The Impact of Travel Medicine on Protecting Public Health

Announcer:
You’re listening to VacciNation on ReachMD, and this episode is sponsored by Valneva. Here’s your host, Dr. Brian McDonough.

Dr. McDonough:
Welcome to Vaccination on ReachMD. I'm Dr. Brian McDonough, and joining me to discuss the important role travel medicine plays in protecting public health around the world is Dr. David Brieff. He's an Infectious Disease Specialist who practices at Saint Francis Hospital in Port Washington and East Hills, New York. Dr. Brieff, thanks for being here today.

Dr. Brieff:
Thanks for having me.

Dr. McDonough:
Let's dive in. Dr. Brieff, can you tell us about the unique health risks faced by international travelers? 

Dr. Brieff:
Yes. When I see somebody in the office for Travel Medicine, the first thing I try to do is assess their underlying health risks, look at whether the person has any underlying medical problems. For example, somebody with cardiac disease may be going on a trip where they may be exerting themselves more than they would at home, so you really want to get a sense for whether there are any underlying medical problems that need attention; somebody with asthma, maybe going to high altitude or somebody with COPD. And at times, cardiac patients may be on Coumadin where they may need to be monitored, so you really want to get a sense for whether there's going to be any problems with their underlying health when they travel and that they can safely access healthcare if they need it. 

The next thing we really look at, and there are very rare times when we will prevent travel with somebody, usually those things can be worked out ahead of time. We then look at what risks they're going to be exposed to that maybe they wouldn't be exposed to in the US, and the major things we look at tend to be insect-borne diseases, particularly mosquito-borne diseases, such as dengue fever or malaria, which are present in many parts of the world. We also look at things they may be exposed to from food and water. Food hygiene in many parts of the world may not be the same as the US, particularly things like hepatitis A or typhoid fever or bacterial gastroenteritis pathogens that they wouldn't be exposed to here. 

And then we look at some of the vaccines that we have here that people may not be up to date on. Infections that have pretty much been eliminated from the US but not from other parts of the world. Typically, infections such as measles, which is getting a lot of press recently with the increased number of cases in the US. We also look at polio, which fortunately has become less of a problem over the year, but there are still some outbreaks, and there are still some people that may need additional immunity from those. 

And then we want to make sure that people can access healthcare abroad. We try to express the importance of having health insurance abroad and having ways to access health care if they need it.  

Dr. McDonough:
Given those risks, what role does travel medicine play in ensuring safe and healthy international travel? 

Dr. Brieff:
It plays a vital role. One of the first things that I look at when I see somebody traveling is to do an assessment of their underlying health to see whether any underlying health conditions will pose risks with travel. So in a cardiac patient, if they're on Coumadin, I want to make sure that they have access to having their INR checked if necessary. If somebody has underlying lung disease, like asthma or COPD, I want to make sure that that's optimally controlled. Some populations may have a lot of air pollution that may pose additional risks with people who are traveling to high altitude.

The other thing we always look at is if somebody's immunosuppressed, are they going to be candidates for vaccines that are necessary? Some vaccines are live vaccines that immunosuppressed people are not candidates for. So establishing whether they're immunosuppressed is important, whether they can receive vaccines is important. 

And then the third thing we look at is certain other populations may have unique risks, very young children, as well as pregnant women. And we want to define the risks per country, looking to see whether they're at risk for mosquito-borne infections, such as malaria or dengue. We like to establish that they understand the concepts of safe food and beverage precautions. Certain food-borne infections, such as hepatitis A or typhoid fever, could be prevented. And we also like to establish a few other safety measures. 

When we look at vaccines, I always look at vaccines with what I call the three R’s of vaccines; those that are recommended; those that are required; and those that are routine. Some patients need to have updates on routine vaccinations, such as tetanus, diphtheria, pertussis, as well as measles. And then there are the required vaccines, which are yellow fever.

Dr. McDonough:
As a quick follow up to that, how can preventive measures like vaccines impact individuals and communities around the world? 

Dr. Brieff:
They can have a major impact. I always like to think vaccines are their own worst enemy because the more effective the vaccine, the less common the diseases is and the less people think they need it. But when you look at vaccines in general, the incidence of measles has been eliminated, or close to eliminated, from many Western countries. Polio has been eliminated for most of the world. Hepatitis A, which is a vaccine that came out in early 2000s, has made a significant impact in countries like the US, where the number of cases are down maybe 90 to 95 percent. We really haven't seen very much.

And I think what's very exciting right now is that there are some newer vaccines that are on the horizon and that eventually I think are going to make a significant impact. Particularly, two infections, one being dengue fever, the other being chikungunya. Both of those infections are viral infections that are mosquito-borne where there are newer vaccines out that may make a major impact in the future. 

Dr. McDonough:
Dr. Brieff, I know you are involved in travel medicine; you recognize the importance of it. For doctors in the community, what's your thoughts about them taking advantage of experts like yourself to help people when they're traveling around the world? 

Dr. Brieff:
It's important for people to see travel medicine doctors when they're traveling to underdeveloped countries. People are traveling now more than ever. Many parts of the world have malaria, dengue fever, other infections that we’re not exposed to, and I think it's useful for people to—an ounce of prevention is worth a pound of cure—and I think that a half-hour travel medicine consultation is valuable for many people.

Dr. McDonough:
For those just tuning in, you’re listening to Vaccination on ReachMD. I'm Dr. Brian McDonough, and I'm speaking with Dr. David Brieff about the importance of travel medicine, and we're just talking about immunizations. 

Now if we switch gears a bit, Dr. Brieff, what common challenges do travel medicine specialists face? 

Dr. Brieff:
For most parts of the world, you don't need to see a travel medicine doctor. Maybe you should for certain parts of the world, but outside of the yellow fever vaccine, which is the only mandated vaccine in certain parts of the world, there's a lot of people that travel who don't see a travel medicine doctor. But I think establishing trust with the patient, there's a lot of vaccine hesitancy in the US right now, so some of the people that come, often they'll be a family member or maybe somebody that they're traveling with that will recommend they see a travel medicine doctor. Sometimes people will come because they know they need the yellow fever vaccine, and they can't get into the country without it. And so it's a good time to establish a relationship with the person, review what the risks are in the region that they’re traveling to, and each person comes with their own fears and has their own what I call, risk tolerance.

But trying to establish the risk of different infections in different parts of the world, what the options are for prevention, working with people on their levels. Some people come with a lot of knowledge; some people come with very little knowledge; and really educating them. The other major hassle is really, unfortunately in the US, is cost. Vaccines are not cheap. Travel vaccines tend not to be covered by insurance companies. Some people have the resources, and some people don't, so we always try to prioritize. I always say there are certain, what I consider, never-events. You never want somebody to travel and get malaria. At least, you never want somebody to travel and get, let's say, hepatitis A. So we always try to prioritize and establish trust, educate the person so that there's buy-in, so that they understand why they're getting the vaccines because it's difficult for somebody to spend $300 or $400 on vaccines when they're healthy for something that they've never seen, an infection they've never seen before.

Dr. McDonough:
You brought up a lot of challenges, and you talked about them. And obviously, you deal with this all the time. Are there any strategies or tools that can help you and other specialists overcome those challenges?

Dr. Brieff:
I think education is important, and try to establish where they're getting their information from and recognize that some people are going to come with preconceived notions. Try to work with people. I always say if I can't convince somebody to take three vaccines, maybe I can convince them to take one or two. If I can’t convince them to take any vaccines, maybe I can stress other measures; mosquito-avoidance measures or to have them be very careful with safe food and beverages, so they understand that there are risks and try to get them to minimize their risks. But it really becomes dealing with people on their level, trying to establish trust, and trying to educate them. Spend some time with them, understand their fears, and hopefully overtime, you can build up a relationship. And I always like to leave an open door. If somebody doesn't want to listen to my advice, I always give them some information. Speak to your friends. Go on the Internet. Call me in a few days. Maybe if you have any questions, we can always do something. We can always vaccinate somebody later on.

Dr. McDonough:
Before we close, Dr. Brieff, can you share some takeaways on, just in general, the importance of travel medicine?

Dr. Brieff:
I think it's incredibly important. I think we live in a global community, and I think what happens in one part of the world may happen in another part of the world. And one of the things about travel medicine is you have to become educated on infections that are present and that maybe what's in India this year may be in the US next year. What's in Western Africa, as we've found with Ebola, maybe in the US. 

The other, I think, important thing that the travel medicine practitioners bring to the table is there's an established worldwide network. And I think sometimes when people see what are called Sentinel events, unusual infections, unusual outbreaks, there are systems in place to try to track things and try to recognize infections early. And I guess the perfect example is SARS COVID-1, which was probably about 15 years ago, which was an outbreak of respiratory infection that was really picked up very early in the travel medicine community and global community responded and was able to control it in a fairly prompt fashion. So I think that we live in a—I guess I like to use the term One World Health—what happens in people and animals and agriculture ties them together. And when you look at the amount of people traveling and the amount of food going from one country to another, it's really become a global community.

Dr. McDonough:
With those key takeaways in mind, I want to thank my guest, Dr. David Brieff, for joining me to discuss how travel medicine can help safeguard public health around the world. Dr. Brieff, it was great having you on the program. 

Dr. Brieff:
It was great being here. Thank you. 

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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!