Country Factors Associated With the Risk of Hospitalization and Aeromedical Evacuation Among Expatriate Workers

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: To assess country factors associated with the risk of requiring aeromedical evacuation and hospitalization among expatriate workers and their dependents. : The 2009-2010 data including 5725 aeromedical evacuations and 17,828 hospitalizations, and 2009 data of hospitalizations and aeromedical evacuations among 94,651 at-risk expatriates, were analyzed to assess 2 country risk rating tools. Each tool utilized four risk categories and reflected level of development and medical capabilities. : Country risk category was strongly associated with risk of evacuation and/or hospitalization for each risk rating tool (eg, 46-fold increase from lowest to highest country risk category). : Country risk tools strongly associate hospitalization and aeromedical evacuation with country risk category, and thus can be important indicators of relative medical risk. Employers may use these results to implement targeted prevention programs to support expatriate workers and their families.

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... Currently, MNCs place international expatriates or assignees in more than 20 countries on average, and the number of countries continues to grow. For MNCs, 95% of the consumers are outside the United States, and the growth in revenues from developing countries will drive continued globalization and the need for business travel and overseas assignments [12][13][14]. ...
... Business travelers' health and safety risks have historically been considered "low". However, studies have shown that these risks are similar to the risks of other international travelers [14,15]. In fact, in a recent study of travelers to Asia, more than 60% of high risk travelers listed a business reason for the trips [16]. ...
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The epidemiology of Japanese Encephalitis and risk to the traveler has changed and continues to evolve. The spread of Japanese Encephalitis virus into new environments, changes in agricultural practice and animal vectors, climate change, peri-urban growth, changes in international travel to Asia, personal risk factors, mosquito vector free transmission, interactions with other flaviviruses and better information on infections without encephalitis and other factors make Japanese Encephalitis an underappreciated risk. There has also been a change in the incidence of Japanese Encephalitis cases that questions the current travel duration and geographic based recommendations. A safe, effective vaccine (Ixiaro) that may be administered in a short course regimen is now available in the United States without the risks of the previous vaccine. However, the vaccine is significantly underutilized. These changes in the epidemiology and new data on the risks of the Japanese Encephalitis virus require a review of the practice guidelines and expert recommendations that do not reflect the current state of knowledge.
... Crises have further been defined by location. For example, there are workplace threats such as chemical spills, industrial accidents and aircraft crashes (Claus, 2011), and nonwork-related threats like illness, road accidents and medical emergencies (Druckman et al., 2012). Similarly, there are regional threats such as pandemics (SARS, MERS; Tan and Enderwick, 2006) and natural disasters such as landslides, earthquakes and tsunamis (Schneid and Collins, 2001;Merlot and De Cieri, 2011) that can result in infectious disease, homelessness or life-threatening illness (Dagan et al., 2011). ...
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Purpose The purpose of this paper is to develop a conceptual framework of severe expatriate crises focusing on the occurrence of “fit-dependent” crisis events, which is when the crisis is “man made” and triggered by expatriates’ maladjustment or acculturation stress in the host country. The authors focus on the causes, prevention and management of fit-dependent expatriate crises. Design/methodology/approach The authors develop a conceptual framework of fit-dependent expatriate crises that involves different levels of analysis. Findings The conceptual framework shows that crises can be triggered at micro, meso and macro levels ranging from the personal and family domains (micro), to the network and organisational domains (meso) as well as the host country domain (macro). The authors conceptualise these “domains of causes” as triggering maladjustment and acculturation stress that ultimately leads to a severe crisis event with correspondingly serious and potentially life-changing consequences. Furthermore, using a process perspective, the authors outline strategies for preventing and managing crises before, during and after the crisis occurs, discussing the support roles of various internal (organisational) and external (specialist) stakeholders. Originality/value Studying the link between expatriation and crises is a highly relevant research endeavour because severe crisis events will impact on HRM policies, processes and procedures for dealing with employees living abroad, and will create additional challenges for HRM beyond what could normally be expected. Using attribution theory to explain why organisational support and intervention to assist expatriates during a crisis is not always forthcoming, and theories of social networks to elucidate the “first responder” roles of various support actors, the authors contribute to the expatriate literature by opening up the field to a better understanding of the dark side of expatriation that includes crisis definition, prevention, management and solutions.
... Although using data on general travelers to make interferences about travel-related illness in occupational travelers is possible, there is evidence that business travelers (especially expatriates, i.e. occupational travelers with an assignment for a longer period abroad) may be confronted with higher rates of illness, injury and psychiatric disorders [7,8,9,10,11]. ...
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Background Although 17.5% of German travelers were business travelers in the years 2011–2013, little is known about their pathologies. Recent publications indicate that infections are the primary health issue in general travelers. Our aim was to investigate whether business travelers from Germany to China also primarily suffer from infections. Methods From 2011 to 2013, 587 calls for service of German business travelers to China were collected by a medical assistance provider. 482 of these calls were evaluated regarding demographics, reported diseases and conditions and the type of service provided by the medical assistance company. Results The most common reasons for calls for service were “factors influencing health status and contact with health service” (18.8%), “injury and poisoning” (16.0%) as well as “symptoms, signs, and ill-defined conditions” (13.7%). Most patients asked for “medical advice” (37.8%), referral to “outpatient care” (25.1%) or “inpatient care” (16.6%). “Evacuation and/or repatriation” was required mainly due to “injury and poisoning” (n = 12), “diseases of the circulatory system” (n = 5) or “mental disorders” (n = 3). Conclusion German business travelers to China are seeking primarily administrative support from a medical assistance provider and are mostly affected by non-infectious diseases. Pre-travel preparation of such travelers need to place more emphasis on non-communicable health risks and prevention.
... 38 The risk of hospitalization and evacuation of expatriate workers has been strongly linked to the World Health Organization Human Development Index for the destination country. 39 We found that expatriate workers appear less likely to require evacuation for medical problems than nonexpatriate business travelers, perhaps due to more stringent screening, better knowledge of local resources, and better local support structures, or reporting bias. ...
Background: Analysis of a large cohort of business travelers will help clinicians focus on frequent and serious illnesses. We aimed to describe travel-related health problems in business travelers. Methods: GeoSentinel Surveillance Network consists of 64 travel and tropical medicine clinics in 29 countries; descriptive analysis was performed on ill business travelers, defined as persons traveling for work, evaluated after international travel 1 January 1997 through 31 December 2014. Results: Among 12 203 business travelers seen 1997-2014 (14 045 eligible diagnoses), the majority (97%) were adults aged 20-64 years; most (74%) reported from Western Europe or North America; two-thirds were male. Most (86%) were outpatients. Fewer than half (45%) reported a pre-travel healthcare encounter. Frequent regions of exposure were sub-Saharan Africa (37%), Southeast Asia (15%) and South Central Asia (14%). The most frequent diagnoses were malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), acute bacterial diarrhea (5%) and chronic diarrhea (4%). Species was reported for 973 (90%) of 1079 patients with malaria, predominantly Plasmodium falciparum acquired in sub-Saharan Africa. Of 584 (54%) with malaria chemoprophylaxis information, 92% took none or incomplete courses. Thirteen deaths were reported, over half of which were due to malaria; others succumbed to pneumonia, typhoid fever, rabies, melioidosis and pyogenic abscess. Conclusions: Diarrheal illness was a major cause of morbidity. Malaria contributed substantial morbidity and mortality, particularly among business travelers to sub-Saharan Africa. Underuse or non-use of chemoprophylaxis contributed to malaria cases. Deaths in business travelers could be reduced by improving adherence to malaria chemoprophylaxis and targeted vaccination for vaccine-preventable diseases. Pre-travel advice is indicated for business travelers and is currently under-utilized and needs improvement.
... So far, major contributions to the field of 'employer duty of care' have come mainly from outside of HR and academia, for example, from the fields of training (Bensimon, 1998), tourism (Reisinger and Mavondo, 2005;Ritchie, 2004), hospitality (Chien and Law, 2003), medicine and occupational health (Patelet al., 2000;Peytremann et al., 2001;Druckman et al., 2012;Druckman et al., 2014), and law (Knauer, 2002;Meunier, 2007). A number of consulting reports and articles have also contributed to the duty of care debate, e.g., Brookfield Global Relocation Services (Aldred and Zipf, 2013), Santa Fe Group (Lockwood et al., 2014), Worldwide ERC (Williams, 2013), Business Review Weekly (Bleby, 2013), and International SOS (Claus, 2009;Claus, 2011). ...
Organizations cannot function without healthy and safe employees, a stark reality evidenced by the COVID-19 pandemic in 2019-20: when lives are threatened, everything else becomes secondary. Few would question that there is a critical need to build HR-relevant knowledge of how to manage the health and safety of employees. Despite the duty of care carried by organizations and the fact that those who work across national borders are a particularly vulnerable group, there is surprisingly little discussion about their health and safety. We examined the literature relevant to the health and safety of international employees across four research disciplines. Our review of 180 papers found a growing yet fragmented field offering important insights with implications for HRM. Our paper is intended as both a review and a call for future advancement. We bring together disparate but related research streams in order to understand what is known about occupational health and safety related to working across national borders and to outline a roadmap for future research and practice.
The fields of travel and international medicine are rapidly changing and growing. The role of occupational and travel health nurses is expanding and should be a focus for the future. At the American Association of Occupational Health Nurses Annual meeting on March 24, 2015, in Boston, five presentations were included in the session, An Update on Travel Vaccines and Issues in Travel and International Medicine. This article summarizes three of the presentations and includes a portion of the information generated by the Centers for Disease Control and Prevention (CDC) included in the fourth presentation. The first section focuses on the Essential Elements of Travel Medicine Programs including the pre-travel care assessment, trip research and risk identification, medication intervention review, non-pharmaceutical and prevention strategies, and post-travel care. The next section is an overview of key issues for business travelers. The growth in the number of international business travelers and unique aspects of business travel are emphasized in a comprehensive travel health program. This section also includes a discussion of expatriates and their special risks identified in recent literature (e.g., an assessment of the significant costs of health events and productivity losses by both business travelers and expatriates). The final section offers a specific example of a vaccine-preventable disease, namely, Japanese encephalitis (JE) virus, and needed changes in JE vaccine recommendations.
The requests for assistance to an assistance service provider of international assignees and their dependents employed in corporate, governmental and non-governmental organisations were compared in terms of closing diagnoses and case outcome types. Using institutional theory and the resource-based view of the firm, we hypothesise that these sectors have different approaches to duty of care that lead to different medical diagnoses and outcomes when international assignees need assistance for issues impacting their health. The findings indicate that there are differences in duty of care between the sectors with international assignees sent by government and non-governmental organisation employers experiencing different medical diagnoses and case outcomes upon diagnosis from those sent by corporate employers. These results have important implications for managing the duty of care considerations and the necessity of providing support for international assignees and their dependents.
Objective: To identify factors affecting the likelihood of requiring medical services during international business trips. Methods: Data from more than 800,000 international trips and medical assistance cases provided to 48 multinational corporations in 2009. Travel destination countries were grouped into four a priori risk-related categories. Results: Travel to "low" medical risk countries in aggregate accounted for more hospitalizations and medical evacuations than travel to "high" medical risk countries. Nevertheless, the risk per trip was much higher for travel to higher medical risk countries. Conclusions: Corporations with employees on international travel should allocate sufficient resources to manage and ideally prevent medical issues during business travel. Travel medicine must focus on more than infectious diseases, and programs are necessary for both high- and low-risk regions. Improved understanding of travel-related needs determines resource allocation and risk mitigation efforts.
Illness in business travelers is associated with reduced productivity on the part of the employee as well as the employer. Immunizations offer a reliable method of preventing infectious diseases for international business travelers. The authors review the travel patterns of business travelers, available data on illnesses they encounter, their potential travel-associated risks for vaccine-preventable diseases and recommendations on immunizations for this population. Routine vaccines (e.g., measles, tetanus and influenza) should be reviewed to assure that they provide current coverage. The combined hepatitis A and hepatitis B vaccine with a rapid schedule offers options for those with time constraints. Other vaccine recommendations for business travelers need to focus on their destinations and activities and underlying health, taking into account the concept of cumulative risk for those with frequent travel, multiple trips or long stays.
Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries. We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices. World Health Organization.
Incl. bibl., statistical annex, pp. 207-236, biographical note on the author
The decision whether to immediately evacuate an international traveler who has become ill is a challenge for physicians of aeromedical evacuation companies. The aim of this study is to characterize international aeromedical evacuations in order to identify predictive factors that indicate urgent evacuation. The records from all consecutive aeromedical evacuations and overseas repatriations carried out by Mondial Assistance France between August 2006 and July 2007 were reviewed for this study. Patients were allocated to one of two groups: those requiring immediate aeromedical evacuation by air-ambulance and those whose condition allowed subsequent, nonurgent repatriation. Data were compared between the two groups. Overseas repatriations numbering 402 were executed: 35 immediate aeromedical evacuations with air-ambulance and 367 nonurgent repatriations. Age < or =15 years [odds ratio (OR), 7.0; 95% CI, 1.6-30.6], whether there was a high standard structure in the country (OR, 0.28; 95% CI, 0.09-0.85), and location in sub-Saharan Africa (OR, 12.6; 95% CI, 2.3-71.4) were independent factors indicating the need for immediate aeromedical evacuation. Patient age, availability of local resources, and locations are the criteria associated with the need for immediate aeromedical evacuation. Creation of a specific standardized scoring system based on these criteria could be of great value to help physicians of aeromedical evacuation companies in initial management of cases.
Thousands of international aeromedical evacuations are conducted every year. An increasing number of travelers are elderly or have chronic illnesses, and there is more travel to regions where road trauma and infectious diseases are endemic but dependable medical care is not available. This review explains the indications for aeromedical evacuation, as well as the logistics, safety considerations, and principles of in-flight care for sick or injured patients.
Expatriate health and welfare: the hidden costs of getting it wrong. Paper presented at: SPE Asia Pacific Health, Safety, and Security Environment Conference and Exhibition
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Cox R, Jeremjenko A, Doig KM. Expatriate health and welfare: the hidden costs of getting it wrong. Paper presented at: SPE Asia Pacific Health, Safety, and Security Environment Conference and Exhibition; September 10-12, 2007;
Medical Aspects of Fitness for Offshore Work: Guidance for Examining Physicians
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Talent Mobility 2020: the next generation of international assignments
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International assignees at risk: employers have a duty of care for workers around the globe. HR Magazine.
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