Navigating the risks of flying during COVID-19: a review for safe air travel.

Rationale For Review: With air travel restarting, there has been much discourse about the safety of flying during the pandemic. In travel medicine, risk assessment includes estimating baseline risk to the traveller, recognizing factors that may modify that risk, considering the role of interventions to decrease that risk and accounting for a traveller's perception and tolerance of risk. The goals of this review are to identify the in-flight transmission risks of commercial air travel, provide recommendations about the risks of flying during the pandemic and propose strategies to mitigate the spread of COVID-19.

Key Findings: The airline industry has taken a layered approach to increase passenger safety through effective onboard ventilation, extended ventilation at the gate, boarding and deplaning strategies, improved aircraft disinfection and pre-flight screening such as temperature checks and COVID-19 testing. Proximity to an index case may contribute to the risk of transmission more than the seat type or location. The use of face masks has significantly reduced onboard transmission, and mandatory in-flight mask-wearing policies are being enforced. Innovations such as digital health passports may help standardize screening entry requirements at airports and borders, allowing for a safer return to travel.

Recommendations: In-flight transmission of SARS-CoV-2 is a real risk, which may be minimized by combining mitigation strategies and infection prevention measures including mandatory masking onboard, minimizing unmasked time while eating, turning on gasper airflow in-flight, frequent hand sanitizing, disinfecting high touch surfaces, promoting distancing while boarding and deplaning, limiting onboard passenger movement, implementing effective pre-flight screening measures and enhancing contact tracing capability. Assessing risk is a cornerstone of travel medicine. It is important to evaluate the multiple factors contributing to the cumulative risk of an individual traveller during the COVID-19 pandemic and to employ a multi-pronged approach to reduce that risk.