key: cord-0859032-3ogk88tm authors: Michelle L A, Tufnell; Juliane, Kause; Steve, Iley title: Pre-travel risk assessment for international business travellers during the COVID-19 pandemic date: 2021-09-09 journal: Travel Med Infect Dis DOI: 10.1016/j.tmaid.2021.102162 sha: 8b90ed707e9b54df55d983e79f3bdd161138ac07 doc_id: 859032 cord_uid: 3ogk88tm nan There has been significant disruption to travel caused by COVID-19 due to its international spread and restrictions imposed by countries in their bids to control transmission. International travel is essential for many types of business, despite the increasing use of telecommunication. Preparation for safe travel must be thorough and include additional considerations compared to the pre-COVID era. Business travel may be defined as travel for the purpose of working, including corporate travel, field work and attending meetings or conferences. Business travellers may have different health-seeking behaviour due to employment requirements as well as better access to medical care while overseas due to company insurance and medical assistance programmes. International business travellers have been compared to non-occupational travellers in previous analysis of 23,534 travellers [1] . More business travellers were men (61% vs 43%), more had less time to departure, over half sought pre-travel consultations largely on the advice of their employer and they had shorter periods of travel. Hotel accommodation was most common (>80%) with more travel to urban areas and they often travelled multiple times a year. Studies in travel-related illness in business travellers show a similar range of disease to nonoccupational travellers, but illness rates and particularly psychological problems, tend to be higher. The rates of medical insurance claims in World Bank travellers were 80% higher in men and 18% higher in women, compared with colleagues who did not travel. Rates were highest for psychological illness, then intestinal disease and respiratory disease [2] For a business, defining what is 'essential travel' helps to avoid unnecessary and potentially risky travel, whilst ensuring that those who do need to travel get appropriate support before, during and after the trip. An overseas business travel policy should state what criteria need to be met; either travel is required to fulfil compliance and regulatory obligations and/or without the trip the company would be liable to financial loss, legal implications, damages or penalties and/or the business travel is needed to support critical business activity. For the last criterion it is important that the most senior decision maker, for example executive officers, are deciding criticality, not the individual traveller who may have a conflicting self-interest. The process for who travels is a dynamic assessment taking into account external factors as well as internal factors. External changes, for example reduced local medical care as a result of a global pandemic, will change the risk profile of a trip making it more dangerous, or the sudden loss of a supply chain due to locally increasing cases can make a trip more important. Internal changes to an individual's medical condition or willingness to travel can mean substituting who goes as well as when they go. It is in the best interest of employers to ensure the health and wellbeing of their employees working internationally; before, during and after travel, which may be via a provider organisation or on-site occupational health department. Illness may disrupt business activities during or after travel, cause loss of time and productivity and increase medical costs. It is important for an employer to ensure health insurance policies give coverage if their employee should become severely ill abroad with COVID-19. Quality and infrastructure of local healthcare in the destination country may be negatively impacted by the COVID-19 pandemic, leading to an increased need for medical evacuation if a traveller were to develop a severe COVID-19 infection. Medical evacuation of patients with COVID-19 is complex, with lengthier processes and subsequent cost impact. In some cases air evacuation may be deemed too high a risk, due to severity of illness. The risk of developing severe or fatal infection with COVID-19 depends largely on the traveller's personal vulnerability should infection occur. The Association of Local Authority Medical Advisors (ALAMA) has developed an evidence-based risk model that can be used to estimate personal vulnerability [3, 4] . This tool, known as 'covid-age' was first published on 20 th May 2020 and has been periodically updated as new data becomes available. At our organisation we have developed a detailed health questionnaire to collate relevant medical information from employees prior to business travel. As return to some essential travel for business commenced following the UK's first lockdown, our questionnaire reviewed Covid-19 infection exposure including confirmed and probable COVID-19 infection, and close contacts with suspected or confirmed cases as well as antibody test results.. We also reviewed adverse life events during the pandemic such as hospital admissions, loss of loved ones, relationship breakdowns and significant loss of motivation. This enabled us to have a holistic picture of the employees' experience during lockdown and provide relevant advice, such as current understanding on immunity, and suggestions on mental health support and how it can be accessed. The medical information requested on the questionnaire enables a review of risk factors known to increase vulnerability and calculation of covid-age. This may also involve review of medical reports from specialists and telephone consultations with the employees to gain further understanding and assessment. Medical factors that may increase risk of sudden incapacity or other need for medical care while travelling are also reviewed. These include cardiovascular risk factors and level of control of chronic conditions such as diabetes, asthma and epilepsy. There is also the importance of subtle incapacity, involving aspects of lifestyle that can impact the traveller over time. Factors such as alcohol use, smoking and BMI are reviewed, providing opportunity for health promotion advice. An important part of our risk assessment is a review of factors that may have affected the traveller's psychological wellbeing. Individuals with a pre-existing mental health disorder in the last year have been shown to score significantly higher on the COVID Stress Scales than those without [5] . Travel may exacerbate or precipitate a variety of psychological disorders. Data on occupational travellers has shown that frequent international travel is associated with increased insurance claims for psychological illness [2] . Review of previous or existing mental health disorders, coupled with details on adverse life events over the lockdown period such as hospital admissions, loss of loved ones, relationship breakdowns and significant loss of motivation, have enabled identification of employees that may require additional mental health support. This may include referral to an appropriate health professional or Employee Assistance Programme for further assessment and management, as well as provision of information and self-help resources. Psychological sequalae occurring after traumatic life events are well documented [6] , however, the study of collective traumatic occurrences is limited to physically and mentally extreme situations affecting relatively small sections of populations, for example arctic explorers, soldiers in combat and people experiencing natural disasters. The COVID-19 pandemic has refocussed attention on psychological resilience and initial concerns that a global disaster would have different psychological consequences has not manifested at the time of writing. However, the pandemic has reinforced previous knowledge that people experience distress after their exposure to an extreme event. In the case of people with good psychosocial resilience and access to social support, their distress may be relatively transient as people call on a set of inner capabilities and supporting relationships to spring back and begin the processes of adaptation. Employers have a big part to play in ensuring that conditions are optimised for this to occur. Mental disorders occur often, but less commonly than distress, and in some cases they may require intensive and long term continuing interventions and treatment. The Department of Health in the UK [7] and work done by NATO [8] differentiate between distress and mental disorders following a disaster. Early identification of a mental health disorder or psychological distress can prevent long-term impacts on the traveller and the business and therefore their wider communities. As the covid-age tool is based on health data from adults in England, it is likely that it can only reliably be used for risk stratification for workers in the UK. Multiple confounders would come into play to affect the risk of individuals based in other countries. Genetic risk factors have been implemented for increased severity of disease with COVID-19, which are present in about 50% of people in South Asia [9] . With the number of deaths from COVID-19 being relatively low in Africa, it has been hypothesised that regular exposure to malaria or other infectious diseases could prime the immune system to fight new pathogens like SARS-CoV-2 [10] . However, particularly when assessing UK-based travellers, the covid-age tool should still give an indication of vulnerability when travelling internationally. Several studies have identified factors affecting geographical vulnerability of disease with COVID-19. Low levels of national preparedness, scale of testing and population characteristics have been associated with increased national case load and overall mortality [11] . Low temperature and low humidity have been seen to likely favour the transmission of COVID-19 [12] . Public health infrastructure in the destination country and their ability to appropriately detect cases and implement isolation and quarantine is an important factor in reduction of COVID-19 transmission. The employer will need to consider quarantine requirements in the destination country and on return. If new restrictions are imposed during time abroad, such as border closures or lockdowns, the employees may risk being stranded abroad for a period of time. J o u r n a l P r e -p r o o f There will be a certain amount of responsibility laid on the employee during travel to ensure they are taking appropriate precautions according to local guidance and company policy. Airlines or country entry requirements may include negative results from COVID-19 swab tests on arrival or within a timeframe before departure, which needs to be included in timing of business trips. Confirmed in-flight cases have been published [13] , although the risk of in-flight transmission is considered to be very low when stringent hygiene measures are enforced inflight [14] . Pre-Travel Medical Preparation of Business and Occupational Travelers: An Analysis of the Global TravEpiNet Consortium Medical insurance claims associated with international travel Assessment of worker's personal vulnerability to Covid-19 using 'covid-age' Development and initial validation of the COVID stress scales Secondary stressors and extreme events and disasters: a systematic review of primary research from NHS Emergency Planning Guidance: Planning for the psychosocial and mental health acre of people affected my major incidents and disasters: Interim national strategic guidance. 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