Authors: Alfredo Roma* and Vincenzo Nasillo**
*Member of the Advisory Council of The European Space Policy Institute, Vienna – Former President of the Italian Civil Aviation Authority and of the European Civil Aviation Conference.
* *Medical doctor, Department of Medical and Surgical Sciences, Section of Haematology, University of Modena and Reggio Emilia (Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy).
Each year nearly three billion people travel by air on domestic and international airlines. The International Air Transport Association (IATA) has predicted that in the coming two decades, the number of passengers would double. A global increase in travel, as well as an increasingly aged population in many countries, makes it reasonable to assume that there will be a significant increase in older passengers and passengers with illness. Modern commercial aircraft are very safe and, in most cases, considerably comfortable. However, air travel, in particular over long distances, exposes passengers to a number of factors that may have an effect on their health and well-being. Passengers with pre-existing health problems are more likely to be affected and should consult their doctor or a travel medicine clinic in good time before travelling. Health risks associated with air travel can be minimized if the traveller plans carefully and takes some simple precautions before, during, and after the flight. In 2005 the World Health Organisation (WHO), in collaboration with IATA and the International Civil Aviation Organisation (ICAO), prepared a document on air travel and relevant health considerations (1). The main factors that can influence the passenger’s health are:
- Cabin pressure: although aircraft cabins are pressurized, cabin air pressure at cruising altitude is lower than air pressure at sea level. At typical cruising altitudes in the range 10,500–12,000 metres (35,000–40,000 feet) air pressure in the cabin is equivalent to the outside air pressure at 1,800–2,400 metres (6,000–8,000 feet) above sea level. As a consequence, less oxygen is taken up by the blood and gases within the body expand. The effects of reduced cabin air pressure are usually well tolerated as cabin contains ample oxygen for healthy passengers and crew. However, because cabin air pressure is relatively low, the amount of oxygen carried in the blood is reduced compared to sea level. Passengers with certain medical conditions, in particular heart and lung disease, and blood disorders such as anaemia, may not tolerate this reduced oxygen level (hypoxia). Such passengers are usually able to travel safely if arrangements are made with the airline for the provision of an additional oxygen supply during flight.
- Gas expansion: As the aircraft climbs, the decreasing cabin air pressure causes gases to expand in accordance with Boyle’s Law (Pressure x Volume = Constant). Similarly, as the aircraft descends, the increasing pressure in the cabin causes gases to contract. This can cause problems to individuals with ear, nose, and sinus infections.
- Cabin humidity and dehydration: The humidity in aircraft cabins is low, usually less than 20% while in the home is normally over 40%. Low humidity may cause skin dryness and discomfort of the eyes, mouth and nose.
- Immobility, circulatory problems and Deep Vein Thrombosis (DVT): prolonged immobility (especially in long haul flights) may cause problems, especially for people who have suffered from previous DVT or pulmonary embolism, or for pregnant women.
- Psychological aspects: travelling by air is a stressing activity for many people and may lead the passenger to a disruptive behaviour that can be dangerous for the safety of flight.
Other minor factors identified by the WHO are: jet leg, cosmic radiation, diving (before flying). The same document of the WHO also considers the case of passengers with reduced mobility that need to move on a wheelchair and be assisted during the flight.
The WHO document recalls that airlines have the right to refuse to carry passengers with conditions that may worsen, or have serious consequences, during the flight. Airlines may require medical clearance from their medical department/adviser if there is an indication that a passenger could be suffering from any disease or physical or mental condition that: i) may be considered a potential hazard to the safety of the aircraft; ii) adversely affects the welfare and comfort of the other passengers and/or crew members; iii) requires medical attention and/or special equipment during the flight; iv) may be aggravated by the flight.
In 2003 the Aerospace Medical Association has published a more detailed analysis – compared with the WHO document – on medical guidelines for airline travel (2).
Finally, in 2004 the British Medical Association, with the contributions of many external experts, published another important document analysing the passengers’ eventual diseases that may negatively affect the safety of flight. The document offers a precise description of “aviation and physiology” and a useful inflight management of medical conditions (3), including visual impairment and hearing impairment.
The regulatory framework
Airlines tend to facilitate passengers with “reduced mobility” (this term includes sensory or motor impairment) to travel by air to increase the number of their clients. Besides the problems created by factors connected with flying, the increased threat of terrorism has created additional problems for passengers with some medical conditions. This is most apparent for those who wish to carry sharp items in their hand luggage, such as hypodermic needles for use by insulin dependent diabetics or oxygen for respiratory diseases or simply liquids. In the US, the Transport Security Administration (TSA) has issued specific guidelines for acceptance of such items, which include requirements for a covering letter from the treating doctor and a pharmacy label on all medications.
ICAO does not include in its role any reference to health issues. For this reason, governments have generally prioritised safety (and other ICAO requirements) but the European Union and the US have given a considerable attention to this matter.
The main European Union provisions are those contained in the Regulation No.1107/2006/EC of 5 July 2006 (4).
The Regulation stresses that “…disabled persons and persons with reduced mobility, whether caused by disability, age or any other factor, should have opportunities for air travel comparable to those of other citizens”. Therefore: “assistance to meet their particular needs should be provided at the airport as well as on board aircraft, by employing the necessary staff and equipment. In the interests of social inclusion, the persons concerned should receive this assistance without additional charge”(5). To finance such assistance the Regulation provides that “The managing body of an airport may, on a non-discriminatory basis, levy a specific charge on airport users for the purpose of funding this assistance”(6). And “For the purpose of funding either of these, the managing body may levy a charge on the air carrier additional to that referred to in Article 8(3), which shall be transparent, cost‑related and established after consultation of the air carrier concerned” (7).
The Regulation defines “disabled person or person with reduced mobility any person whose mobility when using transport is reduced due to any physical disability (sensory or motor, permanent or temporary), intellectual disability or impairment, or any other cause of disability, or age, and whose situation needs appropriate attention and the adaptation to his or her particular needs of the service made available to all passengers” (8). On 11 June 2012 the Commission published a Staff Working Document containing guidelines for the interpretation of Regulation 1107/2006/EC (9). Nevertheless, some provisions or definitions still remain unclear like, for example the definition of “disabled person” (Q1 page 2) and the medical assistance on board (page 8, point b). Despite from Whereas (1) and (4) it seems that assistance should be offered without additional charge, the Staff Working Document states that “Air carriers may choose to provide oxygen directly to the passenger. However, there is no obligation on air carriers to do so. Where oxygen is provided directly, the air carrier may charge for its provision. Where charges are imposed for the provision of medical oxygen, carriers may wish to consider offering it at a discounted rate. Carriers have to publish the cost of this service as part of the rules and restrictions applicable”.
Actually, oxygen for passengers with respiratory problems is offered for free by some airlines (Etihad, British Airways, Vueling, Air Baltic, Tarom) while other airlines (Air France, Alitalia, Lufthansa) require a contribution that varies from €200 to €350 per leg, that looks unreasonable in respect of the actual cost of the service. This happens despite the Regulation 965/2012/EC states that “There shall be a sufficient number of oxygen dispensing units, but in no case less than two, with a means for cabin crew to use the supply”(10), service that should be at no cost for the passenger.
The same Regulation 1107/2006/EC suggests that “In organising the provision of assistance to disabled persons and persons with reduced mobility, and the training of their personnel, airports and air carriers should have regard to document 30 of the European Civil Aviation Conference (ECAC), Part I, Section 5 and its associated annexes, in particular the Code of Good Conduct in Ground Handling for Persons with Reduced Mobility as set out in Annex J thereto at the time of adoption of this Regulation”(11). The main attention has been given to the assistance to be provided to passengers during the flight, considering the particular conditions existing in an aircraft cabin in respect of ground, but it is clear from the above that the assistance has to be offered also at the airport by its managing body(12).
Article 4 of the regulation provides for the cases of denied boarding to a person with reduced mobility on the ground of the same reasons foreseen by the WHO document mentioned here above.
Assistance provided by airport and airlines
The assistance provided by airport normally concerns persons with reduced physical mobility, i.e. persons who need a wheelchair and an assistant assuring a smooth embarkation and disembarkation. Procedures are normally easy, requiring only a notification of the person’s particular needs to the air carrier for such assistance to be provided 48 hours before the published time of departure of the flight.
The situation is more complicated when the assistance is requested for sick persons during the flight. The airline is responsible for carrying its passengers safely and efficiently to the destination. The airline has no real means of ensuring that all passengers are fit to begin their journey. The medical department is responsible for ensuring, as far as possible, that passenger health does not deteriorate during the journey, and that there are adequate measures in place to deal with any unforeseen in-flight medical emergency. Due to the marked increase of the number of passengers with reduced mobility or difficult medical conditions, the medical advice to the passenger by the airline medical department has assumed great importance and is a major factor in successful airline operations. Many airlines release medical clearance for passengers with recent or unstable medical conditions requiring a special medical form based on the IATA Medical Information Form (MEDIF) (13). Those passengers with chronic, but stable, medical conditions, and those with additional needs, may be issued with a FREMEC card, copy of which is kept in the airline reservations system for easy reference for future travel. Cabin crew must be well trained in First Aid to enable them to assist a passenger, or fellow crewmember who becomes unwell in-flight. They must be prepared for virtually any sort of medical emergency and airlines now put crew through a rigorous training programme, to incorporate all aspects of First Aid including CPR (Cardio Pulmonary Resuscitation) and emergency childbirth. The crew must be trained in their use and limitations and be sufficiently confident and competent to use them promptly when the need arises. Services may include:
- First aid and emergency medical kits (EMKs);
- Trained cabin personnel;
- Air to ground communication between the cockpit and ground physicians;
- Automatic External Defibrillation;
- Telemedicine (14).
However, it should be noted that the emergency medical kits contain only a limited number of devices, drugs or other medication items. The first step in designing any airline’s medical kit is to survey and determine what medical events are occurring more frequently on board. Certainly, cardiac events are more frequent in respect of other illness, which include, inter alia: blood disorders, respiratory diseases, neurological disorder, after surgery situation, etc.
One of the more significant changes in the last ten years has been to carry on board automatic external defibrillators (AEDs) to face inflight problems with passenger having heart disease. Airlines have also trained flight attendants to use the defibrillators. The U.S. Congress passed the Aviation Medical Assistance Act (15) in 1998 requiring the Federal Aviation Administration (FAA) to collect inflight and in-airport medical events data over a one-year period to determine whether current minimum requirements for air carrier to carry on board medical equipment and train their crewmembers should be modified. In response to the Act, the study was conducted from July 1998 to July 1999. It revealed 188 deaths (43 occurred inflight) of which approximately 2/3 were believed to be cardiac (Jordan J. Personal communication).
On June 12, 2001, in response to the Aviation Medical Assistance Act, the FAA issued a final rule that required passenger aircraft of more than 7,500 pounds maximum payload capacity, with at least one flight attendant, to carry at least one automatic external defibrillator (AED) and at least one enhanced emergency medical kit. The new rule became effective on April 12,
2004, giving the airlines 3 years to meet the standards. In addition to the AEDs, the expanded medical kit contains additional equipment and medication as listed in Tables I and II (30,31) of the Act. Airlines also implemented flight crewmember training programs to use the AED.
In the European Member States this matter has been ruled by Regulation No. 965/2012/EU (16). Annex IV of the regulation gives only a limited number of provisions regarding the Medical Kit to be carried on board, but the AMC (Acceptable Means of Compliance) to the Regulation (EU) No 965/2012, issued by the European Air Safety Agency (EASA) (17), shows a quite detailed list of medication and instrumentation items, suggesting, however, that “these kits should be complemented by the operator according to the characteristics of the operation (scope of operation, flight duration, number and demographics of passengers”). It also recommends for commercial air transport operations, to carry an automatic external defibrillator on aeroplanes required to carry an emergency medical kit (those having a passenger seating configuration of more than 30 seats) when any point on the planned route is more than 60 minutes flying time at normal cruising speed from an aerodrome at which qualified medical assistance could be expected to be available. Namely the acceptable means of compliance to the rule concerned (CAT.IDE.A.225),listing the content of the Emergency Medical Kit, recommends operators to determine through risk assessment the need to carry the defibrillator. So there is no strict requirement for operators, but only a recommendation based on the result of a risk assessment. Actually, EASA states that the AMC “is an unofficial courtesy document, intended for the easy use of stakeholders, and is meant purely as a documentation tool. The Agency does not assume any liability for its contents”. The above is however in line with the current ICAO Annex 6 recommendations (18).
Medical assistance to passengers when travelling by sea and inland waterway.
Similar provisions for disabled persons and persons with reduced mobility travelling by sea and inland waterways have been established in the European Union by the Regulation 1177/2010/EU (19). Like Regulation 1107/2006/EC for air passengers, this regulation recalls the Charter of Fundamental Rights of the European Union stressing the right of non-discrimination and of receiving assistance in terminals and on board. The definition of “disabled person or person with reduced mobility” is the same for both regulations. Obligations for air carriers and airport managing bodies are the same established for sea carriers and terminal operators. EU Member States provide penalties for infringement of both regulations. However, it should be noted that health problems that can occur inflight do not occur at sea level. In addition vessels normally offer an equipped infirmary and doctors able to face any health emergency.
The above concise description shows that the medical assistance provided by the air carriers has not a clear and homogeneous set of rules binding for all airlines. It differs from one country to another and it is to some extent based on soft rules like codes of conduct; consequently the kind of assistance offered varies substantially from one air carrier to another. A clear example is that of oxygen supply reported here above. In addition, this uneven regulatory framework is reflected in the fitness to fly guidelines. Regarding anaemia, for example, the minimum level of haemoglobin required to fly without oxygen varies enormously from one airline to another. Only a few airlines publish in their site a clear table showing for any illness or difficult health conditions a precise status or value acceptable or not acceptable for flying (short/medium haul and long haul) and relevant comments. However, regarding anaemia it should be pointed out that it is impossible to establish an absolute haemoglobin value permitting a “safe flight”. Even from a clinical point of view, symptoms and signs may not be closely related to the degree of anaemia and my vary to patient to patient. Consequently medical measures for anaemia (e.g. transfusion) are usually clinically based rather than defined by a certain haemoglobin threshold. Therefore, the value of haemoglobin suggested by the airlines is precautionary measure to avoid problems during the flight.
Considering the scenario described here above, it seems recommendable that, at the European level, the European Commission, EASA and the European Airlines Association (AEA), in agreement with IATA, take the initiative to design a complete and clear regulatory framework providing binding standards applicable to all European air carriers.
(1) World Health Organisation – Travel by air – Health considerations. 2005.
(2) Aerospace Medical Association – Alexandria, VA – Medical Guidelines for Airline Travel – 2nd Edition – 2003.
(3) The impact of flying on passenger health: a guide for healthcare professionals. British Medical Association – Board of Science and Education 2004 – www.bma.org.uk
(4) Regulation (EC) no 1107/2006 of the European Parliament and of the Council of 5 July 2006 concerning the rights of disabled persons and persons with reduced mobility when travelling by air.
(5) ibid. Whereas (1) and (4).
(6) Ibid. Article 8(3).
(7) Ibid. Article 9(5).
(8) Ibid. Article 1 – Definitions.
(9) Commission Staff Working Document – Interpretative Guidelines on the application of Regulation (EC) N° 1107/2006 of the European Parliament and of the Council of 5 July 2006 concerning the rights of disabled persons and persons with reduced mobility when travelling by air. 11 June 2012. See also the European Commission Memo of 14 June 2012.
(10) Regulation 965/2012/EU Annex IV – CAT.IDE.A.230 First-aid oxygen
(11) ECAC Policy statement in the field of civil aviation facilitation ECAC/CEAC doc no. 30 (part i) 10th Edition/December 2006.
(12) Regulation 1107/2006/EC Article 7.
(13) MEDIF Information Form (English language is a must) is used for providing confidential information of passengers requiring special assistance. The information enables the airline’s Medical Centre to assess fitness of the passenger for air travel and to determine the use of medical equipment during travel e.g. stretcher, incubator, etc. In same cases the airline may require a detailed Medical Report to accompany the MEDIF, which should be presented to the air carrier at least 48 or 73 hours before the scheduled time of departure.
(14) IATA Medical Manual – Montreal -2015.
(15) 1998 Public Law 105-170, 49 USC 44701.
(16) Commission Regulation (EU) No U/2012 of 5 October 2012 laying down technical requirements and administrative procedures related to air operations pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council. Annex IV – Part CAT.
(17) Acceptable Means of Compliance (AMC) and Guidance Material (GM) to Annex IV – Part-CAT to Commission Regulation (EU) No 965/2012 on air operations including the initial issue of and all subsequent amendments to the AMC/GM associated with this Annex. Issued by the European Air Safety Agency (EASA) on 20 February 2015.
(18) Annex 6 – Attachment B – Medical supplies – Chapter 6, 6.2.2 a), which reads as follows:
Based on the limited available evidence, only a very small number of passengers are likely to benefit from the carriage of automated external defibrillators (AED) on aeroplanes. However, many operators carry them because they offer the only effective treatment for cardiac fibrillation. The likelihood of use, and therefore of potential benefit to a passenger, is greatest in aircraft carrying a large number of passengers, over long duration sector lengths. The carriage of AEDs should be determined by operators on the basis of a risk assessment taking into account the particular needs of the operation.
(19) Regulation (EU) no. 1177/2010 of the European Parliament and of the Council of 24 November 2010 concerning the rights of passengers when travelling by sea and inland waterway and amending regulation (EC) no 2006/2004.