Expatriate Health

Whether you are intending to take up an overseas posting as an individual level or whether you are responsible for the overseas placement of a worker, the health preparation should still follow a similar format.  Expatriate workers, particularly to low- and middle-income countries, face health issues which may be very different to those living in high income countries like Australia.

Support medical services low and middle income countries are also very different to those at home.  While expatriate workers face similar risks for the same location, the preparation for any posting should never be generic. People and places vary considerably.  Nor should a mountain of paperwork obscure major concerns.  An embassy placement in Bangkok differs considerably from an oil and gas site in West Africa.  

Individuals also have their own experience profiles and these are central to the clearance process.  A worker undertaking his/her 4^th placement should be viewed differently to a newcomer.  It is possible to build on past experiences in the management of risk in the former while education and resources on personal health risk is fundamental for the newcomer.

A seasoned expatriate has little patience for a “cookbook” style of preplacement preparation; however, they may be more attentive if their management of common health issues such as hypertension, hyper-lipidaemia and alcohol is questioned.  These reviews are also a good time to reflect on how a health concern such as fever might have been managed differently. 

It is the responsibility of organisations who send people overseas, to seek out providers who have a track record in disease prevention, particularly in unfamiliar environments. It is in their interest to have a healthy workforce whether at home or overseas.  Pre-departure programs are an essential component of the planning process.

• The majority of expatriate workers will experience at least one health issue in the first month of stay with less than 20% having no issues during an entire stay abroad.
• Expatriate workers are more likely to die from accidents than from infectious disease, but infectious disease is largely preventable and early recognition of serious disease has been found to reduce significant morbidity and mortality.
• Animal bites are very common, and many go unreported. Less than 30% of rabies-prone injuries receive adequate post-exposure prophylaxis.
• Adherence to the rules of eating and drinking safely reduces with time.
• Traveller’s diarrhoea is very common (80%) in low and lower middle-income countries, particularly early in the placement.
• A diagnosis of malaria is common in risk areas in Africa, Papua New Guinea and the Solomons. Chemoprophylaxis for malaria wanes with time (compliance fatigue). Counterfeit medications are a concern, especially when used as emergency standby treatment EST).
• Mental health issues are common. Psychological support should always be offered to those engaged in humanitarian relief and disasters. Counselling should be considered in pre-placement programs.
• Long term placements increase the risk of exposure to tuberculosis. The risk is higher for health workers. Pre and post placement testing is advised in higher risk locations.
• Repatriation rates are usually less than 2%. Hospitalisation rates can be as high as 4%.
• Parasite exposures are common in Africa. Screening should be considered in certain areas.
• Vector-borne disease is very common with dengue being mostly responsible in Asia.
• STI’s are common amongst expatriate workers. Counselling must be included in the pre-placement program.

Pre-placement medical review.

A structured medical review is central to the preparation process. Much of this can be undertaken through a detailed questionnaire. It must include family history and any previous experience as an expatriate worker.  Physical characteristics such as current weight and height may be requested. This alerts the worker to the purpose of the review – to see if they are a fit for the proposed location.

The role in the placement must also be considered. Are there environmental stressors to be considered?  Is it mostly office duties in a tropical location or does it contain a significant amount of physical exertion in an outside environment.

Medical examinations may be part of the preparation process.

Vaccinations are very important in managing preventable disease. Expatriate workers should understand that many serious childhood diseases have been eliminated in Australia. Australia was declared free of Measles in 2014 but it took 44 years of vaccination to achieve this status.  Unvaccinated individuals in Australia are protected by the “herd”. This is not the case in many overseas locations, and it should be known that Measles encephalitis in an older person can cause serious neurological damage.  

Global programs for polio elimination have also been very successful but unless a high level of coverage is maintained it can return. Wild polio cases are now few, but outbreaks of vaccine associated polio are often reported.  The COVID-19 pandemic impacted on many international vaccination programs, and it will take a few years to recover.

The expatriate worker should be current for all the routine immunisations under the National Immunisation Program.

Extra vaccines might be considered “routine” based on the individual’s past medical history.  

Recommendations on travel vaccines are very dependent on the location of stay.  

Hepatitis A might be considered a routine vaccine for expatriate workers who might holiday in more exotic destinations even if their primary resident might be considered low risk. It is now a recommended childhood vaccine in the USA.  

Longer exposure times in locations of risk might influence whether protection against rabies, japanese encephalitis and tick-borne rncephalitis might be considered.  

A BCG vaccine might be considered for the children of expatriate workers based in locations where the reporting of tuberculosis is high.  Screening for TB exposure should always be considered pre-placement and on returning home from high prevalence countries.

Expatriate workers need to be self-reliant. They can’t always depend on easily accessible medical advice, so therefore require a good understanding of the common health issues in their proposed location.  The advice should be targeted and not generic. They do not appreciate information overload. It may be concerning that 20-40% short term travellers report a health issue in a 2 week stay overseas but it is also comforting to know that less than 4% expatriate workers are hospitalized and only 1% require repatriation for a health concern.

Most illnesses are non-life threatening, and the concerns are more about the cause and how to manage it. It might be just a minor coral cut but they need to know that the seas around human habitation in many countries are often contaminated, and a minor injury can turn septic quite quickly. It is as much about prevention as it is about treatment.

Common health concerns include travellers diarrhoea, respiratory tract infections, vector-borne disease, skin infections and sexually transmitted infections (STIs). Environmental stressors such as air pollution, temperature extremes and humidity should be addressed for certain locations.

Resource material should be provided to all workers.  See a Pocketbook on Healthy Travel.

Most expatriate workers will experience a health issue in the first month of a stay overseas. It is usually minor. Very few can say they have had no issues over a 12-month stay.

To be able to manage a bout of traveller’s diarrhoea, food poisoning or clean and dress a wound helps generate more confidence for the rest of the stay.  If medication is used and they have been taught to retain the packaging, they will be able to replace it from the local pharma in country.  This builds resilience where the individual accepts some responsibility for their own good health.  Unfortunately, if they don’t have the tools (medical kit plus information) then it’s not possible.

The cost of a targeted medical kit is miniscule when considering relocation expenses for an expatriate worker plus or minus family.

An expatriate kit should include a range of first aid materials.  Trauma is very common amongst expatriate workers, and it is more likely to happen away from work than at work.