December 2014, Vol 2, No 6 - Inside Continuing Education
Adele Chatellier, PharmDc
Ann Johnson, PharmD

International travel has been increasing exponentially over the years, and it will continue to increase with the number of international tourists expected to reach 1.6 billion by 2020.1

In the United States, citizens travel not only for tourism, but also for business, study abroad programs, research, visiting friends and family, and mission work. With travel increasing, there will be a greater demand for travel health services, and pharmacists and retail clinicians are in an excellent position to provide these services.2 Traveling poses a risk for various illnesses and health hazards, especially in certain patient populations such as pregnant women and persons with diabetes.

For healthcare practitioners to administer quality travel healthcare, they need to have specialized knowledge and training, and be up to date on the most recent risks associated with geographic areas.

Travel Clinics Defined
Travel clinics offer travel health services to minimize the risk of acquiring illnesses while traveling abroad.3

Clinics provide preventive health advice to avoid spreading diseases and minimize environmental risks. They may also provide necessary warnings regarding the destination of travel and travel-related medications (prescription and nonprescription). Travel consultations also address nonbiologic health risks, discuss behavioral risk factors, and identify measures that special populations and those with chronic disease states must undertake.

Practical travel-related information, such as required documents and records, is also given. The Centers for Disease Control and Prevention (CDC) recommends that travelers consult a travel clinic 4 to 6 weeks before traveling to allow ample time for vaccines and/or medications to take effect before departure.

Pharmacists’ Roles
Pharmacists are in an excellent position to become involved in travel medicine because of their high accessibility and visibility to the public.

Community pharmacies that are not equipped to run as travel clinics can still play an active role in travel medicine. Pharmacists can identify patients with travel plans who warrant pretravel medication and confirm that physicians have selected appropriate vaccines.

By understanding the patient’s drug history, pharmacists can identify any drug–drug interactions before initiating preventive care or treatment. They can also better counsel patients on the efficacy of medications and discuss other nonpharmacologic ways to prevent malaria and other communicable diseases. Not only can every pharmacist assist with pretravel health needs, but they can also identify signs and symptoms of diseases when patients return.

Multidisciplinary teams that include pharmacists run many travel clinics, some of which are incorporated into community pharmacies. Many independent and community pharmacies are developing travel-related health services to attract business and increase profits.

Currently, a leading pharmacy chain advertises that they offer travel services at select locations. In addition to retail chain pharmacists, independent pharmacists and others can become integral members of the interprofessional teams at more traditional travel clinics.

Pharmacies offering travel health services are expanding because of a growing need. They are open longer hours than primary healthcare providers, in more accessible locations, and have many travel supplies available on-site, making it more convenient for patients to get the required pretravel care. Thorough risk assessments require patients to provide their medical history, immunization history, and medication records, which are easily accessible at the traveler’s local pharmacy.

The travel risk assessment also requires identification of drug–drug and drug–disease interactions for therapy recommendations. Pharmacists are the healthcare professionals with the most medication knowledge, and they are specifically trained to correctly identify these interactions.

Conducting a pretravel consultation requires background knowledge of epidemiology, disease transmission, and preventive measures. Elements that pharmacists should address during a pretravel consultation include patients’ overall health, travel itinerary, and duration, season, and manner of travel. Pharmacists should address unmet vaccination needs, and provide education on preventive measures and health maintenance.4 From there, pharmacists can select appropriate prescription, over-the-counter, and ancillary prophylactic and therapeutic products related to other travel health needs.

Some common topics of discussion include ways for patients to protect themselves against foodborne, bloodborne, and respiratory infections during travel. Pharmacists should update patients on travel vaccinations as well as routine vaccinations, such as the influenza vaccination.

Pharmacists may also want to discuss ways to prevent travelers’ diarrhea, including dietary restrictions, use of self-treatment methods for prophylaxis, and the risks and benefits of prophylactic antibiotics. Currently, the CDC does not recommend the use of prophylactic antibiotics to prevent travelers’ diarrhea for most people. However, people who are on short trips and/or a part of high-risk special populations with immunosuppression may benefit from prophylactic therapy.

Malaria prevention is necessary for people departing to malaria-endemic regions, which encompass approximately half of the world’s population.5 The CDC estimates that about 1500 cases of malaria occur in the United States each year from patients becoming infected while traveling abroad.6 Malaria is estimated to cause 627,000 deaths worldwide each year.7 An infected person can also contaminate local mosquito populations, further spreading the disease. To choose the appropriate drug regimen, it is necessary to know the species of malaria that is common in the area, whether that species is resistant to antimalarial medications, current medications that could interact with prophylactic agents, and medical conditions that are contraindicated for travel to the area altogether. The duration of the trip is also important, since it can affect which antimalarial agent is chosen. Some medications, such as mefloquine, require treatment for up to 4 weeks after an individual’s return home. This would be prohibitory for individuals planning a short trip, in which case Malarone would be a better option. Prophylactic agents are not 100% effective, so pharmacist-provided counseling on personal protective measures is also necessary.

Packing Lists for Travelers
Pretravel counseling should also address the practical matters of traveling. The CDC recommends that travelers pack certain health-related items to ensure safety (ie, they strongly recommend that travelers pack copies of prescriptions for all of their medications). Some countries prohibit certain medications (eg, narcotics), even if the patient has a valid medical need and prescription.8 Travel clinics can assist patients in identifying these forbidden medications.

If patients with diabetes require needles and syringes, they should pack these supplies along with a letter from their physician and a copy of the prescription.8 All health insurance documents, claim forms, and a list of all current medications—including the drug, route of administration, formulation, strength, and frequency—should be carried with travelers at all times.

Patients should wear medical alert bracelets when appropriate. Pharmacies can help patients create a medication list if necessary, and they can also provide, first aid, preventive illness and injury supplies, and over-the-counter medications recommended for travel. At a minimum, patients should pack medications for mild pain or fever, stomach upset, diarrhea, and upper respiratory irritations.8

Pharmacists can recommend products specific to patients’ needs depending on their destination and mode of travel. Finally, pharmacists should remind patients to check with their health insurance provider to determine if they have international coverage when appropriate.

Pharmacist Resources
Retail pharmacists may be unsure where to get started when implementing a travel health clinic. One of the premier resources for travel health education is the CDC’s biennially published book, CDC Health Information for International Travel, commonly referred to as The Yellow Book.

The Yellow Book is a guide to the practice of travel medicine, as well as the authoritative source of US government recommendations for immunizations and prophylaxis for foreign travel.9 Although the book can be used by travelers themselves, its main purpose is to serve as a reference for healthcare workers.

From counseling tips to disease state references, The Yellow Book is indispensable for any healthcare worker advising patients on travel overseas. The book is an excellent resource not only for pharmacists who wish to open a travel health clinic, but also for those who just need a reference for the occasional travel-related patient question, such as retail clinicians.

Call to Action
For pharmacists wishing to expand their business, they may want to consider specialized training that would enable them to offer travel health services in their pharmacy. The lack of knowledge about the risks of traveling and the limited availability of travel health clinics are barriers preventing patients from seeking travel health services. Pharmacists are in an excellent position to identify and educate travelers requiring travel health services. Ultimately, providing these extra clinical services will contribute to expanding the role of the pharmacist while potentially increasing pharmacy profits.




References
  1. World Tourism Organization. Tourism 2020 Vision. www.unwto.org/facts/eng/vision.htm. Accessed November 10, 2014.
  2. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004;11:23-26.
  3. Centers for Disease Control and Prevention. See a doctor before you travel. wwwnc.cdc.gov/travel/page/see-doctor. Updated January 13, 2011. Accessed November 10, 2014.
  4. Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1499-1539.
  5. Hartjes LB. Preventing and detecting malaria infections. Nurse Pract. 2011;36:45-53.
  6. Centers for Disease Control and Prevention. CDC and malaria. www.cdc.gov/malaria/resources/pdf/fsp/cdc_malaria_program.pdf. Published April 2014. Accessed November 10, 2014.
  7. World Health Organization. 10 facts on malaria. www.who.int/features/factfiles/malaria/en/. Published March 2014. Accessed November 10, 2014.
  8. Amanda Whatley Lee; Centers for Disease Control and Prevention. Travel health kits. wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/travel-health-kits. Updated August 1, 2013. Accessed November 10, 2014.
  9. Centers for Disease Control and Prevention. CDC Health Information for International Travel 2014: The Yellow Book. New York, NY: Oxford University Press; 2013.
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