Pre-Travel Assessment and Advice for Expatriates and Volunteers

Definitions

Expatriates are defined as travelers who reside abroad for work or volunteer reasons but intend to return eventually to their home country, in contrast to immigrants, who intend to stay in the destination country. They typically spend longer durations abroad than tourists or short-term business travelers.

Type of Expatriate

Exposures depend largely on the nature of work. This may range from executives in large cities to missionaries or relief workers in rural settings or disaster sites. Working in healthcare facilities, refugee camps, or orphanages increases infectious risks.

Expatriates employed by well-established organizations have better access to pre-travel preparation and may have extensive medical resources, including evacuation policies. By contrast, self-sponsored travelers or those sent by smaller organizations may limit their pre-travel preparation due to cost constraints and may have inadequate support if they fall ill abroad.

Destination

The most important factor to consider in pre-travel preparation is destination. Health exposures vary greatly by continent; for example, the risk of malaria is generally higher in sub-Saharan Africa compared with Asia or Latin America. Urban versus rural settings also modify exposure risks and access to care.

Decisions about vaccinations and advice about malaria prophylaxis also depend on which other countries or areas the expatriate is likely to go to while abroad, other than the stated destination country. This can include official or recreational side trips to rural areas, such as might occur for consular staff responding to emergencies.

Duration

Long-term residence abroad (>3-6 months) puts expatriates at risk for an extended range of health problems. First, longer duration mathematically increases exposure opportunities. Second, compliance with precautions becomes challenging to sustain over time. Third, long-term expatriates may have higher risk for specific exposures, depending on their work (humanitarian relief, medical, orphanages), and living conditions may approximate that of local or poorer populations (missionaries).

Emerging Trends

Although “expatriate” may conjure images of white-collar executives, it encompasses lower-income migrant workers from developing countries. These may include Indonesian domestic helpers in Hong Kong, Filipino nurses in Saudi Arabia, or Bangladeshi construction workers in Singapore. An emerging trend is south-to-south work migration, for example, the large influx of Chinese investment and construction in Africa. Pre-travel preparation and access to healthcare resources for these workers may be minimal.

History

A detailed medical and surgical history should be obtained with attention to those that need to be stabilized. Review of systems should include symptoms that may indicate undiagnosed problems, psychiatric issues, and substance abuse, because these may be exacerbated by the stress of travel abroad. Social history should elicit tobacco, alcohol/drug use, and sexual practices to guide advice about risk behaviors, with reference to the destination country.

Document medication allergies and review medications the patient is taking, their availability abroad, and any testing required. Patients on warfarin, insulin, injectable agents, or controlled substances will require detailed counsel on making prior arrangements for monitoring, safe supply, and legal access in the destination country.

Complete immunization records are required in order to provide appropriate advice about vaccinations. Specific forms, tests, or vaccinations may be required by the organization or the destination country. If accompanying children will attend school at the destination country, there may be additional school-related requirements.

Physical Exam

Perform a comprehensive physical examination, including vital signs, height, weight, and body mass index. Preventive health screening for women should include a breast exam (if ≥30 years), and a Pap smear for the sexually active or those ≥21. Men should have a testicular exam and, if ≥50 years, a digital rectal exam. A dental exam is recommended if dental care overseas may not be readily accessible.

Laboratory Tests

There are few evidence-based recommendations for screening laboratory tests for long-term expatriates. Health screening guidelines appropriate for age and occupation would be a minimum starting point. Additional screening tests for tuberculosis, human immunodeficiency virus (HIV), or syphilis may also be required by the destination country for long-term travelers.

These are screening tests to consider, based on age, risk factors, and destination:

• Complete blood count (CBC), chemistry, liver function tests, and fasting glucose and lipids

• Mammograms for women age >40

• Colonoscopy for men and women age >50

• Tuberculin skin test (TST) or interferon gamma release assay (IGRA)

• Baseline electrocardiogram (EKG) for persons age >45 and those with cardiovascular risk factors

• Baseline chest radiograph for patients with positive TST or pulmonary conditions

• HbA1c for diabetics

• HIV serology

• Hepatitis B and C serologies (HBsAg, HBsAb, HBcAb total, HCV Ab)

• Rapid plasma reagin and Treponema pallidum hemagglutination

For patients with specific risk factors or medical history, some of the following tests may also be required:

• β-human chorionic gonadotropin

• Thyroid stimulating hormone, free thyroxine

• Cardiac stress testing

• Pulmonary function testing

Test results should be reviewed, follow-up discussed, and a copy of the results provided. Baseline EKG or chest radiograph may be needed for comparison when residing abroad long term.

Assessing Fitness for Travel

Assessing fitness for travel may be required by the organization or requested for personal health reasons. Employer or country visa requirements can be quite specific. Information from the history, physical exam, and laboratory tests will help determine this. Stabilize newly diagnosed or pre-existing medical illness before departure.

Complex medical conditions in travelers should prompt a careful evaluation of availability at the destination for access to modern medical resources:

• Bleeding or clotting disorders (requiring blood products)

• Cancer (requiring treatment in the past 5 years or ongoing monitoring)

• Cardiovascular disease (symptomatic)

• Diabetes (HbA1c >8, end-stage organ disease)

• HIV (symptomatic or CD4 count <200)

• Renal failure (requiring renal replacement therapy)

• Rheumatologic disease (symptomatic in the last 6 months, on immunosuppression)

• Solid organ or bone marrow transplant recipient (within 2 years from transplant)

• Psychiatric disorder (symptomatic within the last 12 months)

These need not preclude travel. But if travel or assignment is to a remote location with poor access to appropriate medical care, travelers and their organizations should be made aware of the potential risks and options to mitigate those risks.

Depending on resources available, long-term travelers may need to make arrangements for medical follow-up at destination or else return home for this. Travelers need to check on availability of medications in the destination country. Local regulations may restrict the use of benzodiazepines and narcotics, and purchasing medications in-country may risk counterfeit medications or treatment interruptions due to stock-outs.