Depending on the destination, children traveling internationally most
commonly need vaccines against a variety of diseases, including hepatitis A,
hepatitis B, typhoid fever, yellow fever, Japanese encephalitis, and
meningococcal disease. Children traveling abroad also may require medication to
prevent malaria and antibiotics for travelers' diarrhea. The discussion below
will cover current immunization recommendations, review travel medication
options, and offer general advice on safe international travel with
children.
Travel immunizations
Information on the most commonly used travel vaccines is summarized in
Tables 1-6 (below), including destinations of risk, dosing schedules and other
important considerations. Physicians also should ensure that all routine
childhood immunizations are up-to-date. Note that in the latest schedule (2006),
the first dose of the hepatitis A vaccine is now advised for children as young
as 1 year of age. Also, the meningococcal conjugate vaccine now is recommended
routinely for all 11- to 12-year-olds, for adolescents around 14 to 15 years of
age, and patients who will be college freshmen living in a dormitory.
Less commonly used travel vaccines are against rabies and tuberculosis (TB).
The cholera vaccine is not available in the United States. If a country requires
this vaccine for entry, physicians should provide a medical exemption.
Rabies is endemic in developing countries of Asia, Africa, and Latin America, especially in rural areas. Children are
especially at risk when staying in these areas more than 30 days, with no
medical attention available within 24 hours. The rabies vaccine for pre-exposure
prophylaxis is administered intramuscularly in 3 doses (1 ml each) on day 0, 7,
and 21. If this schedule is followed, the rabies immune globulin is not
necessary. Patients with an egg allergy should be given the HDCV vaccine,
instead of the PCEC vaccine. Booster shots are needed every 2 years, or the
antibody titer can be checked.
The live-attenuated BCG vaccine may be considered for children traveling
to and living in rural areas of developing countries for several months, where
drug resistant TB is highly endemic. The vaccine is administered as a single
dose (0.1 ml) intradermally. For infants less than 3 months of age, the dose is
0.05 ml. No booster shots are recommended.
Malaria prophylaxis
Malaria is endemic in large areas of Central and South America, the
island of Hispaniola (includes Haiti and the Dominican Republic), Africa, Asia (including
India, Southeast Asia and the
Middle East), Eastern Europe, and the South
Pacific. Several antimalarial drug options are discussed below.
Chloroquine is recommended for children traveling to Mexico (to very
specific rural areas), Haiti, Dominican Republic, Central America (north and
west of Panama Canal), and Middle East (except Iran, Yemen and Oman). The dosage
is 8.3 mg/kg (max. 500 mg) weekly, to be started 1 week before travel and
continued through 4 weeks after return to a non-endemic area.
Mefloquine is the standard malaria prophylaxis for most other endemic
areas. Mefloquine is also taken on a weekly basis. It is started 1 week before
travel and continued through 4 weeks following return. It is available in
quarter, half, three-quarter, and whole tablets, based on weight. Mefloquine
generally should be avoided in children weighing less than 5 kg, although
one-eighth of a tablet can be given to young infants traveling to highly endemic
areas. The major toxicity is neurologic, including headache, dizziness, vivid
dreams, and visual disturbances. Children with history of psychiatric disorders,
seizures, or cardiac conduction abnormalities should not take
mefloquine.
Doxycycline is an option for children older than 9 years of age traveling
in areas where mefloquine-resistant malaria is found (Thailand-Cambodia and
Thailand-Burma borders). It is taken daily, beginning 2 days before travel and
through 4 weeks after return. Doses are based on weight. Because of the risk for
possible photosensitivity reactions, the drug should be taken during the evening
hours.
Atovaquone/proguanil is effective for all malaria endemic areas. Quarter
dose pediatric tablets are available, and are taken daily with food, starting 1
to 2 days before travel and through 1 week after return. It should be avoided in
children weighing less than 11 kg. Although it is twice as expensive as
mefloquine, the potential gastrointestinal and liver adverse effects are mild,
and effectiveness is 80% to 100%.
To help prevent malaria, insect repellant with up to 30% to 35% DEET
should be applied to exposed areas of skin, except for the child's face and
hands, to avoid accidental ingestion. If sunscreen is needed, it should be
applied prior to insect repellant. Clothes and mosquito netting must be treated
with permethrin (a repellant that should not be used on skin), and the room
sprayed with pyrethroid-containing flying insect repellant. Light-colored
clothing, as well as long-sleeved shirts and pants are recommended.
Antibiotics for travelers' diarrhea
Azithromycin is a good choice to treat diarrhea in travelers of all ages.
Trimethoprim-sulfamethoxazole (TMP/SMX) can be used for any age, although it is
no longer routinely recommended due to growing drug resistance worldwide.
Ciprofloxacin can be an effective option for children 12 years of age and older.
Another alternative is ofloxacin. These antibiotics can be used with bismuth
subsalicylate. Loperamide hydrochloride, however, should be avoided if a child's
diarrhea is accompanied by fever and/or blood. Antibiotic treatment should be
started after the third loose stool in 24 hours, any bloody stool, or any loose
stool with fever. Note that ciprofloxacin and ofloxacin are not FDA approved for
pediatric use at this time.
Safe food and drink practices will help prevent travelers' diarrhea and
other food-related diseases. Advise families to avoid foods that are raw (unless
self-peeled) or not completely hot. International travelers also should not eat
unpasteurized dairy products, baked goods (containing creams or custards), and
food from street vendors. Tap water and ice must be avoided. Only water that is
bottled, filtered, boiled, or purified should be used for drinking, washing
fruits and vegetables, brushing one's teeth, and mixing infant formula and
foods.
O N L I N E R E S O U R C E S
[1.] Recommendations for immunization and other medical precautions by
destination, from Centers for Disease Control and Prevention:
http://www.cdc.gov/travel/destinat.htm. Accessed October 17, 2006.
[2.] Latest information on avian flu: http://www.cdc.gov/flu/avian.
Accessed October 17, 2006.
[3.] Childhood Immunization Schedule and Catch-Up Schedule, 2006:
http://www.cispimmunize.org. Accessed October 17, 2006. |  |
