Approximately 1 billion people travel by commercial aircraft every year and this is expected to increase to 2 billion people within 20 years. The opportunities to acquire a communicable disease or be subjected to unwanted chemical contamination not only includes the point of origin but also the potential contaminants found in buses, trains, taxis, and public waiting areas before boarding the plane. Within the plane are the concerns of potentially contaminated indoor air, close proximity to other passengers who may have subclinical cases of a disease or be clinically sick, lack of hand washing after using toilet facilities, or remnants of disinfectants and insecticides which may have been used in or on the plane. There is a concern with the transmission of: tuberculosis from person to person by airborne respiratory droplet nuclei; meningococcal disease caused by Neisseria meningitidis transmitted by direct contact with respiratory droplets and secretions, which may be quickly fatal; measles; influenza; and other upper respiratory or oral-fecal route diseases. (See endnote 1.)

The 2003 SARS (severe acute respiratory syndrome) outbreak started in China and spread to 25 countries and Taiwan, principally along air transport routes. This phenomenon is not new since the pandemic of bubonic plague in the 14th century followed the trade routes across the Mediterranean Sea. SARS is a viral respiratory disease caused by a recently discovered coronavirus which results in flu-like symptoms and commonly leads to pneumonia. (See endnote 4.)

In March and April 2003, a new swine-originated 2009 H1N1 influenza A virus was spreading rapidly through the United States and Mexico and a total of 30 countries worldwide. It was the first pandemic of the 21st century and was extremely fast moving because of a rapid rate of globalization through sharply increased travel and trade, leading to very large outbreaks of the disease which causes severe illness and may cause death especially in the very young, the very old, immune-suppressed people, and those who are debilitated. The disease originally is transmitted from animals or birds to people and then transmitted from person to person by aerosols which contain the virus or by direct contact with the saliva, nasal secretions, and feces of sick individuals. (See endnote 5.)

These two examples of outbreaks of communicable diseases spreading along trade and travel routes, obviously including airlines, are but a foretaste of the potential for the spread of disease which has been an unwanted consequence of globalization. It has always been this way and always will be this way.

Other health problems may not be environmentally related but will still reduce an individual’s resistance and may increase the ability to be affected by communicable diseases or chemicals found in the environment. These conditions may include fatigue from walking long distances, carrying baggage, airline delays, noise, vibration on the plane, cramped sitting spaces, inability to exercise muscles, and frustration; low cabin humidity resulting in dehydration; exacerbation of various chronic diseases especially those of a respiratory nature; barotrauma which occurs when the pressure in the middle ear, sinuses, or abdomen is not the same as the air pressure in the aircraft cabin and may cause pain and potentially allergic reactions for individuals who have allergies; deep venous thrombosis (blood clots) due to long-term immobility of the lower limbs; decompression sickness (bends) for scuba divers especially when returning from the sport location; peanut allergies; use of alcohol which can contribute to severe dehydration; motion sickness; eye diseases which can be exacerbated by changes in cabin pressure and the dry cabin air; mental health conditions which can be exacerbated by numerous changes brought on by air flight; heart disease which may be exacerbated by changes in air pressure and increased heart rate; diabetes which can be exacerbated by the long flights and missing necessary meals; and surgical conditions where anesthesia had been used recently. (See endnote 2.)

Best Practices for Preventing Spread of Communicable Disease or Exacerbation of Existing

Chronic Conditions in the Use of Airline Transportation (See endnotes 6, 7)

  • • Advise the Division of Global Migration and Quarantine, part of the Centers for Disease Control and Prevention (CDC) National Center for Emerging and Zoonotic Infectious Diseases in Atlanta, of any actual or potential outbreaks of communicable disease including those which are quarantinable: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, SARS, and viral hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet identified). (See endnote 9.)
  • • Utilize the quarantine stations supervised by the CDC as needed to help prevent and control outbreaks of communicable diseases at the ports of entry in Anchorage, Atlanta, Boston, Chicago, Dallas, Detroit, El Paso, Honolulu, Houston, Los Angeles, Miami, Minneapolis, New York, Newark, Philadelphia, San Diego, San Francisco, San Juan, Seattle, and Washington, DC. (See endnote 10.)
  • • Evaluate all sources of information including the media and electronic reports to determine if an outbreak of disease is occurring or likely to occur and report this to the CDC.
  • • If there is an existing clinical disease outbreak in a specific country or region, provide immediate active surveillance of all individuals, those who are flying, and people in all of the support services which are involved in processing materials or people for the flights throughout the airports. Active surveillance may include taking the temperatures of the individuals and other procedures outlined by the appropriate medical staff. In the case of an active surveillance program, all of the workers need to wear appropriate personal protective equipment. (See endnote 6.)
  • • Establish a disease-specific response including appropriate epidemiological and medical screening techniques for all individuals having symptoms of communicable diseases or having traveled from an area of severe outbreaks of communicable diseases to prevent a major public health problem and contain the spread of the microorganisms to others. This means that there has to be a constant flow of information from areas of potential or actual outbreaks of disease to all other areas of the world. Medical and epidemiological investigation must be done immediately and extremely thoroughly and the results broadcasted to all appropriate world entities as rapidly as possible, especially to the airports since this mode of travel can result in immediate contamination of areas and people by healthy and sick carriers of the disease. Disease alerts should be issued by all forms of media and electronic devices to all potential passengers and airline workers.
  • • Follow the Airports Council International document “Airport Preparedness Guidelines for Outbreaks of Communicable Disease.” (See endnote 7.) This guideline involves the following: communications especially with the public; screening processes; transportation of infected people to health facilities; equipment which should be used for the prevention and control of disease; entry and exit procedures for all aircrafts, especially the one which is affected, personnel and passengers; and coordination with all local, state, national, and international public health agencies.
  • • Travelers from areas of known outbreaks of disease such as Ebola should not be permitted to board an aircraft if potentially exposed to the disease and showing symptoms. The individual should undergo medical evaluation prior to departure to determine when it is safe for him/her to travel on a commercial carrier if he/she is asymptomatic and is in a low but not necessarily zero risk category. The individual should still be monitored actively for 21 days. Individuals in the no identifiable risk category do not have to be monitored or have travel restrictions. (See endnote 8.)
  • • When traveling abroad, obtain all appropriate vaccinations prior to leaving and carry the vaccination certificates which may be required by some countries.
  • • Have a physician determine if anti-malarial drugs should be taken prior to the flight to help prevent the spread of this disease. A special concern is that some of the drugs may have a profound effect upon pregnancy and therefore should not be used.
  • • People with uncontrolled or frequent seizures should avoid traveling on airlines.
  • • People who have had a recent stroke or TIA (transient ischemic attack) should not be flying until the acute phase has passed and a physician has cleared the individual.
  • • Persons with recent surgery, especially if it relates to the spine and back, should be cleared by their physicians before they fly.
  • • Individuals with heart disease should be cleared by their physician and carry with them all medications, a copy of their most recent electrocardiogram, a pacemaker card if applicable, and limit walking by requesting wheelchair assistance. They should also request a special diet and medical oxygen if necessary.
  • • Patients with ear, nose, and throat problems should not fly until the conditions are cleared up unless absolutely necessary and then carry proper medications.
  • • Passengers with existing chronic conditions which may worsen during flight should receive a medical evaluation prior to departure.
  • • Individuals requiring special meals because of diabetes, other conditions, or for religious purposes should contact the airlines prior to departure.
  • • Request wheelchair assistance or trolley service within the airport if needed to reduce levels of fatigue.
  • • If an individual requires oxygen, determine in advance if the airline provides it in flight and if so make a request for this service. The individual will not be able to bring his/her own oxygen aboard the plane.
  • • Wash hands thoroughly with soap and water or use an alcohol-based disinfectant after touching surfaces, after using toilet facilities, and before eating or drinking.
  • • Exercise legs, walk around the cabin periodically to avoid blood clots forming in the legs, and make sure that the individual is well hydrated. Keep seatbelts fastened continuously while seated especially if pregnant and make sure that the belt is snug over the pelvis or upper thighs to prevent injury to the abdomen.
  • • If the individual has been scuba diving, in order to reduce the risk of severe joint or muscle pain and even a stroke or collapse of the cardiovascular system, avoid flying for at least 12-24 hours after the last scuba dive.
  • • Worldwide but not in the United States, the World Health Organization recommends that the cabin of an aircraft be sprayed with an aerosol, usually pyrethroids, to kill insects that may carry disease and have been transferred from the point of origin to the destination in the aircraft.
  • • For individuals with peanut allergies, do not consume them aboard the aircraft and ask for a seat in the peanut-free area.
  • • Individuals with asthma or emphysema should consider not flying unless absolutely necessary and if necessary carry on board all asthma medications. These individuals should be especially well hydrated during the flight and avoid caffeine and alcohol.
  • • Individuals with diabetes should carry all medications as well as needles, syringes, blood glucose monitors, snacks etc., in carry-on luggage and not in checked luggage. For security reasons have a note from the physician that these are necessary. Be careful to eat all meals especially prepared by the airlines to help control blood sugar levels.
  • • Use alcohol with great care since it will cause dehydration and may interfere with sleep.
  • • Avoid motion sickness by taking appropriate medication determined by a physician prior to travel, flying in large airplanes, sitting in a window seat and looking at the horizon, having cool air focused on the face, and avoiding alcohol.
  • • Avoid flying for at least 72 hours after a cast is put on a body part because of a fracture to prevent excess swelling and pain.
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