An ongoing dialogue on HIV/AIDS, infectious diseases,
April 8th, 2023
Travel Clinics and a Travel History to Beat All Travel Histories
I’ve received some very helpful and quite critical comments about the original post that was here. Having re-read the original, I’m acknowledging my mistake and want to apologize to my colleagues, many of whom do travel medicine with true expertise, excellent intentions, and for the benefit of travelers everywhere. My bad for not emphasizing this fact in the first part of the post.
Awaiting input from my editors, I temporarily removed it yesterday, but now have replaced it below. There are some edits to parts that I especially regret, but the essence is there.
Thanks everyone for reading, and helping me keep this a useful, supportive, and I hope educational place.
Confession: I have mixed feelings about travel clinics.
On the one hand, they provide a useful service to people who might be unaware of the dangers of the exotic places they plan to visit. It’s a place for sensible counseling:
Don’t eat street food! Don’t play with the stray dogs! Don’t swim in the Omo River!
Travel clinics offer a cornucopia of vaccines — yellow fever, typhoid, hepatitis A, rabies. A good travel doctor or nurse — optimally an experienced and enthusiastic traveler themselves — really knows the risk of Japanese encephalitis on your 3-week trip to Myanmar. They also have wise advice about malaria prophylaxis and other treatments to take along, just in case.
Plus, falling outside of many insurance plans and serving a generally well-to-do crowd, travel clinic is one of the few places ID doctors generate revenue in the outpatient setting. These money-makers are so few and far between for us that it’s hard to pass them up.
We have an active travel clinic, and the patients are really happy to have this convenient, one-stop service. They love it! And our travel clinic providers are great. Demand is sky-high, showing a reassuring return to pre-pandemic travel.
All good so far.
On the other hand, travel clinics sometimes cater to the worried well, offering dubious value if the destination is simply a long trip, the planned activities not so risky. Does the business traveler to Bangkok or Johannesburg, the honeymooner to Fiji, or the tennis enthusiast going to a resort outside of Buenos Aires really need to go to a travel clinic before their trips? Of course not, yet I’ve seen all of these examples come through our doors.
Additionally, the education component can paradoxically make the worried traveler feel worse. A recently retired ID doctor here in New England regularly did travel clinic at his hospital, but so hated to travel himself that he sometimes bluntly told his patients — “Look, if it were me, I wouldn’t go.” No doubt he was responsible for a high volume of canceled first-class airfares.
Last, some of the people who really need travel clinics can’t access them because, as mentioned, insurance often doesn’t cover it. This creates a two-class level of care analogous to traveling business vs. coach, but since it involves healthcare, is far more disquieting.
Travel clinics are on my mind because I recently had the distinct pleasure of reconnecting with a college friend, Mike Reiss. Professionally a comedy writer (he’s one of the original writers for The Simpsons, among other credits), Mike loves to travel.
Or more accurately, Mike’s wife Denise loves to travel, and Mike is totally smitten with Denise and will do whatever she wants.
Let me emphasize that “loves to travel” barely begins to describe their enthusiasm. They’ve now logged well over 100 countries, travel regularly to places you have not been (trust me on this one), and have had some remarkable experiences — many of which Mike details in his podcast, What Am I Doing Here?, which I highly recommend.
Mike chatted with me recently, and our conversation is incredibly funny — that’s because everything Mike talks about is incredibly funny! Listen here at the bottom of this post, or wherever you get your podcasts. You won’t want to miss it. His travel history reads like a parody of an ID certification exam question.
And Mike, here’s some friendly advice — if you don’t want to go to a travel clinic, here are the big three I’d recommend for a traveler like you, easy stuff you can get from your primary care doctor:
- Get the hepatitis A vaccine. Two shots, you’re good for a lifetime.
- Take some azithromycin with you in case of traveler’s diarrhea.
- If you’re going to a malaria hotspot, take malaria prophylaxis.
Even better, check out the CDC’s travel web site. I use it all the time.
Azithro for traveler’s diarrhea – really? Based on 1. resistance patterns (and risk for causing resistance) 2. drug-related adverse effects and 3. the fact that most traveler’s diarrhea is self-limited (and often not even bacterial in etiology), how could Dr Sax himself be advocating for unnecessary antibiotics? (yes, you are complicit by publishing your friend’s advice!)
Dr Sax – I absolutely adore your blog and am constantly sending your posts to our fellows because they sum things up so well.
I run our ID division’s travel clinic at an academic medical center, and have mixed feelings about it for many of the same reasons you do. I hate that my patients have to pay out of pocket for what are essentially preventative services, and that my clinic is effectively not financially accessible for many of the patients going on high risk trips who really need it (right, as opposed to low risk travelers who could get more basic preventative measures from their primary care doctor).
Here’s the part you may not be aware of: travel clinics in many hospital systems actually don’t make money, and sometimes even the opposite. At our center, we had to stop offering many vaccines on site, because our division lost money with every single injection (has to do with hospital network contracts with insurance companies, and insurance reimbursing less than the cost of purchasing the vaccine). For doctors under an RVU system, the RVU value of a travel consult is so low that from a purely financial standpoint, it’s actually not worth the time … and travel visits can be time consuming even for low risk trips by the time you address malaria/dengue, vaccines (and where to get them affordably), travelers diarrhea, COVID-19 etc etc. So I admit the “ka-ching” irritated me. We maintain our travel clinic as part of our division services primarily to make sure that people who really need it (immunocompromised, pregnant, complex itinerary) can get counselling from a specialist, and to provide access to the yellow fever vaccine. Seeing too many travelers in any given week, as opposed to patients with other infectious disease problems, actually decreases my salary!
Having hosted in our division a money-losing travel clinic for many years for similar reasons, I feel your pain — so excellent point. And this is just another example of how the RVU system hurts ID doctors even when we’re providing a highly in-demand service.
I tend to disagree with what Mike says because for a lot of people, traveling to exotic locations signifies spending a significant amount of money and probably a once or twice-in-a-lifetime opportunity. Getting sick from malaria, gastroentheritis or other tropical diseases might ruin those experiencies. Aditionaly, people may not be able to cover expenses derived from medical care abroad. Thus, a travellers medicine specialist consultation prior to travel might be a very good idea.
– Hey moooooommmm !!!! Dr Sax just wrote a prescription of “if you need it” Azythromicin !!!
– Don´t listen to him, dear.
– But I like him, mom … snifs
– Itś all right, he is not a bad man, he was jsut lured to the dark side this time.
– Ok … snifs
Some points in the blog are valid, but please allow me to point out:
1. Most travel clinics at hospital networks accept all insurance – including Medicare, Medicaid, MassHealth, etc – although most travelers have difficulty navigating insurance coverage on top of referrals, in/out of network issues, and copays and deductibles. The contracted reimbursements between insurers and institutions cover vaccine costs at varying levels – some at a loss. Even when we are aware of under-reimbursement, we still provide those vaccines – it’s best for the patient/traveler.
2. Travel clinics/ travel medicine providers are not the ones causing lack of insurance coverage, but the blog may mislead readers to associate them. Advocacy by diverse groups of stakeholders for insurance coverage is needed for change. Please see a commentary by travel medicine colleagues in The Hill https://thehill.com/opinion/healthcare/3675466-ensure-access-to-all-vaccines/
3. Many travel clinics fill the gaps to catch up on routine vaccines, and contribute to public health efforts.
4. Additional efforts by travel clinics should be highlighted – in preparing high-risk travelers such as immunocompromised traveler, preventing additional episodes of diseases such as malaria or conditions such as altitude illness in travelers who previously returned with these conditions, in surveillance of emerging infections, and in researching travel-related antimicrobial resistance (i.e. GeoSentinel Network and Global Travel Epidemiology Network).
5. The “big 3” overly simplifies precautions and can potentially dissuade travelers who are unaware of other preventable health problems, where the pre-travel advice would address specific itinerary/activities/likely exposures. Not every traveler needs azithromycin – discretion is needed in prescribing self-treatment to acknowledg antimicrobial stewardship efforts.
6. Some for-profit clinics with under-educated staff may only follow protocol (hence give every vaccine listed) – but the repeated “ka-ching” in the blog leaves the impression that this applies to all travel clinics. We need to figure out how to assess/monitor/educate rather than associate all travel clinics with the for-profit nature.
7. Finally, improving insurance coverage of travel vaccines and malaria chemoprophylaxis should lead to more equitable health care access and benefit. Optimizing education and training of travel medicine providers should lead to more balanced benefit-versus-risk advice for travelers.
Lin H. Chen, MD, FACP., FASTMH, FISTM
Immediate Past President, International Society of Travel Medicine
Director, Mount Auburn Travel Medicine Center
Division of Infectious Diseases and Travel Medicine, Mount Auburn Hospital
Associate Professor of Medicine, Harvard Medical School
Lecturer, Massachusetts Institute of Technology
As an infectious diseases specialist, and longtime academic clinician and educator in the field of travel and tropical medicine in the U.S., I want to comment on Dr. Paul Sax’s blog posted on April 11, 2023, where he made some comments about travel clinics. He correctly points out that not every trip warrants a trip to a travel clinic. Many primary care providers can give adequate advice with regard to required or recommended vaccines, malaria chemoprophylaxis, and strategies to prevent and relieve traveler’s diarrhea among the generally healthy patients in their practice—especially since online access is readily available to guidance from the CDC and other expert resources. Certain travel vaccines are not likely to be stocked in a general medicine clinic, so a patient may have to seek required and recommended travel vaccines from a local public health clinic, pharmacy immunization clinic, private travel clinic, or travel medicine service at a regional or academic medical center.
However, some traveling patients will benefit from a pre-travel consultation with a specialist in travel medicine: these include the very young, the very old, pregnant or nursing mothers, patients with chronic health conditions requiring certain medications, immune compromised patients (e.g., organ transplant, HIV, cancer, taking immunosuppressive drugs, etc.). Healthy travelers embarking on mission-driven activities abroad also will benefit from the expert analysis given by a travel medicine specialist on the particular health risks of their planned activities at destination and optimal measures for lowering risks: expatriate workers, missionaries, humanitarian relief workers, elite athletes, adventure travelers (e.g., mountain climbers, SCUBA divers, wilderness explorers, and field biologists). The length of the trip influences the risk that travelers will experience illness away from home either due to underlying health conditions or exposure to exotic conditions during travel: persons on extended trips benefit from pre-travel planning regarding access to medical care abroad, availability of safe blood products and specialized drugs, securing adequate supplies of routine medications, and consideration of emergency evacuation. Two newer categories of travelers have been recognized that should get informed advice: immigrants to the U.S. who wish to return their country of origin to visit family and friends (VFRs) and medical tourists who seek to undergo elective medical procedures abroad at a lower cost than at home.
Travel medicine is a large tent, and practitioners come from multiple traditional medical and nursing specialties. It can be challenging for the general public to differentiate between basic clinics that provide vaccines and formulaic travel health advice, and those that perform comprehensive pre-travel evaluations based on an individual ‘s or a group’s particular circumstances with advice provided by expert travel medicine consultants who have advanced training, experience, and enthusiasm for ensuring healthy and successful trips. The International Society of Travel Medicine (ISTM) and the American Society of Tropical Medicine and Hygiene (ASTMH) are two professional societies that sponsor Certificate educational programs that cover the core clinical content of travel and tropical medicine. The Wilderness Medical Society (WMS) is another professional society that has educational programs relevant to the health of international travelers. As the saying goes, one size does not fit all.
Elaine C. Jong, MD, FIDSA, FASTMH
Clinical Professor of Medicine Emerita
Division of Allergy and Infectious Diseases
University of Washington School of Medicine, Seattle, WA.
Founding Director, UWMC Travel and Tropical Medicine Service
Founding Director, UW Refugee Clinic
Past President, Clinical Group – American Society for Tropical Medicine and Hygiene
In response to Dr. Paul Sax’s blog, I wish to remind readers about the history of travel medicine—which emerged as a clinical field of practice in the late 1950’s. That era signaled a rapid expansion of international travel made possible by the development of commercial airplane routes affordable to increasing numbers of recreational travelers. Some of the travelers of that era experienced travel-associated ailments during travel such as diarrhea and skin lesions, and some returned home with life-threatening illnesses such as malaria and hepatitis. Thus began the decades-long work of countless dedicated travel medicine practitioners advising travelers of health risks when travelling.
History, as demonstrated by published articles in the medical literature, shows that the impact of educating travelers and general practitioners of health risks overseas has reduced the incidence and fatalities of malaria in travellers and improved the availability of drugs available for treatment for returning travelers, just to mention one example.
What would Dr. Sax say to a young man returning from Africa who was told he had bladder cancer, but
after a complete history was taken which revealed his swimming in lake Malawi, was diagnosed with urinary schistosomiasis? What would he say to the person bitten by a viper in a forest near Paris, but nearly died because the local hospital did not have the correct antivenom? Who would know that France reports between 500 to 1000 case of snake bites yearly?
The field of travel medicine encompasses a large array of different disciplines, but requires a good knowledge of geography, epidemiology, and knowledge of tropical and exotic disease risk factors.
Dr. Sax’s blog glosses over the importance of patient education in travel clinics. Instead of highlighting the role of travel clinics in implementing catch-up administration of missed doses of routine vaccines during review of travel vaccines that may be needed, it implies that profit is a motivating factor in vaccine recommendations. This thought plays into the hands of the anti-vaccine lobby at a time when the current global vaccination rates are decreasing and outbreaks of vaccine preventable diseases, such as measles, occur regularly in schools and campuses.
The revised blog Dr. Sax currently posted is a gracious gesture, however, it does not erase the first impression that many health care personnel might have formed after reading the original blog and moving on. It is hoped that sometime in the future, a more considered analysis of the contributions of travel medicine in general medicine will be published. Given the global society we live in, travel medicine experts recommend that all patient encounters include the query: “Where have you been? Where are you going?”
M. Assunta Uffer- Marcolongo, FISTM
International Association of Medical Assistance to Travellers (IAMAT)– a division of the
FOUNDATION FOR THE SUPPORT OF INTERNATIONAL MEDICAL TRAINING