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Clinical Review |

Travel Medicine Considerations for North American Immigrants Visiting Friends and Relatives FREE

Nina Bacaner, MD, MPH, DTM&H; Bill Stauffer, MD, MSPH, DTM&H; David R. Boulware, MD; Patricia F. Walker, MD, DTM&H; Jay S. Keystone, MD, FRCPC
[+] Author Affiliations

Author Affiliations: Community University Health Care Center, Department of Internal Medicine (Dr Bacaner) and Division of Infectious Disease and International Medicine (Drs Stauffer, Boulware, and Walker) University of Minnesota, Minneapolis; Regions Hospital, Center for International Health & International Travel Clinic, St Paul, Minn (Drs Stauffer and Walker); and Centre for Travel and Tropical Medicine, Division of Infectious Diseases, Department of Medicine, University of Toronto, Ontario (Dr Keystone).


Clinical Review Section Editor: Michael S. Lauer, MD, Contributing Editor. We encourage authors to submit papers for consideration as a Clinical Review. Please contact Michael Lauer, MD, at lauerm@ccf.org.


JAMA. 2004;291(23):2856-2864. doi:10.1001/jama.291.23.2856.
Text Size: A A A
Published online

Context In the United States, 10% of the population was born outside of its borders. Immigrants and their children frequently return to visit their homeland, referred to as visiting friends and relatives (VFRs). They account for a disproportionately high volume of international travel.

Evidence Acquisition Searches of MEDLINE, World Health Organization, Centers for Disease Control and Prevention, International Society of Travel Medicine, and American Society of Tropical Medicine computerized databases, conference proceedings and abstracts, US Census Bureau, bibliographies of pertinent articles, and travel medicine texts. Priority was given to recent (1996-2003) evidence, addressing VFR travelers. General sources including travel medicine and immigrant health were also used.

Evidence Synthesis Immigrants visiting friends and relatives experience excessive rates of travel-related morbidity and mortality. Lack of pretravel care is common due to patient and clinician barriers to care, preexisting health beliefs, and incomplete childhood vaccinations. Travel patterns increase risk with VFRs traveling to high-risk destinations. Susceptibility to infectious and noninfectious illnesses is often increased because of multiple preexisting medical problems and extremes of age. Infectious diseases differ in etiology and magnitude from those of traditional travelers. For example with malaria, VFRs are frequently prescribed inappropriate prophylaxis or take none at all, have longer stays, spend time in high-risk areas, and do not appropriately adhere to chemoprophylaxis regimens. Effective pretravel health advice, guidelines, and services for this high-risk population are essential. There are already a number of useful and readily available databases that may aid clinicians in providing optimal travel-related preventive and therapeutic care.

Conclusions Immigrants who are visitors of friends and relatives in other countries account for a high volume of international travelers and are at markedly increased risk of travel-related illness. New strategies are needed to properly address the needs of VFR travelers. Pretravel services should be convenient, accessible, affordable, culturally competent, and if possible, located within clinics serving immigrant populations. Clinicians caring for VFRs should be knowledgeable about their travel-related risks and have access to regularly updated, detailed pretravel health information.

Travel medicine traditionally focuses on assisting tourist and business travelers avoid travel-related illnesses. It is now clear that immigrants returning to their home countries, termed visiting friends and relatives (VFRs), are at particularly high risk and that traditional travel services are inadequate for protecting this population. This article will review existing data concerning the increased risk and discuss practical recommendations that may assist the primary care and travel clinicians.

International migration has risen from 120 million in 1990 to 175 million in 2002.1,2 In 2002 more than 1 million persons legally immigrated to the United States from more than 220 countries.3 Twenty percent of the US population are first-generation immigrants or their children are.4 In spite of being a minority of the population, VFRs comprised approximately 40% of US international air travelers in 2002.5 Similarly, in the United Kingdom, VFRs made 40% of the 2 million visitors to Africa in 2000.6,7 Although no VFR demographics exist, it is assumed that national statistics pertaining to immigration patterns reflect subsequent travel patterns for immigrants. There have been major shifts in immigration away from European predominance as before 1970 toward developing nations from Asia, Africa, Latin America, Mexico, and Central America. Therefore, with more immigrants from developing countries located largely in tropical areas, expectations are that more VFRs will be visiting those areas. Statistics show large increases in trips from the United States to tropical countries since 1970, shifting the epidemiology of imported infections (eg, malaria, severe acute respiratory syndrome).8,9

Immigrants visiting friends and relatives assume greater risk than traditional travelers. They choose often to travel despite being pregnant, having multiple medical problems, and accompanying young children. Immigrants visiting friends and relatives frequently return to visit family members whom they had left behind or to introduce new additions to the family of origin. Last-minute travel to visit sick relatives or attending funerals is not uncommon, allowing little time for pretravel advice. Other travel reasons include finding a spouse, locating missing family, or returning for traditional or cultural ceremonies

Many VFRs stay in family settings in which they may encounter suboptimal sanitation and increased malaria risk.10 They may be reluctant to eat differently than their hosts. Close proximity to the local population increases risk of diseases such as tuberculosis and meningococcal infection.11,12 Immigrants visiting friends and relatives tend to have prolonged stays, increasing the risk of morbidity and mortality.13,14

Motor vehicle collisions are frequent causes of injury and are associated with considerably higher mortality in developing countries.1517 The risk of injury may be higher for VFRs because they often use high-risk, local transportation and drive independently on poorly maintained roads in dimly lit rural areas. Lack of availability or use of safety devices also increases risk.15 Furthermore, health care for injury or severe illness, especially in remote areas, is frequently inadequate.1820 Evacuation insurance, which covers expenses for airlift or other rapid transportation needed for provision of high-quality emergency health care, is uncommonly used.

Many VFRs have experienced upheaval, armed conflict, and torture prior to emigration and may have residual posttraumatic stress disorder.21,22 Stress-related health problems may be exacerbated by travel or by seeing ailing, impoverished family members.

In a survey of 2000 travelers departing from Amsterdam, almost one third were VFRs returning to home countries, and 70% had not sought pretravel advice.23 Even when pretravel advice is sought, adherence to travel recommendations, suboptimal in standard travelers,2427 may be worse among VFRs.28,29 Of 307 Canadians of Asian origin traveling to India, only 31% intended to use malaria chemoprophylaxis and fewer than 10% intended to use mosquito prevention. The majority sought pretravel advice from family practitioners of whom 76% prescribed inappropriate malaria chemoprophylaxis.30

Financial considerations often limit use of pretravel services among VFRs, because pretravel services are rarely reimbursed by third-party payers.31,32 Language barriers, health beliefs, lack of awareness, and fear of immigration authorities may adversely affect pretravel health care. Importantly, VFRs often believe they are immune to diseases from their homeland. In some cases they may be correct either because of childhood immunization (eg, Japanese encephalitis) or previous exposure (eg, hepatitis A virus), but many infections produce little long-term protective immunity.

Malaria presents interesting dilemmas relating to partial immunity and popular beliefs. Individuals living in highly endemic areas often develop partial immunity protecting them from severe disease. In fact, most adults are either asymptomatic or experience minor illness "African flu" even when infected with Plasmodium falciparum. Immune priming may lead to less severe malaria than in naive individuals.33 However, persistence of partial immunity is dependent on reexposure once outside endemic areas. Therefore, even with a distant history of multiple malaria episodes, VFRs are highly vulnerable to clinical malaria. Immigrants visiting friends and relatives may seek health care practitioners with similar backgrounds and who may share their mistaken beliefs about preexisting immunity and therefore not recommend optimal malaria prevention strategies.34 Most notable among malaria-naive individuals who are at great risk of severe disease and death are the children of VFR caregivers, who were born in developed nations and travel to endemic areas.

Health care systems and clinicians also present barriers in providing optimal pretravel and posttravel care.35 Inadequate use of medically trained interpreters limits communication. Written materials, even when in the patient's native language, are encouraged but may be ineffective because of illiteracy. Primary clinicians may not be knowledgeable about travel medicine or the geography and disease epidemiology of the destination country. Many clinics rely on the Centers for Disease Control and Prevention or other Web sites providing broad country or region-based recommendations. Most clinics do not have access to regularly updated pretravel health databases that offer information on regional disease distribution, seasonal factors, and ongoing epidemics (Box).

Box. Practical and Quick Pretravel Resources for Health Care Professionals

Interactive Web-Based Sources

Centers for Disease Control and Prevention Travel Information
http://www.cdc.gov/travel

World Health Organization International Travel
http://www.who.int/ith

Health Canada Travel
http://www.TravelHealth.gc.ca

Malaria Maps

For information, contact listserv@wehi.edu.au

Surveillance and Outbreak Information

Morbidity and Mortality Weekly Report
http://www.cdc.gov/mmwr

Weekly Epidemiological Review
http://www.who.int/wer

EuroSurveillance Weekly
http://www.eurosurveillance.org/

Canada Communicable Disease Report
http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr

ProMedmail

For information, contact majordomo@promedmail.org

Listserv Discussion Groups for Travel Medicine

TravelMed, sponsored by the International Society of Travel Medicine
listserv/@yorku.ca

Medical Assistance and Physicians for Travelers:
International Society of Travel Medicine
http://www.istm.org

International Association for Medical Assistance to Travellers
http://www.iamat.org

CDC Health Info for Travelers
http://www.cdc.gov/travel/yb/toc.htm

Books

Travel & Routine Immunizations. Milwaukee, Wis: Shorland; 2002

Red Book Am Acad of Pediatrics, 26th ed. Elk Grove Village, Ill:
American Academy of Pediatrics; 2003

Travel Medicine. Philadelphia, Pa: Mosby; 2004

A World Guide to Infections. New York, NY: Oxford University Press; 1991

Travel Medicine Health 2001. 2nd ed. London, England: Decker

Tropical Infectious Diseases. Philadelphia, Pa: Churchill Livingstone; 1999

Manson's Tropical Diseases. Edinburgh, Scotland: Elsevier Science Ltd; 2003

Hunter Tropical Medicine. Philadelphia, Pa: Saunders; 2000

There are no published recommendations and little data on providing care to this population of travelers. We present herein practical recommendations and highlight special issues arising in the care of VFR travelers (Table 1).

Table Graphic Jump LocationTable 1. Specific Diseases Risk, Proposed Reasons for Risk Variance, and Recommendations to Reduce Risk Specific to Travelers Visiting Friends and Relatives

Providing Appropriate Care. To serve this community effectively, it is imperative to publicize and emphasize the need for comprehensive pretravel services. Promotion of travel medicine services may be disseminated through leaflets, posters, and popular ethnic radio programs or newspapers. Ideally, quality travel medical services would be offered in primary care clinics36 frequented by immigrants since familiarity, trust, and ease of access might encourage use. Routine adult vaccinations that are also travel-related (eg, hepatitis A and hepatitis B) may readily be incorporated into primary care visits for other reasons. Pretravel medical services are superior when administered by a practitioner who has travel medicine training,31 and clinics should have designated travel medicine providers. For VFRs on limited budgets, providers may help prioritize vaccines and choose less expensive malaria prophylaxis.

Overcoming language barriers is critical. When available, medically trained, cross-cultural interpreters or multilingual health care practioners are best. Interpreter telephone services are suboptimal. Family members should be used to translate only when absolutely necessary. Pretravel advice, medication instructions, prescription bottles, and health information about destination should be provided in appropriate languages.37

Food and Waterborne Illnesses. Traveler's diarrhea is the most common illness among travelers to the developing world, affecting 30% to 60%.38,39 Although the typical advice often quoted by health care practitioners is "Boil it, cook it, peel it, or forget it,"27 the effectiveness of this dogma is questionable.40 In addition, food recommendations traditionally given may be difficult for VFR travelers to adhere to because they are often house guests. It is more practical to stress the effectiveness of frequent handwashing,41 including use of hand-sanitizing solutions that simplify hand cleaning.42,43 Other simple suggestions such as using dilute halide solutions to clean vegetables, boiling drinking water, and avoiding street vendor food may help.27,4446 Milk may be made safe by bringing it to a boil. Food or beverages served steaming hot are generally safe.

Cultural foods may put travelers at risk of specific infectious diseases. For example, one might advise Latin Americans to avoid white cheese (queso fresca) to prevent brucellosis and listeriosis.47,48 Fish and seafood consumption may pose further risk. An estimated 25 000 cases of ciguatera poisoning occur annually from eating affected large carnivorous reef fish of tropical and subtropical waters.49,50 The disease causing toxin is not destroyed by cooking or processing. In many cultures, the common practice is to eat the head, intestines, liver, and roe where the toxin is concentrated. Ceviche and other preparations of raw, freshwater fish (sushi, koi pla) may transmit Vibrio species (ie, cholera), gnathostomiasis, and liver flukes.5153 Raw or poorly cooked shellfish may contain hepatitis A virus or Salmonella typhi.54

When addressing treatment of traveler's diarrhea, simplified recommendations are advisable. For example, rather than traditional self-treatment with 3 days of antibiotics, it may be preferable to recommend a single fluoroquinolone or azithromycin dose, which has been shown to be effective.55,56 With small children, proper hydration therapy should be stressed.

Insect Avoidance and Malaria Chemoprophylaxis. Barrier precautions and chemical insecticides protect travelers not only from malaria but also from other common serious diseases such as dengue. Persons previously exposed to dengue, as have many immigrants, are at increased risk of severe dengue infection with subsequent exposure. Clothing can be impregnated with permethrin, effective for 2 to 6 weeks even through multiple washings.57 Long-acting DEET mosquito repellents are practical and 99% effective when combined with permethrin-impregnated clothing.58 Specific instructions on purchasing and product use should be carefully reviewed. Insecticide-treated bednets are inexpensive and readily available in endemic countries.

Malaria is the most serious infectious risk to travelers in many parts of the world. Cases of malaria imported to industrialized countries exceed 25 000 annually.59 Despite its frequency, malaria may be misdiagnosed as often as 60% of the time on initial presentation,60 especially in children.61

Rates of malaria are higher in VFRs than any other group of travelers. Of malaria cases imported into Brescia, Italy, from 1990 through 1998, 71% were in migrants compared with 12% among nonimmune Italians.62 Pooling of malaria cases in European centers found 43% occurred in nonnationals, frequently immigrant VFRs.63 Furthermore, the geosentinel surveillance network of International Society of Travel Medicine showed an 8-fold relative risk of acquiring malaria in VFRs compared with tourists (Joe Torresi, MD, oral communication, November 2001).

It is important to stress to VFR travelers that malaria chemoprophylaxis does not prevent infection but rather prevents clinical disease when the parasite emerges from the liver into the blood. If medication is stopped sooner than prescribed, a substantial risk of acquiring clinical malaria exists. Mefloquine, now available as a generic, is relatively inexpensive and convenient, but due to neuropsychiatric adverse effects,6466 it is not recommended for those with depression, anxiety, or posttraumatic stress disorder,21,22 all of which are common in VFR travelers.67 Newly required warning sheets from dispensing pharmacies may discourage some from taking mefloquine, unless specifically reassured. An effective strategy if time permits, is to start prophylaxis with mefloquine 3 to 4 weeks before departure to monitor for adverse events. Doxycycline is inexpensive but is a daily medication and has some potential adverse effects (eg, gastrointestinal effects, photosensitivity, predisposition to candida vaginitis) and is contraindicated in pregnant women and children younger than 8 years. Atovaquone-proguanil hydrochloride (Malarone; GlaxoSmithKline, Research Triangle Park, NC) is expensive, especially with prolonged stays. Chloroquine remains an affordable choice for travel only to the few remaining countries where chloroquine is still effective. Chloroquine frequently causes itching in persons of African descent. The use of primaquine is a welcome new option especially for VFRs who are unable to tolerate mefloquine or afford atovaquone-proguanil. G-6PD enzyme levels must be checked prior to use to identify patients at risk for serious drug-induced hemolytic anemia. Occasionally, stand-by, self-administered malaria treatment will be the only affordable, tolerated option for long-term visitors although several studies have shown that it is often used incorrectly.6870

Immigrants visiting friends and relatives should be told to continue malaria prophylaxis even if they have been diagnosed as having malaria while abroad because of the likelihood of an incorrect diagnosis due to a false-positive smear result.71,72 In many African countries, symptomatic individuals first treat themselves with over-the-counter antimalarials instead of seeking health care.73 In addition to receiving inappropriate malaria treatment (ie, chloroquine in Africa), other potential hazards exist, such as halofantrine treatment in persons taking mefloquine chemoprophylaxis putting them at risk of cardiac arrhythmia. Immigrants visiting friends and relatives must be made aware that suspected malaria is a medical emergency and that they should insist on malaria smears when returning home ill even if they are afebrile or informed that they "only have a virus." Clinicians should strongly suspect malaria in ill febrile persons having traveled to endemic areas within the last year and should be aware that multiple thick and thin smears may be necessary for diagnosis.

Tuberculosis. The tuberculosis bacillus infects one third of the world's population.74 Immigrants from high-incidence countries are a well-recognized risk group for tuberculosis.75,76 Theoretically, close contact with infected populations, long-term travel, and potential exposure to persons coinfected with tuberculosis and the human immunodeficiency virus (HIV) increase risk of clinical disease. Among US-born VFR children, those who traveled within the last year were 5 times as likely to have positive tuberculin skin test results than those who did not.77 Preventing tuberculosis is difficult, and it is appropriate to caution patients to avoid persons with a cough.

Blood and Body Fluid Transmissible Disease. Travel may increase the risk of contracting sexual and body fluid transmissible diseases from tattoos, sexual encounters, especially with commercial sex workers, and improperly sterilized medical equipment.78,79 Immigrants visiting friends and relatives may be at further risk from local manicures and shaves or from acupuncture treatments, dental care, and medical injections. 8082

Hepatitis virus B or C, sexually transmitted diseases, and HIV are highly prevalent diseases in many areas of the developing world.83 The predominance of HIV-1 non-B subtypes, and concurrent sexually transmitted diseases substantially increase the risk of HIV transmission to travelers.84,85 Immigrants visiting friends and relatives are more likely to have sexual encounters with persons in the local population than other types of travelers. Additionally, condoms purchased in developing countries may be of unreliable quality; therefore, VFR travelers should be advised to purchase condoms before travel.86

Other Travel Precautions. Commonly, VFRs purchase malaria chemoprophylaxis, other medications, or traditional remedies at greatly reduced prices in their home country. Many of these substances are substandard or even counterfeit, leading to increased risk of drug failure or adverse effects.87,88 Recently, samples of the antimalarial drug, artesunate, purchased from shops in 5 Southeast Asian countries contained artesunate only 62% of the time, even though packaged in standard blisterpacks.89 An estimated 10% to 20% of medicines manufactured in China and India are counterfeit, but rates may exceed 40% to 50% in certain locales.90 In an urban area in Nigeria, 48% of 581 tested pharmaceuticals were substandard.91,92

Water exposure predisposes to several risks. In the United States more than 50% of children who drown were not intending to swim at the time (ie, fell into bodies of water). It should be stressed to caregivers traveling with children that caution must be exercised around water. Freshwater swimming or wading in slow-moving fresh water predisposes travelers to schistosomiasis or leptospirosis in endemic areas. Other environmental risks are also increased in VFRs (eg, envenomations, geohelminths, environmentally induced asthma), and simple suggestions may prevent morbidity associated with these risks (Table 1).

To reduce risk of trauma, VFR travelers should avoid high-risk vehicles (eg, motorcycles) and should be encouraged to use safety devices whenever possible (eg, seat belts, car seats, helmets). Above all, they should avoid rural travel by road after dark.

Official national and international organizations do not formally recognize differences between VFR and non-VFR travelers when making routine travel vaccine recommendations (Table 2). However, some vaccines deserve special mention because some immigrants may be behind on routine immunizations and at risk with travel (eg, diphtheria), have received some travel vaccines as routine in their country of origin (eg, Japanese encephalitis), or may be immune due to previous exposure to disease (eg, hepatitis A virus ). In addition, VFR travelers have increased risk for some diseases and deserve a low threshold for immunization (eg, typhoid, rabies). Some of the pertinent differences and special considerations to general vaccine recommendations will be discussed.

Table Graphic Jump LocationTable 2. Special Vaccine Issues for Travelers Immigrants visiting Friends and Relatives (VFRs)

Routine Vaccines. The pretravel visit presents an opportunity to evaluate immunization status and update routine vaccines. When time allows, serologic testing can help assess immune status in those without a clear history of disease (eg, measles) or lacking adequate documentation. When routine vaccination is necessary, an accelerated schedule may be used to facilitate completion.45

Many immigrants are behind on routine immunizations.93 Although US immigrants are required to meet minimal vaccine standards, most immigrants will not have received certain vaccines due to their scarcity in developing countries of vaccines, such as Haemophilus influenzae, mumps, rubella, pneumococcal, or influenza. Even when a vaccine record is presented, it must be viewed cautiously because some areas of the world have excessive rates of vaccine failure (eg, eastern Europe, China).94,95 When inspected closely, the immunization record may be difficult to interpret accurately. Furthermore, special categories of US immigrants such as refugees, asylees, and international adoptees are exempt from vaccine requirements on migration. In some areas of southeast Asia, carrier rates exceed 10%.96 Thus, upon arrival in the United States, it is recommended that all immigrants receive hepatitis B virus screening and that nonimmune individuals be vaccinated.97

Those VFR travelers not adequately immunized may be exposed to vaccine-preventable diseases that are ubiquitous (eg, tetanus). They may enter areas during outbreaks such as occurred with diphtheria in the former Russian Federation during the 1990s and is currently occurring with polio in Nigeria. Furthermore, preexisting immunity to varicella is lower in adult VFRs because in many developing countries, varicella is an infection of adolescence rather than early childhood.25,98,99

Travel Vaccines. There are several factors influencing vaccine recommendations that are relevant to VFR travelers. Hepatitis A virus, the most frequently acquired vaccine-preventable travel disease, deserves special attention.100,101 Hepatitis A virus risk is based on residence location and duration, age, immigration year, and history of jaundice. Behrens et al102 showed that United Kingdom VFRs younger than 15 years traveling to India were at 10 times the risk of hepatitis A infection than native-born tourists. Previously, immigrants from hepatitis A virus–endemic countries were assumed to be immune from prior childhood infection.103,104 A study of 129 VFRs found that 95% were immune. However, as standards of living improve, seroprevalence declines.105,106 A study of Thai medical students showed hepatitis A antibody seroprevalence decreased from 77% in 1981 to 7% in 2001.107 Another multicenter study in 6 Latin America countries found 20% to 70% of preadolescents were not immune to the hepatitis A virus.108 Hepatitis serology or vaccination is indicated for VFRs younger than 20 years. In older VFRs, it is cost-effective to check IqG antibodies.109

Another vaccine-preventable disease disproportionately represented in VFR travelers is typhoid fever. Of imported typhoid fever cases into the United States from 1994 through 1999, the Centers for Disease Control and Prevention reports that 77% were among VFRs of whom 26% were younger than 10 years and half were acquired in fewer than 4 weeks of travel.110 Similarly, but less common, imported cholera is predominately found in VFR travelers. The Centers for Disease Control and Prevention statistics indicate 78% of 160 cases from 1992-1994 occurred in VFRs.111 In the United States, there is currently no effective cholera vaccine available. Several vaccines are currently used in other countries including an oral vaccine (CVD 103-HgR, Mutacol, Swiss Serum and Vaccine Institute, Bern, Switzerland) licensed in Canada for persons older than 2 years and the Dukoral (BS-WC, Aventis Pasteur, Toronto, Ontario) oral vaccine licensed in 18 countries that is effective against cholera and partially protective against enterotoxogenic Escherichia coli for up to 3 months.112

Meningococcal meningitis occurs worldwide although most cases occur in 15 countries in Africa's sub-Saharan meningitis belt. Large epidemics involving more than 100 000 people occur periodically throughout the region, predominately during the dry season.113,114 Small outbreaks of Neisseria meningitidis W135 have occurred with Hajj/Omra pilgrimages and in the African meningitis belt.115,116 High rates of nasopharyngeal carriage have been documented in VFR Hajjis, including those previously vaccinated and have been responsible for spread from persons returning from travel. Vaccination is required for travel to the Hajj/Omra and is recommended for any traveler to sub-Saharan endemic areas during the dry season or during ongoing epidemics. It should be considered year round for VFRs due to their increased contact with local populations.

Up to 70 000 deaths due to rabies occur worldwide annually, the majority in Southeast Asia and the Indian subcontinent. Almost 50% of deaths occur in children.117 Ten percent of traditional tourists to Thailand have been shown to have a potential risk of exposure to rabies.118 Despite this risk, only a quarter of general practitioners provide any pretravel advice concerning rabies.119 In developing countries, 60% of animal bites occur in or around the home, increasing VFR risk.120 An animal wound, even a lick or scrape, should be extensively cleaned with soap and water. Immigrants visiting friends and relatives should avoid contact with dogs, cats, monkeys, bats, rodents, raccoons, and other animals, even if they do not seem to be behaving strangely or appear ill.120 Preexposure rabies vaccination should be a serious consideration in VFRs traveling for more than 30 days, especially children; however, vaccination cost is significant.

Interestingly, imported cases of yellow fever and Japanese encephalitis have occurred almost exclusively in non-VFR adults. It is unclear is whether this is simply chance because there are very few imported cases or is due to previous exposure or routine childhood immunization. However, VFR children may be at increased risk.

Immigrants visiting friends and relatives, who account for a high volume of international travelers, have markedly increased risk of travel-related disease compared with tourists or business travelers. Factors leading to decreased likelihood of high-quality pretravel health care include financial barriers, accessibility, language, and health beliefs. New strategies are needed to address the needs of VFR travelers. Medical and public health organizations should use media resources and consider novel approaches to increase awareness and disseminate information to medical practitioners and VFRs. Research is needed to address ways in which barriers that keep VFRs from seeking and adhering to pretravel heath advice can be lowered. In addition, health professionals working with VFRs need to identify methods for providing advice that ensures optimal patient satisfaction and behavioral change. Private payers and public health services should share in the cost of pretravel services which, ultimately, will lead to less morbidity and mortality and lower acute care costs to the health care system. Until these issues are better defined and addressed, VFRs will continue to be at high risk for travel-related illness, with potentially serious personal and public health implications.

Zuckerman JN. Travel medicine.  BMJ.2002;325:260-264.
PubMed
 International Migration Report 2002, New York, NY: United Nations, Dept Economic and Social Affair; October 25, 2002. Available at: http://www.un.org/esa/population/publications/ittmig2002/ittmigrep2002.htm.
 US Department of Homeland Security, Yearbook of Immigration Statistics, 2002 . Washington, DC: US Government Printing Office; 2003. Available at: http://uscis.gov/graphics/shared/aboutus/statistics/Yearbook2002.pdf. Accessed April 8, 2004.
US Census Bureau.  Profile of the Born Outside the United States Population 2000Washington, DC: US Government Printing Office; 2001. Available at: http://www.census.gov/prod/2002pubs/p23-206.pdf. Accessed December 15, 2003.
 2002 Profile of U.S Resident Traveler Visiting Overseas Destinations Reported From: Survey of International Air Travelers. Office of travel and tourism Industries, US Department of Commerce. Available at: http://tinet.ita.doc.gov/cat/f-2002-101-001.html. Accessed December 14,2003.
McCarthy M. Should visits to relatives carry a health warning?  Lancet.2001;357:862-865.
PubMed
Behrens RH. Visiting friends and relatives. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner, BA, eds.Travel Medicine. London, England: Elsevier Ltd; 2004:281-285.
 Local transmission of Plasmodium vivax malaria—Palm Beach County, Florida 2003.  MMWR Morb Mortal Wkly Rep.2003;52:908-911.
PubMed
 Local transmission of Plasmodiam vivax malaria – Virginia, 2002.  MMWR Morb Mortal Wkly Rep.2002;51:921-923.
PubMed
Horvath LL, Murray CK, Dooley DP. Utility of Services provided by a free travel medicine clinic. In: Program and abstracts of the 52th American Society of Tropical Medicine and Hygiene; December 2003; Philadelphia, Pa. Abstract 521:26.
Cobelens FG, van Deutekom H, Draayer-Jansen JW.  et al.  Risk of infection with Mycobacterium tuberculosis in travelers to areas of high tuberculosis endemicity.  Lancet.2000;356:461-465.
PubMed
Robbins JB, Schneerson R, Gotschlich EC.  et al.  Meningococcal meningitis in sub-Saharan Africa.  Bull World Health Organ.2003;81:745-749.
PubMed
Valerio L, Guerrero L, Martinez O. Travelling immigrants.  Aten Primaria.2003;32:330-336.
PubMed
Weiner L, Alkan M. Incidence and precipitating factors of morbidity among Israeli travelers abroad.  J Travel Med.2002;9:227-235.
PubMed
Andrews CN, Kobusingye OC, Lett R. Road traffic accident injuries in Kampala.  East Afr Med J.1999;76:189-194.
PubMed
McIness RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel.  J Travel Med.2002;9:297-306.
PubMed
Odero W, Garner P, Zwi A. Road traffic accidents in developing countries.  Trop Med Int Health.1997;2:445-460.
PubMed
Kolars JC. Rules of the road: a consumer's guide for travelers seeking health care abroad.  J Travel Med.2002;9:198-202.
PubMed
McFarlane S, Racelis M, Muli-Muslime F. Public health in developing countries.  Lancet.2000;356:841-846.
PubMed
Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile?  Bull World Health Organ.2002;80:900-905.
PubMed
Walker PF, Jaranson J. Refugee and immigrant health care.  Med Clin North Am.1999;83:1103-1119.
PubMed
Eiseman DP, Gelberg L, Lui H, Shapiro MF. Mental health and health related quality of life among adult Latino primary care patients living in the United States with previous exposure to violence.  JAMA.2003;290:627-634.
PubMed
Dijkshoorn H, Schilthuis HJ, van den Hoek JA, Verhoeff AP. Travel advice on the prevention of infectious diseases insufficiently obtained by indigenous and non-native inhabitants of Amsterdam, the Netherlands [in Dutch].  Ned Tijdschr Geneeskd.2003;147:658-662.
PubMed
Duval B, De Serre G, Shadmani R.  et al.  A population-based comparison between travelers who consulted travel clinics and those who did not.  J Travel Med.2003;10:4-10.
PubMed
Hughes NJ, Carlisle R. How important a priority is travel medicine for a typical British family practice?  J Travel Med.2000;7:138-141.
PubMed
Laver SM, Wetzels J, Behrens RH. Knowledge of malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travelers exiting Zimbabawe from Harare and Victoria Falls International airport.  J Travel Med.2001;8:298-303.
PubMed
Kozichi M, Steffen R, Scgar M. "Boil it, cook it, peel it, or forget it!" does this rule prevent travelers' diarrhoea.  Int J Epidemiol.1985;14:169-172.
PubMed
Casalino E, Bras JL, Chaussin F, Fichelle A, Bouvet E. Predictive factors of malaria in travelers to areas where malaria is endemic.  Arch Intern Med.2002;162:1625-1630.
PubMed
Minodier P, Nassur A, Hassid S.  et al.  Antimousquito precautions and medical chemoprophylaxis in French children with malaria.  J Travel Med.2003;10:318-325.
PubMed
Dos Santos CC, Anvar A, Keystone JS, Kain KC. Survey of malaria prevention measures by Canadians visiting India.  CMAJ.1999;160:195-200.
PubMed
Badrinath P, Ejidokun OO, Barnes N, Ramaiah S. Change in NHS regulations may have caused increase in malaria.  BMJ.1998;316:1746-1747.
PubMed
Backer H, Mackell S. Potential cost-savings and quality improvement in travel advice for children and families from a centralized travel medicine clinic in a large group-model health maintenance organization.  J Travel Med.2001;8:247-253.
PubMed
White NJ. Malaria. In: Cook GC, Zumla A, eds. Manson's Tropical Diseases. 21st ed. Philadelphia, Pa: Saunders; 2003:1205-1296.
Campbell H. Imported malaria in the UK: advice given by general practitioners to British residents traveling to malaria endemic areas.  J R Coll Gen Pract.1987;37:70-72.
PubMed
Stauffer WM, Kamat D, Walker PF. Screening of international immigrants, refugees, and adoptees.  Prim Care.2002;29:879-906.
PubMed
Christenson JC, Fischer PR, Hale DC, Derrick D. Pediatric travel consultation in an integrated clinic.  J Travel Med.2001;8:1-5.
PubMed
Bauer I. The health of host communities: missing from printed travel health advice.  J Travel Med.2003;10:350-353.
PubMed
Von Sonnenburg F, Tornleporth N, Walyaki P.  et al.  Risk and aetiology of diarrhea at various tourist destinations.  Lancet.2000;356:133-134.
PubMed
Steffen R, Kollaritsch H, Fleischer K. Travelers' diarrhea in the new millennium: consensus among experts from German-speaking countries.  J Travel Med.2003;10:38-45.
PubMed
Steffen R, Collard F, Tornieporth N.  et al.  Epidemiology, etiology, and impact of TD in Jamaica.  JAMA.1999;281:811-817.
PubMed
Boulware DR, Forgey WW, Martin WJ. Medical risks of wilderness hiking.  Am J Med.2003;114:288-293.
PubMed
Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer use on elementary school absenteeism.  Am J Infect Control.2000;28:340-346.
PubMed
White CG, Shinder FS, Shinder AL, Dyer DL. Reduction of illness absenteeism in elementary schools using an alcohol-free hand sanitizer.  J Sch Nurs.2001;17:258-265.
PubMed
Mensah P, Yeboah-Manu D, Owusu-Darko K, Albordey A. Street foods in Accra Ghana: how safe are they?  Bull World Health Organ.2002;80:546-553.
PubMed
 Health Information for International Travel 2003-2004 . Atlanta, Ga: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2003.
Stauffer WM, Konop RJ, Deepak K. Traveling with infants and young children, I: anticipatory guidance: travel preparation and preventive health advice.  J Travel Med.2001;8:254-261.
PubMed
Young EJ. Brucella species (brucellosis). In: Long S, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed. New York, NY: Elsevier; 2003:877-878.
Tasbakan MI, Yamazhan T, Gokengin D.  et al.  Brucellosis: a retrospective evaluation.  Trop Doct.2003;33:151-153.
PubMed
Barbier HM, Diaz JH. Prevention and treatment of toxic seafoodborne diseases in travelers.  J Travel Med.2003;10:29-37.
PubMed
Ansdell V. Food-borne illnesses. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner BA, eds. Travel Medicine. London, England: Elsevier Ltd; 2004:443-446
Stauffer WM, Sellman JS, Walker PS. Liver flukes (opisthorchiasis and clonorchiasis) in immigrants in the United States.  J Travel Med.2004;11:157-160.
Morris JG. Cholera and other types of vibriosis: a story of human pandemics and oysters on the half shell.  Clin Infect Dis.2003;37:272-280.
PubMed
Deardorff TL. Epidemiology of marine fish-borne parasitic zoononses.  Southeast Asian J Trop Med Public Health.1991;22(suppl):146-149.
PubMed
Koopmans M, Duizer E. Foodborne viruses: an emerging problem.  Int J Food Microbiol.2004;90:23-41.
PubMed
Hoge CW, Gambel JM, Srijan A, Pitarangsi C, Echeverria P. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years.  Clin Infect Dis.1998;26:341-345.
PubMed
Adachi JA, Ericsson CD, Jiang ZD.  et al.  Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.  Clin Infect Dis.2003;37:1165-1171.
PubMed
Schreck CE, McGovern TP. Repellents and other personal protection strategies against Aedes albopictus J Am Mosq Control Assoc.1989;5:247-250.
PubMed
Lillie TH, Schreck CE, Rahe AJ. Effectiveness of personal protection against mosquitoes in Alaska.  J Med Entomol.1988;25:475-478.
PubMed
Wellems TE, Miller LH. Two worlds of malaria [perspective].  N Engl J Med.2003;349:1496-1498.
PubMed
Kain KC, Harrington MA, Tennyson S, Keystone JS. Imported malaria.  Clin Infect Dis.1998;27:142-149.
PubMed
Ladhani S, El Bashir H, Patel VS, Shingadia D. Childhood malaria in East London.  Pediatr Infect Dis J.2003;22:814-819.
PubMed
Castelli F, Matteelli A, Caligaris S.  et al.  Malaria in migrants.  Parassitologia.1999;41:261-265.
PubMed
Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria.  J Travel Med.2003;10:106-107.
PubMed
Schlagenhauf P, Tschopp A, Johnson R, Nothdurft HD. Tolerability of malaria chemoprophylaxis in non-immune travelers to sub-Saharan Africa.  BMJ.2003;327:1078-1083.
PubMed
Overbosch D, Schilthuis H, Bienzle U.  et al.  Atovaquone-proguanil vs mefloquine for malaria prophylaxis in non-immune travelers.  Clin Infect Dis.2001;33:1015-1021.
PubMed
Petersen E, Ronne T, Ronn A, Bygbjerg I, Larsen SO. Reported side effects to chloroquine, chloroquine plus proguanil, and mefloquine as chemoprophylaxis against malaria in Danish travelers.  J Travel Med.2000;7:79-84.
PubMed
 Consumer guide for malaria drug.  FDA Consumer Magazine.2003;37:7. Available at: http://www.fda.gov/fdac/departs/2003/503_upd.html#malaria. Accessed December 19, 2003.
Schlagenhauf P, Steffen R. Stand-by treatment of malaria in travelers: a review.  J Trop Med Hyg.1994;97:151-160.
PubMed
 Behavioural aspects of travellers in their use of malaria presumptive treatment.  Bull World Health Organ.1995;73:215-221.
PubMed
Jelinek T, Amsler L, Grobusch MP, Nothdurft HD. Self-use of rapid tests for malaria diagnosis by tourists.  Lancet.1999;354:1609.
PubMed
Silvers MJ, Purnomo Tracy LA, Woodward C, Barcu M, Ohrt C. Assessing and improving accuracy of malaria slide reading for clinical trials. In: Program and abstracts of the American Society of Tropical Medicine annual meeting; November 2001; Atlanta, Ga. Abstract 248.
Holtz TH, Onikopo F, Lama M, Cokou F, Kachur SP, Barat LM. Malaria microscopy in eight secondary health care facilities in Oueme. In Program and abstracts of the American Society of Tropical Medicine annual meeting; November 2001; Atlanta, Ga. Abstract 546.
World Health Organization.  The global malaria situation: current tools for prevention and control. In: 55th World Health Assembly. Global Fund to Fight Aids, Tuberculosis and Malaria. WHO document no. A55/INF.DOC./6. Available at: http://www.who.int/gb/ebwha/pdf_files/WHA55/ea55id6.pdf. Accessed November 16, 2003.
 Tuberculosis. Geneva, Switerland: World Health Organization; August 2002. Fact sheet No. 104. Available at: http://www.who.int/mediacentre/factsheets/who104/en. Accessed November 1, 2003.
Long R, Njoo H, Hershfield E. Tuberculosis, III: epidemiology of the disease in Canada.  CMAJ.1999;160:1185-1190.
PubMed
 Reported tuberculosis in the United States, 2002. Atlanta, Ga: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination Surveillance; 2002. Available at: http://www.cdc.gov/nchstp/tb/surv/surv.htm. Accessed January 15, 2004.
Lobato MN, Hopewell PC. Mycobacterium tuberculosis infection after travel to or contact with visitors from countries with a high prevalence of tuberculosis.  Am J Respir Crit Care Med.1998;158:1871-1875.
PubMed
Fischer PR. Pediatric, neonatal and adolescent travelers. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner, BA, ed. Travel Medicine. London, England: Elsevier Ltd; 2004:221-226.
Correia JD, Shafer RT, Patel V.  et al.  Blood and body fluid exposure as a health risk for international travelers.  J Travel Med.2001;8:263-268.
PubMed
Hutin YJ, Hauri AM, Armstrong JL. Use of injections in health care settings worldwide, 2000: literature review and regional estimates.  BMJ.2003;327:1075-1078.
PubMed
 World Health Organization International Travel and Health Web site. Available at: http://www.who.int/ith/chapter05_05.html. Accessed December 21, 2003.
 Prevention of Health Care Associated HIV Infection . Geneva, Switzerland: World Health Organization; 2003. Available at: http://www.who.int/bct/EHTadvfolder/finaldesing/HealthCareHIV.pdf. Accessed December 21,2003.
 The World Health Report, 2002.  .Geneva, Switzerland: World Health Organizaton; 2002:1-14. Available at: http://www.who.int/whr/2002/en. Accessed November 4, 2003.
De Schryver, Meheus A. International travel and STD.  World Health Stat Q.1989;42:90-99.
PubMed
Thompson MM, Hajera R. Travel and the introduction of human immunodeficiency virus type I non-B subtype genetic forms into Western countries.  Clin Infect Dis.2001;32:1732-1737.
PubMed
 High condom quality essential to reduce HIV spread.  Network.1988;10:6-7.
PubMed
Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs: time for international action.  BMJ.2002;324:800-801.
PubMed
Shakoor O, Taylor RB, Behrens RH. Assessment of the use of substandard drugs in developing countries.  Trop Med Int Health.1997;2:839-845.
PubMed
Newton P, Proux S, Green M.  et al.  Fake artesunate in Southeast Asia.  Lancet.2001;357:1948-1950.
PubMed
Saywell T, McManus J. What's in that pill?  Far Eastern Rev.February 2002:34-40.
Taylor RB, Shakoor O, Behrens RH.  et al.  Pharmacopoeial quality of drugs supplied by Nigerian pharmacies.  Lancet.2001;357:1933-1936.
PubMed
Shakoor O, Taylor RB, Behrens RH. Assessment of the use of substandard drugs in developing countries.  Trop Med Int Health.1997;2:839-845.
PubMed
Strine TW, Barker LE, Mokdad AH, Luman ET, Stutter RW, Chu SY. Vaccination coverage of foreign-born children 19 to 35 months of age.  Pediatrics.2002;110(2 pt 1):e15.
PubMed
Nagy G, Kosa S, Takatsy S, Koller M. The use of IgM tests for analysis of the causes of measles vaccine failures.  J Med Virol.1984;13:93-103.
PubMed
Chuang SK, Lau YL, Lim WL, Chow CB, Tsang T, Tse LY. Mass measles immunization campaign: experience in the Hong Kong Special Administrative Region of China.  Bull World Health Organ.2002;80:585-591.
PubMed
Chaudhary RK, Nicholls ES, Kennedy DA. Prevalence of hepatitis B markers in Indochinese refugees.  Can Med Assoc J.1981;125:1243-1246.
Hedley AJ, Abdullah ASM. East Asia. In: Dupont HL, Steffen R, ed. Textbook of Travel Medicine and Health. 2nd ed. London, England: Decker; 2001:71-72.
Barnett ED, Christianson D, Figueira M. Seroprevalence of measles, rubella and varicella in refugees.  Clin Infect Dis.2002;35:403-408.
PubMed
Lee BW. Review of varicella zoster seroepidemiology in India and Southeast Asia.  Trop Med Int Health.1998;3:886-890.
PubMed
Ryan ET, Kain KC. Health advice and immunizations for travelers.  N Engl J Med.2000;342:1716-1725.
PubMed
Barnett ED, Holmes AH, Geltman P, Phillips SL, Harrison TS. Immunity to hepatitis A in people born and raised in endemic areas.  J Travel Med.2003;10:11-15.
PubMed
Behrens RH, Collins M, Botto B, Heptonstall J. Risk for British travelers of acquiring hepatitis A [letter].  BMJ.1995;311:193.
PubMed
Sawayama Y, Hayashi J, Ariyama I.  et al.  A ten year serological survey of hepatitis A, B, and C viruses infections in Nepal.  J Epidemiol.1999;9:350-354.
PubMed
Batra Y, Bhatkal B, Ojha B, Kaur K.  et al.  Vaccination against Hepatitis A virus many not be required for school children in northern India: results of a seroepidemiological survey.  Bull World Health Organ.2002;80:728-731.
PubMed
Kosuwan P, Sutra S, Koralaraksa P, Poovorawan Y. Seroepidemilogy of hepatits A virus antibody in primary school children in Khon Kaen Province, northeastern Thailand.  Southeast Asian J Trop Med Public Health.1996;27:650-653.
PubMed
Poovorwan Y, Theamboonlers A, Sinlaparatsamee S.  et al.  Increasing susceptibility to HAV among members of the younger generation in Thailand.  Asian Pac J Allergy Immunol.2000;18:249-253.
PubMed
Chatchatee P, Chongsrisawat V, Theamboonlers A, Poovorawan Y. Declining hepatitis A seroprevalence among medical students in Bangkok, Thailand, 1981-2001.  Asian Pac J Allergy Immunol.2002;20:53-56.
PubMed
Ruttimann RW, Clemens RL. Argentine and Latin American hepatitis A.  J Travel Med.2002;9:220-221.
PubMed
Lee KK, Beyer-Blodget J. Screening travelers for hepatitis A antibody.  West J Med.2000;173:325-329.
PubMed
Steinberg E, Frisch A, Rossiter S, McClellan J, Ackers M, Mintz E. Typhoid fever in travelers: who should we vaccinate [abstract]?  Am Soc Trop Med Hyg: 2000;60.
Mahon BE, Mintz ED, Greene KD, Wells JG, Tauxe RV. Reported cholera in the United States, 1992-1994: a reflection of global changes in cholera epidemiology.  JAMA.1996;276:307-312.
PubMed
Clemens JD, Sack DA, Harris JR.  et al.  Cross-protection by B subunit-whole cell cholera vaccine against diarrhea associated with heat-labile toxin-producing enterotoxigenic Escherichia coli: results of a large-scale field trial.  J Infect Dis.1988;158:372-377.
PubMed
 Weekly Epidemiologic Report. 2003;133:294-296.
Leake JA, Kone ML, Yada AA.  et al.  Early detection and response to meningococcal disease epidemics in sub-saharan Africa: appraisal of the WHO strategy.  Bull World Health Organ.2002;80:342-349.
PubMed
 World Health Organization Communicable Disease Surveillance and Response 2003. Accessed November 22, 2003.
 Emergence of W135 meningococcal disease: Report of a WHO consultation. Geneva, Switzerland: World Health Organization; September 17-18, 2001.
 World Health Organization fact sheet No 99. June 2001. Accessed November 19, 2003.
Phanuphak P, Ubolyam S, Sirivichayakul S. Should travellers in rabies endemic areas receive pre-exposure rabies immunization?  Ann Med Interne (Paris).1994;145:409-411.
PubMed
Krause E, Grundmann H, Hatz C. Pretravel advice neglects rabies risk for travelers to tropical countries.  J Travel Med.1999;6:163-167.
PubMed
Pancharoen C, Thisyakorn U, Lawtongkum W, Wilde H. Rabies exposure in Thai children.  Wilderness Environ Med.2001;12:239-243.
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Specific Diseases Risk, Proposed Reasons for Risk Variance, and Recommendations to Reduce Risk Specific to Travelers Visiting Friends and Relatives
Table Graphic Jump LocationTable 2. Special Vaccine Issues for Travelers Immigrants visiting Friends and Relatives (VFRs)

References

Zuckerman JN. Travel medicine.  BMJ.2002;325:260-264.
PubMed
 International Migration Report 2002, New York, NY: United Nations, Dept Economic and Social Affair; October 25, 2002. Available at: http://www.un.org/esa/population/publications/ittmig2002/ittmigrep2002.htm.
 US Department of Homeland Security, Yearbook of Immigration Statistics, 2002 . Washington, DC: US Government Printing Office; 2003. Available at: http://uscis.gov/graphics/shared/aboutus/statistics/Yearbook2002.pdf. Accessed April 8, 2004.
US Census Bureau.  Profile of the Born Outside the United States Population 2000Washington, DC: US Government Printing Office; 2001. Available at: http://www.census.gov/prod/2002pubs/p23-206.pdf. Accessed December 15, 2003.
 2002 Profile of U.S Resident Traveler Visiting Overseas Destinations Reported From: Survey of International Air Travelers. Office of travel and tourism Industries, US Department of Commerce. Available at: http://tinet.ita.doc.gov/cat/f-2002-101-001.html. Accessed December 14,2003.
McCarthy M. Should visits to relatives carry a health warning?  Lancet.2001;357:862-865.
PubMed
Behrens RH. Visiting friends and relatives. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner, BA, eds.Travel Medicine. London, England: Elsevier Ltd; 2004:281-285.
 Local transmission of Plasmodium vivax malaria—Palm Beach County, Florida 2003.  MMWR Morb Mortal Wkly Rep.2003;52:908-911.
PubMed
 Local transmission of Plasmodiam vivax malaria – Virginia, 2002.  MMWR Morb Mortal Wkly Rep.2002;51:921-923.
PubMed
Horvath LL, Murray CK, Dooley DP. Utility of Services provided by a free travel medicine clinic. In: Program and abstracts of the 52th American Society of Tropical Medicine and Hygiene; December 2003; Philadelphia, Pa. Abstract 521:26.
Cobelens FG, van Deutekom H, Draayer-Jansen JW.  et al.  Risk of infection with Mycobacterium tuberculosis in travelers to areas of high tuberculosis endemicity.  Lancet.2000;356:461-465.
PubMed
Robbins JB, Schneerson R, Gotschlich EC.  et al.  Meningococcal meningitis in sub-Saharan Africa.  Bull World Health Organ.2003;81:745-749.
PubMed
Valerio L, Guerrero L, Martinez O. Travelling immigrants.  Aten Primaria.2003;32:330-336.
PubMed
Weiner L, Alkan M. Incidence and precipitating factors of morbidity among Israeli travelers abroad.  J Travel Med.2002;9:227-235.
PubMed
Andrews CN, Kobusingye OC, Lett R. Road traffic accident injuries in Kampala.  East Afr Med J.1999;76:189-194.
PubMed
McIness RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel.  J Travel Med.2002;9:297-306.
PubMed
Odero W, Garner P, Zwi A. Road traffic accidents in developing countries.  Trop Med Int Health.1997;2:445-460.
PubMed
Kolars JC. Rules of the road: a consumer's guide for travelers seeking health care abroad.  J Travel Med.2002;9:198-202.
PubMed
McFarlane S, Racelis M, Muli-Muslime F. Public health in developing countries.  Lancet.2000;356:841-846.
PubMed
Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile?  Bull World Health Organ.2002;80:900-905.
PubMed
Walker PF, Jaranson J. Refugee and immigrant health care.  Med Clin North Am.1999;83:1103-1119.
PubMed
Eiseman DP, Gelberg L, Lui H, Shapiro MF. Mental health and health related quality of life among adult Latino primary care patients living in the United States with previous exposure to violence.  JAMA.2003;290:627-634.
PubMed
Dijkshoorn H, Schilthuis HJ, van den Hoek JA, Verhoeff AP. Travel advice on the prevention of infectious diseases insufficiently obtained by indigenous and non-native inhabitants of Amsterdam, the Netherlands [in Dutch].  Ned Tijdschr Geneeskd.2003;147:658-662.
PubMed
Duval B, De Serre G, Shadmani R.  et al.  A population-based comparison between travelers who consulted travel clinics and those who did not.  J Travel Med.2003;10:4-10.
PubMed
Hughes NJ, Carlisle R. How important a priority is travel medicine for a typical British family practice?  J Travel Med.2000;7:138-141.
PubMed
Laver SM, Wetzels J, Behrens RH. Knowledge of malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travelers exiting Zimbabawe from Harare and Victoria Falls International airport.  J Travel Med.2001;8:298-303.
PubMed
Kozichi M, Steffen R, Scgar M. "Boil it, cook it, peel it, or forget it!" does this rule prevent travelers' diarrhoea.  Int J Epidemiol.1985;14:169-172.
PubMed
Casalino E, Bras JL, Chaussin F, Fichelle A, Bouvet E. Predictive factors of malaria in travelers to areas where malaria is endemic.  Arch Intern Med.2002;162:1625-1630.
PubMed
Minodier P, Nassur A, Hassid S.  et al.  Antimousquito precautions and medical chemoprophylaxis in French children with malaria.  J Travel Med.2003;10:318-325.
PubMed
Dos Santos CC, Anvar A, Keystone JS, Kain KC. Survey of malaria prevention measures by Canadians visiting India.  CMAJ.1999;160:195-200.
PubMed
Badrinath P, Ejidokun OO, Barnes N, Ramaiah S. Change in NHS regulations may have caused increase in malaria.  BMJ.1998;316:1746-1747.
PubMed
Backer H, Mackell S. Potential cost-savings and quality improvement in travel advice for children and families from a centralized travel medicine clinic in a large group-model health maintenance organization.  J Travel Med.2001;8:247-253.
PubMed
White NJ. Malaria. In: Cook GC, Zumla A, eds. Manson's Tropical Diseases. 21st ed. Philadelphia, Pa: Saunders; 2003:1205-1296.
Campbell H. Imported malaria in the UK: advice given by general practitioners to British residents traveling to malaria endemic areas.  J R Coll Gen Pract.1987;37:70-72.
PubMed
Stauffer WM, Kamat D, Walker PF. Screening of international immigrants, refugees, and adoptees.  Prim Care.2002;29:879-906.
PubMed
Christenson JC, Fischer PR, Hale DC, Derrick D. Pediatric travel consultation in an integrated clinic.  J Travel Med.2001;8:1-5.
PubMed
Bauer I. The health of host communities: missing from printed travel health advice.  J Travel Med.2003;10:350-353.
PubMed
Von Sonnenburg F, Tornleporth N, Walyaki P.  et al.  Risk and aetiology of diarrhea at various tourist destinations.  Lancet.2000;356:133-134.
PubMed
Steffen R, Kollaritsch H, Fleischer K. Travelers' diarrhea in the new millennium: consensus among experts from German-speaking countries.  J Travel Med.2003;10:38-45.
PubMed
Steffen R, Collard F, Tornieporth N.  et al.  Epidemiology, etiology, and impact of TD in Jamaica.  JAMA.1999;281:811-817.
PubMed
Boulware DR, Forgey WW, Martin WJ. Medical risks of wilderness hiking.  Am J Med.2003;114:288-293.
PubMed
Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer use on elementary school absenteeism.  Am J Infect Control.2000;28:340-346.
PubMed
White CG, Shinder FS, Shinder AL, Dyer DL. Reduction of illness absenteeism in elementary schools using an alcohol-free hand sanitizer.  J Sch Nurs.2001;17:258-265.
PubMed
Mensah P, Yeboah-Manu D, Owusu-Darko K, Albordey A. Street foods in Accra Ghana: how safe are they?  Bull World Health Organ.2002;80:546-553.
PubMed
 Health Information for International Travel 2003-2004 . Atlanta, Ga: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2003.
Stauffer WM, Konop RJ, Deepak K. Traveling with infants and young children, I: anticipatory guidance: travel preparation and preventive health advice.  J Travel Med.2001;8:254-261.
PubMed
Young EJ. Brucella species (brucellosis). In: Long S, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed. New York, NY: Elsevier; 2003:877-878.
Tasbakan MI, Yamazhan T, Gokengin D.  et al.  Brucellosis: a retrospective evaluation.  Trop Doct.2003;33:151-153.
PubMed
Barbier HM, Diaz JH. Prevention and treatment of toxic seafoodborne diseases in travelers.  J Travel Med.2003;10:29-37.
PubMed
Ansdell V. Food-borne illnesses. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner BA, eds. Travel Medicine. London, England: Elsevier Ltd; 2004:443-446
Stauffer WM, Sellman JS, Walker PS. Liver flukes (opisthorchiasis and clonorchiasis) in immigrants in the United States.  J Travel Med.2004;11:157-160.
Morris JG. Cholera and other types of vibriosis: a story of human pandemics and oysters on the half shell.  Clin Infect Dis.2003;37:272-280.
PubMed
Deardorff TL. Epidemiology of marine fish-borne parasitic zoononses.  Southeast Asian J Trop Med Public Health.1991;22(suppl):146-149.
PubMed
Koopmans M, Duizer E. Foodborne viruses: an emerging problem.  Int J Food Microbiol.2004;90:23-41.
PubMed
Hoge CW, Gambel JM, Srijan A, Pitarangsi C, Echeverria P. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years.  Clin Infect Dis.1998;26:341-345.
PubMed
Adachi JA, Ericsson CD, Jiang ZD.  et al.  Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.  Clin Infect Dis.2003;37:1165-1171.
PubMed
Schreck CE, McGovern TP. Repellents and other personal protection strategies against Aedes albopictus J Am Mosq Control Assoc.1989;5:247-250.
PubMed
Lillie TH, Schreck CE, Rahe AJ. Effectiveness of personal protection against mosquitoes in Alaska.  J Med Entomol.1988;25:475-478.
PubMed
Wellems TE, Miller LH. Two worlds of malaria [perspective].  N Engl J Med.2003;349:1496-1498.
PubMed
Kain KC, Harrington MA, Tennyson S, Keystone JS. Imported malaria.  Clin Infect Dis.1998;27:142-149.
PubMed
Ladhani S, El Bashir H, Patel VS, Shingadia D. Childhood malaria in East London.  Pediatr Infect Dis J.2003;22:814-819.
PubMed
Castelli F, Matteelli A, Caligaris S.  et al.  Malaria in migrants.  Parassitologia.1999;41:261-265.
PubMed
Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria.  J Travel Med.2003;10:106-107.
PubMed
Schlagenhauf P, Tschopp A, Johnson R, Nothdurft HD. Tolerability of malaria chemoprophylaxis in non-immune travelers to sub-Saharan Africa.  BMJ.2003;327:1078-1083.
PubMed
Overbosch D, Schilthuis H, Bienzle U.  et al.  Atovaquone-proguanil vs mefloquine for malaria prophylaxis in non-immune travelers.  Clin Infect Dis.2001;33:1015-1021.
PubMed
Petersen E, Ronne T, Ronn A, Bygbjerg I, Larsen SO. Reported side effects to chloroquine, chloroquine plus proguanil, and mefloquine as chemoprophylaxis against malaria in Danish travelers.  J Travel Med.2000;7:79-84.
PubMed
 Consumer guide for malaria drug.  FDA Consumer Magazine.2003;37:7. Available at: http://www.fda.gov/fdac/departs/2003/503_upd.html#malaria. Accessed December 19, 2003.
Schlagenhauf P, Steffen R. Stand-by treatment of malaria in travelers: a review.  J Trop Med Hyg.1994;97:151-160.
PubMed
 Behavioural aspects of travellers in their use of malaria presumptive treatment.  Bull World Health Organ.1995;73:215-221.
PubMed
Jelinek T, Amsler L, Grobusch MP, Nothdurft HD. Self-use of rapid tests for malaria diagnosis by tourists.  Lancet.1999;354:1609.
PubMed
Silvers MJ, Purnomo Tracy LA, Woodward C, Barcu M, Ohrt C. Assessing and improving accuracy of malaria slide reading for clinical trials. In: Program and abstracts of the American Society of Tropical Medicine annual meeting; November 2001; Atlanta, Ga. Abstract 248.
Holtz TH, Onikopo F, Lama M, Cokou F, Kachur SP, Barat LM. Malaria microscopy in eight secondary health care facilities in Oueme. In Program and abstracts of the American Society of Tropical Medicine annual meeting; November 2001; Atlanta, Ga. Abstract 546.
World Health Organization.  The global malaria situation: current tools for prevention and control. In: 55th World Health Assembly. Global Fund to Fight Aids, Tuberculosis and Malaria. WHO document no. A55/INF.DOC./6. Available at: http://www.who.int/gb/ebwha/pdf_files/WHA55/ea55id6.pdf. Accessed November 16, 2003.
 Tuberculosis. Geneva, Switerland: World Health Organization; August 2002. Fact sheet No. 104. Available at: http://www.who.int/mediacentre/factsheets/who104/en. Accessed November 1, 2003.
Long R, Njoo H, Hershfield E. Tuberculosis, III: epidemiology of the disease in Canada.  CMAJ.1999;160:1185-1190.
PubMed
 Reported tuberculosis in the United States, 2002. Atlanta, Ga: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination Surveillance; 2002. Available at: http://www.cdc.gov/nchstp/tb/surv/surv.htm. Accessed January 15, 2004.
Lobato MN, Hopewell PC. Mycobacterium tuberculosis infection after travel to or contact with visitors from countries with a high prevalence of tuberculosis.  Am J Respir Crit Care Med.1998;158:1871-1875.
PubMed
Fischer PR. Pediatric, neonatal and adolescent travelers. In: Keystone JS, Kozasky PE, Freedman DO, Northdurft HD, Conner, BA, ed. Travel Medicine. London, England: Elsevier Ltd; 2004:221-226.
Correia JD, Shafer RT, Patel V.  et al.  Blood and body fluid exposure as a health risk for international travelers.  J Travel Med.2001;8:263-268.
PubMed
Hutin YJ, Hauri AM, Armstrong JL. Use of injections in health care settings worldwide, 2000: literature review and regional estimates.  BMJ.2003;327:1075-1078.
PubMed
 World Health Organization International Travel and Health Web site. Available at: http://www.who.int/ith/chapter05_05.html. Accessed December 21, 2003.
 Prevention of Health Care Associated HIV Infection . Geneva, Switzerland: World Health Organization; 2003. Available at: http://www.who.int/bct/EHTadvfolder/finaldesing/HealthCareHIV.pdf. Accessed December 21,2003.
 The World Health Report, 2002.  .Geneva, Switzerland: World Health Organizaton; 2002:1-14. Available at: http://www.who.int/whr/2002/en. Accessed November 4, 2003.
De Schryver, Meheus A. International travel and STD.  World Health Stat Q.1989;42:90-99.
PubMed
Thompson MM, Hajera R. Travel and the introduction of human immunodeficiency virus type I non-B subtype genetic forms into Western countries.  Clin Infect Dis.2001;32:1732-1737.
PubMed
 High condom quality essential to reduce HIV spread.  Network.1988;10:6-7.
PubMed
Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs: time for international action.  BMJ.2002;324:800-801.
PubMed
Shakoor O, Taylor RB, Behrens RH. Assessment of the use of substandard drugs in developing countries.  Trop Med Int Health.1997;2:839-845.
PubMed
Newton P, Proux S, Green M.  et al.  Fake artesunate in Southeast Asia.  Lancet.2001;357:1948-1950.
PubMed
Saywell T, McManus J. What's in that pill?  Far Eastern Rev.February 2002:34-40.
Taylor RB, Shakoor O, Behrens RH.  et al.  Pharmacopoeial quality of drugs supplied by Nigerian pharmacies.  Lancet.2001;357:1933-1936.
PubMed
Shakoor O, Taylor RB, Behrens RH. Assessment of the use of substandard drugs in developing countries.  Trop Med Int Health.1997;2:839-845.
PubMed
Strine TW, Barker LE, Mokdad AH, Luman ET, Stutter RW, Chu SY. Vaccination coverage of foreign-born children 19 to 35 months of age.  Pediatrics.2002;110(2 pt 1):e15.
PubMed
Nagy G, Kosa S, Takatsy S, Koller M. The use of IgM tests for analysis of the causes of measles vaccine failures.  J Med Virol.1984;13:93-103.
PubMed
Chuang SK, Lau YL, Lim WL, Chow CB, Tsang T, Tse LY. Mass measles immunization campaign: experience in the Hong Kong Special Administrative Region of China.  Bull World Health Organ.2002;80:585-591.
PubMed
Chaudhary RK, Nicholls ES, Kennedy DA. Prevalence of hepatitis B markers in Indochinese refugees.  Can Med Assoc J.1981;125:1243-1246.
Hedley AJ, Abdullah ASM. East Asia. In: Dupont HL, Steffen R, ed. Textbook of Travel Medicine and Health. 2nd ed. London, England: Decker; 2001:71-72.
Barnett ED, Christianson D, Figueira M. Seroprevalence of measles, rubella and varicella in refugees.  Clin Infect Dis.2002;35:403-408.
PubMed
Lee BW. Review of varicella zoster seroepidemiology in India and Southeast Asia.  Trop Med Int Health.1998;3:886-890.
PubMed
Ryan ET, Kain KC. Health advice and immunizations for travelers.  N Engl J Med.2000;342:1716-1725.
PubMed
Barnett ED, Holmes AH, Geltman P, Phillips SL, Harrison TS. Immunity to hepatitis A in people born and raised in endemic areas.  J Travel Med.2003;10:11-15.
PubMed
Behrens RH, Collins M, Botto B, Heptonstall J. Risk for British travelers of acquiring hepatitis A [letter].  BMJ.1995;311:193.
PubMed
Sawayama Y, Hayashi J, Ariyama I.  et al.  A ten year serological survey of hepatitis A, B, and C viruses infections in Nepal.  J Epidemiol.1999;9:350-354.
PubMed
Batra Y, Bhatkal B, Ojha B, Kaur K.  et al.  Vaccination against Hepatitis A virus many not be required for school children in northern India: results of a seroepidemiological survey.  Bull World Health Organ.2002;80:728-731.
PubMed
Kosuwan P, Sutra S, Koralaraksa P, Poovorawan Y. Seroepidemilogy of hepatits A virus antibody in primary school children in Khon Kaen Province, northeastern Thailand.  Southeast Asian J Trop Med Public Health.1996;27:650-653.
PubMed
Poovorwan Y, Theamboonlers A, Sinlaparatsamee S.  et al.  Increasing susceptibility to HAV among members of the younger generation in Thailand.  Asian Pac J Allergy Immunol.2000;18:249-253.
PubMed
Chatchatee P, Chongsrisawat V, Theamboonlers A, Poovorawan Y. Declining hepatitis A seroprevalence among medical students in Bangkok, Thailand, 1981-2001.  Asian Pac J Allergy Immunol.2002;20:53-56.
PubMed
Ruttimann RW, Clemens RL. Argentine and Latin American hepatitis A.  J Travel Med.2002;9:220-221.
PubMed
Lee KK, Beyer-Blodget J. Screening travelers for hepatitis A antibody.  West J Med.2000;173:325-329.
PubMed
Steinberg E, Frisch A, Rossiter S, McClellan J, Ackers M, Mintz E. Typhoid fever in travelers: who should we vaccinate [abstract]?  Am Soc Trop Med Hyg: 2000;60.
Mahon BE, Mintz ED, Greene KD, Wells JG, Tauxe RV. Reported cholera in the United States, 1992-1994: a reflection of global changes in cholera epidemiology.  JAMA.1996;276:307-312.
PubMed
Clemens JD, Sack DA, Harris JR.  et al.  Cross-protection by B subunit-whole cell cholera vaccine against diarrhea associated with heat-labile toxin-producing enterotoxigenic Escherichia coli: results of a large-scale field trial.  J Infect Dis.1988;158:372-377.
PubMed
 Weekly Epidemiologic Report. 2003;133:294-296.
Leake JA, Kone ML, Yada AA.  et al.  Early detection and response to meningococcal disease epidemics in sub-saharan Africa: appraisal of the WHO strategy.  Bull World Health Organ.2002;80:342-349.
PubMed
 World Health Organization Communicable Disease Surveillance and Response 2003. Accessed November 22, 2003.
 Emergence of W135 meningococcal disease: Report of a WHO consultation. Geneva, Switzerland: World Health Organization; September 17-18, 2001.
 World Health Organization fact sheet No 99. June 2001. Accessed November 19, 2003.
Phanuphak P, Ubolyam S, Sirivichayakul S. Should travellers in rabies endemic areas receive pre-exposure rabies immunization?  Ann Med Interne (Paris).1994;145:409-411.
PubMed
Krause E, Grundmann H, Hatz C. Pretravel advice neglects rabies risk for travelers to tropical countries.  J Travel Med.1999;6:163-167.
PubMed
Pancharoen C, Thisyakorn U, Lawtongkum W, Wilde H. Rabies exposure in Thai children.  Wilderness Environ Med.2001;12:239-243.
PubMed

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