Physicians can help prepare patients for international travel

Incorporate questions about travel plans into the well-baby and well-child visits.

When the Bureau of Consular Affairs at the US Department of State issued a warning about escalating violence along the US-Mexico border, several universities told their students to use common sense — such as remaining aware and sober — when traveling to Mexico for spring break.

Pediatricians can help prepare patients and families before the trip, whether it is for spring break in Cancun or to visit family in the Philippines.

“Travel medicine preparation begins with the primary care pediatrician,” said Elizabeth Barnett, MD, pediatric infectious disease specialist at Boston Medical Center. “The pediatrician should inquire about plans for travel on a regular basis, especially with immigrant families who may go home to visit family members on short notice.”

Robert Frenck Jr., MD, who is professor of pediatrics, division of pediatric infectious diseases at Cincinnati Children’s Hospital Medical Center, said pediatricians should inquire about travel because more children are traveling internationally.

“It is important to incorporate these questions into well-child or well-baby visits.”

Children are at particular risk for three infectious diseases when traveling, according to James H. Diaz, MD, DrPH, professor and Head of Environmental and Occupational Health Sciences in the School of Public Health at the Louisiana State University Health Sciences Center in New Orleans. These are foodborne infectious diseases, particularly Escherichia coli, malaria and tuberculosis.

Physician consultation

Andrea P. Summer, MD, associate professor of pediatrics at the Medical University of South Carolina and a member of the American Society of Tropical Medicine and Hygiene, said the time to begin preparing a child or young adult for travel should be dictated by the destination and duration.

“For brief trips lasting less than 3 weeks, preparation between 4 to 6 weeks in advance is usually adequate,” she said. “For prolonged trips and trips to exotic locations in less developed countries, trip preparation should begin at least 2 months prior to departure.”

The CDC advises patients with special considerations to visit a travel clinic before departure. Barnett advises a pre-travel medicine consultation between pediatricians, families and patients to discuss food and water precautions to prevent traveler’s diarrhea, safety while traveling, and vaccinations and malaria prevention.

Diarrheal disease, motor-vehicle accidents

Because the rate for traveler’s diarrhea and subsequent dehydration is high among children younger than 3 years, counseling about preventing this illness before the trip is important, Summer said.

“Management of traveler’s diarrhea involves good oral hydration techniques and presumptive treatment with an oral antibiotic such as azithromycin,” she said.

Sheila Mackell, MD, pediatrician and travel medicine specialist of Mountain View Pediatrics in Flagstaff, Ariz., said she advises parents and patients about the importance of hydration and how to recognize whether the diarrhea is severe enough to warrant antimicrobial treatment.

“Parents are generally well-versed in how to take care of diarrhea,” Mackell said. “But in our practice, we discuss with them how to find oral re-hydration salt and mix it up appropriately, as well as how to make it if they can’t find it in the country they are visiting.”

In a 2005 article in Clinical Infectious Diseases, Mackell and colleagues discussed the treatment parameters for traveler’s diarrhea in the pediatric population and said the best treatment option for children would be based on efficacy, palatability, adherence and cost.

“While firm evidence-based guidelines are lacking, the antimicrobial treatment of choice at this point favors azithromycin vs. off-label quinolone use,” the researchers wrote. “Ongoing surveillance and evolving treatments will contribute to the evidence supporting treatment choices and recommendations.”

According to Diaz, the routine rotavirus vaccine should help combat diarrhea.

“For traveler’s diarrhea, routine prophylaxis other than drinking bottled water is not indicated,” Diaz recently told Infectious Diseases in Children. “Nevertheless, parents should carry oral rehydration solutions and consider obtaining a prescription for a powdered azithromycin formulation that can be reconstituted in bottled water for oral use in severe infectious diarrhea.”

Pediatricians should also counsel parents and patients about the possibility for motor vehicle and water-related accidents in other countries.

“Since the majority of mortality in young travelers is due to motor vehicle accidents, followed by drownings, general safety measures such as the use of car seats, seatbelts and approved flotation devices are extremely important,” Summer said.

She advises parents to pack a car seat and water-safety devices because they may not be available for use in less developed countries. In addition, traveling by car during the day may be safer than travel at night.

As for young travelers heading to a foreign country for spring break, heavy alcoholic consumption and drug abuse may lead to various health consequences.

In a 2008 study by Hesse and colleagues, researchers from Denmark conducted an ethnographic observation study and cross-sectional survey among young travelers, aged 16 to 30 years, vacationing in Sunny Beach, Bulgaria, between June 19, 2007, and Aug. 12, 2007.

The researchers observed tourists (n=54) and tour guides (n=9) during the day and night at bars, hotels, the beach and other locations.

Results indicated that although the associations with acute adverse side effects of young tourists who chose a “party package travel agency” were modest, heavy drinking was significantly associated with tourists who went with this agency (P=.048). Male gender was also associated with heavy drinking (P<.001).

“In general, guides should do more to warn against the negative effects of heavy drinking and give advice about how to limit some of these negative effects, for example, by emphasizing that is it vital to eat food and drink sufficient amounts of water,” the researchers wrote in the journal BMC Public Health. “Tour guides should also avoid encouraging heavy drinking and instead shift their focus to other party activities such as dancing and non-alcoholic party games and competitions.”

Pre-travel vaccination

A pre-travel visit is an opportunity to make sure children are up to date with routine immunizations. Vaccinations may be accelerated for children with imminent departures or for those who are behind in routine vaccines. For infants, first doses may be given as early as 6 weeks of age, and for older children, intervals between doses may be shortened according to the recommendations in the immunization schedules published by CDC and other sources.

The next step is to provide itinerary-specific vaccinations. Vaccination against yellow fever, hepatitis A, typhoid fever and Japanese encephalitis may be considered, depending on the destination.

Yellow fever vaccine may be indicated for travel to parts of Africa and South America. Because the epidemiology of the disease is undergoing frequent changes, it is important to consult up-to-date sources of information about this disease to be certain of the areas affected.

For example, the Brazilian Ministry of Health announced in 2009 that the southern, coastal area of Bahia state and the northern, coastal area of Espirito Santo were no longer considered risk areas for yellow fever transmission; however, yellow fever risk areas have expanded to the states of Sao Paulo and Parana in Brazil.

“The yellow fever vaccine is often not required to go into Brazil but is required to come back into the United States,” Frenck said. “So if someone were in a yellow fever zone and were not vaccinated, then they have a risk of getting quarantined before being let back into the United States.”

The yellow fever vaccine is contraindicated in children younger than 6 months and should be given with caution in the 6- to 9-month and older age groups.

“But for those people in the middle-aged group, it is a safe vaccine. It is a bad disease, and getting the vaccine is well worth it,” he said.

Meningococcal vaccines are recommended for countries in and around what is known as the “meningitis belt” in Africa, as well as for travelers participating in the Hajj pilgrimage in Saudi Arabia.

Because country requirements may change at any time, the CDC recommends that travelers check with the appropriate embassy or consulate before departure.

Children are also at risk of acquiring rabies while traveling. WHO estimates that about 55,000 deaths are caused by rabies every year, with most occurring in Asia and Africa.

“Children are very likely to approach a stray dog or cat, and rabies prevention in animals is not a big priority in the tropics,” Diaz said, adding that families should be advised to stay away from stray animals, especially dogs, in some areas. Families should also be advised to have a plan of how to seek medical attention should a bite occur. All dogs and cats, bats and monkeys have the potential to transmit rabies. Most significant exposures to rabies occur outside of the developed world.

Risk of malaria

“Children are at great risk for a number of endemic diseases in the tropics, especially malaria, due to their limited immune status,” Diaz said. Children are at high risk of parasitic illnesses “due to hand-to-mouth behavior and tick-borne diseases due to their short stature.”

According to a 2008 review by Fischer and colleagues, about 20% of the imported cases of malaria in the United States and in Europe are among children.

When providing advice on preventing malaria, the physician should explain the basic pathophysiology of malaria infections, researchers said in Travel Medicine and Infectious Disease.

“In particular, it should be made clear that the currently available antimalarial chemoprophylactic medications do not protect the child from infection — as most patients and parents believe — but only prevent disease by killing the parasite once it leaves the liver.”

According to Summer, measures should be taken to limit mosquito bites for travelers to malaria endemic areas. Prevention of mosquito bites will also help prevent diseases such as dengue fever or chikungunya fever, diseases also transmitted by mosquitoes.

“These measures typically include wearing long sleeves and pants, using insect repellents and bed nets. Malaria chemoprophylaxis is also recommended,” she said. “The physician must be familiar with malaria-resistance patterns, as well as specific contraindications and side effects of each antimalarial, to determine which one may be suitable for each patient.”

According to Diaz, Malarone (GlaxoSmithKline) is a malaria prophylaxis agent that must be taken every day and is not recommended for children less than 5 kg. Another option is doxycycline, which is not recommended for children younger than 8 years. Mefloquine is an option that only should be taken weekly, but may cause psychiatric effects.

Primaquine is used only for prophylaxis of malaria in individuals who are visiting an area were P. vivax malaria predominates, and it should only be used in individuals who have normal G6PD activity, Barnett said.

Because most antimalarials do not come in liquid form, the adult tablet may be cut and crushed to administer to children unable to swallow the pill, Summer said.

Post-travel follow-up

Although symptoms may manifest during travel, some symptoms may become clinically apparent days, weeks or even years after the child has returned home. Parents should be advised to monitor the child for illness both during and after travel.

“Any illness in a returned traveler should be evaluated thoroughly,” Summer said. “The differential diagnosis for illness in returned travelers is broad and includes both routine and destination-specific infections. Fever in the returned traveler should be considered a medical emergency, especially if the child has traveled to a malaria-endemic area.”

Pediatricians who want more tips on travel health should check the International Society of Travel Medicine’s website, or the CDC’s travel website.

“It is such a fun part of medicine to help people prepare safely for their trips, and there are a multitude of resources available,” Mackell said. – by Jennifer Henry and Emily Shafer

For more information:

• Hesse M. BMC Public Health. 2008;8:351.
• Mackell S. Clin Infect Dis. 2005;41(Suppl 8):S547-552.
• Stauffer W. Travel Med Infect Dis. 2008;6:101-113.

Disclosures: None of the sources report any relevant financial disclosures.

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