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Survey illuminates challenges families with food allergies face in air travel

Survey illuminates challenges families with food allergies face in air travel

March 06, 2023

5 min read


Warren CM, et al. Understanding experiences, barriers, & facilitators of safe airline travel – A global survey of food allergy patients and caregivers. Presented at: AAAAI Annual Meeting; Feb. 24-27, 2023; San Antonio.

Warren reports receiving research grants from the National Institute of Allergy and Infectious Disease, Food Allergy Research and Education and Sunshine Charitable Foundation.

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SAN ANTONIO — People with food allergies face multiple challenges when they travel by air, as airline responses to their needs vary, according to data presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

“The skies are busier than ever,” Christopher M. Warren, PhD, director of population research at the Center for Food Allergy & Asthma Research, Northwestern University Feinberg School of Medicine, said during his presentation.

boy eating on a plane
The survey of 4,704 people affected by food allergy revealed 400 in-flight incidents, including five cases requiring an emergency landing. Image: Adobe Stock

Warren noted that one in 10 adults and one in 13 children have food allergies in the United States and that 2.9 million passengers pass through airports in the US each day.

“But outside of a handful of often well publicized stories and articles written by patient advocates about the specific experiences of air travelers managing these kinds of food allergy reactions during travel, it’s remarkable how little we know,” he said.

Study design, population

Warren and his colleagues collaborated with stakeholders in food allergy as well as clinical and health psychology, primary care, health behavior research, patient advocacy, epidemiology and survey research to develop a survey in a multi-year effort.

With the help of 45 partners, the researchers disseminated the survey throughout five countries in a 3.5-month span.

Christopher M. Warren

“I’m happy to report we got 4,704 complete surveys out of 6,300 that were started for a 75{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} completion rate,” Warren said. “We’re pleased with how eager folks were to share their experiences.”

Respondents were 88.4{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} female, 75.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} white and predominantly aged 40 to 49 years (40.{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}).

Also, 98.6{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had a food allergy diagnosed by a physician, 95.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had an epinephrine prescription, 52.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had a history of epinephrine use, 70{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had visited an ED for a food allergy issue and 24.4{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had been hospitalized due to their food allergy.

In the air

Overall, 8.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of the respondents reported a total of 400 in-flight allergic reactions to food. During these events, 59.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} reported the incident to the flight crew or airline once they landed, and 30.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} were transferred to a hospital or urgent care once they landed. Also, 3.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} requested an emergency landing, which happened in five of 15 cases.

The most common triggers were peanut (3.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), tree nut (2.4{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) and milk (0.6{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), along with egg, shellfish, fish, soy, wheat and sesame, with 1.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of respondents saying they were unsure of the trigger and 0.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} reporting “other.”

Reactions included cutaneous symptoms for 87.25{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of the respondents, oropharyngeal symptoms for 57.75{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}, gastrointestinal for 29.75{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}, respiratory for 51.25{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} and cardiovascular for 16.75{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}.

In-flight treatments include antihistamine (60.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), epinephrine (15.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) and inhaled bronchodilators (15.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), with 7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} considered “other” and 1.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of respondents unsure.

“In almost all of the cases, the epinephrine was self-carried, but there were documented cases of other passengers volunteering their epinephrine and also epinephrine provided by the airline,” Warren said, with the airline providing vials of epinephrine in two cases and an autoinjector in a third.

Airline behavior

Patients frequently requested specific accommodations from the airline before boarding, such as an opportunity to preboard, announcements pertaining to food allergy on board, alternative snacks, buffer zones and other modifications. Primarily, these accommodations involved peanuts and tree nuts.

According to the survey, 47{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of the respondents said airlines provided accommodations as promised, 36{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said the airlines assured them that they would meet these requested accommodations but failed to deliver.

When the survey asked respondents about how well they were treated by airline staff, including gate agents, flight attendants and baggage handlers, 35.6{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said they had experienced unprofessional or insensitive behavior, 58.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said they had not.

Also, 76.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of those who had experienced unprofessional or insensitive behavior said that these experiences impacted how they fly.

Conversely, 32{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} reported that an airline or a member of the flight crew went “above and beyond” in accommodating the food allergy, with more than a thousand specific examples provided by respondents.

“Perhaps unsurprisingly, when these folks are treated well, they are more likely to choose that airline due to these positive experiences,” Warren said.

This positive treatment led 73.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} to say they were a lot more likely to choose that airline again.

Patient behavior

“Folks generally were taking considerable amounts of steps to proactively manage food allergy during air travel,” Warren said.

These steps included carrying epinephrine (93.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), attempting to bring their own food (82.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), bringing antiseptic wipes (81.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), carrying additional epinephrine (74.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), contacting the airline ahead of time (67.2{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) and ordering allergen-free meals (23.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}).

When respondents brought their own food, 40.2{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said airport security or customs inspected it, 27.3{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said the food was “ruined” during this inspection, 15.2{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} requested special handling and 13.4{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said food was confiscated.

11.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} for a doctor’s note, 91{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} had one ready. Also, 15.6{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said that security asked to see their epinephrine autoinjector (EAI), and 1.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said their EAI was confiscated.

Additionally, 11.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said that they had been asked to leave a flight or that they had been prevented from boarding. Warren indicated that this frequency may be why so many respondents carry doctor’s notes with them.

“Also, a troubling trend we’re seeing is requesting that patients sign additional waivers to absolve the airlines of liability before being allowed to fly,” Warren said.

Respondents reported if they had been asked once to sign such a waiver once (3.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) or more than once (1.1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), as well as if they signed it one time (53.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) or more than one time (17.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}).

“Another troubling trend that we identified that’s in need of future work is the fact that a third of folks reported deliberately not disclosing a food allergy while they were flying,” Warren said.

By frequency, 15.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} 9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} Reasons included concerns that they would get in trouble (13.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}), beliefs that disclosures would lead to unwanted accommodations (11.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}) and the belief that disclosures were unnecessary (9.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}).

“That probably is another contributor to the fact that overwhelmingly, patients and parents do report that food allergy adds a substantial amount of anxiety to the travel experience and is a primary driver of airline travel decisions,” Warren said.

Food allergy adds “a lot” of anxiety to travel for 63.3{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} of the respondents, “some” anxiety for 24.2{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} and “a little” for 10.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}.

But if airlines implemented better policies or made the right accommodations, the survey asked,61.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} .1{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} with 5.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} saying it would go away and 2.4{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} saying it would not decrease.

When asked how much food allergy affects whether they travel, 20{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said extremely, 19.5{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said a lot and 21.9{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} said somewhat. Similarly, said food allergy affects their travel method, 21.8{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667} 24.7{6932ee47e64f4ce8eedbbd5224581f6531cba18a35225771c06e4f1b3f0d9667}.

Clinician takeaways

Allergists should address these issues with their patients, Warren told Healio after the presentation, but the topic of how to best manage food allergies during air travel may not come up during the limited time that allergists and patients often have together.

“Given that air travel can clearly be a challenging domain for many food allergy patients and families, it may be advisable for allergists to consider being proactive and asking families about upcoming travel plans so they can offer appropriate guidance,” Warren said.

Along these same lines, Warren continued, allergists also may consider having form letters available and ready for patients to carry when they travel. These letters would document their specific allergy and highlight the need for them to carry allergy-safe food and medications for emergency treatment.

“Allergists can also make sure that patients have up-to-date emergency action plans and make sure that they are fully empowered to identify and effectively treat anaphylaxis, even if it happens at 30,000 feet,” Warren said.

Few resources fully address air travel for patients with food allergies, Warren said, but he did note an online list of tips created by study coauthor, patient advocate and founder of No Nut Traveler Lianne Mandelbaum, MS, PT.

The researchers plan on continuing to work with their 45 partner organizations to publish manuscripts that detail their findings and share them with a wide range of policymakers and other food allergy stakeholders, Warren said.

“We anticipate that this process will also lead to the development of follow-on surveys and research that builds upon the successes of this collaborative effort to paint a fuller picture of the experiences, barriers and desired facilitators of safe airline travel among food allergy patients and their families,” Warren said.