Health and Productivity in Business: Occupational Travelers, Assignees and Expatriates

Transcription

1 IJHP INTERNATIONAL JOURNAL OF HEALTH & PRODUCTIVITY Health and Productivity in Business: Occupational Travelers, Assignees and Expatriates W. B. Bunn, III INTRODUCTION The number of international travelers exceeded one million in 2014 with 1,600,000 expected by Studies report that business/occupational travelers constitute from 18 to as much as 35 percent of this total. Business travel and international assignment have been growing with the globalization of corporations. Multinational Corporations (MNCs) have expanded outside their home countries not only to produce goods at lower costs for home country consumption, but to move into overseas markets (Khan, 2016; OSHA, 2002). Many MNCs international revenues already exceed domestic revenues. The number of international manufacturing and other facilities is rapidly increasing and the trend will continue. Currently, MNCs place international expatriates/assignees on average in more than 20 countries and the number of countries continues to grow. For these MNCs, 95% of their consumers are outside the U.S. and the growth in revenues from developing countries will drive continued globalization and the need for business travel and overseas assignment (Druckman, 2012; Rogers, 2016). The international business traveler (IBT) represents the group who travel for their work (also termed occupational travelers), which includes growing numbers of travelers for education, research or volunteer work. Several categories of overseas assignments require regular business travel., and IBTs usually make a number of trips annually to different locations. Another category of IBT is the business commuter who generally returns to the same international facility weekly or monthly (Druckman, 2012). The number of international assignees also is rapidly increasing, with a 50% rise expected by 2020, and many of them travel regularly. Expatriates are employees on long-term assignment whose families often move to the host country for from 2 to 5 years, although some expatriates relocate without their family but have frequent visitation benefits. A group increasing in size is the shortterm assignee (e.g., 4-12 months) who travels to international sites usually for specific time-limited objectives (such as engineers, finance managers, auditors, and job specialists). The assignee does not relocate to the site but returns home on a scheduled basis,and has temporary housing while performing a specific task. Studies have shown that short- term assignees are less prepared and at higher risk for adverse health events than expatriates (Druckman, 2012). HEALTH RISKS OF IBTS The risks of IBTs have historically been considered low. Studies show, however, that the risks of business travelers are similar to other international travelers (Chen, 2013). Travel patterns are changing, with increased business travel to Asia and to developing countries (Druckman, 2014). In a recent study of travelers to Asia, more than 60 percent of high-risk travelers listed a work-related reason for the trips (Deshpande, 2014). Studies also have shown more hospitalizations and evacuations for low risk travelers in total, although the country risk level is a predictor, as well. A study of World Bank employees showed overall health plan costs 70% higher for international business travelers than for non-traveling counterparts (Liese, 1997). On international business trips (10 days to two weeks) approximately one-third of travelers will develop an infectious illness (e.g., diarrhea or a respiratory condition) or suffer 30 IJHP Volume 8, Number 1 April

2 HEALTH AND PRODUCTIVITY IN BUSINESS: OCCUPATIONAL TRAVELERS, ASSIGNEES AND EXPATRIATES an injury. Moreover, a significant increase in the risk for high mental stress is reported among business travelers (Liese, 1997); sleep disorders and substance abuse are common, and non-communicable chronic disease categories showed similar increases to infectious diseases. Risks are greatly increased for accidents and injuries, as well, and risk of death from traffic accidents is increased five times (Liese, 1997; Bunn, 2014). Health risks are very different from the home country for IBTs and assignees. Infectious diseases vary widely by country and region. The diseases encountered may change rapidly and information may be outdated; infectious diseases absent from developed countries may be significant risks (e.g., malaria, typhoid, cholera, rabies, encephalitis). In addition, there are increased risks of other illnesses and injuries. Exposures to air and water pollution, allergens, physical (cold, heat) and chemical hazards are significant. Accommodations for disabilities are not available in many countries (e.g., elevators, ramps) nor are protective devices (seat belts, air bags), which increases the risk of accidents/injuries (Rogers, 2016). The risk from illnesses and injuries is compounded by the medical care available. Many regions lack quality health care and particularly emergency/acute care. Emergency transportation (e.g., ambulances) may not be available. Access to care also is challenging because many facilities are funded through a public health system and private care may be limited and have special payment requirements. Even treatment of a minor illness may not be easily available or may require significant periods away from work to seek appropriate care. For serious illnesses, quality local care may not be available and evacuation to regional health care centers or to the home country may be necessary (Rey-Herme, 1997; Bunn, 2014). International occupational travel health programs (ITHP) for travelers, expatriates and assignees have been recommended by many medical expert groups. Program components include medical screening, health education, vaccination and prophylaxis, computerized databases with updated travel and destination health risk information, travel kits, and information on best care facilities and access to evacuation. Such programs are not available, however, to most business travelers or many expatriates and assignees (Rogers, 2016). There are additional risks to MNCs for business travelers, assignees, and expatriates. Effective travel programs for health, safety and security are expected by employeetravelers; their absence can cause a loss of confidence which itself can impact productivity in addition to the impact of adverse health events. Corporations also are liable for tort suits for negligence as well as Workers Compensation claims; resulting damage to public image and corporate trust also can affect overall company performance. EARLIER STUDIES OF BUSINESS TRAVELERS, EXPATRIATES AND ASSIGNEES THAT ADDRESS HEALTH AND PRODUCTIVITY There are remarkably few studies that address the issue of productivity loss due to health or that specifically address business and occupational travelers in the literature. The issues may be mentioned but are not addressed in detail or analyzed. One often-cited study that addresses a working population was published in 1997 by Liese and colleagues at the World Bank. The study analyzed medical insurance claims filed by 4,738 regular international travelers, using data available on specific diagnoses and frequency of international travel, adjusted for age and gender. Rates of insurance claims for international travelers versus nontravelers were 80% higher for males and 18% for females, and the risks increased with the number of international missions. For infectious disease, the Standardized Risk Ratios (SRR) were 1.28, 1.54 and 1.97 for men who had completed one, two, and three or more missions, and 1.16, 1.28 and 1.61 for women. The authors emphasized that the risks to international travelers go beyond infectious disease and include mental as well as physical illnesses. The study showed that even limited international travel increased risk in every of the 20 disease categories assessed (Liese, 1997). Of particular note, psychological disorders showed the highest SRRs , 3.13 and 3.06 for men, and 1.47, 1.96 and 2.59 for women. Although lost time and productivity loss were not addressed specifically in the IJHP Volume 8, Number 1 April

3 IJHP INTERNATIONAL JOURNAL OF HEALTH & PRODUCTIVITY study, they should correlate with the trends of disease-based risk. A 2001 paper by Bunn in the Journal of Travel Medicine discussed the importance of corporate vaccination and international health programs, and described a proactive approach to international travelers and expatriates. The opportunity cost savings for 100 expatriates assuming six actual repatriations (the average rate) at a cost of $600,000 a piece was $3,600,000. If a screening program cost of $500 combined with international medical support eliminated the need for any repatriations, the incremental costs of an International health and Immunization program would be about 1.5 % of the avoided cost of repatriations. This analysis assumes an available corporate medical program as a baseline. The costs do not include productivity losses but do include the costs of repatriations and replacement. The savings assume the elimination of all repatriations and are considered opportunity cost savings (Bunn, 2001 and 2014). In 2008, Wang et al published a study on Economics Aspects of Travel Diarrhea. Travel Diarrhea (TD) is the most common illness for business/occupational travelers. The incidence can be greatly reduced by effective travel counseling with knowledge of the risks at the destination. In addition, the rapid treatment of diarrhea minimizes its impact on productivity. Productivity loss costs were calculated for returning travelers with untreated TD, assuming 1-2 workdays lost per traveler on return resulting in a projected annual lost productivity cost of 654 million dollars for United States travelers in 2005 (Wang, 2008). These three peer-reviewed papers are not a comprehensive literature review, but they do address working populations and the cost impact of health for international travelers. These studies illustrate the limited scope of the assessment so far of the health and lost productivity impact for international travelers and assignees. The World Bank study shows a significant impact for all types of disease, not just infectious disease, on healthcare costs (and lost productivity) for workers that travel regularly. The paper by Bunn shows the significant opportunity costs for assignees and the potential savings for an effective vaccine and international health program. The Wang paper looks at diarrhea as the most common travel illness, and its potential resulting productivity loss. A welldesigned study of the productivity impact of international travel, however, does not appear in the earlier literature searched. RECENT ARTICLES ON BUSINESS TRAVELERS, EXPATRIATES AND ASSIGNEES Two 2014 JOEM articles (Druckman, 2014; Bunn, 2014) recently addressed specific issues for IBTs that will impact productivity. The Druckman article included more than 800,000 business trips and almost 1,200 medical cases. The article focused on hospitalizations, evacuations and risk factors. The results showed that aggregate trips to low risk countries resulted in a greater number of hospitalizations and evacuations than did trips to high risk countries. The country risk categorization (CDC categorization of risk) was a predictor of an adverse event; however, the article suggests that there is a significant risk even in low risk countries that must be considered. Each evacuation and hospitalization resulted in significant absenteeism and productivity loss. Aggressive pre-travel and destination medical support programs (ITHP) would have substantially reduced the risks. The accompanying editorial by Bunn (Bunn, 2014) discussed the Druckman article and an article by Kogelman (Kogelman, 2014). The Kogelman article revealed the lack of knowledge of vaccines and of vaccine-preventable diseases among providers of travel medicine, which itself is a risk for travelers. The study showed that, particularly for rare diseases, the gap was much greater -- particularly among Primary Care Physicians (PCPs) practicing travel medicine. The study compared their knowledge of Hepatitis A, Yellow Fever and Japanese Encephalitis. Although the familiarity (very familiar) with Hepatitis was 78.6%, it was only 18.9% for Yellow Fever and merely 9.8% for Japanese Encephalitis (JE). JE is a rare but often fatal disease (20-30% of cases are fatal and 50% of survivors have permanent neurological sequelae). Despite a safe, effective vaccine, other studies have shown that only 1-11% of at-risk groups are vaccinated and that, even in the Global 32 IJHP Volume 8, Number 1 April

4 HEALTH AND PRODUCTIVITY IN BUSINESS: OCCUPATIONAL TRAVELERS, ASSIGNEES AND EXPATRIATES TravEpiNet -- a sophisticated consortium of travel clinics -- only 28% were vaccinated according to ACIP/CDC recommendations (Bunn, 2014; Kogleman, 2014). The most common reason for failure to vaccinate has been the failure to consider or recognize the need for vaccination -- despite the existence of ACIP guidelines. Although these studies demonstrate the need for a careful review of the vaccine needs of IBTs,the responsibility is not only in the travel clinic but also in the referring occupational health clinic to assure appropriate education and access to vaccines are given. The potential loss of productivity from the failure to vaccinate and provide effective international health programs must be considered, as well as special legal and public relations risks for corporations (Bunn, 2014). A 2016 article in the Journal of Occupational and Environmental Medicine addresses the Pre Travel Preparation of Business and Occupational Travelers (Khan, 2016). The article does not address productivity loss directly, but it does distinguish business/occupational travelers from other travelers. The study is focused on the Global TravEpiNet travel medicine clinics, which are specialized and should provide a high-quality level of care for travelers. A specific concern identified for business/ occupational travelers, though, is the appropriate vaccination of business travelers. The assumption of the referring business (more than half of the travelers were referred by businesses) is that vaccinations will be administered according to guidelines, and decisions to vaccinate will be made conservatively to minimize any health risk. Despite the business concern for reducing all risks, vaccination rates were lower than expected with only 60% of indicated vaccination for Hepatitis B and Influenza and very low vaccination rates for Japanese Encephalitis and Rabies. An accompanying Letter to the Editor does address lost productivity, and suggests that updated vaccine recommendations with clear wording as well as comprehensive business travel programs also reduce risk and improve the health of business travelers. In particular, the letter contains updated recommendations for Japanese Encephalitis (Bunn, 2016). These studies show that business travelers and assignees do not receive the counseling and vaccinations needed. Ineffective pre-travel and vaccination programs will increase risk and lead to a higher level of adverse health events and lost productivity. Although productivity is not addressed in detail in the recent literature on frequent international travelers, assignees and expats, the articles address business travelers and the potential risk for adverse health events and lost productivity. CASE STUDIES OF HEALTH AND PRODUCTIVITY OF INTERNATIONAL BUSINESS TRAVELERS, ASSIGNEES AND EXPATRIATES Although studies have not been published that specifically address Health and Productivity or quantify the costs of Health and Productivity of international travelers, there are case examples and scenarios of the adverse impact of health on the productivity of international travelers and assignees that will show the potential for significant cost savings using effective ITHP. The following 10 examples illustrate the productivity loss associated with adverse health events. The cases and scenarios were taken from actual situations reported by Medical Directors of MNCs. CASE STUDY I The senior country manager with responsibility for a number of international operations developed an alcohol problem. Alcohol and drug consumption increase significantly with overseas assignments, and assignees should be screened and counseling should be required before placement. The problem led to bad relations with the employees (lost productivity) and with external parties. It is particularly important that the external governmental relations are preserved for each expatriate country manager; bad relations and repatriation resulted in a loss of confidence, and a poor transition to the next country manager. The repatriation was not only expensive but also resulted in a major loss of productivity, as well as damaged external and internal relations and the loss of business opportunities. Repatriation and replacement resulted in months of business IJHP Volume 8, Number 1 April

5 IJHP INTERNATIONAL JOURNAL OF HEALTH & PRODUCTIVITY disruption and lost revenues. CASE STUDY II A professional couple was transferred to a Middle East country with traditional Muslim practices. The husband was able to perform the needed services to the company, but the wife needed to continue her practice in health care. Psychological screening and adaptability testing had not been conducted and pre-assignment cultural preparation was not conducted. Due to cultural differences in medical practice, there was a significant mental health issue; the assignment failed and repatriation was necessary. This led to significant issues with the host country partner, and a loss of confidence and business opportunity with the partner company. Replacement of the executive was difficult and led to a significant productivity loss, because particular education, experience, and language skills were needed for the assignment. CASE STUDY III A financial audit group leader was given a two-month assignment overseas. After developing several infections and not being able to find adequate medical care, the auditor returned home along with the entire audit group before completion of the audit. The auditor had not received pre-travel counseling or advice on medical care in the host country, and corporate medical support was not available. A new group had to be sent. The efforts of the local managers during the unfinished audit were lost and the audit had to be repeated, with a significant reduction in the productivity and profitability of the country operations and disruption to the audit department. CASE STUDY IV A senior executive was assigned to negotiate a deal with an overseas corporation. The executive commonly had difficulty sleeping during international f lights. A new medication was prescribed by his personal physician at the executive s request. On return the executive had loss of memory during most of the trip and the meeting. The medication was new but similar effects had been reported; however, the corporate medical group was not consulted. The entire negotiation had to be repeated and was more difficult after the first attempt. (A more common executive travel issue for missed business meetings is traveler s diarrhea which is preventable and treatable.) CASE STUDY V The lead engineer (and only experienced manager) assigned to a construction project in a major overseas oil drilling operation became ill at a key point in the construction project. The engineer was ineffective while ill so evacuation was necessary. On return, it was determined the engineer had contracted hepatitis A and had not been vaccinated or received counseling before the assignment. The project was delayed for three weeks. Replacement was expensive, but the major loss to the company was three weeks of production. CASE STUDY VI A senior marketing executive for a large affiliate became fearful due to recent violence in the assigned country. Rather than requesting special protection, he purchased weapons and began to carry a gun, which the executive knew was strictly against corporate policy and increased the risk. The executive had not received psychological screening or adaptability or sensitivity training for the assignment. He had previously had an issue with carrying a weapon, but the history was not known because there was no pre-assignment screening except for vaccinations. His return resulted in the costs of replacement, lost productivity, and a major loss in sales. CASE STUDY VII A marketing executive was assigned a major overseas responsibility for a new product. During his pre-assignment history-taking, physical and testing, a significant cardiac risk was identified and treated. He was rejected for the assignment and reassigned to a domestic position. Despite treatments, he suffered a myocardial infarction one month later resulting in a disability that would have required repatriation with a significant productivity loss. CASE STUDY VIII An environmental auditor/engineer was assigned to do due diligence on the purchase 34 IJHP Volume 8, Number 1 April

6 HEALTH AND PRODUCTIVITY IN BUSINESS: OCCUPATIONAL TRAVELERS, ASSIGNEES AND EXPATRIATES of an overseas operation. The audit was in a peri-urban area 25 miles from a major city in a malaria risk area. The auditor was not advised to take malaria prophylaxis by his personal physician. He became ill due to malaria and was evacuated. The audit and due diligence was delayed and the purchase was made by a competing company. CASE STUDY IX An expatriate was assigned to supervise construction of a large facility over two years. Both the expatriate and spouse were diabetic and the local care was poor, which was not known prior to assignment. The engineer/ manager decided that he would retire and return to the United States, endangering the completion of the project because he was the only individual in the corporation with the experience needed to achieve it. Although the project was delayed, it was completed after a combination of local and regional diabetic care was arranged by the International Medical Director. CASE STUDY X A Senior Financial Executive who traveled regularly to overseas operations had significant renovascular hypertension managed by a number of medications. Because of pressure to complete the needed year-end financial reporting, he postponed trips back to the United States and ran out of his medication. Having not been advised of the risk of counterfeit medications, he purchased local medications which were not effective. After a major hypertensive episode, he suffered a stroke and had to be transferred back to the United States. The required financial reporting was late, resulting in a corporate reporting delay which impacted the stock price in addition to the cost of repatriation and replacement. FUTURE STUDIES ON HEALTH AND PRODUCTIVITY AND THE CALCULATION OF MONETARY IMPACT FOR INTERNATIONAL BUSINESS TRAVELERS, ASSIGNEES AND EXPATRIATES These 10 studies/scenarios suggest (1) a major monetary impact from lost productivity due to health for IBTs, assignees, and expatriates, and (2) most illnesses are preventable with an effective ITHP. There are very limited earlier or recent studies published, however, on business/occupational international travelers, and their health risks and productivity loss are rarely addressed. Given the huge number of business/occupational travelers and growing numbers of assignees and expatriates, this is an important area for research in Health and Productivity. In addition to quantifying the costs of lost productivity, analysis of the impact of effective ITHPs on health risks and medical cost savings also is clearly needed. Cross sectional studies would offer an assessment of the impact on health and the costs of lost productivity. Retrospective cohort data on health events and productivity loss could be obtained from records of corporate and government frequent travelers seen at travel clinics. Several questionnaires have been validated in the Health and Productivity literature, and they can be short and easy to administer. These questionnaires could be used to analyze the impact of previous trips by groups of business travelers, or administered before and after travel to assess productivity loss during travel and return from overseas. Questionnaires are given routinely to travelers in travel medicine and corporate studies cited. The costs of ill health and lost productivity, however, were not part of the study. Corporate and government entities could use productivity questionnaires to collect data from international travelers, assignees and expatriates. The use of questionnaires during the purchase of international travel tickets is common in business, and it would be simple to implement a health and productivity survey. The World Bank study illustrates the use of health benefits claims to identify risk. Similar data bases exist in self-insured industries (almost all MNCs) government and other groups. Data on the cost of medical care as well as the incidence of specific diseases are available. Absenteeism, Workers Compensation and disability data also may be available. The World Bank study used available data to define a cohort for which medical claims and numbers of trips were available. Similar retrospective data could be collected for previous years to identify increased risks, and combined with questionnaire responses to measure health status and IJHP Volume 8, Number 1 April

7 IJHP INTERNATIONAL JOURNAL OF HEALTH & PRODUCTIVITY related productivity impacts to blend direct and indirect costs of health issues. Similarly, prospective cohort studies could follow a group of IBTs over a period of time. The cohort could be compared with nontravelers to assess the risk impact of increasing international travel generally or travel to specific regions or high-risk destinations. If an ITHP has been initiated or prevention program changes made, the impact of that program or those changes then could be determined. Interventional studies of international business travelers clearly are needed. The impact of pre-travel health consultations, vaccinations and international destination medical programs (ITHP) have not been established. Specific vaccines or new vaccines could be evaluated for reduced incidence of illness and related cost savings, and the return on investment in such programs then assessed. The return on investment (ROI) from prevention programs has been the subject of recent debate. The ROI from a successful pre-travel ITHP can be calculated using different approaches. One approach is to calculate savings in cost avoidance from high-risk travelers and expatriates who were screened out and not sent on assignments, compared with the cost of the prevention program. A second approach is to calculate savings based not only on those screened out, but also those for whom a specific successful intervention (physical or mental health) led to a successfully completed assignment. These two approaches, however, do not include the impact of general preventive practices e.g., vaccination prophylaxis and education or of host country support programs. A third approach is to calculate the costs of all repatriations and evacuations (opportunity savings, cost avoidances) and assume they were preventable with an effective program (opportunity savings). There are limited data on any of these approaches, but calculations using the third opportunity savings approach show a huge ROI (Bunn, 2001). A more precise and, therefore, presumably accurate approach would be to (1) compare a company that has an ITHP for travelers, expatriates and assignees with a company that does not, (2) compare an employee group before and after an ITHP was put in place, or (3) use two randomized groups in the same employer, with one using an ITHP. Even with a randomized approach, though, the calculation of overall productivity loss and particularly presenteeism could be challenging. There are many studies, however, which have assessed and measured the cost of Health and Productivity and shown the potential for major indirect as well as direct savings from implementing effective prevention programs. The indirect productivity related costs in these studies consistently have been significantly higher than direct medical costs, leading to a markedly higher return on investment. These studies would be useful to the process of making a management decision whether to initiate or continue ITHP for a company s business and occupational travelers. CONCLUSION There are millions of business/occupational travelers, assignees, and expatriates each year from the United States and globally and the numbers are expected to continue growing with business globalization. This is one of the largest at-risk groups in occupational health and safety. Although the increased health risks have been documented, there is little mention of productivity loss. The cases and scenarios show that productivity is a major consideration for MNCs and other businesses, as well as for governments and other organizations with international travelers. Studies to define the risk of ill health and the economic cost burden of lost productivity are required. Further studies should address the impact of ITHP for international business and occupational travelers, assignees and expatriates. Analysis of compliance with current vaccine recommendations and guidelines is an area of special interest, and the full cost/benefit of existing or new vaccines should include lost productivity as well as clinical impact and cost. The opportunity for return on investment is significant, but detailed analysis is needed to evaluate the full costs of ill health and lost productivity. The health and productivity of international business travelers and assignees is a fertile area for future research, and the work is sorely needed. 36 IJHP Volume 8, Number 1 April

8 HEALTH AND PRODUCTIVITY IN BUSINESS: OCCUPATIONAL TRAVELERS, ASSIGNEES AND EXPATRIATES REFERENCES Bunn, W. (2001). Vaccine and international health programs for employees traveling and living abroad. Journal of Travel Medicine, 8 (supp 1), s Bunn, W. (2014). Assessing risk and improving travel vaccine programs for business vaccine programs for business travelers. Journal of Occupational and Environmental Medicine, 56(11), Bunn, W (2016). Pre-travel preparation of business and occupational travelers: Analysis of Global TravEpiNet Consortium (Letter to the Editor), Journal of Occupational and Environmental Medicine, 58(2) e58. Chen, L.H., Leder, K., Wilson, M.E. (2013). Business travelers: vaccination considerations for this population. Expert Rev Vaccines, 12: Deshpande, B., Rao, S., Jentes, E., Hills, S., Fischer, M. (2014). Use of Japanese vaccine in US travel medicine practices in global TravEpiNet. American Journal of Tropical Medicine and Hygiene, 91(4) Druckman, M., Harber, P., Liu, Y., Quigley, R. (2012). Country factors associated with the risk of hospitalization and aeromedical evacuation among expatriate workers. Journal of Occupational and Environmental Medicine, 54: Druckman, M., Harber, P., Liu, Y., Quigley, R. (2014). Assessing the risk of work related international travel. Journal of Occupational and Environmental Medicine, 56, Khan, N.M., Jentes, E.S., Brown, C., Han, P., Rao, S.R., et al. (2016). Pre-travel medical preparation of business and occupational travelers: An analysis of Global TravEpiNet Consortium 2009 to Occupational Travelers, Journal of Occupational and Environmental Medicine, Volume 58, 1: Kogelman, L., Barnett, E., Chen, L., Quinn, E. (2014). Knowledge, attitudes and practices of US practitioners. Journal of Travel Medicine, 21, Liese, B., Mundt, K., Dell, L., Nagy L., Demure, B. (1997). Medical insurance claims associate with business travel. Occupational and Environmental Medicine, 54: Rey-Herme, P., De Jongh, R. Travel and Expatriate Medicine. International Occupational and Environmental Medicine, Mosby, 1997, pps Rogers, B., Bunn, W., Connor, B. An Update on Travel Vaccines and Issues in Travel and International Medicine. Workplace Health and Safety, 2016 (in Press). U.S. Depart of Labor, Occupational Safety and Health Administration. Safety and Health During International Travel. Technical Information Bulletin, TIB , Wang, M., Szucs, T., Steffen, R. Economic Aspects of Travelers Diarrhea. Journal of Travel Medicine, Volume 15, Issue 2, pps IJHP Volume 8, Number 1 April