Pre-Travel and Post-Travel Consultation for Fitness to Fly,

Preparing Travellers with Comorbid and Travel Health Risk

Mario Damianus Daniel Hadinoto, MD

Yogyakarta - Indonesia
May 2024
 Educational Background
• Mario Damianus Daniel Hadinoto, MD
• DOB: Jakarta, 23 March 1987
• Medical Doctor (Dr.) - Faculty of Medicine, Universitas Diponegoro,
Semarang, 2005-2012
• Aviation Medicine Specialist (Sp.KP) - Faculty of Medicine, Universitas
Indonesia, Jakarta, 2015-2018
• Diploma of Travel Medicine (DTM) - Barcelona, Spain, 2018
• Certificate in Travel Health (CTH) - Bangkok, Thailand, 2018
• Guest Speaker - International Conference of Aviation and Space
Medicine (ICASM), Debrecen, Hungary, 2019
• Guest Speaker - International Conference of Aerospace Medicine
(ICAM), Paris, France, 2022
 Organization & Work Background
• Member of International Society of Travel Medicine (ISTM)
• Member of Asia-Pacific Travel Health Society (APTHS)
• Member of Travel and Adventure Medicine of Asia (TAMASIA)
• Member of Aerospace Medical Association (AsMA)
• Voting Member - Committee of Air Transport Medicine (CATM) of AsMA
• Certified of Aviation Trainer (ToT Certificate) - 2020-now
• Guest Lecturer - Faculty of Medicine, Universitas Indonesia - 2021-now
• Guest Lecturer - Garuda Indonesia Training Centre (GITC) - 2022-now
• Grha Kedoya Hospital, Jakarta - 2019-now
• Medistra Hospital, Jakarta - 2021-now
• Mayapada Hospital Kuningan (MHKN), Jakarta - 2024-now
• VVVIP Medical Escort Services - 2022-now
What is Travel Medicine?
Travel medicine is the field of medicine concerned with the promotion of health
and the prevention of disease or other adverse health outcomes in the
international traveler.

The primary goals of travel medicine are:

• to prevent disease and injury in travellers.

• to treat medical problems in travellers when travelling.

Prof. Dr. Med. Robert Steffen – The Founder of Travel Medicine

Department of Epidemiology and Prevention of Infectious Diseases, University of Zurich
Characteristics of Travel Medicine Practice
Aspect Travel Medicine Conventional Medicine
Main focus Promotive, Preventive Curative
Client Traveler (healthy person) Patient (sick person)
Relationship between Informative Therapeutic
doctor and client
Form of evaluation Risk assessment Diagnostic work-up
Management Risk management (health Treatment (medicine,
advice, vaccines, surgery, etc.)
chemoprophylaxis)
The Process of Travel Medicine

DURING
PRE-TRAVEL POST-TRAVEL
TRAVEL
• Risk assessment • Local medical care • Further treatment
• Risk reduction • Medical evacuation • Diagnosis and treatment
interventions of ill-returned travelers

Home Country Destination Country Home Country

Travel Medicine Clinic Medical Service Abroad Travel Medicine Clinic

Travel Medicine Service
1. Initial consultation

2. Pre-travel consultation

3. Follow-up visits

4. Vaccination and prophylaxis

5. Drug prescription (if needed)

6. Online consultation (if needed)

7. Post-travel treatment (when returned ill)

 Pre-Travel Consultation
• To assess travel-related health risks.
• To give updated and accurate advices to
travelers prior to their trip regarding the
health risk and its prevention.
• To recommend and to provide preventive
measures.

Knowledge of Medical Geography and Information

Resources is Important
Type of Travelers

Corporate Group travel Adventure

Family holiday Pilgrimage Humanitarian aid

Special Group of Travelers
• Athletes • Pregnant women
• Elderly travelers • Travelers with chronic diseases
• Infant and children • Travelers with disabilities
• Expatriate • Immunocompromised travelers
• Immigrants • Military personnel
• Displaced persons
 Travel-Related Health Risks
INFECTIOUS DISEASES
• Food & Waterborne IDs
• Airborne IDs
• Vector-borne IDs
• Person-to-Person Contact IDs
• Sexual contact
• Body fluid
NON-INFECTIOUS DISEASES
• Accident & Injury
HEALTH • Environment-Related Hazards (e.g.
RISKS high altitude, underwater)
• Animal Bites & Envenomation
• Food Poisoning
• Others: motion sickness, jet lag,
deep-vein thrombosis
Risk Reduction Interventions
• Information enabling behaviour modification
• Vaccinations
• Medications
• Other: travel insurance, pre existing medical problems, medical
kits
General Assessment
6. What activities? 1. Where to go?
• In-door • Countries
• Out-door • Cities
• Areas

5. How long? 2. What kind of place?

Destination
• < 2 weeks • Urban
• 2-4 weeks • Sub-urban
• >1 month • Rural

4. Where do you stay? 3. How do you get there?

• Hotel • By air
• Apartment • By land
• Home stay • By water
• Camp, etc. • On foot
General Pre-Travel Assessment
Surname: Last name:
Date of birth: Address:

Purpose of travel [ ] Holiday / tourism [ ] Business [ ] VFR [ ] Education: [ ] Other, specify:

Type of
[ ] Luxury hotel [ ] Budget accommodation [ ] Home-stay
accommodation
High-risk activity [ ] Diving [ ] Mountain Hiking [ ] Trekking [ ] Other sports, specify:
Date of departure:
Places to visit:
Country City Rural area Date
[ ] Yes [ ] No From to

[ ] Yes [ ] No From to

[ ] Yes [ ] No From to

[ ] Yes [ ] No From to

[ ] Yes [ ] No From to
 General Pre-Travel Assessment
Past medical history:
Vaccination history:
Current health status:
Chronic illness:
Current or recent medications received:
History of jaundice or hepatitis:
Allergy profile (e.g. egg, peanut, pollen, antibiotics, sulphonamides)
For women [ ] Currently pregnant
only

[ ] Very likely to be pregnant in the next 3 months

[ ] Currently breast-feeding
History of anxiety or depression:
[ ] If yes, prescribed medicine received:

Neurological disorders (e.g. epilepsy, multiple sclerosis, etc.):

Cardiovascular disorders (e.g. thrombosis, cardiac pacemaker):
Pre-Travel Recommendation
• Items to be considered:
• General advice?
• Vaccination?
• Malaria prophylaxis?
• Self-treatment?
• Medical kit?
• Insurance?
• Other preventive measures?
Benefit of Pre-Travel Vaccinations
• Protecting travelers against infectious disease whilst abroad.
• Protecting travelers against infectious diseases when they
come back home.
• Protecting host populations against carriage of infectious
diseases during travel.
• Improving the herd immunity of the travelers’ home countries
against infectious diseases.
 Asian vs Western Travelers
1.Vaccine-preventable diseases that are rare in the West may be endemic in
Asia
• e.g. malaria, typhoid fever, hepatitis A, hepatitis B, dengue, rabies,
Japanese encephalitis).
2.Some Western “travel vaccines” are included in Asian country vaccination
program.
• e.g. hepatitis B
3.Natural immunity may be present in Asian travelers.
• e.g. hepatitis A (vaccine-preventable), diarrheal disease (non-vaccine
preventable)
4. Different behavior between Asian and Western travelers

Piyaphanee W, et al. J Trav Med. 2012;19:335–7.

 Fitness to Travel: Flying
• Flying is generally a safe and comfortable method of
transportation.
• However, it can induce cardiovascular stress even in men with
good physical fitness.1
• Several environmental and physiologic stresses may be
encountered in modern commercial aircraft.

Oliveira-Silva I, et al. Physical Fitness Front Physiol. 2016;7:648.

 Cabin Air Pressure
• Commercial airlines generally cruise between 30,000 and 43,000 feet.
• Cabin pressure are set to 5,000 - 8,000 feet above sea level.

1. https://aerosavvy.com/aircraft-pressurization/
2. http://www.who.int/ith/mode_of_travel/cab/en/
 Effect of Cabin Air Pressurization
• Reduced partial pressure of
atmospheric oxygen:
• PaO2 of 10 kPa
• Reduced O2 saturation
• Expansion of gases within
enclosed cavities
• Volume increase by ⅓.

Walker E, Williams G. Br Med J (Clin Res Ed). 1993;286:865–7.

 Oxygen Saturation
Percentage of oxygen
saturation at 8000 feet above
sea level for a normal, healthy
adult and a patient with COPD

Carvalho AM, Poirier V. Can Fam Phys. 2009;55:992–5.

 Contraindication to Air Travel (WHO)
1.Infants less than 48 hours old. • recent myocardial infarction and
2.Women after the 36th week of stroke
pregnancy (32nd week for multiple • recent surgery or injury where
pregnancies). trapped air or gas may be present;
3.Those suffering from:
• angina pectoris or chest pain at rest;
• severe chronic respiratory disease,
• any active communicable disease; breathlessness at rest, or
• decompression sickness after unresolved pneumothorax;
diving; • sickle-cell anemia;
• increased intracranial pressure due
to haemorrhage, trauma or • psychotic illness, except when fully
infection; controlled.
• infections of the sinuses or of the
ear and nose, particularly if the
Eustachian tube is blocked
http://www.who.int/ith/mode_of_travel/contraindications/en/
 Pregnancy and Air Travel
• Occasional air travel during pregnancy is generally safe.
• Most airlines allow pregnant women to fly up to 36 weeks of gestation.
• Air travel is not recommended for women who have medical or obstetric
conditions that may be exacerbated by flight or that could require
emergency care.
• Preventive measures can be used: Support stockings, periodic movement
of the lower extremities, avoidance of restrictive clothing, adequate
hydration.

ACOG. Obstet Gynecol. 2009;114(4):954–5.

 Cardiovascular Contraindication
1. Uncomplicated myocardial infarction within 2-3 weeks
2. Complicated myocardial infarction within 6 weeks
3. Unstable angina
4. Congestive heart failure, severe, decompensated
5. Uncontrolled hypertension
6. CABG within 10-14 days
7. CVA within 2 weeks
8. Uncontrolled ventricular or supraventricular tachycardia
9. Eisenmenger syndrome
10. Severe symptomatic valvular heart disease

Aviat Space Environ Med. 2003;74(5 Suppl II); A1–A19.

THANK YOU
TERIMA KASIH
Travel Health Assessment Practice
Mario Damianus Daniel Hadinoto, MD
Yogyakarta - Indonesia
May 2024
CASE 1
• A family of four is leaving from Jakarta, Indonesia in January for
a 2-year stay in Gabon. The family consists of a 46-year-old
father, a 34-year-old mother who is 5 months pregnant, a 4-
year-old boy, and a 2-year-old girl. They have learned of a
meningitis epidemic that has just begun in most African
countries. Assuming that the epidemic strain is covered by an
available vaccine, which members of the family should be
vaccinated?
CASE 2
• A traveller who has had no prior rabies immunization is bitten by
a dog in Bali. The traveller doesn't seek rabies postexposure
treatment in Bali, but presents 2 weeks after the bite. The
recommended treatment at this point is to administer?
CASE 3
• A 35 year old pregnant woman, with diagnosis G2P1A0, is
going to travel to Sydney, Australia for her labor plan. Her first
labor was 3 years ago, with normal baby. Current time, she is at
34-35 weeks of gestation. After last visit with her obstetric and
gynaecologist, her doctor is not recommended to do late travel,
due to risks of eclampsia. After physical examination with you,
everything seems normal. What is your recommendation and
action as travel medicine doctor and also aviation medicine
specialist?
CASE 4
• A lady, 36 years old, has hospitalized at X hospital since two
weeks ago, with present complaints: painful in rectovaginal
area, and slight weakness. She has a history of cervix cancer
stadium 3B, with almost 20 times history of radiotherapy.
• Her family plans to bring her to Y hospital at Penang, Malaysia.
• Current Diagnoses: Progressive cervix cancer stadium 3B with
pyometra; fistula rectovaginal; anemia; with lower extremity
oedema.
• What is your complete assessment for this lady?
• What is your aeromedical reccomendation for this lady?
CASE 5
• A young lady, 36 years old, has hospitalized at X Hospital since
three weeks ago, with present complaints: fell down and
fracture in femoral area; painful in lower extremities area.
• She plans to continue her medication / treatment at her
hometown, Quezon City, Philippines.
• Current Diagnoses: Bilateral femoral fractures post cast / gips
(refused ORIF); Anemia; Cushing's syndrome.
• What is your complete assessment for this young lady?
• What is your aeromedical reccomendation for this young lady?
CASE 6
• A girl, 13 years old, has hospitalized at X Hospital since two
weeks ago, with present complaints: vomitting with puffiness on
facial area, edema in extremities.
• Her family plans to continue her medication / treatment at
Singapore.
• Current Diagnoses: Chronic Kidney Disease (CKD)
• What is your complete assessment for this girl?
• What is your aeromedical reccomendation for this girl?