TravelByte #32: It’s Not About the Shots: My Evolving Career in Travel Health Nursing from the Student Health Perspective

When I started working our student health center 12 years ago, our medical director asked me if I had any interest in training for our travel clinic. I always say “yes” to free training.  The idea was also intriguing. It fit very nicely with my strong interest in international travel, global health and women’s advocacy.  I’m an avid traveler and a big believer in its benefits.  Diving in, I realized how nuanced preparing international travelers could be. Everyone assumes you can just “look up what shots you need” online   and that’s about it. Well that’s not it at all -as many of you know, it’s a very sophisticated risk analysis incorporating a multitude of factors about the individual and the specific trip.

Things to consider about the traveler include age, prior travel experience, the possibility of pregnancy, medical or psychiatric conditions, medications, risk-taking tendencies regarding  sex, drug, or extreme sports, allergies, prior immunizations, and “Visiting Friend or Relatives” status which actually has a higher risk associated with it.  Trip specific details include destination(s), departure date, order of countries to be visited, duration in each country, season at destination, type of accommodations, activities, modes of transportation, purpose, and current outbreaks. After collecting all that information you put together a customized plan that includes education (e.g. travel insurance, food and water precautions, insect precautions, personal protective measures, plan for care while abroad, when to seek care after you get home), medications (e.g. malaria, traveler’s diarrhea, altitude illness, leptospirosis prophylaxis), and last but not least “the shots” which includes not only routine vaccines but also travel vaccines (e.g. typhoid, yellow fever, rabies, cholera). There are pregnant travelers, disabled travelers, immunosuppressed travelers, transgender travelers, travelers with chronic illnesses, researchers camping in remote areas, business travelers, travelers doing human rights work in high risk areas; the list goes on and on.  I soon realized I needed additional training. I took The Westchester Course, a three day course that focuses on care of the pre-travel patient and started to attend travel health conferences like the one at the University of Washington.

After joining the travel clinic team, it was clear that to provide the best care, only members of the team should provide travel advice. We established a policy that prevents our other clinicians from providing these services. Travel health is an area that one needs to do as a regular part of practice. Just periodically “looking stuff up online” can lead to outdated recommendations and poor outcomes. Unfortunately, we still do a lot of damage control for patients who see well-intentioned non-travel health clinicians for their travel health needs instead of competent travel health professionals with the appropriate training and expertise.  Sometimes patients take anti-malarials or antibiotics that are not appropriate considering current resistance patters or they purchase unnecessary vaccines. I continually educate patients, staff, the broader campus community and health care professionals at home and abroad to improve the quality of care patients receive.

The need for travel health nurses continues to grow. The number of student travelers has dramatically increased over the last 3 decades and more and more students are going to non-traditional destinations and engaging in all types of activities. I consult more and more with the various programs on campus that not only encourage but mandate that students have an international experience.  Of course, students, faculty and staff travel privately as well, and we only see a small percentage of these travelers – there’s simply a huge unmet demand.

Obviously, travelers need post-travel care too – and sadly most primary care providers and nurses have no idea how to manage these patients. Moreover, the public health implications are huge as new illnesses emerge and some old illnesses (e.g. yellow fever in urban areas of Brazil), regain a foothold. To address this need, I joined the International Society of Travel Medicine and The American Travel Health Nurses Association and found wonderful mentors in both organizations.  I eventually passed the exam for ISTM’s “Certificate of Knowledge in Travel Health”.  I encouraged my travel nurse colleagues to join these professional groups as well.  ISTM is multi-disciplinary and international, while ATHNA is the only organization that focuses on nurses in travel health in the US.  As a nurse practitioner with specialized knowledge, colleagues started referring patients to me with post-travel illnesses.  Soon I was seeing patients with traveler’s diarrhea and at times more problematic illnesses such as various types of malaria, enteric fever, dengue, schistosomiasis, Entamoeba histolytica, South African Tick Typhus, etc. Here’s what might pop up in my schedule:

  • Febrile traveler from Vietnam, went camping and spelunking
  • Febrile traveler doing research on primates in sub-Saharan Africa with blood exposure
  • Immunosuppressed febrile traveler with bloody diarrhea returning from Ecuador
  • Febrile traveler – recently went all over India, lived in Kenya up until December
  • Ill traveler that visited a meat-packing plant in Peru

Unfortunately, patients don’t come in with a diagnosis stamped on their forehead.  In actuality, the majority of these patients have “flu-like” symptoms initially. First, they ALL need to be asked about travel – a very common error in many hospitals and clinics. They mandate a very thorough history and physical exam with details of the itinerary (and past itineraries), accommodations, specific activities etc. You need to check for clues on the physical exam (e.g. the typhoid rash that may only be visible on the abdomen,   lymphadenopathy to help rule out malaria, the eschars of South African Tick Typhus that can get missed on the legs, the dengue rash that is “white islands on a sea of red”, the conjunctivitis of Zika).  You must understand what is in the differential depending on the region, current outbreaks, exposures, and activities.  You also must know the appropriate labs to order depending on the particular stage of illness and incubation periods (e.g. serology, v. PCR, stool, urine, skin biopsy, etc.) Evaluate the nuances in lab results (e.g. how does the CBC vary in dengue v. chikungunya v. malaria v. typhoid v. Zika?). Establish a plan for ongoing monitoring with repeat labs and treatment (e.g. to rule out malaria you need to check 3 smears 12-24 hours apart and malaria species and parasitemia levels dictate treatment, treat suspected rickettsial infections with doxycline before results are available, don’t recommend NSAIDs in a traveler with fever from a dengue area, determine the species of leishmaniasis before treatment,).

Initially referring complex patients to the emergency room, it became clear that tropical medicine is not something on everybody’s radar.   I reached out to infectious disease specialists, but they are very impacted and usually can’t see these patients in a timely fashion, nor do all of them have current experience in travel health. Many health care professionals do not realize that time is of the essence: Plasmodium falciparum malaria can kill a patient within 72 hours and public health risks such as MERS-CoV, avian influenza, and viral hemorrhagic fevers (VHF) are ever present.  Long before the first case of Ebola landed up in the US, I notified the ED of a potential case of VHF. This helped point out many flaws in our system we were able to address in advance.  I didn’t want patients to fall through the cracks, nor did I want to see my colleagues with less knowledge of travel health to create a liability risk.

While the highest risk of death in young travelers is due to motor vehicle accidents, disease can also result in tragic outcomes, especially serious illnesses like malaria. Sadly, many patients simply do not understand the risks and a pre-travel consult with a travel health nurse or other travel health professional can prevent an unnecessary death. Knowing when and where to seek appropriate care is critical. There are several drugs that can prevent malaria and treatment is straightforward –assuming it is diagnosed and treated very quickly.

In order to provide optimal care to our students and staff, we needed to identify and educate all the stakeholders (e.g. faculty, all staff, risk management, parents, emergency room and infectious disease personnel) regarding our travel health concerns.  We put together a reliable network of key players. I contact the ER directly before sending anyone over now and let them know what I’m concerned about and what we want to rule out.  I track down labs the same day and arrange for follow-up the next day as appropriate– not two days or next week.  I identified some of tropical medicine experts to collaborate with and maintain ongoing relationships with them.

We developed special templates in our EMR specifically for travel related concerns and added a question on our regular visit form so that every patient gets asked about travel within the last 3 months.  I update our physicians, nurses, nurse practitioners, and physician assistants at least once a year on travel health epidemiology, clinical evaluation, and laboratory updates.  I put together order sets so that primary care providers without much training in travel health can order critical labs initially and then refer the same day for further evaluation.

It’s also essential to train non-medical staff (psychological and counseling services, health promotion services, clerical staff, and physical therapy) regarding the need to ask about travel when they encounter an ill student and refer them to medical services immediately.  I consult regularly with other student health centers, various professional organizations, schools of nursing, and community organizations to educate about travel health.

Throughout the evolution of my role, I turned to ATHNA time and again for education and guidance.  I could not do what I do without this network of expert travel health nurses. I have served in a variety of roles and offices including President. We run a website that is full of relevant, reliable, evidenced-based content, and keeping with our core values, a lot of it is provided free of charge. I develop CE programs and am co-editor and a regular contributor to our blog Travel Bytes.  I’m a program planner and frequently give presentations at our Networking, Education, and Development events. I’m currently involved in a large research project with the International Society of Travel Medicine and the Centers for Disease Control that will provide insight into student travelers – a population that has been woefully understudied.  We’ve partnered with other non-profits such as the International Association for Medical Assistance to Travelers and the American College Health Association to help support and educate our travel health colleagues and consequently improve the quality of care to patients while protecting the broader community.

It’s really time for ANA to recognize travel health nursing as a specialty. We need ANA to join us in this important effort and provide legitimacy and recognition for the valuable preventive and life-saving work travel health nurses do. International travel helps us see the common humanity in all people – and ultimately that we are all more alike than different.  If we help travel health nurses keep our travelers and their surrounding communities safe, the world is likely to end up being a better place – and that’s a long way from “just giving shots”.

Julie Richards
Past President
American Travel Health Nurses Association
July 31, 2019