Ignorance is no excuse

ITIJ 199, August 2017
As previously reported in ITIJ, research from travel insurance provider Columbus Direct has shown that four out of 10 British travellers do not always get the necessary immunisations before travelling. But the problem is not limited to lackadaisical leisure travellers, according to Dr Saifulla Khan, a student of clinical tropical medicine and medical doctor at marmassistance, a Turkish travel and medical assistance provider that operates in Europe, North Africa and the Middle East. “From the corporate travel point of view,” he warns, “despite many developed countries having some form of employer duty of care legislation in place, most employers and travellers are considered to overlook immunisation needs.”
Corporate duty
“International health regulations are generally limited to yellow fever jabs for travel to certain countries in sub-Saharan Africa and tropical South America, and the mandatory meningococcal jab for Hajj pilgrims travelling to Mecca,” says Dr Khan. “Travel immunisation trends seem to be influenced by individual dispositions. Available statistics show these to be relatively healthy – when compared to the global averages – in some countries, such as Finland and Germany; while the UK and Norway are falling below.”
For companies with globally mobile employees, it’s important to be aware of where the responsibility lies with regards to whether or not the employer has to provide access to immunisation advice and the actual jabs that may be recommended for a particular destination.
“This most definitely falls under the remit of a company’s duty of care to its travelling employees, unless a company’s travel policy clearly outlines that it is the responsibility of the business traveller to manage their own vaccinations and exposure to disease,” says Randall Gordon-Duff, head of corporate travel at Collinson Group in the UK. He explains that this responsibility is not limited solely to immunisations, but also to the prevention of illnesses such as malaria: “If the company has failed to understand if their travellers are at risk and does not try to mitigate it, and an employee contracts the disease while on company business, then it can be held liable. There are medical issues to which the company should alert their travelling staff, and the need for professional support and advice is becoming more prevalent.”
four out of 10 British travellers do not always get the necessary immunisations before travelling
The first injectable malaria vaccine, Mosquirix, will be piloted in 2018, according to the World Health Organization (WHO). Requiring multiple injections, and not 100-per-cent effective, it is unlikely to be seen as appropriate for short-stay visitors to malarial areas, but might one day be deemed suitable for longer-stay travellers to risk areas, such as corporate employees or NGO staffers. It's therefore not inconceivable that specialist insurers writing policies for such workers might consider insisting on proof that they have been given the new malaria immunisation as a condition of cover – much as certain countries insist on seeing a certificate of yellow fever vaccination before admitting a traveller from a country that is suffering from an outbreak of the disease. This kind of evidence is not feasible with current malaria prophylaxis, as it is impossible to prove that an insured has or has not been taking oral anti-malarial tablets as recommended.
Recommended protection
Britain’s National Health Service (NHS) recommends vaccinations for eight of the 30 countries most visited by UK residents. Not having appropriate inoculations before travelling could invalidate a travel insurance policy, according to Stuart Lloyd, travel commercial manager at Collinson Group, the parent company of Columbus Direct: “In the event of a claim for a tropical disease that the NHS would advise you to be protected against, insurers usually ask for a GP report confirming that the appropriate vaccination has been administered. If a customer has not had the appropriate vaccinations, a travel insurer will generally not pay for any claims arising due to the disease.” 
Regarding the issue mentioned above, Lloyd believes that if a working malaria vaccine were to come on the market, the insurer’s approach would have to change from its current state. “If a simple-to-administer, 100-per-cent effective vaccine became available,” he says, “then the approach from insurers would then be the same to malaria as it is to other tropical diseases, on the basis that a customer’s medical record should show they have had the recommended vaccination.”
However, Kate Huet, managing director of International Travel and Healthcare Ltd in the UK, says she knows of no cases of denied claims: “I’ve not seen any claims in the last 10 years that have been declined because a traveller did not have the correct immunisation. This may be because our market is mature and this audience are just more careful about their health.”
According to Columbus’s research, reasons for not obtaining a vaccination ranged from fear of unpleasant side effects to time and cost considerations and simple ignorance, with seven per cent saying they were unable to gain medical advice and seven per cent saying they did not know if their destination required specific vaccinations.
For companies with globally mobile employees, it’s important to be aware of where the responsibility lies with regards to … immunisation advice
Arguably, though, there is no excuse for ignorance. Clear advice on recommended health precautions for literally every destination in the world is readily available from sources such as the US Centers for Disease Control and Prevention, the UK’s NHS, WHO and MASTA, the largest network of private travel clinics in the UK. Government departments like the UK’s Foreign and Commonwealth Office, the US State Department and the Australian Department of Trade and Foreign Affairs draw on such sources for their own travel advisories.
Some diseases, like cholera, which were once prevalent worldwide (with outbreaks that reached Italy and Portugal, both popular European holiday destinations, in 1973 and 1974) now affect so few leisure travellers that immunisation is no longer routinely advised. Smallpox, another disease for which vaccination used to be recommended for travellers to many destinations, was declared officially extinct in 1980. The Global Polio Eradication Initiative has reduced poliomyelitis, once feared everywhere, by 99 per cent, according to WHO.
There may, however, be confusion in the minds of consumers between the quite numerous diseases for which immunisation is commonly recommended and those for which in a limited number of situations it is mandatory. For example, a vaccination certificate is required by many countries for arriving travellers who have spent more than 12 hours in a country where there is a risk of yellow fever. But words such as ‘advised’ or ‘recommended’ are open to interpretation. Therefore, an insured making travel plans might scan advice only for ‘required’ vaccinations and dismiss those that are only ‘recommended’. 
“There are very few vaccines that are ever listed as ‘required’,” points out Michelle Sellors, clinical informatics and communication nurse lead at MASTA. “These tend to be yellow fever and polio for certain countries and in specific circumstances. Other vaccines are often listed as ‘recommended’ or ‘to be considered’, and are dependent on activities and type of trip.”
A travel health consultation should present the pros and cons of vaccination and allow travellers to make informed consent based on their individual risk, Sellors says: “There is much variation on what is recommended for an individual traveller visiting a particular destination based on a whole lot of risk assessment factors.”
Prominent media coverage of disease outbreaks such as the SARS epidemic of 2003, the Ebola crisis in Africa in 2014-16 and the Zika outbreak that affected parts of South America, the Caribbean and the US in 2016 may focus consumers’ minds on the need for immunisation when travelling, she suggests, especially if they take place in regions that are perceived to be near popular holiday destinations.
“A well-publicised outbreak encourages travellers to seek specialist advice, which is a great opportunity to discuss underlying risks,” Sellors told ITIJ. However, she argues, there is no substitute for allowing travellers to make their own minds up: “Travel health specialists shouldn’t be completely prescriptive with their advice. If we communicate the risks effectively, travellers should be able to make reasoned decisions, but it’s ultimately a personal decision.”
Dr Khan concurs: “Travel insurers contemplating rejecting claims based on proof of immunisation may possibly not find it to be a black and white affair.”
Industry cohesion?
Some travel insurers may disagree. “Australian insurers are definitely getting tougher on claims where a traveller has been diagnosed with a preventable illness such as malaria because they have not taken the right precautions,” says Lisa Fryar, head of international benefits management at World Nomads Group. “There is an appreciation that travellers have a right to choose to immunise, but it can be considered placing yourself at needless risk should you choose not to immunise. The cost of claims arising from preventable illnesses is increasing.”
The number of such claims has increased by as much as 10 per cent, Fryar suggests, which is no small amount when you consider the margins on travel insurance to be very slim indeed, so these costs have to be passed on. “These claims contribute to future premiums being raised for other travellers,” she says, “which is why insurance companies are looking at ways to mitigate ongoing financial risk.” However, insurers aren’t going to be unreasonable about this issue: “Where the traveller is in a life-threatening situation, most insurers will cover the costs to ensure the traveller receives the appropriate treatment in a timely manner to avoid any further risk to their health.” But she warns that many insurers reserve the right to recover those costs in the event that the traveller has chosen not to vaccinate.
“I haven't seen an insurer declining the costs of emergency treatment, but this doesn't mean it won't happen in the future,” she told ITIJ. “Costs of medical expenses are on the rise, with many travellers finding themselves in critical situations requiring air ambulance evacuations.”
Fryar cites the case of an Australian insured who had not taken malarial prophylaxis and who contracted potentially fatal cerebral malaria in Indonesia. His condition deteriorated rapidly and he required air ambulance evacuation to Darwin. While the client, who was not immunised, recovered, the cost of medical expenses and air ambulance evacuation was in excess of AU$300,000. “The insurer covered the cost due to the life-threatening nature of his illness and did not seek to recover from the traveller,” Fryar says. “He was lucky. With an increase in cases like this, there is significant impact to the loss ratios for insurers and it really is only a matter of time before we start to see a change in practice.”
Travel insurers contemplating rejecting claims based on proof of immunisation may possibly not find it to be a black and white affair
There are also indications of a worldwide backlash against parents who refuse to accept medical advice to immunise their children against common childhood diseases. Declining immunisation has resulted in a surge in reported cases of measles, mumps and chicken pox, according to the European Centre for Disease Prevention and Control. In May 2017, prompted by a 2015 measles outbreak, Italy made vaccination against measles mandatory. In June this year, Germany passed a law requiring infant schools to report parents who do not immunise their children, imposing fines of up to €2,500 on parents who refuse to take medical advice on immunisation. The Australian state of New South Wales has introduced legislation that cuts off some childcare benefits for parents who cannot prove their children are immunised. The Canadian provinces of Ontario, Manitoba and New Brunswick require proof of immunisation for school admissions, although three allow exemptions on certain grounds.
Such action is intended primarily to reinforce national immunisation programmes and maintain 'herd immunity' against childhood diseases that occur worldwide, but it could conceivably create a further precedent that travel insurers might invoke in order to deny claims.
Many once common (and often fatal) illnesses are no longer to be routinely feared, either at home or abroad, but that doesn't mean travellers should ignore the real risks that still prevail. A growing reluctance on the part of insurers to settle claims from travellers who neglect to immunise might go some way to raising awareness of an issue that is unlikely to disappear.