Travel-related Illness

Many immigrant families travel back to their home countries. This puts them at risk for illnesses they may not be exposed to in Canada.

Here is a snapshot of Canadians travelling abroad:

• About 7.4 million Canadians travel internationally each year.²
• About 300,000 of these international travellers are children.²
• About 3 million Canadian international travellers visit friends and relatives abroad each year, and approximately 100,000 of them are children. These people are known as “VFRs”.³
• References to “paediatric VFRs” include not only immigrant children, but also Canadian-born children of immigrants.  

If you see immigrant families in your practice, ask whether they are planning to travel.  For guidance on pre-travel care, see:

• Travel-related illnesses in paediatric VFRs
• Safe and healthy travel: Preventing illness while abroad

Travel-related illnesses in paediatric VFRs

Who are VFRs?

People who visit friends and relatives abroad (known as “VFRs”) make up about 40% of people travelling internationally from Canada.  A substantial proportion of these are children and adolescents.³ Paediatric VFRs may be foreign-born, or born in Canada to parents from other countries.

VFR families:

• tend to travel frequently between Canada and their country of origin.
• are more likely to travel for longer time periods and to visit rural areas.
• are less likely to have sought pre-travel advice and care than other families travelling abroad.

According to a recent analysis of pre-travel consultations in a large pediatric centre in Toronto¹⁰:

• Young children (less than five years of age) are more likely to travel to visit friends and relatives than for other purposes; and
• Paediatric VFRs are:
  • more likely to travel for long durations (>28 days)
  • travelling more to Asia (51%)
  • travelling mainly to urban destinations (98%)

Historically, VFRs were taught to travel more to rural areas. The trend toward urban destinations may reflect a different population of immigrant families (country of origin and socio-economic level).

Long-term travel is associated with a unique profile of health risks, including vector-borne illness, contact-transmitted diseases, and psychological problems.

Paediatric VFRs account for a disproportionate number of travel-related hospitalizations when they return to Canada,³ so it’s important to ensure they get proper advice and preventive care before they go abroad.

Travel-related infections

A number of studies show that paediatric VFRs are at increased risk of acquiring significant but preventable infections when they travel.^1,4,5

One large study⁴ of children returning from international travel showed:

• Children and youth were more likely than adults to be visiting friends and relatives abroad. Younger children are more likely to be VFR travellers than older children.
• VFR children were less likely than other paediatric travellers to have received pre-travel advice.  Approximately half of all paediatric travellers and one-third of paediatric VFRs received pre-travel medical advice. Possible reasons for this difference include:
  • Barriers to health care access for VFR families
  • Low perception of risk by VFR families
• VFR children were more likely than VFR adults to present with illness after travel (17% vs. 10%).
• Among paediatric travellers, VFRs were significantly more likely to have a febrile condition upon return than non-VFRs (adjusted odds ratio 2.68 vs. 1.86).

The study also confirmed the high risk of febrile illness in all paediatric travellers (VFRs and non-VFRs) returning from sub-Saharan Africa.

Among ill travellers, VFRs are more likely to have serious though largely preventable travel-related illnesses than non-VFRs.⁵

A Canadian Paediatric Surveillance Program (CPSP) study of travel-related illnesses in children has confirmed results of other studies:¹

• Over 70% of paediatric VFRs with illness needed to be hospitalized. The average length of stay was 12 days.
• The average duration of travel was 7.5 weeks, mostly to urban areas.
• The two most common travel-related illnesses were enteric (typhoid) fever and malaria, followed by hepatitis A, dengue fever, tuberculosis, measles, brucellosis, non-typhoidal Salmonella bacteremia, and various parasitic infections.  Syndromic diagnosis, such as severe diarrheal illness, respiratory infections and urinary tract infections with multi-drug resistant organisms, were also notable.
• Less than half of families received pre-travel advice.
• Most illnesses were preventable.

Safe and healthy travel: Preventing illness while abroad

Immunizations

No one immunization schedule will suit all travellers. Clinicians need to personalize vaccine schedules for individual patients, taking the following factors into account:⁶

• Age
• Immunization history
• Existing medical conditions
• Countries to be visited
• Length and nature of travel (e.g., rural vs. urban)
• Legal requirements for entry into countries
• Amount of time available before departure (ideally, travellers should be seen 6 months before leaving)

A number of organizations provide up-to-date information on health precautions and health risks for specific countries.  A list of links is available in this guide.

Immunizations for travel can be routine, recommended or required.

• Routine immunizations for children and youth are funded through provincial/territorial health programs. Contact regional health authorities for up-to-date information.
• Recommended travel vaccines must be personalized to the individual traveller, as well as to the nature and duration of travel.
• Required vaccines are mandated by international law or needed to obtain a visa.

The Committee to Advise on Tropical Medicine and Travel (CATMAT) has a statement on paediatric travellers (2010)⁷ that includes information about pre-travel immunization.

An American-based study¹¹ showed that the VFR population is much more reluctant to get vaccinated. They tend to decline recommended vaccinations more than other travellers, even though they have sought pre-travel care. The reason to decline may be related to cost, concerns about safety, delayed timing of the pre-travel visit, or lack of perceived risk. Therefore, medical counselling should be even more targeted for this population.

Pre-travel preparation

Because vaccines may not be completely effective in preventing disease—and are not available for all travel-related diseases—travellers should take other preventive measures to stay healthy.

The PHAC’s Committee to Advise on Tropical Medicine and Travel (CATMAT) has a number of statements and recommendations on travel-related health, including preventive measures specific to children and youth.^7,8  These guidelines are summarized below.

When travelling with children, parents should bring oral rehydration solutions (to prevent dehydration due to diarrhea) and anti-diarrheal medication (for travellers’ diarrhea). For some destinations, anti-malarial medication is essential. The PHAC provides useful information on what to include in a travel health kit.  A parent handout on dehydration and diarrhea is available from the Canadian Paediatric Society.

Preventive measures for paediatric travellers^7,8

Personal protective measures against insect-borne infections (e.g., malaria, dengue, yellow fever, Japanese encephalitis):

• Behaviour (e.g., staying indoors when insects are actively biting)
• Physical barriers (e.g., appropriate clothing, bed nets)
• Chemical barriers (e.g., repellents, insecticides)
• Malaria chemoprophylaxis

To prevent enteric infections:

• Food and water precautions
• Handwashing
• Being prepared to self-treat travellers’ diarrhea (e.g., keeping oral rehydration solutions or a prescribed antibiotic on hand, consideration of loperamide)

To prevent respiratory infections:

• Handwashing
• Covering coughs and sneezes

Tuberculosis information is available in this resource and from the Public Health Agency of Canada.

Other conditions or risks to prepare for:

• Air travel
• Injuries
• Environmental extremes (e.g., too much sun, altitude sickness)
• Parasitic infections

Selected resources

• Australian Government, Department of Health and Aging. Vaccination for international travel (sect.3.2). In: The Australian Immunisation Handbook, 10th edn, 2013.
• Canadian Paediatric Society, Community Paediatrics Committee, 2007. Air travel and children’s health issues.
• Canadian Paediatric Surveillance Program. Travelling abroad with your child? [Poster]
• Centers for Disease Control and Prevention. The Yellow Book: CDC Health Information for International Travel, 2012. Atlanta, GA: CDC, 2012.
• Centers for Disease Control and Prevention. Travelers’ Health: provides information based on scientific studies, disease surveillance and best practices about vaccines, medications and other measures necessary to prevent illness and injury during international travel.
• Keystone JS, Kozarsky PE, Freedman DO, Nothdurft HD, Connor BA, eds. Travel Medicine, 2nd edn. Philadelphia, PA: Mosby Elsevier, 2008.
• Public Health Agency of Canada. See the Travel Health section of this website for destination- and illness-specific notices, news and updates, as well as the Committee to Advise on Tropical Medicine and Travel (CATMAT), for statements and recommendations for travel health.
• World Health Organization. International travel and health, 2012 edn. Visit this page for traveller updates, disease distribution maps, and links to other international health resources.
• Government of Canada. Travel vaccines. 

Other works consulted

• Committee to Advise on Tropical Medicine and Travel. Fever in the returning international traveller: Initial assessment guidelines. Can Commun Dis Rep 2011;37(ACS-3, July 2011):1-14.
• Han P, Yanni E, Jentes ES, et al. Health challenges of young travelers visiting  friends and relatives compared with those traveling for other purposes. Pediatr Infect Dis J 2012;31(9):915-9.
• Hui C, Kuhn S, Ugnat A-M, Skinner R, Grenier D. Know before you go: Safe travels. Paediatr Child Health 2009;14(2):123.
• Public Health Agency of Canada. Canadian recommendations for the prevention and treatment of malaria among international travellers - 2009: Supplement. Can Commun Dis Rep 2009;35S1:1-82.

References

1. Crockett M, Ford-Jones L, Grondin D, et al. Travel-related illnesses in paediatric travellers who visit friends and relatives abroad. March 2009 to February 2011 – Final report. CPSP 2011 Results:35.
2. Crockett M. Canadian children who travel abroad: What are the risks? Paediatr Child Health 2009;14(3):175-6.
3. Crockett M. Travel-related illnesses in paediatric travellers who visit friends and relatives abroad. CPSP 2011 study protocol.
4. Hagmann S, Neugebauer R, Schwartz E, et al; GeoSentinel Surveillance Network. Illness in children after international travel: Analysis from the GeoSentinel Surveillance Network. Pediatrics 2010;125(5):e1072-80.
5. Leder K, Tong S, Weld L, et al; GeoSentinel Surveillance Network. Illness in travelers visiting friends and relatives: A review of the GeoSentinel Surveillance Network. Clin Infect Dis 2006;43(9):1185-93.
6. Public Health Agency of Canada. Canadian Immunization Guide: Evergreen edn., 2012.
7. Committee to Advise on Tropical Medicine and Travel. Statement on pediatric travellers. Can Commun Dis Rep 2010;36(ACS-3, June 2010):1-31.
8. Committee to Advise on Tropical Medicine and Travel. Statement on personal protective measures to prevent arthropod bites. Can Commun Dis Rep 2005;31(ACS-4, 15 May 2005):1-20.
9. Stäger K, Legros F, Krause G, et al. Imported malaria in children in industrialized countries, 1992-2002. Emerg Infect Dis15(2):185-91.
10. Ma XW, Pell LG, Akseer N, Khan S, Lam RE, Louch D, Science M, Morris SK. Characteristics and pre-travel preparation of travelers at a Canadian pediatric tertiary care travel clinic: A retrospective analysis. Travel Med Infect Dis. 2016 Mar-April;14(2):148-54.
11. LaRocque RC, Deshpande BR, Rao SR, Brunette GW, Sotir MJ, Jentes ES, Ryan ET; Global TraveEpiNet Consortium. Pre-travel health care of immigrants returning home to visit friends and relatives. Am J Trop Med Hyg. 2013 Feb;88(2):376-80. Erratum in: Am J Trop Med Hyg. 2013 Mar;88(3):606.