Comment from No Nut Traveler

I wanted to share my thoughts concerning implementation of Section 368 of the FAA Reauthorization Act and the upcoming emergency medical kit rulemaking related to anaphylaxis and epinephrine. I recognize the agency is managing many priorities, but I did want to reiterate the urgency of this issue from both my perspective as founder of the non-profit No Nut Traveler and in my role as airline correspondent for Allergic Living, where I continue to report on in-flight allergic reactions and interview physicians who have had to troubleshoot emergencies onboard when appropriate epinephrine was not readily available. Unfortunately, these incidents continue to occur with concerning frequency. Within just the past several weeks, No Nut Traveler has received reports involving: • A United passenger reacting to an airline meal on a Sydney to Los Angeles flight (4/3/2026) • A 14-year-old passenger experiencing a first-time cashew reaction on a United domestic route (3/28/2026) • A passenger with a tree nut allergy reacting to an airline meal on a United flight from São Paulo to Chicago (2/16/2026) Over the years, I have also interviewed physicians who responded to in-flight anaphylaxis emergencies and described the difficulties created when easy-to-use epinephrine was unavailable onboard. These situations have included epinephrine vials missing from emergency medical kits, epinephrine stocked in the wrong concentration, physicians forced to crowdsource passengers’ auto-injectors, and physicians improvising with cardiac-concentration epinephrine products not intended for rapid anaphylaxis treatment. I have even interviewed a physician who, upon opening the emergency medical kit, found a sticker stating there was no epinephrine in the kit. As I reported in Allergic Living, Dr. Kimberly Blumenthal of Massachusetts General Hospital described walking the aisles of two separate international flights within a year asking passengers, “Does anyone have an epinephrine auto-injector or antihistamines?” On both ocean-crossing flights, airline crews told her the aircraft did not carry epinephrine auto-injectors. Thankfully, both passengers survived. However, for the best possible outcome, airlines must stock easy-to-use epinephrine on every flight. Relying on fellow passengers to provide their personal epinephrine is neither an acceptable nor ethical safety strategy. Borrowing someone else’s lifesaving medication places two people at risk: the passenger experiencing anaphylaxis and the individual who may later need that medication themselves, particularly while traveling internationally where refills may be unavailable or delayed. Dr. Mikhail Varshavski described treating a passenger experiencing first-time anaphylaxis on an international flight where the only epinephrine available was a cardiac-concentration vial requiring dosage troubleshooting under emergency conditions. He later told me that without proper epinephrine for anaphylaxis, “you’re leaving the medical professionals to battle a fire without water.” NJ orthopedist Dr. Samara Friedman, after unsuccessfully crowdsourcing for an auto-injector, had to jerry-rig a cardiac epinephrine device to treat a young woman with worsening symptoms of nut anaphylaxis during a transatlantic flight. In that case, the passenger, despite having a known allergy, did not have her auto-injectors with her, further underscoring why airlines cannot rely on passengers alone to provide lifesaving medication during foreseeable medical emergencies. Other cases have involved physicians fumbling through disorganized emergency medical kits, calculating pediatric doses under pressure, improvising delivery methods, or relying on passengers’ personal or borrowed medication because the correct treatment was not practically available onboard. I also believe it is important for the FAA to closely examine the continued use of exemptions related to epinephrine availability in emergency medical kits when determining what will be required for allergic reactions onboard aircraft. While these exemptions may originally have been tied to shortages or operational concerns, the ongoing real-world incidents being reported raise important questions about whether current practices adequately protect passengers experiencing anaphylaxis at 30,000 feet. At a time when aircraft are equipped for other foreseeable medical emergencies, including cardiac and respiratory events, anaphylaxis should be treated with the same seriousness and preparedness. The issue is not simply whether epinephrine exists somewhere within an emergency medical kit, but whether it is available in a form that can be administered quickly, safely, and reliably during a rapidly evolving medical emergency. One article documenting many of these incidents and concerns can be found here: Allergic Living article: https://www.allergicliving.com/2022/08/16/its-come-to-this-borrowing-epinephrine-on-planes/ Lianne Mandelbaum