Provide appropriate travel prophylaxis for foreign travel based on the indigenous organisms and geographic location

Provide appropriate travel prophylaxis for foreign travel based on the indigenous organisms and geographic location: Excerpt from Avoiding Common Pediatric Errors

Author: Mindy Dickerman, MD

What to Do - Take Action

Immunizations and preventative medicines are an important part of travel preparation and reducing the risk of acquiring infections while traveling internationally. Travel prophylaxis for foreign travel should be based on the individual's risks for exposure to specific travel related diseases, the epidemiology of vaccine-preventable diseases, and the time available before trip departure. Travel prophylaxis includes updating and boosting routine immunizations, administering legally required vaccinations, and prescribing recommended vaccines and medicines to help prevent diseases. A physician also needs to be knowledgeable about the adverse events and contraindications associated with each vaccine and medication.

The first step in prescribing appropriate travel prophylaxis is a thorough assessment of a patient's risk of travel-related disease. The details of the planned travel are important, including the itinerary, all geographic destinations, type of lodging booked, planned activities, particular season of travel, duration of stay, and anticipated contact with local residents. This information needs to be integrated with an assessment of the patient's general health, medical problems, allergies, and current medications. It is important to identify travelers at high risk for acquiring travel-related illnesses. Patients considered at high risk are backpackers, those who are immunocompromised, or those currently living in the United States but born in another country who are traveling back to their country of origin. Consultation with a travel clinic may be advisable and early consultation when planned travel is to developing countries is encouraged. Consultations need to be based on current epidemiology and can be obtained from the Centers for Disease Control and Prevention in an annual publication or via their Web site at http://www.cdc.gov/travel. The World Health Organization (WHO) operates a similar Web site: http://www.who.int/ ith/en.

It is very important to review and update a patient's routine immunizations prior to international travel. If 5 or more years have elapsed since the last tetanus immunization and the patient is traveling to an area where postexposure tetanus immunization may be unavailable, a booster dose of tetanus should be considered. Measles is still endemic in many developing nations, and children 6 to 11 months of age should receive one dose of measles, mumps, rubella vaccine if traveling to highly endemic areas and must receive two doses after 12 months to be considered fully immunized. Polio is also still found in several countries around the world, including in India and Pakistan. Travelers to these countries may need a single booster of the polio vaccine. Varicella immunity and hepatitis B immunity should be reviewed and the vaccines given if necessary. Pneumovax should be considered for patients with chronic illnesses or who are immunocompromised. The influenza vaccine is recommended for all international travelers during influenza season, which peaks in different months in the Northern and Southern hemispheres.

There are some vaccines that are required for entry into endemic areas. Many yellow fever-endemic countries require proof of vaccination for entry. Yellow fever is a potentially fatal viral infection that is endemic in equatorial African and South America, and is transmitted by day-biting mosquito vectors. The yellow fever vaccine is recommended for any patient older than 8 months at least 10 days prior to traveling to areas where yellow fever is reported. The vaccination is not recommended in pregnancy. It is a live- attenuated virus given in a single subcutaneous injection. Immunity may be lifelong but revaccination is required at 10-year intervals. Country-specific epidemiology and requirements can be obtained from the CDC.

The inactivated hepatitis A virus vaccine is recommended for many international travelers, including travelers to areas in Mexico. Vaccination is preferred 4 weeks prior to departure, and a booster is needed 6 to 12 months latertoprovideprotectiveantibodylevelsfor>10years.Japaneseencephalitis virus is an arboviral infection transmitted by mosquitoes that is prevalent in the Indian subcontinent and other Asian countries. The vaccine should be offeredtopatientswhoplantoremainfor30daysorlongerinanendemicarea during the transmission season or to short-term travelers who are planning to engage in extensive outdoor activities. Primary immunization consists of three doses given on days 0, 7, and 30, and should ideally be completed at least10dayspriortotripdeparture,duetotheriskofreaction.Typhoidfever immunization is recommended for travelers to areas in Central and South America, the Indian subcontinent, and Africa. The two types of typhoid vaccines are only 50% to 80% effective and, therefore, cannot substitute for careful selection of food and drink. There is an intramuscular and an oral regimen, depending on the age of the patient. Meningococcal vaccine is recommended for travelers to areas in sub-Saharan Africa during certain times of the year. Pre-exposure rabies vaccination should be considered for travelers to certain areas that are planning to engage in certain activities. It is extremely important for a physician to provide appropriate prevention for malaria as well.

Suggested Readings

Center for Disease Control and Prevention. Traveler's Health. Available at: www.cdc.gov/ travel/contentVaccinations.aspx. Accessed January 7, 2008.
Chen LH. Vaccines for travel: hepatitis A, meningococcal disease, and typhoid fever. Clin Fam Pract. 2005;7:675–696.
Lo Re V 3rd, Gluckman SJ. Travel immunizations. Am Fam Physician. 2004;70:89–99.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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