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CSTE
Position
Statements 2000 ID-#2
COMMITTEE: Infectious
Disease
TITLE:
Guidelines for Management of Contacts of a Patient with Meningococcal
Disease who has Recently Traveled by Airline
ISSUE:
The Centers for Disease Control and Prevention (CDC) receives
reports of approximately 12 cases of confirmed meningococcal disease per year
where the index case was likely contagious aboard an international conveyance.
Most of these reports are received within days of transit; rarely is the
diagnosis made in transit. Because
of concerns about the possibility of secondary transmission to other passengers
and crew, CDC is frequently asked to provide guidance on the need for
antimicrobial chemoprophylaxis in these settings.
The public
health decision to offer antimicrobial chemoprophylaxis should be based on an
assessment of the risk of transmission in conjunction with the difficulty in
identifying and notifying those passengers and the potential severity of
illness. There are no documented
instances of secondary disease among passengers, but, similar to household
contacts, passengers who are seated next to a passenger with meningococcal
disease for a prolonged flight may be at higher risk of developing meningococcal
disease.
There is a need
to more systematically collect data on the risk of transmission to passenger
contacts to better guide public health recommendations.
POSITION TO
BE ADOPTED:
CSTE recommends
that CDC adopt the following recommendations:
-
Household
members traveling with the index patient as well as people traveling with
the index patient who have prolonged close contact (e.g., roommates, members
of the same sports team) should be identified and the need for antimicrobial
chemoprophylaxis evaluated.
-
The health
department from the state where the patient resides should be contacted
promptly to facilitate antimicrobial chemoprophylaxis of household members,
day care center contacts, and other possible close contacts.
Antimicrobial
chemoprophylaxis should be considered for:
-
CDC and
state health departments should enhance surveillance for secondary cases
associated with airline travel as identification of such cases would alter
these recommendations. To facilitate this, state and local health
departments should consider asking for recent travel history, including
flight information, on all meningococcal cases.
The CDC meningitis form should add a variable on
recent airline travel (within 10-14 days of onset) that includes
details on flight (airline, date, time, locations).
CDC should track this information to facilitate the identification of
cases that may involve passengers who were on the same flight and had
illness onset within 14 days of disembarkation.
-
Airlines
should be responsible for maintaining a passenger manifest to aid in
identification of passengers at risk for secondary infections.
CDC should work with airlines to identify the location of potentially
exposed passengers. With the
assistance of the airline, CDC should identify the states where these
passengers reside and contact the appropriate state and local health
officials. The state or local
health department will then contact passengers as necessary.
BACKGROUND
AND JUSTIFICATION:
Neisseria
meningitidis is
the leading cause of bacterial meningitis in children and young adults in the
United States, with an estimated 2,600 cases each year and a case-fatality rate
of 13%. N.
meningitidis is spread through direct contact with the
respiratory secretions of a patient with meningococcal disease, and
antimicrobial chemoprophylaxis of persons in close contact with the index
patient is the primary means for prevention of endemic meningococcal disease in
the United States. Close contacts
who have been identified to be at high risk of secondary disease include a)
household members, b) day care center contacts, and c) anyone directly exposed
to the patients’ oral secretions (e.g., through kissing, mouth-to-mouth
resuscitation, endotracheal intubation, or endotracheal tube management).
The attack rate for household contacts exposed to patients who have
sporadic meningococcal disease has been estimated to be four cases per 1,000
persons exposed, which is 500-800 times greater than for the general population.
Therefore, when a sporadic case of meningococcal disease occurs, the
first priority for prevention of additional cases is identification of these
close contacts to recommend antimicrobial chemoprophylaxis.
Because the rate of secondary disease for close contacts is highest
during the first few days after onset of disease in the primary patient,
antimicrobial chemoprophylaxis should be administered as soon as possible
(ideally within 24 hours after the case is identified).
Conversely, antimicrobial chemoprophylaxis administered >14 days after
onset of illness in the index case-patient is probably of limited value.
At least 7
investigations have examined possible transmission of Mycobacterium
tuberculosis on airplanes (Tuberculosis and Air Travel: Guidelines
for Prevention and Control. World
Health Organization 1998). One
of these investigations documented transmission of M.
tuberculosis from a symptomatic index passenger to six passengers,
with no other risk factors, sitting in the same section of a commercial aircraft
during a long flight (>8 hours) (N.
Engl. J. Med., Vol. 334, No. 15, p. 933-8).
The assessment
of risk to passengers and flight crew members
should be guided by two principles: the flight duration and the seating
proximity to the index patient. For
flights > 8 hours, passengers who are seated directly next to the
index patient are more likely to be directly exposed to the patient’s oral
secretions and are therefore probably at higher risk than those seated farther
from the index patient. In the
absence of data of elevated risk among other passengers, antimicrobial
chemoprophylaxis should be considered for those passengers seated directly next
to the index patient. Given the
increased frequency of ground delays prior to takeoff and after landing one
needs to count the total time not just the air transit time; the >8
hour time period should include the total time from when the passengers are
seated for takeoff until they disembark.
COORDINATION
WITH OTHER AGENCIES:
Agencies for
Response:
James
M Hughes, MD
Centers
for Disease Control and Prevention
National
Center for Infectious Disease
1600
Clifton Road, NE
M/S
C12
Atlanta,
GA 30333
Agency for Information:
Association of
State and Territorial Health Officials
CONTACT
PERSON:
Matthew
Cartter, MD, MPH
Epidemiology
Program Infectious Diseases Division
Connecticut
Department of Public Health
410
Capitol Ave. MS 11-EPI
P.O.
Box 340308
Hartford,
CT 06106
Tel:(860)
509-7994
Fax:
(860) 509-7910
Email:
Matt.cartter@po.state.ct.us
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