Measles Airline Recommendations

Recommendations for Measles Prevention

This webpage provides

• Aircraft crews with recommendations for practical methods to protect themselves, passengers, and other crew members when someone on board is suspected of being sick with measles.
• Instructions on required reporting of illness or death on board under U.S. regulations.
• Airline management with responsibility for overseeing health matters within their company recommendations for strategies to reduce the risk of measles transmission on board an aircraft or in destination communities.

Promoting measles education and awareness

Among Crews

Airlines should ensure flight crews are aware of

• Global risk of measles during international travel
• Signs and symptoms that may indicate a sick traveler has measles
• Strategies to reduce the risk of measles transmission on board
• Requirement for reporting a suspected or known measles case on board to CDC
• Benefits of vaccination
  • Encourage employees who don't have presumptive evidence of immunity to measles to be fully vaccinated against measles.
  • For international travel, fully vaccinated means 2 doses of measles-mumps-rubella (MMR) vaccine at least 28 days apart.
• Importance of not working on an aircraft while sick with fever, especially if a rash is present

Airlines should also review their sick leave polices and communicate them to employees.

Among Passengers

Airlines should consider communication strategies to encourage passengers to

• Be fully vaccinated against measles before travel, or have other evidence of measles immunity
• Delay travel if sick with fever and a rash

For information on measles signs and symptoms, incubation period, and complications, visit www.cdc.gov/measles.

Vaccination Recommendations for International Travelers

The measles-mumps-rubella (MMR) vaccine is very safe and effective.

CDC recommends that all people planning international travel, including aircraft crew, be vaccinated.

Helping sick travelers to avoid flying when sick

People should not travel if they have fever and a rash, or have a measles diagnosis, until a doctor or health department clears them for travel. Health officials may also ask travelers exposed to measles and not immune to delay travel until they are no longer at risk of becoming infectious. Passengers are more likely to comply in delaying travel for public health reasons if airlines allow them to modify itineraries when they are known or suspected to have measles, or if public health officials have advised them to delay travel.

Ensuring measles immunity among crew

Airlines should consider ensuring all aircraft crew and other employees who may travel internationally or interact with passengers have presumptive evidence of immunity to measles.

• Maintain documentation of immune status of all employees.
• To the extent possible, minimize barriers to employee vaccination, for example, by offering MMR vaccines to employees.

Presumptive evidence of immunity to measles

Acceptable presumptive evidence of immunity to measles includes at least one of the following:

• Written documentation of adequate vaccination:
  • 1 or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk
  • 2 doses of measles-containing vaccine for school-age children and adults at high risk, which includes college students, healthcare personnel, and international travelers
• Laboratory evidence of immunity
• Laboratory confirmation of measles
• Birth in the United States before 1957

Managing passengers and aircraft crew with suspected measles

Cabin crews should follow company policy for managing in-flight medical events. Airlines should incorporate these recommendations for when their cabin crew encounter a passenger or fellow crew member with suspected measles. These recommendations aim to reduce transmission by

1. identifying travelers (passengers or crew) who may be contagious with measles during flights and
2. implementing appropriate control measures. They supplement broader CDC recommendations for cabin crew when managing sick travelers.

Cabin crews who identify travelers with signs and symptoms suggestive of measles should:

• Ask the sick person to wear a face mask. If a face mask is not available or the sick person can't tolerate a mask, ask them to cover their mouth and nose with tissues when coughing or sneezing.
• Minimize contact of passengers and cabin crew with the sick person. If possible, separate the sick person from others, and designate one crew member (who has presumptive evidence of immunity to measles) to serve the sick person. Crew members should check their own medical history and vaccination records to be aware of their measles immunity status.
• Treat any body fluids (including sputum or other respiratory secretions) as potentially infectious.
• Wear disposable gloves when serving the sick person or touching potentially contaminated body fluids or surfaces. Properly dispose of gloves and other disposable items that came in contact with the sick person or body fluids.
• Clean potentially contaminated surfaces according to airline protocol.
• Practice proper handwashing, especially after removing gloves or touching potentially contaminated surfaces or items.
• Separate all infants, all travelers who may have a weakened immune system, and pregnant travelers without known immunity to measles as far as possible from the sick person. To maintain passenger privacy, cabin crew could pose a general question to passengers, for example, "If you have a medical condition or are taking a drug that weakens your immune system or are pregnant, please let me know." Given how full commercial flights can be, cabin crew may limit this intervention to those seated closest to the sick traveler, taking into account flight time remaining and their other safety responsibilities.

Reporting possible measles before port arrival

The U.S. Code of Federal Regulations (42 CFR 70.11 and 71.21) contains requirements for reporting to CDC deaths and illnesses that occur on domestic interstate flights, and on international flights arriving to the United States. Deaths and illnesses that meet CDC's definition for an "ill person," including fever and rash, must be reported before arrival or as soon as recognized.

Managing possible measles after airport arrival

While the plane is at the gate, its ventilation system should be kept running. Before anyone disembarks, CDC port health officers or airport emergency medical services will board the aircraft to rapidly assess the sick person, and then work with cabin crew members and airport attendants to disembark the sick traveler to a cleared area in the airport terminal.

The sick traveler should disembark first while wearing a face mask if tolerated. CDC port health officers and airport emergency medical staff will further evaluate the sick traveler and help get medical transportation to a local healthcare facility, if needed. CDC port health officers will notify the state or local health department. If the sick traveler is transported to a healthcare facility, CDC port health officers will obtain the results of diagnostic testing and notify the airline if the sick traveler is diagnosed with measles.

Cooperating with CDC contact investigations

When CDC notifies an airline about a confirmed case of measles on a recent flight, the airlines should rapidly provide to CDC all available contact information for potentially exposed passengers and crew. CDC shares this information with health authorities at exposed travelers' destinations so they can be assessed for immunity to measles, offered preventive treatment if needed, and monitored for signs and symptoms of measles if they are not immune.

Managing crew member contacts

• Airlines should contact crew members who may have been exposed to a traveler with confirmed measles and assess them for presumptive evidence of immunity.
• For the purpose of contact investigations on aircraft, CDC defines crew contacts as follows:
  • On a flight with passenger capacity of more than 50 passengers, all cabin crew on board;
  • On a flight with passenger capacity of 50 passengers or less, all crew on board, including pilots;
  • On a flight with an infected crew member, all crew on board, including pilots.
• Exposed crew members who don't have presumptive evidence of immunity to measles should be offered 1 dose of vaccine within 3 days after the flight. Immune globulin within 6 days after the flight is an alternative for those with contraindications to vaccine (such as pregnancy or severe immunosuppression).
• Exposed cabin crew members with presumptive evidence of measles immunity or who received post-exposure prophylaxis during the recommended time frames may continue to work. However, they should monitor their health with the airline's oversight for 21 days after the last possible of exposure.
• Airlines should consider establishing a policy to exclude exposed crew members from working on an aircraft when they
  • Have no presumptive evidence of measles immunity, and
  • Do not receive post-exposure prophylaxis (vaccine or immune globulin) during the recommended time frames.
  • Exclusion is recommended starting on Day 5 after the first possible exposure through Day 21 after the last possible exposure.

• CDC will additionally notify health departments in the states where exposed crew members live. Health departments may choose to coordinate with the airline in managing exposed crew members.

Managing a crew member with suspected or confirmed measles

Crew members who develop signs and symptoms of measles should

• Limit contact with others as much as possible.
• Notify airline supervisor of the illness.
• Contact a doctor for medical evaluation and management. Before visiting a healthcare facility, sick crew members should inform staff at the facility about their illness and recent exposure to measles, so the facility can take necessary precautions to prevent transmission to others.

Crew members diagnosed with measles should

• Notify airline supervisor of the measles diagnosis.
• Remain isolated until no longer infectious—for 4 days after beginning of the rash. Crew members can return to work on Day 5 after rash onset (with beginning of rash as Day 0).