Travellers & infectious disease: should we worry?

Travellers & infectious disease: should we worry?
Travellers & infectious disease: should we worry?

Kevin Featherly looks into the growing risks posed by infectious diseases

Kevin Featherly looks into the growing risks posed by infectious diseases, and asks what travel insurers could be doing to better protect insureds 

In mid-April, Albie de Frey got an urgent call from Mozambique to his Johannesburg office. The caller identified himself as a ‘horse medic’ and explained that his patient, a foreign worker at a remote petroleum production site, was gravely ill and needed de Frey’s immediate help. De Frey is travel director of International Health Management Consultants (iNHEMACO) S.A., a Geneva-based company that provides medical support to construction and mining interests in Africa. De Frey was eager to lend a hand, but was unsure how. The medic told de Frey that the patient — an expatriate from Italy —suffered from both malaria and dengue fever. That gave de Frey immediate pause. “You doubt the diagnosis,” de Frey says. “Why would the guy have malaria and dengue?” The medic also told him that, because the patient had received five units of blood, he couldn’t be transported by air. That made no sense, de Frey says. Most peculiar of all, de Frey says, the caller told him a surgeon in the local government hospital was refusing to operate on the man.  To operate? “Why would you want to operate on a guy who has got a bleeding disorder because of an infectious disease?” he says. Despite all those confusing signals, de Frey indicated that iNHEMACO would do whatever it could and awaited further instructions. They never came. De Frey received a text an hour later informing him that the man was dead. De Frey believes the patient probably contracted simple malaria that was allowed to develop into deadly complicated malaria. “He must have been sick for a couple of days and they waited too long to sound their alarm bells,” de Frey reckons. “It’s so sad.”

between 34 and 50 per cent of claims could be related to possible infectious disease

As that case suggests, when it comes to risks faced by the travelling public and expatriates, headline-grabbing infectious diseases like Ebola and the Zika virus are often not the biggest problems. There are far more common ailments affecting travellers – and they range in severity from those that may simply cause a portion of a trip to be interrupted, to those that can result in the repatriation of the insured’s mortal remains. Insurers, needless to say, keep track of which diseases are prevalent in different areas, and build strategies into their cover to deal with travellers who are unfortunate enough to become ill while abroad. But can more be done to educate travellers about disease prevention, and what do insurers themselves really need to know?

Key diseases

Some maladies, like traveller’s diarrhoea, are generally more annoying than dangerous. But they can be truly pervasive and severely disrupt vacations and business trips. Dipti Patel is director of National Travel Health Network & Centre (NaTHNaC), an agency set up by the British government to develop guidance for international travellers. She says that, for travellers moving from the developed to certain parts of the developing world, this malady is all but inevitable. “The chances can be as high as 70 per cent that travellers might experience traveller’s diarrhoea,” Patel says. The way travellers can avoid it, she says, is to closely monitor what they eat and drink. But that, she admits, is easier said than done. The good news is that the illness generally is mild and self-limiting, ‘but it does mess up your holiday’. Dengue fever is another disease common in the tropics – probably even more common than was once assumed, Patel says. However, while painful and debilitating, for most travellers it generally is not life threatening.  Tracey McLoone, senior medical director for Unitedhealthcare Global (UHC), adds several more to the list of diseases to watch out for. Lassa fever, for instance, is a West African haemorrhagic viral infection that kills 5,000 people a year – though mostly native residents in the countries where it occurs. Hepatitis viruses also are a risk, as is rabies and the parasitic disease leishmaniasis. “Some of the diseases are specific to certain regions; it’s important travellers do their research, so they are aware of the risks and appropriately prepared – before they go,” she says. Outbreaks can crop up suddenly, any time and anywhere – even in developed countries like the US, where mumps raged on college campuses in 2015. 

insurers could do a better job running through pre-travel disease prevention checklists with covered individuals

There are many ways that savvy travellers can stay abreast of such outbreaks. The US Centers for Disease Control and Prevention (CDC) posts online travel health notices that list the most current outbreaks. Zika virus outbreaks are listed in around 50 Western countries, with the most recent outbreak, in the Caribbean territory of Anguilla, added on 28 June. Also listed by the CDC is a yellow fever outbreak in Angola, polio outbreaks in Myanmar, Laos and Nigeria, and Lassa fever outbreaks in Benin and Nigeria. TravelHealthPro is a similar resource. Amongst the most recent additions to its list of outbreaks was a 1 July alert about a mosquito-borne chikungunya virus outbreak in Bolivia, with 17,000 suspected and 1,200 confirmed disease transmissions – nearly double the rate from the previous year. A Middle East Respiratory Syndrome (MERS) coronavirus outbreak in Qatar was added to that list on 17 June. Even archaic measles – easily preventable with a cheap, effective vaccine – has broken out in Mongolia.   Some dangerous infections, rabies for example, can be prevented by prophylaxis – the administration of preventative antibiotics – preferably prior to taking a trip. De Frey recently was asked to advise a 22-year-old American woman heading to a job in Zambia on the disease. She was interested in vaccination, she indicated, but could not afford one in the US. She wondered if it would be available locally. De Frey told her to get the shot in the US, whatever the cost. The vaccine is hard to come by in Africa in the best of circumstances, because the continent has only one rabies immune globulin manufacturer – National Bioproducts in Durban, South Africa. Recently, de Frey got a phone call from a colleague at the South African National Institute of Communicable Diseases saying that the company has had a production stoppage that will likely last several months. That may make the vaccine impossible to find locally. “That is why my advice to this person is that they must get exposure pre-prophylaxis,” de Frey says. 

What can insurers do?

Clearly, travellers can benefit greatly from pre-flight awareness. So how can the insurance industry get the word out and help limit travellers’ infectious diseases exposure? In some ways, sources agree, travel insurers are already educationally proactive. Many offer mobile device apps that covered individuals can use to dial up advice, insurance policy details, foreign language phrase books, even information on pre-screened hospitals closest to the traveller’s destination.  There is only one problem with apps, several experts agree – even if people install them, many never use them. “Apps are not sticky for people,” says Jim Grace, president and CEO of InsureMyTrip, a US website that acts as a kind of Expedia for travel insurance. “How many apps do you have on your iPhone that are kind of one and done apps? I tried it, it worked great – I never go back. It is really tough to get engagement there.” NaTHNaC’s Patel is more bullish on digital technologies, at least for younger travellers. “I think particularly the millennial generation will be more savvy to things like apps and social media,” she says. That is why NaTHNaC makes an effort to use Twitter to disseminate the latest information about disease outbreaks, she says. Patel does believe, though, that insurers could do a better job running through pre-travel disease prevention checklists with covered individuals, asking, for instance, whether the traveller has consulted with their general practitioner about pre-flight prophylactics or vaccines. “Assistance companies can get involved in that sort of thing, as well,” she says. “They can help people sign up to alerts and highlight where outbreaks are occurring, for example.” 

travel insurers could help limit the risk of spreading disease from country to country

For his part, De Frey would like to see more information collected by insurance companies at the time claims are processed. He cites Peter Liggett’s 2002 study in the Journal of Travel Medicine, one of the rare studies to track insurance claims by travellers returning home from abroad. The most common ailments found were respiratory (20 per cent) and gastrointestinal (14 per cent). Ear, nose and throat maladies accounted for another 12 per cent. To de Frey, the results of that Australian study – which he suspects are representative of the global travelling public – suggest that somewhere between 34 and 50 per cent of claims could be related to possible infectious disease. It would be nice to narrow down that figure, he says, but it is impossible. Insurance claim forms too often fail to ask about the exact nature of illnesses. If they were more diligent about collecting that information, it might aid the cause of disease surveillance and help curb international outbreaks. “One would be able to say how many of these infectious cases might have been prevented by pre-travel interventions or education,” he says. UHC’s McLoone agrees that travel insurers could help limit the risk of spreading disease from country to country; and some are taking steps to do just that. She notes that Optum, UHC’s health services technology platform, collects vast quantities of infectious disease data and transforms it into actionable information for consumers and providers. However, she emphasises, the value of that data is limited if people ignore it. “People need to feel empowered and interested enough to go get that information – but they also need to then adhere to the guidance,” she says. InsureMyTrip’s Grace echoes the sentiment. It is hard for insurers to get the travelling public, Americans especially, to pay attention to the risks of infectious disease and deal with this accordingly. “I think travellers should take a lot of responsibility for what they’re doing, as well, and make sure they understand the risk going in,” Grace says. “It is hard for us to get that message to them without them coming to get it.”

What, me worry?

Bastian Nagelschmidt is deputy managing director for German Red Cross Assistance Services. Given his role, Nagelschmidt has a fair idea of the scope of infectious disease and the level of such risks posed to casual and business travellers, and to working expats. So how worried is he about them? The short answer: not very. “Actually, we are talking about not even one per cent of all sick travellers and expats that have an infectious disease,” Nagelschmidt says. “And that one per cent gets things like gastrointestinal infections, not Ebola, haemorrhagic fevers or really dangerous uncommon or unknown infections.” Truly dangerous infections, he says, frequently occur less than 100 times a year worldwide. True, he cautions, that might well be 90 more such cases than were seen 10 or 20 years ago, so the risks are slowly growing. “We need capacity and we have to make training available, and we have to do everything to get in position to deal with more of these patients,” he says. But he feels the global healthcare infrastructure is keeping up. There is no cause for panic, he says. De Frey agrees that the most virulent infectious diseases are rare – and so are ‘common’ infections. Malaria – which de Frey regards as the single most dangerous disease for travellers because it is both easily acquired through mosquito bites and potentially fatal – makes up only about one per cent of the cases his company manages annually.  So how serious, in the end, is the problem of infectious disease? De Frey draws upon theology for his answer. “It’s a little bit like Christianity – it’s very complicated and it’s very simple,” he says. “Malaria kills. So although the incidence is small, if you mismanage it, uncomplicated malaria will turn into complicated malaria, and possibly death, in three days.” So even if the incidences are low, the implications can be massive. That is why de Frey thinks insurance companies should look beyond education efforts and actively incentivise travellers to face the risks head on. Insurers could require covered employers to show they are not sending high-risk employees into disease hot zones, he suggests. Travel insurers could require pre-travel vaccinations or GP counselling sessions. They could lower premiums for those who can demonstrate that they are following the rules.    “Don’t get bitten. Seek early treatment. Take a pill,” de Frey says. “If insurers can show that they have policies in place and that their customers are adhering to them, they are going to save themselves millions. And certainly they are going to save a couple of lives – which I would like to think the insurance industry has some interest in.” ⬛