Workers traveling? Think health and safety

Occ-health nurse should help with planning

International travel has become an almost routine component of business as more and more corporations extend their interests globally. For the occupational health nurse, this means not only keeping tabs on workers at the home office, but those whose work takes them to potentially hazardous parts of the world.

Most business travelers assume they might need shots before they travel, but the employee's current health as well as conditions where he or she is traveling are factors for the occ-health nurse to consider, says travel medicine consultant Gail A. Rosselot, MS, MPH, NP, COHN-S, president of Travel Well of Westchester, NY.

OSHA in 2002 issued a technical bulletin, "Safety and Health During International Travel," in which it recommended that employers identify employees who travel internationally and refer them to qualified health care professionals for obtaining travel information and vaccinations, but does not mandate that employers provide those services or vaccines.

Occupational health nurses, should identify all international travelers in their workplaces and establish a policy that sets out what pre-travel preparations those travelers should receive. The policy should be applied consistently to employees at all sites and employment category, Rosselot adds.

Prevention starts with an educated nurse

Although vaccines are the first thing that most people think of when contemplating travel to a country where disease is an issue, most travel health concerns are not vaccine preventable. Injury, illnesses, and recurrence of prior health problems are all risks when traveling, and almost all can be prevented with pre-travel preparation.

"Vaccines are important, but there are many more prevention measures that are much more important," Rosselot says.

The responsibility of knowing what the health and safety risks are for employees traveling abroad naturally falls to the occupational health nurse, and it can be a constant challenge to keep up with. The risks and disease threats change almost daily in some areas of the world, and there are few opportunities for formal or ongoing training, because the information changes so rapidly.

Despite the challenge of keeping up with the ever-changing field of travel health, the occ-health nurse should push employers to provide resources for them to stay abreast of the potential health risks to their traveling employees.

Most information is web-based, so it can be quickly updated, but some occ-health nurses don't have ready access to the Internet at work.

"It's not enough to have a plan and policy. The person delivering the message to employees has to be adequately educated, and most nurses know this and quickly realize when they're out of their element," Rosselot says. "Most employers are reluctant to provide the resources necessary for them to train, but it's worth it for nurses to push for it."

Once a policy is in place, it should be disseminated early and often. New hires and newly promoted employees should be sent a letter describing the company's business travel policy, with encouragement to visit the company nurse long before the trip is imminent. Rosselot says she encourages nurses to send the letters home in any materials that might be seen by a spouse who could act as an additional reminder to the business traveler.

If there is a positive outcome of the SARS and avian influenza outbreaks, Rosselot says, it is the heightened recognition they have brought to the need for precautionary travel medicine.

Plan before packing

While some business travelers will show up at the nurse's door with bags packed and ticket in hand, some advance preparation is far preferable to cover as many anticipated risks as possible.

Rosselot suggests the nurse get to know the patient and any inherent risks in his or her background. Ask about the traveler's current health, any medicines being taken, and the duration of the time away.

"Once you have the employee there, you have your baseline, and then you become a partner with that person throughout the time they travel," she suggests. "You are their partner for prevention, and it's a rewarding part of the job."

If the traveler will be gone for a long period of time (many weeks or months), preventive care such as dental checkups and physical exams should be scheduled; the occupational health nurse may need to help facilitate "rush" appointments, and Rosselot says having a network of practitioners who can be called on in emergencies is helpful in these cases.

"The plan follows the general outline for occupational health: pharmacological and non-pharmacological risk reduction," she says. "That's what we're talking about—reducing risk for injury and illness."

Pre-travel preparation includes educating the traveler so that he or she can maximize self-care on the road if prevention measures don't work, and reducing their exposure to potential risks.

"The bottom line for employers is the bottom line, and that means keeping the trip successful from a business point of view. A sick traveler who has to stay in bed, get medical treatment on the road, or return home early is not a successful business traveler," Rosselot points out.

The nurse's challenge, then, is to prioritize the known risks and customize a prevention plan that is realistic. Downloading and printing out reams of information about tropical diseases that might be encountered could make for interesting reading on the plane, but too much information can overwhelm and unnecessarily scare the traveler, Rosselot cautions.

Practical information that applies to that traveler is more likely to be retained and of benefit. Risk minimization — hiring a driver or taking a cab rather than renting a car and driving — deserves plenty of attention from the occupational health nurse.

Accidents — motor vehicle accidents, drownings — are the #1 cause of morbidity and mortality in people traveling abroad, says Rosselot. And underlying health problems (versus exotic diseases) are the more frequent cause of hospitalization.

"You have to prioritize and identify what the real risks are to that employee, and weed out the less likely risks," she says.

"Certainly corporate travelers can be told not to rent a car on their own and not to participate in certain activities, like corporate bungee-jumping with the clients."

Some companies elect to make corporate travel contingent upon the employee being evaluated by the company doctor or nurse before getting on the plane, or checking in every year with employee health.

"When you see someone in private practice in an outpatient setting, you don't have a lot of control over their trip, but their employer does," says Rosselot. "The Peace Corps, for example, will not pay out a dollar in insurance benefits if a volunteer is hurt or killed riding a motorcycle. The employer can say that if you do certain things, it's at your own risk."

Traditional travel advice — don't drink the water, don't eat raw fruits and vegetables, and avoid areas where mosquitoes are plentiful if malaria is a risk — still holds true, and many travel medicine clinicians suggest a baseline tuberculosis test before travel to at-risk areas and one upon return.

Cover pharmacological measures

Immunizations are the obvious first-line pharmacological measures to review for a business traveler. Some vaccines can be given once, and as late as the day of travel. Others need repeat doses, usually a total of three, so if the first shot is given just before departure, the nurse may need to locate a health resource at the destination for the immunization to be completed.

Travel medications that cover traveler's diarrhea (which affects up to 60% of travelers in some settings) and malaria should be included in a medical kit that accompanies the traveler. Basic first aid supplies should also be included, as should a broad-spectrum antibiotic in case travel diarrhea is acquired. With any medications, the traveler should be thoroughly familiarized about how and when it should be used.

Another pharmacological strategy is to monitor and evaluate the employee's health while he or she is traveling. This is particularly important if there is a chronic or serious health issue with that person. The nurse might choose to have the patient call in at scheduled times during the trip, or if a medical resource is available at the destination, the traveler could be monitored on location.

"When they come back, do a follow-up and find out how they did," Rosselot suggests. "Ask what they used in their medical kit, what risks they encountered, and what worked for them and what needs to be improved. This tells you if you're meeting your goals for traveling employees, and also looks good in year-end reports."

Rosselot says it's a horrible thing to consider, but since the first outbreaks of avian influenza two years ago, she has made it a point to talk with business travelers about making sure they don't find themselves unable to return home.

"I talk about avian flu to every traveler, whether they're gong to countries that have reported outbreaks or not, because it's a global issue," she says. "I tell them that if they become aware of sustained human-to-human transmission, they should get themselves home immediately, and that's it. I'm not concerned with Tamiflu, I am concerned with people being locked out [outside U.S. borders]."

Among the United States' contingency plans should avian influenza or other disease become pandemic is to close its borders, to try to limit or slow the spread as much as possible. This won't happen overnight, but airports could quickly become overwhelmed and air travel could be crippled in the ensuing panic.

"I tell travelers that if they become aware of a situation, they should get to the airport immediately and get on line for a flight home," says Rosselot. "If someone is stranded outside our borders, it's unthinkable, but we don't have any magic bullets here in the U.S. We're just as vulnerable to the spread as anyone else, and trying to control our borders is all they'll be able to do."

Pandemics are not the only threat travelers should be advised to watch for. Political unrest and natural disasters — such as approaching hurricanes — are worthy of attention. "Don't ruin their travels by dwelling on the negative," Rosselot advises nurses. "Just tell them to keep their wits about them and stay aware."

[For more information, contact:

Gail A. Rosselot, MS, MPH, NP, COHN-S, president, Travel Well of Westchester, 140 Todd Lane, Briarcliff Manor, NY 10510. E-mail:]