Ebola and Zika may grab the headlines, but more travellers are likely to suffer from gastroenteritis or ‘travellers’ diarrhoea’ than any other health issue, according to Dr Lynn Gordon, Chief Medical Officer at CEGA, a UK-based travel risk, assistance and claims company. “Travellers may go to great lengths to guard against serious diseases, but overlook the risks of travellers’ tummy, or diarrhoea, which is caused by viruses, bacteria or protozoa (tiny organisms that live as parasites),” she said. “It’s important to remember that diarrhoea can become a serious health threat, especially in undeveloped areas with unsophisticated medical care, and it’s vital to take the right precautions against it.” Seasonal flu is also a common threat to travellers, as the spread of such respiratory illnesses happens easily in airports and aeroplanes, where travellers are in close proximity with one another, and air is circulated.
More complex infectious diseases, though, still pose a risk to travellers, especially those that are unvaccinated, or where the appropriate protective measures are not taken against mosquito bites. “Malaria is the primary infectious disease risk for travellers, despite some recent eradication successes,” said Tom Waters, Director of Medical Content for Shoreland Inc., publisher of travel health resource Travax. “High-profile emerging infections such as Ebola, MERS/SARS coronaviruses, chikungunya and Zika tend to present short-term risks to travellers with specific destinations and risk exposures.” Outbreaks of cholera (Democratic Republic of the Congo – DRC, Kenya, Yemen, and Zambia), dengue (Cambodia, Samoa, and Senegal), diphtheria (Bangladesh, Brazil, Haiti, Indonesia, Venezuela, and Yemen), measles (Bangladesh, Greece, Indonesia, Romania, Serbia, Somalia, Ukraine, United Kingdom, and Venezuela), and yellow fever (Brazil and Nigeria) are also currently occurring, Waters said.
Prioritising flu prevention
According to new estimates published as a result of a collaborative study by the US Centers for Disease Control and Prevention (CDC) and global health partners, between 291,000 and 646,000 people worldwide die from seasonal influenza-related respiratory illnesses each year, higher than a previous estimate of 250,000 to 500,000. The estimate excludes deaths during pandemics. “These findings remind us of the seriousness of flu and that flu prevention should really be a global priority,” said Dr Joe Bresee, Associate Director for Global Health in CDC’s Influenza Division and a study co-author.
The new estimates use more recent data, taken from a larger and more diverse group of countries than previous estimates (47 countries contributed data). Researchers calculated annual seasonal influenza-associated respiratory deaths for 33 of those countries (57 per cent of the world’s population) that had death records and seasonal influenza surveillance information for a minimum of four years between 1999 and 2015. Statistical modelling with those results was used to generate an estimate of the number of flu-associated respiratory deaths for 185 countries across the world. Data from the other 14 countries was used to validate the estimates of seasonal influenza-associated respiratory death from the statistical models.
Dr Charlie Easmon, Medical Director of Your Excellent Health Service and President of the International Association of Physicians for the Overseas Services (IAPOS), noted how much the severity of a flu season can change: “On the viral level we are more aware that seasonal flus can vary in their lethality and morbidity, and the terrible flu of Australia 2017 is causing problems in Europe 2018 with at least one teenager already dead,” he said.
There is much to be done by travel insurers to plan and prepare in advance of the next pandemic or epidemic
Dr Lori Stetz, Senior Medical Director, Aetna International, added: “It takes just a single crisis – an epidemic, a natural disaster or even the death of a key physician who falls victim to disease – to make whole healthcare systems and economies come crashing to the ground. To have any hope of containing future outbreaks, it’s essential to understand the nature and transmission pathways of infectious diseases and involve local communities in detection, prevention and communication efforts. We have made significant strides, but more vital action is needed.” She continued: “So if there is the potential for H7N9 – a flu virus circulating in poultry in China – to soon be felt around the world, what should the world do to stop the next pandemic before it starts? At Aetna International, we believe three steps are required: investing in well-performing health systems, strengthening disease surveillance and engaging local communities.”
Spotlight on malaria and MERS
International travellers could be at risk of malaria infection in 91 countries around the world, according to the World Health Organization (WHO); mainly in Africa, Asia and the Americas. People infected with malaria often experience fever, chills and flu-like illness at first. Left untreated, the disease can lead to severe complications and, in some cases, death.
Between 2007 and 2016, around 1,500 cases of malaria were reported annually in travellers returning to or arriving in the UK from malaria endemic countries, according to the Travel Health Pro website. Travellers visiting friends and relatives in their country of origin accounted for 80 per cent of these cases, and the majority acquired the disease in West Africa.
Shoreland recommends that travellers wear clothing that covers as much skin as possible and apply a repellent that contains either DEET or picaridin. Sleeping under permethrin-impregnated bed nets is also recommended for travellers heading to countries where malaria and Japanese encephalitis are present.
Middle East Respiratory Syndrome (MERS) is an illness caused by a virus (more specifically, a coronavirus) called Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Most MERS patients develop severe acute respiratory illness with symptoms of fever, cough and shortness of breath. About three to four out of every 10 patients reporting with MERS have died, according to figures from the CDC. All reported cases have been linked to countries in or near the Arabian Peninsula. Most infected people either lived in the Arabian Peninsula or recently travelled from the Arabian Peninsula before they became ill. A few people became infected with MERS-CoV after having close contact with an infected person who had recently travelled from the Arabian Peninsula. The largest known outbreak of MERS outside the Arabian Peninsula occurred in the Republic of Korea in 2015 and was associated with a traveller returning from the Arabian Peninsula.
Antimicrobial resistance (AMR) – the ability of a microbe to resist the effects of medication previously used to treat it – occurs when bacteria change in a way that reduces the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. The bacteria survive and continue to multiply, causing more harm.
WHO has called resistance to antimalarial medicines ‘a threat to global efforts to control and eliminate malaria’. “Use of oral artemisinin-based monotherapy (oAMT) is considered a contributing factor to the development and spread of resistance to artemisinins,” said WHO, which has urged regulatory authorities in malaria-endemic countries to take measures to halt the production and marketing of oAMT, and promote access to quality-assured ACTs for the treatment of falciparum malaria.
Dr Charlie Easmon said: “Infectious diseases will always be with us and since, at a microbiological level, events occur like Darwin at the speed of light, resistance to antibiotics will be passed on rapidly and we now know that because of something called plasmids this occurs in quantum leaps not steps.”
The fight against antimicrobial resistance is well underway
The fight against antimicrobial resistance is well underway. In India, for example, Bugworks is a biotech startup company that is the first one outside of the US or Europe to secure funding from the CARB-X accelerator programme, which is dedicated to combating antimicrobial resistance. India has some of the highest resistance rates in bacteria responsible for common infections, according to the Center for Disease Dynamics, Economics and Policy in Delhi, as a result of the uncontrolled use of antibiotics in both humans and livestock, combined with high disease transmission rates and poor sanitation.
Doing one’s duty
When it comes to disease outbreaks, Carl Carter of Voyager Insurance in the UK believes insurers are lagging.
“There is much to be done by travel insurers to plan and prepare in advance of the next pandemic or epidemic,” he said. “Too many travel insurance policies provide little if any coverage for those outbreaks that require an evacuation. We include this cover on several of our leisure and business policies, or as an optional extra. Much can be done by linking policy data to destination and epidemic data. In many cases, the travel insurer will know the destination country of a policyholder. The insurer will also, in most cases, have an email address and a mobile phone number. This allows the travel insurer to broadcast important travel or epidemic information to the insured person in the event of an outbreak. Many mobile apps include geo-tracking. This can provide more detailed information allowing closer matching of the insured’s location and epidemic information.”
For individual travellers, meanwhile, the onus is on them to ensure they are taking all possible preventive measures to combat the risk of infection while they are abroad – whether that is a vaccination or taking prophylactics. If they don’t, then they run the risk of not only becoming sick, but their travel insurer not paying out when they try to make a claim, as they have not demonstrated due care and attention to minimising their risk. Research from travel insurance provider Columbus Direct in 2017 found that British travellers are placing themselves at risk of contracting a serious illness while abroad by not having vital vaccinations, with statistics revealing that only six out of 10 travellers would always get the necessary inoculations prior to travelling. A spokesperson for Collinson confirmed: “Like most travel insurers, Columbus Direct includes an exclusion relating to costs incurred from a tropical disease where there are National Health Service recommendations to be inoculated against the disease prior to travel. We would expect that most claims arising under those circumstances would be excluded. However, claims are of course reviewed on an individual basis so this would be decided based on the circumstances of the case and the reason why the customer did not take the necessary precautions.”
For globally mobile employees, however, the situation is a bit more complex. They’ve been sent abroad by their employer, and that employer therefore has a duty to make sure that person is prepared for the risks they are facing, including health risks. Carrying out a pre-travel risk assessment to ascertain how serious a risk of infection there is in a given destination is a must, followed by a strong recommendation that the employee gets the necessary vaccines and any malaria prophylactics they may need.
Suzanne Garber, board member for VIGILINT, which provides telemedicine services, commented: “With regards to infectious disease risks, two key words continue to dominate the responsibility of duty of care: reasonable and foreseeable. Is it foreseeable for an employer to expect that an employee being sent out to a site that is known for infectious diseases could potentially be exposed to and even be diagnosed with that disease? Simple searches to respected sites such as WHO would instantly reveal the risks for endemic diseases in the area. The next question would then be, is it reasonable to expect the employer to do something about it with regard to the employee?” It would be impossible, said Garber, to determine all of the possibilities one could contract, as infectious diseases can be airborne, waterborne, passed through human or animal and be bacterial, viral or fungal in nature. “Further,” she added, “even when disseminating information or requiring activities (like mandatory vaccinations) that could potentially stave off an infectious disease, some companies may still find themselves embroiled in a lawsuit, as was the case with a Minnesota healthcare company that required mandatory flu vaccinations of all employees. Employees cited an infringement upon their civil or religious rights.”
So, what can an organisation do to protect its workers while protecting its reputation? Garber recommends looking at existing case law in a given country as well as (in the US) Workers Compensation and OSHA citations. “Another best practice is engaging with other organisations and partners who have a wealth of knowledge about not only the types of infectious disease that could be encountered by employees but also the protocols that should be rolled out,” she concluded. “Education, communication and preparation are the best tools to ward off the potential threat of infectious disease.”
the bugs that changed wars, histories and countries are no less prone to change the lives of our travellers
Case by case
Dr Lynn Gordon from CEGA said that providing assistance to travellers suffering from a potential infectious disease requires attention on a case-by-case basis. She explained: “An assistance request from a policyholder with an infectious disease will always necessitate a bespoke approach. It can involve anything from a visit to a local doctor, to hospitalisation, or even repatriation – and costs can vary accordingly. A good medical assistance provider will assess the patient thoroughly and provide the best response for their particular condition.”
Dr Easmonn stated: “We need to be vigilant about all infections and be aware that the bugs that changed wars, histories and countries are no less prone to change the lives of our travellers. Like the Romans, many infections came, saw and conquered but unlike the Romans they still do.”
Dr Gordon concluded that as we travel more often, and further afield, disease avoidance will mean anticipating and managing health risks associated not just with our destinations, but also with our journeys. “A quick stop-off in South America, for instance, could expose a traveller to a risk (like malaria) that may not be prevalent at his or her journey’s end, with symptoms not manifesting themselves until weeks or months later,” she said. “Business and leisure travellers alike need to be aware of the risks (and employers of the duty of care obligations) before, during and even after a trip abroad.” ■