RISK ASSESSMENT IN TRAVEL MEDICINE

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RISK ASSESSMENTIN TRAVEL MEDICINE

• Dr Peter A. Leggat
• MD, PhD, DrPH, FAFPHM, FACTM, FFTM
• Associate Professor
• School of Public Health and Tropical Medicine
• James Cook University
• Visiting Professor
• School of Public Health
• University of the Witwatersrand

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About the author

• Dr Peter Leggat has co-ordinated the Australian
  postgraduate course in travel medicine since
  1993. He has also been on the faculty of the
  South African travel medicine course, conducted
  since 2000, and the Worldwise New Zealand Travel
  Health update programs since 1998. Dr Leggat has
  assisted in the development of travel medicine
  programs in several countries and also the
  Certificate of Knowledge examination for the
  International Society of Travel Medicine.

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Objectives

• In this lecture, we will
• Define the term risk
• Gain an appreciation of its importance in
  providing pre-travel health advice
• Develop an approach to undertaking a risk
  assessment in travel medicine
• Examine how risk can be modified for travellers

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What is risk?

• the likelihood of injury, disease, damage or
  loss from a real or potential hazard (CCH
  Australia)

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Balancing risks

• Probability of harm and the severity of possibly
  consequences of travel
• Balance these with
• Probability and the severity of adverse
  consequences of any interventions

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• the art of travel medicine is selecting the
  necessary prevention strategy without unnecessary
  adverse events, cost or inconvenience
  (Steffen, 1994)

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Risk perception is important

• Travellers may confound the likelihood and
  severity of outcomes
• Familiarity, visibility and controllability of a
  hazard all influence the perception of risk
• We need to understand the perceptions as well as
  the reality of the risk in travel

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Risk assessment

• Needs to be undertaken as part of the pre-travel
  consultation
• Needs exact itinerary and medical history of the
  traveller
• Needs time emphasise the need to get this
  information well before travel

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Risk assessment

• Risk assessment preferably starts before the
  traveller enters the consulting room
• Document the risk assessment

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Standardised questionnaire
www.who.int/ith
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Establish the risks

• Destination
• Mode of travel
• Travellers medical history
• Intervention

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Risks of the destination
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Risks of the destination

• What countries and what parts of these countries
  are they visiting?
• How long are they going to stay?
• What time of the year are they visiting?
• What are the living conditions?
• What are the current security concerns?
• What activities are they undertaking? Do they
  need a diving medical?
• What can the traveller tell you?
• Is there anything special about the destination
  culturally or legally?

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Risk of the destination

• CDC Travel Health, see http//www.cdc.gov/travel/i
  ndex.htm
• MASTA, see http//www.masta.org
• TRAVAX, see http//www.travax.nhs.uk
• Shorelands, see http//www.tripprep.com

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World Health Organizationwww.who.int/ith
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Risks of the destination

• Are they travelling alone or as a group?
• What is the travellers prior travel experience?
• What access is there to appropriate medical care?
• Does the traveller know first aid?
• Does the traveller have travel insurance with
  full coverage?

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Risks of the destination

• Categorise Living Conditions
• Rural and remote areas and villages and/or close
  contact with local people, e.g. health workers.
• Towns and cities, not rural and remote and/or
  lower standard accommodation and/or stay over
  four weeks/month.
• Major cities and tourist resorts and/or medium to
  high standard accommodation and/or reliable water
  and food sources and/or short term stays of less
  than four weeks/month.
• In transit and not exposed to local environment,
  eg staying in plane or short-term stay in modern
  airport terminal.

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• Disease or safety risks may be associated only
  with particular parts or areas of a country and
  not be a uniform risk throughout a country.

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Risks of the mode of travel

• Modes of travel can present particular medical
  problems of varying severity, e.g. motion
  sickness, painful ears, phobias, DVT
• Can they fly?

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Risks of the mode of travel

• Some travellers may not meet medical guidelines
  to travel or may need special clearance to fly on
  commercial aircraft, such as with
• pre-existing illness,
• pregnancy,
• recent surgery or
• serious physical or mental incapacity

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Risks of the mode of travel

• Accidents and injuries
• Travellers may use modes of travel not normally
  used, including at destination, e.g. 4WDing,
  motor bike riding, cycling, rollerblading,
  skiing, jet skiing, etc

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Risks of the mode of travel

• Cruise ship Vessel Sanitation Program
• http//www.cdc.gov/nceh/vsp/default.htm

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Risks of medical history

• Past travel history, particularly involving any
  significant medical issues,
• Past medical history, eg need for adjusting
  diabetic treatment,
• Past surgical history, eg recent surgery,
• Most recent dental examination
• Current medications, including the oral
  contraceptive pill,
• Last menstrual period for females (are they
  pregnant?),
• Smoking and alcohol history,
• Allergies, including medications and foods,
• Any current illnesses and regular medication, and
• Are they travelling alone or with children or
  with older travellers?
• How fit are they to undertake any proposed
  exertional activities?

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Risks of medical history

• Asthma - Asthma management plan precipitants
  environmental concerns consider influenza
  vaccination and antibiotics for medical kit.
• Diabetes - Consideration of time zone changes
  control
• Ulcer management - Reduced acidity may predispose
  to diarrhoeal disease

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Risks of medical history

• Psoriasis - May get worse with chloroquine
• Arthritis - May have difficulties with treks,
  climbing (also general fitness) may need standby
  NSAID treatment
• Hypertension - Caution in prescribing mefloquine
  and Beta blockers
• Immunosuppression - Immune response to
  vaccination may be less live vaccines may give
  rise to disease

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Risks of medical history-allergies

• Sulphurs (Maloprim), Diamox other sulphur
  based medications
• Egg allergies Yellow fever vaccine,
  influenza vaccine, MMRII
• Neomycin, polymixin Measles, Mumps, Rubella
• Iodine iodine water purification tabs
• Quinine Chloroquine
• Food allergies Various, including, seafood,
  peanuts
• Pets Cats

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Risks of intervention

• Addressing risk in travel medicine is generally
  all about trying to modify risks established from
  the travel health consultation
• All interventions have potential risks, including
  giving the wrong advice

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Risks of intervention

• Advice and education
• Vaccination
• Chemoprophylaxis
• Screening and Effective management

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Risks of the intervention

• Can the traveller tolerate the intervention?
• Does the risk of the exposure justify the
  intervention/cost?
• Can the traveller afford the intervention?
• What do you do if you cant provide optimal
  protection because of risks from the medical
  history or other considerations, such as age of
  the traveller or cost?

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Risk assessment

• Policies
• Guidelines
• Consensus statements
• Epidemiological evidence
  (weak to strong)

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Risks can be further modified

• Safety nets
• travel insurance evacuation services
• Access to good quality medical care
• Travelling with others, medical team etc
• Knowledge of first aid
• Post-travel screening and intervention

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Conclusion

• Risk assessment is an important part of the
  travel health assessment
• Risk assessment needs to be documented
• Largely determines advice given within the
  relevant guidelines / evidence used
• Risks can be modified