VFR Parents and Children…”
Transcript of VFR Parents and Children…”
![Page 1: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/1.jpg)
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
![Page 2: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/2.jpg)
Conflict of Interest
• I have no conflict of interests to declare.
2
![Page 3: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/3.jpg)
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
![Page 4: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/4.jpg)
Pre-CISTM14 Course --- Stefan Hagmann 4
![Page 5: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/5.jpg)
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-CISTM14 Course --- Stefan Hagmann 5
![Page 6: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/6.jpg)
![Page 7: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/7.jpg)
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
Pre-CISTM14 Course --- Stefan Hagmann 7
![Page 8: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/8.jpg)
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)
Pre-CISTM14 Course --- Stefan Hagmann 8
![Page 9: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/9.jpg)
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”)
Pre-CISTM14 Course --- Stefan Hagmann 9
![Page 10: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/10.jpg)
Strategies to Engage Pediatric VFRs
Routine Screen for Future Travel Activities
Outreach in Newborn Nursery and Outpatient Clinics
Screen shot of clinic template
Pre-CISTM14 Course --- Stefan Hagmann 10
![Page 11: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/11.jpg)
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
![Page 12: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/12.jpg)
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.
Pre-CISTM14 Course --- Stefan Hagmann 12
![Page 13: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/13.jpg)
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
*
*
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
Pre-CISTM14 Course --- Stefan Hagmann 13
![Page 14: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/14.jpg)
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
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
Pre-CISTM14 Course --- Stefan Hagmann 14
![Page 15: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/15.jpg)
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)
Pre-CISTM14 Course --- Stefan Hagmann 15
![Page 16: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/16.jpg)
Back to the Clinic
Pre-CISTM14 Course --- Stefan Hagmann 16
![Page 17: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/17.jpg)
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? …..
Pre-CISTM14 Course --- Stefan Hagmann 17
![Page 18: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/18.jpg)
What are you concerned about?
Pre-CISTM14 Course --- Stefan Hagmann 18
![Page 19: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/19.jpg)
What are you concerned about?
• Malaria and other vector-borne infections
• Invasive bacterial infections
• Respiratory infections
• Gastrointestinal infections
• Trauma
• Rabies
Pre-CISTM14 Course --- Stefan Hagmann 19
• Ebola
![Page 20: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/20.jpg)
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.
Pre-CISTM14 Course --- Stefan Hagmann 20
![Page 21: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/21.jpg)
What are you concerned about? 2. Invasive bacterial infections
Pre-CISTM14 Course --- Stefan Hagmann 21
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
![Page 22: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/22.jpg)
What are you concerned about? 3. Respiratory infections
Pre-CISTM14 Course --- Stefan Hagmann 22
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
![Page 23: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/23.jpg)
What are you concerned about? 4. Gastrointestinal infections
Pre-CISTM14 Course --- Stefan Hagmann 23
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
![Page 24: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/24.jpg)
What are you concerned about? 5. Trauma / Rabies
Pre-CISTM14 Course --- Stefan Hagmann 24
GeoSentinel network, 20101 N=1,594
Regional Causes of Childhood Death, Africa 20102
1Hagmann S, Pediatrics 2010;125(5):e1072-80. 2Liu L, Lancet 2012;379:2151-61.
• Animal bites: 6%
• Affects disproportionately children, aOR: 3
![Page 25: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/25.jpg)
What questions would you ask?
Pre-CISTM14 Course --- Stefan Hagmann 25
![Page 26: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/26.jpg)
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?
Pre-CISTM14 Course --- Stefan Hagmann 26
![Page 27: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/27.jpg)
What would you recommend?
Pre-CISTM14 Course --- Stefan Hagmann 27
![Page 28: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/28.jpg)
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:
Pre-CISTM14 Course --- Stefan Hagmann 28
• Good tolerability in children • Ease of use (once a week) • Relative Affordability
Likely Reasons for Preferred Use of mefloquine
Hagmann et al. J Ped Infect Dis 2013;2(4):327-334.
![Page 29: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/29.jpg)
Personal Protection Measures
Pre-CISTM14 Course --- Stefan Hagmann 29
• 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
![Page 30: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/30.jpg)
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
Pre-CISTM14 Course --- Stefan Hagmann 30
![Page 31: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/31.jpg)
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
Pre-CISTM14 Course --- Stefan Hagmann 31
![Page 32: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/32.jpg)
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!
Pre-CISTM14 Course --- Stefan Hagmann 32
![Page 33: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/33.jpg)
Last but not least
• What is the budget?
– Need to address actively with families!
• Provide written information in patient’s primary language if possible.
Pre-CISTM14 Course --- Stefan Hagmann 33
![Page 34: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/34.jpg)
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!
Pre-CISTM14 Course --- Stefan Hagmann 34
![Page 35: VFR Parents and Children…”](https://reader031.fdocuments.us/reader031/viewer/2022021010/6203e9422784f14458524fd7/html5/thumbnails/35.jpg)
Thank you!
35