Pre-Travel Preparation of Business and Occupational Travelers

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Readers are invited to submit letters for publication in this department. Submit letters online at http://joem.edmgr.com. Choose “Submit New Manuscript.” A signed copyright assignment and financial disclosure form must be submitted with the letter. Form available at www.joem.org under Author and Reviewer information. To the Editor: The recent Journal of Occupation and Environmental Medicine article, “Pre Travel Preparation of Business and Occupational Travelers Analysis of Global TravEpiNet Consortium”1 points out the importance of and differences in business occupational travelers and leisure travelers. Business travelers are one of the largest and fastest growing at-risk occupational groups and the article is timely and addresses key issues in occupational and environmental medicine. Pre-travel preparation is the key to the prevention of illness and accidents during international travel. A specific concern in business/occupational travelers is appropriate vaccination. As noted in the abstract/article, the refusal rates for the more common influenza, hepatitis B, and meningococcal vaccines were striking for business travelers. In addition to protection of the traveler, the importation of influenza to the workplace and loss of productivity is a special concern. Hepatitis B is a concern for all business travelers, yet only 60% receive vaccination. Another significant issue is the very low proportion of the population who received rabies and Japanese encephalitis (JE) vaccinations despite relatively low refusal rates. Although it may be unlikely that business travelers will come in contact with animals infected with rabies, the risks for JE are different and changing. JE has been characterized as a mosquito-borne disease contracted in rural rice growing areas in travelers with a long stay. Currently, the Advisory Committee on Immunization Practice (ACIP) only recommends JE vaccine “for travelers who plan to spend a month or longer in endemic areas during the transmission season.”2 The length of stay of 1 month is arbitrary and there have been deaths with short visits and without plans to travel to rural or “agricultural areas.” Historically, most cases have been associated with “longer stays”; however, the demographics are changing. A study of travelers from 1973 to 2008 (Hills et al)3 reported that 65% of cases stayed 1 month or longer. However, a study of cases from 1992 to 2008 (Buhl and Lindquist)4 showed less than half of the visits were over 1 month. In addition, most of the cases were not visits to rural or farming areas and often were not during the transmission season. ACIP recommendations do include “consideration for short term travelers that are engaged in ‘at risk”’ activities (eg, trekking, hunting, farming), but the demographics of Asian travelers have changed.2 In a recent article that is also based on the Global Travel EpiNet Consortium (GTEN), 63% of Asian travelers at high risk for JE listed business/occupational (business, research/education, humanitarian service work) as a reason for travel.5 For example, a significant change in JE risk for business/occupational travelers is peri-urban exposure. Manufacturing and housing facilities are often located outside major cities in higher risk areas. With increased numbers of US-owned manufacturing facilities, more travelers/assignees provide engineering, finance, training, and auditing support. The study by Deshpande et al5 also showed that only 28% of travelers deemed by current ACIP recommendations to be at high risk received vaccination even in the sophisticated GTEN network. Other studies have shown that 1% to 11% of at-risk Asian travelers receive JE vaccine in peri-urban areas.6 This finding suggests that vaccine providers were not able to follow current guidelines. The primary reason for the failure to receive indicated vaccination in the study by Deshpande et al5 was the vaccine “was not indicated,” which is consistent with the current GTEN study. In the current GTEN study, despite low vaccination ratio, JE had the lowest refusal rate 12% for JE (19% for rabies), which supports previous findings that costs and concerns about the vaccine safety are not the significant issue.6 Guideline changes are currently under consideration by the ACIP. New guidelines for JE vaccine were proposed at a Japanese Encephalitis Working Group that met in conjunction with the American Society of Tropical Medicine and Hygiene (ASTMH) Annual Meeting in November 2014. The revised recommendations would be (1) A discussion of JE and availability of a safe and effective vaccine with all travelers to endemic areas of Asia; (2) travelers to rural or peri-urban areas in endemic countries, irrespective of duration of travel or itinerary, should be offered the vaccine; (3) all expatriates living in endemic countries or frequent travelers who may visit rural or peri-urban areas in endemic countries should be offered the vaccine; (4) travelers with uncertain itineraries or itineraries that may change should be offered the vaccine; and (5) the vaccine is not generally recommended if travel is restricted exclusively to urban areas. Most business/occupational travelers to GTEN clinics were referred by the business. It is anticipated that all indicated vaccines will be administered and that the decision to recommend vaccination will be made using conservative guidelines that will minimize health risks and reduce liability for the business. The failure to administer safe, effective vaccinations and the use of outdated recommendations are a significant concern for business and occupational travelers. In order to ensure compliance and reduce risk, clear guidelines are needed for all vaccines. Clear guidelines must be combined with a meaningful discussion with the traveler of the disease risks and safety of each travel vaccine. Both the differences in business/occupational travelers and the special risks of the company/payer and the need for comprehensive vaccinations must be understood by the travel health provider, the traveler, and the referring business.

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