Guidance - H1N1 Flu Virus

Prevention and Management of Influenza-Like-Illness (ILI), including the Pandemic (H1N1) 2009 Influenza Virus, on Conveyances including Airplanes, Trains, Ferries and Buses

Introduction

This document has been developed by the Public Health Agency of Canada to provide guidance to conveyance operators and crew onboard airplanes, trains, ferries and buses, Canadian or foreign, as well as conveyance terminal operators and staff in Canada on the prevention and management of influenza-like-illness (ILI) in passengers or crew boarding or on board the conveyance. It updates the October 23, 2009 “Prevention and Management of Influenza-Like-Illness (ILI), including the Pandemic (H1N1) 2009 Influenza Virus, on Conveyances including Airplanes, Trains, Ferries and Buses”.

This guidance is targeted primarily at passenger conveyances with longer journeys, particularly those traveling between jurisdictions (i.e. between metropolitan areas, between provinces or between countries) where, because of closer proximity and prolonged contact between people, the risk of ILI transmission may be greater.

It should be noted that this document has been developed based on the Canadian situation and thus may differ somewhat from guidance developed by other countries.

For guidance regarding the prevention and management of cases of ILI that may be due to pandemic (H1N1) 2009 influenza virus on cruise ships, please see: Prevention and management of cases of influenza-like-illness (ILI) that may be due to pandemic (H1N1) 2009 influenza virus on cruise ships

Background

Pandemic (H1N1) 2009 influenza virus is a type A influenza virus that began circulating in the spring of 2009. Infection with this virus results in an ILI similar to seasonal influenza. Information for the public on the symptoms of influenza can be found on the FightFlu website.

The surveillance case definition for ILI is defined as the acute onset of respiratory illness with fever and cough and one or more of the following - sore throat, muscle aches, joint pain, or weakness which could be due to influenza virus. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.

It has been observed with the pandemic (H1N1) 2009 influenza virus that gastrointestinal symptoms have been present in at least one third of the cases and a wider age range of individuals may not experience fever.

Like seasonal influenza, the pandemic influenza (H1N1) 2009 influenza infection in humans can vary in severity from mild to severe, with approximately 60% of hospitalized cases to date occurring in individuals with known risk factors for complications from influenza such as chronic illness, immunosuppression or pregnancy. This virus also appears to result in more severe disease in the 5-64 year old age group than does seasonal influenza; however, most individuals with pandemic (H1N1) 2009 influenza have not required hospitalization and have recovered in the community.

Pandemic (H1N1) 2009 influenza virus is spread from person to person predominantly through droplets created by coughing or sneezing. Spread can also occur through contact with surfaces and objects contaminated with the virus from affected persons. The incubation period¹ for pandemic (H1N1) 2009 influenza virus is understood to be approximately four days with a range of one to seven days and the period of communicability² seven days in uncomplicated cases. This may be longer in children (up to ten days) and other individuals in whom symptoms and virus shedding may persist (i.e. those who are immunocompromised or severely ill). Consistent with seasonal influenza transmission, the pandemic (H1N1) 2009 influenza virus is most likely transmitted during the initial days of infection when the individual is most symptomatic.

The risk of transmission of pandemic (H1N1) 2009 influenza virus may be increased on conveyances due to increased proximity and sometimes prolonged contact between people in an enclosed environment; however, it should also be recognized that under circumstances of widespread community transmission, the risk of acquiring ILI on a conveyance may not be significantly greater than in other community settings.

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¹ Incubation period: The time interval between invasion by an infectious agent and appearance of the first sign or symptom of the disease in question.

² Period of communicability: The time during which an infectious agent may be transferred directly or indirectly from an infected person to another person.

Recommendations Regarding Infection Prevention and Control

Immunization against influenza is the most effective intervention in the prevention and control of influenza.

In addition to usual infection prevention and control practices, it is recommended that the following measures be instituted on-board conveyances.

1. Self-Screening

Passengers – In keeping with the recommendation that individuals with ILI remain home until they are feeling well and able to fully participate in their regular activities, passengers who are currently experiencing symptoms of ILI should avoid travel and not board conveyances if possible. To facilitate communication of this recommendation, it is suggested that conveyance operators and staff consider providing relevant information for passengers by, for example, displaying signage advising passengers of the symptoms of ILI and the recommendation to stay home if experiencing ILI symptoms. Communicating this key message to passengers in advance of their departure dates may be helpful to passengers as they assess their fitness to travel.

Passengers with ILI who cannot avoid or delay travel may be referred to the Individual and Community Based Measures to Help Prevent Transmission of Influenza-Like-Illness (ILI) in the Community, Including the Pandemic Influenza (H1N1) 2009 Virus guidance  for recommendations regarding reducing the risk of transmission of infection within the community. These recommendations include measures such as using proper hand hygiene, respiratory etiquette, and, if possible, avoiding mass transit to avoid exposing others to the virus.

Conveyance operators may wish to develop policies which facilitate re-booking of travel for reasons of illness, if such policies do not already exist.

Crew – It is also recommended that crew perform self-assessments for symptoms of ILI and be instructed to report immediately to a designated crew member if symptoms develop. Conveyance operators may wish to develop mechanisms to facilitate and encourage reporting.

For passengers or crew who develop symptoms of ILI while traveling, the advice given in the section on management below would apply.

2. Hand Hygiene and Respiratory Cough/Sneeze Etiquette

Conveyance operators may wish to consider the development of signage reinforcing good hand hygiene and respiratory etiquette practices. Such signage could be placed on board conveyances and inside conveyance terminals in conspicuous locations.

Regarding hand hygiene, it is recommended that:

• All persons on board conveyances practice good hand hygiene.
• Hand cleaning is practiced frequently, using soap and water or alcohol based hand rubs (60-90% alcohol concentration).
• Soap and water are used if hands are visibly soiled. Additional information can be found at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/public/handtech-eng.php.
• Conveyance operators ensure adequate hand washing supplies and/or alcohol-based hand rubs (60-90% alcohol concentration) be readily available. Material Safety Data Sheets for alcohol-based hand rubs and the product labels provide additional information regarding placement, storage and warnings associated with the product.

It is also recommended that all persons on board practice good respiratory etiquette. This includes the practice of coughing or sneezing into a tissue or into one’s sleeve or elbow. Used tissues should immediately be placed in a waste receptacle and hand hygiene performed.

3. Other Precautions

The use of gloves, gowns, respiratory protection, including surgical or high-quality procedure masks, facemasks, or N95 respirators and eye protection is not recommended for crew members engaging in general work activities. 

Rather, it is recommended that the focus be on ensuring good hand hygiene and respiratory etiquette.  If an ill person is unable to practice respiratory etiquette, and if available, a surgical or high-quality procedure mask could be worn to reduce the risk of spreading the virus within the setting.

Conveyance operators who wish to implement additional infection control practices may consult the following guidance document: Guidance: Infection Prevention and Control Measures for Prehospital Care - H1N1 Flu Virus (Human Swine Flu) - Public Health Agency of Canada

4.  Cleaning and Disinfection

It is advised that equipment and surfaces that may have become contaminated with droplets or respiratory secretions be cleaned and disinfected according to Health Canada’s Recommended Disinfection Procedures for Conveyance (aircraft, passenger trains, ferries, buses and cruise ships) and Terminal (airport, cruise ship, bus, ferry and train) Operators and their Staff available at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guidance_lignesdirectrices/convey-trans-eng.php.

Management of Passengers and Crew with ILI

It is recommended that passengers and crew with ILI should be separated from other passengers and crew as much as possible, preferably by at least 2 metres, without compromising safety. Ideally, persons experiencing symptoms of ILI would be isolated or grouped together (if multiple persons with ILI) in a separate cabin with a dedicated washroom until they are feeling well and able to fully participate in their regular activities or disembarked, whichever comes first. It is advised that the number of crew interacting with the ill person(s) be minimized to the extent possible and that persons with ILI be encouraged to continue good hand hygiene and respiratory etiquette practices. A surgical or high-quality procedure mask, if available, could be worn by the ill person to help protect others. It is advised that isolated persons be monitored and, if necessary, permitted to disembark at the next scheduled stop unless medical evacuation is required sooner and is feasible.

If it is possible, it is recommended to isolate sick passengers with a family member or companion and provide the companion with the information contained in How to look after someone at home with H1N1 flu virus.

Crew or caregivers who have had contact with a person who has ILI do not need to be isolated if feeling well, but it is recommended that they monitor their health for seven days following exposure and to isolate themselves at the first sign of symptoms of ILI.

If a traveller on a conveyance is exhibiting symptoms of ILI, the first priority may be to arrange for immediate medical attention, if required, as per the company protocol and any applicable laws in the jurisdiction where the conveyance is located at the time.

It is recommended that individuals who become ill with ILI while travelling be advised to arrange accommodation at the point of disembarkation if not in home community, until they are feeling well and able to return to regular activities. The FightFlu website provides additional information on influenza.

Reporting

International Conveyances – The Quarantine Act requires the operator of any airplane, train, ferry or bus arriving in Canada to inform a quarantine officer or cause a quarantine officer to be informed of, any person on board the conveyance that could cause the spread of a communicable disease listed in the schedule to the Quarantine Act, including pandemic (H1N1) 2009 influenza. This should be done as soon as possible, before the conveyance arrives in Canada.

Air operators can report to a quarantine officer by advising an air traffic controller or their air carrier centre. The information will then be relayed to the airport duty officer/airport operation centre who would inform the quarantine officer.

Reporting to a quarantine officer for train and bus operators should be done by contacting the Public Health Agency of Canada duty officer at 1-800-545-7661 prior to entering Canada or, if advanced notification is not possible, by reporting to a Canada Border Services Agency border services officer upon arrival at the first point of entry. The duty officer or border services officer will in turn contact a quarantine officer.

Once notified of an ill traveller on board a conveyance arriving in Canada, the quarantine officer, who may collaborate with the border services officer, will assess the situation and advise on whether further action under the Quarantine Act is required for the ill traveller. The quarantine service will also notify Health Canada and/or provincial and local public health officials as per established protocols.

If the conveyance is proceeding to the Canadian border, the operator must inform a quarantine officer or intermediary as soon as possible. Even if the ill traveller is disembarked prior to arrival, notification must still be made so a quarantine officer can assess if further action under the Act is required for those who have been in contact with the ill traveller.

International Ferries: This reporting can take place through the procedures described in the Radio Aids to Marine Navigation, Part 4, General Procedures, under the heading Quarantine Message:

Domestic Conveyances – Public health authorities are available for consultation regarding suspected cases or outbreaks of ILI on conveyances travelling within Canada.  It is recommended that conveyance operators consult, as necessary, with the public health authority responsible for the jurisdiction in which they are stopping.

Patient Transfer

It is recommended that persons with ILI who require transfer off of the conveyance be provided with a high-quality procedure or surgical mask during transfer, if available and if tolerated.

It is advised that crew involved in transfer follow the recommendations provided in the Management of Passengers and Crew with ILI section above.

A disembarkation plan, including how to organize safe and timely exit routes for ill persons and other travellers and crew, to limit the possibility of spreading the infection is recommended.

It is recommended that conveyance terminal and emergency medical services be notified, as appropriate, that they will be receiving a patient with ILI so any required actions can be undertaken.