The Massachucetts Institute of Technology study points to New York, Los Angeles and Honolulu as the three top airports as the most likely places to spread an infectious diseases in the early days of a pandemic.

"It can come out of nowhere, and can occur quickly and affect lots of people," said Toby Clairmont, Hawaii Healthcare Association Emergency Services Director

The first two airports on the list are the largest and busiest in the country.

Location, layover times, and connectivity push Hawaii up on the list.

The days of swine flu and SARS forced the world to take stock of how well we could respond to a deadly outbreak.

"SARS was a wake-up call. It was lethal. It killed people. It certainly got everyone's attention." said Clairmont.

Four years ago a joint drill with the Centers for Disease Control, state civil defense and Hawaii’s hospitals tested our response.

"We talked about an airline coming into Honolulu with an infected casualty. We set up a clinic down at the airport and transported some of the patients to the hospitals. I think we demonstrated in concept that everything works," said Clairmont.

Last year’s gathering of world leaders for an economic conference helped the state.

The recent military war games and disaster drills were good practice for the state's first responders and hospitals.