Trying to Prevent Illness in Kids Who Travel Diagnosing it when they Return Disclosure I have nothing to disclose 46 th Advances & Controversies in Clinical Pediatrics Jay Tureen, M.D. International Travel with Kids Health and Travel general information Outbound Inbound Health and Travel CDC estimates ~ 1.9 M children travel to developing countries annually 22-64% of all travelers self report illness during or after travel Car accidents and drowning are most common cause of death in international travelers Infection is a rare cause of death, a common cause of morbidity, mostly preventable 8% of all travelers require medical care during or after travel (Freedman DO, NEJM, 2006) Outbound Anticipatory guidance Immunizations Medications Other stuff Anticipatory guidance: Data Contact Card with information to have in one place Personal ID for minor children (but not visible) Notarized letter from other parent if single parent traveling with child internationally 1
Contact Card Travelers should carry a contact card with the addresses and phone numbers of the following: Designated person back home contact information Health care provider(s) at home Place of lodging at the destination Medical insurance information, Travel insurance and medical evacuation insurance information Area hospitals or clinics, including emergency services MDs in other countries: ISTM.org, IAMAT.org US embassy or consulate in the destination country or countries Anticipatory Guidance: Stuff Safety considerations car seats, sunblock Medical kits (CDC website) Water sterilization tabs/ors powder Chart for estimating dehydration Immunizations for Travelers General principles Required Recommended Immunizations: General Make sure current on routine Anticipate risk of exposure Season, Location and Type of travel Traveler specific issues PCP can do all (easily) except YF, JE, rabies Immunizations: Required Yellow Fever For endemic countries or regions Sub-Saharan Africa, Tropical So America or if traversing Live virus contraindicated if immune-comp For 9 mos or older, contraindicated < 4 mo Meningococcal vaccine - Required for pilgrims to Hajj age 15 or older Immunizations: Recommended Routine immunizations need to be UTD Hepatitis A (common vaccine preventable) Meningococcal Recommended for Sub Saharan meningitis belt in dry winter months of Nov-June Typhoid Vi polysaccharide, IM, 2y/0; Ty 21a, oral, 6 yr) Rabies (risk determined) Japanese B encephalitis (risk determined) 2
Immunizations: Planning Hep A: 0, 6 mos Rabies: 0, 7, 21-28d JE: 0, 7, 14-30d (delayed hypersensitivity up to 10 d) Typhoid: IM x1, PO over 7 d; 2 wks before exposure YF: SQ 10 d before travel (will need referral to YF licensed provider) Outbound: Issues to anticipate Malaria Bite prevention Meds Travelers diarrhea Avoidance Management Malaria 3 M cases worldwide ~1800/yr in US civilians 59% in Sub Saharan Africa 19% Asia 14% Caribbean, Central and So America 7% other Malaria: Prevention Mosquito bite avoidance Anopheles are dusk to dawn feeders avoid exposure Repellents DEET (20-30%) Long sleeves, pants Permethrin-treated mosquito netting Chemoprophylaxis Malaria: Resistant P. falciparum Chloroquine-resistant P. falciparum Africa, Asia, tropical So. America Chloroquine-sensitive P.f. Mexico to Costa Rica; So. South America North Africa, Turkey-Iraq, Soviet republics, Korea 3
Malaria Chemoprophylaxis Mefloquine infants (5 kg) and children Malarone (atovaquone-proquanil) toddlers (11 kg) and children Doxycyline children >8 yr Chloroquine infants and children Malaria: terminal prophy Primaquine Used to eliminate hepatic reservoir of P vivax and P ovale Contraindicated in G6PD def (test if at risk) Used in patients with prolonged exposure Traveler s Diarrhea Most common travel health problem Fecal-oral transmission Bacteria (80%) ETEC, campylobacter, salmonella, shigella Viruses rotavirus, norovirus Parasites Giardia, amoeba, cryptosporidium TD: Prevention Risk reduction Cook it, peel it, boil it or don t eat it Advise bottled drinks, no ice Prophylaxis bismuth subsalicylate: (65% effective) Antibiotic prophylaxis: (90% effective) Short-term manage with loperamide with Abx as back up Cipro, azithro (esp SE Asia), rifaxamin TD: if it happens Assessment of fluid losses Assessment of Clinical severity Assessment of dehydration in infants (Modified from CDC) SIGN MILD MODERATE SEVERE GENERAL Thirsty, agitated Thirsty, irritable Less responsive, rapid respiration FONTANELLE, Normal Sunken Very sunken EYES TEARS Present Absent Absent MUCOUS Slightly dry Dry Dry MEMBRANES URINE OUTPUT Normal Reduced None for several hours 4
TD: if it happens Assessment of clinical severity Mild (1-2/24h, minimal sx, watch hydration) Moderate (>3/24 hr, add loperamide) Severe (mod-severe abdominal pain, bloody, fever) Start antibiotics, maintain hydration Inbound GeoSentinel survey Clinician-based surveillance of ill child travelers in travel clinics worldwide 1997-2007»Pediatrics 2010 Demographics 1840 children Age evenly distributed 0-5, 6-11, 12-17 14% req d hospitalization, highest < 5y/o 40-45% were <7 d from travel c/w adults, less likely to have pre-travel information Clinical Syndromes 21 broad syndromic categories identified 93% in 5 categories: Diarrheal disorders (28%) Dermatologic disorder (25%) Systemic febrile illness (23%) Respiratory disorders (11%) Non-diarrheal GI disorder (7%) Syndrome: Diarrheal Disorder Acute (80%) Bacterial (29%) [campylobacter, salmonella] Parasitic (25%) [giardia 47%] Gastroenteritis, no cause identified (28%) Chronic [> 2 wks] (20%) post-infectious IBS Syndrome: Dermatologic dz Animal bites (24%) Cutaneous larva migrans (17%) Insect bites (12%) 5
Cutaneous Larva Migrans Most common skin dz in travelers to tropics Larvae of dog hookworm (Ancystoloma braziliense) Soil, sand contact Rx topical thiabendazole, PO ivermectin Syndrome: Systemic febrile illness Malaria (35%) Viral syndromes (28%) Unspecified febrile illness (11%) Dengue (6%) Enteric fever (6%) Mononucleosis Sd (4%) [EBV,CMV, Toxo] Syndrome: Respiratory dz URI (38%) Reactive airway dz (20%) AOM (17%) Syndrome: Non-diarrheal GI Schistosomiasis (15%) Middle East, SubSaharan Africa, Caribbean Strongyloidiasis (11%) Hepatitis A (11%) Geographic association with illness Malaria: Sub Saharan Africa Dengue: Asia, Latin America, Caribbean Dermatologic (CLM): Latin America, Carib Derm (animal bites): Asia, N Africa Diarrheal illness: N Africa, Middle East Final Thoughts Travel advice within the purview of PCP Handouts, checklists can be developed (or modified from existing) Most vaccines can be given in ofc (x YF) with pre-planning Prophylaxis can be rx d Anticipatory guidance relating to most common conditions can be provided. 6
References: Travel Medicine www.cdc.gov/travel www.who.int Travel Medicine; Keystone, Kozarsky, Freedman, Nothdurft, Connor, 2004 Health Information for International Travel 2005-2006; Arguin, Kozarsky, Navin, Eds. CDC Illness in Children after International Travel: Analysis from the GeoSentinal Surveillance Network. Hagmann S et al, Pediatrics 2010, e1072 Travel: Summary 1. Pre-travel advice/guidance by the PCP may prevent some adverse health outcomes. 2. Custody issues may arise with a sole parent and children crossing international borders. 3. Malaria prevention - bite avoidance and chemoprophylaxis - should be instituted for all family members. 4. Traveler s diarrhea is a common problem in most developing countries. 5. Workup for illness upon return from international destinations needs to be primarily guided by areas visited. 7