preparing children for travel in asia

Wilderness and Environmental Medicine, 18, 222 229 (2007)

REVIEW ARTICLE

Preparing Children for Travel in AsiaChristine E. Waasdorp, MD, FAAP; Ji Yeon Kim, MD

From the U.S. Army, 121st Combat Support Hospital, Seoul, South Korea (Dr Waasdorp and Dr Kim).

Category 1 Continuing Medical Education credit for WMS member physicians is available forthis article. Go to http://wms.org/cme/cme.asp?whatarticle�1833 to access the test questions.

Families are traveling with their children in increasing frequency. Travel to Asia offers children manyopportunities to learn about new cultures and history. It also offers the potential for exposure tonumerous infectious agents not commonly encountered in the United States. Families must begin toprepare for travel to Asia weeks before departure. Children should be up to date on routine vaccina-tions. Appropriate education should be given on arthropod avoidance and malaria prophylaxis. Ad-ditional education and possible prophylaxis should be completed for other infectious agents frequentlyencountered in Asia. With appropriate pretrip immunizations and prophylaxis, children can travel toAsia with minimal risk of acquiring infection. This article provides general advice to assist providerswith pretravel preparation and education of families traveling with children to Asia.

Key words: travel, Asia, children

Introduction

Families are traveling with their children on an increas-ing basis, with an estimated 1.9 million children trav-eling overseas each year.1 Many of these families par-ticipate in adventure vacations, traveling to developingcountries to hike, bike, rock climb, and camp. Asia, arapidly modernizing continent, has seen a 32% increasein vacation travelers in the last decade, most of whomvisit the developing countries.2 Travel to these areas pre-sents opportunities for children to be exposed to newcultures, as well as to new infectious agents not com-monly encountered in the developed world. Due to var-iable immunity, children are at higher risk of acquiringtravel-related infections during trips than adults, requir-ing that appropriate medical preparation be initiatedweeks before travel is to commence. This article will

The views, opinions, and findings contained in this report are thoseof the authors and should not be construed as official Department ofthe Army position, policy, or decision unless so designated by otherofficial documentation. Citations of commercial organizations andtrade names in reports do not constitute an official Department of theArmy endorsement or approval of the products or services of theseorganizations.

Corresponding author: Christine E. Waasdorp, 121st Combat Sup-port Hospital, Box 662, APO, AP 96205 (e-mail: [email protected]).

review the most common infectious agents children mayencounter while traveling in Asia and the appropriatepreventative measures to reduce the risk of illness duringand after travel.

Routine health care

Children traveling to Asia should be up to date on allthe routine childhood immunizations, including diphthe-ria, tetanus, pertussis, measles, mumps, rubella, polio,varicella, Haemophilus influenzae type b, pneumococcal,hepatitis B, and hepatitis A. Influenza vaccine shouldalso be given when traveling during the peak transmis-sion seasons. The most recent recommendations for im-munizations according to the American Academy of Pe-diatrics (AAP) and Centers for Disease Control and Pre-vention (CDC) are summarized in Table 1. Diphtheria,tetanus, and acellular pertussis (DtaP); polio (IPV); hep-atitis B (hep B); and H influenzae b (Hib) vaccines may-be initiated as early as 6 weeks of life and may be ac-celerated with vaccinations every 4 to 6 weeks in orderto complete the full series before traveling to endemicareas.3 The first dose of measles-mumps-rubella (MMR)vaccine may be given as early as 6 months of life iftraveling to an area with an active outbreak.3 Childrenreceiving the early dose of MMR vaccine still require 2

223Preparing Children for Travel in Asia

Table 1. Routine immunizations

VaccineTotaldoses

Minimuminterval

Earliest agefor first dose

Usual agefor first dose Booster age

Hepatitis B 3 4 wk At birth At birth Consider at 12 mo if athigh risk

Diphtheria, tetanus, acellular per-tussis 4 4 wk 6 wk 2 mo 4–6 y

Haemophilus influenzae type b 3 4 wk 6 wk 2 mo 15 moInactivated polio 4 4 wk 6 wk 2 moMeasles-mumps-rubella* 2 4 wk 6–11 mo 12–15 mo 4–6 yVaricella† 2 4 wk 12 mo 12–18 mo 4–6 yPneumococcus 3 4 wk 6 wk 2 mo 12–15 moInfluenza Yearly 6 mo 1 yHepatitis A 2 6 mo 12 mo 12 mo

*Children who receive the accelerated schedule still require 2 measles-mumps-rubella vaccinations after 12 months of age.†Children �12 years old, without clinical or serological evidence of varicella infection, require 2 doses of varicella vaccine.

MMR vaccinations, with the recommended timing ofsubsequent vaccinations being 12 months of age andagain at 4 to 6 years of age to maximize immunity.3

Varicella vaccine should be given prior to travel to allchildren older than 1 year. Children who are older than12 years of age, with no clinical or serologic evidenceof varicella infection, will require the first of a 2-shotseries 4 to 8 weeks apart prior to departure to maximizeimmunity.3

Hepatitis A

Hepatitis A (hep A) is the most common vaccine-pre-ventable disease experienced by travelers to Asia.4 TheCDC has listed Asia as a high-prevalence area for ex-posure to hep A.4 This is supported by recent data iden-tifying travel to Asia as the source for 6% of all hep Ainfections in the United States.5 Hepatitis A is an RNApicornovirus transmitted by fecal contamination of foodand water. Infected children may present with fever, mal-aise, jaundice, anorexia, and nausea. Although adults aremore likely to be symptomatic, children may also dem-onstrate a wide spectrum of symptoms. The disease isgenerally self-limited, lasting 7 to 87 days, and requiresminimal supportive care and monitoring for resolutionof the hepatitis.6 The mortality rate is less than 1.5% inchildren.6

Travelers to developing countries are at greater riskfor infection due to poor food and water sanitation.Therefore, prevention of hep A is best achieved withclose attention to good food and water hygiene. This isaccomplished by drinking bottled water, or more con-servatively water that is personally disinfected by boil-ing or by microfiltration combined with halide treatment,

in addition to carefully selecting all foods. Fruits andvegetables should be cooked or carefully peeled. Streetvendors’ food and beverages should be avoided due toincreased likelihood of contamination. Additional pre-vention measures involve vaccination by the inactivatedhep A virus vaccine, of which there are currently 2 li-censed for use in the United States: Havrix (Glaxo-SmithKline Biologicals) and Vaqta (Merck & Co Inc).This vaccination is now considered a routine childhoodvaccination. Children traveling to Asia should receivethe first shot in this 2-shot series a minimum of 6 weeksprior to travel. The first vaccination may be given asearly as 1 year of age, with the second 6 to 12 monthslater.7 If the departure is imminent, the child should re-ceive both the vaccine and the immunoglobulin simul-taneously to maximize protection. It is recommendedthat children younger than 1 year of age be evaluatedfor potential risk of virus exposure. If traveling to anendemic area and exposure to local water and food can-not be avoided, immunoglobulin should be administeredat 0.02 mL/kg for those traveling less than 3 months and0.06 mL/kg for those children traveling greater than 3months. This will provide coverage during the durationof travel.

Hepatitis B

Hepatitis B (hep B) is caused by a DNA hepadnavirustransmitted by contaminated blood, blood products, sa-liva, and sexual activity with an infected partner andpotentially via contact with the skin lesions of infectedpersons. Hepatitis B is endemic in Asia, with greaterthan 8% of the population infected with chronic hep B.8

Disease presentation in children includes a spectrum of

224 Waasdorp and Kim

symptoms ranging from subacute illness with nonspe-cific complaints (eg, anorexia, nausea, malaise), to clin-ical hepatitis that includes jaundice, to, most severely,fulminant and fatal hepatitis. Children have a higher riskfor developing chronic hep B infection, with 90% ofinfants, 25 to 50% of 1- to 5-year-old children, and 6 to10% of older children developing chronic hep B after anacute infection.9 Of those children who become chron-ically infected, 25% will develop hepatocellular carci-noma, cirrhosis, or chronic liver disease.9

Prevention is best accomplished with completion ofthe vaccination series. There are 2 licensed recombinantvaccines available in the United States: Energix(SmithKline Beecham) and Recombivax (Merck). Vac-cination for hep B has been routine for children in theUnited States since 1991.10 For children who havemissed their routine vaccinations, it may be given on theschedule of 0, 1, and 6 months or an accelerated sched-ule of 0, 1, and 2 months to accomplish full immuni-zation prior to travel in high-risk areas, such as Asia. Ifthe accelerated schedule is used, a fourth dose should begiven at 12 months.

Typhoid

Typhoid fever is caused by the bacterium Salmonellatyphi and transmitted via the fecal-oral route. The infec-tion lasts 7 to 14 days with nonspecific complaints offever, chills, malaise, headache, dry cough, myalgia, ab-dominal discomfort, and occasionally mental statuschanges. There are documented cases of more severecomplications, such as gastrointestinal bleeding, intesti-nal perforation, and encephalopathy, but these are rare.Asia is considered a high-risk area for exposure to Styphi, with 22 million new cases reported each year.7

Although it can be treated with oral antibiotics, in someareas of Vietnam, India, and Pakistan, there has been anincreasing emergence of antibiotic-resistant strains of Styphi.5 Treatment of these resistant strains is increasinglydifficult, and thus it is recommended that travelers whoplan to visit high-risk areas consider immunization. Al-though vaccination demonstrates an efficacy rate of only70%, this provides substantial protection and can be fur-ther improved with the addition of strict food and waterhygiene.5

There are 2 types of vaccinations: oral Ty21a (VivotifBerna) and the parenteral purified Vi polysaccharide ty-phoid vaccine Typhim VI (Pasteur Merieux Connaught).The oral Ty21a vaccine is a live attenuated vaccine thatcan be given to children as young as 6 years of age.5

The child takes one capsule by mouth, 1 hour before or2 hours after a meal, every other day for a total of 4doses. A booster dose is needed every 5 years.5 The Vi

capsular vaccine requires a single injection and can begiven to children older than 2 years of age.5 A boosterdose is required every 2 years. Vaccinations should begiven at least 1 week before travel for the greatest pro-tection.

Malaria

Malaria is endemic in tropical countries of Asia andfound in almost all Asian countries.11 Plasmodium vivax,P falciparum, and P malariae are all found in parts ofAsia.10 It is a mosquito-transmitted, blood-borne para-sitic infection. The incubation period is typically 1 to 4weeks, with many cases initially presenting with mini-mal symptoms.10 Children have elevated levels of par-asitemia.11 They may present with paroxysmal fever,nausea, vomiting, diarrhea, cough, arthralgias, and ab-dominal and back pain. Children have an increased riskof severe complications, such as shock, seizures, coma,and death, making prevention of the infection vital.There are approximately 300 to 500 million new casesworldwide, with 1.5 to 2.7 million deaths annually.12

Travelers to malaria-endemic countries should becounseled on prevention. The primary means of protec-tion is mosquito avoidance, with a reduction in outdooractivity at dawn and dusk (times of increased mosquitoactivity). Lodging should be equipped with screens andair conditioning to decrease mosquito exposure.11 Trav-elers should wear long pants and long-sleeved shirts todecrease the skin surface area available for a mosquitoto find a blood meal. Clothing and equipment should betreated with permethrin, a mosquito insecticide. Mos-quito netting, used over sleeping quarters, should be im-pregnated with permethrin to decrease contact with mos-quitoes while sleeping. Additionally, the insect repellantdiethyltoluamide (DEET) should be used on all exposedskin surfaces. Twenty to 35% DEET may be used safelyon children 2 months of age and older.13 Higher per-centages of DEET, used in excess, have been associatedwith dermatitis, bullae formation, skin necrosis, andscarring in children. Toxic encephalopathy has also beendocumented in a small number of children who usedelevated levels of DEET, likely due to the increased ab-sorption associated with their large body surface area.13

For improved safety, DEET should not be appliedaround the mouth or on the hands in order to reduce therisk of accidental consumption. Finally, DEET shouldbe applied over sunscreen or lotion for the first morningapplication.13 Sunscreen will often require more frequentapplication than DEET, and thus the sunscreen may beapplied over DEET later in the day without affecting theperformance of DEET or sunscreen.

Pharmacological prevention is also recommended for


all children traveling to endemic areas. There are manyoptions for prophylaxis, with selection based on the itin-erary, malaria risk of the destinations, and the speciesand their resistance patterns for each destination. Weeklydosed medications provide elevated serum levels andmay provide slightly increased coverage if a dose is de-layed. All malaria medications are most effective whentaken exactly as prescribed. The most commonly usedmalaria prophylaxis agents for travel to Asia are mef-loquine, doxycycline, and atovaquone-proguanil.14

Chloroquine (Aralen) continues to be used in chloro-quine-sensitive areas of Asia, currently only Korea. Mef-loquine (Lariam), dosed weekly, can be used in chloro-quine-resistant areas, including China and Southeast andSouthwest Asia.14,15 Patients prescribed mefloquineshould be encouraged to initiate treatment 3 weeks be-fore travel to evaluate for significant side effects, suchas anxiety and night terrors, that would prevent properusage of the medication during travel. If intolerance isidentified, the medication may be changed prior to de-parture. Patients with seizure and cardiac disordersshould not use mefloquine. Doxycycline is a third optionfor pharmacological prophylaxis, with documented re-sistance remaining low worldwide. Use is limited to chil-dren 8 years of age and older due to concerns of dentaldiscoloration and enamel hypoplasia. Atovaquone-pro-guanil (Malarone) is another medication available forprophylaxis in resistant areas and, given the ease of use,may be the preferred medication. This medication maybe stopped 1 week after return from endemic areas,whereas most must be continued for 4 weeks. Malaronemay be used on children 11 kg and heavier.14 It shouldnot be used in conjunction with rifampin, metoclopra-mide, or tetracycline due to a decrease in efficacy of 1or both drugs. For dosage information of these malariamedications, see Table 2.10,14

The CDC maintains current data on worldwide resis-tance patterns. Its website includes a map with up-to-date information and destination-specific recommenda-tions for prophylaxis.16 Providers are highly encouragedto confirm malaria prophylaxis recommendation withthis website due to changing resistance patterns and thepossible development of new medications and recom-mendations.

Dengue fever

Dengue fever is caused by a mosquito-transmitted ar-boviral infection in tropical and subtropical zones of theworld, including South Asia. The vector is both Aedesaegypyti and A albopictus mosquitos.10 Children maypresent with high fever, headache, chills, anorexia, nau-sea, vomiting, myalgias, and arthralgias, much like ma-

laria. The course is self-limited, and there are currentlyno medications or vaccinations to prevent or treat den-gue. Supportive care measures should be utilized. Hem-orrhagic dengue, a more severe form of dengue infec-tion, presents with hypotension and shock that requirecardiovascular support and intervention. Treatment in-cludes fluid resuscitation, pressors, and respiratory sup-port required to maintain perfusion. Dengue fever pre-vention is best achieved with strict arthropod avoidancemeasures, application of permethrin and DEET, properclothing, and activity modifications, as discussed in theMalaria section. Travelers should be advised to seekmedical attention immediately to be evaluated for ma-laria, which presents similarly, given that delay in treat-ment of malaria may be life threatening, particularly inchildren.

Japanese encephalitis

Japanese encephalitis is the leading cause of mosquito-transmitted viral encephalitis in Asia, mostly affectingyoung children and adults older than 65 years of age.The incidence in Asia is 30 000 to 50 000 new infectionsannually.5 The symptoms of Japanese encephalitis vary,depending on the severity of infection, from fever andheadache to rapid onset of headache, high fever, neckstiffness, altered mental status, coma, tremors, and spas-tic paralysis. Treatment is limited to supportive care.

It is not recommended that all travelers to Asia receiveJapanese encephalitis vaccine due to the low risk forinfection in most travelers. The vaccination is an inac-tivated viral vaccine, JE Vax (Biken with distribution inthe United States by Connaught).10 The vaccine shouldbe recommended to travelers to endemic areas who planto stay for at least 30 days during the peak transmissionseason (spring and monsoon season), especially thosevisiting rural areas with a large number of rice pattiesand subsequent large mosquito populations.10 Vaccina-tion should be strongly recommended to travelers on ad-venture vacations with anticipated frequent exposure toarthropods. Table 3 summarizes the dosage informationof JE Vax. The last dose of JE Vax must be given aminimum of 10 days before departure due to possiblesevere adverse effects, including urticaria and angioede-ma, which have been documented up to 10 days postvaccination. All travelers should be educated on arthro-pod avoidance measures to decrease possible exposure.

Traveler’s diarrhea

Traveler’s diarrhea affects 30 to 50% of travelers to thedeveloping world.10,17 Children are at a significantlyhigher risk due to limited pre-existing immunity and


Table 2. Malaria chemoprophylaxis based on destination and resistance patterns in Asia

Drug Dosage Travel destination Contraindications

Chloroquine phosphate(Aralen)

5–8 mg/kg orally once/wk;begin 1 wk before traveland continue once a wk for4 wk after return

Korea and chloroquine-sensi-tive Plasmodium falciparumareas

Children allergic to chloro-quine; may exacerbate pso-riasis

Mefloquine (Lariam) 10–19 kg: ¼ tablet once/wk;20–30 kg: ½ tablet once/wk; 31–45 kg: ¾ tabletonce/wk; �45 kg: 1 tabletonce/wk

*1 tablet � 250 mg; begin 1wk before travel and con-tinue once a wk for 4 wkafter return

China, Southeast and South-west Asia, and areas withchloroquine-resistant P fal-ciparum

Children with cardiac or sei-zure disorder, allergic tomefloquine, or with depres-sion or other mental healthdiagnosis

Doxycycline 2 mg/kg/d; begin 1–2 d be-fore travel, take daily andcontinue for 4 wk after re-turn

Thailand, Irian Jaya, Sumatra,Indonesia, Papua NewGuinea, and areas withchloroquine- or mefloquine-resistant P falciparum

Children �8 y or allergic todoxycylcine and other tetra-cylcines

Atovaquone-proguanil(Malarone)

11–20 kg: 1 tablet/d; 21–30kg: 2 tablets/d; 31–40 kg: 3tablets/d; �40 kg: 4 tablets/d

*1 tablet � 62.5 mg/25 mg;begin 1–2 d before traveland continue for 7 d afterreturn

Thailand, Irian Jaya, Sumatra,Indonesia, Papua NewGuinea, and areas withchloroquine or mefloquineresistant P falciparum

Children �25 lbs, or allergicto atovaquone or proguanil,or with severe renal impair-ment

*See references 10 and 14.

Table 3. Japanese encephalitis vaccination (JE Vax) dosageinformation

Age of child (y) Dose of vaccine Days to be given

0–3 0.5 mL 0, 7, 304� 1.0 mL 0, 7, 30

likely increased contact due to frequent hand-to-mouthbehaviors.1,18 Adventure travelers are also at increasedrisk due to presumed increased exposures. Asia is rankedby the CDC as a high-risk area for the development oftraveler’s diarrhea, with an increased risk during thewarm months preceding monsoon season.5 The causecan be bacterial, viral, protozoal, or toxin mediated. Bac-teria, including enterotoxigenic Escherichia coli, re-mains the most common cause (50–85% of the cases).19

However, the pathogen remains unknown in many cas-es.19 Traveler’s diarrhea in children is defined as 3 ormore unformed stools daily, with an additional symptomof fever, nausea, vomiting, abdominal pain, or tenesmus.Very young children will demonstrate a twofold increase

in bowel movements. It is important to identify and treatinvasive bacterial diarrhea, which presents with suddenonset of diarrhea, cramping, urgency, watery stools, fe-ver, and possibly bloody stools. Protozoal diarrhea hasa more gradual and less severe course, often presentingafter return from travel.

Prevention of traveler’s diarrhea requires strict foodand water precautions and good hand washing tech-niques for the duration of travel in developing countries.With a large percentage of traveler’s diarrhea being bac-terial and protozoal, good water and food precautionscan reduce exposure to the pathogens and therefore theincidence of diarrhea. Raw or poorly cooked meat, sea-food, and unpasteurized dairy products should be avoid-ed.18 Water should only be consumed from sealed bot-tles, personally boiled water, or water purifiers. Iceshould be avoided due to the unknown source of thewater. Fruits and vegetables should be peeled or cookedbefore consumption. Food vendors should also be avoid-ed due to concern of contamination. In addition to intakeprecautions, travelers older than 12 years of age mayconsider taking prophylactic bismuth subsalicylate (Pep-to-Bismol), which has been shown to have a 60% effi-


cacy in diarrhea prevention over a 7-day period.19 It isdosed at 200 mg 4 times per day for the entire trip.19

Children younger than 12 years of age are at an in-creased risk of Reye’s syndrome and therefore shouldnot take salicylate products.

Travelers who experience severe diarrhea can beginantibiotics to treat the possible bacterial sources. Treat-ment with oral antibiotics has been shown to signifi-cantly reduce the duration of the illness. In childrenyounger than 12 years of age, azithromycin is the treat-ment of choice at a dose of 10 mg/kg/day for 1 to 3days.17,20 Young adults may use ciprofloxacin at a doseof 500 mg twice daily for 3 days to treat the presumedbacterial diarrhea.20 An increasingly popular choice forchildren older than 12 years of age, due to concerns ofincreasing fluoroquinolone resistance, is rifaximin,dosed at 200 mg 3 times daily for 3 days.21,22 Rifaximinis effective against E coli, making this a poor choice fortravelers in Thailand, where Campylobacter remains theprimary cause of traveler’s diarrhea.22 Travelers to Thai-land younger than 18 years of age should use azithro-mycin as the first line. Prophylactic antibiotics are notrecommended by the CDC; instead, treatment should beinitiated at the onset of severe diarrhea.18 Loperamidemay also be given to children older than 2 years of agefor treatment of nonbloody diarrhea to shorten diarrheaby an average of 1 day.17 Loperamide is dosed at 0.1mg/kg/dose after each lose stool, not exceeding 1 mgper day in children weighing less than 20 kg and 2 mgper day in children weighing more than 20 kg.23 Finally,there is increasing research on Lactobacillus as a pre-vention measure and treatment for traveler’s diarrheawith widely varying results of 15 to 60% reduction inthe incidence of diarrhea.19 The optimal dose is not yetknown, and therefore no recommendation can be made.Theoretically the Lactobacillus colonizes the gastroin-testinal tract and prevents pathogenic organisms fromcausing infection.

Parents should be educated on signs of dehydration,use of oral hydration solutions, and the importance ofearly feeding in the event the child has traveler’s diar-rhea during the trip. Early feeding has been shown todecrease changes in intestine permeability and improvenutritional status during a gastrointestinal illness. Edu-cation prior to travel ensures that parents are preparedto treat early in the illness and avoid dehydration thatrequires medical evaluation.

Rabies

Rabies, caused by the RNA Rhabdoviridae virus, is en-demic in China, Southeast Asia, Indonesia, the Philip-pines, and India. The clinical presentation is character-

ized by an acute prodromal illness with progressive cen-tral nervous system manifestations, including seizures,paresis, and dysphagia.24 Infection occurs after a bite orscratch by an infected animal or mucus membrane ex-posure. Dogs remain the primary reservoir in the devel-oping world.25 Travelers who are unable to report bites(young children), work with animals, have extensive un-protected outdoor exposure (hiking, camping, biking), orwill be spending significant time in rural areas more than24 hours away from a major medical facility should con-sider vaccination prior to travel. Prophylaxis consists ofvaccination on days 0, 7, and 21. There are 2 culture-derived inactivated virus vaccines currently available inthe United States: human diploid cell vaccine (Rab-Immune, Aventis) and purified chick embryo cell vac-cine (Rabvert, Chiron). Rabies vaccine absorbed(SmithKline Beecham) is no longer produced. The ob-jective of prophylaxis is to prevent neural tissue infec-tion with the virus. This prevention is initiated with im-mediate cleansing of the contaminated tissues by woundflushing and cleaning with a povidone-iodine prepara-tion, if available, or soap and water.25 Postexposure pro-phylaxis, rabies immunoglobulin, must be given as soonafter the exposure as possible in all nonimmunized in-dividuals.24 These individuals also require the full post-exposure immunization series (on days 0, 3, 7, 14, and21).24,25 In comparison, the fully immunized traveler re-quires thorough wound cleaning and a 1-mL rabies vac-cination on days 0 and 3 after the possible exposure.

Prevention of this infection with pretravel immuni-zation is increasingly warranted because the availabilityof rabies immunoglobulin is rapidly waning with signif-icant reductions in production worldwide. Due to theseshortages, it is vital that travelers be educated on thesteps required after exposure so the patient can be a self-advocate and ensure proper treatment, which includesimmunoglobulin. Pretravel prophylaxis simplifies thepostexposure requirements, which is vital for travelersto countries with limited medical capabilities.

Tuberculosis

Tuberculosis is endemic in the developing world, in-cluding the majority of Asia. Eighty percent of cases areconcentrated in 22 countries, with India accounting for30%.26 Children present 1 to 6 months after exposurewith fever, growth delay, weight loss, cough, nightsweats, and chills.27 In Asia the Bacillus Calmette-Gue-rin vaccine is used to prevent active infections in veryyoung children, but it has little effect on lifelong pre-vention of tuberculosis.27 The recommendation is for pu-rified protein derivative placement 12 weeks after returnfrom an endemic area to screen for latent tuberculosis.27


If the purified protein derivative is positive, the travelermust take isoniazid for 9 months to treat chest radio-graph-confirmed latent tuberculosis infection.

Meningococcal Disease

Invasive meningococcal disease is caused by Neisseriameningitides, a gram-negative diplococcus. There are 5serotypes: A, B, C, W135, and Y. It is transmitted byperson-to-person contact, often by an asymptomatic car-rier. Children generally present with symptoms of men-ingitis, including high fever, chills, malaise, and rash,with more fulminant cases presenting with purpura, dis-seminated intravascular coagulation, and shock.28 Moreatypical presentations include septicemia, pneumonia,arthritis, acute otitis media, epiglottis, and pericarditis.It is recommended that travelers be immunized if trav-eling to areas of recent outbreak, as identified on thetravel pages of the CDC website. There are 2 differentvaccinations currently in use. The first, Menomune (San-ofi Pasteur), is a quadrivalent polysaccharide vaccinethat covers serotypes A, C, W135, and Y.29 It may begiven as early as 2 years of age, with all children youn-ger than 4 years receiving a booster dose after 24 to 36months. The second vaccine is a conjugated polysaccha-ride diptheria toxoid quadrivalent vaccine, Menactra(Sanofi Pasteur) that also covers serotypes A, C, W135,and Y. Menactra may be used starting at 11 years of ageand has been shown to provide a better immune responseand therefore better protection against meningococcaldisease.

Travel considerations

Children traveling to foreign countries are at risk forexposure to a multitude of infectious organisms not en-countered at home. Children who are accompanyingadults to visit friends and relatives in the developingworld are at higher risk for acquiring infection due totravel in areas of the country that are not as well devel-oped.26 Developing countries often have a poorly de-veloped health infrastructure, resulting in an increasedrisk of exposure to infectious agents. In addition, thesevisits are often of a longer duration than other vacations,increasing the risk of infection by prolonged exposure.26

Car seats are not available in much of Asia. It is vitalthat children younger than 4 years of age and 40 pounds(18 kg) travel with their car seat to ensure safety duringlocal transport. Families of such children must be en-couraged to travel with car seats and be educated onproper installation.

Travelers requiring medication should travel with asufficient supply to last the duration of the trip. It can

be difficult to acquire the correct medications duringtravel. In many parts of Asia, prescriptions are not need-ed to obtain medications from the local pharmacy. How-ever, there is a large problem with counterfeit medicationsales. Travelers should be educated on the importanceof bringing a full supply of their own medications intheir carry-on luggage. More information is availableon the FDA website at http://www.fda.gov/oc/initiatives/counterfeir/qa.html.

Evacuation insurance should be strongly consideredwhen traveling to less developed countries. Each insur-ance company provides different coverage for medicalevacuation varying from country to country. It is rec-ommended that travelers discuss this with their healthinsurance company and consider additional evacuationinsurance. Additionally, families should be encouragedto research medical facility options for each destinationof the itinerary to reduce time to medical care in caseof an emergency.

All families traveling with children should prepare abasic first-aid kit to pack in their carry-on luggage forunexpected accidents and emergencies. The kit shouldinclude bottled water and snacks if travel is delayed andfood is not readily available. Adhesive bandages andwraps should be packed for minor abrasions or sprains.Antibiotic ointment, diaper rash ointment, and 1% hy-drocortisone cream will cover the basic abrasions, heatrashes, and diaper rashes that often occur when travelingto warm climates. Oral hydration solution packets shouldbe added to support hydration and are available onlineand at many pharmacies and camping stores. Finally, asupply of antipyretic, antihistamine, antidiarrheal, andantimalarial medications should be packed in child-proofcontainers with appropriate dosing information. Manykits are available prepacked, or families can pack theirown first-aid bag to meet their individual travel andmedical needs.

Conclusions

Traveling with children to Asia is becoming increasinglycommon and provides many wonderful opportunities forchildren and their families. Children are more at risk fortravel-related illness and infection due to lack of previ-ous exposures and age-related behaviors that place themat higher risk. Appropriate pretrip medical screening andplanning can greatly reduce their risk of acquiring in-fections during travel. There are many resources avail-able to help medical practitioners select appropriate im-munizations and medications to be used for travel inAsia. All families traveling to developing countriesshould receive education and a thorough medical screen-ing prior to departure.


Acknowledgments

The authors thank Timothy Hurtado, DO, and Mark Bur-nett, MD, FAAP, for their assistance with the reviewprocess of this article. The authors received no outsidefunding or grants for this study.

Resources

International Association for Medical Assistance toTravelers (http://iamat.org)

Travax EnCompass (http://www.shoreland.com)International SOS (http://www.internationalsos.com)Medex (http://www.medexassist.com)Centers for Disease Control and Prevention Yellow Book

for travel information (http://www.ced.gov/travel)World Health Organization (http://www.who.int.ith)

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