Active Shooters: Reflections and Talking to Kids

Area flags are at half mast today as we are mourning the loss of innocent lives from another mass shooting at a Texas church over the weekend. We are sad for grieving families once again. What we can do to protect ourselves and our loved ones from random violence and acts of hate?

My generally safe town has had two incidents of violence that have made national news in recent years. A man opened fire at a Jewish Community Center and a Jewish Retirement Home and killed three innocent people. Another man shot two men eating at a local restaurant after yelling racial slurs and telling them to leave his country. One of the men died.

My kids have been on lockdowns at their schools on several occasions over the years. Our kids are getting used to lockdown drills and even real events. Thankfully none of the local school lockdowns turned tragic. Being a parent who cannot do anything while a school is in lockdown is stressful. Not knowing what is happening during a lockdown when my children are most likely sitting on a floor of a crowded dark room is terrifying. My kids have never felt that scared, even when it’s a real lockdown, probably because they’ve practiced and feel prepared. For many kids this seems to be the case, but I’m sure there are some who start having separation anxiety or other manifestations of trauma-related stress.
Today my front office staff saw policemen with weapons in hand enter our building and run down the hall. They did not come into our office.
We locked our front door, closed the blinds, and kept patients in exam rooms. We saw several police cars in the parking lot for our building and those near ours.
Our office manager called the police department to find out what was happening and not a lot was learned, but there was a potential active shooter in the area, so they recommended lockdown.
Because I was only in the office for meetings on my “day off” I was able to help tell staff and patients what we knew. I helped bring some of the families into the office. I checked Facebook and Twitter repeatedly to find out what was going on. (But I didn’t grab these screenshots until hours later.)

I had planned on updating our social media, but couldn’t find any real information to post.

At one point we were told they apprehended someone in a creek area behind our building and got the all clear to open back up and let people leave.
41ActionNews
A few minutes later we were told to put our building back on lockdown. No one knew what was going on.
Our receptionists covertly monitored the parking lot for patients so they could get the door for them – we didn’t want families stuck in a potentially dangerous parking lot. Several patients called that they would be late to their appointments because police had blocked one of the roads into our parking area.
I am very proud of my staff and the families that were in the building. Everyone remained calm. No one complained that they were told to not leave the building. I didn’t hear anyone complain when the rooms started to fill, which affected the flow of seeing patients. I must admit that I didn’t really feel scared during all of this, since it seemed like police were all over and our office felt secure. It was frustrating not knowing what was going on, but the anxiety was much worse when the potential shooter was near my children’s school and they were on lockdown.
It is sad that a false alarm like this must be taken seriously. I’ve heard that it was just a man with a stick. Or maybe it was just a prank. No one really knows at this time.
But what I do know is that there are many good people in this world. We can help each other in times of need. We can support one another. Mr. Rogers says:

When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers. You will always find people who are helping.”

When you have to explain these things to your children, remember to keep it simple. Answer their questions, but don’t go deeper than they’re ready to go. Find out what they already know and help them to understand it in ways that mean something to them. Try to keep the news off when kids are in earshot and monitor their screen time online. It’s okay to share your feelings, but try to reassure their safety and list some positives, like Mr. Rodger’s mother did.

Resources for parents to talk to kids about tragic news, such as mass shootings:

Common Sense Media: Explaining the News to Our Kids
PBS: Talking with Kids About News – sorted by ages
HealthyChildren: Talking to Children About Tragedies & Other News Events
American Psychological Association: How to talk to children about difficult news

Lead by Example

We’ve all heard the saying: kids will do what they’re shown, not as they’re told. Lead by example.

It’s so true. Think about all the times your kids are watching you. They are learning from you.

What can you do to help them have healthy habits?
  • Eat your vegetables.
  • Get daily exercise.
  • Wear your seatbelt.
  • Stop at stop signs.
  • Don’t use your phone while driving.
  • Wear a life vest near a lake or river.
  • Maintain your composure during times of stress.
  • No phones at the dinner table.
  • Don’t tell lies- even little ones.
  • Get enough sleep.
  • Be kind to others.
  • Call home- your parents and siblings would love to hear from you.
  • Don’t permit violence in your presence.
  • Give your time and talents to others.
  • Take care of your things.
  • Limit screen time.
  • Brush your teeth at least twice a day and floss daily.
  • Wear a helmet when on a bike.
  • Don’t mow the lawn without proper shoes.
  • Make time for family.
  • Lead by example every day!

 

helmets, exercise
Exercising together safely as a family sets great lifelong habits!

Car Seats for Safety

It’s been years since I’ve written about car seat safety and since September 17-23, 2017, is Child Passenger Safety Week I thought I’d take a moment to review car seat safety basics and share some of my favorite car seat safety links.

Most parents are now aware that all infants must be in a rear facing car seat, but many turn their toddlers around too early or let older kids move to the next level too soon.

I tell kids all the time that the state law is the bare minimum, but it isn’t necessarily the safest way to ride. I use the example that in my state an adult can ride a motorcycle without a helmet, but that’s not safe. They usually agree, and I think it helps them understand that just because it’s legal to do something, it doesn’t make it safe to do.

Kids learn from the behaviors they see their parents display, so all parents should buckle up for safety!

Which car seat is best?

When looking for a car seat or booster seat, don’t assume spending more money will buy a better seat.

You need to be sure it fits your vehicle and your child.

Whatever seat you buy, be sure to register it so you are notified of any recalls.

Infants and children under 2 years or 30 pounds

Infants and children under 2 years should ride rear facing unless they are bigger than the height or weight maximum for the seat.

Children over 2 years who still fit in the height and weight requirements of the rear facing car seat can still ride rear facing safely.

Another safety factor for infants and young children: don’t leave them in the car!

Young children often fall asleep in the car.

If sleep deprived (no parent is ever really well rested) and in a hurry, even the best parent can be distracted and forget about the sleeping baby.

There are many tips to follow to be sure you don’t leave your baby unattended in the car.

Children 2 years and older

Kids over 2 years (and those larger than the rear facing car seat maximum height or weight) should use a forward facing car seat with a 5 point harness.

They should continue the harness until they are mature enough and big enough. This means they must be capable of staying seated during the duration of the drive. Of course they must meet the minimum height and weight requirements for a booster seat.

Learn to use the tether properly with your forward facing car seat.

There are limits to using the LATCH system. LATCH stands for “Lower Anchors and Tethers for Children.” It was developed to help parents more easily install seats in cars and eliminate seatbelt incompatibilities. What you may not know is that the LATCH anchors are currently designed for a maximum combined weight of the child and child seat of 65 lbs.  Once the child + seat exceeds this weight, the seat must be installed using the vehicle seat belt, not LATCH. Depending on the weight of the child seat, your child may weigh quite a bit less than 65 lbs and need to stop using the LATCH.

Moving to a booster

Children should remain in a booster seat until the vehicle’s lap and shoulder seat belt fits them properly.

This is generally between 10 and 12 years of age and about 4 foot 9 inches, but varies based on the size of the vehicle’s seat.

Everyone should always use the vehicle’s seat belt (or car seat harness) when riding.

Have your kids take the 5 Step Test to see if kids can safely ride without a booster.

Sitting up front

Only teens and adults should sit in the front seat. It’s always safer in the back seat.

If you look at the sticker on the passenger side visor, it will say something to the effect that children 12 and under are safer in the back seat. That means wait until 13 years of age to sit up front.

Airbags can be dangerous if a passenger is too short for it to hit properly in the chest. The force of the airbag can cause significant injury to the face or neck. If the airbag is turned off, the passenger is at risk of hitting the dashboard or being ejected from the car.

Even big kids don’t have the muscle or bone strength to be safe up front. They aren’t mini-adults.

Winter safety

In the winter months it’s important to avoid over bundling infants and children in car seats.

The added layers and padding of clothing can increase the amount a child can move in the force of a crash or sudden stop. The Car Seat Lady has great tips to keep kids warm and safe in the cold weather.

Car seat additions and accessories

Don’t use car seat attachments and accessories that were not sold with the seat. They may look cute or seem to make your child more comfortable, but if they haven’t been tested with the seat they may not be safe.

This includes neck rolls, shoulder pads, winter covers that go between the child and the seat, dangling toys, and more.

If you’re in an accident and have these additions they might void the warranty of the seat.

What if kids try to escape the car seat?

Do you have a Houdini? If your toddler or preschooler is able to weasel out of the car seat harness, try this button down shirt trick.

How can you be sure your kids are buckled correctly?

Take your kids to a certified car seat installer to see if they’re buckled in properly. Car Seats for the Littles has information about how to find an installer near you.

Register your car seats so you can be alerted if they are recalled.

Identification Stickers

Car Seat Stickers are a great way to notify first responders who to call if you’ve been in an accident and aren’t able to communicate.

I recommend putting them under the cloth part of infant seats so they aren’t visible when you’re carrying the seat in public. You can put a small sticker on the handle to let emergency personnel know to look under the padding for emergency contact information.

Once kids are out of the infant seat you can put the sticker on the outside of the seat, just not over any important information. Never cover the height/weight max information or other things you’ll want to see later.

My office gives stickers from the W.H.A.L.E. Program to patients, but you can print your own at home and attach them to your seat with wide clear tape. Information to include would be:

  • Child’s name, birth date, address, allergies, important health history, medications
  • Parent’s names and phone numbers (cell and work)
  • One emergency contact name and phone number (not a parent)
  • Doctor’s name and number
  • Childcare provider name and number if applicable

After an accident

Remember that if you’re in an accident, your car seats might need to be replaced. Talk to your insurance company.

Used car seats

Used and borrowed seats cautions

  • Be sure to know when your seats expire. The seats typically expire about 6 years after manufacturing. This is due to unseen breakdown in the materials used to make the seat.
  • Never buy a used seat from someone you do not know. A friend should verify that it hasn’t been in an accident and it’s not expired before you use it.
  • Don’t just throw your old car seat away. Someone might try to use it past its expiration date. You can break it down into pieces to make it unusable or you can see if you can recycle it.

Just for fun…

The model in the top photo is my daughter at a car seat check many years ago. She now is (hopefully) a safe driver herself.

The original car seat safety blog was on by old blogspot site. 
Talk to teens about safe driving.
Teen Safe Driving Tips will be covered in another blog… coming June 2018!

 

 

 

 

 

 

 

 

Teen safe driving tips will be covered in a June 2018 blog. Watch for it if you have new drivers!

For more information:

 

Share Quest for Health

 

It’s Back to School Time, Time to Think Safety!

Walking to school is wonderful for kids because they get exercise, which can help with focus at school and their overall health. It can be also be a time to talk with friends or family and build community bonds. As kids are heading back to school after the summer break, we must think about their safety.

Walking to school can pose dangers, especially if drivers are distracted talking to their own children or texting. Please stop texting and driving. Don’t touch your phone at all while driving. Calls and texts can wait. If they can’t, pull over and check the message while parked.

Really.

Talk to your kids about safety:

walking to school with others

Kids should walk with an adult until they show the maturity to walk safely without direct supervision. The specific age will depend on the area as well as the child’s maturity.

Are there safe sidewalks? Are there busy roads to cross? Are there other kids walking the same route? Are there homes along the way they can go to in case of emergency? How long is the walk?

When kids have mastered the route and are competent to walk the distance alone, find walking partners. Have kids stay in groups or with a walking buddy as much as possible.

See if your school can help arrange walking buses, where kids all walk the same route to school with adult walk leaders.

Find the safest route

Choose sidewalks wherever possible, even if that means the trip will be longer. If there are no sidewalks, walk as far from vehicles as possible, on the side of the street facing traffic.

If possible, avoid areas near high schools, where there are more teen drivers.

Cross streets safely

If there are crossing guards, use those intersections. If there are street lights, wait until the “walk” symbol appears.

Never cross in the middle of a block, use intersections.

Look both ways twice before crossing.

Do not text or play games when in the street.

Remind kids that if they are crossing a street, they should make eye contact with a stopped driver before crossing, even if there’s a “walk” symbol. Drivers turning right might turn on red and not notice small pedestrians.

Know the route

Teach kids to use the same route every day or discuss which route they will take each day if they use different routes.

If they don’t arrive to school or home as planned, you know the route to search.

Walk the routes with them until they know how to safely navigate each.

Avoid distractions

Listening to music (especially with earbuds), playing video games, watching videos, and texting all keep kids from paying attention to their surroundings.

Even talking on the phone is distracting, so don’t assume they are safer if they talk to you all the way home when you’re at work. They are more likely to trip and fall, step into a street without looking first, or not notice that they’re being followed if they’re distracted.

They should be aware of their surroundings at all times.

Getting a ride rules

Remind kids to never accept a ride from anyone unless you pre-plan it. Rain, snow, and cold weather make it tempting to hop in a car, so have kids dress appropriately for the weather and arrange safe rides as needed.

Contact information

Have kids keep important contact information in their backpacks in case of emergency. At least two people should be on this list. People on the list could include a parent, grandparent, or trusted adult friend/neighbor. Names and phone numbers should be included.

Going on wheels

If they are riding a bike, scooter, or skateboard to school, they should follow the rules of the road and proper safety.

Suggestions for adults:

Be alert

Be extra cautious when driving in the before and after school times, especially near schools and in neighborhoods.

Make your sidewalk walkable

Be nice and don’t use your sprinklers in the before and after school times so kids can stay on the sidewalks and not wander into the street to avoid getting wet.

In the winter, clear snow and ice as needed.

Never text and drive

Put your phone on silent and in a place you can’t reach it while driving.

Texts can wait.

Buckle up for safety!

If kids are in your car, make sure they are properly buckled.

Only teens and adults should be in the front seat.

Use an appropriate car seat or booster seat.

Kids shouldn’t wear their backpack in the car, nor should they unbuckle while in a drop off line to get their backpack on before the car is stopped.

Carpools

If your kids will carpool with other families, be sure they are in proper seats at all times.

It’s tempting to not use boosters for short drives, but it’s never safe to have kids improperly restrained. Find boosters that are easy to move between cars.

 

Talk to kids about safety when walking to school.

Dry Drowning – What Parents Need to Know

I thought about calling this one “We’re drowning in dry drowning phone calls” because we are getting many worried calls about dry drowning, but that’s overly dramatic and I hate headlines that make things seem like the sky is falling…

I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I’ve never seen it, I’d forgotten the term. Either way, it isn’t very common at all.

Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It’s when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work – the air tubes are swollen, so air can’t get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

Symptoms you need to recognize and act upon by taking your child to an ER:
  • Cough: If your child has coughing for a minute or more after being in water, he’s at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
  • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
  • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
  • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn’t the same thing as being tired after a long day. The medical definition is “Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction.”
  • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It’s best to check it out in the ER.
What will happen in the ER?

Many parents don’t want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don’t have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child’s symptoms and exam. There is no specific treatment for this, only supporting your child’s airway and breathing as the swelling goes down.

  • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling).
  • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well.
  • Oxygen levels will be monitored and extra oxygen might be given.
  • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
  • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.
Prevention is important!
swimming
Watch your kids when around water!

As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds.

  • Childproof your home when you have little ones who might play in a pet water bowl or the toilet.
  • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn’t pretend they’re drowning because it might distract a lifeguard from a true emergency.
  • Learn infant and child CPR.
  • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
  • Watch your kids closely and keep them within reach when they’re in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present.
  • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue.
From this site, signs of drowning:
  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs – Vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back

Addendum:

    • I just read a post that gives references regarding drowning definitions. It appears I didn’t forget learning about dry drowning in medical school.

It isn’t really a thing.

The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause.

Check these out:

On “Dry Drowning”

Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

Drowning is never dry: Two ER doctors explain the real swimming danger kids face

Traveling Around the World

Spring Break is around the corner, which means many of my patients will be traveling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor’s office) be sure to bring the records with you.

Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your primary medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic.

Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness.

As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the “T” zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

Medicines for travelers Diarrhea

  • Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea.
  • This is not recommended by many experts due to the rise of “superbugs” with the use of unnecessary antibiotics.
  • In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods.
  • The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day.
  • Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome.
  • Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting.
  • Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children.
  • Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos…

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant. See below for prevention medication options.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.
  • Learn local laws prior to travelling.
  • Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.
  • Remind everyone to stay in groups and to not venture out alone.
  • Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.
  • Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn.
  • For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC’s travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

  • Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
  • Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression.
  • Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
  • Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
  • Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother’s antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday.

Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

  • Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older.
  • There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.
  • Meningitis vaccines should be given at least 7-10 days prior to potential exposure.
  • Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years.

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States.

Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness.

Appropriately treating the TB before it causes active disease is beneficial for the long term.

 

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

  • Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years.
  • The oral vaccine for children over 5 years and adults is given in 4 doses over a week’s time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years.
  • Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC’s Zika page.