Health Advice for Children Traveling Internationally

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Chapter 168 Health Advice for Children Traveling Internationally

Jessica K. Fairley, Chandy C. John

The health risks and pretravel requirements for children traveling internationally, particularly those <2 yr of age, differ from those for adults. In the USA, recommendations and vaccine requirements for travel to different countries are provided by the Centers for Disease Control and Prevention (CDC) and are available online at www.cdc.gov/travel/content/vaccinations.aspx.

General Travel Preparation

Parents of traveling children should seek medical consultation ≥4-6 wk before departure to obtain a realistic assessment of health risks, a schedule of vaccinations and list of medications, and instructions on dealing with disease during travel.

Health Insurance

Parents should be encouraged to determine whether their health care plan covers health care internationally. If it does, parents should ask about the need for preauthorization for medical treatment, the level of copayment required, and whether emergency medical evacuation is covered. Additional travel insurance that covers emergency medical evacuation and the costs of local care is available at reasonable rates through various providers, and parents should be made aware of this option.

Underlying Medical Illness

Parents of traveling children should be asked whether the child has any current health problems or has had any problems in the past that have required medical evaluation or medication. Parents of children with medical conditions should take with them a brief medical summary and a sufficient supply of prescription medications for their children, with bottles that are clearly identified. For children requiring care by specialists, an international directory for that specialty can be consulted. A directory of physicians worldwide who speak English and who have met certain qualifications is available from the International Association for Medical Assistance to Travelers (www.iamat.org/index.cfm). If medical care is needed urgently when abroad, sources of information include the American embassy or consulate, hotel managers, travel agents catering to foreign tourists, and missionary hospitals.

Children with chronic cardiopulmonary disease, diabetes, allergies, and gastrointestinal (GI) problems, especially diarrhea associated with malabsorption or inflammatory bowel disease, are at particular risk for health problems when traveling. Children with severe food allergies should take several epinephrine autoinjectors with them. Patients with type 1 diabetes or hemophilia should carry an adequate supply of sterile needles, syringes, and disinfectant swabs. Special arrangements should be made for patients with bleeding disorders, those on anticoagulation therapy, and those who require hemodialysis. Biologic products such as clotting factor concentrates or immune globulin should be avoided if they are manufactured abroad. A travel health kit consisting of prescription medications and nonprescription items such as acetaminophen, an antihistamine, oral rehydration solution packets, antibiotic ointment, bandages, insect repellent, and sunscreen is highly recommended for all children.

Safety

Injuries and motor vehicle accidents are the major causes of serious disability, hospitalization, and death during travel. The use of safety belts for children, preferably sitting in the rear seat, as well as the use of larger vehicles and differences in traffic patterns should be emphasized. When possible, child safety-restraint seats should be taken on the trip. Travelers to remote areas should be warned about the risks of venomous animals, because snake and scorpion bites can be fatal in infants. Sunburns are also a major risk when traveling, and vigilantly applying sunscreen to children should be emphasized. Many illnesses that develop in traveling children are related to risks that can be modified with proper advice and supervision by parents.

Infectious Disease Precautions

Infectious disease risks to traveling children can generally be divided into four categories: foodborne infection, insect-borne infection, infection from contact with infected persons or through needle exposure, and infections from infected animals or the environment.

Foodborne Infections

Ingestion of contaminated food or water makes travel-associated diarrhea the most common health complaint among international travelers. Among the bacterial and protozoan infections that children can acquire from contaminated water are shigellosis, salmonellosis, Escherichia coli infections, cholera, giardiasis, amebiasis, and cryptosporidiosis. Viral infections, particularly rotavirus infections, are also a major cause of travel-associated diarrhea in children. Boiled water, hot beverages made with boiled water, and canned or bottled carbonated beverages are generally safest. Ice should be avoided, and tap water should not be used when brushing teeth. Boiling water for ≥1 min (or 3 min at altitudes >2000 m) is the most reliable method of disinfecting water. An acceptable alternative is the use of a micropore filter with an on-demand iodine-release system. Unpeeled fruit, uncooked vegetables, unpasteurized milk or other dairy products such as cheese, and undercooked meat or fish may all be contaminated and should be avoided. Fish, especially reef fish, red snapper, and barracuda, are of particular concern, because they can contain toxins. Breast-feeding should be encouraged for young children, especially infants <6 mo of age.

Insect-Borne Infections

Insect-borne infections for which traveling children are at risk include malaria, yellow fever, dengue, Japanese encephalitis, filariasis, trypanosomiasis, and onchocerciasis, depending on the area of travel. Malaria, yellow fever, Japanese encephalitis, and filariasis are typically caused by night-biting mosquitoes, whereas dengue is usually caused by day-biting mosquitoes.

Exposure to insect bites can be avoided by restricting high-risk activities, staying indoors in a screened and protected area from dusk to dawn, wearing appropriate attire, and using insect repellents containing permethrin or N,N-diethyl-m-toluamide (DEET). Rare instances of toxic encephalopathy have been reported in young children with exposure to high concentrations of DEET, but use of repellent with no more than 40% DEET and avoidance of repeated applications as well as avoiding application to mucous membranes minimize the risk of this complication. Concentrations of 25-35% DEET, to be applied every 4-6 hours as needed, are recommended for children, although longer-acting DEET products are available.

For infants, the parent should apply the repellant to the parent’s hands and then transfer it to the infant, avoiding the infant’s hands and face. Immobile young infants can also be protected by a microenvironment: chemically treated netting placed over car seats, strollers, or carriers. The American Academy of Pediatrics (AAP) recommends avoiding the use of DEET in infants <2 mo of age, given increased skin permeability.

Spraying clothing with permethrin, a synthetic pyrethroid, is a safe and effective method of reducing insect bites in children. Permethrin-sprayed clothes remain effective for ≥2 wk, even with laundering. Bed nets, particularly permethrin-impregnated bed nets, also decrease the risk of insect bites, and their use is highly recommended.

Infections from Contact with Infected Persons or Through Needle Exposure

Many of the infections that may be acquired by children traveling internationally through contact with other individuals are preventable by routine childhood immunizations. Other diseases transmitted through human contact include viral respiratory and GI infections, viral hepatitis, tuberculosis (TB), and sexually transmitted diseases, including HIV infection. Adolescent travelers should be reminded that sexual encounters and needle or blood exposure (including tattooing and body piercing) carry a significant risk of HIV and hepatitis infection. Systematic screening of blood donations for HIV and other bloodborne infections is not yet feasible in many developing countries, so the safety of transfusion services in these countries cannot be ensured. Travelers might wish to have their blood typed before departure to determine whether family members or travel companions have compatible blood types and might be able to donate blood for transfusion in an emergency.

Infections from Infected Animals or Environments

Infections potentially acquired from contact with animals include rabies from stray dogs and plague from rodents. Swimming or diving in contaminated water can result in serious injury and increase the risk of infections such as schistosomiasis, leptospirosis, and primary amebic meningoencephalitis. Proper footwear at all times as well as using a barrier such as a towel to play on the ground should be emphasized, because some parasitic infections, such as hookworm, are transmitted from the soil directly through exposed skin.

Immunizations

Parents should allow 4-6 wk before departure for optimal administration of vaccines to their children, because some immunizations require repeated doses for full protection and some vaccines and medications require either simultaneous or staggered dosing for optimal efficacy. Live-attenuated viral vaccines should be administered concurrently or ≥30 days apart to minimize immunologic interference. Intramuscular immunoglobulin (IG) interferes with the immune response to measles immunization and possibly to varicella immunization. If a child requires measles or varicella immunization, the vaccines should be given either 2 wk before or 3 mo after IG administration (longer with higher doses of intravenous IG). IG does not interfere with the immune response to oral typhoid, poliovirus, or yellow fever vaccines.

Vaccine products produced in eggs (yellow fever, influenza) may be associated with hypersensitivity responses including anaphylaxis in persons with known severe egg sensitivity. Screening by inquiring about adverse effects when eating eggs is a reasonable way to identify those at risk for anaphylaxis from receiving influenza or yellow fever vaccines. Although measles and mumps vaccines are produced in chick embryo cell cultures, children with egg allergy are at very low risk for anaphylaxis with these vaccines. Most hypersensitivity reactions to measles-containing vaccines have been attributed to trace amounts of gelatin or neomycin.

In general, live-virus vaccines (measles, varicella, live-attenuated influenza) and live bacterial vaccines (bacille Calmette-Guérin [BCG], oral typhoid) are contraindicated in immunocompromised persons. However, HIV-infected children who are not severely immunocompromised should receive measles and varicella vaccines (see Table 165-6). Asymptomatic HIV-infected children may also be vaccinated against yellow fever if the risk is significant, but children with symptomatic HIV infection should not receive yellow fever vaccine. Inactivated vaccines and toxoids are not contraindicated in immunocompromised children but may be associated with diminished immune responses.

Routine Childhood Vaccines

All children who travel should be immunized according to the routine childhood immunization schedule with all vaccines appropriate for their age (Chapter 165). The immunization schedule can be accelerated to maximize protection for traveling children, especially for unvaccinated or incompletely vaccinated children (see Fig. 165-4).

Diphtheria, Tetanus, and Pertussis

Diphtheria is endemic in many developing countries. After the disintegration of the Soviet Union in 1991, diphtheria re-emerged in the new independent states, highlighting the potential for new outbreaks under the right circumstances. Tetanus is a major cause of worldwide neonatal mortality and is most prevalent in tropical countries. Pertussis is common in developing countries and in some developed nations where pertussis immunization is less widespread than in the USA because of earlier concerns about the pertussis vaccine’s adverse effects. The incidence of pertussis also appears to be increasing in the USA with concern of waning immunity in adolescents and adults. Children traveling internationally should be up to date on diphtheria and tetanus toxoids and acellular pertussis (DTaP) immunization with completion of 5 doses by 4-6 yr of age. A single dose of an adolescent preparation of tetanus and diphtheria toxoids and acellular pertussis (TdaP) vaccine is recommended at 11-12 yr of age for those who have completed the recommended diphtheria, tetanus toxoids, and pertussis (DTP)/DTaP series and have not received a tetanus-diphtheria (Td) booster dose. Adolescents 13-18 yr of age and adults who have completed the DTP/DTaP series, have never received Tdap, and in whom it has been 5 yr or more since their last Td booster dose also should receive a single dose of TdaP.

Infants and children <7 yr old who have not completed the series may be immunized using an accelerated schedule in preparation for international travel (see Fig. 165-4). There is some protection after 2 doses 4 wk apart, but there is little benefit with only 1 dose.

Haemophilus Influenzae Type B

H. influenzae type b remains the leading cause of meningitis in children 6 mo to 3 yr of age in many developing countries. Before they travel, all unimmunized children <60 mo of age and all children with chronic illness at risk for H. influenzae type b infections should be vaccinated (Chapter 165). If a child <15 mo is unvaccinated, ≥2 doses 4 wk apart starting no younger than 6 wk of age should be given before travel. Between 15 and 59 mo, 1 dose should be given. Unvaccinated children >59 mo of age do not need vaccination unless they are at risk due to an immunosuppressive condition.

Hepatitis B

Hepatitis B is highly prevalent in eastern and southeastern Asia, sub-Saharan Africa, and the Pacific basin. In certain parts of the world, 8-15% of the population may be chronically infected. Disease can be transmitted via blood transfusions not screened for hepatitis B surface antigen, exposure to unsterilized needles, close contact with local children who have open skin lesions, and sexual exposure. Exposure to hepatitis B is more likely for travelers residing for prolonged periods in endemic areas. Partial protection may be provided by 1 or 2 doses, but ideally 3 doses should be given before travel. See Figure 165-4 for the accelerated schedule. For unvaccinated adolescents, the first 2 doses are 4 wk apart, followed by a third dose 4-6 mo after the second one.

Measles, Mumps, and Rubella

Measles is still endemic in many developing countries and in some industrialized nations. Measles vaccine, preferably in combination with mumps and rubella vaccines (MMR), should be given to all children at 12-15 mo of age and at 4-6 yr of age, unless there is a contraindication (Chapter 165). In children traveling internationally, the second vaccination can be given as soon as 4 wk after the first. In the accelerated schedule, the first MMR vaccination can be given to children as young as 6 mo of age, but if the vaccine is given earlier than 12 mo of age, the child should be considered unvaccinated and given 2 additional doses ≥4 wk apart after 12 mo of age (see Fig. 165-4). Infants <6 mo of age are protected by maternal antibodies. HIV-infected children who travel abroad should be vaccinated unless they are severely immunocompromised (Chapter 268), because measles in HIV-infected children can be a devastating illness.

Pneumococcus

Streptococcus pneumoniae is the leading cause of bacterial pneumonia and among the leading causes of bacteremia and bacterial meningitis in children in developing and industrialized nations. Immunization against S. pneumoniae with a protein-conjugated pneumococcal vaccine is now part of routine childhood immunization in the USA. Unimmunized children should be immunized if they are at high risk, such as children with sickle cell disease, asplenia, HIV infection, congenital immunodeficiency, nephrotic syndrome, or chronic cardiac or pulmonary disease and those on immunosuppressive medication (Chapter 165). The Advisory Committee on Immunization Practices (ACIP) recommends that these children receive both the conjugate pneumococcal vaccine and the 23-valent polysaccharide vaccine ≥8 wk after the last conjugate vaccine dose. The ACIP also recommends that vaccination with conjugate pneumococcal vaccine be considered in all healthy unimmunized children 24-59 mo of age with 1 dose; conjugate pneumococcal vaccination of unimmunized children in this age group traveling internationally should be strongly considered for unvaccinated children between 6 wk and 12 mo of age should receive 2-3 doses of conjugate pneumococcal vaccine (depending on the age when starting the series) ≥4 wk apart with a booster at age 12-15 mo. For unvaccinated children ages 12-23 mo, 2 doses should be given ≥8 wk apart.

Poliomyelitis

Poliomyelitis was eradicated from the Western hemisphere in 1991 but remains endemic in several developing countries, and the 2004 epidemic in Nigeria underscored the importance of vaccination for preventing this disease. The poliovirus vaccination schedule in the USA is now a 4-dose, all-inactivated poliovirus (IPV) regimen (Chapter 165). Oral poliovirus vaccine (OPV) is no longer available in the USA. Unvaccinated adults who are at increased risk for exposure to poliovirus and who cannot complete the recommended IPV regimen (0, 1-2, and 6-12 mo) should receive 3 doses of IPV given ≥4 wk apart. For an accelerated dosing schedule for children, see Figure 165-4. Length of immunity conferred by IPV immunization is not known; a single booster dose of IPV is recommended for fully vaccinated adults traveling to endemic areas. Proof of vaccination is required to enter Saudi Arabia for the Hajj.

Rotavirus

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