Linda S. Nield MD, is Associate Professor of Pediatrics, West Virginia University School of Medicine, Morgantown, WV.
Dr. Nield has disclosed no relevant financial relationships.
Address correspondence to: Linda S. Nield, MD, PO Box 9214, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV 26505; fax: 304-293-1216; email: email@example.com.
Adolescent travel can provide rewarding educational experiences that foster independence, but it also has potential health implications. The pediatric health care provider must be familiar with travel-associated morbidity and mortality so proper medical advice can be administered when families seek pre-travel care. The potential travel-associated health implications are described in this review, along with strategies that may maximize the well-being of the adolescent during travel.
Adolescent Travel Statistics
Ten percent of the more than 30 million travelers per year from the US to foreign destinations are students.1 In a survey of individuals aged 9 years to 18 years by Han et al, 7.7% of respondents had visited a nonindustrialized country in the last year.2 The mean age of the adolescent traveler was 14 years. Approximately 20% of the children traveled without their parents; the mean age of the solo traveler was 15.5 years. Results of a study from 2005 revealed that approximately 60% of surveyed households included a 12- to 18-year-old member who traveled without his or her family, and approximately 8% of the trips were taken to international locations.3
Reasons for adolescent travel could include vacation, visitation of family and friends, study, volunteerism, sporting events, religious affiliations, adventure travel and work. A popular time of year for adolescents to travel in groups without parents is February through April for spring break. It is estimated that approximately a half-million “spring breakers” visit national or international destinations every year.4
Morbidity and Mortality of Teens
By knowing the specific health risks of adolescent travel, the parent and the pediatrician can better prepare the adolescent for a safe and fulfilling experience (Sidebar 1, see page 360). The duration, location and nature of the journey will determine the potential health implications. In general for all travelers, longer jaunts result in greater likelihood of experiencing a medical issue.5 Visits to developing areas or tropical locations often expose adolescents to pathogens and environmental factors not commonly encountered in the US. The nature of travel determines the potential exposures. For example, an adolescent visiting family in Europe experiences different health risks than one meeting friends in a tropical location for spring break or adventure travel.
- Sexual Hazards
- Substance/alcohol Abuse
There are sparse numbers of studies that address the travel-related health implications for adolescents specifically.2,6 However, 20% of the adolescents surveyed by Han et al had experienced a health concern during their travel to nonindustrialized countries, including diarrhea, fever, motor vehicle accidents, respiratory disorders, and other injury and illness.2 The rate of each specific concern was not included in the report.
In Sadnicka’s study, illness or injury was reported in 64% of travelers aged 15 to 18 years who participated in a month-long youth expedition to various destinations around the world.6 Gastrointestinal disorders (diarrhea, nausea and vomiting), upper respiratory tract symptoms (“cold,” sore throat), headache and trauma were the most common health issues recorded. Less prevalent illnesses included those due to environmental exposures (heat illness or altitude sickness) or disorders of various bodily systems (urogenital, ear, eye, skin, teeth, and psychological). Medical problems which required hospitalization or more intense attention resulted from dehydration, motor vehicle accidents, lacerations, malaria (all occurred in Africa), and animal bites. Gautret et al found that injuries secondary to animal bites in their study were most likely to occur in individuals younger than 15 years old and those who traveled to rabies-endemic areas in Asia.7
Adverse consequences from alcohol and drug use and unprotected sexual activity are major concerns for the adolescent traveling without parental supervision. Excessive alcohol use during spring break is a common phenomenon 4,8,9 and some students may choose certain travel destinations for their lenient enforcement of underage drinking laws. Heightened drug use may also occur during spring break.8 Sexual promiscuity, laxity of safe sex practices and lessened inhibitions due to alcohol or drug use may lead to acquisition of sexually transmitted infections (including HIV) or pregnancy. Being male and younger than age 20 years is associated with a high frequency of casual sexual encounters during travel.10 The risk of an adolescent’s conceiving during travel is unknown,11 but it is a worry for young female travelers. Schwartz’s survey of adolescent girls revealed that 15% of respondents were concerned about the possibility of being pregnant after vacationing for a week without parental authority.12
Death of an adolescent during travel is uncommon. Hargarten et al reported that 2% of decedents in their 2-year surveillance of fatalities of US travelers were individuals younger than age 15 years.13 All of the deaths in travelers aged 15 to 34 years were secondary to injury. Injuries in all ages resulted mainly from motor vehicle accidents and drownings; homicides, suicides, animal bites and falls were other less common causes. Infections (malaria, typhoid and hepatitis B) caused only 1% of the deaths. Nurthen and Jung’s study included 20 deaths of Peace Corps volunteers, aged 18 to 24 years, occurring in a 20-year period.14 The deaths were rarely secondary to unintentional injury (motor vehicle or bicycle accidents and drowning), and suicide or homicide. Injuries, therefore, are a serious health implication for the adolescent traveler, and the use of alcohol and recreational drugs potentially contributes to this major cause of adolescent travel mortality.15
Strategies for Safe Adolescent Travel
In general, adolescents who travel without parents may tend to be more risk-takers compared with the non-traveling adolescent.2
Before an adolescent is allowed to travel independently, he or she should already be considered dependable and trustworthy by parents and other adults. A pattern of reckless sexual behavior and substance abuse is a red flag and may be reason enough to disallow solo travel. Unhealthy activities have a tendency to increase while the adolescent is away from parental authority.9,12
After it has been decided that solo adolescent travel will occur, a pre-travel clinic visit can be scheduled several months before the actual journey, in order for the completion of vaccine series and infectious disease and safety counseling to occur. However, if pre-travel counseling is obtained too far in advance, its impact may be diminished. Han’s survey of traveling youths revealed that fewer than one-fifth of respondents received pre-travel advice and about two-thirds did not receive vaccines or malaria chemoprophylaxis.2 Clinicians should make parents aware of the necessity of a pre-travel health visit, perhaps by poster displays in the waiting room or during anticipatory guidance discussions at well visits.
At the pre-travel visit, the pediatrician can offer some general travel advice (Sidebar 2), along with the provision of injury-prevention strategies, infection-control measures, vaccine implementation, and medication prescriptions. The details of the travel itinerary can be reviewed and will determine which health risks are most likely for a particular traveler. Practical travel advice includes the suggestions of ensuring consistent contact between parents and the adolescent during travel via telephone or the Internet and encouraging the purchase of a travel insurance plan with medical-evacuation coverage. Another practical suggestion is the recommendation to register the adolescent’s travel with the US State Department.
— Ensure consistent contact with the adolescent during travel
— Purchase travel insurance with medical-evacuation coverage
— Register the travel with the US State Department
— Locate physician at travel destination for an adolescent with a chronic disorder
- Infection Control
— General measures: hand hygiene, food preparation/precautions
— Malaria prophylaxis if needed
— Vaccinations as indicated
- Injury Prevention
— Ensure adequate supply of maintenance medications
— Provide powdered electrolyte solution and education about preparation
— Consider fluoroquinlone prescription with instructions for use in travelers aged 16 years or older
- Safe Sex Counseling
- Substance/alcohol abuse counseling
- Violence Prevention
If the adolescent has an underlying chronic illness, then an adequate supply of maintenance medications must be provided. The adolescent should be well-versed on the nature of the health condition and already responsible for daily management of medications and other interventions. Worrisome signs and symptoms or exacerbations of disease must be discussed so the need for further medical treatment is recognized. It is prudent for parents to locate, beforehand, a physician at the travel destination who may be called upon if medical care is needed for the traveling adolescent.
Injury and Infection Prevention
Infection control is an important part of the pre-travel advice. In general for all travelers, longer travel duration is associated with a higher risk of infection acquisition in developing countries.16 As with any older traveler, the destination will determine the need for certain vaccinations and chemoprophylaxis. The adolescent should receive the full series of vaccines routinely recommended in the US and those recommended for the area of travel.17 Hand washing should be stressed for prevention of most respiratory and gastrointestinal disorders. Packing portable containers of liquid hand sanitizers is a convenient means of hand sanitation. Hygienic eating practices, such as avoidance of raw or undercooked food and local water supplies, especially in developing countries, are strongly recommended.
Empiric use of antibiotic prophylaxis for travelers’ diarrhea is not routinely recommended for children; however, treatment of individuals with significant diarrheal symptoms with fluoroquinolones is an option for those aged 16 years or older.18 The need for aggressive hydration restoration and maintenance should be stressed, and supplying the adolescent with powdered electrolyte solution packets and the education to prepare the solutions properly with bottled water is advised. Malaria prevention, including the prescription of appropriate medications and counseling about mosquito avoidance, will need to be addressed if the adolescent is traveling to an affected area.
Safe sex counseling concerning infection and pregnancy avoidance should be provided, particularly for the high-risk adolescent. Ideally, parents should be having ongoing dialogues about this issue, not just because of upcoming travel, and the reader is referred to a review of interventions to improve parental communication about sex.19 Condoms and other birth control products should be made available to the traveling adolescent, and proper and consistent use of these products must be emphasized. In one study, taking condoms along on the journey and reading information about sexually transmitted infections were predictors of practicing protected sex during travel.20
A discussion about injury prevention is paramount, since injury is the main cause of death of the adolescent traveler. Adolescents should avoid driving on unfamiliar and unsafe roads with inexperienced drivers. Water sports, hiking, biking and other activities that expose one to the natural elements should not be done alone. To further avoid adverse environmental health effects, the adolescent should be properly prepared for the potential dangers of nature, including animal and insect encounters and sun and altitude exposures. Intensive sporting activities for which the adolescent has not been trained should not be attempted for the first time in a foreign land.
References are available to help parents and pediatricians counsel adolescents about avoiding alcohol and substance use.21,22 The adolescent should be warned that avoiding illicit drug use will not only decrease the risk of adverse health effects, but it will also eliminate the possibility of drug-related legal offenses. Participation in any type of crime may carry much harsher penalties abroad than one may experience in the US, and due process is not always guaranteed. Avoiding violence may be possible if basic safety practices are employed, such as not walking alone at night or in unfamiliar or disreputable places. Using common sense and the “buddy system” can go a long way in protecting the adolescent in most instances. In order that all aspects of pre-travel advice are addressed, parents and the adolescent can be referred to further resources.11,17,23–25
- USDCITC: United States Department of Commerce International Trade Commission. Office of Travel and Tourism Industries. Profile of US Resident Travelers Visiting Overseas Destinations: 2009 Outbound. Available at: tinet.ita.doc.gov/outreachpages/download_data_table/2009_Outbound_Profile.pdf. Accessed March 18, 2011.
- Han P, Balaban V, Marano C. Travel characteristics and risk-taking attitudes in youths traveling to nonindustrialized countries. J Travel Med. 2010;17(5):316–321. doi:10.1111/j.1708-8305.2010.00444.x [CrossRef]
- Holecek DF, Warnell GR, Langone LA, et al. Characteristic, Scale and Economic Importance on Independent, Overnight Travel by 12 to 18 year olds in the United States. Survey Results for 2005. Report prepared for Student and Youth Travel Research Institute. Michigan State University. East Lansing, Michigan. Sept. 30, 2006. Available at: www.syta.org/downloads/MSUFinalReport.pdf. Accessed May 2, 2011.
- Smeaton GL, Josiam BM, Dietrich UC.College students’ binge drinking at a beach-front destination during spring break. J Am Coll Health. 1998;46(6):247–254. doi:10.1080/07448489809596000 [CrossRef]
- Hill DR. Health problems in a large cohort of Americans traveling to developing countries. J Travel Med. 2000;7(5):259–266. doi:10.2310/7060.2000.00075 [CrossRef]
- Sadnicka A, Walker R, Dallimore J. Morbidity and determinants of health on youth expeditions. Wilderness Environ Med. 2004;15(3):181–187. doi:10.1580/1080-6032(2004)15[181:MADOHO]2.0.CO;2 [CrossRef]
- Gautret P, Schwartz E, Shaw M, Soula G, Gazin P, Delmont J, Parola P, Soavi MJ, Matchett E, Brown G, Torresi JGeoSentinel Surveillance Network. Animal-associated injuries and related diseases among returned travellers: a review of the GeoSentinel Surveillance Network. Vaccine. 2007;25(14):2656–2663. doi:10.1016/j.vaccine.2006.12.034 [CrossRef]
- Lee CM, Maggs JL, Rankin LA. Spring break trips as a risk factor for heavy alcohol use among first-year college students. J Stud Alcohol. 2006;67(6):911–916.
- Grekin ER, Sher KJ, Krull JL. College spring break and alcohol use: effects of spring break activity. J Stud Alcohol Drugs. 2007;68(5):681–688.
- Shah AP, Smolensky MH, Burau KD, Cech IM, Lai D. Recent change in the annual pattern of sexually transmitted diseases in the United States. Chronobiol Int. 2007;24(5):947–960. doi:10.1080/07420520701648325 [CrossRef]
- Nield LS. Advising the adolescent traveler. Clinics in Family Practice. 2005;7(4):761–772.
- Schwartz RH, Milteer R, Sheridan MJ, Horner CP.Beach week: a high school graduation rite of passage for sun, sand, suds, and sex. Arch Pediatr Adolesc Med. 1999;153(2):180–183.
- Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travelers: an analysis of deaths related to international travel. Ann Emerg Med. 1991;20(6):622–626. doi:10.1016/S0196-0644(05)82379-0 [CrossRef]
- Nurthen NM, Jung P. Fatalities in the Peace Corps: a retrospective study, 1984 to 2003. J Travel Med. 2008;15(2):95–101. doi:10.1111/j.1708-8305.2008.00185.x [CrossRef]
- McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med. 2002;9(6):297–307. doi:10.2310/7060.2002.30168 [CrossRef]
- Riordan FA, Tarlow MJ. Imported infections in east Birmingham children. Postgrad Med J. 1998;74(867):36–37. doi:10.1136/pgmj.74.867.36 [CrossRef]
- Centers for Disease Control and Prevention. Travelers’ Health. Available at: www.cdc.gov/travel. Accessed April 18, 2011.
- American Academy of Pediatrics. Immunization in special clinical circumstances. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:104.
- Akers AY, Holland CL, Bost J. Interventions to improve parental communication about sex: a systematic review. Pediatrics. 2011;127(3):494–510. doi:10.1542/peds.2010-2194 [CrossRef]
- von Sadovszky V. Preventing women’s sexual risk behaviors during travel. J Obstet Gynecol Neonatal Nurs. 2008;37(5):516–524. doi:10.1111/j.1552-6909.2008.00274.x [CrossRef]
- Kodjo CM, Klein JD. Prevention and risk of adolescent substance abuse. The role of adolescents, families, and communities. Pediatr Clin North Am. 2002;49(2):257–268. doi:10.1016/S0031-3955(01)00003-7 [CrossRef]
- Alcohol PolicyMD.com. (AMOD). A Matter of Degree. The national effort to reduce high-risk drinking among college students. Available at: www.alcoholpolicymd.com/programs/amod.htm. Accessed April 18, 2011.
- Breuner CC. The adolescent traveler. Prim Care. 2002;29(4):983–1006.
- Centers for Disease Control and Prevention. Spring break health and safety tips. Available at: www.cdc.gov/family/springbreak. Accessed April 18, 2011.
- US Department of State. Students abroad. Available at: studentsabroad.state.gov. Accessed April 18, 2011.