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Air travel and Norovirus

By Dr. Hemantha Wickramatillake and Capt. Menaka Fernando
Recently a commercial airliner was temporarily quarantined on arrival at its destination after some passengers fell sick with what was suspected as a stomach bug. A team of doctors was organised to medically examine the passengers. They were subsequently diagnosed with Norovirus (Norwalk virus) infection, more commonly known as the winter vomiting bug.

Further investigations to the cause of the virus revealed that the said passengers had all stayed at the same hotel in a popular city of one of the world’s famous tourist destinations. All affected passengers received treatment and none required hospitalisation. There had been a number of other tourists from the same hotel who had also caught a similar illness.
Outbreaks of Norovirus infection are common in situations where people from diverse backgrounds congregate, such as at hotels, camps and on cruise ships. Norovirus poses a unique threat in that it’s transmitted from employee (whether chef or server) to customer via the improper handling of food.

One of the reasons Norwalk is so common is the extended time an infected person can infect others. For instance, if a person preparing the food fails to wash his hands after using the bathroom, he could then contaminate the food he’s preparing with the virus. Also in the case of Norovirus, the preparer needn’t be sick; he may be a mere carrier of the virus.
So what if someone gets infected with Norovirus on board an airplane? Most passengers have a fear of falling sick, particularly on an airplane, train or cruise-ship where the state of washrooms typically leave a lot to be desired. Unlike most forms of food poisoning, Norovirus is highly infectious; it explodes through a population.

Although it passes quickly, the virus generates projectile vomiting (occurrences of gastrointestinal illness), diarrhoea with either abdominal cramps or nausea and, if one isn’t careful, dehydration. Less common symptoms are low-grade fever, chills, headache, muscle aches, and tiredness.
One can become infected with the virus by:
• Consuming food and drinks infected with Norovirus
• Touching surfaces or objects infected with Norovirus and then touching own mouth, nose, or eyes
• Person-person contact with Norovirus-infected person (being in the presence of someone who is vomiting)
• Sharing food or eating from the same utensil
• Shaking hands with an infected person
• Not washing hands after using the bathroom, changing diapers, and before eating or preparing food
• Caring for an infected person


It is suggested that inside an aircraft during flight, the spread of Norovirus via airborne droplets of vomitus will not circulate widely through an aircraft (and infect passengers and crew) if vomiting is confined to toilets. Then again, even in a clean washroom there could be unapparent environmental contamination with Norovirus.
Thus, in the case of airlines, it is not only important to quarantine the aircraft but steps must also be taken to disinfect the aircraft. Effective disinfection procedures are now easily available.

A few months ago, during a routine flight to Pekanbaru, one of our flight attendants began to feel quite sick and complained of stomach cramps and a growing pressure in his chest and throat. He was immediately relieved of his in-flight duties. The crewmember made it to the washroom just in time to begin a horrible stretch of vomiting that lasted until the flight landed in Pekanbaru. He was badly affected with cramps and could barely walk.

Immediately after landing he was rushed to the nearest hospital where he convalesced thanks to the restorative power of intravenous re-hydration. The vomiting had inflamed his oesophageal lining and gave him an acid reflux disease that has lasted to date – albeit in attenuated form. The doctor had suspected that his vomiting may have been due to Norovirus transmitted via the food that he had consumed at a party earlier on the day of the incident.

Although Norovirus is highly infectious and transmitted by multiple routes in closed settings, not many cases of in-flight transmission of the virus has been documented. Research on Norovirus has been done by gathering information (via questionnaires) from crew members and passengers about their on-board exposures and in-flight activities. Information on class of travel, consumption of food, beverages, and ice, and number of visits to the airplane restrooms were taken into account for the research. In some instances, stool specimens have also been tested for the virus.

Because Norovirus infection is common and often disembarked passengers disperse before becoming ill, in-flight transmission of Norovirus is likely underreported. Strategies to control Norovirus transmission during flight should include rapid removal of the affected persons into separate areas and they should be allocated separate lavatory facilities. Particular attention must be paid to disinfect all bathroom surfaces, even in the absence of obvious soiling.

Being affiliated to a budget airline, I always suggest to crew members that we carry with us our own refreshments such as homemade sandwiches, crackers, chocolate bars, dried fruit and cereal bars, etc. Although this may not be the most sensational form of cuisine, it surely is most preferable to being bent over an under-sized toilet making a mess of things.

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