Process for contact management for measles cases communicable during air travel

On this page

• Background
• Roles and Responsibilities
• Process
• Annex A: Email template to contact airline
• Annex B: Template for public advisory
• Annex C: Template for direct messaging to passengers
• References

Background

When a measles case travels by plane while they are infectious, there is the potential for measles transmission to susceptible contacts on the plane. Evidence suggests that transmission can occur on flights of all durations^{Footnote 1Footnote 2Footnote 3}, and can be spread to passengers seated outside of the case's immediate proximity, including the cabin crew^{Footnote 1Footnote 4Footnote 5}. Contact management is important for early identification of secondary cases to minimize onwards transmission and prevent large outbreaks. The administration of post-exposure prophylaxis (PEP) to susceptible individuals may be possible in some instances where susceptible contacts are identified within the timeline for administration (within 6 days of exposure) and a pre-arranged pathway is available for passengers to seek PEP.

Previous guidance for measles cases that are infectious during air travel focused on the timeline for PEP administration to guide public health action. The previous guidance recommended that if contacts were within the 6-day window to administer PEP after exposure, provincial and territorial public health authorities should initiate contact tracing using the flight manifest in addition to posting a Canadian Network for Public Health Intelligence (CNPHI) alert and public media release. When outside of the 6-day window, it was recommended that provincial and territorial public health authorities post a media release and CNPHI alert. However, contact tracing using the flight manifest has been found to be resource-intensive and rarely results in notifications that allowed for action within the PEP timelines^{Footnote 1Footnote 6}. Furthermore, based on the Canadian experience, the manifest usually required considerable cleaning before use, and the information on the manifest was often lacking the necessary contact details for all passengers. Finally, contacting each passenger on the flight can take considerable time and resources that the provincial and territorial public health authorities may not have available.

In order to take a risk-based approach and balance public health resources with timely notification, PHAC recommends issuing a public advisory in all instances where the case was infectious during air travel (four days before and after rash onset). This strategy allows for timely notification and has the added benefit of potentially notifying individuals that were not on the flight but may have been exposed at the airport. In addition to this, at their discretion based on risk assessment and available resources, public health authorities may choose to request the flight manifest to directly notify passengers on the flight of potential exposures. In this instance, it's recommended that the lead public health authority send a single email containing public health recommendations to all passengers on the flight, instead of contacting each passenger individually.

Roles and responsibilities

Lead public health authority

• In most instances, the provincial or territorial public health authority that diagnoses the measles case will be responsible for public health follow-up, including interviewing the case, contact management (including determining if a flight manifest for contact management is required), determining public health actions, issuing a public advisory, and notifying PHAC. This document does not distinguish between actions taken at the provincial/territorial and at the local level as the roles and responsibilities may differ between jurisdictions.
• In instances where a jurisdiction identifies a measles case that resides in another province or territory, interjurisdictional notification mechanisms should be followed in order to ensure rapid public health follow up, including case and contact management (including determining if a flight manifest for contact management is required), determining public health actions, issuing a public advisory, and notifying PHAC.

Table 1. Roles and responsibilities for lead public health authority, Public Health Agency of Canada, and airline
Lead public health authority (province/territory)Footnote 1
Assess available information and identify next steps Notify PHAC for awareness and provide necessary information for interjurisdictional notifications (IJNs) Notify all airlines involved in the passenger's journey for Occupational Health & Safety follow-up Issue public advisory and CNPHI alert Request flight manifest from the airline as needed, and disseminate direct messaging to passengers Administer post-exposure prophylaxis to susceptible contacts as required Report confirmed cases through Canadian Measles and Rubella Surveillance System
PHAC
Maintain contact info list for airlines and provide contact info to P/T as needed Maintain tools and templates for notification Issue IJNs to other countries to inform them of exposures and/or cases in their jurisdiction
Airline
Occupational Health & Safety follow-up of flight crew Provide flight manifest to appropriate public health authorities as soon as possible upon request
Footnote 1 These actions may be taken at the provincial/territorial or local level, as per usual jurisdictional practice. Return to footnote 1 referrer

Process

Figure 1 : Text description

Step 1: Lead jurisdiction to assess available information to determine next steps. Consider the following questions:

Step 1a: Did the flight occur in the past 21 days?

• If your answer is "yes": continue to question 2.
• If your answer is "no": no further action is needed.

Step 1b: Was the case infectious during air travel? (Infectious period: 4 days before to 4 days after rash onset)

• If your answer is "yes": continue to question 3.
• If your answer is "no": no further action is needed.

Step 1c: Is there a need for direct messaging to passengers?

• If your answer is "yes": continue to step 2.
• If your answer is "no": continue to step 2.

Step 2: Lead jurisdiction to notify PHAC for awareness and provide necessary information for interjurisdictional notification (IJN) (flight number, travel dates, other relevant exposures or close contacts).

• If there is no need for direct messaging to passengers: continue to step 3.1.
• If there is a need for direct messaging to passengers: continue to step 3.2.

Step 3.1: Lead jurisdiction to email the airline to notify them of potential flight crew exposure. Continue to step 4.

Step 3.2: Lead jurisdiction to email the airline to notify them of potential flight crew exposure and to request the flight manifest. Continue to step 4.

Step 4: Lead jurisdiction to post an alert on the Canadian Network for Public Health Intelligence (CNPHI). If exposure took place in another province/territory (P/T), consider notifying the P/T directly to coordinate messaging and follow-up. Continue to step 5.

Step 5: Issue a media release via usual jurisdictional mechanism. The media release should contain flight details, date of exposure, additional community exposures and instructions for monitoring for symptoms and seeking care.

• If your answer to step 1c. is "yes": is there a need for direct messaging to passengers: continue to step 6a.

Step 6a: Develop messaging if there is a need for direct messaging to passengers. The letter should inform passengers of the exposure, and contain instructions to monitor for symptoms and seek PEP, if applicable. Continue to step 6b.

Step 6b: Send a single email to the passenger email list from the manifest.

1. Lead jurisdiction to assess available information to determine the next steps. Consider the following questions:
   1. Did the flight occur in the past 21 days? This is the maximum incubation period for measles, and the maximum time that cases can appear after exposure. If the flight occurred more than 21 days ago, no further action is required.
   2. Was the case infectious during air travel? Infectious period is 4 days before to 4 days after rash onset. If the case did not travel while infectious, no further action is required.
   3. In addition to a public advisory, should there be direct messaging to passengers? Consider if there is indication of increased risk (such as multiple cases) and available resources.
2. Lead jurisdiction to notify PHAC of the event.
   1. Send an email to the Vaccine Preventable Diseases (VPD) division (vpd-mev@phac-aspc.gc.ca) to notify PHAC-VPD of the event and the next steps. Include the flight details, travel dates, and other relevant exposures or close contacts abroad. PHAC-VPD will use this information to send an interjurisdictional notification (IJN) to other countries if appropriate.
      1. If there is an urgent need for an IJN outside of business hours (8am-4pm Eastern time), contact HPOC (hpoc-cops@phac-aspc.gc.ca) with the necessary information listed above and request that they initiate an IJN.
   2. If contact information for the airline is required, contact the Central Notification System (cns-snc@phac-aspc.gc.ca). If outside of business hours (8am-12am Eastern time), cc HPOC (hpoc-cops@phac-aspc.gc.ca)
3. Lead jurisdiction to email the airline to notify them of the potential flight crew exposure and if required, request the manifest.
   1. It is recommended that the lead jurisdiction notify all airlines involved in the case's travel, not just the Canadian airlines or the airline that brought the case to Canada.
   2. An email template is available in Annex A to contact the airline.
   3. If requesting the manifest, it is important to include the authority under which you are requesting it.
4. Lead jurisdiction to notify public health community via CNPHI posting.
   1. If exposure took place in another P/T, notify the P/T directly to coordinate messaging and follow-up.
5. Lead jurisdiction to draft and issue public messaging.
   1. The media release should contain flight details, dates of exposure, any additional community exposures, and instructions for monitoring for symptoms and seeking care. A template is available in Annex B to assist with drafting the messaging. When using the template, be sure to update with jurisdiction-specific information for seeking PEP and accessing care.
   2. The messaging should be disseminated via usual jurisdictional mechanisms (i.e., posting to website, issuing media release, etc).
6. For direct messaging, draft and disseminate letter to passengers.
   1. The letter should inform passengers of the exposure and contain instructions to monitor for symptoms and seek post-exposure prophylaxis if required. A template is available in Annex C to assist with drafting the letter. When using the template, be sure to update with jurisdiction-specific information for seeking PEP and accessing care.
   2. Use the flight manifest to obtain a list of email addresses for passengers on the flight and send a single email to all passengers using bcc to protect their personal information. Note that all passengers on the manifest should be contacted, regardless of citizenship or seating arrangement.

Annex A: Email template to contact airline

Download in Word format the email template to contact airline

Note: Contact information for airlines can be obtained from the Central Notification System: cns-snc@phac-aspc.gc.ca

Template for airline notification of measles exposure on airplane:

Dear Sir/Madam,

<Insert agency> has been informed of a confirmed case of measles that was infectious during the flight.

The flight details are as follows:

• Airline/flight number:
• Departure airport:
• Departure date and time:
• Arrival airport:
• Arrival date and time:

This disease is highly contagious and could have been transmitted to passengers or crew members on the plane. We are writing to inform you of the exposure and to recommend that the airline's occupational health services follow up directly with the flight crew who serviced this flight.

If you have any questions, please feel free to contact me at <insert contact phone number>.

If requesting the manifest, include the following:

I am also requesting the flight manifest containing name(s) and contact information for the passenger(s). This would include all passengers on the flight. This request is being made under <insert authority and act>.

The information requested is required so that passengers can be notified of their exposure and provided advice on monitoring symptoms and seeking care. The information should be sent to <insert email address>.

Annex B: Template for public advisory

Download in Word format the template for public advisory

<Insert public health authority name> is investigating a confirmed case of measles linked to international travel. The case traveled on the following flight(s):

• Airline/flight number:
• Departure airport:
• Departure date and time:
• Arrival airport:
• Arrival date and time:

Individuals who were on the flight may have been exposed to the measles virus.

Measles is a highly contagious viral infection that spreads through the air and close contact, such as breathing, coughing, or sneezing. It can cause a serious illness that may require admission to a hospital. Vaccination against measles is close to 100% effective in preventing measles.

Symptoms may start around 10 days after exposure but can start anywhere from 7 to 21 days. People who were on the flight should monitor for symptoms until <insert end date of the communicable period>.

Symptoms of measles include:

• Fever; and
• Cough, runny nose or conjunctivitis (red, watery eyes); and
• A red rash that appears three to seven days after fever starts, beginning behind the ears and on the face and spreading down the body and then to the arms and legs.

You are considered protected against measles if:

• You have already had measles or
• You have had 2 doses of a measles containing vaccine or
• You have had a blood test that shows antibodies to measles
• For Canadian residents, you are also considered protected if born before 1970.

If you or your family members or travel companions are not protected against measles, it is recommended that you get vaccinated against measles as soon as possible by scheduling an appointment with your Local Public Health or in a clinic that offers measles vaccination.

If you or your family members are not protected against measles and you are pregnant, under one year of age, or if any of you are immunocompromised (even if you are vaccinated), immediately contact your health care provider and present this letter.

If you or your family members develop symptoms described above from now until <insert end date of the communicable period>:

• Consult a health care provider as soon as possible.
• Avoid being in contact with other people, specifically people considered at high risk: children under the age of 12 months, pregnant women and immunocompromised individuals.
• Wear a mask if you leave your household.
• To get to your medical appointment, avoid taking public transportation.
• Inform your healthcare provider and healthcare facility that you have been in contact with a measles case before presenting yourself for your appointment so that appropriate measures can be taken to prevent spreading the disease to others.

<Insert information specific to residents of your jurisdiction>

Annex C: Template for direct messaging to passengers

Download in Word format the template for direct messaging to passengers

Dear Sir/Madam,

On behalf of <insert public health authority>, we would like to inform you that you may have been in contact with a person who was diagnosed with measles during a recent flight you took on <insert date>, from <insert country of departure> to <insert country of arrival> (<insert flight name and number>).

Measles is a highly contagious viral infection that spreads through the air and close contact, such as breathing, coughing, or sneezing. It can cause a serious illness that may require admission to a hospital. Vaccination against measles is close to 100% effective in preventing measles.

Symptoms may start around 10 days after exposure but can start anywhere from 7 to 21 days. People who were on the flight should monitor for symptoms until: <insert end date of the communicable period>.

Symptoms of measles include:

• Fever; and
• Cough, runny nose or conjunctivitis (red, watery eyes); and
• A red rash that appears 3 to 7 days after fever starts, beginning behind the ears and on the face and spreading down the body and then to the arms and legs.

You are considered protected against measles if:

• You have already had measles or
• You have had 2 doses of a measles containing vaccine or
• You have had a blood test that shows antibodies to measles
• For Canadian residents, you are also considered protected if born before 1970.

If you or your family members are not protected against measles, it is recommended that you get vaccinated against measles as soon as possible by scheduling an appointment with your Local Public Health or in a clinic that offers measles vaccination.

If you or your family members are not protected against measles and you are pregnant, under one year of age, or if any of you are immunocompromised (even if you are vaccinated), immediately contact your health care provider and present this letter.

If you or your family members develop symptoms described above from now until <insert end date of the communicable period>:

• Consult a health care provider as soon as possible.
• Avoid being in contact with other people, specifically people considered at high risk: children under the age of 12 months, pregnant women and immunocompromised individuals.
• Wear a mask if you leave your household.
• To get to your medical appointment, avoid taking public transportation.
• Inform your healthcare provider and healthcare facility that you have been in contact with a measles case before presenting yourself for your appointment so that appropriate measures can be taken to prevent spreading the disease to others.

More information on measles disease is available on the Public Health Agency of Canada measles webpage.

<Insert information specific to residents of your jurisdiction>

We thank you for your valuable collaboration.