Getting help while traveling abroad

Even when you’re fully prepared for your trip, traveling with children is more likely to bring along something unexpected.  And when you’re far from the comforts of home, it is difficult to know what to do or where to go for help when you or your child is ill.  Here are some tips that may help:

  • Strongly consider purchasing travel health insurance and medical evacuation insurance.  Before your trip, check with your health insurance provider to see if they will cover medical costs while abroad.   Before my trip to Asia, I purchased travel health insurance and medical evacuation insurance for our family. As a travel medicine physician, I’ve heard too many stories from colleagues of an ill person who had to fly to another country to obtain proper health care. One example was a child who was bitten by a monkey in Bali and had to be flown to Singapore to receive the proper anti-rabies treatment. The costs of a medical evacuation are astronomical (upwards of $100,000) and having an insurance policy that covers these unexpected situations is definitely something worth considering.  You can find out more about travel insurance providers on the US Department of State website on travel health insurance plans.
  • Know how to contact your doctor at home for help while abroad.   When you’re traveling internationally and across different time zones, one of the most convenient ways to ask your doctor a question is to use your health care provider’s patient portal.  Our pediatric practice group, Allegro Pediatrics, now has a patient portal that allows parents to ask their child’s care team a question and receive an answer online.  So if, for example, your child gets a very itchy rash while traveling and you’re not sure which over-the-counter cream to use,  you could login to the patient portal and ask your provider this question.   You will receive an answer within 1 business day.  Being able to message your care team over the internet is far more convenient than having to call, especially across different time zones.  Keep in mind that when it is 1:30 pm in India, it is 12:00 AM in Seattle.  No one likes getting woken up in the middle of the night for a non-urgent question.
  • Look up health care providers and facilities at your destination before your trip.  This is important especially if you or your child have a chronic health condition.  There are many trusted resources that list health care providers and facilities around the world.    If you purchased travel health insurance, you may need to call your insurance company’s 24 hour emergency hotline and they will inform you of the appropriate facility to go to.  The International Society of Travel Medicine has a directory of travel medicine physicians worldwide.  The Joint Commission International (JCI) has a list of medical facilities that meet a standard level of quality.  In case of an emergency, the US Department of State can help travelers locate medical services and notify loved ones of an emergency.  Before your trip, you can also enroll in the state department’s Smart Traveler Enrollment Program and they will send you travel warnings about your destination and be better able to assist you in case of an emergency.
  • Be wary of counterfeit medications. Bring with you all the medications you think you will need for your trip, whether it be over-the-counter or prescriptions.  Pack it in your carry-on luggage!  When traveling abroad, be wary of counterfeit medications, including antibiotics and anti-malarial medications.  According to the CDC, “an estimated 10%–30% of medicines sold in developing countries are counterfeit.”  Not only can medications purchased in pharmacies overseas be fake but they can also be dangerous.
  • Don’t travel if you or your child is sick. This is another good reason to buy travel insurance before your trip.
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Don’t bring back measles as a souvenir from your trip

I’m planning a trip to Walt Disney World with my family next month and can’t wait to see how my 4 year old daughter will react. She tells me, “I can’t wait to meet Elsa in real life!”  Secretly, I am also excited to relive my childhood again.  As I’m planning the trip and booking the hotel rooms, I can’t help but remember what happened last year on January 5, 2015 in Disneyland.

This was the day when an 11 year old unvaccinated child along with 4 other people were diagnosed with measles after visiting Disneyland.  The outbreak spread quickly and by February 11, 2015, there were 125 confirmed cases of measles connected to this outbreak and the disease spread to 6 western states, Canada, and Mexico.  As of June 2015, a record number of 397 cases of measles were reported in the US.  This is the highest number of  measles cases reported in a given year over the last 20 years!  Almost all of these measles cases were imported from travelers, most who were not vaccinated.

Measles is a highly contagious viral illness that can lead to serious complications and death.  You can check out the CDC website on measles for more information about the disease and its possible complications.  On July 2, 2015, Washington state reported a measles-related death in an undiagnosed woman.  The CDC states that the virus can live for up to two hours in a room where the infected person coughed or sneezed. If other people breathe the contaminated air or touch the infected surface, then touch their eyes, noses, or mouths, they can become infected.  Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected.  This is incredibly scary for parents with children too young to be vaccinated or have other conditions that prohibit vaccination.

In 2000, the US declared that measles was eliminated.  However, measles is common in most other countries in the world, including parts of Europe, Asia, the Pacific, and Africa.  The CDC reports that every year, 20 million people get measles and  about 146,000 people die from it.  ‘Measles has been brought back to the US by unvaccinated travelers, which then has led to secondary outbreaks in the U.S.

The best way to prevent getting measles on your trip is to make sure you get all the recommended MMR vaccines your doctor recommends.  It is best to get these vaccines at least 2 weeks before your trip.  For people going on international trips, the recommendations for MMR vaccine is  different than the routine immunization schedule.  According to the CDC:

Before any international travel—

  • Infants 6 months through 11 months of age should receive one dose of MMR vaccine.
  • Children 12 months of age and older should receive two doses of MMR vaccine separated by at least 28 days.
  • Teenagers and adults who do not have evidence of immunity* against measles should get two doses of MMR vaccine separated by at least 28 days.
  • * Acceptable presumptive evidence of immunity against measles includes at least one of the following: written documentation of adequate vaccination, laboratory evidence of immunity, laboratory confirmation of measles, or birth in the United States before 1957.
  • Infants who get one dose of MMR vaccine before their first birthday should get two more doses (one dose at 12 through 15 months of age and another dose at least 28 days later).

It was unfortunate that the “happiest place on earth” became the breeding grounds for  measles last year.  It certainly was not Disney’s fault.   This huge outbreak ignited a national debate about vaccinations.  With its growing number of anti-vaxxers, many US communities are at risk for more large outbreaks.  For my traveling families, I always urge them to get their MMR vaccines before their trip according to the CDC recommendations to provide maximum protection.   Their children, families, friends, and community will be thankful they did.

 

Get your flu vaccine!

The seasonal flu vaccine has arrived in all of our clinics.  The WHO and CDC collect data from May-September and analyze the circulating influenza virus strains around the world.  Since it is winter in the Southern Hemisphere, other countries are able to identify the types of influenza virus strains that are causing most of the illnesses. This information gives us a clue about what to expect for our upcoming winter and flu season.

Influenza or “the flu” is highly contagious and kills healthy children and adults every year.  Each year, an average of 20,000 children under age 5 are hospitalized due to influenza complications.  For travelers, getting influenza is one of the most common illnesses that occur while away from home. Crowded airplanes, trains, and buses are breeding grounds for the flu.  Our clinic has seen a few cases of influenza this season already.

I always highly recommend getting the flu vaccine at least 2 weeks before the trip.  All children and adults over 6 months should be getting the flu vaccine every year.  It is best to get the flu vaccine EARLY in the fall season, before getting exposed to the flu.  People often forget that you can get the flu ANYWHERE, and even in warm, tropical locations year-round.  Getting the flu vaccine will not only provide the best protection against a miserable illness but also help to protect those around you and your community!

Traveling with Food Allergies

Every parent of a child with a serious food allergy worries when eating out at a restaurant. What happens if the chef made this dish with peanut oil?  Or if the pot wasn’t cleaned thoroughly before my child’s dish was made and could be contaminated?  Or if someone ate shrimp at this table recently?  In my case, my daughter has a fish allergy so I avoid all sushi and seafood restaurants.

Traveling abroad when you or your child has a serious food allergy is daunting but NOT impossible.  When I talk about a serious food allergy, I mean the kind that involves whole-body hives, lip or throat swelling, wheezing, vomiting, loss of consciousness, or even death. When you have this kind of food allergy or anaphylaxis, you need to be very careful of what you eat and the possible hidden exposures or “contaminants” you are in contact with.  Here is a list of what you need to do if you are planning a trip:

  1. Take your destination’s cuisine into consideration during trip planning.   Since my daughter cannot be exposed to any fish proteins, I have decided not to visit Thailand or Vietnam since fish sauce is used ubiquitously like salt in these countries.  My friend’s child is allergic to dairy so going to France was not a good option for her.  And if your child has a peanut allergy, I would avoid Southeast Asia.  My recommendation is to be thoughtful in your trip planning as to where you want to go with a food allergy since you will likely be eating out at restaurants while you’re there.
  2. Research airline food allergy policies before you book your flight.  The No Nut Traveler  is a great website for people who have food allergies and want to fly safely on commercial airplanes.  Some airlines, like Jet Blue, will create a buffer zone to keep your child safe from food allergies.  Some will also make an announcement to all passengers on the flight not to eat peanuts on the flight if you or your child have a serious peanut allergy.  You can also ask for early boarding so that you can wipe down the seats and tables with wet wipes before your child sits down.  I would also recommend bringing a blanket to cover the seat to further protect from potential allergens.  If your child has an allergic reaction to airborne nut proteins, you will want to choose an airline that does not serve nuts  and will make an announcement to fellow passengers.  When booking your flight and checking in at the airport, notify the agent of your food allergy and request that the gate agent/cleaning crew are also aware.  Pack plenty of safe snacks/food.  It pays off to be prepared at every step of your trip.
  3. Plan your accommodations with food allergies in mind.  If your child has a serious food allergy, staying in a suite or condo with a kitchen will be more convenient and safer for you to prepare your child’s food.  Staying at high-end hotels or all-inclusive resorts means that you will be eating out with every meal which will increase your risk of an allergic reaction.
  4. Learn some key phrases in your destination country’s language to warn others about your child’s food allergy.  I’ve used the Google Translate app on my phone multiple times during my trips abroad.  Figure out how to say the following: “My child is very allergic to _____.  If she eats this, she may die.”  It would also help to have this phrase written down in that language.
  5. Find out which hospitals are near your accommodations and figure out how to dial “911” in that country.  If your child has a serious allergic reaction, like throat swelling or wheezing, DO NOT call the local clinic or hotel doctor.  He/she will likely NOT have the necessary emergency medications or equipment to give appropriate care. It may end up delaying the right treatment for your child.  It is best to get emergency care and go directly to a hospital emergency room.
  6. Pack at least 2 Epipens auto-injectors in your CARRY ON LUGGAGE and 2 doses of oral Benadryl (Diphenhydramine).  For children under 55 pounds, they need the Epipen Jr (0.15 mg).  For children over 55 pounds, they need the Epipen (0.30 mg).  If you have the Auvi-Q auto-injector, please call your doctor for a prescription for the Epipen or Epipen Jr instead.  ALL Auvi-Q devices were recently recalled.  You can return your Auvi-Q to the company and get reimbursed by calling 1-877-319-8963.   Benadryl comes in chewable tablets and single dose vials, which are more convenient to carry in your travel health kit.  If you don’t know your child’s dose of Benadryl, you can ask your doctor. If you child also uses an inhaler, be sure to pack this in your carry-on luggage too.
  7. Know your Food Allergy and Anaphylaxis Emergency Care Plan.  You can download a copy of the plan on the food allergy.org website and pack it in your travel health kit.  If you have any questions about your child’s plan, review it with your child’s doctor before your trip.

 

If you are the only parent traveling with your child, don’t forget that consent letter!

I took my daughter on a girls only trip to Vancouver recently. In order to make sure the border crossing went smoothly, I downloaded a copy of a consent letter for my husband to fill out allowing me to bring her across the border. There are numerous examples of these consent letters on the internet. We got this letter notarized.  When the US Customs officer asked to see my consent letter at the border, I was glad that I took the extra time and effort to get this done before our trip.

Due to concern about international child abductions, many countries are now very strongly recommending a notarized consent letter if a child is traveling overseas without BOTH parents or even with just ONE parent present. Take time to obtain all the necessary documents for your international trip by reviewing this website: Documents for Travel.  This will save you a lot of time and trouble at the border!

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Stingers, gators, and sharks, OH MY!

jellyfish   beach at palm cove

One of my dreams since high school was to scuba dive at the Great Barrier Reef in Australia.  I loved the movie, “Finding Nemo,” and wanted to show my daughter where Nemo lives. During my sabbatical, I finally had my chance.  I thought I had planned everything out perfectly.  We rented a condo in Palm Cove, Australia for 2 weeks in the middle of December.  It was going to be sunny and hot in the high 80’s or low 90’s.  Great weather to be swimming in the beautiful ocean.  Or so I thought.  When we finally arrived at the beach, the first thing I noticed, besides the blue water and the soft white sand, was that NO ONE was swimming in the water!  No one was even dipping their feet in the water.  And then we started asking the locals why.  We discovered that the waters near the beaches were infested with JELLYFISH (really big and long ones).  On top of that, it was ALLIGATOR mating season.  And to make it worse, plenty of SHARKS were around!  I kept wondering why I never read about this before on Tripadvisor or Lonely Planet.

On every beach in tropical Queensland that we visited, there were signs warning people of jellyfish, or “stingers,”  and bottles of vinegar around.  If you really wanted to swim in the ocean, it was best to wear a “stinger suit,”  which is a full-body wet suit with hoodie, gloves, and shoes.  On some beaches, there were also swimming enclosures with nets to keep the jellyfish out.  But even these preventive measures were not 100% protective.  I witnessed a boy who was wearing a full stinger suit get painfully stung in the ankle, where there was exposed skin between the suit and the shoe!  I think he was crying for about 2 hours. Poor child!

Jellyfish stings are common and PAINFUL but rarely life threatening. If you think you just got stung by a jellyfish, follow these simple steps:

  1. Get out of the water. Calmly.
  2. Rinse the area with seawater.  Don’t rub the area.  If you have vinegar, rinse the area with vinegar for 30 seconds.  (Vinegar helps prevent the tiny stingers, called nematocysts, from firing.)  A paste of baking soda and seawater can also be used.
  3. Use a credit card to scrape off the stingers still on the skin.  
  4. Take Acetaminophen or Ibuprofen for pain.  Ice packs can also help relieve pain and swelling.

If you get stung, you will likely have skin redness, swelling, tingling/numbness, a “print of tentacles” on the skin, and throbbing pain. However, severe jellyfish stings can also occur and affect other body organs.

Call 911 or seek emergency treatment if there are signs of the following:

  1. Trouble breathing
  2. Swollen mouth or tongue
  3. Nausea/Vomiting
  4. Headache and dizziness
  5. Loss of consciousness
  6. Muscle spasms
  7. Stings over a large part of the body or in the eye/mouth
  8. Stung by a very dangerous jellyfish, such as the box jellyfish, Portuguese man-of-war, Lion’s mane jellyfish, or sea nettle.

I was still able to visit the Great Barrier Reef on a boat excursion. We had a great time in the underwater submarine ride.  We did a little bit of snorkeling. My daughter had fun seeing the coral and colorful fish (sadly, no Nemo).  No one in my family got stung by a jellyfish.  But the next time we want to go to a tropical beach destination, I will be sure to ask the locals whether it is safe to swim in the waters there before booking the trip.

Breakbone Fever a.k.a. Dengue Fever

Most travelers have heard about dengue but don’t really know what it is or how bad it can be.  The nickname, breakbone fever, gives people a clue.  Dengue is a viral infection that is transmitted by infected mosquito bites and is endemic throughout the tropics and subtropics.  That means it is common in Mexico, Central and South America, Caribbean, South Asia, Southeast Asia, Africa, and northeastern Australia.  Over 100 countries have a risk of dengue.  According to the WHO, about half of the world’s population is now at risk for dengue.  Over the last few years, I’ve met many U.S. families returning from their trips worried about dengue or knew someone who recently got infected with dengue.  It is a leading cause of fever in returning travelers.

Dengue is a mean and smart virus.  It is more common in urban areas, as opposed to rural areas.  And the mosquitoes that carry dengue like to bite during the daytime as opposed to the nighttime.  There are 4 types of dengue viruses.  This means that many people who live in endemic country get infected with dengue more than once.  About 75% of people who get infected with dengue virus have no symptoms at all.  The rest, however, can develop a range of different symptoms, including fever, nausea/vomiting, abdominal pain, severe headache and eye pain, joint and bone pain, rash, and easy bleeding.  The incubation period ranges from 3-14 days.

Here’s the scary part.  As many as 5% of people who get dengue develop SEVERE DISEASE, which is called dengue hemorrhagic fever and dengue shock syndrome.  Children are more vulnerable to severe disease and more likely to die.  And people who had dengue in the past are more at risk for severe disease if they get infected with a different type of dengue virus a second time.  Dengue can cause leaky blood vessels which can lead to extra fluid in the lungs and abdomen and SHOCK.  Severe dengue also causes bleeding from GI tract, which shows up as bloody emesis or bloody/dark black stools.  Dengue can also cause hepatitis, pancreatitis, myocarditis, and encephalitis.

There are currently no licensed vaccines, prophylactic medications, or antivirals in the U.S. that protects us from dengue.  However, I learned at a recent international travel medicine conference that there are a few promising dengue vaccines in the pipeline.  The best way to prevent dengue currently is to AVOID MOSQUITO BITES by doing the following:

1. Use insect repellant, such as 20-30% DEET.

2. Wear loose clothing that covers exposed skin.  Clothing can also be pre-treated with permethrin, which will give extra protection.

3. Stay in places with window and door screens, bed netting, or air-conditioning.

4. Cover or avoid having standing or open water containers around the place you are staying in.  These are breeding grounds for mosquitoes.

What do you do if you or your child has a fever and develops other symptoms worrisome for dengue within 2 weeks after you return from your trip?  Go see your doctor right away.  There are blood tests available than can tell whether you have dengue. Many cases of dengue can be mild and be treated supportively at home.  But knowing the signs of severe dengue and getting EARLY appropriate treatment can be life-saving.