GUIDELINES AND RECOMMENDATIONS
Interim Guidance for Airline Flight Crews and Persons Meeting Passengers Arriving from Areas with Avian Influenza
(Released February 18, 2004)

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Since December 2003, outbreaks of highly pathogenic avian influenza – mostly influenza A (H5N1) – among chickens and ducks have been reported in several countries in Asia. Human cases also have been reported. For more information, see http://www.who.int/csr/disease/avian_influenza/en/. No evidence for sustained person-to-person transmission of influenza A(H5N1) has been identified; however, influenza A viruses can change rapidly, and therefore the situation in these countries is being monitored carefully. The Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and national authorities in Asian countries are working to assess the outbreak, provide support, and assist with control efforts. As part of this response, CDC issues interim recommendations for various prevention and control measures.

This interim guidance is intended to assist airline flight crews and personnel meeting arriving passengers in establishing appropriate precautions in the event they must interact with a person suspected of having avian influenza. Recommendations are based on standard infection control practices and on available information on the disease.

Information on the Spread of Avian Influenza

Avian influenza viruses usually do not infect humans. The ability of avian viruses to transmit from person to person appears limited. Rare person-to-person infection was noted in the influenza A (H5N1) outbreak in Hong Kong in 1997 and in the Netherlands in 2003, but these secondary cases did not result in sustained chains of transmission or community-wide outbreaks. These previous experiences with avian influenza viruses suggest that limited person-to-person transmission of the current H5N1 viruses could occur.

Infected birds shed virus in saliva, nasal secretions and feces. Avian influenza viruses spread among susceptible birds when they have contact with contaminated nasal, respiratory, and fecal material from infected birds; however, fecal-to-oral transmission is the most common mode of spread. Humans become infected from contact with infected poultry or contaminated surfaces.

All influenza viruses can change, and therefore it is possible that an avian influenza virus could change so that it could infect humans and spread easily from person to person. Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population.

For additional information on avian influenza, please consult this web page: http://www.cdc.gov/flu/avian/facts.htm.

General Infection Control Precautions

• As with all infectious illnesses, the first line of defense to prevent transmission is careful hand hygiene. As a general rule, wash hands frequently with soap and water or use an alcohol-based hand rub if hands are not visibly soiled.
• Cover your cough. Passengers who are coughing should be encouraged to contain their coughs.
• Avoid traveling when ill.

Passengers with Symptoms of Possible Avian Influenza: Management on a Conveyance

• Personnel should be aware of the symptoms of avian influenza (http://www.cdc.gov/flu/avian/facts.htm. Although experience with human infection is limited, persons infected with avian influenza would likely have fever and respiratory symptoms (cough, sore throat, shortness of breath).
• If flight crew members or other personnel are concerned that a passenger traveling from an area in which avian influenza cases have been reported may be ill with a fever or respiratory illness, they should keep the sick person separated from close contact with others as much as possible. A surgical mask can reduce the number of droplets coughed into the air. Ask the sick person to wear a mask if one is available provided the person can tolerate it (that is, if the sick person does not have such severe difficulty breathing that he or she cannot use a mask). If a surgical mask is not available, provide tissues and ask him or her to cover the mouth and nose when coughing. When a sick person is unable to wear a surgical mask, personnel should wear surgical masks when working directly with that person.
• Personnel should wear disposable gloves for direct contact with blood or body fluids of any passenger. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be carefully removed and discarded and hands should be cleaned. Gloves must never be washed or reused.
• The captain of an airliner bound for the United States is required by law to report the illness to the nearest U. S. Quarantine Station prior to arrival or as soon as illness is noted (see http://www.cdc.gov/ncidod/dq/quarantine_stations.htm). Quarantine officials will arrange for appropriate medical assistance to be available when the airplane lands and will notify state and local health departments and the appropriate CDC Headquarters officials. Quarantine officials will work with the airline and local and state health departments to assist with medical transportation of the patient upon arrival, disease control and containment measures, passenger and crew notification and surveillance activities, and airline disinfection procedures.

Management on Arrival

For Transportation Security Administration (TSA), Bureau of Customs and Border Protection (BCBP), and other personnel interacting with passengers arriving from areas with avian influenza, CDC does not recommend protective measures beyond those already in use for interacting with the general public. As with all infectious illnesses, the first line of defense is careful hand hygiene. As a general practice, personnel should wash hands frequently with soap and water or use an alcohol-based rub if hands are not visibly soiled.

Personnel who have to detain or assist a passenger who appears to have a respiratory illness and who may have traveled from an area with avian influenza should try to keep him or her separated from the other passengers as much as possible and immediately contact the appropriate authorities, such as the U.S. Quarantine Station with local jurisdiction (http://www.cdc.gov/ncidod/dq/quarantine_stations.htm), and Emergency Medical Services (EMS). In the interim, provide the ill passenger with a surgical mask if one is available to reduce the number of droplets coughed into the air and if the passenger can tolerate a mask. If a surgical mask is not available, provide tissues and ask the sick person to cover his or her mouth and nose when coughing. When an ill passenger is unable to wear a surgical mask, personnel should wear surgical masks when working directly with the sick person.

Personnel should wear disposable gloves if touching blood or body fluids. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be carefully removed and discarded and hands should be cleaned. Gloves must never be washed or reused.

Management of Ill Crew

Flight crew members and ground personnel who become ill and who believe they have been exposed to avian influenza should take the following precautions:

• If illness onset occurs while traveling away from home, notify employer for assistance with locating a health care provider. Let employer know you are concerned about possible exposure to avian influenza, and ask about your health-care options. If illness onset occurs while outside the United States, the U. S. embassy or consulate can also provide names and addresses of local physicians. Do not travel while sick, and limit your contact with others as much as possible to help prevent the spread of any infectious illness. If a visit is planned to a doctor’s office, clinic, or emergency room, tell the healthcare provider in advance about your possible exposure so that arrangements can be made, if necessary, to prevent transmission to others in the health-care setting.
• If illness onset occurs after return home, contact your healthcare provider and tell him or her what your symptoms are and the countries you have visited before going to the doctor’s office or emergency room. Precautions can then be taken, if necessary, to prevent transmission to others in the healthcare setting.

For more information about avian influenza, see http://www.cdc.gov/flu/avian/facts.htm and http://www.cdc.gov/flu/avian/index.htm.