- Email: [email protected]
Planning for Travel With Children in the Modern World
’
Planning for Travel With Children in the Modern World Martin G. Ottolini, MD,a,b Michael Rajnik, MD,b and Patrick W. Hickey, MDc
Introduction ou are part of a busy group, primary care, practice in a mid-sized “college town” that serves an economically and culturally diverse patient population. Your first patients of the day are two siblings, a 3-year-old girl and a 9-month-old boy who present with upper respiratory tract symptoms and concern about possible otitis media. The parents, both of whom emigrated approximately 4 years ago to the United States, mention that the family is “traveling home to Cameroon” next week to spend 2 weeks visiting the childrens’ grandparents. Standing in the doorway on the way, the mother asks you if the children “need any shots?” A week later, a family of four comes in to discuss that they are moving to Thailand for an estimated 3 years to follow the parents’ newest positions in a large non-governmental organization (NGO). They include a 47-year-old father with no health problems, a 49-year-old mother who is on chronic therapy for rheumatoid arthritis, and three healthy children with the ages of 9, 14, and 16. They will reside in Bangkok, but will be working on a rural development project in the north near the city of Chiang Mai, will likely visit displaced persons camps near the Thailand-Cambodia border, and plan to travel extensively as a family in the region. Later that day, one of your “routine physical exam” appointments is a healthy 17-year-old female high-school student, who is
Y
From the aOffice of Curriculum, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; bDepartment of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; and cDepartment of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814. The views expressed herein are those of the authors and are not necessarily representative of those of the Uniformed Services University or the Department of Defense. Curr Probl Pediatr Adolesc Health Care 2015;45:209-214 1538-5442/$ - see front matter & 2015 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.cppeds.2015.06.002
Curr Probl PediatrAdolesc Health Care, August 2015
going to work for 8 weeks at a rural church mission site in the Amazon basin of Peru. She will help staff a program that provides early childhood education in a community of subsistence farming families. She anticipates traveling with another friend, planning to use any free time to extensively explore the region through hiking and kayaking. Each patient or family is asking the same questions, in general. “What can we do to reduce our risk of becoming ill or injured during our stay in these foreign sites? What should we do to prepare for our trips? Do you have any advice we should follow during travel?” The family from Cameroon is not too concerned—after all, they are revisiting a country where they spent most of their lives, and have relatives who know their way around. They have however, not been back home in several years, and the health infrastructure of their country is limited. You are concerned about their “lack of concern” and casual attitude towards advanced preparation. The family moving with the NGO has already had a series of briefings and studied both written and web-based preparation materials. They are also receiving advice from a sponsoring family residing in their future county, arranged by their agency, to help orient them to the culture, challenges, and opportunities of living overseas. They will be residing in a large, rapidly developing country, with access to a modern health care system in most of the major population areas. They do plan to visit several remote sites, and are very proactive about their “planning.” The young missionary is highly enthused and very motivated, but is working with a small group of volunteers working under a newer agency, and does not seem to have as much institutional support for travel preparation. While all three sets of travelers are focuses their concerns on preventing infectious diseases, you note that their planned activities will include several other potential travel risks; including motor vehicle and water-sport hazards, extreme environmental conditions, crime, potential government stability issues, and the simple challenges of the travel infrastructure.
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Overall they wish to anticipate and reduce their “risks” of travel-related illnesses and injuries, and to be ready to take more control of their health and potential therapies in regions where they would need to rely less on ready access to the substantial safety net of a modern health care system.
Extent of Travel in the US Population In 2013, more than 61.8 million U.S. Residents traveled internationally.1 If one excludes travel to the well developed nations of Canada and Europe, 39.8 million U.S. residents traveled to areas of the world that would justify a pre-travel health assessment, risk-based counseling, and preventive medical services (Including 20.9 million travel visits to Mexico). The Figure demonstrates the trends over the last decade in travel to locations outside of North America.2 Overall, 8% of outbound travel parties include children, accounting for approximately 1.2 million child international travelers annually.3 Among all international travelers, the average duration of travel is 16.6 days (median 10 days) showing that both the magnitude and duration of overseas travel as a health-related exposure are quite significant.1 Further, the incubation periods for many travel-associated diseases are such that the illness is most likely to occur after return home.4 Despite a substantial mean lead time from “decision to time of travel” of 106 days, pre-travel health visits are sought out in only 11% of international travelers overall, and in only 36–46% of those traveling to low and lowmiddle income countries.2,5,6
Health Risks in International Travel The majority of travel medicine advice focuses on the prevention, diagnosis, and treatment of infectious diseases, as will the majority of this supplement. Compared to adults, pediatric travelers may be more likely to develop diarrheal, dermatologic, and respiratory illnesses as well as suffer animal bites.7 While the incidence rate of traveler’s diarrhea during a 2-week trip is approximately 30%, and that of influenza approximately 1%, the risk of other vaccine preventable diseases are lower, ranging from 1:3,000 for typhoid fever; to r1:100,000,000 for Japanese encephalitis and meningococcal meningitis.8 These statistics highlight the importance not only of
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risk-benefit and cost-benefit considerations but also consideration and discussion of risk-tolerance and avoidance behaviors on the part of parents, stressing that travel planning options involve a shared decisionmaking process between families and providers. Furthermore, despite the typical focus on infectious health risks, it is important to remind families that serious injuries occur at higher rates when traveling. The major source of pediatric traveler mortality is actually due to both motor vehicle accidents and drowning, both of which are disproportionately high when compared to adults.9 Some parents may have concerns whether it is safe to fly with young infants. A recent review of serious inflight emergencies resulting in consults to a ground based medical support center found that passengers under 18 years of age account for 9.3% of the total inflight emergencies with a rate of 2.24 events per 1 million passengers.10 Deaths were rare (10 total, 0.13% of all pediatric emergencies). While exact cause of death could not be abstracted from the available data, four of the ten had known pre-travel health conditions, with additional associated factors of young age (median 3.5 months), and being a “lap infant” (9 of 10), bringing up the possibility of sudden unexplained infant death (SUID) during trips with sleeping infants.10 More common concerns whether over-thecounter medications can be utilized as either a sedative or prophylactic against barotrauma-related otalgia merit direct discussion with parents as both antihistamines and decongestants pose serious risks to children under the age of two and have shown no benefit in reducing symptoms of air-travel-related otalgia.11,12 Rather, there should be emphasis on enhancing safe, comfortable seating for children, age-appropriate activities, and use of sucking and swallowing techniques to reduce barotrauma with changes in cabin-pressure.13,14 Adolescent (up to age 21) travelers also have unique age-specific considerations when traveling. They are likely to be adventurous and engage in riskier activities, like the missionary in our introduction, both increasing the chances of injury and also creating new infectious disease exposures from fresh-water or soil/ mud contact. Blood borne pathogens (tattoos and piercings) and sexually transmitted infections become significant concerns that should be discussed, as well as broader issues of reproductive health such as contraceptives and sexual violence. Additionally, chronic diseases should be addressed, in terms of direct risk of an exacerbation during travel,
Curr Probl Pediatr Adolesc Health Care, August 2015
as well as their potential to increase risk and severity of secondary or opportunistic infections. While children with chronic diseases such as type I diabetes can safely travel, attention must be given to dosage adjustments, dietary considerations, and activity modification; as well as sufficient supplies for the entire trip.15 For those with immunosuppression due to disease or as a result of medication, there are unique considerations for food and water safety counseling, modified vaccine indications and safety, medication interactions, and dosing considerations for prophylactic medications. There is also a greater need to plan for the contingencies of self-treatment and when needed know how to access to quality medical services while traveling in less-resourced regions. While most travel medicine services can be readily provided in the primary care setting, patients with more complex medical needs may be better served by a travel medicine specialist. Travel medicine requires “situational awareness” the anticipation of the unique risks of the geographic locations to be visited, planning for the likely activities that visitors engage in, as well as being informed of any outbreaks of disease occurring at that time. Travel medicine providers have the responsibility to obtain the most current information about the risks of the sites to which their patients are traveling, and to be prepared to appropriately counsel patients about them. While the risks of some endemic or epidemic infectious diseases can be mitigated through behavioral changes, prophylaxis, or vaccinations, many situations, including natural or man-made disasters, or rapidly emerging infectious diseases cannot be anticipated and leave the
8
traveler at the mercy of the local infrastructure, their own adaptability, and contingency planning. These will be expanded in the pre-travel preparation article, which will include a discussion about the role of additional traveler’s health and evacuation insurance.16
The Practice of Travel Medicine This supplement will present general information regarding travel preparations and post-travel assessment, which although applicable to travelers of all ages will focus on the specific nuances of young children and adolescents. Some of the general principles involved in the management of pediatric travel, which are different than those for adults, are listed in Table 1. As with all good medical practice, basic approaches such as planning and organization of the environment of care, anticipating both common and life-threatening problems, and a practical common sense approach to health counseling in a way that enhances adherence can go a long way to reducing the risk of travel injury and illness. The field of travel medicine has a defined body of knowledge and scope of practice as well an evolving body of research literature upon which to draw.17–20 Access to current disease surveillance information, updated practice guidelines, and other clinical management resources for consultation, all help ensure quality care. We cannot emphasize this final point enough as few practitioners (particularly in a busy primary care practice) can remember the constantly changing
Overseas Travel Destinations for U.S. Residents*
Travelers in Millions
7 6 5
Caribbean South America Central America
4
Africa
3
Middle East
2
Asia
1
Oceania
0
FIG. *Adapted from U.S. Department of Commerce Data. Does not include Mexico, Canada, or European travel.
Curr Probl PediatrAdolesc Health Care, August 2015
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recommendations for drug choice or doses, regional patterns of malaria or enteric pathogen drug resistance, risk-based vaccine recommendations, or the impact of current epidemics, natural disasters, social unrest, or other issues unique to a specific geographic region. In our practice we regularly consult with the Center for Disease Control & Prevention’s general and pediatric travelers’ health websites,3,21 including print and electronic versions of “Health Information for International Travel” (known as the Yellow Book).22 Additional pediatric-specific references include the electronic and print versions of the American Academy of Pediatrics Report of the Committee on Infectious Disease (known as the Red Book).23 Subscription travel health information services, such as Shoreland’s “Travax” can provide itinerary-specific threat assessments, prevention and treatment recommendations, as well as embassy and health care site contact information.24 The use of these and other resources are covered in greater detail later in this supplement. For health practitioners seeking to demonstrate a higher level of knowledge and mastery in the field of travel medicine, two certificate programs exist. The American Society of Tropical Medicine & Hygiene supports training programs and an examination that leads to a Certificate of Knowledge in Clinical Tropical Medicine and
Travelers Health (CTropMed©) and the International Society of Tropical Medicine offers a examination leading to the Certificate of Travelers Health. Instructions on how to obtain these levels of expertise are available at the respective society websites.25–27 A summary of resources for the travel medicine provider is provided in Table 2. One major limitation has been the lack of evidencebased guidance for developing pediatric-specific practices and adapting adult-based recommendations. This was noted in a recent editorial in the Journal of Travel Medicine, which pointed out that while serious pediatric travel-related illness is fortunately less common, many travel medicine experts are uncomfortable with very young children, and are even less confident of evaluating illnesses in the returning travelers.28 A fairly recent development has been the establishment of the “Pediatric Interest Group” (PedIG) within the International Society of Travel Medicine in 2010, in response to the recognition of the significant numbers of pediatric travelers and need for consistent research and training. As pointed out in a recent survey of members, the diversity of training and practice among those working in this area indicates a need for formulation and adherence to age-specific evidencebased guidelines.29
TABLE 1. Unique considerations in planning for travel with children and families
Family centered care is ideal. Families with children should visit a travel clinic/travel medicine provider at least 1 month prior to travel to allow for
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effective prophylactic immunization, beginning prophylactic medications and consult with necessary specialists if children have chronic conditions that may be exacerbated or require management related to travel. Some travel medications (particularly malaria prophylaxis) are not specifically formulated for children, and may require a compounding pharmacy, or parental training in dividing and/or crushing tablets. Ensure previously prescribed chronic and as needed medication supplies are available for the entire duration of a planned trip (e.g., insulin, inhalers, and epinephrine injectors). Controlled substances such as stimulants used for attention deficit disorder may require additional documentation and should be kept in their original packaging. Caution and advanced coordination should be used if traveling with narcotics. Using the same chemoprophylaxis medication for the entire family (or at least those with the same doing interval) may aid adherence. Empiric self-treatment is indicated for some conditions and requires additional counseling compared to that for an adult to do this safely and effectively. Off-label use of medications is common in this setting. Age and risk-factor based vaccine recommendations differ from routine guidance. Off-label use of vaccines, with expert guidance, is sometimes indicated (e.g., Japanese encephalitis vaccine prior to pediatric licensure had modified dosing for children) [Centers for Disease Control and Prevention (CDC). Update on Japanese encephalitis vaccine for children: United States, May 2011. MMWR Morb Mortal Wkly Rep. 2011 May 27;60(20):664–5], and labeled, but non-standard timing, of vaccines is common (e.g., Measles–Mumps–Rubella for travelers aged 6–11 months). Encourage advanced planning regarding health care infrastructure at the destination with consideration for both acute-minor illnesses and emergency care. Recommend purchase of travel health and evacuation insurance if not already covered under an existing program. Young children are totally dependent on adults for food and water safety, medication adherence, protection against insect bites, environmental exposures, and other safety concerns. Age-appropriate verbal and written instructions for counseling are recommended. Children are less cautious and at higher risk of animal bites, accidental trauma, and swimming and other water-related accidents. Specific counseling on these topics is recommended. Low and middle income countries are less likely to have/enforce safety aspects of building codes or have ready availability of safety devices such as car seats, seat belts, and protective fencing. Parents may need to make specific prior arrangements for access to what would be considered routine child safety features in the United States. Particular care should be made to engage international travelers with children who are “Visiting Friends and Relatives,” as this population has unique health risks and health-seeking behavior. Primary care providers should inquire about the potential for upcoming international travel during routine child wellness visits with immigrant families.
Curr Probl Pediatr Adolesc Health Care, August 2015
TABLE 2 Important resources for the travel medicine provider.
Resource
Internet address
Information provided
Centers for Disease Control and Prevention (CDC): travel health webpage and CDC Health Information for International Travel (Yellow Book) CDC Advisory Committee on Immunization Practices (ACIP) CDC: Malaria
http://wwwnc.cdc.gov/travel http://wwwnc.cdc.gov/travel/page/ yellowbook-home also available in print http://www.cdc.gov/vaccines/schedules/ hcp/child-adolescent.html www.cdc.gov/malaria
Destination specific information sheets Disease specific travel information
CDC Vaccines and Immunizations
www.cdc.gov/vaccines
American Academy of Pediatrics: Report of the Committee on Infectious Diseases (Red Book) World Health Organization (WHO): International Travel and Health
www.aap.org
Global Travel EpiNet
www.gten.travel
International Society of Travel Medicine
www.istm.org
American Society of Tropical Medicine & Hygiene
www.astmh.org
Shoreland Travax
www.shoreland.com
U.S. Department of State
www.state.gov/travel
also available in print www.who.int/ith also available in print
References 1. US Department of Commerce, International Trade Commission, National Travel and Tourism Office. 2013 United States Resident Travel Abroad. Washington, DC: July 2014. http:// travel.trade.gov/outreachpages/download_data_table/ 2013_US_Travel_Abroad.pdf; 2015 Accessed 15.01.15. 2. US Department of Commerce, International Trade Commission, National Travel and Tourism Office. Profile of U.S. resident travelers visiting overseas destinations: 2013 Outbound. Washington, D.C.: July 2014. http://travel.trade.gov/ outreachpages/download_data_table/2013_Outbound_Profile. pdf; 2015 Accessed 15.01.15. 3. Travelers’ Health/Centers for Disease Control and Prevention, Traveling with children. http://wwwnc.cdc.gov/travel/ page/children; 2015 Accessed 09.01.15. 4. Flores MS, Hickey PW, Fields JH, Ottolini MG. Evaluating illness in the returning pediatric traveler. Curr Probl Pediatr Adolesc Health Care 2015;45(8).
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Travel/vaccine clinic directory Birth-18 years and catch-up immunization schedules Current recommendations regarding the diagnosis, prevention and treatment of malaria in travelers Latest vaccine recommendations Updates on vaccine preventable diseases Pediatric-specific updates on infectious diseases diagnosis, prevention and treatment (Subscription) International travel health recommendations Updates for travelers IHR International Certificate of Vaccination or Prophylaxis WHO Guide on safe food for travelers Travel Clinic Directory Pre-travel providers’ rapid evaluation portal Traveler’s rapid health information portal Global travel clinic directory On-line travel medicine training materials (subscription) GeoSentinel Surveillance Network Information on the Certificate in Travel Health (CTH) Tropical and travel medicine consultant directory Tropical and travel medicine training materials (subscription) Information on the Certificate of Knowledge in Clinical Tropical Medicine and Traveler’s Health (CTropMed©) Destination specific information sheets Disease specific travel information Traveler safety updates Physician and traveler information sheets (Requires a subscription) Travel Document Requirements Preparing for trips abroad Emergency Information for Travelers Country specific data sheets
5. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med 2004;11(1):23–6. 6. LaRocque RC, Rao SR, Tsibris A, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med 2010;17(6):387–91. 7. Hagmann S, Neugebauer R, Schwartz E, et al. GeoSentinel Surveillance Network. Illness in children after international travel: analysis from the GeoSentinel Surveillance Network. Pediatrics 2010;125(5):e1072–80. 8. Steffen R, Behrens RH, Hill DR, Greenaway C, Leder K. Vaccine preventable travel health risks: what is the evidencewhat are the gaps? J Travel Med 2015;22(1):1–12. 9. Guse CE, Cortés LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med 2007;14(5):279–87. 10. Rotta AT, Alves PM, Mason KE, et al. Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide. Pediatr Crit Care Med 2014;15(8):e360–3.
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11. Buchanan BJ, Hoagland J, Fischer PR. Pseudoephedrine and air travel-associated ear pain in children. Arch Pediatr Adolesc Med 1999;153(5):466–8. 12. FDA. OTC Cough and cold products: not for infants and children under 2 years of age. 18.11.14. http://www.fda.gov/ ForConsumers/ConsumerUpdates/ucm048682.htm; Accessed 22.01.15. 13. American Academy of Pediatrics. Flying with baby. 28.02.14. http://www.healthychildren.org/English/safety-prevention/ on-the-go/Pages/Flying-with-Baby.aspx; Accessed 22.01.15. 14. American Academy of Pediatrics. Travel safety tips. http:// www.aap.org/en-us/about-the-aap/aap-press-room/news-featuresand-safety-tips/Pages/Travel-Safety-Tips.aspx; Accessed 22.01.15. 15. Levy-Shraga Y, Hamiel U, Yaron M, Pinhas-Hamiel O. Health risks of young adult travelers with type 1 diabetes. J Travel Med 2014;21(6):391–6. 16. Sainato RJ, Rajnik M. Preparing families with children for international travel, pediatric traveler. Curr Probl Pediatr Adolesc Health Care 2015;45(8). 17. Hill DR, Ericsson CD, Pearson RD, et al. Infectious Diseases Society of America. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43(12):1499–539. 18. Kozarsky PE, Keystone JS. ISTM Committee to establish the body of knowledge. Body of knowledge for the practice of travel medicine. J Travel Med 2002;9:112–5. 19. Kozarsky P. The Body of Knowledge for the practice of travel medicine—2006. J Travel Med 2006;13(5):251–4. 20. Talbot EA, Chen LH, Sanford C, McCarthy A, Leder K. Research Committee of International Society of Travel
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21. 22.
23.
24. 25.
26.
27.
28. 29.
Medicine. Travel medicine research priorities: establishing an evidence base. J Travel Med 2010;17(6):410–5. Traveler’s Health/Centers for Disease Control and Prevention. http://wwwnc.cdc.gov/travel; 2015 Accessed 09.01.15. Centers for Disease Control and Prevention. In: GW Brunette, PE Kozarsky, NJ Cohen, et al, (Eds.), CDC Health Information for International Travel, 2016 ed, New York, NY: Oxford University Press; 2016. Red Book 2015: Report of the Committee on Infectious Disease. DW Kimberlin, MT Brady, MA Jackson, and SS Long, eds. 30th ed. Elk Gove Village, IL. American Academy of Pediatrics; 2015. Shoreland Travax. 2015. https://www.travax.com; Accessed 09.01.15. American Society of Tropical Medicine & Hygiene. Approved diploma courses. http://www.astmh.org/Approved_Diploma_ Courses/6237.htm; Accessed 23.01.15. American Society of Tropical Medicine & Hygiene. CTropMeds—Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health. http://www.astmh.org/Certif ication_Program/6167.htm; Accessed 23.01.15. International Society of Travel Medicine. ISTM Certificate of Knowledge. http://www.istm.org/certificateofknowledge; Accessed 23.01.15. Neumann K. Pediatric travel medicine: where we are and where we hope to go. J Travel Med 2012;19(3):137–9. Hagmann SHF, Leshem E, Fischer PR, Stauffer WM, Barnett ED, Christenson JC. Preparing children for International Travel: Need for Training and Pediatric-Focused Research. J Travel Med 2014;21(6):377–83.
Curr Probl Pediatr Adolesc Health Care, August 2015
Planning for Travel With Children in the Modern World Martin G. Ottolini, MD,a,b Michael Rajnik, MD,b and Patrick W. Hickey, MDc
Introduction ou are part of a busy group, primary care, practice in a mid-sized “college town” that serves an economically and culturally diverse patient population. Your first patients of the day are two siblings, a 3-year-old girl and a 9-month-old boy who present with upper respiratory tract symptoms and concern about possible otitis media. The parents, both of whom emigrated approximately 4 years ago to the United States, mention that the family is “traveling home to Cameroon” next week to spend 2 weeks visiting the childrens’ grandparents. Standing in the doorway on the way, the mother asks you if the children “need any shots?” A week later, a family of four comes in to discuss that they are moving to Thailand for an estimated 3 years to follow the parents’ newest positions in a large non-governmental organization (NGO). They include a 47-year-old father with no health problems, a 49-year-old mother who is on chronic therapy for rheumatoid arthritis, and three healthy children with the ages of 9, 14, and 16. They will reside in Bangkok, but will be working on a rural development project in the north near the city of Chiang Mai, will likely visit displaced persons camps near the Thailand-Cambodia border, and plan to travel extensively as a family in the region. Later that day, one of your “routine physical exam” appointments is a healthy 17-year-old female high-school student, who is
Y
From the aOffice of Curriculum, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; bDepartment of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814; and cDepartment of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814. The views expressed herein are those of the authors and are not necessarily representative of those of the Uniformed Services University or the Department of Defense. Curr Probl Pediatr Adolesc Health Care 2015;45:209-214 1538-5442/$ - see front matter & 2015 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.cppeds.2015.06.002
Curr Probl PediatrAdolesc Health Care, August 2015
going to work for 8 weeks at a rural church mission site in the Amazon basin of Peru. She will help staff a program that provides early childhood education in a community of subsistence farming families. She anticipates traveling with another friend, planning to use any free time to extensively explore the region through hiking and kayaking. Each patient or family is asking the same questions, in general. “What can we do to reduce our risk of becoming ill or injured during our stay in these foreign sites? What should we do to prepare for our trips? Do you have any advice we should follow during travel?” The family from Cameroon is not too concerned—after all, they are revisiting a country where they spent most of their lives, and have relatives who know their way around. They have however, not been back home in several years, and the health infrastructure of their country is limited. You are concerned about their “lack of concern” and casual attitude towards advanced preparation. The family moving with the NGO has already had a series of briefings and studied both written and web-based preparation materials. They are also receiving advice from a sponsoring family residing in their future county, arranged by their agency, to help orient them to the culture, challenges, and opportunities of living overseas. They will be residing in a large, rapidly developing country, with access to a modern health care system in most of the major population areas. They do plan to visit several remote sites, and are very proactive about their “planning.” The young missionary is highly enthused and very motivated, but is working with a small group of volunteers working under a newer agency, and does not seem to have as much institutional support for travel preparation. While all three sets of travelers are focuses their concerns on preventing infectious diseases, you note that their planned activities will include several other potential travel risks; including motor vehicle and water-sport hazards, extreme environmental conditions, crime, potential government stability issues, and the simple challenges of the travel infrastructure.
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Overall they wish to anticipate and reduce their “risks” of travel-related illnesses and injuries, and to be ready to take more control of their health and potential therapies in regions where they would need to rely less on ready access to the substantial safety net of a modern health care system.
Extent of Travel in the US Population In 2013, more than 61.8 million U.S. Residents traveled internationally.1 If one excludes travel to the well developed nations of Canada and Europe, 39.8 million U.S. residents traveled to areas of the world that would justify a pre-travel health assessment, risk-based counseling, and preventive medical services (Including 20.9 million travel visits to Mexico). The Figure demonstrates the trends over the last decade in travel to locations outside of North America.2 Overall, 8% of outbound travel parties include children, accounting for approximately 1.2 million child international travelers annually.3 Among all international travelers, the average duration of travel is 16.6 days (median 10 days) showing that both the magnitude and duration of overseas travel as a health-related exposure are quite significant.1 Further, the incubation periods for many travel-associated diseases are such that the illness is most likely to occur after return home.4 Despite a substantial mean lead time from “decision to time of travel” of 106 days, pre-travel health visits are sought out in only 11% of international travelers overall, and in only 36–46% of those traveling to low and lowmiddle income countries.2,5,6
Health Risks in International Travel The majority of travel medicine advice focuses on the prevention, diagnosis, and treatment of infectious diseases, as will the majority of this supplement. Compared to adults, pediatric travelers may be more likely to develop diarrheal, dermatologic, and respiratory illnesses as well as suffer animal bites.7 While the incidence rate of traveler’s diarrhea during a 2-week trip is approximately 30%, and that of influenza approximately 1%, the risk of other vaccine preventable diseases are lower, ranging from 1:3,000 for typhoid fever; to r1:100,000,000 for Japanese encephalitis and meningococcal meningitis.8 These statistics highlight the importance not only of
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risk-benefit and cost-benefit considerations but also consideration and discussion of risk-tolerance and avoidance behaviors on the part of parents, stressing that travel planning options involve a shared decisionmaking process between families and providers. Furthermore, despite the typical focus on infectious health risks, it is important to remind families that serious injuries occur at higher rates when traveling. The major source of pediatric traveler mortality is actually due to both motor vehicle accidents and drowning, both of which are disproportionately high when compared to adults.9 Some parents may have concerns whether it is safe to fly with young infants. A recent review of serious inflight emergencies resulting in consults to a ground based medical support center found that passengers under 18 years of age account for 9.3% of the total inflight emergencies with a rate of 2.24 events per 1 million passengers.10 Deaths were rare (10 total, 0.13% of all pediatric emergencies). While exact cause of death could not be abstracted from the available data, four of the ten had known pre-travel health conditions, with additional associated factors of young age (median 3.5 months), and being a “lap infant” (9 of 10), bringing up the possibility of sudden unexplained infant death (SUID) during trips with sleeping infants.10 More common concerns whether over-thecounter medications can be utilized as either a sedative or prophylactic against barotrauma-related otalgia merit direct discussion with parents as both antihistamines and decongestants pose serious risks to children under the age of two and have shown no benefit in reducing symptoms of air-travel-related otalgia.11,12 Rather, there should be emphasis on enhancing safe, comfortable seating for children, age-appropriate activities, and use of sucking and swallowing techniques to reduce barotrauma with changes in cabin-pressure.13,14 Adolescent (up to age 21) travelers also have unique age-specific considerations when traveling. They are likely to be adventurous and engage in riskier activities, like the missionary in our introduction, both increasing the chances of injury and also creating new infectious disease exposures from fresh-water or soil/ mud contact. Blood borne pathogens (tattoos and piercings) and sexually transmitted infections become significant concerns that should be discussed, as well as broader issues of reproductive health such as contraceptives and sexual violence. Additionally, chronic diseases should be addressed, in terms of direct risk of an exacerbation during travel,
Curr Probl Pediatr Adolesc Health Care, August 2015
as well as their potential to increase risk and severity of secondary or opportunistic infections. While children with chronic diseases such as type I diabetes can safely travel, attention must be given to dosage adjustments, dietary considerations, and activity modification; as well as sufficient supplies for the entire trip.15 For those with immunosuppression due to disease or as a result of medication, there are unique considerations for food and water safety counseling, modified vaccine indications and safety, medication interactions, and dosing considerations for prophylactic medications. There is also a greater need to plan for the contingencies of self-treatment and when needed know how to access to quality medical services while traveling in less-resourced regions. While most travel medicine services can be readily provided in the primary care setting, patients with more complex medical needs may be better served by a travel medicine specialist. Travel medicine requires “situational awareness” the anticipation of the unique risks of the geographic locations to be visited, planning for the likely activities that visitors engage in, as well as being informed of any outbreaks of disease occurring at that time. Travel medicine providers have the responsibility to obtain the most current information about the risks of the sites to which their patients are traveling, and to be prepared to appropriately counsel patients about them. While the risks of some endemic or epidemic infectious diseases can be mitigated through behavioral changes, prophylaxis, or vaccinations, many situations, including natural or man-made disasters, or rapidly emerging infectious diseases cannot be anticipated and leave the
8
traveler at the mercy of the local infrastructure, their own adaptability, and contingency planning. These will be expanded in the pre-travel preparation article, which will include a discussion about the role of additional traveler’s health and evacuation insurance.16
The Practice of Travel Medicine This supplement will present general information regarding travel preparations and post-travel assessment, which although applicable to travelers of all ages will focus on the specific nuances of young children and adolescents. Some of the general principles involved in the management of pediatric travel, which are different than those for adults, are listed in Table 1. As with all good medical practice, basic approaches such as planning and organization of the environment of care, anticipating both common and life-threatening problems, and a practical common sense approach to health counseling in a way that enhances adherence can go a long way to reducing the risk of travel injury and illness. The field of travel medicine has a defined body of knowledge and scope of practice as well an evolving body of research literature upon which to draw.17–20 Access to current disease surveillance information, updated practice guidelines, and other clinical management resources for consultation, all help ensure quality care. We cannot emphasize this final point enough as few practitioners (particularly in a busy primary care practice) can remember the constantly changing
Overseas Travel Destinations for U.S. Residents*
Travelers in Millions
7 6 5
Caribbean South America Central America
4
Africa
3
Middle East
2
Asia
1
Oceania
0
FIG. *Adapted from U.S. Department of Commerce Data. Does not include Mexico, Canada, or European travel.
Curr Probl PediatrAdolesc Health Care, August 2015
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recommendations for drug choice or doses, regional patterns of malaria or enteric pathogen drug resistance, risk-based vaccine recommendations, or the impact of current epidemics, natural disasters, social unrest, or other issues unique to a specific geographic region. In our practice we regularly consult with the Center for Disease Control & Prevention’s general and pediatric travelers’ health websites,3,21 including print and electronic versions of “Health Information for International Travel” (known as the Yellow Book).22 Additional pediatric-specific references include the electronic and print versions of the American Academy of Pediatrics Report of the Committee on Infectious Disease (known as the Red Book).23 Subscription travel health information services, such as Shoreland’s “Travax” can provide itinerary-specific threat assessments, prevention and treatment recommendations, as well as embassy and health care site contact information.24 The use of these and other resources are covered in greater detail later in this supplement. For health practitioners seeking to demonstrate a higher level of knowledge and mastery in the field of travel medicine, two certificate programs exist. The American Society of Tropical Medicine & Hygiene supports training programs and an examination that leads to a Certificate of Knowledge in Clinical Tropical Medicine and
Travelers Health (CTropMed©) and the International Society of Tropical Medicine offers a examination leading to the Certificate of Travelers Health. Instructions on how to obtain these levels of expertise are available at the respective society websites.25–27 A summary of resources for the travel medicine provider is provided in Table 2. One major limitation has been the lack of evidencebased guidance for developing pediatric-specific practices and adapting adult-based recommendations. This was noted in a recent editorial in the Journal of Travel Medicine, which pointed out that while serious pediatric travel-related illness is fortunately less common, many travel medicine experts are uncomfortable with very young children, and are even less confident of evaluating illnesses in the returning travelers.28 A fairly recent development has been the establishment of the “Pediatric Interest Group” (PedIG) within the International Society of Travel Medicine in 2010, in response to the recognition of the significant numbers of pediatric travelers and need for consistent research and training. As pointed out in a recent survey of members, the diversity of training and practice among those working in this area indicates a need for formulation and adherence to age-specific evidencebased guidelines.29
TABLE 1. Unique considerations in planning for travel with children and families
Family centered care is ideal. Families with children should visit a travel clinic/travel medicine provider at least 1 month prior to travel to allow for
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effective prophylactic immunization, beginning prophylactic medications and consult with necessary specialists if children have chronic conditions that may be exacerbated or require management related to travel. Some travel medications (particularly malaria prophylaxis) are not specifically formulated for children, and may require a compounding pharmacy, or parental training in dividing and/or crushing tablets. Ensure previously prescribed chronic and as needed medication supplies are available for the entire duration of a planned trip (e.g., insulin, inhalers, and epinephrine injectors). Controlled substances such as stimulants used for attention deficit disorder may require additional documentation and should be kept in their original packaging. Caution and advanced coordination should be used if traveling with narcotics. Using the same chemoprophylaxis medication for the entire family (or at least those with the same doing interval) may aid adherence. Empiric self-treatment is indicated for some conditions and requires additional counseling compared to that for an adult to do this safely and effectively. Off-label use of medications is common in this setting. Age and risk-factor based vaccine recommendations differ from routine guidance. Off-label use of vaccines, with expert guidance, is sometimes indicated (e.g., Japanese encephalitis vaccine prior to pediatric licensure had modified dosing for children) [Centers for Disease Control and Prevention (CDC). Update on Japanese encephalitis vaccine for children: United States, May 2011. MMWR Morb Mortal Wkly Rep. 2011 May 27;60(20):664–5], and labeled, but non-standard timing, of vaccines is common (e.g., Measles–Mumps–Rubella for travelers aged 6–11 months). Encourage advanced planning regarding health care infrastructure at the destination with consideration for both acute-minor illnesses and emergency care. Recommend purchase of travel health and evacuation insurance if not already covered under an existing program. Young children are totally dependent on adults for food and water safety, medication adherence, protection against insect bites, environmental exposures, and other safety concerns. Age-appropriate verbal and written instructions for counseling are recommended. Children are less cautious and at higher risk of animal bites, accidental trauma, and swimming and other water-related accidents. Specific counseling on these topics is recommended. Low and middle income countries are less likely to have/enforce safety aspects of building codes or have ready availability of safety devices such as car seats, seat belts, and protective fencing. Parents may need to make specific prior arrangements for access to what would be considered routine child safety features in the United States. Particular care should be made to engage international travelers with children who are “Visiting Friends and Relatives,” as this population has unique health risks and health-seeking behavior. Primary care providers should inquire about the potential for upcoming international travel during routine child wellness visits with immigrant families.
Curr Probl Pediatr Adolesc Health Care, August 2015
TABLE 2 Important resources for the travel medicine provider.
Resource
Internet address
Information provided
Centers for Disease Control and Prevention (CDC): travel health webpage and CDC Health Information for International Travel (Yellow Book) CDC Advisory Committee on Immunization Practices (ACIP) CDC: Malaria
http://wwwnc.cdc.gov/travel http://wwwnc.cdc.gov/travel/page/ yellowbook-home also available in print http://www.cdc.gov/vaccines/schedules/ hcp/child-adolescent.html www.cdc.gov/malaria
Destination specific information sheets Disease specific travel information
CDC Vaccines and Immunizations
www.cdc.gov/vaccines
American Academy of Pediatrics: Report of the Committee on Infectious Diseases (Red Book) World Health Organization (WHO): International Travel and Health
www.aap.org
Global Travel EpiNet
www.gten.travel
International Society of Travel Medicine
www.istm.org
American Society of Tropical Medicine & Hygiene
www.astmh.org
Shoreland Travax
www.shoreland.com
U.S. Department of State
www.state.gov/travel
also available in print www.who.int/ith also available in print
References 1. US Department of Commerce, International Trade Commission, National Travel and Tourism Office. 2013 United States Resident Travel Abroad. Washington, DC: July 2014. http:// travel.trade.gov/outreachpages/download_data_table/ 2013_US_Travel_Abroad.pdf; 2015 Accessed 15.01.15. 2. US Department of Commerce, International Trade Commission, National Travel and Tourism Office. Profile of U.S. resident travelers visiting overseas destinations: 2013 Outbound. Washington, D.C.: July 2014. http://travel.trade.gov/ outreachpages/download_data_table/2013_Outbound_Profile. pdf; 2015 Accessed 15.01.15. 3. Travelers’ Health/Centers for Disease Control and Prevention, Traveling with children. http://wwwnc.cdc.gov/travel/ page/children; 2015 Accessed 09.01.15. 4. Flores MS, Hickey PW, Fields JH, Ottolini MG. Evaluating illness in the returning pediatric traveler. Curr Probl Pediatr Adolesc Health Care 2015;45(8).
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Travel/vaccine clinic directory Birth-18 years and catch-up immunization schedules Current recommendations regarding the diagnosis, prevention and treatment of malaria in travelers Latest vaccine recommendations Updates on vaccine preventable diseases Pediatric-specific updates on infectious diseases diagnosis, prevention and treatment (Subscription) International travel health recommendations Updates for travelers IHR International Certificate of Vaccination or Prophylaxis WHO Guide on safe food for travelers Travel Clinic Directory Pre-travel providers’ rapid evaluation portal Traveler’s rapid health information portal Global travel clinic directory On-line travel medicine training materials (subscription) GeoSentinel Surveillance Network Information on the Certificate in Travel Health (CTH) Tropical and travel medicine consultant directory Tropical and travel medicine training materials (subscription) Information on the Certificate of Knowledge in Clinical Tropical Medicine and Traveler’s Health (CTropMed©) Destination specific information sheets Disease specific travel information Traveler safety updates Physician and traveler information sheets (Requires a subscription) Travel Document Requirements Preparing for trips abroad Emergency Information for Travelers Country specific data sheets
5. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med 2004;11(1):23–6. 6. LaRocque RC, Rao SR, Tsibris A, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med 2010;17(6):387–91. 7. Hagmann S, Neugebauer R, Schwartz E, et al. GeoSentinel Surveillance Network. Illness in children after international travel: analysis from the GeoSentinel Surveillance Network. Pediatrics 2010;125(5):e1072–80. 8. Steffen R, Behrens RH, Hill DR, Greenaway C, Leder K. Vaccine preventable travel health risks: what is the evidencewhat are the gaps? J Travel Med 2015;22(1):1–12. 9. Guse CE, Cortés LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med 2007;14(5):279–87. 10. Rotta AT, Alves PM, Mason KE, et al. Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide. Pediatr Crit Care Med 2014;15(8):e360–3.
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