RISK

ASSESSMENT
IN TRAVEL MEDICINE
RISK ASSESSMENT
 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
 What is risk?
 “the likelihood of injury, disease,
damage or loss from a real or potential
hazard” (CCH Australia)
 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
 “the art of travel medicine is selecting
the necessary prevention strategy
without unnecessary adverse events,
cost or inconvenience” (Steffen, 1994)
 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
 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
 Risk assessment
 Risk assessment
preferably starts
before the traveller
enters the consulting
room

 Document the risk

assessment
Standardised questionnaire

www.who.int/ith
 Establish the risks
 Destination

 Mode of travel

 Traveller’s medical history

 Intervention

Risks of the destination
 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?
 Risk of the destination

 CDC Travel Health, see

http://www.cdc.gov/travel/index.htm

 MASTA, see http://www.masta.org

 TRAVAX, see http://www.travax.nhs.uk

 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?
 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.
 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

 Modes of travel can present particular

medical problems of varying severity,
e.g. motion sickness, painful ears,
phobias, DVT;

 Can they fly?

 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
 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
 Risks of the mode of travel
 Cruise ship Vessel Sanitation Program
 http://www.cdc.gov/nceh/vsp/default.htm
 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?
 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
 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
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
 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
 Risks of intervention
 Advice and education

 Vaccination

 Chemoprophylaxis

 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?
 Risk assessment
 Policies

 Guidelines

 Consensus statements

 Epidemiological evidence
(weak to strong)
 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

 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