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HIV and travel.

There is a high demand for travel among HIV-positive individual. This demand arises partly from those who have benefited from advances in antiretroviral therapy as well as those with disease progression. The key to a successful and uneventful holiday lies in careful pre-trip planning, yet many patients fail to obtain advice before travelling. Travel advice for HIV patients is becoming increasingly specialized. In addition to advice on common travel-related infectious diseases, HIV-positive travellers are strongly advised to carry information with them and they need specific advice regarding country entry restrictions, HIV inclusive travel insurance, safety of travel vaccinations and highly active antiretroviral therapy-related issues. A wide range of relevant issues for the HIV-positive traveller are discussed in this review and useful websites can be found at the end.

AIDS-Related Opportunistic Infections↗

Differences in sexual risk behaviour between young men and women travelling abroad from the UK.

BACKGROUND: Identification of people who most frequently engage in sexual risk behaviour while travelling abroad would be useful for the design and targeting of health education and promotion campaigns. METHODS: Eligible participants were people living in the UK aged 18-34 years who had travelled abroad without a partner in the previous 2 years. Respondents were first screened for eligibility as part of representative face-to-face and telephone surveys by a market research company. Eligible individuals who agreed to take part then underwent a computer-assisted telephone interview. Reinterviewing continued until 400 eligible people had been contacted. We also interviewed a control group of 568 young people who had travelled abroad without a partner in the previous 2 years but who did not report a new sexual relationship during their travels. FINDINGS: One in ten of the eligible participants reported sexual intercourse with a new partner. Travellers who reported a new sexual relationship abroad were also likely to report large numbers of sexual partners at home. Of the 400 people who had a new sexual partner abroad, 300 (75%) used condoms on all occasions with the new partner. Logistic regression modelling showed differences between men and women in those factors linked to the practice of unsafe or safer sex while travelling. For men, patterns of condom use abroad with casual partners (p<.0001) reflected patterns of use at home (p<0.001), whereas for women, patterns of condom use varied according to their partners' backgrounds (p<.0001). INTERPRETATION: Condoms are widely used among young travellers, but patterns of use vary by sex. Campaigns about sexual health targeted at international travellers should continue, not least because young people who meet new sexual partners abroad may be a convenient proxy group for that minority of the population who report most sexual partners at home. Such campaigns should be designed differently for men and women.

Adolescent↗

Evaluation of ELISA-based sero-diagnosis of dengue fever in travelers.

Diagnosis of dengue virus infection in travelers is often based on commercially available ELISA-based serological assays and not on the more difficult and costly procedures of Hemagglutination inhibition (HI), virus isolation or RT-PCR. These standard assays are not quantitative and are designed to diagnose primary and secondary dengue virus infections by testing for IgG and IgM antibodies. However, cross reactivity between various flaviviruses and the fact that most travelers today are prevaccinated against Japanese encelphalitis (JE) and yellow fever (YF) create a potential problem in such diagnosis. Our study was aimed at measuring the extent of false positive diagnosis in prevaccinated travelers which we have assessed by testing for dengue IgG and IgM antibodies in a group of prevaccinated healthy travelers using the PanBio indirect IgG ELISA and IgM capture ELISA kits. The IgM test was negative in all healthy vaccinees, thus, being highly specific. However, the kit had a disadvantage, which was recognized in other travelers clinically ill with dengue fever (DF), in which the IgM response was detected only 4-8 days after onset of the clinical symptoms. The IgG test yielded 11-17 and 15-44% positives in healthy travelers vaccinated against JE and YF, respectively. We conclude that the specificity of the IgG-ELISA assay in prevaccinated travelers is much lower than in unvaccinated populations. Thus, an IgG-positive results in a vaccinated traveler and IgM negative result during the 1st week of the illness period, are both inconclusive.

Adult↗

The traveller and emerging infections: sentinel, courier, transmitter.

The movement of populations shapes the patterns and distribution of infectious diseases globally. The consequences of travel are seen in the traveller and in places and populations visited and may persist long after travel. The traveller can be seen as an interactive biological unit who picks up, processes, carries and drops off microbial genetic material. A traveller can introduce potential pathogens in the absence of signs or symptoms of illness. Travellers can serve as a sentinel population; study of them can provide insights into the presence and level of risk of transmission of infections in other geographical regions. Travellers can also be seen as couriers who inadvertently ferry pathogens and microbial genetic material to regions where researchers can carry out detailed analyses that can help to map the location and movement of strains, genotypes and resistance patterns. The laboratory plays a key role in the identification and characterization of pathogens, which can inform management of individual patients and the public health response. The connectedness and mobility in the world today facilitate the emergence of infectious diseases in humans and also in animals and plants. Many traditional barriers have been breached by travel, roads and technology. Population size and density favour spread of many infections. The rapid generation time of microbes and their capacity to adapt to changes in the physico-chemical and immunological environment will pose continuing challenges.

Animals↗

Risk of hepatitis A infection following travel.

Travel to endemic areas is one of the most frequently reported risk factors for infection with the hepatitis A virus (HAV). We evaluated the association between HAV infection and travel, by area of destination. We conducted a case-control study on all cases of HAV infection reported to the Italian National Surveillance System for Acute Viral Hepatitis in the period 1996-2000. The study population consisted of 9695 persons with HAV infection (cases) and 2590 with HBV infection (controls). The risk of acquiring HAV was highest for travel to Asia, Africa and Latin America [Odds Ratio = 9.30 (95%CI = 6.71-12.9)]; a three-fold statistically significant excess of risk was found for travel to southern Italy (OR = 3.03) and to the Mediterranean Area and Eastern Europe (OR = 3.15). Travel was implicated in 28% of the cases of HAV infection. When stratifying the analysis by area of residence (northern and central Italy vs southern Italy and the Islands), the above-mentioned risks were confirmed only for those residing in northern and central Italy, with no significant risk for those residing in southern Italy and the Islands. Travel to areas endemic for HAV infection constitutes a considerable risk. Our results highlight the importance of developing health policies for improving environmental and hygienic conditions, as well as the prevention of certain eating habits. Vaccination before travelling to a medium or high endemic area could be a safe and effective means of preventing travel-related HAV infection.

Adolescent↗

Severe pulmonary embolism associated with air travel.

BACKGROUND: Air travel is believed to be a risk factor for pulmonary embolism, but the relation between pulmonary embolism and distance flown has not been documented. The aim of this study was to investigate whether the duration of air travel is related to the risk of pulmonary embolism. METHODS: From November 1993 to December 2000, we systematically reviewed all cases of pulmonary embolism requiring medical care on arrival at France's busiest international airport. Data on the geographic origins of all flights and the numbers of passengers were collected in order to evaluate the incidence of pulmonary embolism per 1 million passenger arrivals as a function of the distance traveled. RESULTS: A total of 135.29 million passengers from 145 countries or other areas arrived at Charles de Gaulle Airport during the period of the study, of whom 56 had confirmed pulmonary embolism. The incidence of pulmonary embolism was much higher among passengers traveling more than 5000 km (3000 mi) (1.5 cases per million, as compared with 0.01 case per million among those traveling less than 5000 km). The incidence of pulmonary embolism was 4.8 cases per million for those traveling more than 10,000 km (6000 mi). CONCLUSIONS: A greater distance traveled is a significant contributing risk factor for pulmonary embolism associated with air travel.

Aerospace Medicine↗

Seroepidemiology of Rickettsia africae infection in Norwegian travellers to rural Africa.

Rickettsia africae is the causative agent of African tick bite fever (ATBF), an acute febrile illness frequently accompanied by inoculation eschars, regional lymphadenitis, myalgia and severe headache. Recently, ATBF has been recognized as an emerging health problem for international travellers to rural sub-Saharan Africa. To estimate the incidence, risk factors for and proportion of symptomatic cases of travel-associated R. africae infection, we performed a seroepidemiological study of 152 first-time Norwegian travellers to rural areas in sub-Equatorial Africa. Seropositivity was based on the detection of specific antibodies to R. africae in microimmunofluorescence and/or Western blotting assays. Thirteen (8.6%) travellers were seropositive to R. africae. Eight (62%) seropositive travellers reported symptoms consistent with ATBF; of these, 2 had received antirickettsial therapy. Using multiple logistic regression, the following factors were found to be significantly associated with seropositivity: hunting as the purpose of travel [odds ratio (OR) 10.1; 95% confidence interval (CI) 1.5-69; p=0.019] and stay in rural areas of > 7 d (OR 6.0; 95% CI 1.5-24; p=0.012). This first seroepidemiological study on travel-associated R. africae infection suggests that the infection may be common in international travellers to rural sub-Saharan Africa but that most cases are asymptomatic or clinically mild and self-limited.

Adolescent↗

Influenza virus infection in travelers to tropical and subtropical countries.

BACKGROUND: Influenza outbreaks have been reported among travelers, but attack rates and incidence are unknown. METHODS: A cohort study was conducted. Travelers to subtropical and tropical countries recruited at the University of Zurich Travel Clinic (Switzerland), January 1998 to March 2000, were investigated with pre- and posttravel assessment of hemagglutination inhibition and by questionnaire. RESULTS: Among 1450 travelers recruited who completed questionnaires and provided serum samples before departure, 289 (19.9%) reported febrile illness during or after traveling abroad; of these, 211 (73.0%) provided paired serum samples. Additionally, paired serum samples were collected from 321 frequency-matched afebrile control subjects among the remaining 1161 subjects of the study population. Seroconversion for influenza virus infection was demonstrated in 40 (2.8%) of all travelers; 18 participants (1.2%) had a > or = 4-fold increase in antibody titers. This corresponds to an incidence of 1.0 influenza-associated events per 100 person-months abroad. Among the 211 febrile participants, 27 (12.8%) had seroconversion, 13 (6.2%) with a > or = 4-fold increase; among the 321 afebrile control subjects, 13 (4.0%) had seroconversion, 5 (1.6%) with a > or = 4-fold increase. Twenty-five seroconverters (62.5%; P = .747) acquired influenza outside of the European epidemic season. Sixteen patients (40.0%) sought medical attention either abroad or at home, and 32 (80.0%) were asymptomatic at the time of completion of the survey. CONCLUSIONS: This survey indicates that influenza is the most frequent vaccine-preventable infection among travelers to subtropical and tropical countries. Infections occur mainly outside the domestic epidemic season, and they have a considerable impact. Pretravel vaccination should be considered for travelers to subtropical and tropical countries.

Adolescent↗

Absence of efficacy of nonviable Lactobacillus acidophilus for the prevention of traveler's diarrhea: a randomized, double-blind, controlled study.

BACKGROUND: Diarrhea is the most common illness associated with international tourism. We evaluated the efficacy of a probiotic preparation of nonviable Lactobacillus acidophilus (hereafter referred to as LA) for the prevention of traveler's diarrhea. METHODS: We conducted a randomized, double-blind, controlled trial. Travelers were randomized to receive either LA or placebo twice daily from 1 day before their departure to 3 days after their return. On each day of the trip and the week following the return, travelers had to record the number and consistency of stools and their adherence to the treatment. Diarrhea was defined as > or =3 unformed stools in a 24-h period. RESULTS: From January 2001 to September 2004, a total of 174 subjects were randomized to each treatment group. Half of the travelers went to West Africa, and organized tours or backpacking were the most common modes of traveling. The incidence of diarrhea did not differ between the 2 groups; it was 61.4 cases per 100 person-months in the LA group (95% confidence interval [CI], 44.1-85.5) and 43.4 cases per 100 person-months in the placebo group (95% CI, 30.0-62.9) (P=.14). Adjustment for travel duration and other variables did not reveal any difference between the 2 groups (adjusted hazard ratios comparing the LA and placebo groups were 1.43 [95% CI, 0.87-2.36] in an intent-to-treat analysis and 1.38 [95% CI, 0.79-2.39] in an efficacy analysis). CONCLUSIONS: There was no beneficial effect of treatment with LA for the prevention of travelers' diarrhea. More studies are required to assess the efficacy of other specific probiotics (e.g., a Lactobacillus rhamnosus GG preparation) for preventing traveler's diarrhea.

Diarrhea↗

Tropical diarrhoea: new developments in traveller's diarrhoea.

Traveller's diarrhoea is the most common illness acquired by visitors to developing countries, affecting 20-50% of the 35 million people who travel from industrialized countries each year. Important risk factors include point of origin and destination of the traveller, host factors, and exposure to contaminated food and water. The most common causes of traveller's diarrhoea in adults in developing countries include infection with Escherichia coli, Shigella spp., Salmonella spp., Campylobacter spp., Vibrio parahaemolyticus (in Asia), rotavirus (in Latin America), and protozoa (Giardia, Cryptosporidium and Cyclospora spp., and Entamoeba histolytica). No pathogen is identified in over half of patients with traveller's diarrhoea, however. The primary objectives of treatment of traveller's diarrhoea are to reduce the symptoms and duration of diarrhoeal illness, to reduce inconvenience caused by such illness and to prevent cancellation of planned activities. These important objectives are best accomplished by empirical self-therapy with a combination of antimicrobial agents and loperamide. Since the first use of ciprofloxacin, fluoroquinolones have become the drugs of choice in empirical therapy for moderate-to-severe traveller's diarrhoea in adults. The options for children include nalidixic acid, trimethoprim-sulfamethoxazole (along with erythromycin if Campylobacter infection is a possibility) and furazolidone. Education on hygiene and safe food preparation help to prevent many diarrhoeal diseases, including traveller's diarrhoea.

Anti-Bacterial Agents↗

Prevention and treatment of travel-related infections in compromised hosts.

PURPOSE OF REVIEW: The numbers of international travelers and complexity of their underlying medical conditions continue to increase. Traveling with compromised immunity warrants special consideration regarding the prevention and treatment of travel-related diseases, ideally with the help of a travel medicine specialist. There is a need for careful weighing of the potential health risks in persons with severe immunosuppression, including that related to HIV, use of immunomodulating agents, malignancy and cancer chemotherapy, solid organ and bone marrow transplantation, and asplenia. RECENT FINDINGS: Over the past year, a number of articles and texts have been published addressing the health risks and management strategies for travelers with underlying immune compromise, including the potential interactions between HIV and malaria, and transplant outcomes for those receiving transplants through medical tourism. SUMMARY: Tailored advice and treatment strategies for compromised travelers can help facilitate safe travel for individuals who choose risk-taking travel.

Communicable Disease Control↗

Illness in returned travellers presenting at GeoSentinel sites in New Zealand.

OBJECTIVE: To describe illnesses of returned travellers presenting at GeoSentinel sites in New Zealand. METHODS: Record data for all patients presenting for travel-related illnesses seen at two GeoSentinel sites, operating as commercial travel clinics, in Auckland and Hamilton, NZ, were extracted for the period November 1997 to December 2001. RESULTS: 205 patients were identified with 262 diagnoses. Just over half were females (54.21%) and nearly half were in the 25-35 years age group (47.3%). About two-fifths of patients reported a pre-travel health consultation (41.0%). The commonest diseases diagnosed were diarrhoeal illnesses (23%), dermatological diagnoses (16%, excluding animal bites), animal bites (10%), and non-specific viral illnesses (8%), many of which manifest as respiratory infections. Tropical diseases, such as schistosomiasis (4%) malaria (2%) and dengue fever (0.5%), were not common. CONCLUSIONS: Information on travel-related illnesses, when reported through a global reporting system, can be useful for the travel health adviser in identifying issues of current concern. Although the frequency of tropical disease is low, it remains important to prevent these potentially fatal diseases. IMPLICATIONS: GeoSentinel makes a global contribution to the surveillance of emerging and re-emerging infectious diseases through a network of individual sites in various countries including New Zealand. This information can be used to help provide preventive advice for travellers as well as help in assessing illness in post-travel patients and potentially assist in preventing the secondary spread of some diseases acquired abroad following return.

Adolescent↗

Knowledge, attitudes and health outcomes in HIV-infected travellers to the USA.

BACKGROUND: The USA bans entry to non-citizens unless they obtain a waiver visa. AIM: To establish how many people with HIV infection travelled to the USA, whether they were aware of the travel restriction, whether they travelled with a waiver visa and HIV inclusive medical insurance and how they managed with their antiretroviral medication (ARV). DESIGN: Collation of data from cross-sectional studies conducted independently at three different medical centres, Manchester, Brighton and London, using a structured self-completion questionnaire. RESULTS: The overall response rate was 66.6% (1113 respondents). 349 (31%) had travelled to the USA since testing HIV positive, of whom only 14.3% travelled with a waiver visa. 64% and 62% of the respondents at Manchester and Brighton were aware of the need of a waiver visa. 68.5% (212) were on ARV medication at the time of travel and, of these, 11.3% stopped their medication. Of those taking ARV medication, only 25% took a doctors' letter, 11.7% posted their medication in advance. Of those discontinuing treatment (n=27), 55.5% sought medical advice before stopping, 11 were on NNRTI-based regimen and one developed NNRTI-based mutation. Only 27% took up HIV inclusive medical insurance. Many patients reported negative practical and emotional experiences resulting from travel restrictions. CONCLUSION: The majority of HIV patients travel to the USA without the waiver visa, with nearly half doing so with insufficient planning and advice. A significant minority (11.3%) stop their medication in an unplanned manner, risking the development of drug resistance.

Adolescent↗

Culture shock and travelers.

As travel has become easier and more affordable, the number of people traveling has risen sharply. People travel for many and varied reasons, from the business person on an overseas assignment to backpackers seeking new and exotic destinations. Others may take up residence in different regions, states or countries for family, business or political reasons. Other people are fleeing religious or political persecution. Wherever they go and for whatever reason they go, people take their culture with them. Culture, like language, is acquired innately in early childhood and is then reinforced through formal and complex informal social education into adulthood. Culture provides a framework for interpersonal and social interactions. Therefore, the contact with a new culture is often not the exciting or pleasurable experience anticipated. When immersed in a different culture, people no longer know how to act when faced with disparate value systems. Contact with the unfamiliar culture can lead to anxiety, stress, mental illness and, in extreme cases, physical illness and suicide. "Culture shock" is a term coined by the anthropologist Oberg. It is the shock of the new. It implies that the experience of the new culture is an unpleasant surprise or shock, partly because it is unexpected and partly because it can lead to a negative evaluation of one's own culture. It is also known as cross-cultural adjustment, being that period of anxiety and confusion experienced when entering a new culture. It affects people intellectually, emotionally, behaviorally and physically and is characterized by symptoms of psychological distress. Culture shock affects both adults and children. In travelers or workers who have prolonged sojourns in foreign countries, culture shock may occur not only as they enter the new culture, but also may occur on their return to their original culture. Children may also experience readjustment problems after returning from leading sheltered lives in expatriate compounds. This readjustment back to their own culture after a period of time abroad has been termed "reverse culture shock, a condition which has been studied in both corporate managers and Peace Corps volunteers. With culture shock and many other processes of psychological adjustment, people tend to suffer alone, thinking that they are the only ones not coping well with their new circumstance. The objective of this paper was to bring the phenomenon of culture shock to the awareness of travel health advisors, who can in turn advise travelers, especially longer term travelers, about having realistic expectations of their travel and life in new cultures.

Acculturation↗

Pharmacists and travel advice for tropics in Lisbon (Portugal).

BACKGROUND: In Portugal, little is known about the quality of advice given to international travelers by pharmacists. The aim of this study was to determine pharmacists' training, experience, and interest in travel medicine and to assess the technical quality of the information given. METHODS: We sent a postal questionnaire to all pharmacies in the Lisbon area. The technical director or another graduate pharmacist was asked to complete the questionnaire. RESULTS: A total of 251 pharmacists participated in the study. Most of them (93.2%) did not have any training in travel medicine, and most of them expressed a wish to be informed and/or updated on this subject. The number of advised travelers was low. The use of repellent, protective clothes, and mosquito bed nets was the most frequent advice on protection against mosquito bites. From a subgroup of 170 pharmacists, 43.5% indicated mefloquine and 44.1% indicated chloroquine as malaria chemoprophylaxis to African countries. A significant association existed between the variables "to indicate mefloquine" and "seeks to be informed/updated on travel medicine." Those who indicated chloroquine tended to like travel medicine less. Concerning diarrhea prevention and treatment, the consumption of bottled and/or treated water and the administration of antibiotics during the episode were the most reported advice. Concerning vaccination against yellow fever, only 8 of 91 pharmacists correctly indicated all Portuguese-speaking countries with and without the risk of this disease. CONCLUSIONS: Studied pharmacists need training in travel medicine. Travel advice was incomplete and/or incorrect and must be improved.

Adult↗

Awareness of rabies risks and knowledge about preventive measures among experienced German travel health advisors.

BACKGROUND: Every year, millions of people travel to countries where rabies is enzootic. However, the quality of rabies-specific information provided by travel health advisors and the extent of their knowledge about pre- and postexposure prophylaxis have not been examined on a large-scale basis up to now. METHODS: 5,780 German physicians and pharmacists, who identified themselves as active travel health advisors, were chosen from a database. The selected providers were asked to complete an Internet-based questionnaire. The form requested both demographic information and the assessment of different concrete scenarios, each of which featured individuals seeking pre-travel advice on rabies or appropriate postexposure treatment after returning from abroad. RESULTS: Overall, 496 physicians and pharmacists completed the questionnaire. Almost all respondents indicated that they would mention the risk of rabies and appropriate preventive measures to long-term travelers and tourists planning to visit rural areas. However, only 35% to 60% of the advisors would provide this information to individuals on business trips, package tours, or travelers in urban centers as well. The assessment of the scenarios yielded 51% to 98% of adequate advice. Potentially harmful decisions included, for instance, the failure to recommend further prophylactic measures after exposure of already vaccinated people or the fact that the necessary postexposure prophylaxis was inappropriately withheld in cases where treatment had been initially delayed. CONCLUSIONS: Although the participants of this study were well aware of the travel-associated rabies risks and provided adequate information about this health hazard to most of their clients, evident flaws exist regarding the correct assessment of specific situations in pre- and postexposure rabies prophylaxis. Our findings therefore provide important cues on topics that should be more intensely covered during future postgraduate training in travel medicine and also underline the need for more practically orientated, readily available information on specific prophylactic treatment against rabies.

Attitude of Health Personnel↗

Comparison of adverse events associated with use of mefloquine and combination of chloroquine and proguanil as antimalarial prophylaxis: postal and telephone survey of travellers.

OBJECTIVE: To compare the frequency of adverse events, particularly neuropsychiatric effects, from mefloquine and from chloroquine plus proguanil as used for malaria chemoprophylaxis. DESIGN: Retrospective questionnaire to travellers taking either regimen between November 1993 and February 1995; telephone interview with those reporting pronounced side effects. SETTING: Travellers from Britain who consulted an advisory helpline. SUBJECTS: 1214 adults taking mefloquine and 1181 taking chloroquine plus proguanil. MAIN OUTCOME MEASURES: Reported presence of and degree of disability from 12 neuropsychiatric and other symptoms, as assessed by the subjects and by referees and on the basis of behaviour change. RESULTS: There were equal rates of any side effects (40%) and of stopping or changing medication. Overall, neuropsychiatric adverse events were significantly more common in travellers taking mefloquine. In all, 333 neuropsychiatric adverse events were reported by 1214 travellers taking mefloquine, compared with 189 such events in 1181 travellers taking proguanil plus chloroquine (P < 0.001). In all, 0.7% of travellers taking mefloquine had disabling neuropsychiatric adverse effects, compared with 0.09% of those taking proguanil plus chloroquine (P = 0.021). Two travellers taking mefloquine (1 in 607) were admitted to hospital as a result of the adverse event, compared with 1 in 1181 travellers taking proguanil plus chloroquine. CONCLUSION: There is a significant excess of adverse neuropsychiatric events of intermediate degrees of severity associated with the use of mefloquine compared with proguanil plus chloroquine. This finding may also explain the discrepant findings between earlier studies and clinical experience.

Adult↗

The association between air travel and deep vein thrombosis: systematic review & meta-analysis.

BACKGROUND: Air travel has been linked with the development of deep vein thrombosis (DVT) since the 1950s with a number of plausible explanations put forward for causation. No systematic review of the literature exploring this association has previously been published. METHODS: A comprehensive search was undertaken (Data bases searched were: MEDLINE, EMBASE, Cochrane Library) for studies that estimated both the incidence and the risk of DVT in air travellers relative to non-air travellers. RESULTS: In total 254 studies were identified but only six incidence studies and four risk studies met inclusion criteria justifying their use in a systematic review. Incidence of symptomatic DVT ranged from (0%) in one study to (0.28%) which was reported in pilots over ten years. The incidence of asymptomatic DVT ranged from (0%) to (10.34%). Pooled odds ratios for the two case control studies examining the risk of DVT following air travel were 1.11 (95% CI: 0.64-1.94). Pooled odds ratios for all models of travel including two studies of prolonged air travel (more than three hours) were 1.70 (95% CI: 0.89-3.22). CONCLUSION: We found no definitive evidence that prolonged (more than 3-hours) travel including air travel, increases the risk of DVT. There is evidence to suggest that flights of eight hours or more increase the risk of DVT if additional risk factors exist.

Aerospace Medicine↗