The Occupational Health and Safety of Flight Attendants

Transcription

1 REVIEW ARTICLE The Occupational Health and Safety of Flight Attendants G RIFFITHS RF, P OWELL DMC. The occupational health and safety of flight attendants. Aviat Space Environ Med 2012; 83: In order to perform safety-critical roles in emergency situations, flight attendants should meet minimum health standards and not be impaired by factors such as fatigue. In addition, the unique occupational and environmental characteristics of flight attendant employment may have consequential occupational health and safety implications, including radiation exposure, cancer, mental ill-health, musculoskeletal injury, reproductive disorders, and symptoms from cabin air contamination. The respective roles of governments and employers in managing these are controversial. A structured literature review was undertaken to identify key themes for promoting a future agenda for flight attendant health and safety. Recommendations include breast cancer health promotion, implementation of Fatigue Risk Management Systems, standardization of data collection on radiation exposure and health outcomes, and more coordinated approaches to occupational health and safety risk management. Research is ongoing into cabin air contamination incidents, cancer, and fatigue as health and safety concerns. Concerns are raised that statutory medical certification for flight attendants will not benefit either flight safety or occupational health. Keywords: cabin crew, flight attendant, purser, medical certification. F LIGHT ATTENDANT health and medical fitness have become topical, with a focus on fatigue as an occupational health and safety hazard ( 54 ) and the establishment of statutory medical certification systems in some jurisdictions ( 33 ). The question now is whether 125 journal articles were identified as being relevant to these approaches adequately address Copyright: either flight Aerospace safety Medical the review. Association concerns or the occupational health and safety needs Delivered of by Ingenta A structured review was preferred over a systematic flight attendants. The focus of the Congress of the United States on applying fatigue risk management strategies to flight attendants is laudable. Crew fatigue might threaten passenger safety and personal health if it occurs. Evidence that flight attendant performance impairment or incapacitation poses a flight safety risk is scant and the costs of a new regulatory framework do not seem to be matched with corresponding benefit. However, concerns do exist about mental health, injury prevention, circadian dysrhythmia, ionizing radiation, reproductive disorders, and cancer. Characterizing flight attendants lifetime exposures and consequential health outcomes is complicated by diverse international practices on contracting and working conditions, and the disseminated and occupationally mobile nature of their employment, particularly outside the United States. The lack of standardized approaches to collecting data on exposures and health outcomes for flight attendants makes it very difficult to make inferences about health outcomes. What is needed is an evidence-based, comprehensive, and international approach to health and fitness concerns for this Robin F. Griffiths and David M.C. Powell important occupational group, and a clear understanding about priorities and accountabilities for managing them, so that funding and priorities can be set in a transparent agenda. Methodology A search of Medline, EBM Reviews, Cinahl, PsycInfo, and Embase for key words flight attendant, cabin crew, and air hostess identified 179 relevant healthor safety-related articles. Google Scholar identified an initial 3360 possible references, of which a further 380 were relevant to health and safety. Further searches of the same databases for flight crew and aircrew yielded a further 2451 references for cross referencing. A search of crew health was also conducted to provide 41 further references. The literature search was further refined by exploring key words for health issues as they were identified by the search, including occupational reproductive hazards, occupational cancer, circadian rhythm disease, occupational stress, and sickness absence. Hand searching of identified journal articles provided further references. After filtering and de-duplication, literature review, as the latter would have excluded coverage of some clinical areas. However, systematic and meta-analytic reviews were available on some topics, notably cancer. Eight important areas of health and safety were selected for review on the basis of suitable research information and relevance to the discussion. Overall Mortality and Morbidity Experience The degree to which health risks to flight attendants can be understood is limited by confounding factors (such as the healthy worker effect, if it exists). There is From the Occupational and Aviation Medicine Unit, Department of Medicine, University of Otago Wellington, Wellington, New Zealand. This manuscript was received for review in September It was accepted for publication in January Address correspondence and reprint requests to: Dr. Robin Griffiths, Director, Occupational and Aviation Medicine Unit, University of Otago Wellington, 23A Mein St., Newtown, Wellington, New Zealand; rob.griffiths@otago.ac.nz. Reprint & Copyright by the Aerospace Medical Association, Alexandria, VA. DOI: /ASEM Aviation, Space, and Environmental Medicine x Vol. 83, No. 5 x May 2012

2 a statistically significant elevation of air accident injury mortality, reflecting greater exposures to injury risk, which for aircraft accidents are vanishingly small in the general population. Standardized incidence ratios (SIR) and standardized mortality ratios (SMR) for most ICD codes indicate significantly lower mortality from cardiovascular disease ( 72 ), cirrhosis, most cancers, diabetes, suicide, AIDS, and all causes (5,10,90 ). In contrast, a small but significant elevation of risk is observed for malignant melanoma and breast cancer. Studies of hematopoietic malignancies, brain, colon and rectum, prostate, and uterus have demonstrated inconsistent results or results outside statistical significance, but warrant ongoing monitoring. HIV infection-related mortality is raised in many studies, but only for male flight attendants and the rate generally shows a decline since its peak in the 1990s. On the other hand, the morbidity experience of flight attendants based on sickness absence, often due to respiratory disorders ( 119 ), and self-rated health reports ( 6, 109 ) suggest worse health experience than the general population, although this is confounded by the extra requirements arising from their occupation. Medical retirements ( 91 ) indicated a high incidence of permanent disability due to ENT disorders, musculoskeletal, psychiatric disorders, heart disease, and cancer. Noise-induced hearing loss, which historically impacted flight attendants working on older, propeller-driven aircraft, is apparently much less of an occupational health and safety issue currently (70 ). Air Quality There has been a significant reduction in cabin environment toxicological risks to flight attendants since the elimination of smoking on board aircraft ( 31 ), but sporadic concerns about air quality occur, including some Acute injuries are typically sustained by flight atten- Flight Attendant Injury fume and odor incidents. Work is ongoing Copyright: in Aerospace the UK, Medical dants as Association the result of working unrestrained in the cabin United States, and Australia to identify the nature Delivered and by in Ingenta turbulence or during emergency evacuation from the cause of these incidents. General concerns about air quality focus on air dryness ( 81 ), which appears to be ameliorated by cabin air humidification (87 ). Prolonged exposure to dry air is reported to cause symptoms of local irritation such nasal stuffiness, sore eyes, nose, throat, and chest wheeziness without asthma, or generalized symptoms such as headache, fatigue, and difficulty in concentration ( 69, 119 ). Crew fatigue experience was also more intense on longer sectors ( 82 ) and flights where smoking was permitted ( 68 ). The latter is now generally prohibited; however, the exceptionally high historical levels of chronic exposure levels to ETS sidestream smoke are likely to have a persistent effect on flight attendants health outcomes ( 97 ). Current disinsection methods may still pose hazards to susceptible crew and passengers ( 107 ). Generally, apart from vapors derived from ethanol and human occupancy, cabin air is of equivalent or superior quality to many workplaces ( 111 ); however, two health concerns require further consideration. The first concern is the potential for some crew to react to cabin air contamination by toxic substances from engine bleed air, ozone (in jet airliners not fitted with catalytic converters) ( 110 ), or sources within the passenger cabin. A number of cases of serious symptoms from cabin air contamination have been reported ( 26, 50 ); why some aircraft and some cabin occupants are particularly affected is unclear. The current evidence linking neurological symptoms with contaminated air events was said to be incomplete ( 55 ), leaving many unanswered questions ( 40, 80 ). A recent systematic review found that there were some sporadic and variable incidents of fume-associated symptoms, but there was insufficient evidence to provide a case definition of an Aerotoxic Syndrome (84 ). Several independent reviews (40,55,83,100 ) recommended further data collection and research into potential adverse health effects of fume events. A cabin air sampling study by Cranfield University has been unable to provide an unequivocal answer to the issue ( 56 ) because it was unable to capture information on a fume event incident, and the debate continues in various forums. The second concern is the potential for microorganism transmission within passengers and crew in the cabin, although most are harmless commensals. Higher than normal rates of viral gastroenteritis, colds, and flulike symptoms are reported in flight attendants and teachers ( 119 ). While high efficiency particulate air (HEPA) filters appear to effectively limit the risk of disease transmission to distant occupants, person-to-person transmission in the aircraft cabin may occasionally cause clusters of infections such as SARS ( 67, 89 ), tuberculosis (30 ), coryza (125 ), influenza, and meningitis ( 106 ). Flight attendants may also be exposed to destination infectious disease hazards during layover. aircraft; the severity of reported injuries is almost equally split between serious and minor injuries ( 22 ). Risk of sustaining serious injuries was related to whether the crewmember was restrained, whether the Fasten Seat Belts sign had illuminated, flight level and phase, and protocols for seating during turbulence ( 113 ). Because they are required to spend more time moving through the galley and aisles, notably to check passengers after warnings of impending turbulence, flight attendants are 12 times more likely to be injured than passengers ( 77 ). Strategies to reduce turbulence injuries have focused on injury prevention training ( 34 ), improved restraint systems ( 35 ), and avoiding unrestrained cabin activities in turbulence (78 ). Injuries in non-turbulent conditions can be reduced by improved trolley design, reducing service numbers especially outside flight cruise phases, and encouraging passengers to undertake their own lifting of cabin baggage in and out of overhead stowage bins ( 63 ). Many slips, trips, and falls and pulling, pushing, lifting injuries relate to cabin service ( 1 ), either in the aisles or in the galley ( 105 ). Musculoskeletal injuries related to Aviation, Space, and Environmental Medicine x Vol. 83, No. 5 x May

3 constrained postures or repeated effort and movement account for a high proportion of work incapacity ( 73 ) and up to 87% of flight attendants report musculoskeletal symptoms ( 64 ). Ergonomic assessments found that in-flight service trolleys exceeded desirable size, weight, and center of gravity parameters for safe use by many flight attendants, especially when pushed or pulled against an incline during climb-out during short flight sectors (43,44,99 ). Innovative galley designs may reduce some of the ergonomic deficiencies of current galley and trolley designs. A number of studies have found a correlation with both demographic and psychosocial factors and workload factors, the latter determined by the number of sectors on short haul operations, and by sector length and duty during sleeping hours for long haul operations ( 47 ). Other studies identified personal risk factors such as female gender ( 51 ), work experience, low body weight ( 1 ), job insecurity ( 65 ), and lack of decision latitude ( 79 ). Radiation Flight attendants are treated as radiation workers in most countries, being occupationally exposed to elevated levels of cosmic ionizing radiation in flight, of the order of 2-5 msv per annum above background and approximately 80 msv in a lifelong career ( 117 ). Cosmic radiation differs from terrestrial exposures i n having a high linear energy transfer (LET) contribution, which creates difficulties in extrapolating terrestrial studies to aviation crew. The absorption of high-energy cosmic radiation and secondary radiation reduces the overall received radiation dose, and influences the distribution of radiation received by Reproductive Hazards aircraft operating at altitudes from sea level up to Although difficult to study ( 118 ), factors in the aviation environment 60,000 ft (18,288 m) ( 39 ). Environmental Copyright: factors Aerospace affecting exposure are the 11-yr solar cycle and solar Delivered proton by ductive Ingentaoutcomes ( 38 ), with the exception of Medical Association itself do not appear to affect repro- radiation events or solar flares ( 66 ). Operational factors include duration of flight, altitude, and latitude; the intensity of radiation increases with altitude up to a maximum of 60,000 ft (18,288 m) and is maximal at the poles. Recent trends toward longer sector durations may lead to higher rates of exposure, especially where long-haul polar routes are used ( 9, 15 ). Adverse radiation effects reported in flight deck crews include damage to chromosomes ( 122 ), potentially associated with increased risk of some cancers ( 28, 86 ). Fetal exposure to ionizing radiation may be associated with genetic defects and prenatal death ( 39 ), and pregnant flight attendants exposures should be limited to 1 msv over the period of the pregnancy ( 9 ). Many airlines ground flight attendants on confirmation of pregnancy, especially in Europe, while others monitor the predicted radiation dose to keep fetal exposure within applicable guidelines such as those of the ICRP or NCRP. Models such as CARI 6 and EURADOS are used to indirectly estimate flight attendant (and pilot) radiation exposure, having been progressively validated against data obtained from direct measurement, and enable airlines to monitor and limit radiation exposures for at-risk crew ( 88 ). Model-based predictors tend to over-estimate exposure due to duty time miscalculations ( 46 ). Continuing to estimate the annual received radiation doses sustained by flight attendants using a recognized model is vital as a way of providing exposure data that may relate to future health outcomes in this unusual (high LET) radiation exposure group. In addition, if acceptable occupational exposure limits for ionizing radiation, especially involuntary exposure by the fetus, continue their downward trend, aviation medicine practitioners will need access to retrospective exposure data to evaluate health risks. In addition, airlines are informed of SPE-related radiation flares by the National Oceanic and Atmospheric Administration s Solar Radiation Alert system. Increases in solar radiation are heralded by less harmful electrons before high LET particles reach the atmosphere, enabling avoidance strategies aimed at the reduction of risk of acute over-exposure of susceptible individuals in a single sector during increased solar activity. Exposure to non-ionizing radiation in the aircraft cabin is primarily microwave and radio frequency radiation. In addition, magnetic fields on the flight deck are greater than 17 mg due to the proximity to avionic equipment and range from 3 to 8 mg in the aircraft cabin. The health impacts of these exposures are uncertain ( 86 ). Ultra-violet light exposure during layover has been considered to explain the increased risk in malignant melanoma noted among flight attendants, but it is suggested that this may not account for all of the risk (93 ). ( 41, 57 ). Occupational factors such as long or irregular working hours, bending, standing, and lifting may have an adverse effect on reproductive outcomes ( 17, 36, 121 ), although a recent study ( 13 ) only found that repeated bending for more than 1 h a day after 34 wk of pregnancy to be a significant risk. Early studies ( 27, 114 ) reported an increased risk of fetal death in flight attendants when compared to other employed women, but not to all women. Two recent studies (23,62 ) suggested that menstrual irregularities and infertility, as well as fetal death, are more common in flight attendants. A meta-analytic study ( 75 ) reported consistently higher rates of intrauterine fetal death and spontaneous abortions in flight attendants; other rates of adverse pregnancy outcomes were not elevated. Rates of induced abortions were lower, suggesting more effective use of birth control, which may affect the spontaneous fetal death rates. One case-control study ( 76 ) of women with endometriosis has suggested that the observed increased risk of developing endometriosis was potentially correlated with circadian dysrhythmia, radiation, and possibly environmental chemical exposures. 516 Aviation, Space, and Environmental Medicine x Vol. 83, No. 5 x May 2012

4 Cancer Studies of cancer mortality and incidence in flight attendants One study ( 6 ), reporting psychological distress in 17% record consistently lower SMR and SIR rates of Alitalia flight attendants, has identified a number of for most cancers, except for breast cancer and melanoma potential stressors like fatigue, isolation, difficult passengers, ( 49, 112 ), for which there are possible confounding factors low supervisory support, low job satisfaction, ( 96, 120 ). On the other hand, less consistent risk elevation and demanding work. Despite this, many flight atten- of brain and prostate cancers, leukemia at least dants felt that job benefits, such as independence and in pilots ( 7 ), and non-hodgkins lymphoma ( 124 ) may travel, outweighed any disadvantages ( 4 ). Work-home be explained by non-occupational factors such as socioeconomic imbalance is frequently cited by flight attendants as a class or immune compromise. Three bio- cause of stress, especially for those with children, for logically plausible extraneous factors for the increased whom extensive absences from home is reported as breast cancer incidence can be identified: 1) increased causing reduced social interactions and child care difficulties exposure to ionizing radiation (94,101); 2) circadian de- (19,74). synchronosis on long-haul flights across multiple time Susceptible individuals may experience exhaustion zones ( 32 ); and 3) non-occupational factors such as delayed and stress due to excessive emotion work ( 52 ). Flight parity, tobacco, and alcohol consumption, which attendants who perceive emotional dissonance between might explain some of the observed excess ( 16 ). Metaanalytic their internal true feelings and the displays of profes- reviews of breast cancer in flight attendants, all sional friendliness required in their work are more likely focusing on the potential relationship between breast to experience stress ( 29 ). Flight attendants reporting low cancer and radiation (3,16,112), and circadian rhythm perceived job control ( 29 ) and job insecurity ( 109 ) are at disruption ( 32, 79 ) have been based on studies that raise risk of developing exhaustion, stress, and burn-out. as many questions as answers. A number of studies Passenger unruliness or abuse ( 14, 37, 42, 103 ), cabin across Europe ( 60, 123 ), Nordic countries ( 92 ), and in or flight safety incidents ( 61, 75 ), or in-flight medical Germany (11), Norway (48), Sweden (71), Iceland (95), emergencies ( 74 ) contribute to perceived stress. Sexual Finland ( 59 ), and the United States ( 98, 116 ) have observed harassment by passengers or other airline employees is that there may be an approximately 40 50% ele- common ( 6 ) and distressing. Medical symptoms such vation in breast cancer incidence in flight attendants. as gastrointestinal disturbance, fatigue, headache, and However, whether these observations are due to occupational impaired concentration are common in flight attendants causes remains unproven, as confounding by ( 51, 115 ). Flight attendants also experience anxiety and surveillance-related earlier diagnosis and socioeconomic confusion about communications with the flight deck factors could at least partially explain these findings. ( 20, 102 ). Anxiety about the personal safety risks of flying The potential for confounding is greatest for a condition is not uncommon in flight attendants; in one study such as breast cancer, where significant non-occupational 37% of flight attendants reported anxiety on takeoff factors exist, and the effect of any employment-attributable ( 104 ). risk is small. For example, in a nested case-control study in Finnish flight attendants ( 58 IP: ), the majority On: of the Sat, 03 Fatigue Nov 2018 and Circadian 08:18:21Dysrhythmia excess breast cancer risk was linked Copyright: to a positive Aerospace family Medical Association Delivered by Ingenta Fatigue arising from job strain, extended duty periods, history of breast cancer. Of the known personal risk factors for breast cancer, some are intuitively absent (obesity and inactivity), potentially protective (menstrual irregularities), or are paradoxically related to breast cancer risk ( 94 ). A current study by NIOSH may shed more light on the roles and weightings of occupational exposures and confounders. Similar controversy exists over occupationally attributable risks for melanoma, with the traditional wisdom that the doubled rate of melanoma risk in flight attendants is attributable to sun exposure during layovers ( 18 ) has been challenged by some studies ( 93 ). High LET radiation typical of altitude exposure ( 101 ) may also have a greater relative biological effect in inducing malignant change in melanomas and reduced melatonin levels associated with time zone changes may impair oncosuppression ( 32 ). As many of the flight attendant cancer studies reviewed were from high latitudes where resting crews would be exposed to higher levels of nonaviation ultraviolet light than controls from their home population, some caution needs to be applied to the interpretation of the results. Mental Health disrupted schedules, irregular hours of work, and sleeping away from home was widely reported. International crews operating on routes that disrupt time zones, experience symptoms and performance decrements caused by sleep-wake, melatonin gradient, and sleep efficiency displacements due to circadian dysrhythmia ( 45, 108 ). Chronic hypoxia may also lead to reduced peak melatonin levels, which may exacerbate fatigue from other causes ( 25 ). Intolerance to working atypical schedules depends on external factors like the duration of the duty and flight periods, pre-duty rest periods, the degree of misalignment of circadian physiological rhythms and accumulated sleep debt, and personal factors such as age, parenting, etc., which are highly dependent on individual tolerance ( 12 ). The FAA Civil Aerospace Medical Institute and NASA have been conducting a comprehensive work program looking into fatigue at the instigation of Congress for the past 6 yr ( 85 ). The 2011 FAA Reauthorization and Reform Act requires further FAA action on flight attendant fatigue by The FAA Duty, Rest and Fatigue study ( 2 ) recorded that 83% of flight attendants had experienced Aviation, Space, and Environmental Medicine x Vol. 83, No. 5 x May

5 fatigue while on duty in the previous bid period and that 93% of flight attendants considered fatigue to be a flight attendant safety hazard. Of flight attendant Aviation Safety Reporting System (ASRS) incident reports, 2.4% specifically mentioned fatigue terms, ascribed mainly to scheduling and duty time factors ( 53 ). The U.S. regulations were considered less protective than ICAO-derived Fatigue Risk Management Systems and a working group has been established to evaluate the potential for an adaptive fatigue mitigation safety system that would apply to flight attendants (8 ). Conclusions Fatigue is being tackled as a significant risk both personally and operationally. The FAA fatigue studies have provided governments and the airline industry with opportunities to minimize the passenger safety and personal health consequences of flight attendant fatigue. Developing an evidence-based Fatigue Risk Management System based on a validated flight attendant fatigue model would enable airline employers to ensure that adequate controls for safe operations and health protection were in place. The FAA studies will inform much needed evidence-based approaches. Many countries do not treat pilots and flight attendants as radiation workers, and do not collect data on radiation exposure in flight and health outcomes. The unusual nature of high LET radiation to which aircrews are exposed may warrant some caution regarding standards derived from terrestrial exposure and health outcome data. Ongoing collection of standardized data on radiation exposure, either directly or indirectly, and correlating these with health outcomes will help us to understand whether chronic low-dose occupational exposure differs from that for other radiation workers such as those in the nuclear power industry. More clarity is needed on cancer and Copyright: exposure Aerospace to possible causes of increased malignancy risk. Overall Delivered mor- Authors and affiliation: Robin F. Griffiths, M.B., Ch.B.(Hons.), MPP, Medical ACKNOWLEDGMENT Association by Ingenta tality statistics for flight attendants indicate low SIR and SMR for most conditions, with the exception of melanoma and possibly breast cancer. However, the risks of occupationally attributable breast cancer and melanoma in flight attendants have still to be fully clarified due to the difficulties of conducting studies in this occupational group. Non-occupational factors play significant roles in determining the absolute risk for developing either malignancy, and health promotion programs and education would help flight attendants to find alternative strategies to minimize their risk by reducing non-occupational risk factors. Information booklets such as that published by CAMI ( 39 ) provide flight crew with best practice information on radiation exposure minimization; similar guidance is needed for risk minimization for malignancy. Cabin air quality has improved significantly with the prohibition of smoking on board aircraft and the introduction of HEPA filters. There is some controversy around reported incidents of cabin toxic exposures. While incidents are sporadic and rare, the symptom complexes require ongoing investigation. Initiatives to introduce medical certification for flight attendants in Australia ( 21 ) and Europe have raised issues about the respective roles and responsibilities of the airline employers and government regulators. There is no evidence that the medical fitness of flight attendants has affected their safety performance in either routine or unusual conditions. It is also unclear how government involvement in medical certification adds value to employers decisions about whether flight attendants are fit to work and risks prolonging periods of unfitness following illness or injury while awaiting formal recertification. The role of governments in managing the occupational health and safety of flight attendants is also complex. While NIOSH and the U.S. FAA have contributed a great deal to international knowledge of the health and safety concerns for flight attendants, the current accountabilities for actually managing these concerns are fragmented. Transport Canada appears to have overcome this problem by greater co-ordination and communication between aviation and non-aviation agencies to provide a tailored occupational health and safety approach for aviation staff that closely parallels its groundbased equivalent programs ( 24 ). It would be sensible to emulate the success of Transport Canada in promoting a comprehensive and coordinated occupational health and safety service for aviation personnel. Only if safety authorities have a clear mandate and adequate resources can we hope for better occupational health and safety for this key occupational group. To avoid the distraction of unjustified interventions like medical certification, there is a need for regulators, employers, employee representatives, and scientists to engage in frank debate on the funding and research priorities for a flight attendant health and safety agenda worldwide. Director, Occupational and Aviation Medicine, and David M. C. Powell, M.B., Ch.B., Dip.Av.Med.(Otago), FRNZCGP Course Director, Aviation Medicine, University of Otago, Wellington, Wellington South, New Zealand. REFERENCES 1. Agampodi SB, Dharmaratne SD, Agmapodi TC. Incidence and predictors of onboard injuries among Sri Lankan flight attendants. 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