1. 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

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. 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 In this lecture, we will Define the term risk Define the term risk Gain an appreciation of its importance in providing pre-travel health advice Gain an appreciation of its importance in providing pre-travel health advice Develop an approach to undertaking a risk assessment in travel medicine Develop an approach to undertaking a risk assessment in travel medicine Examine how risk can be modified for travellers 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) “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 Probability of harm and the severity of possibly consequences of travel Balance these with Balance these with Probability and the severity of adverse consequences of any interventions 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 Travellers may confound the likelihood and severity of outcomes Familiarity, visibility and controllability of a hazard all influence the perception of risk 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 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 to be undertaken as part of the pre-travel consultation Needs exact itinerary and medical history of the traveller Needs exact itinerary and medical history of the traveller Needs time: emphasise the need to get this information well before travel 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 Risk assessment preferably starts before the traveller enters the consulting room Document the risk assessment Document the risk assessment

10. Standardised questionnaire www.who.int/ith

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

13. Risks of the destination

14. What countries and what parts of these countries are they visiting? What countries and what parts of these 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 they need a diving medical? What activities are they undertaking? Do they need a diving medical? What can the traveller tell you? What can the traveller tell you? Is there anything special about the destination culturally or legally? Is there anything special about the destination culturally or legally?

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

16. World Health Organization World Health Organization www.who.int/ith

17. Risks 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 experience? What is the traveller’s prior travel experience? What access is there to appropriate medical care? What access is there to appropriate medical care? Does the traveller know first aid? Does the traveller know first aid? Does the traveller have travel insurance with full coverage? Does the traveller have travel insurance with full coverage?

18. Risks of the destination Categorise Living Conditions: Categorise Living Conditions: Rural and remote areas and villages and/or close contact with local people, e.g. health workers. 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. 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. 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. 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. 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; Modes of travel can present particular medical problems of varying severity, e.g. motion sickness, painful ears, phobias, DVT; Can they fly? 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 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, pre-existing illness, pregnancy, pregnancy, recent surgery or recent surgery or serious physical or mental incapacity serious physical or mental incapacity

22. Risks of the mode of travel Accidents and injuries 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 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 Cruise ship Vessel Sanitation Program http://www.cdc.gov/nceh/vsp/default.htm http://www.cdc.gov/nceh/vsp/default.htm

24. Risks of medical history Past travel history, particularly involving any significant medical issues, Past travel history, particularly involving any significant medical issues, Past medical history, eg need for adjusting diabetic treatment, Past medical history, eg need for adjusting diabetic treatment, Past surgical history, eg recent surgery, Past surgical history, eg recent surgery, Most recent dental examination Most 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, and Any current illnesses and regular medication, and Are they travelling alone or with children or with older travellers? Are they travelling alone or with children or with older travellers? How fit are they to undertake any proposed exertional activities? 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. Asthma - Asthma management plan; precipitants; environmental concerns; consider influenza vaccination and antibiotics for medical kit. Diabetes - Consideration of time zone changes; control Diabetes - Consideration of time zone changes; control Ulcer management - Reduced acidity may predispose to diarrhoeal disease Ulcer management - Reduced acidity may predispose to diarrhoeal disease

26. Risks of medical history Psoriasis - May get worse with chloroquine Psoriasis - May get worse with chloroquine Arthritis - May have difficulties with treks, climbing (also general fitness); may need standby NSAID treatment Arthritis - May have difficulties with treks, climbing (also general fitness); may need standby NSAID treatment Hypertension - Caution in prescribing mefloquine and Beta blockers Hypertension - Caution in prescribing mefloquine and Beta blockers Immunosuppression - Immune response to vaccination may be less; live vaccines may give rise to disease 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 Sulphurs(Maloprim), Diamox & other sulphur based medications Egg allergies*Yellow fever vaccine, influenza vaccine, MMRII Egg allergies*Yellow fever vaccine, influenza vaccine, MMRII Neomycin, polymixin Measles, Mumps, Rubella Neomycin, polymixin Measles, Mumps, Rubella Iodineiodine water purification tabs Iodineiodine water purification tabs QuinineChloroquine QuinineChloroquine Food allergies Various, including, seafood, peanuts Food allergies Various, including, seafood, peanuts PetsCats PetsCats

28. Risks of intervention Addressing risk in travel medicine is generally all about trying to modify risks established from the travel health consultation 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 All interventions have potential risks, including giving the wrong advice

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

30. Risks of the intervention Can the traveller tolerate the intervention? Can the traveller tolerate the intervention? Does the risk of the exposure justify the intervention/cost? Does the risk of the exposure justify the intervention/cost? Can the traveller afford the intervention? 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? 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 Policies Guidelines Guidelines Consensus statements Consensus statements Epidemiological evidence (weak to strong) Epidemiological evidence (weak to strong)

32. Risks can be further modified Safety nets Safety nets travel insurance & evacuation services travel insurance & evacuation services Access to good quality medical care Access to good quality medical care Travelling with others, medical team etc Travelling with others, medical team etc Knowledge of first aid Knowledge of first aid Post-travel screening and intervention Post-travel screening and intervention

33. Conclusion Risk assessment is an important part of the travel health assessment Risk assessment is an important part of the travel health assessment Risk assessment needs to be documented Risk assessment needs to be documented Largely determines advice given within the relevant guidelines / evidence used Largely determines advice given within the relevant guidelines / evidence used Risks can be modified Risks can be modified