vfr parents and children…”

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.

2

Objectives

• Describe characteristics of pediatric travelers visiting friends and relatives (Pediatric VFRs)

• Highlight challenges of pediatric pre-travel care

Pre-CISTM14 Course --- Stefan Hagmann 3

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.


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


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)


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”)


Strategies to Engage Pediatric VFRs

Routine Screen for Future Travel Activities

Outreach in Newborn Nursery and Outpatient Clinics

Screen shot of clinic template


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

11

• 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

Pre-CISTM14 Course --- Stefan Hagmann

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.


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

*

*



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



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)


Back to the Clinic


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? …..


What are you concerned about?


What are you concerned about?

• Malaria and other vector-borne infections

• Invasive bacterial infections

• Respiratory infections

• Gastrointestinal infections

• Trauma

• Rabies


• 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.


What are you concerned about? 2. Invasive bacterial infections


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






What are you concerned about? 4. Gastrointestinal infections






What are you concerned about? 5. Trauma / Rabies


GeoSentinel network, 20101 N=1,594


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?


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?


What would you recommend?


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:


• Good tolerability in children • Ease of use (once a week) • Relative Affordability

Likely Reasons for Preferred Use of mefloquine


Personal Protection Measures


• 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


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


http://www.healthychildren.org/English/tips-tools/Symptom-Checker/Pages/Vomiting-With-Diarrhea.aspx










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!


Last but not least

• What is the budget?

– Need to address actively with families!

• Provide written information in patient’s primary language if possible.


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!


Thank you!

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vfr parents and children…”

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