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

August 5, 2009 5:00 PM ET

Background

The novel influenza A (H1N1) virus that has infected humans in the United States, Mexico and elsewhere is a new influenza A (H1N1) virus that has not previously been identified in North America or anywhere else in the world. 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 novel influenza A (H1N1) influenza are similar to the symptoms of seasonal influenza and include fever, cough, sore throat, body aches, runny or stuffy nose, headache, chills and fatigue. Some people have also reported diarrhea and vomiting associated with novel influenza A (H1N1) virus. On-going human-to-human transmission is occurring with confirmed cases identified in the United States and other countries.

Transmission of Influenza Viruses

Novel influenza A (H1N1) 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 influenza viruses on it and then touching their mouth, nose, or eyes.

Interim Recommendations

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.

Hand Washing

Wash your hands often with soap and water for at least 20 seconds, 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.

Cough Etiquette

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

Stay Home From Work If You Are Sick

If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities (Your fever should be gone without the use of a fever-reducing medicine.) Keep away from others as much as possible. This is to keep from making others sick.

Personal Protective Equipment (PPE)

CDC does not recommend the routine use of personal protective equipment (PPE), such as gloves, facemasks, or respirators for protection against influenza exposure, except when interacting directly with an ill person or cleaning potentially contaminated surfaces.

Gloves

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.

Facemasks and Respirators

On May 27, 2009, CDC issued updated Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission.

People with symptoms of novel influenza A (H1N1) virus infection should not leave home or travel. If symptoms of novel influenza A (H1N1) virus infection develop during flight, the ill person should protect others by wearing a facemask if tolerable to reduce the number of droplets coughed or sneezed into the air or use a tissue to cover their nose and mouth when coughing or sneezing.

Use of N95 respirators or facemasks generally is not recommended for airline crew members for general work activities. The following recommendations should be followed when possible for work activities that involve contact with passengers or crew members who have influenza-like illness (ILI), such as escorting a person with ILI, interviewing a person with ILI, or providing assistance to an individual with ILI:

maintain a distance of 6 feet or more from the ill person;
keep interactions with ill persons as brief as possible;
ask the ill person to follow good cough etiquette and hand hygiene and to wear a facemask, if able, and one is available;
workers at increased risk of severe illness from influenza infection (see footnote 3 of table 1) should avoid people with ILI (possibly by temporary reassignment); and,
where workers cannot avoid close contact with persons with ILI, some workers could consider wearing a facemask or N95 respirator on a voluntary basis. Requirements for the voluntary use of respirators in the workplace can be found on the OSHA website (http://www.osha.gov/SLTC/etools/respiratory/voluntaryuses.html).

Facemasks provide barrier protection against droplet and contact transmission of the virus, but they do not protect against inhalation of very small airborne particles. Droplets are still considered to be the primary route of influenza virus transmission, but airborne transmission can not be ruled out at this time. Disposable facemasks and respirators should not be reused; once removed they should be discarded.

Management of Passengers or Crew Members with Symptoms of Influenza

If a cabin or flight deck crew member or passenger is displaying signs and symptoms of an ILI 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 to protect others. Hands should be washed after contact with respiratory secretions or contaminated objects or materials.

Cabin and flight deck crew should be aware of the possible symptoms of novel influenza A (H1N1) virus infection including fever, cough, sore throat, body aches, headache, runny or stuffy nose, chills, fatigue, and in some cases, diarrhea and vomiting. For more information, see H1N1 Flu and You.
Minimize the number of personnel directly exposed to the ill person.
Separate the ill person from others as much as possible (at least 6 feet) without compromising flight safety.
Have the ill person protect others by wearing 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. Provide a plastic bag for proper disposal of contaminated tissues.

Personnel should wash hands for 20 seconds with soap and warm water before tending to the ill person, and after handling garbage, touching commonly touched surfaces, contacting respiratory secretions or tending to the sick person.
Personnel should wash hands before removing a respirator and after removing gloves and a respirator.
Use waterless, alcohol-based hand gels when soap is not available and hands are not visibly soiled.
Personnel tending to the ill person or contacting potentially infectious materials should wear disposable impermeable gloves. 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 keep their interactions with the ill person as brief as possible and may choose to wear a facemask or a N95 respirator on a voluntary basis. Workers at increased risk of severe illness from influenza infection (see http://www.cdc.gov/h1n1flu/masks.htm#table1) should avoid people with ILI.
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.
If a person shows observable signs of novel influenza A (H1N1) illness while on a flight bound for the U.S., the captain is required by law to report the illness to CDC Quarantine Station, in the jurisdiction of the airport where the plane is expected to land prior to arrival or as soon as illness is noted. 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.
The flight deck crew should ensure that the aircraft air conditioning/ventilation system stays 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 novel H1N1 influenza should monitor their health for 7 days after the exposure. If they become ill with influenza-like symptoms, including fever, body aches, runny or stuffy 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. CDC recommends that people with flu like illness stay home for at least 24 hours after their fever is gone except to get medical care or for other necessities (Their fever should be gone without the use of a fever-reducing medicine.)
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 in a public place, or when others are present at home, protect others by wearing a facemask if available and tolerable to reduce the number of droplets coughed or sneezed into the air. If a facemask can not be tolerated, use a tissue to cover nose and mouth when coughing or sneezing.
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.