Chapter 6Conveyance & Transportation Issues

Nancy M. Gallagher, Karen J. Marienau, Petra A. Illig, Phyllis E. Kozarsky

Travelers often have concerns about the health risks of flying in airplanes. Those with underlying illness need to be aware that the entire point-to-point travel experience, including buses, trains, taxis, and public waiting areas, can pose challenges. While illness may occur as a direct result of air travel, it is uncommon; the main concerns are:

• Exacerbations of chronic medical problems due to changes in air pressure, humidity, and oxygen concentration
• Relative immobility during flights (risk of thromboembolic disease, see Chapter 2, Deep Vein Thrombosis and Pulmonary Embolism)
• Close proximity to other passengers with certain communicable diseases
• Spraying of airplane cabins with insecticides (disinsection) before landing in certain destinations

EXACERBATION OF CHRONIC DISEASE

During flight, the aircraft cabin pressure is usually maintained at the equivalent of 6,000–8,000 ft (1,829–2,438 m) above sea level. Most healthy travelers will not notice any effects. However, for travelers with cardiopulmonary diseases (especially those who normally require supplemental oxygen), cerebrovascular disease, anemia, or sickle cell disease, conditions in an aircraft can exacerbate underlying medical conditions. Aircraft cabin air is typically dry, usually 10%–20% humidity, which can cause dryness of the mucous membranes of the eyes and airways.

People with chronic illnesses, particularly those whose conditions may be unstable, should be evaluated by a physician to ensure they are fit for air travel. For those who require supplemental in-flight oxygen, the following must be taken into consideration:

• Federal regulations prohibit airlines from allowing passengers to bring their own oxygen aboard; passengers requiring in-flight supplemental oxygen should notify the airline ≥72 hours before departure.
• Information regarding the screening of respiratory equipment (such as oxygen canisters or portable oxygen concentrators) at airports in the United States, and regulations regarding oxygen use on aircraft, can be found at www.tsa.gov/travelers/airtravel.
• Airlines might not offer in-flight supplemental oxygen on all aircraft or flights; some airlines permit only portable oxygen concentrators.
• Travelers must arrange their own oxygen supplies while on the ground, at departure, during layovers, and on arrival. The National Home Oxygen Patients Association provides information to assist patients who require supplemental oxygen during travel (www.homeoxygen.org/airtrav.html).

BAROTRAUMA DURING FLIGHT

Barotrauma occurs when the pressure inside an air-filled, enclosed body space (such as the middle ear, sinuses, or abdomen) is not the same as air pressure inside the aircraft cabin. It most commonly occurs during rapid changes in environmental pressure, such as during ascent, when cabin pressure rapidly decreases, and during descent, when cabin pressure rapidly increases. Barotrauma most commonly affects the middle ear; it occurs when the eustachian tube is blocked and thus unable to equalize the air pressure in the middle ear with the outside cabin pressure. Middle ear barotrauma is usually not severe or dangerous and can usually be prevented or self-treated. It may rarely cause complications such as a perforated tympanic membrane, dizziness, permanent tinnitus, or hearing loss.

The following suggestions may help avoid potential barotrauma:

• People with ear, nose, and sinus infections or severe congestion may wish to temporarily avoid flying to prevent pain or injury. This is particularly true for infants and toddlers, in whom obstruction occurs more readily.
• Oral pseudoephedrine 30 minutes before flight departure, or a nonsteroidal anti-inflammatory agent, may alleviate symptoms.
• Travelers with seasonal allergies should continue their regular allergy medication.
• Travelers should stay hydrated to help avoid irritation of nasal passages and pharynx and to promote better function of the eustachian tubes.
• Travelers sensitive to abdominal bloating should avoid carbonated beverages and foods that can increase gas production.
• Patients who have had recent surgery, particularly intra-abdominal, neurologic, intrapulmonary, or intraocular procedures, should consult with their physicians before flying.

VENTILATION AND AIR QUALITY

All commercial jet aircraft built after the late 1980s and a few modified older aircraft recirculate 10%–50% of the air in the cabin mixed with outside air. The recirculated air passes through a series of filters 20–30 times per hour. In most newer-model airplanes, the recycled air passes through high-efficiency particulate air (HEPA) filters, which capture 99.9% of particles (bacteria, fungi, and larger viruses) between 0.1 and 0.3 µm in diameter. Air flow occurs transversely across the plane in limited bands, and air is not forced up and down the length of the plane. As a result, the air cabin environment is not conducive to the spread of most infectious diseases.

IN-FLIGHT MEDICAL EMERGENCIES

Worldwide, more than one billion people travel by commercial aircraft every year, and this number is expected to double in the next 20 years. Increasingly, large aircraft combined with an aging flying population makes the incidence of onboard medical emergencies likely to increase. Approximately 1 in 10,000 to 40,000 passengers has a medical incident during air transport. Of these, approximately 1 in 150,000 requires use of in-flight medical equipment or drugs. The most commonly encountered in-flight medical events, in order of frequency, are the following:

• Vasovagal syncope
• Gastrointestinal events
• Respiratory events
• Cardiac events
• Neurologic events

Deaths aboard commercial aircraft have been estimated at 0.3 per 1 million passengers; approximately two-thirds of these are caused by cardiac problems.

In addition to standard first aid kits, and depending on the size of the aircraft and applicable regulations, enhanced emergency medical kits may include, but are not limited to, the following:

• Automatic external defibrillators
• Intubation equipment (pediatric and adult)
• CPR masks (pediatric and adult)
• Intravenous access equipment and solutions
• Intravenous dextrose
• Antihistamines (oral and injectable)
• First-line cardiac resuscitation drugs (atropine, epinephrine, lidocaine)
• Nitroglycerin
• Bronchodilators
• Analgesics

Although flight attendants receive training in basic first aid procedures, they are generally not certified in emergency medical response. Many airlines use ground-based medical consultants via radio or phone communication to assist volunteer passenger responders and flight attendants in managing medical cases.

The goal of managing in-flight medical emergencies is to stabilize the passenger until appropriate ground-based medical care can safely be reached; it should not be considered a method of maintaining the original flight route in order to reach the scheduled destination. The captain must, therefore, weigh the needs of the ill passenger with other safety considerations such as weather, landing conditions, and terrain. Certain routes, such as transoceanic flights, may severely restrict diversion options, while others may present a number of safe landing choices. In the latter circumstance, consideration should be given to choosing an airport that has timely access to an appropriate medical facility.

IN-FLIGHT TRANSMISSION OF COMMUNICABLE DISEASES

Communicable diseases may be transmitted to other travelers during air travel; therefore, people who are acutely ill, or still within the infectious period for a specific disease, should be discouraged from traveling. Travelers should be reminded to wash their hands frequently and thoroughly (or use an alcohol-based hand cleaner), especially after using the toilet and before preparing or eating food. Travelers should also be reminded to cover their noses and mouths when coughing or sneezing.

If a passenger with a communicable disease is identified as having flown on a particular flight (or flights), passengers who may have been exposed may be contacted by public health authorities, for possible screening or prophylaxis. When necessary, public health authorities will obtain contact information from the airline for potentially exposed travelers so they may be contacted and offered appropriate intervention. To assist in this process, travelers can provide airlines with current contact information.

Tuberculosis

Although the risk of transmission of Mycobacterium tuberculosis onboard aircraft is low, international tuberculosis (TB) experts agree that contact investigations for flights >8 hours are warranted when an ill traveler meets World Health Organization (WHO) criteria for being infectious during flight. The concern is most serious when a person may have flown with a highly drug-resistant strain of TB. People known to have infectious TB should not travel by commercial air (or any other commercial means) until they are no longer infectious. State health department TB controllers are valuable resources for advice (http://tbcontrollers.org/?p=10).

Neisseria meningitidis

Meningococcal disease (caused by Neisseria meningitidis) can be rapidly fatal; therefore, close contacts need to be quickly identified and provided with prophylactic antimicrobial agents. Antimicrobial prophylaxis should be considered for any of the following:

• Household member traveling with a patient
• Travel companion with very close contact
• Passenger seated directly next to the ill traveler on flights >8 hours

Measles

Most measles cases diagnosed in the United States are imported from countries where measles is endemic. Travelers should ensure they are immune to measles before travel. An ill traveler is considered infectious during a flight of any duration if he or she traveled during the 4 days before rash onset through 4 days after rash onset. Intervention may prevent or mitigate measles in susceptible contacts if MMR vaccine is given within 72 hours of exposure or immune globulin is given within 6 days of exposure.

Influenza and Severe Acute Respiratory Syndrome

Transmission of the influenza virus aboard aircraft has been documented, but data are limited. Transmission is thought to be primarily due to large droplets; therefore, passengers seated closest to the source case are believed to be most at risk for exposure.

The avian influenza virus (H5N1) has infected hundreds of humans since 1997 and is primarily associated with direct contact with infected birds or bird products. No cases have been associated with air travel. The 2009 influenza A (H1N1) pandemic began in April 2009, and while air travel played a significant role in its global spread, there are limited data about in-flight transmission. However, data published to date indicate that in-flight transmission did not occur frequently. Severe acute respiratory syndrome (SARS) can be transmitted anywhere people are gathered, including aircraft cabins. The last known case of person-to-person transmission occurred in 2003. See the CDC Travelers’ Health website (www.cdc.gov/travel) for more general information and up-to-date, specific guidelines for travelers and the airline industry.

DISINSECTION

To reduce the accidental spread of mosquitoes and other vectors via airline cabins and luggage compartments, a number of countries require disinsection of all inbound flights. WHO and the International Civil Aviation Organization (ICAO) specify 2 approaches for aircraft disinsection:

• Spraying the aircraft cabin with an aerosolized insecticide (usually 2% phenothrin) while passengers are on board
• Treating the aircraft’s interior surfaces with a residual insecticide while the aircraft is empty

Some countries use a third method, in which aircraft are sprayed with an aerosolized insecticide while passengers are not on board.

Disinsection is not routinely done on incoming flights to the United States. Although disinsection, when done appropriately, was declared safe by WHO in 1995, there is still much debate about the safety of the agents and methods used. Guidelines for disinsection have been updated for the revised International Health Regulations (www2a.cdc.gov/phlp/docs/58assembly.pdf PDF). Many countries, including the United States, reserve the right to increase the use of disinsection in case of increased threat of vector or disease spread. An updated list of countries that require disinsection and the types of methods used are available at the Department of Transportation website: http://ostpxweb.ost.dot.gov/policy/safetyenergyenv/disinsection.htm.

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