Examination of Witnesses (Questions 40-59)
Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger
Wiltshire
26 JUNE 2007
Q40 Baroness Perry of Southwark:
When you say that you are a small group and you all know each
other, does that include the low-cost airlines?
Dr Dowdall: It is not just airlines but those
people who are interested in aviation medicine. Not every airline
has a fulltime or indeed any medical adviser—and I am talking
globally here, not necessarily within the UK. Those of us who
are working in the area do tend to know each other because we
meet at the same international meetings.
Q41 Baroness Finlay of Llandaff:
I wonder if you could tell us actually to what extent the airlines
overall collect data on in-flight medical emergencies and whether
this data is pooled and what is done with it?
Dr Popplestone: That is quite a complex question.
We are talking about in-flight medical incidents are we?
Q42 Baroness Finlay of Llandaff:
Yes, in-flight medical emergencies.
Dr Popplestone: Most airlines now use a remote
medical adviser, ground-to-air medical advice, and the biggest
provider—it is not the only provider—is a company
called MedAire, based in Phoenix, which provides a service called
MedLink. MedLink will collate data individually for the airline,
which is fed back to that airline specifically, and it will also
provide information back to every airline on the industry data,
so it gives an industry-wide picture as well so that I in Virgin
can compare my figures to the industry as a whole—all subscribers
to the MedLink service. There are a couple of big difficulties
with analysing the data, particularly on the medical information
and medical diagnosis, and that is that the category that MedLink
assign to a particular case is based on information provided by
a lay person in any respect, so if somebody has, for example,
abdominal pain, it may go into a gastrointestinal category, it
might go into a gynaecological category or it might even go into
a cardiac category, depending on its nature, so it can be very
difficult to analyse consistently what that information means
and then act on it afterwards. Certainly, speaking for Virgin
Atlantic, in respect of the major incidents—the diversions
or anything like that—we do get as much information as we
can possibly get back from MedLink, analyse that data and then
try and learn from it and see what we can do better in the future.
Q43 Baroness Finlay of Llandaff:
What about incidents where MedLink is not involved and where you
might have a doctor or a nurse on the plane who is the person
who responds to a call? Is that data collected anywhere or is
it lost?
Dr Popplestone: Again, speaking for Virgin Atlantic,
we train all our crew—our crews when they arrive at the
airline get five days of extensive medical training and they then
get a refresher on an annual basis. The protocol that they follow
is that in the event of a medical emergency—for minor incidents
such as if somebody has a headache they might just give them two
paracetomol—or anything where they need advice or it is
more complex, their training is that their first port of call
should be to contact MedLink, and there is virtually nowhere in
the world that you cannot contact them because you contact them
by satellite phone. If the advisers at MedLink, who are doctors,
believe that it would be helpful to get a hands-on medical assessment,
at that point a call will go out for a medical volunteer. I will
pass on to Dr Dowdall in a moment and he can describe what happens
when you cannot get hold of MedLink, but that is the protocol.
The crew fill in a form after the incident and we get a report
back later on from MedLink and we can then marry them up and learn
from that data.
Q44 Baroness Finlay of Llandaff:
With diversions does the qualification of the person who does
the in-flight assessment influence the number of decisions taken
to divert?
Dr Popplestone: I do not know that there is
an easy answer to that because there are so many factors involved
in a medical diversion, one of which is quite rightly the medical
condition of the passenger and, clearly, if you have a medically
qualified volunteer with that individual you might be more confident
in what the diagnosis is. Just because you may have somebody in
front of you with a heart attack, it does not necessarily mean
you would divert as soon as possible because it really does depend
on where you would be diverting to and what the facilities would
be.
Q45 Baroness Finlay of Llandaff:
What I was getting at is whether the risk assessment process correlates
with the qualification of the person, so whether you find that
one group of people such as nurses or pharmacists may be more
risk averse than senior clinicians who have got quite a lot of
experience behind them and may feel "we can carry on and
I can manage this, the chances of it getting any worse are much
lower"?
Dr Popplestone: I do not think I have any evidence
to say anything on that.
Dr Dowdall: The only thing I would say on that
is remembering British Airways' experience in the time before
we took on the MedLink service and we were seeing a rising trend
in diversions. We then switched to the MedLink service and what
we saw was a fall in diversions. We did a comparison of diversions
where MedLink had been involved and diversions where an on-board
physician had been involved and what the outcome was on the ground;
we found that the MedLink-advised diversions were much more likely
to result in a significant medical condition being identified
on the ground. You might well have a physician on board but they
are out of their normal sphere of activity, they do not have their
normal equipment—
Q46 Baroness Finlay of Llandaff:
And their specialty.
Dr Dowdall: They may well be from the wrong
specialty, it is a very uncomfortable and difficult situation
for them. What we have found is that in a situation where you
have contacted MedLink and they would like a further assessment,
if you then have an on-board physician working with MedLink that
is often a very effective combination. We do not use it very often,
we are talking about tens of flights out of hundreds of thousands
flights.
Q47 Baroness Finlay of Llandaff:
Is there a discernible pattern to these medical emergencies and
does that pattern correlate with pre-existing conditions now these
data have been collated?
Dr Dowdall: If you looked at the biggest single
cause of diversions for most airlines it is probably chest pains,
and that is simply because it is the one where it is hardest to
be sure what is the underlying problem and the consequences of
making the wrong decision are perhaps more significant, so we
are more likely to divert for a chest pain; 50% or more will turn
out to be trivial chest pain that did not indicate a serious medical
condition.
Q48 Baroness Finlay of Llandaff:
How much do chest pain diversions cost your airline in a year;
do you have any idea?
Dr Popplestone: I could not answer that, I do
not think it is possible to quantify how much it costs. Just to
put the chest pain thing into perspective, less than 5% of the
in-flight incidents according to BA figures a couple of years
ago were thought to be due to cardiac problems yet they accounted
for more than 20% of diversions. It is the same from a neurological
point of view, which of course will include headaches and things,
20% fall into that category, and will also include faints, but
they accounted for over 35% of the diversions, so there is a disproportionate
thing with neurological and cardiac problems. We do not know how
much they cost, there are so many different factors involved and
it is not a factor that is taken into consideration when it comes
to diverting.
Dr Dowdall: A diversion can be what is called
a "fuel and go" which is literally you land, offload
the passenger, put in some extra fuel and go, and that costs you
essentially a bit of extra fuel and a landing charge, to the one
where you land, the crew go out of duty time and you have to put
everybody in hotels, so you are talking from a couple of thousand
to hundreds of thousands in terms of the range of costs.
Q49 Lord Patel: The general perception
that the airline cabin environment is such, particularly the air
circulation, that it is more conducive to the transfer of particular
infectious diseases and therefore airlines ought to have some
precautionary measures in place—first of all what are the
regulations relating to control of diseases? The Department of
Health currently is consulting on the Control of Diseases 1984
Act because of the WHO international guidelines that came out;
are the airlines responding to that and what do you learn from
previous episodes such as SARS in terms of control of infectious
diseases in the air cabin environment or the recent resistant
tuberculosis?
Dr Dowdall: You talked about perception and
the myth that we see is that recirculated air causes problems
and increases the risk of transmission of infection. The evidence
is very clear that following recirculation, which is through the
HEPA filters that we discussed earlier, the microbial content
and the quality of the air is very good and that recirculation
is not a factor in the transmission of disease. Clearly, in an
aircraft you are in a confined environment, you are sat close
to other people and as in any other case where you are in a situation
where you are sat close to other people, there is the potential
for the direct spread of infection, usually by the droplet method,
so somebody coughs, there is a spray of germs and if you are in
the path of that cough then you are exposed to it. In air travel,
the air quality is good but you cannot control who you are sat
next to although clearly we try to avoid boarding people who look
unwell, so we try and minimise that. You mentioned SARS and what
is evident is that air travel moves people around the world very
quickly; if you have somebody who is well, has no symptoms or
minimal symptoms, is perhaps incubating an illness, they can get
on board when they are well, they can get off when they are still
well and 24 hours later is when they develop symptoms. That is
something that we cannot prevent and talking about pandemic flu,
the current major concern, if you were to stop air travel the
belief is that it would delay the spread of a pandemic—
Q50 Lord Patel: It would stop anyway
because you would have no crew.
Dr Dowdall: The concern actually from the airline
point of is will we have any passengers. If you were to stop air
travel you would delay the spread of a pandemic from an origin
in Asia to the UK by, at best, a few weeks. Air travel does take
people from one part of the world to another part of the world
very quickly; if they are unwell before they board then you can
stop them, if they become unwell on board then we have protocols
for how we deal with it, if they get on appearing well and get
off appearing well there is nothing we can do about it.
Q51 Lord Patel: If I heard you clearly
you save a few weeks; therefore if pandemic flu occurred in south-east
Asia it would delay it by a few weeks by not transferring people
from there to here; that is quite significant.
Dr Dowdall: Clearly if you were to stop air
travel completely then that would have a substantial economic
effect on a global scale and is something that governments quite
rightly would be very reluctant to do. There would be little benefit
to the public health, I would suggest, if you were to do that.
Q52 Lord Patel: We will not get into
it, but it might save a lot of lives.
Dr Dowdall: But we are not talking about stopping
the spread of a pandemic, we are talking about delaying it in
that scenario.
Q53 Lord Patel: Let me come back
to my original question which was are you consulting on the Department
of Health consultation on the spread of diseases and does this
have any implications for the airlines?
Dr Dowdall: In terms of the new international
health regulations the international airline industry has had
some input into the discussions with WHO and ICAO.
Q54 Lord Patel: What has been your
input? How would you like to see the regulations change?
Dr Dowdall: It is not a case of how I would
like to see the regulations change. What is proposed in the international
health regulations, which is to be implemented in the UK, is perfectly
sensible and I am very comfortable with those regulations being
implemented as they are. It is a step forward in terms of international
travel and health.
Dr Popplestone: I would echo everything that
Dr Dowdall has said and the only thing I would add to that is
that we communicate with the public health bodies and the Health
Protection Agency, we work with them and, ultimately, anything
that is brought into place we want to see work. We want to be
practical but we work with them to try and make sure that what
is being implemented in the airports on the ground is actually
compatible with what we do and is practical.
Q55 Lord Patel: What happens in a
situation like the case recently about resistant tuberculosis
and therefore there was a risk to other passengers. Is there any
follow-up or is there any advice given to the other passengers
who were in that aeroplane?
Dr Dowdall: That is a matter that the public
health authorities would lead on. Again, I was involved in the
reworking of the WHO booklet on air travel and tuberculosis and
there were very clear recommendations on first of all what the
treating physician should do, what their responsibilities are,
what the airline's responsibilities are and what the public health
responsibilities are. We frequently co-operate with the public
health authorities.
Q56 Lord Patel: If I was a passenger
on an aeroplane and it subsequently was found out that someone
was carrying at the same time as the flight I was on resistant
tuberculosis, an infective passenger, how would I know? Who would
contact me to say that I need to be screened or whatever?
Dr Dowdall: First of all it is important to
emphasise that the risk is very low and of the studies that have
been done of transmission of tuberculosis—
Q57 Lord Patel: When I read the newspaper
as a member of the public I am not going to think that.
Dr Dowdall: I agree and one of the things I
would like to point out is that the 2000 report highlighted the
role of the media in responsible publicity, and we have seen signs
that they still have not taken that on board. In terms of that
situation, if you have travelled on board a flight where somebody
with contagious TB has been identified—and usually they
are identified some time after travel—then the public health
authority that is managing the case would contact the airline
and say "We believe this person travelled on a flight."
We would check our records to see if that person did travel on
that flight, and the standard information we would be looking
for is those passengers believed to be potentially at risk would
be those people who were sat in the same row and the two rows
either side—that is the standard. We would look to provide
the public health authorities with whatever contact information
we had available so that the public authorities could contact
those individuals, explaining what the risk is and what they should
do about it.
Q58 Lord Patel: Even in a case of
such a serious contagious disease as resistant TB it would only
be two rows of passengers either side who would be informed.
Dr Dowdall: Because the risk is very, very small
and worldwide there have only been eight documented cases where
TB actually has been transmitted from a passenger on an aircraft
to another passenger. TB is not that easy to catch and so, for
example, there have been no cases where the duration of travel
was less than—
Q59 Lord Patel: But generally any
infectious disease would be two rows?
Dr Dowdall: Yes, and that is based on droplet
spread, so if you cough how far do you spread bugs basically.
That is the risk assessment, that is where the evidence says this
is where it is worthwhile doing the contact tracing.
Dr Popplestone: The only thing I was going to
add goes back to the responsible journalism point. The recently
highlighted case of the multi-drug-resistant TB, there are a number
of factors that are in the guidelines as to whether or not you
should do contact tracing, one of which is whether or not the
person had bacteria in their sputum at the time. This person did
not have it and he was not coughing at the time of travel either,
so although he had multi-drug-resistant TB, there was absolutely
no evidence that he was contagious and ironically, I believe,
had been told that he could fly by a relative who worked for the
CDC in the States. Although he had multi-drug-resistant TB, I
do not think there was any evidence at all that he was infectious
at the time of travel. Clearly it was undesirable that he flew,
but there was not actually any risk, I do not believe, to any
other passenger.
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