Asthma and Allergy Foundation of America

Statement of the Asthma and Allergy Foundation of America August 8, 2010 Founded in 1953, the Asthma and Allergy Foundation of America (AAFA) is a national foundation dedicated to serving the more than 60 million Americans with asthma and allergic diseases. AAFA provides free information to the public, offers educational programs to consumers and health professionals, leads efforts to improve patient care and supports research to find better treatments and cures. AAFA conducts outreach to patients in the form of online surveys, advocacy training and focus groups. Summary Anaphylaxis is a serious medical complication, which can be life-threatening if rapidly developing symptoms are not treated promptly. On planes, this risk is heightened due to limited medical care and resources. Curtailing distribution and consumption of peanut products will decrease a peanut allergic passenger’s sense of risk when flying. Providing clear notice of airline policies, effective emergency treatments and training for airline personnel to support policies and treatments is reasonable. So is having epinephrine auto-injector availability on all commercial flights. The Department should require that airlines offer the peanut-allergic flying public no less. AAFA urges the Department of Transportation to: 1. Require airlines to implement consistent, uniform policies and practices that provide better access to air travel for people who have severe peanut allergies; 2. Require airlines to provide mandatory training to airline personnel on policies and practices that promote the safety and comfort of peanut allergic travelers; 3. Require airlines to include epinephrine auto-injectors in the emergency medical kit on every passenger flight; 4. Ban airlines from serving peanuts and products containing peanuts; and 5. Require that airlines offer peanut allergic patients a peanut-free zone or peanut free flights upon request. Discussion In recent decades, the medical community has documented a rise in atopic conditions, specifically affecting young children. Reported food allergy prevalence among those younger than 18 years of age has increased 18% from 1997 to 2007. This overall trend reflects the growth of peanut allergies in the United States. During the five years between 1997 and 2002, the prevalence of peanut allergies in children nearly doubled. The most severe symptom associated with peanut allergy is anaphylaxis, a rapid onset, immunologic reaction that can be fatal. In order to avoid serious complications, allergic individuals often carry self-injectable epinephrine in the event of an episode. To an extent, most airlines recognize the risks that confront allergic individuals who travel by air, but airline policies and practices vary. Some request information about allergies at the time of ticketing, and some suggest letting gate personnel know of any allergy requests. Some will announce that there is an allergic passenger on board. Some airlines continue to serve peanuts. Some will stop doing so at the request of a passenger, and others will request that other passengers refrain from opening packages containing nuts. Another leaves the decision to curtail peanut distribution to the crew. At least one says it will assist in assuring cooperation from other passengers; however, another states it will not make such announcements or request restraint by other passengers. Even where airlines have policies, their personnel may apply them inconsistently, or they may not make them available in advance of travel. Allergic consumers report that at least one airline aspires to “forward looking” policies but another posted a recommendation that travelers assess the extent of their allergies to determine if air travel is appropriate. It should come as no surprise that many peanut allergic families face increased anxiety of suffering anaphylaxis thousands of feet in air, or avoid air travel altogether. Over the years, allergic travelers have complained to AAFA about airline policies and practices that are inconsistent, unevenly applied, not available in advance of travel or expose them to allergy triggers. In a recent case, the mother of a nine year old with severe peanut allergies expressed concern that her son might have a significant allergic reaction while traveling onboard a domestic flight. Various gate and crew personnel from the air carrier gave mixed messages to her, first allowing her to board early to wipe down the assigned and nearby seats, then removing her and her son from the flight, and ultimately allowing them back after ascertaining that she was carrying two EpiPens® and Benadryl®. Granted, no airline can guarantee that passengers with severe allergies will have an absolutely safe flying experience, completely free of exposure to peanuts or other triggers. Airline passengers do not expect guarantees but peanut allergic passengers would benefit from consistent airlines policies and practices that they can ascertain well in advance of their flights so that they can make appropriate choices. Therefore, AAFA welcomed the June 2010 notice of proposed rulemaking (NPRM) by the United States Department of Transportation (DOT) requiring airlines to make policies protecting passengers with severe peanut allergies in accordance with the Air Carrier Access Act disability provisions. DOT invited the public to comment on the following options: • Banning the serving of peanuts and all peanut products on all flights covered by DOT's disability rule • Banning the serving of peanuts and all peanut products on all such flights where a passenger has requested a peanut-free flight in advance • Requiring a peanut-free buffer zone if a passenger has requested a peanut-free flight in advance DOT also solicited comments on whether epinephrine auto-injectors would sufficiently protect individuals with severe peanut allergies, and whether the individual or the airline should be responsible for providing the device. Shortly after the Department released the NPRM, the Secretary of Transportation noted that the Department would uphold the terms of a 2000 Appropriations Act, which limited a 1998 attempt to increase protections for air travelers with peanut allergies. The Act forces the DOT to wait 90 days after a peer-reviewed scientific study that determines there are severe reactions by passengers is submitted to both Congress and the Secretary of Transportation before it can regulate peanut distribution on airlines. Notwithstanding this development, AAFA is commenting on the proposed rule because of its importance to the allergy and asthma community, and because certain aspects of the proposed rule relating to peanut allergic airline passengers' interests are unrelated to peanut distribution on commercial airlines. The next section presents four areas of recommendation. 1. Allergic Airline Passengers Deserve Clear, Consistent Policies and Practices. Allergic passengers face extraordinary challenges in flying on commercial carriers. Once the Department is able to fully regulate peanut distribution on airlines, AAFA urges it to adopt rules requiring airlines to implement consistent, uniform policies and practices that provide better access to air travel for people who have severe peanut allergies. Those policies should require the airlines to adopt rules mandating that airlines post their allergy policies, implement a clear and accessible process for passengers to request a reasonable accommodation for their peanut allergy, and offer a means for immediately reporting and redressing complaints to airline personnel. The benefit to passengers will be significant because they will have access to information about airline policies in advance and those policies will be consistent across air carriers. Consistent policies and practices will not guarantee safety, but may encourage passengers who now avoid flying due to health concerns and uncertainty about whether and how their chosen air carrier will accommodate their peanut allergy or refuse them service. In addition, airline personnel should be familiar with such policies and practices so that passengers will not be endangered, inconvenienced or humiliated by ignorance and misinformation about the nature of severe allergies and practices that lower the risk of anaphylaxis. Therefore, AAFA urges the Department to adopt rules requiring airlines to provide mandatory training to airline personnel on policies and practices that promote the safety and comfort of peanut allergic travelers. 2. Protect passenger safety by requiring airlines to carry epinephrine auto-injectors on every passenger flight. Currently, the 2000 Federal Aviation Regulation requires two 1:1000 and 1:10,000 dosages of epinephrine on all passenger-carrying planes as part of an enhanced emergency medical kit (EEMK). Epinephrine has been in emergency medical kits since 1986, but no regulation requires auto-injectable epinephrine. The Federal Aviation Administration (FAA) declined to require them, stating that studies did not reveal a need to make epinephrine auto-injectors available and suggested a greater need for oral treatments to allergic reactions. As allergic patients await improved breakthrough oral treatments, auto-injectable epinephrine is available now and offers substantial benefits for use on airlines since the handy, premeasured device reduces administration time and improves dosing accuracy. Both are crucial when treating anaphylaxis. The Department has the opportunity to improve the flying conditions for all travelers with allergic reactions by requiring epinephrine auto-injectors on all flights. Therefore, AAFA urges the Department to require airlines to include epinephrine auto-injectors in the EEMK on every passenger flight. Further, the Department should require airlines to train flight crews to properly administer the medication. 3. Promote accessibility by prohibiting airlines from serving peanuts. AAFA urges the Department to ban airlines from serving peanuts and products containing peanuts as soon as the Department determines that it is permitted to make such regulations. AAFA recognizes that distributing peanuts and snacks that contain peanuts on airlines has become culturally iconic. Yet safety considerations have forced the flying public to adopt behaviors unfathomable before 9/11, like surrendering one’s coat, jacket and shoes for a search, limiting liquids in carry-on luggage, even submitting to a revealing three-dimensional whole body scan. Passengers subject themselves to these intrusive measures for safety’s sake. AAFA asks that the Department expect the flying public to cooperate by giving up its expectation of onboard peanuts, in favor of other salty snacks, to promote the safety of severely allergic passengers. 4. Promote accessibility by offering peanut allergic patients a peanut-free zone or peanut free flights upon request. In 1998, DOT required airlines to make a reasonable accommodation to air travelers who are allergic to peanuts (pursuant to the disability provisions of the Air Carrier Access Act [ACAA]). The agency suggested that airlines, if given advance notice, provide a peanut-free buffer zone in the immediate area of a passenger with a medically-documented severe peanut allergy. Then, Congress intervened and directed DOT to stop regulating peanut distribution or face a funding cutoff. As the Department’s previous regulatory proposal indicates, limiting the distribution and consumption of peanut products on covered flights is a reasonable approach to making airlines safer for severely peanut allergic passengers. This alternative is distinct from the ban on peanut distribution because it impacts choices made by other passengers to consume peanuts onboard. AAFA understands that prohibiting possession and consumption by passengers may be impractical for airlines to enforce. However, discontinuing serving peanuts by airlines may not be a complete strategy for enhancing peanut-allergic passenger safety. Peanut dust and residue on seats and tray tables can trigger reactions in passengers who occupy nearby seats and rows. For some, peanut residue and dust anywhere on the plane can be a life-threatening. We are encouraged that passengers who are informed by courteous airline crewmembers about the need to accommodate a severely allergic traveler will comply with those requests.