It was no surprise to anyone who travels by plane – that air travel was a culprit in the fast spread of H1N1 globally.
Commercial air travel is often characterized by the movement of large numbers of people in closed and semi-closed settings. As with other close contact environments, these settings can facilitate the transmission of influenza from person to person or through contact with contaminated environmental surfaces. CDC recommends that efforts to reduce the spread of influenza on commercial aircraft focus on encouraging air carrier employees and passengers who have an influenza-like illness (ILI) not to travel.
The new guidance provides guidance for the management of ILI during and after a flight, including personal protective measures for the crew, and is meant to supplement CDC’s recent guidance for employers on ways to decrease the spread of seasonal and 2009 H1N1 influenza in the workplace. See CDC’s Guidance for Businesses and Employers to Plan and Respond to the 2009-10 Influenza Season, which is available at http://www.cdc.gov/h1n1flu/business/guidance/.
Management of Passengers and Crew Members with ILI Influenza-Like Illness (ILI)
Symptoms of influenza can include some or all of these symptoms: fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, tiredness, diarrhea, or vomiting. Not everyone with influenza will have a fever (a temperature of 100° F [37.8° C] or greater). Flight crew should consider someone to have a fever if the ill person feels warm to the touch, gives a history of feeling feverish, or has an actual measured temperature of 100°F (37.8°C) or greater. Because the symptoms of influenza are not specific and most persons who have a respiratory illness are not tested for influenza, an ILI has been defined as an illness with fever or feverishness plus either cough or sore throat.
Passengers or Crew with ILI before a Flight
If a cabin or flight deck crew member or a passenger has an ILI prior to a flight, CDC recommends that he or she not board the aircraft until at least 24 hours after fever has resolved without the use of fever-reducing medications. Airline crew should also follow individual company policy if ILI develops prior to a flight. More information for travelers is available at http://www.flu.gov/individualfamily/travelers/index.html.
Development of ILI in Passengers or Crew during a Flight
Crew members should take the following actions if a person develops ILI during a flight:
- Minimize the number of persons directly exposed to the ill person and if possible separate the ill person from others by 6 feet without compromising flight safety
- Keep interactions with the ill person as brief as possible
- If a face mask cannot be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing
- Provide a plastic bag for proper disposal of used tissues
- Practice good hand hygiene and encourage others, including the ill person, to do the same
- Hands should be washed with soap and water especially after coughing or sneezing, after using the restroom, or after touching potentially contaminated surfaces or items. If soap and water are not available, an alcohol-based hand rub can be used
- Dispose of soiled material, such as items contaminated with body fluids and used personal protective equipment, in a sturdy plastic bag that is tied shut and not reopened, according to state solid waste regulations
- Report to CDC, on a voluntary basis, persons with ILI on international flights bound for the United States who require medical assistance. The need for medical assistance can be based on consultation with the airline in-flight medical consultant or per the ill person’s request
- Notify the CDC Quarantine Station (http://www.cdc.gov/ncidod/dq/quarantine_stations.htm) at or closest to the airport where you are arriving of the ill person prior to arrival or as soon as illness is noted. If unable to reach the Quarantine Station, call 866-694-4867 to speak with the Quarantine Duty Officer covering that airport
- If possible, continue operating the aircraft air conditioning or ventilation system until all passengers and crew have disembarked to maximize air circulation in the cabin and thus the filtering of virus particles. Safety concerns may preclude this step on some aircrafts.
If the ill person is a crew member, CDC recommends, in addition to the actions listed above, that the ill crew member
- Follow individual company policy for onset of illness or incapacitation during flight operations
- Discontinue work as soon as possible without impacting flight safety, and
- Return to work after fever has resolved for at least 24 hours without the use of fever-reducing medications.
Quarantine officials will work with the airline and airport partners to assist with arrangements for medical transportation of the ill person, if indicated, and will implement any necessary infection control measures and surveillance activities.
Personal Protective Measures
Routine hand hygiene is an important line of defense against the influenza virus, as well as other viruses and bacteria. Wash hands with soap and water for 15-20 seconds. If soap and water are not available, use an alcohol-based hand rub. Hands should always be washed before donning and after removing gloves and other personal protective items.
Crew members should wear impermeable, disposable gloves if they are physically tending to the ill passenger or have contact with potentially contaminated surfaces or lavatories. Crew members should avoid touching their faces with gloved or unwashed hands. Hands should be washed with soap and water or with a hand rub after removing gloves. Improper use or disposal of gloves may actually increase transmission.
Face Masks and Respirators
Routine use of face masks and N95 respirators is not recommended for airline crew members (see CDC’s Interim Recommendations for Face Mask and Respirator Use to Reduce 2009 Influenza A (H1N1) Virus Transmission at http://www.cdc.gov/h1n1flu/masks.htm). Crew members should consult company policies for the voluntary use of a face mask or N95 respirator.
Employers that allow workers to voluntarily use an N95 respirator should review the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard (29 CFR 1910.134). Information for the voluntary use of respirators in the workplace may be found in Appendix D, Information for Employees Using Respirators When Not Required Under the Standard, available at:
Post-Flight Management of Crew Exposure
Flight deck and cabin crew members and ground personnel who may have been exposed to a passenger or worker with ILI should monitor their health for 7 days after the exposure. Any of the following signs or symptoms should be reported per employer guidance: fever, cough, sore throat, runny or stuffy nose, body aches, tiredness, nausea, vomiting, or diarrhea. CDC recommends that flight deck and cabin crew members who develop ILI should remain isolated at home or in a hotel and should not travel until at least 24 hours after they are free of fever (a temperature of 100° F [37.8° C] or greater) without the use of fever-reducing medications. Flight deck and cabin crew members who develop symptoms while outside the United States should follow their airline’s policy to obtain medical care overseas, if required.
Personnel at increased risk for severe complications of influenza, such as persons who are pregnant or have chronic health conditions like asthma or heart disease, should consult their primary-care or occupational health providers. Guidance for people at high risk of developing flu-related complications may be found at http://www.cdc.gov/h1n1flu/highrisk.htm.