Managing Travel Health Risks, Behaviors, & Outcomes: Best Practices - Seminar, April 28, 2000

Jonathan Reed, MD, Senior Occupational Physician, Liberty Occupational Health, Aberdeen, UK

DR. GRIZZARD: Jonathan, it's all yours.

DR. REED: Hello. I think it's an imposter syndrome, isn't it, when you feel you've been over-promoted and you're not actually capable of the job you've been asked to do. I feel a bit like that at the moment. I'm certainly not an expert in travel medicine or travel health. I'm principally an occupational physician, and I guess travel medicine is actually only a small part of my day-to-day activity. But we have kind of accrued management responsibility, I guess, for the service that we offer in our health center in Aberdeen.

As I say, primarily we function as occupational physicians where we're involved much more in the risk management and health management and other areas of occupational health. But it's become quite apparent to me that the risks associated with travel in a business setting are actually quite significant. You know, and if you just thought for one minute, in any other industrial process if about half the workers experienced some form of ill effect, there would be a lot more note taken of that, and really, currently our client companies have difficulty appreciating that there is actually a significant problem.

I'll just put the overhead on.

I just wanted to describe very briefly what our practice—actually, what our situation is in Aberdeen. We see at least 100 consultations every month for pre-travel preparation. We provide services to—it's literally hundreds of different clients nationally, as many as that in Aberdeen alone, but predominantly oil and gas workers or industries associated with that, providing support services, but by no means all. About 70 percent of our business comes from that industry.

We do a fair amount of work on fitness-to-travel preparation. I was quite interested by the comments yesterday that some organizations didn't feel that fitness to travel was a particularly significant issue. In our particular setting, I think it is. We are constantly finding people who are really unfit to travel or who we recommend that they don't travel to certain locations. The oil industry, however, has always had fairly strict fitness criteria for working in remote and hostile environments, and I guess that has kind of spilled over into our practice in that area.

One of our mottos is never assume that someone is fit to travel just because they've come in for a travel consult.

We'll obviously provide post-travel health assessments as required. We look at periodic fitness-for-work and fitness-for-travel assessments. Some companies institute annual of biannual travel fitness assessments.

We've got the full range of laboratory support available, which is off-site, obviously. We have fairly good links with the local infectious disease unit in Aberdeen, who, interestingly, do get a fair amount of imported disease, maybe more than your average hospital, because of the concentration of oil workers that particularly work in West Africa and come back and import things like malaria to Aberdeen. And they've published a couple of papers just outlining their experiences, and about 60 percent of their patients are returning oil workers.

We've obviously got the full range of vaccinations, usual, you know, pre-travel prophylaxis, medical kits and equipment. That is pretty standard. We'll do HIV testing for visa purposes.

Since I got involved in this and have been looking at it a bit more closely, we do have fairly well-defined operational policies and procedures that really I think give a fairly good evidence-based platform to the work we do in the clinic, which I think is something that's quite rare to see, certainly in the U.K. We obviously use online reference sources for the latest advice and notifications, but it's primarily a nurse run service. The occupational physician team provide the kind of professional supervision, but on a day-to-day basis, it's not—it's fairly rare for us to get involved in a case. It's only really the ones where there's potential concern raised by the nurse over a particular aspect of the preparation.

If you could just raise it up a wee bit there? That's great.

As I said, I think West Africa probably is the dominant destination for travelers, and that obviously involves some short-term travelers, but also people that rotate month on, month off, and, more rarely, expatriating families. So malaria prophylaxis is a big issue.

Reference was made earlier to the extremely bad press that mefloquine has received in the U.K. We have to battle against that somewhat in our clinic, in our practice, and what's quite annoying is that there's a huge inconsistency in the advice these workers receive. They'll go abroad and they'll find that other workers from other companies have been prepared in different parts of the country and by doctors with very different attitudes, and that's actually probably the biggest enemy when it comes to trying to achieve optimal preparation and prophylaxis for these chaps.

Another huge issue for us is short notice travel, people that come in with no time really to achieve optimal preparation. This is the bane of our life. You know the story. I'm sure everyone here experiences that. They're going off to Nigeria at 5 o'clock tonight and have never had a vaccine in their life. And, understandably, they're actually very agitated about this.

I must make the point that a lot of our clients travel to these locations out of necessity. They wouldn't be choosing to go there. It's not the sort of job they actually joined up to do. The oil industry in Aberdeen has had to adapt very quickly to economic circumstances, and they've had to switch a lot of their operations offshore in order to maintain employment and maintain viability. So a lot of these workers are fairly inexperienced and naive about what's to be expected, and they're very agitated about it. But they can't refuse. They know that if they don't do this, they're not going to have a job. We do have to counsel people quite strongly at times because they're literally at the point of refusing to travel, and they've been told they're going in three hours, and they're very unhappy about the situation. That's quite a big issue for us.

I guess from the client perspective, the biggest issue we have to deal with is this item of service mentality compared to a more managed approach to employee care. I guess when you're a service provider, that's kind of part of the ball game that we have to play, and corporate occupational health and health departments I don't think have to deal with this problem to quite the same extent. And it does make a difference. They just see it as they're coming in to buy their jobs, and just as long as they get the book signed up and they've got the reguired certificate, that's all they need to worry about.

And, of course, this is a vaccine-centered ritual, which is what people think pre-travel preparation is, is really what the company views it as, and it's actually very difficult to battle against. So, really, it's a failure of the employers to actually regard this as a serious occupational risk and a risk to health they really need to manage and control, like any other workplace hazard. They're quite happy to adopt workplace management, risk management techniques in other areas of the business and do so quite successfully. Why don't you do this for travel?

The additional services, we're trying to kind of combat this by providing sort of electronic bulletins every month, or more than monthly, in fact, where we as a matter of principle always mention a travel health issue and try and focus the attention on that, amongst a whole lot of other occupational health issues we may be discussing, which all our clients will receive.

We do seminars on travel health for both managers, people who are logistically organized and organizing travel abroad, and for frequent travelers and employees, to go into travel health preparation and discussing the hazards and issues surrounding travel in a lot more detail. We get assistance from the University of Aberdeen. There's a mosquito biologist who is very knowledgeable on malaria and has worked a lot in the tropics, and he gives a very good account of what life is like in these situations and gives very good practical advice. We find that is quite helpful, in fact.

On top of that, we are just promoting very hard the concept of optimal preparation. It's quite disappointing when you look at research, and again and again it's very clear what optimal preparation is and should consist of. There's a fair amount of evidence out there. But when you actually look at what happens in practice, you just never see it or you rarely see it, even within corporate occupational health departments or any of the published literature constantly shows that we're failing to achieve optimal preparation. So we need to look at this. And also the evidenced literature for 20 years have quoted the same incidence of disease 20 years down the line. Nothing we're doing seems to be affecting that.

I think Dr. Ericsson's point this morning about behavioral change and how we effect that is really key to this. So we're trying to promote very hard the idea of optimal preparation which is auditable and which you can demonstrate, you know, that you've actually done something that's evidence-based and potentially beneficial to the individual, actually managing that process of travel health risk much more closely and getting the company involved at the policy and procedure level to make sure that they, you know, accept their part in managing that risk themselves.

Thank you very much.

DR. GRIZZARD: Thank you, Jon.

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