Travel with care

The increase in use of the internet in the 1990s was widely predicted to significantly impact on the level of business travel. In fact, with the growth in foreign travel and increasing economic globalisation, together with the expansion of foreign markets, particularly in South East Asia, recent statistics reveal that there were 8.1 million business visits made in 2004,1 many to high-risk destinations.

Little data exists on working hours lost through travel-related illness and it seems that many of such illnesses are widely likely under-reported.
The traveller may not see the point in reporting an illness that resolves before returning home, even if the illness has disrupted working hours on the trip. Also, there may be particular reluctance to report an illness that could have been acquired either by risky travel behaviour or by lack of compliance with advice. What is certain is that to fly thousands of miles and then be unable to perform at optimum levels due to travel-related illness is not a cost-effective or desirable situation for traveller or employer.

An employee returning to the UK suffering from illness acquired while abroad on business can also have a negative impact on both company productivity and staff morale. It is clear that both employer and employee have much to gain from ensuring that the risks of contracting travel related illness are, as far as possible, minimised.

The business traveller does, however, have some considerable advantages over tourists regarding safe and healthy travel. Many travellers venture abroad each year without seeking pre-travel health advice,2 but some of the issues that may deter tourist travellers are not relevant to the business traveller.

Difficulty in making travel appointments is seldom a problem as OH departments usually recognise the importance of equipping employees with protection and will arrange appointments even at very short notice. Cost issues do not limit the choice of vaccines and anti-malarial tablets, and if medical attention is required while abroad, the business traveller usually has the reassurance of a sound and supportive infrastructure to facilitate healthcare.

Travel risks
Advising business travellers provides a unique challenge. They usually have little opportunity to avoid seasonally-transmitted disease by changing either the destination or the time of the visit, and their trip may involve multiple destinations. The duration may be extended or very brief, and each of these can affect their well-being. Endemic disease, climate extremes and the planned work and recreational pursuits can impact upon physical and psychological health. Time constraints might be tight and the departure date may be imminent before travel health advice can be sought. A thorough risk assessment is the essential first step.

Risk assessment is a two-way process, involving adviser and traveller in information gathering, evaluation of risks and provision of advice and vaccinations. The information required falls into two categories: personal details and trip itinerary. These two sets of information are ‘dovetailed’ to provide advice tailored to the needs of the individual traveller.

Some OH departments begin risk assessment by providing travellers with a pre-consultation form for self-completion. Although these forms provide a useful starting point, they should not be relied upon fully, as many travellers do not recognise the importance of providing accurate and complete details.3

Omissions on the form may result in travellers not receiving the protection they require (see case study on page 26) so this form should be used as a discussion prompt rather than accepted as comprehensive. A sample pre-consultation form is shown in Figure 1 (above).

A risk assessment will highlight how the health requirements of business travellers differ from the needs of tourists. Whereas tourists generally choose to travel and anticipate the trip with pleasure, the business traveller may not relish coping psychologically with the stress of travel, separation from family and friends, and possible culture shock during the trip. Physical health may also concern the business traveller. The circumstances of the visit may limit individual control over health issues. For example, to avoid giving offence while being entertained by local people, the traveller might accept unfamiliar food and drink, which would usually be declined. One example is a recent business traveller to Kyrgystan, who felt obliged to consume raw goat’s liver and entrails when dining with a prospective client.

Travellers are often unpleasantly surprised to learn that they do not have to venture too far from home to be at risk from travel related disease.
The World Health Organisation (WHO) identifies southern and eastern Europe, and some regions of the Middle East, as moderate risk areas for contracting hepatitis A4, and The Green Book recommends immunisation for frequent travellers to areas such of moderate to high endemicity.5

usiness travellers should be warned how easy it is to contract this potentially serious disease and how readily they can be protected.

Myths about hepatitis A being ‘a mild disease’ abound, but a typical case would mean considerable disruption to lifestyle, which could involve five days in hospital, one month off work and six months avoiding alcohol.

Recognising the potential risks close to home emphasises the importance of providing pre-travel advice for all travellers, not just those who will undertake long-haul travel.

Many business trips are made to exotic destinations and it is a common misconception that all business travellers spend a week or so staying in high standard hotels within cities. Both the oil and the aviation industry frequently require employees to travel, often at short notice, to some of the world’s most inhospitable regions. West Africa is a commonly visited destination for these employees, and they are occasionally housed in very remote regions for extended periods of time. Considerable disease risks are present, including malaria, yellow fever and other insect-borne diseases. Hepatitis A, typhoid, polio and cholera are also a risk, because clean water supplies are frequently difficult to obtain, and non-vaccine preventable diseases like schistosomiasis and intestinal helminth infections can also be acquired.

Workers within the chemical industry often visit India, where many factories and production plants are based. Travel to the Indian sub-continent carries significant health risks and the area is recognised as being the most common region for acquiring both typhoid and cholera. Also, more than half the worldwide deaths from rabies occur here.6

Visitors to India may also face a host of other endemic diseases, and discussions with business travellers frequently reveal travel activities that further increase risk factors. Advice was recently given to a group of such travellers, who were travelling through rural India taking water samples from public toilets. The list of disease risks they faced was extensive and included diphtheria, tetanus, polio, hepatitis A and B, typhoid, rabies, cholera and meningoccocal disease. They also faced non-vaccine preventable diseases, including malaria and dengue.

The skilled travel health adviser must encourage the traveller to take some responsibility for maintaining good health when abroad. To do this, the traveller will need to be equipped to recognise and minimise risk factors and also be able to manage minor illnesses effectively. The key is self-education and there are a huge range of books, websites and other resources available to travellers. Some of these are shown on the resources page (page 31) and can be used to direct business travellers towards self-teaching.

Is it ever too late to administer vaccinations to a business traveller whose departure is imminent? The answer is a very definite ‘no’.
There may be insufficient time for full protection to develop before the immediate trip, but nevertheless, the traveller will still be acquiring a little more protection each day.

It is also helpful to consider the ‘bigger picture’. Few business travellers make only one trip so it is worth bearing in mind even vague future travel plans when deciding on vaccine schedules. Fortunately, the travel health adviser now has a wide range of vaccinations and schedules available, which helps to meet the needs of ‘late presenting’ business travellers. Vaccines currently available are shown in Figure 2 below.

The introduction of combined vaccines and the use of new accelerated schedules have also made schedule planning easier and more flexible.
In addition to the frequently used travel vaccines, business travellers often also need protection against diseases rarely encountered by holiday tourists, such as rabies, cholera, Japanese B encephalitis or yellow fever. Time constraints may be tight, but fortunately there are options available for very short notice protection.

Sourcing rabies specific immunolobulin (RIG) for post-exposure prophylaxis has become difficult in recent months due to supply shortages. As travellers who have had pre-exposure rabies vaccines do not need RIG (although they do still require two post-exposure doses of rabies vaccine), pre-exposure vaccines are becoming more widely used. The schedules for rabies vaccine administration require three doses to be given over a 21 or 28-day period to achieve immunological protection. However, short-notice travellers can be given two doses at least seven days apart. A reinforcing dose is required at six months to ensure longer-term protection.6

A recent addition to the range of available travel vaccines is the oral cholera vaccine. This vaccine provides a high level of protection for those whose plans are so uncertain that they might find themselves in areas where it is difficult to ensure hygienic facilities.

The importance of seeking timely pre-travel health advice should be emphasised to all business travellers, as highlighted by yellow fever and Japanese B encephalitis vaccines. A yellow fever certificate only becomes valid 10 days after vaccine administration, while the Japanese B encephalitis vaccine courses should be completed at least 10 days before travel to reduce the risk of delayed allergic reactions while travelling (the Japanese B encephalitis vaccine remains unlicensed in the UK).

The use of recall systems to encourage business travellers to complete schedules, even after their trip, is worthwhile as they can simplify future consultations.

Vaccine administration
Historically, some practitioners have been wary of administering several vaccinations simultaneously. A recent study has, however, increased acceptance of the practice by demonstrating that people who received several vaccinations simultaneously showed a high level of tolerability.7

Administering multiple vaccines can greatly increase the range of vaccine protection given to late presenting business travellers, and many nurses have already adopted the now widely accepted practice of administering two vaccines into the same limb, keeping the injection sites at least 2cm apart.

In 2004, 59 cases of imported malaria occurred in business travellers.8 As just one bite from an infected mosquito can transmit this potentially fatal disease, compliance with chemoprophylaxis and bite avoidance measures are vitally important even for the shortest of trips to infected areas.

The current UK Guidelines on Malaria Prevention emphasise the importance of complying with antimalarial regimens.9 A study examining the attitudes and practices of business travellers with regard to malaria risk concluded that greater knowledge might improve compliance.10 OH travel advisers may consider adding an ‘E’ to the usual ‘ABCD’ of malaria avoidance, with the ‘E’ being for Education!

Recently a shorter, more ‘user-friendly’ anti-malarial regime has made compliance with chemoprophylaxis much easier. Atovaquone and proguanil, started one or two days pre-travel, taken during the visit and continued for one week after leaving a malarial area, is an ideal choice for business travellers, particularly those making repeated short trips.

Follow-up consultations
All business travellers should be offered a follow-up meeting post travel. This gives them the opportunity to discuss in confidence any health worries that arose from their trip, or to highlight where travel services could be improved. The use of a self-completed form again makes a good starting point for the meeting.

Some useful questions would include: Did the traveller suffer from any illness while travelling or on their return? What was the illness? Was medical help sought and, if so, what was the outcome? Did the illness disrupt business objectives? If a travel pack was supplied, were the contents adequate? Can the traveller highlight any potential risk factors at the destination that haven’t previously been identified?

Follow-up meetings also allow the travel adviser to collect anonymous data to assist with departmental reviews, audits of services and sickness reporting.

It can also contribute to shaping future travel health policies. In 2004, the Health Protection Agency produced a report detailing illness associated with foreign travel.11 This report will assist health professionals to target travel health advice more effectively, but the value of the report relies on the accurate recording and reporting of illnesses acquired abroad.

Business trips require self-management of health risk factors and illness, and the traveller must be discouraged from the unrealistic expectation that ‘the company’ should wholly assume responsibility for his health. Those who travel regularly may have become blas and every pre-travel consultation should be used to increase awareness of risks

Although some travel-related illness is relatively minor, travellers’ iarrhoea for example, and others including hepatitis B, can impact on lives for months or even years after the visit. Others, such as malaria, may only present months after the visit.

Addressing the diverse travel health needs of business travellers can be complex. There is no convenient ‘one-size-fits-all’ type of traveller or trip. Each industry has widely varying expectations of employees, and the travel adviser must fully appreciate the health hazards that may arise from each journey, to provide advice relevant to the individual traveller.

Norma Evans is an independent specialist nurse in travel health and immunisations. She works with a company that provides in-house travel health sessions for business travellers and manages a private travel health clinic. She also runs a company, established in 2004, providing travel health training for all disciplines of health professionals. Evans is a member of the British Travel Health Association and the International Society of Travel Medicine.

1. Office for National Statistics (2005)
2. Calvert L (2000) Provision of travel medicine services. In: Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F (Eds). Travel Medicine and Migrant Health. Harcourt Publishers, London, 59-69
3. Raeside F (2000) Risk Assessment. In: Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F (Eds). Travel Medicine and Migrant Health. Harcourt Publishers, London, 59-69
4. World Health Organisation (2005)
5. Department of Health (1996). Immunisation against infectious disease (The Green Book)
HMSO. London
6. National Travel Health Network and Centre (2005).
7. Borner N, Muhlberger N, Jelinek T (2003). Tolerability of Multiple Vaccinations in Travel Medicine, Journal of Travel Medicine.10, 2, 112-116
8. Health Protection Agency (2005) CDR Weekly 15, 24, June.
9. Health Protection Agency (2003) Guidelines for malaria prevention in travellers from the United Kingdom for 2003.
10. Weber R, Schlagenhauf P, Amsler L, Steffen R, (2003). Knowledge, Attitudes and Practices of Business Travellers Regarding Malaria risk and Prevention. Journal of Travel Medicine 10, 4, 219-224
11. Health Protection Agency (2004). Illness in England, Wales and Northern Ireland Associated with Foreign Travel: A Baseline report to 2002. HPA. London.

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