those who have direct contact with the public, epidemiologists are best placed to define the risks of travel related illness. Developing appropriate surveillance systems, improving communication between health professionals, quantifying risks, and facilitating targeted education are the keys to healthy travel. JOHN D H PORTER Consultant Epidemiologist ROSALIND STANWELL-SMITH Consultant Epidemiologist GIL LEA Travel Physician Division of Field Services and Training, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
1 Behrens RH. Ptotecting the health of the international traveller. Trans R Soc Trop Med Hyg 1990;84:61 1-2, 629. 2 Cossar JH, Reid D. Health hazards of international travel. World Health Organisation Quarterly 1989;42:61-9. 3 Phillips-Howard PA, Breeze E, Larkin C, Bradley DJ. Short term travel to malarious areas; malaria risk in British residents. Travel Medicine Intratonal 1988;6:51-60. 4 Bradley DJ, Warhurst DC, Blaze M, Smith V. Malaria imported into the UK 1989 and 1990. Communicable Disease Report 1991;1:R45-8. 5 PHLS Communicable Disease Surveillance Centre. Insect-borne imported infections (communicable disease quarterly report). J Public Health Med 1992;14:84-92. 6 Noone A, Gill ON, Clarke SE, Porter K. Travel, heterosexual intercourse and HIV-1 infection. Communicable Disease Report 1991;4:R39-43. 7 Bannister BA. Infection and the traveller. Reviews inMedicalMicrobiology 1990;1:185-95. 8 Gunn ADG. Uprooting-the psychosocial problems on the international student. In: Steffer R, Lobel HO, Haworth J, Bradley DJ, eds. Travel medicine: proceedings of the first conference on international travel medicine. Berlin: Springer-Verlag, 1988:476-80. 9 Committee of Inquiry into the Future Development of the Public Health Function. Public health in England. London: HMSO, 1988. (Acheson report.) 10 Lloyd GER, ed. Hippocratic writings. Hendon: Penguin, 1983. 11 Business Statistics Office. Business monitor annual statistics-overseas travel and tourism. London: HMSO, 1991:MA6.
Altitude induced illness If in doubt go down Mountaineers are still dying of altitude induced illness despite of the deathand Last yearoxygen, its dangers. increasing toawareness supplementary descent ofand respond in then madesixinternational Nepal4 mg Jessop on(8hermghoneymoon Cathy hourly) will initially and dexamethasone descend the north west ridge of She dieddescent trying to headlines. in an emergency.9 probably facilitate the recognised her ishusband Kangru pulmonary (6369 m) after Kusum by rapid characterised oedema High altitude oedema.' The of high altitude nocturnal pulmonary.dyspnoea, symptoms pain, chestdescent onset of breathlessness, Mrs whenoften waited until and the difficult, was condition Thisdawn, andcouple haemoptysis. cough, headache, down. to gooxygen. beforeandattempting slightly better, Jessop supplementary to descent respondsfeltdramatically and died on collapsed nifedipine Nevertheless, releaseand six mgfirst slowabseil, (20the is impossible When descent she finding m before 500altitude her bodyhigh lowerRecently hadof to husband her has illness value.'0 may be hourly) the 1986 another in broughtbag" tragedy her. Inpressurisation bury acute somewhere a "pressure been treatedtowith when public attention altitude highbags dangers to facilitate alleviateto symptoms mightclimbing because of such the world's died on K2 (8611 13 mountaineers use. " second existm), on their But fewcontrolled data descent. themaretoocaused high for when a storm trapped mountain,of highest the by too induced illness altitude The symptoms long.2 physiological response to environmental hypoxia, which beenatquantified have climbing altitude of highand Theamong dangerspeople different person the same even in varies overelucidated. 7000 m during peaksfully British expeditions The in a study has nottobeen Its ofpathogenesis times. 1968-88. Of 533vasculature climbers, 23to died 20 years tissue(mortality hypoxia the pulmonary of the response by causedHow pressure. arterialwere deaths, which and ismost a riseofinthepulmonary 4-3%), at altitude were probably and altitude rockfalls avalanches), oedema accidents in high (such pulmonary the oedema fluidasfound resulting to the attributable is, however, hypertension thisdisorientation pulmonary and is linked with misjudgment associThe range of ofaillness altitude from permeability fluid hashypoxia?3 the characteristics as theinduced unclear is describedleak. by three syndromes: with altitude ated hypoxia of a hydrostatic than those leak rather and cerebral are oedema, altitudesickness probably acute of acutehigh mountain Themountain symptomssickness, altitude symptoms of factors altitude combination pulmonary oedema. AtA high high cerebral oedema. caused by mild If in doubt down. capillary and fluidgoretention, may be confusing. These include signs seems responsible. 2500 m is characterised causedbybya to altitudes above presumably changes Rapid ascent and haemodynamic leakiness, sickacute mountain syndrome in known benign relatively and carbon asdioxide concentration. alteratioris hypoxia of headache, dizziness, anorexia, (and response ventilatory ness, which hypoxicnausea, withconsists the highest People be illness isconcentration) short lived andhave maythe Thedioxide andlowest insomnia. carbon dyspnoea, therefore the ascent.4 in severity have decreased by a more they gradual because or reduced supposedly prevented least symptoms, m a day for twoa days of 300 m flow a rateand of ascent Above 3000 less tissue oedema. high Indeed, blood cerebral but this is recommended,5 a day thereafterwhether air followed by 150 mconcentration, from inspired carbon dioxide each day of threeorhours progress a maximum represents from of relative hypoventilaconditions under experimental andventilatory such slow progress the mostwith difficult ground, a low response,is except hypoxic tion inonsomeone make symptoms of acute mountain sickness worsebe popular. seems to to unlikely of the presence flow indaily) blood release by increasing probably provides Acetazolamide mg slow (500 cerebral acute mountain sickness6 and should be increased capillary against permeability.8 protection m for of 3000 informed an altitude abovedoctors are well the day of ascent and their started Mostonmountaineers with recommended emergency is not equipped Dexamethasone about sickness, are mountain currently prophylaxis. action taketo appropriate time acclimatising, facilitate descent.7 used drugs, spend but may beand for routine prophylaxis relievesIncapacitating when supervenes. symptoms. illness, difficult Descentillness immediately descent makemountain weatherwithmay, however, or bad(usually terrain, of acute Some people symptoms impossible.may suddenly deteriorate, developing ataxia, sickness) led theconsciousness, Himalayas hasand The recent hallucinations, popularity of trekking cloudingin of irrationality, the high into This to altitude novicesoedema of manycerebral to an asinflux may develops.8 coma high altitude mountains in organised and do it yourself groups (including 1324
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BMJ VOLUME 304
23 MAY 1992
over 20 000 people from the United Kingdom in Nepal each year). For various reasons many of these groups do not leave adequate time for acclimatisation, with potentially disastrous results. A study of trekkers on the Thorong Pass (5400 m) in Nepal in 1986 found that nearly two thirds were suffering from acute mountain sickness.'2 It is common to meet trekkers with acute mountain sickness, too ill to walk, who are being carried over high passes in Nepal so as not to inconvenience other trekkers in their group or interfere with their trekking company's itinerary. The only safe management of severe acute mountain sickness is descent; further ascent may lead to cerebral oedema and death. Building days for acclimatisation into trekking itineraries will reduce the number of people who get acute mountain sickness and may even prevent cerebral oedema, pulmonary oedema, and death. As well as allowing time for acclimatisation trekking companies must train their trek leaders to recognise and deal with symptoms of high altitude illness and to arrange urgent descent when necessary. In the meantime, travel clinics and general practitioners should ensure that they know how to obtain literature about high altitude illness to
advise would be trekkers who consult them. A wealth of information exists; reading it-may save lives. Information on acute mountain sickness and other altitude problems is available from the UIAA Mountain Medicine Data Centre, c/o Dr Charles Clarke, St Bartholomew's'Hospital, London ECIA 7BE. A J POLLARD
Children's Hospital, Birmingham B16 8ET 1 2 3 4 5 6 7 8 9
10 II 12
Venables S. Killer that strikes in the heights. Weekend Telegraph 1991 December 7:3. Curran J. K2 triumph and tragedy. London: Collins, 1989. Pollard A, Clarke C. Deaths during mountaineering at extreme altitude. Lancet 1988;i: 1277. Heath D, Williams DR. High altitude medicine and pathology. London: Butterworths, 1989:121-30. Milledge JS. Acute mountain sickness. Thorax 1983;38:641. Birmingham Medical Research Expeditionary Society Mountalb Sickness Study Group. Acetazolamide in control of acute mountain sickness. Lancet 1981 ;i :180-3. Johnson TS, Rock PB. Acute mountain sickness. N EnglJ Med 1988;319:841-5. Ward M, Milledge J, West J. High altitudenmedicine and physiology. London: Chapman and Hall Medical, 1989. Ferrazzini G, Maggiorini M, Kriemler S, Bartsch P, Oelz 0. Successful treatment of acute mountain sickness with dexamethasone. BMJ 1987;294:1380-2. Oelz 0, Maggiorini M, Ritter M, Waber U, Jenni R, Vock P, et al. Nifedipine for high altitude pulmonary oedemn.Lancet 1989;ii: 1241-4. Kayser B. Pressure bags: some history. Newsletter of the International SocietyforMountain Medicine. 1991;I(2): 7. Kayser B. Acute mountain sickness in western tourists around the Thorong Pass (5400 m) in Nepal. Journal of Wilderness Medicine 1991;2: 110-7.
Making air crashes more survivable Much could be done now at little cost Although air travel is safer than in the 1960s, the chances of surviving an accident have not greatly improved. Worldwide, in survivable accidents in which at least one person died, the annual survival rate is around 60% with -no clear trend of improvement over the past few decades' (Taylor, personal communication). Often deaths seem to have been, in principle, preventable. According to the Civil Aviation Authority, improvements in cabin safety could have increased the chances of survival in at least one in five accidents during 1967-86.2 Increasing survivability was the theme of a recent conference of the Parliamentary Advisory Council for Transport Safety. Two British accidents illustrate the need for such a conference. The accident at Manchester in 1985 caused unnecessary deaths and injuries in the evacuation from the burning aircraft. Studies of the crash on the MI at Kegworth in 1989 have shown how many of the casualties caused by the impact might have been avoided.3 4 Many features of the design of aeroplane cabins require attention. To improve seat design the whole system needs review: the seats' spacing, orientation, and anchorage to the floor; the floor's toughness; seat belts and air bags and other passive restraints; and the "impact friendliness" of the seat in front. At Kegworth the seats proved strong but anchorages failed and part ofthe floor disintegrated, causing much injury.34 Though other factors probably helped, the crew fared better in their rear facing seats. Being heavier, rear facing' seats would reduce the possible number of seats per ffight and fares would therefore increase. They would need upper torso restraints and might be unpopular. They should, however, be safer,5 reducing injuries to the head, legs, and pelvis.3 Current restraints have long been regarded as inadequate,6 and upper torso restraints in particular would increase protection.5 This would also mean stronger seats and floors and greater weight. Children are badly catered for. Those under 2 must now be restrained; a special infant seat is approved but not obligatory, and parents may provide a car restraint. Mostly, however, a supplementary loop is used on BMJ
VOLUME
304
23 MAy 1992
an adult's lap; this is not adequate.7 At Kegworth a child restrained thus was severely injured and his mother died, probably through holding him.3 From 2 years children use ordinary lap belts but these are unsuitable until a child weighs over 18 kg.7 Loose objects-notably overhead lockers and contentsflying about the cabin are important causes of injury and obstruction.6 At Kegworth most lockers became detached and latches burst; severe head injuries were probably caused by a locker or its contents.3 Yet this hazard has been recognised at least since 1981,5 and there is consensus that lockers should be strengthened or eliminated. The Civil Aviation Authority and the United States Federal Aviation Authority are currently considering this; the alternative of floor storage would mean losing seats. Speakers at the conference urged that airlines and passengers should be strict about the amount of cabin baggage; one speaker had witnessed "bulky bags-, bottles, bidets, and bowling balls," in the cabin. Carriage of duty free alcohol is widely criticised; the government, however, disagreed about having duty free facilities at arrival as well as departure points.8 Plastic bottles are becoming commoner. Briefings on safety on passengers are notoriously ignored, and ways of making them more useful were discussed. One is demonstrating a "crash brace" position. A brace position apparently helped protect against head and abdominal injury at Kegworth, and a video could be shown before every flight.' Speakers at the conference also called for urgent action to protect against fire and fumes (see Hill, p 1326) and to improve further the configuration of seats and aisles to allow speedy evacuation.9 Evidence given to the -House of Commons transport committee showed that much could be done at little extra cost.5 Some things could be done only in new aircraft or after further research, but others, such as providing smoke hoods and proper infant and child restraints, could happen now. As a member of the Manchester survivors' group, SCISAFE, said, pointing out the slow progress since 1985, we need more research but also action to improve things now. The joint action required by the 1325
1 Behrens RH. Ptotecting the health of the international traveller. Trans R Soc Trop Med Hyg 1990;84:61 1-2, 629. 2 Cossar JH, Reid D. Health hazards of international travel. World Health Organisation Quarterly 1989;42:61-9. 3 Phillips-Howard PA, Breeze E, Larkin C, Bradley DJ. Short term travel to malarious areas; malaria risk in British residents. Travel Medicine Intratonal 1988;6:51-60. 4 Bradley DJ, Warhurst DC, Blaze M, Smith V. Malaria imported into the UK 1989 and 1990. Communicable Disease Report 1991;1:R45-8. 5 PHLS Communicable Disease Surveillance Centre. Insect-borne imported infections (communicable disease quarterly report). J Public Health Med 1992;14:84-92. 6 Noone A, Gill ON, Clarke SE, Porter K. Travel, heterosexual intercourse and HIV-1 infection. Communicable Disease Report 1991;4:R39-43. 7 Bannister BA. Infection and the traveller. Reviews inMedicalMicrobiology 1990;1:185-95. 8 Gunn ADG. Uprooting-the psychosocial problems on the international student. In: Steffer R, Lobel HO, Haworth J, Bradley DJ, eds. Travel medicine: proceedings of the first conference on international travel medicine. Berlin: Springer-Verlag, 1988:476-80. 9 Committee of Inquiry into the Future Development of the Public Health Function. Public health in England. London: HMSO, 1988. (Acheson report.) 10 Lloyd GER, ed. Hippocratic writings. Hendon: Penguin, 1983. 11 Business Statistics Office. Business monitor annual statistics-overseas travel and tourism. London: HMSO, 1991:MA6.
Altitude induced illness If in doubt go down Mountaineers are still dying of altitude induced illness despite of the deathand Last yearoxygen, its dangers. increasing toawareness supplementary descent ofand respond in then madesixinternational Nepal4 mg Jessop on(8hermghoneymoon Cathy hourly) will initially and dexamethasone descend the north west ridge of She dieddescent trying to headlines. in an emergency.9 probably facilitate the recognised her ishusband Kangru pulmonary (6369 m) after Kusum by rapid characterised oedema High altitude oedema.' The of high altitude nocturnal pulmonary.dyspnoea, symptoms pain, chestdescent onset of breathlessness, Mrs whenoften waited until and the difficult, was condition Thisdawn, andcouple haemoptysis. cough, headache, down. to gooxygen. beforeandattempting slightly better, Jessop supplementary to descent respondsfeltdramatically and died on collapsed nifedipine Nevertheless, releaseand six mgfirst slowabseil, (20the is impossible When descent she finding m before 500altitude her bodyhigh lowerRecently hadof to husband her has illness value.'0 may be hourly) the 1986 another in broughtbag" tragedy her. Inpressurisation bury acute somewhere a "pressure been treatedtowith when public attention altitude highbags dangers to facilitate alleviateto symptoms mightclimbing because of such the world's died on K2 (8611 13 mountaineers use. " second existm), on their But fewcontrolled data descent. themaretoocaused high for when a storm trapped mountain,of highest the by too induced illness altitude The symptoms long.2 physiological response to environmental hypoxia, which beenatquantified have climbing altitude of highand Theamong dangerspeople different person the same even in varies overelucidated. 7000 m during peaksfully British expeditions The in a study has nottobeen Its ofpathogenesis times. 1968-88. Of 533vasculature climbers, 23to died 20 years tissue(mortality hypoxia the pulmonary of the response by causedHow pressure. arterialwere deaths, which and ismost a riseofinthepulmonary 4-3%), at altitude were probably and altitude rockfalls avalanches), oedema accidents in high (such pulmonary the oedema fluidasfound resulting to the attributable is, however, hypertension thisdisorientation pulmonary and is linked with misjudgment associThe range of ofaillness altitude from permeability fluid hashypoxia?3 the characteristics as theinduced unclear is describedleak. by three syndromes: with altitude ated hypoxia of a hydrostatic than those leak rather and cerebral are oedema, altitudesickness probably acute of acutehigh mountain Themountain symptomssickness, altitude symptoms of factors altitude combination pulmonary oedema. AtA high high cerebral oedema. caused by mild If in doubt down. capillary and fluidgoretention, may be confusing. These include signs seems responsible. 2500 m is characterised causedbybya to altitudes above presumably changes Rapid ascent and haemodynamic leakiness, sickacute mountain syndrome in known benign relatively and carbon asdioxide concentration. alteratioris hypoxia of headache, dizziness, anorexia, (and response ventilatory ness, which hypoxicnausea, withconsists the highest People be illness isconcentration) short lived andhave maythe Thedioxide andlowest insomnia. carbon dyspnoea, therefore the ascent.4 in severity have decreased by a more they gradual because or reduced supposedly prevented least symptoms, m a day for twoa days of 300 m flow a rateand of ascent Above 3000 less tissue oedema. high Indeed, blood cerebral but this is recommended,5 a day thereafterwhether air followed by 150 mconcentration, from inspired carbon dioxide each day of threeorhours progress a maximum represents from of relative hypoventilaconditions under experimental andventilatory such slow progress the mostwith difficult ground, a low response,is except hypoxic tion inonsomeone make symptoms of acute mountain sickness worsebe popular. seems to to unlikely of the presence flow indaily) blood release by increasing probably provides Acetazolamide mg slow (500 cerebral acute mountain sickness6 and should be increased capillary against permeability.8 protection m for of 3000 informed an altitude abovedoctors are well the day of ascent and their started Mostonmountaineers with recommended emergency is not equipped Dexamethasone about sickness, are mountain currently prophylaxis. action taketo appropriate time acclimatising, facilitate descent.7 used drugs, spend but may beand for routine prophylaxis relievesIncapacitating when supervenes. symptoms. illness, difficult Descentillness immediately descent makemountain weatherwithmay, however, or bad(usually terrain, of acute Some people symptoms impossible.may suddenly deteriorate, developing ataxia, sickness) led theconsciousness, Himalayas hasand The recent hallucinations, popularity of trekking cloudingin of irrationality, the high into This to altitude novicesoedema of manycerebral to an asinflux may develops.8 coma high altitude mountains in organised and do it yourself groups (including 1324
1324
BMJ VOLUME 304
23 MAY 1992
over 20 000 people from the United Kingdom in Nepal each year). For various reasons many of these groups do not leave adequate time for acclimatisation, with potentially disastrous results. A study of trekkers on the Thorong Pass (5400 m) in Nepal in 1986 found that nearly two thirds were suffering from acute mountain sickness.'2 It is common to meet trekkers with acute mountain sickness, too ill to walk, who are being carried over high passes in Nepal so as not to inconvenience other trekkers in their group or interfere with their trekking company's itinerary. The only safe management of severe acute mountain sickness is descent; further ascent may lead to cerebral oedema and death. Building days for acclimatisation into trekking itineraries will reduce the number of people who get acute mountain sickness and may even prevent cerebral oedema, pulmonary oedema, and death. As well as allowing time for acclimatisation trekking companies must train their trek leaders to recognise and deal with symptoms of high altitude illness and to arrange urgent descent when necessary. In the meantime, travel clinics and general practitioners should ensure that they know how to obtain literature about high altitude illness to
advise would be trekkers who consult them. A wealth of information exists; reading it-may save lives. Information on acute mountain sickness and other altitude problems is available from the UIAA Mountain Medicine Data Centre, c/o Dr Charles Clarke, St Bartholomew's'Hospital, London ECIA 7BE. A J POLLARD
Children's Hospital, Birmingham B16 8ET 1 2 3 4 5 6 7 8 9
10 II 12
Venables S. Killer that strikes in the heights. Weekend Telegraph 1991 December 7:3. Curran J. K2 triumph and tragedy. London: Collins, 1989. Pollard A, Clarke C. Deaths during mountaineering at extreme altitude. Lancet 1988;i: 1277. Heath D, Williams DR. High altitude medicine and pathology. London: Butterworths, 1989:121-30. Milledge JS. Acute mountain sickness. Thorax 1983;38:641. Birmingham Medical Research Expeditionary Society Mountalb Sickness Study Group. Acetazolamide in control of acute mountain sickness. Lancet 1981 ;i :180-3. Johnson TS, Rock PB. Acute mountain sickness. N EnglJ Med 1988;319:841-5. Ward M, Milledge J, West J. High altitudenmedicine and physiology. London: Chapman and Hall Medical, 1989. Ferrazzini G, Maggiorini M, Kriemler S, Bartsch P, Oelz 0. Successful treatment of acute mountain sickness with dexamethasone. BMJ 1987;294:1380-2. Oelz 0, Maggiorini M, Ritter M, Waber U, Jenni R, Vock P, et al. Nifedipine for high altitude pulmonary oedemn.Lancet 1989;ii: 1241-4. Kayser B. Pressure bags: some history. Newsletter of the International SocietyforMountain Medicine. 1991;I(2): 7. Kayser B. Acute mountain sickness in western tourists around the Thorong Pass (5400 m) in Nepal. Journal of Wilderness Medicine 1991;2: 110-7.
Making air crashes more survivable Much could be done now at little cost Although air travel is safer than in the 1960s, the chances of surviving an accident have not greatly improved. Worldwide, in survivable accidents in which at least one person died, the annual survival rate is around 60% with -no clear trend of improvement over the past few decades' (Taylor, personal communication). Often deaths seem to have been, in principle, preventable. According to the Civil Aviation Authority, improvements in cabin safety could have increased the chances of survival in at least one in five accidents during 1967-86.2 Increasing survivability was the theme of a recent conference of the Parliamentary Advisory Council for Transport Safety. Two British accidents illustrate the need for such a conference. The accident at Manchester in 1985 caused unnecessary deaths and injuries in the evacuation from the burning aircraft. Studies of the crash on the MI at Kegworth in 1989 have shown how many of the casualties caused by the impact might have been avoided.3 4 Many features of the design of aeroplane cabins require attention. To improve seat design the whole system needs review: the seats' spacing, orientation, and anchorage to the floor; the floor's toughness; seat belts and air bags and other passive restraints; and the "impact friendliness" of the seat in front. At Kegworth the seats proved strong but anchorages failed and part ofthe floor disintegrated, causing much injury.34 Though other factors probably helped, the crew fared better in their rear facing seats. Being heavier, rear facing' seats would reduce the possible number of seats per ffight and fares would therefore increase. They would need upper torso restraints and might be unpopular. They should, however, be safer,5 reducing injuries to the head, legs, and pelvis.3 Current restraints have long been regarded as inadequate,6 and upper torso restraints in particular would increase protection.5 This would also mean stronger seats and floors and greater weight. Children are badly catered for. Those under 2 must now be restrained; a special infant seat is approved but not obligatory, and parents may provide a car restraint. Mostly, however, a supplementary loop is used on BMJ
VOLUME
304
23 MAy 1992
an adult's lap; this is not adequate.7 At Kegworth a child restrained thus was severely injured and his mother died, probably through holding him.3 From 2 years children use ordinary lap belts but these are unsuitable until a child weighs over 18 kg.7 Loose objects-notably overhead lockers and contentsflying about the cabin are important causes of injury and obstruction.6 At Kegworth most lockers became detached and latches burst; severe head injuries were probably caused by a locker or its contents.3 Yet this hazard has been recognised at least since 1981,5 and there is consensus that lockers should be strengthened or eliminated. The Civil Aviation Authority and the United States Federal Aviation Authority are currently considering this; the alternative of floor storage would mean losing seats. Speakers at the conference urged that airlines and passengers should be strict about the amount of cabin baggage; one speaker had witnessed "bulky bags-, bottles, bidets, and bowling balls," in the cabin. Carriage of duty free alcohol is widely criticised; the government, however, disagreed about having duty free facilities at arrival as well as departure points.8 Plastic bottles are becoming commoner. Briefings on safety on passengers are notoriously ignored, and ways of making them more useful were discussed. One is demonstrating a "crash brace" position. A brace position apparently helped protect against head and abdominal injury at Kegworth, and a video could be shown before every flight.' Speakers at the conference also called for urgent action to protect against fire and fumes (see Hill, p 1326) and to improve further the configuration of seats and aisles to allow speedy evacuation.9 Evidence given to the -House of Commons transport committee showed that much could be done at little extra cost.5 Some things could be done only in new aircraft or after further research, but others, such as providing smoke hoods and proper infant and child restraints, could happen now. As a member of the Manchester survivors' group, SCISAFE, said, pointing out the slow progress since 1985, we need more research but also action to improve things now. The joint action required by the 1325
