Pre-CISTM Course, 24 May 2015 : Pediatric Travel Medicine: what we know, what we think we know and what we actually end up doing! about VFR Parents and Children Stefan Hagmann, MD MSc Associate Professor of Clinical Pediatrics Division of Pediatric Infectious Diseases, Bronx-Lebanon Hospital Center Albert Einstein College of Medicine, Bronx, New York
Conflict of Interest I have no conflict of interests to declare. 2
Objectives Describe characteristics of pediatric travelers visiting friends and relatives (Pediatric VFRs) Highlight challenges of pediatric pre-travel care Pre-CISTM14 Course --- Stefan Hagmann 3
Pre-CISTM14 Course --- Stefan Hagmann 4
Who is a VFR? Definition by the ISTM - Migration Health Sub-committee...a VFR traveler is a traveler whose primary purpose is travel to visit friends and relatives, where there is a gradient of epidemiological risk between home and destination Barnett E et al. J Travel Med 2010;17(3):163-70. A traveler categorized as a VFR is an immigrant (with) residence in a higher-income country who returns to his or her home country (a lower income country) to visit friends and relatives. Included in the VFR category are family members, such as spouses and children who were born in the country of residence. Keystone J. Chapter 8, Yellow Book 2014. Pre-CISTM14 Course --- Stefan Hagmann 5
Pre-Travel Health Disparities among VFRs Lack of awareness of risk or belief that they are immune Low rate of insurance coverage Financial barriers Lack of trust in the medical system Cultural and language barriers Low rate of pre-travel health care Disproportionate risk for travelrelated infectious diseases Angell SY, Cetron MS. Ann Intern Med 2005;142:67-72 Pre-CISTM14 Course --- Stefan Hagmann 7
Low Rate of Pre-travel Health Care in Pediatric VFRs GeoSentinel network (2010) 1,591 children with travel-related diagnoses 275 Pediatric VFRs Pre-travel care: 60% 50% 40% 30% 20% 10% (P<.001) Hagmann et al. Pediatrics 2010;125(5):e1072-80. 0% VFR Non-VFR Pre-CISTM14 Course --- Stefan Hagmann 8
Strategies to Engage VFRs Health Fairs: Places of faith, schools, libraries Radio/TV programs Diaspora clinic (Bronx): Providing medical and support services needed by the growing West African community Global TravEpiNet: Travel Agents ( Travel Health Ambassador Program ) Pre-CISTM14 Course --- Stefan Hagmann 9
Strategies to Engage Pediatric VFRs Outreach in Newborn Nursery and Outpatient Clinics Routine Screen for Future Travel Activities Screen shot of clinic template Pre-CISTM14 Course --- Stefan Hagmann 10
Distribution of Age and Reason for Travel of Pediatric Travelers in (GTEN) Global TravEpiNet Clinics, 2009-2012 N= 3,332 children Reason for travel: VFR 36.0% Leisure 35.9% Other 28.2% 70% 60% 50% 40% 30% 20% 10% 0% 12-6-11y 5y 17y Leisure (%) VFR (%) P<.01 Hagmann et al. J Ped Infect Dis 2013;2(4):327-334. Pre-CISTM14 Course --- Stefan Hagmann 11
Age of Pediatric VFRs seen at U.S. GTEN Clinics 2009-2012 18 16 Median Age (IQR), y 14 12 10 8 6 4 2 0 Hagmann et al. J Ped Infect Dis 2013;2(4):327-334. VFR Leisure Other Pre-CISTM14 Course --- Stefan Hagmann 12
Time to Departure and Duration of Travel in Pediatric VFRs at U.S. GTEN Clinics, 2009-2012 80% 70% 60% 50% 40% 30% 20% 10% 0% VFR Leisure Other Time to departure <14days * Travel duration, >28 days * *P<.01 Hagmann et al. J Ped Infect Dis 2013;2(4):327-334. Pre-CISTM14 Course --- Stefan Hagmann 13
Region of Destination 70% 60% 50% 40% 30% 20% 10% 0% VFR Leisure Other African Central America/Caribbean South American South East Asian Europe Eastern Mediterranean Western Pacific Hagmann et al. J Ped Infect Dis 2013;2(4):327-334. Pre-CISTM14 Course --- Stefan Hagmann 14
Take Home Points so far! 1. Pediatric VFRs represent a significant proportion of pediatric international travelers. 2. Pediatric VFRs compared to other pediatric travelers are: Less likely to seek pre-travel health care. ( 30%) Younger. (Infants/toddlers/preschoolers) Present often late to pre-travel care. (<14 days) Travel for longer periods. (>1 month) Travel more frequently to high-risk destinations. (Africa, Asia, Americas) Pre-CISTM14 Course --- Stefan Hagmann 15
Back to the Clinic Pre-CISTM14 Course --- Stefan Hagmann 16
Your Friday Afternoon Case A mother is taking her 1- month-old infant to rural Guinea to visit family. Among many things, you are concerned about?... What would you recommend?.. Pre-CISTM14 Course --- Stefan Hagmann 17
What are you concerned about? Pre-CISTM14 Course --- Stefan Hagmann 18
What are you concerned about? Malaria and other vector-borne infections Invasive bacterial infections Respiratory infections Gastrointestinal infections Trauma Rabies Ebola Pre-CISTM14 Course --- Stefan Hagmann 19
What are you concerned about? 1. Malaria Children account for 15-20% of all imported malaria cases. 1 Pediatric VFRs 2-times more likely to acquire malaria, compared with pediatric tourists. 2 Pl. falciparum the most common species Sub-Saharan Africa most common regions of exposure. 1 Stäger K et al. Emerg Infect Dis 2009;15(2):185-91. 2 Hagmann S et al. Pediatrics 2010;125(5):e1072-80. Pre-CISTM14 Course --- Stefan Hagmann 20
What are you concerned about? 2. Invasive bacterial infections Causes of Fever in Outpatient Tanzanian Children 1 Regional Causes of Childhood Death, Africa 2010 2 70.5% viral 22.0% bacterial 10.9% parasitic 1 D Acremont V, N Engl J Med 2014;370:809-17. 2 Liu L, Lancet 2012;379:2151-61. Pre-CISTM14 Course --- Stefan Hagmann 21
What are you concerned about? 3. Respiratory infections Causes of Fever in Outpatient Tanzanian Children 1 Regional Causes of Childhood Death, Africa 2010 2 70.5% viral 22.0% bacterial 10.9% parasitic 1 D Acremont V, N Engl J Med 2014;370:809-17. 2 Liu L, Lancet 2012;379:2151-61. Pre-CISTM14 Course --- Stefan Hagmann 22
What are you concerned about? 4. Gastrointestinal infections Causes of Fever in Outpatient Tanzanian Children 1 Regional Causes of Childhood Death, Africa 2010 2 70.5% viral 22.0% bacterial 10.9% parasitic 1 D Acremont V, N Engl J Med 2014;370:809-17. 2 Liu L, Lancet 2012;379:2151-61. Pre-CISTM14 Course --- Stefan Hagmann 23
What are you concerned about? 5. Trauma / Rabies GeoSentinel network, 2010 1 N=1,594 Animal bites: 6% Affects disproportionately children, aor: 3 Regional Causes of Childhood Death, Africa 2010 2 1 Hagmann S, Pediatrics 2010;125(5):e1072-80. 2 Liu L, Lancet 2012;379:2151-61. Pre-CISTM14 Course --- Stefan Hagmann 24
What questions would you ask? Pre-CISTM14 Course --- Stefan Hagmann 25
What questions would you ask? 1. When is the infant leaving? 2. How long is the trip? 3. Where and with whom will the infant stay? 4. With whom will the infant travel to the destination? 5. What is the PMHx / newborn history? 6. Which vaccines has the infant received so far 7. Has the mother been immunized during pregnancy or postpartum? Which vaccines? 8. Is the mother breastfeeding this infant? Pre-CISTM14 Course --- Stefan Hagmann 26
What would you recommend? Pre-CISTM14 Course --- Stefan Hagmann 27
Malaria Chemoprophylaxis in Children at U.S. GTEN Clinics 2009-12. Proportion of drugs used by age groups Mefloquine use associated with: VFRs, aor:2.37 Prolonged travel, aor:2.38 Younger age (0-5y), aor: 4.29 (6-11), aor: 3.53 Hagmann et al. J Ped Infect Dis 2013;2(4):327-334. Likely Reasons for Preferred Use of mefloquine Good tolerability in children Ease of use (once a week) Relative Affordability Pre-CISTM14 Course --- Stefan Hagmann 28
Personal Protection Measures 3-prong Approach Nets Repellent Permethrin Strategy Based on Developmental Stage of Child Carry-on stage (~0-8 months) Primary Prevention strategy: =>Protective environment Permethrin-impregnated nets for crip/bed/stroller/car seat Stauffer WM et al. J Travel Med 2003;10:225-240 Pre-CISTM14 Course --- Stefan Hagmann 29
Vaccinations Accelerated schedule for basic series: Starts at 6 weeks and can be completed by 14 weeks (Rotavirus, Pneumococcus, Diphtheria, Tetanus, Pertussis, HiB, Polio) Hepatitis B: Ideally started at birth, continue series Hepatitis A: Immunoglubulin Meningococcal: Men ACWY-CRM (Menveo) (2, 4, 6, 12 months) BCG: to be considered and discussed Pre-CISTM14 Course --- Stefan Hagmann 30
Diarrhea Care 1. What is diarrhea and how to recognize it 2. Care Advicewww.healthychildren.org/English/tips-tools/Symptom- Checker/Pages/Vomiting-With-Diarrhea.aspx. Reassurance Preparation and use of ORS Avoidance of medicines Expected course When to seek professional help 3. Nutrition counseling Pre-CISTM14 Course --- Stefan Hagmann 31
Mother (or other caregiver)/ Overlap with migrant health care Care giver (e.g. mother) interested to receive pretravel care? Offer actively. Review existing serologic results Pre-natal or others if available, e.g. hepb, MMR etc. Consider to order if none available Review PPD status Review immunization history Link to specialist care if needed, e.g. hepatologist (Mother): Breastfeeding? = Precaution for yellow fever vaccine! Pre-CISTM14 Course --- Stefan Hagmann 32
Last but not least What is the budget? Need to address actively with families! Provide written information in patient s primary language if possible. Pre-CISTM14 Course --- Stefan Hagmann 33
Key-points 1. Look for how you can engage pediatric VFRs in your service area! 2. Have time to discuss in details with the care givers the real-world circumstances of planned trip: where?, when?, how long?, with whom? 3. Offer pre-travel care to adult caregivers! 4. Know a good and reliable compounding pharmacist! 5. Be familiar with and utilize accelerated immunizations schedules! 6. Provide instructions and hand-outs in the caregiver s best language! Pre-CISTM14 Course --- Stefan Hagmann 34
Thank you! 35