Guidance for Air Travel Industry on Reporting of Onboard Deaths or Illnesses to CDC

U.S. Federal Regulations

The U.S. Code of Federal Regulations [42 CFR 70.4 and 71.21(b)] contains death and illness reporting requirements for flights engaged in interstate traffic and international flights arriving into the United States, respectively. 42 CFR 70.4 requires the commander in charge of the aircraft (interstate flights) to report before arrival a case or suspected case of communicable disease among passengers or crew members to the local health authority with jurisdiction for the arrival airport. 42 CFR 71.21(b) requires the commander of an aircraft (international flights) destined for the United States to report before arrival any deaths or illnesses (as defined in the regulations) among passengers or crew members to the Centers for Disease Control and Prevention’s (CDC) quarantine station. Early reporting ensures prompt ground response to maximize timely care, reduce the risk for spreading disease, and minimize travel disruption.

The regulations specifically state:

Sec. 70.4 Report of disease (interstate)
The master of any vessel or person in charge of any conveyance engaged in interstate traffic, on which a case or suspected case of a communicable (contagious) disease develops shall, as soon as practicable, notify the local health authority at the next port of call, station, or stop, and shall take such measures to prevent the spread of the disease as the local health authority directs.

Sec. 71.21 (b) Radio report of death or illness (international)

(b) The commander of an aircraft destined for a U.S. airport shall report immediately to the quarantine station at or nearest the airport at which the aircraft will arrive, the occurrence on board of any death or ill person among passengers or crew.

Conditions that require reporting are explicitly defined in the regulations for international travel, but not in the regulations for interstate travel. CDC recommends that airlines apply the same standards for “required” and “requested” reporting to both international flights and interstate flights.

Required Reporting:

The commander of an aircraft arriving into the United States must report to CDC any onboard deaths as well as the presence of persons with any of the following physical conditions, which may indicate a serious contagious illness.

• Fever* reported to have lasted more than 48 hours; or
• Fever* of any duration, plus any one of the following: rash, swelling of the lymph glands, or jaundice (yellowing of skin or eyes); or
• Persistent diarrhea

Requested Reporting:

Other physical conditions may also indicate a contagious illness that could pose a public health threat. Therefore, CDC requests reporting of any person with the following physical conditions:

• Fever* of any duration, plus any one of the following:
  • persistent cough
  • persistent vomiting
  • difficulty breathing
  • headache with stiff neck
  • reduced level of consciousness
  • unexplained bleeding

* Cabin crew should consider someone to have a fever if the ill person feels warm to the touch, gives a  history of feeling feverish, or has an actual measured temperature of 100° F (37.8° C) or greater.

See “Specific explanations for crew onboard aircraft” at the bottom of this guidance for explanations and examples of the contagious diseases that such signs and symptoms might indicate.

Please note that CDC Quarantine Station staff can be consulted to assist in evaluating an ill traveler, provide recommendations, and answer questions about reporting requirements; however, reporting to CDC does not replace usual company procedures for in-flight medical consultation or obtaining medical assistance.

Information to be included in the report to CDC about a death or suspected contagious disease

Cabin crew should provide the pilot with the following information:

• Traveler’s name (indicate whether passenger or crew)
• Seat number or work area
• Approximate age
• City of departure and countries visited on this trip
• Conditions or symptoms that brought the ill traveler to the attention of the cabin crew or passengers  

How to report to CDC

Federal Interstate Quarantine regulations require reporting of any suspected case of communicable (contagious) disease to the local health authority with jurisdiction for the arrival airport.  Instead of reporting to the local health authority, the aircraft commander may alternatively notify CDC. CDC will then notify the local health authority in accordance with the regulations.

Federal Foreign (International) Quarantine regulations require reporting of any death and ill person to the CDC Quarantine Station with jurisdiction over the airport of arrival (http://www.cdc.gov/quarantine/QuarantineStationContactListFull.html).  

For both international and interstate flights CDC may be notified through:

1. Air Traffic Services (ATS) if in international airspace or Air Traffic Control (ATC) if in U.S. airspace
   This reporting option also complies with International Civil Aviation Organization (ICAO) reporting standard (ICAO document 4444 and Annex 9 of the Chicago Convention).
   
   

   ATC will notify CDC’s Emergency Operations Center (EOC) through the Domestic Events Network; the EOC will notify the appropriate CDC Quarantine Station and the local health department of jurisdiction. Quarantine staff will communicate with the airline’s designated point of contact to obtain necessary information about the death or ill traveler.

   OR

2. Airline’s land-based point of contact (e.g., Operations Center, Flight Control, airline station manager)
   Instruct the airline’s point of contact to notify CDC by contacting the:
   1. CDC Quarantine Station at or closest to the airport where the flight is arriving: http://www.cdc.gov/quarantine/QuarantineStationContactListFull.html
   or
   2. CDC EOC (770.488.7100), which will then notify the appropriate CDC Quarantine Station.

Specific explanations for crew onboard aircraft

To assist flight crews in identifying persons with potential cases of a reportable illness, CDC provides the following explanations and examples of the communicable diseases that such signs and symptoms might indicate:

Fever: Normal temperature varies from person to person. The term “fever” means that the person’s core body temperature is above the normal temperature for that person.  An operational definition of fever is a measured temperature of at least 100° F (38° C), or that the person feels warm to the touch, or gives a history of feeling feverish.

While measuring temperature is the preferred and most accurate method to determine whether a person has a fever, it is not always possible to do this. For example, a thermometer is not one of the items prescribed by the Federal Aviation Administration (FAA) to have in an airplane's emergency medical kit. For this reason, this guidance includes two additional methods that may be used by flight crew as proxies for a measured temperature:  a)  A self-reported history of feeling feverish is included in the event that the ill person has taken medication that would lower the measured temperature, and b) If it is not feasible to touch the person or if he or she does not disclose a history of feeling feverish, then, while not definitive, the observer should consider the appearance of a flushed face, glassy eyes, or chills as possible indications of fever.

Skin rash: This term means that the person has abnormal areas on the skin that are most often red or pink, but that can also be the same as the person’s skin tone, light-colored, purple, or even black. These areas may be flat, raised, blister-like, or crusted. In some diseases, chickenpox for example, areas with more than one of these characteristics can be found at the same time. The rash may be discrete or it may run together; it may include one area of the body, such as the face, or more than one area. Examples of diseases that can cause fever plus rash include measles and rubella (German measles). 

Persistent diarrhea: This term means that the diarrhea is frequent and severe enough that the crew notices, for example, that the person has been to the restroom numerous times, or the individual or another passenger voices concern about it. Persistent diarrhea may indicate the person has a food- or waterborne infection, such as norovirus infection or cholera.

Persistent vomiting: This term means that the person has vomited two or more times (not due to air sickness) and either expresses concern to the crew or it comes to the attention of others onboard (crew or passengers). Persistent vomiting may indicate the person has a food- or waterborne infection, such as norovirus infection.

Persistent cough: This term means that the cough is frequent and severe enough that it catches the attention of the crew or another passenger.  Examples of causes of persistent cough that are of public health concern include pertussis, tuberculosis, pneumonia, and influenza. The presence of fever suggests an infectious cause, but fever is not always present with an infection.

Difficulty breathing: This term means that the person is unable to move enough air into or out of the lungs, or can do so only with an unusually great effort.  The person might be gasping for air, be unable to “catch” his/her breath, feel “short of breath,” or be breathing too fast or shallowly.

Difficulty breathing, especially in the presence of fever, may indicate that a traveler has an infectious disease such as pneumonia, diphtheria, or influenza. 

Decreased level of consciousness: This term means that the person is not fully aware of his/her surroundings or does not respond normally to questions or painful stimuli. The person may appear to be sleepy or groggy, or be confused about who they are, where they are going, or the time of day or week.  Decreased consciousness, especially in the presence of fever or rash, may indicate the traveler has a serious neurological infection, such as meningococcal meningitis, or a serious infection in another body system.

Bruising or bleeding (without previous injury): This term means that the person has noticeable and unusual bruising or bleeding from gums, ears, nose, or areas on the skin for which there is no obvious explanation. Bruising or bleeding, especially in the presence of fever, may indicate that the person has a hemorrhagic fever, such as Ebola.