Anaphylaxis knowledge level of cabin crew

INTRODUCTION

Anaphylaxis is a serious and potentially life-threatening allergic reaction. Prompt and effective care has an important role in keeping mortality low [1], but delayed or ineffective diagnosis and treatment are associated with extra costs as well as psychological and health burdens [2].

In-flight medical emergencies are likely to increase as the amount of air travel continues to increase and life expectancy lengthens [3]. Air travel is a major concern for many people with a previous history of anaphylaxis; their concerns revolve around the risk of triggering reactions while in the air and the potential difficulties of carrying self-administered adrenaline on board [4]. The number of airplane flights in Turkiye increased in 2023, reaching 1,685,877 [5]. Global passenger traffic in 2023 was approximately 8.7 billion passengers [6].

Many passengers may have pre-existing chronic conditions that put them at risk of medical emergencies on board. These conditions may develop for the first time during flight. By 2030, half of all air travelers are expected to be over the age of 50 [7]. Up to 44,000 in-flight medical emergencies occur each year [8] and data show that approximately 17% of such cases are referred to hospital and 4% result in hospitalization or death. Systemic allergic reactions (SARs) can occur during air travel. Buehrle and Gabler observed that “allergy” was the 7^th most common cause of inflight medical problems between 2002 and 2007, ranging from 1.5% to 2.5% [7].

Strategies to reduce the risk of SAR during travel should start during early planning of air travel. Advice should be sought from the individual’s treating physicians or allergy/immunologists on preventive measures to be implemented before or during the flight.

Following treatment with intramuscular epinephrine, symptoms resolve in most patients with anaphylaxis. However, some patients have persistent symptoms requiring treatment with additional doses of epinephrine or life-saving resuscitative interventions (e.g. positive pressure ventilation for patients with respiratory failure or vasopressors for those in shock) [9]. On the other hand, some patients may develop recurrent symptoms, termed biphasic or late phase reactions, following an initial asymptomatic period and without re-exposure to the trigger [9, 10]. Current guidelines recommend intramuscular (IM) administration of epinephrine into the anterior thigh with a standard dose of 0.01 mg/kg of a 1 : 1000 (1 mg/ml) solution up to a single maximum dose of 0.5 mg in adults and 0.3 mg in children [11, 12]. If symptoms do not resolve, dosing should be repeated every 5 to 15 min [11, 12]. An epinephrine autoinjector (EAI) allows epinephrine to be administered by non-medical persons in an outpatient setting [13].

The number of SARs during flights is likely to increase in the future. Therefore, passengers at risk should be aware of the necessary measures to prevent and manage these emergencies. It is also vital that airlines are prepared to deal with these illnesses by providing the necessary strategies to reduce the incidence of SARs. They should have the necessary tools and crew to treat these reactions when and if they occur.

AIM

This study aims to assess the current level of knowledge and response competencies of cabin crews who have encountered cases of anaphylaxis on board aircraft, and to develop recommendations to improve their capacity to ensure the safety of passengers in these critical situations. The survey results may contribute to restructuring and strengthening cabin crew training programs.

MATERIAL AND METHODS

This cross-sectional study was conducted to evaluate the knowledge and experience of cabin crew regarding anaphylaxis management on board aircraft. The data of the study were collected through a 19-question online questionnaire prepared via Google Forms. Cabin crew working for various airlines and involved in flight operations participated in the survey. The questionnaire included questions to assess the demographic information of the participants (such as age, gender and length of professional experience) as well as questions to assess their knowledge and awareness of anaphylaxis and its management. The questions covered topics such as recognition of symptoms of anaphylaxis, emergency response procedures, allergen recognition, and use of emergency response equipment available on board the aircraft. Finally, the participants were asked about whether they had encountered cases of anaphylaxis during the flight and what intervention methods they applied in such cases.

RESULTS

A total of 63 cabin crew members participated in the survey. Regarding the length of service of the participants, 19% (n = 12) reported 0–1 years, 15.9% (n = 10) 1–4 years, 27% (n = 17) 5–9 years, 31.7% (n = 20) 10–19 years, and 6.3% (n = 4) 20 years or more. Regarding anaphylaxis intervention training, 46% (n = 29) stated that they had received such training, while 54% (n = 34) stated that they had not. Among the participants who stated that they had received training, 36.5% (n = 23) stated that they had received training within the last year, 7.9% (n = 5) 2 years ago, 4.8% (n = 3) 3 years ago and 1.6% (n = 1) 5 years or more ago, while 49.2% (n = 31) stated that they had never received training.

All participants (100%, n = 63) agreed that allergy can be life-threatening. While 33.3% (n = 21) stated that they had heard of an adrenaline autoinjector before, 66.7% (n = 42) stated that they did not have any information about it. In the question about the method of adrenaline administration, 14.3% (n = 9) of the participants stated that intramuscular (IM) injection was the correct method, 11.1% (n = 7) found the intravenous (IV) method correct, and 74.6% (n = 47) stated that they were uninformed about this subject. In the question about the adrenaline reapplication interval, 1.6% (n = 1) of the participants said it was 5 min, 4.8% (n = 3) said it was 30 min, and 93.7% (n = 59) stated that they had no knowledge on this subject. In response to a question asking whether there was an adrenaline injector in the emergency kit on the airplane, 30.2% (n = 19) of the participants said that there was, 33.3% (n = 21) said that there was not, and 36.5% (n = 23) said that they were not informed about this issue.

When the situation of encountering anaphylaxis while on duty was evaluated, 15.9% (n = 10) stated that they had experienced such an event, while 84.1% (n = 53) stated that they had not. Of the 10 participants who had experienced anaphylaxis, 1 had experienced it four times, while the other 9 had experienced it once. When asked about the gender of the passenger in these cases, 20% (n = 2) of the participants stated that they were female, 20% (n = 2) stated that they were male, and 60% (n = 6) could not remember. In terms of age groups, 10% (n = 1) were between 13 and 25 years old, 40% (n = 4) were between 26 and 64 years old, and 50% (n = 5) could not remember their age group. When asked whether the passenger who had anaphylaxis had his/her own adrenaline autoinjector, 80% (n = 8) answered “no” and 20% (n = 2) stated that they did not have information on this subject. 100% of these participants (n = 10) answered “no” when asked about the passenger’s use of an autoinjector.

When asked whether the passenger’s complaints disappeared after adrenaline was administered, 30% (n = 3) stated that the complaints disappeared, 10% (n = 1) stated that they did not and 60% (n = 6) could not remember. Regarding the causes of anaphylaxis in the passenger, 60% (n = 6) reported food-induced, 10% drug-induced, 0% insect sting, 30% (n = 3) idiopathic (unknown cause), and 10% (n = 1) other causes. Symptoms included 0% skin rash and blistering, 30% (n = 3) shortness of breath, 20% (n = 2) swelling of the lips and eyes, 20% (n = 2) abdominal pain, 30% (n = 3) vomiting and diarrhea, 20% (n = 2) syncope and 10% (n = 1) other symptoms. When asked about the presence of a doctor on board during the incident, 40% (n = 4) answered yes and 60% answered no (n = 6). When asked whether an emergency landing was made, 10% (n = 1) answered yes and 90% (n = 9) answered no (Table 1).

While the percentage of those who had heard of an adrenaline autoinjector was 30.8% among those with less than 10 years of cabin crew service, this percentage was 37.5% among those with more than 10 years of service (p = 0.582). The percentage of those who knew the correct route of administration of adrenaline was 15.4% among those who had worked less than 10 years and 12.5% among those who had worked more than 10 years, and this difference was not statistically significant (p = 1.000). The percentage of those who heard the adrenaline autoinjector among cabin crew members who received anaphylaxis training was 37.9%, while this rate was 29.4% among those who did not receive training (p = 0.475). The percentage of those who knew the correct route of administration of adrenaline was 17.2% among those who had received training and 11.8% among those who had not received training, and this difference was not statistically significant (p = 0.721) (Table 2).

DISCUSSION

The findings of our study show that the knowledge and experience levels of cabin crew on anaphylaxis are highly variable. A large proportion of the participants (54%) had not received any training on anaphylaxis intervention, and even among those who had received training, the percentage of those who had received such training within the last year was only 36.5%. This shows that a large proportion of cabin crew members do not have up-to-date knowledge on anaphylaxis intervention.

The percentage of those who knew about adrenaline autoinjectors was 33.3%. Furthermore, only 14.3% of the participants knew that the correct method of adrenaline administration is intramuscular (IM) injection. These findings reveal that there is a serious problem regarding the effective and correct use of the adrenaline autoinjector in emergency situations such as anaphylaxis. In addition, 93.7% of the respondents did not know the interval of adrenaline re-administration, which may negatively affect timely intervention in emergency situations. In a survey conducted by Rapiejko et al. [14] among medical students regarding anaphylaxis, 58% of the participants knew the correct dose of epinephrine. Additionally, 12% of the students rated their skills in managing severe anaphylaxis as good, while 41% expressed feeling insecure due to a lack of practical experience in this area. The results indicate that while the majority of students are aware of anaphylaxis, a significant portion lacks sufficient practical experience in this area, highlighting the need to develop crisis management skills even among medical students.

A significant proportion of the respondents (36.5%) did not know whether there was an adrenaline injector in the emergency kit on board the airplane. Considering that 80% of passengers with anaphylaxis do not have an autoinjector, the importance of having adrenaline in the emergency kit on board is clear. This finding suggests that cabin crew members should be better informed about the availability and use of emergency equipment.

The rate of anaphylaxis cases was 15.9%, and in the majority of these cases, passengers did not have their own adrenaline autoinjectors. In this case, it is vital to have adrenaline in the airplane’s emergency kit. Furthermore, 60% of the respondents did not remember whether the passenger’s complaints went away after the adrenaline was administered, indicating the need for more careful reporting and monitoring of such incidents.

It was observed that food allergies were the most common cause of anaphylaxis. This finding suggests that food allergies play a critical role in the management of in-flight anaphylaxis. Food allergies are showing an increasing prevalence in the general population, and this brings with it potential risks that may arise during flight. Food served in aircraft cabins often contains many different allergens, which can increase the likelihood of allergic reactions occurring. It is important for cabin crew to be prepared for such emergencies and to be knowledgeable and equipped, especially as regards food allergies. According to the literature, SARs on airplanes are most commonly triggered by food (peanuts, tree nuts and seafood) or medications. They are very rarely triggered by insect stings or insecticide spray [15].

Our study did not show a statistically significant difference in the level of knowledge of adrenaline autoinjectors and the way of administration of an adrenaline autoinjector among cabin crew according to variables such as working time and anaphylaxis training. However, the lack of significant differences may be due to the insufficient sample size used in the study.

In conclusion, this study shows that cabin crew need more training on intervention for anaphylaxis and use of an adrenaline autoinjector. In the literature, a European study by Feketea et al. showed that school teachers were not well informed about anaphylaxis [16]. In other studies, it was observed that the majority of teachers could not recognize the symptoms of anaphylaxis, had no knowledge about adrenaline autoinjectors (AAI), lacked confidence in providing emergency first aid during anaphylactic reactions, and were not aware of their school’s anaphylaxis management action plan [17, 18]. In a study conducted in a different country in the literature, it was documented that schools were unprepared to deal with severe allergic reactions because only 12% had access to AAIs and less than half had a trained teacher [19]. In a study conducted by Güneş et al., the rates of knowing the signs and symptoms of anaphylaxis were found to be similarly low in both groups according to years of professional experience in anaphylaxis-related questionnaires administered to pediatric nurses [20]. In order to be prepared for emergencies, both educational programs and anaphylaxis awareness should be enhanced through regular updates and practical applications.