Villanova University

College of Liberal Arts and Sciences

The Not So Friendly Skies

How Air Travel Can Spread Global Disease and Pandemic

Connor Lees

GEV 3308 – Environmental Health

Professor Leggiadro

December 6th, 2018

Abstract:

Rapid population growth and a globalizing economy have lead to an increase in the need

for humans to travel globally and consequently the amount of people traveling via commercial

air travel has been increasingly rapidly. Air travel is becoming more of a reality across the globe

with massive growth occurring in the Asian-Pacific Region. With this rapid growth in air travel

comes a global health risk. Commercial air travel has the ability to spread infectious diseases and

vaccine preventable diseases across the globe. Just recently there was a situation in which an

aircraft had to be quarantined in NYC due to several passengers being stricken by a mysterious

illness. Researchers have been examining the risks air travel poses for the spread of global

disease, but much more search needs to be done to determine concsluviely the risks posed by air

travel. This paper will discuss the current research findings out their on the topic of global

disease spread caused by air travel.

Introduction:

The earth is going through a period of major change. Global population size is nearing

eight billion people, the economy is becoming increasingly globalized, which is spreading

economic opportunity across the globe, and people are moving from place to place with ease. A

facilitator for a lot of this change is air travel. The International Air Transport Association

forecasts that by 2036 people traveling the friendly skies will nearly double from about 4 billion

people to about 7.8 billion people (2036 Forecast Reveals). Their reasoning for this projection is

the growing need for global connectivity in light of a global economy and large populations. The

IATA states that the biggest driver of demand is the Asia-Pacific region, which will be the

source for over half of these new passengers in the coming two decades (2036 Forecast Reveals).

Forecasters believe China will be the fastest growing market with the US and India following in
its footsteps (2036 Forecast Reveals). Global commerce requires individuals to move from

country to country to fulfill their duties and air travel is the means by which they will travel.

While the growth of air travel may indicate a thriving world with greater economic

opportunities present than were in the past, air travel poses a significant health risk. In the past

decade there has been resurgence in vaccine preventable diseases, even in countries with high

standards of living and easy access to vaccinations. The Global Health Program has been

monitoring the resurgence of these diseases since 2008. There have been several global

outbreaks of measles, mumps, polio, rubella, whopping cough, and other preventable diseases

across the world (Brady 2015). Figure one shows the prevalence of vaccine preventable

infections across the globe in 2008. When compared to figure two, which shows the prevalence

in 2018 there is a clear increase of vaccine preventable infections and disease outbreaks globally

(Vaccine-Preventable). The resurgence of these diseases is not limited to the developing world –

they are happening worldwide. According to figure 2 there is a large outbreak of the measles

across Europe and the United States (Vaccine-Preventable). This begs the question of how and

why this is happening – air travel is a potential answer to that question.

While air travel is not the only means by which these vaccine preventable diseases are

spreading across the developed world it is a potential source that has been studied and has been

making the news recently. On September 5th, 2018 an aircraft departed Dubai, United Arab

Emirates en-route to JFK international Airport in New York City. The Airbus A380 aircraft

contained 520 passengers when it landed in NYC, 100 of which were complaining of symptoms

such as fever, vomiting, and coughing (Roy, “Sick Passengers”). The aircraft was immediately

quarantined by the Centers for Disease Control upon landing in NYC. Nineteen of these

passengers turned out to be sick – 10 of which were shipped off to an area hospital for further
treatment and evaluation (Roy, “Sick Passengers”). The mysterious sickness was later

determined by public health officials to be the flu (Influenza Caused). Given the departure

location of the aircraft and the fact that the Hajj was occurring in Mecca there was some

concerns that the ill passengers were infected with MERS or Middle East Respiratory Syndrome

(Brueck, “Harvard Professor Says”). Fortunately, in this instance this was not the case.

However, experts in the field say that this event was a warning shot. Experts agree that this could

have been a very different story if the infection had been something deadly. Harvard professor of

epidemiology Marc Lipsitch stated, “there’s inadequate surveillance around the world of human

illness to really detect infections,” (Brueck, “Harvard Professor Says”). This was not the only

example of passengers taking ill, two flights bound for Philadelphia the same week also had

passengers with similar symptoms though these flights were not quarantined.

The purpose of this paper is to examine the ability of air travel to spread diseases and

infections across the globe. The paper will provide a thorough review of the literature that is

currently out there on the topic and discuss possible mitigation strategies as discussed in the

literature. In light of earth’s rapidly expanding population and the rapid growth of air travel, air

travel is becoming increasingly likely to increase the spread of communicable diseases globally.

With billions of passengers traveling the friendly skis annually the risk of spreading a global

pandemic via commercial aircraft is increasing. This paper will examine the research that is

currently out there on the matter and discuss the possible global ramifications of air travel

facilitated disease spread.

Methods of Transmission:
 Unfortunately the impact of air travels on the spread of global infectious diseases has

been studies in a limited capacity though it is a source of major concern. Andrew Pavia tries to

fill some of the void by explaining the ways in which air travel is able to influence the spread of

diseases globally. One of the main ways air travel can spread infectious diseases is through the

spread of airborne droplets or small particle aerosols. Another way that infectious diseases can

be spread is through the food – food prepared by people who are ill or carriers for an infectious

disease can infect those aboard aircraft eating said food and spread the illness to other regions

around the globe. The transport of infected vectors such as mosquitos or rats is also of great

concern. However, perhaps the most pressing and greatest concern for global health is the ability

of a person with a contagious illness to board a plane and travel to virtually any part of the globe

without restriction provided they have a valid passport (Pavia, 2007).

Historical Evidence and Research:

The avian influenza strain H5N1 first appeared in 1997 in Hong Kong. The disease

started when bird to human transmission first occurred. The disease has a high case mortality

rate. A total of 637 cases have been reported in fifteen countries to date– 378 deaths were

confirmed as a result of the illness resulting in a case fatality rate of nearly 60%. Scientists

believe that the next pandemic to kill millions of people will be the result of a particular strain of

the avian influenza. This is where the concern lies; scientists and researchers are concerned that

when the pandemic strain surfaces, it will spread globally within days via air travel especially

given its origination in Asia and the rapid growth of air travel in Asia (Tuncer and Trang, 2014).

In Tuncer and Trang’s paper on this topic they developed mathematical models to analyze the

spread of the avian influenza from Asia or Australia to major locations in the United States. In
their paper they described a two city mathematical model that involved an infected individual

traveling from one city to another. Tuncer and Trang made an important assumption that the flu

could now be transmitted from human to human, which it is currently not able to do. Tuncer and

Trang found that air travel has substantial impacts on the spread of influenza and potentially

pandemic from city to city. The affects are further heightened when travel out of the origin city is

high and vaccination rates are low (Tuncer and Trang, 2014).

Historically there is empirical evidence that air travel increases the speed at which an

illness or infectious disease spreads. In the aftermath of September 11th, 2011 there was a major

drop off in the amount of individuals traveling by air as a result of a federal moratorium on air

travel within the United States and a global fear of traveling; this sudden decline in air travelers

lead to a delay in the onset of the seasonal influenza (Pavia, 2007). Researchers have attempted

in the past to examine the spread of respiratory illnesses, in particular those traveling to Germany

who were suspected of SARS. The issue lies that while people or passengers may develop

respiratory symptoms it is very hard to identify travelers who have a specific illness such as

SARS or tuberculosis. In addition to the inability to properly determine the illness, current

understanding on how respiratory illnesses spread in aircraft is still relatively unknown (Pavia,

2007). In the SARS outbreak investigators examined 40 flights and determined that transmission

had happened on five out of the 40 flights. In four of the flights those who became infected were

seated within a few rows of the original patient, which according to researchers is consistent with

the spread of large droplets. This was not the case on the fifth flight; on this flight 22 of the 120

passengers and crew aboard the plane became ill. This suggested that the illness was airborne

and spread over a large distance. While many commercial aircraft have high efficiency air
cleaners and HEPA filters there are not requirements for this and thus they are not regularly

tested (Pavia, 2007).

Much of the focus of air travel exacerbated illnesses are communicable sicknesses such

as influenza or SARS. There is substantially less popular focus on vector borne illnesses. Malaria

a tropical illness spread by mosquitos is of particular importance when it comes to vector borne

illnesses because it continues to cause significant harm worldwide. There is a phenomenon called

airport malaria. Airport malaria is when non-travelers who live near or work at airports are

infected by a mosquito imported via air transportation (Findlater and Bogoch, 2018). Given the

ease by which an infected mosquito can board the passenger compartment of an aircraft or the

cargo hold of an aircraft this is of particular concern. If a malaria containing mosquito can board

an aircraft so too can a mosquito carrying Zika virus, which is a much more serious viral

infection. Air travel can clearly spread vector borne illnesses globally with relative ease.

Mitigation and Prevention:

In order to avoid a situation in which aircraft spread what should be vaccine preventable

diseases to new locations or cause the next global pandemic steps need to be taken to insure that

aircraft are being adequately protected. For starters HEPA air filters need to be required on all

commercial aircraft (Pavia, 2007). In addition there also needs to be better methods for ensuring

proper hand hygiene on aircraft (Pavia, 2007). The seatback trays need to be properly disinfected

to ensure that there are not contagions still present on them after every flight. Andrew Pavia

recommends that in order for authorities to screen arriving and departing passengers accurately, a

rapid diagnostic kit would need to be developed and deployed at airports across the globe (Pavia,

2007). Others suggest that restricting travel to known culprit cities and promoting disease control
measures such as vaccines will help prevent and eradicate a possible pandemic (Tuncer and

Trang, 2014). At the current moment the United States lacks a comprehensive plan designed to

deal with and prevent the spread of infectious diseases via air travel. Under federal guidelines

American airports and airlines are not required to have individual plans in place to deal with

these situations. While international treaty requires airlines and airports operating within the

USA to have these plans, the FAA reports that individual airport plans, if they even have them,

are not aimed at handling an epidemic let alone a pandemic (Rubin, “Plan Needed to Prevent”).

Conclusion and Call to Action:

In light of recent events such as the Emirates flight that landed in NYC and the two

flights that landed in Philadelphia in which passengers had fallen ill more research is needed in

order to come up with effective and concrete solutions and mitigation strategies to prevent the

spread of illness via air travel. These events are not only occurring in the United States – aircraft

arriving in Europe have also been quarantined for fear of the spread of infectious diseases. While

the current research out there clearly illustrates that air travel has the ability to spread disease

quickly and with ease across the globe, there has not been a lot of research or action in regards to

putting preventive measures in place to prevent the spread of disease and possible pandemic. To

ensure that the friendly skis remain friendly more research on preventive measures needs to be

done to safeguard the globe from infectious disease spread via air travel.
Appendix:

Figure 1: Figure shows the outbreak of measles, mumps, polio, whooping cough, and typhoid
fever across the globe in 2008. The bigger the shape, the bigger the outbreak. At this time there
is starting to be outbreaks of measles across Europe and China. There is also an outbreak of
typhoid in China.
Figure 2: Figure shows outbreaks of cholera, diphtheria, measles, meningitis, mumps, polio,
rubella, whooping cough, yellow fever, and meningococcal meningitis across the globe in 2018.
There is a massive increase in the number of outbreaks worldwide. Much of Europe is seeing
measles outbreaks. In addition the USA, which did not see many measles cases in 2008, is seeing
outbreaks in what appears to be most of the major cities.
 Works Cited

“2036 Forecast Reveals Air Passengers Will Nearly Double to 7.8 Billion.” IATA, 24 Oct. 2017,
www.iata.org/pressroom/pr/Pages/2017-10-24-01.aspx.

Brady, Mark P. “Reemergence of 5 Vaccine-Preventable Diseases.” Medscape Drugs &

Diseases - Page Not Found, 14 May 2015,
reference.medscape.com/features/slideshow/vaccine-preventable-diseases.

Brueck, Hilary. “A Harvard Professor Says the Dozens of Passengers Sickened on International
Flights Are a Clear 'Warning Shot' of a Worst-Case Scenario.” Business Insider, Business
Insider, 7 Sept. 2018, www.businessinsider.com/emirates-plane-flu-harvard-doctor-says-
were-lucky-it-wasnt-mers-2018-9.

Findlater, A., & Bogoch, I. I. (2018). Human mobility and the global spread of infectious
diseases: A focus on air travel. Trends in Parasitology, 34(9), 772-783.
doi:10.1016/j.pt.2018.07.004

“Influenza Caused Emirates Flight to Be Briefly Quarantined at JFK.” Empr.com, 11 Sept. 2018,
www.empr.com/news/influenza-flu-emirates-airplane-quarantined-jfk-airport-new-
york/article/794479/.

Pavia, A. T. (2007). Germs on a plane: Aircraft, international travel, and the global spread of
disease. Journal of Infectious Diseases, 195(5), 621-622. doi:10.1086/511439

Roy, Lipi. “Sick Passengers On Flight From Dubai: Key Facts About Illness On Airplanes.”
Forbes, Forbes Magazine, 5 Sept. 2018, www.forbes.com/sites/lipiroy/2018/09/05/sick-
passengers-on-flight-from-dubai-key-facts-about-illness-on-airplanes/#225f9ade7421.

Rubin, R. (2016). Plan needed to prevent infectious disease spread via air travel. Jama-Journal
of the American Medical Association, 315(6), 549-549. doi:10.1001/jama.2016.0164

Tuncer, N., & Trang Le. (2014). Effect of air travel on the spread of an avian influenza pandemic
to the united states. International Journal of Critical Infrastructure Protection, 7(1), 27-
47. doi:10.1016/j.ijcip.2014.02.001

“Vaccine-Preventable Disease Outbreaks.” Vaccines Work, Jan. 2018,

www.vaccineswork.org/vaccine-preventable-disease-outbreaks/.