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16. Infectious Diseases

Patients with chickenpox are infectious until the vesicles have dried out, normally 10 days after the onset of symptoms.

Photo: Nis Kentorp


General

 


The most important problem for air passengers with infectious diseases is the risk of infecting fellow passengers.


In general, passengers who are able to infect are not accepted on scheduled flights.


Nevertheless, thousands of patients with less serious contagious disorders such as colds, flu and childhood diseases are every day passengers on scheduled flights without being rejected.
However, it is important that patients with fever do not fly. Fever results in increased oxygen consumption. There is lower oxygen partial pressure in the cabin in flight and a febrile patient may become hypoxic. This is especially true in patients with reduced lung function.
In an epidemic with a serious drop-borne illness, scheduled flights pose a great risk of spreading the infection. During scheduled flights passengers sit close to each other and often for a long time. In addition, airports where passengers from many different countries meet constitute a high-risk area for rapid spread of infection.
Therefore, a global shutdown of scheduled flights with airport closures can be an important aid in reducing and slowing down the spread of infection, as happened during the Covid 19 pandemic.
At present, following the partial reopening of air traffic, it is a requirement of authorities and many airlines to wear a face mask at airports and in flight.

The following are guidelines for when patients with infectious diseases should travel by a scheduled flight:



Common cold, influenza


Aetiology:

Influenza A, B, parainfluenza, RSV, and so on.

Risk of transmission:

Excretion of the virus decreases considerably after approximately 5-7 days along with an improvement in symptoms.

Air travel:

At the time of transportation, the patient’s temperature should be normal, thereby giving some assurance that complications or other febrile illnesses are not being overlooked.



Tonsillitis, pharyngitis


Aetiology:

Viral or bacterial (streptococcus etc.). Infectious mononucleosis must be considered. In certain geographic regions (Russia, the Baltic countries), diphtheria must be considered and excluded.

Risk of transmission:

Not particularly contagious.

Air travel:

Shall be afebrile. Generally, patients with infectious mononucleosis should not travel during the first 10 days after first appearance due to the risk of splenic rupture. For upper respiratory infections, it must be ensured that there is no tubal blockage before traveling by air.



Bronchitis, pneumonia


Aetiology:

Legionella sp., Mycoplasma sp., Chlamydia sp., Pneumococci, Haemophilus influenza, and so on.

Risk of transmission:

There is no particular risk during transportation.

Air travel:

Transport prescription as per rules applying to patient’s general condition.



Chickenpox


Aetiology:

Varicella – zoster virus.

Risk of transmission:

Untreated disease in the acute phase involves risk of infection by fellow passengers, especially passengers on immunosuppressive therapy. It is contagious until vesicles have dried up.

Air travel:

It is contagious 2-3 days before the appearance of rash and for 5 days after. Pragmatically, the patient can fly 10 days after the onset of the rash. No fresh vesicles, only dry crusts.



Herpes zoster (Shingles)


Aetiology:

Varicella – zoster virus.

Risk of transmission:

Not contagious, unless you are in direct contact with the affected skin area. If the patient is on antiviral therapy, he or she is not contagious after a few days.

Air travel:

The affected skin area must be covered during the flight.



Gastroenteritis


Aetiology:

Most “traveller’s diarrhoea” is caused by “Enterotoxigenic” E. coli; the remaining are virus infections (rotavirus, Norwalk-like viruses). Salmonella/Shigella infections are rare.

Risk of transmission:

No risk of contact infection. No risk for passengers or cabin crew. Mode of transmission is mainly through food.

Air travel:

When bowel function is stable (no vomiting and formed stools or only mild degree of thin stools). MEDIF can be ticked as “not contagious”. In the case of Salmonella/Shigella infections, the patient can travel when his or her temperature is normal and bowel function is stable. It is not necessary to obtain negative stool cultures from the patient before transportation (see also section on Typhoid fever). The patient must be instructed to perform thorough hygiene when going to the toilet.



Cholera


Aetiology:

Classic cholera is caused by Vibrio cholerae, which forms a protein exotoxin. Other vibrio species – V. alginolyticus, V. parahaemolyticus, and V. vulnificus – can also provoke cholera-like symptoms.

Risk of transmission:

Very small. No risk for contagion where ordinary rules of hygiene are observed. No risk to passengers or cabin crew.

Air travel:

Patients with acute cholera symptoms may not be transported, but must receive on-the-spot treatment. It should be remembered that even previously healthy patients can develop severe hypotension within an hour of the onset of symptoms and, without treatment, may die of shock 2-3 hours later.



Hepatitis


Hepatitis A

Aetiology:

Hepatitis virus.

Risk of transmission:

Viral shedding will be virtually over when jaundice appears.

Air travel:

Can be undertaken 4-5 days after the appearance of jaundice. The airline must be informed that the patient is not contagious.

 


Hepatitis B + C

Aetiology:

Hepatitis virus.

Risk of transmission:

No risk of infection for passengers or cabin crew during transportation.

Air travel:

When the patient’s condition permits.



Febris Typhoidea


Aetiology:

“Typhoid fever” is an internationally recognised term for the human Salmonella species (S. typhi, S. paratyphi A., paratyphi B). It is a febrile illness where the patient’s temperature is 40-41° Celsius. Multiresistant strains are now appearing and these are difficult to treat.

Be aware that fevers from the tropics often trigger the diagnosis Febris typhoidea on a loose basis (positive serology due to previous vaccination (Widal)).

Risk of transmission:

A negative stool culture from the patient is not necessary in order to carry out transportation, but the patient should have formed stools.

Air travel:

The patient shall be afebrile and clinically stable.



Dengue


Aetiology:

Arbovirus, transmitted by mosquitoes. Many tourists contract this febrile viral disease in Asia, Africa, and Central America. Duration is 5-6 days, but may have longer periods of reconvalescence.

Risk of transmission:

No risk of infection.

Air travel:

When the patient's general condition permits.



Malaria


Aetiology:

Malaria plasmodium. Transmitted by mosquitoes. The diagnosis should include information about the species. Four species exist: P. falciparum, P. vivax, P. ovale, and P. malariae. P. falciparum malaria is an acute life-threatening illness, whereas the other three species are so-called benign malarias. Relevant acute treatment is mandatory and must not be delayed. Be aware that fevers from the tropics often trigger the diagnosis “malaria” without laboratory detection of the malaria parasite. A febrile illness with onset <1 week after arrival at a malaria area is not malaria.

Risk of transmission:

No risk of infection to other passengers or cabin crew.

Air travel:

Only after treatment has resulted in a significant decrease of parasites in the blood (repeat smears) and when the patient's general condition permits.



Pulmonary tuberculosis


Aetiology:

Mycobacterium tuberculosis (TB).

Risk of transmission:

The infection is not contagious after 2 weeks of rule-based anti-TB treatment.

Patients with multiresistant tuberculosis (MDR-PB) are an increasing problem and there are contagious until the infection is treated – if possible.

Air travel:

Can be performed 2 weeks after the initiation of therapy if sputum microscopy is negative. Escort recommended (compliance with hygiene precautions). If there are no facilities locally to examine the patient's sputum, and thus the effect of the treatment, the patient should be treated one month before travelling by commercial aircraft.

Patients with MDR-TB are not accepted before the infection is eradicated, secured by several negative sputum cultures. Inability locally for the treatment of clinically treatment refractory TB and multidrug-resistant TB require evacuation by air ambulance.

Transportation of patients with TB should be discussed with a specialist in infectious diseases.



HIV / AIDS


Aetiology:

HIV virus. Transmitted sexually, blood, and semen.

No special rules for air transportation of HIV / AIDS patients.

Risk of transmission:

There is no risk of transmission to other passengers or cabin crew.

Air travel:

No restrictions. It is only the patient's clinical condition that determines form of transportation and whether an escort is necessary.



Plague


Aetiology:

Yersinia pestis.

Risk of transmission:

Highly communicable person to person. Patients with pneumonia can cause airborne infection followed by fatal course of disease within 1-2 days.

Air travel:

Patient must be treated on the spot and must not be transported.



Severe viral infections


Viral haemorrhagic fevers

Aetiology:

Includes a long series of diseases: Marburg disease, Ebola disease, Lassa fever, etc., involving complex diagnostic and treatment problems. Severe infections where outcome is often fatal.

Risk of transmission:

Extremely high.

Air travel:

Patient must be treated on spot and must not be transported.

In case of imperative requirements of repatriation, the transport shall be in ambulance aircraft in total isolation regime.”


Severe corona virus infections

SARS, MERS and Covid 19 (and others).

Etiology:

Various corona viruses

Common to these diseases is that they can cause severe, often lethal, lung inflammation. Lethality is high: SARS 9.6%, MERS 34% and Covid 19 1.5-3.5%. Human-to-human infection varies widely: MERS is hardly contagious, SARS limited while Covid 19 is highly contagious.

Air travel:

Patients with Covid 19 should be treated primarily on site and not transported. If this is not possible, they must be transported by ambulance aircraft in total isolation regime.



Concerning multiresistant bacteria


In order to limit the introduction of MRSA (Methicillin-Resistant Staphylococcus Aureus), multiresistant pneumococci, drug-resistant group A streptococci, vancomycin-resistant strains of gram-positive pathogens, and ESBL, all patients, when transferred from a hospital abroad, should ideally be examined for these multiresistant strains, independently of their current illness. However, many hospitals do not carry out these examinations, either due to a lack of facilities, lack of awareness or for other reasons, and repatriation must be carried out anyhow. However, if such results exist, it is important that the host hospital of transmission is advised at the time of repatriation. Routinely, all hospitals in Scandinavia will examine patients repatriated from abroad for the presence of multiresistant bacteria, often by prior admission to a department of infectious diseases.






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