Joint Memorandum by the Department for
Transport (DfT), the Department of Health (DH) and the Civil Aviation
Authority (CAA)
The Department for Transport (DfT), the Department
of Health (DH) and the Civil Aviation Authority (CAA) note that
the House of Lords Science and Technology Committee intends to
inquire into aviation health and in particular to look at developments
since 2000 when it published its last report on Air Travel
and Health. Considerable advances have been made since then
and the parties to this Memorandum welcome the opportunity to
set out what has been achieved.
The Memorandum follows the order of the questions
on which the Committee has invited evidence.
What progress has been made in research
into the priority areas identified by the Committee in 2000? Do
gaps remain in the evidence base, and, if so, are they being filled?
Greater numbers of people than ever before,
and of variable general health, are flying. The understanding
of health issues in relation to this growing population is therefore
developing. We cannot in such circumstances list definitively
gaps in evidence; as knowledge of aviation health issues grows,
so research will be undertaken as necessary.
However, we set out below important areas where
research has been undertaken in recent years and where the Committee
has expressed interest.
Deep Vein Thrombosis (DVT)
The UK and the European Commission funded a
World Health Organisation (WHO) research programme costing €2.8
million (to which the UK contributed €1.8 million from DfT
and DH funds) to look at the incidence and mechanisms of DVT.
Known as the WRIGHT project, the results of this two-year study
showed that long-distance travel leads to a small but increased
risk of DVT. The risk, which applies to all forms of travel, appears
to be predominantly the result of prolonged immobility. A summary
of results was published on the DfT website in December 2005,
to promote understanding of the nature of the risk and higher
risk groups. DH updated its web advice to reflect the findings.
The WRIGHT phase 1 report is due to be published by the WHO on
28 June 2007. The WRIGHT team are seeking funding for a second
phase of the study, to look at interventions. The UK would be
sympathetic to contributing but the scale of study needed is likely
to need international funding.
DH separately commissioned research into the
use of aspirin as prevention against DVT. The "Synovate"
report was published on the DfT website in April 2006. This study
examined the aspirin-taking behaviour of UK residents who were
undertaking long-haul air travel. It found that 20% had taken,
or planned to take aspirin before, during or after their flight.
The DH website contains useful information on DVT and travel.
Links to this information are also provided on the CAA's Aviation
Health Unit website.
Seating
In response to the Committee's recommendation
a CAA funded research study into the relationship between aircraft
seat dimensions and passenger size was published in 2001 and submitted
to the Joint Aviation Authorities (JAA). Although the seat-spacing
issue is not currently on the European Aviation Safety Agency
(EASA) rulemaking programme, it will need to be addressed by EASA
once it assumes responsibilities for regulation of operations,
expected in early 2008.
The CAA is the only regulatory authority to
have made regulations on seating, which relate to spacing on safety
grounds. The UK minimum seat space criteria require that
the minimum distance between the back support cushion of a seat
and the back of the seat in front is 26 inches in the upright
position. Otherwise seat pitch is a matter for individual airlines.
Generally, first class and business class cabin configurations
provide passengers with a greater amount of seat space than economy
class cabins. Most airlines give information on their websites.
Ideal Cabin Environment (ICE)
The UK is actively participating in the EU-led
Ideal Cabin Environment (ICE) project. The Head of the Aviation
Health Unit in the CAA is the medical chair of the project. The
ICE project is concerned with both health and wellbeing in flight;
it is the first study to address both these issues and will assist
in the exploration of the relationship between them. The ICE project
is therefore looking into the multiple effects of long-haul travel
with differing cabin environment parameters (eg altitude, humidity,
noise) on people of different ages and also at "risk"
groups with heart and lung disease.
Cabin air
The principal gap in research evidence, and
one which Government is now trying to fill, relates to potential
contaminants in cabin air. Two important pieces of work are under
way:
(i) In 2006 the Aviation Health Working Group
(AHWG) commissioned the independent Committee on Toxicity (COT)
to look into the evidence submitted by the British Air Lines Pilots'
Association (BALPA) in relation to cabin air "fume events".
This work has been progressing for a year. The COT secretariat
has agreed that the following information can be cited, although
it is to be noted that the COT have not published a statement
detailing conclusions at the time of writing. As well as from
BALPA, the COT has received information from oil companies, airlines,
engine manufacturers, independent scientific experts and pressure
groups.
The COT work, though not finished, is already
increasing our knowledge of the reporting of fume events. For
example, the COT has analysed the databases of BALPA, CAA and
some airlines. In the BALPA database (up to April 2006), approximately
25% and 35% of reports on the database referred to the BAe 146
and the Boeing 757 respectively. A difference in the pattern of
fume events was seen with regard to phase of flight. Thus, the
majority of such events for the Boeing 757 appeared to be associated
with take off and climb whereas there was no discernable pattern
with regard to the BAe 146/Avro RJ. The information submitted
by BA to the COT showed that from 2002-05, a total of 197 reports
were submitted on the B757 fleet related to alleged fume events.
Two pilots made 38% of reports. Approximately 153 pilots did not
submit a fume related safety report and the remainder (30) made
one or two reports over the four year period. From the information
submitted by Flybe to the COT about the BAe146/Avro RJ, it was
noted that approximately 78% of crew reported one fume event,
12% reported two events, 5% reported three events, and 5% reported
four or more events over the reporting period 2004-06.
The COT is now preparing a first draft working
paper which is not a finalised statement but outlines draft conclusions
for further discussion. We expect this to be posted on the COT
non food website towards the end of June. The Government has said
it will be guided by the finalised COT statement in relation to
further research but also asked for advice before the end of the
review on in-flight air sampling, so that development of a project
could progress as soon as possible (see below).
(ii) Since 2000 both the CAA and BRE (Building
Research Establishment) have undertaken research into this topic.
The next stage is development of an exposure monitoring strategy.
DfT is advanced in preparations for conducting research into cabin
air fume events using a variety of test equipment. There are three
basic questions to answer: (1) Is there any substance(s) in cabin
air which is potentially harmful at the concentration measured?
(2) Could this substance(s) cause acute symptoms?; and (3) Can
continued exposure to such a substance(s) lead to long term ill
health? From its analysis the COT has advised that 1,000 flight
sectors need to be sampled to maximise the likelihood of capturing
an oil-related fume event (as opposed to incidents of burnt food,
toilet smells, etc).
This estimate depends on the particular aircraft
(engine/airframe combination) to be investigated. This approach
should help to answer to the first of the three questions. Airline
co-operation is vital. A similar proposed study in the USA has
not yet found airline partners; DfT is very grateful for co-operation
from airlines operating in the UK.
As a preliminary to this research, functionality
tests of the proposed sampling equipment are currently under way
to examine how it performs in an aircraft environment and determine
effective positioning within the aircraft.
Long term effects from exposure to the aircraft
cabin environment
The CAA has undertaken a study in conjunction
with epidemiologists at the London School of Hygiene and Tropical
Medicine comparing cancers and causes of death in flight crew
and Air Traffic Control Officers (ATCOs) with the UK general population.
Preliminary results have confirmed that flight crew have an increased
risk of melanoma that previous studies have suggested, but have
a significantly reduced risk of other cancers. Overall mortality
and cancer incidence is lower than the general population in both
these occupational groups and is similar for flight crew and ATCOs.
The study has found no clear relationship between the mortality
and cancer experience of flight crew with the cumulative number
of flying hours.
Have any new health concerns emerged since 2000,
and what is being done to address them? For example: are steps
being taken to address concerns over the role of air travel in
the spread of diseases such as SARS or pandemic influenza?
Subjects raised at recent AHWG (see paragraph
17) meetings have included: defibrillators, disinsection, toilet
facilities, flying when pregnant and cockpit light levels.
It is important to distinguish between health
issues which might be caused by flying, and health problems which
may be transmitted into a country by air travel. These latter
issues include SARS and pandemic flu which can be brought into
a country by any transport mode.
The International Health Regulations (IHR) 2005,
which were adopted by the WHO in May 2005 and which come into
force globally on 15 June 2007, aim "to prevent, protect
against, control and provide a public health response to, the
international spread of disease in ways that are commensurate
with and restricted to public health risks and which avoid unnecessary
interference with international traffic and trade". They
provide for the WHO to make recommendations on how to respond
to the risk of international spread of disease. DH is currently
consulting on changes that might be made to the Public Health
(Control of Disease) Act 1984 in the light, amongst other things,
of the IHR 2005.
Meanwhile, local authorities remain responsible
for port health: the Health Protection Agency (rather than individual
Primary Care Trusts) now has the operational lead in England for
providing local authorities with the health input they need to
discharge that function. The current process if there is a suspected
case of infectious disease (including SARS or pandemic flu) on
board is for the pilot of an inward bound aircraft to notify the
Port Health Unit of the receiving airport and implement recently
revised IATA guidance with respect to action taken by cabin crew
to prevent possible spread. If required, the sick passenger would
be assessed by Port Health staff onboard the aircraft upon landing
or taken to the Port Health Unit or directly to hospital.
Much work is being done to ensure preparedness
for a possible flu pandemic and for other contagious diseases
such as SARS. DfT has worked closely with airlines and airports
and other modal operators to ensure they have preparedness plans
in place. This includes taking part in planning exercises involving
other Whitehall departments, local authorities, transport providers
and operators. In addition the International Civil Aviation Organisation
(ICAO) has introduced a standard for Contracting States to establish
a national aviation plan in preparation for an outbreak of a communicable
disease. DH and Cabinet Office have already published a national
framework for responding to an influenza pandemic and DfT is about
to start considering, in conjunction with CAA's Aviation Health
Unit, a national aviation plan in the light of that framework.
How effective has the inter-departmental Aviation
Health Working Group been in taking forward the Committee's recommendations?
The establishment of the Aviation Health Working
Group (AHWG) was part of the Government's response to the Committee's
report of 2000. It first met on 26 March 2001. The function of
the AHWG is to bring together relevant government agencies, to
enable them to engage with stakeholders and to advise Ministers.
It is chaired by DfT and includes DH, the Health and Safety Executive
(HSE), airlines, Trades Unions, the CAA and the Air Transport
Users Council (AUC). Notes of its meetings are published on the
DfT website. There is also a research sub-group which meets under
the chair of the DH to consider research proposals and needs.
In full, the remit of the AHWG is:
"The Aviation Health Working Group will
meet on a regular basis and will work in partnership with other
interested parties to give effect to the Government response to
the House of Lords Inquiry into Air Travel and Health. Particular
responsibilities identified in the response are to:
— provide a forum for interested
Government departments and agencies to consider issues relevant
to aviation health;
— provide an interface with the
air transport industry, health experts and other interested parties
on aviation health issues of mutual interest;
— evaluate the need for research
into issues related to air travel and health, and consider the
role of Government in supporting such research;
— ensure Ministers are kept informed
and receive comprehensive advice on aviation health matters;
— monitor developments that impinge
on the health of those travelling by air."
The AHWG may invite to its meetings speakers
with expertise on aviation health issues. These have included
Crawley Borough Council (covering Gatwick) to talk about disinsection
and Pall Aerospace to talk about air filtration technology.
The establishment of the AHWG has brought industry
and government agencies closer together, not just through meetings
but by embedding day-to-day contact as part of the working culture.
The AHWG has adopted an approach based on openness and information
gathering to underpin policy. It has recently reviewed its operations
and agreed to invite representatives of aviation construction
and manufacturing to attend in future.
How are the arrangements for governance and regulation
of the industry working?
In addition to the establishment of the AHWG,
there have been two substantive developments since 2000.
First, the law governing aviation health has
been amended. The Civil Aviation Act 2006 charged the Secretary
of State with "the general duty of organising, carrying out
and encouraging measures for safeguarding the health of persons
on board aircraft." The functions of the CAA as set out in
section 3(c) of the Civil Aviation Act 1982 were also amended
to include the health of persons on board aircraft. This change
was welcomed in Parliament. For example, John Smith MP said:[1]
"...it is radical and courageous. By creating
the aviation health unit, the Government became the first in the
world to provide such an institution. Under the auspices of the
Bill, the Government will be the first to create a Minister for
aviation health and to finance the aviation health unit, which
is part of the Civil Aviation Authority at Gatwick, with a levy
on the industry. The Government have a commendable record that
sets an example to the rest of the world... They made the largest
single financial contribution to the WHO's study of the health
risks of travelling, especially the risk of developing deep vein
thrombosis... I congratulate and commend the Government on the
lead that they have shown in the past few years by making Britain
the only country to make available... specific health advice for
passengers about to engage on long-haul travel."
Second, and in response to the Committee's report
of 2000, an Aviation Health Unit (AHU) has been established in
the CAA to improve understanding and knowledge of these issues.
This unit, which acts as a focal point for aviation health issues
in the UK, was set up on 1 December 2003. It reports to the Chief
Medical Officer at the CAA. The Head of the AHU is a member of
the AHWG and takes direction from stakeholder input via the AHWG
Chair. Dr Annette Ruge, the first Head, has now moved to EASA
and is still in contact. Dr Raymond Johnston, who currently heads
the AHU, was selected by open competition last year.
How successful have the Government been in raising
international awareness of passenger and crew health, and in improving
international collaboration?
The UK has been an active participant in international
co-operation, presenting at key international conferences eg the
Scientific Meeting of the Aerospace Medical Association (AsMA),
and the Congress of the International Academy of Aviation and
Space Medicine (ICAASM). The UK is represented on the Medical
Provisions Study Group of ICAO, which is tasked with reviewing
and updating ICAO's Medical Standards and Recommended Practices.
The UK has advocated a move towards increasing the educative,
and therefore preventative, aspects of the periodic medical assessments
undertaken by flight crew and the incorporation of this within
international regulation. The CAA is actively involved in the
discussion in international fora of flight crew health issues
which may impact on flight safety including the JAA, EASA, the
International Academy of Aviation and Space Medicine, AsMA and
ICAO.
DfT has sought to foster international collaboration
in the field of cabin air research into fume events. In this respect,
the CAA and the Federal Aviation Administration (FAA) in the USA
signed a Memorandum of Co-operation (MOC) with respect to joint
research on "Cabin Air Quality" on 6 June 2007. DfT
wrote to other members of the European Civil Aviation Conference
(ECAC) in June 2006 to see if they had any experience of or research
on fume events (some countries replied but not substantively).
What progress has the airline industry itself
made since 2000? For example:
— To what extent has the aircraft
cabin environment improved?
— Are aircraft better equipped,
and aircrew better trained, to respond to in-flight medical emergencies?
To what extent has the information supplied to
travellers been improved and integrated since 2000?
These are questions best answered by the aviation
industry. With respect to information supplied to travellers we
recognise that electronic communication via the internet is now
the norm. Consequently the AHU is developing its website with
FAQs addressing issues such as DVT, disinsection, carriage of
medication and provision of therapeutic oxygen.
18 June 2007
1 Hansard House of Commons 25 June 2005. Col
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