Healthy Tourism: challenges in program and research at destinations dr. I Md. Ady Wirawan, MPH, PhD Department of Public Health and Preventive Medicine & Travel Medicine Unit Faculty of Medicine, Udayana University

Outline Healthy tourism scopes and concepts Challenges in program development and implementation Challenges in research Current progress in Bali

Definitions Health Tourism – Medical Tourism Travel Health – Travelers’ Health Travel Medicine Tourism Health – Healthy Tourism Health Tourism – Medical Tourism Wellness Travel – Wellness Tourism

Healthy Tourism Supporting Factors Infrastructure Tourism Industry Policies Hazard Identification and Risk Assessment Public Health Epidemiology Demography Health Policy Occupational Health Food Safety Environmental Health Health Promotion MCH – RH Impacts Traveler’s Health Local Community Health Tourism Area Environment Specifically related to Travel Medicine Tropical and Infectious Diseases Non-Communicable Diseases Traffic accidents and other conditions Control Measures Wirawan (2016)

Challenges in program development and implementation Disease Surveillance Networking and Collaboration GeoSentinel-like network Collaboration between government and private sectors Health Workforce Tourism Industry Involvement Competition

Travel Disease Surveillance Travellers Epidemiologically an important population High mobility More susceptible to diseases compare to local host population Risk of “importing” and “exporting” diseases Heterogeneous groups, each sub-group has different risks

Travellers

Challenges in providing data on travel epidemiology Limited knowledge on risk of diseases for specific regions Difficulty in measuring risk (number of cases per 100,000 travellers) Difficulty in finding numerator data (travellers with diseases/cases) Difficulty in finding denominator data (total number of travellers at risk)

Challenges in providing data on travel epidemiology Travelers infected to a disease has gone back to their origin when signs and symptoms appear  surveillance problems at the destination Diseases with short incubation period  surveillance problems at the origin Mild diseases tend to be not reported, or reported with inaccurate diagnosis Travelers visit many places  difficulty in determining infection site/location

Surveillance on Travellers Most relevant surveillance data GeoSentinel Surveillance Network: ISTM and CDC, 57 clinics in 6 continents, >200,000 medical records TropNet in Europe Global TravEpiNet (GTEN), based in US, 26 travel clinics, primary care and public health sites Challenges in developing such kind of surveillance system in Bali or Indonesia?

http://www.istm.org/geosentinel

Limitation of GeoSentinel Data Convenience sampling using ill returned travellers  not representatives of all traveller population Differences in population and travel destination between sites/clinics  difficulty in determining denominator (absolute and relative risks are difficult to calculate)

Challenges for health workforces Familiar with basic concepts of epidemiology Understand geographical distribution of diseases and travel-related conditions Able to assess risk by looking at current and previous disease trends  provide optimal information, health promotion, and pre-travel counselling

Challenges in Tourism Industry Creates problems such as: Environmental degradation Pollution Natural resource degradation Economic imperialism Sexual exploitation

Tourism Industry Sustainable tourism Ecotourism “Development of global tourism capacity and the quality of its products without adversely affecting the environment that maintains and nurtures the industry” Ecotourism 10% of tourism industry “Responsible travel to natural areas which conserves the environment and improves the welfare of local people”

Tourism Industry Involvement Generally supportive to travel health measures Western Australia (1999) 145 Travel Agents 56% supportive Quebec (2002) 708 Travel Agents 81% supportive Bali (2015) 500 Travel Agents and Tour Guides 70.6% supportive

Challenges in research Developing research capacity to fill the gap in travel health scientific information Health Impact Assessment (HIA) at tourism areas Emerging and Re-emerging Diseases Anti-Microbial Resistance Talbot E.A., et. al, Travel Medicine Research Priorities: Establishing an Evidence Base. Journal of Travel Medicine 2010; Volume 17 (Issue 6): 410–415

Research Priority in Travel Medicine What is the benefit of pre-travel counseling (for example, what counseling leads to safer sexual behaviors and fewer road travel accidents, animal bites, drownings, and other noninfectious threats to health)? How effective is the pre-travel encounter in ensuring that the traveler is up-to-date with locally relevant immunizations (which may or may not be considered travel immunizations)? What are the risks during medical tourism (such as bloodborne pathogens, nosocomial infections, and procedure complications)?

Research Priority in Travel Medicine Do long-term travelers behave differently than short-term travelers? Do travelers who develop traveler’s diarrhea take their standby antibiotics? Is the repeated or long-term use of permethrin and other insecticides safe in the ways that travelers use them (on clothing, for example)? What is the role of travelers in the spread of emerging infections such as chikungunya, zika?

Emerging and Re-emerging Diseases HIV/AIDS Avian Influenza Swine Flu SARS Japanese encephalitis Ebola haemorrhagic fever MERS-CoV Zika Re-emerging Tuberculosis Malaria Cholera Dengue fever Rabies Anthrax

Anti-Microbial Resistance Methicillin-resistant Staphylococcus aureus (MRSA) Glycopeptide-resistant enterococci and staphylococci Gram-negative enterobacteria Streptococcus pneumoniae and Neisseria spp. Salmonella and other bacteria causing diarrhoeal disease Tuberculosis Malaria (Plasmodium falciparum)

Tourism Areas in Bali

Mapping of tourism spots and health facilities

Risk analysis at tourism areas

Level of health and safety risk by types of tourism areas in Bali

Conclusions Challenges in healthy tourism program development Travel health surveillance at destinations Collaboration between government and private sectors Health workforce competencies in travel health Tourism industry involvement Challenges in research Developing research capacity to fill the gap in travel health scientific information – ISTM research priorities Health Impact Assessment (HIA) at tourism areas Emerging and Re-emerging Diseases AMR

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