraska–Lincoln 
Charles W. Durham School of Architectural Engineering and  
Construction, Lincoln, Nebraska, USA (T.L. Stentz,  
K.R. Kopocis-Herstein)
DOI: https://doi.org/10.3201/eid2505.181948
Circumstances exist that call for the aeromedical evacuation 
high-level containment transport (AE-HLCT) of patients with 
highly hazardous communicable diseases. A small number 
of organizations maintain AE-HLCT capabilities, and little is 
publicly available regarding the practices. The time is ripe 
for the development of standards and consensus guidelines 
involving AE-HLCT.
During a highly hazardous communicable diseases (HHCD) outbreak, most patients are likely to be 
treated within the affected region. However, circumstances 
exist for which aeromedical evacuation high-level contain-
ment transport (AE-HLCT) of patients with HHCDs is 
necessary (e.g., political considerations, resource limita-
tions, armed conflict). Although AE-HLCT has occurred 
since the 1970s, the 2013–2016 Ebola virus disease (EVD) 
outbreak in West Africa brought this practice to the fore-
front of public consciousness (1). During that outbreak, at 
least 33 patients with confirmed or suspected EVD were 
transported to EVD treatment facilities in the United States 
and Europe that were capable of high-level isolation. As-
ymptomatic persons with high-risk exposures (e.g., needle 
sticks, blood or body fluid splashes) have also been trans-
ported for quarantine. In 2016, two patients with Lassa fe-
ver were transported by AE-HLCT from Togo, 1 each to the 
United States and Germany (2). Despite the introduction of 
an EVD vaccine, the Democratic Republic of the Congo is 
experiencing the second largest EVD outbreak in history; 
in December 2018, a US citizen exposed to EVD was trans-
ported to the University of Nebraska Medical Center for 
observation before being discharged in January 2019 (3). 
Clearly, AE-HLCT is an ongoing need.
The death rate from certain HHCDs can exceed 70%, 
as was the case with EVD in parts of West Africa (4). Thus, 
streamlined policies and procedures for efficient, timely 
AE-HLCT can decrease transmission risk and optimize pa-
tient management in flight. Because of the significant risks 
to crews and receiving communities, HHCD patients must 
be managed by highly trained teams and organizations, es-
pecially considering the uncontrolled environment of AE-
HLCT missions and the potential for the rapid deterioration 
of patient condition. Historically, AE-HLCTs for HHCDs 
have been conducted by a limited number of military or-
ganizations or private corporations contracted by national 
governments or relief organizations to protect the well-
being of their citizens or their volunteer personnel. Pro-
viders of AE-HLCT maintain teams of highly trained staff 
and regularly test, validate, and exercise their systems and 
procedures to ensure mission readiness. Moreover, these 
experienced organizations have recently developed sys-
tems with the capability of transporting multiple patients of 
varying levels of acuity during the same operation, expand-
ing the capacity of AE-HLCT missions that historically had 
been limited to a single patient (5,6).
Isolation of HHCD patients during aeromedical evacu-
ation is a complex process with numerous requirements re-
lated to the preflight, in-flight, and postflight environments, 
involving highly knowledgeable and trained persons from a 
variety of professions, as well as specialized equipment and 
validated infection control processes (Table) (7). The safe 
and successful use of these AE-HLCT systems requires 
coordination and approval at all levels of government, as 
well as between governments, given that most AE-HLCT 
missions will cross international borders. Despite this com-
plexity, no generally accepted standards exist outside the 
few organizations that have conducted them. Moreover, 
the processes, operations, and capabilities used, as well 
as the lessons learned from postmission evaluations, are 
not found in the peer-reviewed literature. Only a few case 
studies have been publicly disseminated because of secu-
rity concerns, a desire to maintain proprietary information, 
or simply because of the niche field and limited audience. 
The literature is sparser still regarding the methods associ-
ated with the transportation of asymptomatic persons with 
high-risk exposures. Although we are aware that coopera-
tion between these organizations often occurs, the lack of 
literature disseminated to the larger academic and practice 
community remains a problem. Without knowledge of the 
1034 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 25, No. 5, May 2019
RESEARCH LETTERS
science that established these procedures or a broad con-
tinual review of such science, an inherent barrier persists 
for current or future researchers or practitioners attempting 
to build on ongoing research and experiences.
Finally, the limited amount of information about the 
processes, procedures, and equipment available from a 
small number of aeromedical organizations impedes scal-
ability should the need arise. Most of the organizations that 
have historically conducted AE-HLCT missions often have 
limited capacity, personnel, or systems to conduct multiple 
missions, with most only able to conduct 1 or 2 AE-HLCT 
missions simultaneously. The lack of nonorganizational 
specific standards and specialization diminishes the abil-
ity to transfer such capabilities to other organizations that 
might have the desire and personnel to assist or to nations 
that currently lack such capabilities but might have a cur-
rent or future need for such capabilities. A critical evalu-
ation of the literature would enable the dissemination of 
lessons learned, thereby enhancing best practices and 
driving the field forward, ultimately leading to safer out-
comes for patients, caregivers, and receiving communities. 
Because much of this information does not exist within 
peer-reviewed literature, much would be gained through a 
conference on the subject that evaluates various procedures 
and establishes consensus recommendations for best prac-
tices, including creation of a verified information exchange 
mechanism. The time is ripe for the development of stan-
dards and consensus guidelines involving AE-HLCT.
About the Author
Dr. Gibbs is executive associate dean and professor of 
environmental health at Indiana University School of Public 
Health–Bloomington. His research interests include industrial 
hygiene and environmental exposure assessment, focusing on 
environmental microbiology and disrupting transmission of 
highly infectious diseases.
References
  1. Lotz E, Raffin H. Aeromedical evacuation using an aircraft transit 
isolator of a patient with Lassa fever. Aviat Space Environ Med. 
2012;83:527–30. http://dx.doi.org/10.3357/ASEM.3094.2012
  2. Woodruff Health Sciences Center. Experimental antiviral combo + 
immunology [cited 2019 Jan 15]. http://news.emory.edu/ 
stories/2017/06/lassa_kraft_mcelroy
  3. Martinez G. American flown to Nebraska hospital after  
possible Ebola exposure in the Congo [cited 2019 Jan 15].  
http://time.com/5490412/ebola-doctor-nebraska-medical-center
  4. Uyeki TM, Mehta AK, Davey RT Jr, Liddell AM, Wolf T, Vetter P, 
et al.; Working Group of the U.S.–European Clinical Network on 
Clinical Management of Ebola Virus Disease Patients in the U.S. 
and Europe. Clinical management of Ebola virus disease in the 
United States and Europe. N Engl J Med. 2016;374:636–46.  
http://dx.doi.org/10.1056/NEJMoa1504874
  5. Wade S. Scott Airmen train on transport isolation system [cited 
2018 Apr 15]. http://www.af.mil/DesktopModules/ArticleCS/Print.
aspx?PortalId=1&ModuleId=850&Article=562739
  6. Phelps D. Ready for the challenge: Dobbins selected as home  
for new biocontainment system [cited 2018 Nov 8].  
https://www.thefreelibrary.com/Ready+for+the+challenge%3A+ 
Dobbins+selected+as+home+for+new+...-a0435001746
  7. Thoms WET, Wilson WT, Grimm K, Conger NG, Gonzales CG, 
DeDecker L, et al. Long-range transportation of Ebola-exposed  
patients: an evidence-based protocol. American Journal of  
Infectious Diseases and Microbiology. 2015;2(6A):19–24.
Address for correspondence: Jocelyn J. Herstein, College of  
Public Health, University of Nebraska Medical Center, 984388  
Nebraska Medical Center, Omaha, NE 68198, USA; email:  
jocelyn.herstein@unmc.edu
 
Table. Processes to be considered during an aeromedical 
evacuation high-level containment transport 
Environment, process to consider 
Preflight 
 Types of diseases 
 Decision to aeromedically evacuate 
 Training/drills 
 Regulations and legal limitation 
 Communication plan 
 Layout/space assessment 
 Other preparations 
In-flight 
 Personnel 
 Personal protective equipment 
 Type of isolation units 
 Procedures/capabilities inflight 
 Liquid and solid waste handling 
 Death in flight 
 Other contingency procedures 
Postflight 
 Decontamination 
 Equipment reuse 
 Waste disposal 
 Personnel monitoring 
 
Corrections
Vol. 24, No. 10
A grant number was listed incorrectly in Human Pegivirus in Patients with Encephalitis of Unclear Etiology, Poland  
(I. Bukowska-Ośko et al.). The Polish National Science Center grant number should be 2017/25/B/NZ6/01463. The 
article has been corrected online (https://wwwnc.cdc.gov/eid/article/24/10/18-0161_article).
Vol. 25, No. 2
The number of cases of West Nile neuroinvasive disease was listed incorrectly in the abstract of Acute and Delayed 
Deaths after West Nile Virus Infection, Texas, USA, 2002–2012 (D.C.E. Philpott et al.). The article has been corrected 
online (https://wwwnc.cdc.gov/eid/article/25/2/18-1250_article).


Need for Aeromedical
Evacuation High-Level
Containment Transport Guidelines

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