Human factors & aviation medicine september-october 1994

F L I G H T S A F E T Y F O U N D A T I O N HUMAN FACTORS &
AVIATION MEDICINE
For Everyone Concerned with the Safety of Flight Air Crews Face Stomach and Intestinal Illness
Risks at Many Layover Sites Around the World
Medications are available to help prevent and treat intestinal illnesses caused
by bacteria and viruses. Pilots should consult an aviation medical examiner
before taking antibacterial and antiviral medications, but avoiding certain foods
and drinks may be the best strategy for prevention of illness.
Wright State University School of Medicine During layovers, air crews risk food poisoning, particularly in the condition, and to determine the crew member’s flight developing countries. Advance planning to avoid contracting fitness status. Notifying the other crew members, company food- and water-borne bacteria or viruses, which can cause flight operations personnel and any available medical “travelers’ diarrhea” and other gastrointestinal upsets including personnel is the first step. The notification can be in person, vomiting, will minimize the chances of becoming a victim.
by telephone or by radio (if in flight). Those notified shouldbe apprised of the symptoms (what the victim feels, e.g., A crew member might experience nausea, fever, head- weakness, nausea, fever or headache) and signs (what can ache, rapid heart rate, gastrointestinal colic, vomiting, di- be seen by others, e.g., vomiting or diarrhea).
arrhea and other symptoms and clinical signs of acutegastrointestinal illness. Severity can range from barely Most cases of travelers’ stomach and intestinal upset are ascribed to bacteria, viruses or both. In most cases, aspecific cause is not sought because, following treat- When gastrointestinal illness attacks a crew member on duty ment, the condition usually goes away with no need for or on a layover, the problems are to decide what to do about Bacteria and Viruses Are Common
physicians.3 Noroxin (norfloxacin) may also be given. An- Causes of Gastrointestinal Illness
other substance, Vibramycin (doxycycline), is also pre-scribed at times. These medications are prescription drugs.
Common causes of gastrointestinal upset with diarrhea are the Bismuth subsalicylate (available in nonprescription medica- group of bacteria known as E. coli. In addition, Shigella and tions such as Pepto Bismol) has often been found to be effec- Salmonella bacteria are often culprits, and a group known as tive for prevention and for symptom treatment, when symptoms Campylobacter has also been found to cause these intestinal begin.4 It is best to get some advance advice from a physician upsets and diarrhea. Various gastrointestinal viruses have been about such medication’s characteristics and treatment regime.
pronounced causes. A little one-celled protozoa, Giardia, mayoccasionally cause diarrhea that lingers for weeks. It is neces- Also available without a prescription is loperamide hydro- sary to obtain stool tests to clearly establish the presence of chloride (available in nonprescription medications such as this organism. Another agent, Cryptosporidium, has been found Imodium), a medicine that slows intestinal motility (move- as a cause of diarrhea in Russia and, from time to time, in the ment). It is used almost exclusively for treatment following drinking water in certain U.S. cities.
onset of diarrheal symptoms.4 It should not be used for morethan two days except under supervision by a physician.
A traveler to an area where there is a probability of exposureto one or more of these organisms can obtain preventive medi-cation from a physician to keep symptoms from occurring Precautions Can Minimize
should some of these organisms be ingested.1 Areas with the Layover Medical Risks
greatest risk are in developing countries.2 When flying to areas where travelers commonly experi- The side effects of these preventive medicines may prohibit ence gastrointestinal illnesses, other precautions can be operation of an aircraft because of physical or mental impair- taken that will minimize (but not completely eliminate) ment. Each crew member must be considered individually for the risk of swallowing bacteria or viruses. Avoid drinking any treatment or preventive procedure. Pilots should always tap water or any water that likely came directly from a discuss with a flight surgeon medications that they intend to faucet. Instead, use bottled water and beverages that inso- far as can be determined contain uncontaminated, sterileor pasteurized contents.
The choice of medication depends on the suspected organismand the individual patient, and should be selected by a physi- Faucet water, if used for brushing the teeth, can be a source cian. Table 1 gives general guidelines.
of bacterial or virus ingestion. This danger is frequentlyoverlooked by otherwise cautious individuals. Using Antibiotics known as Cipro (Ciprofloxacin) and Floxin uncontaminated bottled water when brushing avoids this (Ofloxacin) are sometimes prescribed as preventatives by General Guidelines for Treatment of
Stomach and Intestinal Illness
Occurrence
Probable Cause
Treatment
(Re-formed toxin infood — food poisoning) FLIGHT SAFETY FOUNDATION • HUMAN FACTORS & AVIATION MEDICINE • SEPTEMBER–OCTOBER 1994 Raw fruits and vegetables can be contaminated in many loca- meats, especially fowl and seafood, omelettes and some tions because of the use of human waste as fertilizer in fields high-risk desserts, including those with meringue.
where fruits and vegetables are grown. In addition, workerspicking these items may, through unhygienic conditions and Every airline should have an action plan that enables treat- practices, contaminate the produce. The same can occur in ment for illnesses at layover sites. Preventive medications, with kitchens where these items are prepared as salads, fruit cups instructions approved by a company doctor or an aviation or juices. In such areas, it is better to rely on boxed cereals as medical examiner, should be carried. Procedures to obtain therapeutic medications should be established at each layoversite and the action plan should be coordinated and supervised Some hotels in developing countries have their own water pro- cessing systems and kitchens that meet sanitary standardsequivalent to those in more developed countries. Thus, crew References
layovers should be in hotels selected for high quality healthstandards.
DuPont, H. and Ericsson, C. “Prevention and Treatmentof Travelers’ Diarrhea.” New England Journal of Medi- The irritative effects of alcohol on the esophagus, the esoph- cine Volume 328 (June 24, 1993):25.
ageal stomach junction and the stomach lining are well estab-lished. Judicious travelers should avoid or limit alcoholic Steffen, R.; Rickenbach, M.; Wilhelm, U.; Helminger, A.
beverage consumption when in areas where the risk of gas- and Schar, M. “Health Problems After Travel to Develop- ing Countries.” Journal of Infectious Disease Volume 156(1987):84–91.
One strategy that can be used for brief periods in high-riskareas is to carry food bars that can be substituted for res- Taylor, D.; Sanchez, J.; Candler, W.; Thornton, S.; taurant meals. Beware of street vendors in developing coun- McQueen, C. and Echeverria, P. “Treatment of Travelers’ tries who offer finger-held foods ranging from sweets to Diarrhea: Ciprofloxacin and Loperamide.” Annual of grain and meat products. Numerous reports exist of gastro- Internal Medicine Volume 114 (1991):731–734.
intestinal illnesses acquired from these foods. Unpasteur-ized cheese, ice cream made with unpasteurized milk, Johnson, P.; Ericsson, C.; DuPont, H.; Morgan, D.; Bitsura, meringues (which are made with uncooked egg whites) and J. and Wood, L. “Comparison of Loperamide with Bis- numerous other items carry a high risk. Also to be avoided muth Subsalicylate for the Treatment of Acute Travelers’ is raw or barely cooked meat or fish. The risk of meat conta- Diarrhea.” Journal of the American Medical Association It is important to avoid food that has been left outside for Mohler, S. “Controlling the Hazards of Aircrew Food an hour or more following removal from a refrigerator or a Poisoning.” Human Factors & Aviation Medicine Volume chilled area, giving gastrointestinal disease–causing bacte- About the Author
Inflight Meals May
Also Pose Risks
Stanley R. Mohler, M.D., is a professor and vice chairman atWright State University School of Medicine in Dayton, Ohio, Even inflight meals represent a possible risk for crew mem- U.S. He is director of aerospace medicine at the university. bers. Through the years, numerous cases of multiple food poi-soning have resulted from on-board airline food.5 Mohler, an airline transport pilot and certified flight instructor,was director of the U.S. Federal Aviation Agency’s Civil Avia- During the past two decades, catering services have made tion Medicine Research Institute (now the Civil Aeromedical progress in ensuring that the foods they deliver to aircraft Institute) for five years and chief of the Aeromedical Applica- are free of hazardous viral or bacterial contaminants.
Nevertheless, departure delays can result in food warmingfrom its refrigerated state while sitting on the tarmac before He has written several books on pilot medications and a book loading. Under these circumstances it is prudent to avoid FLIGHT SAFETY FOUNDATION • HUMAN FACTORS & AVIATION MEDICINE • SEPTEMBER–OCTOBER 1994 The Air Transport System — Aircrew and
Air Traffic Management Integration
a joint meeting of
FLIGHT SAFETY FOUNDATION
FRENCH NATIONAL ACADEMY OF AIR & SPACE
Toulouse, France
November 8–10, 1994
For more information contact J. Edward Peery, FSF.
(This meeting follows the joint meeting of FSF and the International Federation of Airworthiness in Lisbon, Portugal, October 31–November 3, 1994.) HUMAN FACTORS & AVIATION MEDICINE
Copyright 1994 FLIGHT SAFETY FOUNDATION INC. ISSN 1057-5545
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FLIGHT SAFETY FOUNDATION • HUMAN FACTORS & AVIATION MEDICINE • SEPTEMBER–OCTOBER 1994

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