Tuberculosis and Air Travel
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Tuberculosis and Air Travel Ibrahim Abubakar, MBBS, PhD, FFPH Consultant Epidemiologist / Section Head Tuberculosis Section Respiratory and Systemic Infections Department Centre for Infections Colindale, London Talk outline Rationale Evidence base WHO Guidelines NICE HPA Interpretation

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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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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



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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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…………….

  • 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 >8 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, 272:1031–1035.

McFarland JW et al. Exposure to Mycobacterium tuberculosis during air travel. Lancet, 1993, 342:112–113.

Exposure of passengers and flight crew to Mycobacterium tuberculosis on commercial aircraft, 1992–1995. Morbidity and Mortality Weekly Report, 1995, 44:137–140.

Miller MA, Valway SE, Onorato IM. Tuberculosis risk after exposure on airplanes. Tubercle and Lung Disease, 1996, 77:414–419.

Kenyon TA et al. Transmission of multidrug-resistant Mycobacterium tuberculosis during a long airplane flight. New England Journal of Medicine, 1996, 334:933–938.

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, 67:1097–1100.

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):233–238.

Parmet AJ. Tuberculosis on the flight deck. Aviation, Space, and Environmental Medicine, 1999, 70(8):817–818.

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):353–355

Tuberculosis exposure feared on India-to-U.S. flight. Clinical Infectious Diseases News, 2008, 46:1 March.