Ebola Updates

Precautions Against Virus

Ebola Guidance for Airlines: Interim Guidance about Ebola Infection for Airline Crews, Cleaning Personnel, and Cargo Personnel
U.S. Centers for Disease Control and Prevention, Atlanta <www.cdc.gov/quarantine/air/managing-sick-travelers/ebola-guidance-airlines.html>. Sept. 19, 2014.

This page on the public website maintained by the U.S. Centers for Disease Control and Prevention (CDC) provides airline personnel access to the latest authoritative information about Ebola — which health care professionals call Ebola virus disease. As a preliminary point, it says that “the risk of spreading Ebola to passengers or crew on an aircraft is low because Ebola spreads by direct contact with infected body fluids. Ebola does not spread through the air like flu.”

Precautions against such direct contact, however, rely on aircraft crewmembers to always follow basic infection control precautions and procedures — such as strictly applying their training on hand hygiene — applicable to any type of infectious disease. Above all, this means treating all body fluids as though they are infectious. When warranted, crews also are expected to follow their routine procedures for retrieving and wearing airline-furnished personal protective equipment, stored in a universal precautions kit, CDC said.

“Ebola spreads through direct contact by touching the blood or other body fluids (like feces, saliva, urine, vomit and semen) of a person who is sick with Ebola,” the website guidance says. “Infected blood or other body fluids can spread Ebola through breaks in your skin or if they get into your eyes, nose, or mouth. … Employers must provide protective clothing and equipment for workers who may perform tasks that could result in exposure to Ebola virus. This would include employees whose work tasks include cleaning up blood, vomit or other body fluids from a sick passenger.”

The website’s information and links help airline workers with relevant duties to be effective in preventing people with symptoms of Ebola (and any other serious contagious disease) from boarding the aircraft; in managing sick travelers aboard the aircraft and properly reporting their condition to health care professionals and public health authorities; in protecting themselves, aircraft crewmembers and passengers from infection; and in post-flight cleaning of the airplane and the disinfection of contaminated areas.

The reporting duty is significant, CDC says, partly because, “If a traveler is confirmed to have had infectious Ebola on a flight, CDC will conduct an investigation to assess risk and inform passengers and crew of possible exposure. … Reporting to CDC does not replace usual company procedures for in-flight medical consultation or getting medical assistance.”

Exposure Risks

One CDC-linked web page maintained by the U.S. Occupational Safety and Health Administration (OSHA; see “Airline-Focused Ebola Knowledge.”) elaborates on the theme of constantly being prepared for exposure. OSHA said, “Workers involved in airline and airport service operations — including flight attendants, cleaning and provisioning staff, and cargo personnel — may be exposed to Ebola virus in a number of scenarios, including exposure to infectious body fluids in lavatories and direct exposure to individuals sick with [Ebola hemorrhagic fever, a previous term for Ebola still in use]. Currently, airline service worker exposure to Ebola virus is unlikely. … Passengers originating from locations affected by the ongoing [Ebola] outbreak pose the greatest hazard to workers in the airline service industry.”

The first stage in managing Ebola exposure to crewmembers and passengers should be invoking the U.S. regulation (and its international counterparts) that permits airlines — specifically, all U.S. airlines and all non-U.S. airlines conducting direct flights to/from the United States — to deny boarding to air travelers with serious contagious diseases that could spread during flight. In the case of an Ebola-infected traveler, this means watching for and recognizing potential Ebola symptoms, such as a specified level of fever, and/or linking the travelers to other defined risk factors such as personal contact, during the preceding 21 days (the longest-known virus incubation period), with a person diagnosed with or suspected of having Ebola or someone who has traveled from a country experiencing an Ebola outbreak.

CDC’s recommended links clarify the difference between an air traveler who may have been infected with Ebola but has no symptoms — such as fever 101.5 degrees F (38.6 degrees C) or higher — and an air traveler who has Ebola symptoms, which indicate that the virus can be spread by direct contact with body fluids infected with the virus.

To manage an in-flight situation in which an ill person is suspected of having Ebola, the CDC says, “It is important to assess the risk of Ebola by getting more information. Ask sick travelers whether they were in a country with an Ebola outbreak. Look for or ask about Ebola symptoms: fever ([the person] gives a history of feeling feverish or having chills), severe headache, muscle pain, vomiting, diarrhea (several trips to the lavatory), stomach pain, or unexplained bleeding or bruising.

“Even if the person has been in a country with Ebola, cabin crew won’t know for certain what type of illness a sick traveler has. Therefore, cabin crew should follow routine infection control precautions for all travelers who become sick during flight, including managing travelers with respiratory illness to reduce the number of droplets released into the air. … [They should] consider providing sick travelers with surgical masks (if the sick person can tolerate wearing one) to reduce the number of droplets expelled into the air by talking, sneezing or coughing.” Airsickness bags, not masks, should be given if the ill person reports feeling nauseated or is vomiting, CDC noted.

Universal precautions for providing direct care to any ill passenger begin with wearing waterproof disposable gloves before directly touching the sick person, blood or other body fluids, and separating the sick person from other airplane occupants to the extent possible. In the specific case of a person who shows the Ebola symptoms and who acknowledges coming from a country with an Ebola outbreak, CDC recommends that the flight attendant(s) “wear a surgical mask (to protect from splashes or sprays), face shield or goggles, and protective apron or gown.” A surgical mask also should be worn by the sick person unless the person is vomiting or nauseated, or he or she should use tissues to cover the nose and mouth when coughing or sneezing, with a plastic bag at hand for waste disposal.

A critical aspect of preventing Ebola infection, CDC says, is awareness that the personal protective equipment worn can transfer infected substances to the wearer or others, and so requires absolutely correct adherence to training for safe removal and disposal — including the precise sequence of donning and removal steps.

Exposure Concerns

The CDC recommends that any airline workers who think they may have been exposed to Ebola immediately notify their company and then follow CDC guidance to self-monitor their health for 21 days. “Watch for symptoms of Ebola: fever (temperature of 101.5 [degrees] F/38.6 [degrees C] or higher), severe headaches, muscle pain, diarrhea, vomiting, stomach pain, unexplained bleeding or bruising. … If you develop symptoms after possible exposure to Ebola, get medical attention right away. Before visiting a health care provider, alert the clinic or emergency room in advance about your possible exposure to Ebola so that arrangements can be made to prevent transmission to health care staff or other patients.”

The web page similarly makes clear the need to adhere to every detail of prescribed aircraft-cleaning procedures to eliminate the possibility of direct contact with Ebola virus, beginning with cabin crew ensuring that the cleaners have been fully informed of the situation. “Disinfection and clean up should include wiping down lavatory surfaces and frequently touched surfaces in the passenger cabin, such as armrests, seat backs, tray tables, light and air controls, and adjacent walls and windows with an Environmental Protection Agency (EPA) registered cleaner/disinfectant that has been tested and approved for use by the airplane manufacturers. … Do not use compressed air, pressurized water or similar procedures, which might create droplets of infectious materials.”

As for air cargo personnel, CDC advises, “Packages or luggage should not pose a risk. Ebola virus is spread through direct contact with blood or body fluids … from an infected person. Don’t handle packages visibly dirty from blood or body fluids. Wash your hands … often to prevent other infectious diseases.”