Visiting Relatives and Friends (VFR), Pregnant, and Other Vulnerable Travelers

Malaria risk perceptions and barriers for effective prophylaxis among sub-Saharan African 'visiting friends and relatives' travellers in Hamburg, Germany

BACKGROUND

The African visiting friends and relatives (VFR) community in the Global North is at high risk of contracting preventable travel-associated infections including malaria when travelling to sub-Saharan Africa. This study aimed to assess barriers to effective prevention and to develop tailored travel counselling.

METHODS

A questionnaire-based survey was conducted from January to August 2023 at the Hamburg Airport among adult sub-Saharan African VFR travellers returning from malaria-endemic destinations in Africa to assess malaria risk perceptions, attitudes towards prophylaxis and counselling and their experiences with travel medicine and malaria prophylaxis.

RESULTS

A total of 389 participants completed the survey. Of these, 67 % (n = 261) demonstrated adequate knowledge of malaria transmission. Fifty-one percent (n = 198) perceived minimal risk of contracting malaria in the malaria-endemic country leading to lower uptake of prophylaxis. Ten percent (n = 37) mistakenly believed they were vaccinated against malaria. Approximately half of the respondents did not seek medical travel advice prior to departure or take antimalarial prophylaxis due to perceived minimal risk of disease. Of those who took antimalarial drugs, 77 % (n = 149) completed the full course. On return, 5 % (n = 20) of the respondents had malaria-like symptoms and of these, 55 % (n = 11) either self-medicated or did not seek medical treatment.

CONCLUSIONS

VFR travellers mistakenly perceive a low risk of malaria, resulting in low uptake of travel medical advice and chemoprophylaxis. Mistrust of advice from healthcare providers was found. Insights from this survey are valuable for practitioners and travel medicine clinics to provide more tailored and culturally sensitive travel advice to VFR travellers.

Travel patterns and advice-seeking behaviour of pregnant women in the Australian context: A multicentre cross-sectional analysis

BACKGROUND

Travel poses risks to pregnant women, but little data exist describing the travel habits of women during pregnancy or pre-travel recommendations given.

AIMS

To examine travel patterns of pregnant women including frequency of pre-travel consultation, and advice recalled.

MATERIALS AND METHODS

Cross-sectional analysis of post-partum women admitted to five Victorian maternity hospitals between 21 May 2019 and 22 April 2020 in Australia.

RESULTS

Forty-four percent (182/410) of women travelled during pregnancy, 32.9% (135/410) interstate and 19.5% (80/410) internationally. Fifty-five percent travelled for leisure (118/215) and 27% to visit friends/relatives (58/215). Overall, 68.1% (124/182) sought pre-travel advice, primarily from an obstetrician (60.5%, 75/124) or general practitioner (29.8%, 37/124). Only one woman attended a travel clinic. The most common reason for not seeking pre-travel advice was the belief that travel posed no risk (63.4%, 45/71). Pre-travel advice was sought least by those visiting friends/relatives (61.4%, 35/57). Women recalled recommendations regarding travel restrictions by gestational age and venous thromboembolism precautions, but not infectious disease prevention for those to whom it was relevant. Of international travellers, 48.8% (39/80) sought advice from the internet, one-third (13/39) as an alternative to seeing a healthcare provider.

CONCLUSIONS

Travel is common during pregnancy and women seek pre-travel advice from the healthcare provider they see most often during pregnancy. All pregnant women should be provided with consistent, evidence-based pre-travel advice regardless of whom they consult. Further work is needed to educate and provide resources to maternity care providers to optimise pre-travel counselling.

Risk of malaria associated with travel to malaria-endemic areas to visit friends and relatives: a population-based case-control study

BACKGROUND

Reports relying on population-based data and using epidemiologic methodologies such as case-control study designs for malaria in travellers and multivariable regression analysis of risk factors are rare. The aim of this study was to investigate the epidemiologic characteristics of travellers who tested positive for malaria after visiting friends and relatives in malaria-endemic areas to determine the risk of malaria associated with such travel.

METHODS

Using routinely collected data from a population-based laboratory database, we conducted a case-control study of symptomatic people returning from travel to malaria-endemic areas who presented for malaria testing in Calgary from 2013 to 2017. We used a multivariable logistic regression to analyze the association between the presence of malaria and other risk factors.

RESULTS

There were 251 confirmed malaria cases during the study period, of which 219 were matched to 1129 returning travellers without malaria. Based on the multivariable regression, the odds of a traveller who visited friends and relatives in malariaendemic areas being diagnosed with malaria was 2.82 (95% confidence interval [CI] 1.42-5.92) times greater than that of other travellers to these regions. Adults (odds ratio [OR] 3.62, 95% CI 1.66-8.84), males (OR 2.70, 95% CI 1.56-4.80), travellers to Africa (OR 11.52, 95% CI 6.33-22.05) and those who did not seek pretravel advice (OR 0.38, 95% CI 0.20-0.70) were more likely to be diagnosed with malaria. Although those travelling to visit friends and relatives tended to stay longer in endemic areas than other travellers, visit duration was not associated with an increased likelihood of malaria in the model. The annual incidence of malaria was highest (13.34 per 100 000) in metropolitan wards associated with lower socioeconomic status and immigrant communities.

INTERPRETATION

Travellers who visited friends and relatives in malaria-endemic areas were less likely than other travellers to these regions to seek pretravel advice, take prophylaxis and have a visit duration less than 2 weeks; travelling to Africa and being male increased the odds of being diagnosed with malaria, independent of other factors. These data suggest that targeted strategies to provide pretravel care to travellers who visit friends and relatives in malaria-endemic areas may aid in reducing the burden of malaria in this population.

Evaluation of the sick returned traveler

Infections are common during travel, and frontline physicians frequently must evaluate sick returned travelers. Sick travelers can be clinically challenging due to the wide range of endemic diseases in different geographic regions. To guide the diagnostic and treatment plan, consideration of endemic and emerging infections in the region of travel, as well as careful review of the travelers' exposures and preventative measures are necessary. Routine laboratory tests and cultures cannot confirm many tropical infections, and pathogen directed testing is typically required. Common tropical infections that can be severe, such as malaria, dengue, and enteric fever, should always be considered in the diagnostic evaluation. Providers should also be vigilant for rare but highly pathogenic emerging infections such as Ebola virus disease and Middle East respiratory syndrome (MERS).

Preventing diseases in round-the-world travelers: a contemporary challenge for travel medicine advice

Providing advice for travelers embarking on long-term trips poses a challenge in travel medicine. A long duration of risk exposure is associated with underuse of protective measures and poor adherence to chemoprophylaxis, increasing the chances of acquiring infections. Recently, in our clinic, we observed an increase in the number of travelers undertaking round-the-world trips. These individuals are typically aged around 32 years and quit their jobs to embark on one-to-two-year journeys. Their destinations include countries in two or more continents, invariably Southeast Asia and Indonesia, and mostly involve land travel and visiting rural areas. Such trips involve flexible plans, increasing the challenge, especially with regard to malaria prophylaxis. Advising round-the-world travelers is time-consuming because of the amount of information that must be provided to the traveler. Advisors must develop strategies to commit the traveler to his/her own health, and verify their learnings on disease-prevention measures. Contacting the advisor after the appointment or during the trip can be helpful to clarify unclear instructions or diagnosis made and prescriptions given abroad. Infectious diseases are among the most frequent problems affecting travelers, many of which are preventable by vaccines, medicines, and precautionary measures. The dissemination of counterfeit medicines, particularly antibiotics and antimalarial medicines, emphasizes the need for travelers to carry medicines that they may possibly need on their trip. Additional advice on altitude, scuba diving, and other possible risks may also be given. Considering the difficulties in advising this group, we present a review of the main recommendations on advising these travelers.

Guidelines for the prevention of travel-associated illness in older adults

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.

The elderly, the young and the pregnant traveler -- A retrospective data analysis from a large Swiss Travel Center with a special focus on malaria prophylaxis and yellow fever vaccination

BACKGROUND

Vulnerable individuals such as elderly, children/adolescents and pregnant/breastfeeding women increasingly travel overseas. We describe the travel and vaccination patterns of these groups at the largest Travel Clinic in Switzerland especially focusing on travel to yellow fever and malaria-endemic countries, and yellow fever vaccination (YFV) and malaria medications.

METHOD

An analysis of pre-travel visits between 2010 and 2012 at the Travel Clinic of the University of Zurich, was performed assessing differences between the elderly, young and middle-aged travelers as well as between pregnant/breastfeeding and other female travelers.

RESULTS

Overall, the vulnerable groups did not differ from other travelers regarding their travel patterns. YFV was the most often administered vaccine to elderly travelers; half of them received it for the first time. More than 30% of children/adolescents received YFV, but no child below six months was vaccinated. 80% of young travelers and a similar percentage of pregnant women went to malaria-endemic regions. Twenty-five pregnant/breastfeeding women traveled to YF endemic areas.

CONCLUSIONS

Travel patterns of vulnerable travelers are comparable to those of other travelers. In view of the limited data on malaria medications and precautions against YFV during pregnancy and at the extreme ages of life, giving travel advice to these groups is challenging.

Ebola virus disease in nonendemic countries

The 2014 West African outbreak of Ebola virus disease was unprecedented in its scale and has resulted in transmissions outside endemic countries. Clinicians in nonendemic countries will most likely face the disease in returning travelers, either among healthcare workers, expatriates, or visiting friends and relatives. Clinical suspicion for the disease must be heightened for travelers or contacts presenting with compatible clinical syndromes, and strict infection control measures must be promptly implemented to minimize the risk of secondary transmission within healthcare settings or in the community. We present a concise review on human filoviral disease with an emphasis on issues that are pertinent to clinicians practicing in nonendemic countries.

A profile of travelers--an analysis from a large swiss travel clinic

BACKGROUND

Globally, the Swiss have one of the highest proportions of the population traveling to tropical and subtropical countries. Large travel clinics serve an increasing number of customers with specific pre-travel needs including uncommon destinations and preexisting medical conditions. This study aims to identify health characteristics and travel patterns of travelers seeking advice in the largest Swiss travel clinic so that tailored advice can be delivered.

METHODS

A descriptive analysis was performed on pre-travel visits between July 2010 and August 2012 at the Travel Clinic of the Institute of Social and Preventive Medicine, University of Zurich, Switzerland.

RESULTS

A total of 22,584 travelers sought pre-travel advice. Tourism was the main reason for travel (17,875, 81.5%), followed by visiting friends and relatives (VFRs; 1,715, 7.8%), traveling for business (1,223, 5.6%), and "other reasons" (ie, volunteer work, pilgrimage, study abroad, and emigration; 1,112, 5.1%). The main travel destination was Thailand. In the VFR group, the highest proportions of traveling children (258, 15.1%) and of pregnant or breastfeeding women (23, 3.9%) were observed. Mental disorders were more prominent in VFRs (93, 5.4%) and in travel for "other reasons" (63, 5.7%). The latter stayed for the longest periods abroad; 272 (24.9%) stayed longer than 6 months. VFR travelers received the highest percentage of yellow fever vaccinations (523, 30.5%); in contrast, rabies (269, 24.2%) and typhoid vaccinations (279, 25.1%) were given more often to the "other travel reasons" group.

CONCLUSIONS

New insights into the characteristics of a selected and large population of Swiss international travelers results in improved understanding of the special needs of an increasingly diverse population and, thus, in targeted preventive advice and interventions.