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