key: cord-0688437-esym0ezy authors: Choi, Hyo Jeong; Kim, Ho Jung; Seo, Gon title: Overseas Air Medical Repatriation of National Soccer Players infected with COVID-19 and contacted staffs from Austria to South Korea date: 2021-04-02 journal: Air Med J DOI: 10.1016/j.amj.2021.03.014 sha: 30c235389d404165c1c99915931befda18f3f03d doc_id: 688437 cord_uid: esym0ezy Korea rarely has a system to transport patients from abroad. However, single patient transfer was steadily being carried out, and there was an experience of transferring a large number of personnel regardless of whether they were confirmed or not due to COVID-19. Recently, a national soccer game was held abroad, and a total of eight players and staff were infected. A total of 15 people, including these, were transported through a charter fully equipped with quarantine equipment by medical response team with experience in air transport. COVID-19 is known to transmit via airborne particles in humans. 1,2 The biggest hurdle when transporting patients suspected of having such infectious diseases is the risk of further infection. In particular, when transporting patients from abroad, there are many things to consider, such as longdistance travel time, meals, and toilet use. In countries where overseas transport systems are well established, such as the United States, there are dedicated airplanes, transport personnel, and companies involved in these transports. Korea's overseas medical transport system is extremely under-developed, although there have been reports of the transport of non-infectious patients abroad. 3 However, during a pandemic like COVID-19, countries have to evacuate a large number of their citizens from dangerous areas, and as such, Korea has transported a large number of people from Japan, Iran, Spain, Italy, and Wuhan, China. 4 Unfortunately, such transports have been performed without knowing confirming if the patients were actively infected, and military personnel were often utilized for the safety of the flight crew and rescue personnel. Additionally, these transports had insufficient protection for passengers, and the possibility of in-flight disease transmission may be very high. Currently, COVID-19 vaccines are still being developed, and unfortunately, the number of infections is increasing. We are hopeful that this situation will improve in the future, particularly with the development of a COVID-19 vaccine. 5 In the event that multiple confirmed cases occur in foreign countries, requiring the transport of those patients home, more advanced methods are needed to ensure the safety of crew members as well as patient stability, instead of just evacuating patients in large numbers, as has occurred in the past. In the United States, a report published by Cornelius et al. 6 contains relatively systematic content regarding transporting infectious patients, but there are limited experience and reports to learn from which are appropriate for each country's situation and number of infected people. Therefore, the authors would like to report the experience of transporting covid-19infected athletes and staff in contact with them in Austria, where the national game was held. Covid-19 infection of players and staff occurred after the Korean men's soccer team arrived in Vienna, Austria for the national friendly match. After the game, the non-infected athletes returned to Korea, and a total of 16 infected and some staff members remained on site. The transfer request was received through the Korea Football Association and the Ministry of Culture, Sports and Tourism. The charter was prepared by Asiana Airlines plane which departed at 12 p.m. local time on November 25 th , 2020 for Incheon International Airport, to arrive at 6 a.m. on the 26 th . The plane was a Boeing 777 model (H8254) with 24 business class and 271 economy class seats, and a total of 12 crew members, 4 captains and 8 cabin crew members. Two emergency medicine specialists were on board each of them worked at an emergency medical center for 10 to 20 years and experienced a variety of patients, who each had more than three months experience in working and treating confirmed COVID-19 patients at medical institutions, and who also were experienced in long-distance overseas transport for 2 years more, sports-related research groups, and academic societies. 2) Preparations Two experts prepared equipment for specialized resuscitation. These included airway management instruments, monitors that measure oxygen saturation and heart rate, and oxygen generator (AirSep FreeStyle 3 ® ) and ventilator (Hamilton T-1 ® ) certified by Federal aviation administration (FAA). In addition, emergency medications for resuscitation, antipyretics, and respiratory-related medications were prepared. Means and standard deviations were used for all variables and were expressed as percentages. 5. This study was approved by IRB and supported by Soonchunhyang university. There was none conflict of interest. 1) Seating arrangements Asiana Airlines' pre-written flight arrangement (Fig. 1A ) was divided into three zones: Zone A was a clear zone for crew and captain, Zone B was a non-confirmed zone for staff and response teams, and Zone C was a confirmed zone for athletes and staff. After take-off, the response team received a final report on the status of the Asiana Airlines route, flight attendants, and passengers, Zones A, B, and C were in the same group. The response team's section was changed to Zone A, and all Zones B and C were revised to include the window seats and one row back (Fig. 1B) . Movement between each zone was limited to a minimum, and if inevitable movement was required, the safety protective clothing of Level D was worn and removed. One medical staff and one flight attendant were in a group and decided to take turns every two hours. When working, wait in buffer zone 2 and check each area every 30 minutes. 2) Buffer zones The buffer zone screens were made of a swinging plastic disposable doors, with magnets attached to both sides, and were meticulously installed on both sides of each zone ( Fig. 2A) . Buffer zones were designated in three places, with Zone 1 designated as a space for crew and response teams to change in and out of protective suits. After the central portion was blocked-off, the left side was designated for crew members, and the right side was designated as a toilet for the response team. Zone 2 was designated for non-infectious patients on the left and right sides of Zone B, with designated toilets on each side and double-installed screens to distinguish Zones B and C. Zone 3 had two toilets designated for confirmed passengers on the left side and two at the entrance, and the central portion was separated by a screen. The right side was designated as a space for two crew members for stand-by or take-off in protective clothing, and a dedicated toilet (Fig. 2B ). After departure, the response team covered the area based on the relevant research report 6 because the upper area of the screen was empty. Vehicles with a staircase type structure was placed at the entrances through an outdoor moor (Fig. 3A) . The entrance at the front of the plane, No. 1, was designated as a dedicated passageway for flight attendants and response teams to board first. The central passage, No. 2, was designated as a dedicated passageway for passengers in Zone B, and the rear passage, No. 3, was designated as a passageway for passengers in Zone C. At each location, ambulances and transport vehicles were ready and waiting (Fig. 3B) . The response team conducted training for all crew members, except the captains, on their way to Austria. A detailed description of the passengers' responses and precautions for each zone was provided. Since the flight attendants had no experience in wearing protective clothing, the response team conducted a demonstration for training on protective wear (Fig. 4) . Optimal personal protective equipment (PPE) was used, including Tyvek suits with booties and a hood, a double layer of gloves (either taped in place or secured with a thumbhole technique to prevent a sleeve gap), and an N95 mask with a face shield. Level D set was used by MG2000 (manufactured by 3M, USA). All passengers' movements were monitored, and directory signs, such as those indicating toilets, were manufactured and installed to prevent confusion among passengers. Loading was carried out simultaneously at the central and rear entrances, using the same method. Specifically, individuals came up the stairs one by one, after which each passenger doffed their protective gear, sprayed disinfectant, donned a new mask, facial shields and gloves, sprayed disinfectant on their belongings, and was then guided to their seat. The logic behind doffing the original protective clothing was that it was highly likely to be contaminated between take-off and landing due to bathroom use during the long flight, and the National Emergency Management Agency and the response team decided to proceed after a meeting just prior to departure. After boarding, the basic safety rules during flight were notified by the crew through the broadcast, and.the response team additionally broadcast the following major precautions. a. Keep passengers from moving as much as possible, allowing them to use only their designated restrooms, with no waiting in line b. Seat passengers by windows, keeping their head by the window, even when lying in the seat c. Structured in-flight meals d. Make sure to wear masks, facial shields, and gloves while moving about the cabin e. Educate passengers on the use of the call button for flight attendants in case of emergency f. Every 30 minutes, the crew and medical staff worked together to inspect each area. Patients with symptoms were equipped with equipment on their fingers to measure oxygen saturation and heart rate. The passengers' meals were packed in boxes and loaded in advance. To minimize the time during which masks were not worn, there were dedicated meal times. A dedicated plastic bag was provided for waste collection, and it was required that meal trash be disposed of in these plastic bags, which were collected in batches following an announcement by the response team after landing. An hour before landing, after the meal announcement, the response team delivered a notice regarding preparations for getting off the plane. After landing, the plane stopped at the mooring station, and the seat belt sign was turned off under the captain's direction. The response team handed out Level D protective suits (MG2000, manufactured by 3M, USA) prepared in advance, demonstrated how to wear them, and checked passengers for appropriate use. Afterwards, they verified the names of passengers assigned to ambulances that had arrived in advance, and those passengers boarded the ambulances to be taken to the National Medical Center. Non-infectious passengers and the response team got off were then taken from the mooring station to a special quarantine station by bus, and after inspection, they were moved to the Paju Training Center or their homes. 1) Enroll group characteristics A total of 16 people were targeted before leaving Korea. Of these, 9 (5 soccer players) were infected and 7 were reported as non-infected. At the pre-departure inspection in Vienna, one player was judged negative and returned to the foreign team, and a total of 15 were transferred. Eight out of 15 were positive, four were soccer players and four were staff. The remaining 7 were non-infected and were all staff. They returned home 18 days after their departure. After being confirmed in Austria, they were in self-isolation at the hotel. Of these, four had respiratory symptoms, but only two had symptoms when boarding because the treatment was carried out by the remaining team doctor and the local hospital physician, and the others were asymptomatic. 2) Passengers symptom Of 8 COVID-19 patients, 1 (13%) had respiratory symptoms, such as coughing, and 1 (13%) had symptoms of nasal congestion, while the other 6 confirmed COVID-19 patients had no symptoms. Although there were mild respiratory and nasal symptoms in some positive passengers, they were very stable in vital sign during the flight 3) In-flight requirements execution results Of the passengers, 3 non-COVID-19 passengers failed to maintain their window seats. There were no other unusual findings. Eight infected people were immediately transported to the National Medical Center and quarantined by conducting Polymerase chain reaction (PCR; A screening test was conducted to test the RdRp & E gene with real time PCR by Seegene.Bio company of South Korea) tests at a special place. Seven non-COVID passengers were tested via PCR at airport, five of whom were quarantined at the Paju National Football Center (NFC) and two were self-isolated at home for two weeks. Two response team members also received negative results from PCR tests yet were subject to quarantine, due to being classified as active monitoring targets being required to report symptoms for two weeks. Flight attendants and emergency medical professionals also performed COVID-19 tests and were all tested negative. Except for the previous confirmed cases, there were no additional positive cases. It took an average of 7 minutes and 36 seconds per person to take a seat after removing their protective clothing (Fig. 5) , which was provided locally in Austria. It took an average of 2 minutes and 52 seconds per person to take off the double-layer protective suit. It took an average of 4 minutes and 34 seconds for each person to sit down after spraying the disinfectant. Most time undressing was spent removing the protective suit from the lower body due to the extra layer, and additional time was spent arranging the luggage after moving to the seat. Figure 5 . A staff wearing protective clothing provided locally in Austira. It was not very different from domestic protective clothing, but the overshoes were made of rubber bands and could not completely cover the feet. Any infection carries the risk of propagation, and methods of minimizing transmission include reducing contact as much as possible, maintaining social distancing, and not allowing many people in one place. Transporting patients abroad, in particular, is a very difficult task, because it must be performed in accordance with these principles. In the late 1970s, the US Army Medical Response Institute of Infectious Diseases created the air aero-medical isolation team, which was designed to safely care for and evacuate contagious patients in high-level containment conditions. It was primarily intended as a bioterrorism response and for the extraction of scientists or health care workers with infections in foreign countries. Early missions focused on hemorrhagic fevers, and although the team was deployed only 4 times, it was also used in an advisory capacity for respiratory including SARS and multidrug-resistant tuberculosis. Korea also transferred patients from Japan, Iran, Spain, Italy, Wuhan, China, via chartered planes, which targeted ordinary Koreans whose diagnoses were not confirmed, and these long distance transports were handled by the military-led collective transport system. In the United States, the US Department of Health and Human Services (HHS) air medical evacuation teams (AETs) of the National Disaster Medical System (NDMS) directly supported 39 flights, moving over 2,000 individuals, all of whom were either COVID-19 positive, persons under investigation (PUIs), or individuals who were asymptomatic. During these transfers, many countries, airlines, and experts discussed how to create and maintain the environment on the plane. The response team described in the present report performed by referring to the only study reported thus far 6 . Plastic sheeting was used to create an area in which to segregate and treat patients who developed symptoms while airborne. We were able to block areas off more effectively using magnetic products. On long-distance flights, the front of the plane was designated as a space for flight attendants and response teams to rest, taking into account the flow of air in the plane. PPE were to be worn if the contact distance is less than 6 feet, and at a minimum, a fitted N95 mask and gloves were recommended to be worn when the contact distance was at least 6 feet. Based on this information, flight attendants and response teams entering and leaving Zones B and C were required to wear such PPE; otherwise, gloves and masks were required, and face shields were only required when moving about the cabin. For safe work practices, response teams, restrooms for crew members, passengers, and moving lines were all divided and marked. Additionally, an alcohol-based hand-sanitizer was placed in various places for self-hand hygiene. To meet these recommendations, it is necessary to involve various human resources and agencies, and more reporting and references from various agencies are needed in the future. In 2014, when Ebola spread, the US government and World Health Organization (WHO) worked together to develop and use the connected Bio-Contention System, which allows intensive medical treatment on planes. 4 The transfer of a number of COVID-19 patients and contacts in Korea should be carried out with a combination of state, sports association, and private medical personnel. Before COVID-19 in 2019, the number of overseas travelers in Korea was very high, reaching nearly 40 million, and there were numerous accidents and transfers. 6 Fortunately, in this case, the patients being transferred were not seriously ill, but it is also necessary to introduce such a critical patient transfer system in Korea in the future. It also calls for training professional personnel, guidelines for each disease, and the introduction of private jets. Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center Epidemiological and clinical profile of Korean travelers receiving international medical repatriation Korea Ministry of Health and Welfare Available at: who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines? Mass Air Medical Repatriation of Coronavirus Disease 2019 Patients Statistics by year The authors have no conflicts of interest to disclose and There is no funding for this study.