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
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
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
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