A severe allergic reaction is a life-threatening condition that requires immediate treatment, but what if it happens when you're sealed in an aircraft cabin mid-flight?
In 2014, a four-year-old girl on a Ryanair flight suffered anaphylactic shock caused by a nearby passenger eating peanuts. The child's face swelled, her mouth blistered, her throat was closing and she was struggling to breathe. After losing consciousness, the outcome could have been a tragedy but for an ambo on board who responded to the cabin crew's call for medical assistance and used the child's EpiPen to deliver a shot of adrenaline that stabilised her condition.
It doesn't always end well. In other cases, airline passengers have died when they suffered similar allergic reactions and were unable to be revived. Allergies are an ever-increasing problem. According to the US Centre for Disease Control and Prevention, food allergies in children increased approximately 50 per cent between 1997 and 2011. They now affect about 7.6 per cent of all children in the USA, and Australia reports similar levels of allergic reactions among children. About 90 per cent of those allergies can be attributed to milk, eggs, peanuts, tree nuts, soy, wheat, fish and shellfish. Peanut allergy causes more problems than other food allergies, but peanuts and peanut products such as oils feature regularly in the food that is served on flights.
So what are airlines doing about the problem? Some warn that nuts are served on board, including peanuts, and insist that passengers need to be responsible for their own wellbeing. Some go the extra yards, eliminating peanuts and peanut products, and asking flyers to refrain from eating peanuts when notified of passengers with a peanut allergy on the flight.
What's lacking is a combined approach, and that, as well as industry-wide regulation, is problematic. Given that exposure to even small traces of peanut residue is enough to cause an allergic reaction in some sufferers, is it possible that airline regulators can impose a far-reaching ban? How would they guard against the possibility that a passenger might dip into a bowl of peanuts before boarding the aircraft and transfer peanut residue from their hands to cabin surfaces? Is such a minute concentration a risk even to highly sensitised travellers? What about animal hair stuck to clothing, is that enough to trigger a severe allergic reaction – and how do you guard against such an eventuality?
Qantas has removed peanuts as a bar snack from all its flights and also from Qantas lounges. The airline's inflight menus minimise the use of peanut products and special nut-free inflight meals are available to anyone who requests them; however the airline points out it cannot guarantee an allergy-free environment. It also notes that passengers may be served other nut varieties such as almonds, cashews and macadamia nuts.
British Airways has a similar policy, although it warns "Our in-flight meals … may be produced at a facility that handles peanuts therefore we are unable to offer a peanut-free special meal".
Qatar Airways does not ban nuts and points out that passengers with mild allergies are responsible for carrying any medication they might need onboard. Those with a history of severe allergic reactions are required to complete a medical information form at least 48 hours before departure. They are allowed to bring their own allergy-free meals onboard but they may be required to sign a waiver of liability.
Emirates makes no promises about nut-free flights. According to the airline's dietary requirements website, nuts are served on all Emirates flights and the airline recommends passengers with nut allergies bring their own food on board. The website also notes that the airline has no control over other passengers who may bring food on board containing nuts. Traces of nut residue oils could be transmitted via aircraft surfaces such as seats and door handles, or even via the air conditioning system.
Those at risk of anaphylaxis are advised to carry an EpiPen, since this is not always part of an aircraft's standard medical equipment. EpiPens are allowed onboard aircraft in carry-on luggage, although passengers with EpiPens might have to notify security screening staff. For that reason it's suggested they carry EpiPens in the original packaging. In the US, travellers can request a visual inspection of their EpiPen since the effects of X-rays on epinephrine, the active ingredient, are unknown. Some travellers insist that you should carry a letter from your doctor identifying your requirement for an EpiPen, others say they've carried one for years and never been queried.
The Australasian Society of Clinical Immunology and Allergy website has a travel plan and checklist to assist passengers at risk of anaphylaxis and who need to carry an EpiPen on airline flights.
Another great resource for air travellers is the "Airline comparison for passengers with food allergy", published in January 2018 by Allergy and Anaphylaxis Australia.