Published online: June 11, 2019
“Is there a doctor on board?” has become idiomatic, given in-flight medical emergencies (IMEs) occur in around 1 in 600 flights. Respiratory and cardiovascular events account for 17% of IMEs, and diversion costs range from $20,000 to $725,00 (diversion occurs in 4-5% of emergencies). Only 2% of IMEs result from allergic reactions, and 1:1000 strength epinephrine is carried aboard every United States commercial aircraft per Federal Aviation Administration (FAA) requirement. Though dosing and use of epinephrine ampules is straightforward to an allergist, this may not be the case for many other health care providers or first responders. As such, food allergy and anaphylaxis advocates have pushed to stock epinephrine autoinjectors on flights, a practice which only occurs in Australia presently.
In The Journal of Allergy and Clinical Immunology: In Practice, Shaker and Greenhawt describe the cost-effectiveness of adding stock epinephrine autoinjectors to domestic aircraft. The authors randomized 200,000 simulated passengers with food allergy to travel on aircraft having supplemental epinephrine autoinjectors in addition to the the epinephrine 1:1,000 and 1:10,000 ampules in current in-flight emergency kits, compared to just the kit ampules. The model used a ceiling epinephrine autoinjector price shown to be cost-effective in a prior model of stock school epinephrine autoinjectors ($338), with costs distributed across 30,840,000 at-risk travelers each year and 7,309 commercial aircraft.
Stocking supplemental epinephrine autoinjectors for undesignated use as a shared resource across millions of lives was cost-effective if devices provided a minimal 1.4% reduction in fatal anaphylaxis. When distributed across at-risk passengers, this supplemental policy only cost $0.08 per passenger per year.
Prompt administration of epinephrine is first-line management of anaphylaxis, and delay may increase risks for protracted anaphylaxis, biphasic reactions, and fatalities. Because many at-risk travelers fail to carry personal epinephrine (in addition to those not at-risk who may experience anaphylaxis but do not have a personal autoinjector), autoinjector availability can add value and increase response speed for in-flight anaphylaxis management. While this study only explored if the supplemental addition of autoinjectors was cost-effective, and did not study if such a policy was actually necessary, in the current climate of airline fees, this supplemental policy seems worth the 8 cents.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.