GUIDELINES PROVIDED BY AVIATION REGULATORY AGENCIES AND ORGANIZATIONS DURING THE H1N1 AND COVID-19 OUTBREAKS: A COMPARATIVE ANALISYS

Aviation has emerged as an additional and quicker vector for infectious diseases. Therefore, preparedness plans are put together to assist the public health and aviation sectors in a pandemic. This paper went through these preparedness plans, as well as the guidelines issued during two events, the H1N1 and COVID-19 pandemics, so to study, understand, assess and compare them. The method used was a thorough theoretical review supported by specific research questions, which are the basis for the analysis and discussion. The examination reveals consistent data which can work as a basis for measures of precaution and/ or mitigation of diseases.

regarding financial instability, lack of revenue and other expenses amidst a pandemic. In light of the current pandemic situation caused by the novel coronavirus, the world's economy has been plummeting and many countries are faced with serious economic recession scenarios. Like many other fields, the aviation industry is highly sensitive to economic downturns. Therefore, there also needs to exist some sort of economic guideline and recommendation for airlines and airports to follow in order to stave off as much as possible any utterly severe financial condition. In pandemic times, governments may very well impede the entry of foreign citizens and reduce the daily number of domestic flights, directly affecting the revenues of airports and airlines.
In the last 11 years, the world has seen two major pandemics caused by viruses: the H1N1 outbreak in 2009 and 2010 and the ongoing outbreak of COVID-19 in 2020.
Pandemics have long been a part of humanity, and thus international health and aviation organizations as well as national agencies have to be able to learn from past experiences, build clear preparedness plans and also issue guidelines for the aviation industry to follow. As delicate as pandemic situations are, these preparedness plans and guidelines must be in accordance with each situation and must instruct airports and airlines with the best, most suitable courses of actions.

As the American journalist Derek Thompson stated in a recently published article on
The Atlantic magazine, because the pandemic pauses the present, it forces us to live in the future (THOMPSON, 2020). For many, aviation is facing the worst crisis in history. The current drop in air travel is shockingly bigger than the ones after the terrorist attacks on September 11th, 2001 and during the Great Recession in 2008(ISIDORE, 2020. What happens now will directly affect the future of thousands of employers and employees in the aviation sector. As ruthless as pandemics are, they force us to ponder and warily assess how prepared the aviation industry actually was, what we could do to improve joint public health and aviation measures and to project ways to buoy the economy once again.
RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies Hence, this article aims to assess these guidelines and recommendations as they are so paramount to guide the airport industry in the right direction with the proper and correct procedures to be taken. Accordingly, the H1N1 and COVID-19 pandemics have been chosen as they provide a clear opportunity for reviewing the preparedness of States and organizations within the aviation sector upon impending outbreaks of communicable diseases, as well as to inspect what has changed guideline and preparedness-wise in a decade marked by the end of one pandemic and the start of a brand new and deadlier one. The article is intended to study, assess and compare the guidelines, measures and recommendations provided by regulatory agencies, organizations and associations to airport operators and airlines regarding economic issues and sanitary measures amidst the outbreaks of H1N1 in 2009/2010 and COVID-19 in 2020.
Therefore, the guidelines covered were the ones provided by international organizations and associations, such as the WHO and ICAO. Likewise, this paper aimed to conduct a specific analysis of the procedures suggested and/or demanded by Brazilian regulatory agencies.
This study targets the following: a) to provide an outline of the H1N1 and COVID-19 pandemics through a chronological list of the most impactful events on aviation b) to analyze the guidelines provided by the regulatory agencies and associations to airports and airlines amid the H1N1 pandemic with respect to economic actions and strategies; c) to study the sanitary and health-related actions and procedures to be taken by airports and airlines during the outbreak of H1N1; d) to carry out a historical retrospective of the period marked by the end of the H1N1 pandemic and the beginning of the COVID-19 pandemic in order to offer an overall RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies account for possible precautionary measures that could be used in an attempt to mitigate contamination. e) to assess the guidelines provided by the regulatory agencies and associations to airports and airlines during the COVID-19 pandemic regarding the recommendations on how to face an unprecedented economic debacle; f) to address the sanitary and health-related actions and procedures to be taken by airports and airlines during the outbreak of COVID-19; and g) to project the preparedness of the sectors studied for future outbreaks of infectious diseases.
In order to accomplish it, we chose to use a theoretical qualitative method of analysis. Firstly, we present a literature review of the biological aspects of both viruses, as well as travelling as a vector, enriched with the reading of as many online guidelines as possible so that the discussion could be made following a clear view of the preparedness and guidance scenario. These guidelines were then analyzed within the framework of four research questions, presented in the methodology section, namely: (1) how prepared were the agencies and organizations to face a pandemic?; (2) what were their recommendations?; (3) how did Brazilian national agencies act upon them?; and (4) what has been learned and/or improved in order to face future pandemics?. The answers to the questions are expected to provide fruitful ideas to the discussion, grasping a perspective of how prepared the aviation and public health sectors were prior to both pandemics, what has been learned since and how prepared they are now for impending outbreaks in the future, as they still strive to go through the deadly and ongoing COVID-19 pandemic.  SUBBARAO, 2000). An Influenza A virus is made up of two envelope glycoproteins: viral haemagglutinin (HA) and neuraminidase (NA), which are considered antigens by human immune systems. These two proteins are used to subtype Influenza A viruses into 18 HA and 11 NA, as of May 2020 (TONG et al., 2013). Aquatic birds are the main reservoir for influenza subtype viruses, although some subtypes have become established in other species, such as H1 and H3 in pigs, H3 and H7 in horses, equine H3 subtype in dogs (PEIRIS et al., 2009) and, more recently, H18 in Peruvian bats (TONG et al., 2013). It is believed that influenza pandemics happen when a novel avian influenza HA and/or NA is picked up through reassortment by human influenza virus that already existed, or by human-adapted entirely avian virus. Since pigs are susceptible to infection by avian and human virus strains and many reassortments have been isolated from pigs, they have been proposed as an intermediate host (TAUBENBERGER et al., 2006). H1N1, also referred to as swine flu, is an upper respiratory tract disease and may cause inflammation of the upper respiratory passages and trachea, in addition to the lower respiratory tract, with an incubation period ranging from 1 to 4 days, averaging 2 days in most individuals. However, it could be up to 7 days in some individuals. The RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies contagious period for adults is comprehended between the day prior to the symptoms appearance to as long as 7 days after the symptoms onset. Children and individuals with weakened immune systems may be susceptible to longer contagious periods (JILANI; JAMIL; SIDDIQUI, 2019).

SARS-CoV-2
Little over 10 years after the first H1N1 confirmed cases began to show up, the WHO became aware of a cluster of pneumonia cases in Wuhan, Hubei Province, China.
Shortly after, it was revealed that a new type of coronavirus was being responsible for human-to-human transmissions, which was termed 2019-nCoV (WHO, 2020a).
On February 11th, 2020, the WHO gave it a taxonomic designation "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), which became the official means to refer to this virus strain (BAIG, 2020). Later on that same day, the WHO officially renamed the disease as COVID-19, which stands for coronavirus disease.
Coronaviruses are a large group of enveloped, positive single-strained large RNA viruses that not only affect humans, but also a wide variety of animals (VELAVAN; MEYER, 2020). The protein spikes on the envelope give it the appearance of a crown; and crown, in Latin, is called corona. There are several types of coronaviruses that cause respiratory and sometimes even gastrointestinal symptoms.
However, there are some types of coronaviruses that can cause severe diseases, such as the SARS-CoV (Severe Acute Respiratory Syndrome coronavirus), first identified in China in 2002, and the MERS (Middle East Respiratory Syndrome), first identified in Saudia Arabia in 2012. There are four subfamilies, namely alpha-, beta-, gamma-and delta-coronaviruses, of which alpha-and beta-coronaviruses apparently originate from mammals, mainly bats, whilst gamma-and delta-viruses seem to originate from pigs and birds (VELAVAN; MEYER, 2020). For example, the MERS coronavirus is known to be transmitted from camels, whereas the SARS-CoV from civet cats (WHO AFRICA, 2020; PAHO, 2020). The beta-coronaviruses are known to be the most threatening among the seven subtypes of coronaviruses, leading to severe disease and fatalities. The SARS-CoV-2 virus belongs to the B lineage of RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies beta-coronaviruses and it has already been linked initially to a single local fish and wild animal market in Wuhan, although it is not confirmed yet (LAU et al., 2020;WHO, 2020b). It is, ipso facto, closely related to two bat-derived SARS-like coronaviruses, namely bat-SL-CoVZC45 and bat-SL-CoVZXC21 (88-89% similarity), but only 79% similar to the SARS-CoV virus responsible for the SARS outbreak in 2002(LAU et al., 2020, as there are key features that distinguish the two (GAO et al., 2020).
In line with a World Health Organization (WHO) report, 2019-nCoV is an unparalleled virus that causes respiratory disease. Transmission occurs via oral and nasal droplets -healthy people are also at risk of getting infected since the virus is able to float in the air in the form of aerosols (KOLIFARHOOD et al., 2020). The average incubation period was reported as 5 to 6 days, varying from 2 to 14 days.
COVID-19 and influenza diseases are quite similar in a sense of presentation, as they both cause respiratory complications. They both present a wide range of illness that goes from asymptomatic cases, through mild ones, and, in more severe cases, it can lead to death. In addition, both viruses can be transmitted by means of contact, droplets and fomites. Hence, essentially the same public health measures may be taken or at most adapted in order to prevent infection, such as hand hygiene.
Notwithstanding the similarities, there are plenty differences as well. The number of secondary infections spawned from one infected individual seems to be between 2 and 2.5 for COVID-19 virus, higher than for influenza. However, comparison between the two viruses and the respective diseases should be coupled with the knowledge that they are very circumstance and time-specific (WHO, 2020b).
For COVID-19, data to date, as of March 17th, 2020, indicate that 80% of infections are mild or asymptomatic; 15% are severe infection, requiring oxygen; and 5% are critical infections, requiring ventilation. These percentages of severe and critical infection would be greater than what is observed for influenza infection. Individuals prone to severe influenza differ from COVID-19the latter seems to be more harmful to older people and to individuals with comorbidities, when the former impairs

TRAVELLING AS A VECTOR
Travel is a powerful force in disease spread. Migration of humans has been the pathway for disseminating infectious diseases throughout recorded history (WILSON, 1995). Infectious diseases that began to affect indigenous populations in Africa, North and South America and the Pacific can be linked to the European colonization of these territories (INGOLD, 1994). Commercial and trade routes were absolutely key for the spread of the bubonic plague through Asia, Europe and the Mediterranean in the XIV Century (COSSAR, 1994;HELMS, 2018). Human mobility, travel and migration will invariably continue to shape the emergence, frequency, and spread of infections in geographic areas and populations. The current volume, speed, and reach of travel are unprecedented, though (WILSON, 1995). As previously featured in Helms (2018), aviation can be a vector in disease spread as it speeds up the process regarding how fast certain diseases reach different parts of the world. The necessity to travel to farther regions, more and more frequently has continuously boosted the aeronautical sector. Larger aircraft, more places been Travelling has also shown how fast pulmonary infections can be transmitted. Data suggest that the risk of transmission to an assymptomatic passenger inside an aircraft cabin can be associated to sitting within the distance of two rows from an infected passenger for longer than eight hours. This association is mainly derived

COVID-19 PANDEMIC
The core of this research is a historical retrospective made from the start of the Consequently, the enforcement of measures and procedures concerning air transport ultimately rests with national public authorities, airlines and airports. As published on ACI's airport preparedness guidelines for outbreaks of communicable disease, the responsibility for management of the risk of communicable diseases at airports rests primarily with the local/regional/national public health authority and the relevant airport operator (ACI, 2020).

THE COVID-19 PANDEMIC
Similar to the H1N1 study, as many guidelines and recommendations as possible were read concerning the COVID-19 pandemic. Special attention was given to any updates on these regulations or any change of epidemic response approaches. To better understand the events that have happened so far, a timeline for the COVID-19 pandemic was organized. It begins with the first reports of pneumonia cases of unknown cause in the Chinese city of Wuhan. Therefore, all events depicted took place in the timespan between December 31st, 2019 and February 1st, 2021. This timeline is shown below.

METHODOLOGY
This study is mainly based on the written guidelines, procedures and recommendations provided by the following regulatory agencies and organizations:   As the aviation sector was steadily growing since the IHR were first adopted in 1969, with its natural ups and downs, several outbreaks of various diseases helped to strengthen the preparedness of public health and aviation agents on how to deal with the international spread of such diseases. When the H1N1 pandemic came, they were preparedprepared with what had been learnt so far. There had already been other influenza pandemics in the past, which also helped the global community to take action against the H1N1 outbreak. The screening practice at airports had long been a known method of safety measure, as seen on the SARS outbreak in the beginning of this century. The efficacy of this method is arguable, though. In a study conducted on Narita International Airport, in Tokyo, during the H1N1 pandemic, as low as 22.2% among the confirmed cases had fever identified by the thermoscanner, attempt to halt international spread of influenza. An article published by the WHO says that the interventions to mitigate the spread of infectious diseases would have a potentially heftier impact if implemented as close as possible to the source of the epidemic threat (KHAN et al., 2013).
One thing to ponder before jumping to any conclusions when comparing the preparedness of the aviation sector for the H1N1 and COVID-19 pandemics is that the world has become way more technological during the past 10 years. In 2009, the world was already technology-dependent; nowadays, even more so. As the international organizations, government bodies, airlines and airports made themselves more and more present on the web, online guidelines, instruction packs and even webinars became more common therefrom.
During the 2010s, different parts of the world experienced several disease outbreaks, such as MERS, dengue, chikungunya, Ebola and Zika, just to name a few. From each and every one of these outbreaks, something useful was learnt aviation-wise.
Distinct ways of controlling the spread of a disease by reason of different viruses, preparedness plans previously put together, among other points contributed to a state of alertness to the new possible epidemic. However, when a merciless virus suddenly hits, it sets the world on action mode in a matter of weeks. There are two distinct moments when dealing with a pandemic threat: avoidance/preparedness and, then, action, for which there is a very fine line that separates them. Being 100% ready for a pandemic is somehow utopian, considering that there is no way of knowing which virus or bacteria will hit next.
The COVID-19 pandemic came up as a relentless one, spreading from China to the other continents very quickly. When the pandemic hit hard, airlines and airports started to have severe financial issues of their own, all of which amidst the stern sanitary protocols they were required to follow closely. When the world is faced with a deadly virus, government's travel restrictions and screening measures are put into effect. When dealing with a situation as global as a pandemic, and even though 193 RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies countries are ICAO Contracting States (ICAO, 2019), it is invariable that politics is going to be a part of the picture and thus hinder the optimal adherence to the settled action plans against international spread of a disease.
In short, there is not an exact technique or scale to measure the preparedness of an entire sector; however, it is conceivable to say that aviation and public health authorities were prepared with what had been learnt so far, with numerous preparedness plans hammered out and, as the outbreak evolved, adjustments were bound to be made. Dealing with a pandemic and its forthcoming effects is something that takes previous knowledge into consideration as well as clear-cut adjustments and improvements where they are needed.

WHAT WERE THEIR RECOMMENDATIONS?
Concerning the H1N1 pandemic, the WHO issued technical guidance and recommendations to the aviation sector, many of which were developed in cooperation with ICAO. In fact, throughout the pandemic, travel restrictions were not encouraged by the WHOsince the virus had already spread worldwide, the focus shifted to minimizing the impact of the virus rather than stopping its spread internationally. Those sorts of measures were validated by historical records of success on previous influenza pandemics, as well as the SARS outbreak in 2002-2003(WHO, 2009BOWEN;LAROE, 2006 As for the COVID-19 pandemic, several guidance packs had already been built from the experience of previous communicable disease outbreaks. Throughout this pandemic, numerous bulletins, guidelines, protocols and other sorts of instruction documents were issued. Based on the massive number of guidance documents available online, meticulous remarks on each one of them would make this article incredibly extensive; wherefore it is viable to say that the majority of these documents were issued intending to (1) provide the most accurate and updated information as possible, (2) endorse and promote global cooperation in order to halt the international spread of COVID-19 and (3) to avoid any unnecessary meddling on air travel. As the COVID-19 outbreak continues to unfold, updated guidance keeps being released, as well as plans for the sector's rebuilding following an implacable sanitary and economic crisis.

HOW DID BRAZILIAN NATIONAL AGENCIES ACT UPON THEM?
Respecting the H1N1 outbreak, in Brazil the Ministry of Health reaffirmed the WHO recommendation that there was no need for any travel restrictions whatsoever. The Ministry oriented travelers that were arriving from pandemic affected countries to seek medical assistance should they begin to have symptoms up to ten days after the arrival. In short, the National Civil Aviation Agency of Brazil (

AND/OR IMPROVED IN ORDER TO FACE FUTURE PANDEMICS?
COVID-19 has been a true test to the aviation and public health sectors on so many levels. On March 26 th , 2020, COVID-19 had already killed more people than H1N1 did in totalstaggering numbers that show how brutal a virus the world is dealing with. Even though it is a far-sighted move to project the sector's preparedness for a future pandemic, it is imperative to point out that the current coronavirus pandemic is far from over, meaning that adjustments regarding this outbreak are still bound to happen.
Financially speaking, pandemics can leave grim scars on the aviation field for years to come. Like terrorist attacks or economic crises, the best way to be financially prepared for a pandemic is to keep an austere economic policy and to have ways of safeguarding the company during troubling times. Amid a pandemic, government assistance and other sorts of agreements are feasible ways to battle the crisis, and are often urged by international organizations, such as ACI and IATA.
contribute to sharpen the cleanse of airplanes and airports.
One essential instrument that will be used in future pandemics is the online tools and portals that gather information and redirect the user to the proper websites. CAPSCA has been of great assistance, uniting in one page all sorts of useful documents and updates concerning any disease outbreaks that may affect the aviation sector.
As said before, there is no scale or technique that can measure the preparedness of the aviation and public health sectors for the next pandemic. Notwithstanding the uneasiness to be as prepared as possible, the guidelines and the various response plans are all there, sorted out and available to be followed. The world is not unprepared when it comes to assistance by means of guidance and protocols, although this is just part of the equationwhen a pandemic strikes, it is noticeable that the ultimate form of action rests with national governments and their agencies.
Therefore, there can be as many available guidelines as possible and there are still going to be several underdeveloped countries with alarming infrastructure problems that will not be completely able to adhere to them. Moreover, it should be said that notwithstanding the few resources some countries might have, the seriousness which the pandemic is dealt with is a critical and paramount factor. Being resourceful can be pointless if the disease outbreak is underestimated. The risk is serious, and the threat is real; therefore, a pandemic should not be downplayed whatsoever. Suffice to say that being ready for a pandemic is more than a matter of having guidelines and preparedness plans; it is a socioeconomic and geopolitical issue.

FINAL CONSIDERATIONS
This paper intended to carry out a historical retrospective of an entire decade, starting with the H1N1 outbreak and ending with the ongoing COVID-19 pandemic.
To this end, special attention was given to the existing preparedness plans that were arranged before, during and after those outbreaks. They are not entrenched documents, in that they are constantly being refined with the most accurate RC: 99838 Available in: https://www.nucleodoconhecimento.com.br/health/regulatory-agencies information possible. This article also meant to study the several guidelines and other guidance packs that are provided during these sanitary crises. Most of them are available online, which was helpful so as to find and read them. A positive point that ought to be made is that these guidelines are well-organized on the websitesthey are often easy to find. Some websites are better than others, with better arrangement and organization as well as an enhanced server. CAPSCA website was extremely helpful, redirecting to the pages of the various organizations involved in such a crisis.
The qualitative research was the best, most feasible way to evaluate what had been proposed as the subject of study. The analysis mainly consisted of a thorough reading of the documents available online, which were enough to ideate a viewpoint regarding the preparedness of both public health and aviation sectors for a pandemic.
However, it should be noted that, amongst the challenges faced in writing this article is the unavailability to read or access some resources, like specialized journals or articles. We are also aware that, ultimately, medicine and biology academics could speak with higher authority regarding the biological aspects of this research, although this facet was carefully read about.
Disease outbreaks can have a roiling effect in a society in a matter of weeks, if not days, and the aviation sector has got to acknowledge that it plays a fundamental part in preventing a certain communicable disease from becoming unbridled. Managing the international spread of a disease is an effort that should be spearheaded by international organizations and the countries' national agencies, in combination with not only the aviation sector representatives, but also other parts that may be involved