A methodology for estimating SARS-CoV-2 importation risk by air travel into Canada between July and November 2021

BACKGROUND

Estimating rates of disease importation by travellers is a key activity to assess both the risk to a country from an infectious disease emerging elsewhere in the world and the effectiveness of border measures. We describe a model used to estimate the number of travellers infected with SARS-CoV-2 into Canadian airports in 2021, and assess the impact of pre-departure testing requirements on importation risk.

METHODS

A mathematical model estimated the number of essential and non-essential air travellers infected with SARS-CoV-2, with the latter requiring a negative pre-departure test result. The number of travellers arriving infected (i.e. imported cases) depended on air travel volumes, SARS-CoV-2 exposure risk in the departure country, prior infection or vaccine acquired immunity, and, for non-essential travellers, screening from pre-departure molecular testing. Importation risk was estimated weekly from July to November 2021 as the number of imported cases and percent positivity (PP; i.e. imported cases normalised by travel volume). The impact of pre-departure testing was assessed by comparing three scenarios: baseline (pre-departure testing of all non-essential travellers; most probable importation risk given the pre-departure testing requirements), counterfactual scenario 1 (no pre-departure testing of fully vaccinated non-essential travellers), and counterfactual scenario 2 (no pre-departure testing of non-essential travellers).

RESULTS

In the baseline scenario, weekly imported cases and PP varied over time, ranging from 145 to 539 cases and 0.15 to 0.28%, respectively. Most cases arrived from the USA, Mexico, the United Kingdom, and France. While modelling suggested that essential travellers had a higher weekly PP (0.37 - 0.65%) than non-essential travellers (0.12 - 0.24%), they contributed fewer weekly cases (62 - 154) than non-essential travellers (84 - 398 per week) given their lower travel volume. Pre-departure testing was estimated to reduce imported cases by one third (counterfactual scenario 1) to one half (counterfactual scenario 2).

CONCLUSIONS

The model results highlighted the weekly variation in importation by traveller group (e.g., reason for travel and country of departure) and enabled a framework for measuring the impact of pre-departure testing requirements. Quantifying the contributors of importation risk through mathematical simulation can support the design of appropriate public health policy on border measures.

Risk of transmission of SARS-CoV-2 on international flights, a retrospective cohort study using national surveillance data in England

BACKGROUND

It is not yet fully understood to what extent in-flight transmission contributed to the spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This study aimed to determine the occurrence and extent of SARS-CoV-2 transmission in-flight and assess factors associated with transmission risk to inform future control strategies.

METHODS

Retrospective cohort study using data obtained from contact tracing of international flights arriving in England between 02/08/2021-15/10/2021. Transmission risk was estimated by calculating the secondary attack rate (SAR). Univariable and multivariable analyses of the SAR by specific risk factors was undertaken, including: number of in-flight index cases; number of symptomatic index cases; contact vaccination status; flight duration; proximity to the index case(s); contact age.

RESULTS

11,307 index cases linked to 667,849 contacts with 5,289 secondary cases reported. In-flight SAR was 0.79% (95% CI: 0.77-0.81). Increasing numbers of symptomatic cases (when > 4 index cases compared to one index case aOR 1.85; 95% CI: 1.40-2.44) and seating proximity to an index case (seated within compared to outside of two rows OR 1.82; 95% CI: 1.50-2.22) were associated with increased risk of secondary cases. Full vaccination history was protective (aOR 0.52; 95% CI: 0.47-0.57).

CONCLUSIONS

This study confirms that in-flight transmission of SARS-CoV-2 occurred. There are factors associated with increased risk of infection. Contact tracing identified exposed persons who subsequently developed infection. A targeted approach to contact tracing passengers with the highest exposure risk could be an effective use of limited public health resources.

Safety of helicopter transport in patients with acute coronary syndrome

BACKGROUND

ST-elevation myocardial infarction (STEMI) systems of care have reduced inter-hospital transfer times and facilitated timely reperfusion goals. Helicopters may be an option when land transportation is not feasible; however, the safety of air transport in patients with acute coronary syndrome (ACS) is a factor to consider.

OBJETIVES

The aim of this study was to evaluate the safety of helicopter transport for patients with ACS.

METHODS

Prospective, observational, and descriptive study including patients diagnosed with ACS within the STEMI network of a metropolitan city transferred by helicopter to a large cardiovascular center to undergo percutaneous coronary intervention. The primary outcome of the study was the incidence of air-travel-related complications defined as IV dislodgement, hypoxia, arrhythmia, angina, anxiety, bleeding, and hypothermia. Secondary outcomes included the individual components of the primary outcome.

RESULTS

A total of 106 patients were included in the study; the mean age was 54 years and 84.9% were male. The most frequent diagnosis was STEMI after successful fibrinolysis (51.8%), followed by STEMI with failed fibrinolysis (23.7%) and non-reperfused STEMI (9.4%). Five patients (4.7%) developed at least one complication: IV dislodgement (1.8%) and hypoxemia (1.8%) in two patients and an episode of angina during flight (0.9%). A flight altitude of > 10,000 ft was not associated with complications.

CONCLUSIONS

The results of this study suggest that helicopter transportation is safe in patients undergoing acute coronary syndrome, despite the altitude of a metropolitan area.

Flying to high-altitude destinations: Is the risk of acute mountain sickness greater?

BACKGROUND

Altitude sojourns increasingly attract individuals of all ages and different health statuses due to the appeal of high-altitude destinations worldwide and easy access to air travel. The risk of acute mountain sickness (AMS) when flying to high-altitude destinations remains underemphasized. Thus, this review aims to evaluate the altitude-dependent AMS incidence depending on the mode of ascending, e.g. by air vs terrestrial travel.

METHODS

A literature search was performed to identify the observational studies assessing AMS incidence after acute ascent of primarily healthy adults to real high altitude. In addition, placebo arms of interventional trials evaluating the prophylactic efficacy of various drugs have been separately analysed to confirm or refute the findings from the observational studies. Linear regression analyses were used to evaluate the altitude-dependent AMS incidence.

RESULTS

Findings of 12 observational studies, in which the AMS incidence in 11 021 individuals ascending to 19 different altitudes (2200-4559 m) was evaluated, revealed an impressive 4.5-fold steeper increase in the AMS incidence for air travel as compared with slower ascent modes, i.e. hiking or combined car and/or air travel and hiking. The higher AMS incidence following transportation by flight vs slower means was also confirmed in placebo-treated participants in 10 studies of drug prophylaxis against AMS.

CONCLUSIONS

Due to the short time span in going from low to high altitude, reduced acclimatization likely is the main reason for a higher AMS risk when travelling to high-altitude destinations by flight. To avoid frustrating travel experiences and health risks, appropriate and timely medical advice on how to prepare for air travel to high altitude is of vital importance. Effective preparation options include the use of modern pre-acclimatization strategies and pharmacological prophylaxis by acetazolamide or dexamethasone, or even considering alternate itineraries with more gradual ascent.

An empirical analysis of American Passenger's willingness to fly in commercial airplanes after vaccination against COVID-19

Although several studies have explored the effects of the pandemic on aviation, little remains known about whether members of the public are willing to fly again after they have been vaccinated. The current study uses the Health Belief Model (HBM) to fill this missing gap by manipulating the following variables: 1) whether or not the participant is vaccinated; 2) whether or not airlines require that all passengers and crew receive vaccinations; 3) length of flight; 4) destination; and 5) the number of passengers. The data from 678 participants revealed that willingness to fly is much higher if the participants themselves have been vaccinated, if the airlines require all passengers to be vaccinated, if the flight is short, if the destination is domestic, and if the number of passengers is low. These findings did not appear to differ as a function of flying business versus pleasure. We discuss the practical implications of these data as airlines struggle to bring back their customer base.

COVID-19 cases reported in Colorado following screening at selected US airports, January - July 2020

OBJECTIVE

We sought to estimate the proportion of air travelers who may have been infected with SARS-CoV-2 upon arrival to Colorado by comparing data on Colorado residents screened upon entering the US to COVID-19 cases reported in the state. Data on Colorado's screened passengers arriving into the US between January 17 and July 30, 2020 were compared to Colorado's Electronic Disease Reporting System. We conducted a descriptive analysis of true matches, including age, gender, case status, symptom status, time from arrival to symptom onset (days), and time from arrival to specimen collection date (days).

RESULTS

Fourteen confirmed COVID-19 cases in travelers who were diagnosed within 14 days after arriving in Colorado were matched to the 8,272 travelers who underwent screening at 15 designated airports with a recorded destination of Colorado, or 0.2%. Most (N = 13/14 or 93%) of these infected travelers arrived in Colorado in March 2020; 12 (86%) of them were symptomatic. Entry screening for COVID-19 and the sharing of traveler information with the Colorado Department of Public Health and Environment appeared to identify few cases early in the pandemic. Symptom-based entry screening and sharing of traveler information was minimally effective at decreasing travel-associated COVID-19 transmission.

A case of recurrent flight-induced cerebrospinal fluid shunt overdrainage

Shunted patients often complain of headaches after flights. The effect of air travel on shunt systems is unknown. We describe the case of a patient with longstanding hydrocephalus, who suffered flight-induced clinical deterioration and shunt overdrainage in two independent occasions. The patient, clinically stable for 1.5 and 5 years before each episode, reported severe headaches starting during the descent stages of the air travel. On both occasions, brain MRI imaging demonstrated pronounced ventricular size reduction. This case suggests that flight-induced shunt overdrainage can occur and should be suspected in patients with prolonged headaches and/or clinical deterioration triggered by air travel.

Feline Stress Management During air Travel: A Multimodal Approach

PRACTICAL RELEVANCE

More cats are travelling by air every year; however, air travel involves several common causes of stress for cats, such as environmental changes and a lack of control and predictability. The use of a multimodal stress management protocol for all stages of the relocation process, including appropriate and effective anxiolytic medication where necessary, is therefore important in order to safeguard the cat's welfare while travelling.

CLINICAL CHALLENGES

Cats may be presented to veterinarians for the purpose of preparing them and/or their documentation for air travel. Maintaining and protecting a cat's physical, mental and emotional health in a stressful environment, while subjected to likely unfamiliar sights, noises, smells and the movement of the aircraft, and additionally dealing with international legislation, regulations and documents, can pose a complex challenge to veterinarians.

AIMS

This review describes the importance of stress management during air travel for cats, aims to raise awareness about the often poorly understood challenges involved, and outlines effective and airline-compliant stress management modalities. While the discussion is focused on air travel specifically, the stress management methods described can be applied to all types of longer distance travel, such as a long road trip or a ferry crossing, as well as a stay in a holiday home.

EVIDENCE BASE

There are currently no studies specifically on air travel in cats and, similarly, there are also limited data on air travel in other species. Many of the recommendations made in this review are therefore based on the authors' extensive experience of preparing pets for travel, supported by published data when available.

Air travel choice, online meeting and passenger heterogeneity - An international study on travellers' preference during a pandemic

This study empirically identifies business travellers' preferences during the COVID-19 pandemic across different regions. A stated preference study was conducted during April to June 2021 on respondents in the U.S., the city of Shanghai in mainland China and Hong Kong. Generalised mixed multinomial logit (GMXL) models are estimated incorporating attributes of travel characteristics, severity levels of the pandemic, and health control measures at the airport. When an online meeting is inapplicable, respondents from Shanghai and Hong Kong highly value heath control measures, and are not sensitive to the time spent at airport health checkpoints. In comparison, U.S. respondents are averse to the time spent for health check, the reporting of personal information, travel history, symptoms, and the requirements of compulsory mask wearing and onsite sample testing. However, when online meeting is applicable, all the respondents show no appreciation for health control measures, while the U.S. respondents are twice more averse to the time spent at airport health checkpoints. Online meeting reduces the intention of international business travel amid the pandemic for passengers in Shanghai and Hong Kong, but imposes no significant effects on U.S. travellers. Such significant heterogeneity in traveller preference partly explains the different recovery patterns observed in various aviation markets, and justifies individualized travel arrangements and service priority in fulfilling pandemic control requirements across different regions. Our study also suggests that there are commonly accepted areas for global cooperation such as the sharing of vaccination record, and the option of online meeting calls for convenient travel arrangements amid pandemic to all countries.

The effect of online meeting and health screening on business travel: A stated preference case study in Hong Kong

This study quantifies the effects of health control measures at the airport on passenger behaviour related to business travel. A stated preference survey was conducted over potential air travellers in Hong Kong in the context of COVID-19 pandemic. Panel latent class models were estimated to understand passenger preference toward new travel requirements given the applicability of online meeting. Online meeting is applicable in cases where it is a good substitute of air travel and achieves the same outcomes of a trip, and inapplicable otherwise. Empirical results indicate that traveller subgroups are affected in different ways. When an online meeting is inapplicable, nearly 75% of the respondents prefer to travel for business and undertake health screenings. These passengers (identified as "captive" business travellers) perceive such measures necessary to lower health related risks during air travel. As such, they are willing to spend up to 21 to 38 min on the health control measures such as vaccination record requirements and test involving sample collection. When an online meeting is applicable, the share of "choice" business travellers is about 45%, among whom the attitudes towards health control measures become more averse. The average weighted willingness-to-pay for the time saved at health checkpoints increase significantly. The aviation industry thus faces a "double-hit" problem: operation costs will increase due to pandemic control measures, and the resultant inconvenience, extra time and costs further reduces travel demand. Unlike previous short pandemics, business travel is likely to suffer with an extended decline until the pandemic is fully controlled. These identified challenges call for financial and operational support to help the aviation industry reach a sustainable "new normal". The high value of time saved at check points also justifies investments that make the pandemic control and health measures efficient and smooth. Travellers' time spent on airport health control should be within 20 min to avoid substantial negative impacts on business travel demand.

The impact of the COVID-19 pandemic on tourists' air travel intentions: The role of perceived health risk and trust in the airline

Travel restrictions as well as travellers' increased risk perceptions have changed travel patterns around the globe during the COVID-19 pandemic. As such, the aviation industry has been particularly affected by the changing environment. Several airlines have reacted to travellers' rising concerns about becoming infected with the COVID-19 disease by introducing safety measures to guarantee a safe journey. Although research has noted the relevance of good communication during crises, the impact of communicating safety measures by rational (safety) advertising appeals on air travel intention has not been explored thus far. The current study investigates consumers' reactions to two different types of advertising appeals during the COVID-19 pandemic and their effect on air travel intentions and airline recommendation intentions. An online experiment reveals that travellers react more positively to safety as compared to emotional advertising appeals during the COVID-19 pandemic. Furthermore, the results confirm the hypothesized mediating effect of perceived health risk and trust in the airline on the impact of safety appeals in terms of air travel intention and airline recommendation. The results of this study uncover the underlying mechanisms that have driven consumers' air travel intentions during the COVID-19 pandemic and offer various theoretical and managerial implications.

The impact of COVID-19 on reducing carbon emissions: From the angle of international student mobility

Global carbon emissions have been rapidly increasing in recent years, negatively influencing the global climate. Thereby, it is urgent to reduce carbon emissions and achieve carbon neutrality. During the COVID-19 pandemic, strict quarantine plans have led to a sharp decline in the number of international student flights, which will, in turn, decrease aviation carbon emissions. This study predicts the carbon emission reduction caused by the decrease in international student mobility during the COVID-19. The result shows that the carbon emission was about 1326 Gg, a staggering value equivalent to two-thirds of the carbon emissions of the UK's agriculture sector in a year. Furthermore, this study analyzes the implications of current mitigation policies and makes recommendations for future strategies.

Underlying lung disease and exposure to terrestrial moderate and high altitude: personalised risk assessment

Once reserved for the fittest, worldwide altitude travel has become increasingly accessible for ageing and less fit people. As a result, more and more individuals with varying degrees of respiratory conditions wish to travel to altitude destinations. Exposure to a hypobaric hypoxic environment at altitude challenges the human body and leads to a series of physiological adaptive mechanisms. These changes, as well as general altitude related risks have been well described in healthy individuals. However, limited data are available on the risks faced by patients with pre-existing lung disease. A comprehensive literature search was conducted. First, we aimed in this review to evaluate health risks of moderate and high terrestrial altitude travel by patients with pre-existing lung disease, including chronic obstructive pulmonary disease, sleep apnoea syndrome, asthma, bullous or cystic lung disease, pulmonary hypertension and interstitial lung disease. Second, we seek to summarise for each underlying lung disease, a personalized pre-travel assessment as well as measures to prevent, monitor and mitigate worsening of underlying respiratory disease during travel.

Commercial Air And High-Altitude Travel by Pregnant Women: A scientific review commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG)

Air travel and long distance travel may have adverse effect on the pregnancy-induced physiology and these effects are more marked among those with pre-existing medical conditions. There are significantly increased risks of deep venous thrombosis, inflight transmission of infections, preterm labour, and other significant obstetric and medical complications that may be exacerbated by the flight and may require emergency care. Transient changes in cardiotocographic tracings during third trimester of pregnancy have been reported following air travel. It has been suggested that pregnant members of the flight crew may be at a slightly higher risk of spontaneous miscarriages. There are no contra-indications for healthy pregnant women on air travel. Those with underlying medical conditions should only embark on long distance travel following consultation with their obstetrician. Pregnant women should be advised to familiarise themselves with the healthcare system in the country/region they will be visiting and draw up an emergency plan of how they will contact the healthcare system at their destination.

SARS-CoV-2 aerosol risk models for the Airplane Seating Assignment Problem

Transmission of SARS-CoV-2 between passengers on airplanes is a significant concern and reducing the transmission of SARS-CoV-2 or other viruses aboard aircraft could save lives. Solving the Airplane Seating Assignment Problem (ASAP) produces seating arrangements that minimize transmission risks between passengers aboard an aircraft, but the chosen risk model affects the optimal seating arrangement. We analyze previous risk models and introduce two new risk models, masked and unmasked, based on previous experiments performed aboard real aircraft to test aerosol dispersion of SARS-CoV-2 sized particles. We make recommendations on when each risk model is applicable and the types of seating arrangements that are optimal for each risk model.

Perioperative air travel increases the risk of venous thromboembolism following lower limb arthroplasty

Purpose

Venous thromboembolism (VTE) is a significant complication following lower limb arthroplasty (LLA). There is a paucity of evidence with regard to air travel following LLA. Orthopaedic surgeons are often asked by patients regarding air travel following LLA, and there is a need for evidence to guide these patients.

Methods

This was a retrospective cohort study. We identified two cohorts, one travelling to and from the hospital by air and another, by land. All patients received routine preoperative and post-operative care, and thromboprophylaxis, as per our hospital guidelines. We collected baseline demographics, ASA score and incidence of VTE at 90 days using local patient records and a national joint registry. We also recorded data on flight time and overland distance of travel.

Results

Two hundred and forty-three patients travelled by air; mean flight time was 74 min. In total, 5498 patients travelled a mean 25.3 miles over land to the hospital. No differences in baseline demographics or ASA score were observed. Four patients developed a VTE in the flight group, with 32 patients suffering a VTE in the control group. There was a significant difference in the VTE rate between the flight and control groups (p < 0.05); the relative risk of developing a VTE in the flight group was 2.85.

Conclusions

In our cohort, perioperative short haul air travel is associated with an increased risk of VTE at 90 days following LLA. Orthopaedic surgeons must ensure that their patients are cognizant of the risks associated with perioperative air travel and take measures to minimise these risks.

The Role of Moral Foundations, Anticipated Guilt and Personal Responsibility in Predicting Anti-consumption for Environmental Reasons

In response to the growing importance of environmental issues, more and more consumers are turning to anti-consumption by reducing, rejecting, or avoiding consumption. Covering the intersection of sustainable consumption and anti-consumption, previous studies relied on socio-cognitive models to explain this decision. In order to extend their findings, we consider the moral and emotional perspectives to examine reducing consumption for environmental reasons in a particular context, i.e. air travel. It is against this backdrop that we propose a conceptual model that includes moral foundations as the main antecedent, followed by anticipated guilt and personal responsibility, while intention to reduce consumption (i.e. air travel) for environmental reasons, positive word of mouth about reducing air travel (WOM) and environmental activism represent the outcomes. The proposed model is tested on a sample of 511 respondents from a UK online consumer panel. Our results confirm the importance of moral foundations, anticipated guilt and personal responsibility and their interplay in the prediction of intention to reduce consumption for environmental reasons. Anticipated guilt influences WOM, while personal responsibility influences activism. In addition, intentions to reduce consumption for environmental reasons have a positive impact on WOM and environmental activism. There are several implications for public policy makers and NGOs that fight against climate change that derive from these findings, as well as research opportunities for academics interested in this topic.

Air travel with pneumocephalus: a systematic review

INTRODUCTION

Concerns arise when patients with pneumocephalus engage in air travel. How hypobaric cabin pressure affects intracranial air is largely unclear. A widespread concern is that the intracranial volume could relevantly expand during flight and lead to elevated intracranial pressure. The aim of this systematic review was to identify and summarise models and case reports with confirmed pre-flight pneumocephalus.

METHODS

The terms (pneumocephalus OR intracranial air) AND (flying OR fly OR travel OR air transport OR aircraft) were used to search the database PubMed on 30 November 2021. This search returned 144 results. To be included, a paper needed to fulfil each of the following criteria: (i) peer-reviewed publication of case reports, surveys, simulations or laboratory experiments that focussed on air travel with pre-existing pneumocephalus; (ii) available in full text.

RESULTS

Thirteen studies met the inclusion criteria after title or abstract screening. We additionally identified five more articles when reviewing the references. A notion that repeatedly surfaced is that any air contained within the neurocranium increases in volume at higher altitude, much like any extracranial gas, potentially resulting in tension pneumocephalus or increased intracranial pressure.

DISCUSSION

Relatively conservative thresholds for patients flying with pneumocephalus are suggested based on models where the intracranial air equilibrates with cabin pressure, although intracranial air in a confined space would be surrounded by the intracranial pressure. There is a discrepancy between the models and case presentations in that we found no reports of permanent or transient decompensation secondary to a pre-existing pneumocephalus during air travel. Nevertheless, the quality of examination varies and clinicians might tend to refrain from reporting adverse events. We identified a persistent extracranial to intracranial fistulous process in multiple cases with newly diagnosed pneumocephalus after flight. Finally, we summarised management principles to avoid complications from pneumocephalus during air travel and argue that a patient-specific understanding of the pathophysiology and time course of the pneumocephalus are potentially more important than its volume.

Multiple introductions of SARS-CoV-2 B.1.1.214 lineages from mainland Japan preceded the third wave of the COVID-19 epidemic in Hokkaido

BACKGROUND

The third wave of the COVID-19 epidemic in the island of Hokkaido, the second largest island in Japan, began abruptly in October 2020.

METHODS

We conducted a phylodynamic analysis of the SARS-CoV-2 genome sequences obtained from tertiary medical centers in the Greater Tokyo Area and Sapporo, the largest city in the island of Hokkaido, and genome sequences published by GISAID, an international SARS-CoV-2 genome database. We also analyzed the statistics on the person-nights of travelers in the island of Hokkaido from the Greater Tokyo Area in 2019 versus 2020.

RESULTS

At least eight sub-lineages belonging to the B.1.1.214 lineage were introduced to the island of Hokkaido from the island of Honshu, the mainland of Japan from late July to November 2020, during the governmental travel promotion program. Five of the eight sub-lineages originated from the Greater Tokyo Area. Comparison of the monthly ratios of the person-nights of travelers in the island of Hokkaido from the Greater Tokyo Area in 2019 and 2020 revealed that the highest value occurred in October 2020.

CONCLUSION

We contend that the Japanese governmental travel promotion program contributed to the introduction of the B.1.1.214 sub-lineages from the main island of Honshu to the island of Hokkaido, and drove the third wave in Hokkaido, even if we are unable to establish the causality.

Pre-air travel health-seeking behaviour, prevalence of barotitis media, its knowledge and associated factors among recently travelled patients in Kano, Nigeria

Introduction

Existing evidence suggests that barotitis media (BM) is common among air travellers, and it has the potential to cause severe discomfort and sometimes permanent hearing and balance deficits. It has not been studied in Nigeria.

Objective

This study aimed to assess the pre-air travel health-seeking behaviour, prevalence of BM, knowledge of BM and its associated factors among a cohort of outpatients with a history of recent air travel in Kano, Nigeria.

Materials and Methods

This questionnaire-based survey involved 97 participants systematically and proportionately selected from adult patients or caregivers of children with recent air travel history attending two outpatients clinics over 7 weeks. Information on biodata, pre-air travel advice-seeking behaviours, air travel experience and BM knowledge were obtained. Data were analysed using the descriptive statistical methods, Chi-square or Fisher's exact tests and odds ratio (OR).

Results

Most participants were male (54.6%) with tertiary education (87.6%); the prevalence of BM was 44.3% (43/97). Only 2.1% (2/97) had ever sought pre-air travel advice from a doctor; 83.5% (81/97) had heard of BM before; 42% had adequate knowledge of BM. Employment status (Fisher's exact, P = 0.001), clinic at recruitment (Fisher's exact, P = 0.00008), duration of last flight (Fisher's exact, P = 0.0001) and persistent ear-pain after landing (Fisher's exact, P = 0.001) were significantly associated with participants' knowledge of BM. Persistent ear-pain after landing was the predictor of BM knowledge (OR = 0.04, 95% confidence interval [0.002-0.67], P = 0.025).

Conclusion

The BM knowledge level of this cohort suggests the need for further studies to ascertain the complete picture and justify improved pretravel education of air travellers in our setting.

Commuting before and after COVID-19

Major life events like COVID-19 have the potential to change how people think about and use transport systems. The COVID-19 pandemic has created an extended period of disruption in peoples' lives and could result in long-term changes towards travel attitudes, and use of transport services. There has previously been little research available on changes towards travel attitudes and use of domestic travel as a result of pandemics. To investigate the changes in attitudes to travel resulting from COVID-19 we distributed a survey to 787 respondents in Australia and New Zealand asking about car use, car sharing, public transport, and air travel before, during, and after COVID-19 travel restrictions. The results showed attitudes towards travel were negatively affected, particularly attitudes towards public transport and international air travel. Further, although respondents indicated some recovery in attitudes when asked to consider when travel restrictions were removed, they did not recover to the levels of positivity seen pre-COVID. There were slight differences between the two countries in their post-COVID attitudes, possibly due to their different experience of travel restriction. Both countries, however, may be useful as a preview for the rest of the world given the early cessation of the COVID-19 pandemic at the time of the survey.

Estimating the impact of COVID-19 on air travel in the medium and long term using neural network and Monte Carlo simulation

The COVID-19 pandemic has had a substantial impact on the airline industry. Air travel in the United States declined in 2020 with significantly lower domestic and international flights. The dynamic change and uncertainty in the trend of COVID-19 have made it difficult to predict future air travel. This paper aims at developing and testing neural network models that predict domestic and international air travel in the medium and long term based on residents' daily trips by distance, economic condition, COVID-19 severity, and travel restrictions. Data in the United States from various sources were used to train and validate the neural network models, and Monte Carlo simulations were constructed to predict air travel under uncertainty of the pandemic and economic growth. The results show that weekly economic index (WEI) is the most important predictor for air travel. Additionally, daily trips by distance play a more important role in the prediction of domestic air travel than the international one, while travel restrictions seem to have an impact on both. Sensitivity analysis results for four different scenarios indicate that air travel in the future is more sensitive to the change in WEI than the changes in COVID-19 variables. Additionally, even in the best-case scenario, when the pandemic is over and the economy is back to normal, it still takes several years for air travel to return to normal, as before the pandemic. The findings have significant contributions to the literature in COVID-19's impact on air transportation and air travel prediction.

In-flight transmission of wild-type SARS-CoV-2 and the outbreak potential of imported clusters of COVID-19: a review of published evidence

International air travel has been highlighted as a concern since the beginning of the COVID-19 pandemic with respect to importation of cases. We summarise the available evidence for in-flight transmission of wild type SARS-CoV-2 during 2020, and for imported COVID-19 clusters to cause outbreaks. This paper provides a data baseline prior to the emergence of new mutations causing SARS-CoV-2 variants of concern, whose characteristics may increase the potential risk of in-flight transmission and imported outbreaks. The evidence on in-flight transmission of wild-type SARS-CoV-2 is limited, and is described in a small number of published reports. Most of the available evidence pertains to the early phase of the COVID-19 pandemic, during a period without non-pharmaceutical interventions such as distancing and in-flight mask wearing. There is considerable potential for outbreaks of COVID-19 from imported cases or clusters when public health guidance around quarantine of travellers and self-isolation of cases is not adhered to. Risks can be mitigated by measures such as: avoiding non-essential travel, targeted testing and quarantine of travellers from high incidence regions or regions of concern, managed quarantine processes, and protocols for rapid investigation and control of transmission from a possible variant of concern. Measures should be dynamically assessed and proportionate to the level of risk.

Assessing air travel safety in neuromuscular disease: standard versus prolonged hypoxic challenge tests

PURPOSE

The hypoxic challenge test (HCT) is used to evaluate safety for air travel in individuals with respiratory disease by breathing in 15% oxygen for 20 min. Our aim was to determine if a prolonged HCT, lasting 120 min, identified more individuals with neuromuscular disease at potential risk than the standard HCT lasting 20 min.

METHODS

This was a cross-sectional study. All of the clinical testing took place at SickKids, Toronto, Canada. Patients were included in the study if they had a diagnosis of NMD, greater than 6 years of age, resting oxygen saturation ≥ 94%, and partial pressure of carbon dioxide (pCO2) ≤ 45 mmHg. Notable exclusion criteria were left ventricular ejection fraction < 30%, presence of a tracheostomy, and use of non-invasive ventilation for more than 12 h daily. Participants underwent a standard HCT as well as the prolonged HCT on the same day.

RESULTS

Twenty-three patients consented to the study. One patient was withdrawn because he was unable to follow the study procedures. The 22 study participants had a mean age of 14.9 years (standard deviation (SD) of 5 years). Seventeen (77%) participants were male. Two participants were withdrawn on the day of testing due to hypercapnia. Twenty participants completed the standard and prolonged HCTs. None of the participants had a positive standard or prolonged HCT.

CONCLUSION

Our results suggest that performing a standard or prolonged HCT may, in fact, not be of clinical utility in individuals with less severe NMD.

The role of high-speed rail and air travel in the spread of COVID-19 in China

Background

Public transportation is a major facilitator of the spread of infectious diseases and has been a focus of policy interventions aiming to suppress the current COVID-19 epidemic.

Methods

We use a random-effects panel data model and a Difference-in-Differences in Reverse (DDR) model to examine how air and rail transport links with Wuhan as well as the suspension of these transport links influenced the development of the epidemic in China.

Results

We find high-speed rail (HSR) and air connectivity with Wuhan resulted in 25.4% and 21.2% increases in the average number of daily new confirmed cases, respectively, while their suspension led to 18.6% and 13.3% decreases in that number. We also find that the suspension effect was dynamic, growing stronger over time and peaking 20–23 days after the Wuhan lockdown, then gradually wearing off. It took approximately four weeks for this effect to fully materialize, roughly twice the maximum incubation period, and similar dynamic patterns were seen in both HSR and air models. Overall, HSR had a greater impact on COVID-19 development than air transport.

Conclusions

Our research provides important evidence for implementing transportation-related policies in controlling future infectious diseases.

Pretravel consultation on COVID-19 testing before international travel: lessons learnt from the Thai Travel Clinic, Bangkok, Thailand

The demand for COVID-19 testing has been on the rise after many countries have eased travel restrictions for essential travel to aid their economy. Thus, we discuss our lessons learnt of the crucial points that need to be considered by the clinicians when dealing with individuals seeking COVID-19 testing before international travel.

Successful containment of a flight-imported COVID-19 outbreak through extensive contact tracing, systematic testing and mandatory quarantine: Lessons from Vietnam

Background

The importation of SARS-CoV-2 through air travel poses substantial risks to generate new COVID-19 outbreaks. Timely contact tracing is particularly crucial to limit onwards transmission in settings without established community transmission.

Methods

We conducted an in-depth analysis of the response to a big flight-associated COVID-19 outbreak in Vietnam in March 2020 that involved contact tracing, systematic testing and strict quarantine up to third generation contacts.

Results

183 primary contacts from the flight as well as 1000 secondary and 311 third generation contacts were traced, tested, and quarantined across 15 provinces across Vietnam. The protracted confirmation of the index case at 3 days and 19 h after arrival resulted in isolation/quarantine delays of 6.8 days (IQR 6.3–6.8) and 5.8 days (IQR 5.8–7.0) for primary and secondary cases, respectively, which generated 84.0 and 26.4 person-days of community exposure from primary and secondary cases, respectively. Nevertheless, only 5 secondary cases occurred.

Conclusions

A large flight-related COVID-19 cluster was successfully contained through timely, systematic and comprehensive public health responses despite delayed index case identification. Multiagency collaboration and pre-established mechanisms are crucial for low and middle income countries like Vietnam to limit community transmission after COVID-19 importation through air travel.

Hand hygiene and facemask use to prevent droplet-transmitted viral diseases during air travel: a systematic literature review

Background

Transmission of viral diseases (e.g., influenza A H1N1) via respiratory droplets takes place mainly in confined spaces, including in aircraft during commercial air travel. The adoption of hygiene measures may help to prevent disease spread aboard aircraft. This review summarizes the evidence on hand hygiene and the use of facemasks as viral disease prevention measures in aircraft.

Methods

A literature search was performed in the PubMed, Scopus, and Web of Science databases up to 10 June 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A population, intervention, comparison, outcomes, and study design (PICOS) approach was used to define the review question.

Results

We included four studies published between 2007 and 2020, all targeting influenza virus disease, in the qualitative synthesis. Three studies used mathematical models to simulate single- or multiple-direction flights, and two of them showed that facemask (e.g., N95 respirator) use considerably reduced infection probability. In the third study, hand cleaning by 20 to 60% of people at any time in all airports (including on aircraft) reduced the measure of airports’ power to spread the disease across the globe by ~ 24 to 69%. The fourth study was a case-control study designed to trace an influenza outbreak in two flights during the 2009 influenza A H1N1 pandemic. The study showed that none (0%) of nine infected passengers compared to 15 (47%) of 32 healthy control passengers in the aircraft cabin during one of these flights wore a facemask (odds ratio, 0.0; 95% confidence interval, 0.0–0.7). In contrast, both case and control passengers appeared to be equally compliant in self-assessed hand hygiene.

Conclusions

Facemask use combined with hand hygiene may minimize the chance of droplet-transmitted virus spread by air travelers. Thus, it is necessary that hygiene measures become an integral part of standard procedures in commercial air travel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10814-9.

Adapting Bodies to Infrastructures

The material interrelations between bodies and objects are a wide, worthwhile and absorbing field, which has not been sufficiently examined yet. Focusing on such interrelations within air travel, this article contributes to the exploration of this field. It delineates that such interrelations do not simply happen, but that they have to be accomplished continuously by different participants with a certain risk to fail at many points. Within mobilities, such processes of interrelating occur under the specific circumstances of a moving vehicle. Based on empirical data from an ethnographic study on air travel, the paper is concerned with the ongoing dynamics of body-object-interrelations. Based on this analysis, it suggests emphasizing the continuous modification that material assemblages built of people and objects undergo even when "only" staying immobile during a flight. Passengers do not simply enter and exit a vehicle staying identical with themselves. Rather, they are continuously adapting to a material infrastructure that shapes and adjusts their corporeal needs and capacities, including their senses.

Public support for air travel restrictions to address COVID-19 or climate change

An improved understanding of public support is essential to design effective and feasible climate policies for aviation. Our motivation is the contrast between high support for air travel restrictions responding to the COVID-19 pandemic and low support for restrictions to combat climate change. Can the same factors explain individuals' support for restrictive measures across two different problems? Using a survey, we find that largely the same factors explain support. Support increases with expected effectiveness, perceived threat and imminence of the problem, shorter expected duration of the measure, knowledge, and trust, while support decreases with expected negative consequences for self and the poor. When controlling for all perceptions, there is no significant residual difference in support depending on whether the measures address climate change or COVID-19. The level of support differs because COVID-19 is perceived as a more imminent threat, and because measures are expected to be shorter-lasting and more effective.

High-altitude Illnesses and Air Travel: Pediatric Considerations

Healthy children may present acute mountain sickness (AMS) within a few hours after arrival at high altitudes. In few cases, serious complications may occur, including high-altitude pulmonary edema and rarely high-altitude cerebral edema. Those with preexisting conditions especially involving hypoxia and pulmonary hypertension shall not risk travelling to high altitudes. Newborn from low altitude mothers may have prolonged time to complete postnatal adaptation. The number of children and adolescents traveling on commercial aircrafts is growing, and this poses a need for their treating physicians to be aware of the potential risks of hypoxia while air traveling.

Air travel in a COVID-19 world: Commercial airline passengers' health concerns and attitudes towards infection prevention and disease control measures

BACKGROUND

COVID-19 and its associated travel bans have reduced international passenger traffic by over 80% below 2019 levels. If airlines are to resume flying at commercially sustainable levels, they must work to restore passengers confidence and sense of security. This study examined commercial airline passengers' health concerns and attitudes towards infection prevention and control measures for travel health and safety in the current COVID-19 global pandemic.

METHODS

A cross-sectional study was conducted inviting adult members of 39 frequent flyer groups across three social media platforms to participate in an online survey.

RESULTS

A total of 205 respondents completed the survey. The majority (75.6%) reported feeling 'somewhat' to 'extremely concerned' about contracting an infectious disease while flying, particularly respiratory-related. Few (9.8%) reported perceiving their health as an 'essential priority' for their preferred airline. Most respondents agreed airlines should provide complimentary hand sanitisers (86.8%), sanitary wipes (82.9%) and masks (64.4%) for passengers to use while flying as well as more information about preventing the spread of infections (90.7%), which would make the majority feel safer to fly.

CONCLUSION

COVID-19 has extensively challenged the air travel industry. Passengers have signalled that they expect more from airlines, and that they would actively engage in additional infection prevention and disease control measures while flying. Airlines must ensure passengers about the steps taken to minimize travel-associated risks, and their commitment towards passengers' health and wellbeing, in order to rebuild consumers' confidence in the recovery of the air travel industry.

Pneumopericardium, pneumomediastinum and air travel: A case report in a patient with Gardner syndrome

Onboard aircraft medical emergencies are on the rise as commercial air traffic is increasing. However, thoracic injury secondary to air travel is extremely rare and, most reported injuries are cases of pneumothoraces. Spontaneous pneumomediastinum and pneumopericardium have been barely reported in the medical literature as a complication of air travel. We are reporting a case of spontaneous pneumopericardium and pneumomediastinum in a patient with Gardner's Syndrome after a flight from Central America to New York City. The patient presented with chest discomfort. He was managed conservatively with oxygen therapy as he was hemodynamically stable throughout his stay in the hospital. A thorough work up in hospital including and esophagogram and a CT scan of the chest were none revealing of the cause. However, the patient was noted to have metastatic rectal cancer with lung involvement. The patient was discharged with instructions to avoid air travel.

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Air travel emergencies are on the rise with the increasing air traffic.

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Pneumomedisatinum and Pneumopericardium post air travel are rare but reported complications.

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Treatment consists of treating the underlying cause. Management Guidelines are absent to date.

Insights into the impact of COVID-19 on household travel and activities in Australia - The early days under restrictions

When 2020 began, we had no idea what was to unfold globally as we learnt about the Novel-Coronavirus in Wuhan, in the Hubei province of China. As this virus spread rapidly, it became a matter of time before many countries began to implement measures to try and contain the spread of the disease. COVID-19 as it is referred to, resulted in two main approaches to fighting the viral pandemic, either through a progressive set of measures to slow down the number of identified cases designed to 'flatten the curve' over time (anticipated to be at least six months), or to attack it by the severest of measures including a total lock-down and/or herding exposure to fast track 'immunisation' while we await a vaccine. The paper reports the findings from the first phase of an ongoing survey designed to identify the changing patterns in travel activity of Australian residents as a result of the stage 2 restrictions imposed by the Australian government. The main restrictions, in addition to social distancing of at least 1.5 m, are closure of entry to Australia (except residents returning), and closure of non-essential venues such as night clubs, restaurants, mass attendee sporting events, churches, weddings, and all social gatherings in any circumstance. With some employers encouraging working from home and others requiring it, in addition to job losses, and many children attending school online from home, the implications on travel activity is extreme. We identify the initial impacts associated with the first month of stricter social distancing measures introduced in Australia.

Attitudes of ageing passengers to air travel since the coronavirus pandemic

The coronavirus pandemic has had a devastating impact on the demand for air transport. One passenger segment that has received relatively little attention is ageing passengers (defined as aged 65+), in spite of the fact that this group has been disproportionately affected by COVID-19, and in recent years has been viewed as a potential growth market. Therefore, the aim of this brief paper is to analyse the attitudes of ageing passengers by assessing air travel plans in the next 12 months, examining the factors influencing future flying decisions, and investigating the impact of the coronavirus pandemic on perceived risks and experiences associated with flying. The findings show that over 60% of ageing passengers are planning to travel by air in the next 12 months, although the nature of their trips may change. Factors such as flexible ticket booking and quarantine rules do not appear to be key drivers affecting travel decisions and within the different stages of the air journey, getting to/from the airport is perceived as the safest stage. The findings suggest that there are various COVID-19 implications for airlines and airports serving this market segment, ranging from the use of self-service technology, the generation of commercial/ancillary revenues and the design of surface access policies.

Potential transmission of SARS-CoV-2 on a flight from Singapore to Hangzhou, China: An epidemiological investigation

BACKGROUND

Between January 24, 2020 and February 15, 2020, an outbreak of COVID-19 occurred among 335 passengers on a flight from Singapore to Hangzhou in China. This study aimed to investigate the source of the outbreak and assess the risk of transmission of COVID-19 during the flight.

METHOD

Using a standardized questionnaire, we collected information on the travelers' demographic characteristics and illness before, during, and after the flight. We also collected data on factors potentially associated with COVID-19 transmission during the flight.

RESULTS

A total of 16 COVID-19 patients were diagnosed among all passengers; the overall attack rate was 4.8%. The attack rate among passengers who had departed from Wuhan was significantly higher than that among those who had departed from other places. One passenger without an epidemiological history of exposure before boarding developed COVID-19. During the flight, he was seated near four infected passengers from Wuhan for approximately an hour and did not wear his facemask correctly during the flight.

CONCLUSIONS

COVID-19 transmission may have occurred during the flight. However, the majority of the cases in the flight-associated outbreak could not be attributed to transmission on the flight but were associated with exposure to the virus in Wuhan or to infected members in a single tour group.

Assessing spread risk of Wuhan novel coronavirus within and beyond China, January-April 2020: a travel network-based modelling study

Background

A novel coronavirus (2019-nCoV) emerged in Wuhan City, China, at the end of 2019 and has caused an outbreak of human-to-human transmission with a Public Health Emergency of International Concern declared by the World Health Organization on January 30, 2020.

Aim

We aimed to estimate the potential risk and geographic range of Wuhan novel coronavirus (2019-nCoV) spread within and beyond China from January through to April, 2020.

Methods

A series of domestic and international travel network-based connectivity and risk analyses were performed, by using de-identified and aggregated mobile phone data, air passenger itinerary data, and case reports.

Results

The cordon sanitaire of Wuhan is likely to have occurred during the latter stages of peak population numbers leaving the city before Lunar New Year (LNY), with travellers departing into neighbouring cities and other megacities in China. We estimated that 59,912 air passengers, of which 834 (95% UI: 478 - 1349) had 2019-nCoV infection, travelled from Wuhan to 382 cities outside of mainland China during the two weeks prior to Wuhan's lockdown. The majority of these cities were in Asia, but major hubs in Europe, the US and Australia were also prominent, with strong correlation seen between predicted importation risks and reported cases. Because significant spread has already occurred, a large number of airline travellers (3.3 million under the scenario of 75% travel reduction from normal volumes) may be required to be screened at origin high-risk cities in China and destinations across the globe for the following three months of February to April, 2020 to effectively limit spread beyond its current extent.

Conclusion

Further spread of 2019-nCoV within China and international exportation is likely to occur. All countries, especially vulnerable regions, should be prepared for efforts to contain the 2019-nCoV infection.

Supplemental oxygen therapy recommendations in patients with sickle cell disease during air travel: A cross-sectional survey of North American health care providers

INTRODUCTION

Air travel may expose patients with sickle cell disease (SCD) to an increased risk of disease-related complications. Several factors are felt to contribute including prolonged hypoxia, dehydration, temperature changes, and stress. The Canadian Paediatric Society (CPS) position statement, published in 2007, recommends that SCD patients use supplemental oxygen on flights. While the National Heart, Lung and Blood Institute (NHLBI) recommend that SCD patients dress warmly, stay hydrated, and move about the cabin. Other guidelines do not make specific recommendations.

METHODS

A cross-sectional online survey was circulated through the Canadian Hemoglobinopathy Association (CanHaem) and American Society of Pediatric Hematology and Oncology (ASPHO) listservs to North American health care practitioners (HCPs). Participants were asked to share their air travel recommendations for patients with SCD. Similarly, a patient survey regarding experiences with air travel was circulated through the Sickle Cell Disease Association of Canada (SCDAC) and the Sickle Cell Foundation of Alberta (SCFOA) listservs and discussion boards.

RESULTS

Although air travel is perceived to be a risk factor for sickling complications, only 18% of HCPs recommend supplemental oxygen. Most HCPs advise patients to increase hydration, carry analgesics, and wear warm clothes to prevent sickling complications. The patient survey was limited by a low response rate.

CONCLUSION

The majority of HCPs are not routinely recommending prophylactic oxygen to patients with SCD during air travel.

Carbon footprint of the RSNA annual meeting

PURPOSE

To determine the airplane travel-related carbon footprint of the Radiological Society of North America (RSNA) annual meeting, the associated health burden, and the costs to offset these greenhouse gas emissions (i.e. compensation of emissions by funding an equivalent CO₂ saving elsewhere).

METHODS

The RSNA's website was used to determine the reported country of origin of attendees to the 2017 meeting that took place in Chicago from November 26 to December 1. It was assumed that attendees had traveled from the airport nearest to the largest city in their country or state to Chicago's O'Hare international airport. The total amount of air travel-related CO₂-equivalent emission (based on round-trip economy class travel), the imposed health burden in terms of disability-adjusted life years (DALYs) in the global population, the total CO₂ offsets costs, and the CO₂ offsets costs per DALY were calculated.

RESULTS

The calculated airplane travel-related CO₂-equivalent emissions of 11,223 attendees from the United States and 10,684 attendees from other countries were 7,067,618 kg and 32,438,420 kg, totaling 39,506,038 kg. This caused an estimated 51.4-79.0 DALYs. The calculated amount of Total CO₂ offset costs were calculated to be $474,072, which corresponds to $6,001-9,223 per DALY averted.

CONCLUSIONS

The airplane travel-related carbon footprint of the RSNA annual meeting and the associated disease burden are relevant, and potential attendees and organizers should take measures to overcome this undesired side effect. Offsetting this carbon footprint is cost-effective and this initiative should be taken by the radiological community.

Boarding issue in a commercial flight for patients with cavitary pulmonary tuberculosis: A case report

BACKGROUND

Several studies have demonstrated that airborne transmission of Mycobacterium tuberculosis bacteria from patients with active pulmonary tuberculosis (TB) to other passengers or crew members can occur during long flights. As such, non-infectious TB patients are usually allowed to undertake air travel after taking the appropriate anti-TB drugs. However, the global guidelines for air travel for patients with TB are inconsistent and insufficiently detailed with respect to cavitary pulmonary TB (CPTB).

CASE SUMMARY

Here, we report a case in which a patient with multiple CPTB was permitted air travel, following negative sputum acid-fast bacilli smear tests after administration of proper anti-TB medication. The patient’s culture results were pending.

CONCLUSION

This case revealed that more specific guidelines regulating air travel for patients with CPTB are necessary.

Flying with Colloid Cyst: A Cautionary Note

BACKGROUND

Colloid cysts are benign and rare tumors of the brain. The growth rates of these tumors are unpredictable. These cysts can increase in size and obstruct the cerebrospinal fluid pathways producing obstructive hydrocephalus. Consequently, this can manifest as acute severe headaches followed by deterioration in consciousness, or even sudden death in patients. Such remarkable episodes occurring in patients during air travel have been reported sparsely in the literature.

CASE DESCRIPTION

In this report, we narrate the ordeal of a patient who had severe headache followed by loss of consciousness during his air travel. After his arrival, he was taken to a referral center where the diagnosis of a colloid cyst obstructing the cerebrospinal fluid pathway resulting in acute obstructive hydrocephalus was revealed. We analyze the physiologic effects of cabin pressure and high altitude on the intracranial pressure and present a brief review of the literature.

CONCLUSIONS

Changes in cabin pressure during flight may play a role in worsening of intracranial pressure in patients with colloid cyst with marginal brain compliance.

Why you should wear your seatbelt on an airplane: Burst fracture of the atlas (jefferson fracture) due to in-flight turbulence

The Jefferson fracture is a burst-type fracture to the atlas first described in 1919, characterized by anterior and posterior fractures of the weak C1 ring caused by a sudden axial load to the vertex of the skull. Here we report a Jefferson fracture caused by head trauma due to mid-flight turbulence in an unrestrained 56-year-old male airline passenger. Imaging revealed a comminuted burst fracture of the atlas with an avulsion fracture of the transverse atlantal ligament. The patient was treated conservatively in a Miami-J collar with close clinical and radiographic follow-up. Lateral flexion-extension radiographs demonstrated fracture stability, and clinically the patient lacked pain or neurologic symptoms at 12 weeks from injury. To our knowledge this is the first report of a Jefferson fracture caused by axial compression attributable to in-flight turbulence. Traditionally associated with automobile crashes and diving headfirst into shallow pools, the axial load results in a compressive force to the atlas and subsequent lateral separation of the two halves of the C1 vertebral ring. The purpose of this case study is to alert providers, aircraft personnel, and passengers of the inherent risk of air travel and the importance of wearing a seatbelt at all times, describe the signs and symptoms of this often-overlooked fracture, and provide general treatment guidelines based on radiographic assessments of fracture stability.

Global commercial passenger airlines and travel health information regarding infection control and the prevention of infectious disease: What's in a website?

BACKGROUND

Air travel has never been easier, cheaper or faster, with large volumes of people travelling around the world. These factors increase the risk of the spread of infectious diseases by air travel. Little is known, however, about the extent to which airlines provide information to passengers on infection control and measures to prevent the spread of infectious diseases. This study examined the websites of the global commercial passenger airlines to see if they contained information about infection control and prevention of infectious diseases and appraised the clinical usefulness of that information.

METHOD

A cross-sectional text-based analysis of the 73 airline websites from the six global commercial passenger airline conglomerates was performed to identify information about infection control and prevention of infectious between July and August 2019.

RESULTS

Of the 73 airline websites, less than half (n = 35, 28.6%) contained information deemed useful for passengers. While there was a range of general health advice within the websites, there was limited information about infection control and preventing infectious diseases. A minority of websites contained information about vaccination status prior to travel, and to a lesser extent handwashing and hand hygiene, with very few including disease-specific advice or preventive measures.

CONCLUSIONS

Airline websites are an underutilised source of information for infection control and the prevention of infectious diseases. Providing passengers with information on basic infection control and prevention measures may support the global efforts against the spread of infectious diseases.

Spontaneous pneumothorax and air travel in Pulmonary Langerhans cell histiocytosis: A patient survey

BACKGROUND

The optimal approach for management of spontaneous pneumothoraces (SPs) and the safety of air travel in patients with pulmonary Langerhans cell histiocytosis (PLCH) are not well established.

METHODS

Patients with PLCH were recruited from the Rare Lung Diseases Clinic Network and the Histiocytosis Association, and surveyed about disease manifestations and safety of air travel.

RESULTS

A total of 94 patients completed the survey. Median age at diagnosis of PLCH was 40 years (range: 15-67 years). Average interval between symptom onset and diagnosis was 2.9 years (range: -4 to 31 years). Twenty-two patients (23%) had at least one SP, of which 14 (64%) had at least one additional SP that showed either an ipsilateral recurrence (10 patients; 45%) or a contralateral recurrence (8 patients; 36%). Mean age at the time of first SP was 29 years. SP was the presenting manifestation that led to the diagnosis of PLCH in 19% of patients, typically after the second episode. Surgical pleurodesis reduced the recurrence rate of SP by half in comparison with conservative management (29% vs. 65%, p = 0.025). Two patients experienced an episode of SP during air travel, consistent with an air travel-related pneumothorax rate of 2.4% per patient and 0.27% per flight.

CONCLUSIONS

SP is a common manifestation of PLCH, can be seen in approximately one-fourth of the patients, and has a high recurrence risk. Surgical pleurodesis leads to a substantial reduction in the SP recurrence risk. The risk of an air travel-related SP in patients with PLCH is about 2-3 per thousand flights. TRIAL REGISTRY CLINICALTRIALS.GOV: NCT03052101.

Countries at risk of importation of chikungunya virus cases from Southern Thailand: A modeling study

Southern Thailand has been experiencing a large chikungunya virus (CHIKV) outbreak since October 2018. Given the magnitude and duration of the outbreak and its location in a popular tourist destination, we sought to determine international case exportation risk and identify countries at greatest risk of receiving travel-associated imported CHIKV cases. We used a probabilistic model to estimate the expected number of exported cases from Southern Thailand between October 2018 and April 2019. The model incorporated data on CHIKV natural history, infection rates in Southern Thailand, average length of stay for tourists, and international outbound air passenger numbers from the outbreak area. For countries highly connected to Southern Thailand by air travel, we ran 1000 simulations to estimate the expected number of imported cases. We also identified destination countries with conditions suitable for autochthonous CHIKV transmission. Over the outbreak period, we estimated that an average of 125 (95% credible interval (CrI): 102–149) cases would be exported from Southern Thailand to international destinations via air travel. China was projected to receive the most cases (43, 95% CrI: 30–56), followed by Singapore (7, 95% CrI: 2–12) and Malaysia (5, 95% CrI: 1–10). Twenty-three countries were projected to receive at least one imported case, and 64% of these countries had one or more regions that could potentially support autochthonous CHIKV transmission. The overall risk of international exportation of CHIKV cases associated with the outbreak is Southern Thailand is high. Our model projections are consistent with recent reports of CHIKV in travelers returning from the region. Countries should be alert to the possibility of CHIKV infection in returning travelers, particularly in regions where autochthonous transmission is possible.

Measles transmission at an international airport - Taiwan, March-April 2018

During March-April 2018, an infectious measles index case traveling from Thailand led to two successive generations of measles transmission in Taiwan, with 21 cases confirmed. The median patient age was 30.5 years (range 22-47 years); six (27%) had documented receipt of one (n=3) or more (n=3) previous measles-containing vaccine doses at age ≥12 months. Epidemiological investigation and sequence analysis found that most (n=16, 76%) measles transmissions had occurred in airport and flight settings; secondary and tertiary cases included cabin crew (n=7), airport staff (n=2), and passengers who had been at the same airport or on the same flight (n=7). This investigation serves as a reminder that an international airport can be a hotspot for measles transmission. International travelers, airline cabin crew, and airport employees are recommended to check their vaccination status and ensure that they are fully vaccinated against measles. Furthermore, it is recommended that airline and airport employers have an occupational health vaccination program in place to ensure appropriate pre-employment assessment of measles immunity and vaccination.