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Guidelines
for the Management of Airline Passengers Exposed to Meningococcal Disease
Please see the Destinations
section for recommendations for specific countries. |
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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.
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.
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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.
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3. |
Antimicrobial chemoprophylaxis
should be considered for: |
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- 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).
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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.
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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.
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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.
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