Appendix D: Airplanes & Cruise Ships: Illness & Death Reporting & Public Health Interventions
Federal Regulations Governing the Control of Communicable Diseases
CDC has a regulatory mission to protect US public health by preventing the introduction, transmission, and spread of communicable diseases from foreign countries into and within the states or territories of the United States. As part of a range of authorized public health activities, presidential executive orders specify the diseases for which CDC may issue a federal public health order; that is, a federal quarantine, isolation, or conditional release order (cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, new or emerging types of influenza, and severe acute respiratory syndromes). The list of federally quarantinable diseases can be revised by executive order if an emerging infectious disease that is not on the list becomes a public health threat.
For more information on specific laws and regulations governing the control of communicable diseases, see www.cdc.gov/quarantine/specificlawsregulations.html.
CDC Actions Before, During, and After Travel to Protect the Public’s Health
CDC conducts public health actions before, during, and after commercial aviation and maritime travel to prevent and mitigate the introduction and spread of diseases of public health concern into communities in the United States. Many of these actions are carried out by CDC staff working at quarantine stations located at or near the US ports of entry through which the majority of travelers transit.
A health authority may notify CDC that a person with a communicable disease of public health concern is planning to travel on commercial flight. In 2007, CDC and the US Department of Homeland Security developed a public health do not board (DNB) list that prevents issuance of a boarding pass to any flight originating or landing at a US airport. US and international public health officials can recommend adding a person to the list if he or she has (or has been exposed to) a communicable disease that poses a public health threat during travel and meets specific criteria.
Regulations mandate that the person in charge of a conveyance destined for a US port report before arrival any death or “ill person” (as defined in the regulation) among passengers or crew members to the CDC quarantine station at or nearest the port of entry. The definition of an ill person on an airplane or maritime vessel—which applies to all travelers, including crew and passengers, US citizens or non-US citizens—is detailed in Table 12-2.
CDC quarantine station staff receives most illness and death reports during travel on airplanes from the airlines or from emergency medical personnel at the arrival airport. Most non-gastrointestinal illness and death reports on cruise ships are received directly from the vessel’s medical staff. Reports for both airplane and cruise ship illnesses and deaths may also originate from federal partners or state and local health departments.
CDC provides guidance and tools to facilitate reporting of ill travelers on aviation and maritime conveyances at www.cdc.gov/quarantine.
Box D-1. Regulatory definition of an “ill traveler” for the purposes of reporting illness on commercial airplanes and ships
- Fever 1 plus ≥1 of the following:
- Skin rash, difficulty breathing (or, for maritime conveyances, suspected or confirmed pneumonia), persistent cough (or, for maritime conveyances, cough with bloody sputum), decreased consciousness or confusion of recent onset, new unexplained bruising or bleeding (without previous injury), persistent diarrhea (air conveyances only), persistent vomiting (other than air or sea sickness), headache with stiff neck, or appears obviously unwell (air conveyances only); OR
Fever for >48 hours; OR
Acute gastroenteritis 2 (maritime conveyances only); OR
Symptoms or other indications of communicable disease, as the CDC may announce through posting of a notice in the federal register.
1 Measured temperature ≥100.4°F (≥38°C); feels warm to the touch; or a history of feeling feverish
2 Diarrhea (≥3 episodes of loose stools in a 24-hour period or what is above normal for the person) OR vomiting accompanied by ≥1 of the following: ≥1 episode of loose stools in a 24-hour period, abdominal cramps, headache, muscle aches, or fever (temperature ≥100.4°F [≥38°C])
CDC’s goals in responding to illness reports during air travel are to determine if the illness is a public health threat and to take public health actions. The 3 possible outcomes of a response during travel are to:
- Recommend that the ill traveler seek medical care or delay further commercial travel until noninfectious if the traveler has a suspected communicable disease;
- Require the ill traveler to be medically evaluated if he or she is suspected of having a quarantinable communicable disease; or
- Allow the ill traveler to resume travel if the illness does not pose a risk of spreading to others onboard.
CDC may board an arriving airplane with airport/public health response partners (e.g., emergency medical services, local public health authorities) to undertake a public health assessment of the ill traveler and to make recommendations regarding the potentially exposed passengers. Potentially exposed travelers may be asked to provide their contact information before disembarking, so that health authorities can follow up and provide additional health information if the ill traveler is diagnosed with a disease of public health concern.
CDC provides guidance to airlines on managing ill travelers onboard on its website at www.cdc.gov/quarantine/air/managing-sick-travelers/index.html.
Cruise Ship Response
For public health responses to ill cruise ship travelers, most control measures are initiated while the ship is at sea. CDC quarantine station staff obtains clinical, medical, and epidemiologic information about the ill or deceased traveler, determine public health risk, and provide guidance to the ship’s clinicians about case findings, infection control measures, and contact investigations.
The CDC quarantine station staff may respond by meeting a ship at the port of entry to further investigate or assist a local health department with surveillance and control measures. On-site response is usually done for outbreaks or clusters of disease, quarantinable communicable diseases, and some vaccine-preventable diseases (such as measles or rubella). CDC’s Vessel Sanitation Program (www.cdc.gov/nceh/vsp/default.htm) is responsible for responding to reports of acute gastroenteritis on cruise ships.
CDC provides guidance to cruise ships on managing ill passengers and crew at www.cdc.gov/quarantine/cruise/management/index.html.
If CDC is notified by a US or foreign health authority of an illness of public health concern in an airplane or cruise ship traveler after the traveler has reached his or her final destination, CDC may conduct a public health contact investigation. The primary purpose of the contact investigation is to identify and notify the potentially exposed passengers and crew, so that clinical evaluation, postexposure prophylaxis (when indicated), and health education can be offered. CDC provides information about potentially exposed to travelers to public health authorities in the states or countries where the travelers live, in order to facilitate these interventions.
Reporting Illness after Travel
Travelers who become ill after returning home should inform their health care providers of where they have traveled. Clinicians should report cases of communicable diseases of public health concern in returning travelers to their local public health authority according to state-specific reportable disease requirements. Health departments may notify CDC of situations with risk of communicable disease transmission during travel by contacting the quarantine station with jurisdiction for their region (www.cdc.gov/quarantine/quarantinestations.html) or the Emergency Operations Center at 770-488-7100 or firstname.lastname@example.org. CDC may be notified of legionellosis cases associated with travel by sending an email to email@example.com.
- CDC. Criteria for requesting federal travel restrictions for public health purposes, including for viral hemorrhagic fevers. Fed Regist. 2015:16400e2. 80 FR 1640. [cited 2018 Aug 15]. Available from: www.federalregister.gov/documents/2015/03/27/2015-07118/criteria-for-requesting-federal-travel-restrictions-for-public-health-purposes-including-for-viral.
- CDC. Vessel Sanitation Program Operations Manual. 2018. [cited 2018 Jun 15]. Available from: www.cdc.gov/nceh/vsp/pub/pub.htm.
- Department of Health and Human Services. 42 Code of Federal Regulations Parts 70 (Interstate Quarantine) and 71 (Foreign Quarantine). [cited 2018 Aug 15]. Available from: www.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42tab_02.tpl.
- Jungerman MR, Vonnahme LA, Washburn F, Alvarado-Ramy F. Federal travel restrictions to prevent disease transmission in the United States: An analysis of requested travel restrictions. Travel Med Infect Dis. 2017 Jun;18:30–5. [PMID:28648932]
- World Health Organization. Report of the WHO Ad-hoc Advisory Group on aircraft disinsection for controlling the international spread of vector-borne diseases. Geneva, Switzerland, April 2016. [cited 2018 Mar 21]. Available from: www.who.int/ihr/publications/WHO_HSE_GCR_2016_12/en/.
- World Health Organization. Guide to Hygiene and Sanitation in Aviation, 3rd Ed. WHO, Geneva; 2009. [cited 2018 Mar 21]. Available from: www.who.int/ihr/ports_airports/guide_hygiene_sanitation_aviation_3_edition_wcov.pdf.
Rebecca Hall, Kara Tardivel, Robynne Jungerman, Clive Brown