Prevention of Medical Events During Air Travel: A Narrative Review

Injuries and medical emergencies among international travellers

BACKGROUND

Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings.

METHODS

We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled).

RESULTS

All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur.

CONCLUSIONS

Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.

Clinical Characteristics and Long-Term Outcomes of Patients with Acute Coronary Syndrome During Travel

Cardiovascular disease is a major cause of death among travelers, but the clinical characteristics and clinical outcomes of patients who develop acute coronary syndrome (ACS) while traveling have not been assessed. We evaluated 2548 patients with ACS who underwent primary percutaneous coronary intervention (PCI) between 1999 and 2015 and compared the incidences of all-cause and cardiac death during follow-up between travelers and locals. We assessed 192 (7.5%) patients who developed ACS while traveling. These patients were younger and had a higher prevalence of ST-elevation myocardial infarction than local patients. During a median follow-up period of 5.3 years, 632 (24.8%) all-cause deaths were identified, including 310 cardiac deaths (12.2%). Kaplan-Meier analysis revealed that the cumulative incidence of all-cause death was significantly lower among the travelers than locals (P = 0.001, log-rank test). Multivariate Cox hazard analysis revealed that travel was significantly associated with a lower rate of all cause death (hazard ratio, 0.53; 95% confidence interval, 0.33-0.80; P = 0.002). Cardiac mortality did not significantly differ between travelers and locals (P = 0.29). Patients with ACS treated with primary PCI while traveling had more favorable long-term clinical outcomes than local patients. Appropriate initial treatments and secondary preventions might improve the prognosis of travelers.

Medical Events on Board Aircraft: Reducing Confusion and Misinterpretation in the Scientific Literature

INTRODUCTION: A topic in aviation medicine that attracts much attention from the scientific community as well as from the media concerns medical incidents on board commercial airline flights. It was noticed that many papers on the subject were written by authors whose specialization was outside that of aviation medicine and that they sometimes made basic errors concerning the application of scientific principles of the subject. A review was undertaken to determine if there were any patterns to the observed errors and, if so, to consider whether recommendations might be provided that could reduce their frequency.METHOD: A literature search was undertaken of MEDLINE using PubMed for English-only articles published between January 1, 1974, and February 1, 2019, employing the following search terms: air emergency, air emergencies, air passenger, air travel, aircraft, airline, aviation, commercial air, flight, and fitness to fly. In addition, other relevant papers held in the personal collection of the authors were reviewed.RESULTS: Many cases of misinterpretation or misunderstanding of aviation medicine were found, which could be classified into eight main categories: references; cabin altitude; pressure/volume relationship; other technical aspects of aircraft operations; regulations; medical events; in-flight deaths; and automated external defibrillator.CONCLUSION: Papers were identified as having questionable statements of fact or of emphasis. Such instances often appeared to result from authors being unfamiliar with the subject of aviation medicine and/or the commercial aviation environment. Simple steps could be taken by authors to reduce the future rate of such instances and recommendations are provided.Thibeault C, Evans AD. Medical events on board aircraft: reducing confusion and misinterpretation in the scientific literature. Aerosp Med Hum Perform. 2021; 92(4):265273.

Commercial Air Travel for Passengers With Cardiovascular Disease: Recommendations for Common Conditions

The exponential growth of commercial flights has resulted in an explosion of air travelers over the last few decades, including passengers with a wide range of cardiovascular conditions. Notwithstanding the ongoing COVID-19 pandemic that had set back the aviation industry for the next 1-2 years, air travel is expected to rebound fully by 2024. Guidelines and evidence-based recommendations for safe air travel in this group vary, and physicians often encounter situations where opinions and assessments on fitness for flights are sought. This article aims to provide an updated suite of recommendations for the aeromedical disposition of passenger with common cardiovascular conditions, such as ischemic heart disease, congestive heart failure, valvular heart disease, cardiomyopathies, and common arrhythmias.

Stranded abroad: a travel medicine approach to psychiatric repatriation

BACKGROUND

The incurred mental alteration of a traveler abroad should be an alarming signal for patient, for family and for the local healthcare professionals alike. It is estimated that 11.3% of travelers experience some kind of psychiatric problem, with 2.5% suffering from severe psychosis and 1.2% requiring more than 2 months of therapy upon return from a trip abroad. Acute psychotic episode represents approximately one-fifth of travel-related psychiatric events. Yet, the travel-related mental problems have been a neglected topic till today. Now a good selection of literature is available to help further researches.

METHODS

Besides describing the most relevant literature of travel-related mental disturbances, authors present two key issues of dealing with psychiatric problems of travelers abroad: to identify the origin of the mental alteration and the process of the patient with psychiatric problems.

RESULTS

Identifying the origin and the nature of the mental symptoms of travelers is often difficult because of the language barrier, among extraordinary circumstances. A simple two-step three-branch algorithm could make the decision easier for the attending physician. Some of the brief psychotic disorder and organic origin of mental disturbance can be and often are treated in place.

CONCLUSIONS

Some mental problems probably originated from or triggered by the travel or a foreign environment itself. In these cases the full recovery will be expected if the triggering factor is eliminated. The solution is early repatriation. The repatriation for psychiatric reasons is highly different from repatriation for other medical emergencies. The authors describe a proposal of a step-by-step action of repatriation of a psychotic patient. By the help of this suggested protocol, the patient may successfully be taken home.

Guidelines for the prevention of travel-associated illness in older adults

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.