Health Disparities among Travelers Visiting Friends and Relatives Abroad

Key Summary Points People who visit friends and relatives make up over 40% of all U.S. resident travelers abroad. U.S. resident VFR travelers are largely foreign-born persons and children of foreign-born persons. VFR travelers to developing countries are at greater risk for many largely preventable infectious diseases (such as malaria, typhoid fever, hepatitis A, hepatitis B, and tuberculosis) compared with persons traveling for other purposes, such as tourism. Morbidity in U.S. resident VFR travelers is the product of global inequities in disease burden, combined with the ineffective delivery of available preventive travel-related medical services in the United States. Barriers to the delivery of preventive travel-related medical services for U.S. resident travelers exist at many levels, including the systems level (low insurance coverage), patient level (misperception of disease risk), and provider level (inadequate knowledge of travel medicine). Addressing morbidity in VFR travelers could disrupt the cycle of transmission of preventable illnesses in communities at home and abroad. Unpredictable economic and political changes directly affect global travel, yet a significant and growing subgroup of U.S. travelers continues to predictably cross national boundariespeople who visit friends and relatives. Excluding travel to Canada and Mexico, over 10 million plane trips abroad in 200244% of the totalwere made by U.S. residents who included visiting friends and relatives (VFR) as a reason for travel (1). Compared with travelers for other purposes, VFR travelers going to developing countries are at greater risk for many travel-related illnesses. These include diseases routinely vaccinated against in childhood, such as hepatitis B, as well as tuberculosis (2-5). Disparities exist in the number of cases of malaria (6, 7) and typhoid fever (8) reported and in the rates of hepatitis A (9). For example, according to Centers for Disease Control and Prevention (CDC) malaria surveillance data for 2002, only 10% of reported malaria cases in persons with a known purpose of travel occurred in tourists, while 45% were in VFR travelers (6). A 1-year review of all reported travel-related cases of typhoid fever in the United States showed that tourists accounted for 4% while VFR travelers accounted for 40% (8). A British study showed that VFR travelers younger than 15 years of age going to the Indian subcontinent reported hepatitis A rates 8 times those in like-aged tourists to the same destination (9). Relative to their volume of travel, people who visit friends and relatives account for a disproportionate burden of these illnesses when compared with tourists. Although global travel and migration have long been recognized as key contributors to the dispersal of infectious diseases (10), the prevention of illness in this large population of high-risk VFR travelers receives limited attention. Related morbidity affects individual travelers and potentially the health of communities in which they reside, both abroad and in the United States. In this paper we describe the population of travelers who visit friends and relatives in developing countries, provide a framework for understanding their travel-related risk, and recommend ways to eliminate disparities in their travel-related illnesses. For our search methods see the Appendix. Who Are VFR Travelers? U.S. residents who travel to visit friends and family abroad largely consist of foreign-born persons and their U.S.-born children. This group now totals 56 million people, or one fifth of the U.S. population (Figure). Over 70% of the U.S. foreign-born are concentrated in 6 states (California, New York, Florida, Texas, New Jersey, and Illinois) (12); however, their presence is also increasingly evident across U.S. rural and urban communities (13). Nationally, the foreign-born make up over 10% of the population, although urban areas vary in their composition. For example, 60% of Miami, Florida, residents are foreign-born compared with only 3.2% of Toledo, Ohio, residents (14). Figure. Foreign-born U.S. population, 18502000. Where Do VFR Travelers Go? Destinations of VFR travelers reflect the travelers' individual or family origin. Most U.S. immigrants now come from developing countries. More than half of U.S. foreign-born residents are from Latin America, and one quarter are from Asia (12). In 2002, the top 5 sources of legal immigrants were Mexico, India, China, the Philippines, and Vietnam (15). The circumstances that lead to initial U.S. immigration influence the likelihood of return travel to countries of origin. While earlier immigrant waves were largely due to inhospitable conditions at home (so-called push factors), the most recent wave is more strongly attracted by opportunities in the United States (so-called pull factors). The latter includes employment or family reunification. In 2002, just over 1 million people were granted lawful permanent resident status in the United States. Sixty-three percent received family sponsorship, while 16% entered because of employment preferences. Only 12% were refugees or asylees (15). With increasingly affordable air travel and fewer socioeconomic and political obstacles, these New Americans and their families may be more likely to return to visit their country of originalthough not without potential health consequences. What Are VFR Traveler Risks while Abroad? U.S. residents en route to a developing country traverse more than just a national border. They cross the health care divide to destinations characterized by disproportionately limited resources for public health and sanitation when compared with the United States. Because of characteristics associated with their travel, VFR travelers going to developing countries are commonly considered at higher risk for illness than tourists going to those countries (16). They may go to more rural destinations, stay away for long periods, and make return visits (4, 5, 17). Sleeping accommodations may not include window screens or bed nets (18, 19). While staying with family members, they may have less control over their diet and be more likely to drink untreated water and eat uncooked foods. They may spend increased time in crowded living conditions and in markets, and may have sexual contact with local residents. They may use local medical and dental services for the treatment of acute and chronic illness, as well as for special procedures not available or unaffordable in the United States, such as plastic surgery. By approximating the living conditions of the local community, these behaviors increase VFR travelers' risk for disease exposure to a level similar to that of the local population in the developing country. Yet, to conclude that increased risk for infection is merely a function of VFR travel characteristics would be to simplify a more complex pattern of risk distribution. We have the means to prevent most travel-related illnesses reported in VFR travelers, so why are we not effectively reaching this population? Prevalence gaps in disease and disparities in access to care exist not only across countries but also within countries. Context for Disparities in Predeparture Care Delivery Consider the socioeconomic status of potential VFR travelers. Although heterogeneity exists, foreign-born residents of the United States have higher rates of poverty and lower levels of formal education than the U.S. native-born. For example, among Latin American immigrants, the largest subgroup of the U.S. foreign-born residents, half of those older than 25 years of age had less than a high school education in 2000, and more than one fifth lived in poverty during 1999. In comparison, 13% of U.S. native-born residents older than 25 years of age had less than a high school education, and only one tenth lived in poverty. (12). In the United States, most foreign-born residents and their children are of minority race or ethnicity. These factors are associated with higher rates of morbidity and lower levels of access to and utilization of many general and specialty services (20, 21). Travel-related care appears to be no exception. What Are the Systems-Level Barriers to Predeparture Care? Barriers to care for VFR travelers exist at all levels. At a systems level, low rates of insurance coverage are important. Travel clinic visits are often considered nonessential care and are not typically covered by general health insurance. A visit to a primary care provider for select immunizations and travel advice, however, is often covered, although this may vary by state. For resource-restricted travelers, this may be their only source of travel-related care. Yet, only about 50% of foreign-born persons residing in the United States for less than 10 years have insurance coverage (12). Foreign-born adults are twice as likely as U.S.-born adults to be uninsured (22, 23). As a subgroup, children with foreign-born parents also have lower rates of insurance than U.S.-born children (24), especially children who are foreign-born themselves (25). Lower rates of insurance coverage translate into lower levels of access to travel-related care. Even when specialty travel care is accessible, it may not be optimal for VFR travelers. Travel medicine clinics and care have evolved largely around the tourist industry. Such free-standing clinics are often not integrated into the patient's longitudinal health care services. As a result, primary care provider access to travel-related records to assure that immunizations are up to date and to facilitate the exchange of other important information, such as adverse drug reactions and travel-related illnesses, can be delayed. Separate medical records are especially problematic when VFR travel is frequent or regular or occurs at the last minute (for example, in the case of a family emergency). Another systems-level contributor is incomplete routine childhood immunization coverage. In the United Sta