July 3, 2003

Global Protection for Traveling Employees

Peter Greaney, MD
Board-Certified Occupational Physician
President, WorkCare

The primary responsibility of environmental health and safety professionals (EHS) is to protect and maintain employee health and safety at the worksite. In today's global economy, the “worksite” can be in Asia or Africa, depending on the business. Travel health is designed to assist EHS managers in extending the reach and impact of their corporate health programs to even remote corners of the world. This paper covers preventive measures to reduce risk while traveling abroad; outlines major risk categories, vaccines and treatments and provides an overview of selected hazards and risk reduction measures.

The trend toward globalization of commerce means an increase in out-of-country travel. According to the U.S. Office of Travel and Tourism Industries, more than 25.2 million U.S. residents traveled overseas in 2001, and about 30 percent of these travelers were on International business trips. Travel health experts estimate that 65-75 percent of travelers who visit Asia, Africa or Latin American become ill after one month of stay in these countries, with about one-third requiring a doctor's visit.

Becoming ill overseas is quite different than getting sick at home. When a traveler is stricken by a disease or illness while in a foreign country, the road to recovery is often more complex and challenging. Business travelers in a foreign country who seek medical attention may face language barriers or administrative obstacles that can adversely affect healthcare treatment. Healthcare resources we take for granted, such as clean blood supplies, appropriate medications and facilities, may be limited or unavailable in foreign or developing countries. The cost of seeking medical attention in a foreign country can also be costly. The average medical evacuation cost is about $10,000 per person.

These facts underscore the real risks posed by international travel. Companies that are engaged in international business that require employees to travel abroad will minimize travel health risks to their employees by adopting inclusive, preventative health and safety techniques and processes. To ensure broad coverage, policies and processes should be communicated to the following affected groups:

• Employees whose job requires frequent business travel to foreign countries; their family members
• Employees who are on rotating assignments to foreign countries; their family members
• Expats

Pre-Travel Preventive Measures

Taking pre-travel preventive measures is perhaps the single most effective method to guard against travel health/safety hazards. These measures go a long way in ensuring the health/safety of your business-traveling employees. The following information is not inclusive of every pre-travel consideration, but represents primary preventive measures. For a more complete list, review the resources listed at the end of this article.

Immunizations and Vaccines

Persons traveling abroad should check their family medical records before they travel to ensure they are fully immunized against measles, mumps, rubella (MMR), diphtheria, tetanus, pertussis (DTP or DtaP) and polio.

Typhoid vaccination is not required for international travel, but it is recommended for travelers to areas where there is a recognized risk of exposure to S. typhi. Risk is greatest for travelers to the Indian subcontinent and to other developing countries (in Asia, Africa, and Central and South America) who may have prolonged exposure to potentially contaminated food and drink.

A healthcare provider may recommend a booster dose of polio vaccine to a person traveling to an area where the disease still occurs. Also, a physician may recommend a tetanus/diphtheria booster, if the person has not received one in more than 10 years.

The risk of acquiring Hepatitis A (HAV) during foreign travel varies with living conditions, length of stay, and the incidence of the disease in the area visited. According to the Centers for Disease Control and Prevention (CDC), this illness is the most common vaccine-preventable disease in travelers. The HAV vaccine or immune globulin (IG), or both, is recommended for all susceptible people traveling to or working in countries with an intermediate or a high endemicity of infection. The CDC has a traveler's health web page, located at http://www.cdc.gov/travel/index.htm , that provides detailed information on those countries associated with a high-disease risk.

The risk of Hepatitis B (HBV) infection for international travelers is generally low, except for certain travelers in countries with moderate to high levels of HBV infections. Risk factors include the prevalence of chronic HBV infection in the local population; the extent of direct contact with blood or secretions, or of sexual contact with potentially infected people; and the duration of travel. HBV vaccination should be considered for travelers who plan to reside for 6 months or longer in areas with intermediate to high levels of endemic HBV transmission.

Travelers will need an International Certificate of Vaccination, which is signed and dated by a healthcare professional when the vaccines are administered. The Certificate is recognized worldwide, and is required for entry to some countries.

Other Preventative Health Measures

International travelers are recommended to contact their physician or a travel health clinic prior to travel. A travel medicine physician or healthcare professional experienced in travel medicine can provide an explanation of travel health issues and risks associated with a particular itinerary. These experts can also provide preventive vaccines and medications, a pre-travel health assessment and written documentation, including an International Certificate of Vaccination.

Contact with a travel medicine professional should be made at least one month prior to departure to make sure all appropriate immunizations can be received. Some inoculations take several months to complete. Some Asian, African, and Latin American countries require vaccinations against yellow fever in order to enter the country.

Travelers should also consider a pre-assignment health evaluation as a means to assess personal health prior to a trip. The physical exam may include a complete physical, bloodwork, EKG, chest x-ray, stress test, and pregnancy test. Other health screenings to consider are dental exams, and special health assessments for infants and nursing mothers, who may have unique travel medical considerations. Some countries require a certificate stating travelers are HIV negative.

Travel Preparation Essentials

For those with preexisting medical conditions, a letter should be obtained from the personal physician, describing the medical condition and any prescription medications, including the generic name of prescribed drugs.

If prescription medications are used, the traveler should pack an ample supply of the medication, keeping it in its original container and clearly labeled. It's advised to check with the foreign embassy of the destination country to make sure any required medications are not considered to be illegal narcotics. Travelers are also advised to:

• Carry duplicate copies of required prescriptions (make sure both the generic and trade name of the drug is given)
• Complete the emergency contact information on the inside of the passport page
• Plan ahead. Consult the U.S. Department of State and CDC for health and travel advisories. Study the language, customs and currency of the destination country and carry the address and phone number of the U.S. Embassy for that country.
• Carry an extra pair of glasses and a copy of your eyeglass prescription
• Duplicate the following travel documents: passport, airline ticket, travelers cheques, medical information, itinerary, and emergency and business contact addresses and telephone numbers. Include country code.

Culture & Customs

• Research the cultural traditions, as well as business etiquette. Become familiar with the rules that govern society.
• Consular Information Sheets are available for every country of the world. These information sheets provide valuable insight and can help a traveler effectively navigate the customs and rules of a foreign country. They include such information as location of the U.S. Embassy or Consulate in the subject country, unusual immigration practices, health conditions, minor political disturbances, unusual currency and entry regulations, crime and security information, and drug penalties. This information can be accessed at http://www.travel.state.gov/travel_warnings.html

Security Precautions

The U.S. State departments details security precautions to take when traveling in foreign countries. The information can be accessed at http://travel.state.gov/asafetripabroad.html These security precautions include the following guidelines:

• Be cautious in areas where you are likely to be victimized---crowded subways, train stations, elevators, tourist sites, market places, festivals and marginal areas of cities,
• Beware of pickpockets. They often have an accomplice who will jostle you, ask you for directions or the time, point to something spilled on your clothing, or distract you by creating a disturbance,
• Maintain your privacy. Avoid mentioning your hotel name or destination to strangers. Do not leave personal or business papers in your room. Remove nametags at the end of business meetings. Limit your activities to people with whom you're familiar,
• Be alert. Women should keep purses close to the body. Men should carry wallets in an inside front pocket. Consider a money-belt or necklace purse. Travel major thoroughfares. Use only marked taxicabs. Let a colleague know your destination and expected time of return.
• Be informed. Register with the U.S. Embassy. Listen to local news for information about criminal activity or unfriendly political developments. Avoid clothing or places that mark you as an American. Arrange an overseas phone card and be familiar with its use. In the face of trouble, quickly leave the area.

Selected Hazards

Automobile Accidents
An estimated 1.17 million deaths occur each year worldwide due to road accidents. The majority of these deaths, about 70 percent, occur in developing countries. Automobile accidents are the most likely type of injury to occur during international travel, and pose the greatest risk for death and serious injury. The most common reasons for accidents are faulty driving, road and weather conditions and vehicle safety issues. Following are a few tips on safe driving techniques in foreign countries:

• Obtain an International Driving Permit (IDP),
• Carry both your IDP and your state driver's license with you at all times,
• Many countries have different driving rules. If possible, obtain a copy of the foreign country's rules before you begin driving in that country. Information may be available from the foreign embassy in the United States,
• Be aware that road conditions may be poor, and very different from U.S. standards,
• Certain countries require road permits, instead of tolls, to use on their divided highways, and they will fine those found driving without a permit,
• Always "buckle up." Some countries have penalties for people who violate this law
• Drive defensively, keep the car's gas and water at full levels, and allow extra time to arrive at your destination—be late but alive,
• Always know the route you will be traveling. Have a copy of a good road map, and chart your course before beginning.

Food- and Water-Borne Diseases

Traveler's Diarrhea
Traveler's diarrhea (TD) is the most common problem for foreign travelers, especially in countries with poor sanitation and water purification practices. While TD does not usually develop into a serious disease, it may seem serious and very inconvenient at the time.

Destinations that pose a high risk for this disease are developing countries in Latin America, Africa, the Middle East and Asia. This illness is caused by viruses, bacteria, or parasites found in food or water.

Infectious agents are the primary cause of TD. These pathogens include Escherishia coli, Salmonella Shigella and and Campylobacter. Escherichia coli is the most common causative agent of TD, accounting for one-third of all cases.

The symptoms of TD include abdominal cramps, nausea, bloating, urgency, fever and malaise. Episodes of TD usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited. The medium duration of TD is 3-4 days. Ten percent of cases persist longer than a week.

There are two approaches to prevent the onset of TD: following proper usage and preparation instructions for food and beverage consumption, and use of medications. Selecting appropriate foods and following proper procedures for food and drink consumption can greatly reduce the risk of TD. Travelers should avoid risky foods such as raw or undercooked meat and seafood and raw fruits and vegetables. Tap water, ice and unpasteurized milk and dairy products are also associated with an increased risk of TD, and thus should be avoided. Travelers should limit their drinks to “safe” beverages, such as bottled carbonated beverages, beer, wine, hot coffee, tea or water boiled appropriately or treated with iodine or chlorine. Food eaten from street vendors is considered a higher-risk food than restaurant food.

Using medications that contain the active ingredient Bismuthy Subsalicylate, which is found in products like Pepto-Bismol®, may also be effective in preventing TD. Prophylactic antibiotics are not recommended to prevent TD. Antibiotics should be used as a treatment option. The effectiveness of antibiotic therapy will depend on the agent and its sensitivity to the drug. Bactrim®, Septra® and Cipro® are among the most effective of these drugs. Other antibiotics, such as Noroxin®, may be equally effective. Consult your doctor for instructions on dosage and information on side effects .

Hepatitis A
Hepatitis A (HAV) is viral disease that causes fever, malaise, anorexia, nausea, and abdominal discomfort, followed within a few days by jaundice. It is endemic in underdeveloped countries, and is transmitted by direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested from sewage-contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked, and which can become contaminated during harvesting or subsequent handling. Two HAV vaccines are currently licensed in the United States: HAVRIX® (manufactured by GlaxoSmithKline) and VAQTA® (manufactured by Merck & Co., Inc).

Insect and Animal Vectors

Malaria
Malaria is caused from the bite of a female Anopheles mosquito. Symptoms of the disease include fever and flu-like symptoms, including chills, headache, myalgia and malaise. These symptoms can appear as early as six days after exposure and up to several months after leaving a high-risk area. The disease may also be associated with jaundice and anemia. Kidney failure, coma and death have occurred in persons affected by a severe strain of the disease. High-risk destinations for this disease include: large portions of Central and South America, Haiti and the Dominican Republic, Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania.

Those traveling to areas where malaria exists should practice personal protection measures and use the appropriate drug regime to prevent the disease. Personal protective measures include avoiding exposures in mosquito-prone areas between dusk and dawn (when the mosquitoes are active), using mosquito nets and pyrethroid-containing insect spray, wearing clothes that cover the entire body and remaining in well-screened areas. Travelers are also advised to purchase insect repellant that contains N,N diethylmetatoluamide (DEET). Follow all instructions regarding usage of DEET to minimize adverse reactions.

If the destination is high risk for Malaria, travelers should consider the medicinal use of chemoprophylaxix, which should be taken prior to, during and after travel to such areas. Your travel health doctor can provide consultation on the regime to take, if warranted, based upon known allergic reactions to anti-malaria drugs, and consideration of possible side affects.

Yellow Fever
Yellow Fever occurs in Africa and South America. It is a viral disease transmitted between humans by a mosquito and is a very rare cause of illness in travelers. Most countries have regulations and requirements for Yellow Fever vaccination that must be met prior to entering the country. General precautions to avoid mosquito bites should be followed. These include the use of insect repellent, protective clothing, and mosquito netting. There is a highly effective vaccine for Yellow Fever.

Dengue
Dengue is a viral illness transmitted by mosquitoes. It is found in parts of Africa, Southeast Asia, China, South America and parts of Australia.

Dengue Fever is characterized by sudden onset, high fever, severe headaches, joint and muscle pain, nausea/vomiting, and rash. The rash may appear 3–4 days after the onset of fever. This disease can often be confused with influenza, measles, malaria, typhoid or scarlet fever .

The symptoms of Dengue can be treated with bed rest and fluids. Medications to reduce fever, such as acetaminophen, should be avoided.

Since there is no vaccine for Dengue Fever, travelers should avoid mosquito bites by remaining in well-screened or air-conditioned areas. Travelers to tropical areas are advised to use mosquito repellents on skin and clothing, bring aerosol insecticides to use indoors, and use bed nets.

Other Contagious Diseases

SARS
Severe acute respiratory syndrome (SARS) is a respiratory illness believed to be caused from a new mutation of the corona virus. The disease affects all age groups, yet the highest number of deaths has occurred from patients with pre-existing chronic conditions. The disease causes atypical pneumonia. Symptoms include a fever greater than 100.4°F, with some patients experiencing headache, an overall feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms. After 2 to 7 days, SARS patients may develop a dry cough and have trouble breathing.

The most frequent method of transmission of the corona virus from person to person is droplet transmission. Most cases of SARS have involved people who cared for or lived with someone with SARS, or had direct contact with infectious material (for example, respiratory secretions) from a person who has SARS. For example, if the sick person coughs or sneezes, the virus can be carried in saliva droplets to people nearby, infecting them. According to current data, infected people do not pass on the virus to others during the incubation period. They become infectious only when the first symptoms appear: cough, sneezing – which spreads droplets containing virus particles.

Infectivity is the ability of a virus to jump from one person to another. The recipient must receive a dose large enough to cause the disease. From epidemic reports, it appears that SARS virus has low infectivity (i.e., it requires a large dose to pass on to the recipient). Other members of the corona virus family have very high infectivity.

Virulence is the property of the virus to cause damage to the patient's organs. The SARS virus is very virulent. Other members of the coronavirus family have low virulence.

Only a very small percentage of the population has the disease. Therefore, wearing masks in public places will not give any appreciable protective benefit. However, if a person suspects that they have become infected with SARS, wearing a mask when traveling to the hospital is a civic responsibility.

What To Do If You Think You Have SARs

If you develop fever, cough and muscle pain:
–Inform your supervisor
–Go to the company doctor immediately

If you are quarantined by health authorities:
–Inform your supervisor
–Compile a list of colleagues and customers you have had contact with for the last 3 days and forward it via e-mail to your supervisor
–Do not leave your house for any reason, or entertain visitors during the quarantine period
–If you develop any of the symptoms during the quarantine period, inform relevant health authorities immediately

Summary

The events of September 11th have drastically changed the geo-political climate. EHS professionals who manage employees that are deployed to foreign country job sites now have greater responsibilities in protecting the health and safety of their workers. Emerging terrorist threats have to now be considered a probable security risk for employees working overseas. This requires EHS managers to include updated security guidelines in their corporate health travel policies. Resources for this can be found at the links listed below.

Although it is impossible to eliminate every travel hazard for employees working abroad, a comprehensive travel health and safety program that raises awareness of travel risks and communicates preventive guidelines will provide your employees with the knowledge and tactics needed to reduce illness, injury and harm during international business travel.

Selected References and Resources

U.S. Department of Commerce, ITA, Office of Travel & Tourism Industries. In-Flight Survey. Washington, D.C,: OTTI, 2003.

U.S. Department of State, Bureau of Consular Affairs, American Citizens Services. Road Safety http://travel.state.gov/road_safety.html#safety

The Centers for Disease Control and Prevention. Basic Information about SARs.
http://www.cdc.gov/ncidod/sars/factsheet.htm

CNN.Com. Tips for Enhancing Personal Safety, Reducing Fear.
http://www.cnn.com/2001/US/10/30/tips.personal.safety/

The Federal Emergency Management Agency. Fact Sheet on Terrorism.
http://www.fema.gov/hazards/terrorism/terrorf.shtm

The United States Department. Patterns of Global Terrorism.
http://www.state.gov/s/ct/rls/pgtrpt/2002/