What You Should Know About Travel Vaccines

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Inspirations podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Steven Gordon, MD:

Well, hello. My name is Steve Gordon, and I'm Chairman of the Department of Infectious Disease at the Cleveland Clinic, and it's a pleasure for me to be hosting two of my colleagues today on something that's very near and dear to many of our hearts, and that's travel medicine and prevention. So, I have with me Pooja Cerrato, who's our Infectious Disease Pharmacist with a specialty in travel medicine, and Dr. Steve Mawhorter, a colleague who is Head of our International Travel program at the clinic. Welcome to you both.

Pooja Cerrato (Mehta), Pharm.D.:

Thank you, Dr. Gordon.

Steven Mawhorter, MD:

Yeah, thanks.

Steven Gordon, MD:

I wanted to start with a prelude as we're emerging from three years of the pandemic's shadow. There's been a big backup and backload of appetite for travel, both domestically and internationally. The latest statistics that I've seen is that in 2023 we will probably exceed the pre-pandemic levels, which was almost 100 million Americans traveling overseas. And I think this is great, but I think this is also timely for us to talk about prevention in terms of before you would embark on the plane or the or the ship. So, in terms of this topic today, Steve, can we just start with level-setting in terms of: Why's it important to seek a travel health consultation before international travel?

Steven Mawhorter, MD:

Thanks, Steve. A key thing of course is: Staying healthy to enjoy your trip is a top priority. There are risks when traveling internationally. It's actually easier to come in contact in countries where the water isn't as clean as it is in the United States. And there's very little that may be truly required at an international level for travel, and that's yellow fever vaccine to only some parts of Africa and South America. But there's a lot of things you can do to be empowered to avoid unwanted illness, and deal with it if it happens.

Steven Gordon, MD:

Well, thank you. I mean, I think that as you map this out as a prevention, there’s a lot of things that maybe provide value in terms of this preventive visit. And I'm wondering, Pooja, when you look at patients in terms of this nature, what are the questions or what are you thinking about when someone comes to you saying, "Look. I have international travel. What should I be worried about? Or what are the things that you'd recommend mitigating any risk?" Whether it's infection or non-infection.

Pooja Cerrato (Mehta), Pharm.D.:

Sure. Thanks, Dr. Gordon. So, we do, with our travel visits start with just a few basic questions. So, we really want to ask the patient, "Where are you going?" And we really want them to have their itinerary available. Because it's not really just about which country you're going to, but we want to get to that detail of, of which exact cities or regions are you visiting? And really, we want to know about general travel plans.

So, for some of our patients that travel frequently and business travelers, there may be some additional considerations. We also want to know how long, you know, you're planning to be at that particular destination, whether it'll be more of a short stay as opposed to a long stay. Because I think that would really change our approach to counseling medications and potentially vaccines.

Additionally, we'd like to know why you're traveling. So, there are many reasons that folks travel. So, this could of course include things like vacation or business travel. But some travel for volunteer work or for medical missions. Some travel to visit friends and relatives. And so, the purpose of travel is really important, in terms of evaluating risks associated with those activities.

And then we'd like to know when you're leaving. So, it's really optimal for a travel consult to take place four to six weeks prior to travel, as we know that it can take about two weeks to build immunity to a vaccine. However, even seeing a provider in our International Travel Clinic would be valuable even if it was last-minute or just a few days before travel.

Steven Gordon, MD:

Well, thank you, Pooja. So, that is nice to keep top-of-mind in terms of, as you're making those airline reservations, to think about this. There's no time too early I suspect in terms of preparation.

Pooja Cerrato (Mehta), Pharm.D.:

Absolutely.

Steven Gordon, MD:

So, Steve, to kind of piggyback onto that, a traveler should have, what types of things would you prefer? Or what do you like to see when you're face-to-face with a patient that has a travel itinerary?

Steven Mawhorter, MD:

You know, again, we want to see people in the International Travel Clinic mostly because there's this, the specifics of the itinerary matter. Things change rather frequently, actually. And that's what we stay up to date on in the International Travel Clinic so that we can really prepare people for what they need and don't need.

It helps us a lot if especially they have vaccine records from the past. A lot of the information is in the medical record, but not all of it. And we love to know about people who've had any recent changes in their medical history or medications, and those sorts of things can really make a big difference in how we help and prepare someone.

Steven Mawhorter, MD:

Also, how we help advise them potentially on where they're going and seek if we need to help them make any adjustments to stay as safe as possible.

Steven Gordon, MD:

Well, that's a great tip. I mean, some of us gray hairs still have our yellow card, our travel card. I do think that one of the beautiful things about the electronic health record is providing hopefully data that can lead to good judgments without, as you said, repeating things. But I also, you know, I thought, I love your mitigation of risk strategy, Steve, and categorization. So, I wonder if you can explain that for our listening audience in terms of how you view this prevention strategy.

Steven Mawhorter, MD:

Yeah. My overarching approach to this, and whether we're talking about traveler's diarrhea, malaria, or any other sort of travel-related illnesses or illnesses in general, is, the first is to avoid risky behaviors and unnecessary exposures. Think about safe eating and insect avoidance as good examples. And then second, consider vaccines. Especially when it's difficult to avoid the risk, like with eating and drinking, food and water-borne illnesses come to the fore, and that's where a lot of our vaccination efforts are focused. And then the third thing is, we'll use either preventive or symptom-triggered medication when needed.

I look at these elements, the first of risk avoidance being like defensive driving on the highway. The second, vaccines really function as seatbelts. And third, medicines are airbags. And the illness issue, when you think about it, is sort of like the driver who's running a stop-sign on you. So, having all three at our utilization, important. And on occasion where there aren't options for a vaccine, say to certain illnesses like traveler's diarrhea, we'll focus on the first and third elements. It helps us have conversations and get people prepared.

Steven Gordon, MD:

Well, thank you.

Pooja Cerrato (Mehta), Pharm.D.:

To piggyback on to what Dr. Mawhorter just explained, a big part of the pre-travel consultation is really counseling on risk avoidance. So, there are some things that I would like to review during the visit. I'm definitely focusing on safe food and water practices. And then, we spend a lot of time on bite and sting avoidance, since we know that that is not only challenging during the travel itself but can also lead to some exposure to disease.

Depending on the location of travel, there's also a variety of insects which may be present at that particular destination. And if it's safe to, for example swim in freshwater. So, I also tailor the conversation to the patient. We spend a great deal of time on vaccines. I might start with required, which would only be yellow fever in most cases, and recommended vaccines. And then we also go through routine vaccines that the patient may need, such as tetanus, Covid boosters, flu vaccines, etc.

And we know that air travel can increase the risk for lung infections, and some particular patients may be at higher risk. Additionally, there are some medications that are warranted for a particular destination. For example, malaria prophylaxis for Kenya, altitude sickness medication for Ecuador, and antibiotics for traveler's diarrhea for many destinations. And you can visit my.clevelandclinic.org/health to search our health library, keyword "travel", to learn more about all of this.

Steven Gordon, MD:

Well, that's great information, Pooja. Thank you. You know, Steve, one of the questions might be from our listeners, is, "Hey, I can go to the CDC website and maybe get all this information." I just want to know your thoughts about that and also, potentially other helpful information that patients may go to besides the CDC website.

Steven Mawhorter, MD:

Yeah. The CDC is a really good place to start for general information. There is a travel subsection, and you can put in the countries of travel. But it's really an overview at the level of the country. It's not as granular as we would like it to be. As Pooja mentioned earlier, focusing really on people's specific itinerary, their specific reason for travel.

So, the CDC is a starting point. But individualization really can matter both in getting what you need and not being exposed to what you don't need. Such as, some parts of Thailand can have really bad Malaria. But the average person traveling rather extensively throughout Thailand won't really need antimalarials at all.

Steven Gordon, MD:

Well, thank you. So, Pooja, I think we've hopefully explained maybe the return on investment without getting into what we'd call "catastrophic bias" that every traveler's gonna end up with a life-threatening infection. But I wonder if you can explain to our audience now what you and the team have developed in terms of trying to increase access, and how patients can now access the Cleveland Clinic travel, you know, pre-travel clinic.

Pooja Cerrato (Mehta), Pharm.D.:

Absolutely. Thanks, Dr. Gordon. So, I'd like to explain the process of how a Cleveland Clinic patient can seek out a referral. So, we ask that our Cleveland Clinic patients request the referral through their primary care provider, or pediatrician in some cases. The way to do this is to bring up that you're traveling on your next visit or send a MyChart message to the office explaining that you have international travel coming up and you'd like a consult.

Once that referral is placed to the Pharmacy Travel Clinic, a self-scheduling ticket will be released in MyChart. And so, the patient is able to then go ahead and look at the available options in terms of days and times, and schedule what would be convenient for them. Again, we do recommend that you schedule the visit at least four to six weeks in advance, just to have an opportunity to coordinate care and get those vaccines in. But there is also a benefit in even last-minute consultations. If patients are having any issues with scheduling, they can always contact our central scheduling line or the infectious disease scheduling line to coordinate and appointment.

Steven Gordon, MD:

Well, thank you, Pooja. You know, it would be helpful to understand or explain, as a pharmacist, your role in a team base. But also, the special training that you have undergone, and our travel pharmacists undergo in terms of putting you in a position to help patients and work with physicians like Dr. Mawhorter to execute. Can you give us a little background on your training?

Pooja Cerrato (Mehta), Pharm.D.:

Sure. My background is that I've been a pharmacist at the Cleveland Clinic for several years. I'll be celebrating my 10-year anniversary this year. So, plenty of experience with the organization itself. And in terms of the travel medicine training, I completed training with the International Society of Travel Medicine, and also completed several months of side-by-side training with our travel physicians, seeing patients in collaboration with them.

So, that's really given me the opportunity to see a wide variety of itineraries and patient scenarios, and we work in collaboration. So, if there are any patients that I'm seeing where there are unique situations or questions or concerns, I'm always reaching out to them for their input. Additionally, for our more complex patients, such as our patients who are immunocompromised or pregnant, those patients are triaged to our travel medicine physicians for review.

Steven Gordon, MD:

Well, thank you for that clarification. And both of you have always put our patients first, which I think is our North Star in, in terms of this and for prevention. You know, one of the questions that comes up is: What about the kids? From the mom or the parent, "I have kids travel." Is this clinic appropriate? Or do you have the capacity to see kids? Can you explain that process?

Pooja Cerrato (Mehta), Pharm.D.:

Absolutely. So, we are supportive of family visits, as well as seeing our young, our pediatric patients. And so, we ask that if you are requesting a family visit that you do reach out to our infectious disease scheduling line as opposed to scheduling through MyChart, just to give us an opportunity to understand who in your family needs to be seen, what the ages are, so that we can triage that appropriately or schedule a group visit as appropriate. And we do ask that each member of the family be a Cleveland Clinic patient with an active referral. 

Steven Gordon, MD:

Well, thank you. Now, to level-set, so, I see you virtually, with my family or not. You e-script the prescriptions and order vaccines. How is that executed virtually for the patient?

Pooja Cerrato (Mehta), Pharm.D.:

Sure. So, a majority of visits for our pharmacy travel clinic are conducted virtually. Of course, we do make exceptions to telephone visits and the occasional in-person visit if that is necessary. During the visit, after we review all of the counseling, review any medications or prescriptions that may be needed and order vaccines, the vaccine appointment is then coordinated. So, there are a few options for vaccine appointments.

One option is that we have a clinic here at the main campus in our infectious disease department. So, that is an option for in-office administration of some vaccines. And then, something new and exciting that is coming in a few weeks, we are rolling out travel vaccines in addition to the existing offering of routine vaccines at five of our ambulatory Cleveland Clinic pharmacies. And so, geographically the pharmacies are spaced so that we have a, you know, East Side option, a West Side option, a South Side option, etc. for our patients to be able to then easily access vaccines and their medications in a one-stop-shop following the virtual visit with the pharmacist.

Steven Gordon, MD:

Wow. I mean, I'm sure our patients truly appreciate having all the information to make the best choice for themselves, their family. One issue that comes up is: What is the cost? Or can you explain a little bit about what the state of coverage for travel is? And I know that's gonna vary from individual to individual.

Pooja Cerrato (Mehta), Pharm.D.:

Sure. So, I can definitely comment on what a patient may expect to pay for travel vaccines and medications. The question is a little bit challenging just because we know that, as you mentioned, insurance can vary on what they provide coverage for. We do expect insurance to pay for routine vaccines. So, these are vaccines that are recommended by the Advisory Committee on Immunization Practices, as long as the patient meets the recommended criteria for those vaccines.

However, for vaccines that are specifically for travel, such as yellow fever and typhoid, these vaccines tend to not be uniformly covered by insurance companies. And so, we always say it's best to check with your insurance company in advance of your vaccine appointment to check on coverage. Additionally, medications follow a similar line.

But the nice thing with our medications is that the pharmacy is able to process those medications and give the patient a price on what they would expect to pay for those medications. Vaccines that are offered in the pharmacy are actually similar to medications in that a price can be presented to the patient at the time of vaccine administration. So, that is one of the big benefits of having vaccines administered in a pharmacy setting.

Steven Gordon, MD:

Well, thank you for that nice explanation. You know, Steve, you've had a lot of experience, and oftentimes you have patients with a lot of comorbidities, high risks, in terms of this. What else may you suggest to these patients in addition to medications and vaccines and advice on exposure?

Steven Mawhorter, MD:

The first thing is to try to get to us as early as possible, so that we can go over things and try to optimize your healthcare both in the things we're focused on, as well as other elements that may need to happen. We're focused in the International Travel Clinic on getting to "yes". We really want to empower what people's needs are, what their bucket list is, and it is really rare that we would ever recommend somebody not travel. And there's many, many things we can do to enhance someone's safety, and of course those things get very individualized depending on someone's particular health needs.

In addition to that, the Cleveland Clinic itself actually has an air medical evacuation membership called Global CARE. For this, it's an extra thing to sign up for, but can give a lot of comfort in knowing that you're covered. For those over 65, Medicare is very United States-focused. It does not work internationally. Some supplemental insurance might, but a lot consider international travel to be a very elective thing, and if you look at the fine print, it isn't necessarily gonna cover it.

So, memberships in the air medical evacuation are called Global CARE. And if you're hospitalized fortunately more than 150 miles from home, Cleveland Clinic medical staff and flight crew can actually transport that patient to a Cleveland Clinic facility or other facility of their choice. And there's, you know, this kind of additional insurance sometimes really gives you a lot of peace of mind. We've had patients really need it, and it really is a top-level service.

Steven Gordon, MD:

Wow.

Steven Mawhorter, MD:

And that can be accessed at clevelandclinic.org/globalcare.

Steven Gordon, MD:

Well, I really want to thank you both for your wealth of knowledge. I also want to thank you both for standing up what I consider to be an access program for our patients and their families in terms of getting the appropriate information for prevention and hopefully to enjoy your travel whether it's for business or pleasure. This has been another just interesting from my viewpoint, podcast, and I appreciate you putting the patients first.

I want to thank again our guests that we have here, Dr. Steve Mawhorter, who's Head of our International Travel program here at the clinic, and Pooja Cerrato, who is our Chief Travel ID Pharmacist who is actively engaged in putting this exciting program in place. I want to thank you all for listening today. And again, this is one of the RI podcasts that are available and thank you both.

Pooja Cerrato (Mehta), Pharm.D.:

Thank you. Thanks for having us.

Steven Mawhorter, MD:

Thank you.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Inspirations podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.