Chapter 9 Travel for Work & Other Reasons
The Business Traveler
In 2017, an estimated 4.8 million US residents traveled overseas for business, and with an increasingly global economy, this number is expected to increase. Business travelers (also known as occupational travelers) include people traveling for work-related training, conventions, research, and volunteer work. Business travelers may fall into any of several different categories according to duration and purpose of travel (Table 9-01).
For international business travelers (IBTs), the likelihood of an adverse health event increases with the number of trips made to at-risk areas and the time spent there. Since most IBTs take multiple trips each year, travel health consultants should consider the cumulative risk to the traveler and not just the risks of the current trip.
HOW THE IBT DIFFERS FROM OTHER TRAVELERS
Unlike leisure travelers, IBTs are employees. Their employers have an interest and responsibility in protecting them from health threats. Employers should cover the cost for all vaccinations, required and recommended, either through a sponsored health plan or through direct reimbursement to the IBT.
In the United States, employers are liable for tort suits for negligence and workers’ compensation claims. Adverse outcomes resulting from a failure to vaccinate or to provide “US-style” medical care to employees working overseas have led to legal settlements against companies. Employers must be prepared to evacuate IBTs 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. Healthier IBTs mean fewer instances of urgent repatriations (including emergency medical evacuations) and hospital admissions. Additional advantages include enhanced employee confidence, improved productivity overseas, and better public relations. Midsized and smaller businesses with significant numbers of IBTs may also benefit from the cost savings realized by an ITHP.
Table 9-01. Types of international business travelers (IBTs)
|IBT CATEGORY||TRAVEL DURATION||TRAVEL DESCRIPTION||ADDITIONAL TRAVEL DETAILS||REPRESENTATIVE PROFESSIONS|
|Short-term traveler||≤2 weeks||Single destination for a specific meeting or event||Make presentations, attend conventions or association meetings||Academicians, business executives, health care professionals|
|Frequent traveler||2 weeks on
|Multiple trips per year to different locations||Most often over a number of years to same site but may repeat assignment||Auditors, business executives, engineers, managers (including financial managers), researchers, technical trainers, volunteer workers|
|Commuter or recurrent traveler||Varies||Regular international travel, multiple times per year||Special projects||Managers (such as financial or engineering), researchers|
|Assignee||3–12 months||Travels for specific, time-limited objectives||Does not relocate; may return home on a regular basis||Engineers, managers, specialists (such as legal or financial), volunteer workers|
|Expatriate||Long-term assignments (often 2–5 years or more)||Moves to host country||Usually relocates with family||Business executives, managers, researchers, technical experts|
SPECIAL CONSIDERATIONS FOR THE IBT
Traditionally, the risk of travel-related adverse health outcomes in IBTs was considered low, but 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 destination and following return decreases, this is no longer the case. Studies suggest that the profile of diseases an IBT encounters during travel and the likelihood of being injured or developing a travel-related illness is now similar to that of other international travelers. More than 60% of travelers going to areas within Asia considered “high risk” for infectious diseases listed a work-related reason for their travel. Whereas IBTs are just as likely as other travelers to develop some travel-related illnesses (among them, travelers’ diarrhea, respiratory diseases, and malaria), they are more likely to become infected with influenza, sexually transmitted pathogens, and hepatitis B.
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 IBTs than for their nontraveling counterparts, and that the likelihood of developing a noncommunicable disease increased with frequency of travel. The study also showed increased incidence for 20 noncommunicable disease categories.
Although IBTs should receive all indicated vaccines and prophylaxis prior to travel, studies demonstrate gaps in practitioner adherence to the most current guidance, insufficient pretravel counseling, and the failure of travelers to follow recommendations when provided. Adequate prophylaxis against malaria, despite information and counseling, remains a challenge. A 2017 study showed that 89% of IBTs who contracted malaria while traveling, and 50% of those who died, did not take prophylaxis, although the authors did not specify the reasons for nonadherence.
The pretravel consultation should determine and document fitness for travel. Fitness for travel and, in particular, the risk of adverse health events overseas, depends on several factors: 1) how well underlying medical conditions are controlled, 2) how easily preexisting medical conditions can be managed during travel, 3) duration of time spent away from home, 4) destination-specific health risks, and 5) access to health care while away. As much as possible, IBTs (especially recurrent travelers, assignees, and expatriates) 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.
Making the decision that the risk to a person’s health is too high for the assignment rests with the employer, not the IBT. Although almost all medical risks can be managed, it is up to the provider to ascertain whether a health condition (given the medical resources expected to be available) will prevent a traveler from fulfilling occupational obligations. Diabetic monitoring and care, for example, may represent a challenge during international travel, particularly in more austere environments.
If, during the pretravel consultation, a provider identifies underlying medical conditions that cannot be accommodated reasonably at the destination, a full discussion with the IBT of the risks associated with travel, and careful documentation for the employer, must occur. Disability laws apply to all employees. Tort suits and workers’ compensation liability are considerations for situations where a US standard of medical care is not readily available or when an increased risk of illness, accident, or injury is expected.
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 other key elements of the consultation. To best prepare an IBT 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 IBTs 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. IBTs include travelers to industrial sites where there may be exposures to chemical or physical toxins or poor air quality. Some work locations may pose slip, trip, and fall hazards or the possibility of other unintentional injuries. IBTs visiting hospitals or medical environments may require protection from biological hazards. Compared with those traveling internationally for other reasons, then, providing requisite personal protective equipment—including education regarding its proper use—is unique to the pretravel consultation for people preparing to work internationally.
A mental health assessment is another component of the pretravel consultation for IBTs. IBTs show more psychological stress than other travelers, which can manifest as sleep disorders, circadian rhythm disruption, and increased alcohol or substance abuse. Because IBTs must be able to perform effectively in a wide variety of business and social settings, the inability to adapt to other cultures can reflect negatively not only on the traveler but also on the company he or she represents. The ramifications of sending an impaired or culturally inflexible person overseas for work can be serious and costly.
Testing can help predict whether an IBT has the skills to deal effectively with other cultures (cultural adaptability). Used more commonly as part of the pretravel assessment for those being sent to work overseas for extended periods (assignees and expatriates), cultural adaptability testing should be included as part of the pretravel consultation of frequent travelers, particularly when previous incidents have occurred. Attend to mental health and adaptability issues before the IBT embarks on international travel or assignment.
Once mental health issues and risks associated with a particular travel itinerary have been identified and addressed, the next step in the pretravel consultation involves evaluating the traveler for needed vaccines. This includes updating routine vaccines such as influenza, tetanus, and measles, where indicated. Unlike the leisure traveler, there is typically more of a need for the IBT to be fully productive when traveling overseas. The inability to perform one’s job because of illness can have serious negative financial implications; for this reason, practitioners are encouraged to immunize IBTs against all potential vaccine-preventable health risks.
Administer vaccinations with a view toward the IBT’s total travel over the course of a year or next several years, not just an individual trip. A single business trip of only 1 or 2 weeks’ duration to a low-risk destination may not warrant immediate vaccination against a particular disease. However, future work trips may present a risk of exposure. Due deliberation should be given to initiating a vaccine course, even if the travel requiring it has not yet been planned. Because business travel is often last-minute, it is reasonable to begin vaccinating the IBT for later trips when immunity against specific diseases is required. This is true even if the traveler does not complete the full vaccine series in advance of the most current trip.
Simply providing prescriptions for necessary prophylaxis against travel-related diseases, malaria in particular, is not enough. As noted above, in a recent study nearly 90% of IBTs who contracted malaria while traveling did not take their prescribed medication. Even though IBTs 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 (such as apps on handheld devices) can help.
Travel plans often change. Before departing, IBTs should know where to access health and safety information for destinations not included on the original itinerary. Destination-specific health recommendations are available from www.cdc.gov/travel.
All family members accompanying the IBT should also visit a primary care provider for a pretravel physical and mental health screen; the inability of a spouse or a child to adjust to an international environment is often a cause for early repatriation. Each family member also requires his or her own consultation with a travel health specialist.
TRAVEL HEALTH ISSUES DURING TRAVEL AND AT THE DESTINATION
Advance planning and adherence to guidance provided by medical and human resource personnel can mitigate health and wellness risks posed by lengthy flights. These risks include dehydration, deep vein thrombosis, motion sickness, and jet lag. Multiple-leg, complex itineraries can aggravate and increase the likelihood of these conditions. Counseling travelers to limit or refrain from in-flight alcohol consumption and to use hypnotics judiciously to facilitate sleep can decrease the chances of a hangover, which is particularly important when work duties are scheduled on or close to arrival.
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 may be a challenge for the IBT; be prepared to help create schedules for travelers taking medication, both on the way overseas and when returning. Anticipating the possibility that checked luggage could be delayed or lost during international travel, IBTs should carry with them a travel health kit containing all necessary medications in sufficient quantities.
On arrival, IBTs should review with their hosts all safety, security, occupational, and environmental hazards specific to the destination. In developing countries in particular, IBTs may encounter occupational and environmental health risks significantly different from what they have at home; chemicals used in some locations may no longer be used (or were never approved for use) in the United States because of their hazardous properties. Foreign governments may lack or not enforce exposure limits, requirements for personal protective equipment use, or worker safety laws. Moreover, IBTs should know in advance what to do in case of a health emergency, as well as which hospitals and health clinics in the vicinity provide the highest levels of medical care. Details about how to access quality outpatient and inpatient care must be available to the IBT throughout the trip and updated as needed.
IHTPs provide IBTs 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 IBT 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 to that of the other workers at that jobsite.
The US Occupational Safety and Health Administration does not have jurisdiction or requirements to report illness or accidents for work done outside the United States. Nevertheless, an employer has 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 may require medical monitoring and referral to occupational health specialists for the person, and exposure mitigation by a hierarchy of controls at the location. IBTs should also provide intelligence about any changes in the quality of available medical care, accommodations, security, and any other medical or legal issues that may have a deleterious impact on the health of future travelers.
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