Is it safe to travel for the holidays this year? Join us on a 12-month journey to see them all. Case 1 was the only symptomatic person on board and was the only person with a flight-associated case who had established contact with a person with a confirmed case (her sister) during her incubation period. Initial investigations of the probable index case generated our working hypothesis of in-flight transmission and guided further investigations. Please use the form below to submit correspondence to the authors or contact them at the following address: Cong-Khanh Nguyen, Department of Communicable Diseases Control, National Institute of Hygiene and Epidemiology, 1 Yersin St, Hai Ba Trung District, Hanoi 100000, Vietnam. Transmission on flight VN54 was clustered in business class, where seats are already more widely spaced than in economy class, and infection spread much further than the existing 2-row (36) or 2 meters (37) rule recommended for COVID-19 prevention on airplanes and other public transport would have captured. Face masks were neither recommended nor widely used on airplanes in early March, in particular not among travelers from Europe (24–26), who constituted the majority of passengers on flight VN54. Although Vietnam Airlines keeps business class passengers separated from economy class passengers during most procedures before and during the flight, contact with the 2 economy class cases might have occurred after arrival during immigration or at baggage claim. Potential transmission of SARS-CoV-2 on a flight from Singapore to Hangzhou, China: An epidemiological investigation. Affected persons were passengers, crew, and their close contacts. Contact with case 1 might also have occurred outside the airplane at the airport, in particular among business class passengers in the predeparture lounge area or during boarding. A study of a COVID-19 cluster with 16 infected flight passengers from Singapore in February 2020 identified only 1 instance of potential in-flight transmission (28). https://thepointsguy.com/news/united-airlines-covid-risk-planes-study She was seated in business class and continued to experience the sore throat and cough throughout the flight. Flight-associated cases were considered to have very likely acquired infection on board VN54 and were hence classified as probable secondary cases in this analysis if the following 3 criteria were met: 1) they experienced signs/symptoms 2–14 days after arrival or if they were SARS-CoV-2 positive by PCR 2–14 days after arrival in the absence of signs/symptoms; 2) in-depth investigation did not reveal any potential exposure to SARS-CoV-2 before or after the flight during their incubation period; and 3) they had shared cabin space with the probable index case during the flight (14–17). Saving Lives, Protecting People, National Institute of Hygiene and Epidemiology, Hanoi, Vietnam (N.C. Khanh, P.Q. https://www.cnn.com/travel/article/airplanes-ventilation-study-covid-19 A total of 16 crew members and 201 passengers were on board. Transmission of SARS-CoV 2 During Long-Haul Flight. First, thermal imaging and self-declaration of symptoms have clear limitations, as demonstrated by case 1, who boarded the flight with symptoms and did not declare them before or after the flight. As long as COVID-19 presents a global pandemic threat in the absence of a good point-of-care test, better on-board infection prevention measures and arrival screening procedures are needed to make flying safe. 2These last authors contributed equally to this article. We defined cases of SARS-CoV-2 infection according to Vietnam Ministry of Health guidelines in place at the time of our investigation (12). Third, our assessment of passengers’ preflight exposure to other confirmed cases relied on interviews only. 1These first authors contributed equally to this article. Among >1,300 close contacts of VN54 passengers and crew members, 5 confirmed cases were identified, 3 of whom were household personnel linked to case 1. H. Thi, F. Vogt), Ministry of Science and Technology, Hanoi (P.C. No in-depth investigations among passengers on those flights were conducted, and no evidence indicated that transmission had occurred during the flights themselves. Furthermore, all persons with suspected or confirmed flight-associated cases were asked to identify persons with whom they had had close contact (<2 meter distance for >15 minutes) between arriving in Vietnam and the start of quarantine/isolation. We also thank the Civil Avian Administration, Immigration Bureau, Vietnam Airlines, and all passengers on flight VN54 for their cooperation and support. This policy change eliminated the need for resource-intensive contact tracing of flight passengers altogether and enabled detection of another 106 cases among »5,000 passengers on 44 flights until all international flights were halted on March 28. Specifically, we defined suspected flight-associated COVID-19 cases as passengers or crew members on board flight VN54 landing in Hanoi on March 2 who reported fever and cough, with or without shortness of breath, during March 1–16. Similar results with similar limitations have been reported from flights arriving in France (31,32) and Thailand (33) in January and February. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Investigation Team. Thai, H.-L. Quach, N.-A.H. Thi, T.N. https://www.latimes.com/business/story/2020-10-29/covid-19-risk-airplanes Tu, D.D. A case report published in the CDC journal Emerging Infectious Diseases in March analyzed an 18-hour flight of … At that time, the use of face masks was not mandatory on airplanes or at airports (18). Among persons in business class, the attack rate was 62% (13/21). Combating the COVID-19 Epidemic: Experiences from Vietnam. These close contacts were also contacted, tested, and quarantined for 14 days. Harvard study: Flying has lower COVID-19 risk than grocery shopping or eating out There has been little evidence of transmission of the disease on planes, according to the study. Similar conclusions were reached for SARS-CoV superspreader events on a flight in 2003, in which a high risk for infection was observed for passengers seated farther than 3 rows from the index case (4). We defined confirmed flight-associated COVID-19 cases as passengers or crew members on flight VN54, regardless whether signs or symptoms developed, who had positive SARS-CoV-2 real-time reverse transcription PCR results from nasopharyngeal swab samples (13). However, given the logistic and economic implications of such policies, developing a quick and reliable point-of-care test that covers the entire infectious period remains paramount. A passenger seated three rows away who developed coronavirus but who never had symptoms also used the lavatory. Review article: influenza transmission on aircraft. In Vietnam, for example, as a result of this investigation, national policy was changed toward mandatory testing at arrival irrespective of departure location and 14-day quarantine irrespective of test result or clinical signs/symptoms (41). The US Department of Defense study supports earlier research showing the ventilation systems on aircraft filter the air efficiently and take out particles that could transmit viruses. Initial investigations of flight VN54 led us to hypothesize potential in-flight transmission originating from 1 symptomatic passenger in business class (the probable index case). We also note that 2 passengers, in the seats between the 2 cases in economy class, were lost to follow-up. According to a new CDC study, leaving the middle seat empty on airplanes may help reduce COVID-19 transmission on board. As of March 1, 2020, only 16 cases of COVID-19 had been reported in Vietnam, and 17 days had passed since the last reported case (case 1 reported here became Vietnam case no. There was an unexpected error. Our findings have several implications for international air travel, especially because several countries have resumed air travel despite ongoing SARS-CoV-2 transmission. Seating proximity was strongly associated with increased infection risk (risk ratio 7.3, 95% CI 1.2–46.2). COVID-19: Facemask use prevalence in international airports in Asia, Europe and the Americas, March 2020. Our investigation did not reveal strong evidence supporting potential SARS-CoV-2 exposure either before or after the flight for any of the additional persons with flight-associated cases other than having traveled on the same flight as case 1 (Appendix). On March 7, three of her household personnel received positive SARS-CoV-2 results, as did a friend of hers, whom she had visited in London on February 29, on March 10. Identification and monitoring of international travelers during the initial phase of an outbreak of COVID-19—California, February 3–March 17, 2020. Whether either of these passengers could represent a separate index case in economy class is unknown. In-depth epidemiologic investigations strongly suggest that 1 symptomatic passenger (case 1) transmitted SARS-CoV-2 infection during the flight to at least 12 other passengers in business class (probable secondary cases). Whether these cases reflect unusually long incubation periods or symptoms caused by conditions other than COVID-19 is unknown. Through these efforts, we identified an additional 15 PCR-confirmed COVID-19 cases, 14 among passengers and 1 among crew members, resulting in a total of 16 confirmed flight-associated cases. All successfully traced passengers and crew members were interviewed by use of a standard questionnaire, tested for SARS-CoV-2, and quarantined in designated facilities or at home. The findings of the report are similar to that of a recent U.S. Department of Defense (DOD) study, which revealed that the risk of COVID-19 transmission on board a plane … Quang). Figure 2. Message not sent. Dr. Khanh is an epidemiologist at the Department of Communicable Diseases Control, National Institute of Hygiene and Epidemiology. Khanh N, Thai P, Quach H, et al. We found no strong evidence supporting alternative transmission scenarios. In-flight transmission that probably originated from 1 symptomatic passenger caused a large cluster of cases during a long flight. The business class was exclusively reserved and separated from the premium economy and economy classes by a service/toilet area (Figure 1). This finding also concurs with transmission patterns observed for influenza virus (38) and is generally in line with the mounting evidence that airborne transmission of SARS-CoV-2 is a major yet underrecognized transmission route (39,40). The study, which was released without peer review, did not take into account other ways that people could catch the virus on aircraft -- including from others coughing or breathing directly on them, from surfaces or from confined spaces such as restrooms. We also note that cases 3 and 14 experienced symptom onset 17 days after flight VN54. "Contamination of surfaces via non-aerosol routes (large droplets or fecal contamination) is more likely in lavatories and other common areas and is not tested here," they added. Dan Vergano BuzzFeed News Reporter Posted on April 14, 2021, at 11:13 a.m. "Similarly, the mannequin remained facing forward, uncertainty in human behavior with conversations and behavior may change the risk and directionality in the closest seats to an index patient, especially for large droplets.". Of the 15 persons with flight-associated cases, 12 (80%) had traveled in business class with case 1, and 2 travelers (cases 14 and 15) and 1 flight attendant (case 16) had been in economy class (Figure 1). All persons in quarantine were checked twice daily for clinical signs/symptoms and fever; oropharyngeal swabs were collected on the day of admission, after 3–5 days, and on day 13, unless signs/symptoms developed, in which instance a specimen was collected immediately and the person was isolated and monitored until receipt of the test result. To assess the role of in-flight transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), we investigated a cluster of cases among passengers on a 10-hour commercial flight. First, we did not have genomic sequencing data available to support our hypothesis of in-flight transmission. Similar intervals between arrival and positive SARS-CoV-2 test results among 3 case-pairs suggest a common exposure event rather than subsequent infection from one partner to the other. In January 2020, no secondary cases were detected after a 15-hour flight to Canada with a symptomatic person with COVID-19 on board (29), although contact tracing and monitoring were limited (30). During the first 6 months of 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread to almost all countries and infected »4 million persons worldwide (1). There were 4 traveling companion couples on board, and individuals within each couple sat next to each other in business class. All of these studies limited contact tracing to passengers within 2 rows of the index cases, which could explain why secondary flight-related transmission was not detected by those studies. We were able to quarantine, interview, and collect swab specimens for PCR testing from all passengers and crew members who remained in Vietnam. Transmission and control of an emerging influenza pandemic in a small-world airline network. A new coronavirus study gives us a first look at the transmission rate on airplanes, suggesting that the risk of catching COVID-19 might be small — though it still exists. Her signs and symptoms (fever, sore throat, fatigue, and shortness of breath) progressed further after arrival, and she self-isolated at her private residence in Hanoi and had contact with household personnel only. However, the conclusiveness and unambiguity of our in-depth epidemiologic upstream and downstream investigations coupled with extensive laboratory testing make us confident of our main findings. Blocking middle seats, currently recommended by the airline industry (7,35), may in theory prevent some in-flight transmission events but seems to be insufficient to prevent superspreading events. On March 1, she boarded flight VN54. Among the 16 persons in whom SARS-CoV-2 infection was detected, 12 (75%) were passengers seated in business class along with the only symptomatic person (attack rate 62%). Epidemiologic and clinical timeline for passengers on Vietnam Airlines flight 54, from London, UK, to Hanoi, Vietnam, March 2, 2020, for whom SARS-CoV-2 infection was later confirmed. Second, we lacked detailed data on activities of the cases while on board (e.g., movements or seat changes, use of toilets, or sharing meals), which might have enabled us to pinpoint the precise route of transmission. We consider local transmission after arrival in Vietnam unlikely. Public masking: an urgent need to revise global policies to protect against COVID-19. https://www.cnn.com/travel/article/odds-catching-covid-19-flight-wellness-scn On March 5, she sought care at a local hospital in Hanoi, where an oropharyngeal swab sample was taken and tested; SARS-CoV-2 infection was confirmed by real-time reverse transcription PCR on March 6. Although the international flight industry has judged the risk for in-flight transmission to be very low (7), long flights in particular have become a matter of increasing concern as many countries have started lifting flight restrictions despite ongoing SARS-CoV-2 transmission (8). Transmission of SARS-CoV 2 During Long-Haul Flight. They were sucked quickly into the ventilation system, the team concluded, and were unlikely to contaminate nearby surfaces or blow into the breathing zones of people seated nearby. Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy. Duong, L.T.Q. Last, we found a clear association between sitting in close proximity to case 1 and risk for infection (Table 2). Rationale for universal face masks in public against COVID-19. Dinh), Ha Noi University of Public Health, Hanoi (L.N. At that time, 1,593 persons had tested negative for SARS-CoV-2 infection in Vietnam, and according to official policy at that time, another 10,089 contacts and travelers returning from COVID-19–affected areas overseas were under preemptive quarantine directly at the time of arrival. The study found that on a flight with … Figure 1. Other reports have found people became infected with coronavirus on flights, perhaps when they took off masks to use restrooms. The team used fluorescent aerosol tracers to see where particles emitted from the coughing "passenger" went. Evidence of airborne transmission of the severe acute respiratory syndrome virus. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Guidelines for preventing SARS-CoV-2 infection among air passengers should consider individual passengers’ risk for infection, the number of passengers traveling, and flight duration. Severe acute respiratory syndrome coronavirus 2 shedding by travelers, Vietnam, 2020. None of the additional cases showed COVID-19 symptoms while on board VN54. On the 2-row rule for infectious disease transmission on aircraft. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. "Testing assumes that mask wearing is continuous, and that the number of infected personnel is low," the research team wrote. Spread of SARS-CoV-2 across international borders by infected travelers has been well documented (5,6); however, evidence and in-depth assessment of the risk for transmission from infected passengers to other passengers or crew members during the course of a flight (in-flight transmission) are limited. A 27-year-old businesswoman from Vietnam, whom we identified as the probable index case (hereafter case 1), had been based in London since early February. Any symptomatic person was isolated immediately until the test result was received. His research interests include epidemiology of viral and bacterial respiratory infectious diseases and zoonotic diseases including COVID-19, severe acute respiratory syndrome, avian influenza (H5N1), and seasonal influenza. The first case of coronavirus disease (COVID-19) in Vietnam was recorded on January 23, 2020; the patient was a visitor from Wuhan, China (9). 2020;26(11):2617-2624. https://doi.org/10.3201/eid2611.203299. We also recognize Matt Moore for his suggestions and support in the course of investigation and writing the paper. https://thepointsguy.com/news/coronavirus-airplane-risk-study-iata data, https://www.medrxiv.org/content/10.1101/2020.03.28.20040097v1.full.pdf). By March 10, all 16 (100%) of the flight crew and 168 (84%) of the passengers who remained in Vietnam had been traced; 33 (16%) passengers had already transited to other countries. Lack of COVID-19 transmission on an international flight. ET Air travel is contributing to the extent and speed of the pandemic spread through the movement of infected persons (2–4); consequently, in March, many countries either completely halted or substantially reduced air travel. The role of fomites and on-board surfaces such as tray tables and surfaces in toilets remains unknown. To identify factors associated with in-flight infection risks, we calculated risk ratios and 95% CIs. 2.4.9 Lack of COVID-19 Transmission on an International Flight (Schwartz et al., 2020)..... 32 2.4.10 Absence of In-flight Transmission of SARS-CoV-2 likely due to use of Face Masks on Board CDC twenty four seven. Passengers and crew had traveled on to 15 provinces in Vietnam, ranging from Lao Cai and Cao Bang in the north to Kien Giang in the south. Similarly, for case 4, who reported having visited India before the United Kingdom during his incubation period, the possibility of preflight transmission remains slim because by March 1, only 3 cases of COVID-19 had been reported in India, although testing in India was still limited (20–22). Furthermore, none of the 30 colleagues of case 4, who shared the same preflight travel history but were all seated in economy class, were infected (Appendix). In the absence of genomic analysis, we were unable to completely rule out alternative transmission routes. First imported case of 2019 novel coronavirus in Canada, presenting as mild pneumonia. On airborne transmission and control of SARS-Cov-2. 2019 Novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission. It has been hypothesized that a combination of environmental factors on airplanes (humidity, temperature, air flow) can prolong the presence of SARS-CoV-2 in flight cabins (27). Second, long flights not only can lead to importation of COVID-19 cases but also can provide conditions for superspreader events. Also, systematic testing, quarantine policies, or both, for inbound passengers at arrival might be justified for countries with low levels of community transmission, high risk for case importation, and limited contact tracing capacity (5). Thai, T.-T. Nguyen), Australian National University, Canberra, Australian Capital Territory, Australia (H.-L. Quach, N.-A. Mai, N.D. Nghia, T.A. Two meals were served, and flight attendants worked in 2 teams, 1 for the business and premium economy sections and 1 for the economy section. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. "These alternative routes of exposure are more challenging to predict because of uncertainty in human behavior.". They continued to reside in London until February 29, when case 1 started to experience a sore throat and cough while attending meetings and visiting entertainment hubs with friends. Of the 12 additional cases in business class, symptoms subsequently developed in 8 (67%); median symptom onset was 8.8 days (interquartile range 5.8–13.5) after arrival (Figure 2). In early March, when much of the global community was just beginning to recognize the severity of the pandemic, we detected a cluster of COVID-19 cases among passengers arriving on the same flight from London, UK, to Hanoi, Vietnam, on March 2 (Vietnam Airlines flight 54 [VN54]). We traced 217 passengers and crew to their final destinations and interviewed, tested, and quarantined them. Guidelines, law, and governance: disconnects in the global control of airline-associated infectious diseases. Emerg Infect Dis. 17) (18). Both studies involved cases connected to long flights early in the pandemic, before airlines began requiring face masks. Transmission of SARS-CoV 2 During Long-Haul Flight. The CDC study noted that because aircraft can hold large numbers of people in close proximity for long periods, there is increased risk for transmitting infectious diseases like COVID-19. Although testing had not been implemented on a large scale nationwide at that time (19), community transmission in the United Kingdom was not yet widely established (20), making the presence of multiple persons on board incubating the illness unlikely. In particular, we investigated all possible exposures of all persons with flight-associated cases during their incubation period in relation to the timing of the flight, including locations where flight-associated cases may have crossed paths before and after the flight. In-flight transmission has been hypothesized but not substantiated sufficiently in a non–peer-reviewed report of a cluster of 10 flight-associated cases in China in February (N. Yang et al., unpub. No evidence indicated that the regular air conditioning and exchange system on flight VN54 were malfunctioning. Of note, the temporal sequence of symptom onset among cases in economy class and the crew member serving in economy class also allows for the possibility of a second in-flight transmission event, independent of the cluster in business class (Figure 2). At that time, importation of COVID-19 had been documented in association with 3 flights to Vietnam, including a cluster of 6 persons who had index cases and were evacuated from Wuhan; 6 secondary cases resulted from virus transmission in Vietnam (11). On February 22, case 1 and her sister returned to Milan, Italy, and subsequently traveled to Paris, France, for the yearly Fashion Week before returning back to London on February 25. Transmission of the severe acute respiratory syndrome on aircraft. 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