Disclosure I have nothing to disclose Trying to Prevent Illness in - PDF document

5/16/13 Disclosure • I have nothing to disclose Trying to Prevent Illness in Kids Who Travel…Diagnosing it when they Return 46 th Advances and Controversies in Clinical Pediatrics Jay Tureen, M.D. International Travel with Kids Health and Travel • CDC estimates ~ 1.9 M children travel to • Health and Travel – general developing countries annually information • 22-64% of all travelers self report illness during or after travel • Outbound • Car accidents and drowning are most common cause of death in international travelers • Inbound • 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) 1

5/16/13 Outbound Anticipatory guidance: Data • Contact Card with information to have in • Anticipatory guidance one place • Immunizations • Personal ID for minor children (but not visible) • Medications • Notarized letter from other parent if single parent traveling with child internationally • Other stuff Contact Card Anticipatory Guidance: Stuff • Travelers should carry a contact card with the • Safety considerations – car seats, addresses and phone numbers of the following: sunblock • Designated person back home contact information • Medical kits (CDC website) • Health care provider(s) at home • Water sterilization tabs/ORS powder • Place of lodging at the destination • Chart for estimating dehydration • 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 2

5/16/13 Immunizations for Travelers Immunizations: General • General principles • Make sure current on routine • Anticipate risk of exposure • Required • Season, Location and Type of travel • Recommended • Traveler specific issues • PCP can do all (easily) except – YF, JE, rabies Immunizations: Required Immunizations: Recommended • Routine immunizations need to be UTD • Yellow Fever • Hepatitis A (common vaccine preventable) – For endemic countries or regions – Sub- • Meningococcal Saharan Africa, Tropical So America – or if – Recommended for Sub Saharan meningitis belt in dry traversing winter months of Nov-June – Live virus – contraindicated if immune-comp • Typhoid – For 9 mos or older, contraindicated < 4 mo – Vi polysaccharide, IM, 2y/0; Ty 21a, oral, 6 yr) • Meningococcal vaccine • Rabies (risk determined) • Japanese B encephalitis (risk determined) -Required for pilgrims to Hajj age 15 or older 3

5/16/13 Immunizations: Planning Outbound: Issues to anticipate • Hep A: 0, 6 mos • Malaria • Rabies: 0, 7, 21-28d – Bite prevention – Meds • JE: 0, 7, 14-30d (delayed hypersensitivity • Travelers diarrhea up to 10 d) – Avoidance • Typhoid: IM x1, PO over 7 d; 2 wks before – Management exposure • YF: SQ 10 d before travel (will need referral to YF licensed provider) 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 4

5/16/13 Malaria: Prevention Malaria: Resistant P. falciparum • Mosquito bite avoidance • Chloroquine-resistant P. falciparum – Anopheles are dusk to dawn feeders – avoid – Africa, Asia, tropical So. exposure America • Chloroquine-sensitive P.f. – Repellents – DEET (20-30%) – Mexico to Costa Rica; So – Long sleeves, pants South America – Permethrin-treated mosquito netting – North Africa, Turkey-Iraq, Soviet republics, Korea • Chemoprophylaxis Malaria Chemoprophylaxis Malaria: terminal prophy • Mefloquine • Primaquine – infants (5 kg) and children – Used to eliminate hepatic reservoir of P vivax and P ovale • Malarone (atovaquone-proquanil) – Contraindicated in G6PD def (test if at risk) – toddlers (11 kg) and children – Used in patients with prolonged exposure • Doxycyline – children >8 yr • Chloroquine – infants and children 5

5/16/13 Traveler’s Diarrhea TD: Prevention • Risk reduction • Most common travel health problem – “Cook it, peel it, boil it or don’t eat it” – Fecal-oral transmission – Advise bottled drinks, no ice • Bacteria (80%) • Prophylaxis – ETEC, campylobacter, salmonella, shigella – bismuth subsalicylate: (65% effective) • Viruses – Antibiotic prophylaxis: (90% effective) – rotavirus, norovirus • Short-term manage with loperamide with Abx as • Parasites back up • Giardia, amoeba, cryptosporidium – Cipro, azithro (esp SE Asia), rifamaxin Assessment of dehydration in infants TD: if it happens (Modified from CDC) SIGN MILD MODERATE SEVERE • Assessment of fluid losses GENERAL Thirsty, agitated Thirsty, irritable Less responsive, • Assessment of Clinical severity 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 6

5/16/13 TD: if it happens Inbound • Assessment of clinical severity • GeoSentinel survey • Clinician-based surveillance of ill child – Mild (1-2/24h, minimal sx, watch hydration) travelers in travel clinics worldwide – Moderate (>3/24 hr, add loperamide) • 1997-2007 – Severe (mod-severe abdominal pain, bloody, fever) • Start antibiotics, maintain hydration » Pediatrics 2010 Demographics Clinical Syndromes • 1840 children • 21 broad syndromic categories identified • Age evenly distributed 0-5, 6-11, 12-17 • 93% in 5 categories: • 14% req’d hospitalization, highest < 5y/o – Diarrheal disorders (28%) • 40-45% were <7 d from travel – Dermatologic disorder (25%) • c/w adults, less likely to have pre-travel – Systemic febrile illness (23%) information – Respiratory disorders (11%) – Non-diarrheal GI disorder (7%) 7

5/16/13 Syndrome: Diarrheal Disorder Syndrome: Dermatologic dz • Acute (80%) • Animal bites (24%) – Bacterial (29%) [campylobacter, salmonella] • Cutaneous larva migrans (17%) – Parasitic (25%) [giardia 47%] • Insect bites (12%) – Gastroenteritis, no cause identified (28%) • Chronic [> 2 wks] (20%) – “post-infectious IBS” Cutaneous Larva Migrans Syndrome: Systemic febrile illness • Most common skin dz • Malaria (35%) in travelers to tropics • Viral syndromes (28%) • Larvae of dog • Unspecified febrile illness (11%) hookworm (Ancystoloma • Dengue (6%) braziliense) • Enteric fever (6%) • Soil, sand contact • Rx topical • “Mononucleosis Sd” (4%) thiabendazole, PO – [EBV,CMV, Toxo] ivermectin 8

5/16/13 Syndrome: Respiratory dz Syndrome: Non-diarrheal GI • URI (38%) • Schistosomiasis (15%) • Reactive airway dz (20%) – Middle East, SubSaharan Africa, Caribbean • Strongyloidiasis (11%) • AOM (17%) • Hepatitis A (11%) Geographic association with illness Final Thoughts • Malaria: Sub Saharan Africa • Travel advice within the purview of PCP • Dengue: Asia, Latin America, Caribbean • Handouts, checklists can be developed (or modified from existing) • Dermatologic (CLM): Latin America, Carib • Most vaccines can be given in ofc (x YF) • Derm (animal bites): Asia, N Africa with pre-planning • Diarrheal illness: N Africa, Middle East • Prophylaxis can be rx’d • Anticipatory guidance relating to most common conditions can be provided. 9

5/16/13 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 10