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OCR for page 190
6
HEALTH EFFECTS ASSOCIATED WITH EXPOSURE
TO AIRLINER CABIN AIR
The survey of airliner cabin contaminants in Chapter
5 suggests a diverse set of adverse health effects that
could arise from exposure to the cabin environment--from
acute effects, such as irritation, inflammation, and
infection, to long-term effects, such as neoplasms,
reproductive disorders, and decrement in pulmonary
function. The following sections review the
epidemiologic literature on adverse health effects that
have stemmed from cabin air, as manifested in passengers
and crews of commercial airliners. Where it is relevant,
we also include studies on general aviation and military
aircraft crews.
Our review of the literature overlaps with that of
Kraus, 33 who reviewed epidemiologic studies of health
effects in commercial pilots and flight attendants.
Although his review focused on occupational effects
unrelated to cabin air quality, he did present original
data on occupational illness that are relevant to our
study. He used 1979 California statistics on
occupational illness and injury to compare the reported
numbers of illnesses and injuries in flight attendants
with the numbers expected, which were based on combined
overall percentage distributions for all occupations.
Flight attendants' reported occupational illness is
generally much less than expected, except for infection,
disease of the inner ear, respiratory disease, and
aerotitis media; for these, ratios of observed to
expected frequencies range from 9.8:1 (infections) to
209.1:1 (aerotitis media). It seems that the latter
conditions are occupationally induced, but we know of no
further relevant analyses of occupational-illness
statistics.
We found almost no studies of health effects in
airliner passengers, other than a few isolated case
190
OCR for page 191
191
reports of miscellaneous diseases. The one exception is
a Danish retrospective study47 of 773 airline passengers
admitted to a Danish emergency ward from Copenhagen
Airport in Kastrup in 1975-1976. The estimated annual
turnover at that airport during the period was 8-9
million passengers. The most common illnesses were
injury and poisoning (219 passengers), "symptoms, signs,
and ill-defined conditions" (120), diseases of the
circulatory system (67), diseases of the respiratory
system (62), and infections and parasitic diseases (57~.
Many illnesses classed as "symptoms, signs, and ilI-
defined conditions" might have been related to the cabin
environment, including hyperventilation, syncope and
collapse, and ear problems; but it is not possible to
attribute any of these illnesses or injuries directly to
cabin air quality.
HEALTH EFFECTS OF CONCERN
IRRITATION AND INFLAMMATION
Passengers and cabin crew in an airliner can be
exposed to a number of substances that can cause eye,
nose, and respiratory irritation, which also appear to
be commonly reported by passengers and crew when
complaining about the air quality in airplanes. There
has been relatively little evaluation of these symptoms
among aircraft occupants.
A questionnaire survey of flight attendants in 1978
found a high prevalence of reported eye discomfort.21 22
The survey form was distributed through the monthly
magazine of the Association of Flight Attendants, which
at that time represented flight attendants on 18 mayor
airlines. Of the 774 who responded, 95X reported some
eye discomfort while on an aircraft. Dry eyes and
redness were reported by approximately 90X of the
respondents; fewer reported other eye symptoms, such as
blinking, blurred vision, and tearing. Over 90%
reported smoking as a cause of their discomfort.
_ _ ~ ~. .
~ . Air-
conul~lonlng' cabin Lights, wing reflection, and napping
were also reported as contributing to eye problems. In
general, the complaints were not correlated with the use
of contact lenses, but attendants wearing soft contact
lenses did report more problems with blurred vision and
tearing. Although a high prevalence of eye discomfort
OCR for page 192
192
was reported, the value of the study's conclusions is
limited by the possibility of selection bias in the
respondents to the survey and by the lack of a
comparison group.
Three studies have attempted to evaluate symptoms
due to ozone exposure on aircraft. In 1978, Reed et
al., at the California State Department of Health,
conducted a questionnaire study of flight attendants in
three airlines: Pan American World Airways, which
usually flew long distances at high altitudes; Pacific
Southwest Airlines, which flew only short distances at
lower altitudes; and Trans World Airlines, which flew
both types of routes. 50
Of questionnaires mailed to 3,280 flight attendants,
1,330 completed questionnaires were received. The
authors estimated that 61% of flight attendants on
active status returned questionnaires, which included
questions on symptoms related to ozone exposure, on
other risk factors, on characteristics of the flights,
and on the time course of symptoms.
_ Ozone exposures
were believed to be much higher in the high-altitude
long-distance flights. The prevalence of some symptoms
possibly related to ozone exposure (chest pain,
difficulty in breathing, and persistent cough) wan
significantly higher among the attendants on the
high-altitude flights than among those in the other two
airlines. No significant differences were found in the
prevalence of other symptoms, such as extreme fatigue
and back pain, which would not be expected to be caused
by exposure to ozone. - ~
Flying on particular high-altitude
aircraft (e.g., B-747 and B-747-SP, not equipped with a
catalytic unit to abate ozone in the cabin air) was
associated with symptoms of ozone toxicity.
-
~ ~ In general,
this study found a higher prevalence of symptoms of
ozone toxicity among flight attendants with higher
exposures to ozone. Although limited by the response
rate and the lack of direct ozone measurements, this
studs did indigo possible problems due to exposures
-
during high-altitude long-distance flights.
Another questionnaire study of symptoms due to ozone
exposure among flight attendants was conducted in 1977
by Tashkin et al., at the University of California, Los
Angeles.52 A questionnaire directed at flights on the
B-747-SP was sent to 450 flight attendants in the Los
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lg3
Angeles area, of whom 248 responded; a questionnaire
directed at flights on the B-747 was sent to the same
248 attendants and produced only 38 responses; and a
similar questionnaire directed at both aircraft was sent
to 850 attendants in the New York area, of whom only 65
responded. The questionnaire results were evaluated by
three independent observers, who knew which aircraft the
respondents had worked on and who graded symptoms on the
basis of their possible relationship to ozone exposure.
In addition, 21 flight attendants who had experienced
severe respiratory symptoms while on B-747-SP aircraft
received a more detailed medical evaluation, including
pulmonary function testing, about 2 wk after the problem
flight. The attendants who flew on the B-747-SP aircraft
reported a higher prevalence of ozone-related symptoms
(throat irritation, cough, difficulty in breathing, etc.)
while on the aircraft than afterward and a higher
prevalence than the attendants who flew on the standard
B-747 in both the New York and Los Angeles portions of
the study. The results of all the pulmonary function
testing on the 21 selected participants were normal, as
expected on the basis of time since exposure. Although
it suggested that symptoms were due to ozone exposure,
this study was limited by the lack of direct measurements
of ozone exposure and by the very poor rate of response
to the questionnaires, particularly in the comparison
group.
A third study was performed by the Occupational
Health Clinic of San Francisco General Hospital in 1984
at the request of the Independent Union of Flight
Attendants.30 The study was designed to see whether the
prevalence of ozone-related symptoms reported by Reed et
al* 50 persisted on long-haul, high-altitude flights
and whether respiratory symptoms on these flights were
associated with objective decreases in pulmonary
function. The study consisted of two phases. In Phase
I, all Pan American World Airways flight attendants
based in San Francisco, London, or California were
mailed a self-administered questionnaire concerning
symptoms, medical diagnoses, smoking, and occupational
history. Results of the questionnaire were compared
with the data of Reed et al. A small selected group of
flight attendants who noted ozone-related symptoms on
the questionnaire were asked to participate in Phase
II. For Phase II, each participant was instructed in
the use of a Mini-Wright peak flow meter to measure peak
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194
expiratory flow rate (PEFR) and measured PEFR every 2 h
while awake (total duration was not reported). Preflight
(more than 12 h since last flight) and postflight (any
time within 12 h of landing) PEFR measurements were then
compared with unpaired t tests.
For Phase I, approximately 1,OOO flight attendants
were sent the survey; 280 returned completed
questionnaires. A followup survey indicated that many
nonrespondents failed to respond because their identity
would not be protected. Demographically, the responding
sample was similar to that of the Reed et al. sample,
but older. Prevalence rates of chest pain or tightness
(65%), shortness of breath (65%), and cough (57%) were
similar to or slightly higher than those reported by
Reed et al. Symptoms were more prevalent on B-747-SP
flights and were more prevalent among those who had ever
smoked than among nonsmokers.
Of the 20 flight attendants asked to participate in
Phase II, only eight yielded analyzable data. Mean
preflight PEFRs were always higher than postflight
PEFRs, by 7-35 L/min (average, 21 L/min). The
statistical analysis of the data is incorrect, so it is
difficult to judge the statistical significance of these
results. Two flight attendants had preflight-postflight
differences in PEFR of over 20% in 24 h associated with
long flights.
These results suggest that efforts to reduce onboard
ozone concentrations have not had an effect on the
prevalence of ozone symptoms and that flights might be
accompanied by decreases in PEFR. Phase I had several
limitations, including a lower response rate and an
older population than the Reed et al. study, a self-
administered questionnaire, and a lack of ozone
measurements. Phase II was hampered by very small
numbers, self-selection, use of flow meters with
questionable accuracy, self-administered data collection,
an ambiguous protocol for data collection (which allowed
different persons to contribute different numbers of
observations), a lack of ozone measurements in flight,
and inappropriate data analysis. If these limitations
are kept in mind, this study's conclusions can be
regarded as only suggestive until confirmed by
appropriately designed studies.
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195
In each instance of potential irritation and
inflammation, passengers and crews with pre-existing
disease or disorders of the organs affected suffer
increased effects. People with unDer resoiratorv
~ _ ~ ~
, _ _ ~
~nrecc~ons stirrer more trom pressure changes and possibly
from low humidity. People wearing soft contact lenses
have more eye symptoms that result from low humidity.
Patients with chronic pulmonary disease might have more
symptoms from inhaling ozone. The medical literature
discusses these increased susceptibilities, but does not
document them.
Asymptomatic sinus disease has been the subject of a
number of studier. One study2 3 of 211 Air Force pilots
aged 25-35 showed radiographic evidence of maxillary
sinus abnormality in 25%, but no control group was
studied. A followup study compared these Air Force
pilots with two groups of Air Force employees who had no
flying experience. ^~
~ ^^ ~. . .
one comparison group consisted of
Mu new airmen trainees Who were below age 25; the
second consisted of 100 men aged 25-35 who were patients
in an Air Force hospital for diagnostic procedures not
related to ear, nose, or throat symptoms and had no
flying experiences The prevalence of maxillary sinus
abnormality among the two control groups was 26X and
29%, respectively. Another study2 7 compared 1,284
asymptomatic flyers with a control group of 200
nonflyers. The reported prevalence of abnormalities of
the paranasal sinuses was 22X in the control group and
15.6% in the flyers. Selection of the controls and
comparability of the two groups were not reported.
Other conditions associated with mucous membrane
inflammation have been found in airliner cabin
occupants. Aerotitis media and other middle ear
conditions have been reported as significant health
problems for flight attendants. 33 55 ~
might be due to cabin pressure changes, but mucous
membrane inflammation could contribute to them.
,INFEC7ION
-l-nese conditions
Only one study has clearly documented the occurrence
of an outbreak of infectious disease related to airplane
use. 4 3 An outbreak of influenza occurred in 1978 in
Alaska. Because of an engine malfunction, an airliner
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196
with 54 persons aboard was delayed on the ground for 3
h, during which the aircraft ventilation system was
reportedly turned off. Within 3 d of the incident, 72X
of the passengers became ill with influenza. One
passenger (the index case) was ill while the aircraft
was delayed. Serologic evidence of influenza infection
was found in 20 of 22 passengers tested, and the virus
was isolated from eight of 31 passengers whose serum was
cultured. Documentation of this outbreak wan assisted
by the circumstance that all the passengers traveled to
one small town and by the alertness of the local
physician. Similar outbreaks could result from crowded
flights with an infectious person and not be documented
or noticed, because passengers would disperse after
landing.
Persons with coincidental acute and chronic
infections suffer more from superimposed infections
acquired on the aircraft. In addition, increasing
numbers of people with diminished resistance to
infection might be traveling as passengers--specifically
patients undergoing chemotherapy or x-ray therapy for
malignancies and those infected with the HTLV-III virus
(acquired immune deficiency syndrome). There is no
evidence that that virus can be transmitted through the
air.
RESPIRATORY IMPAIRMENT
Various constituents of the aircraft environment
could lead to respiratory impairment in passengers or
crew. The manifestations of respiratory impairment are
diverse and include pulmonary diseases, acute respiratory
illness, sinus disease, sarcoidosis, and spontaneous
pneumothorax.
Several studies have investigated pulmonary function
in flight attendants or pilots. One report found that
higher percentages of members of self-selected groups of
Miami- and New York-based Pan American World Airways
flight attendants, but not San Francisco-based flight
attendants, had spirometric abnormalities than of an
age- and sex-matched Michigan group.44 The finding
is difficult to interpret, because of the self-selection
process, questions of comparability of measurements in
the flight attendants and the Michigan group, and
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197
failure to take smoking history into account. Another
study reported, as expected, an absence of pulmonary
function abnormalities in a select group of 21 flight
attendants who were tested 2 wk after experiencing
respiratory symptoms during B-747-SP flights. 52
A study of 257 active United Airlines pilots
revealed that 12% had evidence of minimal to moderate
ventilatory impairment.ls Disease prevalence increased
with age and smoking history, but no comparisons were
made with a nonpilot population, so it is difficult to
assess the importance of the finding. Similar findings
have been reported for general aviation airmen. 37
Dille20 compared the prevalence of asthma, emphysema,
bronchiectasis, bronchitis, and other unclassified
pulmonary diseases in a population of 288,000 active
civil airmen with the prevalence of these diseases
reported in the U.S. National Health Survey and found a
much higher prevalence in the general population. That
was expected, because of the self-selection of active
airmen. The long-term follownp of the U.S. Navy's
"l,OCO-aviator cohort" revealed that decrements in
pulmonary function were associated with cigarette-
smoking, coronary arterial disease, and weight
gain. No correlation was reported between a career in
military aviation and the development of pulmonary
disease; but a career in military aviation was a
dichotomous variable, which was coded (present) if a
person had 15 yr or more of flying history and not coded
(absent) otherwise, and is at best a weak measure of
exposure.
Several incidental reports have noted spontaneous
pneumothorax in pilots, but presented no comparisons
with nonpilot populations, so it is impossible to Judge
whether the risk is increased by a flying career or by
onboard environmental conditions.19 24 25
One British investigational has studied the
prevalence of pulmonary lesions resembling sarcoid
granulomata in 2,000 autopsy reports after 700 aviation
accidents. Military crews had a higher rate than civil
airmen, who had a higher rate than passengers or glider
pilots. Review of the incidence of clinical sarcoidosis
in the Royal Air Force in 1962-1977 showed a much greater
overall incidence than the 3 per 100,000 in the general
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198
U.K. population; the air crew incidence averaged 14.4
cases per 100,000, and the ground crew, 10.8 cases per
100,000. Because of inconsistencies in the autopsy
reports and clinical incidence rates and the lack of
corroborating evidence, no conclusions were drawn by the
author. This pathologic but often asymptomatic lesion
needs to be searched for in other well-controlled
studies.
Jasinski 3 ~ showed acute respiratory illness to be a
common problem in flight attendants, but it cannot be
determined from the report whether the incidence was
higher than that found in other populations. An Italian
study48 of morbidity in flying personnel appeared to
suggest higher rates of acute respiratory illness than
in nonflying airline employees, but the details of the
study were not reported. The work by Kraus33 cited
earlier suggested higher rates of respiratory disease in
flight attendants.
Isolated autopsy findings of hypoxia, intoxication,
hyperventilation, and carbon monoxide intoxication in
military pilots have been reported. 2 6 3 6 4 9 The
relevance of these reports to the commercial airliner
cabin environment is uncertain. One report42 showed
that contamination of the ventilation system (in milita On
aircraft) with lubricating oil could lead to
intoxication.
As noted earlier, patients with underlying pulmonary
disease are more susceptible to changes in cabin air that
affect pulmonary function. Thus, any increase in the
partial pressure of carbon dioxide (pCO2) in the air
will adversely affect patients with chronic obstructive
pulmonary disease (COPD) who are already functioning
with an increased blood ICON and increased alv~1 or
pCO2. A further increase might make
. . .
~^ ~ _ ~ ~ _ _ ~ ^
_ _ ~ _ ~ _
it even more
difficult to maintain a normal blood pH. Similarly, the
decrease in oxygen partial pressure (PO2) that occurs
at 8,000 ft is safe for normal people, but possibly
hazardous for patients with COPD. One study of patients
with COPD who were placed at reduced PO2 as they would
be at 8,000 ft showed that patients without overt
pulmonary failure can expect no trouble and that those
with symptomatic COPD can be tested in advance by their
physicians to determine whether they will need
supplementary oxygen if they must fly.51
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CARDIOVASCULAR_EFFECTS
The effects of cabin air quality on cardiovascular
function in normal persons and patients with underlying
disease are of interest. There is no evidence of any
effects in people with normal hearts and blood vessels,
other than occasional anecdotes of venous thrombosis and
pulmonary embolism, which are much more likely to be
associated with inactivity than with air quality. A
high percentage of adults have some underlying coronary
arterial disease, which theoretically could be made
worse by the products of cigarette-smoking. 3 7 - 9
Although angina pectoris might result from myocardial
ischemia, there is no evidence that myocardial infarction
would be caused by inadequacies in cabin air quality.
The many papers on coronary arterial disease and
resulting sudden death of pilots are not reviewed here,
because they are concerned with screening and related
health examinations, rather than with possible
deleterious effects of cabin air.
Some persons with symptomatic cardiovascular disease
are under medical care, so decisions about the possibly
increased hazards of reduced PO2 and exposure to
cigarette smoke, carbon monoxide, and ozone could be
made by their physicians.
NEOPLASMS
Several constituents of cabin air might increase the
risk of neoplasia, including passive smoking and exposure
to radiation. However, published reports contain little
documentation of cancer incidence in flying personnel.
Kraus33 reviewed Milham's study41 of occupational
mortality in Washington State, which gave proportional
mortality ratios for many occupational categories,
including pilots, navigators, and flight attendants.
Statistically significant increases were seen in rectal
cancer in pilots and navigators, but significant
reductions in lung cancer. These observations have not
been confirmed in other data bases.
In 1981, the Centers for Disease Control carried out
a health hazard evaluation for the Independent Union of
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Flight Attendants (IUFA).45 IUFA mailed a questionnaire
to approximately 6,000 of its members. Responses were
received from 9%; the reason for the low response rate
is that a response was requested only if the member had
cancer. Crude incidence and prevalence rates were
compared with statistics from the Birmingham Regional
and Connecticut Tumor Registries. Only skin cancer
showed an excess risk among flight attendants: 3-10
times the expected rates. The possible environmental
causes relevant to skin cancer are exposures to sunlight'
ionizing radiation, arsenicals, and hydrocarbons.
Although the results were suggestive, the study had
clear limitations, including the possible failure of
those who might have had cancer to respond, unconfirmed
self-reported diagnoses, and lack of a control group.
Three case reports of nasopharyngeal cancer in bush
pilots suggested that the cancers could be related to
pressure charges, 5 6 54 but presented no substantiating
evidence.
REPRODUCTIVE DISORDERS
A few studies on reproductive disorders or pregnancy
outcome in flight attendants have been reported.
Menstrual disorders are thought to be related primarily
to stress and interruption of circadian rhythm, but
there is some speculation that they can be attributed to
solar radiation,, 6 which might also predispose to
unfavorable pregnancy outcome.
Camerons presented data on menstrual function in 98
Swiss flight attendants. Long-term followup data on
reproductive outcome were available on only 50 women.
There was a general suggestion that no increase in
menstrual disorders was associated with flying, but that
the miscarriage rate among married ax-hostesses was high.
Iglesias et al. 2 9 reported the results of interviews of
200 flight attendants who sought medical assistance for
various clinical problems; 39% reported unfavorable
changes in menstrual cycles 6-24 mo after beginning
aeronautical service. Both these studies had problems of
recall and self-reporting, lack of controls, self-
selection, and small numbers of participants
(particularly the long-term followup in the Cameron
study), so no reliable conclusions can be drawn.
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203
MONITORING AND SURVEILLANCE
OF CREW AND PASSENGER HEALTH
Data on the health of passengers and crew have three
potential sources: airlines, flight attendant unions,
and FAA. The populations monitored can be conveniently
divided into pilots, flight attendants, and passengers.
PILOTS
FAA requires medical certification of pilots every
6 ma and thus has considerable information on the health
status of active civil airmen,12 as well as statistics
on medical disqualifications.4 18 Because of this
requirement and the expense of training pilots, many
airlines routinely monitor the health status of their
pilots. 46
Several studies have looked at the health of pilots.
Buleyl3 and Kulak et al. 35 investigated cases of
in-flight airline incapacitation, primarily with an eye
to correlating such incidents with accidents and to
determining whether stricter medical certification could
reduce in-flight incapacitation. No attempt was made to
relate incapacitation to specific occupational hazards
or to contrast incidence rates with those in a comparison
group. There has been one long-term followup study of
mortality and morbidity in military pilots.38 As one
might expect, their health is better than that of the
general population or of age-matched Framingham men, but
there was no comparison with a suitably selected control
group.
The extensive data available on the health of pilots
are of little use in studying the health effects of
cabin air. A primary limitation is that the special
cockpit environment is not indicative of the general
cabin environment. In addition, the orientation of
health monitoring is to ensure that certified pilots are
free of health problems that might jeopardize their
ability to operate a plane safely; thus, its purpose is
not to detect potential health effects of the working
environment. For the system to meet the latter purpose,
several important and fundamental changes would need to
be made, including the addition of followup of retired
airmen, elimination of self-selection problems (airmen
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204
who, for health reasons, elect not to renew their
licenses do not appear in the current records),
collection of additional data (on both health and
exposure) pertinent to occupational hazards, and the
implementation of a sophisticated statistical analysis
and reporting system.
FLIGHT ATTENDANTS AND PASSENGERS
No monitoring or surveillance activities appear to
be directed solely at the health of flight attendants.
A few airlines indicated that some pre-employment health
data were available to them and that some additional
medical records on selected flight attendants were
kept. However, these records are considered proprietary
and were not available to the Committee. More
important, it appears that no airline monitors the
health of all its flight attendants routinely. Airlines
do maintain records of workers' compensation and
disability claims, but only a portion of these data can
be released. A few airlines appear to keep records of
employees' service histories (flight times, routes, and
types of service).
A few airlines indicated that they maintain records
on incidents of passenger illness (some limited only to
oxygen use and passenger complaints about air quality),
but the adequacy of these records for monitoring
purposes is unknown.
Other than accident and incident data (see the
following section), FAA collects no data on the health
of flight attendants or passengers.
The flight attendant unions have periodically
sponsored mail-questionnaire surveys on health-related
issues, but do not sponsor routine data collection
directed,at monitoring the health of flight attendants.
The Association of Flight Attendants receives
reports submitted by flight attendants concerning poor
cabin air quality. From January 1977 to April 1982, 297
reports were received, and descriptive statistics were
tabulated for presentation to the Subcommittee on
Aviation of the U.S. Senate Committee on Commerce,
Science, and Transportation. The value of these reports
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in assessing health risks is questionable, in that they
appear to be voluntary and therefore self-selected. In
addition, no standard protocol for reporting is used, so
the information gathered is fragmentary and selective.
The number of incidents reported per year from 1977
through 1982 varied erratically (21, 70, 6, 46, 135, and
66~. In view of the number of flights per year, the
reported incident rates seem low, although there might
be some underreporting; there is no basis on which to
establish an expected rate for these reports.~°
FAA SURVEILLANCE ACTIVITIES
FAA has claimed regulatory jurisdiction over the
cabin as a workplace. FAA asserts that its
responsibility toward passengers is related to their
safety and claims not to have regulatory authority over
health. No federal agency monitors the health of flight
attendants.
Other than the medical data collected for pilot
certification (discussed above), the health data on
passengers or flight crews that are systematically
collected by FAA are very limited. They are reported in
the Accident/Incident Data System (AIDS), described as
follows in the AIDS user's guide: 5 3
The Accident/Incident Data System (AIDS)
contains data records for general aviation
accidents/incidents, air carrier incidents, and,
beginning with 1982, air carrier accidents. The
system consists of various data bases, computer
hardware, computer programs and manual procedures
which in combination produce a functional capability
for the user. The system gives additional data
elements, provides for English-like retrievals and
reports, puts emphasis on ad hoc retrievals,
provides easily utilized standard reports and
provides user access through data terminals.
The basic design of the AIDS system is to
provide the user with current and accurate
information about general aviation accidents and
incidents coupled with the facility to produce
"standard" reports and "ad hoc" reports based on
specific requirements. Several standard report
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206
formats can be requested by specifying: time-period
of interest, national/regional criteria, and event
selection criteria (type of accident, etc.~.
Specialized queries can be prepared and input by
trained users. Additionally, the tools exist for
conducting statistical analyses of the data
contained in the data base.
The objectives of AIDS are laudable, and the
Committee is optimistic that the system will prove to be
a valuable research aid for aviation safety. We were
impressed by the documentation of the computer system
designed to gain access to the data base and by the data
coding system.
However, AIDS is relatively new and has yet to
realize its full potential. The Committee experienced
two difficulties in using the system. First, we were
unable to find an accessible, concise, and thorough
description of the collection system and its data base
contents. Without good information on the data
collection process, the Committee found it difficult to
judge the quality of the data (for health monitoring
purposes) and the desirability of using them for health
monitoring. For example, the description of the
criteria used for defining an accident or an incident in
the FARs39 is insufficient to enable one to be
certain of the quality of health data that enter AIDS.
In addition, the Committee found that, although access
to the data base itself appears good, descriptive and
summary statistics on such items as number of fires by
cause and number of passenger deaths by cause were not
readily accessible.
In summary, the Committee feels that AIDS has
potential as a health monitoring or surveillance tool,
but that considerably more effort by FAA will be
required to make it effective. It is insufficient
merely to collect data and provide access to them. It
is important that at least basic statistical summaries
of key information be produced routinely. The Committee
also notes that the purpose of AIDS is to monitor
accidents and incidents; therefore, in its current form
it has no value for monitoring chronic health effects of
air travel in passengers or crew.
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GROUPS AT INCREASED RISK
Aircraft at cruising altitudes maintain artificial
cabin altitudes of 5,000-8,000 ft. Because of the
associated decrease in PO2 compared with that at sea
level, passengers with specific health problems might be
at increased risk while flying.
A number of committees
in special and general medical associations publish
guidelines for physicians to use in advising patients
about air travel.1 17 Of most general coverage is a
list, prepared by the American Medical Ansociation's
Commission on Emergency Medical Services, of conditions
in which air travel is contraindicated.2 The list
is presented here for information, although the
Committee found little material on these conditions in
passengers traveling on aircraft.
· Cardiovascular--myocardial infarction within
the preceding 4 wk. cerebrovascular accident within the
preceding 2 wk. severe hypertension, decompensated
cardiovascular disease, or any condition that restricts
cardiac reserve. Patients with chronic cardiovascular
problems, such as cyanotic congenital heart disease or
coronary insufficiency, should have supplemental oxygen
whenever flight altitude is greater than 22,500 ft.
.
BronchopulmonarY--pneumothorax, congenital
pulmonary anomaly, or vital capacity less than 50X.
Patients with chronic pulmonary problems--such as cystic
fibrosis, emphysema, chronic asthma, or fibrotic
pulmonary conditions--should have supplemental oxygen
whenever flight altitude is greater than 22,500 ft.
· Eyed ear, nose, and throat--recent eye surgery,
acute sinusitis, or acute otitis media. Patients who
must fly during the congestive stage of upper respiratory
infection should use local shrinking agents or oral
decongestants.
O Gastrointestinal--abdominal surgery within the
preceding 2 wk. acute diverticulitis or ulcerative
colitis, acute esophageal varices, or acute
gastroenteritis.
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208
· Neuropsychiatric--epilepsy (unless it is well
controlled medically and simulated cabin altitude is
never greater than 8,000 it), recent skull fracture,
brain tumor, or history of violent or unpredictable
behavior.
· Hematolozic--anemia (hemoglobin concentration
of less than 8.S g/dL or red-cell count of less than 3
million/mm3 in adults), sickle-cell disease (unless
cruising altitude is never greater than 22,500 ft), or
hemophilia.
· Pre~nancv--beyond 240 d or if miscarriage is
threatened.
· Miscellaneous--Scuba divers should not fly for
at least 12 h after diving--24 h after repeated deep
diving--before flying. The flight surgeon should be
consulted if a patient requires intravenous fluids or
special medical apparatus.
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Representative terms from entire chapter:
cabin air
