In 2017, more than 38 million U.S. citizens visited overseas destinations, and unfortunately, 22-64 percent of travelers reported some kind of health problem that could have been prevented with a pre-travel consultation.1,2 This translates to between 8.4 million and 24.3 million people with a health problem due to overseas travel. Despite these data, only 36-54 percent of U.S. travelers see a health provider for a pre-travel health appointment before their departure.3 As their scope expands, pharmacists are playing an increasing role in travel health, in which they provide patient education, vaccinations and prophylactic medications related to international travel. Pharmacists are regarded as highly visible and accessible to the public, and pharmacies are well suited to the delivery of patient education, prescription and nonprescription medications and immunization services, which are also the cornerstone of travel medicine. There is a large sample of data demonstrating that pharmacist-run travel health clinics provide positive outcomes and patient satisfaction.4-6
With the decline of prescription drug reimbursements, pharmacists already realize that immunizations, which have become the No. 1 patient care service offered by pharmacies, are a way to boost revenue and patient volume.7-9 Although there are limited published data addressing the financial revenue of travel health in a community pharmacy, one study reported a base revenue of $110.86 to $132.74 per patient seen for a pre-travel consultation.10 This revenue is calculated from the cost of the consultation fee and assumed vaccine administration and prescription dispensing fees. Pharmacies can generate additional revenues from the sale of nonprescription medications and ancillary travel products (such as insect repellent, first-aid kits, mosquito nets and water purification supplies). An additional benefit of adding a travel health service in a community pharmacy is that patients will seek it out year-round, offering the opportunity for the pharmacy to market and increase awareness of the services it provides. A community pharmacist’s involvement in helping patients prepare for international travel can cover a wide range of activities, including offering full pre-travel service, providing only the pre-travel consultation (and arranging for the patient to receive medication and vaccinations elsewhere), recommending nonprescription products and referring the patient to a travel health provider. When making the decision to develop a pharmacist-run travel health service, pharmacy owners must consider staff training, state regulations on scope of practice, physician partnership, logistics and the availability of resources necessary to provide a travel health service. Documents have been published describing these considerations in detail and can be found in the references.11,12 This article focuses on providing an overview of what a pre-travel consultation entails, workflow considerations in a community pharmacy and basic counseling points on common travel health topics.
Practicing in pre-travel health requires a knowledge base in epidemiology, transmission and prevention of travel-associated infectious diseases.13 Pharmacists can obtain certification to demonstrate knowledge in these areas through, for instance, the International Society of Travel Medicine’s Certificate of Knowledge for all travel health professionals or the advanced-competency Pharmacy-Based Travel Health Services training program developed by the American Pharmacist’s Association (APhA). Equally important to travel-specific knowledge is a complete understanding of vaccine indications and procedures.14 For pharmacists, being an authorized provider of immunizations and completing the APhA Pharmacy-Based Immunization Delivery training program are both important for establishing competence in this area.
After initial training and competence are established, pharmacists should maintain a comprehensive knowledge base and have access to the appropriate resources to remain up-to-date on information such as disease outbreaks, country entry requirements and vaccine recommendations. There are various resources pharmacists can use to stay current, from government-funded sources such as the Centers for Disease Control and Prevention’s (CDC) Yellow Book to web-based subscription programs. The Infectious Diseases Society of America offers a comprehensive list of resources for travel health providers.13
Components of a Pre-travel Consultation
The CDC has outlined the main objectives of a pre-travel consultation intended to prepare a traveler for potential health and safety risks while abroad. These are:
• To perform an individual risk assessment.
• To educate the traveler regarding anticipated health risks and methods for prevention.
• To provide immunizations for vaccine-preventable diseases and medications for prophylaxis, self-treatment or both.14
The DIAGRAM outlines the steps that a pharmacist should take to assure these objectives are met. To aid in providing a comprehensive patient- and itinerary-specific plan, a pre-travel consultation collects necessary information, such as a patient’s medical history, immunization history and itinerary details. Many travel clinics use a detailed travel history form that patients complete prior to their appointment. After the patient and itinerary information has been gathered, the pharmacist can then provide verbal and written information on destination-specific health risks.
Along with information on the presence of various diseases, the pre-travel health consultation includes recommendations for prevention of potential illnesses, including preventive measures, immunizations and chemoprophylaxis with appropriate medications.
The protocol varies greatly from state to state regarding the extent to which pharmacists can provide immunizations and medications for pre-travel health independently and whether they must work within in a collaborative practice agreement.15 It is important that pharmacists know the laws in their area and proceed appropriately.
Patient education regarding disease prevention is an important part of a pre-travel health consultation. Since food-, water-, and mosquito-borne diseases are commonly contracted by travelers, the prevention of these should be a focus of discussion during a pre-travel health consultation. Traveler’s diarrhea (TD) is the most common illness that presents when people from industrialized countries visit developing regions, and pharmacists should be prepared to provide education about it.16,17
Educating the traveler about proper food and water avoidance is imperative. This may decrease the likelihood of TD as well as other, more serious fecal-oral-transmitted enteric infections, such as hepatitis A, typhoid fever, larval cestode infections and intestinal helminths.13
Counseling about prevention of mosquito bites is also important, since these can lead to diseases such as malaria and dengue fever. Preventive measures to avoid mosquito bites are also effective in reducing bites from sand flies and ticks, which can also transmit diseases. Travelers should be counseled on the importance of adhering to the malaria chemoprophylaxis regimen if they are traveling to an area with a high risk of the disease. Pharmacists should also strongly encourage travelers to apply insect repellent to exposed skin.
With travel increasing each year, the number of people at risk for travel-related diseases is growing. However, only a small number of people receive the advice, vaccines and medications necessary to minimize the risk of diseases while traveling. Pharmacists are well positioned to provide pre-travel consultation and help travelers stay healthy.
- Monthly Departures to International Destinations: U.S. Department of Commerce, International Trade Administration, National Travel and Tourism Office (NTTO); 2019.
- Keystone J, Freedman D, Kozarsky P, A. Connor B, Nothdurft H. Travel Medicine, 3rd Edition: Elsevier Health Sciences; 2019.
- Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004;11:23-26.
- Gatewood SB, Stanley DD, Goode JV. Implementation of a comprehensive pretravel health program in a supermarket chain pharmacy. J Am Pharm Assoc (2003). 2009;49:660-669.
- Hess KM, Dai CW, Garner B, Law AV. Measuring outcomes of a pharmacist-run travel health clinic located in an independent community pharmacy. J Am Pharm Assoc (2003). 2010;50:174-180.
- Houle SKD, Bascom CS, Rosenthal MM. Clinical outcomes and satisfaction with a pharmacist-managed travel clinic in Alberta, Canada. Travel Med Infect Dis. 2018;23:21-26.
- Doucette WR, McDonough RP, Mormann MM, Vaschevici R, Urmie JM, Patterson BJ. Three-year financial analysis of pharmacy services at an independent community pharmacy. J Am Pharm Assoc (2003). 2012;52:181-187.
- NCPA - The Dose. Trailblazing Pharmacist Immunizer Reflects on Changes, Opportunities for Community Pharmacies2016.
- Weitzel KW, Goode JV. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc (Wash). 2000;40:252-256.
- Houle S. Is travel health a new destination for pharmacy practice and business? An examination of revenue opportunities from pre-travel consultations. Can Pharm J (Ott). 2018;151:383-387.
- Gregorian T, Bach AT, Hess K, Hurley K, Mirzaian E, JA. G. Implementing Pharmacy Based Travel Health Services: Insight and Guidance From Front Line Practitioners. California Pharmacist. January 2017.
- Goad J, Dudas V, Gregorian T, McCabe J, Hess K, Soleimanpou S. Practice of Travel Health for Pharmacists. Joint California Pharmacist Association and California Society of Health-Systems Pharmacists Sub-Commit-Tee on SB493 Travel Medicine Provision.2016.
- Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
- Centers for Disease Control and Prevention. CDC Yellow Book 2018: Health Information for International Travel. New York: Oxford University Press; 2017.
- Hurley-Kim, Keri et al.Pharmacists' scope of practice in travel health: A review of state laws and regulations. Journal of the American Pharmacists Association , Volume 58 , Issue 2 , 163 - 167.e2
- Hill DR. Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000; 62:585–589.
- Steffen R, Van der Linde F, Gyr K, Scha¨r M. Epidemiology of diarrhea in travelers. JAMA 1983; 49:1176-1180.