Preventive pediatric travel medicine

Educational Objectives

The goal of this lecture is to improve the prevention and management of infectious diseases in children traveling to foreign countries. After hearing and assimilating this program, the clinician will be better able to:

1. Administer routine and travel-specific vaccinations to children traveling to foreign countries.

2. Prescribe prophylactic medications for pediatric travelers and give health advice for preventing travel-related illnesses.

Summary

Study: interviews among travelers at Logan Airport traveling to low- or low-middle income countries showed that ≈50% did not pursue any health information before travel; general characteristics of those not seeking advice — foreign born; traveling alone; traveling <14 days; traveling for vacation; reasons — lack of concern; did not think about health issues; sources of information — of those who sought health information, most found it on internet; 11% visited Centers for Disease Control and Prevention (CDC) Travelers’ Health Website

Routine immunizations: question — what change in routine vaccination schedule appropriate for 7-mo-old child traveling to Nigeria? answer — give measles, mumps, rubella (MMR) vaccine early; breakthrough disease increasingly reported; children should be up to date with routine vaccines; initiate immunizations early; alter schedules as needed for specific destination

Accelerated routine for vaccination of infants and toddlers: MMR — can begin at 6 mo of age, but 2 doses at 1 yr of age still required (evidence indicates durability of immunity from these 2 doses better after 1 yr of age); for all infant vaccines, minimum interval ≈4 wk and minimum age to start 6 wk (except hepatitis B vaccine, which can be given to neonates); minimum interval for MMR, 4 wk for 2 doses (repeat both doses after 1 yr of age); varicella and hepatitis A vaccine — minimum age remains 12 mo of age; minimum intervals can be slightly changed

Hepatitis A virus: geographic distribution — areas with questionable safety of food and water supply (also Greenland); vaccination recommended for travel to areas with high or intermediate prevalence; becoming routine vaccination for everyone >1 yr of age; immune globulin (Ig) — use decreasing; indicated for children <1 yr of age (for whom vaccine not indicated); also indicated for those with chronic medical problem (as well as for all adults >40 yr of age) <2 wk before travel if staying abroad for extended period of time; consider for immunocompromised patients; vaccine — indicated for most healthy people ≤40 yr of age; give first dose before travel and second dose later

Yellow fever vaccine recommendations: from CDC Health Information for International Travel (“Yellow Book”; available online); instead of maps showing areas in which disease endemic or epidemic, it now has colorized maps to indicate vaccine recommendations; world locations divided into “recommended,” “generally recommended,” or “not recommended”; children <6 mo of age at highest risk for developing postvaccination encephalitis after yellow fever vaccination (although rare); advise parents of child <6 mo of age against taking child to areas within yellow fever endemic zones; for children 6 to 9 mo of age, weigh risks and benefits; for children >9 mo of age, immunize when indicated or required by country being visited

Typhoid: prevalent in areas similar to those with hepatitis A (except Greenland); recommendations for prevention — for children <2 yr of age, food and water precautions; children 2 to 6 yr of age, add parenteral vaccine; children ≥6 yr of age, add parenteral or oral vaccine; for those who travel to higher-risk areas repeatedly, booster now defined for both parenteral (every 2 yr) and oral (every 5 yr) vaccines; efficacy of vaccines 50% to 80% (hence necessity of food and water precautions); both vaccines safe

Japanese encephalitis (JE): geographic distribution — primarily Asia; vaccine recommendations — for those traveling ≥1 mo during transmission season or taking up residence in endemic area; risk seasonal in temperate climates but year-round in more tropical climates; risk for short-term travel and travel to urban areas low; limited vaccine options for children — enroll in clinical trial; give JE-VC vaccine off label (approved for people ≥17 yr of age); refer to travel clinic in Asia for vaccine licensed in destination country (information on CDC website)

Rabies: geographic distribution — worldwide; cases — 9-yr-old boy visiting India with his family dies of rabies; had no known exposure, except perhaps being licked by dog; 3-yr-old French child dies of rabies after visit to Gabon; had no known exposure to animals; prevention — speak to children about avoiding animals; encourage them to tell parents about any exposures; have plan of action if exposure occurs (eg, travel to location in which rabies immune globulin [RIG] available); World Health Organization (WHO) approach to postexposure prophylaxis differs from approach in United States; United States recommendation — if not previously immunized and exposure occurs, administer RIG plus vaccine; if previously immunized, give or continue vaccine series; WHO recommendation — for category II exposure (ie, nibbling of uncovered skin, minor scratches or abrasions without bleeding), immediate vaccination and local treatment of wound (no RIG)

Traveler’s diarrhea: leading cause of morbidity in returning travelers; azithromycin now approved for use and effective in children <2 yr of age; advise parents about oral rehydration; oral rehydration solution packets commonly available and good option; bismuth subsalicylate compounds (eg, Kaopectate, Pepto-Bismol) not recommended for children because of salicylate component; loperamide (eg, Diamode, Imodium, Kao-Paverin) acceptable for children; however, it may distract from need for oral rehydration and may slow passage of infectious bacteria; no change in diet or food restrictions indicated; azithromycin — drug of choice, but has no standardized regimen; travel medicine experts recommend 10 mg/kg per day for 1 to 3 days; quinolones not approved for children <18 yr of age; amoxicillin, trimethoprim-sulfamethoxazole (eg, Bactrim, Cotrim, Septra), and erythromycin less effective; rifaximin approved for people ≥12 yr of age, but only for traveler’s diarrhea caused by noninvasive strains of Escherichia coli

Food and water precautions: recent studies have found that counseling travelers to "boil it, cook it, peel it, or forget it" does not decrease rates of acquisition of traveler&apos;s diarrhea (not including, eg, typhoid fever, hepatitis A); probably related to difficulty of maintaining regimen; continue to give this advice; location of dining possibly more important than type of food eaten (restaurants less safe than eating at home; food served hot almost always safe (except buffets with food cooked earlier and left sitting out); dry foods (eg, cakes, cookies, bread) generally safe; factory-sealed beverages and carbonated sealed beverages safe; boiling water effective

Prevention of malaria: use chemoprophylaxis plus personal protective measures against mosquito bites (eg, impregnated bed nets, protective clothing [eg, materials saturated with permethrin], insect repellants); 25% N,N-diethyl-meta-toluamide (DEET) — apply every 4 to 5 hr, more frequently if mosquitoes start biting sooner; in study, protection time of product with 25% DEET concentration 5 hr (±37 min) under ideal circumstances; synthetic oil of lemon eucalyptus contraindicated for children <3 yr of age; can use ±30% DEET for children >2 mo of age; products with higher percentages of DEET protect somewhat longer than lower percentages, but ≈50% DEET offers no increase in protection time; time affected by perspiration, level of activity, water exposure, and ambient temperature; advise patients to apply sunscreen first, then DEET repellant (order matters)

Chemoprophylaxis: chloroquine for chloroquine-susceptible Plasmodium falciparum (primarily found in Caribbean); for chloroquine-resistant P falciparum, options include atovaquone-proguanil (Malarone), mefloquine, doxycycline (for individuals ≥8 yr of age), and primaquine (must check for glucose-6-phosphate dehydrogenase deficiency first); pediatric formulation (tablet) of atovaquone-proguanil available (dosed according to weight); can begin taking as little as 1 to 2 days before travel, but must take daily

Readings

Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-4; Multistate outbreak of human Salmonella typhimurium infections associated with aquatic frogs United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;58(51):1433-6; Additional recommendations for use of tetanus toxoid, reduced-content diphtheria toxoid, and acellular pertussis vaccine (Tdap). Pediatrics. 2011;128(4):809-12; Notes from the field: Infections with Salmonella I 4,[5],12:i:- linked to exposure to feeder rodents United States, August 2011-February 2012. MMWR Morb Mortal Wkly Rep. 2012;61:277; Notes from the field: outbreak of salmonellosis associated with pet turtle exposures — United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(4):79; Abougergi MS, Kwon JH: Intravenous immunoglobulin for the treatment of Clostridium difficile infection: a review. Dig Dis Sci. 2011;56(1):19-26; Enoch DA et al: Clostridium difficile in children: colonisation and disease. J Infect. 2011;63(2):105-13; Fradin MS, Day JF: Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002;347(1):13-8; Kim J et al: Risk factors and outcomes associated with severe clostridium difficile infection in children. Pediatr Infect Dis J. 2012;31(2):134-8; LaRocque RC 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; Nylund CM et al: Clostridium difficile infection in hospitalized children in the United States. Arch Pediatr Adolesc Med. 2011;165(5):451-7; Sandora TJ et al: Epidemiology and risk factors for Clostridium difficile infection in children. Pediatr Infect Dis J. 2011;30(7):580-4.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In this lecture, Dr. Hsu presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Hsu was recorded at Current Clinical Pediatrics 2012, held April 16-20, 2012, in Hilton Head Island, SC, and sponsored by Boston University School of Medicine, Department of Pediatrics and Office of Continuing Medical Education. To attend the next Current Clinical Pediatrics, visit www.bumc.bu.edu. The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program. Editor’s note: CDC Health Information for International Travel (Yellow Book 2012) can be accessed at http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD581401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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