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CDC Health Information for International Travel 2008

Guidelines for the Management of Airline Passengers Exposed to Meningococcal Disease

The Centers for Disease Control and Prevention receives reports of approximately 12 cases of confirmed meningococcal disease per year in which the index patient was likely contagious aboard an international conveyance. Most of these reports are received within days of transit; rarely is the diagnosis made in transit. Because of concerns about the possibility of secondary transmission to other passengers and crew, CDC is frequently asked to provide guidance on the need for antimicrobial chemoprophylaxis in these settings.

The public health decision to offer antimicrobial chemoprophylaxis should be based on an assessment of the risk of transmission in conjunction with the difficulty in identifying and notifying those passengers and the potential severity of illness. There are no documented instances of secondary disease among passengers, but, similar to household contacts, passengers who are seated next to a passenger with meningococcal disease for a prolonged flight may be at higher risk of developing meningococcal disease.

There is a need for more systematic collection of data on the risk of transmission to passenger contacts in order to provide a better basis for public health recommendations.


CDC, in conjunction with the Council of State and Territorial Epidemiologists, recommends the following:

  1. Household members traveling with the index patient as well as persons traveling with the index patient who have prolonged close contact (e.g., roommates, members of the same sports team) should be identified and the need for antimicrobial chemoprophylaxis evaluated.
  2. The health department from the state where the patient resides should be contacted promptly to facilitate antimicrobial chemoprophylaxis of household members, day care center contacts, and other possible close contacts.
  3. Antimicrobial chemoprophylaxis should be considered for:

    - Passengers who have had direct contact with respiratory secretions from the index patient;

    - Passengers seated directly next to the index patient on prolonged flights (>8 hours).
  4. CDC and state health departments should enhance surveillance for secondary cases associated with airline travel because identification of such cases would alter these recommendations. To facilitate this, state and local health departments should consider asking for recent travel history, including flight information, for all persons with meningococcal disease. The form for reporting meningitis cases to CDC should add an item on recent airline travel (within 10-14 days of onset) that includes details on flight (airline, date, time, locations). CDC should track this information to facilitate the identification of cases that may involve passengers who were on the same flight and became ill within 14 days of disembarkation.
  5. Airlines should be responsible for maintaining a passenger manifest to aid in identification of passengers at risk for secondary infections. CDC should work with airlines to identify the location of potentially exposed passengers. With the assistance of the airline, CDC should identify the states where these passengers reside and contact the appropriate state and local health officials. The state or local health department will then contact passengers as necessary. 

Background and Justification

Transmission of Neisseria meningitidis

Neisseria meningitidis is the leading cause of bacterial meningitis in children and young adults in the United States, with an estimated 2,600 cases each year and a case-fatality rate of 13%. N. meningitidis is spread through direct contact with the respiratory secretions of a patient with meningococcal disease, and antimicrobial chemoprophylaxis of persons in close contact with the index patient is the primary means for prevention of endemic meningococcal disease in the United States. Close contacts who have been identified to be at high risk of secondary disease include a) household members, b) day care center contacts, and c) anyone directly exposed to the patients’ oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management). The attack rate for household contacts exposed to patients who have sporadic meningococcal disease has been estimated to be four cases per 1,000 persons exposed, which is 500-800 times greater than for the general population. Therefore, when a sporadic case of meningococcal disease occurs, the first priority for prevention of additional cases is identification of these close contacts to recommend antimicrobial chemoprophylaxis.  Because the rate of secondary disease for close contacts is highest during the first few days after onset of disease in the primary patient, antimicrobial chemoprophylaxis should be administered as soon as possible (ideally within 24 hours after the case is identified). Conversely, antimicrobial chemoprophylaxis administered >14 days after onset of illness in the index case-patient is probably of limited value.

Transmission of Infectious Diseases on Airplanes

At least 7 investigations have examined possible transmission of Mycobacterium tuberculosis on airplanes (Tuberculosis and Air Travel: Guidelines for Prevention and Control. World Health Organization, 1998). One of these investigations documented transmission of M. tuberculosis from a symptomatic index passenger to 6 passengers with no other risk factors, sitting in the same section of a commercial aircraft during a long flight (>8 hours) (N. Engl. J. Med. 1996, 334: 933-8).

Rationale for Guidelines

The assessment of risk to passengers and flight crew members should be guided by two principles: the flight duration and the seating proximity to the index patient. For flights >8 hours, passengers who are seated directly next to the index patient are more likely to be directly exposed to the patient’s oral secretions and are therefore probably at higher risk than those seated farther from the index patient. In the absence of data regarding elevated risk among other passengers, antimicrobial chemoprophylaxis should be considered for those passengers seated directly next to the index patient. Given the increased frequency of ground delays prior to takeoff and after landing, one needs to count the total time and not just the air transit time; the >8-hour time period should include the total time from when the passengers are seated for takeoff until they disembark.

See the Diseases section for more information on meningococcal disease.

  • Page last updated: May 27, 2005
  • Content source:
    Division of Global Migration and Quarantine
    National Center for Preparedness, Detection, and Control of Infectious Diseases
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