Interim Guidance for Transporting or Arranging Transportation by Air into, from, or within the United States of People with COVID-19 or COVID-19 Exposure

Background

Individuals with known or suspected COVID-19, or who have had close contact with a person with COVID-19 (i.e., who are considered exposed to COVID-19), should generally remain in place and not travel until they have met CDC criteria for discontinuing isolation or quarantine.  Even with precautions in place, air travel by such individuals poses a risk to ground crew, airport personnel, aircraft crewmembers, other passengers, and others who may come into contact with them during their travel including during ground transport to and from airports. People with confirmed COVID-19 (i.e., those who have tested positive for SARS-CoV-2, the virus that causes COVID-19) or who have had close contact with a person with confirmed COVID-19 are prohibited from traveling on scheduled passenger airline[1] flights. However, there may be circumstances that warrant transportation by air of persons with COVID-19 or who have been exposed to COVID-19. For example, persons with COVID-19 may need medical care that is not available at their location.

The decision to arrange for transportation by air of a person with COVID-19 or known exposure should be carefully considered and thoroughly planned in discussion with public health authorities at origin and destination, relevant federal authorities, and when inpatient health care is needed at destination, personnel at the receiving medical facility. Factors that should weigh into the decision include characteristics of the aircraft, duration of travel, and whether personnel on board are trained in infection control procedures and the correct use of personal protective equipment (PPE). Any such transportation should be conducted in a way that avoids exposure to crewmembers and other passengers on board, within airports, or to communities in the departure location, final destination, and any intermediate stops. For symptomatic infected persons, additional considerations include the health risks to the infected individual (i.e., whether the person is clinically stable enough to travel, whether the person’s clinical condition could deteriorate during transport, and the necessary level of medical management).

CDC has statutory and regulatory authority to prevent the introduction, transmission, and spread of communicable diseases into the United States and between U.S. states and territories. CDC has the authority to issue federal isolation, quarantine, conditional release orders, and interstate travel permits to individuals who are confirmed or suspected of having a quarantinable communicable disease (including COVID-19). CDC can also use federal public health travel restrictions to prevent travel by airline of individuals who are known or suspected to have (or have been exposed to) a communicable disease that threatens public health, and to identify such individuals if they attempt to enter the United States at any port of entry.

Aircraft operators who might transport passengers who have COVID-19 or have been exposed to a person with COVID-19, and others who might arrange for such transport, must know and comply with all applicable federal, state, local, territorial, tribal and foreign health and transport requirements.

Purpose

This document outlines regulatory requirements and recommendations for transportation by air into, from, or within the United States of people with COVID-19 or who have been exposed to a person with COVID-19, including considerations for which passengers may be cohorted (i.e., grouped together) during transport.

Applicability

This guidance applies to all aircraft operators who wish to provide transportation by air into, from, or within the United States to people with confirmed or probable COVID-19 or people who are close contacts of a person with COVID-19. The guidance also applies to any organization or commercial entity (such as a travel insurance company or employer) that arranges for such transportation.

People with COVID-19 and those who meet the definition of a close contact are prohibited from traveling on scheduled passenger airline flights; therefore, this guidance does not apply to scheduled passenger airline flights.

Key Points

  • Travel on scheduled passenger airline flights or other public transportation into, from, or within the United States by people with COVID-19 or their close contacts is prohibited until they have met CDC criteria for discontinuing isolation or quarantine.
  • Private or medical transport (air and ground) should be used to move passengers with COVID-19 or exposed persons from their initial departure location prior to the departure airport all the way to their final destination (e.g., a healthcare facility, their residence, or other suitable location) where isolation, quarantine, or medical care will be provided.
  • In general, people with laboratory-confirmed COVID-19 infection should only be transported with other people with laboratory-confirmed COVID-19.
  • Symptomatic passengers should be evaluated by a healthcare professional before departure to determine if they are medically stable for transport and to identify the appropriate level of medical support required during transport.
  • Transportation by air of persons with COVID-19 or their close contacts should follow all infection control precautions for the safety of crewmembers and other passengers.
  • The aircraft operator must coordinate with the U.S. government for international movements (i.e., Department of State, CDC, Federal Aviation Administration [FAA], and U.S. Customs and Border Protection [CBP]), as well as appropriate foreign, state, territorial, tribal, or localexternal icon governments to ensure compliance with all applicable laws and regulations.

Pretravel Management

Prior to transport, travelers should remain in isolation (if symptomatic or tested positive for SARS-CoV-2) or quarantine (if asymptomatic close contact to person with COVID-19) in accordance with the guidance and mandates of the jurisdiction (e.g., state or country) until transportation by air can be arranged. Any necessary medical evaluation or care before transport should be conducted in accordance with guidance issued by local or national health authorities.

All travelers with COVID-19 should be evaluated by a healthcare professional prior to transport for illness severity, clinical stability, and risk for rapid deterioration of clinical status to determine the appropriateness of transport and level of medical support required during transport.

All close contacts should be evaluated for fever (temperature 100.4o F [38.0o C]) or other symptoms of COVID-19 and should be tested for SARS-CoV-2 using a nucleic acid amplification test (NAAT) or antigen test (i.e., viral test), with preference for NAAT, as close as possible and no more than 3 days before the flight’s departure, with results available before transport. Effective January 26, 2021, this testing is a requirement. Tests used should be approved or authorized by the relevant national authority for the detection of SARS-CoV-2.

All arrangements for transport to the final location, and isolation or quarantine at destination, should be confirmed prior to initiating transport. For travelers needing inpatient medical care, arrangements must be made in advance with the receiving health care facility, including for ground medical transportation at destination.

Procedures for Transportation by Air

Notification of Government Authorities

Prior aircraft operator coordination with applicable authorities is mandatory.

For international transportation by air to the United States, the aircraft operator or the entity coordinating the travel should notify the U.S. embassy or consulateexternal icon for the country where the individual is located. The aircraft operator should coordinate with FAA and CBP to determine the appropriate port of entryexternal icon and obtain instructions for customs and immigration clearances prior to arrival in the United States. Electronic Advance Passenger Information Systemexternal icon (eAPIS) should be filed in advance of arrival.

When transporting people who are known or suspected to have COVID-19 or close contacts of a person with COVID-19 to the United States from a foreign country, aircraft operators must notify CDC in advance of arrival in the United States, preferably no less than 24 hours before the flight’s departure. CDC will notify the state or territorial health department of jurisdiction for the passengers’ destinations. Information about how to report to CDC is available at Guidance for Airlines on Reporting Onboard Deaths or Illnesses to CDC.

For international travel, the aircraft operator should provide CDC the following information. Personally identifiable information and health information for passengers should be provided through secure means.

  • Number of individuals being transported;
  • Date of transport;
  • Planned itinerary;
  • Electronic Advance Passenger Information System (eAPIS);
  • For each individual being transported:
    • Full name;
    • Date of birth;
    • Passport number and country of issuance (or other comparable government-issued identification number);
    • Visa number (if applicable);
    • Address in the United States where the individual will complete isolation or quarantine;
    • For individuals who tested positive for COVID-19: date of positive test, type of test, where test was performed; whether symptomatic and, if so, symptom onset date and a description of symptoms and clinical course;
    • For individuals who have had close contact with a person with COVID-19: date of last exposure; whether symptomatic and, if so, symptom onset date and a description of symptoms and clinical course; and results of any COVID-19 tests, date of test, type of test, and where test was performed; and
    • For individuals requiring inpatient medical care after arrival: name and address of receiving healthcare facility; name and contact information for a point of contact at the facility who is familiar with the patient and arrangements for admission; confirmation of arrangements for ground medical transportation at destination.

For domestic transportation by air between or within U.S. states or territories, with the exception of inter-hospital patient transfer within the United States, the aircraft operator should notify CDC and provide the information listed above.  States or territories may additionally wish to notify their counterparts if they are aware of the transport.

If a passenger’s clinical status changes significantly en route, the aircraft operator must notify the CDC quarantine station of jurisdiction for the airport of arrival as soon as possible before landing, in addition to making arrangements for medical care and ground transportation as needed. Examples of such changes include an asymptomatic exposed person becoming symptomatic, or the condition of an asymptomatic or mildly symptomatic infected person deteriorating and arrangements for medical care and transportation have not been made in advance.

Operational considerations for transportation by air

Aircraft operators should follow these recommended procedures when transporting people who are known or suspected to have COVID-19 or who have been exposed to a person with COVID-19.  These procedures apply to international and domestic transportation by air, to the extent consistent with applicable aviation regulations.

For situations that warrant transportation by air of such persons, aircraft operators should carefully evaluate and plan flights with all relevant public health agencies, civil aviation authorities, and the airport managers at departure, any intermediate stops, arrival, and airports to which a flight could potentially be diverted.

Aircraft operators should evaluate the aircraft to ensure it is of sufficient size and range and has acceptable ventilation. The aircraft used to transport infected or exposed individuals should be of sufficient size to separate passengers and cabin crew into different parts of the aircraft and have ventilation characteristics that reduce the exposure of occupants to airborne infectious particles.  Whenever possible, an aircraft with a separate cockpit and airflow capabilities that comply with American National Standards Institute (ANSI)/ASHRAE Standard 161-2018external icon to delivery at least 7.5 cfm (3.5 L/s) of outside or high-efficiency particulate air (HEPA)-filtered supply air per passenger should be used.  Ideally, the aircraft cockpit should have positive pressure relative to the main cabin and not mix air between the cockpit and cabin.  For additional information regarding airframe selection and recommended cabin airflow characteristics, see Guidance on Air Medical Transport for Middle East Respiratory Syndrome (MERS) Patients.

Aircraft operators should ensure the aircraft is supplied with appropriate PPE in sufficient quantities for crewmembers and any other personnel who might interact with infected or exposed passengers (see infection control precautions section below).

Aircraft operators should plan their itineraries so as to provide transportation by air to passengers’ final destinations or, at a minimum, to a location in proximity to the final destination from where the traveler can reasonably travel by non-commercial ground transportation to the final destination without need for an overnight stay en route.

To minimize the public health risk, passengers with COVID-19 or those considered close contacts should not enter publicly accessible areas of the airport terminal at either origin or destination.  If entry to the public terminal is required for boarding, the aircraft operator should coordinate with civil aviation, customs and immigration, and airport authorities in advance to ensure arrangements are made to ensure safe distance is maintained from others in the terminal building.  Passengers and crewmembers should wear masks[2] and follow infection control precautions in all situations, to the extent consistent with applicable aviation safety regulations.

Aircraft used to transport passengers with COVID-19 or close contacts should be thoroughly cleaned and sanitized after crewmembers and passengers have disembarked, using Environmental Protection Agency List N: Disinfectants for Coronavirus (COVID-19)external icon and in accordance with the instructions of the aircraft manufacturer.

Transport of persons with confirmed COVID-19

Persons with laboratory-confirmed COVID-19 may be transported together as a cohort (group), regardless of symptoms.  However, to account for false positive test results, aircraft operators or others arranging transport should consider confirmatory NAAT or RT-PCR testing for asymptomatic people with only a positive antigen test, if cohorting is planned.  See Interim Guidance for Antigen Testing for SARS-CoV-2 for more information.

Other passengers who do not have COVID-19 should not be transported with infected passengers. If a parent or caregiver is required to accompany a minor or other infected person needing assistance during travel, no other infected persons should be on board. The caregiver should remain separated from the infected person to the extent possible and wear a mask and gloves when in contact with the infected person per guidance for caregivers.

Persons moderately or severely ill with COVID-19 who require medical treatment and monitoring should be transported via an air ambulance service provider with the minimum number of medical personnel to care for and transport the patient.  Transportation via an air ambulance service provider may also be appropriate for persons with mild or no symptoms who are at increased risk for progressing to severe illness during transport. No other patients needing medical care who do not have COVID-19 should be on board. For additional guidance on air medical transport of patients with COVID-19 needing medical care en route, operators may follow Guidance on Air Medical Transport for Middle East Respiratory Syndrome (MERS) Patients.

Asymptomatic or mildly ill persons with confirmed COVID-19 who do not require medical care and are not at an elevated risk for severe illness, may be transported by operators that do not conduct air ambulance operations.

Transport of asymptomatic close contacts who tested negative

Asymptomatic close contacts who have tested negative can be grouped within their existing cohorts (e.g., families or groups of travel companions, etc.) and transported on the same aircraft with other cohorts of asymptomatic close contacts who tested negative, as long as cohorts can be separated by a minimum of 6 feet on the aircraft. If different travel cohorts of close contacts are transported on the same aircraft, all passengers should be informed of the situation in advance of travel, including the risk that some individuals on board may have undiagnosed COVID-19.

Asymptomatic close contacts should be screened immediately prior to boarding. Screening should consist of checking for fever (temperature ≥100.4o F [≥38.0o C]) and other symptoms of COVID-19 and confirmation of negative COVID-19 test results for a specimen collected during the 3 calendar days preceding the flight’s departure. Passengers identified as symptomatic should not be boarded until they have been re-evaluated and retested, as described below.

  • Passengers should be advised to monitor themselves for symptoms of COVID-19 during flight and to notify cabin crewmembers immediately if symptoms develop.
  • If a passenger becomes symptomatic en route, the symptomatic passenger should be separated from other passengers and crewmembers on board to the maximum extent possible, ideally to the rear of the aircraft.

Transport of symptomatic close contacts

Symptomatic close contacts should be assumed to be infectious. Before transport, they should be evaluated by a healthcare professional and tested for SARS-CoV-2, ideally with NAAT. If tested prior to symptom development, they should be retested. Those who test negative by NAAT should be re-evaluated to determine the clinical suspicion of COVID-19; if clinical suspicion is low, they may be transported with asymptomatic contacts as described in the section above.  Symptomatic close contacts who test negative by an antigen detection test should have the result confirmed by NAAT before they are transported with other close contacts who have tested negative. See Interim Guidance for Antigen Testing for SARS-CoV-2 for more information.

Additional cohorting considerations

In addition to the recommendations listed above, if transportation is being considered for a passenger group of which one or more, but not all members, are known to be infected, the aircraft operator should consult with CDC in advance regarding the characteristics of the group and transportation plans. CDC consultation may be obtained by contacting the quarantine station with jurisdiction for the airport of arrival or by calling the CDC Emergency Operations Center at 770-488-7100.

Infection control precautions for aircraft

Non-scheduled aircraft operators should follow these infection control precautions when transporting people with COVID-19 or exposed to COVID-19:

  • Aircraft crewmembers should be informed in advance that passengers may have COVID-19 or have been exposed to COVID-19, and be provided with information about preventing transmission of COVID-19.
  • Aircraft ventilation should remain on at all times during loading, transport, and disembarkation, including during ground delays.
  • Passengers and crewmembers should wear a surgical or cloth mask during transportation by air and supporting ground transport operations.
    • Passengers should not use a mask if they are vomiting or if mask use interferes with medical care such as supplemental oxygen. Masks should not be worn by children younger than 2 years old, anyone who has trouble breathing, anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
    • Passengers and crew may remove masks briefly if necessary, to eat, drink, or take medications.
  • Crewmembers should remain separated from passengers unless they need to render emergency assistance or for safe operation of the aircraft, and in those instances, they should use appropriate PPE.
  • Sufficient PPE comparable to that found in the Universal Precautions Kitpdf iconexternal icon, including eye protection, should be on board for crewmember use during the flight, as well as for possible use by passengers if needed. Cloth masks should not replace the use of surgical masks or other PPE provided in the Universal Precaution Kit (UPK) when interacting with a sick traveler on board an aircraft.
  • Aircraft operators should ensure crewmembers are trained in the correct use of PPE, including correct procedures for donning (putting on) and doffing (taking off).
  • An area should be designated for crewmembers to don (put on) and doff (take off) PPE with handwashing facilities or a supply of hand sanitizer containing at least 60% ethanol or 70% isopropanol, as well as containers for safe disposal of used PPE.
  • Passengers (either infected or exposed) should be seated towards the rear of the plane.
  • Cabin crewmembers should be seated towards the front of the aircraft, as far as possible and at least 6 feet from passengers.
  • Temporary barriers between passenger and crew areas may be considered if each zone maintains connection to cabin air supply and exhaust flow, with the passenger zone preferably under small negative pressure.
    • FAA regulations both require markings be conspicuous and prohibit blocking any passenger’s view of required signs or placards.
    • Any temporary barriers must comply with FAA regulations and be placed in such a manner that their location does not restrict access to or use of any required emergency or regular exit or of the aisle in the passenger compartment.
  • Passengers should have a designated restroom near their seating areas and be requested to use provided cleaning supplies to clean the bathroom after use. Bathroom exhaust fans should run continuously.
  • All passengers and crewmembers should have access to handwashing facilities or hand sanitizer containing at least 60% ethanol or 70% isopropanol and practice good hand hygiene.
  • If provided, meals and beverages should be in single-serve packages or containers to limit need for crewmember and passenger interactions;
  • If cleaning and disinfection are needed during the flight, crewmembers should follow Preventing Spread of Disease on Commercial Aircraft: Guidance for Cabin Crew. Cleaning supplies compatible with the aircraft should be available on board in adequate supply.
  • Crewmembers should monitor themselves for symptoms of COVID-19 for 14 days after the flight under the supervision of their employer’s occupational health program.
  • Any crewmembers with potential unprotected exposures to a person with COVID-19 should notify their employer’s occupational health program immediately and be restricted from working on aircraft until they complete the recommended quarantine period.

Additional infection control considerations, including for rotor-wing and small, non-pressurized fixed-wing aircraft are available in Guidance on Air Medical Transport for Middle East Respiratory Syndrome (MERS) Patients.

Ground Transportation at U.S. Destination

In addition to transportation by air to a U.S. destination airport, the aircraft operator should verify appropriate non-commercial ground transport is available at the destination airport to ensure a prompt, efficient, safe removal of the patient from the aircraft.

For patients who are being evacuated for medical care in the United States, the aircraft operator should verify arrangements are in place in advance with the receiving hospital, the CDC quarantine station of jurisdiction, and the state, territorial, tribal or localexternal icon public health departments of jurisdiction, including arrangements for suitable medical ground transport (i.e., by ambulance) from the airport.

For travelers who do not require hospitalization and are voluntarily transported home to complete self-isolation or quarantine following a COVID-19 diagnosis or exposure, the aircraft operator should verify non-commercial transportation arrangements are in place for travelers to their home, another private residence, or other suitable location where they will complete their isolation or quarantine period under the guidance and jurisdiction of local public health authorities. Planned ground transport arrangements should be communicated to the relevant state, territorial, tribal or localexternal icon health department.

Infection control measures during ground transport

  • Public transportation, rideshare services, or taxis should not be used.
  • Unless they are alone in their vehicle, travelers should continue to wear a mask until they have reached the location where they will complete their self-isolation or quarantine.
  • If a traveler requires the assistance of a driver (e.g., family member), precautions should be in place to protect the driver. The driver should be informed of the potential exposure risk and provided with information about preventing transmission of COVID-19.
    • Driver and passenger(s) should both wear masks during the transport.
    • Driver and passenger(s) should remain separated by at least 6 feet when outside the vehicle. Passenger(s) should sit in the back seat of the vehicle.
    • Driver should avoid using the recirculated air option for the car’s ventilation during passenger transport; use the car’s vents to bring in fresh outside air and/or lower the vehicle windows.
    • Hand sanitizer containing at least 60% ethanol or 70% isopropanol should be available. Driver and passenger should practice good hand hygiene.
  • The vehicles used for ground transportation of persons with COVID-19 or close contacts should be cleaned and sanitized after use.
  • Upon arrival to their home location in the US, travelers must follow U.S. federal, state, and local laws relevant to persons with COVID-19 cases or close contacts and until their isolation or quarantine period is complete.
Footnotes
  1. For purposes of CDC’s Interstate and Foreign Quarantine Regulations, “‘airline’ means any air carrier or foreign air carrier providing air transportation as that term is defined in 49 U.S.C. 40102(a)(2), (a)(5), and (a)(21).” 42 C.F.R. §§ 70.1 and 71.1.
  2. Operators should be mindful of applicable FAA regulations regarding the use of oxygen masks where the operation requires an oxygen mask to be rapidly placed on the face, properly secured, sealed, and supplying oxygen upon demand. Operators should complete a safety risk assessment and provide guidance to their crewmembers on procedures for the use of masks as they may affect the donning of oxygen masks.  Operators should also consider whether wearing a mask would interfere with any required PPE or job tasks.