Health Advice for Children Traveling Internationally

Pediatric Travelers Visiting Friends and Relatives

Compared to most children traveling internationally, the pediatric visiting-friends-and-relatives (VFR) traveler is the most vulnerable population uniquely at risk for travel-related illnesses. VFR travelers may include immigrants, refugees, migrants, students, or displaced persons who are traveling back to their country of origin for purposes of visiting friends and relatives. Pediatric VFR travelers are typically children accompanying their parents or family members back to their ancestral country, where relational, social, and cultural connections remain. Compared to tourist travelers, VFR travelers are more likely to travel for longer durations, visit more remote destinations, travel by higher-risk local transportation modes, experience closer contact with the local population, and utilize fewer insect, food, and water precautions. Adult and pediatric VFR travelers are also less likely to perceive a risk of travel-related illnesses, seek pretravel advice, receive travel immunizations, or use effective malaria prophylaxis on arrival in the destination country. VFR travel comprises 50–84% of imported malaria in U.S. children (i.e., malaria acquired outside the United States), and pediatric VFR travelers are reported to be 4 times more likely than tourist travelers to acquire malaria. Among all travelers, unvaccinated pediatric VFR travelers remain at higher risk for contracting hepatitis A and having symptomatic illness. Several studies suggest that VFR travelers are at disproportionate risk of acquiring typhoid fever and possibly tuberculosis. Providers should inquire if their foreign-born patients will be traveling internationally and seek opportunities to encourage pretravel consultation for VFR travelers.

Health and Evacuation Insurance, Underlying Health Conditions, and Medications

Parents should be made aware that their medical insurance policy might not provide coverage for hospitalizations or medical emergencies in foreign countries and is unlikely to cover the high cost of an emergency medical evacuation. Supplemental travel medical insurance and evacuation insurance may be purchased and are especially recommended for prolonged travel itineraries, for remote destinations, and for children with higher-risk preexistent health conditions going to countries where inpatient care at a level comparable to the traveler's home country may not be available. A list of medical and evacuation insurance providers can be found at the U.S. Department of State International Travel advisory website ( https://travel.state.gov/content/travel/en/international-travel/emergencies.html ).

Parents of children with medical conditions should take with them a brief medical summary and a sufficient supply of prescription medications for their children, with bottles that are clearly identified by prescription labels. For children requiring care by specialists, an international directory for that specialty can be consulted. A directory of physicians worldwide who speak English and who have met certain qualifications is available from the International Association for Medical Assistance to Travelers ( https://www.iamat.org/ ). If medical care is needed urgently when abroad, sources of information include the U.S. embassy or consulate, hotel managers, travel agents catering to foreign tourists, and missionary hospitals.

A travel health kit consisting of prescription medications and nonprescription items, such as acetaminophen, an antihistamine, oral rehydration solution packets, antibiotic ointment, bandages, insect repellent (DEET or picaridin), and sunscreen, is highly recommended for all children. Children with persistent asthma should have bronchodilators and oral corticosteroids prescribed for treatment of any acute asthma exacerbations encountered during overseas travel. Children with a history of angioedema, anaphylaxis, or severe allergies to food or insects should have an epinephrine autoinjector (EpiPen) and antihistamines available for use during travel.

Parents and family members should be aware of the prevalence of counterfeit medication and lack of quality control of medications in many areas of the world, particularly in low- and middle-income countries. Critical medications, including insulin and newly prescribed antimalarials, should be purchased prior to international travel and packed in original prescription containers.

Safety and Injury Prevention

Motor vehicle accidents are a leading cause of traumatic injuries to, hospitalizations of, and deaths of pediatric and adult travelers. Differences in traffic patterns should be emphasized to children, and the use of safety belts should be reinforced. When possible, child safety seats should be taken on the trip. Parents should also be aware of additional risks for small children that may exist overseas, such as open balconies, windows without screens or bars, exposed wires and electrical outlets, paint chips, pest and rodent poison, and stray animals. Water-related activities also are associated with significant injuries in pediatric travelers, and pools and oceanfronts are often unsupervised and without lifeguards at overseas destinations.

Animal Contact

Among travelers, attacks from domestic or stray animals are much more likely to occur than attacks from wild animals. Wounds from animal bites present a risk for bacterial infections, tetanus, and rabies. Dogs are responsible for >95% of all rabies transmission in Asia, Africa, and Latin America. Globally, the World Health Organization (WHO) estimates that approximately 55,000 human deaths result from rabies each year, with the vast majority of cases occurring in South Asia, Southeast Asia, and Africa. Rabies transmission is reported less frequently after bites from cats and other carnivores, monkeys, and bats. Macaque monkeys native to Asia and North Africa can be found in urban centers and tourist sites and pose a risk for rabies and herpes B virus infections following bites and scratches.

Young children are more likely to be bitten and experience more severe facial wounds because of their short stature. As such, they are at higher risk for rabies exposure from dogs and other animals during travel and require greater supervision. Parents should always encourage their children to report bite injuries and to avoid petting, feeding, or handling dogs, monkeys, and stray animals. Before travel, tetanus vaccinations need to be current for all travelers. Children, long-term travelers, expatriates, and all individuals likely to come into contact with animals in a rabies-endemic region (primarily Africa and South and Southeast Asia) should consider preexposure vaccination for rabies before international travel (see Rabies later). Bite or scratch wounds should be washed thoroughly and for a prolonged time (15 min) with copious water and soap. Local wound care will substantially reduce the risk of canine and other mammalian rabies transmission. Rabies postexposure vaccination and rabies immunoglobulin should be considered. Antibiotics (amoxicillin-clavulanate) may need to be administered to a child to prevent secondary infections, especially for animal bites involving the hands and head/neck areas.

Diphtheria-Tetanus-Pertussis

Children traveling internationally should be fully vaccinated with diphtheria and tetanus toxoids and acellular pertussis (DTaP), having completed the 4th or 5th booster dose by 4-6 yr of age. A single dose of an adolescent/adult preparation of tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine is recommended at 11-12 yr of age for those who have completed the recommended primary DTaP (or DTP) series.

Adolescents and adults should receive a single Tdap booster if >5 yr have elapsed since the last dose, since a tetanus-containing booster (Td or Tdap) may not be readily available for tetanus-prone wounds during international travel or in remote settings (adventure travel, wilderness).

Haemophilus influenzae Type b

Haemophilus influenzae type b (Hib) remains a leading cause of meningitis in children 6 mo to 3 yr of age in many low- and middle-income countries. Before they travel, all unimmunized children <5 yr old should be vaccinated (see Chapter 197 ). A single dose of Hib vaccine should also be administered to unvaccinated or partially vaccinated children ≥5 yr old if they have anatomic or functional asplenia, sickle cell disease, HIV infection, leukemia, malignancy, or other immunocompromising condition. Unvaccinated children >5 yr old do not need vaccination unless they have a high-risk condition.

Hepatitis A

Hepatitis A is a routine childhood vaccine in the United States but requires special considerations in the traveling pediatric patient, and protection from hepatitis A in specific children may also involve the provision of immunoglobulin. For this reason, hepatitis A vaccination is covered later in Specialized Pediatric Travel Vaccinations.

Hepatitis B

Hepatitis B is a travel-associated infection. Hepatitis B is highly prevalent throughout much of the world, including areas of South America, sub-Saharan Africa, eastern and southeastern Asia, and most of the Pacific basin. In certain parts of the world, 8–15% of the population may be chronically infected. Disease can be transmitted by blood transfusions not screened for hepatitis B surface antigen, exposure to unsterilized needles, close contact with local children who have open skin lesions, and sexual exposure. Exposure to hepatitis B is more likely for travelers residing for prolonged periods in endemic areas. Partial protection may be provided by 1 or 2 doses, but ideally 3 doses should be given before travel. For unvaccinated adolescents, the 1st 2 doses are 4 wk apart and are followed by a 3rd dose 8 wk later (at least 16 wk after 1st dose).

All unvaccinated children and adolescents should receive the accelerated hepatitis B vaccine series prior to travel. Because 1 or 2 doses provide some protection, hepatitis B vaccination should be initiated even if the full series cannot be completed before travel.