Community Pharmacies Serve as Travel Vaccine and Information Hubs

Community pharmacies, long recognized as crucial hubs for routine immunizations, are increasingly establishing themselves as specialized centers for travel medicine, offering comprehensive care that integrates risk assessment, preventative counseling, and complex vaccine delivery. This expansion is driven by the pharmacist’s accessibility and deepening clinical expertise, positioning the pharmacist as an essential first-line provider for patients preparing for international travel, according to Jeffery A. Goad, PharmD, MPH, president of the National Foundation for Infectious Diseases and a professor of pharmacy practice at Chapman University School of Pharmacy in Irvine, California.

The shift toward specialized services utilizes the skills pharmacists have honed over the past several decades in immunization. Pharmacies are now offering travel health consultations that include risk assessments based on destination, trip duration, and planned activities. Pharmacists in all states can provide consultations on travel health issues, covering topics ranging from altitude sickness to malaria. A complete travel clinic visit, however, requires more than just advice.

“You need to be able to, in any travel clinic visit, provide or ensure that patients get all of these measures, from counseling to products, vaccines, medications, and perhaps even labs that need to be ordered,” Goad said.

Systemizing Risk and Prioritizing Care

Determining a patient's risk and need for specific interventions is not arbitrary. Goad stated that it needs to be a systematic process that a pharmacist runs through, regardless of the patient or the itinerary, so that the risks are well established and the patient is adequately treated.

The assessment process centers on 4 key factors: the itinerary, the patient’s medical history, planned activities, and cost. Understanding the itinerary includes not just the destination but the order of countries visited, including travel layovers, as transiting through a country with a vaccination requirement can require proof of vaccination for entry. Medical history also guides targeted education. For example, for a patient with preexisting liver disease, a provider might spend more time ensuring they understand the importance of receiving the hepatitis A vaccine, he said.

“Not every traveler on the same itinerary has the same needs,” Goad said. “For example, a spelunker, which is a cave diver, is at much greater risk for rabies [because of bats in the caves] than a typical tourist, even to the same destination.”

Finally, cost remains a consideration as not all travel vaccines are covered by insurance. Providers must help patients prioritize their needs when faced with multiple vaccine options to maximize the use of available resources.

“At the end of the day, we want to make the travel consultation patient itinerary specific,” Goad said. "Mostly what we're doing is making sure they understand, have a clear understanding of the risks and benefits."

Navigating Timing and Logistical Complexity

The specialized nature of travel medicine also impacts logistics, starting with timing.

“In travel medicine, almost all of it is appointment-based. Travel medicine really should not be done on a walk-in basis,” Goad said. “Ideally, we'd like all of our patients to make appointments at least 6 weeks in advance of departure."

Although the ideal consultation occurs at least 6 weeks prior to departure, pharmacists must be prepared for the reality of last-minute travelers. They should understand which vaccines, such as hepatitis A or tetanus, diphtheria, or pertussis boosters, can be given the day before departure and still provide immediate benefit. By utilizing intake forms that gather itinerary and medical information, pharmacies can proactively order vaccines. This reduces the risk of vaccine waste and ensures that patients do not have to return for a dose that needed to be specially ordered, which could result in the patient never returning.

However, timing constraints can fundamentally alter travel plans. For instance, the yellow fever vaccine, if required by the destination country, necessitates documentation showing receipt at least 10 days prior to arrival. If a traveler presents immediately before departure, a pharmacist might have to advise them to change their travel plans to avoid quarantine.

“Pharmacists should be well-versed in things like accelerated schedules for Japanese encephalitis [and] for hepatitis B vaccines [and] understanding which vaccines can be given on the day before departure,” Goad said.

Even when a vaccine is administered, the pharmacist must understand the onset of protection. If a patient receives an injectable typhoid vaccine the day before or up to a week before a trip to India, it will not become effective until they return. Even when a trip is imminent, education remains vital.

"We don't recommend waiting [until] the day before, but education does not have an expiration date. It works as soon as you give it," Goad said.

Special Handling for Oral Vaccines

Pharmacies specializing in travel health must also manage the intricacies of oral vaccines, such as those for typhoid and cholera, which differ significantly from standard injectables. Oral vaccines require specific instructions on timing (eg, taking on an empty stomach for oral typhoid), storage (refrigeration), and the avoidance of interactions with medications such as antacids or antibiotics.

"Oral typhoid is actually dispensed to the patient, and the patient takes it home and administers it to themselves.... However, for oral cholera, that's a different story,” Goad said. “Oral cholera vaccine is prepared and administered in the pharmacy.”

The oral cholera vaccine requires patients to avoid eating or drinking for 60 minutes before and after consumption, which must be communicated to them ahead of time. Furthermore, because oral cholera is a live attenuated vaccine administered on site, the cups, stirrers, and packets must be handled as biohazardous waste, requiring the pharmacy to integrate the process into their existing biohazardous waste system for injectable vaccines. For typhoid, adherence is essential since it involves a 4-tablet regimen taken every other day, so pharmacists play a crucial role in ensuring patients understand the timing requirements.

“Because it's a 4-dose vaccine, it makes more sense for them to manage that at home,” Goad said. “When you dispense an oral typhoid vaccine, you'll note that they receive the vaccine, but you don't know 100% that they actually receive the vaccine.”

The specialized management of complex schedules, inventory, and regulatory requirements for prescribing travel medications, along with meticulous attention to timing, cement the pharmacist's evolving role from general immunizer to sophisticated travel health specialist.