A group of U.S. lawmakers has sent a scathing letter to the Federal Aviation Administration about its proposed new rule for the contents of airline emergency medical kits.
The 20 senators and representatives demand changes to the proposed rule, singling out the airline regulator’s approach to anaphylaxis treatment. In that proposed rule, the FAA simply says that airlines “could include” epinephrine to treat anaphylaxis in the emergency medical kits (EMKs).
The lawmakers, in contrast, demand in their letter to FAA Administrator Bryan Bedford that the agency “guarantee” that U.S. airlines have FDA-approved epinephrine delivery methods that can be self-administered “on every flight”. (Those are currently epinephrine auto-injectors or nasal spray.)
The FAA calls its proposed rule a modern approach that offers the airlines “greater flexibility” in deciding what goes into their EMKs.
But the politicians’ group – primarily Democrats with one Republican – blasts that rule as “opaque and dangerous.” The letter was authored by Sen. Tammy Duckworth (D-Ill.), Sen. Chuck Schumer (D-N.Y.) and Congresswoman Doris Matsui (D-Calif). Other senators signing the letter are: Sen. Tammy Baldwin (D-Wis.), Sen. Richard Blumenthal (D-Conn.), Sen. Cory Booker (D-N.J.), Sen. Kirsten Gillibrand (D-N.Y.), Sen. Andy Kim (D-N.J.), Sen. Amy Klobuchar (D-Minn.), Sen. Jack Reed (D-R.I.) and Sen. Sheldon Whitehouse (D-R.I.).
In the House, Rep. Debbie Dingell (D-Mich.), Rep. Brian Fitzpatrick (R-Pa.), Rep. Maxwell Frost (D-Fla.), Rep. Sylvia Garcia (D-Texas), Rep. Josh Gottheimer (D-N.J.), Rep. Raja Krishnamoorthi (D-Ill.), Rep. LaMonica McIver (D-N.J.), Rep. Kelly Morrison (D-Minn.) and Rep. Mike Quigley (D-Ill.) join Matsui in signing. Matsui is the co-chair of the bi-partisan Food Allergy Caucus.
The group’s letter lays out the importance of being ready for in-flight anaphylaxis. “Having multiple doses of epinephrine on every aircraft, in delivery methods that can be easily self-administered by individuals without medical training, is more urgent than ever,” they write.
“This is due to the on-flight presence of food items containing unlabeled allergens, a steady increase in the number of children with food allergies, the increased prevalence of a tick-borne illness that could create life-threatening allergies and the very real possibility that more than one passenger may require epinephrine during a single flight,” they continue.
Airlines Adopting Epi Devices
Allergic Living recently reported that Delta Air Lines is in the process of moving to epinephrine auto-injectors in their emergency kits. Allegiant Air says it will also soon phase in the devices. Other airlines Allergic Living has reported to stock auto-injectors include JetBlue Airways, American Airlines and Southwest Airlines.
The authors of the lawmakers’ letter add a few more to that list. They say United Airlines will soon begin transitioning epinephrine auto-injectors in their EMKs. Meantime, Frontier Airlines and Breeze Airways responded to a survey that Sen. Duckworth and Sen. Schumer circulated to U.S. airlines saying they are already carrying the auto-injectors. (Allergic Living recently conducted updates to our Airlines and Allergies Guide, but United and the other two airlines have not confirmed to us on the auto-injectors.)
Of the airlines’ encouraging news, the lawmakers write: “Even with tight profit margins, including epinephrine in delivery methods that can be easily self-administered, is possible.”
However, their letter insists it’s essential the FAA’s rule explicitly requires epinephrine devices on planes, as opposed to depending on voluntary goodwill. As Matsui told Allergic Living: “Requiring airlines to carry epinephrine in easy-to-use auto-injectors is a commonsense step that can save lives during an anaphylactic reaction.”
“The FAA must direct airlines to include epinephrine in delivery methods that can be easily administered and not reverse course from its previous recommendations by abandoning the requirement to include epinephrine in EMKs in entirety,” the lawmakers say.
Required or Flexible EMK Contents
When speaking of “reversing course,” the lawmakers are referencing that the FAA’s own Onboard Medical Kits Working Group provided recommendations on what should be in EMKs. (Their report was required under the FAA Reauthorization Act of 2024.) The working group included aerospace medicine specialists, physicians and many other experts. They proposed a modernized contents list for airline EMKs, including for anaphylaxis.
In making its new rule, the FAA said it wants to move away from the current “prescriptive list” of required medications. However, the medical kits working group’s report does include a modernized contents list of certain medicines and devices, including epinephrine for anaphylaxis.
The lawmakers write that the working group’s proposed EMK content list “includes both ‘pre-measured auto-delivery device’ or ‘vial-drawn kit.’ Yet, just one year later, the FAA publicly defied the recommendations in this report developed by the expert working group.”
Since epinephrine is the only treatment for anaphylaxis, a severe and life-threatening form of allergic reaction, the lawmakers say it must be there. “The final rule must contain a clear directive that EMKs shall include epinephrine.” Public commenting on the proposed rule ended on Oct. 5.
Cost vs. Safety in Skies
Behind the scenes of this FAA issue, nonprofits have also been speaking out for the food allergy community. The Asthma and Allergy Foundation of America (AAFA) and No Nut Traveler (founded by Lianne Mandelbaum, this article’s co-author) have been meeting with Senate and House offices.
Lianne describes the experience: Like the lawmakers’ group, AAFA and No Nut Traveler have urged these offices to support a national standard that guarantees usable epinephrine on every U.S. flight. As Jenna Riemenschneider, AAFA’s vice president of policy and advocacy, pointed out to congressional staff we met, the first epinephrine auto-injector was approved in the United States in 1987.
Almost four decades later – federal rules still do not require modern epinephrine devices aboard airplanes. For a medical emergency that can unfold at 35,000 feet, that gap is indefensible.
We’ve told congressional staff about the grave public health implications of the FAA proposal. In those conversations, we have repeatedly asked lawmakers to weigh any potential savings for airlines or the FAA against the cost of a human life.
There’s now a food allergy tragedy in the U.S. skies that brings this into painfully sharp focus. Pennsylvania teenager Jason Hu died aboard a foreign carrier headed for New York City in 2024. His family’s lawsuit alleges that Jason and his father discussed his food allergies with a crew member, who assured them an onboard sandwich was safe. (The carrier, Qatar Airways, is not commenting on the case.)
The complaint alleges failures in the emergency response, including a malfunctioning oxygen mask. It describes Jason being placed on seats behind his father and sister. He died there, before the flight landed.
Why Epi Must Be in EMK
As longtime advocates for food allergy safety in the skies, the authors of this article cannot read Jason’s tragic story and accept an airline emergency kit standard that leaves easy-to-use epinephrine to chance.
Lianne thinks of Jason’s father on that flight. “And I think of my own son with allergies, who’s now a college student, traveling frequently without me.”
Allergic Living has documented many physicians responding to in-flight allergic emergencies. We’ve heard reports of them finding only cardiac, not anaphylaxis concentrations of epinephrine or encountering unfamiliar devices that required improvisation over the ocean. Others have crowd-sourced among passengers for an epinephrine auto-injector when there wasn’t one in the emergency kit.
Gwen recalls her own anaphylactic reaction on a flight, which transpired just before landing. She was fortunate to have her own auto-injectors to use, and headed straight to the hospital. But what if she’d needed an additional in-flight dose?
Gwen and Lianne’s son will keep carrying their epinephrine. But Lianne notes that a passenger’s chance of surviving anaphylaxis should not depend on whether they remembered their own medication, whether another traveler can lend them a dose, or which airline sold them the ticket. The right treatment needs to be aboard, in a form even a non-medical person can use, when it is needed.
The lawmakers’ group is right – after all these years of incidents – the FAA needs to step up and guarantee that easy-to-use epinephrine will be there.
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
Anaphylaxis Over Ocean: MD Finds No Epinephrine Vial in Plane’s Kit
Airline Meals and Allergens: 2 Troubling Reactions to Hidden Nut
