Summary of the Statement on International Travellers Who Intend to Visit Friends and Relatives

Background: Travellers intending to visit friends and relatives (VFRs) are a specific group of travellers who have been identified as having an increased risk of travel-related morbidity. Objective: To provide recommendations for risk reduction in international VFRs. Methods: Recommendations regarding VFRs were developed based on available travel medicine literature and CATMAT expert opinion. Specific travel-related risks, including infectious disease epidemiology and burden in this population, were reviewed and recommendations were provided to attempt to mitigate these risks. Previous CATMAT statements related to VFRs were referred to and reiterated. Recommendations: Rates of travel-related illness in VFRs tend to be higher for many conditions. Diseasespecific risk factors and recommendations are discussed throughout this Statement. CATMAT recommends that VFRs’ vaccinations be up-to-date and they be counselled on the importance of various risk reduction activities such as the use of malaria prophylaxis, safe sex practices and injury prevention. Preand/or post-travel tuberculosis testing is indicated in certain situations. Conclusion: The pre-travel health assessment is an important opportunity to address with VFRs issues regarding health beliefs, health behaviours, current health status and the possibility of pre-existing conditions. Discussions addressing the importance of adherence to health advice and potential challenges to achieving adherence may be necessary.


Introduction
In 2012, visiting friends and relatives was the second most common reason for international travel among Canadian travellers and accounted for approximately two million overnight visits to overseas countries (1).Travellers intending to visit friends and relatives (VFRs) are a specific group identified as having an increased risk of travel-related morbidity.The United States Centers for Disease Control and Prevention define a VFR as "an immigrant, ethnically and racially distinct from the majority population of the country of residence (a higher-income country), who returns to his or her home country (lower-income country) to visit friends or relatives.Included in the VFR category are family members, such as the spouse or children who were born in the country of residence" (2).This is a summary of the CATMAT Statement on International Travellers Who Intend to Visit Friends and Relatives, in which a full description of the evidence and recommendations is available (3).The Statement focuses on the abovementioned definition of VFRs and outlines the increased risks faced by VFRs while providing recommendations based on the available literature.Given the current global patterns of population mobility, this definition of VFR may be rather strict.It is reasonable to extend these recommendations to all travellers to any country with an epidemiological gradient of risk compared to the country of residence, whose intent is to visit friends and relatives, regardless of migrant status or ethnicity (4,5).

Methods
A literature search was conducted for both published studies and grey literature.MEDLINE, EMBASE, Global Health, Scopus, Google Scholar and Access MEDLINE databases were used as well as reports and publications from Statistics Canada, the Public Health Agency of Canada (PHAC) and Citizenship and Immigration Canada.
Based on this initial overview, section topics were selected and additional focused literature searches were performed.Literature and evidence from Canada regarding the epidemiology and burden of specific diseases in the VFR population was used when available.The Statement does not contain a comprehensive overview of all travel-related risks, as content was prioritized based on increased risk specifically for VFRs.Therefore, it is important to be familiar with and address all travel-related risks at destination with a special emphasis on the topics discussed below.
The Statement represents a narrative review of the travel medicine literature on VFRs as well as CATMAT expert opinion.The recommendations do not include a description of the strength of the recommendation or grade of the quality of evidence as in previous CATMAT statements.Previous CATMAT statements were referred to and reiterated where they related to VFRs and a comprehensive list of current CATMAT statements can be found on the PHAC travel health website (6).

Risk factors
Rates of travel-related illness in VFRs tend to be higher for many conditions due to several factors.VFRs have an increased potential for last-minute travel plans, often have longer stays, may be reluctant to eat differently than hosts, may stay in places without door or window screens and without bed nets, are often in close proximity to the local population and have an increased likelihood of drinking untreated water (7,8).
VFRs and foreign-born travellers are less likely to seek pre-travel health consultation (9,10,11,12), are more likely to seek advice closer to departure (13) and are more likely to decline a recommended vaccine (13).These differences have been associated with VFRs' low perception of personal disease risk (8), but may also reflect language, cultural and/or financial barriers preventing uptake (14,15).VFRs often believe that they are immune to diseases (such as malaria) in their home country (7,14,16).They may seek advice from health care providers with a similar ethnic background who may not recommend preventive strategies such as chemoprophylaxis due to similar beliefs (17,18).

Malaria
Studies have found that among travellers with malaria, 59 to 99% did not use malaria chemoprophylaxis or took it inadequately (inappropriate drug or adherence) (19).In a Canadian case series of malaria diagnoses, the majority of cases were among travellers who did not seek pre-travel advice and/or did not take appropriate malaria prophylaxis (20,21).
VFRs account for a significant proportion of imported malaria cases in non-endemic countries (19).Studies have found foreign-born VFRs to have up to a 4.5-fold higher risk of contracting malaria than tourist travellers (22).Based on data from the Canadian Malaria Network from 2001 to 2013, 45% of severe malaria cases in Canada, for which information was available, reported visiting friends and relatives as the purpose for travel (23).
Given the characteristics mentioned above that may increase the risk of malaria (such as personal perception of disease risk and immunity) VFRs should be counselled about the importance of malaria prevention when travelling to malaria-endemic countries.Recommendations should include use of personal protective measures to prevent mosquito bites and potential use of chemoprophylaxis, depending upon destination.VFRs should be advised to seek health care if they develop fever during travel or once they return to Canada.Specific recommendations on malaria chemoprophylaxis are available in CATMAT's Canadian Recommendations for the Prevention and Treatment of Malaria (24).

Vaccine-preventable diseases
Due to variation in vaccination schedules or lack of access to vaccines in different countries, Canadian immigrants may be more susceptible to vaccine-preventable disease.

Routine immunization
Studies have found substantial rates of non-immunity to measles, mumps, rubella and varicella among Canadian immigrants from developing countries (25,26,27).Foreign-born VFRs should be evaluated for immunization status and immunity to vaccine-preventable disease and routine vaccinations should be provided as needed.For pediatric VFRs, there may be an opportunity to accelerate the routine schedule in order to provide maximal protection during travel.
Appendix 2 in the full VFR Statement (3) and CATMAT's Statement on Pediatric Travellers (28) contain information on accelerated vaccination schedules for children.

Typhoid
The majority of cases of typhoid fever in North America are associated with travel, particularly travel to South Asia (Afghanistan, Pakistan, India, Nepal, Bangladesh, Maldives, Sri Lanka and Bhutan) (15).Studies have found VFR travel to be a major risk factor for travel-related typhoid fever infection, with VFRs accounting for 66% of cases in the United States (29) and more than 90% of cases in Quebec (30).A study by the global GeoSentinel network found VFRs to have a 7-fold greater risk of receiving a diagnosis of typhoid fever compared with tourist travellers (22).
Age-appropriate typhoid vaccination is recommended for VFRs travelling to South Asia (31).Typhoid vaccine is not routinely recommended for travellers to destinations outside of South Asia; however, it may be considered for VFRs in specific high-risk situations (31).Safe food and water precautions should be discussed and the importance of frequent hand washing should be emphasized.
Refer to CATMAT's Statement on International Travellers and Typhoid (31) for further information on prevention of typhoid fever and use of typhoid vaccine.

Hepatitis A and B
VFRs, especially children, are a major contributor to hepatitis A cases in Europe and North America.Studies from Europe and Quebec have found that VFRs account for 28%-78% of travel-related HA cases (30,32,33,34,35).
Research has shown that over half of immigrants and refugees are non-immune to hepatitis B (36).Several behavioural characteristics of VFR travel (longer periods in country, close contact with local population, greater risk of injury and/or contact with the medical system) and high levels of non-immunity would be considered specific risk factors for hepatitis B acquisition.
Those travelling to countries with poor sanitation and hygiene conditions should be advised to follow safe food and water precautions and to wash their hands frequently (37).VFRs travelling to HB-endemic countries or who may engage in behaviours increasing their risk for blood/body fluid contact should be counselled regarding safe practices (condom use, use of sterile medical equipment) (38).Travellers who are non-immune to HA and/or HB should be vaccinated prior to travel (37).Age-appropriate immunization is advised for children.
Further recommendations on prevention of HA and HB in travellers can be found in CATMAT's Summary of Recommendations for the Prevention of Viral Hepatitis During Travel (37).

Tuberculosis
Travellers to countries with higher tuberculosis (TB) incidence are at risk of acquiring infection during travel.Foreign-born individuals accounted for 64% of all reported cases in Canada in 2012, with the highest incidence rates among those originating from Africa, South-East Asia, Western Pacific and Eastern Mediterranean (39).These cases include TB disease acquired in the country of origin before immigration as well as during return VFR trips.Studies have found that significant proportions of TB in immigrant populations can be attributed to VFR travel (40,41).Additionally, foreign travel, especially VFR travel, has been found to be a risk factor for latent TB infection (LTBI) (42,43).
VFRs travelling to high TB incidence countries should avoid consumption of unpasteurized dairy products to reduce the risk of M. bovis acquisition (44).VFRs should be cautioned to avoid individuals with unexplained chronic cough or known pulmonary TB until the individual is deemed non-infectious.Bacillus Calmette-Guérin (BCG) vaccine may be considered in certain circumstances for individual long-term travellers to high-prevalence countries (45).
Pre-and/or post-travel TB skin tests may be indicated depending on risk at destination, duration of travel and personal health factors.The full VFR Statement contains a decision making model to guide TB skin testing in travellers (3).
Refer to CATMAT's Risk Assessment and Prevention of Tuberculosis Among Travellers (44) for detailed guidance on pre-travel advice for TB infection risk avoidance and post-travel TB screening and to the Canadian Tuberculosis Standards (45) for up-to-date information on TB risk conditions and country-level risk stratification.

Parasitic infections
Certain parasitic infections, such as schistosomiasis, strongyloidiasis, echinococcosis and cysticercosis can be chronic and may cause significant morbidity and even death, while others are self-limiting and have a low impact on health.A Canadian GeoSentinel study found VFRs to be more likely to present with these and other parasitic infections (46).
VFRs should be advised to avoid freshwater activities (such as swimming) in regions where schistosomiasis is endemic (Africa, South-East Asia and parts of South America).Avoidance of skin-to-soil contact (such as walking barefoot) is recommended to prevent strongyloidiasis in tropical countries.Food and water precautions are recommended to prevent other parasitic infections spread via the fecal-oral route.The pre-travel assessment can provide an opportunity to identify risk and recommend screening for these treatable chronic parasitic infections among immigrants.

Sexually transmitted infections and Human Immunodeficiency Virus
New sexual partners and unprotected sexual encounters are common among travellers generally (47), including VFRs (48,49).A recent global GeoSentinel review found that VFR travel was associated with an increased risk of sexually transmitted infections (STI) compared with other travel (50) which adds to existing literature reports that STIs were more likely among VFRs than other travellers (22,51).
Sexual health counselling should be a routine part of the pre-travel consultation and risk of exposure to STIs and Human Immunodeficiency Virus (HIV) should be discussed.The importance of safer sex practices should be emphasized and travellers should be encouraged to bring condoms from Canada to assure their quality (52).HPV vaccine can be considered for adolescent and adult travellers not previously vaccinated.HB vaccination is recommended as above.
Refer to CATMAT's Statement on Travellers and Sexually Transmitted Infections (52) for additional recommendations related to STI risk reduction.

Injury
Injury is a significant cause of morbidity and mortality in travellers and accounts for 18%-25% of traveller mortality abroad (53,54,55).Numerous characteristics of VFRs (longer trip duration, greater likelihood to use local modes of travel) are assumed to increase injury risk, though there is not specific literature on travel-related injury among VFRs.
Road safety precautions such as seatbelts, infant/child car seats and helmets should be recommended (56).VFRs should avoid riding motorcycles or bicycles and should be encouraged to use helmets where this cannot be avoided (56).For more information on injury risk and recommendations for prevention, refer to CATMAT's Statement on Risk of Injury and Travel (56).

Pediatric VFRs
Compared to pediatric tourist travellers, pediatric VFRs are more likely to be younger, travel for longer periods, travel more often to rural areas, present for pre-travel advice closer to the departure date and travel to destinations with higher risk for tropical diseases (57,58).
Pediatric VFRs have an increased risk of travel-related illness and are at particular risk for febrile illness (especially caused by malaria) (59), TB, typhoid and meningococcal meningitis (60).A recent surveillance study of pediatric VFRs from Canada found that enteric fever, malaria, diarrheal diseases and HA accounted for 75% of travel-related illnesses in this group (61).Only 26% of these travellers had received pre-travel advice.
These results emphasize the importance of pre-travel assessment and adherence to recommended interventions for children.Opportunities to accelerate the routine schedule should be evaluated in order to provide maximal protection during travel (refer to Appendix 2 of the full VFR Statement (3) for accelerated vaccination schedules) Parents should be advised that the rates of illness requiring hospitalization are higher among VFR children and that illness during and after travel requires urgent assessment.Also, parents of Canadian-born VFR children should be informed that their children do not have any innate immunity against travel-related illnesses due to genetics alone.For more information on pediatric travellers and recommendations, refer to CATMAT's Statement on Pediatric Travellers (28).

Immunocompromised and older VFRs
There is little research focusing on immunocompromised or older VFRs.Specific characteristics of these populations (comorbid conditions, poorer immune responses, contraindications to vaccines or frailty) which lead to increased health risks while travelling may lead to synergistic risks for VFRs.
Infectious disease risk should be reviewed with the traveller according to the degree of their immune compromise along with risks specific to the destination and appropriateness of travel.
For travel health information on immunocompromised travellers and detailed recommendations on specific conditions, refer to CATMAT's Statement on The Immunocompromised Traveller (62).For information on and recommendations for older travellers, refer to CATMAT's Statement on Older Travellers (63).

Targeting VFRs for pre-travel advice
Health care providers should discuss potential upcoming VFR travel with their patients at routine health visits.Consultation with a travel health specialist should be recommended for all VFRs and particularly for those with risk factors for severe disease.Because some patients may be unwilling or unable to afford the cost of seeking travel medicine consultation, primary care providers should equip themselves with travel health knowledge and clinical resources so they are able to provide appropriate essential recommendations.

Conclusion
The pre-travel consultation for VFRs provides an important opportunity for health promotion, identification of preexisting conditions and risk reduction.VFRs should be made aware of their increased risk for travel-related illnesses and how to prevent them.Higher levels of non-immunity to vaccine-preventable disease and increased prevalence of chronic diseases among VFRs should also be addressed.In addition, health care providers should stress the importance of adherence and address potential challenges to achieving it.
Table 1 summarizes the disease-specific recommendations for VFRs and additional resources.Additional research is required to determine the facilitators and barriers for VFRs in accessing and adhering to pre-travel advice.Engaging ethnic communities and health care personnel that provide their care is necessary to assess knowledge, attitudes and behaviour regarding travel health and to determine optimal ways of providing information to VFRs.

Table 1 : Disease-specific recommendations for visiting friends and relatives (VFR) and additional resources Disease Strategies to decrease travel-associated risk to VFRs Resources for further information
Counsel parents that rates of illness requiring hospitalization are higher among VFR children and that illness during and after travel requires urgent assessment. Address misconceptions around prior immunity (e.g., child is not protected because parent was born in destination country). Accelerated vaccination may be possible. Post-travel TB skin testing and BCG vaccination may be indicated in specific situations, see additional resources for recommendations.