Delta Air Lines tells Allergic Living that it is introducing epinephrine auto-injectors in the emergency medical kits of all its aircraft. Meantime, the smaller Allegiant Air says it too is phasing in auto-injectors.
The good safety news comes as the food allergy community and experts express concerns to the Federal Aviation Administration – because the agency is not planning to make epinephrine devices on airplanes mandatory. In a proposed new rule, the FAA says only that treatment for anaphylaxis in airline emergency kits “could include” epinephrine. (Readers may comment on that rule until October 5 here.)
A Delta spokesperson said adding the auto-injectors is “in line with our continued focus on the health and safety of our people and customers.” The transition to auto-injectors in the emergency medical kits (EMKs) across the Delta’s fleet will continue over the next year.
The spokesperson noted that “availability my vary by aircraft as the rollout progresses.”
Allegiant says epinephrine auto-injectors are being added to its EMKs in addition to epinephrine vials. The airline is not providing a rollout schedule. “Our focus is ensuring our aircraft are equipped to respond to medical emergencies effectively,” said their spokesperson.
Allergic Living’s Airlines & Allergies Guide identifies JetBlue Airways, Southwest Airlines and American Airlines as other U.S. carriers that voluntarily stock auto-injectors in their EMKs. Other carriers carry epinephrine vials that have to be drawn up.
The auto-injector safety upgrades from Delta and Allegiant are a welcome turn of events following the FAA’s unveiling of its proposed new rule. It opts for a “flexible” standard of what EMKs contain.
The FAA says its rule will modernize EMKs while allowing airlines to decide what goes into their kits. However, it leaves great uncertainty over whether airlines will always include epinephrine, and in what format.
MDs’ Case for Required Epi
Allergic Living and No Nut Traveler have for years argued for the inclusion of easy-to-use epinephrine in EMKs, in the form of auto-injector or nasal spray. We’ve reported on cases of anaphylaxis where an allergic traveler left epinephrine in the wrong purse or accidentally checked it in luggage.
We’ve also written of anaphylactic reactions in which a family or individual discovers an allergy for the first time in-flight. And of course, they have no epinephrine.
With the FAA’s proposal, nonprofits including the Asthma and Allergy Foundation of America (AAFA) and FARE are also urging the allergy community to comment to the FAA before the Oct. 5 deadline. “The best way to treat anaphylaxis is to use a modern epinephrine delivery device and we should accept nothing less,” says Kenneth Mendez, AAFA’s CEO.
Physicians are also speaking up. In a letter to the FAA, the American Medical Association expresses its concerns about the new FAA rule. Dr. John Whyte, the AMA’s CEO and executive vice president, says his organization supports the FAA Reauthorization Act of 2024’s intent to take a modern approach emergency kit contents. He notes Congress’s 2024 direction to the FAA to consider whether EMKs include appropriate medications and equipment for anaphylaxis, opioid overdoses, and cardiac arrest.
However, Whyte objects to the FAA’s resulting plan to eliminate a required EMK contents list altogether. He makes the case for updating, not cutting it. Whyte says that eliminating the list would remove expert medical input from the clinical judgment of “what minimum capability is necessary to evaluate and treat a medical emergency safely.” Under the proposed rule, he foresees airlines themselves making these decisions, without a basis in medical science.
He calls for the FAA to adopt the Aerospace Medical Association’s recommendations, developed by a group of physicians and aerospace experts. Whyte says the group identified nine conditions airlines must be prepared for, including anaphylaxis. “A requirement to prepare for anaphylaxis should guarantee that its first-line treatment will be available.”
More generally, he says: “A physician confronting the same emergency on two commercial flights should not face materially different options for diagnosing, treating, or monitoring the patient because the airlines made different judgments about what was sufficient.”
Senators Seek Medical Kit Info
In related news, Democrat Senators Tammy Duckworth and Chuck Schumer have sent a letter to U.S.-based passenger airlines. They request information on the contents of their EMKs, including modern epinephrine devices.
In writing, they share with the airlines their own experiences with constituents facing anaphylaxis in the skies. This includes the story of Alexa Jordan, who had a terrifying in-flight reaction to a salad that turned out to contain tree nuts. Flight attendants on the Chicago-bound flight didn’t know if there was epinephrine in the medical kit. Jordan, then 18, gave herself her one dose and was fortunate not to require a second.
The senators note that if an aircraft’s EMK contains a vial of epinephrine, the lack of an easily self-administered delivery method can make treatment challenging, even for a doctor. They relate the story of Schumer constituent Dr. Mike Varshavski, a prominent New York family medicine physician.
In 2019, Varshavski stepped forward to assist a passenger with no previously known allergies. The man, later diagnosed with alpha-gal syndrome, was experiencing progressing anaphylaxis. Varshavski has told Allergic Living he was surprised to find that, instead of an epinephrine auto-injector, this transatlantic flight’s medical kit contained only an epinephrine vial in the concentration for a heart attack.
The senators describe Varshavski being “forced to make split-second calculations to draw from a vial a safe, diluted fraction of the available cardiac arrest formulation of epinephrine to save the life of a young man.”
In their the letter, the senators ask the airlines which delivery method of epinephrine they have available on flights. And they request the rationale for those choices. They state unequivocally: “we must guarantee that U.S.-based airlines include FDA-approved epinephrine delivery methods designed for self-administration on every flight.”
Requiring Epi Devices
At Allergic Living, we applaud Delta and Allegiant for joining the few other domestic airlines also carrying epinephrine devices for use in anaphylaxis.
But we know that, even with good voluntary approaches, the best approach is to have the FAA officially require modern epinephrine devices. Airline CEOs and policies can change. An FAA rule requires a detailed process and, in this case, has required years to get to a now contentious proposal.
That’s why it’s so important that the food allergy community continues to tell the FAA of the urgent need for epinephrine devices at 30,000 feet. If you haven’t yet commented, do so here before Oct. 5.
Lianne Mandelbaum is Allergic Living’s airlines correspondent, and the founder of NoNutTraveler.com. Gwen Smith is the Editor of Allergic Living.
Related Reading:
FAA’s Proposal for Epi on Planes: a Letdown for Allergy Safety
Airline Meals and Allergens: 2 Troubling Allergic Reactions to Hidden Nut
Anaphylaxis Over Ocean: MD Finds No Epinephrine Vial in Plane’s Medical Kit
