Visiting Friends & Relatives: VFR Travel
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 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.
Disproportionate Infectious Disease Risks in the VFR Traveler
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 14% of the US population is foreign born, in 2016, 44% 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 providers with travel health expertise
- 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 2014, 67% of imported malaria cases in US civilians occurred among VFRs. Data collected from GeoSentinel Global Surveillance Network clinics from 2003–2016 showed that 53% of returned travelers diagnosed with malaria were VFRs, 83% of whom acquired their disease in sub-Saharan Africa. Although malaria disproportionately affects VFRs, severe disease and death from malaria in VFRs have historically been lower than in tourist and business travelers, possibly because of some preexisting immunity or increased awareness. However, in recent years, a number of VFRs have died of malaria after returning to North America. In the United States in 2014, 51% of those with severe malaria for whom the purpose of travel was known were VFRs, mostly returning from West Africa, and in the annual US malaria surveillance reports in 2014 and 2015, 5 of 5 and 5 of 11 reported deaths, respectively, were in VFRs.
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 occurred 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.
Pretravel Health Counseling for the VFR Traveler
Table 9-3 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 provide culturally sensitive educational materials (in multiple languages) and have language translators available. 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.
Reason for Risk Variance 2
Recommendations to Stress with VFR Travelers
Foodborne and waterborne illness
Social and cultural pressure (eat meals served by hosts).
Avoid high-risk foods (dairy products, undercooked foods) and unpurified water.
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. Lack of pretravel counseling.
Avoidance counseling about specific foods (such as raw freshwater fish).
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 TST 2–3 months after return if history of negative tuberculin skin test and long stay (>3 months); use IGRA if history of BCG vaccination.
Educate about tuberculosis signs, symptoms, and avoidance.
Bloodborne and sexually transmitted infections
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 for needed medications for long-term travel.
Recommend hepatitis B immunization if nonimmune.
Schistosomiasis and soil-transmitted helminths
Limited access to piped-in water in rural areas for bathing and washing clothes.
Avoid freshwater exposure.
Towel off quickly and use liposomal DEET preparation with freshwater exposures. 3
Discourage children from playing in dirt.
Use ground cover.
Use protective footwear.
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, leptospirosis, viral fevers, leishmaniasis, anthrax, Chagas disease)
Staying with family where animals are kept.
Increased exposure to insects.
Increased exposure to rodents (mice and rats).
Sleeping on floors.
Avoid animal contact.
Wear protective clothing and use insect repellent.
Check for ticks daily.
Avoid thatched roofs and mud walled accommodations and fresh sugar cane juice in Latin America.
Avoid sleeping at floor level.
Envenomation (snakes, spiders, scorpions)
Sleeping on floors.
Avoid sleeping at floor level.
Wear protective footwear 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
Unclear, partial immunity from 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; TST, tuberculin skin test; DEET, N,N -diethyl-m -toluamide.
1 Adapted from: Bacaner N, Stauffer W, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA. 2004;291(23):2856–64.
2 Hypothetical unless referenced to support assertions.
3 In animal models, DEET (liposomal preparations) prevents Schistosoma cercariae from penetrating the skin.
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/diphtheria) or has a history of specific diseases. Adult travelers, in the absence of documentation of immunizations, may be considered 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.
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 3, 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.
Encourage VFRs to purchase their medications before traveling to ensure good drug quality. Studies in Africa and Southeast Asia show that one-third to one-half of antimalarial drugs purchased locally are counterfeit or substandard.
Heading Home Healthy
The CDC-supported Heading Home Healthy program (www.HeadingHomeHealthy.org) 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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Jay S. Keystone