This site is intended for health professionals only

Sit back, relax and enjoy the flight: not for everyone ...

Liz Rosies
RGN MSc(TravelMed)
PGCE
Travel Health Adviser
Author of www.travelhealth.co.uk
Lecturer, West College
Kent

Over the last 20 years we have seen a dramatic increase in air travel. Some estimates suggest passenger numbers will reach five billion by the year 2010.(1) Flying is not without its challenges. The most recent concerns to affect travellers were in August 2006. A major terror threat saw large amount of liquids banned from flights - affecting many passengers with existing medication requirements. As more travellers take to the skies it is essential that health professionals are aware of the risks involved and are able to provide current and balanced advice to those flying.
The first major government report to address this topic, Air Travel and Health, was published in November 2000 by the House of Lords.(2) While its primary focus was on the issue of deep vein thrombosis (DVT) it also addressed other potential air travel risks. Under the Warsaw Convention, health remains the responsibility of the traveller as airlines carry no legal responsibility to tell passengers about health risks believed to be associated with air travel.(3) Therefore it remains the role of the health professional to assess individuals and offer advice accordingly, as well as the individual to take personal responsibility for their health when planning to fly.

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Anxiety and stress
Flying anxiety is thought to affect 15-25% of the population and displays itself in a variety of ways, from mild nervousness to panic attacks and chest pain.(4) It can also be the cause of uncharacteristic behaviour such as aggression in some travellers. It is unlikely that the travel nurse will have the time to deal with such issues in any depth in a consultation, but helping the patient understand relaxation techniques can be helpful, as can an understanding of aircraft safety. Some patients might consider the use of a tranquilliser before flying while others can be referred to a specialist for cognitive behavioural therapy.(5) For many, fear is based on a lack of understanding of how the aircraft works, and recommending an airline-based course at a local airport might alleviate the patient's fear. 
Airport stress is a new phenomenon, and while it may be linked to a fear of flying, it is also a product of our fast-moving, highly-competitive travel industry. Cardiac problems can be a result of stress and are believed to be a primary factor for inflight emergencies. They account for the highest rate of inflight deaths and flight diversions.(6) Patients suffering from stress need practical common sense ideas on how to deal with their emotional energy. Recommending podcasts that promote relaxation, or downloading music that will enable the traveller to approach their journey in a calm manner, may be helpful. Advising a traveller to allow plenty of time for their journey, prebooking seating, checking-in online and avoiding preflight alcohol are just a few ways to reassure and help a patient manage their anxiety. Many airports also offer specialist help to reduce stress for those with disabilities, providing essential equipment and facilities to get them safely onto the aircraft.

Deep vein thrombosis (DVT)
Preflight assessment of DVT risk should be considered for travellers (see Box 1). The World Health Organization (WHO) suggests that for every journey of more than four hours there is one case of DVT.(8) Travellers should be advised to avoid dehydration by taking in sensible amounts of nonalcoholic drinks and avoiding potentially dehydrating fluids such as tea and coffee. Moving around as much as possible, in a safe manner, will also promote good circulation. It is also recommended to wear loose clothing and store luggage in overhead compartments to allow room to move. Properly fitting below-knee compression stockings are advised for those with any risk factors, as they can help maintain a good blood flow throughout the journey. Those at higher risk should also see a doctor to consider the use of medication such as heparin or aspirin, which has been shown to reduce the risk by of DVT by a third.(9) If a patient is considered at a very high risk it is the health professional's responsibility to advise them to consider postponing their travel.

Travelling with medical conditions
Patients travelling with medical conditions need specialised information based on their situation and individual needs. Medical problems that require the administration of medication during the flight and on arrival will need up-to-date information from the Department of Health before departure. Due to the rapidly changing nature of such information, health professionals should ensure that they have the latest updates and should consider providing patients with a list of relevant information and websites to check before their departure.(10)
Due to the increased terror threat difficulties have arisen for those needing to carry needles and excess liquid medication in their hand luggage. These patients should be advised to check with the individual airline regarding the procedure for carrying such items on board. 

Diseases onboard
Once the traveller is on the flight the airline crew might suggest that they "relax and enjoy the flight". However, there are many potential health concerns. One apprehension among travellers is the potential transmission of diseases. While research indicates that the transmission of communicable diseases onboard a flight is uncommon, there is evidence to suggest that some airborne disease transmission, such as the common cold, can occur when airlines are delayed and passengers are left waiting on the tarmac in planes. However, while infection does occur it does not appear to be any greater than that occurring in normally crowded places.(11) The only sensible preventive measures are for travellers to ensure that they are healthy before travel and maintain strict hygiene procedures, such as washing their hands, while travelling.

Reduced cabin pressure
As the aircraft increases in altitude the traveller is at risk of problems associated with both a lack of oxygen and the expansion of gases in the cavities of the body. This change in air pressure is a minor inconvenience for most healthy travellers and is usually felt most in the middle ear which results in a "popping" sensation; this can be resolved either by yawning or swallowing.(12) However, for those with existing medical problems the increased pressure on the body can cause problems. Those most at risk are travellers with existing heart, lung and blood disorders, due to lower oxygen saturation levels. For those patients requiring oxygen when flying it is important that they contact the airline ahead of time to make the necessary arrangements.
Gases in the body cavities can expand up to 25% during a flight causing distress to those with existing ear problems, recent abdominal surgery, or respiratory infections.(13) With an increasing number of travellers flying abroad for surgical procedures, caution should be emphasised as to the timing of return flights as re-absorption of intestinal gas following surgery can take seven to 14 days. Airlines such as British Airways offer online advice for those flying after illness and operations.(14)

Motion sickness
Travel sickness occurs when a person is moving in unusual and repeated patterns.(15) It is usually treated using over-the-counter medication. Hyoscine, for example, prevents the signals that cause the sickness going to the brain and should be taken 30 minutes before travel. Other options include antihistamines such as cinnarizine, which should be taken two hours before travel and lasts for up to eight hours, sometimes causing drowsiness.(16) Caution should therefore be advised for those who are at risk of DVT or who need to drive following a short flight. Passengers affected by air travel sickness should request a seat over the wing of the aircraft as the central part of a plane will have the least pitching and rolling (as in a boat) and try to schedule flights on larger planes to minimise the effects. Avoiding alcohol and gaseous foods and drinks for 24 hours before the flight has also been suggested. 

Jet lag
Jet lag can result in a loss of concentration and irritability. Travellers should be advised to get plenty of sleep before a journey. While some travellers like to change their watch as soon as they board a plane, those taking medication are usually advised to maintain "home time" until they arrive at their destination. On arrival exercise and exposure to light is a good way of combating jet lag as it gives the body time to adjust. Those travellers with heavy schedules often benefit from a mild sleeping tablet for two to three days in order to adjust.

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References:

  1. Airports Council International. Global traffic forecast executive summary 2006-2025. Available from: http://www.airports.org/aci/aci/file/Press%20Releases/2007_PRs/ACI_Forec...
  2. House of Lords. Report on air travel and health. London: TSO; 2000. Available from: http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/l...
  3. Aviation Health. Available from: http://www.aviation-health.org
  4. McIntosh IB, Power KG, Reed JM. Prevalence, intensity, and sex differences in travel related stressor. J Travel Med 1996;3:96-102.
  5. Harding R. Health problems associated with air travel. In: Lockie C, Walker E, Calvert L, editors. Travel medicine and migrant health. Edinburgh; Churchill Livingstone: 2000.
  6. Possick SE, Barry M. Air travel and cardiovascular disease. J Travel Med 2004;11:243-50.
  7. World Health Organization. Travel by air - health considerations. Geneva: WHO; 2005. Available from: http://whqlibdoc.who.int/publications/ 2005/9241580364_chap2.pdf
  8. Department of Health. Advice on travel-related DVT. Available from: http://www.dh.gov.uk
  9. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP) trial. Lancet 2000;355:1295-302.
  10. Department of Health. Advice for travellers for taking essential medicines on flights in the current security situation. London: DH; 2006. Available from: http://www.dh.gov.uk/PolicyAndGuidance/HealthAdviceForTravellers/Health Updates/fs/en?CONTENT_ID=4138094&chk=qZNBHa
  11. Mangili A, Gendreau M. Transmission of infectious diseases during commercial air travel. Lancet 2005;365:989-96.
  12. British Medical Association. The impact of flying on passenger health. London: BMA; 2004. Available from: http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFFlying/$FILE/Impactofflying.pdf
  13. Aerospace Medical Association. Medical guidelines for air passengers. 2002. Available from: http://www.asma.org
  14. British Airways. Health advice Available from: http://www.british airways.com/travel/healthmedcond/public/en_gb#flying
  15. Sherman CR. Motion sickness: review of causes and preventive strategies. J Travel Med 2002:9:251-6.
  16. NHS Direct. Available from: http://www.nhsdirect.nhs.uk

Resources:
British Airways Health Information
W: www.britishairways.com
TravelHealth Information services
W: www.Travelhealth.co.uk for printable patient leaflets
Flying Without Fear
W: www.flyingwithoutfear.com
Virgin Atlantic Fear of Flying Course
W: www.fearofflying.com
Flying without Fear
by Godfrey K Hampshire: Macroteach Publications; 2003.