Visiting Friends and Relatives: VFR Travel

Introduction

There are multiple definitions of a "visiting friends and relatives (VFR)" traveler. In this chapter, "VFR" is defined as a person who currently resides in a higher-income country who returns to their former home (in a lower-income country) for the purpose of visiting friends and/or relatives. Family members (e.g., children, partners) born in the VFR traveler's higher-income country of residence are also included in this traveler category.

Migration patterns to the United States over the past 30 years have resulted in increasing numbers of refugees, immigrants, and migrants (RIM) arriving from Eastern Europe, the Middle East, Africa, Latin America, and Asia. Approximately 14% of U.S. residents (45 million people) are foreign born, 22% of U.S. households use a language other than English at home, and 45% of all international travelers coming from the United States list VFR as their reason for travel.

Disproportionate infectious disease risks and travel-associated morbidity and mortality

Compared to other groups of international travelers, VFR travelers experience a greater incidence of many travel-associated infectious diseases (e.g., malaria, tuberculosis [TB], typhoid fever). Several underlying reasons for this observation have been identified (Box 9.3.1). VFR travelers are a heterogeneous and complex group, and while assumptions about individuals based on population are not appropriate, understanding population-level differences can inform patient care. Travel medicine specialists should provide individualized counseling and recommendations for the VFR traveler's specific travel situation as with any international traveler. Exploring the nuanced cultural considerations of the individual traveler, including existing knowledge and beliefs about travel health, is key to providing more effective travel recommendations.

Box 9.3.1

Specific notable health conditions which have variance in VFR travelers

Infectious diseases

Many travel-associated infectious diseases occur at disproportionately higher rates in VFR travelers.

Insect-borne diseases

Malaria

Approximately 75% of imported malaria cases in the United States occur among VFR travelers despite <15% of the U.S. population being foreign-born. The majority of infections are imported from Africa, with most cases associated with travel to West Africa and Plasmodium falciparum being the most common species. Immunity is not absolute and begins to wane soon after leaving an endemic area, so VFR travelers are not immune to malaria infection or severe disease. In fact, some years VFR travelers account for the majority of U.S. malaria hospitalizations and deaths.

Travel characteristics that increase the risk of malaria in VFR travelers include more frequent travel to highly endemic areas (e.g., West and Central Africa), longer duration of travel, less pre-travel care, greater mistrust in the medical system, less success implementing and maintaining insect-avoidance measures, and more barriers, particularly financial, to chemoprophylaxis. Although VFR travelers' knowledge, attitudes, and practices (KAPs) have been widely reported in the literature, little systematic or rigorous data are published providing evidence that KAPs differ substantially between VFR and other traveler groups. More recent studies contradict the traditional narrative that VFR travelers are less concerned than other travelers about the possibility of malaria infection. In fact, an evaluation of malaria cases and KAP in an African community compared to non-VFR travelers found that VFR travelers have equal or more concern about malaria. While their concern was higher, they were found to be less successful than non-VFR travelers in implementing preventive strategies such as chemoprophylaxis and insect avoidance due to multiple barriers, including decreased trust in health care, concerns over inconveniencing hosts with recommended interventions (e.g., bed nets), and limited financial access to chemoprophylaxis (especially when prolonged courses of chemoprophylaxis are needed for multiple family members). VFRs who visited a malaria endemic area more frequently (>5 times) were more likely to develop clinical malaria on return—identifying a particularly high-risk group that may benefit from enhanced attention and intervention strategies.

Timely recognition and prompt delivery of appropriate treatment are also critical to improving outcomes when a patient presents with clinical malaria after return. Delayed and missed diagnoses of malaria are common in the United States and may be due to lack of familiarity with malaria by healthcare professionals and not routinely inquiring about a travel history or lack of patient trust in sharing their travel history. The risk of delay in clinical diagnosis and treatment after return emphasizes the importance of appropriate pre-travel care and prevention strategies, including chemoprophylaxis. It is also important to discuss with travelers the need to obtain timely medical care if fever develops during or after travel to a malaria endemic area and to stress that they should notify U.S. healthcare professionals of their recent travel history.

Arboviral infections: chikungunya, dengue, Zika

VFR travel is the second most common reason for travel in those diagnosed in the United States with dengue, chikungunya, or Zika; tourism is the most common, which may reflect U.S. travel patterns (e.g., the Caribbean and Mexico). Dengue is of particular concern among VFR travelers, who are more likely to have had a prior dengue virus infection than other travelers, increasing their risk of severe dengue and complications with subsequent infections (see Dengue chapter). Because vaccines for these infections for travel are not yet widely available, counseling and education regarding daytime insect avoidance, particularly at dawn and dusk when Aedes mosquitoes are most active, is key and should be highlighted (see Mosquitoes, Ticks, and Other Arthropods chapter).

Other insect-borne diseases

VFR travelers may be more likely to encounter certain insect-borne diseases due to more frequent or longer duration travel to endemic areas (e.g., filarial diseases, leishmaniasis, yellow fever) or staying in dwellings with conditions that favor the vector or intermediate hosts (e.g., Chagas, Japanese encephalitis).

Enteric fever

During 2020, about half of all typhoid (48%) and paratyphoid A (64%) cases in the United States occurred in VFR travelers; most traveled to the Indian Subcontinent (84% and 88%, respectively; see Typhoid and Paratyphoid Fever chapter). Decreased susceptibility to ciprofloxacin was present in 86% of Salmonella enterica serotype Typhi and 99% of Salmonella enterica serotypes Paratyphi A, B, and C; 25% of Salmonella enterica serotype Typhi isolates were multidrug resistant. Extremely drug-resistant typhoid has been observed in returning travelers from Pakistan, initially reported in VFR travelers.

Tuberculosis

Travelers to moderate- and high-TB incidence countries have a higher risk of acquisition of TB infection (see Tuberculosis chapter). Prolonged travel and close contact with the local population can increase the risk of TB in VFR travelers. While VFR travelers are likely to be traveling from low- to high-incidence countries, those born outside of the United States may already be infected, which can complicate the evaluation of whether the infection was acquired during recent or prior travel, in the country of birth, or along the migration route. Data on the risk of active TB disease in VFR travelers are unavailable, and TB disease may be more related to underlying risk factors for reactivated TB than travel itself. In VFR travelers without a known TB diagnosis, pre- and post-travel TB screening can be considered.

HIV and other sexually transmitted infections

VFR travelers may be at higher risk for HIV acquisition during travel because they are more likely to travel to areas with higher HIV prevalence and may be more likely to have close contact with local populations (see Sex and Travel chapter). There are limited data about whether other sexually transmitted infections, such as gonorrhea, herpes simplex virus, syphilis, and chlamydia, are more or less common in VFR travelers. Given the demonstrated high likelihood of travelers to have a new sexual partner during travel, pre-travel counseling about contraception and inquiring about sexually transmitted infection risk and need for screening are always appropriate.

Viral hepatitis (A, B, C, E)

VFR travelers often lack immunization records and may not have had serologic testing to evaluate for infection or immunity to vaccine-preventable diseases.

Hepatitis A is one of the more common vaccine-preventable illnesses in non-immune travelers, and VFR travelers have a higher likelihood of exposure based on travel-specific risk factors (prolonged time in rural areas, consumption of local foods and beverages, etc.; see Hepatitis A chapter). Non-immigrant VFR travelers (children of VFR parents who were born in the country in which the parents have resettled) who have not been immunized are at greatest risk for hepatitis A infection. A 2022 GeoSentinel study showed that among VFR travelers with acute hepatitis A, two-thirds were under age 20 years, with a median age of 11.5 years. Adult VFR travelers from areas with historically high prevalence may have had hepatitis A virus infection in the past and are therefore immune. However, endemicity rates of hepatitis A in many countries have been decreasing with improved sanitation, and it is important to either confirm immunity in adults with serological testing or proceed with vaccination, particularly because the risk of exposure is higher in VFR travelers, and infection in adults frequently results in severe disease.

Hepatitis B virus infection is a leading cause of preventable cancer globally (hepatocellular carcinoma). All RIM travelers born in countries with ≥2% prevalence should be screened for infection (hepatitis B surface antigen [HBsAg] testing) if not previously tested, regardless of vaccination status. A pre-travel visit is an ideal time to screen a patient for hepatitis B virus infection and past exposure or immunity and to recommend further testing and treatment in those infected or vaccination in those who are uninfected and non-immune. Although data on enhanced risk for hepatitis B, hepatitis C, and hepatitis E virus infection in VFR travelers are lacking, many risk factors that increase risk for blood-borne infections (hepatitis B and hepatitis C) and food- and waterborne infections (hepatitis E) are present in VFR travelers (see Food and Water Precautions for Travelers chapter).

Rabies

Surveys have revealed that VFR travelers are familiar with the risk of rabies, particularly from dog exposures. Clinical experience suggests that while most adult, first-generation VFR travelers will avoid dog contact because dogs are not seen as pets, their children (who are familiar with dogs as pets in the U.S.) may not have the same aversion. Those traveling with children should be counseled to avoid contact with animals, particularly dogs, and be reminded about managing bites and possible exposures (see Rabies and Zoonotic Exposures: Bites, Scratches, and Other Hazards chapters). Older children should also be directly involved in the discussion regarding animal safety while traveling. Pre-exposure rabies vaccine is recommended in at-risk VFR travelers, particularly those anticipated to have lower access to post-exposure prophylaxis, although cost is often a substantial barrier.

Measles

VFR travelers, particularly infants and young children, have been the source of measles outbreaks following travel (see Measles [Rubeola] chapter). VFR children may be under-vaccinated due to lower vaccination rates in their country of origin or vaccine hesitancy once they are residing in the United States. There is increasing mistrust regarding the safety of the MMR vaccine, particularly in certain RIM groups, leading to delayed immunizations. Education about the increased risk of measles during international travel, stressing the safety of the vaccine, and explaining the risks and potential complications of measles may be helpful in convincing families of the importance of receiving the vaccine.

Other conditions

Trauma

Traffic-associated injuries are a leading cause of morbidity and mortality globally and in travelers, particularly where there are few enforced rules and regulations and poor infrastructure (see Injury and Death During Travel chapter). Although data are lacking, VFR travelers are likely at higher risk for trauma related to transportation during international travel due to travel patterns and risk behaviors (e.g., tendency to travel longer; more likely to take local, riskier transport).

Special groups

Pregnant travelers

VFR travelers may be more likely than others to travel while pregnant and may be at risk of certain infections that may have worse outcomes during pregnancy, such as malaria and hepatitis E (see Pregnant Travelers chapter). Exposure to Zika virus during pregnancy can result in serious fetal and infant complications (see Zika chapter).

Children

VFR travelers are more likely to take or to send very young infants and children for prolonged trips to visit family (see Traveling Safely with Infants and Children chapter). Studies have found that VFR pediatric travelers are less likely to receive pre-travel advice than other groups of pediatric travelers. In 1 analysis, only about one-third of children ≤5 years who presented ill after prolonged (>30 days) travel were seen for a pre-travel visit compared to >50% of their counterpart non-VFR traveling children. Several infections have been demonstrated to be more common in VFR pediatric travelers, such as malaria and foodborne illnesses, including enteric fever. VFR children born in the United States are likely at even higher risk than their adult counterparts because, while they experience the same travel-associated risk factors (e.g., visiting homes where food and water exposures may occur, travel to areas higher in malaria incidence), they lack the previous infectious disease exposures that their caregivers may have had, making them more vulnerable to infection. There is evidence that young children, especially children who have not completed their primary series, are at higher risk of certain vaccine-preventable diseases such as measles. In addition, very young infants and children can be difficult to dose and administer medications (e.g., malaria chemoprophylaxis) to and may be more subject to serious complications of infections (e.g., dehydration). Furthermore, children may be at increased risk of trauma, particularly on or around roadways, because car seat and helmet use and availability may be limited. Other accidents, such as drowning, are also of concern, particularly where water safety regulations, supervision, and appropriate flotation devices are lacking.

Older adults

VFR travelers may be more likely to travel at older ages, when comorbid conditions such as diabetes mellitus and cardiovascular disease may be complicating factors (see Travelers with Chronic Illnesses chapter). Prolonged travel may make it difficult to obtain a full supply of medications, and access to high-level medical care for exacerbations of chronic medical conditions may be lacking. VFR travelers purchase international medical and evacuation insurance less commonly because of decreased awareness or access to these services (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter).

Immunocompromised travelers

More VFR travelers with immunocompromising conditions (e.g., people living with HIV, transplant recipients, and those taking immunosuppressant medications) are traveling, but utilization of pre-travel care remains low (see Travelers with HIV and Immunocompromised Travelers chapters). These travelers have risks associated with immunosuppression, including more severe or unusual infections, lower response rate to vaccinations, contraindications to receiving live vaccinations, drug interaction concerns, and inability to find specialized care in their region of travel, in addition to the already increased risk of travel due to VFR-related factors (see Medication and Vaccine Interactions in Travel Medicine chapter). Obtaining an adequate supply of medications can be of particular concern, particularly with prolonged travel, because immunocompromised travelers often require specialized medications that are expensive or not available at their travel destination.

Pre-travel health counseling

VFR travelers are more likely to seek travel health advice from a primary care clinic than from a travel medicine specialty clinic (see The Pre-Travel Consultation chapter). Given the more complicated nature of their travel, they may be better served in a travel medicine specialty clinic. However, recognizing this is not always feasible, primary care clinicians serving RIM populations should make sure they are equipped to address pre- and post-travel issues and to obtain support from travel medicine specialists and resources.

Providers should use routine healthcare visits for children and adults as an opportunity to ask RIM patients about future travel plans. If able to refer to a travel clinic, consider checking antibodies to hepatitis A, hepatitis B, MMR, and varicella (if no previous documentation of vaccination or infection is available) and updating routine vaccines prior to their travel clinic appointment. Note that live virus vaccines must be given on the same day or separated by 28 days; routine live virus vaccines (MMR, varicella), if needed, should be deferred to the travel clinic visit in case yellow fever vaccine is also recommended.

Certain health risks and prevention recommendations might vary or deserve special attention for VFR travelers. It is important to increase awareness among VFR travelers regarding their unique risks for travel-associated infections and to develop strategies to help overcome the barriers they face in accessing and acquiring travel health services. The best method to increase VFR utilization of pre-travel services is to engage communities (see Health Communication with Refugee, Immigrant, and Migrant Communities chapter). Primary care and travel clinics can employ various strategies to better reach and serve VFR populations (Box 9.3.2).

Malaria prevention

Encourage VFR travelers going to malaria-endemic areas to take prophylactic medications, and also emphasize the benefits of barrier methods of prevention (e.g., insect repellents, mosquito nets, protective clothing), particularly for children (see Yellow Fever Vaccine and Malaria Prevention Information, by Country and Mosquitoes, Ticks, and Other Arthropods chapters). Social pressures from host families can dissuade VFR travelers from implementing prevention techniques (e.g., using insect repellents and mosquito nets, staying indoors during periods of peak mosquito feeding). Discuss any potential concerns, and provide viable alternative options (e.g., clothing pre-treated with insect repellents, odorless repellents, free-standing mosquito nets).

Malaria chemoprophylaxis

Cost can be a major disincentive to purchasing malaria chemoprophylaxis in the United States (see Malaria chapter). Recent research has shown the price for the exact same prescription of most common antimalarial drugs can vary by a factor of 10 among different pharmacies in the same area. Educating VFR travelers regarding ways to decrease costs of malaria medications, as discussed in Box 9.3.2, can help improve access and adherence to chemoprophylaxis (e.g., comparison shopping, discount coupons, online generic pharmacies, vacation overrides). The Minnesota Department of Health has developed a self-advocacy information card with a West Africa Community Advisory Board to help VFR travelers obtain affordable antimalarial drugs. Medical providers caring for VFR travelers could also contribute to advocacy for improved prescription drug coverage because malaria chemoprophylaxis has been shown to be cost effective for payers and travelers.

VFR travelers frequently report that they plan to buy antimalarials at their destination. This should be discouraged because medications should be started prior to departure, certain medications are difficult to find (e.g., atovaquone/proguanil), substandard malaria chemoprophylaxis drugs are common in certain low- and middle-income countries, and certain antimalarials are a frequent target for drug counterfeiting. In addition, because of greater familiarity with products available for purchase or inappropriate provider advice at their destination, VFR travelers might favor or obtain a drug that is inappropriate (e.g., quinine).

Box 9.3.2

Notes

¹Heading Home Healthy

²A study demonstrated that costs of antimalarials in a single neighborhood can vary by a factor of 10× between pharmacies.

³See the self-advocacy information card developed by the Minnesota Department of Health in collaboration with a West Africa Community Advisory Board to help VFR travelers obtain affordable antimalarial drugs.

Vaccinations

Travel vaccine recommendations and requirements for VFR travelers are the same as those for other travelers (see Vaccination and Immunoprophylaxis—General Principles chapter). Establish whether VFR travelers, particularly those born outside the United States, have had routine childhood immunizations (e.g., diphtheria-tetanus-pertussis; measles-mumps-rubella) or a clinical history of vaccine-preventable diseases (e.g., varicella). In the absence of documentation of immunizations, consider adult travelers susceptible and offer age-appropriate vaccinations. Alternatively, perform serologic testing to demonstrate proof of immunity when documentation is lacking (especially if suspicion of a completed vaccination series is high or when clinical or epidemiological evidence to suspect prior infection is present).

Although vaccine recommendations for VFR travelers do not differ substantially from those of other travelers, important specific caveats are listed in Box 9.3.3.

Box 9.3.3

Pre-travel screening for chronic infections

Use pre-travel VFR consultations as an opportunity to screen for common chronic infections found in many RIM populations (e.g., hepatitis B, hepatitis C, HIV, schistosomiasis, strongyloidiasis, latent TB). For more information, see Refugee Health Domestic Guidance. Also see Pre-Arrival Medical Screening and Interventions for Newly Arrived Refugees, Immigrants, and Migrants and Post-Arrival Medical Screening for Newly Arrived Refugees, Immigrants, and Migrants chapters.

Resources for travelers and healthcare professionals

Heading Home Healthy

The Heading Home Healthy program, supported by the Centers for Disease Control and Prevention (CDC), focuses on reducing travel-related illnesses in VFR travelers. The program was developed to provide VFR travelers with resources for safe travel and includes videos, informational resources, and health tools in multiple languages. Heading Home Healthy also offers a clinical support tool for primary healthcare professionals who are preparing their patients to travel home safely. Additional materials for malaria education and engaging communities can be found at the Minnesota Department of Health.

Acknowledgements

The following authors contributed to the previous version of this chapter: Kristina M. Angelo and Danuska Wanduragala.