OVERVIEW:  HOW IT WORKS:

  • Scheduling: Pre-travel consultations should typically be scheduled as 30 minute appointments.

  • Billing: Most pre-travel consultations should be billed as Level 4 visits based on history and medical decision making complexity. (Residents should plan to have preceptors see the patient.) All patients must sign the FMC Travel Clinic Agreement Form stating their understanding that their insurance may not cover their travel immunization costs and that they agree to pay for any uncovered costs incurred by the FMC.

  • Visit Agenda: Providers should use the .FMCTRAVELNOTE smartphrase to guide their pre-travel consultation visit with the patient. The visit should include clarifying the patient's specific travel plans, provide pertinent physical exam, refill and adjust as needed the patient's medications, prescribe additional medications and prophylaxis, including traveler's diarrhea and malaria medication as indicated, and recommend any immunizations needed.

  • Patient Information: All pre-travel consultation patients should be given an FMC Travel Clinic Folder, prepared in advance by the provider and M.A. Providers should also use the .FMCTRAVELPTINSTRUCTIONS smartphrase to add a note of summary into the After-Visit Summary (AVS). Folders are found on the FMC Patient Form Resource Wall and should include the following:

    • Left Folder Pocket (RESOURCES ALREADY IN PACKET--See also "RESOURCES" below for pdfs)

      • FMC-tailored CDC recommendations on Food and Water Safety

      • FMC-tailored CDC recommendations on Traveler's Diarrhea Prevention

      • FMC-tailored CDC recommendations on Insect Bite prevention

      • FMC summary of other Helpful Tips for Healthy Travel

    • Right Folder Pocket (RESOURCES PRINTED BY M.A. OR PROVIDER ON SESSION OF VISIT)

      • CDC country-specific information, "Traveler View" main page (Can be quickly found by googling: "CDC Travel [country name]"). No additional CDC resources need be printed; however, the patient should be encouraged to visit the live website to access the many links that are available, such as recommend packing list, etc.

SPECIFIC INFORMATION FOR KEY TRAVEL MEDICINE TOPICS:

  • Immunizations

    • Immunizations recommended or required can typically be determined by consulting the CDC Yellow Book. (Linked HERE. This can be quickly found by googling "CDC Travel [Country Name]", then choosing "Clinician View" and using the links in column 3 ("Guidance")

    • Typhoid vaccination is the most commonly prescribed travel-specific immunization. It can be prescribed as an oral or IM vaccination. There are advantages and disadvantages to each that should be discussed with the patient:

      • Oral Typhoid Vaccine (TY21a) - ordered as printed Rx or e-prescription (most pharmacy chains have or can quickly obtain); live attenuated; 50-90% effective; boost q5y; must be refrigerated; not taken within 24h of antibiotics; avoid if <6yo or immunocompromised

      • IM Typhoid Vaccine (TyphIM Vi) - available at FMC (and can be ordered if we are out); polysaccharide (inactive); 60-80% effective; boost q2-3y; avoid if <2yo, safe in immunocompromised

    • Yellow Fever vaccination (YF-VAX) is only provided by state and CDC approved sites. The FMC is permitted to administer YF-VAX. For patients needing the vaccine, it will be order after they sign the YF-VAX Informed Consent Form and provide advance payment. NOTE: YF-VAX is OUT of stock in the U.S. (5/2017) due to manufacturer plant relocation. If vaccination is needed, the investigation vaccine Stamaril is being made available in Ohio at select locations only (Passport in Cincinnati). See CDC map of availability here.

      • YF-VAX - Live attenuated; >95% effective; effective in 10 days; current boost guideline is 10y, but may be unnecessary (immunity may be lifelong); avoid in patients with egg allergies, in children <6mo (preferred >/=9mo), in pregnant women, and in immunocompromised; 5% develop flu-like symptoms (d5-14), 1 in 100,000 develop YEL-AND (neurologic/encephalitis SE) or YEL-AVD (viscerotropic/liver SE) which can be fatal.

      • ALL patients receiving YF-VAX must have ALL the following done:

        • Must be given CDC information on the side effects of YF-VAX before the vaccine is administered and have signed the FMC YF-VAX Informed Consent Form.

        • Must pay for the vaccine at the time of order

        • Must be given FMC stamped and signed International Certificate of Vaccination once administered

    • For additional vaccination information, see RESOURCES below, including FMC Travel Clinic Protocol

  • Traveler's Diarrhea (TD) Medication

    • Most travelers to LMIC/developing countries should receive a prescription for traveler's diarrhea treatment. CDC country-specific information can provide helpful guidance. Most commonly prescribed medications include:

      • Azithromycin - Now recommended as TD prophylactic antibiotic of choice for ALL adults and children (Previously preferred only for travelers to South and Southeast Asia, most children, and those with contraindications to FQs)

      • Ciprofloxacin - Still an alternative for most adults, for most parts of the world; caution regarding QT interval and tendinopathies

      • Rifaximin - may be a good choice for travelers to Central America, but cost may be a concern

  • Malaria Prophylaxis

    • Follow CDC Yellow Book guidelines (See above for recommended method to find). Remember, most prescriptions require the traveler to take the medication BEFORE traveling and AFTER returning (often for a full 4 weeks after returning).

    • Tafenoquine is a new FDA-approved weekly-dosed malaria medication (2020), but pre-Rx G6PD deficiency testing is required. It prevents ALL malaria, not just falciparum.

RESOURCES: