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Assessing Risk and Improving Travel Vaccine Programs for Business Travelers

Bunn, William B. MD, JD, MPH

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Journal of Occupational and Environmental Medicine: November 2014 - Volume 56 - Issue 11 - p 1167-1168
doi: 10.1097/JOM.0000000000000318
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The number of US international travelers increased to 982,000,000 in 2011, with travelers for business now consisting almost half international trips. The numbers of expatriates and short-term assignees continues to increase globally. In addition, the geography of international business travelers (sometimes referred to as occupational travel) is changing with increasing travel to emerging economies, particularly in Asia. Although Western Europe trips constitute 39% of international travel, more than 25% of trips are to Asia and the trend will continue.1 Therefore, international occupational and environmental medicine is a growing challenge and an area of increased focus for practitioners of occupational medicine.

The article on international travel by Druckman et al2 in this issue emphasizes the need for detailed assessment of the risks and preventive measures needed for business travel. Safe business travel is a significant issue for global commerce, which is an important and growing issue with expansion into new markets with different health risks.

The findings of this study with more than 800,000 business trips demonstrate that safe business travel is a significant issue and emphasizes the importance of internationalization. Understanding the risk factors and developing programs to prevent illness and accidents is a challenge for business travelers, short-term assignments, and expatriates.

The article focuses on hospitalizations and medical evacuations of business travelers and emphasizes the need for better data to design successful international medicine programs. An analysis of expatriates is discussed in a previous article.3

The results of this study show that aggregate “low-risk” countries required greater demand for serious problems (hospitalizations and medical evacuations) than “high-risk” countries. Nevertheless, country risk categorization remains a major determinant of the risk. The article emphasizes that infectious disease is not the only the focus of international occupational medicine programs for business travelers but accidents must also be a focus of education programs. The article also distinguishes the risks of business travelers and expatriates and the programs needed to protect the groups. Expatriates have better support systems and better information on local health and safety risks and the quality of medical care leading to fewer serious cases. The article concludes that effective programs are necessary for all risk groups, and improved understanding of travel-related risks will help determine resource allocation and mitigation efforts.

Hospitalization and evacuation are often the result of unanticipated risks and the failure to provide effective prevention programs. The goal of international occupational health programs is to reduce or eliminate these adverse risks.

International occupational preventive health programs include effective identification of travelers, assignees, and expatriates, screening for existing medical risks, health education, and appropriate vaccination and prophylaxis, travel and destination health risk information, travel kits, information on best acute care outpatient and inpatient care at each destination, and information on access to evacuation and repatriation. The information must be comprehensive and regularly updated. Although vaccines are a focus of travel medicine clinics, education on preventive measures for accidents and detailed measures to prevent illnesses is a vital component of preventive care for all travelers.

A second recent article by Kogleman in the Journal of Travel Medicine “Knowledge, Attitudes and Practices of US Practitioners Who Provide Pre-Travel Advice” focuses on vaccines and medical advice for travelers.4 The Kogleman article is based on surveys of providers of travel medicine advice (primary care physicians [PCPs], which include most occupational and environmental medicine physicians and travel medicine specialists). The article concludes that PCPs were less prepared to render advice on vaccine-preventable illnesses. The knowledge gap was more significant for less common diseases and unfamiliar locations and recommends travel medicine education and certification (eg, the certificate program of the International Society of Travel Medicine) for PCPs.

The study finds that there are more pronounced differences for “less common” diseases. For example, Kogelman et al4 point out that 70.3% of PCPs were “very unfamiliar or somewhat familiar” with Japanese encephalitis (JE) (54.6% for yellow fever vs 2.6% for hepatitis A), 19.9% were somewhat familiar with JE (26.9% for yellow fever vs 18.8% for hepatitis A), and 9.8% were very familiar with JE (18.5% for yellow fever vs 78.6% hepatitis A). This survey study emphasizes the need for better knowledge of JE vaccine among providers. Despite concern with the safety of earlier vaccines from mouse brain tissue, since 2009 a purified cell culture vaccine with excellent safety profiles has been available. Nevertheless, on the basis of sales of vaccine and World Travel Organization data on travelers to JE endemic countries, less than 1% of travelers who could be at risk are vaccinated.

There are several advisory bodies that have made recommendations for JE and other less common vaccines. The Advisory Committee on Immunization Practices’ JE recommendations state, “JE vaccines are recommended for travelers who plan to spend a month or longer in endemic areas during the JEV transmission season.” The recommendations for vaccination also include long-term travelers and expatriates who may be based in urban areas but are likely to visit endemic rural or quarantined areas during a high-risk period. JE vaccination should also be considered for short-term travelers if they plan to visit outside of an urban area to an area that has an increased risk for JE exposure because of activities, or staying accommodations, or those with uncertain itineraries. In addition to the Advisory Committee on Immunization Practices (Centers for Disease Control and Prevention), the US Department of Defense and US Occupational Safety and Health Administration supports these recommendations. In a 2009 Journal of Travel Medicine article by Bouchard et al,5 an expert panel recommended the vaccination of expatriates, repeat travelers, travelers with a long duration or rural travel to at-risk areas as well as travelers wishing maximum protection. The article notes that although there are successful vaccine programs in Asian countries (eg, Japan, China, and Republic of Korea), the risk for JE persists for the unimmunized traveler.

Rare indications like JE that may be unfamiliar and represent a risk for business travelers if counseling and appropriate immunization are not adequate. Therefore, for occupational and environmental medicine practitioners a sound knowledge of travel medicine, including vaccines, is needed. External providers of travel medicine services should be carefully screened. Although US and international guidelines are available as well as automated decision support systems, the risks of the business traveler and international guidelines change rapidly and require ongoing diligence.

The two articles point out unique considerations for international business travelers. Effective health education on vaccination and evacuation for business travelers is an expectation and considered a cost of doing business for most corporate travelers. Business travelers show a similar incidence of travel-related illness to other types of travelers despite the perception that business travel destinations present less risk. The confidence that the health, safety, and security risks have been minimized is crucial for expatriates, short-term assignees, and business travelers and their families. The cost of indicated vaccination is normally borne by the company and is paid by individual reimbursement from the business, by a contractual arrangement with the provider organization or in an on-site occupational health clinic. Some companies provide traditional insurance coverage for travel vaccines, but this approach is unusual. In the United States, business travelers are usually immunized according to Centers for Disease Control or World Health Organization guidelines, guidelines from expert databases (eg, Travax), or other definitive sources. Many corporations require appropriate travel medicine care before travel, particularly for expatriates.6,7

In addition, for business travelers both tort suits for negligence and Workers Compensation claims may be filed. The costs of damaged public relations as well as legal liability must also be considered. For corporations the costs of evacuation repatriation and lost productivity are significant considerations. Previous studies show that appropriate Travel Medicine and International Occupational Health programs will be cost-effective and reduce the risk for business travelers.6,7

Together, these recent articles highlight the importance of international business travelers in occupational medicine. They emphasize that comprehensive international health programs must focus on “low-risk” destinations and rare diseases. The articles provide specific guidance for the business traveler and emphasize the need for diligence in the protection of all international travelers.


1. Chen LH, Leder K, Wilson ME. Expert review vaccines: “vaccine considerations for business travelers.” Expert Rev Vaccines. 2013;12:453–466.
2. Druckman M, Harber P, Liu Y, Quigley RL. Assessing the risk of work-related international travel. J Occup Environ Med. 2014;56:1161–1166.
3. Druckman M, Harber P, Liu Y, et al. Country factors associated with the risk of hospitalization and aeromedical evacuation among expatriate workers. J Occup Environ Med. 2012;54:1118–1125.
4. Kogelman L, Barnett ED, Chen LH, et al. Knowledge, attitudes and practices of US practitioners who provide pre-travel advice. J Travel Med. 2014;31:104–114.
5. Burchard GD, Caumes E, Connor B, et al. Expert opinion on vaccination of travelers against Japanese encephalitis. J Travel Med. 2013;20:165–170.
6. Bunn WB, Vaccine and international health programs for employees traveling and living abroad. J Travel Med. 2001;8(suppl 1):S20–S23.
7. Bunn WB. Risk and burden associated with the acquisition of viral hepatitis A and B in the corporate traveler. J Occup Environ Med. 2008;50:935–944.
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