The transportation of patients suffering from infectious diseases demands much care, consideration, and planning from air medical crews. While the wellbeing of the patient remains important, the risk of contamination raises the stakes further by risking the wellbeing of medical teams and the general public.

Dr Miguel Cortés, Medical Director at USMX AirLink Air Ambulance, said that the approach taken when handling patients with infectious diseases starts with “one simple question: how is this disease transmitted?

“The answer determines everything that follows,” he continued. “Before selecting personal protective equipment (PPE) or planning the mission, we [must] identify whether transmission is by contact, droplets, airborne spread, or exposure to blood and body fluids.”

He noted that once the route of transmission was understood, the most appropriate level of protection could be selected, “instead of automatically using the highest level available”.

Dr Cortés added: “A patient with Clostridioides difficile or MRSA requires a very different strategy than a patient with pulmonary tuberculosis or influenza. Likewise, blood-borne pathogens such as hepatitis B, hepatitis C, or HIV require strict standard precautions and safe sharps handling, not additional airborne protection.”

A changing world

Daniela Wilson, Chief Commercial Officer at Airlec Ambulance, began by admitting that “at the beginning of the Covid-19 pandemic, the aeromedical industry as a whole was not fully prepared for the scale and complexity of the situation”, despite very strict standard operating procedures (SOPs).

“The main difficulties were operational: fuel stops were not always granted, overflight and landing permits were restricted, airport authorities sometimes did not allow the crew to leave the aircraft, even during fuel stops, and some countries denied access completely,” she explained. “This had a major impact on mission planning. It meant that Covid-19 transports were only possible with aircraft that had sufficient range, or in cases where detours and restrictions could be safely managed.”

By contrast, today’s situation is vastly different, with broad pandemic-era restrictions no longer in place. While authorities continue to apply appropriate precautions when dealing with Ebola and other highly infectious diseases, missions can now be planned and carried out without the same limitations.

Dr Anne-Sophie Ries, Flight Physician and Medical Representative at European Air Ambulance (EAA), also argued that the crisis “brought aeromedical evacuation into the spotlight, and accelerated the refinement, standardisation, and validation of existing practices”.

“Nevertheless, preparedness remains an ongoing process,” she added. “Future infectious threats may present new challenges, requiring continuous training, regular review of procedures, and learning from experience. In the end, good preparedness is not only about equipment, but it also depends on teamwork, communication, and the ability to adapt quickly.”

In the end, good preparedness is not only about equipment, but it also depends on teamwork, communication, and the ability to adapt quickly

Dr Cortés stated that the aeromedical industry’s present-day focus on understanding transmission traces its origin to the Covid-19 pandemic, and echoed Dr Ries, noting that another difference was the greater awareness of infectious diseases among non-medical people, “which provides a helpful starting point”.

“When individuals already have a basic understanding of infectious diseases before receiving our briefing and instructions, communication is more effective and the transport process tends to run more smoothly,” he explained.

Appropriate training in PPE is vital

Wilson explained that when it comes to ensuring the proper use of protective gear, “we have very strict SOPs that describe the complete process in meticulous detail, including the correct donning and doffing of PPE”. Alongside this, she noted that staff received annual training on infectious diseases, isolation units, and PPE procedures.

Wilson added that her company maintained a dedicated team for infectious disease transfers: “Participation in this team is voluntary, and the team members are specifically trained and familiar with the procedures required for highly infectious patient transports.”

Dr Ries reported that her company also had a dedicated high infectious risk team specifically trained to handle infectious patients.

She noted that EAA conducts a minimum of four internal training sessions per year to keep standards up. “Training is based on a detailed, regularly updated protocol and includes simulation exercises, supervised practice, and the use of checklists and a trained watchman during the donning and doffing process.”

Dr Cortés explained that when it comes to training their staff to properly use PPE, the emphasis is less on putting it on than on how to use it effectively.

Anyone can wear PPE. Not everyone knows how to work in it

“Anyone can wear PPE,” he said. “Not everyone knows how to work in it. At AirLink Ambulance, training is built around real operational scenarios, hands-on simulation, and repetition until every movement becomes routine. We dedicate as much time to proper donning as we do to careful doffing because we know the highest risk of self-contamination often occurs during PPE removal.”

Managing fatigue when using protective gear

While Wilson noted that working in protective gear could be restrictive, she said that “the most restrictive protective equipment is mainly required on the ground, especially when the patient is being installed in the isolation unit”.

Once the patient is secure, and the aircraft in flight, the team can usually work with fewer layers of protection, she reported: “This approach significantly reduces the physical burden on the team. Because we use trained staff, clear procedures, and mission-specific protective measures, fatigue is carefully managed and is generally not a major issue during these transports.”

Beyond the patient’s wellbeing, long flights with infectious patients require careful oversight of the crew’s wellbeing as well, particularly when it comes to fatigue.

Long flights in full PPE taught us that heat, dehydration, limited mobility, and hours behind an N95 respirator affect far more than comfort; they affect performance

“Long flights in full PPE taught us that heat, dehydration, limited mobility, and hours behind an N95 respirator affect far more than comfort; they affect performance,” Dr Cortés explained. “During the Covid-19 pandemic, many international missions meant spending six or more hours without removing PPE, using a restroom, or even opening the aircraft door because of local restrictions.

“Those experiences changed the way we work,” he continued. “Today, pre-mission hydration is part of our preparation. We rotate crews whenever possible, plan missions more carefully, and work closely with fixed-base operators (FBOs) and airport authorities to secure an appropriate area for safe doffing after patient handoff.

“During the flight itself, we also actively monitor fatigue by checking in with one another and reflecting on our own physical and mental condition, allowing us to recognise early signs of fatigue and support each other when needed.”

Dr Ries agreed, adding that “fatigue management is applied to every mission, not only those involving infectious patients”. This includes defined maximum duty periods and minimum rest requirements to ensure that crews remain fit for duty.

She also emphasised the importance of staff remaining hydrated, noting that they “are encouraged to hydrate before donning PPE, and to remove protective equipment as soon as it is safe to do so”.

Isolation pods are less commonplace, but still useful

Dr Ries agreed that in the present day, the use of isolation pods is generally reserved for selected high-consequence infectious diseases, such as viral haemorrhagic fevers including Ebola, or for exceptional operational circumstances.

“In contrast, patient masking has become standard practice for suspected airborne or droplet-transmitted infections,” she noted.

Patient masking has become standard practice for suspected airborne or droplet-transmitted infections

Despite this, Dr Ries argued that even if not used frequently, “isolation pods should increasingly be regarded as a standard transport capability within specialised air ambulance services, alongside established capabilities such as neonatal incubator and extracorporeal membrane oxygenation (ECMO) transports”.

Wilson also agreed that isolation pods were no longer used as often as they once were, even for Covid-19 transports. “For other infectious diseases, we follow the requirements set by the relevant authorities. For example, Ebola patients must be transported in an isolation unit or bubble. By contrast, recent hantavirus patients were permitted to be transported in an open cabin with masks, while the medical team wore enhanced protective equipment.”

By contrast, Dr Cortés stated that while the isolation pods that became more common during the pandemic “remain an important tool … they are no longer our default approach to every infectious disease transport”.

“In our experience,” he explained, “they are most useful during short missions involving highly contagious patients or awake patients receiving high-flow oxygen or nasal cannula therapy who can comfortably tolerate the confined environment.”

They do remain useful when transporting patients with emerging infectious diseases, however, Dr Cortés noted, “particularly when the route of transmission is not yet fully understood or when no effective treatment or vaccine is available”.

He explained that many patients fare better with a surgical or respirator mask, to offer more comfort and safety.

Managing air flow

Beyond keeping the contagious illness contained, ensuring that a healthy environment is maintained on board the aircraft itself is important to avoid infecting the crew.

Wilson explained that her company also paid attention to the air flow on its aircraft, with air moving “from the front to back – which means the cockpit crew are not exposed to contaminated air flow from the patient area”.

When it comes to managing airborne diseases, Dr Cortés explained that understanding how air moves through the aircraft is just as important as understanding how a disease spreads.

“In our Learjet 35 and Citation III, the environmental control system (ECS) continuously renews cabin air while the outflow valve maintains cabin pressurisation. Although these systems were designed for aircraft environmental control, not infection prevention, they provide the added benefit of continuous cabin air renewal, an operational advantage during respiratory infectious disease transports.”

Amber Heyer, Director of Quality Assurance at REVA, added that while their aircraft operate on a similar basis, “ground ambulance capabilities vary depending on the provider and country of operation. Some ambulances are equipped with negative pressure compartments, HEPA filtration, or advanced ventilation systems, while others are not.”

Always use full PPE whenever transporting an infectious patient who does not require a full isolation unit

She added that because of this, her company’s approach is to always use full PPE whenever transporting an infectious patient who does not require a full isolation unit.

The importance of decontamination

Wilson stated that when it comes to decontaminating the aircraft, “the exact cleaning and turnaround process depends on the disease involved”.

“Different pathogens require different levels of disinfection and different turnaround times,” she noted. “We also take regular swabs from inside the aircraft to verify the effectiveness of our cleaning and decontamination procedures.”

Wilson concurred that her company also uses defined protocols and checklists to ensure that all relevant areas of the aircraft, medical equipment, and patient environment are properly disinfected.

“The decontamination process includes cleaning and disinfection of the patient area, all surfaces that may have been touched or exposed, reusable medical equipment, and any parts of the aircraft interior included in the protocol,” she said.

While the transfer itself is critical to any air ambulance mission, Dr Cortés noted that decontamination of the aircraft and equipment was equally vital to prevent the spread of a contagious disease.

“Decontamination doesn’t begin when the mission ends; it begins the moment patient care is completed,” he said. “Every crewmember knows their role, from waste management and equipment handling to aircraft cleaning and final inspection. Following the same sequence every time eliminates variability and allows the aircraft to return to service with confidence.”

Decontamination doesn’t begin when the mission ends; it begins the moment patient care is completed

Heyer agreed that safety should always take precedence over turnaround time: “We will not place an aircraft back into service until it has been properly disinfected in accordance with our established protocols. Fortunately, through proactive mission planning and operational coordination, thorough decontamination rarely impacts our ability to respond quickly while maintaining the highest safety standards.”

At the heart of a good decontamination protocol, Dr Cortés said, “is a simple checklist” to ensure that nothing is overlooked. “High-touch surfaces, monitors, stretchers, oxygen equipment, storage compartments, and medical devices are verified before the aircraft is released for the next mission.”

Dr Ries explained that alongside the sterilisation of the aircraft itself, “the post-mission management of our Iso-Pod is based on a risk-adapted approach”.

“Following transports involving high-risk infectious diseases, the Iso-Pod is treated as a single-use device and safely discarded, eliminating any uncertainty regarding decontamination and ensuring the highest level of biosafety,” she explained. “For lower-risk infectious transports, the decision to reuse or discard the device is made on a case-by-case basis, following a structured risk assessment and established infection prevention protocols. In these cases, our Iso-Pod features built-in disinfection nozzles, which allow a complete disinfection of the pod interior without direct contact of the crews.”

Conclusion

The aeromedical sector’s ability to safely transport infectious patients relies on a delicate balance of rigorous standard operating procedures and the flexibility to adapt to new pathogens. While the indiscriminate use of isolation pods and maximum-level protective gear has given way to more targeted, transmission-based strategies, the underlying commitment to safety remains absolute.

As the industry looks to the future, the lessons learned from recent global health crises underscore the need for continuous training, open communication, and strict adherence to decontamination checklists. By maintaining these high standards, air ambulance providers ensure they stand ready to face whatever novel infectious threats may emerge next.