Visiting Friends and Relatives

CHAPTER 58 Visiting Friends and Relatives


Patterns of migration to developed countries have shifted dramatically over the past half century. Since 1980, the number of international migrants more than doubled, mostly from developing to developed countries, rising from 100 million in 1980, just 25 years ago, to 200 million in 2005.1

Migration patterns to the US have reflected the changes in global migration patterns. In 1960, 4.5% of the US population was foreign-born (9.7 million) of whom 9.3% came from Latin America, 5% from Southeast Asia, 9.8% from Canada, and the vast majority, 74.5%, from Europe. By 2004, the US foreign-born population numbered 34.2 million, accounting for 12% of the total US population.2 Currently, in the United States, 20% of the population are either foreign-born, or the children of the foreign-born.3 Within the foreign-born population, 53% were born in Latin America, 25% in Asia, 14% in Europe, and the remaining 8% in other regions of the world, such as Africa and Oceania (Australia, New Zealand, and the island nations in the Pacific). In addition, second-generation Americans, natives with one or both parents born in a foreign country, numbered 30.4 million, or 11% of the total US population.

In this chapter we will define and describe the characteristics of those visiting friends and relatives (VFRs) in their countries of origin, outline the reasons why they are at greater risk for infection than other travelers, describe the barriers that keep them from obtaining pre-travel advice, identify ways in which health advice might be provided in a more effective way, and provide specific pre-travel health recommendations tailored to this important category of travelers.

Many immigrants will at some point return to their country of birth to visit family and friends. This population of international travelers returning to their country of origin has been given a specific designation as VFRs (visiting friends and relatives). By definition, a VFR is an immigrant, ethnically and racially distinct from those in the country of residence, who returns to his/her homeland to visit friends and/or relatives. This definition excludes immigrants returning to their homeland purely for the purpose of tourism, conducting business, as well as for educational or missionary work. Although strictly speaking, European immigrants might be considered VFRs, for the purpose of discussion in this chapter, VFRs are those who have immigrated to a developed country from a developing country. In spite of making up approximately 10% of the US population, in 2002 VFRs made up 44% of all US international air travelers.4 Similarly, in the United Kingdom, VFRs made 13% of 59 million visits for the same purpose, reflecting an annual growth rate of 4.3% annually from 1998 to 2002.5

VFR populations will vary according to immigration patterns. For example, in the United States, more than half of foreign-born residents are from Latin America and one-quarter are from Asia.6 In 2002, the top five sources of documented immigrants were Mexico, India, China, the Philippines, and Vietnam.7 In the UK, in 2003 30% of the immigrants were from Africa, and 24% from the Indian subcontinent.8

It is somewhat controversial as to whether first- or second-generation members of an immigrant family born in the receiving country are considered to be VFRs. Although VFRs are often immune or partially immune to infections in their country of birth, they also have greater health risks because they usually travel to remote areas of the developing world and live in conditions that put them at risk of local infections. On the other hand, children of VFRs born in a developed country are like the native-born population because they are not immune to most overseas infections. However, they are also similar to the immigrant population because their living conditions overseas will often approximate those of nationals in the developing world.

Barriers to Pre-Travel Healthcare

What makes VFR travelers so different from other travelers that they have their own unique category? VFRs are often at greater risk than native-born travelers partly because of their perceptions of risk, health beliefs, and socioeconomic status (the traveler) and partly because of their specific destination risks (the travel). VFR travelers may mistakenly believe that they are immune to many of the infectious diseases endemic to their country of origin, and may be unaware of the true health risks when they return to their homeland. A large Canadian travel survey found that VFRs estimated their risk to be the same as that for intermediate and low-risk travelers.9 These are two of the major reasons why they will not seek pre-travel health advice or adhere to recommendations made by healthcare providers, especially if those practitioners have little or no knowledge of the conditions in their homeland.

For example, multiple past malaria infections (‘like flu to an African’) may deter VFRs from seeking pre-travel health advice and taking malaria prophylaxis; however, they often bring their children, but not themselves, for pre-travel health advice.1012

Surprisingly, even when VFRs visit healthcare providers from their birthplace they may receive incorrect advice since the healthcare provider also may have the same mistaken beliefs as the patient.13 A survey of 2000 travelers in Amsterdam found that almost one-third were VFRs traveling back to their country of origin, particularly Morocco and Turkey, and that 70% had not sought pre-travel advice.14 Even when pre-travel advice is sought, adherence to travel recommendations, suboptimal in many travelers,1517 may be worse in VFRs.14,15 A study of 307 Canadians of Asian origin traveling to India showed that only 31% intended to use malaria chemoprophylaxis and fewer than 10% mosquito bite prevention. For those who did seek pre-travel advice, the majority sought this advice from family practitioners rather than from travel medicine providers; this might explain why 76% of the time the malaria chemoprophylaxis prescribed was inappropriate.9

Financial considerations are one of the most important factors in limiting the use of pre-travel health services among VFRs, particularly when they travel with family members and the cumulative cost of immunizations and antimalarials is considerable.18,19 Language barriers, lack of knowledge or access to healthcare, health beliefs, and fear of immigration authorities may influence pre-travel health-seeking behavior as well.

Healthcare systems and providers may also be responsible for barriers to care. Many immigrants have not received an adequate health screening upon arrival in an industrialized country, have not completed primary vaccinations series, or lack immunization records.19,20 Inadequate use of medically trained interpreters limits a healthcare provider’s ability to impart information, and patients may be illiterate even in their own language. Primary healthcare providers are often not knowledgeable about travel medicine, or the geography and disease epidemiology of the destination country.21 Although many clinicians have access to the CDC or other websites that provide broad country-based disease prevention recommendations, they may not have the expertise to interpret this information in the context of type of travel, local itinerary, living conditions, and other factors.22 Most do not have access to regularly updated pre-travel health databases that give detailed information on regional disease distribution, seasonal factors, and epidemics within a country (Table 58.1). However, in spite of these barriers to adequate pre-travel health advice, there are a number of practical approaches that may be utilized by primary care and public health practitioners that will enable the VFR to obtain and adhere to pre-travel health advice (Table 58.2).23

Table 58.1 Pre-travel health advice resources for healthcare providers

Interactive web-based
CDC travel Info
WHO international travel
Health Canada Travel
National Travel Health (UK)
Malaria maps
Travax UK (fee)
SOS Travelcare (fee)
Travax US (fee)
GIDEON (fee)
EXODUS (fee)
Surveillance/outbreak information
Weekly Epidemiological Review
EuroSurveillance Weekly
Canada CDR
Listserv discussion groups for travel med
TravelMed (ISTM) listserv/
TropMed (ASTMH) listserv/
Medical assistance/physicians for travellers
International Soc Travel Med (ISTMH)
Am Society of Tropical Medicine and Hygiene (ASTMH)
SOS Travel Care (fee)
IAMAT (donation requested)
State Department (Washington, DC)
Book references
CDC Health Information for International Travelers
Travel & Routine Immunizations Thompson R. Milwaukee, WI: Shorland; 2002
Red Book (Am Acad of Pediatrics) Pickering L, ed. 27th edn. Grove Village, IL: AAP; 2006
Travel Medicine Keystone JS, et al. Philadelphia: Mosby; 2004
A World Guide to Infections Wilson M. New York: Oxford University Press; 1991
Travel Medicine Health DuPont HL, Steffen R. 2nd edn. London: Decker; 2001
Tropical Infectious Diseases Guerrant RL, et al. Philadelphia: Churchill Livingstone;1999
Manson’s Tropical Diseases Cook GC, et al. Edinburgh: Elsevier Science Ltd; 2003
Hunters’ Tropical Medicine Strickland TG, et al. Philadelphia: Saunders; 2000

Table 58.2 Decreasing barriers to pre-travel advice and care

Health Risks for Those Visiting Family and Relatives

Those visiting family and relatives may assume more risk than traditional travelers, and have higher levels of morbidity and mortality related to travel. They often choose to travel despite multiple medical problems, during pregnancy, and with small infants and children. VFRs frequently return to visit spouses, parents or children left behind, to introduce ‘new additions’ to their family or to attend weddings and other life cycle events. Last minute travel to visit a sick relative or to attend a funeral is common, allowing little time for pre-travel health advice. Furthermore, many VFRs stay with family members in rural or remote settings where they frequently encounter suboptimal sanitary conditions and are at increased risk of malaria and other infections. Windows may not be screened and bed nets may be in disrepair. Food may be prepared by persons with poor personal hygiene or who are carriers of hepatitis A or other infections, and travelers may be reluctant to eat differently from their hosts. Close contact with the local population puts VFRs at higher risk for respiratory infections such as tuberculosis and meningococcal meningitis.24,25 Also, VFRs tend to have prolonged stays, thereby increasing the risk for morbidity and mortality.26,27

In addition to the greater risk of infectious diseases, injuries among VFRs may also be a problem. Motor vehicle accidents are a frequent cause of injury among travelers and are the single most important cause of death of travelers in developing coun-tries.2831 The risk of injury may be higher for VFRs because they often utilize high-risk, public transportation and travel in rural areas on poor roads without proper lighting. Also, there is an additional risk due to lack of safety devices within motor vehicles that all too often are poorly maintained.32 Furthermore, medical care following an injury or severe illness, especially in remote areas, is frequently inadequate.3335

Many refugees who become VFRs have experienced upheaval, armed conflict, and torture prior to emigration, and may have residual post-traumatic stress disorder (PTSD).36,37 Stress-related health problems may be exacerbated by travel, or by seeing impoverished family members; as a result, some may experience recurrence of pre-existing psychiatric symptoms.

Health Issues and Recommendations for Those Visiting Family and Relatives

The major challenge is convincing VFR travelers that they would benefit from pre-travel counseling. This is difficult especially if there is a cost involved. Information about the benefits of travel medicine services might be disseminated in appropriate languages through leaflets, posters in places of worship or stores selling ethnic foods, and popular ethnic radio programs or newspapers. The paradigm of separating travel advice as a ‘specialty service’ from primary care practice is likely to be least effective for VFRs. Ideally, travel medical services should be offered in primary care clinics frequented by immigrants, preferably by physicians caring for those individuals on a regular basis.38 Familiarity, ease of access, and an established doctor–patient relationship are most likely to encourage use. Essentially, an immigrant should be viewed as a future traveler. Since the majority of VFRs return to their country of birth on one or more occasions, the primary care provider is in the ideal position to screen for their immunization needs well before travel abroad, making travel vaccines an integral part of routine childhood and adult immunization programs. In some primary care clinics, particularly those associated with public health departments, the cost of the travel clinic consultation (coded as health counseling) and many of the vaccines may be covered as part of the clinic service. Finally, since VFRs often seek pre-departure advice for their children and not for themselves, child counseling provides an excellent opportunity to encourage risk management strategies for the parents as well as their children.

When available, it is best to use medically trained, cross-cultural interpreters or multilingual healthcare providers. Family members should be used to translate only when absolutely necessary. Pre-travel advice, medication instructions, prescription bottles, as well as health information about the destination abroad should be written in appropriate languages.39 For VFRs on limited budgets, providers may help prioritize which vaccines they should receive, choose affordable malaria prophylaxis, or refer them to public health clinics where available.

Although the risk assessment of a VFR is similar to that of a national, there are some minor differences. Additional reasons for travel should be explored. For example, is the traveler planning to undergo medical procedures that are costly in their country of residence, such as dental work, elective surgery, or therapeutic interventions (e.g. angioplasty or tattooing of eyebrows)? Also, it is important to determine whether the VFR is staying in a local home or an upscale hotel, since the risk factors for infection vary considerably.

The following abbreviated discussion of travel health risks is focused on issues that are particularly relevant to the VFR traveler. For more comprehensive and general travel health information, the enthusiastic reader is encouraged to consult official government travel medicine web sites such as those of the US Centers for Disease Control and Prevention (CDC) (, the Public Health Agency of Canada (, or the UK National Travel Health Network and Centre (NaTHNaC) (

Food and water-borne illnesses

Travelers’ diarrhea (TD) is the most frequent illness among travelers to the developing world, affecting 30–60% of all travelers.40,41 Although the problem may be less of an issue to recent immigrants because of their acquired immunity, it has been shown that when repeated exposure to enteric pathogens ceases, the risk of TD increases.42 Travelers’ diarrhea is a much greater risk for nonimmune children born in a developed country. The greatest risk for VFR travelers is likely to occur when they eat in local homes where the hygiene practices or the health status of the ‘cook,’ often a poor relative or housekeeper, may be substandard. The typical advice often quoted by healthcare providers, ‘boil it, cook it, peel it, or forget it,’ is often impractical in a household setting, especially when one is a guest. It is interesting to note that a critical review of the literature on TD prevention concluded that there are few or no data to show that increased food precautions and fewer mistakes actually decrease the frequency of TD.43 A recent study of long-stay travelers to India supported this concept that TD was not correlated with the degree of attention to food precautions.44 However, it would be sensible for VFR travelers to try to ensure that food is served hot and that water for home use has been boiled and filtered in their place of residence abroad. It may be more practical to stress the effectiveness of frequent hand washing. or the use of alcohol and nonalcohol-based handsanitizing solutions.45,46 Avoiding food sold by street vendors would certainly be prudent.47 Equally important as prevention would be information about management of diarrhea, especially for young children.

Given the paucity of data showing that travelers’ diarrhea can be prevented by food and water precautions, it is even more important to ensure that VFR travelers are provided with information on the management of illness during travel, particularly concerning their children. For cost-containment purposes, it is advisable to recommend to adults the use of loperamide and a single dose of levofloxacin 500 mg or another fluoroquinolone for self-treatment of TD. Several studies have shown that a single dose of antibiotic with loperamide is as effective as a standard 3-day course of therapy. Azithromycin 1000 mg in one dose or 500 mg daily for 3 days is recommended for Thailand4850 where more than 80% of Campylobacter species are now resistant to quinolones.51,52

Until recently, fluoroquinolone antibiotics were considered to be contraindicated in children. However, recent reviews suggest that these drugs are safe even with long-term use in children.53,54 For this reason, many travel medicine practitioners and pediatric infectious disease consultants increasingly are comfortable recommending off label, 1–3-day quinolone regimens in appropriate doses for children. For children who require a liquid preparation, azithromycin (one daily dose of 10 mg/kg per day) is recommended. By using single dose therapy, VFR travelers with limited communication skills are more likely to utilize treatment regimens correctly. For VFRs with small children, it is important to stress the importance of oral rehydration solutions (ORSs). Many VFR parents may be much more familiar with ORS than are their counterparts born in developed countries.

Specific cultural food practices may put the traveler at risk of specific infectious diseases. For example, one might advise Latin Americans to avoid white cheese (queso fresca) to prevent brucellosis and listeriosis,55,56 and uncooked pork to prevent cysticercosis. Cerviche and other preparations of raw, freshwater fish (sushi, koi pla), common cultural delicacies in many parts of the world, can transmit vibriosis, gnathostomiasis, liver flukes, and other organisms.57,58 Raw or poorly cooked shellfish may contain hepatitis A or Salmonella typhi, posing additional risks for VFRs.59,60 Although ciguatera poisoning is a common problem among those who eat large, carnivorous reef fish found in subtropical and tropical waters,61,62 it is rarely seen in VFRs and is more likely to affect tourists.

Insect-borne diseases


Returned VFR travelers now make up the largest proportion of malaria cases reported in developed countries. In 2003, they accounted for 53.9% of civilian cases in the United States and 35% of 1140 travelers reported to the Geosentinel Surveillance Network of the International Society of Travel Medicine.63,64 VFR travelers from the UK visiting West Africa had a tenfold greater attack rate than tourists65 and made up 82% of cases in children.66 In a review of malaria cases imported into Brescia, Italy, between 1990 and 1998, 71% were in migrants compared to 12% among nonimmune Italians.67 Pooling of malaria cases in European centers found that 43% occurred in non-nationals, frequently immigrant VFRs.68 The Geosentinel Surveillance Network showed an eightfold relative risk of acquiring malaria in VFRs compared to tourists.69

Although the high proportion of malaria cases among VFR travelers can be partly explained by their travel patterns to endemic areas, their rates of prophylaxis use are lower than nonimmunes from developed countries. Low rates of chemoprophylaxis use among VFRs have been the consistent in several studies, i.e. Canada (31%), Italy (8%), and the UK (46–48%).17,64,69

The reasons for inadequate use of chemoprophylaxis are multifactorial: cost,10,18 lower perception of risk by the traveler9 and the healthcare provider,13 and inappropriate medication.9,12

Studies show that severe and fatal malaria is uncommon in VFR travelers, who frequently possess partial immunity to malaria prior to emigration. Although this immunity may be maintained for many years, even in the absence of re-infection, protection is clearly incomplete as evidenced by the high rates of clinical malaria in this group. Due to immunological priming, VFRs appear to have far lower mortality rates from malaria than do nonimmune nationals from developed countries.68,70

However, increasingly, severe malaria and deaths are being reported among VFRs who have either lost their immunity or have been inoculated with a high load of parasites, or both. The Canadian Malaria Network reported that between 2001 and 2005, 49.2% of 31 severe malaria cases occurred in foreign-born individuals from malarious areas (Anne McCarthy, personal communication, 2005). Of the 185 deaths from malaria reported in the US from 1963 to 2001, only 13.8% were VFRs However, between 1989 and 2001, 21.3% of fatal cases were VFRs who made up the largest group of travelers to die from malaria.71 It is important to understand that in few areas of the world is malaria hyperendemic to the point that locals acquire a clinically significant degree of immunity to the infection. The most important of these areas is sub-Saharan Africa and parts of Oceania (e.g. Papua New Guinea and Irian Jaya). Those living in malarious areas in the rest of the world are for the most part nonimmune with respect to malaria and are as likely to die from Plasmodium falciparum malaria as are those born in nonendemic areas. Since, as noted above, malaria immunity wanes in the absence of re-infection, even those VFRs returning to sub-Saharan Africa require chemoprophylaxis. The question that has yet to be answered is how long does it take to completely lose one’s immunity to malaria. From a clinical perspective, the question has little relevance, since exposure to a heavily infected mosquito is likely to lead to clinical disease, an outcome that is preventable with appropriate medication.

As a way of encouraging VFRs to use prophylaxis, perceptions of immunity should be explored as well as the changing patterns of drug resistance and malaria species. For example, VFRs returning to India need to know that over the past decade the life-threatening form of malaria, P. falciparum, has replaced P. vivax as the predominant species.72 As far as VFRs are concerned, the risks and benefits of antimalarials appear to be similar for those born in developed countries. Mefloquine is relatively inexpensive and convenient, but due to neuropsychiatric side effects cannot be used in individuals with depression, anxiety, and PTSD, which are common in VFRs.7375 An effective strategy, if time permits, is to start prophylaxis with mefloquine 3–4 weeks prior to departure to allow time to switch to another drug if side effects develop. However, one interesting anecdotal observation among travel medicine practitioners is that neuropsychiatric adverse events from mefloquine appear to be distinctly uncommon in those of African descent.

Doxycycline is generally well tolerated, and is the least expensive of the antimalarials, but has the disadvantage of daily dosing, GI upset, and vaginal candidiasis in women. Atovaquone/proguanil (Malarone®) is prohibitively expensive for most VFRs, especially with prolonged stays, and is not covered on many formularies. Chloroquine remains an affordable choice for travel but is effective in only a few areas of the world. The use of primaquine, 30 mg/day, for malaria prophylaxis in adults is a welcome new option, especially in VFRs who are unable to afford atovaquone-proguanil or tolerate mefloquine.76 A glucose-6-phosphate dehydrogenase (G6PD) level must be determined prior to use of primaquine. It is a second-line agent due to concerns about toxicity in G6PD deficient patients and the fact that it is about 5–10% less effective than other agents. For some long-term visitors, stand-by, self-administered malaria treatment will be the only affordable option, although several studies have shown it is often used incorrectly.7779

It is important to advise VFRs to continue malaria prophylaxis even if diagnosed with malaria while abroad because of the likelihood of an incorrect diagnosis due to a false-positive smear. Several recent studies have shown that the false-positive rate of blood films done by local laboratories in developing countries may be as high as 75%.80,81 This is a particular problem for those traveling to sub-Saharan Africa.82 The most important practical advice that one can give VFR travelers concerning this situation is to advise them that even if they were to be diagnosed with malaria during travel, they should continue their antimalarial drug as directed and not assume that it had failed to protect them. Finally, VFRs should be advised to avoid buying their antimalarials overseas, even though they might be cheaper, because of the high risk of obtaining counterfeit or low-quality drugs.83 A recent survey of counterfeit drugs in Asia showed that 53% of antimalarials sold commercially were counterfeit or contained a substandard amount of the active drug.84

Barrier precautions and insect repellents not only protect travelers from malaria, but also from many other infections, some of which are more common in and dangerous to VFRs. Because some VFRs will find it challenging to locate outdoor recreational stores, it may be helpful to sell the insect repellent DEET, and the clothing insecticide permethrin at low cost in the clinic setting. Insecticide-treated bed nets (ITNs) are inexpensive and readily available in endemic countries. Currently, the WHO estimates that fewer than 10% of African children and women at risk use ITNs; unfortunately, it is likely that VFRs would follow the example of their hosts and not use ITNs.85 Those who don’t stay in major cities or air-conditioned hotels are at particular risk of insect-borne diseases such as malaria.

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Aug 11, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Visiting Friends and Relatives
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