Updated Interim Guidance for Airlines and Airline Crew: Coronavirus Disease 2019 (COVID-19)

Updated March 04, 2020

Summary of Recent Changes

This document was updated March 04, 2020, as follows:

Added a section on cleaning of aircraft
Updated situation summary
Updated section on ill travelers identified during flight including:
1. Section applies to ill travelers from any country
2. Updated recommendations for hand hygiene
3. Recommendation to ensure adequate supplies of personal protective equipment during flight

Purpose

This document provides interim recommendations for the commercial airline industry about the Coronavirus Disease 2019 (COVID-19) first identified in Wuhan, China. CDC reminds air carriers of the requirement under Title 42 Code of Federal Regulations (CFR) section 71.21 to report to CDC ill travelers who have certain signs and symptoms during flight, and all deaths onboard, before arrival in the United States. This document also contains recommendations for managing ill travelers onboard if COVID-19 infection is suspected.

Situation summary

An outbreak of respiratory illness caused by COVID-19 first detected in Wuhan, Hubei Province, China is ongoing. Cases also have been identified in travelers from Wuhan to other parts of China, and cases have been identified in many other countries, including the United States. Early on, many of the patients in Wuhan reportedly had some link to a large seafood and animal market, suggesting animal-to-person spread. At this time, sustained (ongoing) person-to-person spread is occurring in several countries and many other countries have reported individual cases or limited community spread. Some viruses are highly contagious while other viruses are less so. The virus that causes COVID-19 seems to be spreading easily and sustainably in the community in some affected geographic areas.

Symptoms include fever, cough, and difficulty breathing. These symptoms also can occur with many other common respiratory infections, such as flu.

Investigations are ongoing and these recommendations will be updated as more information becomes available.

Ill Travelers Identified during Flight

Report travelers with specific symptoms to CDC.

Report travelers with
- fever (person feels warm to the touch, gives a history of feeling feverish, or has an actual measured temperature of 100.4°F [38° C] or higher) that has persisted for more than 48 hours
  OR
- fever AND one of the following:
  - persistent cough
  - difficulty breathing
  - appears obviously unwell
Report, as soon as possible before arrival, by one of the methods described in the Guidance for Air Travel Industry Reporting of Onboard Death or Illnesses to CDC.

Airlines and cabin crew should review CDC’s Infection Control Guidelines for Cabin Crew

CDC recommends that companies review and update, as needed, their personal protection policies and communicate and train employees on how to manage sick travelers.

CDC recommends the following measures for cabin crew to protect themselves and others, manage a sick traveler, clean contaminated areas, and take actions after a flight.

Practice routine handwashing.
- Wash hands often with soap and water for at least 20 seconds, particularly after assisting sick travelers or touching potentially contaminated body fluids or surfaces; after coughing, sneezing, or blowing your nose; after using the restroom; and before preparing or serving food or beverages.
- Use alcohol-based hand sanitizer (containing at least 60% alcohol) if soap and water are not available.
  - Airlines should consider providing alcohol-based hand sanitizer to cabin and flight crews for their personal use.

Identify sick travelers who meet the above description.
- Minimize contact between passengers and cabin crew and the sick person. If possible, separate the sick person from others (by a distance of 2 meters or 6 feet, ideally) and designate one crew member to serve the sick person.
- Offer a facemask, if available and if the sick person can tolerate it. If a facemask is not available or cannot be tolerated, ask the sick person to cover their mouth and nose with tissues when coughing or sneezing.
Treat all body fluids (such as respiratory secretions, diarrhea, vomit, or blood) as infectious.
- Wear disposable medical gloves when tending to a sick traveler or touching body fluids or potentially contaminated surfaces. Remove gloves carefully pdf icon[PDF – 1 page] to avoid contaminating yourself, then wash hands.
- When tending to a sick traveler who has fever, persistent cough, or difficulty breathing, use additional personal protective equipment (PPE) in the Universal Precaution Kit pdf icon[PDF – 1 page]external icon: face mask, eye protection, and a gown to cover clothing. Ensure an adequate supply of recommended PPE is available during flight.
- Properly dispose of gloves and other disposable items that came in contact with the sick person or body fluids in biohazard bag or a secured plastic bag labeled as “biohazard.”
Clean and disinfect contaminated surfaces according to airline protocol.

After arrival, CDC Quarantine Station staff will conduct a health assessment of the sick traveler’s symptoms and possible exposures. If necessary, CDC staff will coordinate transport to a health care facility for medical evaluation and testing. CDC will update the airline about the results of the testing and any need for follow-up of exposed crew members or passengers.

Cleaning of Aircraft after Flight

If no symptomatic passengers were identified during or immediately after the flight:
- Follow routine operating procedures for cleaning aircraft, managing solid waste, and wearing PPE.
If symptomatic passenger(s) are identified during or immediately after the flight, routine cleaning procedures should be followed, and enhanced cleaning procedures should also be used as follows:
- Clean porous (soft) surfaces (e.g., cloth seats, cloth seat belts) at the seat of the symptomatic passenger(s) and within 6 feet (2 meters) of the symptomatic passenger(s) in all directions.
  - Clean porous (soft) surfaces (e.g. seat covers and carpet) by removing visible contamination if present and using appropriate cleaners that are compatible with aircraft surfaces and components in accordance with the manufacturer’s instructions. For items that can be laundered, use the warm setting and dry items completely on high heat.
- Clean non-porous (hard) surfaces (e.g., leather or vinyl seats) at the seat of the symptomatic passenger(s) and within 6 feet (2 meters) of the symptomatic passenger(s) in all directions, including: armrests, plastic and metal parts of the seats and seatbacks, tray tables, seat belt latches, light and air controls, cabin crew call button, overhead compartment handles, adjacent walls, bulkheads, windows and window shades, and individual video monitors.
  - Clean non-porous (hard) surfaces with disinfectant products with EPA-approved emerging viral pathogens claims that are expected to be effective against the virus that causes COVID-19 (SARS-CoV-2) and ensure these products are compatible with aircraft surfaces and components. All products should be used according to label instructions (e.g., concentration, application method and contact time, PPE).
- Clean lavatories used by the symptomatic passenger(s), including: door handle, locking device, toilet seat, faucet, washbasin, adjacent walls, and counter.
- Properly dispose of any items that cannot be cleaned (e.g., pillows, passenger safety placards, and other similar items as described below).

Recommended Personal Protective Equipment (PPE) during Enhanced Cleaning:

Disposable gloves that are recommended by the manufacturer of the disinfectant should be worn.
Disposable gowns should be worn while cleaning the cabin and lavatories.
If splashing is possible, eye protection, such as a faceshield or goggles and facemask may be required according to the manufacture’s label.

General Recommendations during the Enhanced Cleaning Process:

Ground and cleaning crews should not board the plane until all travelers have disembarked.
Ventilation systems should be kept running while cleaning crews are working aboard the airplane.
If visible contamination (e.g., a body substance such as blood or body fluids) is present, routine airline cleaning procedures should be followed based on blood or body substance spill management according to , 29 CFR 1910.1030.OSHA’s Bloodborne Pathogen Standard, 29 CFR 1910.1030external icon.
Airlines should ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA’s Hazard Communication Standard, 29 CFR 1910.1200external icon.
Airlines should train ground and cleaning crews on and require that crew members demonstrate an understanding of when to use PPE, what PPE is necessary, how to properly don (put on), use, and doff (take off) PPE.
After doffing (taking off) PPE, cleaning staff should immediately clean hands with soap and water for at least 20 seconds. If soap and water not available and hands are not visibly dirty, an alcohol-based hand sanitizer that contains at least 60% alcohol may be used. However, if hands are visibly dirty, always wash hands with soap and water.
- Airlines should consider providing alcohol-based hand sanitizer to cleaning staff for their personal use.
Cleaning staff should immediately report breaches in PPE (e.g., tear in gloves) or any potential exposures (e.g., contact with blood or body fluids without wearing appropriate PPE) to their supervisor.
Cleaning staff should dispose of PPE and other disposable items used in cleaning following the airline’s routine procedures. Note that all waste from international flights will also fall under jurisdiction of the U.S. Department of Agriculture/Animal and Plant Health Inspection Service (APHIS).
Ground crews assigned to wastewater management operations should follow routine procedures.
Employers should educate workers to recognize the symptoms of COVID-19 and provide instructions on what to do if they develop symptoms.
- Cleaning staff should immediately notify their supervisor if they develop symptoms of COVID-19.