1. 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

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

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

4. 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)

5. 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

6. 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

7. Travellers

8. 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)

9. 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

10. 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?

12. 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)

13. 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

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

15. 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”

16. 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

17. 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

18. 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)?

19. 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?

20. 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

21. 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)

22. Tourism Areas in Bali

23. Mapping of tourism spots and health facilities

24. Risk analysis at tourism areas

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

26. 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

27. Thank You!