Balcom, Dawn

Carrico, Ruth

Didelot, Luanne

Hall, Daniel

Marimuthu, Subathra

Tan, Sarah

Wolf, Leslie A

English

University of Louisville

University of Louisville Journal of Respiratory InfectionsPERSPECTIVE PIECEUniversity of Louisville International Travel Clinic: Pivoting During theCOVID-19 PandemicDawn Balcom1∗, DNP APRN; Subathra Marimuthu1, PhD; Leslie A. Wolf1, PhD; Luanne Didelot1, MSN; Sarah Tan1, BS; Daniel Hall1, BS;Ruth Carrico1, PhD DNP1Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, KY, USA∗dawn.balcom@louisville.eduRecommended Citation: Balcom D, Marimuthu S, Wolf LA, et al. University of Louisville International Travel Clinic: Pivoting during the COVID-19 pandemic. UnivLouisville J Respir Infect 2021; 5(1):Article 30.IntroductionThe Coronavirus Disease 2019 (COVID-19) pandemichas had a dramatic impact on international travel. Ac-cording to the US Travel Association, travel expendi-ture in 2020 declined by 42%, approximately $500 bil-lion, when compared with 2019.[1] Dwindling inter-national travel paralleled a concomitant decline in theneed for services provided by international travel clin-ics. Nonetheless, relationships between travel clinicsand their clientele blossomed during this period. Hav-ing expertise in specialized preventive care and publichealth, travel clinics are equipped with the knowledgeof infectious diseases to establish new avenues for pa-tient and community support during the pandemic andbeyond. In this perspective, approaches taken at the Di-vision of Infectious Diseases International Travel Clinicat the University of Louisville (UL Travel Clinic) willbe used as a model, demonstrating avenues in whichtravel clinic services might pivot to meet communityneeds during the ongoing COVID-19 pandemic and be-yond.Pre-Pandemic Travel Clinic ServicesTravel clinics in the United States and worldwide havemaintained their as primary focus the provision of pre-ventive medical care for anticipating travelers. Thispreventive care utilizes a risk-based approach that ad-dresses the epidemiology of destinations in a travelitinerary, current health and vaccination history of thetraveler, specifics of the travel experience, and the de-sire of the individual to minimize risks associated withcurrent and future travel experiences. The resultantall-encompassing care plan includes vaccines, medica-tions, and alternative preventive adjuncts and is influ-enced by guidelines such as the Centers for DiseaseControl and Prevention (CDC) Yellow Book and WorldHealth Organization (WHO) recommendations, entail-ing risk-based guidance concerning COVID-19.[2, 3]For more than 20 years, the UL Travel Clinic hasbeen operating full-service, providing care for interna-tional travelers before, during, and after travel. Clinicpersonnel—board-certified in infectious diseases, trop-ical medicine, and infection control and InternationalSociety of Travel Medicine–certified in travel health(CTH®)—work closely with the Division of InfectiousDiseases’ Clinical Laboratory Improvement Amend-ments (CLIA)–certified clinical and research laboratoryto provide their full spectrum of services. In additionto the on-site availability of all U.S. Food & Drug Ad-ministration (FDA)–approved vaccines, vaccine clini-cal trials are also performed by research investigatorswithin the Division. The storage of these vaccines isunder meticulous management by the Travel Clinicpersonnel due to fine temperature storage and docu-mentation requirements. Physicians, advanced prac-tice and registered nurses, public health professionals,medical technologists, and laboratory scientists work-ing in the UL Travel Clinic have broad competency-based skillsets, including client care, vaccine handlingand management, vaccine administration, specimencollection and handling, infection control, public healthsurveillance and disease reporting, compliance withVaccine for Children (VFC) program requirements, useof electronic medical records and state immunizationinformation systems, and database development. Sup-plies maintained in the clinic include those needed forvaccination, as well as personal protective equipment(PPE) for specimen collection. PPE includes gowns,gloves, masks, face shields, and N95 respirators. Thecombination of an extensive resource pool and well-designed clinic operations has enabled the provisionof concierge-level care for travelers, forming the basisof new services provided during the COVID-19 pan-demic.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/30 1ULJRI UL Travel Clinic: Pivoting During COVID-19Travel Clinic Services During the COVID-19PandemicBy March 2020, international leisure travel had come toa virtual halt. As experts well-acquainted with spec-imen collection and PPE use and management, ULTravel Clinic personnel switched gears to provide as-sistance to the local health care scene. They beganworking with local hospitals and health care facilities toexpand testing capacity for in-patients and long-termcare residents during the initial wave of the pandemic.In addition, the laboratory personnel began workingwith Luminex to validate a laboratory-developed poly-merase chain reaction (PCR) test for the SARS-CoV-2virus. This test was validated by FDA emergency useauthorization (EUA) in April 2020 [4-6], subsequentlyenabling Travel Clinic personnel to begin providingCOVID-19 PCR tests for the community, as well as busi-nesses engaged in international travel. Bioinformati-cians and database managers in the Division of Infec-tious Diseases were consulted to assist in developmentof a REDCap® database to facilitate electronic registra-tion for COVID-19 testing and support public healthsurveillance and report.[7]Testing is performed via a curbside service (Figure 1).Individuals seeking COVID-19 testing are emailed alink to the online registration database. Upon arrivalto the clinic parking lot, individuals remain in theircars while clinic personnel perform the nasopharyn-geal specimen collection. Thereafter, the PCR labora-tory tests are conducted by laboratory personnel, withresults made available within 24 hours’ turnaroundtime. With the recommencement of international travelin the Fall of 2020, the database was used to providedocumentation of test results required by airlines andvarious international immigration regulations. Face-to-face engagement for travel-related counseling occurredvirtually via a HIPAA-compliant Zoom platform, whilepost-consult vaccinations would be carried out curb-side in the parking lot.In December 2020, when the COVID-19 vaccines werereleased under EUA, the Travel Clinic was able to in-crease the capacity of local vaccination efforts. Massvaccination training was provided as part of theLouisville Vaccination efforts (LouVax), and TravelClinic personnel assisted with the 17-week operation ofLouVax Broadbent, the drive-through community vac-cination site (Figure 2). At that site, over 105,000 dosesof vaccine were administered by a workforce of morethan 2,000 health care workers; Travel Clinic personneldeveloped and coordinated the vaccine handling andvaccine administration training program for that work-force.[8] Due to clinic experience and demonstration ofvaccine handling competence evidenced by participa-tion in the state’s Vaccines for Children (VFC) program,the Travel Clinic was able to obtain COVID-19 vaccineson site and provide them to members of the communityon a walk-in/drive-up basis.Community engagement throughout the first year ofthe COVID-19 pandemic also provided opportunitiesfor research within the Division of Infectious Diseases.With the involvement of researchers, protocols weredeveloped to engage patients seeking COVID-19 test-ing and/or vaccination at the Travel Clinic in researchparticipation. Personnel of the Travel Clinic assistedwith the exchange of information regarding Divisionresearch activities and the enrollment of research par-ticipants. The drive-up mode of research testing wasconducted by the Travel Clinic when in-facility test-ing was not required by the research protocol. Envi-ronmental infection control practices were in place tosafely facilitate interactions that required in-facility re-search testing.Re-imagining Travel Clinic Services Be-yond the COVID-19 PandemicThe COVID-19 pandemic has both required and en-abled a transformation of services provided by inter-national travel clinics. The use of technologies such asthose enabling virtual connections for pre-travel coun-seling (e.g., Zoom), increasing use of laboratory test-ing (e.g., PCR for COVID-19) as part of travel services,and integration of drive-through or curbside vaccina-tion are just a few examples of services that interna-tional travel clinics may encompass in 2022 and be-yond.Based on the experiences gleaned from the 2020–2021phase of the COVID-19 pandemic and its impact on theUL Travel Clinic, approaches to reimagine the servicesof international travel clinics are outlined below:• Develop processes to engage with internationaltravelers using a virtual component (e.g., Zoom).• Ensure that the virtual engagement process pro-tects the privacy and health information of theclient.• Train clinic personnel in modes of disease trans-mission and provide them with appropriate PPE,including fit-tested respirators.• Maintain stock of PPEs, injection supplies, andspecimen collection equipment, recognizing thetypical long shelf life of many of the aforemen-tioned items upon storage under proper environ-mental conditions.• Train clinic personnel to engage with clients, ad-minister vaccines, and perform specimen collec-tion via drive-through or curbside approaches.• Establish and maintain a working relationshipwith a CLIA-certified laboratory.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/30 2ULJRI UL Travel Clinic: Pivoting During COVID-19Figure 1. Curbside testing service process for SARS-CoV-2 infection.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/30 3ULJRI UL Travel Clinic: Pivoting During COVID-19Figure 2. LouVax drive-through vaccination for SARS-CoV-2 at Broadbent Arena, Louisville, KY.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/30 4ULJRI UL Travel Clinic: Pivoting During COVID-19• Evaluate current clinic location, space, and capa-bilities to enable expansion or changes in clientengagement.• Establish and maintain working relationshipswith local public health departments or districts.• Train clinic personnel regarding local reportabledisease and surveillance regulations, includingclinic responsibilities for reporting of results.• Engage clients, possibly through an informal ad-visory board process, to better understand needsand expectations.• Develop and implement competency-based train-ing to ensure clinic personnel are competent toperform every aspect of their work.• Engage with local university/universities and es-tablish dialogue regarding travel clinic capabili-ties as a means of furthering local research capa-bilities and capacities.These points are by no means all-inclusive but aremeant to be a starting point to facilitate discussionsacross the public health and travel clinic industries.Services provided by international travel clinics are vi-tal for the health and safety of the population. Enablingcontinuation and expansion of those services to addressthe current pandemic, as well as emerging pathogensor new pathogens, is crucial for the health and welfareof populations worldwide.Published: October 12, 2021Copyright: © 2021 The author(s). This original article isbrought to you for free and open access by ThinkIR: The Uni-versity of Louisville’s Institutional Repository. For more infor-mation, please contact thinkir@louisville.edu. This article isdistributed under the terms of the Creative Commons Attribu-tion 4.0 International License (CC BY 4.0), which permits un-restricted use, distribution, and reproduction in any medium,provided the original author and source are credited.Funding Source: The author(s) received no specific fundingfor this workConflict of Interest: All authors declared no conflict of inter-est in relation to the main objective of this work.References1. United States Travel Association. Weekly coronavirus im-pact on travel expenditures in the U.S. Available at: https://www.ustravel.org/sites/default/files/media root/document/TE Coronavirus WeeklyImpacts 01.22.21.pdf. Accessed 27September 2021.2. Centers for Disease Control and Prevention. CDC yellowbook 2020: health information for international travel. NewYork, NY: Oxford University Press, 2019.3. World Health Organization. Policy considerations for im-plementing a risk-based approach to international travel inthe context of COVID-19, 2 July 2021. Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-Policy-Brief-Risk-based-international-travel-2021.1. Accessed 27September 2021.4. Rao A, Goldstein DY, Wolk DM, Wolf LA. Developmentand Evaluation of Two SARS-CoV-2 RT-PCR Laboratory De-veloped Tests on the ARIES® Automated, Sample-to-Answer,Real-Time PCR System. White Paper, 2020 12 March 2020.5. U.S. Food & Drug Administration. Fact sheet for health-care providers: ARIES® SARS-CoV-2 Assay – Luminex Cor-poration. Available at: https://www.fda.gov/media/136692/download. Accessed 27 September 2021.6. Marimuthu S, Aliesky H, Connelly B, Malik DA, WolfLA. Development of a real-time Reverse-Transcription PCRfor SARS-CoV-2 on the Luminex ARIES® Platform. UnivLouisville J Respir Infect 2021; 5(1):Article 10.7. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N,Conde JG. Research electronic data capture (REDCap)—Ametadata-driven methodology and workflow process for pro-viding translational research informatics support. J BiomedInform 2009; 42(2):377-81. doi: 10.1016/j.jbi.2008.08.010.PMID: 18929686.8. Wright W, Cherry J. Forty Hours Later, a Shot at a Vac-cine. Available at: https://www.nytimes.com/interactive/2021/02/03/multimedia/virus-vaccine-kentucky.html. Accessed 27September 2021.ULJRI | https://ir.library.louisville.edu/jri/vol5/iss1/30 5

University of Louisville International Travel Clinic: Pivoting During the COVID-19 Pandemic

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University of Louisville International Travel Clinic: Pivoting During the COVID-19 Pandemic

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