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
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.