Tips For Visiting Friends or Relatives in a Foreign Country

People who are traveling to a foreign country to visit friends or relatives(“ VFR travelers ”) are at higher risk for some diseases. The three most common developing countries of birth in the Australian population are China(1.8%), India(1.5%) and Vietnam(0.9%). ³ Many of these overseas born individuals will, at some stage, travel to their country of origin to visit friends and relatives. Such travellers are known as ‘VFR’ (visiting friends and relatives) travellers, and they comprise 25-40% of all international travellers.

The risk is higher because VFR travellers generally stay longer than tourists, eat local food in people’s homes, and may not take the same precautions (such as preventing bug bites) as tourists do. VFR travelers often do not see a doctor for vaccines and advice before they travel, possibly because of cost, cultural or language barriers, or limited time. If you are planning to travel overseas to visit friends or relatives, consider your increased risk of illnesses and plan accordingly. Because the destination is familiar to them or their family; they may underestimate risks to their health.

Reasons for increased travel risks among travellers visiting friends and relatives

Barriers to providing and accessing care

Language bafflers

Financial bafflers (expense of medications and/or vaccines)

Cultural barriers

Differences in belief systems

Problems accessing health services

Belief in ongoing immunity

Lack of perception of disease risk

Behavioural characteristics

Less likely to seek pre-travel health advice

Less likely to be adequately vaccinated (including routine childhood vaccinations)

More likely to visit remote and rural areas

More likely to have close contact with local populations and live the local lifestyle

More likely to consume high-risk food and beverages

More likely to undergo last-minute travel (for family events or to visit ill relatives)

More likely to take longer trips

More likely to travel with small children or while pregnant

Less likely to use malaria chemoprophylaxis

Malaria

VFR travelers are 8–10 times as likely to be infected with malaria as tourists, and in recent years, several VFR travelers have died of malaria after they return home. Many VFR travelers assume they are immune to malaria if they were born or lived a long time in a country with malaria, but any immunity disappears quickly after a person moves away. If you are going to a country with malaria, take malaria-prevention medicine according to your doctor’s instructions, even if your friends and relatives who still live in the country do not.

Mosquito-bite prevention strategies

Apply insect repellents containing an active ingredient such as diethyl-meta-toulamide (DEET≥20%) or picaridin to exposed areas of skin

Minimise areas of exposed skin by wearing long-sleeved shirts, long pants. boots and hats

Treat clothes with an insecticide such as permethrin 2%

Use mosquito nets treated with an insecticide such as permethrin 2%

Sleep in screened, air-conditioned accommodation if possible

Avoid outside activities between dusk and dawn (relevant especially for malaria, which has night-biting vectors)

Foodborne Illness

Illnesses spread through contaminated food are common in VFR travelers, who often feel pressure to eat what they are served by family or friends. VFR travelers also do not have the same immunity to local bacteria as their friends and relatives do. Some foodborne illnesses, such as hepatitis A and typhoid, can be prevented with vaccines, but many others cannot. See a doctor before you travel to get any vaccines you may need, but also be very careful about what you eat and drink. In general, food that is cooked and served piping hot is safe to eat and beverages from sealed containers are safe to drink. Avoid food served at room temperature, raw fruits or vegetables (unless they can be peeled), tap water, and ice made from tap water. Australian-born children of VFR travellers may be particularly vulnerable to vaccine preventable diseases such as hepatitis A ^7,8 while visiting their parent’s country of origin if the family do not seek pre-travel advice.

Prevention of food- and water-borne illness

Avoid high-risk food and drink items such as uncooked salads and beverages containing ice

Select freshly cooked foods served steaming hot. fruit that can be peeled, and beverages that are bottled

Wash hands frequently with soap and water

Use hand-sanitising solutions

Boil or treat drinking water (iodine or chloride)

Other Illnesses

Other health considerations for VFR travelers include dengue and other infections spread by mosquitoes as well as parasites in water, tuberculosis, and sexually transmitted diseases.

VFRs should be educated regarding the risk of tuberculosis, and should try to minimise exposure to individuals who have a cough. The BCG vaccine is not routinely given to babies born in Australia. The Australian Immunisation Handbook suggests BCG for children aged under five living in endemic areas for more than three months.

If the purpose of the VFR trip is to specifically introduce a new baby to family and friends, in an area where TB is prevalent, an even shorter duration of travel might impose a significant risk of exposure to tuberculosis.

HIV and STIs

The risk of HIV and STIs (like Hepatitis B) is increased in VFR travellers, probably related to increased length of travel, exposure through sexual contact with local residents, and use of local medical and dental services or services such as manicures and shaves. ⁶ It is important to educate VFRs on safe-sex practices and the risk of STIs. Condoms purchased in developing countries may be of unreliable/ inconsistent quality, so it is best to advise travellers to purchase condoms before travel. Hepatitis B is vaccine-preventable and where possible; those not previously immunised should be tested for hepatitis B antibodies, and vaccination should be provided.

Tips For Traveling with Children

Parents traveling overseas with children should know health risks and how to avoid them.

Diarrhoea

Diarrhoea is among the most common illnesses experienced by children who are traveling. For infants, the best way to prevent diarrhea is breastfeeding. Older children visiting developing countries should follow basic food and water precautions: eat only food that is cooked and served hot, peel fresh fruits and vegetables or wash them in clean water, and drink only beverages from sealed containers or water that has been boiled or treated. Children should wash their hands or use alcohol-based hand cleaner frequently.

Diarrhoea can be serious in infants and small children because of the risk of dehydration. The best treatment for diarrhea in children is to give plenty of fluids; there is usually no need to give medicine. Oral rehydration salts (Hydralyte, Gastrolyte) may be used to prevent dehydration.

Malaria Prevention

If there is a malaria risk in your destination, your doctor may prescribe pills to prevent malaria. Some of these drugs must be started 1–2 weeks before you leave, so if you’re leaving sooner, let your doctor know. Other drugs to prevent malaria need to be started only 1–2 days before you leave. Since none of the drugs is 100% effective, you will also need to take steps to avoid mosquito bites.

Malaria drugs are not 100% effective, and other diseases (such as dengue) also are spread by insects, so all travellers need to avoid bug bites. Using DEET containing mosquito repellant spray, long pants and sleeves are important. At night, sleep in screened, air-conditioned rooms or under a bed net.

Influenza

Influenza is caused by the influenza viruses (A and B), which are transmitted via respiratory secretions. Influenza transmission is seasonal in temperate regions, like Australia, but year-round in the tropics.

Tips For Pregnant Travellers

Although there are some special considerations for women who travel while pregnant.

Before you book a flight, check how late in your pregnancy the airline will let you fly. Most will let you fly until 36 weeks, but some have an earlier cutoff if travelling overseas and even earlier if going on a cruise. Your feet may become swollen on a long flight, so wear comfortable shoes and loose clothing, and try to walk around every hour or so. To reduce your risk of a blood clot, consider doing leg exercises you can do in your seat, avoid consuming alcohol and ensure you are well hydrated.

Food and Water Safety

Travelers’ diarrhea is caused by eating or drinking contaminated food or water, and dehydration from travelers’ diarrhea can be more of a problem for pregnant women. If you are traveling in a developing country, you should carefully follow food and water safety measures:

Eat only food that is cooked and served piping hot.
Do not eat cold food or food that has been sitting at room temperature (such as a buffet).
Do not eat raw or undercooked meat or fish.
Eat fresh fruits and vegetables only if you can peel them or wash them in clean water.
Do not eat unpasteurized dairy products.
Drink only water, sodas, or sports drinks that are bottled and sealed (carbonated is safer).

Do not drink anything with ice in it—ice may be made with contaminated water.