Travelling for business has similar risks as travelling for leisure, but an employer must consider additional safety and financial issues. Gael Somerville, regional nurse manager at travel health specialist MASTA, explains.
Occupational travellers are a diverse group covering a wide range of activities in many settings and locations. The Office for National Statistics (ONS) estimated that 6.9 million international trips were made for business in 2009 (ONS, 2010).
While many travellers make no distinction between the practicalities of their leisure and occupational travel, employers, not the employee, carry the liability for business trips.
The Government’s Business Link website reminds employers that they need to assess the risks on a trip-by-trip basis (Business Link, 2011), although a survey by PMI Global concluded that 48% of companies fail to conduct assessments of the destinations of their travellers (Floyd, 2010). Costs if an employee is sick or injured overseas include diagnosing and treating the individual, possible repatriation, possible replacement and disruption to business.
The legal considerations also come with a cost. While the Health and Safety at Work Act (1974) applies to UK workplaces only, the UK Government, through its Business Link website, makes it clear that a similar standard of care is expected to be applied to employees overseas.
Under civil law duty of care, there is a potential for employees or dependants to sue employers if illness, injury or death occurs. While many cases are settled out of court, there are precedents for litigation (see box 1).
Box 1: Case law
Cawthorn v Freshfields (1997)
A trainee solicitor, with law firm Freshfields, contracted dysentery while working in Ghana. After her illness and absence from work, she sued her employer, claiming that it was negligent for not ensuring that she had received the proper vaccinations or providing her with dietary and other preventative health advice.
Settled out of court (Colditz, 2004).
Palfrey v ARC Offshore Ltd (2001)
An employee of a UK company died from malaria caught while on assignment in West Africa. Prior to leaving, the UK employer advised the employee to seek medical advice regarding the advisable vaccinations and prophylactics. The employee told his employer that he understood the need to seek medical advice but failed to do so. The employee’s widow brought a claim for damages against the employer.
Court awarded damages for the employer’s breach of duty of care, stating that the employer had a minimum responsibility to ascertain and make available to the employee publicly available information on health hazards (Claus, 2009).
To make a risk assessment we need to know what affects the health of travellers. Of the few studies of occupational travellers, a study for Coca-Cola found that 80% of respondents reported gastrointestinal illness, with 12% of respondents seeking medical attention while overseas for their illness/injury (Kemmerer et al, 1998).
A 1997 study found that the medical insurance claims of travellers for the World Bank were 80% higher for men and 18% higher for women compared with those that did not travel (Liese et al, 1997). Again, the most common claims were for gastrointestinal conditions, but psychological conditions also accounted for a large amount of claims.
More generally, a number of studies in the past 20 years show that older travellers are more likely to die from pre-existing conditions and younger travellers are more likely to die from injury, particularly road traffic accidents (RTAs) (Prociv, 1995; Hargarten et al, 1991; Paixao et al, 1991; McInnes et al, 2002; Tonellato et al, 2009; Bauer et al, 2005).
Apart from RTAs, physical violence is also a risk – this varies depending on the destinations visited and the nature of the business – and it may even be a greater risk than RTAs in some countries (Dahlgren et al, 2009).
In addition, sexually transmitted infections are a risk for occupational travellers. Groups that are thought to be at higher risk include young people, men who have sex with men, expatriates, military personnel and healthcare workers (Hamlyn et al, 2007). One study found that 13.9% of men and 7.1% of women from the UK reported having unplanned, new sexual partners overseas (Mercer et al, 2007). This may also help explain the reported poor use of condoms in this group.
A study looking at the types of illnesses that travellers reported through the global travel and tropical medicine surveillance network GeoSentinel found the most common presenting illnesses were gastrointestinal illness, fevers and skin conditions (Gautret et al, 2009).
When the data was examined by gender it revealed that women most commonly presented with gastrointestinal disease, upper-respiratory tract infections, psychological stressors and oral/dental conditions, while men most commonly presented with fevers, vector-borne diseases and sexually transmitted infections (Schlagenhauf et al, 2010). Stress, in general, is commonly reported in business travellers (Espino et al, 2002; Striker et al, 1999).
There are other risks that occupational travellers should be aware of, such as lifestyle risks, the risk of deep-vein thrombosis (DVT), jet lag and adverse reactions to climate. Also, there is a need to be culturally aware, as demonstrated by the case of the British expatriate working in Dubai who was caught kissing a fellow Briton on a beach and given a three-month prison sentence (Verma, 2008).
In addition, work itself can of course adversely affect health. As an extreme example, in 2009 it was reported that 70 journalists were killed working overseas (Mahoney, 2009).
So, while infectious disease accounts for much of the morbidity in occupational travellers, it is not the most common cause of mortality in this group, indicating that risk assessments for occupational travel cannot be confined to vaccines and malarial tablets only.
For any employer that sends staff overseas, it is important they have a policy clarifying that risks need to be assessed and managed so that staff understand that they need to take precautions, even if they do not take any risks while travelling. It is also important to ensure that insurance and emergency assistance arrangements are in place.
Travel arrangements need to include not only the flights and trains to destinations, but also may need to consider sourcing vehicle hire or taxis from suppliers that are likely to maintain their vehicles well.
For work sites and offices overseas, the usual site management inspections and maintenance also need to be undertaken.
As pre-existing illness is a significant cause of mortality in middle-aged and older travellers it makes sense to try to ensure that employees are fit to travel.
Pre-existing conditions are not necessarily a bar to travel but they need careful consideration. Some conditions, such as asplenia, increase the risk of some infections, in this instance making travel to malarial areas more risky.
Other conditions may require access to specialised treatment which may not be available in some countries, not only developing countries but also in remote areas such as the Falkland Islands. Some knowledge of the medical infrastructure is required to inform decisions regarding suitability of the trip for the individual. Advice is often required from the treating doctor to determine if the condition is stable and would be manageable in a country, considering effects of climate, altitude and medicine availability.
Outside of industrialised countries that tend to have pharmaceutical regulations, there is growing concern about counterfeit drugs (World Health Organisation, 2012) so it is important that individuals either take sufficient supply of medicines or ensure that there is a safe supply. While few people are unable to travel at all, it may be prudent to restrict travel, in some cases, to non-malarial areas, non-remote areas and so on.
It is important to think of infectious disease in three categories. First are the diseases that everyone should be vaccinated against. Therefore, it is worth checking that childhood vaccinations have been completed. Perhaps the area of most concern is measles as there are a number of individuals who have neither had the disease nor the two measles vaccinations, however, all travellers should be brought up to date with the UK immunisation schedule.
Destinations need to be checked via a reliable database to see what vaccine-preventable diseases occur in the country and if any vaccination certificates will be required for travel. There are likely to be some vaccinations that would be recommended for anyone travelling to another country, with others to be considered if trips are long, remote or will include more risky activities such as healthcare or teaching.
Unfortunately there are a great deal of infections in many countries for which there are no vaccines or chemoprophylaxis; for example, the risk of the most common travel-related illness, diarrhoea, is primarily reduced by health education.
The latest health news is also important as this will help clarify where the risks are. Dengue fever, for example, a flavivirus spread by Aedes spp. (daytime biting) mosquitoes, is a re-emerging disease in the UK. This is reflected in statistics that show an increase in the number of cases – from 166 in 2009 to 406 in 2010 – in England, Wales and Northern Ireland (Health Protection Agency, 2011).
As with many other diseases, it is important that employees travelling for work have an awareness of the risks and what behaviours will help prevent these illnesses.
Malaria is a particularly thorny problem for business travellers. Malarial infections are always serious and can be fatal. While most cases in the UK arise from individuals visiting endemic areas, the number of business travellers diagnosed with malaria in the UK has been gradually increasing from around 50 in 2007/08 to 84 confirmed cases in 2011 (Health Protection Agency, 2012).
Older travellers are more likely to die from pre-existing conditions and younger travellers are more likely to die from injury, particularly road traffic accidents”
There is often resistance to taking long-term malarial chemoprophylaxis and this needs to be thoroughly discussed, as non-compliance with malarial chemoprophylaxis will increase the liability for the employer as well as increasing health risks for the employee.
There is some evidence that medication compliance is sufficient if the company has provided education to the employee (Berg et al, 2011), although there is plenty of evidence that expatriate employees are poor at maintaining chemoprophylaxis (Dahlgren et al, 2009; Hamer et al, 2008).
Company policy and corporate culture may help to make it more likely that expatriate employees continue their chemoprophylaxis and, again, it is extremely important that employees understand the risks, as well as know what to do if they have symptoms of malaria, which could take up to a year to present.
Mental health is another factor that needs to be assessed and some thought needs to go into ensuring that there is support for employees travelling overseas.
As noted previously, stress and mental disorders are reportedly high for business travellers and there are a number of reasons why this could be (see box 2, below).
The International Association for Medical Assistance to Travellers (IAMAT) reports that 30% of countries do not have mental health budgets, so in some countries there may be fewer than one psychiatrist to 300,000 people (IAMAT, 2012).
It is good practice to ensure that work is planned to allow for adjustment to local time, and that stress and mental health are discussed. Access to employee assistance programmes may help and it is worth understanding what social support each traveller has.
Where activities are likely to be emotionally difficult, it is helpful for employees to have pre-travel briefings on normal reactions to difficult situations and when it would be appropriate to seek help. Ensuring that employees talk to colleagues and managers can help reduce stress, as isolation and loneliness are particular risk factors.
Box 2: Factors that may affect mental health
Source: IAMAT (2011)
The risk assessment for business travel also needs to consider other issues. These include the country’s climate and altitude. For longer-stay business trips employees will have time to acclimatise, but initially heat and humidity can make it difficult so this needs to be factored in, particularly if working outdoors.
The infrastructure of a country needs to be considered and planned for. For example, if an employee is taken ill, will there be medical facilities in the country or will they need to be flown to another country for treatment, or back to the UK? This needs to include contingency plans as some countries have seasonal flooding or drought and may have unreliable utilities. Travel within a country also needs to be assessed, and safe vehicle hire or drivers may need to be sourced along with guides.
Safety and security cannot be ignored. Apart from general safety assessments, it is useful to advise employees on personal security because western travellers can be subject to robbery.
In some parts of the world the risk of kidnap needs to be considered, while in others the risk of terrorism is present. The British Foreign and Commonwealth Office can provide some security advice but, in some cases, an employer may need to use professional security advisers.
Finally, behavioural risks need to be addressed as demonstrated by reports of illness in travellers. Many illnesses and injuries can be avoided through education on food and water hygiene, bite prevention, alcohol education, sexual health education and sun protection.
Assessing the risks for business travellers is about much more than vaccines and malaria pills. The costs to business of an employee being ill overseas are significant and employers have a duty of care to employees even when they are in another country.
Identifying the risks for each business trip enables planning and preparation to minimise the risks. As with any other occupational risk, awareness, controls and maintenance of controls are key. While employers can put in place policies and processes, employees need to know what the risks are, understand how behaviours affect risks, know what symptoms to look out for and how to report them promptly.
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