Health Problems of Corporate Travelers:

Risk Factors and Management

Terri l? Kernrnerer, Martin Cetron, Lynne Harper, and Phyllis E. Kozarsky

Background: Numerous studies have been done regarding health problems experienced by tourists in developing coun-
tries; however, little data exist about these health risks and illnesses experienced by corporate travelers.
Mefhods:The authors examined by electronic survey the health risks encountered, compliance with pretravel health rec-
ommendations, and illnesses and injuries experienced by employees of the Coca-Cola Company who travel internationally.
Results:Two hundred twenty-six travelers responded. Although most travelers ate meals at their hotels and chose foods
that were cooked and still hot, over half also ate foods that remained at room temperature for prolonged periods and/or

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ate from cold salad bars. Almost half drank untreated tap water.Thirty-five percent of travelers developed diarrhea and
29% reported respiratory illnesses, with 12% seeking medical attention for their problems. Forty-three percent of those
traveling to malarious regions admitted to noncompliance with antimalarial recommendations. Health kits provided were
used by only 51% of travelers.
Conclusions: Although many corporate travelers followed pretravel health recommendations, some did not. Injuries,
fever, and illnesses such as diarrhea and respiratory infections occurred. Strategies t o improve access to the travel clinic
and the acquisition of health information and travel health kits are being implemented.The health risks and behaviors of
corporate travelers, including the potential impact of psychosocial stressors, need greater attention.

The Coca-Cola Company operates in more than 200 Methods

countries worldwide, and its global network demands be-
quent travel to the developing world by numerous
employees. Since over one third of travelers experience
illness abroad,'-3 pretravel education has become impor-
tant in minimizing morbidity and insuring productivity
during t r a ~ e l . ~
Prior to departure, company employees traveling
from the United States to developing countries are evd-
uated and counseled by a travel health advisor in a uni-
versity travel clinic and given health maintenance
information, immunizations,and prescription medications
as necessary. Each traveler is also given a health kit,
which is provided by the Coca-Cola Company, and is
educated in the use of the kit. To evaluate compliance
with pretravel health recommendations, the risk and
exposures encountered, the occurrence of illness, and the
use of the health kit, we designed a retrospective study.
Terri F! Kemmerer, BSN, and Lynne Harper, RN: Department
of Medical Services,The Coca-Cola Company; Martin Cetron,
MD: Surveillance and Epidemiology Branch, Division of
Quarantine, National Center for Infectious Diseases, Centers
for Disease Control and Prevention; Phyllis f.Kozarsky, MD:
Department of Medicine, Emory University School of
Medicine, Atlanta, Georgia.
Reprint requests: Phyllis E. Kozarsky, MD:The Emory Clinic-
Internal Medicine, 25 Prescott Street, 5th Floor, Atlanta, GA
30308.
JTravel Med 1998; 5:184-187.
In September 1994,a 30-question survey was admin-
istered electronically to 350 Coca-Cola employees who
had traveled internationally within the preceding 6
months (April through September 1994).The survey cap-
tured demographic information, travel itineraries, health
risk behaviors, occurrence of illness, and use of the travel
health kits during the most recent trip abroad.
Participants were asked their age, gender, marital sta-
tus, nationality, and years of international travel. The
trip itinerary was recorded, including continent(s) and
country(ies) visited. Trip duration was categorized as
less than 1 week, 1 to 2 weeks, 2 to 4 weeks, 1 to 3
months, or greater than 3 months. Since many travelers
journeyed to more than one region per trip, the num-
ber of countries visited exceeds the number of partici-
pants in the study (Table 1).
Health risk behavior questions focused on food,
water, and beverage consumption. In particular, partic-
ipants were asked what, it any, precautions they took before
consumption of food and drinking water. The level of
hotel accommodations was recorded. Respondents were
also asked whether they experienced any injuries or ill-
nesses while abroad and, if so, were asked to describe the
nature of the event, whether medical treatment was
sought, and if a final diagnosis was made. Additional
questions focused on the utility of the items in the travel
health kit.
Data were entered and analysed by using EpiInfo
software (6.0, CDC, WHO).

184
K e m m e r e r et a l . , H e a l t h P r o b l e m s of C o r p o r a t e T r a v e l e r s : R i s k Factors a n d M a n a g e m e n t 185

Results Table 1 Destinations of 226 Corporate Travelers from

Atlanta April-September 1994
Three hundred and fifty surveys were sent; ofthose Continent Number of Tvavelers Percentage
226 (65%) travelers responded, all by electronic mail. The
Western Europe 140 62.0
mean age of the study population was 41 years old. One South America 82 36.0
hundred and seventy-four of the respondents (77%) were Central America 51 23.0
male. One hundred and ninety (84%) were United States Eastern Europe 49 22.0
nationals and 115 (51%) carried the travel health kits. South Asia 41 18.0
One hundred and forty of the respondents (62%) East Asia 39 17.0
Caribbean 36 16.0
traveled to Western Europe, 82 (36%) to South Amer- Southern Africa 28 12.0
ica, 51 (23%) to Central America, 49 (22%) to Eastern India 23 10.0

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Europe, 41 (18%)to South Asia, 39 (17%) to East Asia, South Pacific 21 9.0
and 23 (10%) to India (Table 1). East Africa 17 7.5
Most travelers (212/94%) ate meals at their hotels, Middle East 15 7.0
West Africa 11 5.0
though 43 (19%) ate from street vendors as well (Table Central Africa 9 4.0
2). The majority (222/98%) reported eating foods that North Africa 8 3.5
were cooked and still hot, but 157 (69%) also ate foods
that remained at room temperature for prolonged peri-
ods. Buffet foods were popular; 154 (69%) ate hot buf-
fet choices and 119 (53%) ate from cold salad bars.
Despite pretravel education to the contrary, 29 (13%) ate eight travelers were unsure of the malaria status of their
raw meat and 39 (17%) ate raw or poorly cooked seafood. destination(s). Four were unsure whether they had taken
Due to an ongoing cholera epidemic in South America antimalarial medication.
at the time, consumption of raw, or poorly cooked One hundred sixteen (51%) used the travel health
seafood was examined in this region. Eighty-two (36%) kit (Table 5). Among the items most frequently used were
of the survey respondents visited South America, with analgesics (75/33%), antidiarrheal agents (63/28%), sinus
the most frequent destinations being Argentina, Brazil and medication (61/27%), insect repellent (54/24%), and
Chile. Surprisingly, 18 (21%) of these ate raw or under- sunscreen (47/21%).
cooked seafood. None reported developing cholera Two open-ended questions addressing the most and
symptoms. least helpful aspects of the travel clinic experience were
Ninety-seven percent of travelers drank bottled soft included in the survey.Among those aspects of pretravel
drinks. Other popular beverages included alcohol (76%) advice deemed “most helpful” were food and beverage
and noncarbonated bottled water (75%); however, 108 precautions, immunization information, and the pre-
(48%) drank tap water. O f the 61 total travelers to India scribing of needed medications.
(23) and East Asia (38), 14 (23%) drank tap water; six
(10%) used a water filter; three (5%) boiled their tap water,
and the remaining five (8%) used no special water treat-
ment precautions.
Traveler’s diarrhea (defined by self-report) was the
most common illness reported, affecting 35% of corpo- Table 2 Foods Eaten by 226 International Corporate
rate travelers (Table 3). Table 4 lists the risk factors for Travelers April-September 1994
diarrheal illness in this population. Other common prob- Number of
lems included upper respiratory infection (29%), skin Persons Eating.. . Percentage
rashes (lo%), fever (7%), vomiting (4%) and muscu- Hot temperature foods 222 98.0
loskeletal injuries (3%). Twenty-seven (12%) sought At hotels 212 94.0
medical treatment for their illnesses or injuries, result- Dairy products 190 84.0
ing in 47 visits to a variety ofhealth-care facilities includ- Room temperature foods 157 69.0
ing hospitals (five visits), clinics (five visits),physician offices Buffet foods 154 69.0
Raw vegetabledunpeeled fi.uits 137 61.0
(nineteen visits), travel health specialists (six visits), and In chain restaurants 119 53.0
other providers (twelve visits). At salad bars 119 53.0
Eighty-one (36%) traveled to countries where malaria In homes 68 30.0
is endemic. O f these, 46 (57%) reported talung malaria At street vendors 43 19.0
chemoprophylaxis as prescribed.Thirty-five (43%) adrmt- Raw seafood 39 17.0
Raw meat 29 13.0
ted to noncompliance with the recommendations. Thrty-
186 J o u r n a l of Tr av el M e d i c i n e , V o l u m e 5, N u m b e r 4

Table 3 Illnesses and Injuries Reported by 226 regarding food and water precautions for corporate travel
International Corporate Travelers April-September 1994 to developing countries are not uniformly followed.
Number of Table 4 shows some of the dietary risk factors for
Illness /Injury Travelers Percentage diarrheal disease. O f note, risk factors which predisposed
Diarrhea 80 35.0 travelers to diarrhea were: eating at fast-food establish-
Upper respiratory infection/sinus 66 29.0 ments, eating room-temperature foods, eating raw fish
infection or meat, and eating at buffets. Eating at one’s hotel
Skin rash 22 10.0 appeared protective though this may represent the behav-
Fever 16 7.0
ior of a more cautious group in general as 89% of the
Vomiting 8 4.0
Injuries 6 3.0 hotel-eaters did not eat in outside restaurants. Interest-
Hepatitdjaundice 0 0.0 ingly, drinking tap water was not a risk factor for diar-

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Sought medical treatment for injury 27 12.0
or illness
Discussion
Limited data have been published regarding the
health and safety of the corporate traveler. AU of the trav-
elers in our study had at least a college education, and
many held graduate degrees. Similar pretravel health
advice was provided regardless of the educational level
of the traveler. All travelers sought medical consultation
from a university-afliliated travel clinic, and some received
further consultation from a nurse at the Coca-Cola
Company. Some travelers were given additional resources
for information as well (e.g., C D C traveler’s hotline). It
was therefore surprising to find associates who drank
untreated tap water and ate raw or poorly cooked seafood
in high risk areas. Clearly, pretravel recommendations
rhea, regardless of whether the individual boiled, filtered,
treated or did not treat the water.
Our results highlight some of the common medical
conditions that afflict corporate travelers. Diarrhea, res-
piratory infections, fever and injuries are just a few of those
that occur routinely, despite a comprehensive pretravel
educational program. Although some of these events
might be preventable with more effective educational
tools, some are inevitable components of foreign travel.
It would have been valuable to ask if or to what extent,
the advice given aided the traveler in coping with ail-
ments and if the self-treatment regimens advised were
used.
To minimize the impact and reduce morbidity from
these adverse health events, medical kits are provided,
which contain basic medical supplies as well as detailed
instructions in their use. The kit is of great benefit for
the management of symptoms related to minor ailments
and for self-treatment of diarrheal illness. In addition, ster-
ile supplies for use by medical personnel are included.
The use of these items allows the corporate traveler to

Table 4 Risk Factors for Diarrheal Illness

Location qf Meals #/Total PA,) Odds Rafio 95%, C.I.* p-value+
Fast food establishment 801’219 (37) 2.0 1.05,3.83 0.02+
In home 80/219 (37) 1.2 0.75,2.00 0.4
Hotel 8/143 (5) 0.06 0.01,0.34 0.001
Street vendor 16/42 (38) 0.97 0.45,2.10 0.9

Food/Beverage Consumed
Dairy products 68/175 (39) 1.02 0.41,2.58 1.0
R o o m temperature foods 65/154 (42) 2.25 1.06,4.83 0.02t
Hot foods 79/217 (36) undefined 0,22 0.36
Hot buffets 63/153 (41) 2.10 1.0,4.5 0.04t
Raw fish 22/38 (58) 2.8 1.3,6.1 0.004t
Raw meat 17/29 (59) 2.7 1.14,6.53 0.01t
Raw vegetables 55/135 (41) 1.67 0.87,3.23 0.1
Salad bar 44/117 (38) 1.04 0.57, 1.91 0.9
Tap water 34/92 (37) 1.01 0.54, 1.87 1.0
Treated/boiled/filtered water 5/16 (31) 1.52 0.22,12.2 0.5
Nontreated water 11/34 (32) 0.68 0.17,2.68 0.5

*Confidence Interval
tp<.05
K e r n r n e r e r et a l . , Health Problems of Corporate Travelers: R i s k Factors a n d Management
Table 5 Reported Use of Travel Kit by 226 International Corporate Travelers April-September 1994
Travel Kit Contents
Use of travel kit
Analgesic medication (acetaminophen,ibuprofen,aspirin)
Diarrhea medicine (loperamide,bismuth subsalicylate)
Sinus medication (pseudoephedrine)
Insect spray
Sunscreen
Thermometer
Bandages
Antibiotic ointment (Neosporin/hydrocortisone cream 1/2%)
Motion sickness medication (Dramamine)
Water purification tablets
Electrolyte drink
Needles
IV Supply
Unused items
Suture + 1% 5cc lidocaine
0 Nonsterile gloves
0 Chlorpheniramine maleate 4 mg
Diphenhydramine 25 mg
continue working and thus maintain productivity while
abroad, despite minor health problems. Considering the
potential value ofthese kits, it is surprising that only 51%
carried them. However, health kits are not dispensed at
the travel clinic, but require a separate visit to the med-
ical department at the Coca-Cola Company. When they
are dispensed the associates are given detailed education
about their contents and use. Although all international
travelers should carry a basic health kit, the kit is not meant
to replace seeking out overseas medical assistance when
needed.
Psychosocial factors may have played a role in the
compliance with pretravel advice. Traveling long distances
to developing countries is stressful. Frequent meetings,
tight deadlines in multiple time zones, and limited recov-
ery time before resuming work responsibilities after
returning home add to fatigue and stress, and result in a
cumulative emotional toll. Most of the corporate trav-
elers rush to the travel clinic and return quickly to work,
or even go directly from the travel clinic to the airport.
In addition, the corporate traveler frequently must bal-
ance work demands with personal and family demands.
Most of these stressors are difficult to quantify and can-
not-and generally should not-be managed by pre-
scription medication. Additional efforts are needed to
evaluate and address the psychological stress that affects
corporate travelers and the ways in which stress impacts
health and the acquisition of pretravel health education.
To prevent and combat travel-related morbidity, a
comprehensive pretravel program should include: (1) edu-
cation, (2) appropriate immunizations, ( 3 ) chemo-
Number of Persons Using Items Percentage Use
116 51.0
75 33.0
63 28.0
61 27.0
54 24.0
47 21.0
27 12.0
24 11.0
16 7.1
9 4.0
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2 0.9
2 0.9
2 0.9
1 0.4
0 0.0
prophylactic agents for the prevention of potentially
serious illnesses such as malaria, as well as medications
for the management of minor problems, and (4) a travel
health kit. The health status of corporate travelers mer-
its greater attention than it has received. Since this sur-
vey was performed, several changes have been instituted
at the Coca-Cola Company to insure appropriate refer-
ral to the travel clinic and to make sure the clinic has ready
access to patient records so that travel advisors can give
adequate recommendations immediately to the corpo-
rate traveler. Issues such as poor compliance despite pre-
travel education and psychosocial stressors need further
evaluation. For example, consideration should be given
to providing a personal leave day before, and/or after travel
to allow the traveler to prepare for and recuperate from
long-distance travel. In addition, to improve access to the
travel health kits, consideration is being given to dispensing
the kits during the individuals’ initial pretravel visit.
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2. Steffen R, Rickenbach M, Wilhelm U, et al. Health prob-
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