PERAN KESEHATAN WISATA DALAM

MENJAGA KESEHATAN PARA

TRAVELER
Kantor Kesehatan Pelabuhan Kelas II
Mataram
 Travel medicine (TM) or emporiatrics
• Adalah cabang Ilmu Kedokteran yang
berhubungan dengan pencegahan dan
penanganan masalah kesehatan pada traveler
atau wisatawan
• Meliputi baik pencegahan maupun
penanganan gangguan kesehatan atau
penyakit yang berhubungan dengan
travel/perjalanan
• Merupakan satu cabang ilmu kedokteran yang
baru dan penting yang memerlukan pengetahuan
spesialis khusus sehingga dapat memberikan
pelayanan yang diperlukan oleh para traveler,
baik wisatawan maupun populasi yang bergerak,
migrasi dalam kaitan dengan faktor ekonomi,
politik maupun sosial .
• Pertimbangan yang esensial meliputi kondisi
kesehatan, pencegahan penyakit, faktor
lingkungan dan keamanan.
• Penting tidak hanya untuk wisatawan, namun
juga bagi negara tujuan ataupun negara asal
sekembali dari travel.
 HISTORY OF TM (1)
• Berkembangnya TM mulai dari penyakit infeksi/penyakit
menular, penyakit tropis dan kedokteran pencegahan, adanya
karantina dan IHR (regulasi kesehatan internasional).
• Bidangnya meliputi aspek klinis dan pencegahan bagi traveler,
termasuk traveler yang memerlukan perhatian khusus seperti,
anak2, orang-orang tua, wanita hamil, orang dengan masalah
penyakit kronis : kardiovaskuler, penyakit paru, ginjal, saluran
cerna, penyakit metabolik, neurologi, kanker, HIV dan
penyakit jiwa
• Komponen penting tidak hanya mengenai vaksinasi dan
profilaksis malaria, tapi lebih dari itu, adalah saran-saran atas
masalah pencegahan kecelakaan, kesehatan seksual,
kontrasepsi, keamanan makanan, minuman dan air
kebersihan dan tindakan kewaspadaan lainnya.
• Proposed by Jane Zuckerman :
the establishment of an academic centre on travel
medicine at the Royal Free Hospital School of
Medicine, University of London. The concept and
the need of such a centre was approved by the R&D
Committee, education and council of the school,

• in 1995 The Centre for Tropical Medicine and

Vaccines was opened.
 The Primary Goal in
Travel Medicine …..

is to keep travelers alive and healthy.

Steffen, 1994
 Disciplines in TM

• Epidemiology, infectious disease, public

health, tropical medicine, high altitude
physiology, travel related obstetrics,
psychiatry, occupational medicine, military
and migration medicine, and environmental
health.
• Special itineraries and activities include cruise
ship travel, diving, mass gatherings (e.g. the
Hajj), and wilderness/remote regions travel.
 Pendekatan dalam Travel Medicine

Traditional Disciplines New Discipline

Tropical Medicine
Infectious Diseases
Internal Medicine
Epidemiology

Specific: travel related

Pediatrics
Geriatrics
Obstetrics TRAVEL
Dermatology MEDICINE
Venerology Prevention
Psychiatry
Ophthalmology
Otolaryngology
Traumatology Self-Therapy
Clinical Microbiology
Physiology (altitude, diving) Therapy
Pharmacology

Robert Steffen, 1994

 Travel Medicine is a unique specialty

Epidemiology Preventive
Medicine • It is part of preventive
medicine
Travel • It includes
Medicine epidemiology of
diseases
• It accommodates
Self-Therapy
curative care and self-
treatment
 Why Travel Medicine?
Increased trend of travelers
 TOURISM 2020 VISION

. International
arrivals are
expected to
reach +1.6
billion:
– 1.2 billion will
be
intraregional
and
– 378 million
will be long-
haul
travellers.
 Why Travel Medicine?
• Scope : has largely evolved in response to changing of
travel trend 
• many more people are travel abroad,
• the reason for travel and types of travel has become much more diverse.
• Organized package tour remain popular, but many traveler are becoming more
adventurous and choose to backpack out with ‘tourist‘ areas, go on
expedition into remote areas sometime in several countries and work as
volunteers for prolonged period.
• Travel for business take a common place.
• In addition, potentially vulnerable groups of people such as the very young,
the elderly, pregnant women and those with underlying medical problems or
disabilities and immunecompromized are traveling more than ever before.

• As a result of these changes: more people need information,

more advise and more prophylactic prior and during travel
Why Travel Medicine
 The Continuum of Travel Medicine

Preventive Medicine
Pre-Travel Traveler

During Travel

Post-Travel
Leggatt PA
 Mengapa kesehatan perjalanan
perlu diperhatikan?
Risiko kesehatan berbeda-beda di
seluruh dunia (>220 negara)
Pola risiko penyakit selalu mengalami
perubahan
Risiko kesehatan meningkat pada
daerah tujuan wisata eksotis dan yang
jarang dikunjungi (adventure travel)

Orang dapat pergi dalam keadaan

sehat, tetapi pulang dalam keadaan
sakit…

STUDI EPIDEMIOLOGI
----------------------------------------------
- -----------------------------------------
--------------------------------------
-------------------------------------
-------------------------------------
-----------------------------------
Robert Steffen, 2003
Hasil penelitian menunjukkan bahwa dari antara
100.000 orang yang bepergian ke negara
berkembang selama +1 bulan
100.000 orang yang bepergian
50.000 orang mengalami gangguan kesehatan
5.000 harus istirahat di tempat tidur
1.100 tidak dapat bekerja
300 orang harus dirawat
50 orang harus dievakuasi melalui udara
1 orang meninggal
 Mortality and morbidity
Mortality studies indicate that the cardiovascular
disease accounts for most deaths during travel
(50-70%), while injury and accident follow
(~25%). Infectious disease accounts for about 2.8-
4% of deaths during/from travel.
Morbidity studies suggest that about half of the
people from a developed country that stay one
month in a developing country will get sick.[1]
Traveler's diarrhea is the most common problem
encountered.
Distribusi 10 kasus utama Traveller yang di rawat di RSUP
Sanglah
Denpasar 2010
No Kasus N %
1 Fractur 54 34
2 Malignancy 34 21
3 Fever 22 14
4 DHF 13 8
5 Cardivascular 11 7
6 Gastroenteritis 10 6
7 Stroke 6 4
8 Alkohol intoxication 4 3
9 Snake bite 3 2
10 Malaria 3 2
160 100
 Risks in Travel
Non Communicable
• Aircraft travel, reduced O2, pressure and humidity
• Motion sickness
• Jet Lag
• DVT’s and immobility
• Altitude
• Heat/cold/humidity
• Sunburn
• Water safety
• Accidents and Injuries
• Animals and Insects
• Accidents, vehicles, marine
• Snakes, (vipers, cobras and kraits )
• Marine stings
 Risks in Travel - Communicable
There are many potential diseases spread via :
• Food and water
• Air-borne
• Insect vectors
• Soil and water
• Sexual contact, Body-fluid exposures
• Animals
 Traveler’s diarrhea
• Affects between 30 – 50% of people in a
2 week stay
• Onset usually during stay
• - 62% in first week
• - day 3 the highest rate of onset
• Mean duration 3.2 + 0.2 days (treated)
• Mean duration 4.1 + 0.2 days (untreated)
 Communicable Diseases
No vaccines
• Dengue
• HIV
• Amoebiasis
• Filariasis
• Novel H1N1 / Avian Influenza
• Others: legionella, leptospirosis, meliodosis,
Typhus, strongyloides, hookworm, hepatitis,
schistosomiasis
 Communicable Diseases
Vaccine Preventable
Routine background
• Diphtheria/tetanus/pertussis
• Polio
• MMR Varicella
• Influenza

Travel Related
• Hep A and B
• Typhoid
• Cholera
• Japanese Encephalitis
• Rabies
• Tuberculosis
 Types of Travellers
• Business Travellers brief, high standards, may be
frequent
• Organised Tours usually 2-6 weeks, “safe”, groups
• Backpackers unpredictable, 8-52+ weeks, wide-ranging,
low budget
• Ex-pats local knowledge, use local systems

 All have different risk profiles

Anthony Geraldine (2009)

 Travelers risk profiles
• Business: URTI, GIT, Alcohol, STDs

• Organised Tours: GIT, URTI, environmental hazards

• Backpackers: GIT, tropical diseases, accidents

• Ex-pats: MVAs, accidents, infectious diseases

Anthony Geraldine (2009)

 Special Risk Groups
• Pregnancy
• Children
• Elderly
• Expats and long-term travelers
• VFR (visiting friends and relatives)
• Cardiac or Lung disease
• Diabetes
• Immuno compromised
 ABOUT IHR
• Since 15 June 2007, the world has been
implementing the International Health
Regulations (2005).
• This legally-binding agreement significantly
contributes to global public health security by
providing a new framework for the coordination
of the management of events that may constitute
a public health emergency of international
concern, and will improve the capacity of all
countries to detect, assess, notify and respond to
public health threats.
 IHR con’t
• The IHR can also apply to other public health
emergencies such as chemical spills, leaks and
dumping, or nuclear melt-downs.
• The IHR aim to limit interference with
international traffic and trade while ensuring
public health through the prevention of
disease spread.
 Pre-Travel Consultation

• To give updated and

accurate advices to
travelers prior to their
trip regarding the
health risk and its
prevention.
• To assess the traveler’s
fitness for travel.

INFORMATION IS IMPORTANT
 Pre-Travel Consultation
The travel consultation
• The opportunity to define the risk profile
• The consultation is the opportunity to consider relevant
current or past history, identify travelers with special needs,
and allows a detailed assessment of the itinerary
• The consultation is also the place to discuss costs, and help a
budget conscious traveler prioritise their requirements.
 Points to consider when advising
• Destination : what are the risks of diseases and other health
hazards in the specific areas to be visited?
• Mode of transport : Are there any potential hazards in the
chosen methods of travel, whether by air, sea or overland?
• Accommodation : Does the accommodation protect the
traveler or expose them to potential risks? Are safety
precautions and procedures in place or is there a risk of
accidents especially for the elderly or disabled?
• Activities: the volunteers or business may come into contact
with local population, sports and vehicle prone to accidents,
overindulge in alcohol prone to STIs. Difficulties due to age,
lack of experience or underlying medical problems . For
migrants or forced refugees, possible conditions may
happened, e.g. Lack of access to essentials such as clean
water, food, shelter and health care facilities, including
immunization
 Diseases distribution Map
1.Malaria 1.Cholera
2.Chikungunya 2.Hepatitis A
3.Schistosomiasis 3.Hepatitis B
4.Crimean Congo HF 4.Meningococcal disease
5.Dengue 5.Poliomyelitis
6.HIV infection 6.Rabies
7.Tuberculosis
8.Yellow Fever
9.Japanese encephalitis
 Key areas to consider are
vaccination and the six I’s:
1. Insects: repellents, mosquito nets, antimalarial
medication
2. Ingestions: safety of drinking water, food
3. Indiscretion: HIV, sexually transmitted disease
4. Injuries: accident avoidance, personal safety
5. Immersion: schistosomiasis
6. Insurance: coverage and services during travel,
access to health care
TRAVELLER’S DIARRHOEA
 Pre-Travel Consultation
Identifying high risk individuals
Certain individuals may be at higher risk of acquiring travel illness, be at risk
of more severe disease, or have contraindications to certain vaccines or
medications.
- Pregnant women
- Children
- Patients with chronic medical conditions (eg. diabetes, heart disease,
respiratory disease)
- Immune suppressed patients, including those with HIV infections
- Those taking stomach acid suppression medication
- Elderly travellers
- Expatriates and long term travellers
- Travellers visiting friends and relatives.
Providing health education
While there are issues relevant to all travellers, not all travellers
are at risk of all problems, and the risk assessment should guide
the particular areas for education and advice, by indicating what
is relevant to the individual.

Common issues to be discussed for all travellers are:

• eating and drinking safely
• insect avoidance
• traveller’s diarrhoea management
• dog bite management, and
• the need for travel insurance.
Selecting appropriate vaccination
 Recommendation of vaccines should follow simple principles,
should be
 based on travel illness epidemiology, and be acceptable to the
traveler’s
 needs and budget.
• Update any routine vaccinations relevant to particular country
• Recommend any vaccines relevant to usual daily
lifestyle and work
• Consider travel vaccines, and make recommendations
based on specific risk
 Pre-Travel Consultation
Preventive medications
• The decision to advise the use of antimalarials is dependent
on the level of risk, but all travellers in malaria prone areas
must have advice about mosquito avoidance and basic
malaria facts
• Various medications all have advantages and disadvantages.
Consideration of the level of risk, the respective
contraindications, likely side effects, compliance issues and
cost will influence the final choice.
• A trial of medications may be required and should be done
well in advance of departure to assess tolerability.
• Providing medications for self treatment
 Malaria prophylaxis agents
• Chloroquin-sensitive malaria
-Chloroquin

• Chloroquine-resistant P falciparum malaria

-Doxycycline
-Mefloquine
-Atovaquone-Proguanil
-(Primaquine)

Choice depends on travel plans, host factors

 Pre-Travel Consultation
Medical kits and health products
• Traveller’s medical kits are part of good preparation.
They contain prescription and nonprescription
medications and first aid items to treat common
travellers' ailments early and avoid complications or
need for accessing treatment while travelling.

• Typically they deal with gastrointestinal and

respiratory infections.
 Pre-Travel Consultation
Medical kits
• Contain : medications
and first aid items to
treat common travelers'
ailments early and avoid
complications.
• Usually deal with
gastrointestinal and
respiratory infections.
Medical travel kits
• Essential items for all travelers
– Items to treat cuts, scratches, burns, strains, splinters
– Paracetamol
– Repellent
– Consider condoms

• Additional items for Europe, USA, Japan

– Antinauseants, eg prochlorperazine
– Broad-spectrum antibiotic for respiratory infection
– Antacids
– Sudafed
– Minor sedative
– Laxative

Tony Gerardine, 2011

Medical travel kits
• Additional items for less developed countries (gastro kit)

– Rehydration solution
– Loperamide
– Tinidazole
– Norfloxacin – or azithromycin for children

• Comprehensive medical kit ; Asia, Africa and South America

– All of the above
– Sterile needles and syringes. Alcohol swabs
– Antihistamines
– Antifungal and antibiotic cream

Tony Gerardine,2011
 Pre-Travel Consultation
Post-travel illness
• Managing post-travel illness is an important part of travel
medicine. Illness following travel is quite common, and much
presents in general practice. Recognition of life threatening
syndromes is paramount, and any fever post-travel must be
investigated including blood films for malaria.
• Common presentations include fever, diarhoea, respiratory
illness and rash
• Referral to an infectious disease physician or travel medicine
centre may be appropriate.
 References
• Supercourse on Travel Medicine
• ^ WHO Travel Information
• ^ CDC re: Yellow Fever
• ^ CDC re: Meningococcal Meningitis
• ^ CDC re:Malaria
• ^ "Health risks and precautions: general considerations
- Contents of a basic medical kit". International travel
and health. Geneva: World Health Organization. 2010.
http://www.who.int/ith/ITH2010chapter1.pdf.
• External links
 External links
• CDC Travelers' Health -includes information on
destinations, outbreaks, and recommended or
required vaccinations
• International Association for Medical
Assistance to Travellers (IAMAT)
• International Society of Travel Medicine
(ISTM)
• WHO - List of Country Members - includes
information on outbreaks and health profiles
.