Air Travel and the Pandemic: an Epidemiologist’s Perspective

by Peter Schnall, MD, MPH*

An epidemiologist walks into an airplane

Prior to COVID-19, I was a frequent flyer: traveling internationally almost monthly for both work and personal reasons, and logging more than one million miles in the past decade. As a physician/epidemiologist, I have had a research and public health focus on working conditions and their impact on physical and mental health for the past 30 years. During plane trips, when passengers beside me asked me what I did for a living, I would talk with them about the impact of work on health, question them about their jobs, and of course, answer many questions they had about how work might impact their health. As the COVID-19 pandemic has vast and mounting impacts on work and working conditions, I believe flying and speaking with others would be even more interesting now.

While flying continues to be a required work activity — not only for airline personnel but for the many business travelers whose jobs require them to fly, air travel (and all public transportation) is more dangerous for the foreseeable future.

Photo by Suhyeon Choi on Unsplash

Pandemic air travel risks

COVID-19 threatens all of our health. To have healthy work and be able to return from work healthy, the COVID-19 pandemic must be controlled. Going to a workplace where the risk of contracting COVID-19 is great, is a threat to many of us, and therefore puts greater demands on our nervous systems. Many articles and studies are reporting increasing stress symptoms among working people and the public as a result of the pandemic. One form of stress found at certain kinds of jobs, such as bus driving, is called threat avoidant vigilance (abbreviated TAV), but it may also be a consequence of the COVID-19 pandemic. The body’s natural response to threatening situations is characterized by biological arousal including increased respiration and blood pressure. A response akin to TAV may now occur when people go outside in public during COVID-19 or need to travel on public transportation or fly in a crowded airplane — situations experienced as threatening and requiring enhanced vigilance to reduce our risks.

Since air travel is one source of increased risk for COVID-19, it is an occupational exposure for flight attendants, pilots, and business travelers. Early in the pandemic, airline personnel reported numerous cases and deaths from COVID-19. It is unclear (there is little published) if mask-wearing and other safety protocols are effective, for flight attendants who work in a confined, often crowded indoor environment for very long hours, and who come in frequent close contact with passengers who at various points during flights are permitted to remove their masks for eating and drinking.

Reliable tests to keep infected people from flying do not exist yet. Temperature checks are unreliable as a means of screening for infected people, since common household pain medications may lower temperatures. Also, many infected people are asymptomatic. While air travel risks have been reduced, in part, due to improved ventilation systems, airlines requiring flight attendants and passengers to wear masks, and efforts on the part of staff to actively encourage mask wearing, the reality of close contact among passengers and staff, as well as periodic relaxation of mask wearing during flights to allow eating and drinking, combined mean that flight attendants and travelers are still at risk of exposure to COVID-19.

Physical distancing is not possible in an airplane even if middle seats are blocked out by airlines. Close proximity of passengers and staff, when combined with intermittent mask removal during flights, means that exposure risk on an airline cannot be reduced to zero. And unfortunately, while the minimum infectious dose of SARS-CoV-2, the virus that causes COVID-19, is unknown so far, researchers suspect it is quite low. “The virus is spread through very, very casual interpersonal contact,” W. David Hardy, a professor of infectious disease at Johns Hopkins University School of Medicine, told STAT.

Photo by Smiley N. Pool on Dallas News

Pandemic air travel precautions for passengers

What measures can staff and passengers take to lower everyone’s risk of contracting COVID-19 while flying? The following are some thoughts (as a frequent flyer and epidemiologist), directed mostly to passengers, about how to execute a proper plan to reduce risk if traveling by plane.

#1 — Don’t fly if there is any other way to get to your destination. Use wheels if at all possible.

#2 — If you do have to fly, understand that the longer you are in an airplane, the greater the risk of infection. Given the substantial number of people on an airplane, there is a very high likelihood that someone on the plane is infected and shedding the virus. There are no government regulations about the density of seating on a plane nor any requirement for adequate physical distance between passengers. The closer you sit to someone who is infected, the greater the risk of contracting the virus. Again, drive when it is at all possible.

#3 — Before your flight, assemble (and wear during the entire flight) an inexpensive HAZMAT outfit as follows:

• an N95 mask (purchasable, sometimes at a premium).
• a faceguard (a clear plastic shield) over your N95 facemask. (A faceguard is designed to prevent the virus from coming down from above and going into one’s eyes or landing on your mask and face.)
• a light jacket with a hood. Fasten the hood around your head and below the faceguard.
• gloves, making sure the jacket fits closely over the gloves.
• from entry into the airport until exit from the airport, including luggage drop-off and retrieval.

#4 — Maximize your personal safety before flying in the plane by researching the airline and determine their policy and safety features as follows:

• Does the plane you will be flying in have a modern HEPA filter air cleaning system? (If not, choose another plane or airline).
• Modern HEPA air filters do remove the COVID-19 virus effectively, but flyers must understand that a HEPA air filter will not protect you from viruses exhaled by the passengers sitting within 10 ft. of you.
• Does the airline keep center seats open to minimize crowding? (This reduces but does not remove the risk).
• Does the airline require passengers to wear masks throughout the flight? Most do not as they allow passengers to remove their masks to eat and drink.
• Do all airplane staff wear masks? They should and usually do.
• Do the staff enforce the airline mask-wearing protocol for passengers? Fortunately, there are fewer stories recently about passengers coming onboard without a mask or being allowed to fly without one.
• Does the airline enforce their policy during the flight? That is, if someone removes their mask to eat, are they required to put it back on after snacking/eating/drinking?

• Purchase the safest seat as follows:

#5 — Maximize your personal safety traversing the airport

• In the airport, always wear a mask; again use an N95 mask when possible.
• Avoid groups.
• Check all baggage if possible. (Anything carried onto a plane can become contaminated.)

#6 — Other precautions before and during your flight

• Before boarding your flight, be sure to use the restroom. Wear your mask and carry alcohol wipes; hold the wipes between your gloves and anything you touch. If you are not wearing gloves, then use alcohol wipes as a barrier in the restroom.
• Before the flight, try not to drink coffee or liquids to reduce the need to use a restroom.
• Do not eat or drink during the flight if at all possible.

• Avoid use of the bathrooms (they are a dangerous hot spot as other passengers may have left the virus on surfaces). Cleaning by airlines is only done before and after flights.
• If you do use the restroom, follow the instructions in the first bullet.

Pandemic air travel precautions for flight attendants

• Wear your mask at all times. They are your best protection.
• Make sure N95 masks are properly fitted.
• Wash your hands after each physical contact with items handled by passengers as well as periodically throughout your shift.
• Remember the airport is a major source of infection. Wear your mask and maintain physical distance while at the airport.
• Face shields offer additional protection, as do eyeglasses.

Even if you can’t take all of these precautions, taking any of these is better than taking none.

Good luck with your next flight.

Please share your thoughts in the comments section.

Learn more:

• If you want to learn more about the challenges of finding work-life balance right now, check out our May 2020 article, “Blurred Boundaries: Work-Life Balance in the Time of COVID19.”
• If you want to know about the impact of precarious work in a pandemic, check out our June 2020 article, “Freelance and Gig Work during COVID-19.”
• If you are interested in our public health perspective on reopening schools, check out our July 2020 article, “Reopening Schools: Mental health vs Health & Safety?”.

*This article was commissioned as part of the Healthy Work Campaign. To learn more and obtain free resources, visit https://healthywork.org.

Dr. Peter Schnall is Co-Director of the Healthy Work Campaign, as well as the Founder and Director of the Center for Social Epidemiology, the nonprofit which established the campaign. An epidemiologist, Peter has studied the impact of working conditions on the development of hypertension among workers for over 30 years, as well as promoting increasing awareness among students, colleagues and the public of the important role psychosocial work stressors play in the development of chronic mental and physical illnesses. He is also a Clinical Professor of Medicine at University of California, Irvine’s Center for Occupational and Environmental Medicine (COEH). (LinkedIn, Twitter)

Acknowledgments

We would like to acknowledge the contributions made to this article by our colleagues:

• For science writing support: Marnie Dobson, Pouran Faghri & Paul Landsbergis
• For editorial support: Maria Doctor

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