52 Travel medicine: what you need to know before you go

Jeanine Abrons, PharmD, MS, FAPhA

Madeline King, PharmD, BCIDP

Marissa Rupalo, PharmD candidate

Introduction

Pharmacists have numerous roles in travel medicine or health consultations. These roles have been well-described in countries like Canada, the United Kingdom, Australia, and more.^1-5 Pharmacists in the United States are increasingly engaging in travel medicine and health consultations and can benefit from the experiences shared from other countries.⁶ Although a patient may be capable of finding answers to initial travel-related questions through other means, pharmacists can provide added specificity and suggest resources to enable the patient to have a successful and healthy trip.

Customization of recommendations is necessary to advise special populations or travel groups, even despite awareness of limitations in the completeness of information based on individual/group travel dynamics. Group or individual consultations may be provided for business travelers, humanitarian workers, students studying abroad, long-term travelers/ex-pats, individuals visiting friends and relatives, adventure travelers, families (e.g., traveling with minors or extended family), traveling to mass gatherings, and for special populations (e.g., chronic illness, pregnancy, etc.), which all have further unique considerations and recommendations.^7-9 Other benefits of a pharmacist’s involvement in travel consultations include convenience of appointments, serving as a “one-stop-shop” for vaccines, availability of travel kits and advice, and clinical benefits.¹⁰

Travel medicine or health consultations may include recommendations and services before the patient embarks on travel, advice of how to seek care or resources during travel, and post-travel consultation on the development of any new conditions/symptoms. A structure that can be implemented within each of these three elements is the 5W model (i.e., who? what? when? where? why?) to maximize the individualization of the patient. Each element of the consultation (pre-travel, during travel and post-travel) can benefit from this structure.¹¹

Potential services prior to travel may include travel health kits for self-care with standard and/or customized items that are beneficial during travel. These may include adhesive tape, bandages, and sterile gauze or dressing, insect repellent or bite treatments, eye drops, antihistamines or nasal decongestants, oral rehydration powder, analgesic, sunscreen, and other self-care items. The benefit of these resources is enhanced with advice on specific dosages, strengths, frequencies of use, which the pharmacist can adjust according to destination.^12-14 The pharmacist can also advise on proper storage, documentation, supply, packing, and legality of prescription medications or adjustments to use to maintain efficacy.¹⁵

Beyond being prepared for self-care, all patients traveling internationally should be up to date with the standard vaccine schedule based upon age and comorbidities.^16-18 Different vaccines are recommended based on the area of travel, and other preventative measures may be supplemented when vaccines are unavailable (e.g., bed nets and source avoidance with vector-borne illness).¹⁹ Most injectable travel-related vaccines are administered at the same visit, with a few exceptions. The Centers for Disease Control and Prevention (CDC) Yellow Book Travel Vaccine Summary Table provides details on dosing schedules and age restrictions for vaccines for common travel-related vaccines such as yellow fever, Japanese encephalitis, typhoid, rabies, and meningitis.²⁰ In general, patients should complete any vaccine series’ at least two weeks before travel to ensure a complete immune response.¹⁹ However, some vaccines can provide sufficient immunity for travel after only one dose (for multiple-dose vaccines). Therefore, even patients traveling last-minute benefit from a review of needed travel-related vaccines.

Case

CC: “It’s going to be my first time outside of the country!”

HPI: MJ is a 24-year-old female traveler going to Costa Rica with her 25-year-old fiancé (BH) and her 70-year-old mother (CJ). All three travelers will be taking direct flights to San Jose from Chicago, IL. MJ states that she and her mother have never been out of the country, but BH visited New Zealand four years ago. The group plans on staying for five days with the following itinerary:

• Day 1: Travel to San Jose
  • Check into hotel
  • Coffee bean plantation tour
  • Visit the National Museum of Costa Rica
• Day 2: Hiking in the Central Valley
• Day 3: Tour/shopping in San Jose
• Day 4: Travel to Liberia
  • Check into hotel
  • Spend day at the beach
• Day 5: Hike/horseback ride

PMH:

• MJ: T1DM (since age three); asthma (x four years)
  • Experiences shortness of breath/wheezing two to three times a month and manages these symptoms with a rescue inhaler
  • Uses an insulin pump, testing her blood glucose eight times daily depending on meals and activity
• BH: ADHD (since start of college)
  • His fiancé states that his current medication regimen seems to be working well
• CJ: VTE (two years ago); HTN (x six years)

SH: Limited information regarding social history is available from the patient. MJ and BH live together when not traveling and enjoy cocktails socially. She states that her mother generally does not drink. None of the travel group members smoke or use illicit drugs to MJ’s knowledge.

Current medications:

MJ

• ProAir HFA two puffs every six hours as needed for shortness of breath/wheezing
• OneTouch Delica lancets to test blood glucose up to eight times daily
• OneTouch Verio test strips to test blood glucose up to eight times daily
• Humulin N 32 units in the morning and 13 units at bedtime
• Humulin R administered after meal via sliding scale (maximum daily dose 80 units)

BH

• Adderall XR 20 mg by mouth every morning

CJ

• Eliquis 2.5 mg twice daily
• Lisinopril/HCTZ 20 mg/12.5 mg daily

Allergies:

• MJ: bee stings (anaphylactic reaction)
• BH: NKDA
• CJ: sulfa antibiotics (rash)

Vaccinations: MJ indicates that her and her fiancé are up-to-date on their routine vaccinations. BH remembers getting a few vaccinations before his trip to New Zealand but can’t recall which ones. Her mother is also current on all of her routine vaccinations, and you can confirm this in your state’s immunization documentation system.

SDOH: MJ is still on her mother’s health insurance as a college student. BH separately receives Medicaid.

Case Questions

1. What clinical recommendations would you make to the travel group related to preparation (e.g., packing, medications, planning, documentation)?

2. What recommendations would you make to the travel group related to preparations for regulatory concerns with medications during travel?

3. What immunizations should each member of the travel group receive? When should they receive these vaccinations to ensure immunity?

4. MJ asks you specifically about mosquito bite prevention. What recommendations would you provide her?

5. What resources or advice on where to seek care can you provide your travel group for any healthcare needs they may have during their trip?

6. What overall recommendations, resources, or information would you provide your travel group?

7. The group’s travel plans include a day at the beach. What recommendations can you make to your group regarding sun safety?

Patient Approaches and Opportunities

Pharmacists have a vital role in patient education prior to, during, and post travel. This includes, but is not limited to, recommendations on traveling with comorbid conditions, what items to include in a self-care kit, what vaccines to receive prior to travel, how to avoid common illnesses when traveling, and where to find emergency services abroad. Patients can locate this information online through the CDC website²¹ and Yellow Book.²² However, without background knowledge it can be difficult for patients to discern what information should be considered, decide when actions should be taken, and determine what information might be missing. A pharmacists’ knowledge and accessibility make them uniquely positioned to ease the travel process and ensure patient safety while traveling. Pharmacists who wish to learn more about the area of travel medicine may pursue certification courses which cover key points of information related to travel medicine. These certificates are offered through the International Society of Travel Medicine¹ and American Pharmacists Association.²³

Author Commentary

When counseling patients, it is important to consider the patient’s ability to provide self-care.

Social determinants of health (SDH/SDOH) such as a patient’s ability to afford medications and access resources are important to consider. Whenever possible, recommendations provided to a patient or travel group should be customized to enhance the benefits to the patient(s) and the likelihood that they will continue to use the service. An example of impacts to SDH/SDOH may include the coverage of vaccines by insurance. In many instances, certain products/schedules may not be covered, or different formulations may be requested under coverage. The pharmacist should help the patient to identify methods of obtaining required travel-related vaccines that minimize out-of-pocket expense (i.e., prior authorization, alternative dosing schedule or product selection). In instances where vaccine may not be affordable to the patient, steps should be taken to determine alternative methods of reducing patient risk or exposure (e.g., social distancing, masks, source exposure reduction, alteration of planned activities, etc.)

A variety of unexpected events such as accidents or emergencies can arise during a patient’s travel itinerary. While a pharmacist might not be able to cover all possibilities during a travel-medicine consultation, they can suggest resources for seeking care when abroad. Additionally, they may recommend travel health insurance and provide clarification on how this differs from normal health insurance or trip-related cancellation insurance.