A guide for health professionals working with
immigrant and refugee children and youth

Travel-related Illness

Key points

  • Travel-related illness in children and youth is an important public health issue.
  • About half of all international travellers are people who visit friends and relatives abroad (known as “VFRs”). A substantial proportion of these travellers are children and adolescents.
  • Paediatric VFRs include not only immigrant children and youth, but also Canadian-born children of immigrants.
  • Paediatric VFRs account for a disproportionate number of travel-related hospitalizations. They are also less likely to have had pre-travel medical advice.
  • A recent Canadian Paediatric Surveillance Program study confirmed that enteric fever and malaria were the most common travel-related illnesses in children and youth, and that most cases are preventable.1
  • If you see immigrant families in your practice, ask whether they are planning to travel.
  • Parents of paediatric VFRs need to be counselled on the importance of seeking evidence-based pre-travel advice, both for their children and themselves.
  • Remember that information on travel risks changes regularly: clinicians should not hesitate to consult and/or refer families to travel medicine specialists.

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

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:
  • 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 travellers7,8

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:

To prevent respiratory infections:

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

Other conditions or risks to prepare for:

Out of Africa

A family of two adults and two children were returning to east Africa to visit relatives during summer holidays. They sought advice from their physician, who did not routinely provide pre-travel advice. Before leaving, they received only the hepatitis A vaccine; a typhoid vaccine should also have been given. Although the parents were prescribed anti-malarial prophylaxis, the physician told them that the children did not require prophylaxis. During their travels, the parents ran out of anti-malarial medication and so, upon returning to Canada, had not completed the full course of treatment as prescribed.

Key messages

  • Parents of paediatric VFRs need to be counselled on the importance of seeking evidence-based pre-travel advice, both for their children and themselves.
  • Cost and language can be practical barriers to obtaining pre-travel care. Health care providers should make an effort to identify and address barriers to accessing appropriate care.
  • Health professionals should support culturally sensitive community-based programs in schools, community centres, churches, sport clubs and the like to raise awareness of VFR families and decrease barriers to care.4,9
  • Remember: Information on travel risks changes regularly and clinicians should not hesitate to consult with or refer families to travel medicine specialists.

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

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.

Editor(s)

  • Danielle Grenier, MD
  • Julie Bailon-Poujol, MD

Last updated: September, 2017

Also available at: http://www.kidsnewtocanada.ca/conditions/travel
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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