4/18/2013 Disclosure Trying to Prevent Illness in Kids • I have nothing to disclose Who Travel… Diagnosing it when they Return 46 th Advances & 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) 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 1
4/18/2013 Contact Card Anticipatory Guidance: Stuff • Safety considerations – car seats, • Travelers should carry a contact card with the 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 Immunizations for Travelers Immunizations: General • Make sure current on routine • General principles • 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 – • Meningococcal Sub-Saharan Africa, Tropical So America – – Recommended for Sub Saharan meningitis belt in dry or if traversing winter months of Nov-June • Typhoid – Live virus – contraindicated if immune-comp – Vi polysaccharide, IM, 2y/0; Ty 21a, oral, 6 yr) – For 9 mos or older, contraindicated < 4 mo • Rabies (risk determined) • Meningococcal vaccine • Japanese B encephalitis (risk determined) - Required for pilgrims to Hajj age 15 or older 2
4/18/2013 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 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; – Long sleeves, pants So. South America – Permethrin-treated mosquito netting – North Africa, Turkey-Iraq, Soviet republics, Korea • Chemoprophylaxis 3
4/18/2013 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 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), rifaxamin 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 4
4/18/2013 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%) 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” 5
4/18/2013 Cutaneous Larva Migrans Syndrome: Systemic febrile illness • Most common skin dz • Malaria (35%) in travelers to tropics • Viral syndromes (28%) • Larvae of dog hookworm • Unspecified febrile illness (11%) (Ancystoloma • Dengue (6%) braziliense) • Enteric fever (6%) • Soil, sand contact • Rx topical • “Mononucleosis Sd” (4%) thiabendazole, PO – [EBV,CMV, Toxo] ivermectin Syndrome: Respiratory dz Syndrome: Non-diarrheal GI • URI (38%) • Schistosomiasis (15%) – Middle East, SubSaharan Africa, Caribbean • Reactive airway dz (20%) • Strongyloidiasis (11%) • AOM (17%) • Hepatitis A (11%) Final Thoughts Geographic association with illness • 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. 6
4/18/2013 References: Travel Medicine Travel: Summary 1. Pre-travel advice/guidance by the PCP may prevent some • www.cdc.gov/travel adverse health outcomes. • www.who.int 2. Custody issues may arise with a sole parent and children • Travel Medicine; Keystone, Kozarsky, Freedman, crossing international borders. Nothdurft, Connor, 2004 • Health Information for International Travel 2005-2006; 3. Malaria prevention - bite avoidance and Arguin, Kozarsky, Navin, Eds. CDC chemoprophylaxis - should be instituted for all family members. • Illness in Children after International Travel: Analysis from the GeoSentinal Surveillance Network. Hagmann S 4. Traveler’s diarrhea is a common problem in most et al, Pediatrics 2010, e1072 developing countries. 5. Workup for illness upon return from international destinations needs to be primarily guided by areas visited. 7
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