about “…VFR Parents and Children…”
Pre-CISTM Course, 24 May 2015 :
Pediatric Travel Medicine: what we know, what we think we know and
what we actually end up doing!
Stefan Hagmann, MD MSc Associate Professor of Clinical Pediatrics
Division of Pediatric Infectious Diseases, Bronx-Lebanon Hospital Center Albert Einstein College of Medicine, Bronx, New York
Conflict of Interest
• I have no conflict of interests to declare.
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Objectives
• Describe characteristics of pediatric travelers visiting friends and relatives (Pediatric VFRs)
• Highlight challenges of pediatric pre-travel care
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Who is a VFR? Definition by the ISTM - Migration Health Sub-committee
“...a VFR traveler is a traveler whose primary purpose is travel to visit friends and relatives, where there is a gradient of epidemiological risk between home and destination…”
Barnett E et al. J Travel Med 2010;17(3):163-70.
A traveler categorized as a VFR is an immigrant …(with) residence in a higher-income country who returns to his or her home country (a lower income country) to visit friends and relatives. Included in the VFR category are family members, such as spouses and children who were born in the country of residence.
Keystone J. Chapter 8, Yellow Book 2014.
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Pre-Travel Health Disparities among VFRs
Lack of awareness of risk or belief that they are immune
Low rate of insurance coverage
Financial barriers
Lack of trust in the medical system
Cultural and language barriers
Angell SY, Cetron MS. Ann Intern Med 2005;142:67-72
Disproportionate risk for travel-
related infectious diseases
Low rate of pre-travel
health care
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Low Rate of Pre-travel Health Care in Pediatric VFRs
• GeoSentinel network (2010)
• 1,591 children with travel-related diagnoses
• 275 Pediatric VFRs
• Pre-travel care:
Hagmann et al. Pediatrics 2010;125(5):e1072-80.
0%
10%
20%
30%
40%
50%
60%
VFR Non-VFR
(P<.001)
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Strategies to Engage VFRs
• Health Fairs:
– Places of faith, schools, libraries
• Radio/TV programs
• Diaspora clinic (Bronx):
– Providing medical and support services needed by the growing West African community
• Global TravEpiNet:
– Travel Agents (“Travel Health Ambassador Program”)
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Strategies to Engage Pediatric VFRs
Routine Screen for Future Travel Activities
Outreach in Newborn Nursery and Outpatient Clinics
Screen shot of clinic template
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Distribution of Age and Reason for Travel of Pediatric Travelers in (GTEN)
Global TravEpiNet Clinics, 2009-2012
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
12-17y
6-11y ≤5y
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• N= 3,332 children • Reason for travel: VFR 36.0% Leisure 35.9% Other 28.2%
0%
10%
20%
30%
40%
50%
60%
70%
Leisure (%) VFR (%)
P<.01
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Age of Pediatric VFRs seen at U.S. GTEN Clinics 2009-2012
0
2
4
6
8
10
12
14
16
18 Median Age (IQR), y
VFR Leisure Other Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
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Time to Departure and Duration of Travel in Pediatric VFRs at U.S. GTEN Clinics, 2009-2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
VFR Leisure Other
Time to departure <14days
Travel duration, >28 days
*P<.01
*
*
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
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Region of Destination
0%
10%
20%
30%
40%
50%
60%
70%
VFR Leisure Other
African
Central America/Caribbean
South American
South East Asian
Europe
Eastern Mediterranean
Western Pacific
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
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Take Home Points so far!
1. Pediatric VFRs represent a significant proportion of pediatric international travelers.
2. Pediatric VFRs compared to other pediatric travelers are: – Less likely to seek pre-travel health care. (≤30%)
– Younger. (Infants/toddlers/preschoolers)
– Present often late to pre-travel care. (<14 days)
– Travel for longer periods. (>1 month)
– Travel more frequently to high-risk destinations. (Africa, Asia, Americas)
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Back to the Clinic
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Your Friday Afternoon Case
A mother is taking her 1-month-old infant to rural Guinea to visit family. Among many things, you are concerned about?....
What would you recommend? …..
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What are you concerned about?
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What are you concerned about?
• Malaria and other vector-borne infections
• Invasive bacterial infections
• Respiratory infections
• Gastrointestinal infections
• Trauma
• Rabies
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• Ebola
What are you concerned about? 1. Malaria
• Children account for 15-20% of all imported malaria cases.1
• Pediatric VFRs 2-times more likely to acquire malaria, compared with pediatric tourists.2
• Pl. falciparum the most common species
• Sub-Saharan Africa most common regions of exposure.
1Stäger K et al. Emerg Infect Dis 2009;15(2):185-91. 2Hagmann S et al. Pediatrics 2010;125(5):e1072-80.
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What are you concerned about? 2. Invasive bacterial infections
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Causes of Fever in Outpatient Tanzanian Children1
Regional Causes of Childhood Death, Africa 20102
1D’Acremont V, N Engl J Med 2014;370:809-17. 2Liu L, Lancet 2012;379:2151-61.
70.5% viral 22.0% bacterial 10.9% parasitic
What are you concerned about? 3. Respiratory infections
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Causes of Fever in Outpatient Tanzanian Children1
Regional Causes of Childhood Death, Africa 20102
1D’Acremont V, N Engl J Med 2014;370:809-17. 2Liu L, Lancet 2012;379:2151-61.
70.5% viral 22.0% bacterial 10.9% parasitic
What are you concerned about? 4. Gastrointestinal infections
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Causes of Fever in Outpatient Tanzanian Children1
Regional Causes of Childhood Death, Africa 20102
1D’Acremont V, N Engl J Med 2014;370:809-17. 2Liu L, Lancet 2012;379:2151-61.
70.5% viral 22.0% bacterial 10.9% parasitic
What are you concerned about? 5. Trauma / Rabies
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GeoSentinel network, 20101 N=1,594
Regional Causes of Childhood Death, Africa 20102
1Hagmann S, Pediatrics 2010;125(5):e1072-80. 2Liu L, Lancet 2012;379:2151-61.
• Animal bites: 6%
• Affects disproportionately children, aOR: 3
What questions would you ask?
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What questions would you ask?
1. When is the infant leaving? 2. How long is the trip? 3. Where and with whom will the infant stay? 4. With whom will the infant travel to the
destination? 5. What is the PMHx / newborn history? 6. Which vaccines has the infant received so far 7. Has the mother been immunized during
pregnancy or postpartum? Which vaccines? 8. Is the mother breastfeeding this infant?
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What would you recommend?
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Malaria Chemoprophylaxis in Children at U.S. GTEN Clinics 2009-12.
• VFRs, aOR:2.37 • Prolonged travel, aOR:2.38 • Younger age (0-5y), aOR: 4.29 (6-11), aOR: 3.53
Proportion of drugs used by age groups
Mefloquine use associated with:
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• Good tolerability in children • Ease of use (once a week) • Relative Affordability
Likely Reasons for Preferred Use of mefloquine
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
Personal Protection Measures
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• Carry-on stage (~0-8 months)
• Primary Prevention strategy: =>Protective environment
• Permethrin-impregnated nets for crip/bed/stroller/car seat
Stauffer WM et al. J Travel Med 2003;10:225-240
Permethrin Repellent
Nets
3-prong Approach Strategy Based on Develop-mental Stage of Child
Vaccinations
• Accelerated schedule for basic series: – Starts at 6 weeks and can be completed by 14 weeks
(Rotavirus, Pneumococcus, Diphtheria, Tetanus, Pertussis, HiB, Polio)
• Hepatitis B: – Ideally started at birth, continue series
• Hepatitis A: – Immunoglubulin
• Meningococcal: – Men ACWY-CRM (Menveo) (2, 4, 6, 12 months)
• BCG: to be considered and discussed
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Diarrhea Care
1. What is diarrhea and how to recognize it
2. Care Advicewww.healthychildren.org/English/tips-tools/Symptom-
Checker/Pages/Vomiting-With-Diarrhea.aspx.
Reassurance
Preparation and use of ORS
Avoidance of medicines
Expected course
When to seek professional help
3. Nutrition counseling
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Mother (or other caregiver)/ Overlap with migrant health care
• Care giver (e.g. mother) interested to receive pre-travel care? Offer actively.
• Review existing serologic results – Pre-natal or others if available, e.g. hepB, MMR etc. – Consider to order if none available
• Review PPD status • Review immunization history • Link to specialist care if needed, e.g. hepatologist • (Mother): Breastfeeding? = Precaution for yellow
fever vaccine!
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Last but not least
• What is the budget?
– Need to address actively with families!
• Provide written information in patient’s primary language if possible.
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Key-points
1. Look for how you can engage pediatric VFRs in your service area!
2. Have time to discuss in details with the care givers the real-world circumstances of planned trip: where?, when?, how long?, with whom?
3. Offer pre-travel care to adult caregivers!
4. Know a good and reliable compounding pharmacist!
5. Be familiar with and utilize accelerated immunizations schedules!
6. Provide instructions and hand-outs in the caregiver’s best language!
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Thank you!
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