Recommendations for Airlines to Help Reduce Risk of Measles Transmission through Air Travel

Measles is a serious and highly contagious disease. Since April 2018, CDC has been conducting an unprecedented number of contact investigations after people traveled on commercial flights while contagious with measles. Airline crew and passengers can avoid becoming infected and prevent the spread of measles by being fully vaccinated against measles (or by having other evidence of immunity against measles), and by not traveling while sick, especially if they have fever.

Purpose

CDC created these recommendations specifically for cabin crews and airline management with responsibility for overseeing health matters within their company. The recommendations provide cabin crew with practical methods to protect themselves, passengers, and other crew when someone on board is suspected of being sick with measles. They also provide instructions on required reporting of illness or death on board under US regulations. This webpage also gives airlines recommendations for strategies to reduce the risk of measles transmission on board an aircraft or in destination communities.

Key Points

• Flight crew members who don’t have presumptive evidence of immunity to measles should be fully vaccinated against measles (2 doses at least 28 days apart)
• Flight crews should be vigilant for travelers (passengers and crew) sick with fever and rash or other signs of measles (see box), and should take steps to minimize transmission on board, as outlined below.
• Flight crews must report to CDC as soon as possible before arrival if they suspect measles in a traveler on board a flight arriving at a US airport.
• Airlines should assist CDC and other public health agencies in conducting contact investigations.

Recommendations

Airlines should consider implementing policies to address the risk of measles transmission that incorporate the following recommendations.

Measles education and awareness

a. Among crews

Airlines should ensure flight crews are aware of

• Global risk of measles during international travel
• Signs and symptoms that may indicate a sick traveler has measles
• Strategies to reduce the risk of measles transmission on board
• Requirement for reporting a suspected or known measles case on board to CDC
• Benefits of vaccination
  • Encourage employees who don’t have presumptive evidence of immunity to measles to be fully vaccinated against measles.
  • For international travel, fully vaccinated means 2 doses of MMR vaccine at least 28 days apart.
• Importance of not working on an aircraft while sick with fever, especially if a rash is present

Airlines should also review their sick leave polices and communicate them to employees.

b. Among passengers

Airlines should consider communication strategies to encourage passengers to

• Be fully vaccinated against measles before travel, or have other evidence of measles immunity
• Delay travel if sick with fever and a rash

Airlines can help sick travelers to avoid flying when sick

People should not travel if they have fever and a rash, or have a measles diagnosis, until a doctor clears them for travel. Health officials may also ask travelers exposed to measles and not immune to delay travel until they are no longer at risk of becoming infectious. Passengers will most likely comply in delaying travel for public health reasons if airlines allow them to modify itineraries when they are known or suspected to have measles, or if public health officials have advised them to delay travel.

Promoting measles immunity among crew

Airlines should consider ensuring all flight crew and other employees who may travel internationally have presumptive evidence of immunity to measles.

• Maintain documentation of immune status of all employees.
• To the extent possible, minimize barriers to crew vaccination, for example, by offering MMR vaccines to employees.

Managing passengers and cabin crew with suspected measles

Cabin crews should follow company policy for managing in-flight medical events. Airlines should incorporate these recommendations for when their cabin crew encounter a passenger or fellow crew member with suspected measles. These recommendations aim to reduce transmission by

1. identifying travelers (passengers or crew) who may be contagious with measles during flights and
2. implementing appropriate control measures. They supplement broader CDC recommendations for cabin crew when managing sick travelers.

Flight crew who identify travelers with signs and symptoms suggestive of measles should:

• Ask the sick person to wear a face mask. If a face mask is not available, ask the sick person to cover their mouth and nose with tissues when coughing.
• Minimize contact of passengers and cabin crew with the sick person. If possible, separate the sick person from others, and designate one crew member (who has presumptive evidence of immunity to measles) to serve the sick person. Flight crew should check their own medical history and vaccination records to be aware of their measles immunity status.
• Treat any body fluids (including sputum or other respiratory secretions) as potentially infectious.
• Wear disposable gloves when serving the sick person or touching potentially contaminated body fluids or surfaces. Properly dispose of gloves and other disposable items that came in contact with the sick person or body fluids.
• Clean potentially contaminated surfaces according to airline protocol.
• Practice proper handwashing.
• Separate all infants, all travelers who may have a weakened immune system, and pregnant travelers without known immunity to measles as far as possible from the sick person. To maintain passenger privacy, cabin crew could pose a general question to passengers, for example, “If you have a medical condition or are taking a drug that weakens your immune system or are pregnant, please let me know.” Given how full commercial flights can be, cabin crew may limit this intervention to those seated closest to the sick traveler, taking into account flight time remaining and their other safety responsibilities.

Reporting possible measles before port arrival

The US Code of Federal Regulations (42 CFR 70.11 and 71.21) contains requirements for reporting to CDC deaths and illnesses that occur on domestic interstate flights, and on international flights arriving to the United States. Deaths and illnesses that meet CDC’s definition for an “ill person,” including fever and rash, must be reported before arrival or as soon as recognized.

Managing possible measles after airport arrival

While the plane is at the gate, its ventilation system should be kept running. Before anyone disembarks, CDC quarantine officers or airport emergency medical services will board the aircraft to rapidly assess the sick person, and then work with cabin crew members and airport attendants to disembark the sick traveler to a cleared area in the airport terminal.

The sick traveler should disembark first while wearing a face mask if tolerated. CDC quarantine officers and airport emergency medical staff will further evaluate the sick traveler and help get medical transportation to a local healthcare facility, if needed. CDC quarantine officers will notify the state or local health department. If the sick traveler is transported to a healthcare facility, CDC quarantine officers will obtain the results of diagnostic testing and notify the airline if the sick traveler is diagnosed with measles.

Cooperating with CDC contact investigations

When CDC notifies an airline about a confirmed case of measles on a recent flight, the airlines should rapidly provide to CDC all available contact information for potentially exposed passengers and crew.  CDC gives this information to health authorities in the states or countries where exposed travelers live so they can be assessed for immunity to measles, offered preventive treatment if needed, and monitored for signs and symptoms of measles if they are not immune.

Managing crew member contacts

• Airlines should contact crew members who may have been exposed to a traveler with confirmed measles and assess them for presumptive evidence of immunity. For the purpose of contact investigations on aircraft, CDC defines crew contacts as follows:
  • On a flight with passenger capacity more than 50 passengers, all cabin crew on board;
  • On a flight with passenger capacity of 50 passengers or less, all crew on board, including pilots;
  • On a flight with an infected crew member, all crew on board, including pilots.
• Exposed crew members who don’t have presumptive evidence of immunity to measles should be offered 1 dose of vaccine within 3 days after the flight. Immune globulin within 6 days after the flight is an alternative for those with contraindications to vaccine (such as pregnancy or severe immunosuppression). Exposed cabin crew members with presumptive evidence of measles immunity or who received post-exposure prophylaxis during the recommended time frames may continue to work. However, they should monitor their health with the airline’s oversight for 21 days after the last possible of exposure.
• Airlines should consider establishing a policy to exclude exposed crew members from working on an aircraft when they
  • Have no presumptive evidence of measles immunity, and
  • Do not receive post-exposure prophylaxis (vaccine or immune globulin) during the recommended time frames.

  Exclusion is recommended starting on Day 5 after the first possible exposure through Day 21 after the last possible exposure.

• CDC will additionally notify health departments in the states where exposed crew members live. Health departments may choose to coordinate with the airline in managing exposed crew members.

Managing a crew member with suspected or confirmed measles

Crew members who develop signs and symptoms of measles should

• Limit contact with others as much as possible.
• Notify airline supervisor of the illness.
• Contact a doctor for medical evaluation and management. Before visiting a healthcare facility, sick crew members should inform staff at the facility about their illness and recent exposure to measles, so the facility can take necessary precautions to prevent transmission to others.

Crew members diagnosed with measles should

• Notify airline supervisor of the measles diagnosis.
• Remain isolated until no longer infectious—for 4 days after beginning of the rash. Crew members can return to work on Day 5 after rash onset (with beginning of rash as Day 0).