A 6 1/2-month-old male came to clinic for a health supervision visit. He is healthy but the parents want to know what they need to do before he leaves the United States in 3 months for a year long visit to China with relatives.
The pertinent physical exam shows a healthy infant with normal growth and development.
The diagnosis of a healthy infant who will be travelling internationally was made and his regular vaccines for a 6 month old were given. Additionally, a measles vaccine was given as he will be living in an endemic area.
The world continues to globalize and more and more people are frequently travelling. Whether it is within the United States or internationally, people must be aware of the potential travel health risks. Some people say, “We’re just taking a cruise,” but they forget that the ship itself is like a small institution with its own health hazards, not to mention the ports of call that they will be going to.
There are no absolute answers as each travel situation is unique. The following is not a comprehensive list, but in general, the risks can be divided into major categories:
Diseases carried by insects including Dengue fever, Japanese Encephalitis, Malaria and Plague.
- Pay special attention to mosquito protection between dusk and dawn. This is when the mosquito transmitting malaria is most active.
- If visiting a malaria area, take malaria prevention medication before, during, and after travel as directed. If a fever or flu-like illness occurs either during travelling or up to 1 year after returning home (for up to 1 year), a physician should be seen and told of the travel history as part of the evaluation.
- Wear long-sleeved shirts, long pants, and hats.
- Use insect repellents that contain DEET (diethylmethyltoluamide). Follow the label directions closely.
- Apply insect repellent to exposed skin, but not to broken skin.
- With DEET, do not breathe, swallow, or get it into the eyes. If using a spray, put the DEET onto the hands and rub it carefully onto the face. The eyes, nose and mouth should be avoided.
- DEET may be used on adults, children, and infants older than 2 months of age. Protect infants by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
- Parents should apply insect repellant to children under 10 years of age. Do not apply to young children’s hands or around eyes and mouth.
- Use a bednet that has been sprayed with permethrin or deltamethrin, unless you are staying in an air-conditioned or well-screened house
Diseases carried in food or water (including those contaminated from animals) include Cholera, Escherichia coli, Hepatitis A, Schistomiasis, Typhoid Fever, Cryptosporidium, Giardia, Hepatitis A, and Norwalk virus.
- Drink only bottled or boiled water, or carbonated beverages in cans or bottles. Avoid tap water, fountain drinks, and ice cubes.
- Use this water to brush teeth and wash/prepare foods, and bathe.
- If these types of water cannot be found, make water safer by BOTH filtering through an “absolute 1-micron or less” filter AND adding iodine tablets to the filtered water. These filters can be found in camping/outdoor supply stores.
- Do not eat food purchased from street vendors.
- Do not handle animals to avoid bites and serious disease. Cats, dogs and monkeys are especially risky.
- Do not swim in fresh water (except for well-chlorinated swimming pools) in certain areas of China to avoid schistosomiasis. Salt water is usually safer. Cryptosporidium, Giardia, Hepatitis A, and Norwalk virus have moderate to very high resistance to chlorine levels commonly found in chlorinated swimming pools. Care must be taken not to drink this water. Remember children often drink water they are swimming or bathing in so even chlorinated swimming pools may not be a good option in some cases.
Diseases from person-to-person contact include Hepatitis B and HIV/AIDS
- Do not have sexual contact (heterosexual or homosexual) with an infected person, or a person likely to be infected such as a sex worker.
- Do not allow the use of contaminated, unsterilized syringes or needles for any injections or other skin-piercing procedures, including acupuncture, use of illicit drugs, steroid or vitamin injections, medical or dental procedures, ear or body piercing, or tattooing.
- Do not allow the use of infected blood, blood components, or clotting factor concentrates. This mode of transmission is rare in cities or countries where donated blood products are screened.
Diseases from animals include many diseases already listed but especially rabies.
- Care should be taken to avoid encountering all wild animals and also domesticated animals in endemic areas.
- Most bites and stings from arthropods are unpleasant but do not cause serious disease.
- Half of snake bite wounds contain venom but any snake bite should be evaluated by medical personnel.
Indications for appropriate travel vaccinations depend on the location, risks and patient age. Again each situation is unique. Often children under 1 year cannot receive vaccines other than the standard vaccines that would be given at their health supervision visits.
Children over the age of 7, often can receive all the indicated vaccines as would an adult. Between 1 and 7 years, the age when a child can receive the vaccine varies greatly between vaccines.
The evaluation of this child’s travel immunization needs included checking the Centers for Disease Control traveller’s Health website at: http://www.cdc.gov/travel/ for information on East Asia. This is a comprehensive government resource with the most current information available for health risks worldwide. He will be going to a Chinese province with known malaria risks. The general recommended vaccines include Hepatitis A, Hepatitis B, Japanese Encephalitis Virus, Typhoid, Diptheria/Tetanus, and Measles.
Because of this child’s age, he could not receive many of these vaccines. He finished the primary series for Hepatitis B and Diptheria/Tetanus and received the Measles vaccine in addition. Note that he will still need 2 measles vaccines after the age of 12 months for full immunity. General information about eating and drinking safe food and water, and decreasing risks from mosquitos and animals was discussed and written information was given to his family.
He will come to clinic before he goes to China and will be given a prescription for Azithromycin for traveller’s diarrhea and will begin his malaria prophylaxis. Liberal use of alcohol-based hand gels to help decrease risks of water contamination will also be recommended to help with hand hygiene. He will also be sent to China with a copy of his immunization records and a brief summary of his medical care to date.
Questions for Further Discussion
1. What information should be given to parents about traveller’s diarrhea?
2. What special considerations should given given to international adoptees?
3. What special considerations should be given to pregnant and nursing mothers?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Traveling with Small Children.
American Academy of Pediatrics. Measles, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;426.
Centers for Disease Control. Animal-Associated Hazards. Available from the Internet at http://www.cdc.gov/travel/other/animal-hazards.htm (rev. 7/03/03, cited 4/28/05).
Centers for Disease Control. Acquired Immunodeficiency Syndrome (HIV). Available from the Internet at http://www.cdc.gov/travel/diseases/hivaids.htm (rev. 7/30/03, cited 4/28/05).
Centers for Disease Control. Rabies. Available from the Internet at http://www.cdc.gov/travel/diseases/rabies.htm (rev. 4/14/04, cited 4/28/05).
Centers for Disease Control. New Drug Approved for the Treatment of travellers’ Diarrhea. Available from the Internet at http://www.cdc.gov/travel/other/drug_for_td_approval_2004.htm(rev. 10/14/04, cited 4/28/05).
Centers for Disease Control. Health Information for travellers to East Asia. Available from the Internet at http://www.cdc.gov/travel/eastasia.htm (rev. 4/14/05, cited 4/28/05).
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
May 30, 2005