Chapter 8 Advising Travelers With Specific Needs
Immigrants Returning Home to Visit Friends & Relatives (VFRs)
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. Thus in this review, the more classic definition is used.
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 2010 a total of 35% 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 safe food and water and bed net use
- 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.)
In 2010, 54% of imported malaria cases in US civilians occurred among VFRs. Data from GeoSentinel Surveillance Network show that among ill travelers who present for medical care, VFRs are 8 times more likely to be diagnosed with malaria than are tourist travelers. Reports from the United Kingdom show similar results for VFR versus tourist travelers to West Africa. 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; in 2010, 53% of those with severe malaria for whom the purpose of travel was known were VFRs, mostly returned from West Africa.
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. A recent Canadian study showed that 94% of typhoid cases in Quebec were in VFRs, mostly from the Indian subcontinent.
VFR children aged <15 years are at highest risk for hepatitis A, and many are asymptomatic. The Quebec study cited above showed that 65% of hepatitis A cases were in VFRs aged <20 years. 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 8-06 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).
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 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.
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, & Other Insects & 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 8-06. 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)||
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)|
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 tuberculin skin test 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 infections, leptopirosis, viral fevers, leishmaniasis, anthrax)||
Stays with family where animals are kept
Increased exposure to insects
Increased exposure to mice and rats
Sleeping on floors
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
Wear shoes outdoors 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 need 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 severe dengue)||Severe dengue occurs on repeat exposure to a different serotype of dengue; VFRs more likely to have had previous exposure||Avoid mosquitoes by taking protective measures|
Abbreviations: VFR, visiting friends and relatives; PPD, tuberculin purified protein derivative; DEET, N,N-diethyl-m-toluamide.
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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