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19 Airline Operators Should Consider Decreasing Ventilation Downtime on Aircraft Parked at the Gate Highly Recommended Rationale. The ventilation systems in operat- ing aircraft are designed to bring in fresh air, filter the air, and circulate the air within the cabin. All of these actions reduce the potential transmission of infectious aerosols. However, once the aircraft is shut down, these systems are also shut down and the risk of transmission of infectious aerosols increases. Many airports have gate-based ventilation systems which are attached to the aircraft once the aircraft engines are shut down. As a result, air movement is maintained within the cabin. However, not all airports or gates are equipped with these gate based ventilation systems. In many cases, when these systems do exist, they are not routinely used. Points to Consider for Implementation 1. Install gate-based aircraft ventilation systems at all gates in an airport, when possible. 2. Attach gate-based ventilation systems to aircraft as soon as the aircraft is shut down. 3. Do not detach gate-based ventilation systems until shortly before aircraft start up. 4. Installation of these systems, as well as their operation, may be expensive. Based on these costs, routine operation may not be warranted in all instances. However, in the case of an emergency or a pandemic, these costs would be justified. Airport operators and airlines should make preparations to provide gate-based ventilation to all parked aircraft in the event of an emergency or pandemic. Airline Operators Should Consider Ensuring That Biohazard Kits Are Available to Employees in Aircraft Highly Recommended Rationale. Infectious diseases, such as norovirus, can be transmitted through vomit. Bloodborne pathogens like hepatitis and HIV can be transmitted through contact with broken skin or mucosa or mucous membranes with contaminated blood. Airline workers, C H A P T E R 3 Airplanes
20 Infectious Disease Mitigation in Airports and on Aircraft including cabin crews, who encounter any biological fluid, including phlegm, blood, vomit, do not know if it came from a contagious person and should therefore treat the fluid as potentially infectious. It is important to minimize the risk of transmitting infectious dis- eases through bodily fluids by donning appropriate personal protective equipment and promptly clean- ing and disinfecting the area following a release. Case reports have demonstrated that inadequate responses to passengers who have vomited can result in transmis- sion of infectious diseases to others in the area. Any personnel involved with cleaning/disinfecting areas should be properly trained (including training on how to report an occupational bloodborne pathogen expo- sure event and obtain immediate medical evaluation) and equipped with appropriate personal protective equipment to ensure their safety. Points to Consider for Implementation 1. Biohazard kits should be available on the aircraft to ensure a timely response to a release. 2. Biohazard kits should include: gloves, face shield, biohazard bags, towels or other absorbent material, disposable scoops, disinfectant, training materials (or short step by step guide for cleaning up vomit and other bodily fluids). 3. Ensure disinfectant in biohazard kit has a long shelf life. 4. Designated personnel who perform cleaning of bodily fluids should be trained on blood- borne pathogens and cleaning procedures on an annual basis. 5. Ensure that training includes all required elements of U.S. OSHA Bloodborne Pathogens Standard, including how to report an exposure event and obtain a medical evaluation. 6. Airline procedures for disposal of waste containing bloodborne pathogens should include typical and atypical quantities (e.g., how to appropriately handle a contaminated airline seat that must be taken out of service and ultimately disposed of). Airline Operators Should Consider Encouraging the Use of Hand Sanitizer Before, During and After the Flight Highly Recommended Rationale. Use of hand sanitizer has been dem- onstrated to reduce infectious disease transmission by reducing microbial loads on hand surfaces. Data from schools, extended care facilities, and acute care facilities show a reduction in absenteeism and infection rates with increased use of hand sanitizer. The use of hand sanitizer prior to boarding, during flight, and during disembar- kation should be encouraged to minimize the potential for disease transmission during the flight, and also to minimize the potential of cross-contamination of the airplane from the airport environment. Hand sanitizers are to be used in addition to, and not to replace, soap and water hand washing.
Airplanes 21 Points to Consider for Implementation 1. Use hand sanitizers that contain at least 60% alcohol, per the recommendation by the Centers for Disease Control and Prevention (CDC). 2. Consider placement of hand sanitizer dispensers in the jetway. 3. Ensure highly visual signage near hand sanitizer stations to encourage use. 4. Appoint staff as responsible person or group to maintain stations and ensure adequate sup- plies of sanitizer product. 5. Educate cabin crew that while hand sanitizer can be effective, the CDC continues to recom- mend that soap and water is the preferred hand cleaning method. Norovirus Transmission on an Airplane In October, 2009, an outbreak of norovirus was reported among flight attendants who had worked different shifts on the same airplane, up to 5 days after a sick passenger was onboard. Norovirus causes stomach flu with symptoms consisting of diarrhea and vomiting, the same set of symptoms reported among the flight atten- dants. The virus is shed usually before and after illness with transmission occurring through oral ingestion of shed virus particles in feces or vomit of infected individuals. The index case was an unidentified male passenger seated in the economy section of the airplane. The index case vomited and soiled the carpet next to his seat which was cleaned during the flight by one of the flight attendants and disposed in a passenger restroom at the rear of the aircraft. Out of the total 77 flight attendants who had worked on the same airplane on the same day as the index case and the subsequent 5 days, 27 developed the illness, with onset being less than 51 hours after the end of their first shift. In addition, the airline had also received reports from five passengers on the same flight that had developed gastrointestinal illness. Results from the study suggested that flight attendants were infected through their work on the same airplane during separate shifts, despite the initial source of the virus (vomit) having been cleaned immediately after discovery on the first day. Although the airplane may have been cleaned and disinfected between flights, this outbreak incident demonstrates that current cleaning practices may not adequately remove disease-causing agents from contaminated surfaces, with the potential for sustained transmission. As a result, the authors recommended the use of biohazard kits, including disinfectants effective against norovirus (and training on the use of the biohazard kits), on airplanes to limit the spread of infectious disease after these types of incidents.
22 Infectious Disease Mitigation in Airports and on Aircraft Airport and Airline Operators Should Consider Using Broad-Spectrum U.S. EPA-Registered Disinfectants Highly Recommended Rationale. Frequently touched surfaces (e.g., bath- room surfaces, seatback trays, and seat armrests) and floors become contaminated with microorganisms from settling airborne bacteria, by contact with hands, shoes, wheels, and other objects, and occasionally by spills and or splashes of human blood or bodily fluids (e.g., vomit). Studies conducted in healthcare facilities have shown that mopping with soap and water (80% reduction) was less effective in reducing the numbers of bacteria than was a phenolic disinfectant (94%â99.9% reduction). Other studies have shown that use of detergents become con- taminated and increase the bacterial load on surfaces after âcleaning.â Studies also have shown that, in situations where the cleaning procedure failed to eliminate contamination from the surface and the cloth is used to wipe another surface, the contamination is transferred to that surface and the hands of the person holding the cloth. The EPA requires that all disinfectants be registered, which includes conducting standardized organism specific efficacy studies. The efficacy study data is submitted to the EPA and used to support claims for disinfection. Substantiated efficacy claim information is available on the EPA website (http://www.epa.gov/oppadOOl/chemregindex.htm). Studies have shown that prod- ucts with limited efficacy can lead to increased transfer of microorganisms from one surface to another. Therefore, it is important to ensure the disinfectant products that are used are proven to be effective against the organisms of interest that are transmitted via contaminated surfaces, such as norovirus and influenza. Appropriate disinfectants have been demonstrated to reduce microbial loads. Disinfectants must be used according to manufacturerâs instructions for the intended pur- pose. To ensure proper use, an SOP should be developed that includes key information such as how to make up working solutions from concentrate, the length of time the working solutions should be used before they lose effectiveness, the contact time for the disinfectant, and any safety precautions that should be taken when working with the disinfectant. Staff should be trained on the SOP. Points to Consider for Implementation 1. Ensure that broad-spectrum, EPA-registered disinfectants are used for the general cleaning of frequently touched surfaces and floors, even in areas other than bathrooms. 2. Regularly clean and disinfect high-touch surfaces with EPA-registered, intermediate-level disinfectants. 3. Frequency of cleaning should be based on cleaning audits, such as visual assessments.. 4. To ensure effectiveness, make certain that disinfectantâs manufacturerâs instructions are followed for preparation (e.g., appropriate dilution) and use (e.g., contact time). 5. During periods of heightened concern for infectious diseases that are transmitted via surfaces (e.g., influenza, norovirus), ensure that the frequency of disinfection on frequently touched surfaces is increased. 6. Review aircraft manufacturer specifications to ensure that disinfectants do not degrade aircraft materials, electrical systems or mechanical components.
Airplanes 23 Airline Operators Should Consider Using HEPA-Filtered Vacuums When Cleaning Carpets and Upholstery Suggested Rationale. Typical vacuums have been shown to not only collect, but to also aerosolize large amounts of sur- face dust, which may contain infectious microorganisms or more commonly, allergens, such as fungal spores. The regular use of vacuums in good repair that are equipped with HEPA filters will minimize dust dispersion. Points to Consider for Implementation 1. Ensure that the use of HEPA-filtered vacuums is specified in contracts with organizations responsible for cleaning aircraft surfaces and other carpeted areas used by passengers and staff.