The Importance of the Pharmacist in Travel Health

Introduction

International travel continues to exponentially grow in popularity.¹ According to the World Tourism Organization, more than 900 million tourists travelled internationally in 2022, which is double the number in 2021.²

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Many travelers fail to seek pretravel health consultation and some even report illness, such as diarrhea, respiratory infections, and skin disorders because of their travels.³ Travel-related mortality is also evident, with an estimated 1 death per 100,000 travelers visiting a developing country for 1 month.⁴

These statistics demonstrate that if patients do not adequately prepare for their international travels, there are significant consequences. As a result, there is a compelling demand for expanded access to preventive health services, including routine and travel vaccinations. Not only are pharmacists and pharmacies in the United States easily accessible to the public, but they are also highly visible as a source for travel immunization services.¹

Travel Precautions

Prior to travels, pharmacists should conduct consultations with patients and consider the following 3 goals:⁵

1. Properly assess the client’s fitness for travel based on their medical history and an understanding of the purpose and type of travel.
2. Analyze the anticipated and potential health risks.
3. Translate the findings into a patient-, destination-, and itinerary-specific counseling of prophylactic measures. Both infectious and noninfectious risks must also be considered.

The above assessment should include a review of the patient’s immunization history with a focus on routine vaccinations. Pharmacists have a responsibility to highlight the importance of ensuring all routine vaccines are up to date prior to traveling because many vaccine-preventable diseases that are not common in the United States may still be common in other countries.⁶

An additional counseling point for patients preparing to travel includes creating a precautionary travel health kit with items that the traveler may need or have difficulty finding at their destination. Items to potentially include are prescription and OTC medications, medical supplies, and a first aid kit. Depending on the destination, travelers may also want to pack insect repellent and/or sunscreen with an SPF of 15 or higher or an SPF of 30 or higher.^6,7

A useful and interactive tool that pharmacists can share with their patients embarking on foreign travels is the US Centers for Disease Control and Prevention’s Travelers’ Health website. This website allows individuals to select a travel destination and will then populate any travel health notices, recommended vaccines, diseases prevalent in the destination, and other additional information that may be helpful for the traveler.⁸

It is imperative that pharmacists not only counsel their patients on health factors that can potentially impact their travels but also recommend actionable precautions that should be made prior to travels.

Travel Vaccines

According to the World Health Organization, certain vaccines are recommended to provide protection against diseases endemic to the country of origin or destination. They are intended to protect travelers and to prevent disease spread within and between countries.

Because there are multiple diseases related to travel, the following are mainly emphasized due to their ability to be prevented by immunization: cholera, Japanese encephalitis, meningococcal disease, rabies, typhoid fever, and yellow fever.⁹ The Table below lists the risk factors for contracting the specific vaccine-preventable disease as well as the recommended preventative measures.

Table. Risk Factors and Prevention Strategies for Select Vaccine-Preventable Travel Diseases^3,9,10

Role of the Pharmacist

Throughout the years, the United States has introduced legislation allowing pharmacists to administer injections. In 1994, the Washington State Pharmacists Association initiated the first formalized training of pharmacists in vaccine administration. Then, on November 1, 1996, the American Pharmacists Association began its nationally recognized immunization training program for pharmacists.¹¹

By 2009, all 50 states had some form of injection authorization in place. Pharmacist-administered vaccinations have had positive patient responses, including high patient satisfaction, patient recognition of the greater accessibility of vaccination through pharmacies as opposed to other health care settings, and overall improvements in vaccination rates.⁵ As a result, pharmacists are the ideal health care professionals to make a significant impact on travel health.

Not only must pharmacists and patients navigate travel-related issues through shared decision making—including the timing of each dose, screening for contraindications and precautions, the number of vaccines to be administered, the educational needs of patients and parents, and the interpretation and response to adverse effects—but pharmacists must also help patients comprehend the foundational need of travel vaccinations.¹²

Although the in-pharmacy administration of travel vaccinations improves patient access to pretravel consultations and recommended preventive measures, promotes the health of travelers, and reduces the burden of communicable disease worldwide, the scope of practice for pharmacists has potential for optimization. Future roles for pharmacists include the prescribing of medications and vaccines for travel.⁵

Currently, the furnishing, prescribing, initiating, and ordering of medications by pharmacists varies by state.¹ For example, in New Jersey, pharmacists are limited in authority to administer travel vaccines. They are strictly limited to vaccines ordered or prescribed by a physician.¹³

Of note, this limitation in New Jersey is specific to travel health and not all vaccines (i.e., pharmacists can administer routine vaccines such as influenza without patient-specific prescriptions).

Conclusion

Pharmacists have long been providing patients with nonprescription drug recommendations for complaints of travelers’ diarrhea, motion sickness, sun protection, and insect bite protection; however, patients requiring prescription pharmacotherapies traditionally had to be referred to their family physician or a travel clinic. As a result, expansion of the pharmacists’ scope of practice to include prescribing, coupled with the authorization to administer a broad spectrum of vaccines, will further allow pharmacists to provide accessible and evidence-based care to travelers.⁵

Overall, there is a definite need for travel health education from both the patient and pharmacist perspective. Depending on the international destination, certain precautions and/or vaccines must be met. Therefore, the role of the pharmacist in travel health immunizations is imperative and dynamically changing.

References

1. Hurley-Kim K, Goad J, Seed S, Hess KM. Pharmacy-based travel health services in the United States. Pharmacy (Basel). 2018;7(1):5. doi:10.3390/pharmacy7010005
2. The World Tourism Organization. Tourism set to return to pre-pandemic levels in some regions in 2023. Published January 17, 2023. Accessed March 31, 2023. www.unwto.org/taxonomy/term/347
3. Freedman DO, Chen LH, Kozarsky PE. Medical considerations before international travel. N Engl J Med. 2016;375(3):247-260. doi:10.1056/NEJMc1610671
4. Mahadevan SV, Strehlow MC. Preparing for international travel and global medical care. Emerg Med Clin North Am. 2017;35(2):465-484. doi:10.1016/j.emc.2017.01.006
5. Houle SK. Pharmacy travel health services: current perspectives and future prospects. Integr Pharm Res Pract. 2017;7:13-20. doi:10.2147/IPRP.S142982
6. Centers for Disease Control and Prevention. Before you travel. Updated October 6, 2022. Accessed March 31, 2023. wwwnc.cdc.gov/travel/page/before-travel
7. American Academy of Dermatology Association. Sunscreen FAQs. Updated February 17, 2023. Accessed March 31, 2023. www.aad.org/media/stats-sunscreen
8. Centers for Disease Control and Prevention. Travelers’ health: destinations. Accessed March 31, 2023. wwwnc.cdc.gov/travel
9. World Health Organization. Travel advice: vaccines. Accessed March 31, 2023. www.who.int/travel-advice/vaccines
10. International Association for Medical Assistance for Travelers. Everything you need to know about travel vaccines. Updated December 11, 2020. Accessed March 31, 2023. www.iamat.org/everything-you-need-to-know-about-travel-vaccines-
11. Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc (2003). 2006;46(2):168-79; quiz 179-182. doi:10.1331/154434506776180621
12. Kroger A, Bahta L, Long S, Sanchez P. General best practice guidelines for immunization. Centers for Disease Control and Prevention. Accessed on March 31, 2023. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf
13. Shoreland. U.S. travel health pharmacy laws by state. Accessed March 31, 2023. www.shoreland.com/downloads/pdf/pharmlawsbystate.pdf