Visiting Friends And Relatives Istm Donegal 29.08.09
Visiting friends and relatives
Dr Peter Noone, ISTM Donegal,29th August 2009
What the future holds?
• Many of the infectious disease challenges
that face Ireland are determined by
• National approaches to ID in low incidence
countries is complex,
• What information do we need to guide
practice and target health needs,
• Opportunities presented.
Push Factors Pull Factors
• Not enough jobs • Job opportunities
• Few opportunities • Better living conditions
• "Primitive" conditions • Political and/or religious freedom
• Desertification • Enjoyment
• Famine/drought • Education
• Political fear/persecution • Better medical care
• Poor medical care • Security
• Loss of wealth • Family links
• Natural Disasters • Industry
• Death threats • Better chances of finding courtship
• Poor housing
• Poor chances of finding courtship
Evolution of Migration Flows, 1960
Source: United Nations - Trends in Total Migrant Stock, http://esa.un.org/migration
Net Migration Rates 2008
Net migration rates for 2008: positive (blue), negative (orange), stable
(green), and no data (grey).
Av number of annual migrants
UN Pop division, World Bank, IMF ,
The territory size shows the number of
international immigrants that live there.
World mapper, www.sasi.group.shef.ac.uk/
Territory size shows the relative levels of net
immigration (immigration less emigration).
Social and Spatial Inequalities Group www.sasi.group.shef.ac.uk/
Territory size shows the relative quantity of net
emigration in all territories (emigration less
Immigration, emigration and net-migration in Ireland, 1987 - 2003
Source: Central Statistics Office (CSO); Dublin
Western Europe's desirability as an immigrant destination is rising
while Latin America's draw is declining.
1870-71 1890-91 1910-11 2000-01
Germany 0.5 0.9 1.9 8.9
France 2.0 3.0 3.0 10.0
United Kingdom 0.5 0.7 0.9 4.3
Denmark 3.0 3.3 3.1 5.8
Norway 1.6 2.4 2.3 6.3
Sweden 0.3 0.5 0.9 11.3
Australia 46.5 31.8 17.1 23.6
New Zealand 63.5 41.5 30.3 19.5
Canada 16.5 13.3 22.0 17.4
United States 14.4 14.7 14.7 11.1
Argentina 12.1 25.5 29.9 5.0
Brazil 3.9 2.5 7.31
Source: Williamson and Hatton, 2005.
(share of foreign-born population in percent)
1Number of foreign nationals in 1900.
• Asylum Seeker: is a person who has submitted an
application for protection under the Geneva
Convention and is awaiting for asylum to be decided
by Minister for Justice, Equality and Law Reform,
• Refugee: 1951 UN Convention relating to refugees,
‘a person who has a well-bounded fear of
prosecution for reasons of race, religion, nationality,
membership of a particular social group or political
opinion; is outside the country they belong or
normally reside in; and is unable or unwilling to return
home for fear of persecution.
• Exceptional leave to remain, replaced on 1.04.03:
– Humanitarian protection, awarded to those refused refugee status.
Cannot return to country of origin as face serious risk to life or person
because of the death penalty, unlawful killing, torture, inhuman or
degrading treatment or punishment. After 3 yrs can apply ILR.
– Discretionary leave, awarded where refused refugee status and not fill
criteria for HP above, but other reasons exist.
– White list countries (s.94 of Nationality, Immigration & Asylum Act
2002), application from these countries clearly unfounded unless
specific evidence to the contrary produced.
• IMMIGRATION, RESIDENCE AND PROTECTION BILL 2008
“Immigrants who are ethnically and/or
racially distinct from the majority
population of their country of residence
and who return to their homeland to visit
friends and/or relatives”
Centers for Disease Control and Prevention. Health information for international
travel 2005–2006: the “yellow book.” Philadelphia, PA: Elsevier, 2006.
• People who are travelling from higher-
income country of residence to their
country of origin (low-income country).
• May include children of foreign-born
parents— “second-generation” immigrants
whose family originated in the country
VFRs account for a
disproportionate fraction of
total travellers and disease
Does the VFR traveller have distinct
• Epidemiology • Health care provided
– Use of travel health
• Risk exposure – Adherence to advice
The travel pattern exposes VFR
to higher health risk both
qualitatively and quantitatively
• 61.4 million visits abroad by UK residents in 2003,
• 2/3 to destinations in the European Union (EU).
• Visits to Indian sub-continent, and SSA/SA
increased by 15% and 19% respectively,
• UK residents primarily travelled for holidays,
• Since 1996, visits by VFRs has increased on
average by nearly 8% each year,
• In 2003 VFR trips 2nd most popular travel reason,
overtook business travel visits for the first time.
VFR UK data
• Of all visits abroad made by UK residents
in 2007, 18% (12,214,367) were for VFR
travel and of those, a significant number
travelled to countries with high prevalence
of malaria, typhoid, paratyphoid, and
VFRs as proportion of total travellers
• In UK ethnic groups represent 6.7% of total
population but 20% of total travellers,
• Source: Behrens RH, Hospital Tropical Dse, London,
• In U.S. immigrants constitute 20% of the total
population but 40% of international travellers,
• Source: US census bureau 2001: US Dept of commerce,
Characteristics of VFR travel
• VFRs and relatives experience excessive rates of travel-
related morbidity and mortality.
• No pre-travel care common- patient and clinician barriers to
care, pre-existing health beliefs, incomplete childhood shots.
• Travel patterns of VFRs traveling to high-risk destinations.
• Susceptibility to infectious and non-infectious illnesses
increased- multiple preexisting medical problems & extremes
• ID differ in etiology & severity from other travellers.
Disproportionate Risk IDs in VFRs
• Lack of awareness of risk
• <30% have a pre-travel health-care advice,
• Financial barriers to pre-travel health care,
• Clinics are not geographically convenient,
• Cultural and language barriers with providers,
• Lack of trust in the medical system,
• Greater last-minute travel plans and longer trips,
• Travel to high-risk destinations, accommodation,
local lifestyle, food and water precautions, bed nets…
• Health beliefs “immune.” ↓ vacc HAV, typhoid and
use of malaria chemoprophylaxis v other travellers.
VFR’s an Asian Airport Survey
• 2101 respondents 419(19.9%) were VFRs.
• 18.1% of VFRs sought pretravel advice, only
6.9% from TM specialist v 36.8% of tourists.
• None of VFRs got Hep A, B or rabies vaccines
v 5.5%, 4.8% and 0.9% of tourist travellers
respectively, (None had malaria prophylaxis).
• VFRs 0.38 (95% CI 0.20-0.70) less likely to get
pre-travel health advice than tourist travellers.
FC04.04 Wilder Smith A et al, VRS –an Asian Airport
Survey, 10th ISTM Vancouver 2007.
• In 2006, >50% of imported malaria cases in U.S. civilians occurred among
• GeoSentinel, ISTM and CDC sentinel surveillance data, VFRs x 8 more likely
to get malaria than tourist travellers.
• UK data shows VFR travellers to West Africa x10 develop malaria than
• The vast majority of malaria cases associated with VFR travel had not taken
any (or appropriate) chemoprophylaxis.
• Many VFRs assume they are “immune”; most VFRs, who left their countries
of origin years ago, immunity waned and is no longer protective.
• In UKTravel-associated malaria, E&W, NI: 2007 VFR cases with
in 2007 the majority of (N=691)
falciparum malaria were of Black African
ethnicity/descent and acquired infection in
countries of their ethnic origin or descent
(mainly Ghana, Nigeria, Uganda);
• The majority of VFR cases with vivax malaria
were of ISC ethnicity and had acquired their
infection in countries of their ethnic origin or
descent (mainly India and Pakistan.
• The notified malaria cases ROI by 62% in 2005.
• In 2007 country recorded for 54 cases, majority from SSA; a
smaller number of cases from Asia and South America.
• Reason for travel recorded for 53 cases. 72%(38/53) of these
cases were VFRs in 2007.
• New entrants accounted for a further 6 cases.
• Other travel reasons were holidays (n=5), business (n=1),
armed services (n=1), other (n=2), not specified (n=18).
• P.falciparum, ~70% of notified cases (n=50).
• 7 P. vivax, 5 ovale, 3 malariae and 6 not specified.
• In the U.S, >75% of typhoid cases occur in VFRs, mostly from SEA
and Latin America; 90% of paratyphoid A cases are imported from
SEA as well. Steinberg E, et al Typhoid fever in travelers: who should we vaccinate?,AmSoc Trop
Med Hyg: 2000;60.
• VFR children <15 years of age are at highest risk of hepatitis A, and
many are symptomatic. In a British study, most cases were acquired
in South Asia. Behrens RH, et al, Risk for British travelers of acquiring
hepatitis A [letter]. BMJ. 1995;311:193
• TB annual incidence in Dutch Travellers 2.7-3.3% per person per yr v
0.01% in resident Dutch population, Coblens, Lancet 2000;356-461.
• Other diseases, such as hepatitis B, cholera, and measles, occur
more commonly in VFRs following travel.
Laboratory reports of hepatitis A, England,Wales, and
Northern Ireland: 1998 – 2007
• US airport study 2005, travellers to India, (294/1302,
23% travelling with kids, 66% got pre-travel health
advice, 57% received meds/vacc. FC04.05 Graham et al, Are Travellers
with Kids better prepared, ISTM Vancouver 2007.
• French prospective cohort study, n=374 kids<6yrs consulting
over 4/12. Africa main destination, mean duration 42/7. Sorge F et al,
Children Morbidity-Prospective Controlled Cohort Study, FC04.06, ISTM Vancouver 2007,
– Ill any cause RR 2.0
– RR fever =2.1 (95% CI=1.2-5.2),
– Malaria incidence was 5% in those visiting endemic areas,
– Those aged 10-20mths increased morbidity 3 (1.2-7.6),
– Travel rural area increased risk 2.7(1.3-5.5),
– Travel <45 days reduced risk child morbidity OR 0.3(0.14-0.6).
Infxns in VFRs
• Cholera excess in VFRs, CDC 78% of 160 cases
1992-1994 occurred in VFRs. Mahon BE et al, Reported cholera in the U.S,
1992-1994: a reflection of global changes in cholera epidemiology. JAMA. 1996;276:307-312,
• Meningococcal meningitis most cases in 15
countries in SSA meningitis belt, mainly in dry
season. Hajj/Omra pilgrimages
• Weekly Epidemiologic Report. 2003;133:294-296. also Leake JA et al Early detection and response to
meningococcal disease epidemics in SSA: appraisal of the WHO strategy. Bull World Health Organ.
• 70,000 deaths due to rabies occur worldwide
annually, the majority in SEA and ISC, almost 50%
of deaths occur in children. World Health Organization fact sheet No. 99.
• June 2001.
• Surinamese and Antillean immigrants in Amsterdam, 47%
of men and 11% of women travelling back home acquired a
sexual partner, Kramer MA et al, Sex Transm Infect. 2005 December; 81(6): 508–510. doi:
• SSA Africans living in London, 40% of men and 205 of
women acquired a new sexual partner while travelling
abroad. Fenton KA, et al, AIDS 2001;15:1442-5.
• Men of 47% with local sexual partner, 36% had unprotected
sex, assoc Surinamese origin OR 11, 1.72-104, Hx STI OR
• Women, of 11% with local sexual partner, 50% unprotected
sex, assoc with >1 partner in last 5 yrs, OR 13.57-250.2,
Kramer MA et al, Sex Transm Infect. 2005 December; 81(6): 508–510
• For typhoid/paratyphoid, majority of VFR cases
2007 were ISC ethnicity (mainly India, Pakistan,
• Factors for disproportionate burden of typhoid,
paratyphoid, and malaria in VFRs were not seeking
travel advice before their trip/not taking adequate
• VFR cases of enteric fever less likely to have
sought health advice before travel than non-VFR
cases, particularly those non-UK born.
Travel-associated cases of enteric fever Laboratory reports of Salmonella
by reason for travel: 2007 (N=305) Typhi and Paratyphi,
E&W, NI: 1998 – 2007
Travel Immunisation acceptance
• VFR’s predominantly female and younger
than business travellers,
• Visit for longer,
• 91% plan to stay with friends or relatives,
• 72% had an mean annual household income
• Lower acceptance rates of HAV, HBV,
typhoid, Rabies, TdaP.
Diener T, Abbas Z, Martin D, Travel Imms Acceptance rates among VFRs compared to business
travellers and those travelling for work and study abroad, ISTM Vancouver.
Drogheda clinic experience
Fig 1. Destination of VFR Clinic Attendees, 2003-2006
Fig 2. Occupations of VFR Travellers
Travel consult 1
Dem Rep Congo Pastor 1
Egypt Mature student 1
Ghana Lecturer 1
India Labourer 1
6.41% IT Engineer 1
5.13% Houseperson 7
Pakistan Fitter/Welder 1
5.13% Pakistan/Kuwait Doctor 7
Saudi Arabia Child 15
5.13% Togo Care assistant 4
44.87% Accountant 2
0 5 10 15 20 25 30
Noone P, Callaghan M, “Audit of needs of VFR Travellers attending an Irish travel medicine clinic” British Travel
Health Association Journal, May 2008; 11: 46-51. (presented as poster at NECTM, Helsinki, 22-24th May “08)
Drogheda experience 2003-2006
• VFRs : 78/1470(5.3%) of all consultations,
• mean trip duration was 4.8 weeks (SD 2.9).
• mean stay in Southern Africa was 4.5, v 5.6 weeks elsewhere.
• Consultations a mean 4.3 (SD 3.8) weeks before departure.
• Malaria prophylaxis was declined by 13% of VFRs.
• Hepatitis A and typhoid vaccines uptake was 97.2%, 91%
respectively overall and 100%, 88% in children respectively.
• 3 VFRs declined yellow fever vaccine.
• Rabies vaccine uptake was low at 2% overall.
• 12 (44%) VFRs travelling home for over 30 days declined
hepatitis B vaccine.
• VFRs cancelled/missed 26(25%) of appointments v 206(12.3%)
appointments overall, OR 2.4(95% CI 1.5-3.8).
• Barriers to the delivery of preventive
travel-related medical services exist at
many levels, including;
– the systems level (low insurance coverage),
– patient level (misperception of disease risk),
– provider level (inadequate knowledge of travel
• Consideration to make malaria chemoprophylaxis
more affordable to VFR family groups travelling to at-
risk areas, reducing financial barriers to protecting all
• Typhoid and hepatitis A vaccination should be offered
free for travellers in most GP practices.
• Advice such as bite prevention and food and water
hygiene advice is available from the open-access
NaTHNaC or CDC website
• New strategies are needed to properly address the
needs of VFR travellers.
• Pre-travel services should be convenient,
accessible, affordable, culturally sensitive, and if
possible, located within existing services to
• Clinicians caring for VFRs need to be
knowledgeable about their travel-related risks and
have access to regularly updated, detailed pre-
travel health information.