CDC Issues Flu Guidance for Flights

Interim Guidance for Airlines Regarding Flight Crews Arriving from Domestic and International Areas Affected by Swine Influenza

By Antonio Percy

April 27, 2009, The swine influenza A (H1N1) virus that has infected humans in the United States, Mexico and elsewhere is a novel influenza A virus that has not previously caused illness in people. Not all details are known at this time, but CDC and HHS are currently investigating and taking appropriate actions to ensure the protection of port-based staff who may encounter ill individuals. Symptoms of swine flu are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have also reported diarrhea and vomiting associated with swine flu. On-going human-to-human transmission is occurring with confirmed cases identified in several states and counties.

Recommendations in this guidance document are based on standard infection control and industrial hygiene practices and should be implemented immediately to protect workers and to delay the spread of this newly emerged influenza virus via airline travel. All airline personnel should follow the practices and instructions described below to prevent spreading infectious disease and becoming ill.

Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol based hands cleaners are also effective. Avoid touching your eyes, nose or mouth because germs spread that way. Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. If you get sick, CDC recommends that you stay home from work and limit contact with others to keep from infecting them.

Swine influenza is likely to spread from person-to-person in the same way as seasonal flu. The main way that influenza is thought to spread is through the coughing or sneezing of people infected with the influenza virus. People may also become infected by touching something with flu viruses on it and then touching their mouth or nose.

Crew members should wear impermeable, disposable gloves onboard aircraft if they need to have direct contact with potentially contaminated surfaces such as airplane seats, tray tables, and lavatories used by ill passengers. They should avoid touching their face with gloved or unwashed hands. Improper use of gloves may actually increase transmission.

People with symptoms of swine influenza should not fly. If symptoms of swine influenza 2 develop during flight, the ill person should wear a surgical mask to reduce the number of droplets coughed or sneezed into the air. Likewise, crew assisting that person should wear a facemask at a minimum, but ideally use a respirator rated N-95 or higher. The optimal use of respirators requires fit testing. Proper use is recommended to maximize effectiveness. The use of facemasks may be considered as an alternative to respirators, although they might not be as effective as respirators. While facemasks provide barrier protection against droplet and contact transmission of the virus, they do not protect against inhalation of very small airborne particles

Disposable facemasks and respirators should not be reused; once removed they should be discarded. It may be difficult for some workers in certain situations, such as cabin crewmembers on lengthy flights, to wear respirators for extended periods of time and during physically heavy work loads.

During an influenza outbreak or pandemic, if a cabin or flight deck crew member or passenger is displaying signs and symptoms of an influenza-like illness prior to flight, they should not board the aircraft. If passengers or crew develop symptoms en route, they should cover their nose and mouth when coughing or sneezing, use tissues to contain respiratory secretions, dispose of used tissues in the nearest waste receptacle after use, and wear a facemask if tolerated. Hands should be washed after contact with respiratory secretions or contaminated objects or materials. If a pilot becomes ill with the symptoms of swine flu, all persons in the cockpit should wear masks.

As the guidelines for swine influenza are being developed and new information is gained, more detailed guidelines will be published to the CDC website. In the event of a widespread outbreak or pandemic, social distancing will play the primary role in preventing exposure of persons to the virus (www.pandemicflu.gov).

For additional updated information about this swine influenza outbreak, consult the CDC swine influenza web page (www.cdc.gov/swineflu/).

Manangement of Passengers or Crew Members with Symptoms of Influenza

• Cabin and flight deck crew should be aware of the possible symptoms of swine influenza including fever, cough, sore throat, body aches, headache, chills, fatigue, and in some cases, diarrhea and vomiting. Visit CDC’s website about swine flu (http://www.cdc.gov/swineflu/key_facts.htm).

• Minimize the number of personnel directly exposed to the ill person.

• Separate the ill person (6 feet) from others as much as possible without compromising flight safety.

• Have the ill person wear a facemask, if it can be tolerated, to reduce the number of droplets coughed or sneezed into the air.

• If a facemask can not be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing along with a plastic bag for proper disposal of contaminated tissues.

• Gloves are not intended to replace proper hand hygiene. Gloves should be carefully removed and discarded and hands should be cleaned immediately following activities involving contact with body fluids. Gloves should not be washed or reused.

• Personnel having close contact with an ill person should wear a facemask at a minimum or, ideally, a NIOSH-certified particulate respirator rated N-95 or better.

• Dispose of soiled material, gloves, items contaminated with body fluids, and disposable respirators in a sturdy plastic bag that is tied shut and not reopened, and disposed of according to state solid waste regulations.

• Personnel should wash hands for 20 seconds with soap and warm water before tending to the ill person, and after removing gloves and mask, touching commonly touched surfaces, contacting respiratory secretions or tending to the sick person.

  • Use waterless, alcohol-based hand gels when soap is not available and hands are not visibly soiled.

• If a person shows observable signs of swine flu illness while on a flight bound for the US, the captain is required by law to report the illness to the nearest U.S. Quarantine Station prior to arrival or as soon as illness is noted (see http://www.cdc.gov/ncidod/dq/quarantine_stations.htm). Quarantine officials will arrange for appropriate medical assistance to be available when the airplane lands and will notify state and local health departments and the appropriate CDC officials. Quarantine officials will work with the airline and local and state health departments to assist with medical transportation of the patient upon arrival, disease control and containment measures, passenger and crew notification and surveillance activities, and airline disinfection procedures.

• If a person on an international or domestic flight is ill with what is believed is to be swine flu illness, crew members should immediately contact the nearest U.S. Quarantine Station (http://www.cdc.gov/ncidod/dq/quarantine_stations.htm) and Emergency Medical Services (EMS) at the destination airport. Quarantine station staff will assist with the situation.

• The flight deck crew should ensure that the aircraft air conditioning / ventilation system stay on until all passengers and crew have disembarked in order to maximize continued removal of virus particles from the cabin air.

Management of Crew Exposure After Flight Completed

Flight deck and cabin crew members and ground personnel who may have been exposed to a passenger or worker suspected of having influenza should monitor their health for 7 days after the exposure. If they become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea they should immediately take the following steps:

• Stay home except to seek medical care; do not report to work.

• Notify their employer.

• Contact their occupational health service or personal physician.

• Inform the occupational health service, clinic, or emergency room before visiting about the possible exposure to influenza.

• Do not travel, unless it is critical to travel locally for health care.

• Limit contact with others as much as possible.

• When not alone or in a public place, wear a facemask to reduce the number of droplets coughed or sneezed into the air.

• If traveling away from home, notify their employer and request assistance in locating a health care provider.

• If illness onset occurs while outside the United States, the airline’s medical consultants or overseas medical assistance companies should be contacted to assist finding an appropriate medical provider in that country.

For More Information

Interim Guidance for Airline Flight Crews and Persons Meeting Passengers Arriving from Areas With Avian Influenza http://wwwn.cdc.gov/travel/contentAvianFluArrivingFromAreas.aspx

Travel Industry Pandemic Influenza Planning Checklist http://www.pandemicflu.gov/plan/workplaceplanning/travelchecklist.html