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Clinical Pearl: Pre-travel counseling for persons visiting friends and relatives (VFRs)

Author(s): J. Carey Jackson, MD, MA, MPH
Date Authored: March 01, 2013

airplaneThose of us who provide medical care for immigrants and refugees are familiar with their inevitable decision to return home for a visit. For many this is a momentous return. They left in terror, to return in safety for a long-imagined reunion. Now years have passed, many friends and family members have died, others have grown up, or grown old, and there are new family members to meet. I have had patients who returned home to Laos, Cambodia, or China for the first time after decades in exile. The excitement of return is overwhelming; to honor the dead, to see childhood landscapes one last time, to eat foods they have missed for years, to sit with a dying sibling in their illness. The exposures many risk upon return are sometimes minimized. Patients may shrug and say they lived there for years and not realize that now 20 years later they have congestive heart failure, breast cancer, and diabetes, and are elderly and cannot tolerate the insults to their immune system they might have weathered in their youth. In addition whatever residual immunity they had to endemic pathogens has waned in the intervening years. Others will want whatever treatment they can get but not realize the expenses may not be covered by Medicaid or their insurance.

Dr. Jackson and Patient at Pharmacy
Photo By: Clare McLean/UW Medicine

Public Health - Seattle & King County (PHSKC) provides useful tips as you discuss issues with traveling patients. These tips (see below) are based on the CDC’s Health information for international travel including detailed guidelines on pre-travel counseling specifically for persons visiting friends and relatives (VFRs).  The decisions to immunize, prophylax, or treat when symptoms arise are a careful calculation based on the duration of the trip, geographic areas and the seasonal prevalence of disease, the urban, rural, or sylvan settings to be visited, and the condition and co-morbidities of the traveler. I would add a few caveats to the guidelines to discuss during the conversation with patients.

  1. Calculate the duration of the trip and the actual percentage of time exposure to mosquito vectors of dengue and malaria may occur. This is where a decision to treat symptoms as they arise vs. take malaria prophylaxis will be decided. The risk of side-effects from mefloquin, or even doxycycline are not insignificant and have to be weighed.
  2. Many devout and / or elderly patients are engaged in religious pilgrimages. I recently had several patients undertake a pilgrimage to the key sites of the Buddha's life: birth, enlightenment, and death. Trips to Saudi Arabia for the Haj, or to Holy sites in Ethiopia are also familiar. At these times there may be special considerations around crowding and the need for meningococcal vaccine as for the Haj, or for Yellow Fever if the trip itinerary includes a country where the disease is endemic.
  3. Unlike tourism which is usually a month or less, a trip home after years away may take 3-6 months.  In these cases patients with chronic illnesses may decompensate if they do not plan a means to assure they have a steady supply of their chronic medications. This needs to be addressed and arranged in advance. 
  4. For individuals who are PPD negative or quantiferon negative the trip home may be another exposure to TB and require a reminder to re-screen after they have been back in the U.S. a few months. Similar arguments can be made for HIV if that is a reasonable concern in the traveler.
  5. The biggest risk to health may not be infectious disease but motor vehicle accidents and traffic in settings where there are no emergency services. The recent pilgrims to India I mentioned were involved in a serious bus accident. Others have been pushed into, or killed by erratic traffic. A thoughtful reminder of these mundane risks may address the most real threat faced daily.
  6. Finally, for many the emotional jubilation of return can be followed by renewed PTSD or depression.  Screening again after reentry can be useful.

In any case, this is not adventure travel or tourism, but a trip home, often to remote locations for prolonged periods and the traveler must be well prepared.

Pre-travel counseling for VFRs:

Excerpted with permission from Epi-Log, Communicable Disease and Epidemiology News, Vol. 52, No. 6, June 2012, Public Health - Seattle & King County:

Persons visiting friends and relatives (VFRs) may be more likely than other travelers to stay in destinations that put them at greater risk of acquiring travel-related diseases, and less likely to take recommended preventive measures and precautions. In fact, according to the Centers for Disease Control (CDC),VFRs experience more malaria, typhoid fever, cholera, tuberculosis, hepatitis A, and sexually transmitted diseases than other groups of international travelers. For example, over the past 3 years, nearly two-thirds of the malaria cases reported in King County occurred in people traveling abroad to visit friends or relatives, especially in Africa and Asia.

The CDC’s Health information for international travel includes detailed guidelines on pre-travel counseling specifically for VFRs, with tips including the following:

  • Many young adults from developing countries may still be susceptible to hepatitis A; consider pre-travel serologies for both hepatitis A and hepatitis B in previously unvaccinated patients.
  • Recommend that VFRs purchase malaria prophylaxis before traveling and begin taking them before departure if appropriate. Drugs that may be available at their travel destination may no longer be effective against malaria due to poor quality, counterfeit, or high levels of resistance.
  • For those at high risk of traveler’s diarrhea from locally served foods at homes and street stalls, simplify empiric treatment by using single dose meds such as azithromycin or ciprofloxacin.
  • Consider varicella vaccination for adult immigrants traveling overseas, especially to South or Southeast Asia and Latin America. Varicella infection occurs at older ages in tropical regions, and deaths and complications are more common in infected adults than children.
  • Because many VFRs may have already had previous exposure to dengue fever, protective measures to avoid mosquito bites are essential to reduce risk of dengue hemorrhagic fever or dengue shock syndrome. Mosquito precautions also reduce the risk of serious mosquito-borne infections including malaria, yellow fever, and Japanese encephalitis.

For a summary table of CDC's recommendations for VFRs, click here.