IATA has set up a structure to contribute to an efficient and cost effective approach to handling medical issues in the airline industry.
In addition to the expertise of IATA’s Medical Advisor, IATA has formed a Medical Advisory Group bringing together airline medical experts from around the globe. A major part of their role is to provide advice to the industry and other stakeholders on a wide range of medical issues, such as those covered in the IATA Medical Manual.
Guidelines on Health and Safety Issues
A series of guidelines have been developed by IATA’s Medical Advisory Group, addressing general medical issues and aviation and communicable diseases. They have been reviewed and welcomed by WHO and are meant to help airlines address emergency public health issues, particularly in the case of suspected communicable diseases.
Passenger Contract Tracing
IATA has developed a position on the controversial issue of passenger contact tracing to recommend a specific approach to countries contemplating contact tracing.
Recommendations for allergen-sensitive passengers helps passengers minimize the risk of an allergic reaction on board an aircraft.
A-passenger contact tracing
*It is the fastest way to retrieve the data when needed and does not require
the involvement of a third party
It involves only the countries that wish to do contact tracing, putting the
onus on them to justify the system
*It limits the cost to those countries that decide to do contact tracing
*It does not interfere with airline operations
*It eliminates the need for harmonization and agreement between countries
*It allows the countries using it to keep the information as long as they want
and/or as long as their own legislation will allow it.
*It eliminates the transfer of information between third parties
After being involved in many different data collection systems and reviewing
others, IATA is convinced that the proposed approach is not only the best one,
but is also the most fair to all stakeholders. IATA will continue to help within its
means and its responsibilities and would be willing to use its expertise to help
any country that wishes to explore this approach.
February 26, 2014
The purpose of this communication is to provide information to allergen-sensitive passengers to help them minimize the risk of an allergic reaction onboard an aircraft.
In that regard, this document will not provide basic information about allergic reactions that most allergen-sensitive passengers know or that they can easily obtain through many different sources, starting with their treating physician. The document will provide information on what airlines can do and on what the allergen
-sensitive passengers can do to facilitate their travel and prevent allergic reactions.
Background Severe allergic reactions on board are an extremely rare occurrence. However, when they do occur,the consequences may be amplified because of the remote environment. In that context, allergen
-sensitive passengers susceptible to severe allergic reactions should do everything in their power to prevent these cases or be prepared if it does happen.
The airlines, on their side, are obliged to meet all the requirements ofthe International Civil Aviation Organization (ICAO) and of their respective government, which incidentally differ from State to State. Regulations for airlines
ICAO’s standard on the requirements for medical equipment is the following “An airplane shall be equipped with accessible and adequate medical supplies”. Then ICAO provides recommendations and guidance material. Each national authority must meet the general standard, but when it comes to details (e.g. first aid kit or emergency medical kit contents), this may be very different from one State to the other.
A similar situation applies to training. The ICAO standard requires that an airline establish and maintain a training program that shall ensure that each member of cabin crew is drilled and capable in
the use of the emergency and life-saving equipment that is required to be carried. This basically requires that all cabin crew be trained in first aid. The details of the training are left to the individual
States and therefore the required skills and the details of the equipment vary.
Over and above ICAO and individual States requirements, airlines may be able to provide other services dependent on different factors such as the size of the airline and the type of operations. By definition these services vary from airline to airline.Recommendations for allergen-sensitive passengers Travelling for allergen-sensitive passenger can be challenging but it is possible to have an enjoyable and uneventful trip with careful planning.
•Contact your physician and discuss the travel related risks involved. If he/she prescribes an epinephrine (adrenalin) auto injector (such as EpiPen®, Anapen® or Twinject®) make sure you always carry this medication, any other prescribed medication for your allergy and your written emergency plan, in your carry-on baggage. Have the medication easily accessible throughout the flight (at your feet or in the pocket in front of you). Whilemany airlines carry epinephrine in accordance with their national regulations, most of them do not carry an epinephrine autoinjector.
The same applies to any other emergency medication that is prescribed for you. You should never assume that the airline will carry the medication you need. Make sure that you carry a prescription for the auto-injector and an emergency plan signed by your doctor to avoid problems when passing through airport security.
• When you make your reservations, you should ask the airline how they deal with allergen-sensitive customers. It is always preferable to deal directly withthe airline and not through a third party. Even if the airline does notserve the food to which you are allergic, it cannot guarantee an allergen-free environment. For example, if you have a peanut allergy, other passengers may bring peanuts on board the aircraft. Airlines are alsounable to provide allergen-free meals because commercial kitchens cannot guarantee compliance.
The reason for this is the presence of allergens, such as peanut and peanut-products, across many types of foods, insufficient labelling of peanut as an ingredient infoodstuff and cross contamination.
• Even though airlines carry out routine cleaning procedures of the aircraft, it is impossible guarantee an allergen-free environment on board.
• Allergen-sensitive minors should never travel unaccompanied.
• If you purchase travel insurance, consider asking the insurance company if you are covered incase of anaphylaxis, or other severe allergic reactions.
Day of travel:
*Arrive early at the airport and allow yourself plenty of time to re-confirm your requests regarding specific seating, early boarding, etc..
*Consider mentioning to the passengers sitting close to you or your allergic child that you or your child has a severe allergy. If it isyour child, try to position the child away from other passenger (a window seat for example or between yourself and your spouse or another one of your children). At reservation time, you can also request the back or front row of a section, which will also limit the proximity to other passengers.
*Consider bringing your own sanitizing wipes if you wish to wipe down the armrests, meal trays and seat back areas of your seats.
*Consider alerting the cabin crew in
-charge that you or your child has a severe allergy so they can respond quickly and appropriatelyif a reaction occurs. However, be advised that many airlines
will not make specific broadcast announcements to passengers for these cases.
Procedures for suspected food poisoning on board
Food poisoning can be caused by chemical agents (a chemical product that was
inadvertently mixed with the food), physical agents (a foreign body that was
inadvertently dropped in the food), or biological agents (viruses, bacteria, toxins or by
-products of bacteria, parasites). Most cases of suspected food poisoning in a passenger or crew member are caused by biological agents and therefore by food usually consumed before the
flight because of the incubation time required for many of these agents. However,it ispossiblethat a passenger or crewmember becomes sick as a result of food eaten on board. If this situation is suspected by a passenger and/or a cabin crew member, the following procedures should be followed:
۱٫Provide first aid
۲٫Notify the purser/senior crew member
۳٫Call the medical ground provider if your company has one, and/or ask if there is a physician on board. Follow the instructions of the medical professionals concerning patient care/preventive measures
۴٫If food poisoning is considered unlikely,then crew should refer to the guidelines onsuspectedcommunicabledisease(http://www.iata.org/whatwedo/safety/health/Pages/diseases.aspx)
۵٫If the diagnosis of food poisoning is likely OR no professional assessment of the situation is availablethen all of the following apply:
۶٫Keep a sample of the suspected food item(s)
-Wrap and label item(s)
-Store items in the refrigerator to prevent further deterioration
-Place foreign matter in a sealed bag and store in the
۷٫Document the incident as per company procedures and include specifics
-Contents of meal served
-Description of any foreign matter found in the meal
-Any food preparation completed on
-board eg. chilled/non
-chilled stowage, time and temperature controls
-Time of food consumption
-Time of symptom onset
-Other customers and/or crew affected
-Ask any affected customers and/or crew members to complete the airline’s suspected food poisoning questionnaire (if available)
۸٫If surfaces have been contaminated by body fluids, clean/disinfect those surfaces according to hygiene and safety regulations
۹٫When possible, designate a specific lavatory for the exclusive use of the ill traveler(s). If not possible, clean and disinfect the commonly touched
surfaces of the lavatories (faucet, door handles, waste bin cover, counter top) after each use by the ill traveler(s)
۱۰٫Notify the captain. Since thissituation could also represent a suspected communicable disease,
he/she is required by the International Civil Aviation Organization regulations(ICAO Annex 9, Chapter 8, and paragraph 8.15) and the World Health Organization International Health Regulations (WHO IHR 2005, Article 28(4)) to report the suspected case(s) to air traffic control. If surfaces have been contaminated, also remind the captain to advise the destination station that cleaning and disinfection will be
۱۱٫Affected passenger(s) or crew member(s) in general should not be allowed to leave theaircraft on arrival at the destination until clearance has been given (by Port Health) and medical follow up arranged.
۱۲٫Hand over the suspected food item(s) or foreign matter to the Customer
Service Manager at the first of your stations where food analysis can be done and pre arrangements have been made.
Person Emitting Radiation
Guideline for the transport of a person who is, or may be, emitting radiation
During the 2011 nuclear accident in Fukushima many stakeholders became aware of publichealth emergencies other than those involving communicable diseases. While some areas of theaviation industry may be quite well prepared to respond to a pandemic or a similar event, it was realized that the response plan for a pandemic isnot automatically relevant to other typesof public health
To help manage this nuclear event, ICAO createdaTransportTaskforcewithsixotherUnitedNations (UN) agencies, including WHO, IAEA (InternationalAtomic Energy Agency), WMO (World MeteorologicalOrganization), WMO (World Maritime Organization), UNWTO (UN World TourismOrganization) and ILO (International Labour Organization). IATA and ACI (Airports
Council International) were members of the task force. This ad hoc collaboration was very helpful insuccessfully managingthe incident.
As a result of this, ICAO and the other partners are considering a more formal cooperation framework to respond to similar future crisis.
ICAO usedthe opportunity to amend its ‘Technical Instructions for the Safe Transport of Dangerous Goodsby Air’. At the time these did not provide for a person who has been subjectedto accidental intake or external contamination ofradioactive materialto be transported for medical treatment. This amendmentcan be found in Part 1, Chapter 6, page1-6-1.IATA believes that guidance material on this subject would be valuable for its member airlines. IATA was also requested by its member airlines to consider guidance material in case of in-flight notification by a person emitting radiation.Pre-flight notificationPersons containing
low levels of radioactive material as a result of medical diagnosticprocedures or treatment
have been transported on commercial aircraft for many years as an accepted ‘exemption’to
the ICAO Dangerous Goods requirements.
However, the ICAO exemption did not apply to an irradiated individual(from a source other than medical diagnosis or treatment)that needed to travel in order to reach a suitable treatment facility.
Airlines usually do not know about radiation from within the body resulting from diagnostic procedures,as advice on travel is given by the treating nuclear medicine physicians who take
into account the public risk before releasing the patient from the hospital. Also the airline may not know aboutcontamination of an individualby radioactive material on the skin or clothes,
but if it happens in the context of a nuclear accident a request may be made to an airline for such
transport, prior to flight.
If arequest is madefor transport of an individual who is emitting radiation, the
airline can consult the guidance material developed by ICAO in coordination with
IAEA(InternationalAtomicEnergyAgency)at:http://www.icao.int/safety/DangerousGoods/Documents/Guidance%20Material/GuidanceMaterial. and advise the requesting physician that the passenger can be transported as long as the criteria described in the guidance material are met.
In-flight notificationIt is most unlikely that a passenger that has decided to travel in spite of knowing that he is potentially emitting radiationwill advise the cabin crewin flight. However,
if it should occur, the followingguidance is provided.
This guidance has been developed in cooperation with ICAO, IAEA and nuclear medicine
-If there are some empty seats on the aircraft, relocate other passengers so that
the suspected case is somewhat isolated from the ot
-If the aircraft is full, but a young child (5 years or less) and/or a pregnant woman
is sitting in the seats beside, in front or behind the suspected case, tactfully
relocate the child and/or pregnant woman.
-Ask the suspected case to minimize movement away from the allocated seat.
-Ask the suspected case to use the same washroom when he/she requires to use one and to wash his/her hands properly. Prevent other people using the washroom.
-Notify the pilot in command of the issue sohe can notify the destination as per ICAO regulations and procedures.
-Prevent access to overhead luggage area where the suspected case’spersonal effects are stored during the flight and,once on the groundwait for the clearance from the State authoritiesbeforeaccessing this particular overhead bin.
Passengers that have no luggage in that particular bin canremove their luggage and disembark.
DEATH ON BOARD
WHEN TO CEASE RESUSCITATIONCabin crew trained to perform cardiopulmonary resuscitation (CPR) should continue CPR until one of the following occurs:
۱٫Spontaneous breathingand circulation resume; or
۲٫It becomes unsafe to continue CPR (e.g.heavy turbulence and/or forecasted difficult landing afterliaising withthe flight deck); or
۳٫All rescuers are too exhausted to continue; or
۴٫The aircraft has landed and care is transferred to emergency medical services; or
۵٫The person is presumed dead: If CPR has been continu
ed for 30 minutes or longer with no signs of life withinthis period,and no shocks advised by an on board Automated External Defibrillator (AED), the person may be PRESUMED DEAD, and resuscitation ceased.
Note:Airlines may choose to specify additional criteria, dep
ending uponthe availability of ground toair medical support or anon board physician.
DEALING WITH DEATH OR PRESUMED DEATH ON BOARD
When a person has been declared dead, or presumed dead, the following protocol is suggested.
۱٫Move the person to a seat – if available, one with few other passengers nearby. If the aircraft is full, put the person back into his/her own seat, or at the crew’s discretion, into another area not obstructing an aisle or exit.
Take extra care when moving the person and be aware of the difficulty of the situation for companions and onlookers.
۲٫ Restrain the person with seat belt or other equipment.
۳٫Close the eyes, and cover the body with a blanket up to the neck.
۴٫Request contact information from travelling companions.
Oxygen deliverysystem for adult passengers
A recent survey of many major airlines has shown that oxygen mask and nasal cannula are still the two most used oxygen delivery systems for passenger requiring in-flight supplemental oxygen. Both systems can deliver the typical amount of oxygen used in airline transport. Historically we are not aware of any significant negative incident with any of those two systems. However, there are several advantages to use the cannula system:
– Most cannula are similar and deliverthe same amount of oxygen, whereas there are many kinds of masks that deliver different amounts of oxygen
– No fitting required
– Lower cost
– Passenger can eat while wearing it
– Better acceptance by the physicians in general
– Ideal with pulse dose system If you haveto choose an oxygen delivery system, you may want to consider the above in your decision.
Guidelines for assessment of fitness to work as Cabin Crew
General Considerations As with all “medical guidelines” it is important that each individual case is assessed on its own merits. No “blanket” bans or restrictions should be imposed without a full individual assessment, a fullandopenconsultationwiththeemployee,andifnecessarycommunication with the individual’s own medical advisers.
All fitness to work decisions must takethe following considerations into account:
۱)Ethical considerations The need to meet operational requirements and maintain employment in a safety critical role, without compromising optimal management of the crewmember’s diabetes.
۲)Effect of Health on Work Are they fit to carry out the role effectively and safely, and will the interaction of their medical condition (and/or its treatment) and the job role pose unacceptable risks to the individual or others?
۳)Effect of Work on Health Will the job have a significant adverse effect on the condition or its management?
۴)Regulations Any relevant State (country) rules and regulations, which include local human rights and disability legislation.
۵) Other medical conditions The presence of a specified medical condition should not distract from the assessment of the individual as a whole; general fitness as well as the existence of
other medical conditions must be considered.
People should be physically and mentally fit in accordance with general standards for crew independent of the type of Diabetesor treatment they have. The main issue of concern withCabin Crewfitness and insulin treated diabetes is that of sudden hypoglycaemic incapacitation resulting in inability to carry out the safety critical role, along with the impact of that incapacitation on fellow crew (i.e. is it significant enough to need the help of others).
The risks to the individual through more subtle cognitive dysfunction as a result of hypoglycaemia whilst on the aircraft and down route and the impact of hypergl ycaemia should also be considered. Additionally, crew have to work irregular hours, cross time zones and potentially stay in areas of the world where medical treatment may not be considered equal to the standard at home base.
Guide to Decision Making :
As a starting point and in order to try and adopt an evidence based approach as far as possible, it would seem reasonable to consider driving recommendations as a baseline for assessments, as this group hasbeen widely researched. In addition, the preparation of these guidelines has also
considered the US Federal Aviation Administration (FAA) and the Australian Civil Aviation Sa
fety Authority (CASA) guidelines for technical crew and the Transport Canada guidelines for Cabin Crew.
There is no agreement on the level of medical incapacitation in cabin crew that is
acceptable for flight safety. Crew are required to manage emergency situations to maximise t
he safety of passengers in such emergencies, and to act in a manner that is not a threat to flight safety. From an operational point of view they are also required to provide a high level of service to passengers, and impaired work performance from hypoglycaemia or hyperglycaemia may lead to reputational risks for the crewmember and operator.
The following is a useful evidence based approach:
۱٫ People should be physically and mentallyfit in accordance with general crew standards.
۲٫ The diabetes should be under regular(at least annual) review by either a specialist or general practitioner (primary care physician) who specialises in the treatment of diabetes.
۳٫ Diabetes should be under stable control.
۴٫ People should self monitor their blood glucose, and be well motivated in diabetes
۵٫ There should be no disabling hypoglycaemia and awareness of hypoglycaemicsymptoms must be preserved.
۶٫ Crew should be discouraged from allowing their blood sugars to run high in order to prevent hypoglycaemic episodes and the risks of adverse long-term health consequences must be explained.
۷٫ The individual should be advised to carrya medical talisman e.g. Medic Alert or similar.
۸٫ There should be no:
c. peripheral or autonomic nerve damage
d. coronary heart disease
e. peripheral vascular disease
f. cerebrovascular disease. that would cause functional incapacity, likely to interfere with the safe exercise of routine or emergency cabin crew duties.
۹٫ Suitability for employment should be re-assessed annually by an Occupational
Health Physician or his designee,and should be based on the criteria outlined above.
Modern long acting insulin preparations are able to give a flat predictable peakof action with an effective duration of up to 24 hours (see below). This allows the individuals to take their bas
al insulin with prandial dosesof short acting insulin at meal times. Cabin crew could therefore stay on home base time with regard to when to take the basal dose, regardless of which time zone they are in. To assist with this, it might help for crewto have an additional or dual zone watch
set to their home time. This only represents one available treatment option. There may be other acceptable approaches.
Guidelines for assessment of fitness to work as Cabin Crew
As with all “medical guidelines”,it is important that each individual case is assessed on its own merits. No “blanket” bans or restrictions should be imposed without a full individual assessment, a full and open consultation with the employee, and if necessary communication with the individual’s own medical advisers.
All fitness to work decisions must take the following considerations into account:
۱)Ethical considerations:The need to meet operational requirements and maintain employment in a safety critical role, without compromising optimal management of the crewmember’sseizure disorder.
۲)Effect of Health on Work:Are they fit to carry out the role effectively and safely, and will theinteraction of their medical condition (and/or its treatment) and the job role poseunacceptable risks to the individual or others?
۳)Effect of Work on Health:Will the job have a significant adverse effect on the condition or its management?
۴)RegulationsAny relevant State(Country) rules and regulations, which include local human rights and disability legislation?
۵)Other medical conditions
The presence of a specified medical condition should not distract from the
assessment of the individual as a whole; general fitness as well as the existence of other medical conditions must be considered.
Seizure ConsiderationsAn assessment of a cabin crewmember’s ability to work with a history of having had a seizure should be made individually and only after a complete assessment with the best medical evidence available as part of that assessment.
The absolute risk
*(probability that a specified event will occur in a specified population)of recurrence of a seizure must be factually considered, and distinction should be made between provoked and unproved seizures.
Specific recommendations for return to work for cabin crewmembers should be similar to guidelines that apply to recommendations made for vehicle operation licensure. However consideration may be given for the inherent “redundancy” in aircrew staffing when there are more crewmembers present than is required for operation of the aircraft or in responding to emergencyprocedures.
Anopinion from a specialist in neurology and preferably in the treatment of epilepsy would ideally be a part of the assessment.
Accommodation into a ground position for a period of documented stability may be considered if available. Recommendations presented below would be applicable for new-hire candidates as well as current employees, as long as there is thorough documentation provided by the applicant verifying the individual factors discussed below.
Relative riskvalues unaccompanied by absolute riskvalues offer insufficient information for decisionsbased on risk assessment
A provoked seizure is a symptomatic seizure caused by an acute insult to the nervous system; examples of provoked seizures are alcohol withdrawal, toxic exposure, hypoglycemia, stroke, or trauma to the nervous system such as a head injury.
A provoked seizure is treated by identifying the cause and subsequent treating of the underlying cause. In an unprovoked seizure,there is no immediate connectable cause for the seizure.When there is an occurrence of Two or more unprovoked seizures that are greater than 24 hours apart, the presence of epilepsy is diagnosed, and medical therapy is normally initiated.
Guide to Decision MakingMany factors impact on a patient’s risk for seizure recurrence; however, the seizure-free interval has been widely adopted as a practical measure of ability to safely return-to-work.Other favorable modifiers which may be considered to shorten a required “seizure-free” interval include:
- Seizures occurring during medically directed changes in medication
- Simple seizures (only) that are confirmed to not interfere with consciousness,motor functionor essential job activities
- Seizures with auras that can be reliably predicted and/or are prolonged such that appropriate work accommodations can be made.
- Seizures related to acute toxic or metabolic states, such as withdrawal from alcohol or drugs,or other illnesses that are not likely to recur or cause epilepsy (acute symptomatic seizures)
- An established pattern occurring during sleep
- Seizures occurring under a clear provocation (sleep deprivation), if that provocation can be avoidedConversely, high seizure frequency,medical non-compliance, and a history of incidents such as Motor Vehicle Accidents(MVAs) should extend the seizure
-free interval before a clearance to work is recommended.
Requirements in the evaluation of a single, unprovoked seizure:
In considering whether a cabin crewmember should be allowed to work with a history ofasingle,unprovoked seizure (no immediate cause identified), the following factors
should be taken into consideration:
- Type of seizure activity and any precipitating factors
- History ofstatus epilepticus
- Complete diagnostic test results, including EEG and Computed Tomography (CT
scan)or Magnetic Resonance Imaging (MRI scan) (note: MRI is generallythe preferred neuro-imaging modality for evaluation of seizures)
- Current medication(s) taken
- Course of treatment(s) for co-occurring conditions
- Length of time seizure free
- Specialist clearance
- Family history of epilepsy
- Ability or difficulty in performing Essential Job Functions
- Age of individualIt is recommended that a minimumperiod of 6months seizure
-free (note: some authorities recommend minimum of 12) be documented before consideration of clearance after a single, unprovoked seizure.Requirements in the evaluation of a cabin crewmember diagnosed withEpilepsyandon medication(s)
- Specific type of seizure disorder
- Frequency of seizures
- Documented compliance on medications
- Course of treatment(s), changes in treatment
- Length of time seizure free
- Physician caution against fatigue, alcohol
A cabincrewmember demonstrating good compliance and who provides adequate documentation may be considered for clearance if there has been a 12month seizure free interval. Special favorable consideration may be given for a diagnosis of epilepsy involving only simple partial seizures or seizure events occurring only during sleep periods.
Requirements in the evaluation of a cabin crewmember that has experienced surgery to prevent seizure recurrenceA cabincrewmember may be considered for clearance after a documented 12monthseizurefree interval, provided there are no other complications affecting the performance of the affected crewmember’s job functions.Special considerations in the evaluation of a cabin crewmember previously diagnosed with epilepsy whose anti
-epileptic drug therapy (AED) has been discontinuedThe risk of seizure recurrence is much higher than in the generalpopulation for someone who has been on AED but has subsequently discontinued that AED. The most important factors predicting seizure recurrence were longerseizure
-free periods before
attempting drug withdrawal (which reduced seizure occurrence) and a history of tonic
-clonic seizures treated with more than one AED (increased recurrence).Additional factors that have been associated with an increased risk of seizure recurrence after discontinuation of AED therapy include the following:
- Identifiable brain disease
- Abnormal neurological examination
- Seizure onset after the first decade
- Multiple seizure types
- Poor initial response to treatment
- Combination therapy at the time of withdrawal
- Selected epilepsy syndromes
- Specifically epileptiform abnormalities detected on EEG
- Family history of epilepsy