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Visiting Friends And Relatives Istm Donegal 29.08.09


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Visiting Friends And Relatives Istm Donegal 29.08.09

  1. 1. Visiting friends and relatives Dr Peter Noone, ISTM Donegal,29th August 2009
  2. 2. What the future holds? • Many of the infectious disease challenges that face Ireland are determined by international factors, • National approaches to ID in low incidence countries is complex, • What information do we need to guide practice and target health needs, • Opportunities presented.
  3. 3. Factors 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 • Slavery • Pollution • Poor housing • Landlords • Bullying • Poor chances of finding courtship
  4. 4. Evolution of Migration Flows, 1960 - 2005 Source: United Nations - Trends in Total Migrant Stock,
  5. 5. Net Migration Rates 2008 Net migration rates for 2008: positive (blue), negative (orange), stable (green), and no data (grey).
  6. 6. Av number of annual migrants 2000-2005 UN Pop division, World Bank, IMF ,
  7. 7. The territory size shows the number of international immigrants that live there. World mapper,
  8. 8. Territory size shows the relative levels of net immigration (immigration less emigration). Social and Spatial Inequalities Group
  9. 9. Territory size shows the relative quantity of net emigration in all territories (emigration less immigration).
  10. 10. Immigration, emigration and net-migration in Ireland, 1987 - 2003 Source: Central Statistics Office (CSO); Dublin
  11. 11. Mixing bowl 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 Europe 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 New world 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.
  12. 12. Definition: • 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.
  13. 13. International status • 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
  14. 14. VFRs “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.
  15. 15. VFRs • 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 visited.
  16. 16. VFRs account for a disproportionate fraction of total travellers and disease
  17. 17. Does the VFR traveller have distinct health risks? • Epidemiology • Health care provided – Use of travel health services, • Risk exposure – Adherence to advice
  18. 18. The travel pattern exposes VFR to higher health risk both qualitatively and quantitatively
  19. 19. UK travellers • 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.
  20. 20. Visits abroad by UK residents 1996-2005
  21. 21. 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 hepatitis A.
  22. 22. 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, 2003.
  23. 23. 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 of age. • ID differ in etiology & severity from other travellers.
  24. 24. 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.
  25. 25. 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.
  26. 26. Malaria • In 2006, >50% of imported malaria cases in U.S. civilians occurred among VFRs. • 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 tourists. • 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.
  27. 27. Malaria • 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.
  28. 28. UK Malaria
  29. 29. Malaria Ireland
  30. 30. Malaria Ireland • 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. •HPSC
  31. 31. Malaria ROI
  32. 32. Other Infections • 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.
  33. 33. TB US
  34. 34. Hep A Laboratory reports of hepatitis A, England,Wales, and Northern Ireland: 1998 – 2007
  35. 35. VFR Kids • 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).
  36. 36. 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. 2002;80:342-349. • 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.
  37. 37. STD’s • 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: 10.1136/sti.2004.014282. • 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 12.51, 3.75-46.95. • 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
  38. 38. UK Data • For typhoid/paratyphoid, majority of VFR cases 2007 were ISC ethnicity (mainly India, Pakistan, and Bangladesh). • Factors for disproportionate burden of typhoid, paratyphoid, and malaria in VFRs were not seeking travel advice before their trip/not taking adequate prevention measures. • VFR cases of enteric fever less likely to have sought health advice before travel than non-VFR cases, particularly those non-UK born.
  39. 39. 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
  40. 40. 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 <$60k, • 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.
  41. 41. Drogheda clinic experience Fig 1. Destination of VFR Clinic Attendees, 2003-2006 Fig 2. Occupations of VFR Travellers Destination Travel consult 1 Student 29 Dem Rep Congo Pastor 1 5.13% 3.85% Egypt Mature student 1 11.54% Ghana Lecturer 1 1.28% India Labourer 1 6.41% IT Engineer 1 11.54% Kenya Infant 5 occupation Nigeria 5.13% Houseperson 7 Pakistan Fitter/Welder 1 5.13% Pakistan/Kuwait Doctor 7 Saudi Arabia Child 15 5.13% Togo Care assistant 4 Administrator 2 44.87% Accountant 2 0 5 10 15 20 25 30 Count 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)
  42. 42. 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).
  43. 43. Barriers • 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), and – provider level (inadequate knowledge of travel medicine).
  44. 44. Recommendations • Consideration to make malaria chemoprophylaxis more affordable to VFR family groups travelling to at- risk areas, reducing financial barriers to protecting all family members. • 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
  45. 45. Conclusion • 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 immigrant populations. • Clinicians caring for VFRs need to be knowledgeable about their travel-related risks and have access to regularly updated, detailed pre- travel health information.