Announcer:
You’re listening to VacciNation on ReachMD, and this episode is sponsored by Valneva. Here’s your host, Dr. Jennifer Caudle.
Dr. Caudle:
This is VacciNation on ReachMD, and I'm your host, Dr. Jennifer Caudle. And joining me to share best practices for identifying and referring patients to travel medicine specialists are Dr. Michael Barnish and Mr. Norman Bizon. Dr. Barnish is an infectious disease specialist practicing at Rowan Medicine. Dr. Barnish, welcome to the program.
Dr. Barnish:
Thank you. It’s a pleasure to be here.
Dr. Caudle:
And Mr. Bizon is a physician assistant who focuses exclusively on travel medicine at Travel Bug Health. Mr. Bizon, it's great to have you here as well.
Mr. Bizon:
Great. Thank you for inviting me to the discussion.
Dr. Caudle:
Of course. So let's start our discussion with you, Mr. Bizon. Which patients would benefit most from a referral to a travel health clinic?
Mr. Bizon:
Well, of course, being a travel health specialist, I think everybody should get a pre-travel health consultation because there's risks at every destination or particular itinerary, but there certainly are groups that are more at risk and would especially benefit, particularly comes to mind are people with immune-compromising conditions. These people are more susceptible and at risk for acquiring disease, tropical diseases overseas, also potentially increased morbidity and mortality, even with common travel-related diseases. And these patients also require special attention to the risks and benefits of vaccines, especially live vaccines, which may be contraindicated. We always discuss these things in the context of their specific itinerary and activities. And of course, anybody taking immune suppressive medications, including biologic agents, which are becoming more and more common for people with conditions like psoriasis, rheumatoid arthritis, or inflammatory bowel disease, they likely need special considerations for the timing of their vaccines, especially live vaccines, for optimum safety and efficacy. And that's a good opportunity for collaboration because we often refer back to their specialists who are prescribing the medications for recommendations and optimum timing when those vaccines will work best for the patients.
Also, a lot of our patients are older with more extensive medical histories just by nature. They're in their 70s or 80s, and they have the time, and they can afford to travel. So they often have chronic medical conditions, multiple cardiac medications, anticoagulants. So we always include a thorough medical history and tailor our recommendations to their specific health risks. We talk about how to manage their chronic conditions when they're traveling, the availability of emergency medical care, the importance of evacuation insurance, and sometimes, we even may suggest changes to their itineraries to minimize their risks. And people who are on a lot of medications also need special considerations when we're talking about anti-malarials and other medications, which could have potential interactions, sometimes with the vaccines too.
So also anyone who's considering specialized travel-related vaccinations, like Japanese encephalitis, cholera, polio, rabies chikungunya, they really need a discussion with someone who's familiar with the medications and can have a further discussion about real risks at their destinations. And often it's travel clinics that have availability and stock these not as commonly used vaccines. And of course, talking about travel-related vaccines, a specific situation is anyone who requires a yellow fever vaccine for travel, in that yellow fever vaccine has to be administered by a yellow fever-certified clinic after a very careful discussion of risks and benefits of the vaccine.
Dr. Caudle:
And with that in mind, let's turn to you now, Dr. Barnish. What steps do you take to identify patients who require specialized travel medicine consultations?
Dr. Barnish:
So a lot of patients that are referred to me from either their primary care physicians or various websites or clinic directories have already committed to scheduling an appointment. So with them, once they show up, we have them complete a very targeted questionnaire, and this includes not only their age, their destination, time and duration of their trip, and any medical conditions they have, but also issues such as allergies to eggs, or thymus disorders, psychiatric conditions, specific in-country itineraries where they're going, the order of the countries they’re going to if it's multiple countries, prior immunizations or prior problems they had with certain medications in the past with trips where they couldn't tolerate a malaria medication, if they are on immunosuppressive drugs or an immunosuppressed condition, as well as pregnancy. And these are all things that may directly impact their trip, so they are on this questionnaire. They all factor in regarding the need, especially with yellow fever vaccine, which is a live vaccine not only because it may be contraindicated for people with certain issues like I just brought up, but they may be going to countries where it may not be necessary, or going to parts of countries where it may not be necessary. So that's where the itinerary comes into play.
We have other potential travel patients who will call to inquire about scheduling an appointment. They haven't committed to coming in yet. They have some questions about what may or may not be needed. And in those cases, I make sure that when my nurse takes the call that I get on the line and speak to them directly. And the reason for that is a lot of times they're calling to see what's required, as well as the cost. And once they find out that nothing is required, they may not seek information, or if they're deterred by the cost of the vaccines or the visit. So that gives me an opportunity to explain to them that just because something is not required, doesn't mean that it's really needed or highly recommended for their safety. So I always try to relay the importance of those interventions, even if they're not mandated.
Dr. Caudle:
That's very helpful. And you know after you've identified these patients, Dr. Barnish, how do you guide them to the right travel health clinic for their unique needs?
Dr. Barnish:
I feel it's a pretty important question because in reality, any healthcare professional can be in a position to provide travel health advice or related prescriptions. But a certified or knowledgeable travel clinic will ask essential nuanced questions that may be missed by a practitioner who just accesses the CDC travel site or the CDC Yellow Book, or if they ask for guidance, they go to a pharmacy chain that just has someone fill out a basic checklist for getting a vaccine without really delving into the traveler’s specific itinerary or pertinent potential medical issues. And like I said, not only will they miss things, but they may end up getting vaccines that they don't really need.
A quality health clinic also has access to real-time disease outbreaks, as well as natural disasters such as flooding or violent protests, for example. And there are certain sites that the travel clinics will use, such as Shoreland’s Travax or promedmail.org, which will provide these real-time outbreaks. I actually got an email this morning from someone I saw a couple weeks ago who's going to Uganda, and she emailed me and said, ‘Do you still think I should be going? Because the World Health Organization just put out a public health emergency on Mpox.’ And I was able to access right away that there are two cases in Uganda as of now in a certain district she's not going to that were purely from sexual transmission. And I relayed that to her, and I also explained what precautions the World Health Organization is recommending. Ultimately, the decision is hers, but it is a low risk based on her activity. So these are very important points that a certified travel clinic is able to provide.
There's a number of ways to tell if you're referring a patient to the right travel health clinic, in addition to utilizing the CDC clinic directory on their travel page or accessing the local or state health department in your state. Expertly-headed clinics will be staffed by practitioners like Mr. Bizon and myself, who've received certification training through the International Society of Travel Medicine. So when you go to a website and you look at the credentials and you see CTM, like we both have, it tells people that we've been certified with specific training in travel medicine. So that's very helpful.
In addition to the ISTM and CDC websites, there are organizations like the American Society of Tropical Medicine and Hygiene that have their own membership clinic directories that can be accessed as well. And you want to make sure the clinic is a full-service operation that's able to provide yellow fever vaccine because not all travel clinics do; you have to be a designated center by the Department of Health in your state. And access to vaccines against exotic diseases, like Mr. Bizon said, including Japanese encephalitis, chikungunya, Dengue, or typhoid.
Dr. Caudle:
Excellent. For those of you who are just tuning in, you're listening to VacciNation on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking today with Dr. Michael Barnish and Mr. Norman Bizon about identifying and guiding patients to travel medicine specialists.
Dr. Caudle:
So coming back to you, Mr. Bizon, what impact could an early referral to specialists like yourself have on patients who plan to travel internationally?
Mr. Bizon:
Well, thank you, Dr. Barnish, for making those excellent points about the value of a travel clinic. So pre-travel preparation for international travelers is essentially about risk management is really how we look at it, and ideally in the context of a patient's full medical history. So when they visit a travel health specialist, especially far enough in advance of their departure, it allows the opportunity and time for a back-and-forth discussion with their own provider, where we can make specific recommendations. And they can go back to their doctor and make sure that sounds okay to them, or if they have any further recommendations, if they want to or if they feel that they need to. And often, referring physicians may not be familiar with travel clinics and what we have to offer. A full-service travel clinic, as Dr. Barnish mentioned, we can provide or even dispense travel-related medications, such as malaria prophylaxis, medications to self-treat traveler's diarrhea, altitude sickness, motion sickness, EpiPens. So the provider benefits from not having to look up all kinds of risks on a potentially complicated multi-destination itinerary, or spend their time writing prescriptions, looking up the contraindications, and they can instead focus on the patient. So the patient benefits because their provider has more time to look after their more current or existing issues.
Dr. Caudle:
Great. And Dr. Barnish, back to you. Given those impacts, can you share some strategies for establishing a referral network with travel health clinics?
Dr. Barnish:
If a clinic director has an affiliation with a hospital system or a medical school, this represents a built-in network for referrals. However, if a center is freestanding or seeks to go beyond a hospital system or academic institution, then it's a little bit more difficult and takes some effort to set up that network. Webinars or conference speaking engagements to the local medical community periodically can be helpful. Websites are essential. Advertisements in regional magazines or newspapers is often utilized, but this method is sporadic at best. Some vaccine manufacturers actually offer travel clinic directory enrollment on their sites, so I certainly take advantage of that when they come up.
Dr. Caudle:
Thank you for those tips. And before we end today, we'll bring this all together. How can the collaboration between primary care physicians and travel clinics help optimize the health and safety of international travelers?
Mr. Bizon:
So with collaboration, I believe that international travelers really get to benefit from the best of both of what we have to offer. To me, one of the most important elements is the trust that our patients have in their primary care providers with a relationship over time. So that a confident referral from one of their providers to us confers some of that trust, and we can complement that care with our unique expertise of what we have access to. What I do is I try to get out, do some outreach, and really get to know the providers in the community so they know what we can do, and they feel more comfortable referring to us. And to me, that's always the most important referral source is our community partners. And then when the patients can see that you are willing to collaborate, and you trust their physicians, then they feel like they're getting care from both of you and that we're addressing their whole health. And I think that's ideally the best outcome that we should all strive for.
Dr. Caudle:
Excellent. And with those final thoughts, this brings us to the end of today's program, and I'd like to thank my guests, Dr. Michael Barnish and Mr. Norman Bizon, for joining me to share their insights on how we can connect patients who are traveling abroad with the right specialists. Dr. Barnish and Mr. Bizon, it was great having you both on the program.
Dr. Barnish:
Thank you again.
Mr. Bizon:
Thank you, Dr. Caudle.
Announcer:
This episode of VacciNation was sponsored by Valneva. To access this and other episodes in our series, visit VacciNation on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
