Air and ship traffic regulations and recommendations applicable to Ebola

Air and ship traffic regulations and recommendations applicable to Ebola I. IATA guidelines of October 2011 Accessible at: http://www.iata.org/whatwedo/safety/health/documents/health-guidelinescabin-crew-2011.pdf SUSPECTED COMMUNICABLE DISEASE General Guidelines for Cabin Crew The following are general guidelines for cabin crew when facing a suspected case of communicable disease on board. During an outbreak of a specific communicable disease, the World Health Organization (WHO) or member states may modify or add further procedures to these general guidelines. However, these general guidelines provide a basic framework of response to reassure cabin crew and help them manage such an event. A communicable disease is suspected when a traveller (passenger or a crewmember) has a fever (temperature 38 C/100 F or greater) associated with one or more of the following signs or symptoms: - Appearing obviously unwell - Persistent coughing - Impaired breathing - Persistent diarrhea - Persistent vomiting - Skin rash - Bruising or bleeding without previous injury - Confusion of recent onset Note 1: This list of signs and symptoms is identical to that listed in the Health part of the ICAO Aircraft General Declaration and in the World Health Organization International Health Regulations (2005) 2nd Edition. Note 2: If food poisoning from in-flight catering is suspected, proceed as per companyestablished protocol. The captain still has to follow the ICAO procedure of section 13 below. Note 3: If temperature of the affected person is normal but several travellers have similar symptoms, think of other possible public health issues such as chemical exposure. 1. If medical support from the ground is available, contact that ground support immediately and/or page for medical assistance on board (as per company policy). 2. If medical ground support and/or on board health professional is available, crew should follow their medical advice accordingly. 3. If no medical support is available, relocate the ill traveller to a more isolated area but only if two rows can be cleared immediately in front of a solid bulkhead. If the ill traveller is relocated, do not reuse the vacated seat and make sure that the cleaning crew at destination is advised to clean and disinfect both locations.

4 Designate one cabin crew member to look after the ill traveller, preferably the crew member that has already been dealing with this traveller. More than one cabin crew member may be necessary if more care is required. 5 When possible, designate a specific lavatory for the exclusive use of the ill traveller. If not possible, clean and disinfect the commonly touched surfaces of the lavatories (faucet, door handles, waste bin cover, counter top) after each use by the ill traveller. 6. If the ill traveller is coughing, ask him/her to follow respiratory etiquette: i. Provide tissues and the advice to use the tissues to cover the mouth and nose when speaking, sneezing or coughing. ii. Advise the ill traveller to practice proper hand hygiene. If the hands become visibly soiled, they must be washed with soap and water. iii. Provide an airsickness bag to be used for the safe disposal of the tissues. 7. If a face mask is available, the ill traveller should be asked to wear it. As soon as it becomes damp/humid, it should be replaced by a new one. These masks should not be reused and must be disposed safely after use. After touching the used mask (e.g., for disposal), proper hand hygiene must be practiced immediately. 8. If the ill traveller cannot tolerate a mask or refuses it, the designated cabin crew member(s) or any person in close contact (less then 1 metre) with the ill person should wear a mask. The airline should ensure that their cabin crewmembers have adequate training in its use to ensure they do not increase the risk (for example by more frequent hand-face contact or by mask adjustment, or by repeatedly putting it on and off.) 9. If there is a risk of direct contact with body fluids, the designated cabin crew member should wear disposable gloves. Gloves are not intended to replace proper hand hygiene. Gloves should be carefully removed as per training syllabus and discarded as per paragraph (10) and hands should be washed with soap and water. An alcohol-based hand rub can be used if the hands are not visibly soiled. 10. Store soiled items (used tissues, face masks, oxygen mask and tubing, linen, pillows, blankets, seat pocket items, etc.) in a biohazard bag if one is available. If not, use a sealed plastic bag and label it biohazard. 11. Ask accompanying traveller(s) (spouse, children, friends, etc.) if they have any similar symptoms. 12. Ensure hand carried cabin baggage follows the ill traveller and comply with public health authority requests. 13. As soon as possible, advise the captain of the situation because he/she is required by the International Civil Aviation Organization regulations (ICAO Annex 9, Chapter 8, and paragraph 8.15) and the World Health Organization International Health Regulations (WHO IHR 2005, Article 28(4)) to report the suspected case(s) to air traffic control. Also remind the captain to advise the destination station that cleaning and disinfection will be required. 14. Unless stated otherwise by ground medical support or public health officials, ask all travellers seated in the same row, 2 rows in front and 2 rows behind the sick traveller to complete a passenger locator card if such cards are available on the aircraft or at the arrival station. A general term referring to any action of hand cleansing, performed by means of applying an antiseptic hand rub (i.e., alcohol-based hand rub) if hands are not visibly soiled, or 2

washing one s hands with soap and water for at least 15 seconds. Touching the face with hands should be avoided. Hands should be washed frequently. II. WHO IHR regulations Accessible at: http://www.who.int/topics/international_health_regulations/en/ Article 28 Ships and aircraft at points of entry 1. Subject to Article 43 or as provided in applicable international agreements, a ship or an aircraft shall not be prevented for public health reasons from calling at any point of entry. However, if the point of entry is not equipped for applying health measures under these Regulations, the ship or aircraft may be ordered to proceed at its own risk to the nearest suitable point of entry available to it, unless the ship or aircraft has an operational problem which would make this diversion unsafe. 2. Subject to Article 43 or as provided in applicable international agreements, ships or aircraft shall not be refused free pratique by States Parties for public health reasons; in particular they shall not be prevented from embarking or disembarking, discharging or loading cargo or stores, or taking on fuel, water, food and supplies. States Parties may subject the granting of free pratique to inspection and, if a source of infection or contamination is found on board, the carrying out of necessary disinfection, decontamination, disinsection or deratting, or other measures necessary to prevent the spread of the infection or contamination. 3. Whenever practicable and subject to the previous paragraph, a State Party shall authorize the granting of free pratique by radio or other communication means to a ship or an aircraft when, on the basis of information received from it prior to its arrival, the State Party is of the opinion that the arrival of the ship or aircraft will not result in the introduction or spread of disease. 4. Officers in command of ships or pilots in command of aircraft, or their agents, shall make known to the port or airport control as early as possible before arrival at the port or airport of destination any cases of illness indicative of a disease of an infectious nature or evidence of a public health risk on board as soon as such illnesses or public health risks are made known to the officer or pilot. This information must be immediately relayed to the competent authority for the port or airport. In urgent circumstances, such information should be communicated directly by the officers or pilots to the relevant port or airport authority. 5. The following shall apply if a suspect or affected aircraft or ship, for reasons beyond the control of the pilot in command of the aircraft or the officer in command of the ship, lands elsewhere than at the airport at which the aircraft was due to land or berths elsewhere than at the port at which the ship was due to berth: (a) the pilot in command of the aircraft or the officer in command of the ship or other person in charge shall make every effort to communicate without delay with the nearest competent authority; (b) as soon as the competent authority has been informed of the landing it may apply health measures recommended by WHO or other health measures provided in these Regulations; (c) unless required for emergency purposes or for communication with the competent authority, no traveller on board the aircraft or ship shall leave its vicinity and no cargo shall be removed from that vicinity, unless authorized by the competent authority; and (d) when all health measures required by the competent authority have been completed, the aircraft or ship may, so far as such health measures are concerned, proceed either to the airport or port 3

at which it was due to land or berth, or, if for technical reasons it cannot do so, to a conveniently situated airport or port. 6. Notwithstanding the provisions contained in this Article, the officer in command of a ship or pilot in command of an aircraft may take such emergency measures as may be necessary for the health and safety of travellers on board. He or she shall inform the competent authority as early as possible concerning any measures taken pursuant to this paragraph. III. International Civil Aviation Organization regulations (ICAO) Accessible at: http://www.icao.int/publications/pages/doc7300.aspx Annex 9, Chapter 8, and paragraph 8.15 to the Convention on International Civil Aviation Annex 9 Facilitation, Chapter 1 (Definitions) and Chapter 8, 8.12 and 8.15, and Appendix 1 (Health Part of Aircraft General Declaration), provides for relevant additional information related to the subject of communicable disease and public health risk on board an aircraft including need for compliance with the pertinent provisions of the WHO, International Health Regulations (2005). ICAO Annex 9, paragraph 8.15, requires that the pilot-in-command of an aircraft shall ensure that a suspected communicable disease is reported promptly to air traffic control for onward timely notification to public health authority, in order to facilitate provision for the presence of any special medical personnel and equipment necessary for the management of public health risks on arrival at destination aerodrome. Annex 9, paragraph 8.16 requires a contracting State to establish a national aviation plan in preparation for an outbreak of a communicable disease posing a public health risk or public health emergency of international concern. The guidance in developing a national aviation plan or the ICAO Template for a National Aviation Public Health Emergency Preparedness Plan can be found on the CAPSCA website www.capsca.org. Briefly an aviation preparedness plan should effectively link all relevant aviation stakeholders (including both public and private sector entities) within the national preparedness plan and in particular, the National Civil Aviation Authority should collaborate with the National Public Health Authority. IV. WHO Travel and transport risk assessment: Recommendations for public health authorities and transport sector Accessible at: http://www.who.int/ith/updates/20140421/en/ 1. Summary of epidemiological facts and experience The incubation period of Ebola virus disease (EVD) varies from 2 to 21 days. Person-toperson transmission by means of direct contact with infected persons or their body fluids/secretions is considered the principal mode of transmission. In a household study, secondary transmission took place only if direct physical contact occurred. No transmission was reported without this direct contact. Airborne transmission has not been documented during previous EVD outbreaks. There is no risk of transmission during the incubation period and only low risk of transmission in the early phase of symptomatic patients. The risk of infection during transport of persons can be further reduced through use of infection control precautions (see paragraphs 3.2 and 3.3). 4

In the current outbreak, infected travellers have crossed land borders with neighbouring countries and there is a possibility that other cases might occur in neighbouring countries. Historically, several cases of haemorrhagic fever (Ebola, Marburg, Lassa, Crimean Congo haemorrhagic fever) disease were diagnosed after long distance travel but none developed the symptoms during the international travel. Long-distance travellers (e.g. between continents) infected in affected areas could arrive while incubating the disease and develop symptoms compatible with EVD, after arrival. 2. Risk of EVD for different groups 2.1. Tourists and businessmen/women returning from affected areas in a country The risk of a tourist or businessman/woman becoming infected with Ebola virus during a visit to the affected areas and developing disease after returning is extremely low, even if the visit included travel to the local areas from which primary cases have been reported. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animal, all unlikely exposures for the average traveller. Tourists are in any event advised to avoid all such contacts. 2.2. Visiting families and relatives The risk for travellers visiting friends and relatives in affected countries is similarly low, unless the traveller has direct physical contact with a sick or dead person or animal infected with Ebola virus. In such a case, contact tracing should confirm the exposure and prevent further spread of the disease through monitoring the exposed traveller. 2.3. Patients travelling with symptoms and fellow travellers There is a possibility that a person who had been exposed to Ebola virus and developed symptoms may board a commercial flight, or other mode of transport, without informing the transport company of his status. It is highly likely that such patients would seek immediate medical attention upon arrival, especially if well informed, and then should be isolated to prevent further transmission. Although the risk to fellow travellers in such a situation is very low, contact tracing is recommended in such circumstances. 2.4. Risk for health care workers posted in affected areas There is a risk for healthcare workers and volunteers, especially if involved in caring for EVD patients. However, if the recommended level of precaution for such settings is implemented, transmission of the disease should be prevented. The risk level can be considered very low to low unless these precautions are not followed, e.g. no personal protective equipment, needle stick injury etc. 3. Recommendations for public health authorities and transport sectors 3.1. Recommendations for countries 3.1.1. Raise the awareness and knowledge of travellers Travellers leaving for or arriving in an area where EVD is occurring should be provided at points of entry (e.g. in airports or ports on boarding or arrival areas or at ground crossing points) with information on the potential risk of EVD (see proposed template below). Information should also be spread among communities that may include cross-border travellers and near all relevant international borders. 5

The information provided should emphasize that travellers or residents in the affected areas of countries can minimize any risk of getting infected if they avoid: Contact with blood or bodily fluids of a person or corpse infected with the Ebola virus. Contact with or handling of wild animals, alive or dead or their raw or undercooked meat. Having sexual intercourse with a sick person or a person recovering from EVD for at least 7 weeks. Having contact with any object, such as needles, that has been contaminated with blood or bodily fluids. Travellers should be informed where to obtain medical assistance at the destination and who to inform (e.g. through hotline telephone numbers). Returning visitors from the affected areas should be alerted that if they develop infectious disease symptoms (such as fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, rash, or bleeding) within three weeks after return or if they suspect that they have been exposed to Ebola virus (e.g. volunteers who worked in healthcare settings) in the affected areas, they should seek rapid medical attention and mention their recent travel to the attending physician. Template message for travellers and EVD Ebola Virus Disease is rare. Infection is by contact with blood or body fluids of an infected person or an animal infected or by contact with contaminated objects. Symptoms include fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, and in some cases, bleeding. Cases of Ebola have recently been confirmed in XXX and YYY. Persons who come into direct contact with body fluids of an infected person or animal are at risk. There is no licenced vaccine. Practice careful hygiene. Avoid all contact with blood and body fluids of infected people or animals. Do not handle items that may have come in contact with an infected person s blood or body fluids. If you stayed in the areas where Ebola cases have been recently reported seek medical attention if you feel sick ( fever, headache, achiness, sore throat, diarrhoea, vomiting, stomach pain, rash, or red eyes). 3.1.2. Raise the awareness and knowledge of health care providers Health care providers managing returning travellers need to question them on travel history and consider the possibility of EVD in person coming back from affected areas. A person suspected of having been exposed to Ebola virus should be evaluated regarding the risk of exposure. 6

If the risk of exposure is considered very low, the person should be reassured, asked to monitor his/her temperature and symptoms for 21 days and seek immediately care if developing symptoms. Other pathologies (e.g. malaria) should be investigated and the patient monitored regularly. Admission to hospital in these observation phases is not necessary. Essential information to be provided to health care providers should include the following: The most common symptoms experienced by persons infected with the virus are the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and at advanced stage, both internal and external bleeding. Laboratory findings include low white blood cells and platelet counts and elevated liver enzymes. The incubation period (interval from infection to onset of symptoms) varies between 2 to 21 days. People are infectious as long as their blood and secretions contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to seven weeks after recovery from illness. Malaria, typhoid fever, shigellosis, leptospirosis, yellow fever, dengue and other viral haemorrhagic fevers are differential diagnoses to consider in these patients. If the risk of exposure is deemed high, (e.g. a healthcare worker having experienced a needle stick injury with a potentially contaminated needle) a transfer to a specialized centre should be considered. More information can be obtained at: Disease Outbreak News (DON) on Ebola Ebola virus disease fact sheet 3.1.3. Prepare health system response In anticipation of EVD introduction, public health authorities need to: Sensitise staff working at points of entry, in healthcare settings or involved in first response (emergency departments, ambulance services, GP offices, fire department, civil defence, airport operators, aircraft operators, port health authority) for early and advanced symptoms of viral haemorrhagic fever. Emphasize systematic recording in health clinics of travel history of those with relevant symptoms. Establish a standard diagnostic procedure for EVD and for common differential diagnoses at an early stage (e.g. malaria, dengue, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis, yellow fever and other viral haemorrhagic fevers). Establish a protocol for notification to the competent public health authorities at an early stage if an EVD case is suspected. Identify and establish laboratory procedures and operational channels to perform Ebola virus diagnostic testing in the country or refer to the closest WHO Collaborating Centre or 7

reference laboratories able to perform viral haemorrhagic fever diagnostics if cases are suspected. Ensure basic training of health care workers on principles of provisional barrier and use of personal protective equipment. Emphasize to personnel working in the travel sector the importance of infection control methods. Keep the regulatory authorities (e.g. national civil aviation authority) informed and involved in decision-making. If a case of EVD is suspected in a traveller, health care facilities attending the individual should apply the same procedures as if the EVD has already been confirmed. This includes: Implementing contact tracing among staff and patients who have been in direct contact with the suspected patient. Setting up medical monitoring of identified contacts (fever and prodromal symptoms); Notifying immediately to the competent public health authorities. Ensuring barrier management in all areas where the suspected patient has been treated (contaminated zone, transition or sluicing zone, clean zone). Retaining waste and any type of body fluids from patient s side in the contaminated zone until appropriate decontamination and disposal provisions are in place. Handling and shipping patient s samples according to the international procedures for transport of category A infectious substances. Suspect cases coming from areas affected (e.g. returning travellers with symptoms) identified on an aircraft) should immediately receive medical attention and be isolated to prevent further transmission (see 3.2). 3.1.4. Screening passengers at points of entry ( ports, airports or ground crossing) is not recommended Screening of passengers at points of entry (arrival or departure) is costly and expected to have very limited impact because it is very unlikely to detect any arriving person infected with EVD. This is particularly true for EVD with its incubation period of 2 to 21 days and symptoms that are not specific. As part of this, the use of thermal scanners that rely on the presence of fever in arriving passengers is costly, unlikely to detect any arriving person infected with EVD and is not encouraged. Travel restrictions, closure of borders at points of entry are not recommended 3.2. Recommendations for international air transport In case of a passenger presenting with symptoms compatible with EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding) on board of an aircraft, the following measures should be immediately considered, in accordance with operational procedures recommended by the International Air Transport Association (IATA): Distancing of other passengers if possible from the symptomatic passenger (re-seating); with the ill travellers preferably near a toilet, for his/her exclusive use. 8

Covering nose and mouth of the patient with a surgical facemask (if tolerated). Limiting contacts to the passenger to the minimum necessary. More specifically, only one or two (if ill passenger requires more assistance) cabin crew should be taking care of the ill passenger and preferably only the cabin crew that have already been in contact with that passenger. This cabin crew should be using the Universal Precaution Kit (see below). Hand washing with soap after any direct or indirect contact with the passenger. Immediate notification of authorities at the destination airport in accordance with procedures promulgated by the International Civil Aviation Organization (ICAO). Immediate isolation of passenger upon arrival. Dedicated crew member to assist the ill traveller, should be using suitable personal protection equipment (PPE) such as that recommended by ICAO Universal Precaution Kit (http://www.capsca.org/capscarefs.html) for dealing with the traveller and for cleaning procedures on board as needed. The possibility of transmission to other co-passengers and crew on board the aircraft should be assessed by health care providers on arrival. If the investigation concludes that the passenger has symptoms compatible with EVD and had a risk exposure in affected countries in the past 21 days, passengers as well as crew members may be at risk if they have been in direct contact with body fluids or heavily contaminated objects. The following epidemiological measures based upon proximity to the index patient should be considered: Passengers and crew with reported direct contact To gather this information, any records of significant events on the flight should be obtained from the airline. Co-travellers and crew members who report direct body contact with the index case should undergo contact tracing. Passengers seated in an adjacent seat to the index patient As direct contact is the main route of transmission for Ebola virus, only passengers who were seated in an adjacent seat to the index case on the side, in front or behind, including across an aisle, should be included in contact tracing. Cleaning staff of affected aircraft section If the case is suspected or diagnosed after leaving the aircraft, the staff who cleaned the section and seat where the index case was seated should also undergo contact tracing. At the request of airport or port health authority, airlines may also ask some or all passengers to provide information on their itinerary and their contact details where there is a particular reason to believe they may have been exposed to infection on board of aircraft (e.g. per the ICAO public health passenger locator form)1. Additionally, countries may consider requiring arriving aircraft to complete and deliver the health part of the aircraft general declaration (in those cases where the information is not communicated to the airport of arrival while in flight) concerning persons on board with communicable diseases or sources of infection (IHR Annex 9). Passengers, crew members and cleaning staff who have been identified through contact tracing should be assessed for their specific level of exposure. Passive self-monitoring of 9

temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day) for those at higher risk level should be continued for 21 days. These measures should also be considered if an individual, who experienced symptoms during the flight, has been identified as a suspect of EVD after arrival. References IATA guidelines for air crew to manage a suspected communicable disease or other public health emergency on board IATA guideline for cleaning crew for an arriving aircraft with a suspected case of communicable disease ICAO Health related documents (1) Procedures for Air Navigation Services; (2) Annex 6 Medical Supplies WHO Aviation Guide which includes information on sanitizing of aircraft 3.3. Recommendations for ships In case of a passenger presenting with symptoms compatible with EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding) on board of a ship, the following precautions must be applied: Keep his/her cabin doors closed, if not placed in an medical isolation room on board. Provide information about the risk of Ebola transmission to persons who will take care of the patient or enter the isolation area. A log listing all people entering the cabin should be maintained. Anyone who enters the cabin to provide care to the person in isolation or to clean the cabin must wear PPE with : A surgical protection mask; and eye protection or a face shield Non-sterile examination gloves or surgical gloves; Disposable impermeable gown to cover clothing and exposed skin. A waterproof apron should be worn over a non-impermeable gown or when coming in close contact with the person in isolation Before exiting the isolation the PPE should be removed in such a way as to avoid contact with the soiled items and any area of the face. Limit the movement and transport of the patient from the cabin for essential purposes only. If transport is necessary, the patient should wear a surgical mask. Clean and disinfect spills without spraying or creating aerosol. Used linen, cloths, eating utensils laundry and any other item in contact with a patient s body fluids should be collected separately and disinfected in such a way as to avoid any creation of aerosol or any contact with persons or contamination of the environment. Effective disinfectant is a dilution of sodium hypochlorite at 0.05 or 500 ppm available chlorine, with a recommended contact time of 30 minutes. All waste produced in the isolation cabin must be handled according to the protocol of the ship for clinical waste. If incinerator is available on board, then waste must be incinerated. If 10

waste must be delivered ashore, then special precautions are needed and the port authority should be informed before waste delivery. Start case investigation immediately. Protective equipment is not required when interviewing asymptomatic individuals, when a distance of one metre is maintained. Close contacts should be identified and asked to do passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day and for 21 days. In the event of a suspected diagnosis of EVD on a ship, immediate expert medical opinion should be sought and the event must be reported as soon as possible to the next port of call by the Captain. The patient should disembark in such a way as to avoid any contact with healthy travellers and wearing a surgical mask. Personnel in contact with the patient during the medical evacuation should wear a surgical protection mask and PPE. The competent authority at port may need to arrange depending on the situation: medical evacuation or special arrangements for disembarkation and hospitalization of the patient and laboratory diagnosis. Passengers, crew members and cleaning staff who have been identified through contact tracing should be assessed for their specific level of exposure. Passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day) for those at higher risk level should be continued for 21 days. At the request of a governmental port health authority, ship operators shall also facilitate obtaining, from some or all passengers, to provide information on their itinerary and their contact details (should they need to be contacted) when there is a particular reason to believe they may have been exposed to infection on board of the ship. Additionally, countries may consider requiring arriving ships to complete and deliver the Maritime Declaration of Health (IHR Annex 8). Measures taken on board should also be noted on the IHR Ship sanitation control certificate (IHR Annex 3) -------------------------------------------------------------------------------- 1ICAO passenger locator form Annex 9 Appendix 13 http://www.icao.int/safety/aviationmedicine/pages/guidelines.aspx 11