1. Air Travel & Infectious Disease Dr David Hagen Consultant in Communicable Disease Control UK Health Protection Agency JAA Advanced Aviation Medicine Course June 2011

2. Incorrect Public Perception of risk whilst flying Sick passenger = higher risk for other passengers  Little direct evidence of on-board transmission  Airport terminals – eating, drinking, socialising, toilet facilities  Previous outbreaks – passengers were on same holiday so acquired prior to flight  Public Health Authorities have propagated the myth  There are existing guidelines and plans

3. Methods of transmission 1) Direct Contact Touching Kissing Sexual Contact Body lesions Close contact: family, household, sexual

4. 1) Direct Contact Sexually Transmitted Diseases  Crew?

5. 2) Indirect Transmission Contaminated surfaces Viruses particularly, can survive for long periods Washrooms, handles, surfaces, handrails Influenza

6. 2) Indirect Transmission Petri Dish after a sneeze

7. 3) Droplet Transmission Large Particles Sneezing Coughing Talking

8. 4) Airborne Transmission Rarer than you think Coughing Dry particles Nuclei Chickenpox, TB measles

9. 5) Faecal - oral Contaminated food and water Outbreaks Hygiene Disinfection of aircraft

10. 6) Vector-borne transmission Mosquito Malaria West Nile Dengue Disinsection of aircraft

11. Infectious Disease: Interventions

12. International Health Regulations (IHRs) 2005 WHO member states ‘protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international trade and traffic’

13. International Health Regs 1) Four diseases:  Smallpox  Poliomyelitis due to wild-type virus  Human influenza caused by new subtype  Severe Acute Respiratory Syndrome (SARS)

14. International Health Regs 2) Other risks which may be chemical, biological & radiological 3) Public Health Emergencies of International Concern (PHEICs) National Focal Point for each country

16. Guidance on infectious disease

17. Tuberculosis – guidance based on: CDC Review of six incidents showed that 2 had possible transmission on long-haul flights 2600 pax, no active disease 3 Factors:  Within 2 rows  Over 8 hours duration  Highly infective case

18. Tuberculosis 3 rd Ed June 2008 MDR TB, although more difficult to treat is not more transmissible 10% world population carry latent infection No real evidence that recent expensive lookbacks have yielded results

19. Severe Acute Respiratory Syndrome (SARS) 2003 Respiratory droplet and faecal-oral Rapid spread to 2 dozen countries in N America, S America, Europe & Asia

20. SARS – The illness Coronavirus Long incubation (3- 10 days) Not infectious until symptoms present General infection control measures

21. SARS – The spread Newly emerging Global Threat November 2002 Guangdong province Physician travelled to Hong Kong by air

22. SARS – The response WHO travel alerts WHO travel advisories Crew and airport advice given Household advice for cases Healthcare facilities infection control advice Public areas - advice

23. SARS – The cost Worldwide flights fell by 3% (mid-June 2003) compared to year before Cost 40b USdollars China flights dropped by 45% Public perception of risk of air travel

24. Pre-requisites for pandemic influenza New influenza A sub-type: Haemagglutinin (H) unrelated to immediate (pre-pandemic) predecessor. Little or no pre-existing population immunity Causes significant clinical illness Efficient person-to-person spread

25. 19201940196019802000 Circulating influenza strains in humans and pandemics in 20 th Century H1N1>H1N1-2009 H2N2 H3N2 1918: “Spanish Flu” 40-50 million deaths 1957: “Asian Flu” 1 million deaths 1968: “Hong Kong Flu” 1 million deaths

26. The Influenza virus 1) An RNA virus 2) Three types: A, B, and C 3) A & B are major human pathogens: give rise to ‘normal’ epidemics in winter 4) Only influenza A virus is recognised as having potential to cause a pandemic

27. Influenza A virus N HH N 16 haemagglutinins (H); 9 neuraminidases (N)

28. Pandemic Flu – Travel Restrictions Modelling suggests that 99% restrictions on world-wide air travel would delay the peak by only 1-2 weeks

29. Pan Flu – The ‘Layered Approach’ Causes of influenza-like illness in passengers will be varied Asymptomatic infected passenger will not be detected on screening Travellers who incubating illness may develop symptoms en-route (long- haul)

30. The Layered Approach Pre-embarkation measures En route measures Upon arrival measures

31. Pre-embarkation Measures Fitness to Fly Self-administered medical questionnaire Questioning pax by trained staff Thermal imaging Airline staff screening at check-in & departure gate (assisted by ground- based medical support)

32. En-route measures Existing IATA Guidelines  Cabin crew  Maintenance crew  Cargo crew  Bird strike  Passenger agents  And more

33. ICAO definition of communicable disease

34. IATA Flu Hygiene Flyer

35. Captain notifies ATS

36. Airport Ops notifies event

37. WHO: Passenger Locator Card WHO endorsed To obtain public health information 2 rows in front and 2 rows behind For use by country’s public health agency

38. PLCs 2 rows either side

39. Airflow Pattern on Aircraft Modern aircraft have little fore and aft flow, and circular flow laterally.

40. Arrival Measures Mirrors pre- departure screening Self-administered questionnaire Staff questioning or administers questionnaire Thermal screening

41. What to do with positives Medical examination Isolation of ill Quarantine of those not yet ill National legislation required as well as facilities

42. Time line: the H1N1 pandemic experience

43. Norovirus Worldwide Direct, indirect & droplet transmission Low infective dose 24-48 hr incubation Sudden onset Self-limiting illness Most common cause of outbreaks WHO Aircraft disinfection document

44. The End Any questions?