​COVID-19 has financially crushed the passenger aviation industry over recent months. According to the US Bureau of Travel Statistics, passenger flights were down 95% in April 2020 compared to April 2019. Yet, with all the new safety cautions put in place by the industry, the risk of infection has been reduced dramatically and made flying more comfortable.

Having recently traveled from Florida to Greece, I want to share what it was like to travel domestically and internationally in this new COVID era and give you tips on how to make flying safer.

I used to fly 2-3 times per month across the country to attend medical meetings and to speak at events, plus a few international trips per year as well. (My experience could be a bit limited, as most of my flights have been with a single airline, Delta.) Yet until this recent trip, I had not flown on an airplane in six months. Like most people, I took the lock-down instructions seriously, canceling several trips, and staying home.

What I noticed during this recent trip from our home in Florida to our sailboat in Greece is that the planes and airports have changed dramatically to keep us COVID-19 safer and many of the changes have actually made it more comfortable to travel.

The information in this blog assumes that you want to avoid a COVID-19 infection. There are some people out there who are not worried about catching this virus and they will likely ignore these recommendations, but I hope you take them seriously. In the USA so far, we have had 2.2 million cases and 120,230 deaths; globally, we have had 8.5 million cases and 450,000 deaths (all these numbers are likely underestimated). Despite the lock-down and our attempt at social distancing, we continue to see 20,000 new cases every day and we have seen 5 times more COVID deaths than we typically see from the flu each year, and this may be just the beginning for us.

While I aim to avoid political comments in my blogs, I cannot help sharing my frustration that the USA has done a terrible job of controlling this virus—one of the worst scenarios in the world. If we had done a better job, we may not have needed to shut down our economy in a dramatic way and suffered such a large loss of life. (South Korea and Germany are 2 examples of better success stories.) We still have the opportunity to turn this around, stop the ongoing first wave, and stop a second wave by adhering to the steps recommended at the end of this blog.

Although it has been less common, even 30 and 40-year olds have been hospitalized, put on ventilators, and tragically died. People with underlying risk factors (age greater than 70, diabetes, hypertension, heart disease, lung disease, and those who are immune-compromised) have had the worst outcomes. Perhaps the scariest part has been how contagious and unpredictable this disease can be.

The good news related to travel is that planes now have filters that remove small air particles, including virus particles. The recirculated air is now usually passed through HEPA (high-efficiency particulate air) filters, of the type used in hospital operating theatres and intensive care units, which trap dust particles, bacteria, fungi, and viruses. They may not remove 100% of particles, but the best science suggests that they remove 99.9%. While on a plane, you can catch COVID-19 from someone coughing on you or speaking to you if you are close enough, less likely although still possible, from surfaces you may touch, but likely not from the air you breathe on a plane.

What differences did I see during my recent plane flight? (Keep in mind I flew with Delta, KLM, and Aegean Air to get to Greece. I suspect that things would be similar on other airlines):

• With the most common 3/3 seating, middle seats are all empty. Your only choice is a window or an aisle seat. No more being packed in like sardines.
• On planes with 2/4/2 seating, they only put 1 person in the 2 seats, and 2 people in four seats—there is really a great deal more room. Nicole and I had a four-seat section to ourselves, which made it much easier to get in a little sleep.
• Food and beverage service are safer (from an infectious disease perspective, but from a nutritional perspective it is worse) but with less choice. Assuming your flight is long enough to warrant giving you something, they hand you a paper bag prepared in advance with a water bottle, an unhealthy snack, and disinfectant wipes. This way the flight attendant has minimal contact with the items you end up touching yourself.
• Everyone wore masks on the plane: I noticed that a few passengers took off their masks when they got on the plane, but the flight attendants asked them to put them back on.
• The magazines and items in the pockets are gone preventing you from being exposed to other people’s germs. Only the emesis bag has persisted in the pockets, and obviously people are not going to reuse those.

These flight changes appear to be straight from the CDC manual and will continue at least through September, and perhaps longer.

Things were also different in the airports we transited in:

• There is a repeated public service message on the intercom every 10-15 minutes saying, “You must wear a mask at all times and stay at least six feet distance from other people.” Most people stayed more than six feet apart, and seats have tape so that every other seat is not available to sit in. In the US airports we passed through, Tampa and Detroit, at least 50% of people were not wearing masks unless they were going through security or boarding the plane, so mask-wearing is not being enforced at the terminals as it is during plane travel.
• The airports are mostly empty. With flights down significantly, it was easy to stay six feet apart from others
• Most of the lounges, restaurants, and shops were still closed.
• Boarding was from the back of the plane to the front.
• There was so little volume of passenger traffic that priority security and regular security were combined.
• In the restaurants (if they were open), employees we required to wear masks. Food was served on disposable plates, cups, and utensils. At least in the US airport restaurants that we saw, the challenge is that the servers pass you plates and glasses that they have touched. This appeared to be the biggest infection risk from the whole trip.

European airports are following these guidelines more strictly. When I compare the US airports with the three European airports we transited through, social distancing and mask-wearing were being followed by everyone, while less than half of people in American airports were compliant.

How Can You Make Flying COVID-Safer?

1. Do not travel if you are sick or if you think you may have been exposed. All of us need to follow this advice every day.
2. Wash your hands for at least 20 seconds with soap whenever feasible, especially before you eat or touch your face; and do your best to avoid touching your face. Keeping your mask on is a good reminder.
3. Bring your own food and since you cannot bring beverages through security, buy a drink for the flight (or carry your own refillable bottle), and wipe the outer surface of the container with a disinfectant wipe. My impression was that the biggest risk from traveling through multiple airports and planes was buying food in the airport.
4. Bring extra disinfectant wipes with you and wipe down surfaces that you contact.
   • Clean your tray in your seat if you are going to use it.
   • Wipe down your seatbelt and the armrests with disinfectant wipe.
   • If you use the bathroom, use the disinfectant wipe to open the door, flush the toilet, turn the nobs to wash your hands, and exit the room, then discard it in the trash without touching the room.
5. Any time you touch a surface that does not belong to you, use a hand sanitizer, and/or wash your hands.
6. Wear your mask, unless it is an N95 mask it will not protect you, but it will help you prevent spreading this disease to others (it is a simple act of courtesy for the people around you) and if everyone did this, we would be better off.
7. If you check a bag, use hand sanitizer after you gather your bag from the carousel, then wipe down the handles of the bag with a disinfectant wipe before you handle it yourself.
8. Avoid touching counters, either when checking in for your flight, buying food, or at any counter.
9. Bring your own reading material and avoid picking up any public magazines.
10. Stay at least 6 feet away from other people all the time in the airport.
11. Keep in mind that the biggest risk for acquiring COVID-19 is being too close to somebody when they cough, sneeze or talk. If somebody is coughing within 6-9 feet from you, move. If you are on a plane, ask the flight attendant to move you. Honestly, nobody with a cough should be out in public in this era.
12. This is a good time to mind your own business and avoid as much as possible talking and visiting with strangers.

After five flight segments from Florida to Leros, Greece, I felt pretty safe following these recommendations. I hope that these suggestions will be helpful for you too.

Once we got to Athens, we were tested at the airport for COVID-19, spent the night confined to our hotel room, and the authorities had our results in 24 hours. The process was quick and organized and fortunately for us, we did not receive a call the following day telling us we had tested positive. (I find it amazing that the testing system in the US continues to be so slow!) Then we flew to our boat and put ourselves into self-isolation for 6 more days as was requested.

After the 7 days of isolation and with a negative test, the Greek government gave us the green light to go out in society. Although we continue to be cautious, especially as foreigners visiting a hosting country; we wear masks when in crowded public places and stores, keep our social 2-meter (six-foot) distance from others, avoid touching public surfaces, and use hand sanitizer before and after shopping and paying for goods. We noticed that every store (even the fruit stands) has hand sanitizer within reach of the customers. Living on a sailboat helps to maintain our social distance in many other ways, as typically unless shopping for food and supplies or eating in a restaurant, we stay away from everyone.

We are back on our sailboat Mariposa, researching Mediterranean recipes, and hoping to sail from Greece to Spain this summer without further COVID delays.

I plan to keep sending you blogs, sharing delicious and healthy recipes from this trip, and health tips as I have done for years.

I wish you the best of health!

Steven Masley, MD, FAHA, FACN, CNS