Pediatric Infectious Disease: Special Considerations for Travel

Educational Objectives

The goal of this program is to improve management of travel-related disease. After hearing and assimilating this program, the clinician will be better able to:

1. Identify patients who require travel-related vaccines.
2. Advise patients on chemoprophylaxis for travel-related diseases.
3. Choose medications for treatment of malaria.

Summary

Travel medicine: 35% to 50% of travelers in North America and Europe seek medical advice; 10% to 20% visit the travel clinic; percentages decline in cases of persons who are visiting friends or relatives; prevention is more important than diagnosis

Required knowledge for providers of travel medicine: geographical knowledge is needed; the epidemiology, transmission, and prevention of travel-associated infectious disease should be familiar; providers must consider travel-related medications and vaccines; timing of vaccines, storage and handling, indications, contraindications, drug interactions, and adverse effects of prescribed medications must all be considered; travel risk not associated with infectious disease (eg, environmental factors) also must be planned for; physicians should recognize major syndromes which involve fever or diarrhea in returning travelers; access to travel medicine resources for travelers should be ensured

Considerations for the pretravel visit: medical history — the country of origin, length of stay, pregnancy status, cardiac risk factors, pulmonary illness, mental health, immune suppression, and level of risk for HIV infection should be considered; medications (consider drug-drug interactions), allergies to medication or food (especially eggs, gelatin, and antibiotics), previous tolerance of vaccines and antimalarial drugs, history of hepatitis or jaundice, history of travel and travel-related illness, and immunization history are relevant; itinerary — destination, season and duration of travel, reason for traveling, mode of travel, standard of accommodation, level of food hygiene and sanitation, and planned activities should be taken into consideration

Risks during travel: travelers should be counseled on vaccine-preventable diseases, avoidance of mosquitoes and other vectors, malaria prophylaxis, and prevention and treatment of traveler’s diarrhea; waterborne illness, personal safety, behavior and sexual health practices, environmental illness (eg, altitude changes), motion sickness, jet lag, risk for animal bites, travel health and medical evacuation insurance, and access to medical care should be discussed; precautions — food should be thoroughly cooked, fruit should be peeled or canned, and beverages bottled or packaged; ice or food made or washed with tap water should be avoided; tap water should be boiled before drinking; sun exposure should be considered; apps are able to record person medical details; medical alert bracelets may be provided; visits to relatives — 50% of malaria cases and 75% of typhoid fever cases in the United States derive from visits to friends or relatives

Travel vaccines: the cost of vaccination is relevant; select vaccines are only available in travel clinics; vaccine information statements and the traveler’s health page on the Centers for Disease Control and Prevention (CDC) website and the CDC Yellow Book may be consulted; travel vaccines are either routine, recommended, or required; individuals should be current on all routine childhood vaccinations; if vaccination records are unavailable, serologic testing should be performed and the traveler considered susceptible to infection; guidelines are available for accelerated courses; travelers may require yellow fever or meningitis vaccines; allergies to vaccine components and concurrent moderate to severe illness should be recorded; select vaccines are contraindicated for a certain duration after immune globulin administration

Vaccinations

Yellow fever: vaccine certification is required for providers; the vaccine is required by international health regulations when traveling to or passing through endemic regions; a live attenuated virus vaccine which should be administered ≥10 days prior to travel; contraindicated in persons with altered thymic function or thymectomy, immunocompromised status, and children <9 mo of age; persons >60 yr of age may be at higher risk for adverse effects

Cholera: single-dose oral vaccine is approved for persons ≥2 yr of age; the Advisory Committee on Immunization Practices recommends this vaccine for travel to areas of toxigenic cholera transmission; not routinely recommended by the World Health Organization or the Infectious Diseases Society of America (IDSA)

Hepatitis A: the highest cause of morbidity for travelers; the vaccine is recommended for all travelers >1 yr of age; the disease is often self-limited and asymptomatic, but the mortality is >2% in people ≥40 yr of age; the seroconversion rate is ≥96% after 1 dose; titers should be checked or a second dose administered; a weight-based serum immunoglobulin for immunocompromised patients and persons <1 yr of age may be used; an inactivated viral vaccine (Havarix, VAQTA are interchangeable) may be given as 2 doses 6 to 18 mo apart; a bivalent vaccine (Twinrix) covers hepatitis A and B; given as a 3-dose series

Japanese encephalitis: a mosquito-borne viral disease with a very low risk of acquisition; the 2-dose vaccine is effective; doses are administered 28 days apart or as an accelerated course with 7 days between doses; associated with a small risk for a hypersensitivity reaction or delayed hypersensitivity (travel may not begin until 10 days after the second dose)

Meningococcus: the vaccine covers strains A, C, Y, and W-135

Rabies: pre-exposure prophylaxis is available; causes encephalopathy and death; occupational and recreational exposure should be considered; individuals should have ≥2 doses before traveling but must finish the series after returning

Tick-borne encephalitis: the risk is highest in spring and summer; exposure occurs when hiking or from consuming unpasteurized dairy products; the TicoVac vaccine was recently approved for children ≥1 yr; 3 doses are administered over 12 mo

Typhoid fever: 77% of cases result from visits to friends, family, and relatives; persons traveling for <4 wk account for ≈48% of cases; 25% of cases occur in children <10 yr of age; there is increased antibiotic resistance to Salmonella typhi; an injectable vaccine and a live attenuated oral vaccine are available; immunity with the oral vaccine is slightly better; protection is 50% to 70%; patients should be informed of water safety practices

Monkeypox: an orthopox virus; a live attenuated nonreplicating vaccine for smallpox is used; 2 doses are administered 4 wk apart in normal circumstances; the population at risk is primarily men having sex with men, but interfamily transmission also occurs with skin-to-skin contact

Hepatitis B: the vaccine is recommended for everyone; ≤75% of injections administered abroad are with reused unsterilized needles; the accelerated schedule uses doses 2 mo apart; ≈65% convert at 1 mo; 3 versions are available; the hepatitis B vaccine (recombinant) adjuvanted (Heplisav-B) contains greater amounts of antigens than others; a repeat course may be needed for individuals who do not fully respond

Other vaccines: the anthrax vaccine is not available; Bacille Calmette-Guérin (BCG) vaccine is not given in the United States; may be considered for children <5 yr of age in endemic areas; a purified protein derivative skin test is recommended before travel and 3 mo after return to assess for latent tuberculosis infection; rotavirus vaccination is recommended for traveling infants

Traveler’s diarrhea: the most common illness for travelers; defined as ≥3 loose stools over 24 hr with fever, nausea, vomiting, and abdominal cramps; most cases resolve over 3 to 5 days; 46% to 60% of people traveling for >2 to 3 wk develop diarrhea; enterotoxigenic Escherichia coli is the most common cause (30%), followed by enteroaggregative E coli, Salmonella, Campylobacter, Shigella, Vibrio cholera, viral infections, and parasites; partial protection from enterotoxigenic E coli is conferred by the cholera vaccine

IDSA guidelines: chemoprophylaxis is recommended; antibiotics are not recommended because of the risk for resistance; bismuth subsalicylate and Lactobacillus GG are recommended; antibiotics may be given for <3 wk to patients with achlorhydria, proton pump inhibitor use, immunodeficiency or HIV/AIDS, history of bowel surgery, inflammatory bowel disease, diabetes mellitus, or diuretic use; ciprofloxacin or rifaximin are recommended

Self-treatment for diarrhea: fluoroquinolones are recommended, but Campylobacter species demonstrate growing resistance in Southeast Asia and India; azithromycin is now advised because of its broad enteropathogenic coverage, short course, and efficacy; rifaximin has <1% absorption, is safe, provides broad coverage; patients with dysentery symptoms should avoid rifaximin; patients should be reassessed in ≥3 days; fluroquinolones may increase the risk for Clostridioides difficile infection and tendon issues in children

Malaria chemoprophylaxis: malaria is the most common cause of preventable death and fever in travelers; chloroquine — the drug of choice when traveling to areas endemic with nonresistant strains; well tolerated and safe in pregnancy; atovaquone/proguanil (Malarone) — the shorter duration of the drug improves compliance; effective against all malaria species except the hypnozoite forms of Plasmodium vivax and P ovale; caution should be exercised with patients with renal disease; not safe in pregnancy; mefloquine — causes a neuropsychiatric reaction in ≈5% of patients; side effects develop in 25% to 40% of patients; effective against all species except multidrug-resistant P falciparum; doxycycline — low cost; well tolerated and covers all malarial species; side effects include gastrointestinal upset, hypersensitivity, photosensitivity rash, and pill esophagitis; primaquine — covers all malaria species including hypnozoite forms of P vivax and P ovale; tafenoquine — approved for patients >18 yr of age; effective against all Plasmodium species; not for use in persons with glucose-6-phosphate dehydrogenase deficiency or unknown status, pregnant women or those who are lactating, persons with psychotic disorders or known hypersensitivity

Post-travel care: patients should be monitored for fever; malaria may present ≤1 yr after return from travel; monitoring for food- and water-borne diseases and skin-related infections is recommended

Readings

Balogun O, Brown A, Angelo KM, et al. Acute hepatitis A in international travellers: a GeoSentinel analysis, 2008-2020. J Travel Med. 2022;29(2):taac013. doi:10.1093/jtm/taac013; Chu CS, Freedman DO. Tafenoquine and G6PD: a primer for clinicians. J Travel Med. 2019;26(4):taz023. doi:10.1093/jtm/taz023; Gabutti G, Rossanese A, Tomasi A, et al. Cholera, the current status of cholera vaccines and recommendations for travellers. Vaccines (Basel). 2020;8(4):606. Published 2020 Oct 14. doi:10.3390/vaccines8040606; Jonker EF, Visser LG, Roukens AH. Advances and controversies in yellow fever vaccination. Ther Adv Vaccines. 2013;1(4):144-152. doi:10.1177/2051013613498954; McBride WJ. Chemoprophylaxis of tropical infectious diseases. Pharmaceuticals (Basel). 2010;3(5):1561-1575. Published 2010 May 18. doi:10.3390/ph3051561; O'Ryan M, Vidal R, del Canto F, Carlos Salazar J, Montero D. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: part II: vaccines for Shigella, Salmonella, enterotoxigenic E. coli (ETEC) enterohemorragic E. coli (EHEC) and Campylobacter jejuni. Hum Vaccin Immunother. 2015;11(3):601-619. doi:10.1080/21645515.2015.1011578; Wieczorkiewicz JT, Lopansri BK, Cheknis A, et al. Fluoroquinolone and macrolide exposure predict Clostridium difficile infection with the highly fluoroquinolone- and macrolide-resistant epidemic C. difficile strain BI/NAP1/027. Antimicrob Agents Chemother. 2015;60(1):418-423. Published 2015 Nov 2. doi:10.1128/AAC.01820-15.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Chen was recorded at the 77th Annual Brennemann Lectures, held September 16-18, 2022, in Anaheim, CA, and presented by the Los Angeles Pediatric Society. For information on future CME activities from this presenter, please visit https://lapedsoc.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

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 1.25 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 1.25 CE contact hours.

Lecture ID:

PD690501

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.