mmm BRIEF Aircraft Cabin Air Recirculation and Symptoms of the Common Cold Jessiea Nutik Zitter, MD, MPH. Context In recent years, new commercial aircraft have been designed to recrculate approximately 50% of the cabin air to increase fuel efficiency. Some older aircraft use only fresh air. Whether air recirculation increases the transmission of infectious dis- ease is unknown; some studies have demonstrated higher rates of the common cold among persons working in buildings that recirulate ar. Objective To evaluate the role of air recirculation as a predictor of postflight upper respiratory tract infections (URIs). IRCRAFT CABINS MAY BE HIGH. Design, Setting, and Participants A natural experiment conducted among 1100 risk environments for trans- passengers departing the San Francisco Bay area in California and traveling to Den- ‘ver, Colo, during January through early April 1999, and who completed a question- naire in the boarding area and a follow-up telephone interview 5 to 7 days later. Forty- seven percent traveled aboard airplanes using 100% fresh air for ventilation, and 53% traveled aboard aircraft that recirculated cabin ai. ‘Main Outcome Measure Incidence of reporting new URI symptoms within 1 week strated tobe tisk factors fortransmission 0 the fight. Of upper respiratory tract infections Results. Passengers on airplanes that did and did not recirculate air had similar rates of postfight respiratory symptoms. The rates of reporting a cold were 19% vs 21% (P= 34); a runny nose and a cold, 10% vs 11%, (P=.70), and an aggregation of & URI symptoms, 3% in both groups (P>.99). Results were similar after statistical ad- justment for potential confounders. Conclusion We found no evidence that aircraft cabin air recirculation inereases the Fisk for URI symptoms in passengers traveling aboard commercial jets. JAMA, 2002288-483-486 wer jama com mission of infectious di eases, Space confinement,! limited ventilation?» prolonged expo- sure times, and recirculating air, ‘all com- mon to air travel, have been demon- (URIs) in other settings. Several ease ports detail outbreaks of influenza and tuberculosis aboard aircraft,” but itis not creased rates of transmission, Aire viruses tha cause the common cold inary barracks, but ths possi has hot been studied in airplanes, Older aireraft that use only fresh air lated ai, aswell a to contol fr ait Inthe arty 1980s toenkancefuelef- are being reted,andall new commet- ferences in arcaft, we targeted only ficiency. actaftmanufacures began to cial ital are equipped to reeitct- cera airplane models. Boting 737% build venation systems that eee late ai. An evaluation of the differ. and Bocing 727s have sia seating ined cabinair Oldersjstemsused 100% ences between the effects of these 2 arrangemenis,eabin setup, seat dete ireshai, compressed humidified, and venuflaion systems must be con sty and pitch, cabin airflow pater, cooled bythe engines in a process that ducted before fresh air systems be- and fsclage size, but 737s eeteulate Consumed significant energy. Newer come obsolete. Our study tim was to approximately 50% of the eabin alt; Sitplane models recitculate-as uch evaluate the role of at eetculation as whereas 727s tse 100% fresh at. We as 50% of eabin ait, decreasing the apredictorofpostigt symptoms con. also argeted fights using DC-10 mod ngine’s work. The veettculated air stent with URIS tls equally samplingaplanes hat used passes trough higheffcienyparticu. ee esha reteulated it This infor late filters before mixing with condi- METHODS tioned fresh air to reenter the passen~ From January through early Apa 1999 gereompetee Abily tecapureviruesis lite, even ignated passenger boardingareas athe 2 0" le ney of Cra Sen ‘at peak function, and filters are ren- San Francisco and Oakland, Calif, air- (5°92, tht Lawn Group, Sen Francico, Calf detedevenlesefeciveifbypased, imports and who were en route to Den Caen Rar nd Rapin: sic se properly used, of clogged by particu. ver, Colo, To stmple evenly heween Zit No Met Uneasy fallen Safar Tne mater" turplanes that used fresh nnd recveu, feat users ‘Author Aflations: Departments of Melcne (rs However, any filter's we recruited subjects who werein des” Site tal aime) and fauunsaogy sr Bostats (©2002 American Medial Association. AI rights reserved. (Reprinted) AMA, July 2671, 2002 Vol 286, No.4 42 ‘Downloaded From: htps:/ijmanetwrrk comn/ by « Instiito Polticnico de Coimbra User «m02106/2023‘AIRCRAFT CABIN AIR AND THE COMMON COLD mation was provided to us by the par Licipating aieline To meet the inclusion criteria, sub- jects had to be 18 years or older, En- slish speaking, willing to complete a brief questionnaire in the boardingarea, and willing to complete a follow-up telephone questionnaire 5 to 7 days a ter the initial contact. They could not hhave engaged in air travel during the previous week (including a connect ing flight on the interview day), have plans for additional air travel before the follow-up interview, or have a cold when the initial questionnaire was dis- tributed. We attempted to recruit ev ceryone who met our inclusion criteria inthe boarding area during the hour fore the flight, Participation implied consent, as approved for our study by the University of California, San Fran- cisco, Committee on Human Re- search. A questionnaire collecting data ‘on behaviors thought to be associated with URIs was then administered to willing and eligible participants in the boarding areas of these targeted flights. In an altempt (o minimize bias, re- search assistants obtained informa- tion about the airplane model at the cend of the preboarding recruitment period, Follow-up of passengers in the Den- ver area occurred by telephone 5 to 7 days after the initial contact. This se fond questionnaire investigated pos- sible URI symptoms during the week after the flight and subjects’ knowl- cedge and beliefs regarding the prac- Lice of air recirculation and the risk of URIs during air travel. To minimize bias, a separate group of research as- sistants who conducted the follow-up telephone interviews was blinded to air= crall type, We assessed symptoms that sug- gested the presence of a URI by using the questionnaire developed by Jack= son etal." The least restrictive defini- lion was self-report of a cold. The next most restrictive definition was the sell report ofacold and a runny nose, which is highly correlated with a clinical di- agnosis of URI." The most restrictive definition of URI was a Jackson score" 484 JAMA, july 2421, 2002-0 No.4 Reprinted) (consisting of the sum of 8 respiratory symptoms, including headache, snee: ing, chilliness, sore throat, malaise, na- sal discharge, nasal obstruction, and cough, each measured from 0 to 3) that was higher than 13, Most data are presented as simple percentages of nonmissing data, For some variables, data were missing for Lup to 30 passengers. Incidence of fol- low-up URI symptoms according to the 3 definitions was calculated for the 2 study groups: passengers on airplanes with partially recirculated air ventila- Udon and those on airplanes with fresh- air ventilation, We used generalized e=- mating equations to examine the possibility that passengers on the same flight had unmeasured common expo- sures and were not completely inde- pendent." The generalized estimating equations analysis estimated an inter- passenger within-flight correlation of 0.02, which was not significantly dif- ferent from zero, Therefore, simpler lo- istic regression models were used for most of the analysis. Dummy vari- ables for flight week were used, and models were fit by using SAS PROC LOGISTIC and PROC GENMOD sta Uistical software, version 8.1 (SAS In- stitute Inc, Cary, NC). We set statisti- cal significance at P=.05, RESULTS Of those approached who qualified for the study, more than 90% agreed to par- Uicipate. We enrolled 1501 partici- pants and collected follow-up data on 100 subjects (73% response rate). Re- spondents resembled nonrespon- dents, except the latter tended to have less child contact and to have been en- rolled during February. Ofthe 401 non- respondents, 337 (84%) were not each- able because of a lack of response to calls or incorrect contact information, The other 64 (16%) were disqualified from the study for having been inad- equately sereened on entry. A total of 516 (47%) of the 1100 respondents traveled aboard airplanes with fresh- air ventilation and 584 (53%) on air- planes with recirculated-air ventila- tion, There were 196 passengers on DC- ‘Downloaded From: htps:/ijmanetwrrk comn/ by « Instiito Polticnico de Coimbra User «m02106/2023 10s and 904 on 727 oF 737 models. Of the 250 flights we studied, 114 (46%) used fresh-air ventilation systems, whereas the rest used recirculated air systems, TABLE 1 compares the baseline char- acteristics of subjects flying on air- ceralt that recirculated cabin air with those lying on aircraft that used fresh- air ventilation. Subjects aboard air- planes that recirculated air were more likely to have sinus problems, to be colder than 40 years, to be in first class, to have flown during March or April, and to have flown out of Oakland rather than San Francisco. Passenger density was not significantly different be- tween aircrall types. We performed univariate analyses of variety of potential risk factors for the 3 definitions of URI symptoms to as- sess possible confounding. All 3 defi- nitions were associated with having chronic URI symptoms, such as aller- sles, sinus problems, or asthma. Being Female was predictive of the outcome of self-reported cold. Believing that air travel increases the risk of URI was not predictive of any of the 3 URI out We compared proportions of the 3 URL-symptom outcomes among pas- sengers lying on airplanes with fresh- air and recirculated-air ventilation, without adjustment for group dilfer ences. There were no significant dif- ferences for any of the outcomes. Self- reported colds occurred in 21% of passengers in airplanes with fresh air and 19% of passengers in airplanes with recirculated air (P=.34). Self-reported, colds anda runny nose occurred in 11% and 10% of these passengers, respe tively (P=.70). Jackson scores higher than 13 occurred in 3% of both groups (P>.99), We looked at odds ratios and 95% confidence intervals (CIs) for the 3 out- comes according to a multiple logistic regression analysis that included rect culation as a risk factor for postflight subjective cold and controlled for po- tential confounding variables that wes not balanced in Table 1. These adjust ments did not alter the finding that (©2002 American Medical Association, All rights reserved.cabin air recirculation was nota risk fac- tor for developing the symptoms of a cold during the week alter flight (TABLE 2), ‘COMMENT We designed a natural experiment to compare outcomes for passengers fly- ing on airplanes that used 100% fresh air vs airplanes that recirculated a sub- stantial fraction of eabin air. The air- craft we selected were similar and flew identical routes. Since most passen- {gers are unaware of whether a particu- lar airplane recirculates or does not circulate air when they make flight arrangements, the findings from this natural experiment resemble what would be found in a blinded clinical trial, Recirculation of eabin air did not emerge as a risk factor for the devel- ‘opment of URI symptoms in our study. This finding asstiages concerns regard- ing the risk of infectious diseases in re- circulated cabin aie” and suggests that if there is @ substantial increased risk ‘of URLamong flyers, the main route for lransmission is not air recirculation, There are, however, several limita tions to this study. Fist, the study's: ‘was limited, and the Cls reveal the pos- sibility of having missed a modest effect. Second, the intergroup differences in some baseline variables were greater than expected. People aboard aizplanes that recirculated cabin air were more likely to be older and have a history of sinus problems, characteristics that might make them more likely to report colds alter flights." They werealso more likely tohhave flown in March or April than in January or February and from Oakland, rather than San Prancisco, These differ- cences, which reflet the fact that the unit ‘of study was the airplane rather than the individual and that the type of aigplane ‘was not randomly allocated, did not al- ter the findings of the study, judging by statistical adjustment for the confound crs and their clustering Another issue is the possibility of a dose-dependent effect of air recircula- lion that would become evident on fights that were longer than 2 hours. We were unable to study a longer flight ‘RIRCRAFT CABIN AIR AND THE COMMON COLD primarily because older airplanes that ingbyairplane.'""” However, the Jackson. do not recirculate air are used almost questionnaire is a relatively nonspe- exclusively on shorter routes. cific indicator of infection. In one The high incidence of subjectively re- _ study,” only 40% of patients with clink- ported postflight symptoms of URI in cal URIs by Jackson criteria had post- oth groups may be in part due toa tive cultures by viral isolation and cell travel effect involving factors such as culture. Therefore, another limitation 16 stress, sleep loss, crowding, and pooreat- this study was an inability to distin- ing, which were not controlled for with — guish between true infection and non- this study design. The attack rate ac- viral causes of URI symptoms, such as, cording to the most restrictive defini- barometric sinusitis, nasal ritation, and, tion of URI symptoms (a Jackson score vasomotor rhinitis. >13) revealed rates on the order of3%, There are several unique aspects of which are consistent with those of pre- this study. The natural experiment de- vious epidemiologic studies of URI in- sign takes advantage of passengers lack. idence in people who were not travel- of awareness ofthe air mixture used in, ‘Table 1. Saseline Characterstis of Passengers Aboard Airplanes With Eher Fresh or Reciculated Air Pak Fay ot a Fito of aus pobione oa History ofastira 7 Facant fa shot 7 Sek contact boone Wal quasars Tid oon a Sinem Aina « ie Fo a =| oot tec 2 % Sars SEO 75 a i ig ane RR OTT 70 = 2 a Fo TEER RIENCE a 7 Fy cai pe cheain spien 7 o % ail age st barge) 7 w ‘Table 2, Maltvarate Analyse of the Rak of Developing Cold Symptoms From Fiing i an ‘plane With Recrculted Av Compared With Fresh A™ ‘Symptoms of U Te: Odes Rais (5TH Faporea a coal 25 a old and Te Te ‘aekson score = % (©2002 American Medial Association. AI rights reserved. (Reprinted) AMA, July 2671, 2002 Vol 288, No.4 485 ‘Downloaded From: htps:/ijmanetwrrk comn/ by « Instiito Polticnico de Coimbra User «m02106/2023‘AIRCRAFT CABIN AIR AND THE COMMON COLD different aircraft to replicate a blinded study. This study design would be dif ficult to duplicate, Airplanes with Iresh- air ventilation systems have been re- tired from most major airline fleets, especially on longer flights, since the lume of the study. Given recent events, gate access and airline participation ‘would be difficult to obtain. We be- lieve that this study was completed dur- ing a window of opportunity thats now largely gone. In summary, we found no differ cence in the likelihood of self-reported cold symptoms during the week after flight when comparing passengers trav. cling aboard aircraft using 100% fresh air with those traveling aboard airerat, that recirculate up to 50% of cabin air. IL is encouraging that the now- widespread, fuel-efficient practice of air recirculation docs not seem (0 in crease the risk of transmission of URIs aboard aircraft on a 2-hour flight ‘Author Contibutions: Study concep and design: ‘ter Mazonzon, We, Bale. ‘eguistion of ant iter ‘analysis andinespretation of data: Diter, Mazorsn, Mae, Huey, Bales. Dratngofthe marist Zr, Mazorson, Hull, aime teal revision ofthe manuscript for mpotant in {elctua content Zier Mazonson, Miler, uly, aime Sabstal expr: ler, Haley. bane nang Zeer, Mazorson,Slmes ‘Administrative, tecnica er materia suppor: ite, azonson her. Study superosion:Zter. Funding Support Tis siudy was funded by pulmo ‘ay tang grant HLOT189 sponsored by the Ne ona iets of Hesh apd The Lewin Group ‘eknowedgment: We tank Megeen Egan fo ed fing and preparaton ofthe manasrpt ana the fo lowing research asta for data cae: Mar Shute Len Meck, Beverly Guo, Regina gman, Joyce Coto Shela Samaden, On Siverberg Kate ryar-ones, Cindy Kwong and ule Fy RNS 4. aakkla J), Heinonen OP. Shared off space and the ak ofthe common cod Eur] Edema 1995; nana 2. Halfpenny P_ Aircraft ventilation, Paper pre Séoted a Fight Attendant Occupational Heath tfsues Confetence, November 12-18, 1990; Wash ington Dc. 50 Donel A, Donn G, Nguyen VA. Al quality, ‘eiatn, temperature and hum aera Ay SccHeatng Regering Aeconaoonng ng 135 Bane 4 Brundage Scott RIM, Lednar WM, Smith DW, iter RN Bling-sscaed kf fete acute es ator diseases nay wanes JAMA, 1985 259. Broszi2 5 Diver CR, Vaway SE. Morgan WA, Onorato aso KG Transmission of Myeobacterum tube lee mocated hate. JAA 1998072 1034 ‘a8 6. Tracy M. Transmission of tuberculosis ring along Silane igh eter Engl Med. 1996335 675. (486 JAMA, july 2471, 2002 Vo 208, No 4 Reprinted 7, Kenyon TA, ValuaySE, he WW, Onoat IM astro KE. Tanamsson of mulbug-esstant my: ‘abuceturnubeclss urmgalongarplane ig Eng Jie, 995;334385 938 4. poste of passengers and fight crew to myco Blt tubereuoss on commer areratt 1952 1395 MMU Mo Moral Wy Rap. 199544 137- 0. 29: Moser MR, ender TR; MargolsHS etal An cut breakof nue aboard aconmeroa sin Amd Eoidemiol 1975.11 5 4 Necdean WA, Peon cabin ato. Pa ber presented at Pall Corp: September, 1957, Pot ‘ating, NY, 1 Jado GC Dowing HF, Speman G Board AV ‘Tramssion of he commen eld volunteers un Gerontol condone Arch Inte. 1358 foraera78. 4. Lang, Zeger SL. Longtuial data anaiyisus- ing generaed near ede. Blometita. 198673 a5 ‘Downloaded From: htps:/ijmanetwrrk comn/ by « Instiito Polticnico de Coimbra User «m02106/2023 43, Hgins , KeatesN, Cstto, How satelsa- plane a? Wal Stet Journal. une 9, 20008. 41 teatangon aft lane hou tesh the a? Con Sunt Reports, August 1994 501-506. 45, Mar PA Bring ay te proposed new stan Anes for a qualty npesenge cb ooo Fe ‘uent Fer Maren 2000-2025, 4" Hurston. bern, ohrson, Mainous AG I citena ised by ante diferente srt ‘Nom wal upper expatary vat ineebon. Jam Pact soe seudl 382 17. Lna, Vale M, Foray Se al. Suveance of erurunity-acquied val fecbons du oes {oryunsein one Apes ance dung wee 1934 {21998 J Cin tera 1996:343007-3071 48, Henley 1, Guat 1M. Mechanar of tans Ison fines intecionsEidemil Rv. 1388 283 258 48, Red DD, Willams REO, Hich A. Colds among ofce more an epemsopeal study Lancet 1923 ‘sau 1306 (©2002 American Medical Association, All rights reserved.