Since the beginning of COVID-19, many people have stopped flying! Why? The reasons are multiple and complex. Business travel has declined thanks to Zoom and other remote meeting options. International restrictions on American passports has put a crimp in leisure travel, and 24/7 media coverage of the virus and its spread has convinced us that the only way to stay healthy and alive is to stay at home, wear a mask, and socially distance ourselves from everyone else. For those who decide to throw caution to the wind and travel by air through airports to other parts of the planet, they are likely to face the wrath of political leaders, medical professionals and the media, forecasting the catching of COVID-19 and its transmission to friends, family, and other passengers.
Airline Passengers. Unhappy Consumers
Travelers have complained about airlines for years. Their irritations focus on confined spaces, seats designed for preschoolers, snacks that deliver empty calories, and recycled air. Even if you are flying in business class, the airplane ride from point A to B is among the least desirable facet of the travel experience. Many travelers who thought airplanes were Petri dishes for viruses and other health/wellness issues are now convinced that flying is in the No No category; not now, maybe later.
Before COVID-19 surfaced on the world stage, 2020 was forecast to be a very good year for the airline industry. The International Air Transport Association (IATA) predicted a 4.1 percent growth in global air traffic and net post-tax profits for North American airlines of $16.5 billion for 2019. Every vendor and service provider in the hotel, travel and tourism industries was ecstatic.
Then came the pandemic and the forecast was turned inside out and upside down. The new prediction heralded the worst financial performance in the history of commercial aviation with economic indicators suggesting a reduction of over two billion international passengers in the second quarter of 2020 and a decline of more than 4.5 billion passengers for the entire year. Airport closures in Europe were predicted to reach unbelievable numbers with 193 out of 740 unable to remain viable as governments placed quarantines and shelter-in-place restrictions on citizens and visitors.
Exposed in Public
There are many ways for airline passengers to be exposed to COVID-19 (or any virus) and include: in flight, during overnight transfer/pre-flight or unknown acquisition before the flight. The incubation period for COVID-19 may be as short as two days – increasing the opportunity for potential in-flight/airport transmission.
Rapid contact tracing can limit the onward spread; however, this requires the cooperation of the airlines. Scientists require a copy of the flight manifest, accurate contact details and enhanced surveillance of movements including transiting information. Unfortunately, contact details can be deficient and some airlines are unwilling to cooperate.
Flying Delivers Health Hazards
Flying has been considered risky in the best of times. Passengers know the cabin is pressurized. While most healthy people can tolerate the pressure, studies of adults with underlying conditions may be at risk. Research has identified potential problems usually associated with acute mountain sickness (fatigue, headache, lightheadedness and nausea) which rises with increased altitude. When the cabins are depressurized with increasing flight time, the decreased oxygen can exacerbate medical conditions including respiratory distress. Low cabin pressure at cruising altitudes can result in abdominal cramping and injury to the ears. Recent surgical procedures places passengers at risk for gas expansion including bowel perforation and wound rupture or splitting. Passengers who scuba dive have an increased risk of decompression sickness if they fly too soon after diving. Gas expansion also affects medical devices including pneumatic splints, feeding tubes and urinary catheters.
Blood clots (Immobilization) has been linked to 75 percent of air-travel cases of venous thromboembolism with the greatest frequency occurring in non-aisle seating where passengers tend to move less. Cosmic radiation comes from outside the solar system and from particles released during solar fires. Radiation levels change throughout the year based on solar cycles, as well as altitude, latitude and length of exposure. Various types of cancer may be linked to cosmic radiation (i.e., breast cancer, skin cancer and melanoma) on flight crews and frequent air-travelers.
Flight attendants have a 3-fold increase in chronic bronchitis despite considerably lower levels of smoking; cardiac disease in female flight attendants was 3.5 times greater than the general population. In-flight personnel also reported 2-5.7 times more sleep disorders, depression and fatigue than the general population. They also report 34 percent more reproductive cancers. The longer the career path with the airlines, the larger the increase in hearing loss, depression and anxiety.
Before COVID-19 over 1 billion passengers traveled annually with over 50 million traveling to developing parts of the world. Reported, (but difficult to document accuracy of the data), are the risks associated with disease transmission during commercial air travel; however, pandemics heighten the awareness to these risks. With more people traveling and with air transportation increasingly their mode of transport, the potential for the transmission of disease to and among passengers and crew while in-flight as well as before and after flights is exacerbated.
Since 1946 there is evidence of several outbreaks of serious infectious diseases aboard commercial airlines, including influenza, measles, severe acute respiratory syndrome (SARS), tuberculosis, food poisoning, viral enteritis, and smallpox. The risk of onboard transmission of infection is mainly restricted to individuals with either close personal contact or seated within two rows of an index passenger.
It is believed that on 3-hour Air China flight 112 (March 2003), 22 passengers and crew developed severe acute respiratory infections from one passenger, spreading SARS to inner Mongolia and Thailand. The 2002-03 SARS epidemic indicated that commercial air travel effects the spread of infectious disease.
The World Health Organization (WHO) estimated that 65 passengers per million who travelled aboard commercial flights originating from regions of active transmission during the outbreak were symptomatic with (probably) SARS. Overall, 40 flights carried 37 probably SARS CoV source cases during the outbreak, resulting in the likelihood of 29 onboard secondary cases.
Studies of flights in Asia and Europe have found instances where scientists think the virus spread via commercial airlines, including one where passengers were wearing N95 masks (CDC Journal). Public health officials in the UK ordered almost 200 passengers and crew into two weeks of quarantine after it was discovered that seven people traveling to Wales from the Greek island of Zante (August 25, 2020), were infectious on the flight. According to BBC reports, plane boarding was a “free-for-all,” and passenger mask rules were not enforced.
Since the beginning of the pandemic, approximately 100 American Airline flight attendants have tested positive for COVID-19. While this may be less than one percent of the 25,000 flight attendants at American Airlines, because of corporate policy, employees are reluctant to share information about the number of workers who have contracted the virus.
Delta’s Chief Executive Officer, Ed Bastian reported approximately 500 employees testing positive for COVID-19 with the majority recovered; however, ten died.
A pilot reported that through message board communications he learned of three pilots and six flight attendants who have or likely have COVID-19.
During this past summer (2020) there was an outbreak of 59 cases of coronavirus disease originated with 13 cases linked by a seven-hour, 17 percent occupancy flight into Ireland. The flight associated attack rate was 9.8-17.8 percent. The spread impacted on 46 non-flight cases, country-wide. Asymptomatic/pre-symptomatic transmission in-flight from a point source is implicated by 99 percent of the virus linked to a common origin (eurosurveillance.org).
Not All Flights Created Equal
Not all aircraft are created equal. In countries where it is winter or whenever the climate is freezing (like Siberia), the cabin temperature can be adjusted by the flight crew by simply rotating a knob in the cockpit. Countries located near the equator and tropical climates (i.e., Philippines) cabin temperature can be changed following the same procedure.
Although the aircraft cabin is ventilated during flight, the air is circulated in an enclosed environment, exposing passengers and crew to a variety of issues including hypobaric hypoxia (the body’s ability to transfer oxygen from the lungs to the blood stream); dry humidity (the feeling of being dehydrated increasing the possibility of getting sick) and, the current major issue, close proximity to other passengers. The cabin is regulated by an environmental system that automatically controls pressurization, temperature, ventilation and air filtration; however, the number of air conditioning packs in operation, zone temperatures, the mixture of fresh and re-circulated air delivered to the cabin can be adjusted by the flight deck.
It is important to note that not all airplanes are equipped with an air conditioning system. Aircraft with a maximum operating altitude limited to approximately 10,000 – 15,000 ft. are not normally designed with an air conditioning system as the amount of oxygen at this altitude is enough for a healthy person to breathe. In larger aircraft, with increased passenger capacity, and designed to fly at higher altitudes, an air conditioning system enables passengers and crew to breathe normally.
Diagrams of air flow throughout the cabin showing HEPA filter efficacy of air circulation do not illustrate turbulent or stagnant air flow which often occurs with passengers and/or hand baggage blocking vents on the floor or seat air vents/nozzles are open.
When parked at the terminal, fresh air is supplied to the aircraft by auxiliary power units and HEPA filters may not be turned on. During flight, fresh air is supplied to the cabin from the engines where the air is heated, compressed, cooled and passed into the cabin to be circulated by the ventilation system. The outside air is assumed to be sterile at typical cruising altitudes. Air circulation patterns aboard standard commercial aircraft are side- to-side with air entering the cabin from overhead, circulating across the aircraft and exiting the cabin near the floor. There is little front-to-back airflow. The air circulation pattern divides the air flow into sections within the cabin, limiting the spread of airborne particles throughout the passenger cabin.
Research has determined that airplanes do have a higher air exchange than most other indoor settings; however, tiny respiratory droplets can spread in tight enclosed spaces. The Center for Disease Control (CDC) travel guidelines finds that travel of any kind increases the chances of getting and/or spreading COVID-19.
Scientists have determined that where you sit on a plane can influence your risk of getting a virus. The study found that of the 35 passengers seated in rows 9-13, the rows immediately in front of the infected passenger – 11 contacted the SARS virus during the flight. This contrasted with only seven of the 81 passengers seated elsewhere on the plane. Conclusion? If you sit behind, a distance in front of, or even directly next to an infected passenger, then your risk of contracting a virus is substantially lower than if you happen to be sitting immediately in front of the infected person.
How Clean is CLEAN
Before the pandemic, the cleaning of aircraft interiors was more of a fantasy than a reality. The very idea of disinfecting the armrests, cleaning the trays, sterilizing the lavatories, washing the seat pockets, wiping the call-staff button, or vacuuming the seats and aisles were on the To-Do list, but rarely implemented. The reason for ignoring cleaning/sanitizing protocols? The airline schedule called for “deep cleaning” every sixth week or after forty thousand passengers had the opportunity to breathe, cough, touch, and sneeze on the plane, in the seat, you were occupying.
Delta Airlines has partnered with Colleen Costello, the Co-founder and CEO of Vyv (Vital Vio) to install its patented, Non-UV antimicrobial lighting into the Delta’s 757 jet lavatories. The Vyv system, in combination with traditional cleaning regimes, reduces surface bacteria resulting in a cleaner toilet experience for passengers and staff. Travelers will find Vyv on Delta’s domestic 757-200 fleet, placed above high-touch sinks and countertops in onboard lavatories.
According to Costello, Vyv is NOT UV light! The Vyv technology stops the growth of bacteria, fungi, mold and mildew, creating a deadly environment for microbes. The lighting meets international standards for continuous and unrestricted use around humans, animals and plants as the lighting targets specific molecules contained exclusively in bacteria, mold, yeast and fungi…not in human cells.
Costello stated that, “Vyv’s lighting has infinite configurations…there is no limit to where this technology can be installed…In 2021, Delta and Vyv will evaluate expansion opportunities within its fleet and other airport areas”.
According to news.delta.com, the company will continue to block middle seats until January 2021, intends to change its HEPA air-filters more frequently than recommended and is the first US airline to install hand sanitizer stations onboard.
JetBlue is focusing on the wellness of its employees by partnering with Northwell Direct offering staffers at the Long Island City location healthcare advice and guidance. The program is designed to detect COVID-19 in its personnel and offer a direct link to medical services for detection and support if the employee tests positive. Through the Northwell Health Solutions program JetBlue personnel can be supported with at-home health care through a tele-med program and if necessary, plug into the Northwell ambulance and hospitalization services. The partnership started in October 2020 and approximately 1000 employees have participated in the program.
It is reported (nz.news.yahoo.com) that American Airlines has added a new disinfectant to its surfaces that is said to kill COVID-19 on surfaces for 7 days after it is applied. Recently approved by the US Environmental Protection Agency for emergency use, the product, known as SurfaceWise2 (manufactured by Allied BioScience) is applied to planes via an electrostatic spraying process when the aircraft cycle through the airline’s Dallas-Fort Worth hub.
AirAsia is protecting its onboard crew with new PPE uniforms that resemble HAZMAT jumpsuits.
The cabin crew on Philippine Airlines wear face shields and medical-inspired white jumpsuits with rainbow stripes to protect against COVID-19. The attire is designed by local designer Edwin Tan who used non-porous material for the PPE’s.
Leave It to Dogs
Perhaps the best way to detect and isolate COVID-19 travelers is the use of sniffer dogs recently piloted in Helsinki, Finland. The dogs can smell coronavirus as accurately as PCR tests and are less expensive and faster than airport testing. Currently three dogs at the Helsinki-Vantaa Airport (HEL) are sniffing swabs of arriving passengers. As the travelers arrive, they are asked to queue for the test and their skin is swabbed with a wipe. The dog passes the negative samples but is attracted to the positive ones. Positive results? Traveler gets a nasal CR test to validate the results. The Deputy Mayor of Vantaa said that the dog results showed the same percentage of accuracy as the traditional nasal swab. Earlier experiments showed a close to 100 percent accuracy up to five days earlier than a PCR test.
There is an abundance of conversation that focuses on attempts to keep passengers and crew safe and healthy; however, at the end of the day, it is up to the consumer to take control of the responsibility for sanitization.
Health hazards lurk everywhere for passengers even before they reach the aircraft. Think about the times you have had to remove your shoes, put them in a tray, walk along the airport floor in your socks. When you retrieve your shoes, you put them on over dirty socks, and perhaps retie them. Before COVID-10, this task was an annoyance, now it can be deadly. Make sure to pull out the Purell or a sani-wipe before moving beyond this touch-intensive zone.
The next COVD-19 heads-up opportunity is waiting for passengers at the departure gate where groups gather prior to boarding. Research suggests that the boarding process, when the plane’s ventilation system is NOT running and people are unable to keep six feet of distance, is one the most dangerous parts of the travel continuum. Medical experts encourage fliers to do their best to minimize this experience and reduce exposure.
Getting to your seat poses the next obstacle as this space requires a thorough cleaning with sanitizing wipes. Start at the top of the seat and the headrest, followed by the cushion and back rest, the overhead storage bin, the tray table and the video screen…then sit down and clean the seatbelt buckle. What…the seatbelt buckle? This necessity is nicely folded across the seat – but it is time for a fact check: the belts are not cleaned and carry memories of the last passenger’s fingerprints, bacteria, and viruses.
Think now about the floor of the aircraft. Twenty percent of passengers visit the toilets without shoes. Do you amble down the aisle to the toilet wearing socks? Did you consider the fact that your socks are absorbing what has been dripped, dribbled, dropped and spilled on the floor? When you and your socks return to your seats do you take off your socks and massage your feet, tainting your hands and fingers?
Oh! Woe Is Me(!) and You
During this holiday period, millions of people are discarding the CDC and healthcare professional guidelines, in an attempt to bring the appearance of normalcy back to their lives.
Researchers and scientists (who live in the real world of Here and Now) forecast a doubling of the current 12.4 million coronavirus cases with an increase to more than 20 million by late January 2021 (Washington University in St. Louis). In excess of 3 million infections have been reported for November (before the end of the month), the most reported in one month this year (CNN). There are almost 86,000 sick people in hospitals throughout the nation (COVID Tracking Project) and hospitalization numbers have broken records for 14 days in a row.
Until the new administration is in place (January 2021) we cannot look to the Department of Transportation for any leadership as the DOT recently denied FlyersRights.org a petition for a mask requirement. The department determined that it is not a public health authority, leaving the issue at the door of the Centers for Disease Control and Prevention (CDC). The DOT determined that airlines have sufficient mask requirements and there should not be more government regulations than necessary.
People traveling through US and international airports will not find consistency in safety policies as they vary by airline and by country, resulting in confusion and increased anxiety. The airlines have put massive amounts of money into their marketing campaigns, even hiring Ivy League universities to provide the copy for the press releases. The media coverage can be overwhelming; however, reports of noncompliance abound. Some airlines claim that passengers who refuse to wear a mask will be denied boarding and will be putting their future travel privileges at risk; however, not all airlines follow this process. Delta has placed many passengers on no-fly lists but some passengers deal with the issue by wearing the mask to board the flight, then remove it to eat/drink for extended time periods and flight personnel are not in a position to enforce the rule.
At the end of the day, “Caveat Emptor,” let the buyer beware! Once passengers are aware of the risks and still decide to fly, then getting sick and/or sharing the virus with others is their responsibility and they should not look to place blame on the commercial air transportation system.
© Dr. Elinor Garely. This copyright article, including photos, may not be reproduced without written permission from the author.