Tuberculosis and Air Travel Ibrahim Abubakar, MBBS, PhD, FFPH Consultant Epidemiologist Section Head

1
Tuberculosis and Air TravelIbrahim
Abubakar, MBBS, PhD, FFPHConsultant
Epidemiologist / Section HeadTuberculosis
SectionRespiratory and Systemic Infections
DepartmentCentre for InfectionsColindale, London
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Talk outline

• Rationale
• Evidence base
• WHO Guidelines
• NICE
• HPA Interpretation

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Rationale
Newsworthy - More political than public
health International cross border
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Evidence

• No cases of TB disease reported among those known
  to have been infected with M. tuberculosis during
  air travel
• All instances of transmission involved highly
  infectious (smear positive) cases
• 2 of whom had MDR disease
• Overall notification rate of 0.05 per 100 000
  long haul passengers (BA)

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Evidence
6
UK incidents
Four All had negative Mantoux
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WHO Guidelines
2006
2008
1998
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Infectious or potentially infectious

• Infectious TB. All cases of respiratory
  (pulmonary or laryngeal) TB which are sputum
  smear-positive and culture-positive (if culture
  is available).
• Potentially infectious TB. All cases of
  respiratory (pulmonary or laryngeal) TB which are
  sputum smear-negative and culture-positive
  (susceptible, MDR-TB or XDR-TB).
• Non-infectious TB. All cases of respiratory TB
  which have two consecutive negative sputum-smear
  and negative culture (if culture is available)
  results.

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WHO guidelines

• For travellers, Public Health Authorities,
  Physicians and Airlines
• Pre and post travel
• For Travellers
• People with infectious or potentially
  infectious TB should postpone all travel by
  commercial air transportation of any flight
  duration until they become non infectious.

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Physicians Pre and Post travel

• Pre-travel
• Inform all infectious and potentially
  infectious TB patients that they must not travel
  by air on any commercial flight of any duration
  until non infectious
• - 2 weeks of adequate treatment and they are
  sputum smear negative on at least two occasions
• - 2 consecutive negative sputum-culture results
  if MDR or XDR.
• Promptly inform the relevant public health
  authority when if such a TB patient intends to
  travel against medical advice.
• Inform the public health authority of
  exceptional circumstances
• Post-travel
• Inform the public health authority when an
  infectious or potentially infectious TB patient
  has a history of commercial air travel within the
  previous 3 months.

WHO guidelines
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Public Health Authorities Pre travel

• Inform the concerned airline of infectious and
  potentially infectious passengers travelling
  against medical advice and request that boarding
  be denied.
• If patient has exceptional circumstances,
  ensure that the airline(s) and all involved
  authorities have agreed the procedures for travel.

WHO guidelines
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Public Health Authorities Post Travel

• Undertake risk assessment
• Inform all countries involved (departure and
  landing).
• Coordination between countries necessary.
• Share passenger information.
• Inform the National IHR Focal Point.
• Collaborate on research concerning TB and air
  travel.

WHO guidelines
13
Assessing whether contact tracing is needed
WHO guidelines
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Aircraft air flow
i.e. those passengers seated in the same row and
in the two rows in front of and behind the index
case
WHO guidelines
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Airline companies

• Pre-travel
• Deny boarding to infectious or potentially
  infectious TB when requested.
• Ensure ventilation is on after 30 minutes
  ground delay.
• Requirements and standards for filtration
  systems.
• Training for cabin crews.
• Adequate emergency supplies on board
• Post-travel
• Airline companies should provide all available
  contact information, in accordance with
  applicable legal requirements including the IHR.

WHO guidelines
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NICE
17
.

• Public health authorities may refine criteria on
  infectiousness according to national guidelines
• Public health authorities may follow national
  policies and guidelines regarding TB contact
  investigation involving potentially exposed
  travellers in their jurisdiction, in accordance
  with requirements under the IHR

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HPA Interpretation Pre travel

• Discourage all passengers with infectious or
  potential infectious TB from travel and inform
  local HPU
• Where there are exceptional personal circumstance
  discuss with HPU

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HPA Interpretation Post travel
Clinician informs HPU
Then HPU sends inform and advise letters to
passengers in the UK
Undertake a risk assessment Index case smear
positive Flight gt8 hrs in last 3/12
International contacts dealt with through TB
Section, CfI in liaison with HPU
HPU liaises with CfI to agree which authority
undertaking the investigation
Crew inform HPU, and therefore, airline
assess as occupational / office type exposure
HPU obtains passenger details for those sitting
in same, and two adjacent rows
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HPA Interpretation During Flight

• Passengers and crew should be reassured
• Airline should be encouraged to keep contact
  details to support subsequent public health
  action

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HPA Interpretation

• Draft agreed
• To be published by the National Knowledge Service
  for TB after further review

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• Thank you
• and now I am off to take my 8 hour train
  to London

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References
Driver CR et al. Transmission of M. tuberculosis
associated with air travel. Journal of the
American Medical Association, 1994,
27210311035. McFarland JW et al. Exposure to
Mycobacterium tuberculosis during air travel.
Lancet, 1993, 342112113. Exposure of passengers
and flight crew to Mycobacterium tuberculosis on
commercial aircraft, 19921995. Morbidity and
Mortality Weekly Report, 1995, 44137140. Miller
MA, Valway SE, Onorato IM. Tuberculosis risk
after exposure on airplanes. Tubercle and Lung
Disease, 1996, 77414419. Kenyon TA et al.
Transmission of multidrug-resistant Mycobacterium
tuberculosis during a long airplane flight. New
England Journal of Medicine, 1996,
334933938. Moore M, Fleming KS, Sands L. A
passenger with pulmonary/laryngeal tuberculosis
no evidence of transmission on two short flights.
Aviation, Space, and Environmental Medicine,
1996, 6710971100. Vassiloyanakopoulos A et al.
A case of tuberculosis on a long-distance flight
the difficulties of the investigation.
Eurosurveillance, 1999, 4(9)96-97. Chemardin J
et al. Contact-tracing of passengers exposed to
an extensively drug-resistant tuberculosis case
during an air flight from Beirut to Paris,
October 2006. Eurosurveillance, 2007, 12(12)6
December. Wang PD. Two-step tuberculin testing of
passengers and crew on a commercial airplane.
American Journal of Infection Control, 2000,
28(3)233238. Parmet AJ. Tuberculosis on the
flight deck. Aviation, Space, and Environmental
Medicine, 1999, 70(8)817818. Whitlock G, Calder
L, Perry H. A case of infectious tuberculosis 16.
on two longhaul aircraft flights contact
investigation. New Zealand Medical Journal, 2001,
114(1137)353355 Tuberculosis exposure feared on
India-to-U.S. flight. Clinical Infectious
Diseases News, 2008, 461 March.