TuberculosisandAirTravelIbrahimAbubakar,MBBS,PhD,FFPHConsultantEpidemiologist/SectionHeadTuberculosisSectionRespiratoryandSystemicInfectionsDepartmentCentreforInfectionsColindale,LondonTalkoutlineRationaleEvidencebaseWHOGuidelinesNICEHPAInterpretationRationaleNewsworthy-MorepoliticalthanpublichealthInternational–crossborderEvidenceNocasesofTBdiseasereportedamongthoseknowntohavebeeninfectedwithM.tuberculosisduringairtravelAllinstancesoftransmissioninvolvedhighlyinfectious(smearpositive)cases2ofwhomhadMDRdiseaseOverallnotificationrateof0.05per100000longhaulpassengers(BA)Evidencen(%)orMedian(IQR)FlightsN=39DurationHours8.9(8-11.7)HighincidencecountryYes36(92.3)FlighttonotificationdelayDays41(21-61)IndexcasesN=24SmearpositivecaseYes19(79.2)No1(4.2)Unknown4(20.8)DrugresistanceMDR2(8.4)Rifampicinresistant1(4.2)Susceptible3(12.5)Unknown18(75)ContactinvestigationN=24AvailabilityofcontactinformationfromairlinesNofurtherinformation13(54.2)Furtherinformationavailable5(20.8)Airlineunwillingtosharedata2(8.4)Passengerdetailsdeletedbyairline2(8.4)Passengerlistsavailablebutnocontactdetails2(8.4)UKincidentsDatereportedFlightoriginanddestinationApproximatedurationSmearstatusResistancePassengercontactinformation/outcomewhereknown25/06/20071.LondontoBangalore10hr35eachway+None1.28contacts:3UK,1withaddress2.BangaloretoLondon2.28contacts:3UK,2withaddress26/07/20071.LondontoHongKong11hr40mineachway+Notknown1.22contacts:7UKwithpersonal/travelagentphonenumber2.HongKongtoLondon2.32contacts:4UKwithpersonal/travelagentphonenumber30/08/20071.Japan*toLondon1.12hr15min+Notknown1.4UKcontactswithtravelagentphonenumbers2.LondontoJapan*2.11hr30min2.2UKcontactswithaddressandphonenumbers(bothhadanegativeMantouxtest)28/12/20071.LondontoMiami*1.9hr45min-MDR1.FollowedupbyCDC2.DelhitoLondon2.9hr30min2.41contacts:9UK,4withaddress,3withphonenumber,1withtravelagentdetails3.Miami*toLondon3.8hr10min3.43contacts:15UK,1withaddressandphonenumber,1withaddress,4withphonenumberande-mail,9withtravelagentdetails4.LondontoDelhi4.8hr10min4.47contacts:9UK,7withphonenumber06/02/2008VietnamtoLondonOver8hoursNotknownNotknownPassengerlistsobtained,nofurtherresponserequired.FourAllhadnegativeMantouxWHOGuidelines199820062008Infectiousorpotentiallyinfectious•InfectiousTB.Allcasesofrespiratory(pulmonaryorlaryngeal)TBwhicharesputumsmear-positiveandculture-positive(ifcultureisavailable).•PotentiallyinfectiousTB.Allcasesofrespiratory(pulmonaryorlaryngeal)TBwhicharesputumsmear-negativeandculture-positive(susceptible,MDR-TBorXDR-TB).•Non-infectiousTB.AllcasesofrespiratoryTBwhichhavetwoconsecutivenegativesputum-smearandnegativeculture(ifcultureisavailable)results.WHOguidelinesFortravellers,PublicHealthAuthorities,PhysiciansandAirlinesPreandposttravelForTravellers•PeoplewithinfectiousorpotentiallyinfectiousTBshouldpostponealltravelbycommercialairtransportationofanyflightdurationuntiltheybecomenoninfectious.Physicians:PreandPosttravel*Pre-travel•InformallinfectiousandpotentiallyinfectiousTBpatientsthattheymustnottravelbyaironanycommercialflightofanydurationuntilnoninfectious*-2weeksofadequatetreatmentandtheyaresputumsmearnegativeonatleasttwooccasions-2consecutivenegativesputum-cultureresults–ifMDRorXDR.•PromptlyinformtherelevantpublichealthauthoritywhenifsuchaTBpatientintendstotravelagainstmedicaladvice.•InformthepublichealthauthorityofexceptionalcircumstancesPost-travel•InformthepublichealthauthoritywhenaninfectiousorpotentiallyinfectiousTBpatienthasahistoryofcommercialairtravelwithintheprevious3months.*WHOguidelinesPublicHealthAuthorities:Pretravel*•Informtheconcernedairlineofinfectiousandpotentiallyinfectiouspassengerstravellingagainstmedicaladviceandrequestthatboardingbedenied.•Ifpatienthasexceptionalcircumstances,ensurethattheairline(s)andallinvolvedauthoritieshaveagreedtheproceduresfortravel.*WHOguidelinesPublicHealthAuthorities:PostTravel*•Undertakeriskassessment•Informallcountriesinvolved(departureandlanding).•Coordinationbetweencountriesnecessary.•Sharepassengerinformation.•InformtheNationalIHRFocalPoint.•CollaborateonresearchconcerningTBandairtravel.*WHOguidelinesAssessingwhethercontacttracingisneeded**WHOguidelinesAircraftairflow*i.e.thosepassengersseatedinthesamerowandinthetworowsinfrontofandbehindtheindexcase*WHOguidelinesAirlinecompanies*Pre-travel•DenyboardingtoinfectiousorpotentiallyinfectiousTBwhenrequested.•Ensureventilationisonafter30minutesgrounddelay.•Requirementsandstandardsforfiltrationsystems.•Trainingforcabincrews.•AdequateemergencysuppliesonboardPost-travel•Airlinecompaniesshouldprovideallavailablecontactinformation,inaccordancewithapplicablelegalrequirementsincludingtheIHR.*WHOguidelinesNICE…………….PublichealthauthoritiesmayrefinecriteriaoninfectiousnessaccordingtonationalguidelinesPublichealthauthoritiesmayfollownationalpoliciesandguidelinesregardingTBcontactinvestigationinvolvingpotentiallyexposedtravellersintheirjurisdiction,inaccordancewithrequirementsundertheIHRHPAInterpretation:PretravelDiscourageallpassengerswithinfectiousorpotentialinfectiousTBfr