Chapter 8Advising Travelers with Specific Needs

Immigrants Returning Home to Visit Friends & Relatives (VFRs)

Jay S. Keystone

DEFINITION OF VFR

A traveler categorized as a VFR is an immigrant, ethnically and racially distinct from the majority population of the country of residence (a higher-income country), who returns to his or her home country (lower-income country) to visit friends or relatives. Included in the VFR category are family members, such as the spouse or children, who were born in the country of residence. Some experts have recently recommended that the term VFR refer to all those visiting friends and relatives regardless of the traveler’s country of origin; however, this more recently proposed definition may be too broad and not take into consideration cultural, economic, and attitudinal issues, and thus we use the more classic definition.

DISPROPORTIONATE INFECTIOUS DISEASE RISKS IN VFRS

Altered migration patterns to North America in the past 30 years have resulted in many immigrants originating from Asia, Southeast Asia, and Latin America instead of Europe. Although 12% of the US population is foreign born, in 2008, 34% of those from the United States traveling overseas listed VFR as a reason for travel. VFRs experience a higher incidence of travel-related infectious diseases, such as malaria, typhoid fever, tuberculosis, hepatitis A, and sexually transmitted diseases, than do other groups of international travelers, for a number of reasons:

Lack of awareness of risk
≤30% have a pre-travel health care encounter
Financial barriers to pre-travel health care
Clinics are not geographically convenient
Cultural and language barriers with health care providers
Lack of trust in the medical system
Last-minute travel plans and longer trips
Travel to higher-risk destinations, such as staying in homes and living the local lifestyle that often includes lack of food and water precautions and use of bed nets
Belief that they are immune (VFR health beliefs likely contribute to lower rates of vaccination against hepatitis A and typhoid and infrequent use of malaria chemoprophylaxis, compared with other international travelers.)

Malaria

In 2008, 65% of imported malaria cases in US civilians occurred among VFRs. Data from GeoSentinel show VFRs are 8 times more likely to acquire malaria than are tourist travelers. Reports from the United Kingdom have shown that VFR travelers to West Africa were 10 times more likely to develop malaria than were tourists. Many VFRs assume they are immune; however, in most VFRs, especially those who left their countries of origin years previously, immunity has waned and is no longer protective. In recent years, a number of VFRs have died of malaria on their return to North America.

Other Infections

In the United States, 66% of typhoid cases occur in VFRs, mostly from South Asia and Latin America; 90% of paratyphoid A cases are imported from South Asia as well. Most typhoid isolates showed lower sensitivity to fluoroquinolones.

VFR children aged <15 years are at highest risk for hepatitis A, and many are symptomatic. In a British study, most cases were acquired in south Asia. Other diseases, such as tuberculosis, hepatitis A and B, cholera, and measles occur more commonly in VFRs after travel.

PRE-TRAVEL HEALTH COUNSELING FOR VFRS

Table 8-09 summarizes VFR health risks and prevention recommendations. It is important to increase awareness among travelers regarding their unique risks for travel-related infections and the barriers to travel health services. If possible, clinics should incorporate culturally sensitive educational materials, provide language translators, and provide handouts in multiple languages (see www.tropical.umn.edu/TTM/VFR/index.htm).

Vaccinations

Travel immunization recommendations and requirements for VFRs are the same as those for US-born travelers. It is crucial, however, to first try to establish whether the immigrant traveler has had routine immunizations (such as measles and tetanus) or has a history of the diseases. Adult travelers, in the absence of documentation of immunizations, may be considered to be nonimmune, and age-appropriate vaccinations (or serologic studies to check for antibody status) should be provided, with 2 important caveats:

Immunity to hepatitis A should not be assumed; many young adults and adolescents from developing countries are still susceptible. Pre-travel serologic testing for both hepatitis A and B may be worthwhile.
Consider varicella immunization for immigrants from South and Southeast Asia and Latin America. These travelers may be more susceptible, because infection occurs at an older age in tropical than in temperate regions. Also, rates of death and complications from varicella disease are higher in adults than in children.

Malaria Prevention

VFR travelers to endemic areas should not only be encouraged to take prophylactic medications, but also be reminded of the benefits of barrier methods of prevention, such as bed nets and insect repellents, particularly for children (see Chapter 2, Protection against Mosquitoes, Ticks, and Other Insects and Arthropods). VFRs should be advised that drugs such as chloroquine and pyrimethamine, as well as proguanil monotherapy, are no longer effective in most areas, especially in sub-Saharan Africa. These medications are often readily available and inexpensive in their home countries but are not efficacious.

VFRs should also be encouraged to purchase their medications before traveling to ensure good drug quality. Studies in Africa and Southeast Asia show that one-third to half of antimalarial drugs purchased locally were counterfeit or substandard; a recently published study from Laos showed that 88% of oral artesunate sold in pharmacies was of poor quality.

Table 8-09. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and recommendations to reduce risks specific to travelers visiting friends and relatives¹

SPECIFIC DISEASES	REASON FOR RISK VARIANCE²	RECOMMENDATIONS TO STRESS WITH VFR TRAVELERS
Foodborne and waterborne illness	Social and cultural pressure (eat the meal served by hosts)	Frequent handwashing Avoid high-risk foods (dairy products, undercooked foods) Simplify treatment regimens (single dose, such as azithromycin, 1,000 mg, or ciprofloxacin, 500 mg) Discuss food preparation
Fish-related toxins and infections	Eating high-risk foods Less pre-travel advice	Avoidance counseling about specific foods (such as raw freshwater fish)
Malaria	Longer stays Higher-risk destinations Less pre-travel advice leading to less use of chemoprophlaxis and fewer personal protection measures Belief that already immune	Education on malaria, mosquito avoidance, and the need for chemoprophylaxis Consider cost in chemoprophylaxis Use of insecticide-treated bed nets
Tuberculosis (particularly multidrug-resistant)	Increased close contact with local population Increased contact with HIV-coinfected people	Check PPD 2–3 months after return if history of negative Mantoux text and long stay (>3 months) Educate about tuberculosis signs, symptoms, and avoidance
Bloodborne and sexually transmitted diseases	More likely to seek substandard, local care Cultural practices (tattoos, female genital mutilation) Longer stays and increased chance of blood transfusion Higher likelihood of sexual encounters with local population	Discuss high-risk behaviors, including tattoos, piercings, dental work, sexual encounters Encourage purchase of condoms before travel Consider providing syringes, needles, and intravenous catheters for long-term travel
Schistosomiasis and geohelminths	Limited access to piped-in water in rural areas for bathing and washing clothes	Avoid freshwater exposure Use liposomal DEET preparation with freshwater exposures³ Discourage children from playing in dirt Use ground cover Use protective footwear
Respiratory problems	Increased close exposure to fires, smoking, or pollution	Prepare for asthma exacerbations by considering stand-by bronchodilators and steroids
Zoonotic diseases (such as rickettsial, leptopirosis, viral fevers, leishmaniasis, anthrax)	Rural destinations Stays with family where animals are kept Increased exposure to insects Increased exposure to mice and rats Sleeping on floors	Avoid animals Wash hands Wear protective clothing Check for ticks daily Avoid thatched roofs and mud walls in Latin America Avoid sleeping at floor level
Envenomations (snakes, spiders, scorpions)	Sleeping on floors	Avoid sleeping at floor level Use footwear out-of-doors at night
Toxin ingestion (medication adverse events, heavy metal ingestion)	Purchase of local medications Use of traditional therapies Use of contaminated products (such as pottery with lead glaze) Eating contaminated freshwater fish	Anticipate and purchase medications before travel Counsel avoidance of known traditional medications (such as Hmong bark tea with aspirin) and high-risk items (such as large reef fish)
Yellow fever and Japanese encephalitis (risk is decreased in adults)	Unclear, partial immunity due to previous exposure or vaccination	Avoid mosquitoes by taking protective measures and receiving vaccination when appropriate
Dengue fever (especially risk of DHF and DSS)	DHF and DSS occur on repeat exposure to a different serotype of dengue; VFRs more likely to have had previous exposure	Avoid mosquitoes by taking protective measures

Abbreviations: DEET, N,N-diethyl-m-toluamide; DHF, dengue hemorrhagic fever; DSS, dengue shock syndrome; VFR, visiting friends and relatives.
¹Adapted from: Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA. 2004;291(23):2856–64.
²Hypothesis unless referenced to support assertions.
³In animal models, DEET (liposomal preparations) prevents Schistosoma cercariae from penetrating the skin.

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