RISK ASSESSMENT IN TRAVEL MEDICINE

1. 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

2. 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.

3. 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

4. What is risk? • “the likelihood of injury, disease, damage or loss from a real or potential hazard” (CCH Australia)

5. 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

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

7. 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

8. 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

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

10. Standardised questionnaire www.who.int/ith

11. Establish the risks • Destination • Mode of travel • Traveller’s medical history • Intervention

13. Risks of the destination

14. 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?

15. Risk of the destination • CDC Travel Health, seehttp://www.cdc.gov/travel/index.htm • MASTA, seehttp://www.masta.org • TRAVAX, seehttp://www.travax.nhs.uk • Shorelands, seehttp://www.tripprep.com

16. World Health Organizationwww.who.int/ith

17. Risks of the destination • Are they travelling alone or as a group? • What is the traveller’s 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?

18. 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.

19. 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.

20. 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?

21. 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

22. 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

23. Risks of the mode of travel • Cruise ship Vessel Sanitation Program • http://www.cdc.gov/nceh/vsp/default.htm

24. 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?

25. 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

26. 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

27. 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

28. 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

29. Risks of intervention • Advice and education • Vaccination • Chemoprophylaxis • Screening and Effective management

30. 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 can’t provide optimal protection because of risks from the medical history or other considerations, such as age of the traveller or cost?

31. Risk assessment • Policies • Guidelines • Consensus statements • Epidemiological evidence (weak to strong)

32. 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

33. 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