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Talk outline

Tuberculosis and Air Travel Ibrahim Abubakar, MBBS, PhD, FFPH Consultant Epidemiologist / Section Head Tuberculosis Section Respiratory and Systemic Infections Department Centre for Infections Colindale, London Talk outline Rationale Evidence base WHO Guidelines NICE HPA Interpretation

Samuel
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Talk outline

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  1. Tuberculosis and Air TravelIbrahim Abubakar, MBBS, PhD, FFPHConsultant Epidemiologist / Section HeadTuberculosis SectionRespiratory and Systemic Infections DepartmentCentre for InfectionsColindale, London

  2. Talk outline • Rationale • Evidence base • WHO Guidelines • NICE • HPA Interpretation

  3. Rationale • Newsworthy - More political than public health • International – cross border

  4. Evidence • No cases of TB disease reported among those known to have been infected with M. tuberculosis during air travel • All instances of transmission involved highly infectious (smear positive) cases • 2 of whom had MDR disease • Overall notification rate of 0.05 per 100 000 long haul passengers (BA)

  5. Evidence

  6. UK incidents Four All had negative Mantoux

  7. WHO Guidelines 2006 2008 1998

  8. Infectious or potentially infectious • • Infectious TB. All cases of respiratory (pulmonary or laryngeal) TB which are sputum smear-positive and culture-positive (if culture is available). • • Potentially infectious TB. All cases of respiratory (pulmonary or laryngeal) TB which are sputum smear-negative and culture-positive (susceptible, MDR-TB or XDR-TB). • • Non-infectious TB. All cases of respiratory TB which have two consecutive negative sputum-smear and negative culture (if culture is available) results.

  9. WHO guidelines • For travellers, Public Health Authorities, Physicians and Airlines • Pre and post travel • For Travellers • • People with infectious or potentially infectious TB should postpone all travel by commercial air transportation of any flight duration until they become non infectious.

  10. Physicians: Pre and Post travel* • Pre-travel • • Inform all infectious and potentially infectious TB patients that they must not travel by air on any commercial flight of any duration until non infectious* • - 2 weeks of adequate treatment and they are sputum smear negative on at least two occasions • - 2 consecutive negative sputum-culture results – if MDR or XDR. • • Promptly inform the relevant public health authority when if such a TB patient intends to travel against medical advice. • • Inform the public health authority of exceptional circumstances • Post-travel • • Inform the public health authority when an infectious or potentially infectious TB patient has a history of commercial air travel within the previous 3 months. * WHO guidelines

  11. Public Health Authorities: Pre travel* • • Inform the concerned airline of infectious and potentially infectious passengers travelling against medical advice and request that boarding be denied. • • If patient has exceptional circumstances, ensure that the airline(s) and all involved authorities have agreed the procedures for travel. * WHO guidelines

  12. Public Health Authorities: Post Travel* • • Undertake risk assessment • • Inform all countries involved (departure and landing). • • Coordination between countries necessary. • • Share passenger information. • • Inform the National IHR Focal Point. • • Collaborate on research concerning TB and air travel. * WHO guidelines

  13. Assessing whether contact tracing is needed* * WHO guidelines

  14. Aircraft air flow* i.e. those passengers seated in the same row and in the two rows in front of and behind the index case * WHO guidelines

  15. Airline companies* • Pre-travel • • Deny boarding to infectious or potentially infectious TB when requested. • • Ensure ventilation is on after 30 minutes ground delay. • • Requirements and standards for filtration systems. • • Training for cabin crews. • • Adequate emergency supplies on board • Post-travel • • Airline companies should provide all available contact information, in accordance with applicable legal requirements including the IHR. * WHO guidelines

  16. NICE

  17. ……………. • Public health authorities may refine criteria on infectiousness according to national guidelines • Public health authorities may follow national policies and guidelines regarding TB contact investigation involving potentially exposed travellers in their jurisdiction, in accordance with requirements under the IHR

  18. HPA Interpretation: Pre travel • Discourage all passengers with infectious or potential infectious TB from travel and inform local HPU • Where there are exceptional personal circumstance discuss with HPU

  19. HPA Interpretation: Post travel Clinician informs HPU • Then HPU sends “inform and advise” letters to passengers in the UK • Undertake a risk assessment • Index case smear positive • Flight >8 hrs in last 3/12 • International contacts dealt with through TB Section, CfI in liaison with HPU • HPU liaises with CfI to agree which authority undertaking the investigation • Crew – inform HPU, and therefore, airline – assess as occupational / office type exposure • HPU obtains passenger details for those sitting in same, and two adjacent rows

  20. HPA Interpretation: During Flight • Passengers and crew should be reassured • Airline should be encouraged to keep contact details to support subsequent public health action

  21. HPA Interpretation • Draft agreed • To be published by the National Knowledge Service for TB after further review

  22. Thank you • ……………………and now I am off to take my 8 hour train to London

  23. * References Driver CR et al. Transmission of M. tuberculosis associated with air travel. Journal of the American Medical Association, 1994, 272:1031–1035. McFarland JW et al. Exposure to Mycobacterium tuberculosis during air travel. Lancet, 1993, 342:112–113. Exposure of passengers and flight crew to Mycobacterium tuberculosis on commercial aircraft, 1992–1995. Morbidity and Mortality Weekly Report, 1995, 44:137–140. Miller MA, Valway SE, Onorato IM. Tuberculosis risk after exposure on airplanes. Tubercle and Lung Disease, 1996, 77:414–419. Kenyon TA et al. Transmission of multidrug-resistant Mycobacterium tuberculosis during a long airplane flight. New England Journal of Medicine, 1996, 334:933–938. Moore M, Fleming KS, Sands L. A passenger with pulmonary/laryngeal tuberculosis: no evidence of transmission on two short flights. Aviation, Space, and Environmental Medicine, 1996, 67:1097–1100. Vassiloyanakopoulos A et al. A case of tuberculosis on a long-distance flight: the difficulties of the investigation. Eurosurveillance, 1999, 4(9):96-97. Chemardin J et al. Contact-tracing of passengers exposed to an extensively drug-resistant tuberculosis case during an air flight from Beirut to Paris, October 2006. Eurosurveillance, 2007, 12(12):6 December. Wang PD. Two-step tuberculin testing of passengers and crew on a commercial airplane. American Journal of Infection Control, 2000, 28(3):233–238. Parmet AJ. Tuberculosis on the flight deck. Aviation, Space, and Environmental Medicine, 1999, 70(8):817–818. Whitlock G, Calder L, Perry H. A case of infectious tuberculosis 16. on two longhaul aircraft flights: contact investigation. New Zealand Medical Journal, 2001, 114(1137):353–355 Tuberculosis exposure feared on India-to-U.S. flight. Clinical Infectious Diseases News, 2008, 46:1 March.

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