Improving Disease Surveillance in

Tourist Destinations

I Md Ady Wirawan
Departemen Kesehatan Masyarakat dan Kedokteran Pencegahan
Travel Medicine Unit, Fakultas Kedokteran, Universitas Udayana
PERKEDWI Bali
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Continuum of travel
medicine services

Post-
travel Improving the quality of medical tourism
services
During
travel
Pre-hospital Post-hospital
services
Pre-travel
services In hospital

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Development of Travel Health/Travel Medicine

Travel medicine practice

Travel medicine education

Travel medicine research

Travel medicine network

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 Tropical
medicine

Travel Medicine Military

medicine
Preventive
medicine

Practice
Aviation and
Infectious
hyperbaric
diseases
medicine
Travel
medicine

Occupational
Migrant and
health environmental
medicine

Clinical and
Family
emergency
medicine
medicine

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Specific Traveler Population and Specific
Itinerary
• Travelers with chronic diseases
• Travelers with disabilities
• Travelers with impaired immune
system
• Senior travelers
• Baby and child travelers
• Pregnant women travelers
• Tourists of extreme activities,
wilderness and remote areas
• Corporate travelers (MICE)
• Athlete
• Pilgrimage travelers such as Hajj,
Umrah, Tirta Yatra, etc
• Cruise ship workers
• International migrant workers
• Immigrant/expatriates
• Medical tourists
Implications of Medical Tourism for Healthcare
Services
• Understanding magnitude/overall volume
of medical tourism
• Reasons for seeking care abroad and
problems associated with medical tourism Identifying medical Assessing the Enhancing hospital
• Understanding infectious diseases service excellence
and develop an
health risks
associated with
quality to comply
with international
associated with medical tourism ideal tour packages
that meet the
provided medical
procedures and
service
requirements
• Measures to assure quality and safety elements of health
and safety
tour packages

from medical tourism and control of

infections
• Focusing on quality and safety and
accreditation of healthcare abroad

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Monitoring and Protecting Indonesian Travelers
• Pre-travel health service is already well established for Hajj travelers
• Low proportion of Indonesian travelers received pre-travel advice,
travel vaccine, and travel insurance (?)
• Expanding/strengthening pre-travel and post-travel health services to
potential groups
• Migrant workers
• Cruise ship workers
• High-risk travelers
• Corporate travelers

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Body of knowledge for the practice of travel medicine as defined by the ISTM

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Body of knowledge for the practice of travel medicine as defined by the ISTM
(2)

www.istm.org/bodyofknowledge

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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)
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
Surveillance on Travellers
Most relevant surveillance data
• GeoSentinel Surveillance Network: ISTM and CDC, 60
clinics in all continents
• TropNet in Europe
• CanTravNet in Canada
• Global TravEpiNet (GTEN), based in US  travel
clinics, primary care and public health sites

Challenges in developing such kind of surveillance

system in tourist destinations?
Surveillance on Travellers
Current travel health surveillance system: GeoSentinel, EuroTravNet,
CanTravNet, GTEN

Aggregated
Database Networks
• Outreach
patients GeoSentiel • Clinical alerts
• Travel clinic Sites • Regular
patients summaries • GeoSentinel Sites
• ISTM members
• Outreach providers
Input
• Other networks
 • No participating site in
Indonesia
• Udayana University
Hospital Travel Clinic is a
GeoSentinel Affiliate
member since 2019

http://www.istm.org/geosentinel
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)
• No participating sites in Indonesia
• lack of information on symptoms, risk factors, and
diseases that could potentially be employed to
improve surveillance system and public health in
general
Local surveillance system
• Little has been known about common
diseases or symptoms experienced
specifically by travelers to Indonesia
• Lack of robust and integrated system that
also involve travelers in such destination
areas
• Current surveillance system in Bali or
Indonesia in general has been focused on
the diseases affecting local population
Local surveillance system
• Current surveillance system has not included
travelers as its one of target population.
• Current data on diseases among travelers have
been relied on the reporting of health facilities
and hospitals that provide services to tourists.
• There is no regular travel health surveillance
currently in place to gather data from all travel
clinics or hospitals.
• One of the efforts related to this has been
sporadic investigation to tourism areas or facilities
when authority got notification of cases
Development of travel health surveillance platform at destinations
InaTravNet.org – Indonesia Travel Health Network
General layout of the platform
• Home
• Traveler Resources
• Health and Safety Risk (kategori risiko –Biological hazard, Safety hazard, dll)
• Risk by destination (artikel risiko kesehatan per destinasi/provinsi – kategori per Provinsi)
• Network Resources
• Workshops
• Info material
• References
• Network Clinic
• Per destinasi/provinsi
• Member Login
• Untuk klinik – daftar klasifikasi penyakit menggunakan ICD-10
• Untuk dokter/perorang: dashboard, forum diskusi
Pelaporan Penyakit
• Form Pelaporan Bulanan
• Jumlah wisatawan yang dilayani
• Jenis penyakit dan jumlah
• Asal Negara
• Form Pelaporan Penyakit Khusus
(dilaporkan saat ada wabah, atau
penyakit yang berpotensi menimbulkan
kedaruratan kesmas)
• Inisial pasien
• Umur
• Jenis kelamin
• Asal negara
• Keluhan dan Gejala
• Diagnosis
• Tindakan
• Upload foto
Pelaporan Stock
• Form Pelaporan Mingguan
• Ketersediaan Vaksin: Jenis Vaksin, Jumlah
• Ketersediaan Obat: Jenis Obat, Jumlah

Forum Jejaring Klinik

• Forum Diskusi
• Subyek/tema
• Reply/Comment
• Upload foto
• Tools untuk konsultasi antar klinik (kontak antar klinik)
• Subyek/tema
• Isi
• Upload foto
• Upload file
Traveler Resources

• Health and Safety Risk (kategori risiko

–Biological hazard, Safety hazard, dll)
• Risk by destination (artikel risiko
kesehatan per destinasi/provinsi –
kategori per Provinsi)

Network Resources
• Workshops
• Info material
• References
Dashboard / Penyajian Data
• Dashboard untuk Administrator
Jejaring
• Bisa menampilkan
• Daftar klinik yang menjadi
anggota jejaring
• Data laporan bulanan klinik
• Data laporan penyakit khusus
• Data ketersediaan stock vaksin
Travel health network activities
• Coordination meeting with travel health providers and
related stakeholders
• Development of travel health network
• Development of technical guidelines for the system
• Dissemination of travel health network technical
guidelines
• Pilot testing of the system
• Capacity building of travel health providers (travel
medicine education materials and training)
• Data collection and data analysis
Evaluation and follow up
• The primary outcome variables are:
• Number of patient receiving travel health services –
ILI cases
• This may include pre-travel, during travel, or post-
travel health services
• Number of travel-related diseases and accidents
reported through the system
• Secondary outcomes :
• User satisfaction
• Workflow “fit”
• Learning curve (design)
• Cognitive performance/errors
• Reliability
Travel health surveillance at destinations
• Integrated approaches to include provision of travel
health information (targeted traveler communication)
that allows digital surveillance to be conducted.

• At the same time, a travel health provider network

should be established to improve accessibility, stock
notification and commodity management, provision
of training and educational material, digital tracking
and decision support, which eventually provide high-
quality travel health services.
Healthy Tourism Initiative strengthens global health security

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Thank You!