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Chapter 8 Advising Travelers with Specific Needs

Immigrants Returning Home to Visit Friends & Relatives (VFRs)

Jay S. Keystone


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 recommended that the term VFR refer to all those visiting friends and relatives regardless of the traveler’s country of origin; however, this proposed definition may be too broad and not take into consideration cultural, economic, and attitudinal issues. Therefore, this review uses the more classic definition.


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 13% of the US population is foreign born, in 2014, 37% of overseas international travelers from the United States 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 pretravel health care encounter
  • Financial barriers to pretravel health care
  • Lack of access to clinics
  • 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
  • High-risk trip characteristics, such as staying in homes and living the local lifestyle, which often includes lack of safe food and water and not using bed nets


In 2012, 54% of imported malaria cases in US civilians occurred among VFRs. Data from the 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 the United States in 2012, 55% of those with severe malaria for whom the purpose of travel was known were VFRs, mostly returned from West Africa.

Other Infections

From 2008 through 2012 in the United States, 85% of typhoid and 88% of paratyphoid A cases occurred in VFRs, mostly from southern Asia. Most isolates were resistant or showed decreased susceptibility to fluoroquinolone antibiotics. Similar rates of resistant infections were noted in imported cases in Switzerland from the Indian subcontinent.

VFR children aged <15 years are at highest risk for hepatitis A, and many are asymptomatic. A Canadian study found that 65% of hepatitis A cases were in VFRs aged <20 years, and in a Swedish study of 636 cases of imported infection, 52% were in VFRs, of whom 90% were <14 years old. Other diseases, such as tuberculosis, hepatitis B, cholera, and measles, occur more commonly in VFRs after travel.


Table 8-04 summarizes VFR health risks and prevention recommendations. It is important to increase awareness among VFR 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. However, studies in the United Kingdom aimed at preventing malaria among VFRs showed that increased awareness and availability of medications do not necessarily increase use of malaria chemoprophylaxis, highlighting the complex socioecological context in which VFRs make travel health decisions.


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 specific diseases. Adult travelers, in the absence of documentation of immunizations, may be considered to be susceptible. 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.
  • Consider varicella immunization for people born outside the United States. Such 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 should 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 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 are counterfeit or substandard.

Table 8-04. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and recommendations to reduce risks1

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 pretravel advice

Avoidance counseling about specific foods (such as raw freshwater fish)

Longer stays

Higher-risk destinations

Less pretravel advice leading to less use of prophylaxis and fewer personal protection measures

Belief that one is already immune

Education on malaria, mosquito avoidance, and the need for prophylaxis

Consider cost of prophylaxis

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, body modification practices)

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 soil-transmitted helminths 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, Chagas disease)

Rural destinations

Staying with family where animals are kept

Increased exposure to insects

Increased exposure to mice and rats

Sleeping on floors

Avoid animal contact

Wash hands

Wear protective clothing and use insect repellent

Check for ticks daily

Avoid thatched roofs and mud walled accommodation and fresh sugar cane juice 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 (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.



The CDC-supported Heading Home Healthy program ( is focused on reducing travel-related illnesses in VFR travelers. The program contains videos, informational resources, and health tools in multiple languages and was developed to assist not only VFR travelers but also their primary care health providers.


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