RISK ASSESSMENT IN TRAVEL MEDICINE Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor School of Public Health and Tropical Medicine.

RISK RISK ASSESSMENTASSESSMENT

IN TRAVEL MEDICINEIN TRAVEL MEDICINE

Dr Peter A. LeggatDr Peter A. LeggatMD, PhD, DrPH, FAFPHM, FACTM, FFTMMD, PhD, DrPH, FAFPHM, FACTM, FFTM

Associate ProfessorAssociate Professor

School of Public Health and Tropical MedicineSchool of Public Health and Tropical Medicine

James Cook University &James Cook University &

Visiting ProfessorVisiting Professor

School of Public HealthSchool of Public Health

University of the WitwatersrandUniversity of the Witwatersrand

About the authorAbout the author

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

ObjectivesObjectives

In this lecture, we willIn this lecture, we willDefine the term riskDefine the term riskGain an appreciation of its importance in Gain an appreciation of its importance in

providing pre-travel health adviceproviding pre-travel health adviceDevelop an approach to undertaking a risk Develop an approach to undertaking a risk

assessment in travel medicineassessment in travel medicineExamine how risk can be modified for Examine how risk can be modified for

travellerstravellers

What is risk?What is risk? ““the likelihood of injury, disease, damage the likelihood of injury, disease, damage

or loss from a real or potential hazard” or loss from a real or potential hazard” (CCH Australia)(CCH Australia)

Balancing risksBalancing risks

Probability of harm and the severity of Probability of harm and the severity of possibly consequences of travelpossibly consequences of travel

Balance these withBalance these with

Probability and the severity of adverse Probability and the severity of adverse consequences of any interventionsconsequences of any interventions

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

Risk perception is importantRisk perception is important

Travellers may confound the likelihood Travellers may confound the likelihood and severity of outcomesand severity of outcomes

Familiarity, visibility and controllability of Familiarity, visibility and controllability of a hazard all influence the perception of a hazard all influence the perception of riskrisk

We need to understand the perceptions We need to understand the perceptions as well as the reality of the risk in travelas well as the reality of the risk in travel

Risk assessmentRisk assessment

Needs to be undertaken as part of the Needs to be undertaken as part of the pre-travel consultationpre-travel consultation

Needs exact itinerary and medical Needs exact itinerary and medical history of the travellerhistory of the traveller

Needs time: emphasise the need to get Needs time: emphasise the need to get this information well before travelthis information well before travel

Risk assessmentRisk assessment

Risk assessment Risk assessment preferably starts preferably starts before the traveller before the traveller enters the consulting enters the consulting roomroom

Document the risk Document the risk assessmentassessment

Standardised questionnaireStandardised questionnaire

www.who.int/ith

Establish the risksEstablish the risks

DestinationDestination

Mode of travelMode of travel

Traveller’s medical historyTraveller’s medical history

InterventionIntervention

Risks of the destinationRisks of the destination

Risks of the destinationRisks of the destination

What countries and what parts of these What countries and what parts of these countries are they visiting?countries are they visiting?

How long are they going to stay?How long are they going to stay? What time of the year are they visiting?What time of the year are they visiting? What are the living conditions?What are the living conditions? What are the current security concerns?What are the current security concerns? What activities are they undertaking? Do What activities are they undertaking? Do

they need a diving medical?they need a diving medical? What can the traveller tell you?What can the traveller tell you? Is there anything special about the Is there anything special about the

destination culturally or legally?destination culturally or legally?

Risk of the destinationRisk of the destination

CDC Travel Health, seeCDC Travel Health, see http://http://www.cdc.gov/travel/index.htmwww.cdc.gov/travel/index.htm

MASTA, seeMASTA, see http://http://www.masta.orgwww.masta.org

TRAVAX, seeTRAVAX, see http://http://www.travax.nhs.ukwww.travax.nhs.uk

Shorelands, seeShorelands, see http://http://www.tripprep.comwww.tripprep.com

World Health OrganizationWorld Health Organizationwww.who.int/ith

Risks of the destinationRisks of the destination

Are they travelling alone or as a group?Are they travelling alone or as a group?What is the traveller’s prior travel What is the traveller’s prior travel

experience?experience?What access is there to appropriate What access is there to appropriate

medical care?medical care?Does the traveller know first aid?Does the traveller know first aid?Does the traveller have travel insurance Does the traveller have travel insurance

with full coverage?with full coverage?

Risks of the destinationRisks of the destination Categorise Living Conditions:Categorise Living Conditions:

Rural and remote areas and villages and/or close Rural and remote areas and villages and/or close contact with local people, e.g. health workers. contact with local people, e.g. health workers.

Towns and cities, not rural and remote and/or Towns and cities, not rural and remote and/or lower standard accommodation and/or stay over lower standard accommodation and/or stay over four weeks/month. four weeks/month.

Major cities and tourist resorts and/or medium to Major cities and tourist resorts and/or medium to high standard accommodation and/or reliable high standard accommodation and/or reliable water and food sources and/or short term stays of water and food sources and/or short term stays of less than four weeks/month. less than four weeks/month.

In transit and not exposed to local environment, In transit and not exposed to local environment, eg staying in plane or short-term stay in modern eg staying in plane or short-term stay in modern airport terminal.airport terminal.

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

Risks of the mode of travelRisks of the mode of travel

Modes of travel can present particular Modes of travel can present particular medical problems of varying severity, medical problems of varying severity, e.g. motion sickness, painful ears, e.g. motion sickness, painful ears, phobias, DVT; phobias, DVT;

Can they fly?Can they fly?

Risks of the mode of travelRisks of the mode of travel

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

Risks of the mode of travelRisks of the mode of travel

Accidents and injuriesAccidents and injuries

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

Risks of the mode of travelRisks of the mode of travel

Cruise ship Vessel Sanitation ProgramCruise ship Vessel Sanitation Programhttp://www.cdc.gov/nceh/vsp/default.htmhttp://www.cdc.gov/nceh/vsp/default.htm

Risks of medical historyRisks of medical history Past travel history, particularly involving any significant Past travel history, particularly involving any significant

medical issues,medical issues, Past medical history, eg need for adjusting diabetic Past medical history, eg need for adjusting diabetic

treatment,treatment, Past surgical history, eg recent surgery,Past surgical history, eg recent surgery, Most recent dental examinationMost recent dental examination Current medications, including the oral contraceptive pill,Current medications, including the oral contraceptive pill, Last menstrual period for females (are they pregnant?),Last menstrual period for females (are they pregnant?), Smoking and alcohol history, Smoking and alcohol history, Allergies, including medications and foods,Allergies, including medications and foods, Any current illnesses and regular medication, andAny current illnesses and regular medication, and Are they travelling alone or with children or with older Are they travelling alone or with children or with older

travellers?travellers? How fit are they to undertake any proposed exertional How fit are they to undertake any proposed exertional

activities?activities?

Risks of medical historyRisks of medical history

Asthma - Asthma management plan; Asthma - Asthma management plan; precipitants; environmental concerns; precipitants; environmental concerns; consider influenza vaccination and consider influenza vaccination and antibiotics for medical kit.antibiotics for medical kit.

Diabetes - Consideration of time zone Diabetes - Consideration of time zone changes; control changes; control

Ulcer management - Reduced acidity may Ulcer management - Reduced acidity may predispose to diarrhoeal diseasepredispose to diarrhoeal disease

Risks of medical historyRisks of medical history Psoriasis - May get worse with chloroquinePsoriasis - May get worse with chloroquine

Arthritis - May have difficulties with treks, Arthritis - May have difficulties with treks, climbing (also general fitness); may need climbing (also general fitness); may need standby NSAID treatmentstandby NSAID treatment

Hypertension - Caution in prescribing Hypertension - Caution in prescribing mefloquine and Beta blockersmefloquine and Beta blockers

Immunosuppression - Immune response to Immunosuppression - Immune response to vaccination may be less; live vaccines may vaccination may be less; live vaccines may give rise to diseasegive rise to disease

Risks of medical history-allergiesRisks of medical history-allergies

SulphursSulphurs (Maloprim), Diamox & other (Maloprim), Diamox & other sulphur based medicationssulphur based medications

Egg allergies*Egg allergies* Yellow fever vaccine, Yellow fever vaccine, influenza vaccine, MMRIIinfluenza vaccine, MMRII

Neomycin, polymixin Measles, Mumps, RubellaNeomycin, polymixin Measles, Mumps, Rubella IodineIodine iodine water purification iodine water purification

tabstabs QuinineQuinine ChloroquineChloroquine Food allergies Various, including,Food allergies Various, including,

seafood, peanutsseafood, peanuts PetsPets CatsCats

Risks of interventionRisks of intervention

Addressing risk in travel medicine is Addressing risk in travel medicine is generally all about trying to modify generally all about trying to modify risks established from the travel health risks established from the travel health consultationconsultation

All interventions have potential risks, All interventions have potential risks, including giving the wrong adviceincluding giving the wrong advice

Risks of interventionRisks of intervention

Advice and educationAdvice and education

VaccinationVaccination

ChemoprophylaxisChemoprophylaxis

Screening and Effective managementScreening and Effective management

Risks of the interventionRisks of the intervention

Can the traveller tolerate the intervention?Can the traveller tolerate the intervention? Does the risk of the exposure justify the Does the risk of the exposure justify the

intervention/cost?intervention/cost? Can the traveller afford the intervention?Can the traveller afford the intervention? What do you do if you can’t provide optimal What do you do if you can’t provide optimal

protection because of risks from the protection because of risks from the medical history or other considerations, medical history or other considerations, such as age of the traveller or cost?such as age of the traveller or cost?

Risk assessmentRisk assessment

PoliciesPolicies

GuidelinesGuidelines

Consensus statementsConsensus statements

Epidemiological evidence Epidemiological evidence (weak to strong) (weak to strong)

Risks can be further modifiedRisks can be further modified Safety netsSafety nets

travel insurance & evacuation servicestravel insurance & evacuation services

Access to good quality medical careAccess to good quality medical care

Travelling with others, medical team etcTravelling with others, medical team etc

Knowledge of first aidKnowledge of first aid

Post-travel screening and interventionPost-travel screening and intervention

ConclusionConclusion Risk assessment is an important part of the Risk assessment is an important part of the

travel health assessmenttravel health assessment

Risk assessment needs to be documented Risk assessment needs to be documented

Largely determines advice given within the Largely determines advice given within the relevant guidelines / evidence usedrelevant guidelines / evidence used

Risks can be modifiedRisks can be modified