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Barb Henry, MSN, APRN-BC Northern Kentucky University DNP 801 Epidemiology

Air Travelers Beware! Respiratory infection is a leading cause of seeking medical care in returning travelers and occurs in up to 20% of travelers. Respiratory infections may be almost as common as travelers diarrhea.

I recall anecdotal data of my own and friends cases of sore throat, colds, and flu bugs after airplane trips over the years (endemic?). I also recall passengers near me who were ill, coughing/sneezing/blowing their noses on tissue, then touching surfaces without hand washing/sanitizing as they make their way back to the bathroom shared by all passengers on the flights! Ive also had vomiting and diarrhea after plane trips, less often than respiratory infections. Surface contact, infected passengers, and/or food or beverages sources on the plane lead to these illnesses.
Laroque & Ryan, 2013.

More Facts on Airplane Acquired Infectious Disease Because of my own experience with airplane acquired infection, I chose this topic for my midterm project. Direct airborne transmission on airplanes is reported to be unusual because of frequent air recirculation and filtration, although sporadic cases of SARS, influenza, tuberculosis, and other diseases have occurred. Infections may be transmitted between passengers who are seated near one another, usually through direct contact or droplets. Air-pressure changes during ascent and descent may be causal factors for sinusitis and otitis media. Other infection sources: Intermingling of large numbers of people in airports, travel stress weakening immune systems, transport vehicles, and hotels.
Laroque & Ryan, 2013.


Pictured are: Airport toilet, Airplane Toilet & Sink, Air Vent & Light Buttons, Airplane Bathroom Door Locks/Handles, Airport Waiting Areas, Check In, Baggage Claim, Ticket Kiosk, Airport Carpet

Photographs by Barb Henry, 2013.

Risk Factors for Airplane Acquired Infection 1) Passenger Immunity 2) Infectiousness of the Source Organism 3) Degree of Pathogen Shedding by Infected Passengers 4) Hygiene Practices of Infected Passengers 5) Proximity to Infected Passengers 6) Hygiene Practice of Other Passengers & Crew 7) Duration of Flight 8) Airplane Cabin Environment
Quinlisk, Redd, Dayan, Gallagher, Lutz, Marienau, & Averhoff, 2006.

Situation #1 Negative Mouth is not completely covered allowing for droplet spread of pathogens
Hand is used to partially catch germs allowing germs to also be spread to surfaces contacted by the hand in addition to the droplet spread
Photo by Barb Henry, 2013.

Situation #1 Positive The cough or sneeze droplets are caught by the passengers sleeve rather than the hand.

Sleeve is used to catch more germs than coughing/sneezing with mouth uncovered or only partially covered by hand, germs on sleeve are less likely to contact surfaces than hands decreasing the likelihood of contact with non-infected passengers
Photo by Barb Henry, 2013.

Situation #1 Positive After coughing or sneezing. hand sanitizer or hand washing are the best way to prevent spread of infection Proper hand washing and hand sanitizing should be done by passengers and crew

Photo by Barb Henry, 2013.

Case Example of Air Travel Outbreak-Mumps The Iowa Department of Public Health identified two passengers who had mumps and were potentially infectious during travel on nine different commercial flights involving two airlines during March 26--April 2, 2006. The commercial airline flights identified with a potentially infectious traveler were listed by date, carrier, and flight number:

Persons on the flights who had mumps symptoms within 21 days of travel were asked to seek evaluation by a health-care provider. Providers were asked to conduct surveillance for mumps among persons with parotitis or salivary gland inflammation and report suspected mumps cases to public health officials.

Quinlisk, et al., 2006.

Case Example-Mumps This investigation used a new software application, eManifest, developed by the CDC Division of Global Migration and Quarantine (DGMQ). eManifest allowed public health officials to securely import, sort, and assign passenger-locating information to jurisdictions and identify of exposed persons. This data was securely transmitted to state and territorial health departments via the Epidemic Information Exchange (Epi-X) Forum (available at to notify potentially exposed passengers. The next slide illustrates the epi curve for 216 confirmed, probable and suspect cases of mumps in Iowa.

Quinlisk, et al., 2006.

Figure 1 from: Quinlisk, Harris, Thornton, & Flamigni, 2006.

The reason this was a mumps epidemic is that after introduction of the mumps vaccine (1967) & widespread immunization with 2 MMR childhood vaccines (1977), incidence of mumps decreased dramatically. 216 cases of mumps in a 3 month period is well above the number of cases that would normally be expected in 2006 and later years.
Quinlisk, et al., 2006.

Patient with bilateral swelling in his submaxillary region due to mumps

Source: Centers for Disease Control and Prevention

Vehicle Transmission of Germs on Planes

Headache, fatigue, fever or breathing problems can occur from low barometric pressure, oxygen content and humidity in the air cabin, jet lag, sleep deprivation, stress, cramped seating, motion sickness, discomfort from vibration and engine noise, and engine fumes that can seep into the cabin. Infections can also occur as a result of airplane water or food contamination. The water in on-flight tanks, especially if filled from contaminated water sources can cause infection. Long or repeated storage within the tank can, despite best efforts, result in bacterial growth. If you dont want to drink the water in the country from whence the flight originated, dont drink the water from the plane tank. Bottled water is always the safest way to maintain hydration.
Quinlisk, et al., 2006.

Vehicle Transmission of Germs on Planes

Airlines offer food wrapped in plastic wrap for sale on flights. A passenger would be unable to determine how long this food has been stored or how hygienically this food was prepared. passengers.
Microwave airplane food served in the past may have reduced bacteria killed by heat. Cold sandwiches sold on planes now would more likely harbor germs, particularly if not refrigerated at proper temperatures. On a recent flight, water bottles given out by airlines in the past were replaced with plastic glasses of water poured from pitchers. This change was most likely due to cost, but may also increase the risk of transmitting bacterial or viral infections from contaminated water sources. One is also at risk of contracting germs from flight attendant hands/droplets.

Reichman, 2006.

Situation #1 Negative
Water poured from pitcher. Sources of possible germ transmission: contaminated water source, pitcher, glasses, server hands or droplets.

Photo by Barb Henry, 2013.

Situation #2 Positive Water bottled under sanitary conditions. One might use an antiseptic wipe to clean the bottle and lid before opening if server droplet exposure is suspected.

Photo by Barb Henry, 2013.

Case Example of Foodborne or Waterborne Outbreaks Noro virus outbreaks have been reported from airplane travel, though in recent years we learned about noro virus outbreaks on cruise ships and in other places. Transmission of noro virus occurs by three general routes: personto-person, foodborne, and waterborne. Person-to-person transmission of noro virus could occur directly through the fecal-oral route, by ingestion of aerosolized vomitus, or by indirect exposure from contaminated environmental surfaces. I was impressed with how clean the airplane bathroom was, though one would wonder how often all surfaces are thoroughly cleaned/sanitized. Eating before plane trips, using sanitizers, avoiding touching multiple surfaces and exposures will prevent epidemics like noro virus as well as more common infections.
CDC, 2011.

The epi curve in this chart tracks multiple outbreaks of gastroenteritis during a 3 year period; some from noro virus (light purple), others from non-noro virus (dark purple) sources, a propagated epi curve rather than single source. CDC, 2011.

The pie chart in the left documents known causes of foodborne illness outbreaks during 4 years when the noro virus first became known in the U.S. The figure on the right shows the where of norovirus confirmed cases; airplanes were not a common source for this epidemic though air travel was a mode of transmission.. CDC, 2011.

Severe Acute Upper Respiratory Syndrome (SARS) In 2003, the World Health Organization (WHO) issued a historic global alert for SARS, a deadly new infectious disease with the potential for rapid spread from person to person and via international air travel. The SARS epidemic illusted the potential for a new disease to suddenly appear and spread, leading to widespread health, social, and economic consequences. This was an impressive case of appropriate public health measures-surveillance, infection control, isolation, and quarantineto contain and control the outbreak. There were only 11 reported SARS cases in the US as the mortality/morbidity table on the following slide shows; a total of 264 cases worldwide as of 3/19/2003-11 years ago. Most of us remember the images of people in the nightly news wearing masks in the countries listed at the top of this table.
CDC, 2005.

Severe Acute Upper Respiratory Syndrome (SARS)

CDC, 2005.

A summary of air travel infection prevention can be found at: /38034186#.UTv8pp0o5Zd
(Please ignore/fast forward the 15 second ad at the beginning of the video!)

Dr. Reichman makes the point that you should take a napkin or tissue to use to open the door handle on the bathroom. The video displays other sanitizing items you can put together for airplane trips, like the travel size sanitizing wipes pictured on this slide. Sanitizers should be 60% alcohol or higher in order to effectively reduce germs.

Reichman, 2006.

Review of Epidemiology Principles

I am including the next 7 slides to reinforce my own learning thus far in this course, followed by 3 reference slides.

Epidemiology Is-the study of the distribution and determinants of disease frequency. health conditions, diseases, & health practices in populations. causation, patterns, & control of diseases in populations. the burden of disease occurring in a population Composed of systematic analyses of health-related issues in population health inductive causal inferences statistical analytic strategies Terms Associationthe interdependence of two or more events, factors, characteristics, or variables. Carriera source that harbors a specific infectious agent and is a potential source of infection.

Epidemiologists in History

JOHN SNOW was an English physician known for cholera studies; viewed as the father of contemporary epidemiology. His best-known studies: investigation of Londons Broad Street pump outbreak in 1854, and a study comparing waterborne cholera cases in two regions of Londonone receiving sewage-contaminated water and the other receiving relatively clean water. Snow showed innovative reasoning and approach to the control of this deadly disease. Snows reputation in anesthesiology, specifically in regard to his knowledge of ether and chloroform, was such that he was asked to administer chloroform to Queen Victoria when she gave birth.

Frerichs, 2009.

Summary of Learning & Epidemiology Principles

Casea person who has a specified health condition or disease

Causationan event, condition, or agent necessary in occurrence of some cases in a given condition Confoundingeffect of the exposure is mixed with other variable(s); also termed confusion of effects Cohortany designated group of individuals followed or traced over time, to measure occurrence Controla person or group that does not have the condition studied Etiologic agentagent postulated to cause a disease Endemica constant low-level presence of a disease, infection, or a health condition Epidemicdisease/condition occurrence clearly in excess of the numbers of cases found/expected; an outbreak when occurring in a limited population. Incubation periodtime between first infectious contact and appearance of disease symptoms

Epidemiologists in History
At the end of the Second World War, Britain had the highest incidence of lung cancer in the world. For the first time lung cancer deaths exceeded those from tuberculosis - and no one knew why. In 1950, RICHARD DOLL concluded in a research paper that smoking cigarettes was a cause and an important cause of the rapidly increasing epidemic of lung cancer. His historic and contentious finding marked the beginning of a life-long crusade against premature death and the forces of Big Tobacco. A political revolutionary and an epidemiologist with a Darwinian heart-of-stone, Doll steered a course through a minefield of medical and political controversy. Opponents from the tobacco industry questioned his science, while later critics from the environmental lobby attacked his alleged connections to the chemical industry. An enigmatic individual, Doll was feared and respected throughout a long and wide-ranging scientific career which ended only with his death in 2005.
Keating, 2009.

Summary of Learning & Epidemiology Principles

Morbidity: Refers to the presence of disease in a population

Mortality: Refers to the occurrence of death in a population Multi-causalityevery causal mechanism involves the joint action of several component factors Pandemicemergence of a new infectious agent, against which the human population has no immunity, resulting in several simultaneous epidemics worldwide Prevalencemeasures of new and existing cases in a population, with and without disease Incidence-the number of new cases of disease that develop in the population during a defined period. Riskan exposure or characteristic associated with increased probability of a health-related condition. Determinants, Occurrence, Distribution. Control, Pattern Still Learning About: Measures of frequency-Counts and rates, Measures of association, Relative risk, Odds ratio. Statistical inference. P-value, and Confidence limits, Hypotheses-Method of difference, agreement, concomitant variation, and analogy

Epidemiologists in History-Florence Nightingale

Nightingales coxcomb figure is now used in the Oncology Nursing Society Logo, ONS, n.d.


What (case definition) Who (person) Where (place) When (time) How many (measures)

MEASURES Counts Times Rates Risks/Odds Prevalence METHODS Design Conduct Analysis Interpretation

ALTERNATIVE EXPLANATIONS Chance Bias Confounding INFERENCES Epidemiologic Causal

ACTION Behavioural Clinical Community Environmental


Why (Causes) How (Causes)

Chaturvedi, N.D.

References Centers for Disease Control (CDC), (2013). Mumps photos. Retrieved from: Chaturvedi, K. (n.d.) Epidemiology Concepts. Power Point Presentation. CDC. (2012). Norovirus Trends & Outbreaks. Retrieved from: CDC. (2011). Updated Norovirus Outbreak Management and Disease Prevention Guidelines. MMWR Vol. 60 (3) pp. 1-12. Retrieved from: Fleischauer, A. (2003). Outbreak of Severe Acute Respiratory Syndrome Worldwide, 2003. MMWR Frerichs, R. (2009). John Snow. Retrieved from:

References Gordis, L. (2009). Epidemiology 4th ed. Philadelphia: Elsevier Saunder. (ISBN10: 1416040021 and ISBN-13: 978-1416040026) Keating, C. (2009). Smoking Kills: The Revolutionary Life of Richard Doll. Retrieved from:

Laroque, C., & Ryan, E. (2013). Respiratory infections. Chapter 2 in Travelers Health. Retrieved from:
Macha, K. & McDonough, J.P. (2011). Epidemiology for Advanced Nursing Practice, (1st Ed.). New York: Jones & Bartlett. ISBN-10: 0763789968 and ISBN-13: 978-0763789961)

Oncology Nursing Society. (n.d.) ONS A New Look the Same Dedication. Retrieved from: ewbranding.pdf

References Quinlisk, P., Redd, S., Dayan, G., Gallagher, N., Lutz, P., Marienau, K., & Averhoff, F. (2006). Exposure to Mumps During Air Travel United States, April 2006. MMWR Weekly. April 11, 2006 55 (Dispatch) 1-2. Retrieved from: d=mm55d411a1_e

Quinlisk, P., Harris, M., Thornton, T., & Flamigni, L. (2006). Mumps Epidemic Iowa, 2006. MMWR Weekly. April 7, 2006 55 (13) 336-3692. Retrieved from:
Reichman, J. (2006). Germs on a plane: Can you get sick from flying? Retrieved from: