Travel medicine is based on the concept of risk reduction. In the context of travel medicine, “risk” refers to the possibility of harm occurring during the course of a trip. Some risks may be avoidable, while others may not. For example, vaccine-preventable diseases may be mostly avoidable, depending on the protective efficacy of the vaccine. Perception of risk is a subjective evaluation of whether a risk is considered large or small; is 1 in 10,000 a large risk or a small risk? Tolerance refers to acknowledging a risk and accepting it; a risk of 1 in 100,000 may be tolerable for one traveler but not for another.
For many years, travel medicine practitioners have felt that statistics for a given risk could help them objectively advise travelers about that risk. However, the rates of diseases in a particular country or location, such as typhoid fever, malaria, or Japanese encephalitis (JE), may not help clinicians or travelers determine the threshold for making a decision based on those statistics alone. With risks of diseases ranging from 1 in 500 (an estimate of the risk of typhoid in unvaccinated travelers in Nepal), to 1 in 1,000,000 (an assessment of the risk of JE in travelers to Asia), travelers still need to determine what these statistics mean. Additional information to help make an informed decision may include length of travel, type of travel, and proposed accommodations.
Even when risk is low, travelers’ decisions will still reflect their perception and tolerance of risk. When told that the risk of JE is 1 in 1,000,000, one traveler might reply, “Then I guess I don’t have to worry about it,” while another traveler might say, “That one traveler will be me!” Each traveler will have ideas about the risks, benefits, and costs of vaccines and drug prophylaxis, and these should be discussed in detail with their clinician.
Perception and tolerance of risk are connected to the concept of commitment, particularly in regards to remote, adventurous travel. Commitment refers to the fact that certain parts of a journey may not easily be reversed once entered upon. For example, a traveler trekking into a remote area may need to accept that rescue, if available at all, may be delayed for days. A traveler who has a myocardial infarction in a country with no advanced cardiac services may have a difficult time obtaining definitive medical care. If the traveler has already contemplated these concerns and accepted them, it will be easier to deal with them if they occur.
The goal of travel medicine should be to assess the risks for the traveler, and educate the traveler to skillfully manage and minimize risk rather than try to eliminate it. Travel medicine practitioners should discuss available risk statistics and assess their clients’ perception and tolerance of risk. Once this is done, the provider can then help travelers find their individual comfort level when making decisions about destinations, activities, and prophylactic measures.
David R. Shlim
Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official recommendations contained in the book. The views and opinions expressed in this section are those of the author and do not necessarily represent the official position of CDC.