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

RISK
ASSESSMENT
IN 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
About the author
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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.
Objectives
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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?
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“the likelihood of injury, disease,
damage or loss from a real or potential
hazard” (CCH Australia)
Balancing risks
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Probability of harm and the severity of
possibly consequences of travel
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Balance these with
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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)
Risk perception is important
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Travellers may confound the likelihood
and severity of outcomes
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Familiarity, visibility and controllability
of a hazard all influence the perception
of risk
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We need to understand the perceptions
as well as the reality of the risk in travel
Risk assessment
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Needs to be undertaken as part of the
pre-travel consultation
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Needs exact itinerary and medical
history of the traveller
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Needs time: emphasise the need to get
this information well before travel
Risk assessment
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Risk assessment
preferably starts
before the traveller
enters the consulting
room
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Document the risk
assessment
Standardised questionnaire
www.who.int/ith
Establish the risks
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Destination
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Mode of travel
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Traveller’s medical history
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Intervention
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Risks of the destination
Risks of the destination
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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?
Risk of the destination
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CDC Travel Health, see
http://www.cdc.gov/travel/index.htm
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MASTA, see http://www.masta.org
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TRAVAX, see http://www.travax.nhs.uk
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Shorelands, see http://www.tripprep.com
World Health Organization
www.who.int/ith
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?
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Risks of the destination
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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 shortterm 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.
Risks of the mode of travel
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Modes of travel can present particular
medical problems of varying severity,
e.g. motion sickness, painful ears,
phobias, DVT;
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Can they fly?
Risks of the mode of travel
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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
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Accidents and injuries
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Travellers may use modes of travel not
normally used, including at destination,
e.g. 4WDing, motor bike riding, cycling,
rollerblading, skiing, jet skiing, etc
Risks of the mode of travel
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Cruise ship Vessel Sanitation Program
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http://www.cdc.gov/nceh/vsp/default.htm
Risks of medical history
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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?
Risks of medical history
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Asthma - Asthma management plan;
precipitants; environmental concerns;
consider influenza vaccination and
antibiotics for medical kit.
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Diabetes - Consideration of time zone
changes; control
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Ulcer management - Reduced acidity may
predispose to diarrhoeal disease
Risks of medical history
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Psoriasis - May get worse with chloroquine
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Arthritis - May have difficulties with treks,
climbing (also general fitness); may need
standby NSAID treatment
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Hypertension - Caution in prescribing
mefloquine and Beta blockers
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Immunosuppression - Immune response to
vaccination may be less; live vaccines may
give rise to disease
Risks of medical history-allergies
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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
Risks of intervention
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Addressing risk in travel medicine is
generally all about trying to modify
risks established from the travel health
consultation
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All interventions have potential risks,
including giving the wrong advice
Risks of intervention
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Advice and education
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Vaccination
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Chemoprophylaxis
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Screening and Effective management
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?
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Risk assessment
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Policies
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Guidelines
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Consensus statements
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Epidemiological evidence
(weak to strong)
Risks can be further modified
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Safety nets
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travel insurance & evacuation services
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Access to good quality medical care
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Travelling with others, medical team etc
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Knowledge of first aid
Post-travel screening and intervention
Conclusion
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Risk assessment is an important part of
the travel health assessment
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Risk assessment needs to be
documented
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Largely determines advice given within
the relevant guidelines / evidence used
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Risks can be modified