1. 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 1 Tuberculosis & Air Travel

2. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 2 Introduction Millions of people travel by air every year. it is not possible to medically assess the majority before their flights. Millions of people travel by air every year. it is not possible to medically assess the majority before their flights.

3. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 3 Tuberculosis on aircraft Most evidence indicates that: Most evidence indicates that: airborne transmission of infectious diseases on board aircraft appears to be limited to close personal contact and / or close proximity. airborne transmission of infectious diseases on board aircraft appears to be limited to close personal contact and / or close proximity.

4. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 4 Practical issues in investigations concerning Exposure to M.TB Adequate and timely contact tracing after potential exposure to M.Tuberculosis may be impeded by practical constraints, particularly: Adequate and timely contact tracing after potential exposure to M.Tuberculosis may be impeded by practical constraints, particularly: the length of time between travel and diagnosis and the length of time between travel and diagnosis and the accuracy and availability of airline records.the accuracy and availability of airline records.

5. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 5 Legal & regulatory issues Airline companies are expected to comply with the: Airline companies are expected to comply with the: International Health Regulations and International Health Regulations and laws of the countries in which they operate. laws of the countries in which they operate.

6. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 6 Reducing the risk of exposure to M.TB on aircraft People known to have infectious TB must People known to have infectious TB must not travel by public air transportationnot travel by public air transportation until at least two weeks of adequate treatment have been completed.until at least two weeks of adequate treatment have been completed. Patients with MDR-TB should not travel until they have been proved to be non-infectious (i.e. culture-negative).not travel until they have been proved to be non-infectious (i.e. culture-negative).

7. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 7 Aircraft ventilation In case of ground delays of more than 30 minutes,adequate cabin ventilation must be ensured. In case of ground delays of more than 30 minutes,adequate cabin ventilation must be ensured.

8. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 8 Cabin air quality There is no evidence that recirculation of cabin air facilitates transmission of infectious disease agents on board. There is no evidence that recirculation of cabin air facilitates transmission of infectious disease agents on board.

9. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 9 criteria for deciding whether to inform passengers & crew Infectiousness of the person with TB Infectiousness of the person with TB Duration of exposure Duration of exposure Time elapsed between the flight(s) and the notification of the case Time elapsed between the flight(s) and the notification of the case Proximity of other passengers and crew to the index patient Proximity of other passengers and crew to the index patient

10. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 10 TB patient should be considered infectious at the time of the flight If : Lab Positive:Lab Positive: Positive Sputum Smear for AFB &/or Positive Sputum Smear for AFB &/or Positive Culture for M.TB Positive Culture for M.TB AndAnd Clinical symptoms of TB including cough Clinical symptoms of TB including cough Not receiving adequate TB treatment or Not receiving adequate TB treatment or Receiving TB treatment for less than 2 weeks or Receiving TB treatment for less than 2 weeks or Receiving adequate TB treatment for more than 2 weeks but with no evidence of response (clinically or paraclinically) Receiving adequate TB treatment for more than 2 weeks but with no evidence of response (clinically or paraclinically) If MDR-TB,If MDR-TB, not receiving adequate treatment or not receiving adequate treatment or Receiving adequate treatment for any time but with no evidence of culture conversion Receiving adequate treatment for any time but with no evidence of culture conversion

11. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 11 criteria for deciding whether to inform passengers & crew Determination of infectiousness Determination of infectiousness Informing close contacts is indicated if total flight duration exceeded 8 hours Informing close contacts is indicated if total flight duration exceeded 8 hours Informing passengers and crew should be limited to flights that took place during the three months before notification of the TB case to the health authorities Informing passengers and crew should be limited to flights that took place during the three months before notification of the TB case to the health authorities Passenger-to-passenger transmission of M.TB has been documented only among close contacts seated in the same section as the person with infectious TB Passenger-to-passenger transmission of M.TB has been documented only among close contacts seated in the same section as the person with infectious TB

12. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 12 Airline employee health The risk of TB among cabin crew members is similar to that of the general population. The risk of TB among cabin crew members is similar to that of the general population. mandatory routine or periodic screening is not indicated for cabin crew mandatory routine or periodic screening is not indicated for cabin crew

13. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 13 Summary Recommendations

14. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 14 For passengers & air crew 1.People with infectious TB must postpone long-distance travel (total flight exceeding eight hours) until they become non- infectious (completion of at least two weeks of adequate treatment) and according to the recommendations of their physicians.

15. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 15 For passengers & air crew 2. People with MDR-TB must postpone any air travel until advised by their physicians that they are no longer infectious, i.e. culture-negative.

16. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 16 For physicians 1.Physicians should inform all infectious TB patients that they must not travel by air on a flight exceeding eight hours until they have completed at east two weeks of adequate treatment. 2.Physicians should inform all MDR-TB patients that they must not travel by air-under any circumstances or on a flight of any duration until they are proven to be culture-negative.

17. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 17 For physicians 3.Physicians should advise TB patients who undertake unavoidable air travel of short duration (less than eight hours) to wear a surgical mask when possible or to cover the nose and mouth when speaking or coughing at all times during the flight. 4.Physicians should inform the relevant health authority when they are aware of an infectious TB patient’s intention to travel against medical advice. 5.Physicians should immediately inform the relevant health authority when an infectious TB patient has a recent history of air travel (i.e. within three months).

18. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 18 For public health authorities 1.Public health authorities who are aware that a person with infectious TB is planning to travel with a commercial carrier on a flight whose total duration could potentially exceed eight hours should inform the concerned airline. 2.Health authorities should promptly contact the airline when an infectious TB patient is known to have traveled on a commercial flight of at least eight hours’ duration ( including ground delay time) within the preceding three months.

19. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 19 For public health authorities 3.Health authorities should promptly contact potentially exposed passengers and crew and advise them to seek medical evaluation. 4.Public health authorities should establish country-specific policies and provide guidance to airlines on the prevention of risks due to infectious diseases.

20. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 20 For airline companies 1.Airline companies should deny boarding to any person who is known to have infectious TB and is intending to travel on a flight whose total duration is likely to be at least eight hours. 2.Airline companies should minimize ground delays to less than 30 minutes if the ventilation system is not in operation.

21. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 21 For airline companies 3.Airline companies should ensure that HEPA filters on all aircraft are changed regularly according to the recommendations of the filter manufacturer. 4.Airline companies should ensure that cabin crews receive adequate training on potential exposure to infectious diseases, in first aid and in using universal precautions when there may be exposure to body fluids.

22. TB & Air Travel 1385 / 5 / 15 نشست سالانه برنامه كنترل سل شهريور 1385 22 For airline companies 5.Airline companies should ensure that there are adequate emergency medical supplies on board of all aircraft ( including gloves, surgical masks and biohazard disposal bags). 6.Airline companies should cooperate with health authorities in providing all contact information needed by them and facilitate contact tracing of passengers and/or crew.