Transcript
Page 1: Pediatric Telehealth child & youth Rounds

Today’s topic:

Travelling with Children Speaker: Dr. Heather MacDonnell

child & youth

Pediatric Telehealth

Rounds

Friday, September 13, 2013

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Complete today’s evaluation & apply for professional credits

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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.

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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

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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

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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

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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

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www.health.gov.on.ca

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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

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vivaxim_cons_risk_map_en.gif

Joint Hepatitis A and Typhoid Travel Risk

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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

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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)

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Areas with frequent epidemics of Meningococcal meningitis

CDC Yellow Book

Mecca

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Areas with Risk of Yellow Fever Virus

Transmission : CDC Yellow Book

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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

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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

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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

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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)

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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

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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

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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?

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www.cdc.gov/travel/destinations/india.htm

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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

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Other disease risks: South Asia

Non-vaccine preventable diseases

– Dengue fever

– Leishmaniasis

– Filiriasis

– Leptospirosis

– +/- Highly pathogenic avian influenza

www.cdc.gov/travel/destinationIndia.aspx

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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

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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

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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

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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

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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?

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Punta Cana

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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

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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

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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

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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

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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

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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

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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

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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

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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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for participating in today’s

Pediatric Telehealth Rounds

Join us next time: Pediatric Headaches: Migraines or Tumour? with Dr. Jane Roberts Friday, September 27th from 12-1 p.m.

Thank you!

[email protected]


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