Overview
Travelling abroad has now become a common feature of many types of employment
Hazards faced by occupational travellers may appear similar to those of the general tourist but various interrelated factors can combine to make travelling for work a less favourable experience
The majority of problems experienced by overseas travellers are minor, self-limiting conditions; but a small proportion will result in hospital admission, repatriation and death
Employers retain a duty of care for staff while they are abroad
Preparation of the occupational traveller should include consideration of individual, occupational and destination related risks
Introduction
In recent years as the world embraces a global economy, travelling abroad, has now become a common feature of many types of employment. Advances in air travel and accessibility have led to the acceptance of this scenario as a typical job task, and many companies often assume that their employees are now ‘transnationally competent’.
Those who travel overseas for work (from hereon referred to as occupational travellers) represent an important group of international travellers, and include both short- and long-term travellers (including expatriates), across a range of occupations. They are exposed to a variety of hazards, including those that may not be present in their home country, and while the hazards faced by occupational travellers may appear similar to those of the general tourist; various interrelated factors can combine to make travelling for work a less favourable experience (Box 19.1). Therefore, protecting the health and safety of those who travel overseas for work has become an increasingly important aspect of occupational and environmental medicine.
- Locations, times and dates are not chosen for enjoyment, interest or potential adaptability to the traveller
- Country, language, people and culture are not usually chosen for their potential compatibility with the traveller
- There is usually no chance for rest upon reaching the overseas destination, although some companies insist on rest on arrival at destination and advise against scheduling important meetings in the first 24 hours
- The occupational traveller is often very busy when away, usually travelling for the sole purpose of working
- The nature of the work may render occupational travellers targets for violence, kidnapping, etc.
- There is usually limited opportunity to recover after returning home as schedules often require a prompt return to work
Travel-Related Health Problems
Various studies have made it possible to obtain some consensus regarding the type of illness and the degree of risk experienced by travellers. Diarrhoea, upper respiratory infections and skin disorders are the most common travel-related illnesses. Although the majority are minor, self-limiting conditions, of those travellers who become unwell up to 30% may be confined to bed, 19% will need to consult a doctor and 2% are admitted to hospital. Deaths are fortunately rare; with cardiovascular disease followed by accidents and injuries being the most frequently recorded cause of death. Accidental death being highest in men in the 20–29 year age group.
Research on occupational travellers reveals similar findings, although illness rates tend to be higher and psychological problems more prominent. For expatriates in particular, as a result of their longer stay overseas, illnesses (including unusual infections), hospital admission, injury, violence and psychological problems are more frequently reported, while accidents and injury account for most deaths. Key findings from some studies on the health of occupational travellers are summarized in Box 19.2.
World Bank Traveller Study
- Medical insurance claim rates were 80% higher for men and 18% higher for women travellers than their non-travelling counterparts
- The rates of claim were increased for all major ICD-9 diagnostic categories for men and most ICD-9 diagnostic categories for women
- Rates of claims were highest for psychological disorders, followed by intestinal disease and respiratory disease
Coca Cola travellers
- Over 80% of respondents reported illness
- Diarrhoea (35%) and respiratory infections (29%) were the most commonly reported problems with 12% of travellers seeking medical attention
In expatriates
- In multinational peacekeepers, orthopaedic complaints, dental problems or injuries were the most frequently reported outpatient problems, and suspected tropical disease and injuries were the commonest cause of hospital admission
- In Voluntary Service Overseas volunteers, diarrhoea was the most prevalent problem and experienced by 80% of respondents. This was followed by skin (40%) and dental problems (23%). Over 25% of volunteers reported ongoing ported ongoing health problems on return home
- In Red Cross expatriates, diarrhoea (44%), fever (26%) and fatigue (20%) were the most common problems. Over one-third reported their health was worse upon return home and 40% reported their assignment had been more stressful than expected, due mostly to the working environment and working relationships
- In British diplomats, 21% consulted a doctor for a new health problem. Injuries (29%), musculoskeletal disorders (19%), and infectious diseases (13%) were the principal problems. 4% were admitted to hospital, and 2% required repatriation. Employees and unaccompanied staff were at greater risk of illness or injury
Air Travel
Air travel itself may pose a risk to health and wellbeing, and although illness directly due to air travel is uncommon, exacerbation of pre-existing conditions due to changes in air pressure, humidity and oxygen concentration, relative immobility during flights and close proximity to passengers with communicable diseases are all potential risks (Box 19.3).
- Cabin air pressure is equivalent to air pressure at 1800–2400 (metres above sea level)
- Healthy travellers will not usually experience any problems
- Hypoxia may affect those with heart and lung diseases and blood disorders such as anaemia
- Gas expansion may cause barotrauma—particularly in those with ear, nose and sinus infections, and following some forms of surgery or medical treatments/tests that introduce air or other gases into a body cavity
- Cabin humidity (humidity is usually less than 20%) may cause skin dryness and discomfort to the eyes, mouth and nose but presents no risk to health and does not cause internal dehydration
- Travellers with pre-existing medical conditions should be assessed by a medical practitioner to determine their fitness to fly-guidelines on assessment for fitness to fly are available from the UK civil aviation authority
Relative immobility and venous thromboembolism (VTE)
- Risk of venous thromboembolism is increased two- to threefold after long-haul flights (>4 hours)
- Risk increases with the duration of travel and with multiple flights within a short period
- In absolute terms, an average of 1 passenger in 6000 will suffer from venous thromboembolism after a long-haul flight
- Measures that can reduce the risk of travel related VTE include:
- avoidance of dehydration and excessive consumption of alcohol
- wearing loose clothing around the waist or lower extremities.
- walking around the cabin as much as is practical at regular intervals during the flight
- regularly flexing and extending the ankles
- wearing properly fitted flight socks
- avoidance of dehydration and excessive consumption of alcohol
- The use of aspirin to prevent VTE is not recommended, but for those at increased risk of VTE (malignancy, antithrombin deficiency, etc.) specialist advice re anticoagulation therapy should be considered
Transmission of communicable diseases
- There is very little risk of any communicable disease being transmitted on board an aircraft. Transmission of infection between passengers is therefore usually as a result of direct contact or indirect contact. However, a major concern is air travel as a vehicle for the international spread of infectious disease
Tuberculosis (TB)
- Although the risk of transmission of TB onboard aircraft is low, experts agree that contact tracing for flights >8 hours are warranted when an ill traveler meets World Health Organization criteria for being infectious during flight
Severe acute respiratory syndrome (SARS)
- While of concern, the risk of transmission of the disease in aircraft was found to be very low
Influenza
- Transmission of the influenza virus aboard aircraft has been documented, but data are limited. The 2009 influenza A (H1N1) pandemic began in April 2009, and while air travel played a significant role in its global spread, there are limited data about in-flight transmission, and to date in-flight transmission does not appear to occur frequently
Other Infections of Concern Include Measles and Bacterial Meningitis
Jet Lag
Jet lag is a syndrome associated with rapid long-haul flights across several time zones. It is characterized by sleep disturbances, daytime fatigue, reduced performance, gastrointestinal problems and generalized malaise. The incidence and severity of jet lag increase with the number of time zones crossed, with eastward travel being worse than westward travel. The adjustment of circadian rhythms to a new sleep–wake schedule can be protracted, although jet lag is generally worst immediately after travel and gradually resolves over 4–6 days as the person adjusts to the new local time. The more time zones crossed, the longer the effects take to wear off. For the short-term occupational traveller, in particular, recovery can be impeded by time and other practical constraints due to inflexible work and/or flight schedules (Box 19.4).
Symptoms
- Poor sleep during the new night-time, including delayed sleep onset (after eastward flights), early awakening (after westward flights), and fractionated sleep (after flights in either direction)
- Poor performance (both physical and mental tasks) during the new daytime
- Negative subjective changes (fatigue, headaches, irritability, decreased concentration)
- Gastrointestinal disturbances (indigestion, frequency of defecation, changed consistency of the stools) and decreased interest in, and enjoyment of, meals
Combating jet lag
- Be as well rested as possible before departure
- Eat light meals and limit consumption of alcohol
- Limit caffeine to normal amounts and avoid within 4–6 hours of an expected sleep
- a minimum block of 4 hours sleep during the local night (anchor sleep) is thought to be necessary to allow adaptation to the new time zone so, at destination, it helps to get as much sleep as possible in the 24 hours after arrival
- total sleep time should be made up by taking naps during the day in response to feelings of sleepiness
- exercise during the day may help, but should be avoided within 2 hours of trying to sleep
- as the cycle of light and dark is one of the most important factors in setting the body’s internal clock, a well-timed exposure to daylight (preferably bright sunlight) will usually help
- when flying west, exposure to daylight in the evening and avoidance in the morning (e.g. by using dark glasses) may be helpful
- when flying east, exposure to light in the morning and avoidance in the evening is recommended
- short-acting sleeping pills may be helpful
- melatonin is available in some countries, and is effective in preventing or reducing jet lag. Occasional short-term use appears to be safe, and should be considered for adult travellers flying across five or more time zones, particularly in an easterly direction
- individuals react in different ways to time zone changes. Frequent flyers should learn how their own bodies respond and adopt habits accordingly
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