Winter 2021 Issue
Volume 13 | Number 1
Stan Grogg, DO, FACOP, FAAP
Certificate in Travel Medicine
Barbara C Grogg, APRN-CNP
Certificate in Travel Medicine
With over 74 million U.S. residents traveling internationally and 32.8 million traveling overseas (1), the importance of adequate pre-travel immunizations and prophylactic medications is critical. Of those travelers, it is estimated that 1.9 million are children. (2) Realistically, pediatricians will treat patients traveling to destinations with both diseases which preventive immunizations are routinely available in the United States, as well as quite different diseases present in those international locations.
As highlighted through cases of Zika, diseases appear unexpectedly in many destinations. Unless the healthcare provider was following the spread of this virus carefully, as well as the warnings and evidence reports of problems associated with this disease, correct, up-to-date information may inadvertently be omitted from a discussion with travelers. Keeping current with the latest travel medicine information is time consuming and, in many cases, confusing and difficult to find.
If available, a specialized travel medicine clinic is recommended early in the pre-travel plans to make certain both parents and children are adequately protected. They should also be informed about risks and avoidance procedures associated with international travel. If a travel medicine clinic is not available in your area, most likely the healthcare provider will be asked to give advice. A current evidence-based source for both healthcare providers and the public is through the Centers for Disease Control (CDC), www.cdc.gov/travel.
Vaccines implementing the latest ACIP recommendations are encouraged. Those schedules are timely upgraded and are easily accessible at http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-schedule.pdf.
If the child needs “catch up” vaccines, detailed information can be found at https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf#page=3.
In reality, many children are traveling to areas with endemic diseases requiring accelerated schedules of routine vaccines. It is important for the child’s health protection to advise acceleration. However, the accelerated vaccines may not “count” toward State policies concerning school entry. Healthcare providers should be aware not all travel-related vaccines are effective in infants, and some are specifically contraindicated. Specific vaccine information will be discussed below.
Schedule modifications may be necessary for traveling children and should be carefully evaluated. Factors such as age-specific risks of the disease, disease complications, and ability to develop adequate immune response to vaccination due to age and immune response should be carefully considered. As a rule, the earliest opportunity to receive vaccines recommended in the US except for Hepatitis B is 6 weeks. Also, live virus vaccines (MMR and yellow fever) should be administered on the same day or 28 days apart considering the minimum age for these vaccines. Those age-related recommendations are based on potential adverse events (yellow fever vaccine), lack of efficacy data or inadequate immune response (polysaccharide vaccines and influenza vaccine), maternal antibody interference (measles, mumps, rubella (MMR) vaccine, or lack of safety data. More detailed information can be found at https://wwwnc.cdc.gov/travel/yellowbook/2018/international-travel-with-infants-children/vaccine-recommendations-for-infants-and-children.
MMR or MMRV vaccine
Children traveling abroad require vaccination at an earlier age than is routinely recommended. Infants aged 6–11 months should receive 1 dose of MMR vaccine before departure, then be vaccinated with MMR or MMRV (measles-mumps-rubella-varicella) vaccine at 12–15 months (≥28 days after the initial dose) and again at 4–6 years, according to the routinely recommended schedule. Children aged ≥12 months should have 2 doses of MMR vaccine before traveling overseas. Children who have received 1 dose should receive their second dose before departure, provided the 2 doses are separated by ≥28 days.
HEPATITIS B vaccine
While vaccinating a child on an accelerated schedule, Hepatitis B may be administered with 4 doses of vaccine given at 0, 1, 2, and 12 months. A final dose may be given upon return from travel.
For children who travel to or reside in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or the Hajj, administer an age-appropriate formulation and series of Menactra or Menveo for protection against serogropus A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children traveling to the meningitis belt or the Hajj due to adequate serogroup A or W coverage.
The preferred age for MenB vaccination is 16–18 years. ACIP also recommends routine use of MenB vaccine for people aged ≥10 years at increased risk for meningococcal disease. This includes patients with persistent complement component deficiency and those having functional or anatomic asplenia. MenB vaccine is not recommended for people who travel to or reside in meningitis belt countries, as serogroup B disease is rare in this region. MenB vaccine is not routinely recommended for travel to other regions of the world unless an outbreak of serogroup B disease has been reported. Although MenB vaccine is not licensed in the United States for children <10 years of age, some European countries have recently introduced MenB vaccine as a routine immunization for infants.
Travelers to countries with evidence of wild poliovirus (WPV) circulation (during the last 12 months) or for travelers with a high risk of exposure to imported WPV infection when traveling to some countries that border areas with WPV circulation should be vaccinated. Refer to the CDC Travelers’ Health website destination pages for the most up-to-date polio vaccine recommendations (wwwnc.cdc.gov/travel/destinations/list). Clinicians should ensure travelers have completed the recommended age-appropriate polio vaccine series and received a single lifetime booster dose, if necessary.
Administer a 2–dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid.
YELLOW FEVER vaccine
Infants aged <9 months should be advised against traveling to areas within the yellow fever–endemic zone, as they are at higher risk for developing encephalitis from yellow fever vaccine, which is a live virus vaccine. ACIP recommends that yellow fever vaccine never be given to infants aged <6 months. Infants aged 6–8 months should be vaccinated only if they must travel to areas of ongoing epidemic yellow fever and if a high level of protection against mosquito bites is not possible. Yellow fever vaccine is available only at State approved vaccine sites.
The FDA has recently approved a cholera vaccine for travelers to high-risk areas. It is only approved for ages 18-64 and offers incomplete protection. Therefore, other prevention and control measures such as purified water, food washed in purified water, and fully cooked foods are necessary.
Rabies virus manifests as acute viral encephalitis that is virtually 100% fatal. Traveling children may be at increased risk of rabies exposure, secondary to dogs roaming streets in developing countries. Children at “eye level” with dogs or making eye contact may be a perceived threat to dogs resulting in attacks or biting. Rabies vaccine is a 3-dose series. Should a bite occur, 2 more doses will be required. No accelerated dosing exists for rabies and if the series is not completed, post-exposure vaccines should be given as if no pre-exposure doses had been received. Finding the appropriate vaccine in many developing countries can be challenging underscoring the importance of evacuation insurance.
JAPANESE ENCEPHILITIS (JE) vaccine
One vaccine, IXIARO, is licensed and available in the US. It is approved for travelers age 2 months and above. It is administered as a two-dose series, with the doses spaced 28 days apart. The last dose should be given at least 1 week before travel. JE vaccine is recommended for travelers who plan to spend 1 month or more in endemic areas during the JE virus transmission season. No accelerated schedule exists for this vaccine. Likewise, this vaccine is not recommended for short-term travelers of less than 30 days, or whose visits will be restricted to urban areas, or times outside a well-defined JE virus transmission season.
According to the CDC, typhoid is most common in Asia, Africa, and Latin America with the highest risk in south Asia. Vaccines available in the US have 50%-80% efficacy. Therefore, food and water precautions are especially important. An injectable vaccine is available and should be administered no less than 10 days prior to travel and is effective for 2 years. The injection is not approved for children under age two. The oral typhoid vaccine is a series of 4 capsules taken every other day. The last dose should be taken one week prior to travel and is recommended for age 6 and above.
Traveling with children can be both fun and educational as well creating meaningful lifetime memories. In general, risks for children mirror parents but may potentially be more serious. Careful pre-travel planning and understanding needs specific to the traveler’s itinerary, can mitigate health risks to children. Attention to vaccines and prophylactic medications recommended by the CDC for the travel itinerary of the child is critical.
“Travel, in the younger sort, is a part of education; in the elder, a part of the experience.” - Francis Bacon
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