Discrepancies between air travelers’ personal reports and airline data suggest the number of anaphylaxis emergencies aboard flights is underestimated, according to a recent paper. A likely underreported incidence of in-flight reactions should not form the basis for federal rules about access to epinephrine on U.S. airlines, the authors assert.
“Low reported numbers offer little comfort when we don’t know how many are being missed,” says Lianne Mandelbaum, founder of NoNutTraveler.com. She is an author of the paper, published in the journal JACI: In Practice in October 2026. “We cannot understand the scope of a problem we are not reliably counting.”
In fact, a lack of standardized documentation from the airlines impedes the ability to assess the frequency of in-flight reactions and their treatment, says Christopher Warren, PhD.
“The truth is, we just don’t know how frequently these events are happening given the underreporting,” Warren tells Allergic Living. He authored the October 2026 paper with Mandelbaum and New York allergist Dr. Anna Nowak-Wegrzyn.
The paper responds to the Federal Aviation Administration’s proposal to update aircraft emergency medical kits (EMKs). The FAA’s proposed rule does not recommend requiring easy-to-use epinephrine in the kits.
The authors assert that the federal proposal is based on information from the airline industry that lacks consistency. Airlines are not required to report and keep records of anaphylactic reactions. Because of this, airline data is based largely on the use of onboard EMKs.
It would be “problematic” to make regulatory decisions based on EMK use alone and excluding passengers who treat themselves, the paper states.
“If the estimate of how frequently these events are occurring is from the very small portion of events where the emergency kit is used, that’s going to be a dramatic undercount,” Warren says.
Survey Reveals Data Gap
The paper points to a 2024 global study on airlines and allergies that shows instances where travelers’ reactions would not appear in airline records. For example, 90 percent of 4,704 survey respondents who reported using epinephrine on an airline said they’d used their own.
“I think about the families whose emergencies may never be counted,” Mandelbaum says. When passengers use their own epinephrine and the medical kit stays closed, their experience could be missing from data used to determine what belongs in that kit, she explains.
“Families are doing everything they can to protect themselves. That should not make their in-flight emergencies less visible,” Mandelbaum says.
The survey also found that 1 in 12 passengers had experienced an allergic reaction while flying. But only 57 percent reported the reaction to the airline, according to the study led by Northwestern University’s Center for Food Allergy & Asthma Research (CFAAR). Warren, the lead author on that study, is CFAAR’s director of population health research.
The survey results contrast with airline industry data, the recent paper contends. For example, a review of airline reports found 0.7 allergic in-flight medical events per million passengers. Data from medical support on the ground estimated about 0.8 allergic events requiring epinephrine.
The FAA says its strategy to update the contents of airline medical kits is based on performance and meant to offer the airlines’ flexibility. But Warren finds it frustrating to base an approach on performance without a system in place that actually measures performance.
“It’s a tremendous missed opportunity to collect the data we would need to understand what is appropriate,” he says. Warren sees the need for a structure to document in-flight anaphylaxis, including standard forms to capture symptoms, treatment, and ground medical assistance.
Anaphylaxis Documentation Needed
The paper criticizes the FAA’s proposed new flexible approach to EMK contents as not appropriate for anaphylaxis emergencies. The FAA rule that is about to be updated requires that airplane EMKs contain certain medications. This includes two epinephrine vials in the dose for anaphylaxis.
A flexible approach would remove this requirement, making it unclear which aircraft will or won’t carry epinephrine. The paper contends that a passenger’s access to epinephrine shouldn’t be “based solely on which airline they happen to be flying, or where that airplane is headed.”
Dr. Marcus Shaker is perplexed that the airline industry, with a proud history of focusing on safety, would take a flexible approach to medical emergencies. The allergist notes that passengers watch a demonstration about how to wear seatbelts, use an oxygen mask, and turn their seat into a flotation device.
Just as those emergency preparations are in place, Shaker says there must also be appropriate preparedness and equipment for anaphylaxis. The professor of pediatrics and medicine at the Geisel School of Medicine at Dartmouth also serves as a member of the U.S. allergist organizations’ Joint Task Force on Practice Parameters (JTFPP).
“I think the solution is really simple,” Shaker says. “Stock all U.S. aircraft with an adequate supply of self-injectable epinephrine.”
Need for Easy-to-Use Epinephrine
Currently, most airline kits contain vials of epinephrine that must be measured in a syringe. However, modern epinephrine devices are easier for someone to use, even if untrained, Shaker notes.
Additionally, supplying easy-to-use epinephrine for in-flight use makes economic sense, he says. Shaker refers to research he conducted in 2019 on the cost-effectiveness of supplying U.S. commercial airlines with stock epinephrine auto-injectors. The study found the auto-injectors would cost 8 cents per food-allergic passenger.
“It seems reasonable to have medications that are usable by people who won’t have extensive training of drawing up medication in a vial in a stressful situation,” Warren says. At a minimum, two easy-to use epinephrine devices in pediatric and adult doses should be available on aircraft, he says.
The October 2026 paper states that in addition to equipment, cabin crews should receive training on what to do in an allergic emergency.
Airlines should be prepared for anaphylaxis, says Mandelbaum, who is also an Allergic Living contributor. While families usually carry their own epinephrine devices on flights, the airline kits need to be a safety net stocked with epinephrine.
For example, a food-allergic passenger might forget their medication or leave it in a bag that gets checked. Another passenger could experience their first allergic reaction in the air or need more doses than they have, she notes.
“In that terrifying moment, they need help they can count on,” Mandelbaum says.
Shaker says stocking epinephrine in aircraft EMKs simply makes regulatory and commercial sense. “When something is a win, win, win like that, we should do it. It shouldn’t be optional, it shouldn’t be flexible. We should do it. That’s not how we fly airplanes,” he says.
Related Reading:
Food Allergy Community Up in Arms Over FAA’s Epi Rule
Airline Meals and Allergens: 2 Troubling Reactions
