The International Business Traveler

Introduction

Globalization trends have resulted in a dramatic increase in business travel, and, in 2017, approximately 4.8 million U.S. residents traveled overseas for business. Despite the slowdown associated with the COVID-19 pandemic, the Global Business Travel Association predicted in 2023 that business travel, although recovering more slowly than leisure travel, would exceed pre-pandemic levels by 2024. Recent economic and political trends have resulted in outsourcing and offshore manufacturing in an increasing number of countries worldwide, including many countries in Southeast Asia, Africa, and Latin America. Despite this trend in globalization, some companies are using web-conferencing and online and hybrid meetings to cut travel budgets; such approaches have the benefit of cost savings and a lower carbon footprint.

Business travelers include people traveling for conventions, research, work-related training, and volunteer work. Some business travelers combine work with tourist activities, by bringing a friend or family member or by extending their business trip to include a leisure component.

For business travelers, the likelihood of an adverse health event increases with the number of trips made to at-risk areas, the length of time spent at the destination, and lifestyle at the destination. Because many international business travelers take multiple trips each year, travel health professionals should consider the cumulative risk to the traveler and not just the risks of the current trip.

Differences from other travelers

Unlike leisure travelers, international business travelers are usually employees, although some may be working as independent contractors. Business travelers' employers have a responsibility to protect their employees from health threats. Employers should cover the cost for all required and recommended vaccinations, prophylactic medications (e.g., antimalarials), and other health-protection measures, either through in-house or contracted occupational health services or a sponsored health plan.

In the United States, employers are liable for tort suits for negligence and workers' compensation claims. Employers should have systems in place to evacuate employees traveling under their auspices; this typically requires a preexisting contractual relationship with an air medical evacuation provider or some form of comprehensive travel health insurance that includes medical evacuation coverage (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Details of coverage should be clear to employees, including whether medical evacuation is to the nearest medical facility deemed comparable to that found in the United States or to the home country.

To better prepare their employees for healthy travel, businesses have developed international travel health programs. Primarily an innovation of larger corporations, these programs focus on disease prevention and health-promotion activities before, during, and after international travel. Potential advantages of corporate travel health programs include fewer instances of urgent repatriation (including emergency medical evacuations) and hospital admissions; enhanced employee confidence; improved productivity overseas; and better public relations. Midsize and smaller businesses with large numbers of international business travelers might also benefit from the cost savings realized by an international travel health program.

Special health considerations for international business travelers

Risks for travel-related adverse health outcomes in international business travelers generally have been considered low. They have increased, however, as the number and types of people (e.g., older, pregnant, immunosuppressed) traveling for work and the overall distance they travel increase and as the time allotted for adjustment after arrival at destinations and after return home decreases. International business travelers are as likely as other travelers to develop some travel-related illnesses; a 2018 GeoSentinel analysis of 12,203 ill business travelers seen following travel during 1997–2014 found that frequent diagnoses included malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), and acute bacterial diarrhea (5%). Notably, only 57% of travelers in the analysis for whom data were available had a pre-travel encounter. Among those who were diagnosed with malaria and for whom malaria prophylaxis data were available, 92% did not take prophylaxis or took an incomplete course (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter).

Extensive business travel also correlates with a higher body mass index and increased cholesterol, hypertension, anxiety, increased stress, and strain on the business traveler's family. A World Bank study showed overall health plan expenditures were 70% higher for international business travelers than for their non-traveling counterparts and that the likelihood of developing a noncommunicable disease increased with travel frequency. The study also showed increased incidence for 20 noncommunicable disease categories among this employee group and highlighted specific mental health issues: stress, anxiety, and depression (see Mental Health in Travelers chapter).

Pre-travel considerations

Fitness for travel

The pre-travel consultation (see The Pre-Travel Consultation chapter) should determine and document fitness for travel. Fitness for travel, particularly the risk for adverse health events overseas, depends on several factors, including how well underlying medical conditions are controlled; how easily preexisting medical conditions can be managed during travel; duration of time spent away from home; destination-specific health risks; access to health care while away; and job tasks and activities. As much as possible, international business travelers, especially assignees, expatriates, and recurrent travelers—and their healthcare professionals—should attempt to improve those factors within their control and to minimize the risks presented by factors outside their control.

A mental health assessment is another component for consideration in fitness to travel (see Mental Health in Travelers chapter). Family and work stressors of any kind may be magnified by international travel for work, and an employee may feel pressure for career reasons to take on overseas obligations for which they have little reserve. Stressors encountered during travel can exacerbate preexisting mental health conditions or cause previously unrecognized conditions to present during travel. Cultural adaptability and having interest in learning and experiencing new cultures are important qualities for someone working abroad, even short-term. Longer trips can be particularly challenging, and mental health issues are among the most common reasons for medical repatriations among long-term expatriates (see Long-Term Travelers and Expatriates chapter). In addition, if long-term travel is a consideration, then adaptability of family members also needs consideration.

Although almost all medical risks can be managed, the healthcare professional must ascertain whether a health condition will, based on the medical resources expected to be available, prevent a traveler from performing their essential job functions. For example, diabetes monitoring and care could be challenging during repeated international travel, particularly to more austere environments (see Travelers with Chronic Illnesses chapter).

Health risks

The pre-travel consultation should be structured to identify and address risks to both physical and mental health. Administering vaccines (see Vaccination and Immunoprophylaxis—General Principles chapter), prescribing prophylactic medications, and educating travelers about how to mitigate health threats while traveling are key elements of the consultation. To best prepare an international business traveler for healthy travel, healthcare professionals must have access to the traveler's full itinerary, including all work sites, stopovers, likely side trips, and potential itinerary changes. The pre-travel provider should not assume that international business travelers will only visit major cities, stay in first-class hotels, and eat at the best restaurants.

The provider should review the traveler's itinerary in detail, including information about conditions at worksites. International business travel can include day or overnight visits to industrial or agricultural sites outside of major cities with less safety infrastructure and higher vector-borne disease risk. Occupational safety regulations can vary internationally or may not be enforced, and consequently travelers might be exposed to physical and environmental hazards beyond those typically encountered. International business travelers visiting hospitals or medical environments might require protection from biological hazards (see International Travel to Deliver Health Care in Resource-Limited Settings chapter). Travelers and occupational health providers should consider the availability of personal protective equipment at the travel destination, and education regarding its proper use should be included in the pre-travel consultation for people preparing to work internationally in areas where such equipment is indicated.

Security risks

Business travelers face increased security risks, including crime, espionage, and terrorism (see Safety and Security Overseas chapter). Risk intelligence training, including special security briefings and resilience training incorporating crisis management, has gained importance for the international business traveler. Crises include those related to health, as well as natural disasters and security threats. Some companies engage consultants to manage such training, including availability for ongoing briefs and telecommunications during travel. The traveler should always have available the tools to contact whatever individual or facility can assist. Business travelers should be advised to use the Smart Traveler Enrollment Program (STEP), a free program offered through the U.S. Department of State, in which international travelers and expatriates enroll their trip with the U.S. embassy in the country of travel or residence. STEP benefits include receiving information alerts from the local embassy about health and safety issues, facilitating contact with the embassy if a problem arises, and helping family and friends reach international travelers through the embassy, in case of an emergency.

Vaccines

The traveler should be evaluated for needed vaccines (see Vaccination and Immunoprophylaxis—General Principles chapter), including updating routine vaccines (e.g., influenza, measles, tetanus-diphtheria-pertussis, COVID-19). Unlike the leisure traveler, the international business traveler typically needs to be fully pro­ductive when traveling overseas. The inability to perform one's job because of illness has serious implications for both employee and employer, so prevention of even mild illnesses can be a major determinant of the success of the trip.

A very important difference between most tourist travelers and the international business traveler is the need to consider repeated travel. A single business trip of only 1- or 2-week duration to a low-risk destination might not warrant immediate vaccination against a particular disease, but future work trips could present a continued risk for exposure and therefore cumulative risk should be considered for certain vaccine-preventable diseases, such as chikungunya, Japanese encephalitis, and rabies. The provider may consider offering a vaccine series even if the travel requiring it has not yet been planned. Because business travel often is scheduled at the last minute, vaccinating the international business traveler for later trips can be prudent. Business travelers on long-term assignments can have different vaccination considerations (see Long-Term Travelers and Expatriates chapter).

Malaria chemoprophylaxis

Simply providing prescriptions for necessary prophylaxis against travel-related diseases, particularly malaria, is not sufficient (see Malaria chapter). Healthcare professionals should educate travelers on the risks of malaria, proper prophylaxis use, and the urgent need to seek evaluation for acute febrile illnesses. The use of electronic reminders (e.g., software applications on handheld devices) can help with adherence.

Additional considerations

Changes in travel plans

Travel plans often change. Before departing, international business travelers should know where to access health and safety information for destinations not included on the original itinerary. Destination-specific health recommendations are available from the Centers for Disease Control and Prevention (CDC) Travelers' Health website. Business travelers should understand that preventive recommendations are unique to specific itineraries and travelers, and that advice for different trips and travelers can vary.

Travel companions

Each family member should have their own consultation with a healthcare professional (e.g., primary care provider or travel medicine specialist) familiar with assessing the impact of travel on health and safety. This pre-travel visit should include pre-travel physical and mental health screening. The inability of a child, companion, or spouse to adjust to an international environment is often a cause for early repatriation (see Traveling Safely with Infants and Children chapter).

Travel health issues during travel and at the destination

Planning for and adhering to guidance provided by medical and human resources personnel can mitigate health and wellness risks posed by lengthy flights. These risks include deep vein thrombosis (see Deep Vein Thrombosis and Pulmonary Embolism chapter), dehydration, jet lag (see Jet Lag Disorder chapter), and motion sickness (see Motion Sickness chapter). Multiple-leg, complex itineraries can aggravate or increase the likelihood of these conditions. To decrease a traveler's chances of experiencing adverse effects—which is particularly important when work duties are scheduled on or close to arrival—travelers should be counseled to limit or refrain from in-flight alcohol consumption and to be cautious in the use of hypnotic drugs (e.g., zolpidem) in flight or when the anticipated duration of sleep might be less than the duration of drug effects.

Medications

Changing time zones can interfere with taking prescribed medicine on time, another potential threat to the health and wellness of international travelers. Adjusting the timing of regular medication during international travel might be a challenge for the international business traveler; the healthcare professional can help create schedules for travelers taking medication(s), both on the way overseas and when returning. Anticipating the possibility that checked luggage could be delayed, broken into, or lost during international travel, international business travelers should carry with them a travel health kit containing sufficient quantities of all necessary medications to last the duration of travel and extra doses for several days to a week or more in case of delays (see Travel Health Kits chapter).

Post-travel care

International travel health programs provide international business travelers with both pre-travel (see The Pre-Travel Consultation chapter) and post-travel care (see Post-Travel Evaluation of the Ill Traveler chapter). Because an international business traveler could be a sentinel for a health risk at an overseas facility or workplace, a correct diagnosis is important not only to the health and well-being of the traveler but also to that of other workers at the jobsite. Returning workers can assist by notifying employers of any work-related incidents or on-the-job exposures. International business travelers also should provide information about any changes in the quality of available medical care, accommodations, security, and any other medical or legal issues that could adversely affect the health of future travelers.