key: cord-0745796-9eyfky6c
authors: Holdik, Elisa Nicola; Beh, Su Fern; Bin, Yu Sun; Cheung, Janet M.Y.
title: Is it safe to fly? Consideration of COVID-19 risk mitigation strategies from the travellers’ perspective
date: 2021-06-11
journal: Travel Med Infect Dis
DOI: 10.1016/j.tmaid.2021.102101
sha: f0eb2021aa8334399ee7d9fe2a635b7ea9f44be9
doc_id: 745796
cord_uid: 9eyfky6c

nan

Dear Editor,

The emergence of COVID-19 has instigated enforcement of strict infection control measures for air travel. This includes physical distancing, mandatory online check-in, temperature screening prior to boarding, the use of medical facemasks, and enhanced support for personal hygiene, including alcohol-based hand sanitizing stations [1] . While the risk of in-flight COVID-19 transmission is reported to be as low as one case per 27 million travellers [2] , confirmed published cases suggest this rate may be higher in real-world settings [3] . A major limitation is that predictive models omit a vital contributor to the effectiveness of the aforementioned strategies -the traveller. This correspondence presents findings from a qualitative exploration of air travellers' experiences and perceptions of infection control and risk mitigation strategies during COVID-19.

We interviewed adults who travelled internationally to or from Australia between January and June 2020 (flight duration ≥ 6 hours). Recruitment coincided with Australia's COVID-19 travel ban beginning March 2020 which restricted the number of international arrivals and departures. Participants completed an online screening survey, which queried the perceived importance of infection control measures. Semistructured interviews were conducted by EH and SB, exploring inflight experiences, personal hygiene measures, travel planning and perceived impact of COVID-19 on current and future travel. Interviews were transcribed verbatim and analysed using the Framework Approach [4] . All authors familiarized themselves with the data through iteratively reading the interview transcripts and fieldnotes. A thematic framework was first identified by EH and SB through merging a priori research questions with participants' responses. The thematic framework was refined by YSB and JMYC. Interviews were subsequently indexed by systematically applying the thematic framework to each interview transcript. Emergent categories were then charted into thematic matrices by EH and SB. In the final stage, cross-case and within-case descriptions of the phenomenon were mapped and interpreted to identify emergent themes. The detailed interview guide, thematic framework, and results of the synthesis are available from the corresponding author.

Eighteen participants were interviewed (7 females and 11 males; mean age of 34.2 years, SD = 17.6). Mean flight duration was 17.06 hours (SD = 7.21) with 17 travelling in economy and 1 in business class. Most travelled alone (n = 11) or with another adult (n = 7). Participants' ratings of the relative importance of broad range of infection control and hygiene measures from the screening survey are presented in Fig. 1 . Participants were assigned the following code to maintain their confidentiality: a participant number, gender female (F) or male (M), age (years), and date of flight (month/year).

Qualitative synthesis of the interview data showed that participants proactively sought ways to mitigate their immediate infection risk. This included procuring hygiene supplies (e.g., hand sanitiser, alcohol wipes, and face masks/shields) and packing their own meals pre-flight. The perceived effectiveness of these measures was affirmed by a participant who "didn't catch anything" despite going through multiple COVID-19 hotspots in Europe and Middle Eastern Asia (P04, M, 30, 3/2020). Participants actively restricted their movement throughout the aircraft cabin, avoiding aircraft bathrooms and limiting contact with surfaces (e.g., entertainment units). There was unanimous agreement about the discomfort of in-flight mask-wearing, but participants felt obligated to keep the masks on as a "civil duty" (P21, M, 21, 5/2020), recognising that mask-wearing was effective for preventing virus transmission. Reluctance towards removing masks on "empty flights" also stemmed from participants who "didn't believe that social distancing would help" (P11, F, 23, 6/2020) due to the enclosed shared space of the aircraft cabin. As such, the availability of a middle seat was not rated as the most important hygiene measure for mitigating the risk of infection (Fig. 1) .

Participants accepted that infection control measures were a necessary part of travel during COVID-19. Most felt adequately prepared with protective measures at an individual level. However, travel anxiety stemmed notably from human error orvariations in environmental conditions, which can increase virus transmission risk, while falling outside of participants' control. Participants developed a heightened awareness of the behaviours of other people in the airport and in-flight, such as compliance with mask wearing, cough/sneeze etiquette, the proximity of other people, and aircrew operation protocols. Deviations from the recommended infection control practices became emotionally triggering as exemplified by Participant 31:

"that woman's mask came off during the plane when she was sleeping. And so it's just kind of scary … You had no idea if you're gonna get COVID or not." (P31, M, 66, 8/2020) Increased aircraft cleaning, airport cleaning, and aircrew wearing personal protective equipment were rated as the most important infection control measures (Fig. 1) . These very measures were heavily scrutinised by participants who sought evidence to verify the aircraft sanitation process had occurred and that in fact "staff had gowns and masks and gloves … to protect us" (P10, F, 73, 7/2020). In contrast, other measures such as staggering food services and having pre-packaged food were rated as less important and may reflect the level of agency that passengers had around eating or not-eating in-flight or preparing their own food. Overall, participants highlighted the need for guidance and uniformity between airports and airlines due to the conflicting messages between policy and practice where there were "spots on the ground for lining up," yet the airport was still "crowded and not well configured" for implementing social distancing measures (P32, F, 65, 8/2020). This ultimately deemphasized the importance of infection control, leaving participants confused and anxious about their safety and the purpose of following the hygiene recommendations.

In conclusion, travellers' perspectives of COVID-19 infection control measures impact on their real-world efficacy. Being attuned to traveller perspectives can better inform the design and implementation of infection control interventions.

Data available on reasonable request from authors.

No funding was received for this study.

The authors have no conflicts of interest to declare.

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