Occupational Health & Safety of Flight

Attendants

Robin Griffiths, David PowellOccupational & Aviation Medicine

University of Otago Wellington

New Zealand

Disclosure Information84th Annual AsMA Scientific Meeting

Speaker Robin Griffiths

I have no financial relationships to disclose.

I will not discuss off-label use and/or investigational use in my presentation

Government Concerns about Flight Attendant Health

1987: Canada Aviation OSHA Regs2000: FAA/OSHA Report2002: CASA Certification Proposal2002: NRC Report CAQ2004: GAO-04-54 Cabin Air Quality2005: FAAA reversal2007: EGOA Report2007: JAR AMC OPS 1.995(a)(2)2007: House of Lords report

Is this fiddling while Rome burns?

Medicals - ?Where is the Value Added?CAQ – Clarity vs hot air?RadiationCancerMusculoskeletal injuryMental healthFatigueReproductive health

All Cause Mortality1

Overall low (SMR 0.80)Aircraft accidentsSuicide (males)HIVCancer

1. Blettner 2002

Medical Disqualifications1

ENT 30%Musculoskeletal 21%Psychiatric 12%Cardiovascular 9%Cancer 7%Visual 5%Other 1. Pombal 2005

Ionizing Radiation

2-6 mSv/year

Longer, higher latitude sectors

High LET radiation

Solar particle events

Strategies

Occupational Exposure LimitsValidation of CARI modelsInformation to crewNOAA SPE notificationsPregnancyCataractChromosomal studiesCancer surveillance

Cancer

Skin– Melanoma– BCC/SCC

Breast Prostate/BladderNHL/LeukaemiaColonBrain?

Controversial AreasHealthy worker effectMethodologies (response rates)Mortality vs incidenceOver-diagnosisConfounding factors

– Exacerbating (Kojo – family history)– Protective

Looking for small risk amongst large onesAttributable risks (Pinkerton)

Breast Cancer4 major systematic reviews, based on

7 studies, average 50% risk increase:Radiation:– Tokumaru 2006– Buja 2006

Circadian rhythms:– Megdal– Erren

Melanoma

Doubling of risk

Concomitant SCC/BCC risk

LET radiation (Sigurdson 2004)

Role of UVL (Rafnsson 2006)

Role of melatonin (Souza 2006)

Cabin Air Contamination

USAUKAustraliaCarbon dioxideETSDryness & skin irritationInfectious disease transmission

Musculoskeletal Injuries

Turbulence (Tvaryanas 2003)

Manual handling (Glitsch,Schaub 2007)

Galley (Spreadborough 2007)

Slips, trips & falls (Agampodi 2009)

Ergonomics (Logie)

Mental Health

17% FA’s “stressed” (Ballard 2006) “Emotion work” (Heuven 2004)Harassment (Gendreau 2006)Operational concerns (Skogstad 1995)Management/job security (Ballard

2004)50% long-term incapacity

is stress-related

Circadian Rhythms & Fatigue

Longer sectors & hoursSleep lossCircadian dysrhythmiaSubjective fatiguePerformanceHypoxiaMelatoninFamily

Strategies

FAA FA Fatigue Studies 1- 5>90% of FA’s report hazardous fatigue2.4% of ASRS incidents fatigue-relatedScheduling/FRMSDuty timesStandby/positioningRecovery time

Reproductive

Menstrual irregularitiesPrimary infertilityFoetal death? (Lauria 2006)Spontaneous abortions (Magann 2010)Endometriosis (Marino 2009)Theoretical associations with long/

irregular hours, bending, stooping, lifting – last trimester (Bonzoni 2009)

Making Real Health Gains for Flight Attendants

Monitor cancer risksInjury preventionMental healthFatigue risk managementInvestigate cabin

contamination incidents

References1. Agampodi SB, Dharmaratne SD, Agmapodi TC. Incidence and predictors of onboard

injuries among Sri Lankan flight attendants. BMC Public Health 2009; 9:227-32 2. Ballard TJ, Romito P, Lauria L, Vigiliano V, Caldora M, et al. Self perceived health and

mental health among women flight attendants. Occup Environ Med 2006; 63:33-383. Blettner M, Zeeb H, Langner I, Hammer GP, Schafft T. Mortality from cancer and other

causes among airline cabin attendants in Germany, 1960-1997. Am Jnl Epidemiol 2002; 156:556-65

4. Buja A, Mastrangelo G, Perisonnotto G, Grigoletto F, Frigo AC, et al. Cancer Incidence among Female Flight Attendants: A Meta-Analysis of Published Data. Jnl Women’s Health 2006; 5:98-105

5. Civil Aviation Safety Authority of Australia. Discussion Paper: Medical Certification of Cabin Crew Members. 2002. Document DP 0223FS CASA, Canberra, Australia

6. Erren TC, Pape HG, Reiter RJ, Piekarski C. Chronodisruption and cancer. Naturwissenschaften. 2008; 95:367–82

7. General Accounting Office. Aviation Safety: More Research Needed on the Effects of Air Quality on Airliner Cabin Occupants. GAO-04-54. 2004. GAO, Washington, DC.

8. Glitsch U, Ottersbach HJ, Ellegast R, Hermans I, Feldges W. Study of the strain on flight attendants of pushing and pulling trolleys on aircraft. BIA-Report 5/2004. 2004 Berufsgenossenschaftliches, Institut fur Arbeitsschutz-BIA. St Augustin Germany

9. Haugli L, Skogstad A, Helleoy OH. Health, sleep, and mood perceptions reported by airline crews flying short and long hauls. Aviat Space Environ Med 1994; 65:27–34

1. House of Lords Select Committee on Science and Technology, Air Travel and Health An Update. House of Lords Select Committee Report, 2007, The Stationery Office, London

2. Kojo K, Pukkala E, Auvinen A. Breast cancer risk among Finnish cabin attendants: a nested case-control study. Occup Environ Med 2005; 62:488-93

3. Linnersjo A, Dammstrom B-G, Johansson M, Eliasch H. Cancer incidence in airline cabin crew: experience from Sweden. Occup Eviron Med 2003;60:810-814

4. Megdal SP, Kroenke CH, Laden F, Pukkala E, Schernhammer ES. Night work and breast cancer risk: A systematic review and meta-analysis. Eur Jnl Cancer 2005; 41: 2023–32

5. Pombal R, Peixoto H, Lima M, Jorge A. Permanent medical disqualification in airline cabin crew: causes in 136 cases, 1993-2002. Aviat Space Environ Med 2005; 76:81-4

6. Rafnsson V. Breast cancer among airline cabin attendants. Occup Environ Med 2006; 63:71-72

7. Schaub K, Berga K, Winter G, Ellegast R, Glitch U, et al. Muscular capabilities and workload of flight attendants for pushing and pulling trolleys aboard aircraft. Int Jrnl Ind Ergo 2007; 37:883–92

8. Sigurdson AJ, Ron E. Cosmic radiation exposure and cancer risk among flight crew. Cancer Investigation 2004; 22:743-61

9. Tokumaru O, Haruki K, Bacal K, Katagiri T, Yamamoto T, Sakurai Y. Incidence of Cancer Among Female Flight Attendants: A Meta-Analysis. Jnl Trav Med. 2006; 13: 127–32

10. Tvayanas AP. Epidemiology of turbulence-related injuries in airline cabin crew, 1992-2001. Aviat Space Environ Med. 2003; 74:970-6.