Visiting Friends & Relatives: VFR Travel
CDC Yellow Book 2024Travel for Work & Other Reasons
In this book, a “visiting friends and relatives (VFR) traveler” is defined as a person who currently resides in a higher-income country who returns to their former home (in a lower-income country) for the purpose of visiting friends and/or relatives. More broadly, family members (e.g., children, partners) born in the VFR traveler’s higher-income country of residence are also included in this traveler category.
Migration patterns to the United States over the past 30 years have resulted in increasing numbers of immigrants arriving from Africa, Latin America, and Asia. Approximately 14% of US residents (≈45 million people) are foreign born, and ≈45% of all overseas international travelers coming from the United States list VFR as their reason for travel.
Disproportionate Infectious Disease Risks
Compared to other groups of international travelers, VFR travelers experience a greater incidence of travel-associated infectious diseases (e.g., hepatitis A, malaria, sexually transmitted infections, tuberculosis, typhoid fever). Several underlying reasons for this observation have been identified (see Box 9-07). VFR travelers are a heterogeneous and complex group, however, and assumptions based on population generalizations are not appropriate.
As with any other international traveler, conduct individualized counseling and recommendations after thoroughly discussing and evaluating the VFR traveler’s existing knowledge and beliefs about travel health, in combination with their specific travel characteristics and plans. Exploring the nuanced cultural considerations of the individual traveler is instrumental to providing more effective travel recommendations.
Box 9-07 Reported reasons travelers visiting friends and relatives (VFR) are at increased risk for travel-associated infections & diseases
CULTURAL & SOCIETAL BARRIERS
- Cultural and language discordance between local travel health care providers and members of the VFR community.
- Immigration status concerns among members of the VFR community.
- Lack of awareness of travel medicine among members of the VFR community.
- Mistrust of the local medical system among members of the VFR community.
HEALTH CARE PROVIDER–DEPENDENT BARRIERS
- Lack of knowledge of malaria prevention, identification, and treatment.
- Underlying unconscious bias and racism (negative social-political determinants of health).
- Financial barriers, including lack of insurance coverage.
- Lack of access (travel health clinics not located in areas where VFR travelers live; less marketing and outreach to VFR communities).
UNIQUE ELEMENTS OF VFR TRAVEL
- Duration: VFR travelers might stay at their destination longer than tourists or other travelers going to the same area.
- Infectious diseases: VFR travelers might travel more frequently to destinations with high disease endemicity and increased exposure risk.
- Last-minute and emergency travel: VFR travelers might need to make sudden travel plans to visit ill family members or attend funerals.
- Other features that place VFR travelers at increased risk for travel-associated illness:
- Less likely to use insect bite precautions (e.g., insect repellent, mosquito nets, protective clothing).
- More likely to stay in the community and at homes of friends and relatives.
- Participation in daily family and community activities (e.g., drinking tap or untreated water, sharing locally prepared foods).
As noted, several travel-associated infectious diseases occur at disproportionately high rates in VFR travelers. Box 9-07 highlights multiple reasons for this (e.g., barriers to receiving appropriate pretravel care, unique features of VFR travel), reasons that have been best studied for malaria. Although the global burden of malaria has been decreasing, malaria importation into the United States has been increasing in recent years; 2,161 confirmed imported cases were reported in 2017, the highest number in 45 years. Of these cases, 73% occurred among VFR travelers; 86% were imported from Africa, and 67% of African cases originated in West Africa. These figures are supported by data collected from the GeoSentinel global surveillance network clinics during 2003–2016, which showed that 53% of returned travelers diagnosed with malaria were VFR travelers, 83% of whom acquired their disease in sub-Saharan Africa.
Although VFR travelers who were born abroad experience a greater incidence of malaria infection than other international travelers, severe disease and death from malaria among this population has historically been lower than in tourists and business travelers, possibly because of preexisting immunity. VFR travelers are, however, still vulnerable to severe malaria; 55% of malaria hospitalizations in 2017 occurred in this population, and deaths also are reported. For instance, VFR travelers accounted for 5/5 reported malaria deaths in 2014 and 5/11 deaths in 2015.
Timely recognition and prompt delivery of appropriate treatment are critical to improving outcomes in malaria patients. Misdiagnoses by health care providers from nonendemic regions who lack familiarity with the disease have been reported, leading to delays in therapy. Potential misdiagnosis underscores the need for VFR travelers to carefully adhere to chemoprophylaxis and other malaria prevention strategies.
The same factors that lead to a greater incidence of travel-associated infectious diseases among VFR travelers generally, also contribute to an increased risk for malaria in VFR travelers going to Africa. Although VFR travelers’ knowledge, attitudes, and practices (KAPs) have been widely reported in the literature, little systematic or rigorous data are published that provide evidence that KAPs differ substantially between VFR and other traveler groups. More recent studies contradict the traditional narrative that VFR travelers are less concerned than other travelers about the possibility of malaria infection. In fact, VFR travelers have equal or more concern about malaria, but existing barriers mean they are less able to act on those concerns.
Other Infections & Conditions
During 2012–2016, about half of all typhoid and paratyphoid A cases in the United States occurred in VFR travelers, mostly those returning from southern Asia. Most isolates were resistant or showed decreased susceptibility to antimicrobial agents like fluoroquinolones.
VFR travelers aged <15 years are at greatest risk for hepatitis A; children and adolescents often have asymptomatic infections. A Canadian study found that 65% of hepatitis A cases occurred in VFR travelers aged <20 years; and in a Swedish study of 636 cases of imported infection, 52% were in VFR travelers, of whom 90% were <14 years old. Other travel-associated infections (e.g., hepatitis B, measles) also occur more commonly in young VFR travelers.
As a group, VFR travelers may be more likely than others to travel internationally while pregnant or at extremes of age, risk factors that can predispose to more severe outcomes from certain infections. For example, malaria during pregnancy is associated with higher morbidity and mortality, and exposure to Zika virus during pregnancy can result in serious fetal and infant complications. The very young and the elderly can have unusual clinical presentations of infections and worse outcomes. For instance, infants develop tuberculosis meningitis more commonly than people in other age groups, and older age is associated with more severe coronavirus disease 2019 (COVID-19) outcomes.
Pretravel Health Counseling
VFR travelers are more likely to seek travel health advice from a primary care clinic than from a travel medicine specialty clinic. Primary care clinics should ensure clinical staff are able to provide basic travel health information and services, and should create systems and working relationships with travel health experts for consultation and referral when appropriate. Primary care and travel clinics can employ various strategies to reach and better serve VFR populations (Box 9-08).
In addition, certain health risks and prevention recommendations might vary or deserve special attention for VFR travelers. Increase awareness among VFR travelers regarding their unique risks for travel-associated infections, and develop strategies to help overcome the barriers they face in accessing and acquiring travel health services. One possible approach is to provide VFR travelers with a comparison of the effect and cost of contracting certain diseases versus the cost of taking preventive measures.
Box 9-08 Improving outreach & service to VFR travelers: recommendations for clinics
PRIMARY CARE CLINICS
(VFR travelers disproportionately seek care at primary care clinics vs. travel medicine clinics)
Ensure clinicians receive continuing education in travel health and travel medicine.
Provide clinicians access to essential travel medicine information (e.g., CDC Yellow Book, Heading Home Healthy, UpToDate).1
Establish systems and relationships with travel medicine experts and infectious diseases specialists for consultation and referral.
TRAVEL MEDICINE SPECIALTY CLINICS
Conduct outreach to local communities:
- Give talks to community or faith groups on travel medicine with Q&A sessions.
- Meet with VFR community leaders.
- Use various forms of media for outreach (e.g., volunteer for community radio call-in programs to discuss travel health).
Consider adding evening and weekend appointments to the clinic schedule; reserve time slots for last-minute, emergency travel, and returned travelers who are ill.
Create a welcoming clinic environment:
- Decorate with artwork and provide reading materials from countries and cultures of the VFR communities being served.
- Provide an area for prayers.
- Provide language-accessible educational materials.
Encourage patients to “shop around” for the lowest price medications and to purchase in the United States before departing.
Encourage local pharmacies and health systems in areas with greater need to stock appropriate chemoprophylaxis agents.
Ensure VFR travelers have adequate supplies of travel medicines (e.g., malaria chemoprophylaxis):
- Direct pharmacists to call if the VFR traveler is not filling the entire prescription.
- Include travel duration on all travel medicine prescriptions.
- Provide cards to help patients advocate for themselves at pharmacies.2
BOTH PRIMARY CARE & TRAVEL MEDICINE CLINICS
Help patients navigate the healthcare system (e.g., assist in making appointments at appropriate clinics, help arrange transportation).
Increase access to professional medical interpreters; train staff how to use interpreters.
Provide culturally and linguistically appropriate educational materials in audio, video, and written formats.
Train clinical staff and health care providers about conscious and unconscious bias, health equity, and to practice cultural humility.
1Centers for Disease Control and Prevention Yellow Book; Heading Home Healthy; UpToDate.
2See the self-advocacy information card developed by the Minnesota Department of Health in collaboration with a West Africa Community Advisory Board to help VFR travelers obtain affordable antimalarial drugs. Available from: www.health.state.mn.us/diseases/travel/medcost.pdf [PDF].
Encourage VFR travelers going to malaria-endemic areas to take prophylactic medications, but also remind them of the benefits of barrier methods of prevention (e.g., insect repellents, mosquito nets, protective clothing), particularly for children (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods). Social pressures from host families can dissuade VFR travelers from implementing effective prevention techniques (e.g., using insect repellents and mosquito nets, staying indoors during periods of peak mosquito feeding). Discuss any potential concerns, and provide viable alternative options (e.g., clothing pre-treated with insect repellents, odorless repellents, free-standing mosquito nets).
Due to cost and other disincentives to purchasing malaria chemoprophylaxis in the United States, VFR travelers frequently report they plan to buy these drugs overseas. Substandard malaria chemoprophylaxis drugs are common, however, in certain low- and middle-income countries; in addition, these drugs are a frequent target for drug counterfeiting (see Sec. 6, Ch. 3, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel). Moreover, because of greater familiarity with products available for purchase at their destination, VFR travelers might favor or endorse a drug that is either inappropriate or contraindicated for use. Counsel against using drugs for which there is documented resistance (e.g., chloroquine, proguanil monotherapy) or that are used for malaria treatment (e.g., artesunate, quinine-based drugs) and not prophylaxis.
For all the above reasons, educate travelers about the risks associated with taking medicines acquired abroad, and advise them to obtain their medications in the United States prior to travel. Recent research has shown the price for the exact same prescription of most common antimalarial drugs can vary greatly among different pharmacies in the same area. Encourage VFR travelers to comparison shop and assist them in finding the best drug price. The Minnesota Department of Health has developed a self-advocacy information card [PDF] with a West Africa Community Advisory Board to help VFR travelers obtain affordable antimalarial drugs.
Patients also can contact their health insurance provider to learn whether prescription coverage can be extended due to a longer trip. Clinicians can include a note to “notify the prescriber if entire prescription is not filled,” and assist the pharmacy and patient to resolve any issues.
Travel vaccine recommendations and requirements for VFR travelers are the same as those for other travelers. In addition, establish whether VFR travelers, particularly those born outside the United States, have had routine childhood immunizations (e.g., diphtheria-tetanus-pertussis; measles-mumps-rubella) or a clinical history of vaccine-preventable diseases (e.g., varicella).
In the absence of documentation of immunizations, consider adult travelers susceptible and offer age-appropriate vaccinations. Alternatively, perform serologic studies to demonstrate proof of immunity when documentation is lacking (but suspicion of a completed vaccination series is high), or when clinical or epidemiological evidence to suspect prior infection is present.
Although vaccine recommendations for VFR travelers do not differ substantially from those of other travelers, important specific caveats are listed in Box 9-09.
Box 9-09 Vaccinating VFR travelers: caveats & recommendations
Hepatitis A infection is common in childhood in low- and middle-income countries (see Sec. 5, Part 2, Ch. 7, Hepatitis A). After infection, natural immunity is life-long. Due to changing epidemiology, however, do not assume immunity to hepatitis A; many young adults and adolescents from low- and middle-income countries are susceptible and should be vaccinated.
Hepatitis B infection is common in most immigrant groups. Because of routine immunization recommendations in the United States, at-risk immigrants might have a record of receiving hepatitis B vaccination but might not have been screened for chronic infection prior to vaccination. If a patient is at risk for hepatitis B (born or resided in a country with ≥2% prevalence), and no record of a negative test for hepatitis B chronic infection is available, screen for chronic infection (hepatitis B antigen testing) regardless of vaccine status (see Sec. 5, Part 2, Ch. 8, Hepatitis B).
Varicella infection occurs later in life in the tropics, and rates of death and complications from varicella disease are higher in adults than in children. Do not assume immunity; perform immunization or antibody testing if no clear clinical history of infection is apparent.
OFF-LABEL VACCINE USE
Experienced providers familiar with the literature may consider off-label use of vaccines for high-risk pediatric VFR travelers when the benefit is felt to outweigh the risk (e.g., measles-mumps-rubella in children <12 months old, typhoid in children <2 years old). See Sec. 7, Ch. 3, Traveling Safely with Infants & Children, and Sec. 7, Ch. 4, Vaccine Recommendations for Infants & Children.
PRETRAVEL SCREENING FOR CHRONIC INFECTIONS
Use pretravel VFR consultations as an opportunity to screen for common chronic infections (e.g., hepatitis B, hepatitis C, HIV, schistosomiasis, strongyloidiasis, latent tuberculosis). For more information, see Guidance for the US Domestic Medical Examination for Newly Arriving Refugees and Sec. 11, Ch. 11, Newly Arrived Immigrants, Refugees & Other Migrants.
ROUTINE HEALTH CARE VISITS: PLANNING AHEAD
Use routine health care visits for children and adults as an opportunity to ask about future travel plans. Offer travel vaccines, advice, and recommendations.
Resources for Health Care Providers
Heading Home Healthy
The Heading Home Healthy program, supported by the Centers for Disease Control and Prevention, focuses on reducing travel-related illnesses in VFR travelers. The program was developed to provide VFR travelers with resources for safe travel and includes videos, informational resources, and health tools in multiple languages. Heading Home Healthy also offers a clinical support tool for primary care health providers who are preparing their patients to travel home safely.
The following authors contributed to the previous version of this chapter: Jay S. Keystone
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