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By ERIC OKWARO | 07 Jun, 2015

Last week I travelled by public means in a bus. My journey was quite long as it was about 400km. Unfortunately, I sat next to someone who had a continuous productive cough but he was furious whenever I asked him to open the window. Since there was an empty seat elsewhere, I moved for fear of acquiring TB should he have been a case. Do you have policies in your countries regarding the conduct of the passengers particularly with regard to prolonged cough in a public vehicle? Please share the experience in your country.



Lora White Replied at 7:29 AM, 7 Jun 2015

This situation also happens in our country, Myanmar, as there is no clear policies concerning travelling in public vehicles for infectious patients especially MDR-TB patients as far as I know. The only way we could do is to educate these patients to avoid public places until sputum conversion is achieved. However, as this mean is connected with changing their behaviour and attitude, it is not possible to be followed by all patients. This problem may be partially tackled by arranging the private vehicles for monthly follow up visits to clinic, frequent counselling and adequate education about transmission. Please let me know if there is any effective measure regarding this issue.

RAJNEESH TRIPATHI Replied at 9:46 AM, 7 Jun 2015

I also faced similar kind of situation in India. There is no such policy

Shengwei Zhu Replied at 10:04 AM, 7 Jun 2015

We did a numerical study to show the airborne transmission of influenza viruses generated through breathing in a bus. The results shows the probability for each passenger to be infected by a source person. The paper can be downloaded from the following URL: https://www.researchgate.net/publication/236855879_An_advanced_numerical_mode...

jayanth devasundaram Replied at 10:31 AM, 7 Jun 2015

As with any policy/ rules, enfircement plays a huge part; unlike in the West where a patient is identified, treatment initiated, and tracked for compliance, and legal action taken in case of infractions, the rest of the world does not have this for many reasons: 1. the numbers are high, 2. No motivated force of enforcers is planned or trained. I see parallels to this in the chaotic traffic patterns in these countries as well. The average citizen in the West follows traffic rules through a combination of self responsibility and efficient enforcement. Neither of these applies to the rest of the world where scenarios such as described by the original poster play out on a daily basis.

ANA MARIA BACUDIO Replied at 10:48 AM, 7 Jun 2015

There is no policy in our country regarding cough etiquetes and most of these coughers are sensitive, that they will shout at you and curse you if you have reprimanded them suddenlyI think cough etiquettes should be taught in school among young students and as part of health education lectures at the health facilityas a Professor I will incorporate cough etiquettes in my lecture in Microbiology Health Care and other subjects as wellPosters and flyers are not always read by people but let us start them among young people and children who will be our future health advocates

Afia Zafar Replied at 10:50 AM, 7 Jun 2015

Unfortunately very true. Afia

S. Mehtar Replied at 11:42 AM, 7 Jun 2015

It is in South Africa.

ERIC OKWARO Replied at 11:54 AM, 7 Jun 2015

Thanks for the great insights on your knowledge and experiences. A majority may lack a clear policy on TB infection prevention in the public transport sector. However, amongst the control strategies you mentioned, I believe health education and counseling are very important. This includes the public service vehicles (PSV) crew who should undergo training by the health and transport ministries on ways of controlling TB. The PSV operators can then transfer the information to their passengers. In addition, TB prevention messages on PSVs through fliers and on vehicle bodies may contribute to the populace understanding of TB control. Movement of smear positive persons in PSVs should also be limited but if a must then they need to wear respiratory masks. The community will understand the consequences of their actions, thus they will take charge of their health and their neighbors’. When one is not willing to change the habit despite numerous reminders on expected standard precautions, then the Public health officials may apply quarantine method until the infected are confirmed sputum smear negative.

Attached resource:

Grigory Volchenkov, MD Moderator Replied at 2:35 PM, 7 Jun 2015

No such policies in Russia as well. Transmission risk in such settings is very high. We had recently such TB case: infant just discharged from maternity home spent two hours in a car with TB treatment defaulter - his father, smear positive susceptible TB case. Windows were closed because of rain. That was the only contact with the father, which moved after to other region. After 5 months child developed pulmonary TB.
I agree: cough education to the public starting from children in school is critical. And FAST strategy...

Edward Nardell, MD Moderator Replied at 6:45 PM, 7 Jun 2015

I pains me to suggest the obvious, that the problem of TB transmission on
crowded public transportation ultimately depends on the success of TB
control in the entire population, since cough is a common symptom, and
there is no way to screen out or prohibit coughing persons from using
public transportation. Although TB can be transmitted on a crowded bus in
the US, Netherlands, or Canada, it is much less likely because TB is so
much less prevalent. That is the ultimate way to control TB in the
community, including public transportation. Fortunately, globally, TB is
inching down - not everywhere - but overall. MDR, of course, remains a
serious threat. If there were an effective vaccine, of course, it could
interrupt transmission and greatly accelerate elimination.

Paul A. Jensen, PhD, PE, CIH Moderator Replied at 11:09 PM, 7 Jun 2015


In addition to a good TB control program (as Ed mentioned), I believe we need a good public health ‎program. While I do not want to re-breath the air from a person with TB, I also do not want to breath in or be exposed to any other airborne-, droplet-, or contact-transmitted microorganisms. So, we want proper cough etiquette for all, not just "people with TB". . . So, we need PSAs (public service announcements/messages) for the PSI (public transportation industry)!!!


Paul J

P.S. Please excuse my fumbling thumbs and the silly autocorrection of my misspelled words!

Indrajit Kumar Replied at 11:36 PM, 7 Jun 2015

Respected Sir,
This situation also happens in my country, I think there is no such policy


Yasir Waheed Replied at 11:49 PM, 7 Jun 2015

In a resource limited setting, the cornerstone would be to educate both the care providers and children at School level, the former being a potential group in terms of breaking the chain of transmission and further disseminating the purposeful knowledge to a fresh set of groups every year.
Expanding TB awareness programs (especially cough etiquettes promotion) to the above target population through multi-pronged approaches would positively bring down the overall TB stigma in community.

jayanth devasundaram Replied at 11:56 PM, 7 Jun 2015

In Vellore, South India, Dr T Jacob John, a well known name in Polio Control has started a comprehensive TB CONTROL (as opposed to ONLY Treatment) program. He has printed posters for distribution in town buses, bus shelters etc as part of the campaign (see enclosed Jpegs). There are three versions of these posters- English only, Tamizh only, and Mixed. TB control requires a comprehensive control program, not just a treatment program.

Attached resources:

Rajbir Singh Replied at 12:05 AM, 8 Jun 2015

I think its high time to have comprehensive guidelines to tackle infection control in public transport systems.

IC Working Group can have a sub-group to collate different ideas, evidences from measures implemented by different countries as of now and come up with guidelines for the Countries to take forward.

Rajbir Singh

Vineet Bhatia Replied at 2:02 AM, 8 Jun 2015

This is an interesting discussion. Personal encounters often lead us to focus on specific problems and rightly so. However, public transport would just be one piece of the puzzle to solve the problem of transmission. There are so many other avenues of close contact - from schools to shopping malls to other public gatherings. Hence, as some members have already said that it should be cough/ sneeze etiquette in general as part of health education rather than a TB programme 'policy'. Moreover a general approach to air-borne infections rather than being TB specific is more likely to succeed.

Haluk Çalışır Replied at 3:54 AM, 8 Jun 2015

This is a very interesting discussion topic. Transmission is not zero
during the public transportation, but I am not sure making a general
expression for the transmission during public transportation is realistic.
Transmission effected very different components such as, bacterial burden
of the patient, frequency of cough, volume of the environment in the bus,
air exchange rate in side the bus, open/closed windows, transportation
duration, patients treatment situation, T0 factor of tuberculosis, host
conditions etc. Another important factor is the tb control and
epidemiological situation of the country. I think all of the components
will affect the transmission depending of the factors. We can't say only
one phrase for the transmission tb during public transportation.
Possibilities are very different and giving a recommendation for one fit
all, may create stigmatization of coughing people and tb cases. I would
like to point out the stigmatization of tb patients.

The Stigmatization is an important problem, come from some
misunderstandings of the transmission concept, particularly in health care
settings. The health access of the tb patients may be diminished by the
health care workers particularly due to fair of transmission and beliefs
come from such "one fit all" phrases.

TB patients frequntly face stigmatization in health care facilities due to
this kind of misconceptions. If a tb patients have any other health problem
such as cardiovascular, gastrointestinal, gynecological complaints even
under tb treatment, it is very difficult to access solutions related
her/his problems.

15% of the workers with tb lost their job due to having tuberculosis in
Istanbul. These are some personal tragedies of tuberculosis patients in
real life.

Yes transmission possibility never zero during travel with coughing and
undiagnosed tb patient but may be different depending on the situation in
real life.

I would like to recommend to look from the patient side as much as the
community side also.

Best regards,
Haluk C.Çalışır M.D.
Assoc. Prof on Chest Disease and Tuberculosis

ZAHOOR ZAHOOR Replied at 6:50 AM, 8 Jun 2015

i never find such type of study in pakistan or policy.

S. Mehtar Replied at 7:34 AM, 8 Jun 2015

There is some work done in South Africa with multiple person transportation taxis- I think it is published

Celso Khosa Replied at 7:42 AM, 8 Jun 2015

In Mozambique there are no policies regarding public transport and
infection control.
DOTs is standard of care, most of patients still need at least one bus to
reach the nearest health center.

In several occasions a patient is diagnosed, he/she is weak to walk needs
to get home and go back for treatment the next days, HCW try the best to
advice to open windows and use a mask-respirator if possible, but then
another question, stigma other public transport users would let someone
with a mask in? Private bus owner would let this person take the bus?

This issue have to be addressed from the patients' and the community
prospective increasing the awareness and knowledge about TB and other
respiratory infections.

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