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A guide to travel health for children

Lynda Bramham
Senior Nurse Adviser
MASTA Ltd

Children have very specific needs when travelling abroad, and for the practice nurse in a pre-travel consultation with a family group it can feel like there is a lot to cover. In this article, Lynda Bramham focuses on some of the issues that need to be considered during the consultation 

Travel from the UK to exotic destinations is increasing. In 1983 there were 1,594,000 UK residents travelling to destinations outside Europe and USA. In 2008 that figure had increased to 9,958,000.1 Not surprisingly we are now seeing many more children travelling abroad.

Travel overseas with children is usually enjoyable and trouble-free; generally, they adapt well to time and climate changes. However, children's resistance to disease is lower, and with some infections, their condition can deteriorate quickly without the correct treatment. Accidents and injuries may be more common and healthcare facilities may be very basic in some countries. Children travelling to visit friends and relatives (VFRs) are a particular risk group. They are known to be at increased risk of food and waterborne diseases, malaria and diseases of close contact as they are more likely to be on prolonged stays in close contact with the local population.   

Risk assessment
The key to making the most of your short pre-travel consultation is to give tailored advice depending on the travel plans and pre-existing knowledge of the family. Spend the first section of your time finding out where and when they are going, where they plan to stay, planned activities, previous travel experience, medical histories and vaccination histories.

Usually the trips are already booked and paid for by the time the family arrives at the clinic. However, on occasion you may want to recommend some additional planning, preparation and research into the planned destination to establish if it is suitable for the children. 

Travel and childhood vaccines
Vaccinations protect the travelling child and help to prevent the spread of diseases among the community at the destination or on return home.
 
Routine vaccines
Children should be up-to-date with their normal UK vaccinations. Keep an eye on the Department of Health website, as Immunisation against Infectious Disease (the Green Book) is being updated, and the new chapters are posted online.2

Children are often not keen on having injections; the techniques to deal with this come with experience and by learning from colleagues, but there is useful information on consent and vaccinating children in the Green Book and in a document called UK Guidance on Best Practice in Vaccine Administration.3 

Occasionally, it may be necessary to bring some of the routine vaccines forward to provide protection before departure. The Green Book chapters can be helpful here. The local health protection agency may also offer advice on scheduling these vaccines.

If children are travelling overseas before the courses are complete, it is important to weigh up the risks at the intended destination. It is sometimes possible for expatriates to continue their vaccination regimen at the destination, but schedules and vaccinations may be different. Local research may be needed to find a good clinic with sterile medical equipment (needles and syringes are routinely reused in some resource poor countries).

If the diseases are highly prevalent at the destination, parents should be aware that the child may not be protected until the vaccination course has been completed. Details on vaccination schedules in different countries can be found on the World Health Organization website. The International Society of Travel Medicine website lists travel clinics around the world on their website (see Resources).

For children on prolonged or regular trips to developing countries, it is usually worth adding hepatitis B and the BCG vaccine to protect against tuberculosis to the schedule. These can be given from birth
if necessary.

Travel vaccines
Check that you have access to an up-to-date source of information on travel vaccines, as things change and books and wall charts can go out of date. Online resources, such as MASTA, Travax or NaTHNaC, are regularly updated and will reflect disease outbreaks overseas.

If you are not regularly seeing children for travel vaccines, it can be quite a challenge remembering which vaccines are suitable at different ages, the recommended dose and the advice to give when a child is too young to be vaccinated. We look now at some of the travel vaccines used in the UK.

Cholera
An oral cholera vaccine, Dukoral, is available for children from two years of age. The immune response to the vaccine in children from two to six years of age is not as strong. In this age group, children should have three doses, each given one to six weeks apart. This is expected to provide good protection for only six months. As young children may struggle to manage a large drink in the clinic, the volume is reduced for them. Check the instructions inside the pack. Children who are seven years of age and older have two doses of the vaccine one to six weeks apart, and this is expected to provide two years of protection.4

The risk of cholera for most children will be low but vaccination should be considered for those going to risks area with poor sanitation, particularly for prolonged stays in rural areas, away from medical help. 

Hepatitis A
Hepatitis A vaccines are recommended for children from one year of age. A single dose provides protection for one year. A booster dose six to 12 months after the first will provide at least 20 years' protection. With some of the vaccines a junior preparation is used for children.

A combined hepatitis A and B vaccine, Twinrix paediatric, is also available for children from one year of age who need cover against both diseases. A course of three vaccines is required. There is no licensed rapid schedule for children; the course is given at 0, one month and six months.

Hepatitis A is usually a mild disease in young children, and those under one will usually have no symptoms at all.5 Infants can, however, contract the disease (without symptoms) and shed the live virus for many weeks.6 Parents and carers of unvaccinated infants should be advised to take extra care with handwashing after toileting and nappy changing for a number of weeks after return.

Japanese encephalitis
The unlicensed Korean Green Cross vaccine has been used in the UK since the late 1980s to protect travellers at risk from Japanese encephalitis. Supplies are still available for the protection of children. A course of three vaccines is given over one month to provide one year's protection. A short course of two doses, seven days apart, is thought to provide protection for about 80-85% of vaccines for approximately three months. Ideally, the last dose should be completed at least 10 days before travel. A half dose, 0.5 ml, is given to children from 12 months to 36 months of age. Children at 37 months of age and older can have the full 1 ml dose.

This Japanese encephalitis vaccine is not normally given to infants under 12 months old as the immune response to the vaccine is less predictable in this age group. These infants should be protected with insecticide treated nets over their cots or by being inside a well screened or air-conditioned room in the evenings.

The new cell cultured vaccine, Ixiaro, is not currently licensed for children below 18 years of age. However, its use may be considered off license for older teenagers.2

Meningitis ACWY
In the UK there are currently two different vaccines for protecting travellers against meningococcal meningitis. These cover four different serogroups: A, C, W and Y. A new conjugated ACWY vaccine, Menveo, has recently been licensed in the UK for children over 11 years of age. Studies so far show it is safe and effective in children from two months of age, although the phase 3 trials are still ongoing.

This conjugate vaccine is expected to provide longer lasting protection, although recommendations on the timing of the booster dose are not yet available, we can expect at least three years' cover.7 The vaccine is also thought to reduce the risk of travellers being carriers of the meningococcal bacteria and passing the disease on to others. It may also be more effective in young infants who do not obtain a good immune response to the polysaccharide vaccine.7 At the time of print the new Department of Health Green Book chapter has not been published but it is expected that it will state that Menveo can be used for children under 11 years of age off license. For younger children a two-dose course is likely to be recommended.

The polysaccharide vaccine ACWYvax is licensed for children from two years of age. The same dose is given to adults and children. It is expected to provide three years' protection. Infants from three months of age can be vaccinated off license, but as their response to the vaccine is suboptimal, a second dose is recommended three months later.2
Remember that pilgrims going to Hajj and Umrah in Saudi Arabia need proof of ACWY vaccine. The vaccine should be administered at least 10 days before travel and currently this “certificate” is valid for three years.

Rabies
Children are at particular risk of rabies, they are attracted to animals and may not always tell their parents if they have been bitten or scratched. The World Health Organization states that between 30-60% of the victims of dog bites are children under the age of 15.8 Animal bites in children are also usually more severe.6 Parents should be aware of the risk and the need to avoid contact with animals where possible. Bite or scratch wounds should be carefully cleaned with soap and water and a disinfectant applied, post-exposure vaccines should be sought immediately. 

Pre-exposure vaccines should be considered for children on longer trips to risk areas (one month or more) and those travelling away from reliable medial help. There is no lower age limit on the license for the rabies vaccines but generally pre-exposure vaccines are given from 12 months' age. At this age the infant is becoming mobile and the immune response to the vaccine is more predictable. Pre-exposure vaccination can also be considered for younger infants after a risk assessment.2 Post-exposure vaccines would be given from birth if required. The same dose is given to adults and children.

Tick-borne encephalitis
Ticovac junior is licensed in the UK for children from one year to 15 years of age. Ticovac adult vaccine is used for travellers of 16 years and older. The full course of vaccines consists of three doses at 0, one month and five to 12 months. However, in the UK most travellers do not attend for vaccines five to 12 months before departure. Reassuringly, more than 96% of children have protective antibodies three to five weeks after the second dose of Tiovac.9 Protection with two doses is expected to last for one year.

Parents should also take steps to avoid tick bites with repellents and protective clothing. Skin should be checked at least every day for attached ticks. Fine tipped tweezers can be used to remove ticks as soon as they are found. They should be gripped as close to the mouthparts as possible and pulled straight out. Care should be taken to avoid squeezing the body of the tick. 

Typhoid
As from 2008, both of the injectable typhoid vaccines Typhim vi and Typherix are licensed for children from two years of age. They are expected to provide three years' protection. These vaccines can be given off license to children from one year of age if there is a high risk of typhoid, but the response may be suboptimal.2 An oral vaccine, Vivotif, is also available for children from six years of age, this is licensed to provide one year's protection for those travelling intermittently to risk areas. None of the typhoid vaccines offer 100% protection, so care still needs to be taken with food and water hygiene.2
The combined hepatitis A and typhoid vaccines are not licensed for young children; they can be used from 15-16 years of age, depending on the brand.

Yellow fever
Ideally, travel to yellow fever risk areas with infants under nine months of age should be discouraged. There is an increased risk of yellow fever vaccine associated neurologic disease in this age group. Most of the reported cases of post-vaccine encephalitis have occurred in infants under four months of age.10 However, the vaccine is contraindicated in infants under six months of age, and is given only after expert consultation to children under nine months of age. Yellow fever vaccine is also contraindicated in people with a confirmed anaphylactic reaction to egg, those considered to be immunocompromised and people with a thymus disorder.11 It is worth noting that children with a history of cardiac surgery may have had their thymus gland removed.

If a child cannot be vaccinated, parents should be aware of the risks. Although the disease is rare in travellers, there is no specific treatment for yellow fever. In non-immune travellers, case fatality rates can be over 50%.2 Great care to avoid daytime biting mosquitoes should be recommended. A medical letter of exemption can be provided if proof of vaccination is required to get into the country.

Malaria and other insect-borne diseases
There are many different diseases spread by insects; unfortunately, we only have vaccines or tablets to prevent a small number of them. Insect bite avoidance is important for children. Repellents should be used on exposed skin day and night unless in an air-conditioned/well screened room or under a treated net. DEET-based repellents can also be used on cotton clothing.

In the evenings, children should be dressed in long sleeves and long trousers if they are outside. When possible they should be indoors in a well screened or air-conditioned room.

Mosquito nets treated with long-lasting insecticides are ideal to protect small children/babies when they are in their cot or pram or when they are immobile and playing. “Knock down” fly sprays can also be used to clear a room in the evening. If staying long term in a risk area, parents should eliminate any potential breeding sites around the home by filling in puddles and clearing rubbish that may collect water.

Malaria prophylaxis is very important for children as their condition can deteriorate quickly with this disease, they are at particular risk of fatal malaria.11 Children visiting friends and family are at increased risk.

Anti-malarial drugs are required from birth in risk areas and the dose is calculated ideally by the body weight of the child rather than the age. Minimal amounts of anti-malarial drugs are thought to be transferred in to breast milk and this should not be expected to provide protection for the infant. Malarone, mefloquine, paludrine and chloroquine are all licensed for children from different ages. Doxycycline should not be used for children under 12 years of age. Chloroquine can be obtained in syrup form; other drugs could be crushed and added to a small amount of jam or chocolate spread or put in the tip of the bottle for infants if necessary. Information on the dosage for children can be found in the UK malaria guidelines (available from the Health Protection Agency website). Parents should understand the importance of completing the full course. Check the online databases to ensure you are recommending the correct drug for the destination. 

Parents taking children into malaria risk areas should also be aware of the need to seek prompt medical attention and a blood test for malaria if the child becomes unwell within a year of leaving a malaria infected area.12  

First aid kit
Childhood illness such as viral nose and throat infections, coughs, colds and ear infections are common overseas as they are at home. Accidents and injuries may be more common in some countries due to different safety standards on pavements, roads, swimming pools, balconies and play areas.
First aid packs with antiseptic, basic wound dressings and basic analgesia such as paracetamol and ibuprofen plus other commonly used medication is really worthwhile. Other useful items include a reusable thermometer, sun block, insect repellent, oral rehydration solution and other items to treat or manage travellers' diarrhoea if appropriate (see below). If travel to areas with poor medical facilities is essential, a sterile medical equipment pack with clean needles, syringes and suture equipment is worthwhile. 

Medical facilities overseas
Research in to the healthcare facilities at the destination is sensible for those going in to developing countries or travelling away from medical help. Travel health insurance covering the cost of flying home if necessary is recommended. Generally, the facilities for looking after children are likely to be better in the larger towns and cities than those in rural areas in developing countries. The travel insurance company or the British embassy can often give advice on the best place to go. The International Association for Medical Assistance to Travellers has a directory of English speaking doctors around the world (www.iamat.org). 

Travellers' diarrhoea
Travellers' diarrhoea (TD) is the most common health problem to affect travellers. It is thought that infants old enough to crawl and children younger than three years of age are at particular risk.10 If children do acquire TD, some studies suggest that their symptoms are more severe and tend to last longer than in adults.10,13 Children are particularly prone to dehydration which can cause significant illness.

Care should be taken to avoid contaminated food and water, including non-pasteurised dairy products. Breastfeeding young infants should be encouraged. Parents should consider taking pre-packed milk for bottle and formula-fed babies. Careful handwashing before eating and after toileting should also be recommended.

Parents should know how to manage TD, particularly if they are going to areas with poor hygiene. Fluid replacement is the most important treatment and this should be started as soon as symptoms appear. Babies should continue to be breastfed.

Rehydration solution may either be made up from commercially available mixtures or by adding one level teaspoon of salt and eight level teaspoons of sugar to 1  litre of clean water. Older children who refuse the rehydration solution can be given other fluids that contain glucose and electrolytes such as sport drinks if necessary. Sufficient fluid should be given to ensure a good output of normal looking urine.
Children should continue to eat if possible. Those who are vomiting should be given fluids frequently and in small quantities, with volumes gradually being increased as tolerated. Feeding should be restarted as soon as possible as this can reduce the duration of the diarrhoea.13

If the child is not able to tolerate any feeds, has prolonged vomiting/diarrhoea, is showing signs of dehydration, severe abdominal pain, altered mental status, fever or has blood/mucous in the stool then medical attention should be sought immediately.

Loperamide anti-diarrhoeal agent is not recommended for young children with TD due to reports of some severe side effects. This drug can, however, be considered for older children. In the UK loperamide can be bought over the counter for children over 12 years of age.

Parents of young infants should consider taking a suitable barrier cream to help prevent nappy rash. This can develop quickly if a child has diarrhoea.

Sun protection
Malignant melanoma is now the most common cancer in young adults (aged 15-34) in the UK and the number of people affected is increasing.14 Skin cancer takes a number of years to develop. A history of sunburn doubles the risk of developing melanoma later in life.14 Most skin cancers are caused by too much ultraviolet (UV) radiation.

Children's skin is delicate and very easily damaged by the sun. Parents should pack protective cool clothing and hats for their children. High-factor, broad spectrum sun lotion, factor 15+ with four to five stars is recommended. Sunscreens formulated for children are likely to be better for sensitive skin. The lotion should be reapplied regularly and particularly after swimming even if the product is said to be waterproof. Babies under six months have very sensitive skin and should be kept away from direct sunlight with sunshades and wide-brimmed hats.14

The journey
Frequent feeding of infants during a flight is not necessary. Sucking on a bottle or breast may add more air into the stomach and intestine, which is already expanded by 20%. This can cause discomfort. Parents should feed infants at normal frequency and allow them to feed briefly during ascent and descent.13 Parents can find having plenty of books and toys to entertain on the journey, plus a small supply of food and drink helpful.

Summary
With adequate preparation, travel with children should be a fun and educational experience. Nurses can help parents reduce the risks of travel-related illness and provide them with the basic skills to deal with some of the common problems themselves. Encouraging a back-up plan with adequate insurance and research on where to seek medical advice could also be a real help if a child were to become ill abroad.

References
1. Office for National Statistics (ONS). Travel Trends 2008: Data and commentary from the International Passenger Survey. London: ONS; 2009. Available from: www.statistics.gov.uk/downloads/theme_transport/Travel_Trends_2008.pdf
2. Department of Health (DH). Immunisation against Infectious Diseases (the Green Book). London: DH; 2007. Available from: www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/dh...
3. Chiodini J, Cotton G, Genasi F et al. UK Guidance on Best Practice in Vaccine Administration. London: Shire Hall Communications; 2001. Available from: www.rcn.org.uk/__data/assets/pdf_file/0010/78562/001981.pdf
4. Crucell UK Ltd. Dukoral Summary of Product Characterisitics. electronic Medicines Consortium (eMC); 2005. Available from: www.medicines.org.uk/EMC/medicine/14463/SPC/Dukoral+Oral+Cholera+Vaccine
5. Stauffer WM, Kamat D. Traveling with infants and children. Part 2: immunizations. J Travel Med 2002;9:82-90.
6. Giovanetti F. Immunisation of the travelling child. Travel Med Infect Dis 2007;5:3
49-64.

7. JCVI Travel Subcommittee Minutes 2009. Available from: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/d...
8. World Health Organization fact sheet Available from: www.who.int/mediacentre/factsheets/fs099/en/
9. Ticovac Junior Summary of Product Characteristics. Available from: www.medicines.org.uk/EMC/medicine/20116/SPC/Ticovac+0.25ml+Junior/
10. Stauffer W, Christenson JC, Fischer PR. Preparing children for international travel. Travel Medicine and Infectious Disease 2008;6:101-13.
11. Stamaril Summary of Product Characteristics. Available from: www.medicines.org.uk/EMC/medicine/9846/SPC/Stamaril/
12. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom 2007, Health Protection Agency Available from: www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1203496943523
13. Neumann K. Family Travel: An Overview. Travel Medicine and Infectious Disease 2006;4:202-17.
14. Sun Smart Campaign, Cancer Research UK Available from: www.sunsmart.org.uk/index.htm

Resources
World Health Organization
Immunization schedules
W: www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

International Society of Travel Medicine
W: www.istm.org