Today’s topic:
Travelling with Children Speaker: Dr. Heather MacDonnell
child & youth
Pediatric Telehealth
Rounds
Friday, September 13, 2013
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Declaration of conflict
Speaker has nothing to disclose with regard to commercial support.
Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.
Travelling with Children
Dr. Heather MacDonnell, FRCPC, FAAP, DTM&H(UK)
Director of Global Health, Dept of Pediatrics
Co-Head International Adoption Clinic
Division of Paediatric Medicine, CHEO
Assistant Professor of Pediatrics, University of Ottawa
Telehealth Rounds September 13, 2013
Objectives
To outline principles of pre-travel advice
To list common travel immunizations
and medications for children
To review the CPS position statement
on ‘Air travel and children's health’
To provide resources for travel
advice and immunizations
Travel Medicine
Factors in determining risk for travellers
– Destination
– Duration of travel
– Patient’s current health status
– Host Factors (age, chronic disease)
– Activities and Exposures*
* For children unique problems because
of variable immunity and different age-
based behaviour
Pre-Travel Advice: Overview
Routine Vaccination Schedule should be up-to-date
Research destination-specific infectious diseases
– Additional vaccinations
– Prophylactic medications
Prevention of vector-borne diseases
Sun safety
Food and water safety
www.health.gov.on.ca
Potential Travel Vaccinations
Hepatitis A – 2 IM doses, 6-12 mos apart, begin at 1 year old (may
give HepA Immunoglobulin before that)
Hepatitis B (if prior to provincial schedule)
Twinrix (Hep A+B) – Age > 1 yr, 3 doses (0, 1, 6 months)
Typhoid (highest risk Indian subcontinent) – IM capsular polysaccharide, 1 dose, age >2 yrs, lasts
for 2 yrs
– oral live attenuated, age > 6 yrs, 3-4 doses depending on preparation, lasts for 5 yrs
See NACI guidelines, AAP Red Book for dosing details
vivaxim_cons_risk_map_en.gif
Joint Hepatitis A and Typhoid Travel Risk
Potential Travel Vaccinations
Meningococcus (African belt)
– Menactra (Groups A,C,Y, W-135)
– IM polysacc conjugate, 1 dose, age > 2 yrs
Yellow Fever (South America, SS Africa)
– IM live attenuated, 1 dose, age > 9 mos, F/X
Japanese Encephalitis (South Asia)
– IM inactivated, 3 doses, given over 3-4 wks (0,1, 3-4 wks), age > 1yr
Rabies
See NACI guidelines, AAP Red Book for dosing details
The Hajj: Oct 13-18, 2013, Saudi Arabia
PHAC and City of Ottawa Public Health Travel
Health Notices http://www.phac-aspc.gc.ca
“largest annual gathering in the world ~ 3 million
people attend spiritual pilgrimage to Mecca”
increased risk: meningococcus, TB, influenza,
GI, “be aware of” Middle East Respiratory
Syndrome Coronavirus (MERS-CoV)
Required with evidence: Meningococcal
ACYW135 (all), Polio (certain source countries),
Yellow Fever (certain source countries)
Areas with frequent epidemics of Meningococcal meningitis
CDC Yellow Book
Mecca
Areas with Risk of Yellow Fever Virus
Transmission : CDC Yellow Book
Malaria Prophylaxis
Chloroquine and Mefloquine (Larium) – Begin one week before travel and continue
through 4 wks after return to non-endemic country
– Safe for > 5 kg (11 lbs) or no lower wt limit
– Easier to crush, better tolerated
Doxycycline – daily, 2 days pre, 4 weeks post, age > 8 yrs
Atovaquone/Proguanil (Malarone) – 1-2 days pre, 1 wk post, expensive (although cost
likely similar to Mefloquine for 2-3 wk trips)
– Safe for > 5 kg, harder to crush tablets
See CDC website for per kilo dosing details
Prevention of Vector-Borne
Illnesses
Insect repellant to exposed skin (DEET)
– CPS recommendations for children
Permethrin impregnated bed nets, screens on
windows
Wear long-sleeved, light coloured clothing,
socks tucked into boots
Avoid prime biting times
– Anopheles mosquitoes (Malaria) are dawn and dusk
biters
– Aedes mosquitoes (Dengue) are daytime biters
CPS DEET recommendations
DEET Protective
Clothing
Citronella or
lavendar oil
Age < 6 mos not recommended best choice Should not
be used
6 mos-2 yrs Once daily
10% DEET or less
Not to face or hands
encouraged same
2-12 yrs Up to 3 times daily
10% DEET or less
Not to face or hands
encouraged same
> 12 yrs 30% DEET or less
Reapply after:
30% 6 hrs, 15% 5 hrs,
10% 3 hrs, 5% 2 hrs
encouraged same
www.cps.ca
Sun Safety
Wear sunscreen daily with min. SPF 30
Generally not recommended < 6 months old
Multiple reapplications, esp with swimming
Do not use combination SPF/DEET
Wear sun hats, use stroller UV shades
Beware of dehydration
Do not stay out in direct sunlight for long periods during the hottest time of day (10am-2pm)
Food and Water Safety
Attention to hand hygiene (alcohol gel)
“Boil it, peel it, cook it or avoid it”
AVOID:
– Raw or not hot foods (eg. fruits + veggies unless self-peeled + washed in bottle H20)
– Unpasteurized dairy products
– Food from street vendors
– Tap water, water in jugs on restaurant table, ice
Infant Feeding
If < 6 months: breastfeeding is best
All anti-malarial medications are excreted in breast milk, but in concentrations insufficient for infant prophylaxis
If already weaned: formula prepared from commercial powder + boiled water is safest
Case 1: India
Healthy 30 yr old parents + 2 daughters ages 11 mos, 2.5 yrs
“VFR’s” = “Visiting Friends and Relatives” in several states, staying in homes
Length of travel = 6 weeks
What diseases are they at risk of contracting?
How should they medically prepare?
www.cdc.gov/travel/destinations/india.htm
Other disease risks: India
Routine vaccine preventable diseases (DPTP-HiB, MMR *could give early)
Other vaccine preventable:
– Hepatitis A
– Hepatitis B
– Rabies
– Typhoid
– Japanese Encephalitis (check state)
– Polio (wild-type), measles outbreaks
www.cdc.gov/travel/destinationIndia.aspx
Other disease risks: South Asia
Non-vaccine preventable diseases
– Dengue fever
– Leishmaniasis
– Filiriasis
– Leptospirosis
– +/- Highly pathogenic avian influenza
www.cdc.gov/travel/destinationIndia.aspx
Medical Packing List
Antibacterial hand gel, wipes
Sunscreen, DEET
Analgesics (infant,adult):ibuprofen,acetaminophen
Antidiarrheal medication (age > 2 yrs)
Antihistamines
Topical antibiotic ointment
Any prescription medications in original containers
Water filter, iodine tablets
Oral rehydration packets
Popular Travel Reports
United States
Mexico *
Cuba
Dominican Republic*
Kenya*
Thailand*
India*
Philippines*
United Kingdom
Pakistan***
Costa Rica*
China*
* indicates travel warning
PLANNING A TRIP
Registration of Canadians Abroad
Before You Go
While Abroad
COUNTRY INFORMATION
Travel Reports & Warnings
Global Issues
Country Profiles
RESOURCES
Travel Updates
Drugs & Travel
Publications
Laws & Regulations
India: Warnings and
Recommendations
Level 1: Exercise normal security precautions
Level 2: Exercise high degree of caution
“There is no nationwide advisory in effect for India. However, you should exercise a high degree of caution due to a continuing threat of terrorist attacks throughout the country at all times.”
<Terrorist attacks have occurred throughout India in 2008, often taking the form of bomb blasts, remotely detonated, in crowded markets of major centres at peak shopping time in the early evening. Such attacks occurred in Jaipur in May 2008, in Bangalore and Ahmedabad in late July and in New Delhi in mid-September and again in late September. The most recent terrorist attacks in Mumbai in late November 2008, were different in nature, as the targets included a railway station, a restaurant and luxury hotels where foreign business people and tourists congregate, and the weapons used were machine guns and grenades. Canadian citizens were among the over 170 persons killed in the Mumbai attack>
www.voyage.gc.ca
India: Warnings and
Recommendations
Level 3: Avoid non-essential travel
“Foreign Affairs and International Trade Canada advises against non-essential travel to Manipur and the border areas of Arunachal Pradesh (border with Burma) due to the threat of insurgency.”
Level 4: Avoid all travel - OFFICIAL WARNING:
Foreign Affairs and International Trade Canada advises against all travel to the following regions:
a) Jammu and Kashmir
b) Border areas in Manipur (border with Burma) and Nagaland (border with Burma),
which are significantly affected by insurgency;
c) Areas in immediate vicinity of border with Pakistan: Gujarat, Rajasthan and
Punjab due to possibility of landmines and unexploded ammunition, as well as
unmarked border areas (within immediate vicinity of the Line of Control: military
control line between India and Pakistan).
www.voyage.gc.ca
Case 2: Dominican Republic
Grandmother travelling to Punta Cana, DR on March break x 2 weeks
Taking 2 healthy grandchildren: 9 and 12 yrs old
Staying at an all inclusive resort
What diseases are they at risk of contracting?
How should they medically prepare?
Punta Cana
Other Disease Risks: DR
Routine vaccine preventable diseases
(DPTP-HiB, MMR)
Other vaccine preventable: – Hepatitis A, B
– Typhoid
– Rabies
Non-vaccine preventable diseases – Dengue fever - Haiti: Anthrax, TB, HIV
– Histoplasmosis
– Cutaneous larval migrans
– Leptospirosis
www.cdc.gov/travel/destinationDominicanRepublic.aspx
Air Travel and Children’s Health
Air Canada medical incidents: 1.7-3.4 per 100,000
passengers (CMAJ 1991)
MD’s should identify which children are at highest
risk during flight
Parents should carry a letter detailing:
– Their child’s medical condition
– Any need for medication or supplies (needles, EpiPen)
– Medical action plan in case of emergencies (contact
numbers of medical personnel)
CPS Position Statement: Paed Child Health Vol 12 No 1 Jan 2007
Infectious Diseases
Airborne Respiratory Illness:
– Higher risk of transmission due to:
• Exposure time
• Recirculated air, limited ventilation in confined area
– Documented cases of: TB, measles, influenza, SARS
– WHO feels same risk as bus or train
Intestinal and vector-borne Illness:
– Food: Salmonella, Shigella, Staphylococcus, Vibrio
– Malaria (despite insecticide spraying)
CPS 2007
Cardiopulmonary disease
Cruising altitudes = 9000-13000m
Cabins pressurized to 2400m (8000ft)
Equals 15% O2 at sea level hypoxia
High risk patients:
– Known hypercapnia, hypoxemia
– Serious obstructive or restrictive lung disease
– Already requiring O2 on ground (eg. BPD)
– Need MD review pre-flight
CPS 2007
Other Recommendations
Holding an infant on a lap is improper restraint, may potentially contribute to injury, look into car seat protocol of airline
Children with AOM should wait 2 weeks before air travel; topical nasal decongestants may be used (oral not recommended)
Some children with cardiopulmonary disease or sickle cell disease may require O2 during flight
Jet lag affects children – try to keep to same nap, sleep routine
Pay attention to food allergies CPS 2007
Air Travel Tips
Usually can gate-check stroller, car seat
Can take car seat on airplane
http://www.safekidscanada.ca
Older child device:
CARES (Child Aviation
Restraint System)
www.kidsflysafe.com
22-44 lbs
Professional Resources
Center for Disease Control (CDC) -Traveller’s Health www.cdc.gov/travel
– “Travelling safely with infants and children, IA”
– “Yellow Book” 2012 = Health info for int’l travel
World Health Organization (WHO)
– International Travel and Health www.who.int/ith
Public Health Agency of Canada (PHAC)
– Traveller’s Health www.phac-aspc.gc.ca/tmp-pmv/
– National Advisory Committee on Immunization (NACI) http://www.phac-aspc.gc.ca/naci-ccni/index-eng.php
AAP Red Book, 29th Ed. 2012 pp103-109
International Society of Travel Medicine
www.istm.org
American Society of Tropical Medicine and Hygiene www.astmh.org
Travel Medicine: Helping Patients Prepare for Trips Abroad www.aafp.org/afp/980800ap/dick.html
Infectious Disease Clinics of North America Volume 19, Issue 1, Pages 1-280 (March 2005) Travel and Tropical Medicine
Canadian Paediatric Society www.cps.ca
Professional Resources
Parent Resources
www.havebabywilltravel.com
www.havekidswilltravel.net
www.travelingwithkids.com
Generally have destination reviews, blogs, travel tips, checklists, products, etc.
www.caringforkids.ca (www.cps.ca)
International Association for Medical Assistance for Travellers www.iamat.org/
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Pediatric Telehealth Rounds
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