633478
research-article2016
WHSXXX10.1177/2165079916633478WORKPLACE HEALTH & SAFETYWORKPLACE HEALTH & SAFETY
Workplace Health & Safety
Article
An Update on Travel Vaccines and Issues in Travel
and International Medicine
Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN1, William B. Bunn, MD, JD, MPH, FACOEM2, and
Bradley A. Connor, MD, AGAF, FACP, FIDSA, FRCPS (Glasg)3
Abstract: 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.
Keywords: acute illnesses, best practices, business
plans, case management, communicable diseases, disease
prevention, global occupational health, immunizations,
occupational health and safety programs, advanced practice
nurses, occupational health and safety team
T
he pre-travel consultation is a key element in assessing
potential health risks and providing education on
anticipated travel risks and the immunizations and
DOI: 10.1177/2165079916633478. From 1University of North Carolina at Chapel Hill, 2Medical University of South Carolina, and 3Cornell University. Address correspondence to:
William B. Bunn, MD, JD, MPH, FACOEM, 137 Coggins Point Road, Hilton Head Island, SC 29928, USA; email: wbbunn@gmail.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2016 The Author(s)
462
October 2016
prophylactic medications needed. The goal of the consultation
is to empower travelers to manage their health during the trip
including self-treatment if necessary.
Pre-travel care has several phases including assessment, trip
research and risk identification, pharmacological interventions,
and non-pharmacological and prevention strategies (Rosselot,
2004). Phase 1, the pre-travel assessment, begins with a full
understanding of the trip. Each destination and any stopovers
must be considered as well as the dates and duration of each
portion of the trip. A comprehensive travel health history is
essential and should include demographic information, health
history including allergies, immune status, medications,
immunizations and vaccinations, any special conditions (e.g.,
pregnancy, breast feeding, disability), and prior travel
experience (CDC, 2008).
Phase 2, trip research and risk identification, begins with a
full review of the planned modes of travel. The timing of a
potential trip is important because the season of the year (e.g.,
rainy or dry season) at each site will impact risk. In addition,
some areas may be prone to natural disasters. The
accommodations should be reviewed for any specific safety or
security issues and the availability of heating, ventilation, and air
conditioning. The activities during planned trips including
events and leisure time should be examined for potential risks.
The type of activities anticipated are an important part of trip
details and how the traveler will prepare for these activities,
particularly outdoor activities. Any disabilities or special needs
(e.g., food) and family members or other members of the travel
group should be considered. Specific cultural issues, laws, and
what to expect in remote and urban areas should be addressed
(Druckman, Harber, Liu, & Quigley, 2014).
After a full understanding of the trip itinerary, Phase 3
includes an evaluation of vaccines and medications. Routine,
required and recommended vaccines, and prior vaccination
history are essential as are risk factors, contraindications,
precautions, and level of immunocompetence. Indicated travel
vaccines should be identified using updated materials from
vol. 64  ■  no. 10
Table 1.  Travel Resources for Outbreaks, Advisories, and Alerts
Resource
National Center for Infectious Diseases: Traveler’s Health
Office of Aerospace Medicine
Travel Health Online
US Department of Transportation: Aviation Consumer Protection
Vaccine Information
Travax/Shoreland
WHO International Travel and Health
government agencies (e.g., Centers for Disease Control and
Prevention [CDC], WHO) and expert databases (e.g., Travax/
Shoreland). The timing of vaccinations must insure adequate
time for the full course of vaccination or a plan for vaccines to
be administered simultaneously at the same visit (Chen, 2014).
All employees must be monitored for adverse reactions. Routine
vaccinations include hepatitis B, human papillomavirus (HPV),
influenza, measles, mumps, rubella, meningococcal,
pneumococcal, polio, tetanus, diphtheria, pertussis, varicella,
and herpes zoster. Common travel vaccines include hepatitis A,
yellow fever, typhoid, meningococcal, Japanese encephalitis
(JE), rabies, tick-borne encephalitis, and cholera. However,
tick-borne encephalitis and cholera vaccines are not available in
the United States (Chen).
The occupational health nurse should also determine the
need for antimalarials, antimotility agents, antibiotics, motion
sickness agents, antivirals, and allergy medications. Both dosage
for prophylaxis and treatment should be ascertained (CDC,
2008).
In Phase 4, the non-pharmacological and prevention
strategies are addressed. Health education must be customized
and includes appropriate presentation of risks, risk
management, psychological impact of travel, and vaccines and
chemoprophylaxis recommendations. Employees must carry
medical records (e.g., electrocardiogram) including all
immunizations (e.g., yellow fever).
Safety and security issues (i.e., vehicular safety, road animals,
and poor signage with unfamiliar language) should also be
discussed. Air travel risks include jet lag, travel-related venous
thrombosis, airborne illness, and aerotitis. Disruption of circadian
rhythm from poor sleep or fatigue is also an area for education.
Specific infectious diseases (e.g., food- and water-borne
illnesses and those caused by blood-borne pathogens and insects)
at each destination and their prevention as well as environmental
factors (e.g., heat and cold, sunburn, air and water pollution,
recreational hazards, altitude, and animals) should be discussed.
Workplace Health & Safety
Website
www.cdc.gov/travel/index.htm
http://www.faa.gov/about/office_org/headquarters_offices/
avs/offices/aam/
www.tripprep.com/
http://www.dot.gov/airconsumer
www.vaccineinformation.org
https://www.travax.com
www.who.int/ith/
Self-management of minor illnesses and injuries, and exercise
options are often provided in concise handouts. Travel medicine
kits with first aid supplies and specific medications can be
provided (Kogelman, Barnett, Chen, & Quinn, 2014). A number of
resources can be used to find travel advisories, outbreaks or alerts,
and travel health resources (see Tables 1 and 2).
Finally, post-travel care is essential. Studies show that upon
return, 22% to 64% of travelers will have a health-related
problem that was not resolved by the conclusion of the trip
(Fairley, 2014). Particularly for business and occupational
travelers, occupational health professionals will be asked to
address these illnesses and injuries. The post-travel visit will
consider the severity of the illness, travel itinerary, duration,
timing, and place of illness onset. The most common illnesses
are diarrhea, upper respiratory infections and dermatologic
conditions, or febrile illnesses. In addition to risk factors during
the trip, a past health history, any current medications or
medications taken during the trip, and a full review of
vaccinations and compliance with chemoprophylaxis (e.g.,
antimalarials) should be conducted. Accommodations, insect
precautions, drinking water sources, types of food consumed
(e.g., raw meat, seafood, unpasteurized dairy products, food
from street vendors), fresh water exposure (swimming, rafting),
scratches, insect or animal bites, body fluid exposures (tattoos),
sexual activity, and health care sought during the trip (e.g.,
injections or transfusions) should be evaluated. Careful case
management of each traveler and appropriate referral such as
infectious disease diagnosis and treatment should be conducted.
Business and Occupational Travelers Assignees
Vaccine Prevention and Productivity Issues
The number of international travelers reached 1,138,000,000
in 2014 with 1,600,000,000 expected by 2020. Business travelers
now constitute approximately half of all international travelers.
Travel patterns are changing with increased business travel to
463
 Workplace Health & Safety October 2016

Table 2.  Travel Health Resources

Resource Website Description

Centers for Disease Control http://www.cdc.gov/ The CDC is a federal agency within the U.S. Department of
and Prevention (CDC) Health and Human Services responsible for protecting
the public’s health and safety. It provides a number of
valuable travel health resources.
Travelers’ Health http://wwwnc.cdc.gov/travel Interactive website for personalized travel health
information
Vaccines & Immunizations http://www.cdc.gov/vaccines Website offering vaccine updates with a separate health
care professionals home page
“Yellow Book” http://wwwnc.cdc.gov/travel/page/ Health Information for International Travel (commonly
yellowbook-home-2014 called the Yellow Book) is published every 2 years by
CDC as a reference for those who advise international
travelers about health risks.
Mortality and Morbidity http://www.cdc.gov/mmwr/ Weekly print and Web report on disease outbreaks and
Weekly Report (MMWR) new vaccine information
The Immunization Action www.immunize.org This nonprofit organization promotes vaccinations for
Coalition (IAC) children and adults. It offers travel health professionals
these resources.
IAC website www.immunize.org Provides immunization information, links to other
vaccine resources, and camera-ready, copyright-free
immunization educational materials
Directory of National http://www.immunize.org/resources/ A comprehensive catalog of immunization resources
Immunization including organizations, websites, and hotlines
Resources
IAC Catalog http://www.immunize.org/handouts/ More than 100 client education items available for print,
such as brochures, posters, slide sets, and handouts
Travax/Shoreland https://www.travax.com Most commonly used expert database/automated support
system for multinational corporations and government
organizations
World Health Organization http://www.who.int/en/ WHO sponsors several resources with updated, useful
(WHO) information for all travel health clinicians.
Immunization, Vaccines http://www.who.int/immunization/en/ Information about WHO regional office activities,
and Biologicals vaccines, vaccine-preventable diseases, and vaccine
administration
International Travel and www.who.int/ith Information about travel risks and prevention strategies
Health Manual
Weekly Epidemiology http://www.who.int/wer/en Reports on worldwide disease outbreaks
Record
International Society of www.istm.org Founded in Atlanta, GA in 1991, this international
Travel Medicine (ISTM) organization includes physicians, nurses, and others
interested in travel health care. ISTM sponsors several
valuable resources for practicing nurses.
ISTM Website http://www.istm.org Includes directory of travel health clinics and information
about the organization and its biannual meeting
Journal of Travel Medicine http://www.istm.org/ Peer reviewed journal devoted to travel medicine
journaloftravelmedicine
TravelMed Listserv http://www.istm.org/travelmedlistserv Internet forum for member concerns about clinical issues

464
vol. 64  ■  no. 10
Asia and developing countries (World Tourism Organization,
2014). Business travelers travel for their occupation or work
(e.g., education, research, or volunteer work) and have also
been termed occupational travelers. The number of international
assignees or expatriates is also rapidly increasing with a 50%
increase expected by 2020.
Business travel and international assignments have been
growing with the globalization of large corporations. Multinational
corporations (MNCs) have expanded outside their home countries
not only to produce goods at lower costs for home consumption
but also to expand overseas markets. For many MNCs, international
revenues have already exceeded domestic revenues (Newman,
2011). The number of countries with expatriates or assignees also
continues to increase. Currently, MNCs place international
expatriates or assignees in more than 20 countries on average, and
the number of countries continues to grow (Druckman, Harber, Liu
& Quigley, 2012). For MNCs, 95% of their consumers live 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 (Druckman et al., 2012,
2014).
Several categories of overseas assignments require regular
business travel. The international business frequent traveler
undertakes a number of trips per year to different locations
focusing on management, marketing, or training. A second
category of travelers is the business commuter who returns to
an international facility on a weekly or monthly basis.
Many international assignees also travel regularly. Expatriates
are employees with long-term assignments; employees and their
families move to host countries for specified time periods (e.g.,
2-5 years). Some expatriates relocate but their families remain in
their home countries with frequent visitation. A group that is
increasing is the short-term assignee (e.g., 4-12 months) who
travels internationally for specific time to achieve limited
objectives (e.g., finance managers, auditors, specialists in
specified jobs). The assignee does not relocate to the site but
has temporary housing, returns home on a scheduled basis, and
is focused on a specific task. Studies have shown that short-term
assignees are less prepared and at higher risk of adverse health
events than expatriates.
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. In fact, in a
recent study of travelers to Asia, more than 60% of high risk
travelers listed a business reason for their trips (Deshpande, Rao,
Jentes, Hills, & Fischer, 2014). Studies have also shown more
hospitalizations and evacuations for “low risk” travelers, although
the country risk level was also a predictor (Druckman et al., 2014).
A study of World Bank employees showed that the overall costs to
their health plan were 72% higher compared with their non-
traveling counterparts. In the study, risks were increased for almost
every physical disease category and mental health diagnoses; most
risks were correlated with the frequency of travel (Liese, Mundt,
Dell, Nagy, & Demure, 1997).
Workplace Health & Safety
For international business trips (e.g., 10 days, 2 weeks),
approximately one third of travelers develop infectious illnesses
(e.g., diarrhea, respiratory) or suffer injuries. Moreover, a
significant increase in the risk of high or very high mental stress
was reported among business travelers. Sleep disorders and
substance abuse are common. Also, non-communicable diseases
showed increases similar to infectious diseases. Thus, health
care costs increase for international travelers because the risks
increase for accidents and injuries; the risk of death from traffic
accidents increases fivefold (Bunn, 2001).
Health risks for business travelers and assignees differ from
the health risks in their home countries. Infectious diseases vary
widely from country to country and region to region. The
diseases encountered may change rapidly and information may
be outdated. Infectious diseases, not encountered in developed
countries, may be significant risks (e.g., malaria, typhoid,
cholera, rabies, encephalitis). In addition, increased risks of
other illnesses and injuries may be related to exposures to air
and water pollution, allergens, and physical (cold, heat) and
chemical hazards. Accommodations for disabilities are not
required in many countries (e.g., elevators, ramps), nor are
protective devices (e.g., seat belts, air bags), which increase the
risk of accidents and resulting injuries.
The risk of developing illnesses and being injured is
compounded by the quality of health care available, particularly
emergency and acute care. Emergency transportation (e.g.,
ambulances) may not be available. Access to health care is also
challenging because many facilities are funded through a public
health system; private care may be limited and have special
payment requirements. Therefore, even treatment for 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 home countries may be necessary.
Risk reduction programs for international travelers,
expatriates, and assignees have been recommended by many
expert groups. Measures include screenings, health education,
vaccination and prophylaxis, computerized databases with
updated travel and destination health risk information, travel
kits, information on best care facilities, and access information
for evacuation. However, these programs are not available to
most business travelers, expatriates, and assignees (Bunn, 2001).
Recent Articles on Business Travelers
Two recent articles (Bunn, 2014; Druckman et al., 2014)
addressed specific issues for business travelers. The Druckman
article included a review of more than 800,000 business trips
and almost 1,200 cases. The article focused on hospitalizations,
evacuations, and risk factors. Aggregate trips to “low risk”
countries resulted in a greater number of hospitalizations and
evacuations than trips to “high risk” countries. The country risk
categorization was predictive for adverse events; however, the
article suggested a significant risk for employees even when
traveling to “low risk” countries.
465
 Workplace Health & Safety
The editorial by Bunn discussed the Druckman article and a
2014 article by Kogelman (Kogelman et al., 2014). The
Kogelman article demonstrated that providers of travel health
care often have limited knowledge of vaccines and vaccine-
preventable diseases. The study showed that for rare diseases,
the knowledge gap was significantly greater than for more
common diseases, particularly among primary care physicians
(PCPs) and offices that offer travel health care. The study also
showed travel and occupational health nurses provided
pre-travel consultation in 41% of travel medicine clinics; PCPs
provided this service in 27% of clinics. The study compared
providers’ knowledge of hepatitis A, yellow fever, and JE.
Although the providers were very familiar with hepatitis
(78.9%), only 18.9% of the providers were familiar with yellow
fever and 9.8% with JE. Japanese encephalitis is rare, but 20% to
30% of cases are fatal and 50% of survivors have permanent
neurologic sequelae. Despite a safe effective vaccine, studies
have shown only 1% to 11% of at-risk groups are vaccinated
and that even in GlobalEpiNet, a sophisticated consortium of
travel clinics, only 28% of clients were vaccinated according to
Advisory Committee on Immunization Practices (ACIP)/CDC
recommendations. The most common reason for failure to
vaccinate has been the failure to consider or recognize the need
for vaccination despite ACIP guidelines.
These recent articles demonstrate the need to carefully
review vaccine requirements prior to business travel. The
responsibility for appropriate vaccination and education is not
solely with a travel clinic. The referring occupational health
clinic must assure appropriate vaccine prophylaxis and
education is provided.
Productivity Among Business Travelers,
Expatriates, and Assignees
The cost per year of an employee on overseas assignment is
US$300,000 to US$400,000 on average. The cost of a failed
expatriate assignment is approximately US$1,000,000; the loss of a
recurrent or frequent business traveler is also high. To evacuate an
employee can easily exceed US$100,000. The rate of expatriate and
assignee failure is estimated to be 6% to 12%. Therefore, the direct
costs of repatriation and assignment failure are high, and
preventive measures can produce significant returns on investment
in terms of care and repatriation costs alone (Bunn, 2001).
Effective travel programs for health, safety, and security are an
expectation, and when programs are either of poor quality or
absent, a loss of confidence by employees and their families can
affect the entire company. Corporations, businesses, and
universities are liable for tort suits due to negligence and workers’
compensation claims. Businesses also may suffer damaged public
relations and corporate trust. These issues impact not only the
health of the traveler but also the productivity of co-workers and
the profitability of the company (Bunn, 2014).
Despite the large and growing number of international
business travelers, continued globalization, increased employee
health risks, limited access to quality care, and the high costs of
466
October 2016
assignment failure and evacuations, little analysis of the direct
costs of clinical care or evaluation of health and productivity of
these workers has been undertaken. Approximations of costs in
a previous article (Bunn, 2001) suggest a significant potential
return on investment, but a full analysis of direct costs is
needed. The indirect costs of absenteeism, disability, workers’
compensation claims, and notably presenteeism have not been
assessed. These costs will be difficult to accurately quantify.
Many international health care expenditures are not included in
health plans and limited data are available on wage replacement
for business travelers, expatriates, or assignees.
Summary
To summarize, occupational health nurses and nurses in
travel clinics provide pre-travel consultations. International
business travelers are one of the largest at-risk worker groups.
The health and safety risks for this group are significant and are
higher for almost all categories of illness and injury, not just
infections. In fact, the health risks for business travelers may
exceed the risks of other travel groups (Deshpande et al., 2014).
Risk reduction programs are complex and comprehensive
and must respond to changes in risk. Business travelers pose
special legal risks for corporations, businesses, and universities.
Studies show current programs for vaccination of business
travelers are not adequate and government/ACIP
recommendations are commonly not followed (Bunn, 2014).
Travel vaccines and prevention programs must be aggressively
offered to business travelers and their employers. Effective
business travel programs will not only protect workers and their
companies but also be cost-effective, particularly when lost
productivity is included in the calculation.
The JE Virus: An Under-Appreciated Risk to
the Business Traveler
Japanese encephalitis is a flavivirus transmitted by Culex
mosquitoes, which breed on farms and in rice paddies; they
bite dusk-to-dawn. This infection is common in Asia, the
tropical areas year round and the temperate areas during the
months of May through October. Recent evidence, however, has
documented cases of JE in temperate areas of Asia outside the
usual transmission months. Japanese encephalitis is endemic in
a large area of Asia, and a careful review of planned itineraries
or potential itineraries is necessary to accurately advise travelers
about this disease (Halstead, Jacobson, & Dubischar-Kastner,
2013).
The risk of infection has been calculated at 1 in 5,000
travelers per month of stay. Risk is correlated with rural
exposure in endemic areas. In addition to visiting rural and
semi-rural areas, outdoor exposure between dusk and dawn,
length of stay, and seasonal variation (i.e., mosquitoes becoming
more active in the rainy season) are all risk factors (Hills,
Griggs, & Fischer, 2010).
The effect of climate change is unclear, but areas at risk of JE
appear to be increasing. A study of JE cases in Taiwan between
vol. 64  ■  no. 10
1991 and 2005 showed that JE cases correlated with rainfall and
temperature in the previous 1 to 2 months. The peak JE
transmission season had shifted from June to October to May to
August. New irrigation projects and increased rice production
may have increased JE transmission in some areas by increasing
vector habitats.
After the bite of a Culex mosquito carrying the JE virus and
an incubation period of 5 to 15 days, those individuals who
develop symptoms display fever, headache, vomiting, and
mental status changes leading to neurologic deficits including
movement disorders. Of JE cases, 15% to 30% die and 30% to
50% of survivors have significant neurologic sequelae. The risk
is highest among long-term travelers and those traveling in rural
areas with extensive outdoor exposure. Specifically, individuals
who travel to agricultural areas where pigs are raised are at
particular risk.
The introduction of pig farming to some parts of Asia may
have led to epidemics of JE. In other areas, centralization and
segregation of pig farms away from population centers may
have reduced human risk. For example, in Singapore, all pig
farms were moved off the island and JE transmission decreased.
Infections with JE by Culex quinquefasciatus, pipiens, and
Aedes albopictus (all urban mosquitoes) have been observed,
and there is speculation regarding their role as vectors for JE.
Interestingly, the flight radius of the Culex tritaeniorhynchus is
about 5 km, but they can be blown by the wind up to 500 km
(Hsu, Yen, & Chen, 2008).
Economic and agricultural changes are blurring the
boundaries of rural areas. Increased migration to cities has led
to urbanization of rural areas, where the natural enzootic
cycle exists. For example, one of the concerns with travel to
Beijing for the Olympics was that many of the Olympic
athletes were housed in quarters outside the city, where the
risk of JE was high. Likewise, industrial corporations are
building plants in areas such as Hanoi when, in fact, the
plants are 45 to 60 minutes outside city limits. Climate
changes and horticultural and agricultural practices have
expanded urban areas and new data on JE vectors suggest
that JE is an unpredictable threat.
Personal risk factors may increase the risk associated with
the JE. Older age is a significant risk factor for clinical illness
with the risk of neuro-invasive illness five to tenfold higher in
adults age 50 and older compared with older children and
young adults. Young age is also a risk factor for symptomatic
illness and is associated with a higher frequency of neurologic
sequelae. In a review of travelers from non-endemic countries
(Hills et al., 2010), 55 cases were reviewed from 17 countries
with an age range of 1 to 91, median 34 years. Eighteen percent
died and 44% had mild to severe sequelae.
Personal protective measures are the first line of defense, but
bed netting, screens, and insect repellants are only partially
effective. Human vaccination is the best means of protection.
The inactivated mouse brain-derived vaccine is no longer
produced, and inactivated cell culture-derived vaccine is
Workplace Health & Safety
recommended with two doses at day zero and 28 for individuals
ages 2 months to 16 years and through adulthood.
In a study of travel clinics with a database of 8,289 U.S.
travelers above the age of 17, researchers collected data about
travelers’ itineraries, vaccinations, and other parameters. The
researchers found that only 26.8% of higher risk travelers received
the JE vaccine. Despite the fact that in some cases travelers had
insufficient time to receive both doses of the vaccine, the vaccine
was not available, or the individual had contraindications for
receiving the vaccine, the majority of high risk travelers, clinicians
did not vaccinate because they deemed the JE vaccine was “not
indicated” (Deshpande et al., 2014). The low vaccination rate
indicates the current recommendations are not being
implemented. Recently, an accelerated dosing Phase 3 blinded
randomized multicenter study of 661 adults was conducted. The
study showed 99% seroconversion at day 15 (7 days after the
second injection) and seroconversion rates remained high after 1
year. Adverse events were similar in the accelerated and
conventional dosing groups (Jelinek, 2015). Short course dosing
should significantly reduce the number of travelers who do not
have time to receive a second dose.
In summary, JE is an unpredictable threat for travelers. Cases
show that travelers visiting for a short time, even with little or
no rural exposure and outside the established transmission
season, have contracted JE. Human vaccination is the best
protection, and all travelers should be assessed for their risk of
contracting JE.
Current ACIP guidelines for JE vaccines are narrowly focused
and have not significantly changed since 1993. The guidelines
recommend JE vaccine should be given to travelers who plan to
spend a month or longer in endemic areas during the
transmission season. The guidelines also include a
“consideration” for short-term travelers with “at-risk” activities:
camping, hiking, trekking, biking, fishing, hunting, or farming.
The recommendations do not address business travelers or the
evolving risks of JE. The 1 month criterion is arbitrary, and
travel patterns and “at-risk” areas are changing. Updated
recommendations are needed and should reflect current risks,
be clear and concise, and always encourage health care
provider–employee discussions.
A Japanese Encephalitis Vaccine Recommendations Working
Group met in New Orleans in conjunction with the American
Society of Tropical Medicine Hygiene (ASTMH) in November
2014. Revised recommendations were agreed upon by consensus
at this meeting and included (a) a discussion of JE and availability
of a safe and effective vaccine with all travelers to endemic areas
of Asia; (b) travelers to rural or peri-urban areas in endemic
countries, irrespective of duration of travel or itinerary, should be
offered the vaccine; (c) all expatriates living in endemic countries
or frequent travelers who may visit rural or peri-urban areas in
endemic countries should be offered the vaccine; (d) travelers
with uncertain itineraries or itineraries that may change should be
offered the vaccine; and (e) the vaccine is not generally
recommended if travel is restricted exclusively to urban areas.
467
 Workplace Health & Safety
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
Bunn, W. (2001). Vaccine and international health programs for employees
traveling and living abroad. Journal of Travel Medicine, 8(Suppl. 1), S20-S23.
Bunn, W. (2014). Assessing risk and improving travel vaccine programs
for business vaccine programs for business travelers. Journal of
Occupational and Environmental Medicine, 56, 1167-1168.
Centers for Disease Control and Prevention. (2008). How to prepare for your
pre-travel appointment. Retrieved from http://wwwnc.cdc.gov/travel/
page/preparing-for-appointment
Chen, L. (2014). The pre-travel consultation. Centers for Disease
Control and Prevention Yellow Book. Retrieved from http://
wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-
consultation/injury-prevention
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, 694-698.
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, 1118-1125.
Druckman, M., Harber, P., Liu, Y., & Quigley, R. (2014). Assessing the
risk of work related international travel. Journal of Occupational and
Environmental Medicine, 56, 1161-1166.
Fairley, J. (2014). General approach to the returned traveler. Centers for
Disease Control and Prevention Yellow Book. Retrieved from http://
wwwnc.cdc.gov/travel/yellowbook/2016/post-travel-evaluation/general-
approach-to-the-returned-travele
Halstead, S. B., Jacobson, J., & Dubischar-Kastner, K. (2013). Japanese
encephalitis vaccines. In S. Plotkin, W. Orenstein, & P. Offit (Eds.),
Vaccines (6th ed., pp. 201-205). Amsterdam, the Netherlands: Elsevier.
Hills, S., Griggs, A., & Fischer, M. (2010). Japanese encephalitis in travelers
from non-endemic countries 1973-2008. American Journal of Tropical
Medicine and Hygiene, 82, 930-936.
Hsu, S., Yen, A., & Chen, T. (2008). The impact of climate change
on Japanese encephalitis. Epidemiology & Infection, 136, 980-
987.
468
October 2016
Jelinek, T. (2015). Short term immunogenicity and safety of an
accelerated pre-exposure prophylaxis regimen with Japanese
encephalitis vaccine in combination with rabies vaccine: A phase III
multicenter, observer blind study. Journal of Travel Medicine, 22,
225-231.
Kogelman, L., Barnett, E., Chen, L., & Quinn, E. (2014). Knowledge,
attitudes and practices of US practitioners. Journal of Travel Medicine,
21, 104-114.
Liese, B., Mundt, K., Dell, L., Nagy, L., & Demure, B. (1997). Medical
insurance claims associate with business travel. Occupational &
Environmental Medicine, 54, 449-503.
Newman, R. (2011, June 30). Why U.S. companies aren’t so American
anymore. U.S. News & World Report. Retrieved from http://money
.usnews.com/money/blogs/flowchart/2011/06/30/why-us-companies-
arent-so-american-anymore
Rosselot, G. (2004). Travel health nursing: Expanding horizons for
occupational health nurses. AAOHN Journal, 52, 28-41.
World Tourism Organization. (2014). Annual report. Retrieved from http://
www2.unwto.org/annualreport2014
Author Biographies
Bonnie Rogers is associate professor and director of the
Occupational Health Nursing Program in the School of Public
Health at the University of North Carolina and is director of the
North Carolina Occupational Safety and Health Education
Research Center. She has published 200 papers and authored
two books. She chairs the National Institute on Occupational
and Heath Board of Scientific Counselors and the National
Occupational Research Agenda Liaison Committee.
William B. Bunn is recently retired vice president of Health
Safety Security and Productivity at Navistar. He now serves as a
consultant/advisor and is an adjunct professor at the Medical
University of South Carolina and Northwestern University. He
has over 150 publications and is author/editor of five books.
Bradley A. Connor is the founder and medical director of the
New York Center for Travel and Tropical Medicine. He is
clinical associate professor at the Weill Medical College of
Cornell University and a coauthor of the textbook, Travel
Medicine, and past president of the International Society of
Travel Medicine.