It's one of your worst nightmares.
You’ve captained a trip to a remote area of an African country, and your first officer and one of the executive passengers have contracted a local disease — maybe dengue fever, but you’re not sure. The trip came up fast, and there was little time to research the health hazards in this developing nation or, for that matter, the level of health care. All of your attention was directed toward flight planning, applying for fast-track overflight and landing permits, arranging visas, making hotel and ground transportation reservations, ensuring ground support and fuel, and setting up security for the aircraft and passengers. Researching disease hazards and health care infrastructure was definitely not on your mind.
But it sure is now, as you scramble to cope with a situation you never had time to envision. You have to hire a truck from two guys armed with AK-47s (at least you brought plenty of cash in American dollars) for a drive 100 km away from the mining town your bosses were visiting in order to get cellphone reception so you can call your trusty scheduler/dispatcher back in the States. She has pulled your posterior out of cracks in the past; maybe she can again.
Sure enough, even though it’s 3:00 a.m. in her time zone, she gets on it, contacting a travel medicine support service, which first diagnoses the malady your people have suffered as dengue fever, based on your description of the symptoms, then vets a hospital in the country’s capital experienced in treating the disease. Working with the hospital staff, the travel medicine service then sets up a transfer of the sick pilot and passenger to the capital aboard a helicopter operated by the country’s military. Following treatment, the medical support service then arranges a medical evacuation out of the country and into Germany by chartered jet for further care. This leaves only the task of getting a relief pilot into the country via airline and then by ground transportation to your location so the company aircraft and remaining passengers can be flown home.
Of course, all this has to be paid for, and, thankfully, your employer is insured for medical emergencies abroad — a fact you should have known but never checked on. Altogether, this trip from hell constitutes both a learning experience and a wakeup call. Your workload will have to be expanded to include health issues affecting your flight crew and passengers with an emphasis on pre-trip research covering dangerous diseases and epidemics in the countries and regions you’ll be traveling to, what preventive precautions you’ll need to take to avoid them, and what support you’re going to need when you’re on the ground in a foreign country and the unexpected happens — which can include injury from an accident or criminal activity in addition to infection with a dangerous disease.
Proactive Risk Management
“You have to incorporate health issues into the flight planning as a routine item,” Quay Snyder, M.D., president and CEO of Aviation Medicine Advisory Service in Englewood, Colorado, told B&CA. A pilot and aviation medical examiner (as well as a graduate of the U.S. Air Force Academy), Snyder emphasizes the importance of being proactive to minimize health risks when traveling abroad. He also points out that when considering the aviation enterprise as a whole, “The pilot is the single element . . . that is most likely to fail.” So, just like your Safety Management System — you do have an SMS in place, right? — you must approach health protection proactively as risk management, regarding it as an essential component of your flight planning.
And for those last-minute trips like the one in our opening scenario, fight departments routinely operating internationally could do well to consider retaining a travel health support service to handle health hazard research for the intended destination, as these agencies constantly monitor the outbreak of epidemics and ongoing hazards on a global scale.
They know the territory intimately and can provide real-time assessments of countries and regions, as well as advice on pre-trip prophylaxis or treatment in the destination area should a crewmember or passenger become infected or injured in an accident. Finally, as our scenario pointed out, these services can arrange for extraction of sick or injured personnel if their on-staff physicians determine such a course of action is necessary.
Corporate travel and medical departments are also resources for operators desiring to handle the health component of preflight planning in-house. This process should start with research of the health situation in the intended destination. Two of the most comprehensive information sources are the websites of the U.S. Centers for Disease Control (www.cdc.gov/travel) and the U.N. World Health Organization (www.who.int/en). Another resource is ProMED, a disease and epidemic monitoring and alert service offered through subscription by the International Society for Infectious Diseases (www.isid.org), which alerts subscribers to epidemics and other health hazards via email.
Regarding the CDC site, Dr. Snyder said, “You can look at it as a health-care consumer and from a provider perspective — every country in the world is listed, and the types of travel you’re doing, either a brief trip or an extended stay, with children or pregnant passengers, are covered. It includes recommendations regarding vaccines, medicines to take and threats.”
The CDC site contains “libraries worth of information,” observed Susan Yates, vice president, operations and international network, at FrontierMEDEX, a travel medicine support service headquartered in Baltimore.
After initial research on what to expect where you’re going, Yates said, “The second thing is to visit a travel health center, clinics run by your county or state, and discuss your itinerary with a travel health nurse. They can provide precautions, vaccinations based on the country you’re going to, and so forth.”
This must be done further in advance of a scheduled trip because some vaccination shots require a two- to four-week lead time before they’re effective — the further in advance the better; however, this can be complicated by the current business cycle, which often results in short-notice trips.
And “make sure that you are healthy,” Yates admonished. “Have annual health checks to determine any underlying conditions, and understand your limitations in terms of some destinations.”
Yates also cited “ongoing educational options that are broad-based,” such as first-aid courses and ensuring flight departments stock high-quality, up-to-date first-aid kits aboard their aircraft. Other options include courses in travel health provided by the International Society of Travel Medicine, courses in CPR and defibrillator use, and shoring up personal proficiency with basic first-aid and intervention tactics. “All this is a good start in terms of knowing before you go,” she said.
‘Normal’ Versus ‘Dynamic’
At MedAire Inc., a division of International SOS, vice president for aviation and maritime health Paulo Alves, M.D. emphasized that the “reality” when traveling abroad is that, generally speaking, there are hazards that are “occasional,” i.e., epidemics, and those that are “normal,” or indigenous. “What is going on today may not be what is going on tomorrow,” he said. “What is known to be prevalent and constant in a region — for example, malaria in Africa — is a constant situation, and what is endemic, like dengue fever in Rio de Janeiro and Thailand, is a dynamic one. You need to update on a constant basis, researching from reliable international sources like CDC and WHO. Sometimes you need to access local sources, too.” Services like MedAire and FrontierMEDEX also contract with agents on the ground in foreign countries to get the local picture of disease prevalence and reliable, safe medical care facilities. “You also have to consider medical events related to violence: auto accidents, local culture, crime,” Alves pointed out. “Use your security chief as a resource, too.”
When we categorize the risk of different countries, Alves contends, there is “a tricky band” that is the “variable risk.” Most developing countries will fall into that category. “You may find in some countries a very-high-quality care facility next to a low-quality one,” he said. “You can have top notch and not so great side by side. You need support to determine how to navigate these risks. You need to do things to avoid problems, but those safeguards could fail, and you might face an emergency abroad and then need to know how to deal with that specific problem.”
Trip preparation also involves making sure your and your passengers’ vaccinations are up to date and fully effective (i.e., that any required lead time is completed prior to departure) and that vaccinations have been received for any disease outbreak prevalent in the destination country, e.g., hepatitis A and B, polio, tetanus, meningococcus, yellow fever, typhoid and rabies, and that you’re carrying medications for the ones that can’t be neutralized via vaccination. (See sidebar with Dr. Snyder’s primer on vaccine-preventable diseases and medications.)
With the destination thoroughly researched, the trip can get underway with a level of confidence that crew and passengers are reasonably protected. Now prevention shifts to strategies employed on the ground in the destination country. Much of this constitutes common sense: “Maintain proper hygiene, good hand-washing, keep your hands out of your mouth, and avoid contact with anyone appearing to be sick,” Yates advised. “If you are susceptible to a compromised immune system, wear a protective mask. Avoid insects and rodents — the most prominent dangerous insect is the mosquito. Have screened-in areas for sleep or use mosquito nets. Wear long sleeves, use [insect repellants with] DEET, and stay away from rats, mice or cockroaches.
“Wear closed-toe shoes in a lot of countries,” she continued, “especially walking in unfamiliar territory — don’t ever wear sandals. Avoid standing fresh water. Be conscious of your environment and stay away from collections of water.”
Don’t Do Anything Stupid
Travel occasionally emboldens us, Yates maintains, and for one’s safety, it is essential to recognize this when it arises and resist it. “In general, when we go to a foreign country, we often find a new empowerment that makes us do risky things, like riding a motor bike without a helmet,” Yates said. “Be conscious of the fact that you need to adhere to the same safety you would at home. Generally, understand traffic flows — including which side of the road they drive on and which way to look when crossing a street — and obstacles like livestock. In some countries, there will be massive chaos on the streets.”
Dr. Alves recommended that flight departments provide their passengers with basic first-aid and blood-borne pathogen training to help them protect themselves from bodily fluids with contagions in them. “Don’t drive if you’re not familiar with the local hazards,” he added. “Don’t eat in shady restaurants. It’s a complex mix of sources and threats. Prevent mosquito and tick bites, provide training to crew and passengers. Make sure they are updated with relevant information about their destinations. Know what medical facilities to go to if there is a need — don’t open a phone book and choose — do your due diligence. When you have a partner [i.e., a travel medicine support service], you can be better directed to select the best resource among the providers in the area.”
OK, but what if something happens? What if someone under your responsibility gets sick or is injured in an accident? Do you have a plan to respond to “your worst nightmare” and/or a service partner to assist you? “You should know before you get there what your options are for medical facilities if something were to happen to you or your passengers,” Yates said. “Check thewebsite [www. travel.state.gov/content/passports/english/alertswarnings], have insurance protection and know who to call in the event of an emergency, whether there are overseas benefits in your policy (and note that Medicare does not cover you beyond U.S. borders), and whether you should buy travel insurance or use an assistance package from a travel support service.”
If something major happens, you need to know what to do. “Call your medical provider and ask if you are covered overseas, for what, and if you have an accident, whether you are covered for evacuation, and who you call to organize that for you,” Yates continued. “Finally, when you have recovered well enough to travel, you may still need medical assistance to get home, so is there a benefit to cover that? Most major health plans do not provide that get-home coverage if you are impaired. You may need to get it from a travel insurance or assistance company. You need access to a 24/7 response center to get that support — and a lot of companies don’t have that in-house.”
If you get sick abroad, Dr. Snyder added, “there are several types of health care insurance to consider, and make sure your carrier offers it or get a supplemental policy. The next type would be medical evacuation insurance, particularly to a location with regular airline travel.” The latter could be (ahem) a life saver in more ways than one, especially when considering the cost of chartered rotary-wing or jet transportation out of a remote area or developing nation.
“You need to understand your benefits and coverage,” Yates agreed. “If you don’t have the emergency response coverage, then do your due diligence before you go to learn what resources are available where you’re going. How are the hospitals accredited? To find out, check with the Joint Commission International [JCI], which accredits hospitals — check its website [www.jointcommissioninternational.org] to find out which ones are.” This is a “piece of a puzzle,” Yates maintains, and the other pieces include what services a hospital provides — for example, cardiac support in the event you’re facing a heart attack situation among your passengers. “What is the right facility for the particular condition? You may need to be evacuated to another country to get that specialized service not provided in the destination country,” Yates pointed out.
Dr. Snyder recommended the State Department website (www.state.gov) as a source for lists of hospitals. “Some vendors combine health information for travelers, lists of reputable medical facilities with English-speaking doctors, medical evacuation insurance and security risk assessments,” he said. “It is reasonable to consider whether to get a health and travel coordination provider if you have the budget to do it. There are also travel medicine clinics that provide the information but not the insurance.”
It May Be Best to Stay
But be aware that “if you contract an infectious disease, a really high-profile pandemic one like Ebola, your chances of being evacuated diminish exponentially,” Yates warned. “No one will fly you out if you have Ebola! You will have to stay there and be treated at a hospital that the government has designated for Ebola treatment. And what country will receive you, if you can find someone to fly you out? Probably none. Your care might be better in the host country anyway, because they may have experience treating it. Their hospitals may know how to take care of that — it ain’t endemic in Cleveland!” And of course, the best advice is to not get maladies like Ebola, SAARS, or H1N1.
Travel is “a fascinating experience,” Dr. Alves concluded. “It is not only going to dangerous destinations but to familiar countries where there might be a presence of something that has popped up or been brought there by an infected person, like SAARS in Canada. Pay attention to what is going on at your destination, not just the problematic countries.”
Know the Source
“If you’re going to be drinking, avoid unbottled water or bottled water where you don’t know the source,” Snyder continued. “Avoid any drinks with ice unless you can determine that tap water is safe. If you have canned or carbonated beverages, those are good, or anything that comes factory-sealed, but clean the outside of the can first. Anything that’s served hot, like coffee or tea, is OK, and alcoholic beverages are OK. Pasteurized drinks are usually OK, too. Be careful about brushing your teeth. Depending on your group, you may not want to be swimming in water that is not treated in some way — avoid lakes, canals, and so forth.”
Because of exposure to water, it’s a good idea to carry medications for traveler’s diarrhea “like doxycycline, trimethoprim, sulfamethoxazole, ciprofloxacin and others including bismuth subsalicylate and azithromycin [for treatment rather than as a prophylaxis].” Also, make sure passengers bring their personal meds because they may not be available overseas or, if they are, may be counterfeit. If your passengers are taking any narcotics, they may want to bring their prescriptions or the original bottle to avoid local prohibitions.
Other health hazards include the sun, “so bring sunscreen,” Snyder advised, “and understand that many of the malarial or diarrhea meds sensitize you to the sun. Wear a hat and long sleeves.” If you’re going to high-elevation places like Nepal, you might want to consider taking medication for altitude sickness: acetazolamide (generic) or Diamox (trade name).
“Another thing to be aware of is deep venous thrombosis,” Snyder warned, which is blood clots in the legs from inactivity for long periods of time — so move around occasionally on those long flights. With doctor’s consultation, take aspirin for it. Recent surgery increases the risk of it, too. Three other hazards are crime, auto accidents and sex — the last responsible for HIV/AIDS, STDs and hepatitis, all transferred by bodily fluid exchange. There is no vaccine for hep C, one of the leading causes of death for liver failure — in the U.S., it kills more people than HIV/AIDS.”
The risk of infection is the “key thing” to be aware of when venturing into places where health hazards exist, Snyder maintained. “Some you can’t prevent, but you can be proactive to food and water safety and medications. However, you need to be a smart, savvy and prepared traveler. If you have any significant medical conditions, you may want to bring a letter from your physician so you can give it to a local provider in the event you need care.”