Transcript Planning for Travel With Children in the Modern World Martin

Planning for Travel With Children
in the Modern World
Martin G. Ottolini et. el,
Edward Hebert School of Medicine
碩研休閒一甲 MA4B0110 呂育衡
Introduction (1)
Case I
 Two siblings, a 3-year-old girl and a 9-month-old
boy who present with upper respiratory tract
symptom (上呼吸道症狀), concern about
possible otitis media (中耳炎).
 The parents, both of whom emigrated 4 years
ago to the US, they’re traveling home to
Cameroon to spend two weeks visiting the
children’s grandparents.
 The mother asks if children “need any shots”(需
要打任何疫苗嗎？)
Introduction (2)
Case II
 Family of four, moving to Thailand for an
estimated 3 years, a 47-year-old father with no
health problem, a 49-year-old mother who is on
chronic therapy for rheumatoid arthritis(類風濕
關節炎的慢性治療), three healthy children with
ages of 9, 14, and 16.
 Will likely visit displaced persons camps near the
Thailand-Cambodia border, to travel extensively
as a family in the region.
Introduction (3)
Case III
 A healthy 17-year-old female high-school
student, work for 8 weeks at a rural church
mission site in the Amazon basin of Peru.
 She will help staff a program that provides early
childhood education in a community of
subsistence farming families.
 She anticipates traveling with another friend,
planning to use any free time to extensively
explore the region through hiking and kayaking.
They all ask the same questions!
 What can we do to reduce our risk of
becoming ill or injured during our stay in
these foreign sites?
 What should we do to prepare for our
trips?
 Do you have any advice we should
follow during travel?
Introduction (Overall)
They wish:
 to anticipate and reduce their “risks” of
travel-related illnesses and injuries
 to be ready to take more control of their
health and potential therapies in regions
where they would need to rely less on
ready access to the substantial safety
net of a modern health care system
Extent of Travel
in the US Population (1)
 In 2013, more than 61.8 million U.S. Residents
traveled internationally.
 39.8 million U.S residents traveled to areas
that would justify a pre-travel health
assessment Including 20.9 million travel visit
to Mexico
 8% of outbound travel parties include children
 1.2 million child international travelers
annually
Extent of Travel
in the US Population (2)
 The average duration of travel is 16.6
days (median 10 days)
 Decision to time of travel of 106 days,
pre-travel health visits are sought out in
only 11% of international travelers overall
 Only 36-46% of those traveling to low
and low-middle income countries.
Extent of Travel
in the US Population (3)
Health Risks in International Travel (1)
 The majority of travel medicine advice focuses
on the prevention, diagnosis, and treatment of
infectious diseases
 Compared to adults, pediatric(兒童的) travelers
may be more likely to develop diarrheal(腹瀉),
dermatologic(皮膚病), and respiratory illnesses
呼吸系統疾病, animal bites.
Health Risks in International Travel (2)
 The incidence rate of traveler’s diarrhea
during a 2-week trip is approximately
30%, and that of influenza
approximately 1%, the risk of other
vaccine preventable diseases are lower,
ranging from 1:3000 for typhoid fever;
to 1:100000000 for Japanese
encephalitis and meningococcal
Health Risks in International Travel (3)
 Despite the typical focus on infectious health
risks, it is important to remind families that
serious injuries occur at higher rates when
traveling.
 The major source of pediatric traveler
mortality is actually due to both motor vehicle
accidents and drowning, both of which are
disproportionately high when compared to
adults.
Health Risks in International Travel (4)
 Passengers under 18years of age account for
9.3% of the total inflight emergencies with a
rate of 2.24 events per 1 million passengers.
Deaths were rare(10 total, 0.13% of all pediatric
emergencies).
 Young age(median 3.5 months), and being a
“lap infant”(9 of 10), bringing up the
possibility of sudden unexplained infant death
(SUID) during trips with sleeping infants.
Health Risks in International Travel (5)
 More common concerns whether over-thecounter medications can be utilized as either a
sedative(鎮靜劑) or prophylactic(預防)
against barotrauma-related(氣壓傷相關)
otalgia merit(耳痛的優點) direct discussion
with parents as both antihistamines(抗組胺藥)
and decongestants(減充血劑) pose serious
risks to children under the age of two and
have shown no benefit in reducing symptoms
of air-travel-related otalgia耳痛.
Health Risks in International Travel (5)
 There should be emphasis on enhancing
safe, comfortable seating for children,
age-appropriate activities, and use of
sucking and swallowing techniques to
reduce barotrauma with changes in
cabin-pressure.
Health Risks in International Travel (6)
 Adolescent travelers also have unique agespecific considerations when traveling. They
are likely to be adventurous and engage in
riskier activities, like the missionary in our
introduction, both increasing the chances of
injury and also creating new infectious disease
exposures from fresh-water of soil/mud
contact.
Health Risks in International Travel (6)
 Blood borne pathogens(血液製病
菌)(tattoos and piercings) and sexually
transmitted infections become significant
concerns that should be discussed, as well
as broader issues(更廣泛的問題) of
reproductive health(再生醫療) such as
contraceptives(避孕藥)
and sexual violence.
Health Risks in International Travel (7)
 Chronic diseases慢性病 should be addressed, in
terms of direct risk of an exacerbation突然發作
during travel, as well as their potential to increase risk
and severity of secondary or opportunistic infections.
While children with chronic diseases such as type 1
diabetes can safely travel, attention must be given to
dosage adjustments劑量調整, dietary considerations,
and activity modification; as well as sufficient supplies
for the entire trip.
Health Risks in International Travel (8)
 For those with immunosuppression(免疫力被
減弱的人) due to disease or as a result of
medication, there are unique considerations
for food and water safety counseling,
modified vaccine indications and safety,
medications interactions, and dosing
considerations for prophylactic medications.
Health Risks in International Travel (9)
 There is also a greater need to plan for the
contingencies of self- treatment and when
needed know how to access to quality
medical services while traveling in lessresourced regions.
 While most travel medicine services can be
readily provided in the primary care setting,
patients with more complex medical needs
may be better served by a travel medicine
specialist.
Health Risks in International Travel (10)
 Travel medicine requires “situational
awareness” the anticipation of the
unique risks of the geographic locations
to be visited, planning for the likely
activities that visitors engage in, as well
as being informed of any outbreaks of
disease occurring at that time.
Health Risks in International Travel (10)
 Travel medicine providers have the
responsibility to obtain the most current
information about the risks of the sites
to which their patients are traveling,
and to be prepared to appropriately
counsel patients about them.
Health Risks in International Travel (11)
 The risks of some endemic or epidemic
infectious diseases can be mitigated through
behavioral changes, prophylaxis, or
vaccinations, many situations, including
natural or man-made disasters, or rapidly
emerging infectious diseases cannot be
anticipated and leave the traveler at the
mercy of the local infrastructure, their own
adaptability, and contingency planning.
Health Risks in International Travel (11)
 These will be expended in the pre-travel
preparation article, which will include a
discussion about the role of additional
traveler’s health and evacuation
insurance.
The practice of Travel Medicine (1)
 The field of travel medicine has a defined
body of knowledge and scope of practice as
well an evolving body of research literature
upon which to draw. (Table 1)
 Access to current disease surveillance
information, updated practice guidelines, and
other clinical management resources for
consultation, all help ensure quality care.
(Table 2)
The practice of Travel Medicine (2)
 In our practice we regularly consult with the
Center for Disease Control and Prevention’s
general and pediatric travelers health website,
including print and electronic versions of
“Health Information for International Travel”
(Known as the Yellow Book).
 Additional pediatric-specific references
include the electronic and and print versions
of the American Academy of Pediatrics Report
of the Committee on Infectious Disease
(known as the Red Book).
The practice of Travel Medicine (3)
 The American Society of Tropical Medicine
and Hygiene supports training programs and
an examination that leads to a Certificate of
Knowledge in Clinical Tropical Medicine and
Travelers Health and the International Society
of Tropical Medicine offers a examination
leading to the Certificate of Travelers Health.
The practice of Travel Medicine (4)
 One major limitation has been the lack of
evidence based guidance for developing
pediatric-specific practices and adopting adultbased recommendations.
 Serious pediatric travel-related illness is
fortunately less common, many travel medicine
experts are uncomfortable with very young
children, and are even lass confident of
evaluating illnesses in the returning travelers.
The practice of Travel Medicine (5)
 A fairly recent development has been
the establishment of the ”Pediatric
Interest Group” within the International
Society of Travel Medicine in 2010, in
response to the recognition of the
significant numbers of pediatric
travelers and need for consistent
research and training.
The practice of Travel Medicine (6)
 As pointed out in a recent survey of
members, the diversity of training and
practice among those working in this
area indicates a need for formulation
and adherence to age-specific evidencebased guidelines.