title: The roles of transportation and transportation hubs in the propagation of influenza and coronaviruses: a systematic review.
abstract: BACKGROUND
  Respiratory viruses spread in humans across wide geographical areas in short periods of time, resulting in high levels of morbidity and mortality. We undertook a systematic review to assess the evidence that air, ground and sea mass transportation systems or hubs are associated with propagating influenza and coronaviruses.
  
  
  METHODS
  Healthcare databases and sources of grey literature were searched using pre-defined criteria between April and June 2014. Two reviewers screened all identified records against the protocol, undertook risk of bias assessments and extracted data using a piloted form. Results were analysed using a narrative synthesis.
  
  
  RESULTS
  Forty-one studies met the eligibility criteria. Risk of bias was high in the observational studies, moderate to high in the reviews and moderate to low in the modelling studies. In-flight influenza transmission was identified substantively on five flights with up to four confirmed and six suspected secondary cases per affected flight. Five studies highlighted the role of air travel in accelerating influenza spread to new areas. Influenza outbreaks aboard cruise ships affect 2-7% of passengers. Influenza transmission events have been observed aboard ground transport vehicles. High heterogeneity between studies and the inability to exclude other sources of infection means that the risk of influenza transmission from an index case to other passengers cannot be accurately quantified. A paucity of evidence was identified describing severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus transmission events associated with transportation systems or hubs.
  
  
  CONCLUSIONS
  Air transportation appears important in accelerating and amplifying influenza propagation. Transmission occurs aboard aeroplanes, at the destination and possibly at airports. Control measures to prevent influenza transmission on cruise ships are needed to reduce morbidity and mortality. There is no recent evidence of sea transport accelerating influenza or coronavirus spread to new areas. Further investigation is required regarding the roles of ground transportation systems and transport hubs in pandemic situations.
authors.affiliation: Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK, Field Epidemiology Service, Public Health England, Bristol, UK and.
authors.forename: Annie
authors.initials: A
authors.lastname: Browne
authors.affiliation: Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.
authors.forename: Sacha St-Onge
authors.initials: SS
authors.lastname: Ahmad
authors.affiliation: Field Epidemiology Service, Public Health England, Bristol, UK and School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Beck
authors.affiliation: Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK, jvt@nottingham.ac.uk.
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Nguyen-Van-Tam
mesh_terms: D064870:Air Travel; D059028:Airports; D018352:Coronavirus Infections / Q000635:transmission*; D006801:Humans; D007251:Influenza, Human / Q000453:epidemiology / Q000635:transmission*; D065207:Middle East Respiratory Syndrome Coronavirus; D012307:Risk Factors; D045473:Severe acute respiratory syndrome-related coronavirus; D045169:Severe Acute Respiratory Syndrome / Q000635:transmission*; D012767:Ships; D014186:Transportation
keywords: Influenza; MERS; SARS; coronavirus; systematic review; transport hubs; transportation