Sources for Post-travel Pediatric Illness

By Phil Fischer, MD, DTM&H

Dr. Fischer is Professor of Pediatrics, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN.

Dr. Fischer reports no financial relationships relevant to this field of study.

Synopsis: Following international travel, children are more likely than adults to require hospitalization for travel-related illnesses. Diarrhea, skin problems, and febrile illness are common presenting problems. Pre-travel care is frequently neglected, and pre-travel interventions likely could have been helpful for many ill returned travelers.

Source: Hagmann S, Neugebauer R, Schwartz E, et al. Illness in children after international travel: Analysis from the GeoSentinel Surveillance Network. Pediatrics DOI:10.1542/peds.2009-1951, published online April 5, 2010.

The characteristics and morbidities of 1591 children who presented to travel and tropical medicine clinics for care in 19 countries following international visits to 218 destinations were investigated as part of the GeoSentinel Surveillance Network research activities. Pediatric data were compared to findings in 32,668 adults who presented similarly for post-travel care.

While tourism was the most common reason for travel, children, especially young ones, were more likely than adults to have traveled to visit friends and relatives. Compared to sick adult travelers, children were more likely to present earlier, to require hospitalization, to have had a shorter international trip, and not to have received pre-travel medical input. Children traveling to visit friends and relatives were less likely to have received pre-travel advice (32%) than were children traveling for other reasons (51%).

Presentation for post-travel care among children commonly was due to diarrhea. It accounted for 28% of the total cases, 80% of acute cases, and was almost evenly split among bacterial, parasitic, and unknown etiologies. For skin problems, fully 25% of the total cases were associated with animal bites, half of which were caused by dogs, about one-fifth by cats, and one-fifth by monkeys, followed by cutaneous larva migrans and insect bites. Febrile illnesses accounted for 23% of total cases, one-third of which were due to malaria, or respiratory disorders (11% of the total) mostly unrelated to tropical infections. Two percent of children had a vaccine-preventable infection. Compared to adults, children were more likely to present with animal bites, cutaneous larva migrans, and bacterial diarrhea.

Dermatologic diagnoses were more likely after travel to Latin America. Diarrheal diseases were most common after travel to the Middle East and North Africa. Malaria was the most common etiology of febrile illness in children returning from Africa, but typhoid fever and dengue were more common than malaria among children returning from Asia.

Commentary

Since 1995, the GeoSentinel Surveillance Network has been gathering information about returned travelers presenting for health care at specialized travel and tropical medicine clinics.1,2 Along the way, the network has produced dozens of research papers informing readers about post-travel health issues, including malaria,3 animal-related injuries,4 skin problems,5 and diarrhea.6,7 Having looked at post-travel problems in other specific sub-populations of travelers, including those visiting friends and relatives,8 people visiting China,9 and long-term travelers,10 this current report provides additional very helpful data relevant to pediatric travelers.

These data are quite relevant to the sorts of travelers who would be seen by practitioners of travel medicine. Of course, primary care providers would be more likely than specialists to see many of the patients who present following travel with common problems, such as respiratory infections and diarrhea. Up to 40% of children experience diarrhea during or shortly after international trips,11 and many of these would not be seen in a specialty GeoSentinel type of clinic. Nonetheless, the GeoSentinel pediatric data do provide a good perspective on severe post-travel health problems as they might present to professionals caring for returned travelers.

The GeoSentinel pediatric findings are directly relevant to the pre-travel practice of travel medicine. Only about half of all children, and only about one-third of children visiting friends and relatives, had received pre-travel care. Pre-travel care including interventions to prevent malaria, information about diarrhea management, and education about avoiding skin contact with animals, insects, and parasites would likely have been time-effective and cost-effective for these ill returned-traveler children. Efforts should be made to better attract internationally traveling children for pre-travel care. Some success has been realized in a hospital-based clinic dealing with underserved populations traveling overseas to visit friends and relatives.12 Multi-lingual handouts to facilitate pre-travel care are widely available. (http://www.tropical.umn.edu/TTM/VFR/index.htm)

Nearly half of the children with cutaneous larva migrans13 in this study had traveled to the Caribbean area. Pre-travel visits for Caribbean travelers should include advice about avoiding skin contact with sand where cats and dogs have defecated. Using sandals to walk on potentially contaminated beaches and sitting on towels or lounge chairs can decrease the risk of infections.

Millions of children cross international borders each year. The provision of adequate pre-travel care will help many of them avoid illness, hospitalization, and costly post-travel care. Those who are ill following their trips often have diarrhea, skin problems, and febrile diseases amenable to thoughtful medical care.

References

  1. Freedman DO, Kozarsky PE, Weld LH, et al. GeoSentinel: The global emerging infections sentinel network of the International Society of Travel Medicine. J Travel Med 1999;6:94-98.
  2. Torresi J, Leder K. Defining infections in international travellers through the GeoSentinel surveillance network. Nat Rev Microbiol 2009;7:895-901.
  3. Leder K, Black J, O'Brien D, et al. Malaria in travelers: A review of the GeoSentinel surveillance network. Clin Infect Dis 2004;39:1104-1112.
  4. Gautret P, Schwartz E, Shaw M, et al. Animal-associated injuries and related diseases among returned travelers: A review of the GeoSentinel Surveillance Network. Vaccine 2007;25:2656-2663.
  5. Lederman ER, Weld LH, Elyazar IR, et al. Dermatologic conditions of the ill returned traveler: An analysis from the GeoSentinel Surveillance Network. Int J Infect Dis 2008;12:593-602.
  6. Greenwood Z, Black J, Weld L, et al. Gastrointestinal infection among international travelers globally. J Travel Med 2008;15:221-228.
  7. Swaminathan A, Torresi J, Schlagenhauf P, et al. A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travelers. J Infect 2009;59:19-27.
  8. Leder K, Tong S, Weld L, et al. Ilness in travelers visiting friends and relatives: A review of the GeoSentinel Surveillance Network. Clin Infect Dis 2006;43:1185-1193.
  9. Davis XM, MacDonald S, Borwein S, et al. Health risks in travelers to China: The GeoSentinel experience and implications for the 2008 Beijing Olympics. Am J Trop Med Hyg 2008;79:4-8.
  10. Chen LH, Wilson ME, Davis X, et al. Illness in long-term travelers visiting GeoSentinel clinics. Emerg Infect Dis 2009;15:1773-1782.
  11. Ptiinger B, Steffen R, Tschopp A. Incidence and clinical features of traveler's diarrhea in infants and children. Pediatr Infect Dis J 1991;10:719-723.
  12. Hagmann S, Benavides V, Neugebauer R, et al. Travel health care for immigrant children visiting friends and relatives abroad: Retrospective analysis of a hospital-based travel health service in a US urban underserved area. J Travel Med 2009;16:407-412.
  13. Fleischer LM, Cataldo R, Syed SS. Visual diagnosis: A 10-year-old boy who has a pruritic rash after travel. Pediatr Rev 2008;29:407-409.