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International Air Transport Association


Recent years have seen an enormous growth in the number of

passengers, long-distance f lights and the length of non-stop
sectors. Airlines take the health of their passengers very
seriously, particularly when they can be seated and inactive
f or long periods of time. They have thus worked with IATA to
compile some recommendations to improve passengers’
awareness of the health risk f actors involved with air travel
and to increase their comf ort both during and af ter a f light.

This document has been compiled using the expert advice of

senior airline medical prof essionals and f rom specialists in
the W orld Health Organisation (W HO). It is intended to serve
as a guideline f or airlines to use when providing health
inf ormation to their passengers.

For more information, or to obtain hard copies of this document, please contact:

IATA Inflight Services

International Air Transport Association (IATA)
P.O. Box 416
CH-1215 Geneva 15 Airport, Switzerland

Tel: +41 22 799 2082, Fax: +41 22 799 2631, Email:

Section Subject Page

1. CABIN ENVIRONMENT………………………………… 1




5. MOTION SICKNESS……………………………………..6

6. STRESS, FATIGUE, JET LAG……………………….. 6




! ! !

1. Cabin Environment

(a) Cabin Air Pressure

Although aircraft cabins are pressurised, the cabin air pressure is

not the same as on the ground. It is equivalent to pressure at the
altitude of 1500-2500 metres above sea level. Consequently, the
available oxygen is reduced and gases within the body expand.
The effects of reduced cabin air pressure are usually well tolerated
by healthy passengers.

(b) Oxygen and Hypoxia

Cabin air contains ample oxygen for healthy passengers. The

oxygen saturation of the blood is slightly reduced, leading to mild
hypoxia (i.e. reduced supply of oxygen to the tissues) as a result
of reduction in cabin air pressure.

The effect of alcohol on the brain is increased by hypoxia.

Passengers with cardiovascular or respiratory disease, or certain

disorders of the blood, such as anaemia or sickle cell disease, may
not tolerate hypoxia well and should consult their physician before

(c) Gas expansion

Air expands in all air-filled body cavities as a result of reduction in

cabin air pressure. Abdominal gas expansion may cause
moderate discomfort, whereas expansion of the air in the middle
ear and sinuses may cause pain particularly during descent.

As the aircraft ascends, air escapes from the middle ear and the
sinuses, usually without causing problems.

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As the aircraft descends, air must be allowed to flow back into the
middle ear and sinuses in order to equalise pressure differences
("clearing the ears"). This is sometimes difficult, but discomfort
can be alleviated by swallowing, chewing or yawning; if the
problem persists, forceful expiration against a closed nose and
mouth will usually help.

People with ear, nose and sinus infections should avoid flying
because injury may result from inability to equalise pressure
differences. If problems arise during flight, detumescent nasal
drops may sometimes be helpful.

(d) Humidity

Relative humidity is low in aircraft cabins, usually less than 20%.

Low humidity may cause discomfort in the eyes, mouth and nose
but presents little risk to health and does not result in central
dehydration as long as normal fluid intake is maintained.

Discomfort can be alleviated by maintaining good fluid intake

before and during the flight, the use of a skin moisturising lotion,
use of a saline nasal spray to moisturise the nasal passages, and
the use of spectacles rather than contact lenses.

(e) Dehydration

Measures should be taken to prevent dehydration on long flights.

Adequate intake of non-alcoholic beverages (water and fruit juices)
should be maintained before and throughout the flight.
Consumption of caffeine-containing beverages (including tea,
coffee and cola) and alcohol cause dehydration and should be
restricted, and preferably avoided, before and during the flight.

2. Immobility and circulatory problems

Prolonged immobility, particularly when seated, may lead to pooling of

blood in the legs, which in turn may cause swelling, stiffness and
discomfort. Circulatory stasis is a predisposing factor for the
development of venous thrombosis (blood clots).

Most venous thrombi do not cause any symptoms and are resorbed
without any consequences. Very rarely, however, small pieces of clot may
detach and be carried through the blood stream to the heart and onward

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into the lungs causing a pulmonary embolus. This usually occurs only
where there is already an extensive clot in the leg and may happen many
hours or days after the formation of the clot. It may result in serious
consequences including chest pain, shortness of breath and even sudden

The risk of developing deep vein thrombosis is very small for travellers
unless they have pre-existing additional risk factors for thromboembolism,
which include:

" previous history of venous thrombosis or pulmonary embolism,

" over 40 years of age,
" use of hormone therapy,
" pregnancy,
" recent surgery or trauma,
" cancer,
" genetic blood clotting abnormalities.

Some researchers also suggest that, in addition, there may be a risk from
tobacco smoking, obesity and varicose veins. People in these risk
groups should seek medical advice before travelling.


Carrying out simple exercises at frequent intervals during the flight can
reduce the negative effects of prolonged immobility. Most airlines provide
helpful advice on in-flight exercises to stimulate the circulation and reduce
stiffness, discomfort and fatigue, as well as lowering the risk of developing
venous thrombosis.
In addition, passengers are advised to:

" Drink adequate fluids,

" Avoid smoking,
" Avoid alcohol,
" Avoid crossing legs when seated,
" Stretch their arms and legs every 30 minutes or so,
" Wear loose fitting comfortable clothes when travelling,
" Avoid taking sleeping tablets.

After arrival at the destination, the effects of the journey can be reduced
by gentle exercise to stimulate the circulation.

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3. Travellers with Special Needs

Most airlines have a policy for the carriage of medical passengers or those
with other special needs. IATA Member airlines have agreed on the
following general recommendations :

(a) Infants

Air travel is not recommended for infants less than 7 days old or
for premature babies. Changes in cabin pressure can cause
distress to infants, which can be alleviated by giving a bottle or

Infants are more susceptible to dehydration than older children and

adults. Adequate fluid intake should be maintained before and
during the flight.

(b) Pregnant women

Commercial flights are normally safe for mother and foetus.

However, air travel is not recommended in the last month of
pregnancy and until 7 days after delivery. Most airlines restrict
acceptance of pregnant women. The common guidelines for
uncomplicated pregnancy are for single pregnancies, until the
th nd
end of the 36 week and until the end of the 32 week for multiple
pregnancies. A letter from a doctor or midwife confirming good
health and expected date of delivery should be carried beyond the
28 week of pregnancy. Medical clearance is required for
pregnant women if delivery is expected less than 4 weeks after the
departure date or if any complications in delivery may be expected.

(c) Pre-existing illness

People suffering from recent or chronic diseases such as

cardiovascular disorders, chronic respiratory disease, severe
anaemia, unstable diabetes, cancer and those taking
immunosuppressive medication or whose fitness to travel is in
doubt for any other reason should consult their doctor before
deciding to travel by air. Medical clearance should be sought from
the airline in such cases. All medication should be kept in cabin
baggage and readily accessible.

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Flying is generally safe for passengers with pacemakers.
However, unipolar lead pacing systems may be susceptible to
electronic interference during flight and guidance on the effect of
airport security screening devices should be obtained. Bipolar
lead pacing systems are not affected.

(d) Smokers

Smoking is not permitted on board aircraft, with the exception of

very few airlines. Smokers who regularly smoke heavily may
experience stress and discomfort, particularly during long flights.

Heavy smokers may benefit from medical advice before travelling.

Nicotine replacement patches or chewing gum may be helpful and
use of a mild tranquilliser can be considered.

(e) Travellers with disabilities

A physical disability is not usually a contraindication for travel.

IATA member airlines have regulations on conditions of travel for
passengers with disabilities. Passengers who are unable to look
after their own needs in flight (including the ability to manage in the
toilet and transfer from wheelchair to seat and vice versa) may
need to be accompanied by an able and willing escort.

4. Transmission of Infectious Diseases

The quality of aircraft cabin air is carefully controlled. Exchange with

outside air and filtration of re-circulated cabin air provide a total change of
air 20-30 times per hour. This level of ventilation is very much greater
than in any building on the ground and it ensures that contaminant levels
are kept low. Modern aircraft re-circulate up to 50% of the cabin air.
The recirculated air is passed through HEPA filters that trap particulate
material, bacteria, fungi and most viruses. Consequently, recirculated
cabin air is very clean.

Transmission of airborne infectious agents between passengers is unlikely

but may occasionally occur if seated close to the source of infection.
Tuberculosis infection has been transmitted in a few instances to
passengers seated close to a traveller suffering from tuberculosis,
however in no case did this result in the development of disease. To
avoid any risk of infecting others, transmitting disease from one country to

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another, as well as for personal health reasons, people with contagious
diseases should not travel by air.


Many countries require disinsection (treatment for the removal of insects)

of aircraft arriving from countries where vectorborne diseases such as
malaria and yellow fever occur. This is to prevent the introduction of
infection by insects inadvertently carried on board. Disinsection is a public
health measure which is mandated by the International Health
Regulations and with which airlines are duty bound to comply.

Disinsection involves treatment of the interior of the aircraft by the

application of insecticides. Different procedures are in use:

• treatment of the interior of the aircraft by application of a quick-acting

pyrethroid insecticide spray, with the passengers on board,
immediately prior to take off

• treatment of the interior of the aircraft on the ground before

passengers come on board, using a residual insecticide aerosol
containing permethrin, plus additional in-flight treatment with a quick-
acting insecticide spray shortly before landing.

• regular application of a residual insecticide to all internal surfaces

except in food preparation areas.

Travellers are sometimes concerned about their exposure to insecticide

sprays while travelling by air. They should be reassured that disinsection
is a safe procedure. There is no evidence of any toxic hazard to
passengers or crew, using any of the recommended methods and
products for disinsection.

For more information, visit the World Health Organisation’s website:

5. Motion Sickness

Travellers by air very rarely suffer from motion sickness. Travellers

susceptible to motion sickness should request a seat over the wings
and/or a window seat. If necessary, medication may be taken to prevent
motion sickness.

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6. Stress, Fatigue, Jet Lag

Jet lag refers to the disruption of sleep patterns and other circadian
rhythms that result from abrupt changes in time zones. The adverse
effects of jet lag may lead to insomnia, indigestion, reduced physical and
mental performance and general malaise.

The effects of jet lag can be reduced by the use of effective strategies.
Travellers who take medication on a strict time schedule (e.g. insulin,
contraceptive pill) should seek medical advice.

General measures to reduce the effects of jet lag may include:

• be well rested before departure and rest as much as possible during

the flight. Ensure that you have as much sleep in every 24 hours
when travelling as you would at home and use sleep opportunities
effectively, including naps. It is not always appropriate to adjust to
local time for short trips - if in doubt seek specialist advice;

• wear loose comfortable clothing;

• drink plenty of water and/ or juices before and throughout the flight;

• eat light meals and limit consumption of tea, coffee and alcohol before
and during the flight;

• short-acting sleeping pills may be helpful in assisting the adjustment of

sleeping pattern after arrival. However, use these only under medical
supervision and ensure that they are tried and tested at home before
using them when travelling;

• Stay out in the natural daylight or in brightly-lit areas at appropate

times during the day to help adjust more quickly to the time zone of
the destination.

7. Medical Assistance on Board

Most airlines operating international flights have a policy for dealing with
medical incidents on board . Cabin crew are trained to recognise and
manage a range of in-flight medical emergencies.

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Airlines carry first-aid kits on board all aircraft, to be used by the crew.
They may also carry,

" a medical kit for the use of doctors or other qualified trained
persons in treating in-flight medical emergencies, and

" an automatic external defibrillator, for use by the crew in case of

cardiac emergencies.

Cabin crew are trained in the use of first-aid materials and in carrying out
first-aid and resuscitation procedures. They are usually also trained to
recognise a range of medical conditions which may cause emergencies
on board and the appropriate measures to be taken during the flight.

8. Medical Restrictions by Airlines

IATA Member Airlines require medical clearance by the medical

department/ adviser of the airline if there is an indication that a passenger
may be suffering from any disease, physical or mental condition, which

" adversely affect the welfare and comfort of the other passengers
and/or crew members;

" be considered a potential hazard to the safety of the aircraft;

" require medical attention and/or special equipment during the flight; or

" be aggravated by the flight.

Airlines reserve the right to refuse to carry passengers with conditions

where adverse effects or hazard may result during the flight.

Frequent travellers who are permanently or chronically incapacitated may

obtain a Frequent Traveller's Medical Card from the airline's medical
department. This card is accepted, under specified conditions, as proof of
medical clearance and for identification of the holder's incapacitation.

When cabin crew suspect that a passenger may be ill, the Commander
will be informed and a decision taken on whether the passenger is fit to
travel or presents a danger for other passengers or the safety of the

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9. Contraindications for Air Travel

Travel by air is contraindicated for a number of conditions, which may

include the following:

• infants less than 7 days old and premature babies;

• women in the last 4 weeks of pregnancy (8 weeks for multiple) and

until 7 days after delivery;

• people suffering from:

- any serious and acute contagious disease,

- recent myocardial infarction and stroke,

- uncontrolled arterial hypertension of more than 200 mmHg (27

kPa) systolic pressure,

- angina pectoris or chest pain at rest,

- severe chronic respiratory disease, breathlessness at rest or

unresolved pneumothorax,

- infections of the ear, nose or sinuses;

• recent surgery or injury where trapped air or gas may be present,

especially abdominal trauma and gastro-intestinal surgery, cranio-
facial and ocular injuries, eye and brain operations;

• recent psychiatric illness.


References: IATA Resolution 700/Recommended Practice 1700
2 st
IATA Inflight Management Manual, 1 edition issued 1 July 2001
World Health Organisation (WHO) International Health Regulations

Link to WHO web site:

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