Travel medicine and pre-travel advice for children — formative SAQs

SAQ 1 (10 marks)

A five-year-old girl is brought to the general paediatric clinic six weeks before the family flies to visit grandparents in rural Bangladesh for one month. Her immunisation record is incomplete — she has not received her preschool boosters. Her parents ask whether she needs "the malaria tablets". They are first-generation migrants and the family has not sought pre-travel advice before. [2]

Question: Outline your structured risk assessment and the pre-travel plan you will deliver to this family. (10 marks) [1]

Model answer

Risk assessment (3 marks). Build a composite risk score from destination, activity and the child. The destination — rural Bangladesh for one month — is high-risk for malaria (chloroquine-resistant), enteric fever (and increasingly XDR Salmonella Typhi in South Asia), hepatitis A, dengue and rabies. The family is a visiting-friends-and-relatives group, the single highest-risk and most-often-missed category for imported paediatric infection, and the child is non-immune to the local pathogens with an incomplete immunisation record. State the VFR risk explicitly and explain that these families are less likely to have taken prophylaxis and more likely to have intense rural exposure. [2] [5]

Immunisation lane (2 marks). Catch up the missing routine immunisations, especially measles-mumps-rubella before travel to an endemic region, and add the travel-specific vaccines: hepatitis A from one year of age, injectable typhoid from two years, and consider Japanese encephalitis vaccine (Ixiaro, licensed from two months) for the prolonged rural-Asia stay. State that the four-to-six-week window allows a primary series to begin, and that the first dose confers at least partial protection. [6]

Prophylaxis lane (2 marks). Choose age-appropriate malaria chemoprophylaxis for a chloroquine-resistant region: atovaquone-proguanil is the default for this five-year-old because doxycycline is avoided under eight years and mefloquine carries neuropsychiatric contraindications and a longer lead-in. Start before exposure, continue through the trip and for one week after return, and address adherence explicitly because a regimen not completed is the commonest reason for breakthrough infection. [4]

Behavioural and response-kit lanes (2 marks). Deliver rigorous insect-bite avoidance (DEET or picaridin repellent, permethrin clothing and bed nets), food and water safety (the cook-it, peel-it, boil-it-or-forget-it rule), and a written response kit: oral rehydration, standby azithromycin (not a fluoroquinolone, given XDR typhoid in South Asia) for severe travellers' diarrhoea, and the fever-after-travel rule in the family's language. [3] [6]

Disposition and follow-up (1 mark). Give a written plan, arrange the remaining vaccine doses, and confirm before departure that the prophylaxis was started and tolerated. The single most important message is the fever-after-travel rule: if the child becomes febrile within months of return, seek care immediately and state the destination. [4]

SAQ 2 (10 marks)

Question: Describe the four lanes of the pre-travel plan for children, and for each give the key decision points and one common pitfall. (10 marks) [1]

Model answer

Immunisation lane (3 marks). Routine catch-up plus travel-specific vaccines, timed for seroconversion ideally four to six weeks before departure. Key decision points: the age thresholds — yellow fever from nine months and contraindicated below, typhoid injectable from two years and oral from six, hepatitis A from one year with immunoglobulin for the infant under one, Japanese encephalitis (Ixiaro) from two months for rural Asia, rabies pre-exposure for high-risk itineraries. Pitfall: treating the encounter as a vaccine visit and omitting the other three lanes. [6]

Prophylaxis lane (3 marks). Age-appropriate malaria chemoprophylaxis chosen by the destination's resistance pattern and the child's age: atovaquone-proguanil from five kilograms and the default for young children, doxycycline from eight years, mefloquine with neuropsychiatric screening and a longer lead-in. Start before exposure and continue after return. Pitfall: the wrong drug for the age — doxycycline under eight years, or a drug started too late to reach protective levels. [4]

Behavioural lane (2 marks). Insect-bite avoidance (the only protection against dengue and Zika, and a vital adjunct to malaria prophylaxis), food and water safety, sun protection, hand hygiene, and road and water safety. Pitfall: forgetting that the most common serious harm to a travelling child is often a non-infective injury — road trauma, drowning, sun damage. [6]

Response-kit lane (2 marks). Oral rehydration and standby antidiarrhoeal therapy (azithromycin not a fluoroquinolone for South Asia), the written fever-after-travel rule in the family's language, travel insurance and medevac arrangements, and a local healthcare contact. Pitfall: no fever-after-travel safety net — the family whose child develops malaria and is treated for influenza at the first unscheduled visit. [3] [4]