Unwelcome baggage: Sick fliers
By Robert Davis, USA TODAY

As Ken Proctor, a shoe company executive from Hot Springs, Ark., settled into his EVA Airline seat for the flight from Taipei to Los Angeles, he began to get nervous about the sweat pouring off the man sitting next to him.

With airlines struggling to cope with the threats of terrorism and biological contamination, he was not the only one concerned that December day. A flight attendant soon appeared and asked the man how he was feeling.

On the surface, such encounters might appear to be just friendly inquiries by helpful flight attendants. But they are often far more than that.

From the time they reach the ticket counter, airline passengers are being observed for signs that they are, intentionally or not, carrying the seeds of a disease that could spread infection to their fellow travelers and beyond.

Airline workers are looking for the flu-like symptoms that may be harbingers of avian flu or severe acute respiratory syndrome (SARS). They watch for measles or chickenpox, which are a deadly threat to organ-transplant recipients, and rubella, which can harm an unborn child.

They're on the alert for all signs of disease, not knowing what could be the next global health threat.

Any evidence of infection, such as a high fever or suspicious rash, could get a passenger left behind or sent to one of eight quarantine stations in major U.S. airports.

The Centers for Disease Control and Prevention has been working with air carriers in a voluntary program to strengthen safeguards against biological threats. This includes training everyone, from those checking in bags to the gate agents inside the secured areas to the flight crews, to watch for signs of trouble.

"Why do you think they have people standing at the Jetway?" says Joan Sullivan Garrett, chief executive and president of MedAire, an emergency medical service that helps airlines deal with passenger health problems. "It's not just to help you find your seat."

The training is not required by the federal government, and the oversight is far more strict in Asia, where the SARS and avian flu outbreaks began. Some overseas airports use high-tech devices to check passengers for high fever as they walk through the terminal.

International airlines want to keep sick passengers off planes. "We educate both our ground and in-flight services staff to be vigilant and target the prevention of ill passengers from boarding our aircraft," says Lisa Wong, a spokeswoman for Cathay Pacific Airways.

Jodie Taylor of Qantas Airways says the carrier "will not carry customers who are suffering from an infectious disease where there is a direct risk of transmission."

Airlines play big part

The World Health Organization routinely updates airlines on the global health situation. But airline officials know they are the front line for keeping a disease at bay.

"Someone who is in the early stage of an illness can be moved around the world and spread it," says Nigel Dowdall, one of British Airway's staff physicians. "The airline industry does have a role in trying to reduce the risk."

British Airways is one of 63 airlines that call on Phoenix-based MedAire when they have an urgent health question. Most of the calls still come from airline crews facing medical emergencies in the air. Fainting, stomach upset and breathing problems are still the leading reasons for the 9,818 calls last year for help from the air.

But in a trend that MedAire says speaks to the airlines' increased focus on bio-surveillance, more calls are coming in from the ground.

Last year, airlines stopped their departure routine to ask for a medical opinion on 631 passengers who already had boarded an aircraft; 48 of them were suspected of having a communicable disease.

Another 4,477 people were the subject of calls from the gate area; 234 calls were for passengers who may have been contagious.

Three or four times a week, the potentially infectious passenger is not identified until the flight is in the air. Another 196 passengers were the subjects of such calls.

In all, 583 of the passengers MedAire nurses or doctors consulted on last year had potentially communicable or infectious disease.

The stakes are high

In almost all cases, the problem turned out to be a garden-variety illness, such as the flu. But the CDC responded to dozens of these airline-related illnesses last year. None of those passengers had SARS, but some did have a contagious disease such as tuberculosis.

Considering that millions of passengers flew last year on airlines that use MedAire, the biological red flag goes up very rarely, but airlines cannot afford to miss anyone.

U.S. airlines have yet to fully recover from both the terrorist attacks of Sept. 11, 2001, and last year's SARS outbreak. The industry halved its losses last year, losing $5 billion, but still must spend about $3 billion a year on security measures. Bio-surveillance is one of them.

"Disease is a global issue along with security," says MedAire's Garrett. "You can't separate the two."

For centuries, people have spread disease through travel. Ships brought colonists — and smallpox — to America in the 18th century. World War I soldiers brought home the Spanish flu.

Health officials are scrambling to stop avian flu in part because of their fear that it could mutate and spread more easily in humans. Because people lack natural defenses against the bird disease, there is the specter of a pandemic, a worldwide outbreak.

Health and airline officials now know just how many people a single passenger can infect.

An elderly man with SARS who flew from Hong Kong to Beijing on March 15, 2003, is believed to have infected 22 of the 119 people onboard. He and five others died.

Researchers who studied the spread on that Boeing 737-300, led by a CDC expert, were surprised by the number of people who were infected who were not seated close to the man.

"It's not just where you are sitting on a flight," says Martin Cetron, CDC deputy director for global migration and quarantine. "It's several factors, including, potentially, contact with contaminated surfaces."

Although many travelers assume that disease is spread by the recirculated air, scientists believe it is more often spread through direct contact with tainted surfaces. A passenger with microscopic bugs on his hands stows a bag in an overhead bin, and another passenger comes along and touches the same surface, picking up the bugs. Garrett says she uses a hand sanitizer frequently while traveling.

While she and others battle to keep the bugs at bay in the cabin, public health officials are preparing for the moment when a disease lands on an American runway. They have been fine-tuning their response plan so they know what to do before opening the cabin door.

The CDC conducts drills with airlines, airport officials, public health agencies and emergency medical crews to practice how to deal with an infected airliner.

President Bush's proposed budget includes money to expand the number of quarantine stations at major airports. The stations allow public health officials to monitor passengers who could be contagious before they leave the airport.

The CDC and the airlines are more stealthy about watching for disease than about looking for weapons. "We're in the background," Cetron says. "The sign of good prevention is that it is silent."

Bonnie McKenna, who was a flight attendant for 34 years before retiring recently, says she spotted trouble by simply paying close attention to her passengers. "We're not medical people, but we can recognize things," she says. "You have to rely on your gut instinct."

Although some travelers consider it a violation of their privacy to be asked about their health, McKenna says flight attendants must protect themselves and other passengers.

"Usually what you do is say something to your flying partner like, 'Check out the guy in 24C.' Then you have a quick discussion," she says. "The next procedure is go to the cockpit and say, 'We've got this guy back here who really looks pretty bad.' "

Are passengers to be trusted?

Some people who are sick leave willingly. "They kind of give in and say 'Fine, just take me away,' " McKenna says. Others put up a fight because they want to get to their destination.

She once had a child removed who appeared to be breaking out in chickenpox. But the more typical encounter was similar to the situation that Proctor, the shoe executive, faced on that flight from Taipei to Los Angeles.

The man who sat next to Proctor insisted he was not sick and explained that he was sweaty because he had rushed to make the flight. The flight attendant "went back and conferred with another flight attendant," Proctor says. "They let him go. I was a little apprehensive."

British Airways' Dowdall says the surveillance system relies heavily upon passenger honesty. And that could be its Achilles' heel.

Proctor, who flies in and out of Asia four times a year, says frequent international travelers sometimes whisper about how to stay below the bio-surveillance radar. In China during the SARS outbreak, some passengers had to have their body temperature taken before they were allowed to board.

"If I have a fever of 101, I'll get held back," Proctor says, and, like many travelers, he would rather suffer through a long flight to be sick at home than be sick in China. How far he might be willing to go, health experts say, illuminates the limits of the efforts to keep bugs off planes.

"If I have to take 100 Tylenols, I'll do it to get my temperature down," Proctor says. "Because I'm getting on that airplane."