Bon Voyage
Nurses in travel medicine arm their clients with the education and protection needed to stay healthy in foreign lands

By Scott Williams
May 17, 2004

Fran Lessans, RN, MSN, stumbled onto a career in travel medicine while working at a college health center 15 years ago. Students who had previously traveled to conventional destinations like Fort Lauderdale, Fla., or even London for spring break began vacationing in more exotic locations.

They came to her for immunizations and returned from the hospitals where she referred them dissatisfied with the treatment they received. It seems the physicians and nurses didn’t know much about the diseases the students might encounter on their trips.

“So I started developing educational materials and before I knew it, I had all kinds of people coming to see me for travel information,” she said.

Today, Lessans, 56, is the owner of Passport Health, a travel medicine business with 50 franchises around the country. She has sold her travel medicine formula to nurses, physicians, hospitals, and entrepreneurs.

Travel medicine, also called travel health care, is a growing field thanks to increased international travel in the past few decades. Corporate executives planning a trip to China, spring breakers vacationing in the South Pacific, and church volunteers involved in relief work in Nicaragua all need immunizations and, more importantly, education to help prevent illnesses.

Bradley Connor, MD, director of the New York Center for Travel and Tropical Medicine and president of the International Society of Travel Medicine, said the ISTM was founded in 1991 with a few hundred members and now has more than 2,000.

The increased interest in travel medicine is evident by the more than 500 travel medicine clinics now open in the United States, a trend, he said, that is driven by increased business and leisure travel. However, a large number of travelers still don’t take advantage of the services. The ISTM’s website estimates that only 8% of the 600 million travelers across international borders seek pre-travel health advice.

Connor said those who don’t visit a travel medicine clinic either don’t visit a physician at all or visit their family physician, who may not know the health risks common to the region to which the patient is traveling.

Karen Kluge-Ramirez, RN, BSN, who owns a Passport Health franchise in Boca Raton, Fla., worked with Lessans in the company’s corporate office in Baltimore before it became a franchise. Business is booming, she said.

“We’re becoming a smaller world,” Kluge-Ramirez said. “Where we used to travel to Europe, now we’re going to Bali, the jungles of Africa 85 and taking trains from Mongolia into Russia. [Travel medicine is] nice because we’re able to get to them first, research it, and let them know what they’re up against.”

Happy trails

Travel medicine is a growing subspecialty, said Christopher Bajkiewicz, RN, BSN, a travel medicine consultant in Chula Vista, Calif. He’s now in his 10th year of hosting seminars and teaching courses on travel medicine. He works mostly as a consultant for relief and development organizations, churches, and mission agencies that are sending people either on short-term trips or as long-term expatriates to work in another country.

Bajkiewicz said common diseases to which travelers are exposed include yellow fever, malaria, dengue fever, typhoid, diarrhea-related diseases, upper respiratory infections, and tuberculosis.

He said Americans, or almost any traveler to a foreign country, are more susceptible to local diseases than the people who live there because they haven’t built up immunity. He said one reason pre-travel education is so important is that it teaches people to avoid certain foods, to only drink bottled or boiled water, and to adhere to rigid sanitation procedures.

“I enjoy travel more now,” he said. “I feel a lot safer and I think the people I have been able to teach feel a lot safer too.”

Bajkiewicz, 46, said when clients seek his counsel he looks at where they’re going, what health risks exist and then decides what he believes they need to know. His focus is on prevention, he said, so prevention is an integral part of everything he does.

“[Travel medicine] is more than vaccines and ‘don’t drink the water.’ ”

Travel medicine and tropical medicine are inseparable, Bajkiewicz said, because so many of the places people travel are tropical. The International Society of Travel Medicine, the American Society of Tropical Medicine and Hygiene (ASTMH), and the International Society for Infectious Diseases (ISID) work together to increase the knowledge and improve the skills of those involved in travel medicine, tropical medicine, and infectious diseases.

The ASTMH offers certification in clinical tropical medicine and travelers’ health. The next certification exam will be in November, before the ASTMH 53rd annual meeting in Miami, scheduled for Nov. 7-11. The ISID also hosts an annual conference and sponsors grants, fellowships, and training programs.

Bajkiewicz said when he meets with a patient he begins with questions designed to build a profile on that person. Considerations include gender, age, past medical history, immune history, immunizations, and allergies. He also takes into consideration whether they are HIV-positive, pregnant, breastfeeding, or on medications for conditions such as heart problems or diabetes.

One of the most important questions he asks is where they’re going.

“The where are they going gets into region, area of the world, city. That right there speaks to a number of things because certain disease entities exist elsewhere that are completely unknown here in America,” Bajkiewicz said.

What’s on your itinerary?

Another important question to ask is what the person plans to do on their trip.

“The body of literature seems to indicate the risk to people is more what they plan on doing than just where they’re going,” he said.

Many travelers return with an unwanted memento of their trip. “There’s a number of people who travel internationally and travel for the purposes of obtaining sex, or they travel and end up having sex” that leads to a sexually transmitted disease, he said.

Colleges and universities are increasingly becoming involved in providing travel medicine to their students, he said. “Almost every university and college has recognized that so many of their students travel, especially during spring break, so universities have identified travel medicine as high priorities within their university system.”

Kluge-Ramirez said expatriates planning a trip back to their homeland also need to seek the advice of a travel medicine practitioner.

“A lot of people think they can go back to their home country and they’ll be fine, and that’s not true,” she said. “When someone leaves their home country, they leave their antibody protection.”

Rebecca Acosta, RN, MHP, is cofounder of Travelers Medical Service in New York. She’s also committee chair for practice and nursing issues for the International Society of Travel Medicine and serves as executive director of her Manhattan-based company. She said nurses, who are referred to in the profession as travel health nurses, have several opportunities to work in travel medicine, including as occupational health nurses, at student health clinics, private clinics, large multiple specialty groups, and airport clinics.

Acosta, who has been a nurse since 1987, began working in travel medicine in 1986 and continued in the profession — with the exception of a three-year period caring for HIV/AIDS patients — until starting her own company in 1996.

“Travelers Medical Service provides pre- and post-travel services,” she said, “and most of the pre-travel services are run by nurses. Physicians become involved in the diagnosis and treatment of illnesses after patients return from their trip, although some may be referred to a specialist.”

Acosta said the International Society of Travel Medicine recently has begun offering an examination in travel health care. Those who pass receive a certificate of knowledge, although they do not receive certification or travel health credentials.

Kluge-Ramirez, 48, who has owned her franchise for five years, said owners have to go through an extensive course on travel medicine before they can purchase a franchise.

Lessans said a franchise costs $25,000 and can be set up in a physician’s office or hospital. Opening in a stand-alone location requires an office of about 500 square feet, she said, along with a desk, chair, computer, syringes, sharps container, vaccines, and a refrigerator.

It’s a great opportunity for a nurse entrepreneur, she said.

Kluge-Ramirez agrees. She describes her job as fulfilling and says she enjoys the autonomy that comes with being an owner. She said it’s a great opportunity but not one that most physicians are interested in. “It’s not one of these operations you’re going to walk in and tomorrow you’re going to be making $100,000,” she said.

Lessans said she originally envisioned nurses owning most of her franchises. “I thought to myself, ‘Nurses really are doing all the work, they ought to be the ones owning the businesses,’ ” she said.

Unfortunately, Lessans said, nurses generally don’t have much money to invest, tend not to be entrepreneurial, and their education doesn’t prepare them to become entrepreneurs.

“It’s a darn shame because I want them to be owners. They do the work.”