General Health Measures
Although pilots are required to have periodic physician visits to ensure they are fit to fly, these may not address some issues that may affect them when they travel internationally, particularly to destinations in the developing world. Flight attendants and others should also consider asking their health-care providers about these recommendations:
- Administering a periodic tuberculin skin test, if traveling frequently to destinations where the prevalence of tuberculosis is much higher than in the United States, where the incidence of antimicrobial resistance is higher, and where the crew member will be in close contact with crowds (www.who.int/tb/challenges/mdr/en/)
- Checking at each visit to make sure that routine immunizations are up to date (see below)
- Immunizing against seasonal influenza every year when the vaccine becomes available
In addition, all medications for chronic conditions should be carried in extra quantities, as they may not be available at some locations, and even if available and less costly, may be counterfeit (see Perspectives: Counterfeit Drugs in Chapter 2). The business of the manufacture of counterfeit medications in developing countries is huge and growing; it is impossible to tell from the packaging or from the pills themselves if they are counterfeit. Some counterfeit drugs contain lesser quantities of active ingredient, or none, and others contain toxic contaminants.
Vaccinations
Because of the frequency of travel to international destinations, air crews may have a greater likelihood of exposure to various diseases that are less common in the United States. For example, measles can be a life-threatening illness for adults and is more common in most of the world, including Europe, due to lack of mandatory childhood immunization against the disease in many countries. International flight crews should consider a travel health visit to ensure as complete protection as possible. Some may have very short notice prior to traveling to new destinations; thus, travelers should be asked about this possibility during their visit, so that vaccinations for an upcoming trip—that may not be imminent—may be given, or a series may be started early. The administration of some vaccinations will be determined by education of the traveler about the health risks in the various destinations and the traveler’s tolerance for risk.
Routine Vaccinations
All travelers should make sure they are up to date with routine vaccinations (see the separate sections on these vaccine-preventable diseases in Chapter 2):
- Measles—If born in the United States prior to 1957, one is assumed to be immune to measles. If born after, it is important to have documentation of having had the disease or having had two vaccine doses against measles. Measles vaccine is typically given as an MMR (measles, mumps, rubella).
- Varicella—Strongly recommended for travelers with no history of having had chickenpox.
- Polio—A single booster is recommended as an adult. (Although transmission of the polio virus is not a problem in the western hemisphere, it remains a risk in some countries in sub-Saharan Africa and in Asia.)
- Diphtheria/tetanus/pertussis—Administered at 10-year intervals for complete protection.
- Hepatitis B—Administered to all children and adolescents in the United States, it is advisable for frequent travelers because of unpredictability of exposure.
- Hepatitis A—Administered to all children in the United States, it is advisable for all travelers.
- Others—Any age-related (e.g., varicella-zoster) or health maintenance-related (e.g., pneumococcal) vaccinations should be considered.
Special Vaccinations for Travel
Although there are no established guidelines or recommendations for the use of travel vaccinations in pilots and air crew, it may be reasonable to offer meningococcal, Japanese encephalitis, yellow fever, and typhoid vaccine to this special population because of their frequent, short-stay, and at times unpredictable travel and destinations.
Malaria Chemoprophylaxis
Crew members are typically informed by their airline which destinations harbor malaria. Some European and Asian air carriers have longer experience in flying to destinations where malaria is endemic, and these airlines have various policies with respect to its prevention. Although there may be malaria transmission in some areas of destination countries, sometimes there is none in the capitals or the larger urban areas to which the major American carriers fly (e.g., China or the Philippines). This is generally not the case in sub-Saharan Africa, where during a short 24-hour layover there can be substantial exposure. Although there may be little risk at the hotels in the destination, risk may be increased at the international airports and during unpredictable delays in transit. There is little published data on the risk of malaria for flight crews with short layovers, but some information suggests that it is less than that for tourists.
Flight crew members should be educated about the risk of malaria at their destinations and have an individual risk assessment for preventive measures. For destinations where there is a high intensity of malaria (e.g., countries in West Africa), crew members should take prophylaxis. For other destinations where crews are thought to be at low risk based on local intensity of transmission, accommodations, and personal behaviors, they may be advised to use insect repellents and no chemoprophylaxis. Flight crews should always—
- Educate themselves as much as possible about malaria.
- Understand the importance of personal protective measures such as repellents, and use them properly.
- Take chemoprophylaxis if recommended by their doctor.
- Know that if fever or chills occur following exposure that it is a medical emergency.
- Know how they can get medical assistance at their destinations or at home in the event of symptoms or signs of malaria.
There are several options for malaria chemoprophylaxis, depending upon the destination city. The combination of country-specific recommendations that can be accessed either in this text (see Malaria Risk Information and Prophylaxis, by Country, section in Chapter 2) or on the CDC Travelers’ Health website (www.cdc.gov/travel) should help with this decision, along with the individual assessment.
Chemoprophylaxis Options for Pilots and Air Crew
- Mefloquine: The current US FDA-approved product label for mefloquine contains a caution against using mefloquine for malaria prophylaxis in pilots.
- Chloroquine: There are no contraindications for use of chloroquine in pilots or air crew. Chloroquine may not be the preferred option for many because of the need to continue taking the drug for 4 weeks after the last exposure, thus requiring over 4 weeks of drug administration for even a single night of exposure.
- Atovaquone–proguanil: There are no contraindications for use of atovaquone–proguanil in pilots or air crew members. In addition, because of the short-stay nature of their travel, use of atovaquone–progunil as chemoprophylaxis may be preferred because of the need to take the drug for only 7 days after leaving an area of exposure risk.
- Doxycycline: There are no contraindications for use of doxycycline in pilots or air crew. Doxycycline may not be the preferred option for many because of the need to continue taking the drug for 28 days after the last exposure, thus requiring over 4 weeks of drug administration for even a single night of exposure.
- Primaquine: There are no contraindications for use of primaquine in pilots or air crew. Like atovaquone–proguanil, use of primaquine as chemoprophylaxis may be attractive because of the need to take the drug for only 7 days after leaving an area of exposure risk.
Food and Water Precautions and Travelers’ Diarrhea
Pilots and air crew members should follow the same safe food and water guidelines and prevention and management of travelers’ diarrhea as other travelers (see the Travelers’ Diarrhea section in Chapter 2). Pilots and air crew should be well versed in the recognition and self-treatment of travelers’ diarrhea to avoid unnecessary morbidity that would impact their job performance.
Blood-Borne Infections and Sexually Transmitted Diseases (STDs)
Although these risks and preventions are addressed in greater detail in other sections, it is worth reiterating that frequent travelers have a greater likelihood of engaging in casual and unprotected sex. It is common to think that others from western countries would have the same risk of HIV and STDs; however, travelers have far higher rates of such infections. Dental procedures and activities such as acupuncture, tattooing, and piercing also are ill advised during travel to developing countries.
