Expanding Travel Health Services in Pharmacies

Counseling patients about safe travel services involves a lot more than just providing information about vaccinations, said Sheri Stensland, PharmD, in a session at McKesson ideaShare, being held in Orlando this week.

To accurately pinpoint everything a traveler might need, pharmacists need to know each destination, the timeline, and the history about the travelers themselves, including, have they traveled frequently, and are they adventurous or more conservative travelers? Those answers could affect the types of treatments the pharmacist recommends.

Many potential illnesses can be avoided by taking precautions around water and food consumption, Stensland said. Advising travelers to drink beverages only from sealed containers and avoid foods that were washed with water, such as vegetables and salads, can reduce their chances of contracting a gastrointestinal illness such as traveler's diarrhea or hepatitis A.

Hepatitis A is one of the most common vaccines Stensland said that she administers. Often spread through foods washed with contaminated water or through person-to-person contact, the symptoms of hepatitis A can include fever, nausea, abdominal pain, and jaundice. The two vaccines available for hepatitis A are Havrix and Vaqta. The vaccine requires 2 doses 6-18 months apart, and the first dose should be given 2-4 weeks prior to travel. Stensland said the most common issue she sees relating to hepatitis A is patients walking into the pharmacy within a few days of their trip, after the recommended advance window for many vaccinations. Regardless, she recommended giving the patients the vaccine. "They might not have the full strength of the vaccination, but at least it's better than nothing," she said.

Typhoid fever often has symptoms that mirror hepatitis A—fever, abdominal pain, headache, and nausea. The highest risk for this illness is in Asia, Africa, and Latin America. Unlike most vaccines, Stensland said Vivotif, a live attenuated virus, must be restarted if the patient misses a dose.

Vectorborne illnesses are another of the most common concerns for travelers, especially in areas of Africa, Asia, and Latin America. Insect-proof clothing, air conditioning, and insecticides are the easiest and most common recommendations, while malaria and Yellow Fever are the most commonly needed vaccinations.

In 2017, there were 219 million cases of malaria and 435,000 deaths, according to Stensland. Symptoms include fever, headache, myalgia, and other flu-like symptoms. Malaria can be prevented by chemoprophylaxis and mosquito avoidance, but the medication must be taken before, during, and after travel. There are several medications for malaria prevention, but chloroquine and mefloquine have shown resistance in some geographical areas. Those two drugs, however, are the only malaria preventatives approved for pregnant or breastfeeding mothers, so treatment must be weighed on a case-by-case basis.

Yellow fever is perhaps the most difficult vaccination for pharmacies to administer, Stensland said, but it's also one of the most requested. Administrators must have a Yellow fever stamp, which is regulated by the state, and must provide specific documentation of when the vaccine was administered because many countries require proof of vaccination before allowing a traveler into the country.

Besides vaccinations, Stensland said there are many other travel health services and advice that pharmacists can provide. Sun protection, advice on altitude sickness, and more specific advice depending on the travelers' plans can all provide opportunities to expand services. For example, Hajj travelers are required to have a meningococcal vaccination, and must carry documentation with them. The US Embassy Smart Traveler Enrollment Program (STEP) includes safety alerts and emergency contact capabilities, and Stensland recommended keeping some information available for travelers interested in those services.