Pediatric travelers visiting friends and relatives (VFR) abroad: Illnesses, barriers and pre-travel recommendations

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Summary

Global mobility has shown a steady rise in recent years, with increased immigration and international travel. The VFR traveler is a traveler whose primary purpose of travel is to visit friends and relatives (VFR), where there is a gradient of risk between home and destination. Children are more likely to be VFR travelers than adults. Pediatric VFR travelers have higher risks for certain infectious travel-related illnesses and face multiple barriers in receiving comprehensive pre-travel care. This review focuses on the current state of knowledge of the pediatric VFR traveler, including epidemiological risks, barriers to adequate pre-travel services, and specific recommendations for disease prevention.

Introduction

International travel continues to remains a global ‘business’, with substantially more adults and children traveling overseas each year. Throughout the past decades, the number of international tourist arrivals has increased dramatically, from 150 million in 1970 to 440 million in 1990 to > 920 million in 2008.1 The World Travel Organization estimates that by 2020 tourist arrivals will exceed 1.6 billion globally. Furthermore, tourist destinations once considered exotic or remote are experiencing the highest rates of annual growth. During 2000–2008, tourism to the Middle East grew by 10.5% annually, followed by Central America (8.4% annual growth), Africa (6.7%), Asia and the Pacific (6.6%), South America (3.9%) and Europe (2.8%). In contrast, tourist arrivals in North America (0.8%) remained essentially unchanged during the first 8 years of this decade.1

Along with the increasing volume of global travelers, the characteristics of travelers are changing. Travelers who are ‘visiting friends and relatives’, referred to as VFR travelers, encompass persons who maintain familial or other social links to a country other than that of their current citizenship or residence. These groups have a higher health–risk profile than other travelers and represent a substantial portion of international travelers. In the United Kingdom, approximately 50% of all travel to Africa or the Indian subcontinent is by VFR travelers.2 Similar ratios are observed among U.S. travelers to foreign countries. In 2008, approximately 46% of the 31 million outbound air flights from the United States were for the purpose of visiting friends or relatives, with 64% of these trips being outside Canada, Mexico, Western Europe and Australia.3 Changes in global travel are also being observed among pediatric travelers. The GeoSentinel Surveillance Network evaluated data regarding ill children presenting after travel and noted that these children were significantly more likely than adults to be VFR travelers, with children aged ≤ 5 years being more than twice as likely as adults to be VFR travelers.4

Pre-travel preparation for pediatric VFR travelers is hampered by multiple factors at both the provider and traveler-caregiver level, the majority of which result from a lack of understanding of this traveler population. Other authors have addressed pre-travel counseling for children5, 6, 7, 8, 9, 10 or the VFR traveler.2, 11, 12, 13 This paper evaluates the state of knowledge, travel-related illnesses, and existing recommendations for pediatric VFR travelers.

Section snippets

Defining the VFR traveler

Starting with a standardized definition of the VFR traveler is necessary to evaluate risk and recommend interventions. We prefer the definition recently published by the Migration Health Sub-Committee of the International Society of Travel Medicine, ‘a VFR traveler is a traveler whose primary purpose is travel to visit friends or relatives, where there is a gradient of epidemiological risk between home and destination’.14 VFR travelers can include immigrants, refugees, asylum seekers, students,

Traveler’s diarrhea

Reviews of studies regarding traveler’s diarrhea (TD) among children have been published elsewhere.5, 9, 20 Attack rates of diarrhea in tropical countries vary by geography but have ranged from 7%21, 22 to > 50%, depending on the location and study.2, 21, 22, 23, 24, 25, 26 Across several studies, Enterotoxigenic and enteroaggregative Escherichia coli (ETEC, EAEC) have been shown to be the most common causes, followed by norovirus, Shigella, rotavirus, and Campylobacter.26

Limited data regarding

Barriers to pre-travel health care

Travel advice is of no value if it cannot be conveyed to the departing traveler. Among non-VFR tourist travelers, rates of seeking pre-travel consultation and adherence to recommendations are suboptimal.47 VFR travelers have been reported to be even less likely than tourist travelers to seek pre-travel care, and by virtue of their social connections are less likely to adhere to food restrictions.17, 77 The reasons for this are multi-factorial and include access to care, language barriers,

Optimizing the clinic environment

Pre-travel consultation should address the needs of both the child and his or her caregiver. Caregivers might schedule a pre-travel visit for the child but not themselves. For providers who are comfortable working with both children and adults, we recommend asking caregivers or guardians who are traveling if they have scheduled a pre-travel consultation and consider adding them to the schedule if they have not.

To address concerns of language and cultural barriers, clinics should be set up to

Conclusion

Pediatric VFR travelers remain an under-studied population, and evidence-based recommendations rarely exist regarding prevention of disease for these travelers at high risk. Pediatric VFR travelers have higher risks for certain infectious travel-related illnesses and face multiple barriers in receiving comprehensive pre-travel care. Addressing disparities in care requires investment of time and resources on the part of providers and health systems. Given recent patterns in global mobility, the

Conflict of interest statement

There is no conflict of interest to report for either author.

References (102)

  • World Trade Organization (UNWTO)

    Tourism highlights, Edition 2009. [cited may 5, 2010]

  • United States Office of Travel and Tourism Industries

    Profile of U.S. Resident travelers visiting oversease destinations (Outbound) 2008

  • S. Hagmann et al.

    Illness in children after international travel: analysis from the GeoSentinel Surveillance Network

    Pediatrics

    (2010 May)
  • W.M. Stauffer et al.

    Traveling with infants and children. Part 2: immunizations

    J Travel Med

    (2002 Mar-Apr)
  • W.M. Stauffer et al.

    Traveling with infants and children. Part IV: insect avoidance and malaria prevention

    J Travel Med

    (2003 Jul-Aug)
  • W.M. Stauffer et al.

    Traveling with infants and young children. Part I: anticipatory guidance: travel preparation and preventive health advice

    J Travel Med

    (2001 Sep-Oct)
  • W.M. Stauffer et al.

    Traveling with infants and young children. Part III: travelers’ diarrhea

    J Travel Med

    (2002 May-Jun)
  • N. Bacaner et al.

    Travel medicine considerations for North American immigrants visiting friends and relatives

    JAMA

    (2004 Jun 16)
  • E. Barnett et al.

    The visiting friends or relatives (VFR) traveler in the 21st century: time for a new definition

    J Travel Med

    (2010 May-Jun)
  • C.C. dos Santos et al.

    Survey of use of malaria prevention measures by Canadians visiting India

    CMAJ

    (1999 Jan 26)
  • S. Hagmann et al.

    Travel health care for immigrant children visiting friends and relatives abroad: retrospective analysis of a hospital-based travel health service in a US urban underserved area

    J Travel Med

    (2009 Nov-Dec)
  • K. Leder et al.

    Illness in travelers visiting friends and relatives: a review of the GeoSentinel Surveillance Network

    Clin Infect Dis

    (2006 Nov 1)
  • H.J. Schilthuis et al.

    Factors determining use of pre-travel preventive health services by West African immigrants in The Netherlands

    Trop Med Int Health

    (2007 Aug)
  • H.C. Baggett et al.

    Pretravel health preparation among US residents traveling to India to VFRs: importance of ethnicity in defining VFRs

    J Travel Med

    (2009 Mar-Apr)
  • S. Mackell

    Traveler’s diarrhea in the pediatric population: etiology and impact

    Clin Infect Dis

    (2005 Dec 1)
  • V. Chongsuvivatwong et al.

    Epidemiology of travelers’ diarrhea in Thailand

    J Travel Med

    (2009 May-Jun)
  • F.G. Silva et al.

    Travelers’ diarrhea in children visiting tropical countries

    J Travel Med

    (2009 Jan-Feb)
  • D.R. Hill

    Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries

    Am J Trop Med Hyg

    (2000 May)
  • C. Newman-Klee et al.

    Incidence and types of illness when traveling to the tropics: a prospective controlled study of children and their parents

    Am J Trop Med Hyg

    (2007 Oct)
  • R. Steffen et al.

    Epidemiology of travelers’ diarrhea: details of a global survey

    J Travel Med

    (2004 Jul-Aug)
  • J. Sanders et al.

    Epidemiology of travelers’ diarrhea

  • B. Pitzinger et al.

    Incidence and clinical features of traveler’s diarrhea in infants and children

    Pediatr Infect Dis J

    (1991 Oct)
  • A.K. Boggild et al.

    Prospective analysis of parasitic infections in Canadian travelers and immigrants

    J Travel Med

    (2006 May-Jun)
  • M.J. Eliades et al.

    Malaria surveillance–United states, 2003

    MMWR Surveill Summ

    (2005 Jun 3)
  • K. Leder et al.

    Malaria in travelers: a review of the GeoSentinel surveillance network

    Clin Infect Dis

    (2004 Oct 15)
  • F. Legros et al.

    Risk factors for imported fatal Plasmodium falciparum malaria, France, 1996–2003

    Emerg Infect Dis

    (2007 Jun)
  • S. Mali et al.

    Malaria surveillance–United states, 2006

    MMWR Surveill Summ

    (2008 Jun 20)
  • S. Mali et al.

    Malaria surveillance–United states 2007

    Morbidity Mortality Weekly Rep Surveillnace Summaries

    (17 April, 2009)
  • J. Skarbinski et al.

    Malaria surveillance–United states, 2004

    MMWR Surveill Summ

    (2006 May 26)
  • J. Thwing et al.

    Malaria surveillance–United states, 2005

    MMWR Surveill Summ

    (2007 Jun 8)
  • S. Ansart et al.

    Illnesses in travelers returning from the tropics: a prospective study of 622 patients

    J Travel Med

    (2005 Nov-Dec)
  • B.J. Brabin et al.

    Imported malaria in children in the UK

    Arch Dis Child

    (1997 Jul)
  • M. Mascarello et al.

    Imported malaria in adults and children: epidemiological and clinical characteristics of 380 consecutive cases observed in Verona

    Italy J Travel Med

    (2008 Jul-Aug)
  • S. Mathai et al.

    Severe malaria in immigrant population: a retrospective review

    J Immigr Minor Health

    (2009 May 3)
  • P. Muentener et al.

    Imported malaria (1985–95): trends and perspectives

    Bull World Health Organ

    (1999)
  • J. Arnaez et al.

    Imported malaria in children: a comparative study between recent immigrants and immigrant travelers (VFRs)

    J Travel Med

    (2010 Jul)
  • K. Stager et al.

    Imported malaria in children in industrialized countries, 1992–2002

    Emerg Infect Dis

    (2009 Feb)
  • A. Lynk et al.

    Review of 40 children with imported malaria

    Pediatr Infect Dis J

    (1989 Nov)
  • R.M. Viani et al.

    Pediatric imported malaria in New York: delayed diagnosis

    Clin Pediatr (Phila)

    (1999 Jun)
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