CEimpact Podcast

The Pharmacist's Role in Travel Health

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Travel health is more than just vaccines—pharmacists play a crucial role in protecting patients from preventable illnesses with essential immunizations, OTC medications, and prescription therapies. This episode explores the key components of a successful travel clinic, from vaccine recommendations to counseling on travel-related health risks. Tune in to learn how you can expand your impact and help travelers stay safe and healthy on their journeys.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Regina Richardson, PharmD
Pharmacist
Bremo Pharmacy

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify key vaccines, OTC medications, and prescription therapies recommended for travelers based on destination-specific health risks.
2. Explain the pharmacist's role in providing travel health services, including patient counseling, risk assessment, and preventive care strategies.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-160-H01-P
Initial release date: 5/12/2025
Expiration date: 5/12/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, CE Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, Josh Kinsey, and, as always, I'm excited about our conversation today. Traveling opens the door to new experiences, but it also comes with health risks that pharmacists are uniquely positioned to help prevent. In this episode, we'll discuss essential vaccines, medications and counseling strategies to ensure travelers stay healthy before, during and after their journey. It's so great to have Regina Richardson with us for today's guest for this episode. Regina, thanks for joining us.

Speaker 2:

Thank you for having me.

Speaker 1:

Yeah. So for our learners out there, Regina, go ahead and take a couple of minutes and introduce yourself. Tell us a little bit about your practice site and maybe why you're passionate about today's topic.

Speaker 2:

Sure. So I am originally from Ohio and I attended Ohio Northern University. Since graduating I have lived in Richmond, virginia, and I've worked for a retail pharmacy and now I work at Brimo Pharmacy, which is a local independent here in Richmond. Our practice site is unique. We like to think of ourselves as cutting edge, so we try to do all the new and great things that are coming in pharmacy, and one of those is we have a travel clinic. So one of my colleagues, probably almost 10 years ago, had the idea to start a travel clinic. It started very small and now it has grown to where we get referrals almost every day of patients who are traveling and looking for our services. So I love to travel myself and I have had challenges in the past, you know, finding what I needed for travel, and so I think it's great to have the service and offer education and medication that patients need.

Speaker 1:

Yeah, that's awesome and I would assume that there probably aren't that many pharmacies or travel clinics nearby. You said that you get a lot of referrals, so I would imagine you probably get probably 60, 90 mile radius of referrals, if not more sometimes with things.

Speaker 2:

So yeah, there definitely are people who come from fairly far away. There is a large travel health. That's all they do. It's not a pharmacy. They, I think, have some restrictions on insurance that you know, kind of pushes people to use us.

Speaker 1:

Yeah, well, that's great. Well, that's great, well, thanks again, regina, for taking time out of your schedule. I can see that you are at work, I know you're at work, so I appreciate you, and also your staff, for allowing you the time to step away and join us for this episode so we're grateful.

Speaker 1:

Well, without further ado, let's jump into some of our topic for today. So one thing I want to talk about it's been a long time since I've traveled abroad I've been on a few trips here and there but probably a couple of decades since I've been like overseas per se. So I feel like I'm not even really in the know anymore. So I'm looking forward to learning more about things. But just remind us what are some of the common risks and preventable illnesses that are associated with international travel? What are the ones that you all see the most of that you're treating patients for?

Speaker 2:

I think the risks fall into two categories. The one is things that people contract from contaminated food and water.

Speaker 2:

And the other is mostly mosquito borne but insect borne infections. So you know, in your bucket of food and water borne illnesses there's I mean there's tons of things obviously that you can run into Viruses, viruses, bacteria, parasites. The things that we really look at preventing are hepatitis A and typhoid. Those are, you know, what vaccines exist to prevent. And then we also really try to set people up with an antibiotic to treat an infection should they get one for their trip? Antibiotic to treat an infection, should they get one for their trip. And then the other bucket of things are insect-borne or mosquito-borne illnesses. So yellow fever and malaria are definitely the most common.

Speaker 1:

The most common and what I guess regions or areas are we looking at to where those are of concern, Like if someone's going to London, England, over the summer, like, is that a concern? Or are we looking at, you know, certain regions and areas of things where we have problems?

Speaker 2:

Yeah, so the biggest, so most of Europe, especially Western Europe, doesn't really there's not a lot of concern there Beyond what you would be concerned about here in the United States, sure. Sure concern there, beyond what you would be concerned about here in the United States. So our most common patient is going to Asia, especially Southeast Asia, Africa and South and Central America. Those are the places where they have these infections and things where we want to provide them some prevention before they go.

Speaker 1:

Sure. So if that's the region where your patients are traveling, then those are the moments where you can jump in as a pharmacist with some counseling, some recommendations, some reminders Great. So what? Obviously, our listeners are pharmacists, so we always like to make sure that we're highlighting the role that they have in this. So what are some of the things that pharmacists can do in this space? Obviously, dispense medication is one of the things, but like specifically talk about what exactly can they dispense? What are some of the things that go along with the prevention and the treatment, and then some of the counseling you know, I think is probably key.

Speaker 2:

So so yeah, as pharmacists, um we have a protocol in place to um to prescribe and administer travel vaccines with the doctor. Our um state we, you know we can prescribe and administer routine vaccines, but travel is kind of exempt from that. So we have a protocol that includes travel vaccines, so that you know anytime a patient you know was asking about them or maybe they request one vaccine they say they're traveling we can kind of assess and make those recommendations in the moment.

Speaker 1:

Sure.

Speaker 2:

So basically like oh, you're going here and you thought you only needed this, but you actually need this too, so yeah, yes, If you're seeing requests for things that are typically for travel, that could be an opportunity for pharmacists to kind of step in. Or even if you receive a prescription for an anti-malarial medication. I mean, that is pretty much only used for travel.

Speaker 2:

So yeah you might be prompted to ask do you have all your vaccines? Is this, you know, something that we can help you with? And then also, yeah, just counseling on the medication. So making sure patients understand that you know if they have an anti-malarial medication, making sure they understand how to take it, that it's for prevention. It doesn't guarantee that they won't get malaria, unfortunately, so they still have to use other precautions. You know, like traveler's diarrhea antibiotics, those are not going to prevent them from getting sick. It's for them to take if they are getting sick or if they do get sick. So you know being the person to provide that additional education when they pick up their medication.

Speaker 1:

Yeah, the clarity over you know this antibiotic prescription is only if you need it, like don't just start taking this when you, when you get to your destination or whatever. So yeah, so we talked a little bit about destination specific risks. So some of the regions and some of the areas where we're looking at those things and I love the fact that you kind of divided it into two buckets. I think that's super helpful to remember what are some of the patient specific factors that we should consider as well?

Speaker 2:

I think that when it comes to foodborne know, foodborne illness and contaminated water, that kind of thing, you just want to be a little bit more cautious. Perhaps provide additional doses of antibiotics if someone is immunocompromised or you know an older patient who might have more complications from some type of infectious diarrhea, or you know GI infection?

Speaker 2:

You also might counsel that they should seek medical attention a little bit sooner than maybe a younger, healthier person who might recover on their own or be less susceptible to dehydration. The same kind of thought process goes along with something we haven't talked about yet, which is altitude sickness. That's something that we don't do all the time, but sometimes we have patients who are climbing Mount Everest or Mount.

Speaker 2:

Kilimanjaro or just going to places like Peru is an example where people are typically going to high altitudes. People who are older are going to be more susceptible to some of those things. So just making sure they understand the risks and that their preventative medication is really important.

Speaker 1:

Yeah, you made me think of something that I'll ask here when we were talking about dosing and if they're an older patient and if they're immunocompromised and whatnot. Are we also do dosage, and you don't have to get into specifics, obviously, but I assume dosages differ based on the age of the patient as well. You know, like, if we have a teenager going on a mission trip or something with that, do you have to consider okay, they only get three days of of antibiotics, whereas somebody else would get five or whatever? Are there? Are there specifications there, or is it pretty much across the board?

Speaker 2:

The guideline for traveler's diarrhea is pretty uniform. It's really only weight-based. Um the only time we really deviate is if someone we typically recommend azithromycin, so if someone has an allergy, is usually the only time we deviate and pick a different agent For anti-malarial medication.

Speaker 2:

That is also usually only weight-based, so for children the dose is different, but adults typically get the same dose. I think there is a contraindication for people with very severe renal impairment, but I mean for the most part I forget the actual number, but for the most part the patients that we're seeing are not in that category. But if they were, then that just isn't an agent that they could take.

Speaker 1:

Gotcha. So there are specifics to look at, like you said just with in general, for dispensing medications. You're going to be looking at allergies and weight-based and things like that. Okay, that's good, that's helpful. What about timelines? So I know that some people are not as organized as I would call myself and so they may not be planning their trip ahead, you know, six months in advance or whatever. Like when should people, if they were to ask you about it, if you don't have a full fledged travel clinic in your pharmacy, and they're just asking you for advice, like when should they be getting certain vaccines? I assume there are schedules based for all of them. And when should they, you know, any sort of preventative treatment? Is there certain timelines that they should be following?

Speaker 2:

I usually tell people that earlier is always better because I mean I think the shortest you know the shortest efficacy for the vaccines that we typically recommend is the typhoid vaccine, but it's good for two years. So I mean you can't get them too early. I guess is my point in saying that it's usually recommended to get vaccines 10 to 14 days before entering wherever you're going, so that gives your body time to have an immune response.

Speaker 1:

Yeah, that's really what I was asking. I guess I didn't set you up very great with that one, but that's what I meant was like you've got it, though, thank you for reading my mind, but that's what I meant was like is there a period of it needs to take this long to work? You know that kind of thing? So the lane superior? Yeah, so that's perfect, that's so. Two to 10 to 14 days is typical. Are there any that are longer than that or specific?

Speaker 2:

Not to my knowledge. The malaria medication that we typically recommend is Malarone and that only needs to be taken two days before you start, at two days before you start, at two days before you enter where you're going, so that you know, gives people some time, you know. I think that if patients are traveling, you know starting the process before the 14 days to make sure you know the pharmacy has everything you need and the doctor needs to be involved and things like that.

Speaker 2:

But yeah, getting the vaccines 14 days before will ensure that an immune response has happened by the time you're traveling.

Speaker 1:

Yeah. So it doesn't have to be you know, it doesn't need to be someone who would pre-plan like I would, you know, five to six months in advance. We're not talking about those kind of pre-planners, but we need at least two to three weeks notice. So okay, that's helpful. So on that note, you've mentioned some already but some additional opportunities for pharmacists to kind of be involved in this space. So you mentioned that your store has a full-fledged clinic. So in my mind when I hear travel clinic, I immediately think of, like this extra little space over in the corner. That's just about travel. Is that how it works? Or is it literally just the fact that you have the knowledge and the protocol and all that kind of stuff? Like, give us a little bit of insight as to how kind of you're set up at your practice site, I guess.

Speaker 2:

Yeah, we have. We have a clinic room at our pharmacy. That's, you know, out in the store. It is its own room, its own space, it's private, so we do all kinds of things in there. That's where we do all of our appointments. Travel is just one part of that. So patients submit a form online and, you know, give us all their information where they're going. We ask, you know, certain health-related questions and then we determine what they need. We reach out to their doctor for the malaria, traveler's diarrhea or altitude sickness medication, if those are needed, and then when they come in, we give them the education and then give them any vaccines that they need.

Speaker 1:

Okay, so I guess my point there was it doesn't have to be a dedicated space. So if someone else, if another store is offering immunization services in general, that patient specific space could also serve for a travel clinic as well, correct?

Speaker 2:

Yeah, I think any space that is set aside for you to give immunizations or counsel a patient could be utilized for yes for travel.

Speaker 1:

Perfect. Yep, you've touched a little bit on some of the education points and how counseling is super important and whatnot. What are some of those nuances Like? What are some of the things that we absolutely want to be sure that we are counseling on? Are there specific side effects from some of the medications that we need to alert people to so that they aren't alarmed? Or if it's something that they're taking by mouth that they don't stop taking because adherence is key? You know, like, what are some of those high key counseling points, pain point medications that need counseling?

Speaker 2:

I think the malaria medication is really important. Sometimes it does cause an upset stomach for patients, so we usually tell them to take it with food. We also frequently will have pediatric patients who need malaria medication. It's only available in a tablet, so we counsel on crushing it, mixing it with food, but then patients should receive the medication right after that. It shouldn't be like mixed and set aside for later.

Speaker 2:

That's something that we counsel on For malaria medication, it's important that they take one tablet a day for the entire trip and then they also have to continue for seven days after they come back.

Speaker 2:

Yes, because there are certain types of malaria that can be latent and present later on. So taking it after they come back is really important For the traveler's diarrhea antibiotics. We make sure they know. You know this is for treatment, this is not for maybe. Like I just ate something that didn't really agree with me and my stomach's a little bit queasy. This is you have maybe some cramping, fever, diarrhea, vomiting. That's not getting better.

Speaker 2:

We also make sure they understand that an antibiotic is obviously for a bacterial infection, but there's parasites and other things that might be present. Parasites and other things that might be present, and if this antibiotic does nothing for your infection, you will need to you know, seek treatment at your destination because, they will have what's best for treating those types of things.

Speaker 1:

Right, and unfortunately some of that is, I imagine. But it's almost like catch 22, where it's like you got sick from the water and now you are dehydrated and you need to hydrate, but like you know. So I would imagine that that could become problematic. Do you all offer any sort of guidance there, or is that kind of the situation where you're like you need to seek medical care because it needs to probably be?

Speaker 2:

replenished. Do we offer education on dehydration?

Speaker 1:

Yeah, like how would you hydrate in an area that you got sick from the water to begin with? Yes, that's true.

Speaker 2:

So part of our education is just about drinking the water generally. So I think it can be challenging because there's no way to know the water quality everywhere and it kind of also depends on where they're staying and what's provided for people who are traveling. But we normally counsel everyone that when there's a doubt, make sure you're drinking bottled water, avoiding ice because it can be made with contaminated water, also understanding that you might be visiting your family or your friends who are drinking the water with no issues. However, they are accustomed to drinking that water, so you know when the water that you are drinking has just different microbes in it in different places and if you've grown up there that's something that you're, you know, you're used to, so someone coming from somewhere else might have, you might have a reaction or get sick from the same water.

Speaker 2:

So we do go over just general water and food safety as part of our education.

Speaker 1:

Yeah, no, I think that's probably what I mean. You've given some great points and they're all resonating, but that one to me really resonates because it's almost like oh well, so-and-so is drinking it, so you know I'm in their house, so it must be fine. So that's really key to also realize. Yeah, that's great, great advice. One thing that you mentioned and I meant to talk about this earlier and I didn't because you mentioned like it depends on where you're going and whatever. So what if you're going into an area that is usually of high concern with water quality? You know, like we have a, you have a lot of issues in this area, but you're, you're going on and it's an all-inclusive resort or you know something like that. Is there still a concern? Or are we assuming that those quote unquote elevated places, you know resort style things or whatever that they're filtering properly? Or should there still be great concern there?

Speaker 2:

I think with food and water, you have to trust the information that's available to you as a traveler. So you should probably ask A lot of times. People are traveling with groups or you know they have travel agents or tour guides, things like that. So asking those questions to you, know the people that are the most knowledgeable about where you're going?

Speaker 1:

Yeah.

Speaker 2:

And then. But you also have to be okay, like with trusting their answer. So I usually say when in doubt, bottled water. However, you know, if there's information that says we use a special filtration system or something like that in our resort, then I think you, you know you can trust it. It varies so much, I think water is something that's really difficult because you don't always have all the information as the person giving them advice.

Speaker 1:

Yeah, no, that's great, that's great advice. I just wondered if there was a different approach in your protocol based on that, and it sounds as though I mean what you've given me is exactly that Like you need to ask the questions, listen to the answers and then that allows you to make informed decisions as to whether or not you want to trust it or if you just want to be super cautious, and yeah so on on our form that we have patients fill out.

Speaker 2:

One of the questions is about where are you staying A? Hotel Are you camping Are you staying with friends, because there are certain things that you are more likely to get if you're staying, you know, somewhere that doesn't have air conditioning, like there's more mosquitoes that are going to be there. So you have to take all of those things into consideration.

Speaker 1:

Yeah, If you're sleeping in a tree house under the stars, you're going to be more susceptible to yes you want to make sure you have mosquito nets and stuff like that, as opposed to an air conditioned hotel.

Speaker 2:

You know the risk.

Speaker 1:

Exactly that makes sense. So those are again. So it's important for for pharmacists to ask the right questions too, and it sounds like your. Your intake form is very thorough, and I think that that is a recurring theme that we're seeing with you is that? You know, we asked them this already and that's how we know to to guide our consultations, which is great. Okay, yeah, so let's talk about some of the challenges. Let's do that in our last few minutes here. So some of the challenges that you might encounter are any of the vaccine schedules complex, like is it difficult to get in all the doses, especially if you have a late comer? Or is it you know that they have to come back for a second dose? And if they don't come back within a certain period, then you know, like some of those kind of issues where it's like, oh, you got to start over again or whatever. So are there any concerns like that with any of the travel vaccines?

Speaker 2:

For the most part, it's fairly straightforward. So, our most common vaccines are hepatitis A, which is two doses one and then one in six months. However, the first dose does give really good coverage for the short term. So, that first dose is going to usually cover that person for their trip, and then we do recommend that they come back after six months to get their second dose for lifetime immunity.

Speaker 1:

But that one is not they wouldn't need to plan ahead six months to come get the first-. No, right, okay, yeah.

Speaker 2:

Yeah, because their first dose does give them Is one Right, okay, yeah, yeah, because their first dose is what covers them.

Speaker 1:

Okay, yeah.

Speaker 2:

The second one is typhoid, so that's just one dose. It lasts for two years, so that one's very straightforward. The other one that is really common is yellow fever. They recently, within the last couple of years, have changed the guidelines on yellow fever, so one vaccine provides lifetime coverage.

Speaker 2:

That one yellow fever is the trickiest vaccine because there's a card that you have to give patients and certain countries require the card, so we have to make sure we're filling it out correctly, that they meet all the requirements. There's also a medical waiver that some patients can get. So it's a live vaccine. So there's, you know, patients who have immuno, who are immunocompromised, might not be eligible to get it. Also, patients over the age of 60 are more likely to have some adverse effects, likely to have some adverse effects which can actually be very serious. So there's like a viscerotropic is what it's called adverse event. It's like can cause multiple organ failure.

Speaker 1:

Wow.

Speaker 2:

And there's also a neurologic, I guess, side effect you could say that can be really severe. So making sure we identify which patients should and should not get.

Speaker 1:

The vaccine is important, yeah, very important. So another concern or potentially with vaccines is sometimes the quantity in which they come. So is this something that you can just offer on a whim, or do you really have to double down because you're going to have to buy 10 yellow fevers or you know what I mean 10 doses of that? So if you can speak to a little bit of kind of how that's packaged and whatnot, that would be helpful.

Speaker 2:

Yeah, that's actually a challenge that we had in the early days of our travel clinic when we had not as many patients. So typhoid luckily comes as a single dose, so that one's easy. Hepatitis A and B are routine enough that you would probably or you could use the doses. Yellow fever does come as a pack of five. You also have to get special, I guess, registration as a site, because you have to get a stamp to give the cards.

Speaker 2:

And then I'm trying to think of other ones. The one that we've had we used to have a challenge with was the polio vaccine, because it's a multi-dose vial and we always operated under the assumption that after 28 days you had to discard it. However, that's actually not the case. We were able to find information that that vaccine is good for the life until the expiration date on the bottle.

Speaker 1:

So that is helpful.

Speaker 2:

Yeah, that's really helpful, okay, so that's been really helpful in us being able to offer that, you know, for more patients.

Speaker 1:

So what I'm hearing is there aren't too many barriers to offering travel help, vaccines and services. So I hope that our listeners are motivated by this and really realizing that this is a viable opportunity to kind of increase services that are offered to patients and, potentially, revenue streams for the pharmacy. So quickly, we only have a couple minutes left, but do you have any barriers to reimbursement? Are there any special considerations? Is there a lot of times where the patient's having to pay cash for things and that's a problem, if you can just kind of speak to that component of it too.

Speaker 2:

Yes, a lot of travel vaccines are vaccines that are specifically for travel, so yellow fever and typhoid are usually not covered by the patient's insurance. So that's an out-of-pocket cost which certainly can be a barrier for the patient. We do sometimes run into issues with some travel vaccines where our reimbursement is not as much as the cost. So where the pharmacy is not being appropriately reimbursed for the vaccine. But the most common issue is honestly for the patient because insurance does not see them as essential.

Speaker 1:

So they don't cover them? Sure, yeah, and if they're planning ahead early enough, then hopefully there's time enough to kind of make arrangements and whatnot. So, yeah, well, that's super helpful. I always say I don't understand how I run out of time so quickly, but lots of great information, but we are already out of time for this episode. So, regina, before we go today, a question I always like to kind of double back to and ask is what's the game changer here? It's our topic of our podcast. Is game changers, um, our title? And so I always like to kind of ask the, the speaker for the day, to just summarize what you feel like is the game changer here? What have we talked about?

Speaker 2:

that is like the key point I think that, as pharmacists role pharmacists roles are expanding this is a really great place for a pharmacist to fill a need that might not otherwise be filled. So it's a great way to have your patients see you in a different light.

Speaker 1:

Absolutely. And you know one thing I'll touch on too. You know you all did your due diligence to determine that in your state you needed to get a collaborative practice agreement and to work under a doctor with protocol and whatever, and so I would encourage our listeners if this is something you're considering, be sure that you're checking your state guidelines and your state board of pharmacy as to what you can and can't do under scope of practice there. But, like you said, this is an opportunity for pharmacists to fill that void and I love how you put it to have your patients see you in a different light. That's great, because I think it's really important that we're continuously sharing with our patients all the different great things that we can do as pharmacists.

Speaker 1:

One thing I will mention as well is Regina is working with us to create a travel health advanced training course. She has a component in that as well and is going to really talk about it. Correct me if I'm wrong, but I think you're part of that content is about implementing and setting up an actual travel clinic. So there'll be other components of that advanced training that will talk more about the medications that Regina's mentioned, go into greater detail on some of those nuances, dosaging as well as side effects, to be aware of counseling tips, that kind of thing. But she's going to be joining that advanced training on kind of how to implement an actual travel clinic.

Speaker 1:

So thank you so much for this information. This is, I feel, like, just a great quick overview that kind of reminds us all that there is a need for this. You know, depending on where you are, you could have a lot of patients that are in need of this, these types of services, and I think that these are things that, from what I'm hearing I'm not trying to downplay the difficulties that you might encounter, but it sounds like services that are fairly easy to implement into a store and to kind of offer for your patients are fairly easy to implement into a store and to kind of offer for your patients. So, yeah, so thank you, regina, again for taking time out of your schedule and to share some of this insights with us. I really appreciate it.

Speaker 2:

Sure. Thank you for having me.

Speaker 1:

Of course, if you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.