Topic #4 – International Travel for Children
and
Adolescents
Chrisanne Timpe DuPuis, MS 06
International Travel
A changing economy and more affordable travel by air have made international travel much more accessible than it used to be to the pediatric population. This presents a new realm of concern for pediatricians with regard to the potential for infectious disease not normally seen in the U.S., such as malaria, polio, and yellow fever. It is imperative that pediatric health care workers be aware of the standard recommendations for immunizations related to travel.
Physicians must also educate their patients on the potential health hazards that they may encounter while abroad. Patients should be counseled on strict hand-washing techniques to help avoid fecal-oral transmission of diseases via the water supply in countries outside of the United States. If the water is not potable, patients should brush their teeth with bottled or treated water only, should not use ice cubes made from tap water, nor should they eat foods bought on the street unless they can be peeled (like bananas or oranges). Patients planning prolonged international visits might consider the use of water purification tablets, boiling, or micropore filters. If the physician feels that the patient is mature enough to handle a prescription judiciously, they might prescribe and counsel the patient on the use of antibiotics in rare types of infectious illness. More importantly, oral rehydration is the best self-treatment.
Patients with a need for electrical equipment such as nebulizers or apnea monitors might consider bringing along a voltage converter and plug adaptor, as these things may not be readily available outside of the U.S. In short, because a physician cannot guarantee ready availability to health care in a foreign country, it is his/her job to discuss with the patient safe ways in which to prevent medical emergencies. Carrying a copy of a childÕs health records and emergency contacts, as well as contacting his/her health insurance regarding travel health insurance is also recommended.
It is important to recognize that the leading cause of death among young travelers is injury, rather than disease. Parents and guardians are advised to teach children about foreign safety regulations and encourage safe travel habits.
The Center for Disease Control provides a website which details the infectious risks and recommendations of different areas of the world. Patients and physicians can use this to stay up to date on international health threats: www.cdc.gov/travel.
Seatbelt use on aircrafts
In addition to concern for the immunization status of international travelers, the American Academy of Pediatrics recommends that all children be restrained by a seatbelt or car seat while onboard aircrafts, regardless of their age. This is contrary to current requirements that only those over 2 years of age be restrained, while those younger than that are allowed to sit on the lap of an adult. The AAP feels strongly that preventable injuries and deaths have occurred in young children due to this rule. Therefore, counseling families on the need for seatbelt/restraint use on aircrafts is another responsibility of the pediatric health care team.
Immunizations
highest rates of disease in children aged 5-14.
á highly contagious, spread by fecal-oral contamination
á Hep A Vaccine (inactivated) is recommended for children >2 years of age who live in or are traveling to high-risk areas. These include areas of the United States that have a high rate of HAV infection and all other countries other than Australia, Canada, Japan, New Zealand, and western European countries. The inactivated vaccine confers long-term protection.
á Hep A Immune globulin is given IM for pre- and post-exposure prophylaxis. However, Hep A Ig is only recommended if a single, short visit is planned. Young people who will be traveling for a long period of time are advised to get the Hep A vaccine rather than the Ig.
á
However, the Hep A vaccine has not been
licensed for
children less than 2 years of age. Therefore,
children < 2 should get the Ig, whereas children >2 years old
should get
the vaccine.
á
The vaccine is given in 2 doses. If
immediate
protection is needed, both Ig (for immediate protection) and the
vaccine (for
long term protection) can be given simultaneously at different sites.
Ÿ
Wear
long-sleeved shirts and pants
Ÿ
Use
insect repellent, up to 30% DEET and Picaridin can be applied to skin
of children older than
2 months of age, avoiding mucous membranes and washing off when child
comes
indoors.
Ÿ
Permethrin
(insecticide) may be sprayed on clothing
Ÿ
Mosquito
netting on beds
á Chemoprophylaxis is the same for children as it is for adults, and will depend on the risk of acquiring the disease in the region visited.
Ÿ Start chemoprophylaxis 1 week before travel
Ÿ Chloroquine or hydroxychloroquine given once per week, continued for 4 weeks after leaving endemic area. This is best used in areas of chloroquine-sensitive Plasmodium falciparum. This includes parts of Mexico, Haiti, the Dominican Republic, Central America, the Middle East, and Eastern Europe.
Ÿ
Mefloquine
q week when traveling to areas with chloroquine-resistant Plasmodium
falciparum (parasite). Not licensed by FDA for kids weighing
< 5 kg or
younger than 6 months, although some argue that it is worth the risk.
Areas
include: S. America, Africa, the Indian subcontinent, Asia, the S.
Pacific. One dose week before travel, weekly while in area,
and weekly for 4 weeks after return.
Ÿ Doxycycline is an alternative to Mefloquine in chloroquine-resistant areas. However, it should not be given to kids less than 8 years old.
Ÿ
Atovaquone-proguanil
is the 3rd alternative for chloroquine-resistant areas. Not
for kids
with renal disease. Not licensed for kids weighing less than 11 kg.
References