Travel-Related Illnesses in Children

There have been many times I have encountered a triage note which states “patient recently returned from … (insert awesome foreign country)…” Not only does this leave me daydreaming about my future travel adventures, but has often caused me to take pause. Thoughts of what endemic illnesses could this child potentially have been exposed to in their travels? Should I get labs on all these patients? It’s probably just a typical virus, right? If you have also had a similar thought process, you are in good company. While there is no “right” work up for these patients, hopefully this morsel will help illuminate your evaluation of Travel-Related Illness in Children:

Travel-related Illness: Basics 

  • International travel has been significantly increasing since commercial airlines made travel much easier. In the 1950’s travel accounted for 25 million international tourists. In 2013 this number had reached over 1 billion (Leuthard 2015)
  • Diarrhea is the most common travel-related diagnosis in multiple studies and accounts for around 40 – 60% (Leuthard 2015, Hagmann 2014)
  • Systemic febrile illnesses (18%) and dermatologic disorders (17%) were the next most common (Hagmann 2014)
    • Dermatologic conditions in pediatrics typically include arthropod bites, scabies and cutaneous larva migrans (Leuthard 2015)
  • Most studies do report limitations in accounting for common viral causes of illness which may disproportionately represent how common travel-related illnesses such as malaria and typhoid are in the returning population (Hagmann 2014)
  • Clinicians should always be aware of ongoing or emerging epidemics as in the last couple of decades alone there has been Covid 19 originating in Asia, Ebola in Africa, Middle East Respiratory Syndrome (MERS-CoV) in the Arabian Peninsula, Zika and Chikungunya in Latin and South America (Abdel-Haq 2021)
  • The CDC offers country-specific information about endemic illnesses including region-specific risks within that country (https://wwwnc.cdc.gov/travel/destinations/list)

Travel-related Illness: History & Physical Exam

  • A careful history can help risk stratify the patient. Make sure you are also asking about long layovers during travel!
    • In one ED study, ALL cases of missed travel-related illness did not have a documented travel history in their ED note, whereas 90% of the identified travel-related illnesses had a provider documented travel history (Greenky 2022) 
    • Those who are visiting friends and relatives (VFR) are typically at highest risk. A study of swiss tourists found they compromised 53.4% of presentations for travel-related illness (Leuthard 2015)
    • Immigrants and VFR travelers are more likely to have malaria, typhoid fever, hepatitis A, hepatitis B, and tuberculosis when compared to tourist travelers (Leuthard 2015)
    • Details of pre-travel vaccinations and compliance with malaria chemoprophylaxis during travel should be obtained (Abdel-Haq 2021) 
  • Travel activities can also increase risk of specific illness (Abdel-Haq 2021) 
    • Exposure to fresh water can increase schistosomiasis and leptospirosis in endemic regionsChildren are more likely to obtain zoonotic infections due to close interactions with animals, diarrhea and the petting zoo
    • Asking about water consumption hygiene and food preparation can help determine risk of typhoid fever, hepatitis A and E, traveler’s diarrhea. 
  • Viral Hemorrhagic Fevers (VHF) should be suspected in a returning traveler from an endemic area within 21 days especially if there are bleeding manifestations on exam including petechial rashes. These patients should be immediately isolated. (Abdel-Haq 2021).
  • Travel dates can help to exclude certain infections by their incubation periods (Abdel-Haq 2021) 
  • Physical examination can sometimes reveal concerning features including hepatomegaly, jaundice or a rash that may guide differential. However It is common to have no focal findings on physical exam for systemic illnesses related to travel (Abdel-Haq 2021)

Travel-related Illness: Management

  • Children with evidence of severe life-threatening illness (signs of hemorrhage, petechiae, meningismus, shock or AMS) require aggressive supportive therapy and very likely empiric antibiotics and/or antimalarials (Flores 2015)
  • In well appearing children with fever returning within 1 month of international travel (particularly if to Asia or Africa) the recommended testing includes CBC, blood cultures, LFTs, CRP and possibly stool cultures (Khan 2021, Abdel-Haq 2021)
    • Thrombocytopenia can be seen in malaria, viral infections including Dengue, and severe sepsis
    • Leukopenia with thrombocytopenia is associated with Dengue
    • Eosinophilia is seen in parasitic diseases including schistosomiasis. However, the destination of travel is also important as helminths have distinct geographical distribution.
    • Unconjungated hyperbilirubinemia may indicate hemolysis associated with malaria or babesios 
    • Conjugated hyperbilirubinemia can be seen in viral hepatitis, leptospirosis, viral hemorrhagic fever, and bacterial sepsis
  • CXR can be helpful in those with pulmonary symptoms as infiltrates are seen in many bacterial/viral pathogens, but also are seen in the the less common schistosomiasis, Legionella, Q fever and leptospirosis
  • Consider a Pediatric Infectious Disease consult for those who who are seriously ill and returning from travel (Abdel-Haq 2021) 

Travel-related Illness: To hospitalize or Not? 

  • Hospitalization for travel-related illness are around 10% for both VFR and tourists (Leuthard 2015)
    • Multiple studies have reported the most common travel infections in various countries.
    • In general these include malaria, dengue, bacteremia, typhoid or paratyphoid fever, hepatitis (Khan 2021, Leuthard 2015, Lalos 2020) 
  • Only 1 study has attempted to identify variables which could be associated with  Internationally Acquired Severe Systemic Infections and found 4 independent variables (Khan 2021)
    • Headache
    • Travel to Africa or Asia
    • Platelets of 150,000 or less
    • ALT level greater than or equal to 30 IU/L
  • Other studies have found risk factors in patients who were hospitalized with travel-related illnesses returning from Southern Asia, showing signs of a febrile systemic illness, neurologic diseases, and nonspecific findings including dehydration (Leuthard 2015). 
  • Pediatric patients with recent travel and fever of unknown origin should be considered for admission if malaria is a possible diagnosis. Malaria requires 3 negative thick and thin smears over 12 hours to fully exclude. With close outpatient follow up this could be accomplished, but typically is easier inpatient. 

Moral of the Morsel

  • Those who don’t know History are doomed to repeat it. Good history taking holds special importance when evaluating travel-related illnesses!
  • Now you have another excuse not to visit your family! The highest risk of travel-related illness is seen in those traveling internationally to visit family and relatives (VFR). 
  • The rule of 30. Most of the illnesses we think about in recent travelers will present within 30 days. Of course there are exceptions, cue malaria, but it is recommended to consider a bigger workup including labs in this population. 

References

Abdel-Haq N, Asmar BI. Fever in the Returned Pediatric Traveler. Glob Pediatr Health. 2021 May; 8:1-16. PMID: 34423077

Flores MS, Hickey PW, Fields JH, Ottolini MG. A “Syndromic” Approach for Diagnosing and Managing Travel-Related Infectious Diseases in Children. Curr Probl Pediatr Adolesc Health Care. 2015 Aug; 45(8): 231–243. PMID: 26253891

Greenky D, Linam M, Yaffee A, Costello B, Gillespie S, Murray B. Triage Travel Screening in the Pediatric ED: A Cross-Sectional Analysis to Evaluate Current Use and Effectiveness in Identifying Travel Related Illness. Am J Emerg Med. 2022 Jun:56:113-116. PMID: 35397349

Hagmann SHF, Han PV, Stauffer WM, Miller AO, Connor BA, Hale DC, Coyle CM, Dahill JD, Marano C, Esposito DH, Kozarsky PE. Travel-associated disease among US residents visiting US GeoSentinel clinics after return from international travel. Fam Pract. 2014 Dec;31(6):678-87. PMID: 25261506

Khan MA, Rosenberg MG, Fein DM, Quezada XH, Reingold RE, Tadros FK, Wolnerman YY, Yao JY, Schneider C, Meltzer JA. Internationally Acquired Severe Systemic Infections in Febrile Pediatric Travelers Presenting to the Emergency Department. Pediatr Emerg Care. 2021 Dec 1;37(12):e1315-e1320. PMID: 31977776

Lalos S, Farrar D, Science M, Morris S. Infectious Disease Acquisition in Pediatric International Travelers: A 10-Year Review at a Canadian Tertiary Care Hospital. Int J Travel Med Glob Health. 2021 Jan. 9(1):25-30. 

Leuthard D, Berger C, Stuabli G, Nadal D, Schmid S, Hamer D, Weber R, Schlagenhauf P. Management of Children with Travel-related Illness Evaluated in a Pediatric Emergency Room. Pediatr Infect Dis J. 2015 Dec;34(12):1279-82. PMID: 26368057

Erica Scott
Erica Scott
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