Author(s): Davidson Hamer

In 2017, ≈4.8 million US residents traveled overseas for business. With an increasingly global economy, this number is expected to increase, although a major slowdown in business travel occurred due to the onset of the coronavirus disease 2019 (COVID-19) pandemic. Business travelers (also known as occupational travelers) include people traveling for conventions, research, work-related training, and volunteer work. Business travelers fall into several different categories according to duration and purpose of travel (see Table 9-01).

For international business travelers, the likelihood of an adverse health event increases with the number of trips made to at-risk areas and the length of time spent at the destination. Because most international business travelers take multiple trips each year, travel health providers should consider the cumulative risk to the traveler and not just the risks of the current trip.

How International Business Travelers Differ from Other Travelers

Unlike leisure travelers, international business travelers are usually employees, although some might be working as independent consultants. Business travelers’ employers have a responsibility to protect their employees from health threats. Employers should cover the cost for all required and recommended vaccinations, prophylactic medications (e.g., antimalarials), and other health protection measures, either through in-house or contracted occupational health services or a sponsored health plan.

In the United States, employers are liable for tort suits for negligence and workers’ compensation claims. Employers should have systems in place to evacuate employees traveling under their auspices; this typically requires a preexisting contractual relationship with an air medical evacuation provider or some form of comprehensive travel health insurance that includes medical evacuation coverage.

To better prepare their employees for healthy travel, businesses have developed international travel health programs (ITHPs). Primarily an innovation of larger corporations, ITHPs focus on disease prevention and health promotion activities before, during, and after international travel. Potential advantages of corporate travel health programs include fewer instances of urgent repatriations (including emergency medical evacuations) and hospital admissions for international business travelers; enhanced employee confidence; improved productivity overseas; and better public relations. Midsized and smaller businesses with large numbers of international business travelers might also benefit from the cost savings realized by an ITHP.

Special Considerations for International Business Travelers

Risks for travel-related adverse health outcomes in international business travelers generally have been considered low. They have increased, however, as the number of people traveling for work (and the overall distance they travel) increases and as the time allotted for adjustment after arrival at destinations and after return home decreases. International business travelers are as likely as other travelers to develop some travel-related illnesses; a GeoSentinel analysis of 12,203 business travelers seen during 1997–2014 found that frequent diagnoses included malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), and acute bacterial diarrhea (5%). Notably, only 45% of travelers in the analysis had had a pretravel encounter and, among the subset traveling to malaria-endemic regions for whom malaria prophylaxis data were available, 92% did not take prophylaxis or took an incomplete course of prescribed medication.

Extensive business travel also correlates with a higher body mass index and increased cholesterol, hypertension, and mental stress. A World Bank study showed overall health plan expenditures were 70% higher for international business travelers than for their nontraveling counterparts, and that the likelihood of developing a noncommunicable disease increased with travel frequency. The study also showed increased incidence for 20 noncommunicable disease categories among this employee group.

Although international business travelers should receive all indicated vaccines and prophylaxis prior to travel, gaps in care exist. For instance, not all practitioners adhere to the most current guidance, some clinicians provide insufficient pretravel counseling, and some travelers fail to follow recommendations when provided.

Pretravel Considerations

Fitness for Travel

The pretravel consultation should determine and document fitness for travel. Fitness for travel, particularly the risk for adverse health events overseas, depends on several factors, including how well underlying medical conditions are controlled; how easily preexisting medical conditions can be managed during travel; duration of time spent away from home; destination-specific health risks; access to health care while away; and job tasks and activities. As much as possible, international business travelers, especially assignees, expatriates, and recurrent travelers—and their health care providers—should attempt to improve those factors within their control and to minimize the risks presented by factors outside their control.

Employers can authorize international travel for their employees after consideration of several factors including an assessment of health and safety risks. Although almost all medical risks can be managed, the health care provider must ascertain whether a health condition will, based on the medical resources expected to be available, prevent a traveler from performing their essential job functions. For example, diabetes monitoring and care could be challenging during international travel, particularly to more austere environments.

If a provider identifies underlying medical conditions during the pretravel consultation, it is their responsibility to have a full discussion with both the international business traveler and the employer regarding the added health risks imposed by international travel, and then carefully document these conversations. Disability laws apply to most employees. Tort suits and workers’ compensation liability are considerations for situations in which a US standard of medical care is not readily available, or when an increased risk for accident, illness, or injury is expected.

Health Risks

Structure the pretravel consultation to identify and address risks to both physical and mental health. Administering vaccines, prescribing prophylactic medication, and educating travelers about how to mitigate health threats while traveling are key elements of the consultation. To best prepare an international business traveler for healthy travel, providers must have access to the traveler’s full itinerary, including all work sites, stopovers, likely side trips, and potential itinerary changes. Do not assume that international business travelers will only visit major cities, stay in first-class hotels, and eat at 5-star restaurants.

Attempt to elicit information about conditions at worksites listed in the itinerary, going into as much detail as possible. International business travel can include visits to industrial sites where travelers can be exposed to chemical or physical hazards or poor air quality. Some work locations could pose slip, trip, and fall hazards or the possibility of other injuries. International business travelers visiting hospitals or medical environments might require protection from biological hazards. Providing requisite personal protective equipment (PPE) and education regarding its proper use is unique to the pretravel consultation for people preparing to work internationally.

Mental Health Assessment

A mental health assessment is another component of the pretravel consultation for international business travelers. Travel- and work-associated stressors can be additive and manifest as circadian rhythm disruption, sleep disorders, and increased alcohol or substance use. The ability to work effectively with people from other cultures is known as cultural adaptability; employers should consider providing cultural adaptability training for frequent travelers, particularly if the employee is being sent to work abroad for extended periods (assignees and expatriates). Predeployment testing can help measure whether an international business traveler has the requisite cultural adaptability skills, and a variety of assessment tools are available. Address mental health and adaptability issues before the international business traveler embarks on international travel or assignment.

Vaccines

Once mental health issues and risks associated with a particular travel itinerary have been identified and addressed, evaluate the traveler for needed vaccines. Update routine vaccines (e.g., influenza, measles, tetanus-diphtheria-pertussis), if indicated. Unlike the leisure traveler, the international business traveler typically needs to be fully productive when traveling overseas. The inability to perform one’s job because of illness has serious implications for both employee and employer; recommend immunizations for international business travelers based on an individualized risk assessment of potential vaccine-preventable health risks.

Administer vaccinations with a view toward the international business traveler’s total travel over the course of a year or next several years, not just a single trip. A single business trip of only 1 or 2 weeks’ duration to a low-risk destination might not warrant immediate vaccination against a particular disease, but future work trips could present a risk for exposure. Consider offering a vaccine series even if the travel requiring it has not yet been planned. Because business travel often is scheduled last-minute, vaccinating the international business traveler for later trips when immunity against specific diseases is required is reasonable. This is true even if the traveler does not complete the full vaccine series in advance of the most current trip.

Malaria Chemoprophylaxis

Simply providing prescriptions for necessary prophylaxis against travel-related diseases, particularly malaria, is not sufficient. As a large GeoSentinel study recently noted, >90% of international business travelers who contracted malaria while traveling did not take their prescribed medication appropriately, or at all. Although international business travelers are aware of the need for prophylaxis, they demonstrate poor adherence that only worsens with the length of the trip. Reported reasons for nonadherence include the challenges posed by daily dosing, presumed immunity, busy schedules or forgetfulness, conflicting advice, and fear of side effects. The use of electronic reminders (e.g., software applications on handheld devices) can help.

Additional Considerations

Changes in Plans

Travel plans often change. Before departing, international business travelers should know where to access health and safety information for destinations not included on the original itinerary. Destination-specific health recommendations are available from the Centers for Disease Control and Prevention (CDC) Travelers’ Health website.

Travel Companions

All family members accompanying the international business traveler also should visit a primary care provider for a pretravel physical and mental health screening; the inability of a child, companion, or spouse to adjust to an international environment is often a cause for early repatriation. Each family member should have their own consultation with a health care provider familiar with assessing the impact of travel on health and safety.

Travel Health Issues During Travel & At the Destination

Planning for and adhering to guidance provided by medical and human resources personnel can mitigate health and wellness risks posed by lengthy flights. These risks include deep vein thrombosis, dehydration, jet lag, and motion sickness (for more details on these conditions, see the relevant chapters in Section 8). Multiple-leg, complex itineraries can aggravate and increase the likelihood of these conditions occurring. To decrease a traveler’s chances of experiencing adverse effects—which is particularly important when work duties are scheduled on or close to arrival—counsel travelers to limit or refrain from in-flight alcohol consumption, and caution against the use of hypnotic drugs to facilitate sleep while flying.

Coronavirus Disease 2019

Because of the COVID-19 pandemic, international travel guidance—ranging from alerts about the risk for COVID-19 in different countries to travel interdictions between certain countries—changes frequently. Countries might require proof of vaccination, quarantine on arrival, or documentation of negative test results before permitting entry. Quarantine can range from stays in a government-mandated facility, at one’s home, or in a hotel; quarantine also could mean travelers need to be available by phone for a daily interview by government health authorities. Employers should check with their human resources office or publicly available references (e.g., CDC, US State Department, government websites in the destination country) for COVID-19 travel information, and work with their employees to help ensure they adhere to the latest requirements and recommendations.

Medication

Changing time zones can interfere with taking prescribed medicine on time, another potential threat to the health and wellness of international travelers. Adjusting the timing of regular medication during international travel might be a challenge for the international business traveler; help create schedules for travelers taking medication(s), both on the way overseas and when returning. Anticipating the possibility that checked luggage could be delayed, broken into, or lost during international travel, international business travelers should carry with them a travel health kit containing sufficient quantities of all necessary medications to last the duration of travel, and extra doses in case of delays.

Occupational & Environmental Hazards

On arrival, international business travelers should review with their hosts all safety, security, occupational, and environmental hazards specific to the destination. In low- and middle-income countries in particular, international business travelers could encounter occupational and environmental health risks much different from what they experience at home; chemicals used in some locations might no longer be used (or might never have been approved for use) in the United States because of their hazardous properties. Foreign governments might lack or not enforce exposure limits, requirements for PPE use, or worker safety laws.

Health Emergencies

Advise business travelers to use the Smart Traveler Enrollment Program (STEP), a free program offered through the US Department of State, in which international travelers and expatriates enroll their trip with the US embassy in the country of travel or residence. STEP benefits include receiving information alerts from the local embassy about health and safety issues, facilitating contact with the embassy if a problem arises, and helping family and friends reach international travelers through the embassy, in case of an emergency.

International business travelers should be well briefed on what to do in case of an overseas health emergency and which hospitals and health clinics in the vicinity provide the highest levels of medical care. This information might be available through the local US embassy and is another reason for travelers to consider enrolling in STEP. Details about how to access quality outpatient and inpatient care must be available to the international business traveler throughout the trip, and updated as needed.

Posttravel Care

ITHPs provide international business travelers with both pretravel and posttravel care. Studies show that, upon returning home, 22%–64% of people traveling internationally for work will have an unresolved health issue meriting careful case management with referral to specialists. Because an international business traveler could be a sentinel for a health risk at an overseas facility or workplace, a correct diagnosis is important not only to the health and well-being of the traveler but also to that of the other workers at that jobsite.

Employers have a general duty to prevent occupational injuries. Returning workers can assist by notifying employers of any work-related incidents or on-the-job exposures. Such workplace hazards might require medical monitoring and referral to occupational health specialists for the person, and exposure mitigation by a hierarchy of controls at the location. International business travelers also should provide information about any changes in the quality of available medical care, accommodations, security, and any other medical or legal issues that could adversely affect the health of future travelers.